Every finding on record at Mangum Skilled Nursing and Therapy

Based on observation and interview, the facility failed to ensure: a. mechanical lifts were free from dirt and debris for 3 of 4 observed, b. return air vents were free from dirt and debris for 2 of 2 observed, c. ceilings were in good repair and free from stains, and d. an air purifier was free from dirt and stains. The administrator identified 26 residents resided in the facility. Findings: On 07/28/26 at 12:30 p.m., the half wall to the entry inside the serving area for the dining room was observed to have many areas of a dried dark substance all across the top of the short wall and down the wall. The back wall where the entry to the serving area was, was observed to have large areas of dried yellow substance and a portable air purifier system, sitting in front of the wall, was observed to be covered in dirt along with a dried dark brown substance. The return air vents in the dining area were observed to be covered in dirt and dust. On 07/28/26 at 1:10 p.m., the drop-down ceilings down hall 100 were observed to have dark brown stains and the sheetrock ceiling in the common area was observed to have the tape separating from the seams with dark areas observed around the exposed sheetrock tape. On 07/28/26 at 1:16 p.m., a mechanical lift was observed in the room of Resident #26 The lift was observed to have a build-up of dirt on the base and up the shaft of the lift. On 07/31/26 at 9:22 a.m., the same observations were made of the dining area, hall 100 and the common area. On 07.31.25 at 11:30 a.m., the housekeeping supervisor was shown the lifts stored in room [ROOM NUMBER]. The housekeeping supervisor state they would clean the equipment if it needed it, but they had laundry to keep up with also and they were usually the only one there in the facility. They stated the lifts needed to be cleaned. On 07/31/26 at 11:35 a.m., the housekeeping supervisor was shown the observations in the dining area, and the air purifier. They stated no that was dietary's responsibility, they just swept and mopped the floors. On 07/31/26 at 11:48 a.m., the maintenance supervisor was shown the vents on hall 100 and the vents in the entry to the dining room. The maintenance supervisor was asked who was responsible for cleaning the vents. The maintenance supervisor stated they did not know who was responsible for cleaning them. They stated all the vents need to be cleaned, and they guessed they would do it. The maintenance supervisor was shown the ceilings. The maintenance supervisor stated they had started cleaning and painting the ceiling tiles. The maintenance supervisor was shown the areas of concern in the dining room. The maintenance supervisor stated it looked like they could use a good power washing. On 07/31/26 at 12:11 p.m., the DON stated they would get the air purifier on the cleaning schedule. The dietary manger stated they would be responsible for cleaning the dietary area. The dietary manager stated housekeeping used to be responsible, but when the new housekeeping supervisor started, they were informed cleaning was dietary's responsibility to keep that area clean.

Based on record review and interview, the facility failed to ensure laboratory tests were not performed without a physician's order for 1 (#2) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 26 residents resided in the facility. Findings:Physician's orders for Resident #2, dated 02/16/26, showed to obtain a complete blood count, a comprehensive metabolic panel, and a lipid panel yearly in July. The clinical record for Resident #2 showed a laboratory report for a complete blood count, a comprehensive metabolic panel, and magnesium level were drawn on 02/04/26. On 07/31/26 at 9:50 a.m., the DON was asked if there were physicians orders to perform the laboratory draws. The DON reviewed the clinical health record and stated they did not see any orders for those laboratory tests. The DON stated sometimes the physicians would want follow-up laboratory tests from current results and they did not write the order for them.

Based on observation, record review, and interview, it was determined the facility failed to ensure: a. equipment used for vital sign readings (measurements including body temperature, heart rate, respiratory rate, and blood pressure that indicate the status of the body's vital functions) among multiple residents was disinfected between residents' uses for 3 (#10, 23 and #34) of 2 sampled residents observed for vital sign readings, and b. properly utilized a barrier when placing a glucometer on contaminated surfaces for 3 (#2, 7, and #15) of 3 sampled residents reviewed for FSBS checks. The administrator identified 26 residents resided in the facility and seven residents received FSBS. Findings: 1. On 07/29/26 at 2:05 p.m., CMA #1 was observed to take a blood pressure cuff off of the medication cart and place on the arm of Resident #23. After obtaining the residents blood pressure, CMA #1 removed the cuff and placed it back on the medication cart. The cuff was not observed to be sanitized. On 07/30/26 at 9:48 a.m., CMA #1 was observed to take the blood pressure cuff off of the medications cart and take the blood pressure on Resident #10. After obtaining the blood pressure, CMA #1 placed the cuff on the medication cart, and briefly wiped down the inside surface with a sanitizer wipe. On 07/30/26 at 10:03 a.m. CMA #1 was observed to take the blood pressure cuff off of the medication cart and take the blood pressure of Resident #34. After obtaining the blood pressure, CMA #1 was observed to briefly wipe down the inside of the blood pressure cuff and place back on the treatment cart. CMA #1 was observed to briefly wipe down the inside of the blood pressure cuff with a Santi wipe. On 07/31/26 at 9:50 a.m., the DON was informed of the above observations. The DON stated they would look at the instructions for use in cleaning the blood pressure cuffs. 2.On 07/29/26 at 4:02 p.m. LPN #2 was observed to pull out two metal trays from the top drawer of the treatment cart. LPN #2 was observed to pull out a hydrogen peroxide wipe and briefly wiped off the glucometer and the inside of one of the metal trays. LPN #2 was observed to gather supplies to perform a FSBS on Resident #15. The metal tray was observed to be placed on the resident's bedside table. After completing the FSBS, LPN #2 picked up the tray and carried it out and sat the metal tray on top of the treatment cart. Resident #15's bedside table or the top of the treatment cart were not observed to be sanitized. LPN #2 was observed to briefly wipe the glucometer and top of the metal tray with a hydrogen peroxide wipe. On 07/29/26 at 4:18 p.m., LPN #2 gathered supplies to perform a FSBS on Resident #2. LPN #2 was observed to place the metal tray on the residents bedside table battery. After performing the FSBS, LPN #2 placed the metal tray on the top of the treatment cart. LPN #2 was observed to wipe the inside of the metal tray and briefly wipe down the glucometer with a sanitizer. Resident #2's bedside table and top of the treatment cart were not observed to be sanitized. On 07/29/26 at 4:35 p.m., LPN #2 was observed to place the metal tray on the bedside table of Resident #7. After LPN #2 performed the same procedure on Resident #7, they returned the metal tray and placed it on top of the treatment cart. After the performing the FSBS, LPN #2 returned the metal tray, obtained a sanitizer wipe and briefly wiped the glucometer and tray down and placed both metal trays together. A facility policy titled Blood Glucose Monitoring Guideline, dated 01/2026, read in part, NOTE: Since the Glucometer normally does not come into contact with bodily fluids, it should be wiped between each use on residents with a disinfectant wipe. If the glucometer does become contaminated, then it must be disinfected using the appropriate EPA-registered disinfectant and dwell times. Refer to EPA registered disinfectant container for directions and dwell time. On 07/29/26 at 5:10 p.m., LPN #2 was asked what the wet time was to be effective to disinfect the glucometers. LPN #2 stated three to four minutes for the Santi wipe and approximately two minutes for the hydrogen peroxide. LPN #2 was asked if that wet time was met when she briefly wiped off the glucometer and the metal trays. LPN #2 stated they wanted to say yes. LPN #2 was asked how often the treatment cart was wiped down with a sanitizing wipe. LPN #2 stated frequently. On 07/29/26 at 5:23 p.m., the IP was informed of the findings from the observations made during the medication pass. The IP stated they understood the concerns and they would educate the staff that evening.

