Every finding on record at Memorial Heights Nursing Center

Based on observation, record review, and interview, the facility failed to ensure:a. proper final cooking temperatures were monitored to check the internal temperature was safe for consumption prior to placing on the steam table for holding before meal service; andb. a log was maintained to reflect the monitoring of final cooking temperatures and holding temperatures for 1 meal service observed. The compliance officer identified 86 residents resided in the facility.Findings:A Position Description Dietary Service Manager, read in part, Assures correct procedures in preparation of food and inspects quality, temperature, and appearance of food prior to serving.On 04/14/26 at 10:32 a.m., an observation was made of peas cooking on the stove, roast beef was in the oven, rolls were rising on the counter, and rice was on the stove. On 04/14/26 at 10:35 a.m., the dietary manager was observed to prepare puree roast with a piece from the pan in the oven and the juice from the pan. There was no observation the dietary manager obtained a temperature of the roast.On 04/14/26 at 10:46 a.m., the dietary manager was observed to puree the peas with the water it was cooked in. There was no observation the dietary manager obtained a temperature of the peas.On 04/14/26 at 10:55 a.m., the dietary manager was observed to puree the rice pilaf with chicken paste and hot water.There was no observation the dietary manager obtained a temperature of the rice.On 04/14/26 at 11:08 a.m., the dietary manager was observed to remove the roast from the oven and placed on the steam table.There was no observation the dietary manager obtained a temperature of the roast. On 04/14/26 at 11:30 a.m., the dietary manager was observed to grab the thermometer and the temperature book and obtained a temperature of the roast at 209 degrees Fahrenheit. The temperature book showed a page for the month of April. The temperature book showed one temperature documented for each meal item for breakfast, lunch. and dinner. The page was blank for all meals from 04/09/26 through 04/14/26. On 04/14/26 at 11:34 a.m., the dietary manager stated they had the breakfast and lunch cooking temperatures wrote down on paper and they were not the evening cook. The dietary manager stated they left the paper in their bag at home.On 4/14/26 at 11:35 a.m., [NAME] #1 stated they were the evening cook, and they had not done the temperatures. On 04/14/26 at 11:36 a.m., the dietary manager stated they cooked the food, placed it on the steam table, and then obtained the temperature of the food. They stated they had not obtained cooking temperatures prior to placing the food on the steam table. On 04/14/26 at 11:39 a.m., the dietary manager stated they were told back in 2020 to cook the food and put it on the steam table and to check the temperature at the steam table. [NAME] #1 stated they were told the same.The dietary manager and cook #1 were asked how they ensured proper cooking temperatures were reached after cooking. They were unable to state how proper cooking temperatures were ensured. On 04/14/26 at 12:50 p.m., the compliance officer stated the cooks were educated to obtain temperatures of the food after cooking and were not required to document the temperature. The compliance officer stated once the food was on the steam table, they were to obtain and document the holding temperature.

Based on record review and interview, the facility failed to ensure catheter care was performed for an indwelling catheter for 1 (#10) of 3 sampled residents reviewed for urinary catheter.The compliance officer identified 6 residents with a urinary catheter resided in the facility. Findings: An undated policy titled Incontinence, read in part, Ensure that a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. A physician order, dated 09/17/25, showed catheter to gravity. A physician order, dated 11/25/25, showed to change catheter every month. There were no orders for catheter care located in the EMR. A quarterly assessment for Resident #10, dated 12/30/25, showed the brief interview for mental status score of 13 indicating cognitively intact. The assessment showed Resident #10 required partial to moderate assistance with mobility and was dependent with toileting due to indwelling urinary catheter and ileostomy. The assessment showed a diagnosis of urinary retention and a urinary tract infection within the last 30 days. Resident #10's care plan, dated 01/30/26, did not show the resident performed their own catheter care and did not indicate staff would provide catheter care. On 04/08/26 at 1:15 p.m., Resident #10 stated staff changed their catheter monthly but did not provide any catheter care. Resident #10 stated they performed their own peri care and catheter care. On 04/15/26 9:54 a.m., Resident #10 stated they did their own catheter care everyday using a washcloth. They stated it was not their preference to do the catheter care. Resident #10 stated the reason they do it was to keep it clean and germ free and did not know why the facility staff did not perform the catheter care. On 04/15/26 at 10:13 a.m., LPN #2 stated the resident received catheter care every shift. They stated they provided catheter care for the resident. LPN #2 stated they had to sign off on the treatment sheet for the catheter care and there should be an order for it. On 04/15/26 at 10:19 a.m., LPN #2 stated the resident should not do their own catheter care. On 04/15/26 at 10:17 a.m., LPN #2 stated there was no order for catheter care but there should have been. On 04/15/26 at 10:24 a.m., the DON stated the catheter care order would be in the orders or in the tasks. They stated the CNA did the catheter care. The DON stated the orders did not show catheter care and the task did not show where it was documented. The DON stated catheter care should have been documented. On 04/15/26 at 10:28 a.m., the DON stated they did not see an order for catheter care and there should have been one.

Based on record review and interview, the facility failed to ensure resident representatives were notified of a change in condition for 2 (#98 and #100) of 3 sampled residents reviewed for change of condition. The administrator identified 86 residents resided in the facility. Findings: An undated facility Notification of Changes policy read in part, The facility must immediately inform.The resident representative(s) when there is.A significant change in the resident's physical, mental or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). A nursing note, dated 10/05/25 at 12:58 a.m., showed Resident #98 received cardiopulmonary resuscitation at the facility and emergency medical services transported the resident to the hospital at 1:03 a.m. There was no documentation Resident #98's representative was notified of the change in condition and transfer to the hospital on [DATE]. On 04/09/26 at 6:23 p.m., LPN #1 stated they were to notify their supervisor and a resident's on-call physician of a change in condition. On 04/09/26 at 6:32 p.m., LPN #1 stated they did not recall documenting the resident's family was notified of the change in condition. On 04/10/26 at 8:58 a.m., resident representative #1 stated they were not notified of Resident #98's change in condition or transfer to the hospital. On 04/10/26 at 9:08 a.m., the DON stated staff were to notify the resident's physician and family of a change in condition. On 04/10/26 at 9:10 a.m., the DON stated they could not locate documentation resident #98's family was notified of the change in condition on 10/05/25. 2. A nurses note, dated 02/24/26 at 4:45 a.m., showed Resident #100 was observed in a seated position on the floor in their room with their head against the bed rail. The nurse note showed Resident #100 stated they fell while going to the bathroom and hit their head. The nurse note showed the facility was unable to locate the contact information for Resident #100's next of kin. The nurse note showed Resident #100 had sustained a large hematoma to their right elbow and right inner forearm, a skin tear to left inner wrist, and an abrasion to their left knee. There was no documentation Resident #100's next of kin was notified of the change in condition and transfer to the hospital. A miscellaneous section of the EMR showed the admission paperwork with Resident #100's family member's name and phone number written on it was uploaded on 02/24/26 at 7:48 a.m. The contact history in the EMR showed the date and time Resident #100's family member was listed as a contact was entered on 02/24/26 at 8:50 a.m. An Oklahoma State Department of Health Incident Report Form, dated 02/24/26, showed Resident #100's family member was at the facility at 7:30 a.m., and 8:20 a.m., and spoke to both the DON and the administrator about the resident's fall. On 04/13/26 at 3:03 p.m., the DON stated the process for sending residents out to the hospital for a change in condition was to assess the resident and if warranted they would notify the physician, then EMS, and then would notify the family and the hospital. The DON stated the process for uploading new admission contact information was to enter it in the misc. section of the EMR or documents tab at the time of completing the admission. On 04/13/26 at 3:04 p.m., the DON stated the contact information for Resident #100 was uploaded to the EMR on 02/24/25 at 8:34 a.m. On 04/13/26 at 3:06 p.m., the DON stated when Resident #100 fell, they looked for the contact information for the family member. They stated the contact information was not in the profile in the EMR, or in the discharge paperwork. The DON stated the next morning after the fall when they saw Resident #100's family member in the facility, they notified them in person of the resident's fall and having been sent to the hospital. The DON stated whoever had gotten the contact information had not uploaded it. On 04/13/26 at 3:13 p.m., the DON stated the nurse that admitted Resident #100 had forgotten to upload the information. They stated they found out when the family member came in that the paperwork with the contact information on it was in a binder/folder in the medication room where the nurse that did the admission had left it. The DON stated since the resident was admitted after hours, the charge nurse was responsible for the admission paperwork. The DON stated Resident #100's family member was not notified at 4:45 a.m., when the resident was sent out to the hospital. The DON stated the family member was notified around 8:00 a.m., when they came to the facility. On 04/13/26 at 3:15 p.m., the DON stated it was not the usual process to store resident contact information in a folder in the medication room. They stated they would give it to the admission person. But they had left for the day.

Based on record review and interview, the facility failed to ensure before and after dialysis assessments and weights were obtained for 1 (#26) of 1 sampled resident reviewed for dialysis. The administrator identified 6 dialysis residents resided in the facility. Findings:A policy titled Dialysis, undated, read in part, The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice. Ongoing assessments of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.A physician's order, dated 01/23/26, showed assess dialysis site to right chest every day and night shift.A physician's order, dated 01/24/26, showed hemodialysis every day shift every Tuesday, Thursday, and Saturday.A physician's order, dated 01/24/26, showed weigh before and after dialysis every day shift every Tuesday, Thursday, and Saturday.An admission assessment for Resident #26, dated 02/04/26, showed the resident had a diagnosis of renal failure. The assessment showed they received dialysis while a resident.There was no before and after dialysis assessments documentation for (Tuesday) 03/31/26, (Thursday) 04/02/26, and (Saturday) 04/04/26. There were no weights located for before and after dialysis. On 04/09/26 at 3:28 p.m., LPN #3 stated prior to residents going to dialysis, there was a head-to-toe assessment completed before each treatment and the documentation was on paper and scanned into the EMR. They stated a form was sent with the resident for the dialysis center to complete and return with the resident and then it was scanned into the EMR. On 04/09/26 at 3:45 p.m., LPN #3 stated they were unable to locate before and after dialysis documentation for 03/31/26, 04/02/26, or 04/04/26, and they did not see documentation of refusal to go to dialysis on the days in question. On 04/09/26 at 3:47 p.m., LPN #3 stated the before and after weights were in the weights section of the EMR. They stated it was only flagged for after dialysis and not before dialysis. LPN #3 stated the weights should have been on the treatment sheet, but the order had been entered incorrectly and did not show up.

Based on observation, record review, and interview, the facility failed to ensure medication was stored separate from personal food and drinks items for 2 of 2 refrigerators observed in the medication room. The DON identified the facility had one medication room. Findings: On 04/13/26 at 2:25 p.m., an observation of the medication room was completed. A small refrigerator was observed containing tuberculin medication, containers of yogurt, two half empty bottles of soda drinks, two bottles of water with one a fourth empty. A second small refrigerator was observed containing insulin bottles, insulin pens, an ice cream sandwich, and a packaged roast beef and cheddar sandwich. An undated facility policy titled Storage of Medications, read in part, Medications must be stored separately from food and must be properly labeled. On 04/13/26 at 2:37 p.m., the DON stated the food and drink items belonged to staff and should not be stored in the medication refrigerators.

Based on record review and interview, the facility failed to ensure a care plan was developed to address hospice services for 1 (#60) of 1 sampled resident reviewed for hospice services. The compliance office identified 11 residents who received hospice services resided in the facility.Findings:An undated facility policy titled Comprehensive Care Plan, read in part, Each resident will have a person-centered comprehensive care plan developed and implemented to meet [their] preferences and goals and address the resident's medical, physical, mental and psychosocial needs.A hospice physician's order, revised 07/07/25, showed Resident #60 started hospice on 04/17/25.Resident #60's quarterly assessment, dated 01/18/26, showed Resident #60 had a diagnosis of chronic obstructive pulmonary disease and received hospice services.Resident #60's care plan, revised on 01/30/26, did not address hospice services.On 04/15/26 at 11:48 a.m., the DON stated Resident #60's care plan did not include hospice interventions.On 04/15/26 at 11:53 a.m., the DON stated Resident #60 started hospice services on 04/17/25. On 04/15/26 at 12:17 p.m., the administrator stated Resident #60's care plan should include hospice interventions.On 04/15/26 at 12:18 p.m., the administrator stated Resident #60's care plan did not include hospice interventions.

Based on record review and interview, the facility failed to ensure a resident's discharge assessment was completed and transmitted for 1 (#74) of 18 sampled residents reviewed for assessments. The compliance officer identified 29 residents had discharged from the facility since 11/2025.Findings: Resident #74's electronic record, under the diagnoses tab, showed Resident #74 had diagnoses which included fracture of the left femur, hypertension, and edema. A Post-Discharge Plan of Care, dated 02/28/26, showed Resident #74 was discharged to home. There was no documentation a discharge resident assessment was completed. On 04/13/26 at 11:31 a.m., the DON stated the MDS coordinator was responsible for the completion of MDS assessments. On 04/13/26 at 11:40 a.m., the administrator reviewed the electronic record for Resident #74. The administrator stated the discharge assessment for Resident #74 had not been completed and should have been completed. The administrator stated ultimately, they were responsible for ensuring the MDS was completed. The administrator stated they were the RN who signed off for completed MDS assessments.

Based on observation, record review, and interview, the facility failed to ensure the call light was within reach for 1 (#84) of 18 sampled residents observed for call lights within reach. The administrator identified 86 residents resided in the facility. Findings: On 04/08/2026 at 10:50 a.m., Resident #84 was observed in bed. The call light was observed on the floor behind the resident's head of bed. On 04/08/26 at 11:14 a.m., CNA #6 went into Resident #84 room and picked up the call light from the floor behind the resident's head of bed. A policy titled Call Light, Use of, undated, read in part, All facility personnel must be aware of call lights at ALL times. Be sure all call lights are placed within the reach of each resident, never on the floor or bedside stand. On 04/08/26 at 10:51 a.m., Resident #84 stated they would yell out when they needed assistance. On 04/08/26 at 11:12 a.m., CNA #6 stated Resident #84 required two people for assistance with activities of daily living. They stated Resident #84 was able to use a call light. CNA #6 stated the call light was kept within residents' reach. They stated call lights were given to residents before they left the rooms; and checks were completed on the resident call lights constantly. On 04/08/26 at 11:15 a.m., The CNA stated the call light was on the floor and not within the reach of Resident #84.