Based on record review and interview, the facility failed to ensure an alleged mistreatment during the provision of grooming and hygiene of a resident was reported to the State Agency within two hours for 1 (#35) of 5 sampled residents reviewed for abuse. The administrator identified 26 residents resided in the facility. Findings: An undated admission Record, showed Resident #35 had a diagnoses of dementia and depression. A quarterly assessment for Resident #35, dated 10/31/25, showed the resident had a BIMS score of 3which indicated the resident had severe cognitive impairment. The assessment showed Resident #35 was dependent on staff for grooming and hygiene. A Concern/Grievance Report for Resident #35, dated 11/19/25, read in part, Type of Issue: Mat removal.Description: Mat of hair to the back of head was removed but reddened area noted after it was removed. The grievance was signed by the administrator on 11/20/25. A nurse's progress note for Resident #35, dated 11/19/25 at 1:32 p.m., read in part, Residents scalp was red and irritated this morning, will monitor for discomfort. Resident did not want to get up today. A review the facility's investigations for abuse and mistreatment, dated 07/01/25 through 07/02/26, showed no documentation the facility had reported an allegation of mistreatment during the grooming of Resident #35's hair on 11/19/25. On 07/31/26 at 9:19 a.m., LPN #2 stated they had worked at the facility since February 2025. LPN #2 stated they have had one allegation of mistreatment alleged against them. LPN #2 stated it was alleged Resident #35 had been mistreated while they were having their matted hair brushed. LPN #2 stated the allegation was investigated and they were not suspended. On 07/31/26 at 9:42 a.m., the administrator was asked about the allegation of mistreatment while Resident #35 was having their matted hair brushed. The administrator stated they completed that allegation as a grievance. The administrator then stated it was caused by the matting of the hair and getting it out. The administrator then stated the facility wrote it up as a grievance due to Resident #35 refusing care and not having their hair brushed routinely. On 07/31/26 at 10:12 a.m., CNA #1 stated Resident #35 refused care a lot and had a matt in their hair. CNA #1 stated someone brushed it out and the next morning the resident was hollering out in pain. CNA #1 stated they reported it to staff other than the administrator. On 07/31/26 at 11:20 a.m., LPN #2 stated they knew it was an allegation of mistreatment because staff that were interviewed came and let them know what was asked. On 07/31/26 at 11:35 a.m., the administrator stated looking this should have been reported like an abuse allegation.

Based on record review and interview, the facility failed to ensure an alleged mistreatment during the provision of grooming and hygiene of a resident was thoroughly investigated for 1 (#35) of 5 sampled residents reviewed for abuse. The administrator identified 26 residents resided in the facility. Findings: An undated admission Record, showed Resident #35 had a diagnoses of dementia and depression. A quarterly assessment for Resident #35, dated 10/31/25, showed the resident had a BIMS score of 3 which indicated the resident had severe cognitive impairment. The assessment showed Resident #35 was dependent on staff for grooming and hygiene. A Concern/Grievance Report for Resident #35, dated 11/19/25, read in part, Type of Issue: Mat removal.Description: Mat of hair to the back of head was removed but reddened area noted after it was removed. The grievance was signed by the administrator on 11/20/2025. A nurse's progress note for Resident #35, dated 11/19/25 at 1:32 p.m., read in part, Residents scalp was red and irritated this morning, will monitor for discomfort. Resident did not want to get up today. A review the facility's investigations for abuse and mistreatment, dated 07/01/25 through 07/02/2026, showed no documentation the facility had investigated the allegation of mistreatment during the grooming of Resident #35 hair on 11/19/25. On 07/31/26 at 9:19 a.m., LPN #2 stated they had worked at the facility since February 2025. LPN #2 stated they have had one allegation of mistreatment alleged against them. LPN #2 stated it was alleged Resident #35 had been mistreated while they were having their matted hair brushed. LPN #2 stated the allegation was investigated. On 07/31/26 at 9:42 a.m., the administrator was asked about the allegation of mistreatment while Resident #35 was having their matted hair brushed. The administrator stated they completed that allegation as a grievance. The administrator then stated it was caused by the matting of the hair and getting it out. The administrator then stated the facility wrote it up as a grievance due to Resident #35 refusing care and not having their hair brushed routinely. On 07/31/26 at 10:12 a.m., CNA #1 stated Resident #35 refused care a lot and had a matt in their hair. CNA #1 stated someone brushed it out and the next morning the resident was hollering out in pain. CNA #1 stated they reported it to staff other than the administrator. On 07/31/26 at 11:20 a.m. LPN #2 stated they knew it was an allegation of mistreatment because staff that were interviewed came and let them know what was asked. On 07/31/26 at 11:35 a.m., the administrator stated looking this should have been investigated like an abuse allegation.

Based on observation, record review, and interview, the facility failed to ensure the MDS assessment accurately reflected the current status of a resident related to urinary status for 1 (#26) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 26 residents resided in the facility and one resident with an indwelling urinary catheter. Findings: On 07/28/26 at 1:16 p.m., Resident #26 was observed to be in their room and had an indwelling urinary catheter. A quarterly assessment for Resident #26, dated 07/14/26, showed the resident's cognition was intact with a BIMS score of 15. The assessment showed the resident was dependent with toileting, personal hygiene, had an indwelling urinary catheter and was frequently incontinent of bladder. On 07/31/26 at 12:48 p.m., the MDS coordinator was asked to review the assessment and if the resident had an indwelling urinary catheter. They stated yes. The MDS coordinator was asked if the resident was frequently incontinent. They stated no, the resident had a catheter. The MDS coordinator was the assessment accurately reflected the current status of the resident. They stated no, corporate had been helping out completing the assessments. The MDS coordinator stated the assessment would be updated with the new assessment.