Based on observation, record review, and interview, the facility failed to ensure an effective pest management program was maintained during daily observations.The administrator identified 78 residents resided in the facility.Findings:1. On 06/08/25 at 4:03 p.m., rodent feces were observed in room [ROOM NUMBER]B's bedside dresser middle drawer. On 06/08/25 at 4:50 p.m., the door in dining room going out behind the facility was observed to have had gaps at the top and along the bottom of the door large enough for flies and rodents to access the facility. Mouse droppings were observed along the wall in the dining room near the back door and flies were all over the facility landing on the glass, residents sitting nearby, and the staff. On 06/10/25 at 12:15 p.m., flies were observed in kitchen landing on a spout of clean and empty pitchers, food prep tables, foil covering food, and clean utensils. Mice droppings were observed under the food prep tables and behind the stove along the external walls. An irregularly shaped hole believed to be a rodent access point was present on the interior wall, just above baseboard. The facility's policy titled Pest Control, undated, read in part, Exclusion: Ensure building are structurally sound with proper sealings of cracks and openings, screened windows, and secure doors to prevent pest from entering.Collaborate with pest control professionals to ensure a comprehensive and effective approach to pest management. Work orders were reviewed from 01/01/25 through 06/12/25. There was no documentation of pest sightings documented. On 06/08/25 at 4:04 p.m., a family representative stated they see mouse feces in the residents' drawers and residents tell them they see mice. On 06/10/25 at 1:49 p.m., CNA #2 stated they see some mouse droppings on the floors, in the hall outside room [ROOM NUMBER]B, and reports them to maintenance. The CNA stated they observed three to four mouse droppings in room [ROOM NUMBER]B's bedside dresser on 06/10/25. CNA #2 stated, we must have mice. CNA #2 stated the flies have been really bad for weeks and residents swat at them. On 06/10/25 at 1:59 p.m., the house keeping supervisor was asked about pest in the facility. They stated on 06/10/25, they observed mouse feces in the bedside dresser drawer in room [ROOM NUMBER]B and they had caught some mice in traps. They stated the flies had been really bad in the facility for the last three weeks. On 06/10/25 at 2:07 p.m., maintenance #1 was asked about the pest problems at the facility. They stated, the facility had been fighting mice, roaches, and flies for last 6 months have been worse. They stated the facility sprayed and put out sticky traps, its less now but the mice and flies were still present. They stated, after replacing the roof recently, the mice had gotten worse.On 06/10/25 at 2:17 p.m., the administrator was asked how effective the facility's pest program was. The administrator stated, It's poorly in-effective because we have flies and mouse droppings everywhere.On 06/12/25 at 10:31 a.m., corporate maintenance stated the facility did not utilize pest sighting logs and staff should use work orders to identify pest problems. They were asked why there were so many flies in the facility. The corporate maintenance stated the back door in the dining room needed to be replaced because it had gaps, allowing pests to access the facility and the door did not fit correctly. 2. On 06/08/25 at 1:45 p.m., the following observations were made in the kitchen:a. the floors under the food prep tables, counters, sinks, storage racks, and behind the refrigerators, stove, and fryer were covered in a thick film of grease with dirt, grime, roach, and mice droppings,b. there was an irregularly shaped hole in the wall beside one refrigerator and just above the baseboard. The hole was the approximate size of an adult mouse, and, c. there were multiple flies in the kitchen, flying and landing on the food prep tables, drink pitchers, plates, utensils, and the foil covering the food prepared for the evening meal. On 06/10/25 at 12:15 p.m., the following observations were made in the kitchen: a. The floors under the food prep tables, counters, sinks, storage racks, and behind the refrigerators, stove, and fryer were covered in a thick film of grease with dirt, grime, roach, and mice droppings; b. There was an irregularly shaped hole in the wall beside one refrigerator and just above the baseboard. The hole was the approximate size of an adult mouse; and, c. There were multiple flies in the kitchen, flying and landing on the food prep tables, drink pitchers, plates, utensils, and foil covering foods yet to be served for noon day meal. On 06/08/25 at 1:55 p.m., cook #1 stated they were not sure where the flies were coming from, but they were a nuisance. The cook stated they had to keep all the food covered because the flies were everywhere. On 06/11/25 at 8:20 a.m., the kitchen environment was observed with the corporate maintenance supervisor. The corporate maintenance supervisor stated there were roach and mice droppings present on storage shelves, food prep table lower shelves, wheels, coasters, and along the baseboards, and floor edge. The maintenance supervisor stated there were flies in the kitchen.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen environment during two of two kitchen observations. The administrator identified 78 residents ate meals prepared in the kitchen.Findings:On 06/08/25 at 1:45 p.m., the following observations were made in the kitchen:a. the ice machine had a slimy looking green and brown substance along the right-side interior wall of the mechanical housing for the dish machine,b. kitchen aide #1 was observed to scrape food residue from steam table pans and resident plates, load the dirty dishes into the dish machine, then walk over to the clean side of the dish machine, remove and stack clean drinking cups, plates, pans, and covers onto drying racks without sanitizing their hands and changing gloves, c. baseboards were covered in a greasy film with dust and debris, d. the floors under the food prep tables, counters, sinks, storage racks, and behind the refrigerators, stove, and fryer were covered in a thick film of grease with dirt, grime, and mice droppings, e. the top of the refrigerators/freezers was covered in grease, dust, and grime, f. there was grease, dust, and grime present on lower shelving and wheels/casters on shelving and food prep tables, g. there was an irregularly shaped hole in the wall beside one refrigerator and just above the baseboard. The hole was the approximate size of an adult mouse, and h. there were multiple flies in the kitchen, flying and landing on the food prep tables, drink pitchers, plates, utensils, and the foil covering the food prepared for the evening meal. On 06/10/25 at 12:15 p.m., the following observations were made in the kitchen: a. baseboards were covered in a greasy film with dust and debris, b. there were missing baseboards, and small opening/holes in the walls and along the edge of the baseboards and door frames,c. the kitchen screen door had holes in the screen,d. the screen on the fan was covered with grease, dirt, and grime, e. the floors under the food prep tables, counters, sinks, storage racks, and behind the refrigerators, stove, and fryer were covered in a thick film of grease with dirt, grime, and mice droppings, f. the top of the refrigerators/freezers was covered in grease, dust, and grime, g. there was grease, dust, and grime present on lower shelving and wheels/casters on shelving and food prep tables, h. there was an irregularly shaped hole in the wall beside one refrigerator and just above the baseboard. The hole was the approximate size of an adult mouse, and i. there were multiple flies in the kitchen, flying and landing on the food prep tables, drink pitchers, plates, utensils, and foil covering foods yet to be served for noon day meal. On 06/08/25 at 1:40 p.m., the corporate maintenance supervisor stated the ice machine was dirty and needed to be cleaned more often. TOn 06/08/25 at 1:55 p.m., cook #1 stated they were not sure where the flies were coming from, but they were a nuisance. The cook stated they had to keep all the food covered because the flies were everywhere. [NAME] #1 stated there were two kitchen staff for the day, including the cook. They stated it was hard to prepare all the days meals and clean as well. [NAME] #1 stated they would mop the kitchen floor before leaving for the day. On 06/10/25 at 12:45 p.m., the dietary manager looked around the kitchen and stated the kitchen needed to be deep cleaned. The dietary manager stated the kitchen staff had their food handler's permits and knew to wash their hands after cleaning or performing a task where their hands/gloves became soiled.On 06/10/25 5:31 p.m., the administrator stated this was the most kitchen staff the facility employed. The administrator stated if the kitchen staff had time to sit outside and play on their phones, they had time to clean. On 06/11/25 at 8:20 a.m., the kitchen environment was observed with the corporate maintenance supervisor. The corporate maintenance supervisor stated there were roach and mice droppings present on storage shelves, food prep table lower shelves, wheels, coasters, and along the baseboards, and floor edge. The maintenance supervisor stated there was grease, grime, and dust present on the surfaces. The maintenance supervisor stated there were flies in the kitchen. The maintenance supervisor stated they needed to deep clean the kitchen.

Based on observation and interview, the facility failed to employ adequate kitchen staff to effectively maintain a sanitary kitchen environment.The Administrator identified 78 residents who ate meals prepared in the kitchen.Based on observation and interview, the facility failed to employ kitchen staff to effectively maintain a sanitary kitchen environment.The administrator identified 78 residents ate meals prepared in the kitchen.Findings:On 06/08/25 at 1:45 p.m., the following observations were made in the kitchen:a. baseboards were covered in a greasy film with dust and debris,b. the floors under the food prep tables, counters, sinks, storage racks, and behind the refrigerators, stove, and fryer were covered in a thick film of grease with dirt, grime, and mice droppings,c. the top of the refrigerators/freezers was covered in grease, dust, and grime,d. there was grease, dust, and grime present on lower shelving and wheels/casters on shelving and food prep tables,e. there was an irregularly shaped hole in the wall beside one refrigerator and just above the baseboard. The hole was the approximate size of an adult mouse, and,f. there were multiple flies in the kitchen, flying and landing on the food prep tables, drink pitchers, plates, utensils, and the foil covering the food prepared for the evening meal. On 06/10/25 at 12:15 p.m., the following observations were made in the kitchen:a. baseboards were covered in a greasy film with dust and debris,b. the floors under the food prep tables, counters, sinks, storage racks, and behind the refrigerators, stove, and fryer were covered in a thick film of grease with dirt, grime, and mice droppings,c. the top of the refrigerators/freezers was covered in grease, dust, and grime, d. there was grease, dust, and grime present on lower shelving and wheels/casters on shelving and food prep tables,e. there was an irregularly shaped hole in the wall beside one refrigerator and just above the baseboard. The hole was the approximate size of an adult mouse, andf. there were multiple flies in the kitchen, flying and landing on the food prep tables, drink pitchers, plates, utensils, and foil covering foods yet to be served for noon day meal. On 06/08/25 at 1:55 p.m., cook #1 stated they were not sure where the flies were coming from, but they were a nuisance. The cook stated they had to keep all the food covered because the flies were everywhere. The cook stated there were two kitchen staff for the day, including the cook. They stated it was hard to prepare all the days meals and clean as well. The cook stated they would mop the kitchen floor before leaving for the day. On 06/10/25 at 12:45 p.m., the dietary manager looked around the kitchen and stated the kitchen needed to be deep cleaned.On 06/10/25 5:31 p.m., the administrator stated this was the most kitchen staff the facility employed. The administrator stated if the kitchen staff had time to sit outside and play on their phones, they had time to clean. On 06/11/25 at 8:20 a.m., the kitchen environment was observed with the corporate maintenance supervisor. The corporate maintenance supervisor stated there were roach and mice droppings present on storage shelves, food prep table lower shelves, wheels, coasters, and along the baseboards, and floor edge. The maintenance supervisor stated there was grease, grime, and dust present on the surfaces. The maintenance supervisor stated there were flies in the kitchen. The maintenance supervisor stated they needed to deep clean the kitchen.

Based on record review and interview, the facility failed to ensure:a. prn medication was limited to 14 days for 1 (#36) of 5 residents sampled for prn medications; andb. failed to ensure an order for a gradual dose reduction for a psychotropic medication was initiated for 1(#2) of 5 residents sampled for gradual dose reductions of psychotropic medications. The Administrator identified 54 resident received psychotropic medications from the facility and all residents received other medications from the facility.Based on observation, record review, and interview, the facility failed to ensure: a) an order for a gradual dose reduction for a psychotropic medication was initiated for 1 (#2) of 5 sampled residents reviewed for physician orders for gradual dose reductions of psychotropic medications, and b) an as needed psychotropic medication order was limited to 14 days for 1 (#36) of 5 sampled residents reviewed for the use of psychotropic medications. The administrator identified 54 residents received psychotropic medications from the facility and 78 residents received other medications from the facility. On 06/08/25 at 3:26 p.m., Resident #2 was observed in bed and their tongue was thrusting from their mouth repeatedly while watching television. An undated facility's policy titled Gradual Dose Reduction, read in part, During the monthly drug regiment review, the pharmacist evaluates resident-related information, including the resident's medical record, for: dose, duration, continued need, and emergence of adverse consequences for all medications. the attending physician reviews the total plan of care, orders, the resident's response to medications, and determines to continue, modify or stop a medication and evaluate mood, function, behavior, and other domains affected by medications. The resident's medical record will reflect such evaluation in the physician's progress notes and orders, as appropriate. 1. Resident #2's admission record showed they were admitted on [DATE] with diagnoses which included bipolar disorder, schizophrenia, Alzheimer's, and major depression. Resident #2's care plan, initiated on 05/03/21, showed they were to monitor for side effects to buspirone (an anti-anxiety medication). Resident #2's physician orders, dated 01/27/23, showed Resident #2 had an order for buspirone 5 mg two times a day. The pharmacist monthly medication review document titled Note to Attending Physician/Prescriber, dated 12/31/24, showed the pharmacist requested the dose of buspirone be considered for a gradual dose reduction. The note showed the physician agreed to a gradual dose reduction attempt and documented to reduce the dose of buspirone to 2.5 mg two times a day on 01/29/25. Resident #2's medication administration record was reviewed from 01/01/25 through 06/11/25. The record showed Resident #2 was receiving buspirone 5 mg two times a day. Resident #2's physician orders, did not show the order of buspirone was reduced from 5 mg two times a day to 2.5 mg two times a day. Resident #2's AIMS, dated 11/11/24, showed a score of 12 and documented moderate facial and oral movements. Resident #2's AIMS assessment, dated 02/08/25, showed their facial and oral movements were severe. Resident #2's AIMS assessment, dated 05/08/25, showed their facial and oral movements were severe. Resident #2's quarterly MDS assessment, dated 05/24/25, showed the residents cognition was significantly impaired with a BIMS score of six and was taking a high-risk antianxiety medication. On 06/11/25 at 10:24 a.m., the ADON stated the new order was never decreased for the buspirone from 5 mg to 2.5 mg when the physician requested the dose to be reduced on 01/29/25. On 06/11/25 at 10:55 a.m., the administrator stated the order to reduce the buspirone from 5 mg two times a day to 2.5 mg two times a day was not noted, and the dose was never reduced. The administrator was asked where the system failure was. They stated the physician response, dated 01/29/25, was filed without a nurse noting the order. On 06/11/25 at 1:52 p.m., physician #1 stated they were not aware the dose of buspirone was not reduced and wanted the facility to continue to attempt a gradual dose reduction of the buspirone 5 mg two times a day to 2.5 mg two times a day. 2. Resident #36's annual assessment, dated 11/20/24, showed the resident had diagnoses which included dementia with mood disturbance, anxiety, depression, and bipolar disorder. The monthly pharmacy review, dated 01/23/25, showed the physician ordered clonazepam, an antianxiety medication, as needed for Resident #36. The pharmacy review showed the medication was not administered in the last 180 days. The pharmacy review, read in part, Per CMS, antipsychotic orders used on a [as needed] basis may not be extended beyond 14 day limit like other psychotropic orders can.The monthly pharmacy review, dated 04/30/25, showed the physician ordered clonazepam as needed for Resident #36. The pharmacy review showed the medication was not administered in the last 210 days. An undated monthly pharmacy review, read in part, [Resident #36] has an order for [as needed] clonazepam, which [they] have not taken in 11 months .Can we discontinue the [as needed] clonazepam order? The June 2025 medication administration order showed Resident #36 had an order for clonazepam as needed. The medication administration record showed clonazepam 2 mg every 24 hours as needed for anxiety was ordered on 07/02/24 and remained an active order. On 06/10/25 at 3:04 p.m., the corporate compliance officer reviewed the monthly pharmacy reviews for Resident #36. The corporate compliance officer stated the pharmacist identified clonazepam ordered as needed back in January 2025 and again in April 2025 but neither review was addressed by the physician. The corporate compliance officers stated it was the responsibility of the ADON to ensure pharmacy recommendations were addressed. The corporate compliance officer stated the state would just have to cite the deficiency because the pharmacy recommendations were not addressed.

Based on observation, record review, and interview, the facility failed to ensure resident assessments were accurate for 1 (#2) of 18 sampled residents reviewed for accurate assessments.The administrator identified 78 residents resided in the facility.Findings:On 06/08/25 at 3:26 p.m., Resident #2 was observed in bed and their tongue was thrusting repeatedly from their mouth while watching television. The resident was observed to be edentulous (no natural teeth or tooth fragments). The facility's undated policy Resident Assessment, read in part, This facility conducts and periodically a comprehensive, accurate, standardized reproducible assessment of each residents functional capacity .Each assessment accurately reflects the residents status. Resident #2's admission record, showed they were admitted on [DATE] with diagnoses which included bipolar disorder, schizophrenia, Alzheimer's, and major depression. Resident #2's annual comprehensive MDS assessment, dated 11/21/24, showed the residents cognition was significantly impaired with a BIMS score of 6 and was not edentulous.On 06/11/25 at 10:24 a.m., the ADON was asked about the resident tongue thrusting. The ADON stated the resident was edentulous and had the tongue thrusting since admission. On 06/11/25 at 10:41 a.m., CNA #2 was asked to discuss Resident #2's oral care. They stated the resident was admitted without any teeth and does not have dentures. CNA #2 stated the resident moved her mouth more frequently lately. On 06/11/25 at 10:55 a.m., the administrator was asked what Resident #2's MDS, dated [DATE], documented in section L. The administrator stated the assessment was not correct because the resident was admitted edentulous and it showed the resident was not edentulous.

Based on record review and interview, the facility failed to ensure the physician was notified of a change in the condition of a wound for 1 (#1) of 4 sampled residents reviewed for wounds. The administrator reported the facility census was 86. Findings: An undated Notification of Changes policy, read in part, The facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his/her authority, the resident representative(s) when there is .A significant change in the resident's physical, mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). Resident #1 had diagnoses which included a displaced fracture of the left tibia and heart failure. A physician's order, dated 01/18/25, showed Resident #1 was to receive wound care to the sacral area three times a week on Tuesday, Thursday, and Saturday. A nurse's note, dated 01/18/25 at 9:33 p.m., showed Resident #1 had a small open sore to the right buttock. A nurse's note, dated 01/19/25 at 8:58 p.m., showed the sacrum dressing was clean, dry, and intact. A nurse's note, dated 01/20/25 at 9:18 p.m., showed Resident #1 had a small open sore to the right buttock that was blackish in color and had a foul odor. The note did not show the physician had been notified of the change in status of the wound. On 02/12/25 at 10:45 a.m., LPN #1 stated any significant change in a wound should be reported to the physician immediately. 02/12/25 at 10:50 a.m., LPN #2 stated the physician should be notified of changes in a resident's condition. 02/12/25 at 10:55 a.m., the administrator stated the physician should have been notified immediately of the change in the status of the wound.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for 1 (#3) of 3 sampled residents reviewed for pressure ulcers. The administrator identified four residents with pressure ulcers. Findings: An undated Enhanced Barrier Precautions policy, read in part, Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] beyond situations in which exposure to blood and body fluids is anticipated. These precautions refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multidrug-resistan organism] to staff hands. High-contact resident care activities include .Wound care: any skin opening requiring a dressing. Resident #3 had diagnoses which included pressure ulcer of sacral region stage four. A physician's order, dated 01/31/25, showed Resident #3 was to receive a dressing change twice a day and as needed for the wound on their sacrum. On 02/12/25 at 9:30 a.m., LPN #1 was observed providing wound care to Resident #3 with the assistance of CNA #1. LPN #1 was observed to begin cleansing Resident #3's wound, then abruptly stopped and put on a gown before continuing to provide wound care. CNA #1 did not don a gown at any time during the wound care. On 02/12/25 at 9:45 a.m., LPN #1 stated they forgot to don a gown before performing wound care. They also stated anyone assisting with wound care should wear a gown also. On 02/12/25 at 10:38 a.m., CNA #1 stated they were not familiar with enhanced barrier precautions. On 2/12/25 at 10:49 a.m., LPN #2 stated gowns should be worn when providing direct care to residents on enhanced barrier precautions.

Based on record review and interview, the facility failed to implement their abuse policy for three (#1, 2, and #4) of four sampled residents reviewed for abuse. The administrator identified 83 residents who resided in the facility. Findings: A policy titled Allegations of Abuse, Neglect, Exploitation or Mistreatment, read in parts All alleged violations involving abuse, neglect, exploitation or mistreatment, .are reported immediately, but not later than 2 hours after the allegation is made .to the Administrator of this facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .All alleged violations, whether oral or in writing, must be immediately reported to the Administrator of this facility .The results of all investigations are reported to the Administrator or his/her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .Documentation that an alleged violation was thoroughly investigated will be recorded and maintained .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 1. Resident #1 had diagnoses which included anxiety and major depressive disorder. A facility incident report, dated 12/14/24, documented a housekeeping staff member alerted the nurse another resident had slapped the right side of Resident #1's face. The report documented the physician and the local police were notified. The report did not document the administrator of the facility was notified. No state agency incident report/investigative findings to the state agency were provided. 2. Resident #2 had diagnoses which included major depressive disorder, absence of left foot, and nicotine dependence. A facility incident report, dated 12/14/24, documented a housekeeping staff member reported the resident slapped another resident on the face while in the smoking area. The report documented the resident stated the other resident slapped them first. The report documented the physician, DON, CCO, and administrator were made aware of the incident. No state agency incident report/investigative findings provided to the state agency were provided. A police incident report, dated 12/14/24, documented the police were called to the facility for an assault complaint regarding Resident #1 and Resident #2. Investigative documentation provided by the facility, dated 12/14/24, documented two nursing staff statements regarding notification of the incident. There were no resident statements or resident/staff witnessed statements provided. 3. Resident #4 had diagnoses which included chronic kidney disease, carcinoma of the skin to the scalp and neck area, and encephalopathy. A facility incident report, dated 11/26/24, documented the staff was alerted to the dining area for an altercation between residents. The report documented during a verbal altercation another resident pushed Resident #3 causing them to fall and sustain an abrasion to the left side of their head. The report documented the family, administrator, and physician were notified of the incident. No state agency incident report/ investigative findings reported to the state agency were provided. On 01/22/25 at 12:16 p.m., the administrator stated they were responsible for allegations of abuse. The administrator reviewed the facility incident reports for Resident #1 and Resident #2 and stated they did not feel it was abuse. The administrator reviewed the facility policy definition for abuse and stated per the policy definition the incident should have been reported within two hours and a thorough investigation completed. On 01/22/25 at 3:44 p.m., the administrator reviewed the facility incident report for Resident #4. The administrator stated per the facility abuse policy and the incident report documentation, an abuse incident report should have been submitted to the state agency within two hours and an investigation completed.