Based on observation, record review and interview, it was determined the facility failed to ensure a comprehensive care plan was completed for 1 (#2) of 1 sampled resident reviewed for hospice care. The administrator identified one resident received hospice services. Findings: On 07/29/26 at 2:14 p.m., Resident #2 was observed setting in their bed watching television. The bed was observed to have a concave mattress. Physician's orders for Resident #2, dated 03/14/26, showed to admit the resident to hospice services with a diagnosis of sarcopenia. A significant change assessment for Resident #2, dated 06/10/26, showed the resident had a diagnoses of non-traumatic brain dysfunction, received routine and as needed pain medications, and was receiving hospice services. A care plan for hospice services for Resident #2, dated 03/16/26, showed a focus of hospice. Interventions showed to consult with the physician and social services to have hospice care and work cooperatively with the hospice team. On 07/31/26 at 12:26 p.m., the MDS coordinator was asked if the care plan identified what the discipline and provider were responsible for. The MDS coordinator stated no it did not. The MDS coordinator was asked if the care plan identified how to contact the hospice 24 hours a day. They stated no. The MDS coordinator was asked if the care plan reflected the coordination between hospice and the facility. They stated no.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident received CPR, per the physician's order and the resident's plan of care, when the resident was found unresponsive and without vital signs. The resident was pronounced deceased by EMS without ever receiving CPR. On [DATE] at 7:08 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 7:11 p.m., the administrator and regional manager were notified and provided the IJ template. Sufficient evidence of correction was provided to determine past non-compliance, with a compliance date of [DATE], when all staff members had been in-serviced, CPR training provided, new processes implemented to prevent lapses in certification and/or licensure, and compliance rounds and code drills implemented with ongoing auditing. Based on observation, record review and interview, the facility failed to initiate CPR, to an unresponsive resident with a full code status for 1 (#1) of 1 sampled resident reviewed for emergency basic life support to include CPR. The administrator reported 2 residents had expired in the facility in the past 90 days. Findings: On [DATE] at 11:00 a.m., a tour of the facility was conducted. Color-coded name strips/tags were observed by each residents door. The name tags were observed to be either green or red. Resident charts at the nurse's station were observed to have green or red tags and observed to match the name tags at the residents doors. A DNR, Advance Directives and End of Life Decisions policy, dated [DATE], read in part, It is the policy of this Facility to comply with a Resident's Advanced Directive and Do Not Resuscitate Consent .In the absence of a DNR Consent Facility staff will routinely initiate cardiopulmonary resuscitation (CPR) in accordance with their training for Residents who suffer cardiac or pulmonary arrest within the Facility and pursuant to the Facility's Emergency Resuscitation Policy. Resident #1 had diagnoses which included dementia, cardiac pacemaker, atherosclerosis, schizoaffective disorder, type 2 diabetes, insomnia, depression, Bipolar disease, anxiety, and chronic pain. A care plan for Resident #1, dated [DATE], showed the resident to be a full code. The care plan showed the resident wished to be resuscitated, their wish would be honored, and the resident would receive all available emergency services and aggressive treatment. The care plan showed if Resident #1 was found in cardiac or respiratory arrest, to start CPR immediately. The care plan showed the green nameplate outside the resident's door indicates full code status. A discharge MDS assessment, return anticipated, for Resident #1, dated [DATE], showed the resident was independent with cognitive skills. The assessment showed the resident required moderate assistance with activities of daily living. A physician order, dated [DATE], showed Resident #1 as full code/CPR status. A progress note for Resident #1, dated [DATE] at 6:23 a.m., showed LPN #1 was called to the resident's room by CNA #1. The note showed the resident was noted to be pale and without respirations or pulse. The note showed 911 was called and emergency personnel confirmed no vital signs and asystole rhythm. There was no documentation to show any other intervention was provided when the resident was found or while waiting for emergency personnel. A CPR/Full Code Response In-service form, dated [DATE], showed RN #1 provided in-service training by lecture to LPN #1. The in-service, read in part, The CPR/Full Code response can be initiated by any staff member that approaches a resident that is non responsive .Review code drill/policy. The form was signed by LPN #1 and RN #1. A typed note, dated [DATE], showed the administrator suspended LPN #1 from [DATE] to [DATE]. A nursing staff schedule was reviewed and showed the LPN had been scheduled to work, but was removed from the schedule while suspended. An In-Service Educational Program form, dated [DATE], showed a code blue class was provided to all staff. The facility's policy for DNR, Advance Directives and End of Life Decisions was used for this training. The in-service sign-in sheets showed some staff members were contacted by phone for training. Copies of Code Drill Guideline forms, dated [DATE] through [DATE], were provided and showed code drills were conducted on each shift. The forms included sign-in for staff members who participated. The code drill guideline included eight steps for conducting the code drill and showed the drills would be conducted each shift monthly. The guideline gave instructions for employees to sign in online to show participation in code drills. An In-Service Educational Program form, dated [DATE], showed a CPR class was provided to nursing staff and activities/social services staff. An email provided by the facility's regional manager, dated [DATE], showed the company was working on CPR certification compliance and instructed facility staff to enter CPR certification expiration dates for all licensed nurses by end of day on [DATE]. The email gave instructions regarding where to enter the data in the system spreadsheet, and how to run a CPR License Expire report to see who was missing an entry or had an expired certification. An In-Service Educational Program form, dated [DATE], showed a CPR class was provided to additional staff members, including a certified nurse aide. Copies of Compliance Rounds forms were provided for [DATE], [DATE], and [DATE]. These were conducted on the day, evening, and night shifts. The compliance rounds included questions to staff regarding how to respond to a code situation, how to know when a resident was a full code or a DNR, and who could participate in a full code situation. A Quality Tip Report, dated [DATE], showed problem identified: CPR response and certification. The report showed plan of correction: code drills every shift for five days, CPR class to be held [DATE] and [DATE]; compliance rounds twice weekly for one month then monthly for six months. The report showed all staff were in-serviced on the CPR/DNR policy. The report showed QA would meet again upon completion of compliance rounds. The report showed date problem identified: [DATE]; date range for compliance rounds: [DATE] through [DATE] then monthly for six months. The report showed date problem reported to QA committee: [DATE]. The report was signed by RN #1. On [DATE] at 11:05 a.m., CNA #2 reported the facility's process for identifying a resident's code status was to use a red name strip if the resident was a DNR and a green name strip if the resident was a full code. The CNA reported the color-coded name strips were at each resident's door, as well as on the resident's hard chart at the nurse's station. The CNA reported this identification process was not new and had been in place for a while. On [DATE] at 11:25 a.m., LPN #2 reported they were not aware of any issues with identifying a resident's code status. The LPN reported the facility's process was to use green for a full code and red for a DNR, and this could be found at the resident's door, on the hard chart, and in the electronic medical record. On [DATE] at 11:30 a.m., LPN #3 reported the facility had CPR training the previous week for all staff who were not already certified or needed to be re-certified. The LPN reported this training was related to a resident being found unresponsive and staff did not initiate CPR. On [DATE] at 12:40 p.m., LPN #1 was interviewed by phone. The LPN reported it was during their last round of the night that CNA #1 called for their help with Resident #1. The LPN reported they checked the resident and grabbed the vital sign machine to see if their suspicion was correct. The LPN reported they were unable to get vital signs on the resident and attempted to call the DON to see what the protocol was in this situation. The LPN reported they were unable to reach the DON so then called 911. The LPN reported they knew the resident was a full code, but since the resident appeared to be deceased and had no vital signs, they were uncertain about starting CPR. The LPN reported EMTs arrived, placed an EKG machine on the resident, and confirmed there was no pulse and pronounced the resident. On [DATE] at 12:55 p.m., CNA #1 was interviewed by phone. The CNA reported it was probably 5:00 or 5:30 a.m., while making rounds, when they found Resident #1 unresponsive in their room. The CNA reported they thought it was probably about 3:00 a.m. when they had last looked in on the resident and heard the resident snoring. The CNA reported they were aware the resident was a full code and immediately called for the nurse who took over from there. The CNA reported in most situations if they thought the nurse was not going to do CPR, they would do it, but in this case the CNA thought the nurse felt it wouldn't help the resident. On [DATE] at 1:30 p.m., RN #1 reported two staff members could not be reached for the code blue in-service on [DATE], but would be in-serviced prior to their next shifts. RN #1 provided a resident roster which listed each resident and their code status. The RN reported in addition to the [DATE] in-service, they checked door tags, advanced directive acknowledgements, and DNR status with each resident's chart to ensure all were correct and identified correctly on the resident's door/name tags. The RN reported they found no discrepancies. On [DATE] at 1:35 p.m., the regional manager reported the new process for tracking CPR certification and licenses would allow the facility to prevent lapses in licensure and certification and had already been initiated as of [DATE]. On [DATE] at 5:10 p.m., the DON reported they told LPN #1 they should always do CPR if the resident was a full code, regardless of the circumstances. The LPN told the DON they did not feel performing CPR on the resident was the right thing to do when they believed the resident was already gone, and was not sure what the protocol was in this situation. On [DATE] at 5:15 p.m., RN #1 reported they told LPN #1 during their 1:1 in-service/lecture that it was not their place to make the decision on whether to perform CPR or not, as the resident was a full code status. The RN reported the LPN and all other staff had been in-serviced.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff were trained and competent to respond to a resident's needs when the resident was found unresponsive and without vital signs. The resident was pronounced deceased by EMS without ever receiving CPR. On [DATE] at 7:08 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 7:11 p.m., the administrator and regional manager were notified and provided the IJ template. Sufficient evidence of correction was provided to determine past non-compliance, with a compliance date of [DATE], when all staff members had been in-serviced, CPR training provided, new processes implemented to prevent lapses in certification and/or licensure, and compliance rounds and code drills implemented with ongoing auditing. Based on observation, record review, and interview, the facility failed to ensure staff were trained and competent to respond to a resident's needs for 1 (#1) of 2 sampled residents reviewed for competency of staff. The administrator reported two residents had expired in the facility in the past 90 days. Findings: On [DATE] at 11:00 a.m., a tour of the facility was conducted. Color-coded name strips/tags were observed by each resident's door. The name tags were observed to be either green or red. Resident charts at the nurse's station were observed to have green or red tags and observed to match the name tags at the resident's doors. A DNR, Advance Directives and End of Life Decisions policy, dated [DATE], read in part, It is the policy of this Facility to comply with a Resident's Advanced Directive and Do Not Resuscitate Consent .In the absence of a DNR Consent Facility staff will routinely initiate cardiopulmonary resuscitation (CPR) in accordance with their training for Residents who suffer cardiac or pulmonary arrest within the Facility and pursuant to the Facility's Emergency Resuscitation Policy. Resident #1 had diagnoses which included dementia, cardiac pacemaker, atherosclerosis, Schizoaffective disorder, type 2 diabetes, insomnia, depression, Bipolar disease, anxiety, and chronic pain. A care plan for Resident #1, dated [DATE], showed the resident to be a full code. The care plan showed the resident wished to be resuscitated, their wish would be honored, and the resident would receive all available emergency services and aggressive treatment. The care plan showed if Resident #1 was found in cardiac or respiratory arrest, to start CPR immediately. The care plan showed the green nameplate outside the resident's door indicates full code status. A discharge MDS assessment, return anticipated, for Resident #1, dated [DATE], showed the resident was independent with cognitive skills. The assessment showed the resident required moderate assistance with activities of daily living. A physician order, dated [DATE], showed Resident #1 as full code/CPR status. A progress note for Resident #1, dated [DATE] at 6:23 a.m., showed LPN #1 was called to the resident's room by CNA #1. The note showed the resident was noted to be pale and without respirations or pulse. The note showed 911 was called and emergency personnel confirmed no vital signs and asystole rhythm. There was no documentation to show any other intervention was provided when the resident was found or while waiting for emergency personnel. A CPR/Full Code Response In-service form, dated [DATE], showed RN #1 provided in-service training by lecture to LPN #1. The in-service read in part, The CPR/Full Code response can be initiated by any staff member that approaches a resident that is non responsive .Review code drill/policy. The form was signed by LPN #1 and RN #1. A typed note, dated [DATE], showed the administrator suspended LPN #1 from [DATE] to [DATE]. A nursing staff schedule was reviewed and showed the LPN had been scheduled to work, but was removed from the schedule while suspended. An In-Service Educational Program form, dated [DATE], showed a code blue class was provided to all staff. The facility's policy for DNR, Advance Directives and End of Life Decisions was used for this training. The in-service sign-in sheets showed some staff members were contacted by phone for training. Copies of Code Drill Guideline forms, dated [DATE] through [DATE], were provided and showed code drills were conducted on each shift. The forms included sign-in for staff members who participated. The code drill guideline included eight steps for conducting the code drill and showed the drills would be conducted each shift monthly. The guideline gave instructions for employees to sign in online to show participation in code drills. An In-Service Educational Program form, dated [DATE], showed a CPR class was provided to nursing staff and activities/social services staff. An email provided by the facility's regional manager, dated [DATE], showed the company was working on CPR certification compliance and instructed facility staff to enter CPR certification expiration dates for all licensed nurses by end of day on [DATE]. The email gave instructions regarding where to enter the data in the system spreadsheet, and how to run a CPR License Expire report to see who was missing an entry or has an expired certification. An In-Service Educational Program form, dated [DATE], showed a CPR class was provided to additional staff members, including a certified nurse aide. Copies of Compliance Rounds forms were provided for [DATE], [DATE], and [DATE]. These were conducted on the day, evening, and night shifts. The compliance rounds included questions to staff regarding how to respond to a code situation, how to know when a resident is a full code or a DNR, and who can participate in a full code situation. A Quality Tip Report, dated [DATE], showed problem identified: CPR response and certification. The report showed plan of correction: code drills every shift for five days, CPR class to be held [DATE] and [DATE]; compliance rounds twice weekly for one month then monthly for six months. The report showed all staff were in-serviced on the CPR/DNR policy. The report showed QA would meet again upon completion of compliance rounds. The report showed date problem identified: [DATE]; date range for compliance rounds: [DATE] through [DATE] then monthly for six months. The report showed date problem reported to QA committee: [DATE]. The report was signed by RN #1. On [DATE] at 11:05 a.m., CNA #2 reported the facility's process for identifying a resident's code status was to use a red name strip if the resident was a DNR and a green name strip if the resident was a full code. The CNA reported the color-coded name strips were at each resident's door, as well as on the resident's hard chart at the nurse's station. The CNA reported this identification process was not new and has been in place for a while. On [DATE] at 11:25 a.m., LPN #2 reported they were not aware of any issues with identifying a resident's code status. The LPN reported the facility's process was to use green for a full code and red for a DNR, and this could be found at the resident's door, on the hard chart, and in the electronic medical record. On [DATE] at 11:30 a.m., LPN #3 reported the facility had CPR training the previous week for all staff who were not already certified or needed to be re-certified. The LPN reported this training was related to a resident being found unresponsive and staff did not initiate CPR. On [DATE] at 12:40 p.m., LPN #1 was interviewed by phone. The LPN reported it was during their last round of the night that CNA #1 called for their help with Resident #1. The LPN reported they checked the resident and grabbed the vital sign machine to see if their suspicion was correct. The LPN reported they were unable to get vital signs on the resident and attempted to call the DON to see what the protocol was in this situation. The LPN reported they were unable to reach the DON so then called 911. The LPN reported they knew the resident was a full code but since the resident appeared to be deceased and had no vital signs, they were uncertain about starting CPR. The LPN reported EMTs arrived, placed an EKG machine on the resident, and confirmed there was no pulse and pronounced the resident. On [DATE] at 12:55 p.m., CNA #1 was interviewed by phone. The CNA reported it was probably 5:00 or 5:30 a.m., while making rounds, when they found Resident #1 unresponsive in their room. The CNA reported they thought it was probably about 3:00 a.m. when they had last looked in on the resident and heard the resident snoring. The CNA reported they were aware the resident was a full code and immediately called for the nurse who took over from there. The CNA reported in most situations if they thought the nurse was not going to do CPR, they would do it, but in this case the CNA thought the nurse felt it would not help the resident. On [DATE] at 1:30 p.m., RN #1 reported two staff members could not be reached for the code blue in-service on [DATE], but would be in-serviced prior to their next shifts. RN #1 provided a resident roster which listed each resident and their code status. The RN reported in addition to the [DATE] in-service, they checked door tags, advanced directive acknowledgements, and DNR status with each resident's chart to ensure all were correct and identified correctly on the resident's door/name tags. The RN reported they found no discrepancies. On [DATE] at 1:35 p.m., the regional manager reported the new process for tracking CPR certification and licenses would allow the facility to prevent lapses in licensure and certification and has already been initiated as of [DATE]. On [DATE] at 5:10 p.m., the DON reported they told LPN #1 they should always do CPR if the resident was a full code, regardless of the circumstances. The LPN told the DON they did not feel performing CPR on the resident was the right thing to do when they believed the resident was already gone, and was not sure what the protocol was in this situation. On [DATE] at 5:15 p.m., RN #1 reported they told LPN #1 during their 1:1 in-service/lecture that it was not their place to make the decision on whether to perform CPR or not, as the resident was a full code status. The RN reported the LPN and all other staff had been in-serviced.