Based on record review and interview, the facility failed to ensure all allegations of abuse were reported immediately to the state agency, but no later than two hours after the allegation was made for three (#1, 2, and #4) of four sampled residents reviewed for abuse. The administrator identified 83 residents who resided in the facility. Findings: A policy titled Allegations of Abuse, Neglect, Exploitation or Mistreatment, read in parts All alleged violations involving abuse, neglect, exploitation or mistreatment, .are reported immediately, but not later than 2 hours after the allegation is made .to the Administrator of this facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .All alleged violations, whether oral or in writing, must be immediately reported to the Administrator of this facility .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 1. Resident #1 had diagnoses which included anxiety and major depressive disorder. A facility incident report, dated 12/14/24, documented a housekeeping staff member alerted the nurse another resident had slapped the right side of Resident #1's face. The report documented the physician and the local police were notified. The report did not document the administrator of the facility was notified. No state agency incident report/investigative findings to the state agency were provided. 2. Resident #2 had diagnoses which included major depressive disorder, absence of left foot, and nicotine dependence. A facility incident report, dated 12/14/24, documented a housekeeping staff member reported the resident slapped another resident on the face while in the smoking area. The report documented the resident stated the other resident slapped them first. The report documented the physician, DON, CCO, and administrator was made aware of the incident. No state agency incident report/investigative findings provided to the state agency were provided. A police incident report, dated 12/14/24, documented the police were called to the facility for an assault complaint regarding Resident #1 and Resident #2. Investigative documentation provided by the facility, dated 12/14/24, documented two nursing staff statements regarding notification of the incident. There were no resident statements or resident/staff witnessed statements provided. 3. Resident #4 had diagnoses which included chronic kidney disease, carcinoma of the skin to the scalp and neck area, and encephalopathy. A facility incident report, dated 11/26/24, documented the staff was alerted to the dining area for an altercation between residents. The report documented during a verbal altercation another resident pushed Resident #3 causing them to fall and sustain an abrasion to the left side of their head. The report documented the family, administrator, and physician were notified of the incident. No state agency incident report/ investigative findings reported to the state agency were provided. On 01/22/25 at 12:16 p.m., the administrator stated they were responsible for allegations of abuse. The administrator reviewed the facility incident reports for Resident #1 and Resident #2 and stated they did not feel it was abuse. The administrator reviewed the facility policy definition for abuse and stated per the policy definition the incident should have been reported within two hours and a thorough investigation completed. On 01/22/25 at 3:44 p.m., the administrator reviewed the facility incident report for Resident #4. The administrator stated per the facility abuse policy and the incident report documentation, an abuse incident report should have been submitted to the state agency within two hours and an investigation completed.

Based on record review and interview, the facility failed to thoroughly investigate allegations of abuse for three (#1, 2, and #4) of four sampled residents reviewed for abuse. The administrator identified 83 residents who resided in the facility. Findings: A policy titled Allegations of Abuse, Neglect, Exploitation or Mistreatment, read in parts All alleged violations involving abuse, neglect, exploitation or mistreatment, .All alleged violations, whether oral or in writing, must be immediately reported to the Administrator of this facility .The results of all investigations are reported to the Administrator or his/her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .Documentation that an alleged violation was thoroughly investigated will be recorded and maintained .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 1. Resident #1 had diagnoses which included anxiety and major depressive disorder. A facility incident report, dated 12/14/24, documented a housekeeping staff member alerted the nurse another resident had slapped the right side of Resident #1's face. The report documented the physician and the local police were notified. The report did not document the administrator of the facility was notified. No state agency incident report/investigative findings to the state agency were provided. 2. Resident #2 had diagnoses which included major depressive disorder, absence of left foot, and nicotine dependence. A facility incident report, dated 12/14/24, documented a housekeeping staff member reported the resident slapped another resident on the face while in the smoking area. The report documented the resident stated the other resident slapped them first. The report documented the physician, DON, CCO, and administrator was made aware of the incident. No state agency incident report/investigative findings provided to the state agency were provided. A police incident report, dated 12/14/24, documented the police were called to the facility for a assault complaint regarding Resident #1 and Resident #2. Investigative documentation provided by the facility, dated 12/14/24, documented two nursing staff statements regarding notification of the incident. There were no resident statements or resident/staff witnessed statements provided. 3. Resident #4 had diagnoses which included chronic kidney disease, carcinoma of the skin to the scalp and neck area, and encephalopathy. A facility incident report, dated 11/26/24, documented the staff was alerted to the dining area for an altercation between residents. The report documented during a verbal altercation another resident pushed Resident #3 causing them to fall and sustain an abrasion to the left side of their head. The report documented the family, administrator, and physician were notified of the incident. No state agency incident report/ investigative findings reported to the state agency were provided. On 01/22/25 at 12:16 p.m., the administrator stated they were responsible for allegations of abuse. The administrator reviewed the facility incident reports for Resident #1 and Resident #2 and stated they did not feel it was abuse. The administrator reviewed the facility policy definition for abuse and stated per policy definition the incident should have been reported within two hours and a thorough investigation completed. On 01/22/25 at 3:44 p.m., the administrator reviewed the facility incident report for Resident #4. The administrator stated per the facility abuse policy and the incident report documentation, an abuse incident report should have been submitted to the state agency within two hours and an investigation completed.

Based on record review and interview, the facility failed to ensure physician orders were obtained for code status for four (#2, 23, 27, and #35) of six sampled residents reviewed for code status. The administrator identified 58 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included CKD, HTN, presence if cardiac pace maker, diabetes mellitus, hypothyroidism, and atrial fibrillation. An Advance Directive/DNR Information Acknowledgement form, dated [DATE], documented the resident wished to have CPR. There was no physician order for the resident's code status. 2. Res #23 had diagnoses which included HTN, heart disease ESRD, GERD, depression, vitamin D deficiency, and diabetes mellitus. An Advance Directive/DNR Information Acknowledgement form, dated [DATE], documented the resident wished to have CPR. There was no physician order for the resident's code status. 3. Res #27 had diagnoses which included pain, heart disease, major depressive disorder, anxiety disorder, COPD, RA, systemic lupus erythematosus, GERD, CKD, pressure ulcer, and diabetes mellitus. An Advance Directive/DNR Information Acknowledgement form, dated [DATE], documented the resident wished to have CPR. There was no physician order for the resident's code status. 4. Res #35 had diagnoses which included phantom limb syndrome with pain, CKD, major depressive disorder, and acquired absence of left and right knee above knee. An Advance Directive/DNR Information Acknowledgement form, dated [DATE], documented the resident wished to have CPR. There was no physician order for the resident's code status. On [DATE] at 3:03 p.m., LPN #1 was asked how staff determined code status for a resident. They stated they looked in the DNR book, hard chart, and EHR. They were asked what was the code status for Res #2, 23, 27, and #35. They stated there was no code status specified for the residents. They stated if the residents did not have a DNR they would perform CPR.

Based on record review and interview, the facility failed to ensure baseline care plans were developed within 48 hours of admission for two (#4 and #23) of 15 sampled residents reviewed for care plans. The administrator identified 58 residents who resided in the facility. Findings: 1. Resident #4 was admitted on [DATE] with diagnoses which included arthrosclerosis, secondary hypertension, chronic obstructive pulmonary disease, diabetes type II, gastroesophageal reflux disease, and Parkinson's disease. There was no documentation in the clinical record a baseline care plan had been completed. On 01/31/24 at 12:12 p.m., the administrator stated the base line care plan had not been completed. 47751 2. Resident #23 was admitted on [DATE] with diagnoses which included end stage renal disease, disorders of the brain, cerebral infarction, diabetes, HTN, Charcot's joint, left ankle and foot, and CAD. On 01/31/24 at 11:51 a.m., the administrator was asked for Res #35's base line care plan. They stated the baseline care plan would be in the EHR or the paper chart. There was no documentation in the clinical record that a baseline care plan had been completed. The administrator stated they would have their MDS coordinator fax it to them. On 01/31/24 at 12:05 p.m., the administrator presented Res #35's baseline care plan. On 01/31/24 at 12:12 p.m., the administrator was made aware the baseline care plan was not dated. They stated they understood that the 48 hours could not be proven.

Based on observation, record review, and interview, the facility failed to ensure a resident was free from abuse for one (#3) of five residents sampled for abuse. On 08/31/23 Res #3 informed the charge nurse that they were struck by CNA #3. CNA acknowledged they had slapped Res #3. The facility was in past noncompliance after having put the final measures in place to correct the deficiency on 09/05/24. The administrator identified 58 residents who resided in the facility. Findings: Res #3 had diagnoses which included major depression disorder, anxiety disorder, and cerebrovascular disease. A state reportable incident form, dated 08/31/23, documented that at 7:03 a.m. the resident informed the charge nurse they had been struck by a staff member. The form documented the charge nurse contacted the administrator and informed them Res #3 had been struck by a staff member. The form documented Res #3 had identified CNA #3 as the staff member who struck them. The form documented the charge nurse immediately assessed the resident and found no injuries. The form documented CNA #3 was questioned about the incident and acknowledged they had slapped the resident. The form documented the CNA was removed from patient care immediately and suspended. The form documented the administrator contacted the physician, family, ombudsman, resident's legal representative, attorney general, adult protective services, local police department, and appropriate licensing board. The form documented all residents residing in the facility were questioned on abuse and neglect by the administrator. Record review revealed, on 08/31/23 at 7:25 a.m., the former DON conducted an assessment on the resident and no injuries found. Record review revealed CNA #3 was immediately removed from patient care and on 08/31/23 at 7:30 was interviewed by the DON. The interview documented the CNA stated that while providing care the resident became combative and out of reflex they slapped the resident. The record review documented the CNA was terminated and reported to the nurse aide registry. The in-service book documented an in-service on abuse and neglect was conducted on 09/05/23 at 1:00 p.m. by the ombudsman for all staff members. Staff members were interviewed and could voice information related to the inservice they attended. A quarterly MDS assessment, dated 11/29/23, documented the resident was severely cognitively impaired and required extensive assistance with transfer, dressing, bathing, and hygiene. Record review, including incident reports, did not reveal any incidents of abuse. Residents were interviewed and denied any abuse by staff. On 01/17/24 at 9:30 a.m., Res #3 was observed in the dining room. The resident did not appear to have any visible bruising and was observed to be clean and without odor. The resident was unable to recall the event and had no complaints related to abuse. On 01/17/24 at 1:30 p.m., the administrator stated they reported the allegation of abuse to OSDH immediately. They stated they conducted a thorough investigation by talking with all residents and staff members in the facility. The administrator stated to prevent recurrence they invited the ombudsman to educate all staff on abuse and neglect during an in-service. The administrator stated CNA #3 was terminated and reported to the nurse aide registry. They stated the QA committee had reviewed the incident and interventions.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received treatment and care to prevent hospitalization s for one (#39) of three residents whose hospitalization s were reviewed. The facility failed to implement interventions to prevent pneumonia for resident #39. The facility identified 14 residents who had been hospitalized in the past three months. Findings: A facility form, labeled criteria for initiation of antibiotics in long-term care residents for lower respiratory tract infection, documented criteria for pneumonia included new or increased cough, oxygen saturation less than 94% on room air or a reduction in oxygen saturation of more than 3% from baseline, new or changed lung examination abnormalities, temperature more than 100 degrees, and an acute change in mental status. A facility policy, labeled change in resident's condition and status, documented the nurse would notify the attending physician or on-call physician when there was a significant change in the resident's condition, a need to alter the resident's medical treatment, or a need to transfer the resident to a hospital. The policy documented a significant change of condition as one which would not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions. Resident #39 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].>pneumonia, dementia, [MEDICAL CONDITIONS] infarction, and [MEDICAL CONDITION]. A physician order, dated 10/11/17, documented the resident was to receive [MEDICATION NAME] (a [MEDICATION NAME][MEDICATION NAME] medication) every six hours via nebulizer as needed for shortness of breath. A quarterly assessment, dated 01/03/19, documented the resident was severely impaired with cognition and required limited assistance to total dependence with activities of daily living. A nurse progress note, dated 03/31/19, documented the resident continued with occasional non- productive cough. The note documented the primary care physician (PCP) was faxed for orders. A nurse progress note, dated 04/01/19 at 9:13 a.m., documented the resident reported she was not feeling well. The note documented the resident had slightly red cheeks, a productive cough with yellow phlegm, and expiratory wheezing upon auscultation to her right upper and lower lungs. The note documented the family and PCP were notified. A nurse progress note, dated 04/01/19 at 5:27 p.m., documented a new physician order [REDACTED]. A nursing progress note, dated 04/01/19 at 10:02 p.m., documented the resident had congested lung sounds. The note did not document the physician was notified. A nursing progress note, dated 04/06/19 at 8:30 p.m., documented the resident had a non-productive cough, wheezing of lung fields per auscultation, and oxygen saturation was 94% on room air. The note did not document the physician was notified. A nursing progress note, dated 04/08/19 at 9:00 p.m., documented the resident had a flushed face, a non-productive cough, and wheezing and congestion in her bilateral lung fields. The note documented the resident had a temperature of 100.2 axillary, a pulse rate was 90 beats per minute, respirations was 20, and oxygen saturation was 95% on room air. The note documented the PCP was notified. The note did not document a response from the physician. A nursing progress note, dated 04/10/19 at 8:18 a.m., documented the resident had not eaten for the previous two days, had chest congestion, and had a non-productive cough. The note documented the PCP was notified. The note did not document a response from the physician. A nursing progress note, dated 04/10/19 at 10:55 a.m., documented the resident had a bounding pulse rate of 129 beats per minute. The note documented the resident had an oxygen saturation of 91% on room air, had poor skin turgor, and had a poor appetite for two days. The note documented the resident had a cough with clear mucus from her nose. The note documented the family and the PCP were notified. The note did not document a response from the physician. A nursing progress note, dated 04/10/19 at 12:27 p.m., documented the resident had an elevated pulse, no intake of food or water in the past 24 hours, and had a decreased level of consciousness. The note documented the family requested the resident be sent to the local emergency room . The note documented the PCP and the ambulance service were notified. The note did not document a response from the physician. A nursing progress note, dated 04/10/19 at 9:41 p.m., documented the resident was admitted to the hospital with [REDACTED]. The Medication Administration Record [REDACTED]. Discharge and entry assessments documented the resident was hospitalized [DATE] through 04/13/19. A hospital physician order, dated 04/13/19, documented the resident was to receive [MEDICATION NAME] 500 mg at bedtime for an upper respiratory infection for five days and [MEDICATION NAME] nebulizer four times a day for five days and every six hours as needed for shortness of breath. A physician order, dated 04/17/19, documented the resident was to receive [MEDICATION NAME] 100 mg two times a day for a upper respiratory infection for 10 days. A nursing progress note, dated 04/20/19 at 9:15 a.m., documented the resident had a beet red face, her blood pressure was 170/90, and her pulse was 117 beats per minute. The note documented the resident was hollering, moaning, and was shaking. The note documented the resident reported she was having chest pain. The note documented the PCP was notified and an order was received to send the resident to the emergency room via ambulance for evaluation. The note documented the family was notified. A nursing progress note, dated 04/20/19 at 1:55 p.m., documented the emergency room reported the resident was transported via helicopter to another hospital for treatment for [REDACTED]. A discharge and entry assessment documented the resident was hospitalized [DATE] through 04/24/19. A nursing progress note, dated 04/24/19, documented the resident was readmitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 04/25/19, documented the resident had a [DIAGNOSES REDACTED]. The care plan documented the resident required weight bearing assistance from staff with activities of daily living and toileting. The care plan documented the resident was to receive [MEDICATION NAME] via nebulizer as needed for shortness of breath. A significant change assessment, dated 05/07/19, documented the resident was severely impaired with cognition and required extensive assistance to total dependence with activities of daily living. The assessment documented the resident required physical and occupational therapy services. A care plan, updated 05/09/19, documented the resident returned from the hospital with increased weakness. The care plan documented the resident was to receive physical and occupational therapy services. On 05/15/19 at 8:22 a.m., the resident was observed in the dining room assisted by staff to eat breakfast. On 05/15/19 at 12:10 p.m., the director of nursing (DON) reported the facility had called the family and they didn't want her to go to the local hospital. The DON reported the facility would have sent her to the emergency room if her oxygen saturation had dropped. The DON reported the facility was waiting for the PCP to respond with orders for tests or treatment. The DON reported the facility would notify the medical director for orders if the PCP failed to respond to reports of a resident's change of condition. The DON reported the facility medical director was not notified of the resident's health status. On 05/15/19 at 1:23 p.m., licensed practical nurse (LPN) #1 reported with any change in a resident's condition, the PCP was notified. The LPN reported if she received no response from the PCP within 15-30 minutes, she would contact the medical director for orders. On 05/15/19 at 1:25 p.m., LPN #2 reported if there was any change in a resident's condition, she would call and fax the PCP. The LPN reported if she did not get a response from the PCP, she would contact the medical director and he would always answer and give new orders. On 05/15/19 at 2:50 p.m., the DON reported she had reviewed the resident's record and did not feel the resident was that sick.