Based on observation and interview, the facility failed to store premixed drinks mixed with water in a safe manner to prevent the possible growth of bacteria. The administrator reported 28 residents resided in the facility. Findings: On 12/02/24 at 10:40 a.m., two drink dispensers were observed sitting in the dining room and were labeled with a date of 11/26/24. On 12/02/24 at 2:00 p.m., two drink dispensers on a shelf in the dinning room were observed to be labeled with a date of 11/26/24. The drink dispensers were not chilled and outside of dispensers felt to be at room temperature by touch. On 12/03/24 at 9:00 a.m., the two drink dispensers on a shelf in the dining room were observed to be labeled with a date of 12/02/24. On 12/03/24 at 1:36 p.m., the dietary manager reported the drink dispensers in the dining room were emptied when they were almost empty. The dietary manager reported the date of 11/26/24 labeled on the drink dispensers date was correct. The dietary manager reported the drinks are a premixed powder drink and the dispensers are set out during the day and refrigerated before dietary staff leave in the evening. On 12/03/24 at 3:41 p.m., the administrator reported they had no policy related to storage of premixed drinks due to it being a non-hazardous food item. On 12/03/24 at 4:07 p.m., the premixed drink mix package obtained from the kitchen was observed to be Thirst Ease pre-sweetened soft drink mix. The instructions on the package, read in part, mix contents of package with water and keep covered and chilled until ready to serve.