Based on interview and record review, it was determined the facility failed to provide care to prevent the development of pressure ulcers for one (#4) of seven residents sampled for pressure ulcers. The facility failed to thoroughly assess, monitor, and track wound progression/deterioration for pressure ulcers for resident #4. The resident's pressure ulcers worsened and the resident required hospitalization . A discharge summary from a name-deleted hospital documented the resident was noted to have a severe infection of the sacral decubitus ulcers. The summary documented the resident was septic at the time of admission and that she was in profound [MEDICAL CONDITION]. The summary documented this was the resident's second admission in the same month [MEDICAL CONDITION] related to the decubitus ulcer infections. The summary documented the resident expired at the hospital. The facility documented 27 residents had pressure ulcers in the last 6 months. Findings: The facility policy on skin and wound management documented all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound would be recorded in the resident's medical records. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The closed record of resident #4 was reviewed. The quarterly assessment, dated [DATE], documented the resident's cognition was intact. The assessment documented the resident required extensive assistance with bed mobility, transfers, dressing, and hygiene/bathing. The assessment documented the resident was at risk for developing a pressure ulcer and had a pressure relieving device on her bed. The assessment documented the resident was on a turning/repositioning program, had applications of ointments/medications, and did not have any pressure ulcers. A weekly skin assessment, dated [DATE], documented the resident's skin was intact. A nurse's note, dated [DATE] at 6:49 a.m., documented a certified nurse aide (CNA) observed a rash on the resident's right hip. The nurse's note documented upon inspection by the nurse, a dried looking rash with two blisters was noted to the right hip, and a small fluid filled blister was noted to the left lateral thigh. The nurse's note documented the resident denied pain. A nurse's note, dated [DATE] at 09:00 a.m., documented the physician was faxed due to three stage II pressure ulcers. The note documented the pressure ulcers as: 1) 0.7 centimeters (cm) x 0.1 cm to right buttocks. 2) 2.5 cm x 2 cm to crease of buttocks. 3) right post mid back 0.6 cm x 9.5 cm. The nurse's note documented PRN [MEDICATION NAME] orders were implemented at that time. A physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The order documented the [DIAGNOSES REDACTED]." A nurse's note, dated [DATE] at 1:30 p.m., documented the physician was notified of a 4 cm x 5 cm dark purple fluid filled blister noted on the resident's the left lateral heel. The nurse's note documented a telephone order to apply [MEDICATION NAME] cream to the resident's left lateral heel and cover two times every day. The nurse's note documented to reduce pressure off the resident's heels. A weekly wound tracking worksheet, dated [DATE], documented a new pressure ulcer on the resident's right buttocks measuring 0.7 cm x 0.1 cm, a new pressure ulcer on the crease of the resident's buttocks measuring 2.5 cm x 2 cm, and a new pressure ulcer measuring 0.6 cm x 9.5 cm on the resident's right post mid back. All pressure ulcers were documented as stage II. The wound tracking worksheet documented a new pressure ulcer described as a dark purple fluid filled blister measuring 4 cm x 5 cm and unstageable on the resident's left lateral heel. A weekly skin audit report, dated [DATE], documented a stage II pressure ulcer to the right buttock. No length, width, or depth was documented. The report documented a stage II pressure ulcer to the gluteal fold. No length, width or depth was documented. A nurse's note, dated [DATE] at 7:35 p.m., documented the resident continued with 2 abrasions to the left post thigh and no signs/symptoms of infection were noted. The nurse's note documented to continue skin treatments per physician orders. A nurse's note, dated [DATE] at 11:30 p.m., documented the resident's left heel fluid filled blister had collapsed and the site measured 4 cm x 5 cm. The nurse's note documented the right lower back stage II pressure ulcer measured 0.5 cm x 3 with a pink wound bed noted. The nurse's note documented a stage II pressure ulcer to the resident's right the buttocks measuring 0.4 cm x 0.2 cm. The nurse's note documented the crease of the buttocks was observed with a stage II pressure ulcer measuring 3 cm x 2 cm with a pink wound bed. The nurse's note documented to continue skin care per physician's orders [REDACTED]. A weekly wound tracking worksheet, dated [DATE], documented a pressure ulcer to the resident's right buttock, measured as 0.4 cm x 0.2 cm, a pressure ulcer to the coccyx/crease of the buttocks which measured 3 cm x 2 cm, a pressure ulcer to the right post mid back which measured 0.5 cm x 3 cm, and all pressure ulcers were documented as stage II. The wound tracking work sheet documented an unstageable blister to the left lateral heel measuring 4 cm x 5 cm. The wound tracking worksheet documented a new, unstageable, pressure ulcer to the left post lower back with yellow slough 2.4 cm x 7.5 cm. The wound tracking worksheet, dated [DATE], documented the wound to the right buttock was resolved on [DATE]. A nurse's note, dated [DATE] at 09:10 a.m., documented the stage II pressure ulcer to the right buttocks was resolved at that time and no redness was noted. A nurse's note, dated [DATE] at 09:10 a.m., documented the resident had an approximately 4 cm diameter abrasion x 2 to the left posterior thigh. The physician and family were notified. The note documented new orders were received. The resident's medical records did not contain documentation on the left posterior thigh from [DATE] to [DATE]. A nurse's note, dated [DATE] at 7:35 p.m., documented the CNAs were directed to turn the resident every 2 hours. The care plan, updated on [DATE], documented the resident had pressure ulcers, a fluid filled blister on the left heel, a stage II to the right buttocks, a stage II to the crease of the buttocks, a stage II to the right lower back, and an abrasion to the posterior thigh. The care plan documented to: Apply [MEDICATION NAME] ointment to the stage II on the crease of the buttocks and cover daily until resolved. Apply [MEDICATION NAME] cream to the fluid filled blister on the left heel and cover two times a day until resolved. [MEDICATION NAME] milligrams (mg) by mouth two times a day for two weeks for a wound infection. Encourage the resident to change position often and staff were to assist every hour and as often as needed. The staff were to turn/reposition in bed every hour until wounds were healed. The staff were to monitor the abrasion to left the thigh until healed. The staff were to report any signs/symptoms of infection to charge the nurse or the physician. The nurse would perform weekly skin assessments. The staff would report any changes in the resident's skin condition to the charge nurse. The nurse would report to the physician if the resident had any worsening of wounds or signs/ symptoms of infection as needed. A nurse's note, dated [DATE] at 2:31 a.m., documented the resident was having episodes of diarrhea and vomiting and the physician was notified for as needed orders for nausea/vomiting. A nurse's note, dated [DATE] at 10:40 a.m., documented the site to the right lower post back was resolved. A nurse's note, dated [DATE] at 11:00 a.m., documented the physician was contacted regarding the resident's wounds. The note documented, "...1) Left posterior lower back unstageable site 2.4 cm x 7.5 cm with x 2 yellow slough site 1) 1 cm x 1.5 cm 2) 0.5 cm x 1 cm. Left lat heel previously with a blister, now unstageable noted with yellowish/black eschar..." The physician's telephone order, dated [DATE], documented: 1) Discontinue current skin treatment to the left lateral heel and coccyx. 2) Start Santyl Ointment and cover left lateral heel and coccyx daily. 3) Apply [MEDICATION NAME] Cream and cover to left post lower back daily until resolved. A weekly skin audit report, dated [DATE], contained the resident's name and no further documentation of the resident's wounds. A weekly wound tracking worksheet, dated [DATE], documented an unstageable pressure ulcer to the resident's coccyx/crease of buttocks and described as necrotic, measuring 5 cm x 6 cm; an unstageable pressure ulcer to the left lateral heel described as necrotic, measuring 2 cm x 2.5 cm; and a new unstageable blister to the right heel measuring 4 cm x 4.5 cm. The wound tracking worksheet documented the right post mid back pressure are was resolved on [DATE]. A new, unstageable pressure ulcer was identified on the left post lower back with yellow slough measuring 1.8 cm x 8.5 cm. A nurse's note, dated [DATE] at 1:32 p.m., documented the site to the resident's left heel was 2 cm x 2.5 cm with brown eschar noted to the wound bed with scant amount of brown drainage noted to the previous dressing. The pressure ulcer to the coccyx measured 5 cm x 6 cm with a foul odor and a moderate amount of drainage noted to the previous dressing with yellow eschar noted to the wound bed. The nurse's note documented a pressure ulcer to the left posterior back with a "z" shaped 1.8 cm x 8.5 cm site with yellow eschar noted. The nurse's note documented a pressure ulcer to the right heel measuring 4 cm x 4.5 cm with black discoloration. The nurse's note documented the physician was notified regarding wound drainage. The nurse's note documented a new order to apply Calcium Alginate to the wound bed after applying Santyl Ointment to the wound bed daily until resolved. The nurse's note documented the physician was notified regarding a fluid filled blister to the right heel. A new order was received to apply Skin Prep two times every day to the right heel "until burst. After burst apply Santyl Ointment and cover daily until resolved." A wound culture report, dated [DATE], documented the wound was cultured on [DATE]. The specimen culture report documented a moderate number of colonies of Proteus marabilis and Morganella morganii to the coccyx and a moderate number of colonies of [MEDICATION NAME] faecalis to the left heel. A nurse's note, dated [DATE] at 3:00 p.m., documented a new physician's orders [REDACTED]." A nurse's note, dated [DATE] at 10:48 p.m., documented the resident was repositioned every two hours. The nurse's note documented the resident had a large bowel movement and the dressing to coccyx area was changed. The nurse's note documented the wound had yellow eschar with dark stringy tissue, a faint odor was noted, and the resident continued on an antibiotic. The annual assessment, dated [DATE], documented the resident was moderately impaired in cognition. The assessment documented the resident required extensive assistance with bed mobility, transfers, dressing, and hygiene/bathing. The assessment documented the resident was at risk for developing a pressure ulcer and had a pressure relieving device on her bed. The assessment documented the resident had four unstageable pressure ulcers due to a non/removable dressing/device. The assessment documented the resident had four unstageable pressure ulcers due to coverage of a wound bed by slough and/or eschar. The assessment documented none of the pressure ulcers were present upon admission/entry or reentry. A nurse's note, dated [DATE] at 07:05 a.m., documented the resident was out of the facility to a wound care appointment. A nurse's note, dated [DATE] at 2:00 p.m., documented a new order was reviewed via fax per the wound care center to clean the resident's coccyx and left heel with normal saline, pat dry with 4 X 4 gauze, apply skin barrier of choice to the periwound tissue, apply Santyl to the wound bed, and then apply border gauze to the coccyx and Kerlix to the left heel daily and as needed. The note documented to cleanse the right heel with normal saline, pat dry with a 4 x 4 gauze, apply a skin barrier of choice to the periwound, apply [MEDICATION NAME] Sheet to the right heel wound bed, and then secure with Kerlix two times every week and as needed. A report from Wound Care Specialists, dated [DATE], documented wound A as a stage IV pressure ulcer to the coccyx measuring 5.5 x 3 x 3. Wound B was documented as an unstageable pressure ulcer to the left heel, measuring 2 x 1.8 x OBS. Wound C was documented as a stage II pressure ulcer to the right heel, measuring 0.5 x 1 x 0.3. The report documented wound A was debrided in the clinic. The report documented to float the resident's heels and use a heel offloading boot. The report documented to keep the dressing dry, no tub bath, no whirlpool/shower, and may give bed bath. A weekly wound tracking worksheet, dated [DATE], documented a wound to the resident's coccyx/crease of the buttocks, a wound to the left lateral heel, a wound to the right heel, and a wound to the left post lower back. The worksheet documented, "See wound care notes," following all wounds. A nurse's note, dated [DATE] at 10:37 a.m., documented the resident had red colored emesis and continued with vomiting unrelieved by as needed meds. The physician was notified of the resident's condition and a telephone order was given to send the resident to the emergency room for evaluation. The note documented Emergency Medical Services (EMS) was contacted to transport the resident to the emergency room . A nurse's note, dated [DATE] at 1:42 p.m., documented the emergency room was contacted regarding the resident's condition and the resident was admitted to the hospital for an upper [MEDICAL CONDITION]. A nurse's note, dated [DATE] at 1:40 p.m., documented the resident was transported back to the facility and transferred to bed via EMS. The nurses assessment documented, "Skin warm and dry, multiple dressings noted to res from previous facility all with soiling noted, all dressings removed and redressed as per PCP orders. Decubitus noted to R and L heel, cleaned and treated. Large unmeasurable ulcerative decub noted to coccyx, cleaned, treated, and covered at this time but continues to remain malodorous, multiple stage II surround decub to coccyx, cleaned and treated at this time, Stage III to L posterior lower rib flank region cleansed and treated as ordered." The nurse's note documented the resident had a new order for Bactrim DS x 14 days for urinary tract infection (UTI.) The documentation did not include the number of wounds, the stages, or measurements of the wounds. A nurse's note, dated [DATE] at 10:35 p.m., documented, "Multiple skin issues noted." A weekly skin audit report, dated [DATE], documented: unstageable pressure ulcer to the coccyx measuring 4.1 cm x 6.1 cm x 4.4 cm, a stage II pressure ulcer to the right buttock measuring 3.6 cm x 2.9 cm x 0.2 cm, a stage II pressure ulcer to the right buttock measuring 6.4 cm x 2.6 cm x 0.2 cm, a stage II pressure ulcer above the coccyx measuring 5.2 cm x 2.6 cm x 0.2 cm, a stage II pressure ulcer to the left coccyx measuring 3.6 cm x 2.4 cm x 0.2 cm, a stage II pressure ulcer to the left buttock measuring 4.2 cm x 2.6 cm x 0.1 cm, a stage II pressure ulcer to the left buttock measuring 3.3 cm x 2.4 cm x 0.2 cm, a stage III pressure ulcer to the right heel measuring 3.4 cm x 3.1 cm x 0.3 cm, a stage III pressure ulcer to the left heel measuring 3.0 cm x 2.9 cm x 0.3 cm, and a stage III pressure ulcer to the left posterior lower rib cage measuring 6.1 cm x .8 cm x 0.2 cm. A nurse's note, dated [DATE] at 3:46 a.m., documented a weekly skin assessment. All wounds and measurements documented on the nurse's note were the same as recorded on the weekly skin audit report. The significant change assessment, dated [DATE], documented the resident was moderately impaired in cognition. The assessment documented the resident was totally dependent on staff for transfers, dressing, and hygiene/bathing. The assessment documented the resident required extensive assistance with bed mobility and eating. The assessment documented the resident was at risk for developing a pressure ulcer and had a pressure relieving device on her bed. The assessment documented the resident had one stage II pressure ulcer, one stage IV pressure ulcer, and two unstageable pressure ulcers due to the coverage of the wound bed by slough and/or eschar. A nurse's note, dated [DATE] at 10:16 p.m., documented the treatment to the resident's coccyx and back was completed per orders by the treatment nurse. The nurse's note did not document the wound appearances, measurements, or stages. A Braden Scale for predicting pressure sore risk, dated [DATE], documented the resident was a very high risk for pressure ulcers. A weekly skin audit report, dated [DATE], documented: a stage IV pressure to the coccyx area measuring 9.5 cm x 8.6 cm x 5.6, a stage III pressure ulcer to the left lower ribcage measuring 10 cm x .8 cm x .2 cm, a stage II pressure ulcer to the right buttock measuring 7.5 cm x 2.0 cm x .1 cm, a stage II pressure ulcer to the left buttock measuring 2.0 cm x 2.5 cm x 0.2, a stage III pressure ulcer to the right heel measuring 3.0 cm x 2.0 cm x 0.2 cm, and a stage II pressure ulcer to the left heel measuring 1.5 cm x 1.0 cm x 0.1 cm. A nurse's note, dated [DATE] at 10:00 a.m., documented a new physician's orders [REDACTED]. The order documented to discontinue the current treatment to the left post lower back, and start Hydrogel and cover the left post lower back every Monday, Wednesday, and Friday until resolved. The order documented to apply Santyl to the left and right heel every Monday, Wednesday, and Friday until resolved. A nurse's note, dated [DATE], documented the dressing to the coccyx was clean, dry, and intact. A nurse's note, dated [DATE], documented the resident received a whirlpool and was transferred back to bed via a lift. The note documented a pressure ulcer to the resident's coccyx as a stage IV, measuring 12 cm x 12.5 cm x 6.5 cm, tunneling @ 3 o'clock 4.5 cm, and gray slough noted @ 6, 9, 12 o'clock. The note documented the resident's left lower post back with yellow slough noted, measuring 1.6 cm x 6 cm x 0.3 cm; left heel with gray slough measuring 1.9 cm x 1.6 cm; and right heel measuring 2.9 cm x 3.5 cm and described as necrotic. The note documented to continue wound care per physician orders. The note documented staff was encouraged to reposition the resident every two hours. A weekly wound tracking worksheet, dated [DATE], documented: a stage IV to the resident's coccyx, 4.5 cm tunneling at 3 o'clock, and measuring 12 cm x 12.5 cm x 6.5 cm; a stage III to the post lower back with yellow slough measuring 1.6 cm x 6 cm x 0.3 cm; a stage III pressure ulcer to the left heel with grey slough measuring 1.9 cm x 1.6 cm; and a stage III pressure ulcer to the right heel, necrotic, and measuring 2.9 cm x 3.5 cm. A nurse's note, dated [DATE] at 12:20 p.m., documented a CNA reported the resident was mumbling and refusing to eat lunch. Upon assessment the resident showed facial grimacing and had a decreased level of consciousness. The note documented the physician was contacted and ordered to send the resident out for hypertension and decreased level of consciousness. A history and physical (H&P) from a name-deleted hospital, dated [DATE], documented the resident has had decubitus ulcers. The H&P documented the resident was admitted earlier in the month for an infection related to the decubitus ulcers and she was also septic at this time. The H&P documented the resident was sent to the emergency room where she was noted to be severely hypotensive and severely volume depleted. The H&P documented the resident was admitted to the intensive care unit [MEDICAL CONDITION]. A discharge summary from a name-deleted hospital, dated [DATE], documented the resident was sent to the hospital for changes in mentation. The discharge summary documented the resident was noted to have a severe infection of the sacral decubitus ulcers. The summary documented the resident was septic at the time of admission and was in profound [MEDICAL CONDITION]. The summary documented this was the resident's second admission in the same month [MEDICAL CONDITION] related to the decubitus ulcer infections. The summary documented the resident expired at 5:36 p.m. on [DATE]. On [DATE] at 1:20 p.m., LPN #1 was interviewed regarding interventions put in place for the resident. The LPN reported nurses were assigned to residents to do skin assessments. A representative from the wound care clinic came one time every month to speak with the DON. The LPN reported when a resident returned from a hospitalization any wounds should have been assessed. The LPN reported the resident was being turned and her heels were floated on pillows. The LPN was not sure if the resident had a special mattress or not. The LPN reported it was the facility practice to turn and reposition a resident with pressure ulcers every hour. On [DATE] at 2:22 p.m., The DON was interviewed regarding wound care and interventions for the resident. The DON reported if the wound clinic did the treatments the facility did not do any treatments. The DON reported the facility assessed the wounds. The DON reported the resident had periods when she would not get up. The DON was asked to provide documentation of the resident's behaviors of refusal of care. The DON left the room. No documentation was provided regarding the resident's refusal of care. On [DATE] at 3:50 p.m., LPN #3 was interviewed regarding measuring and assessing wounds when residents returned from the hospital. The LPN reported all wounds should have been assessed and measured when the resident returned from the hospital. On [DATE] at 10:00 a.m., the registered dietician (RD) was interviewed regarding dietary interventions for the resident with pressure ulcers. The RD reported she usually came to the facility the first week of every month and went to a contact nurse regarding pressure ulcers. The RD reported unless the dietary manager was contacted regarding pressure ulcers she would not know which residents had a pressure ulcer. The RD reported there was a system problem that was resolvable with an electronic system. The RD reported if a problem such as a pressure ulcer came up after she had already come on the first of the month, the facility should have let her know so she could have made a recommendation. On [DATE] at 3:00 p.m., LPN #4 was interviewed regarding wound assessment when a resident was readmitted back to the facility following a hospital stay. The LPN reported usually wounds would be measured during the admission assessment. The LPN reported it would depend on the length of the hospital stay. The LPN was asked about interventions to help prevent the occurrence or worsening of pressure ulcers for the resident. The LPN reported the resident refused care at times. No documentation was provided regarding the resident's behaviors of refusing care or refusing interventions to prevent the occurrence or worsening of pressure ulcers. No documentation was provided by the facility to show the resident was turned and repositioned every hour according to the care plan.

Based on observation, interview and record review, it was determined the facility failed to provide care and services to maintain the highest practicable well being related to interventions for pain relief, a urinary tract infection and a skin treatment for [REDACTED].#4) of four sampled residents. The facility identified a census of 53 residents. The facility failed to: a) identify and provide interventions for pain relief following an injury which resulted in a fracture for one (#1) of four residents placed on the sample for pain. The facility's failure to provide pain medication for over six hours after a fracture resulted in actual pain to the resident. The facility identified 26 residents who were on a pain management program. b) obtain an order and provide a treatment for [REDACTED]. The facility identified 23 residents with a skin impairment in the past 30 days. c) obtain an antibiotic for a urinary tract infection for five days for one (#4) sampled resident with a urinary tract infection. Findings: The facility policy for pain documented the nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was an onset of new pain or worsening of existing pain. The policy documented the staff would observe the resident for evidence of pain and identify any situations where an increase in the resident's pain might be anticipated; for example, wound care, ambulation, or repositioning. The facility policy for administering pain medications documented acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief was obtained. The facility policy on pharmacy services documented the facility should immediately notify the pharmacy when the facility received a medication order which required an interim, stat and emergency delivery. The policy documented the facility should arrange with the pharmacy to include the interim, stat and emergency medications in an earlier scheduled delivery, a special delivery, or arrange for delivery by contract courier. 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated 05/09/12, documented the resident was understood and understood others; had severely impaired cognition skills; and had short and long term memory problems. The assessment documented the resident required extensive physical assistance of one person with locomotion; had impairment of one side with range of motion involving the lower extremity; used a wheelchair for mobility and had denied pain in the last five days. An incident report, dated 06/27/12, documented [MEDICAL CONDITION] was noted to the resident's left ankle area. The incident report documented the physician was notified for an order for [REDACTED]. The incident report documented a thorough investigation was conducted which included interviews with staff and it was discovered the resident received an injury while being transported in the wheelchair from the dining room to the resident's room at approximately 1:00 p.m., on 06/26/12. The report documented the certified nurse aide (CNA) stated the resident's left foot slipped off the foot rest onto the floor and the resident's foot was manipulated to the prone position under her chair. The CNA stated that as soon as it was noticed the chair was immediately stopped and the resident's foot was placed back on the foot rest. The report documented the CNA stated the resident denied pain; the CNA could see no obvious injury and she placed the resident in bed at that time. The CNA stated she did not report the incident to the charge nurse or any other staff member. The report documented the CNA received disciplinary action for the failure to report the incident. The incident report documented swelling and bruising of the left foot was noted by the CNA and a licensed practical nurse at approximately 7:20 a.m. on 06/27/12, and the physician and family were notified. The incident report documented mobile x rays were ordered and after the results were received an appointment was made with the orthopedic clinic. The resident was sent to the emergency room . The investigation report documented interviews were conducted with staff members who had worked on the 7-3, 3-11 and the 11-7 shift on 06/26/12. The staff members reported they had not noticed any changes in the resident during their shifts until the 7-3 shift on 06/27/12. A nurse's note, dated 06/27/12 at 7:25 a.m., documented the restorative aide had pushed the resident to the nurses' station in the wheelchair. The nurse's note documented the restorative aide reported when she tried to put the resident's leg brace on the resident's left leg, the resident grabbed her left foot and began yelling and tried to hit the restorative aide. The nurse's note documented the restorative aide noticed the left ankle was swollen and took the resident to the nurse's station. The nurse's note documented the nurse assessed the resident's left ankle with bruising observed to the left inner ankle with a blue tinge to the left outer ankle; the entire left ankle was observed to have a large amount of swelling. The nurse's note documented the resident was not able to tell the nurse what happened and the resident voiced no pain from the ankle except with touch. The nurse's note documented the physician's office was called and a message was left for the physician to call the nursing home. A nurse's note, dated 06/27/12 at 8:00 a.m., documented the physician returned the phone call with orders for mobile imaging to obtain an x ray of the residents left ankle. A nurse's note, dated 06/27/12 at 8:01 a.m., documented the resident's daughter was notified and given a report on the resident's current condition and the physician's orders [REDACTED]. A nurse's note, dated 06/27/12 at 10:50 a.m., documented the resident complained of left hip pain. The nurse's note documented the physician was notified and an order was received to obtain an X-ray of the left hip. A nurse's note, dated 06/27/12 at 10:52 a.m., documented the nurse went to the medication cart to obtain pain medication for the resident and did not have pain medication in the medication cart. A call was placed to the pharmacy to have the medication brought to the facility stat. A nurse's note, dated 06/27/12 at 12:40 p.m., documented the physician gave an order to send the resident to the emergency room for immobilization of the left ankle. A nurse's note, dated 06/27/12 at 1:15 p.m., documented the resident's pain medication was received. A nurse's note, dated 06/27/12 at 1:15 p.m., documented the emergency services was in the facility; transferred the resident to a stretcher and the resident was transferred out of the facility to the emergency department. A nurse's note, dated 06/27/12 at 1:55 p.m., documented the resident was back to the facility. The nurse's note documented the nurse asked the resident if the resident was having pain. The resident stated she had pain, was unable to rate the pain and pain medication was administered to the resident. The resident had not received pain medication for the ankle fracture first identified at 7:25 a.m. until 1:55 p.m. A pain assessment, dated 06/27/12, documented the resident had complaints of or showed evidence of pain or possible pain one to two days. The pain assessment documented the resident had received pain medication as needed; had received non-medication intervention for pain. A physician's orders [REDACTED]. The order documented the facility was then to apply an ice pack for 20 minutes four times a day. A treatment sheet, dated June 2012, did not document an ice pack had been applied during the 7:00 p.m. to 7:00 a.m. shift. The care plan, dated 06/28/12, documented the resident had a potential for pain due to a closed fracture to the left ankle. The care plan documented the charge nurse would apply an ice pack to the left ankle for 20 minutes every two hours for 24 hours then for 20 minutes four times a day. The care plan documented the facility would anticipate and meet the residents needs. On 07/16/12 at 6:15 p.m., LPN #1 was interviewed. The LPN reported the resident was able to verbalize pain. The LPN reported the ADON had called the pharmacy to bring the pain medication to the resident. The LPN reported she did not administer the pain medication prior to the resident going to the emergency room . The LPN stated the ambulance got to the facility right when the medication arrived so she did not administer the pain medication; when the medication arrived the emergency medical service staff and the family were in the resident's room so she had not attempted to administer the pain medication. The LPN stated two hours was too long for a resident to be in pain. On 07/17/12 at 10:05 a.m., the assistant director of nurses (ADON) was interviewed regarding the resident's pain medication not being in the facility. The ADON reported she wasn't sure why the resident didn't have the pain medication in the building and she thought the resident had been at the emergency room when the pain medication arrived at the facility. The ADON stated the family reported the resident hadn't received pain medication at the emergency room so LPN #1 administered the pain medication when the resident arrived back in the facility. The ADON was asked what the facility policy was for medications if the medication was not in the facility. The ADON reported if the medication was ordered stat and the pharmacy reported it would be over two hours before the medication arrived the facility staff would go to the pharmacy to pick the medication up. The ADON stated two hours would be a long time to wait for pain medication if the resident was in pain. On 07/17/12 at 10:15 a.m., the ADON reviewed a nurse's note, dated 06/27/12 at 7:25 a.m., which documented the resident grabbed her left foot and began yelling and tried to hit the restorative aide when the restorative aide was attempting to apply the leg braces. The ADON reviewed a nurses' notes, dated 06/27/12 at 10:50 a.m., which documented the resident complained of hip pain at 10:52 a.m., and did not have pain medication in the facility at 1:15 p.m. The note also documented the pain medication was received at the facility and was sent to the emergency room . The ADON reviewed a nurse's note, dated 06/17/12, which documented the resident received the pain medication at 3:55 p.m. The ADON stated the pain medication should have been administered before the resident was sent to the emergency room . On 07/17/12 at 11:00 a.m., the resident was observed in the dining room sitting in the wheelchair. The resident was observed with a pad on the foot rests of the wheelchair. On 07/17/12 at 11:45 a.m., the ADON was interviewed regarding the physician ordered ice packs for the fractured ankle. The ADON reviewed the treatment sheets and stated, "The night nurse did not apply ice on 07/27/12. She was written up for it." On 07/17/12 at 12:40 p.m., the facility was asked to have the physician contact the surveyors regarding the incident. On 07/17/12 at 2:15 p.m., an interview was conducted with the administrator. The administrator was asked if she was aware the resident's pain medication was not available on 06/27/12. The administrator reported she was not aware. The physician had not returned the surveyors call prior to the exit. 2. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/22/12, documented the resident's cognition was intact. The assessment documented the resident had no long or short term memory problems and required extensive assistance with transfers and dressing. A careplan, dated 06/28/12, documented the resident required assistance of two staff for transfers. No care plan was found in regard to skin problems. A facility fax to the physician, dated 07/07/12, documented the resident was getting into bed and reported he hit the anterior of his foot on the pedal of his wheelchair. The fax documented the resident had a 1 cm x 0.5 centimeter scratch with a scab and a 1 cm x 0.6 cm scratch with scab with periwound redness and swelling. The fax documented, "please advise." The fax was signed by the physician on 07/13/12. A nurse's note, dated 07/07/12 at 1:15 p.m., documented the resident complained of his right foot being sore. The nurse's note documented the nurse observed a 1 cm x 0.5 cm and a 1 cm x 0.6 cm scratch with a scab and periwound redness noted to the right foot. The nurse's note documented the foot was observed with minor swelling around a scratch. The nurse's note documented the resident stated on Wednesday night (07/04/12) the resident was preparing to get into bed and had bumped his foot. A nurse's note, dated 07/07/12 at 7:45 p.m., documented the nurse observed a scratch on the resident's right foot and a small amount of swelling. The nurse's note documented the resident was to leave his shoe off or make sure the shoes were secured loosely. A nurse's note, dated 07/08/12 at 1:20 p.m., documented the resident's right foot was observed with slight [MEDICAL CONDITION] and two scratches. A nurse's note, dated 07/08/12 at 7:45 p.m., documented the resident continued to have two scratches and [MEDICAL CONDITION] to the right foot. A nurse's note, dated 07/09/12 at 1:44 p.m., documented the resident continued to have two scratches and [MEDICAL CONDITION] to the right foot. The nurse's note documented scabs were forming. A nurse's note, dated 07/10/12 at 9:47 a.m., documented the resident continued to have healing scratches on the right foot. On 07/17/12 at 10:00 a.m., the resident was observed sitting in a wheelchair and propelling him self out of the dining room. Licensed practical nurse (LPN) #1 asked the resident if she could observe his right foot. The resident stated his foot was healed now and the nurse did not need to see it. On 07/17/12 at 10:50 a.m., LPN #1 was interviewed regarding the treatment used for the resident's foot. LPN #1 stated the facility had just received the fax back on 07/17/12, with the treatment order for the resident's right foot. LPN #1 was interviewed regarding the amount of time between 07/07/12, when the physician was faxed for an order for [REDACTED]. order and the LPN stated the staff just observed the skin impairment on the resident's foot. LPN #1 stated the nurses did not have a treatment order for the resident's skin impairment on his right foot. On 07/17/12 at 11:50 a.m., the assistant director of nurses (ADON) was interviewed regarding the physician notification on 07/07/12, and the failure to receive a treatment order until 07/17/12. The ADON stated she did not have any idea why it took ten days to get a treatment order. The ADON stated the nurses should have called the physician and obtained a treatment order. 3. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/26/12, documented the resident's cognition was intact. The resident was frequently incontinent of urine and had frequent urinary tract infections. A careplan, dated 07/03/12, documented the resident had a history of [REDACTED]. A nurse's note, dated 07/11/12 at 9:00 a.m., documented a final urinalysis report was faxed to the physician. A nurse's note, dated 07/13/11 at 10:47 a.m., documented the facility called the physician's office for the urinalysis results. A nurse's note, dated 07/16/12 at 5:50 a.m., documented a new order was received from the physician for [MEDICATION NAME] 875 milligrams (mg) one tablet twice a day for seven days and the local pharmacy was faxed an order for [REDACTED]. A nurse's note, dated 07/16/12 at 7:40 a.m., documented the initial dose of [MEDICATION NAME] was given at 7:10 a.m., with no symptoms of adverse actions observed. On 07/17/12 at 10:20 a.m., the ADON was interviewed regarding the facility time frame for acquiring antibiotics. The ADON stated the facility called the local pharmacy for the initial dose, then the consulting pharmacy would send the additional medication. The ADON stated the resident should never go more than two hours awaiting their antibiotic medications.