Based on record review and interview, the facility failed to accurately reflect residents antiplatelet medication on assessments for two (#3 and #10) of three sampled residents reviewed for accuracy of assessments. The administrator reported 28 residents resided in the facility. Findings: The Resident Assessment Instrument manual, dated 10/01/23, read in part, Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as anticoagulant. 1. Resident #3 had diagnoses which included hemiplegia following cerebral infarction. A physician order for Resident #3, dated 12/14/23, documented Plavix (antiplatelet medication) 75 mg (clopidogrel bisulfate) give one tablet by mouth one time a day. A comprehensive assessment for Resident #3, dated 10/24/24, documented the resident took an anticoagulant medication. 2. Resident #10 had diagnoses which included history of cerebrovascular accident. A physician order for Resident #10, start date 06/22/24, documented Plavix 75 mg (clopidogrel bisulfate) by mouth one time a day for history of cerebrovascular accident. The physician order was discontinued on 11/22/24. A comprehensive assessment for Resident #10, dated 10/07/24, documented the resident took an anticoagulant medication. On 12/04/24 at 2:33 p.m., the MDS coordinator reported the RAI manual was used to complete the comprehensive assessment. The MDS coordinator reported Plavix was coded on the comprehensive assessment as an anticoagulant medication. The MDS coordinator reported a list of medications was used to code medications on the comprehensive assessment and believed Plavix was listed as an anticoagulant, not an antiplatelet medication. The MDS coordinator reported not being aware what the RAI manual instructions were for coding Plavix. The MDS coordinator also reported Resident #3 was currently on Plavix and Resident #10 had been on Plavix when the last comprehensive assessment had been completed. On 12/04/24 at 4:00 p.m., the MDS coordinator reported the RAI manual had been reviewed and Plavix should have been coded as an antiplatelet medication.