Based on record review, observation and interview, it was determined the facility failed to ensure medications were acquired in a timely manner in order to follow physician MEDICATION ORDERS FOR [REDACTED]. The facility's failure to provide pain medication for resident #1 for over six hours after a fracture resulted in actual pain to the resident. This had the potential to affect 53 residents who resided in the facility. Findings: The facility policy on pharmacy services documented the facility should immediately notify the pharmacy when the facility received a medication order which required an interim, stat, and emergency delivery. The policy documented the facility should arrange with the pharmacy to include the interim, stat, and emergency medications in an earlier scheduled delivery, a special delivery or arrange for delivery by contract courier. 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated 05/09/12, documented the resident was understood and understood others; had severely impaired cognition skills; and had short and long term memory problems. The assessment documented the resident required extensive physical assistance of one person with locomotion; had impairment of one side with range of motion involving the lower extremity; used a wheelchair for mobility and had denied pain in the last five days. An incident report, dated 06/27/12, documented edema was noted to the resident's left ankle area. The incident report documented the physician was notified for an order for [REDACTED]. The incident report documented a thorough investigation was conducted which included interviews with staff and it was discovered the resident received an injury while being transported in the wheelchair from the dining room to the resident's room at approximately 1:00 p.m., on 06/26/12. The report documented the certified nurse aide (CNA) stated the resident's left foot slipped off the foot rest onto the floor and the resident's foot was manipulated to the prone position under her chair. The CNA stated that as soon as it was noticed the chair was immediately stopped and the resident's foot was placed back on the foot rest. The report documented the CNA stated the resident denied pain; the CNA could see no obvious injury and she placed the resident in bed at that time. The CNA stated she did not report the incident to the charge nurse or any other staff member. The report documented the CNA received disciplinary action for the failure to report the incident. The incident report documented swelling and bruising of the left foot was noted by the CNA and a licensed practical nurse at approximately 7:20 a.m. on 06/27/12, and the physician and family were notified. The incident report documented mobile x rays were ordered and after the results were received an appointment was made with the orthopedic clinic. The resident was sent to the emergency room . The investigation report documented interviews were conducted with staff members who had worked on the 7-3, 3-11 and the 11-7 shift on 06/26/12. The staff members reported they had not noticed any changes in the resident during their shifts until the 7-3 shift on 06/27/12. A nurse's note, dated 06/27/12 at 7:25 a.m., documented the restorative aide had pushed the resident to the nurses' station in the wheelchair. The nurse's note documented the restorative aide reported when she tried to put the resident's leg brace on the resident's left leg, the resident grabbed her left foot and began yelling and tried to hit the restorative aide. The nurse's note documented the restorative aide noticed the left ankle was swollen and took the resident to the nurse's station. The nurse's note documented the nurse assessed the resident's left ankle with bruising observed to the left inner ankle with a blue tinge to the left outer ankle; the entire left ankle was observed to have a large amount of swelling. The nurse's note documented the resident was not able to tell the nurse what happened and the resident voiced no pain from the ankle except with touch. The nurse's note documented the physician's office was called and a message was left for the physician to call the nursing home. A nurse's note, dated 06/27/12 at 8:00 a.m., documented the physician returned the phone call with orders for mobile imaging to obtain an x ray of the residents left ankle. A nurse's note, dated 06/27/12 at 8:01 a.m., documented the resident's daughter was notified and given a report on the resident's current condition and the physician's orders [REDACTED]. A nurse's note, dated 06/27/12 at 10:50 a.m., documented the resident complained of left hip pain. The nurse's note documented the physician was notified and an order was received to obtain an X-ray of the left hip. A nurse's note, dated 06/27/12 at 10:52 a.m., documented the nurse went to the medication cart to obtain pain medication for the resident and did not have pain medication in the medication cart. A call was placed to the pharmacy to have the medication brought to the facility stat. A nurse's note, dated 06/27/12 at 12:40 p.m., documented the physician gave an order to send the resident to the emergency room for immobilization of the left ankle. A nurse's note, dated 06/27/12 at 1:15 p.m., documented the resident's pain medication was received. A nurse's note, dated 06/27/12 at 1:15 p.m., documented the emergency services was in the facility; transferred the resident to a stretcher and the resident was transferred out of the facility to the emergency department. A nurse's note, dated 06/27/12 at 1:55 p.m., documented the resident was back to the facility. The nurse's note documented the nurse asked the resident if the resident was having pain. The resident stated she had pain, was unable to rate the pain and pain medication was administered to the resident. The resident had not received pain medication for the ankle fracture first identified at 7:25 a.m. until 1:55 p.m. A pain assessment, dated 06/27/12, documented the resident had complaints of or showed evidence of pain or possible pain one to two days. The pain assessment documented the resident had received pain medication as needed; had received non-medication intervention for pain. A physician's orders [REDACTED]. The order documented the facility was then to apply an ice pack for 20 minutes four times a day. A treatment sheet, dated June 2012, did not document an ice pack had been applied during the 7:00 p.m. to 7:00 a.m. shift. The care plan, dated 06/28/12, documented the resident had a potential for pain due to a closed fracture to the left ankle. The care plan documented the charge nurse would apply an ice pack to the left ankle for 20 minutes every two hours for 24 hours then for 20 minutes four times a day. The care plan documented the facility would anticipate and meet the residents needs. On 07/16/12 at 6:15 p.m., LPN #1 was interviewed. The LPN reported the resident was able to verbalize pain. The LPN reported the ADON had called the pharmacy to bring the pain medication to the resident. The LPN reported she did not administer the pain medication prior to the resident going to the emergency room . The LPN stated the ambulance got to the facility right when the medication arrived so she did not administer the pain medication; when the medication arrived the emergency medical service staff and the family were in the resident's room so she had not attempted to administer the pain medication. The LPN stated two hours was too long for a resident to be in pain. On 07/17/12 at 10:05 a.m., the assistant director of nurses (ADON) was interviewed regarding the resident's pain medication not being in the facility. The ADON reported she wasn't sure why the resident didn't have the pain medication in the building and she thought the resident had been at the emergency room when the pain medication arrived at the facility. The ADON stated the family reported the resident hadn't received pain medication at the emergency room so LPN #1 administered the pain medication when the resident arrived back in the facility. The ADON was asked what the facility policy was for medications if the medication was not in the facility. The ADON reported if the medication was ordered stat and the pharmacy reported it would be over two hours before the medication arrived the facility staff would go to the pharmacy to pick the medication up. The ADON stated two hours would be a long time to wait for pain medication if the resident was in pain. On 07/17/12 at 10:15 a.m., the ADON reviewed a nurse's note, dated 06/27/12 at 7:25 a.m., which documented the resident grabbed her left foot and began yelling and tried to hit the restorative aide when the restorative aide was attempting to apply the leg braces. The ADON reviewed a nurses' notes, dated 06/27/12 at 10:50 a.m., which documented the resident complained of hip pain at 10:52 a.m., and did not have pain medication in the facility at 1:15 p.m. The note also documented the pain medication was received at the facility and was sent to the emergency room . The ADON reviewed a nurse's note, dated 06/17/12, which documented the resident received the pain medication at 3:55 p.m. The ADON stated the pain medication should have been administered before the resident was sent to the emergency room . On 07/17/12 at 11:00 a.m., the resident was observed in the dining room sitting in the wheelchair. The resident was observed with a pad on the foot rests of the wheelchair. On 07/17/12 at 11:45 a.m., the ADON was interviewed regarding the physician ordered ice packs for the fractured ankle. The ADON reviewed the treatment sheets and stated, "The night nurse did not apply ice on 07/27/12. She was written up for it." On 07/17/12 at 12:40 p.m., the facility was asked to have the physician contact the surveyors regarding the incident. On 07/17/12 at 2:15 p.m., an interview was conducted with the administrator. The administrator was asked if she was aware the resident's pain medication was not available on 06/27/12. The administrator reported she was not aware. The physician had not returned the surveyors call prior to the exit. 2. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/22/12, documented the resident's cognition was intact. The assessment documented the resident had no long or short term memory problems and required extensive assistance with transfers and dressing. A careplan, dated 06/28/12, documented the resident required assistance of two staff for transfers. No care plan was found in regard to skin problems. A facility fax to the physician, dated 07/07/12, documented the resident was getting into bed and reported he hit the anterior of his foot on the pedal of his wheelchair. The fax documented the resident had a 1 cm x 0.5 centimeter scratch with a scab and a 1 cm x 0.6 cm scratch with scab with periwound redness and swelling. The fax documented, "please advise." The fax was signed by the physician on 07/13/12. A nurse's note, dated 07/07/12 at 1:15 p.m., documented the resident complained of his right foot being sore. The nurse's note documented the nurse observed a 1 cm x 0.5 cm and a 1 cm x 0.6 cm scratch with a scab and periwound redness noted to the right foot. The nurse's note documented the foot was observed with minor swelling around a scratch. The nurse's note documented the resident stated on Wednesday night (07/04/12) the resident was preparing to get into bed and had bumped his foot. A nurse's note, dated 07/07/12 at 7:45 p.m., documented the nurse observed a scratch on the resident's right foot and a small amount of swelling. The nurse's note documented the resident was to leave his shoe off or make sure the shoes were secured loosely. A nurse's note, dated 07/08/12 at 1:20 p.m., documented the resident's right foot was observed with slight edema and two scratches. A nurse's note, dated 07/08/12 at 7:45 p.m., documented the resident continued to have two scratches and edema to the right foot. A nurse's note, dated 07/09/12 at 1:44 p.m., documented the resident continued to have two scratches and edema to the right foot. The nurse's note documented scabs were forming. A nurse's note, dated 07/10/12 at 9:47 a.m., documented the resident continued to have healing scratches on the right foot. On 07/17/12 at 10:00 a.m., the resident was observed sitting in a wheelchair and propelling him self out of the dining room. Licensed practical nurse (LPN) #1 asked the resident if she could observe his right foot. The resident stated his foot was healed now and the nurse did not need to see it. On 07/17/12 at 10:50 a.m., LPN #1 was interviewed regarding the treatment used for the resident's foot. LPN #1 stated the facility had just received the fax back on 07/17/12, with the treatment order for the resident's right foot. LPN #1 was interviewed regarding the amount of time between 07/07/12, when the physician was faxed for an order for [REDACTED]. order and the LPN stated the staff just observed the skin impairment on the resident's foot. LPN #1 stated the nurses did not have a treatment order for the resident's skin impairment on his right foot. On 07/17/12 at 11:50 a.m., the assistant director of nurses (ADON) was interviewed regarding the physician notification on 07/07/12, and the failure to receive a treatment order until 07/17/12. The ADON stated she did not have any idea why it took ten days to get a treatment order. The ADON stated the nurses should have called the physician and obtained a treatment order. 3. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/26/12, documented the resident's cognition was intact. The resident was frequently incontinent of urine and had frequent urinary tract infections. A careplan, dated 07/03/12, documented the resident had a history of [REDACTED]. A nurse's note, dated 07/11/12 at 9:00 a.m., documented a final urinalysis report was faxed to the physician. A nurse's note, dated 07/13/11 at 10:47 a.m., documented the facility called the physician's office for the urinalysis results. A nurse's note, dated 07/16/12 at 5:50 a.m., documented a new order was received from the physician for Augmentin 875 milligrams (mg) one tablet twice a day for seven days and the local pharmacy was faxed an order for [REDACTED]. A nurse's note, dated 07/16/12 at 7:40 a.m., documented the initial dose of Augmentin was given at 7:10 a.m., with no symptoms of adverse actions observed. On 07/17/12 at 10:20 a.m., the ADON was interviewed regarding the facility time frame for acquiring antibiotics. The ADON stated the facility called the local pharmacy for the initial dose, then the consulting pharmacy would send the additional medication. The ADON stated the resident should never go more than two hours awaiting their antibiotic medications.

Based on observation, interview, and record review, it was determined the facility failed to thoroughly assess, monitor, and correlate care with hospice for one (#7) of two sampled residents who had a change in condition and/or received hospice services. The facility failed to thoroughly assess and monitor resident changes, including changes in the resident's behavior. The resident was admitted to the hospital with [REDACTED]. The facility identified three residents who received hospice services. Findings: The facility hospice agreement documented hospice would engage in providing interdisciplinary care and treatment to terminally ill patients in order to allow patients to continue life with minimal disruption in a home environment. The agreement documented hospice care was primarily palliative rather than curative care. The agreement documented the nursing home agreed to appropriately meet the residents' needs when the hospice staff were absent. The agreement documented the facility would assure that each resident received treatments, medications, and the resident would be kept comfortable. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. disease. A hospice care plan, dated 10/26/10, was the only hospice care plan available. A hospice nurse's note, dated 03/22/12, documented the nurse was unable to assess the resident because the resident was combative and hostile. The nurse's note documented the resident had poor skin turgor. The nurse's note documented the resident had a temperature of 99.5. There was no entry in the facility's nurses' notes for 03/22/12. A quarterly assessment, dated 03/24/12, documented the resident was severely impaired with cognition. The assessment documented the resident had long and short term memory problems. The assessment documented the resident required extensive assistance with all hygiene needs. The assessment documented the resident required minimal assistance with eating. The assessment did not identify any behaviors. The assessment documented the resident was occasionally incontinent of bowel and bladder. A hospice nurse's note, dated 03/26/12 at 10:40 a.m., documented the nurse was unable to assess the resident because the resident was combative and hostile. The nurse's note documented the resident had poor skin turgor. The hospice note documented the hospice nurse had a conference with the facility nurse. A facility nurse's note, dated 03/26/12 at 6:45 p.m., documented the resident's family reported to the facility staff the resident had diarrhea. The note documented the resident was given medication for diarrhea. The nurse's note did not address the behavior or poor skin turgor of the resident. A facility nurse's note, dated 03/28/12 at 6:00 p.m., documented the resident had an "episode" of diarrhea. A hospice nurse's note, dated 03/28/12, documented the resident became hostile while being assessed. The nurse's note documented the resident was combative, hostile, mumbling, and agitated. The nurse's note documented the hospice nurse reported the assessment to the facility staff. A facility nurse's note, dated 03/29/12 at 8:30 a.m., documented the facility had contacted the resident's physician and obtained an order to hold all stoll softeners for five days. A facility fax transmittal to the physician, dated 03/29/12, documented the resident had diarrhea for three days. The fax documented an order for [REDACTED]. Facility nurses' notes from 03/30/12 through 04/12/12 documented the resident had no diarherra. The resident's facility care plan, dated 04/04/12, documented the resident received hospice services. The care plan documented the hospice and nursing staff would work together to meet all of the resident's needs. A hospice nurse's note, dated 04/10/12, documented the resident would fall asleep during the assessment by the nurse. The nurse's note documented the resident had, "Very poor skin turgor, poor circulation in her feet and hands." The hospice nurse documented the resident required total assistance with all activities of daily living needs. The hospice nurse documented the facility was to contact the physician for a urinalysis to be done. The hospice note documented the hospice nurse had a conference with the facility nurse. A nurse's note, dated 04/12/12 at 10:14 a.m., documented the resident was observed with a scant amount of blood in her brief. The nurse's note documented a small amount of bright red blood came out of the resident's vagina while staff were performing pericare. The nurse's note documented a call was placed to the physician's office. The nurse's note documented the physician's office stated to send a fax. A nurse's note, dated 04/12/12 at 10:30 a.m., documented the physician called and stated to watch for vaginal bleeding for three days and report back to the physician on 04/16/12. The nurse's note documented a family member was notified of the resident's change of condition and the orders received from the physician. A nurse's note, dated 04/12/12 at 12:00 p.m., documented the resident's family member called and requested the resident be sent to the emergency room for evaluation. A facility fax transmittal to the physician, dated 04/12/12, documented the resident's family requested the resident be sent to the emergency room for evaluation. A nurse's note, dated 04/12/12 at 12:45 p.m., documented emergency medical services had arrived for transport. A nurse's note, dated 04/12/12 at 11:06 p.m., documented the nurse called the hospital after being informed by the previous shift the resident had been admitted to the hospital. The nurse's note documented the resident's [DIAGNOSES REDACTED]. The resident was in the hospital during the four day investigation. A hospital progress note, dated 04/13/12 at 8:00 a.m., documented, "...IMPRESSION: urosepsis with a 3+ bacteria in her urine, dehydration, change in level of consciousness, urinary tract infection...." On 04/16/12 at 11:00 a.m., licensed practical nurse (LPN) #1 was interviewed regarding monitoring and assessing a resident when there was a problem. LPN #1 stated when residents experienced a problem the nurses assessed, monitored, and documented in the nurses' notes. LPN #1 stated if the resident did not improve the physician was notified. LPN #1 stated three or four weeks was too long for a resident to experience problems without someone doing something. On 04/17/12 at 9:40 a.m., the director of nurses (DON) was interviewed regarding the resident's nursing assessments, consults with the hospice, and the resident's status up to admission to the hospital. The DON stated the facility nurses should have followed up with documentation if a problem was reported by hospice. The DON stated documentation was always a problem in the facility. The DON stated he was not aware the resident had ever had behavior problems. The DON stated he was unaware of the change in the resident's condition and could not believe the resident would ever be combative. The DON reported he had never had a conversation with the hospice staff regarding the change in the resident's condition. The DON stated he never read the hospice notes. On 04/17/12 at 1:20 p.m., CNA #1 stated was interviewed regarding resident #7. The CNA stated the resident "hadn't been acting herself" and had experienced "off and on" diarrhea. On 04/18/12 at 9:00 a.m., the physician was interviewed regarding the resident's admission to the hospital. The physician stated the resident's [DIAGNOSES REDACTED]. On 04/18/12 at 10:30 a.m., the hospice nurse was interviewed regarding the resident's condition and behaviors. The hospice nurse stated she thought the resident might be having pain or the behaviors were a symptom of her dementia. The hospice nurse stated she explained the behaviors to the facility nurses. The hospice nurse stated the facility nurses stated the resident had those behaviors and that wasn't abnormal for the resident. The hospice nurse was asked if the resident was provided pain medication before her hygiene care and was asked if the behaviors could be related to pain. The hospice nurse stated she had other residents to take care of outside the facility and she never knew when she was coming. The hospice nurse stated the facility was responsible for administering the resident's medications. On 04/18/12 at 3:45 p.m., the assistant director of nurses (ADON) was interviewed regarding the hospice care plan dated 10/26/10. The ADON was asked how often the hospice care plans were updated. The ADON stated 10/26/10 was probably the last time the care plan was updated. The ADON stated she did not really know how often hospice updated their care plans.