Based on observation and interview, it was determined the facility failed to ensure the ice machine was clean and sanitary. This had the potential to affect 53 residents that received ice from the ice machine. Findings: On 08/05/19 at 8:39 a.m., the ice machine located in the dining area was observed to have had a brown residue substance on the rim of the ice shield plate inside the machine. The residue was easily dislodged and fell into the ice. The dietary manager observed the build-up being dislodged into the ice and immediately started to clean the machine. The dietary manager stated a contract company comes every six months to clean the ice machine. The last date of service was (MONTH) 2019. On 08/06/19 at 8:12 a.m., the administrator was informed of the above findings and stated it would be corrected. She stated it should be cleaned more often.

Based on interview and record review, it was determined the facility failed to ensure quarterly assessments were completed and transmitted within the allowed time frame for two (#4 and #5) of 10 residents whose records were reviewed for assessments. This had the potential to affect 53 residents. Findings: Resident #4's clinical record had a quarterly assessment, dated 03/31/19. Next quarterly assessment due 07/01/19. On 08/06/19 the quarterly assessment, dated 07/01/19, was reviewed and the assessment documented a start date of 06/21/19 was still In Progress and 22 days overdue. Resident #5's clinical record had a quarterly assessment, dated 04/02/19. Next quarterly assessment due 07/03/19. On 08/06/19, the quarterly assessment, dated 07/03/19, was reviewed and the assessment documented a start date of 06/25/19 was still In Progress and was 20 days overdue. On 08/06/19 at 9:24 a.m., the assessment coordinator was shown the above findings and was in agreement the assessments had not been completed and transmitted in the required time frame.

Based on record review and interview, it was determined the facility failed to ensure a discharge summary included a recapitulation of the residents stay and a final summary of the residents status for one (#52) of one resident whose record was reviewed for discharge. This had the potential to affect 10 residents who had been discharged in (MONTH) and (MONTH) 2019. Findings: Resident #52 had [DIAGNOSES REDACTED]. The admission assessment, dated 05/13/19, documented the resident required supervision with eating and extensive assistance for all other activities of daily living. A nurses note, dated 05/06/19, documented the resident was admitted to Grace Living Center (GLC) for respite care. The resident was discharged on [DATE]. The discharge summary nurses note documented: Resident discharged from GLC #14 with {family member} {name deleted}. Medication Administration Record [REDACTED] Discharge Summary assessment documented Recapitulation of entire stay: admitted [DATE] for respite care. Adjusted well. The discharge nurses note or discharge summary assessment had not documented the status or condition of the resident during his stay or upon discharge. There was no documentation in the records the resident went home on home health. On 08/07/19 at 11:26 a.m., the director of nursing was interviewed and informed the final summary status and the recapitulation of the resident's stay had not contained information needed to continue his care. She stated, I will in-service my nurses about it. She stated, He did go home on home health and it's not in here.

Based on record review and interview, it was determined the facility failed to ensure a monthly pharmacy report had identified and reported to the physician an as needed (PRN) antianxiety agent and the required end date for use. This had the potential to affect 53 residents residing in the facility as identified by the administrator. Findings: A care plan, dated 06/07/19, documented the resident was to be administered an antianxiety medication PRN. A physician's orders [REDACTED]. The order had not documented a stop date. The Medication Administration Record [REDACTED]. The record had documented a monthly pharmacist review for (MONTH) and (MONTH) 2019 with no recommendations to the physician. On 08/08/19 at 9:33 a.m., the pharmacist was interviewed and stated a report was given to a facility nurse that was no longer working here. She stated it was a one time report and she could not reproduce the report. She could not provide documentation the PRN medication had been identified and a stop date had been requested for the medication. She stated she had not sent a report to the physician with a recommendation for a stop date of the PRN antianxiety medication. At 9:58 a.m., the administrator and corporate nurse were informed of the above findings and agreed it should have been reported.

Based on record review and interview, it was determined the facility failed to ensure an anti-anxiety medication for an as needed (PRN) had a stop date within the required 14 days of use for one (#51) of two residents reviewed for PRN medications. This had the potential to affect 11 residents who had received anti-anxiety medications according to the Resident Census and Conditions of Residents. Findings: Resident #51 was admitted with [DIAGNOSES REDACTED]. The care plan, dated 06/07/19, documented the resident was to be administered an anti-anxiety medication PRN. A physician's orders [REDACTED]. The order had not documented a stop date. The Medication Administration Record [REDACTED]. On 08/07/19 at 11:17 a.m., the director of nursing was shown the above findings. She reviewed the record and acknowledged no stop date had been ordered.