Based on record review, observation, and interview, it was determined the facility failed: a) to assess pain and provide interventions to alleviate pain before treatments and after surgery for [REDACTED].#3) of six residents sampled for pain management. This had the potential to affect thirteen residents identified by the facility on a pain management program. b) to assess and monitor [MEDICAL TREATMENT] treatments for one (#6) of two sampled residents who received [MEDICAL TREATMENT] treatments. This had the potential to affect three residents who received [MEDICAL TREATMENT] treatments. c) to assess and monitor one (#1) of one resident sampled for tube feedings after a syringe filled with food was identified at the resident's bedside. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 01/03/12, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required extensive assistance with bed mobility and activities of daily living. A nurse's note, dated 11/15/11, documented, "Assessed left heel with a dark purple deep tissue injury, 5.5cm x 5.5cm. Right heel with 5cm x 5cm appears to be a blister without fluid," The nurse's note documented the physician was notified. The nurse's note documented a physician's orders [REDACTED]. A careplan, dated 01/17/12, documented the resident had short term memory impairment. The care plan documented the resident required supervised to limited assist with activities of daily living. The care plan documented the resident had pressure ulcers on bilateral heels. On 01/24/12 at 9:25 a.m., the resident was observed during a wound treatment. LPN #4 reported the resident had gone to the wound clinic for the first time on 01/23/12. LPN #4 reported the resident had developed blisters on her heels bilaterally. The LPN reported the resident's right heel was clear. LPN #4 reported the resident's left heel developed eschar. The wound was observed to have a moderate amount of slough and medication removed during cleansing of the wound. The resident jerked her left leg and said, "Ouch!, that hurts." LPN #4 was asked how she would stage the wound. LPN #4 reported she would stage the would as a stage III. LPN #4 was asked if the resident had pain medication ordered. LPN #4 stated she would check on it. The medication administration was reviewed for 01/24/12. There was no documentation pain medication had been administered prior to the wound treatment. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 12/31/11, documented the resident was alert and oriented with cognition. The assessment documented the resident had no short or long term memory problems. The assessment documented the resident required limited assistance with activity of daily living tasks and bed mobility. A nurse's note, dated 01/10/12, documented the resident returned from the hospital with recent left [MEDICAL CONDITION] repair and 17 surgical staples in the left hip. The Medication Administration Record [REDACTED]. No documentation was available for the effectiveness of the pain medication given. A nurse's note, dated 01/10/12, documented the resident was crying, upset, and complained of left hip pain. The nurse's note documented the resident was given [MEDICATION NAME] 600 mg. A nurse's note, dated 01/13/12, documented [MEDICATION NAME] 5/500 was given to the resident for pain during breakfast. The nurse's note documented the resident requested the pain medication. A care plan, dated 01/14/12, documented the resident complained of pain related to her recent [MEDICAL CONDITION]. On 01/23/12 at 5:25 p.m., the director of nurses was interviewed regarding the resident's pain and a pain assessment. The director of nurses stated that a LPN (licensed practical nurse) completed the pain assessments. The director of nurses stated he did not believe the resident had pain. The director of nurses stated the resident did have pain the other night and she was given pain medication. The director of nurses stated the resident did sleep all night after the medication was given. On 01/25/12 at 10:15 a.m., the physical therapy assistant was observed transferring the resident out of the therapy room. The physical therapy assistant stated the resident was having pain and could not complete her therapy. The resident was asked if she was having pain. The resident did not answer. The resident was observed crying. On 01/25/12 at 11:40 a.m., licensed practical nurse (LPN) #3 was interviewed regarding assessing residents for pain. LPN #3 stated the staff evaluated the residents for pain and called the doctor. LPN #3 stated that most of the time the staff just gave the prn (as needed) medications as often as the physician's orders [REDACTED]. 3. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 11/02/11, documented the resident was moderately impaired in cognition. The assessment documented the resident had short term memory problems but his long term memory was intact. The assessment documented the resident required extensive assistance with activity of daily living tasks and bed mobility. A nurse's note, dated 11/24/11, documented the resident was found in the floor beside his bed. The nurse's note documented the resident was transferred back to bed with assistance of the registered nurse. The nurse's note documented the resident did not "hurt anywhere" and knew where he was. A nurse's note, dated 11/25/11, documented the resident complained of left arm pain. The nurse's note documented the resident's arm was [MEDICAL CONDITION]. The nurse's note documented the registered nurse was notified of the left arm. The nurse's note documented the registered nurse stated, "Give him something for pain and they will take care of it at [MEDICAL TREATMENT]." A nurse's note, dated 11/26/11, documented the [MEDICAL TREATMENT] unit called the facility and inquired about the resident's left arm and if any injuries had occurred. The nurse's note documented the [MEDICAL TREATMENT] unit reported the resident's left arm was swollen and difficult to access. A care plan, dated 12/14/11, documented the resident required [MEDICAL TREATMENT] treatments on Mondays, Wednesdays, and Fridays. An approach to the care plan documented for staff to assess the resident for dehydration, increased weakness, postural [MEDICAL CONDITION], elevated temperature, skin turgor, and increased heart rate. The care plan documented the staff was to notify the physician if needed. On 12/22/11 a nurse's note documented a new order for the facility to discontinue the resident's medication [MEDICATION NAME]. On 12/30/11 a nurse's note documented the resident returned from [MEDICAL TREATMENT]. No nurse's notes were available from 12/22/11 - 12/30/11. No documentation of assessing and monitoring was available for end stage [MEDICAL CONDITION], [MEDICAL TREATMENT] treatments, medication changes, and assessments after an injury to the resident's left arm and shunt site. On 01/24/12 at 10:20 a.m., the director of nurses was interviewed regarding the lack of documentation and assessing the resident's condition after [MEDICAL TREATMENT] treatments. The director of nurses stated the staff had been instructed numerous times about the importance of documentation. The director of nurses stated the assistant director of nurses (ADON) was on leave and she usually critiqued the charts. 4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/12/11, documented the resident was severely impaired with cognition skills and had short and long term memory problems. The assessment documented the resident required total assistance with all activity of daily living needs. A nurse's note, dated 12/21/11 at 8:05 a.m., documented the nurse arrived to the resident's room to give medication and saw a syringe full of white liquid which had an appearance of gravy. The nurse's note documented the nurse did not administer the medications via gastrostomy tube at that time. The nurse's note documented the physician was notified. The nurse's note documented the resident's husband was in the room at the time. The nurse's note documented the director of nurses (DON) was notified. A nurse's note, dated 12/23/11 at 8:10 a.m., documented the nurse was outside the room preparing medications and witnessed the resident's family member with a 60 cubic centimeter (cc) syringe drawing up gravy from a bowl on the meal tray. The nurse's note documented the nurse reported the incident to the DON. There was no further documentation of the incidents with the syringe and gravy. A care plan, dated 12/23/11, documented the resident depended on her husband and staff for all of her decisions related to her care and well being. Approaches included that her husband would be involved in daily care of the resident. The care plan documented the resident had a feeding tube related to her [DIAGNOSES REDACTED]. A nurse's note, dated 01/14/12 at 9:00 a.m., documented the nurse was in with the resident to administer gastrostomy tube medications. The nurse's note documented when the nurse entered the room, the nurse viewed a full 60 cc syringe with biscuit, sausage, and gravy on the night stand. The nurse's note documented the resident's husband was at the bedside. There was no further documentation of the incident with the syringe filled with biscuit, sausage, and gravy. On 01/23/12 at 2:00 p.m., the resident was observed during incontinent care. On 01/24/12 at 5:30 p.m., the DON was interviewed regarding the nurses' notes that documented the syringes observed with food in the resident's room. The DON reported he had just seen the nurse's note, dated 01/14/12, related to the syringe with the biscuit, sausage, and gravy. The DON reported he had not previously been aware of the incident. The DON reported the physician had been notified of the observations of the syringes filled with food on 12/21/11 and 01/24/12. On 01/25/12 at 6:15 p.m., the DON was asked if he had ever observed the resident's family attempt to feed the resident with a syringe or put the contents in her gastrostomy tube. The DON reported he had not observed the family member attempting to feed the resident. The DON reported the family member should not have attempted to put anything through the syringe. The DON was asked if there had been an investigation of what had happened to the contents of the syringe. The DON reported there should have been follow-up documentation related to the incidents.

Based on observation, interview, and record review, it was determined the facility failed to thoroughly assess, monitor, and correlate care with hospice for one (#7) of two sampled residents who had a change in condition and/or received hospice services. The facility failed to thoroughly assess and monitor resident changes, including changes in the resident's behavior. The resident was admitted to the hospital with [REDACTED]. The facility identified three residents who received hospice services. Findings: The facility hospice agreement documented hospice would engage in providing interdisciplinary care and treatment to terminally ill patients in order to allow patients to continue life with minimal disruption in a home environment. The agreement documented hospice care was primarily palliative rather than curative care. The agreement documented the nursing home agreed to appropriately meet the residents' needs when the hospice staff were absent. The agreement documented the facility would assure that each resident received treatments, medications, and the resident would be kept comfortable. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. disease. A hospice care plan, dated 10/26/10, was the only hospice care plan available. A hospice nurse's note, dated 03/22/12, documented the nurse was unable to assess the resident because the resident was combative and hostile. The nurse's note documented the resident had poor skin turgor. The nurse's note documented the resident had a temperature of 99.5. There was no entry in the facility's nurses' notes for 03/22/12. A quarterly assessment, dated 03/24/12, documented the resident was severely impaired with cognition. The assessment documented the resident had long and short term memory problems. The assessment documented the resident required extensive assistance with all hygiene needs. The assessment documented the resident required minimal assistance with eating. The assessment did not identify any behaviors. The assessment documented the resident was occasionally incontinent of bowel and bladder. A hospice nurse's note, dated 03/26/12 at 10:40 a.m., documented the nurse was unable to assess the resident because the resident was combative and hostile. The nurse's note documented the resident had poor skin turgor. The hospice note documented the hospice nurse had a conference with the facility nurse. A facility nurse's note, dated 03/26/12 at 6:45 p.m., documented the resident's family reported to the facility staff the resident had diarrhea. The note documented the resident was given medication for diarrhea. The nurse's note did not address the behavior or poor skin turgor of the resident. A facility nurse's note, dated 03/28/12 at 6:00 p.m., documented the resident had an "episode" of diarrhea. A hospice nurse's note, dated 03/28/12, documented the resident became hostile while being assessed. The nurse's note documented the resident was combative, hostile, mumbling, and agitated. The nurse's note documented the hospice nurse reported the assessment to the facility staff. A facility nurse's note, dated 03/29/12 at 8:30 a.m., documented the facility had contacted the resident's physician and obtained an order to hold all stoll softeners for five days. A facility fax transmittal to the physician, dated 03/29/12, documented the resident had diarrhea for three days. The fax documented an order for [REDACTED]. Facility nurses' notes from 03/30/12 through 04/12/12 documented the resident had no diarherra. The resident's facility care plan, dated 04/04/12, documented the resident received hospice services. The care plan documented the hospice and nursing staff would work together to meet all of the resident's needs. A hospice nurse's note, dated 04/10/12, documented the resident would fall asleep during the assessment by the nurse. The nurse's note documented the resident had, "Very poor skin turgor, poor circulation in her feet and hands." The hospice nurse documented the resident required total assistance with all activities of daily living needs. The hospice nurse documented the facility was to contact the physician for a urinalysis to be done. The hospice note documented the hospice nurse had a conference with the facility nurse. A nurse's note, dated 04/12/12 at 10:14 a.m., documented the resident was observed with a scant amount of blood in her brief. The nurse's note documented a small amount of bright red blood came out of the resident's vagina while staff were performing pericare. The nurse's note documented a call was placed to the physician's office. The nurse's note documented the physician's office stated to send a fax. A nurse's note, dated 04/12/12 at 10:30 a.m., documented the physician called and stated to watch for vaginal bleeding for three days and report back to the physician on 04/16/12. The nurse's note documented a family member was notified of the resident's change of condition and the orders received from the physician. A nurse's note, dated 04/12/12 at 12:00 p.m., documented the resident's family member called and requested the resident be sent to the emergency room for evaluation. A facility fax transmittal to the physician, dated 04/12/12, documented the resident's family requested the resident be sent to the emergency room for evaluation. A nurse's note, dated 04/12/12 at 12:45 p.m., documented emergency medical services had arrived for transport. A nurse's note, dated 04/12/12 at 11:06 p.m., documented the nurse called the hospital after being informed by the previous shift the resident had been admitted to the hospital. The nurse's note documented the resident's [DIAGNOSES REDACTED]. The resident was in the hospital during the four day investigation. A hospital progress note, dated 04/13/12 at 8:00 a.m., documented, "...IMPRESSION: urosepsis with a 3+ bacteria in her urine, dehydration, change in level of consciousness, urinary tract infection...." On 04/16/12 at 11:00 a.m., licensed practical nurse (LPN) #1 was interviewed regarding monitoring and assessing a resident when there was a problem. LPN #1 stated when residents experienced a problem the nurses assessed, monitored, and documented in the nurses' notes. LPN #1 stated if the resident did not improve the physician was notified. LPN #1 stated three or four weeks was too long for a resident to experience problems without someone doing something. On 04/17/12 at 9:40 a.m., the director of nurses (DON) was interviewed regarding the resident's nursing assessments, consults with the hospice, and the resident's status up to admission to the hospital. The DON stated the facility nurses should have followed up with documentation if a problem was reported by hospice. The DON stated documentation was always a problem in the facility. The DON stated he was not aware the resident had ever had behavior problems. The DON stated he was unaware of the change in the resident's condition and could not believe the resident would ever be combative. The DON reported he had never had a conversation with the hospice staff regarding the change in the resident's condition. The DON stated he never read the hospice notes. On 04/17/12 at 1:20 p.m., CNA #1 stated was interviewed regarding resident #7. The CNA stated the resident "hadn't been acting herself" and had experienced "off and on" diarrhea. On 04/18/12 at 9:00 a.m., the physician was interviewed regarding the resident's admission to the hospital. The physician stated the resident's [DIAGNOSES REDACTED]. On 04/18/12 at 10:30 a.m., the hospice nurse was interviewed regarding the resident's condition and behaviors. The hospice nurse stated she thought the resident might be having pain or the behaviors were a symptom of her dementia. The hospice nurse stated she explained the behaviors to the facility nurses. The hospice nurse stated the facility nurses stated the resident had those behaviors and that wasn't abnormal for the resident. The hospice nurse was asked if the resident was provided pain medication before her hygiene care and was asked if the behaviors could be related to pain. The hospice nurse stated she had other residents to take care of outside the facility and she never knew when she was coming. The hospice nurse stated the facility was responsible for administering the resident's medications. On 04/18/12 at 3:45 p.m., the assistant director of nurses (ADON) was interviewed regarding the hospice care plan dated 10/26/10. The ADON was asked how often the hospice care plans were updated. The ADON stated 10/26/10 was probably the last time the care plan was updated. The ADON stated she did not really know how often hospice updated their care plans.

Based on record review, observation, and interview, it was determined the facility failed to ensure residents received necessary services to prevent and/or promote healing of pressure sores for two (#1 and #2) of three sampled residents who were reviewed for pressure ulcers to: a) identify, evaluate, and monitor pressure ulcers for resident #1 who had recurring pressure ulcers. b) evaluate and monitor a pressure ulcer for resident #2 who had been identified as a high risk for the development of pressure ulcers. The facility identified six residents with pressure ulcers. Findings: A facility policy for pressure ulcers documented the nursing staff and attending physician would assess and document an individual's significant risk factors for developing pressure sores. A policy for pressure ulcer risk assessment documented skin would be assessed for the presence of developing pressures ulcers on a weekly basis or more frequently if indicated. The policy documented the nurses would conduct skin assessments at least weekly to identify changes. The policy documented staff would maintain a "skin alert" performing routine skin inspections daily or every every other day as needed. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pressure risk evaluation, dated 07/06/11, documented a score of "35." The evaluation documented a score of 12 or above was considered high risk for the development of a pressure ulcer. A nurse's note, dated 07/25/11 at 11:40 a.m., documented the resident was noted to have a stage II ulcer to the sacral area gluteal cleft and was macerated to the edges with no signs/symptoms of new growth noted. The nurse's note documented the area measured 3cm x 2cm x 1cm. The nurse's note documented a stage II circular wound that measured 1cm x 1cm to the left buttock near the fold. The nurse's note documented no healing progress was noted. The nurse's note documented a new order for treatment was obtained. An annual assessment, dated 09/12/11, documented the resident was severely impaired with cognition skills and had short and long term memory problems. The assessment documented the resident required total assistance with all activity of daily living needs. The assessment documented the resident was at risk for pressure ulcers and had one unhealed stage II pressure ulcer. The assessment documented a pressure relieving device was used on the bed. A quarterly assessment, dated 12/12/11, documented the resident was severely impaired with cognition skills and had short and long term memory problems. The assessment documented the resident required total assistance with all activity of daily living needs. The assessment documented the resident was at risk for pressure ulcers and had one unhealed stage II. The assessment documented a pressure relieving device was used on the bed. A physician's telephone order, dated 12/16/11, documented to apply Santyl ointment and Calcium Alginate and to cover with an opsite every day to the two openings on the coccyx area until healed. A weekly wound tracking worksheet, dated 12/21/11, documented the resident was observed with two new wounds with an onset date of 12/16/11. The wound tracking worksheet documented the wounds had originated in the facility. The wound tracking worksheet documented a wound on the right buttock which measured 2cm x 3cm. The wound tracking worksheet documented a wound on the left buttock which measured 0.3cm x 0.3cm. A care plan, dated 12/23/11, documented the resident had a stage II on her buttock. Approaches included to watch for signs of skin irritation or breakdowns while providing care and to report any areas noted to the charge nurse. A weekly wound tracking worksheet, dated 01/09/12, documented the resident was observed with three new wounds with an onset date of 01/09/12. The wound tracking worksheet documented the wounds had originated in the facility. The wound tracking worksheet did not document where the wounds were located. The wound tracking worksheet documented new wounds which measured 1.5cm x 2.5cm, 0.3cm x 0.5cm, and 0.8cm x 0.4cm. The care plan had not been updated to reflect the residents current pressure ulcers. There were no other weekly wound tracking worksheets observed in the wound book. It could not be determined when the three new pressure ulcers originated between 12/16/11 and 01/09/12. On 01/23/12 at 2:10 p.m., the resident was observed during pressure ulcer treatment. The licensed practical nurse (LPN) treatment nurse reported the resident had a new opening on the right buttock, that had not been present on the last day she worked, four days ago. The LPN measured the new area. The LPN treatment nurse reported the area measured .7cm x .6cm. The LPN treatment nurse reported the resident had four pressure ulcers on the right buttock and one pressure ulcer on the left buttock. On 01/24/12 at 11:40 a.m., the LPN treatment nurse was asked if she conducted weekly skin assessments on the residents. The LPN stated, "No." The LPN treatment nurse reported the certified nurse aides (CNA) had a shower sheet and they would write down if something new was observed on the resident's skin. The LPN treatment nurse reported the CNAs would put the sheets in a box on the office door. The LPN reported the girl in the front office would go through the sheets the next morning. The LPN reported the ADON would look at the sheets. The LPN treatment nurse reported she only saw the residents she provided wound care for. The LPN stated she would then tell the CNAs what corrective measures to put in place for the pressure ulcers after she observed a pressure ulcer. The LPN treatment nurse was asked if the resident's pressure ulcers had developed in the facility. The LPN stated the pressure ulcers had started in the facility. The treatment nurse was asked if the pressure ulcers had improved. The LPN treatment nurse reported the pressure ulcer on the left buttock was smaller. The LPN reported the pressure ulcer on the right buttock that was close to the crease was not better. On 01/24/12 at 11:50 a.m., the DON was asked for the wound documentation. The DON stated he was sure the ADON had the wound sheets. The DON reported the problem was finding them. On 01/24/12 at 5:30 p.m., the DON was asked if the pressure ulcers had originated in the facility. The DON reported the pressure ulcers had originated in the facility because the resident had not been out of the facility. On 01/24/12 at 6:50 p.m., the DON reviewed the weekly wound tracking worksheets. The DON reported the resident should have been assessed between 12/21/11 and 01/09/12. The DON reported the resident should have had a skin assessment on 12/28/11, 01/04/11, and 01/18/12. The DON reported there were three weekly assessments missing that should have been done. On 01/25/12 at 6:25 p.m., the LPN treatment nurse was asked if the resident had a history of [REDACTED]. The treatment nurse reviewed the medical record and reported the nurses' notes documented the resident's coccyx was closed on 09/28/11. On 01/26/12 at 6:25 p.m., the DON was asked what the facility policy was for monitoring pressure ulcers. The DON stated the treatment nurse measured the pressure ulcers and the assistant director of nurses (ADON) documented the measurements in the wound book. The DON reported the ADON was not in the facility and had assigned another nurse to document the measurements while she was on leave. The DON reported he was not aware the measurements had not been done. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 11/15/11, documented, "Assessed left heel, with a dark purple deep tissue injury, 5.5cm x 5.5cm. Right heel with 5cm x 5cm appears to be a blister without fluid." The nurse's note documented the physician was notified. The nurse's note documented a physician's orders [REDACTED]. The weekly tracking worksheets documented the wound had not been assessed on a weekly basis. The resident's record documented an assessment was completed 12/21/11 and nineteen days later on 01/09/12. On 12/28/11, a fax was sent to the physician requesting the resident be sent to the wound care clinic for treatment to her left heel. The fax documented there was black eschar present. A significant change assessment, dated 01/03/12, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required extensive assistance with bed mobility and activities of daily living. A careplan, dated 01/17/12, documented the resident had short term memory impairment. The care plan documented the resident required supervised to limited assist with activities of daily living. The care plan documented the resident had pressure ulcers on bilateral heels. On 01/24/12 at 9:25 a.m., the resident was observed during a wound treatment. LPN #4 reported the resident had gone to the wound clinic for the first time on 01/23/12. LPN #4 reported the resident had developed blisters on her heels bilaterally. The LPN reported the resident's right heel was clear. LPN #4 reported the resident's left heel developed eschar. The wound was observed to have a moderate amount of slough and medication removed during cleansing of the wound. The resident jerked her left leg and said, "Ouch!, that hurts." LPN #4 was asked how she would stage the wound. LPN #4 reported she would stage the would as a stage III. LPN #4 was asked if the resident had pain medication ordered. LPN #4 stated she would check on it. The medication administration was reviewed for 01/24/12. There was no documentation pain medication had been administered prior to the wound treatment. On 01/24/12 at 11:55 a.m., the treatment nurse was asked if the pressure ulcer on the resident's left heel had developed in the facility. The treatment nurse reported there were blisters on both of the resident's heels when the CNA's reported to the treatment nurse. The treatment nurse was asked if the facility conducted weekly skin assessments. The treatment nurse reported the weekly skin assessments were not done by the nurses. The treatment nurse reported the shower aides would fill out any skin problems on a sheet and LPN #4 and LPN #5 would review the skin sheets. LPN #4 reported the skin assessment sheets were then placed on the front office door. On 01/24/12 at 6:55 p.m., the DON was interviewed regarding the resident not having skin assessments for nineteen days, from 12/21/11 to 01/09/12. The DON reported, "I don't know what to tell you about that." The DON reported the ADON had been gone since before Christmas. The DON stated, "I will have to look into it." On 01/25/12 at 10:25 a.m., the resident was observed during wound care. The wound was observed to be pink/yellow in color, with a moderate amount of slough and medication noted. The wound was measured at 2.7cm x 2.9 cm x 1cm.