Based on observation and interview, it was determined the facility failed to provide a dining environment that enhanced dignity for one (#26) sampled resident who required assistance with eating. The administrator identified six residents who required assistance with eating. Findings: On 08/05/19 at 12:14 p.m., resident #26 was observed to be seated at the assisted dining table. Certified nurse aide (CNA) #1 was observed to be standing next to the resident while assisting the resident to eat. At 12:25 p.m., the CNA was still standing while assisting the resident with eating. The CNA was asked if the facility policy required staff to sit while assisting residents with eating. She stated she probably should sit. After the interview she left the area; when she returned she sat down at the assisted dining table and continued to assist the resident with eating. On 08/07/19 at 9:00 a.m., the director of nurses and administrator were asked if the facility policy required staff to sit while assisting residents to eat. They stated staff should sit down. They were informed of the observation of a staff member standing while assisting a resident to eat.

Based on interview and record review, it was determined the facility failed to ensure a care plan documented a resident's 24 hour supervision requirement for potential complications from the [DIAGNOSES REDACTED].#11) of nine residents whose records were reviewed for accurate care plans. This had the potential to affect all 47 residents. Findings: The resident had [DIAGNOSES REDACTED]. Her admission assessment, dated 06/27/18, documented the resident's cognition was intact. She required supervision with all of her activities of daily living. She was continent of bowel and bladder. She received Insulin daily. On 10/01/18 at 11:08 a.m., the resident stated she used to be able to sign herself out of the facility and go walk to the park and walk around town, but all of a sudden on 09/07/18 the director of nursing (DON) told her she couldn't go out anymore because she was a diabetic. A nurse's progress note, dated 09/07/18, documented, Was advised by Social Services Director resident had obtained a membership at a local gym and had gone to the gym and 'worked out.' The management team discussed matter. Given her diabetes, it was felt her Medical Doctor should be included in any exercise program she initiated. Resident also signs herself out of facility and walks to gym and walks back after working out. She verbalized understanding of potential risk of her blood sugar dropping to an unsafe level while out of facility after a vigorous work out and agreed not to attend the gym until it was determined safe for her to do so .Resident was calm and agreeable with staff concerns regarding her safety. Resident's Dr. notified of situation. A nurse's note, dated 09/07/18 documented, Nursing administration consulted with {name deleted} Corporate Legal department regarding resident rights related to a medical condition that is requiring 24 hour supervision. {name deleted} met with resident related to facilities concern of her need for 24 hour supervision and her being away from the facility on a daily basis. Resident verbalized understanding and agreed not to be away from facility unsupervised . The resident's care plan for was reviewed and contained no documentation the resident was to have had 24 hour supervision for the potential complications from her diabetes diagnoses. On 10/01/18 at 03:57 p.m., the DON was asked about the resident not having been able to go out unsupervised. She stated she had talked with corporate about the resident's diabetes and since the resident's blood sugar was so uncontrolled, corporate had said the resident could only go out with staff or family because of needing 24 hour supervision. This was a safety issue in case she collapses while she is out. She does still go out and has been out with family to the movies and gone out with other residents and with staff. The DON stated the resident had been in and out of the hospital multiple times prior to coming to the facility because of her uncontrolled DM. The DON was asked if the supervision should have been care planned. She stated, Yes.

Based on observation and interview, it was determined the facility failed to ensure food was handled in a sanitary way., in order to prevent cross contamination. This had the potential to affect 46 residents who received food from the kitchen. Findings; On 10/01/18 at 11:53 a.m. dietary cook #1 was observed to have used her gloved hands to touch a piece of bread, a food ladle, meal slips, a food ladle, another food ladle, a food scoop, another piece of bread, cooked rice, another ladle, and another piece of bread with the same gloved hand. At 12:20 p.m., certified nurse aid (CNA) #1 was observed to have been assisting a resident to eat a meal. She touched a slice of bread with her bare hand and used her other bare hand to spread food onto another piece of bread using a butter knife. She then used both bare hands to fold the bread in half. She then used her bare hand to assist the resident to eat the sandwich. On 10/02/18 at 8:10 a.m. the dietary manager (DM) was observed to have been serving breakfast and she touched a plate, picked up two pancakes, picked up bacon, picked up sausage, cut the sausage using a knife, touched an egg scoop, picked up a biscuit and tore it and placed it on the plate, touched a gravy ladle, touched another plate, multiple meal slips with the same gloved hands. At 8:12 a.m., the dietary manager was asked the process for food handling. She replied, When should I have washed my hands? At 11:51 a.m., dietary cook #1 was informed of the observation on 10/01/18 for the lunch time meal. She was asked if she should have touched the food and other items with the same gloved hand. She stated she should not have. At 1:40 p.m., the administrator was asked if CNA # should have touched the bread with her bare hand. She stated, No.

Based on observation and interview, it was determined the facility failed to ensure residents' dishes and kitchen equipment were clean and free of dried debris. This had the potential to affect 41 residents receiving food from the kitchen as identified by the director of nursing. Findings: On 08/21/17 at 9:22 a.m., a kitchen tour was conducted. The dried, cleaned dish storage area was observed to have contained one dinner plate with a smeared, greasy film on the food contact surface of the plate. Three coffee cups were observed to have had dried, flaky debris on the inside of each cup. Six beverage glasses were observed to a have had staining, or a gray film, or a dried, accumulated substance on the inside of the glass. The coffee maker was observed to have brown debris on the spout and the surrounding plate. At 11:00 a.m., the dietary manager was shown the above findings. She agreed the dishes were not cleaned and would be cleaned right away.