On [DATE] at 5:15 p.m., the Oklahoma State Department of Health was notified of a possible immediate jeopardy situation. The immediate jeopardy situation was verified in regards to the facility's failure to notify the physician of a resident's condition, after [MEDICAL CONDITION] type activity for one (#6) of seven sampled residents. The resident was sent to the hospital emergency department with the chief complaint of decreased level of consciousness, right sided weakness, and decreased 02 saturation. The resident expired at the hospital. This had the potential to affect seven residents identified by the facility with a change in condition in the past 90 days. On [DATE] at 5:30 p.m., the ADM and the DON were notified of the IJ situation which constituted substandard quality of care (SQC). On [DATE] at 7:15 p.m., an acceptable plan of removal was presented to the survey team. On [DATE] at 3:30 p.m., the immediate jeopardy was removed, effective [DATE] at 12:15 p.m., when all facility staff had been in-serviced and staff were able to validate through interviews an understanding of the inservice. The deficient practice remained at the level of actual harm that was not immediate jeopardy with one or a very limited number of residents affected. The plan of removal was as follows: "1. What actions taken to remove IJ and protect residents. 2. How to communicate to staff and train them on what actions are needed to correct problems. 6:30 PM In-Service training on [DATE] 1. All nurses will complete an in-service training before returning to work on the following policies and procedures: a. Notification of physician/family for acute change in resident status. b. Assessment and monitoring of acute change in resident's condition. c. Care of the diabetic resident. d. Importance of following-up with the physician and family regarding any change in residents' condition. 2. Nurses will also be in-serviced on the importance of 72 hour charting regarding medication change, changes in condition, falls etc. 3. Nurses will acknowledge by signing an in-service sheet, that they have received a copy of the above policies and procedures, and that they understand its contents. 4. The DON, and ADON will monitor, on a daily basis, those residents who have a change in condition and ensure that documentation is in the residents' records that reflect what is happening with that resident. 5. Residents who have a change in condition will be discussed in our quarterly QA meetings. Their medical records will also be reviewed at the QA meeting." Based on record review and interview, it was determined the facility failed to: a. assess, monitor, document, and notify the physician of a resident's condition after [MEDICAL CONDITION] type activity for one (#6) of seven sampled residents. The resident was sent to the hospital emergency department with the chief complaint of decreased level of consciousness, right sided weakness, and decreased 02 saturation. The resident expired at the hospital. This had the potential to affect seven residents identified by the facility with a change in condition in the past 90 days. b. ensure fingerstick blood sugar parameters were obtained for one (#6) of three sampled diabetic residents. This had the potential to affect 17 residents identified by the facility with a [DIAGNOSES REDACTED]. Findings: The facility policy for charting documented the facility was to chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. The facility policy for acute condition changes documented the nursing staff would contact the physician based on the urgency of the situation. The policy documented the nurses would call or page the physician, for emergencies, and request a prompt response (within approximately one-half hour or less.) The policy documented the staff would notify the medical director for additional guidance and consultation if a timely response was not received. The facility policy for Diabetes documented the physician would order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. 1 a. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented the resident had short and long term memory problems and was independent with daily decision making skills. The assessment documented the resident was able to make herself understood and had the ability to understand others. The assessment documented the resident had no indicators of depression, anxiety, or sad mood, and had no behavior symptoms. The assessment documented the resident was continent of bowel and was usually continent of bladder. The care plan, dated [DATE], documented the resident was diabetic. The care plan did not address approaches related to monitoring of the Diabetes. The care plan did not address [MEDICAL CONDITION] type activity. A nurse's note, dated [DATE] at 8:30 a.m., documented the resident began bouncing up and down and crying. The nurse's note documented the resident's blood pressure was ,[DATE]. The nurse's note documented the resident was given tomato juice with salt to increase her blood pressure. The nurse's note documented the resident was assisted to her room and put in bed with her feet elevated. The nurse's note documented the resident's blood pressure was ,[DATE] at that time. There was no documentation the physician or family had been notified of the resident's condition. A nurse's note, dated [DATE] at 6:30 p.m., documented the resident was standing at the nurses station and started having [MEDICAL CONDITION] activity. The nurse's note documented the resident was shaking, nonverbal, non-responsive and incontinent. The nurse's note documented the resident was kept at the nurses station for 1 and a ,[DATE] hours to monitor and was then assisted to bed to rest. The nurse's note documented the resident's condition was reported to the on-coming nurse. There was no documentation the physician or family was notified of the resident's condition at that time. There were no further nurse's notes dated [DATE]. A fax transmittal form to the physician, dated [DATE] at 10:33 p.m., documented the resident had experienced two [MEDICAL CONDITION] during the shift [MEDICATION NAME] ,[DATE] minutes during each episode. The fax documented both [MEDICAL CONDITION] occurred while the resident was ambulating. The fax documented the facility requested the physician to please advise. The fax was signed by the physician on [DATE] at 10:36 a.m. There was no other documentation by the physician. A nurse's note, dated [DATE] at 3:30 p.m., documented the resident had been in bed all day with a poor appetite noted. The nurse's note documented as the staff were assisting the resident up to get ready for supper, the resident had a 30 second [MEDICAL CONDITION] activity. The nurse's note documented the staff would continue to monitor for [MEDICAL CONDITION] activity and would pass the information on to the on-coming nurse in report. There was no documentation the physician or family were notified of the [MEDICAL CONDITION] activity. There were no further nurses' notes dated [DATE]. A nurse's note, dated [DATE] at 5:00 p.m., documented the resident had no [MEDICAL CONDITION] activity noted for the day, but had remained with a poor appetite and weakness was observed. There were no further nurses' notes dated [DATE]. A nurse's note, dated [DATE] at 3:45 p.m., documented a CNA reported the resident had [MEDICAL CONDITION] type activity and the nurse did notice twitching for about 20 seconds. The nurse's note documented the resident had no verbal response. The nurse's note documented the resident did respond to her name being called after about 10 more seconds. The nurse's note documented the resident was asked how she felt and the resident had a blank look. The nurse's note documented the resident did finally state that she was tired and asked the CNAs to leave her in the bed and let her rest. There was no documentation the physician or family was notified of the resident's [MEDICAL CONDITION] type activity. A nurse's note, dated [DATE] at 4:55 p.m., documented the resident was up in her wheel chair for her bath to be given. The nurse's note documented the resident was brought to the nurses' station area. The nurse's note documented the nurse observed the resident slump over to the right side. The nurse's note documented the resident was non-responsive to verbal or tactile stimuli, the resident's eyes were fixed and the respirations were slowed. The nurse's note documented the resident's pulse was 50, the blood pressure was ,[DATE], respirations were 16 and the 02 saturation was at 79%. The nurse's note documented the physician was called, EMS was called, and the resident's daughter was called, with no answer. The nurse's note documented a message was left for the resident's daughter to return the nursing home call. A hospital (name deleted) initial interview form, dated [DATE] at 3:17 p.m., documented the resident presented to the emergency department with the chief complaint of decreased level of consciousness, right sided weakness, and decreased 02 saturation. A hospital patient progress note, dated [DATE] at 10:00 p.m., documented, "Pt is actively dying, Pt is DNR. She is clenching her chest." A hospital patient progress note, dated [DATE] at 10:30 p.m., documented, "Son and daughter in law at bedside. Pt is having [MEDICAL CONDITION] activity. VS are poor with Cheyne-stokes respirations." A nursing facility nurse's note, dated [DATE] at 10:55 p.m., documented the facility contacted the emergency room with regards to the status of the resident. The nurse's note documented the nurse was informed by the ER that the resident had expired at 10:55 p.m. On [DATE] at 1:00 p.m., the DON was interviewed. The DON was asked what interventions should be provided if the facility was aware someone had a change in condition. The DON reported the facility should have notified the physician to get new orders. The DON reviewed the nurses' notes and stated, "My question is why the physician wasn't called." The DON reported if the resident experienced a [MEDICAL CONDITION] the nurse should have notified the physician or gotten orders from the physician on call. On [DATE] at 12:00 p.m., the physician was interviewed. The physician was asked if he had been notified of the resident's [MEDICAL CONDITION] type activity. The physician reported his notes documented he had spoken with LPN #1 on [DATE] and informed the nurse to watch the resident closely before starting any new medications. The physician was asked if he was aware of the [MEDICAL CONDITION] activities on [DATE] and prior to the resident being sent to theER on [DATE]. The physician stated, "No." The physician reported he had only been aware of the two [MEDICAL CONDITION] on [DATE]. The physician was asked if he had been notified of the incident on [DATE] and the [MEDICAL CONDITION] on [DATE] at 3:45 p.m. The physician was asked what his interventions would have been. The physician reported he would have admitted the resident to the hospital and ordered an EEG and a CT scan. b. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The injection sheet, dated ,[DATE], documented fingerstick blood sugar results ranging from 108 to 312. The injection sheet, dated ,[DATE], documented fingerstick blood sugar results ranging from 92 to 319. The injection sheet, dated ,[DATE], documented fingerstick blood sugar results ranging from 95 to 301. There was no documentation the physician had been notified of any fingerstick blood sugar results. On [DATE] at 3:30 p.m., the DON was asked to review the medical record for orders for fingerstick blood sugar results. The DON reviewed the policy for fingerstick blood sugar. The DON reported the policy did not document fingerstick blood sugar parameters. The DON stated, "The doctor has to order parameters." The DON reported the resident should have physician orders [REDACTED]. The DON reported the physician should be notified if fingerstick blood sugar results were abnormal. The DON reported he would notify the physician if the fingerstick blood sugar results were above 300. The DON reviewed the medical record and reported there were no parameters to report fingerstick blood sugar results.

On [DATE] at 5:15 p.m., the Oklahoma State Department of Health was notified of a possible immediate jeopardy situation. The immediate jeopardy situation was verified in regards to the facility's failure to notify the physician of a resident's condition, after [MEDICAL CONDITION] type activity for one (#6) of seven sampled residents. The resident was sent to the hospital emergency department with the chief complaint of decreased level of consciousness, right sided weakness, and decreased 02 saturation. The resident expired at the hospital. This had the potential to affect seven residents identified by the facility with a change in condition in the past 90 days. On [DATE] at 5:30 p.m., the ADM and the DON were notified of the IJ situation which constituted substandard quality of care (SQC). On [DATE] at 7:15 p.m., an acceptable plan of removal was presented to the survey team. On [DATE] at 3:30 p.m., the immediate jeopardy was removed, effective [DATE] at 12:15 p.m., when all facility staff had been in-serviced and staff were able to validate through interviews an understanding of the inservice. The deficient practice remained at the level of actual harm that was not immediate jeopardy with one or a very limited number of residents affected. The plan of removal was as follows: "1. What actions taken to remove IJ and protect residents. 2. How to communicate to staff and train them on what actions are needed to correct problems. 6:30 PM In-Service training on [DATE] 1. All nurses will complete an in-service training before returning to work on the following policies and procedures: a. Notification of physician/family for acute change in resident status. b. Assessment and monitoring of acute change in resident's condition. c. Care of the diabetic resident. d. Importance of following-up with the physician and family regarding any change in residents' condition. 2. Nurses will also be in-serviced on the importance of 72 hour charting regarding medication change, changes in condition, falls etc. 3. Nurses will acknowledge by signing an in-service sheet, that they have received a copy of the above policies and procedures, and that they understand its contents. 4. The DON, and ADON will monitor, on a daily basis, those residents who have a change in condition and ensure that documentation is in the residents' records that reflect what is happening with that resident. 5. Residents who have a change in condition will be discussed in our quarterly QA meetings. Their medical records will also be reviewed at the QA meeting." Based on record review and interview, it was determined the facility failed to: a. notify the physician of a resident's condition after [MEDICAL CONDITION] type activity for one (#6) of seven sampled residents. The resident was sent to the hospital emergency department with the chief complaint of decreased level of consciousness, right sided weakness, and decreased 02 saturation. The resident expired at the hospital. This had the potential to affect seven residents identified by the facility with a change in condition in the past 90 days. b. notify the physician of fingerstick blood sugar results for one (#6) of three sampled diabetic residents. This had the potential to affect 17 residents identified by the facility with a [DIAGNOSES REDACTED]. Findings: The facility policy for acute condition changes documented the nursing staff would contact the physician based on the urgency of the situation. The policy documented the nurses would call or page the physician for emergencies and request a prompt response (within approximately one-half hour or less). The policy documented the staff would notify the medical director for additional guidance and consultation if a timely response was not received. The facility policy for Diabetes documented the physician would order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. 1 a. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented the resident had short and long term memory problems and was independent with daily decision making skills. The assessment documented the resident was able to make herself understood and had the ability to understand others. The assessment documented the resident had no indicators of depression, anxiety, or sad mood, and had no behavior symptoms. The assessment documented the resident was continent of bowel and was usually continent of bladder. The care plan, dated [DATE], documented the resident was diabetic. The care plan did not address approaches related to monitoring of the Diabetes. The care plan did not address [MEDICAL CONDITION] type activity. A nurse's note, dated [DATE] at 8:30 a.m., documented the resident began bouncing up and down and crying. The nurse's note documented the resident's blood pressure was ,[DATE]. The nurse's note documented the resident was given tomato juice with salt to increase her blood pressure. The nurse's note documented the resident was assisted to her room and put in bed with her feet elevated. The nurse's note documented the resident's blood pressure was ,[DATE] at that time. There was no documentation the physician or family had been notified of the resident's condition. A nurse's note, dated [DATE] at 6:30 p.m., documented the resident was standing at the nurses station and started having [MEDICAL CONDITION] activity. The nurse's note documented the resident was shaking, nonverbal, non-responsive and incontinent. The nurse's note documented the resident was kept at the nurses station for 1 and a ,[DATE] hours to monitor and was then assisted to bed to rest. The nurse's note documented the resident's condition was reported to the on-coming nurse. There was no documentation the physician or family was notified of the resident's condition at that time. There were no further nurse's notes dated [DATE]. A fax transmittal form to the physician, dated [DATE] at 10:33 p.m., documented the resident had experienced two [MEDICAL CONDITION] during the shift [MEDICATION NAME] ,[DATE] minutes during each episode. The fax documented both [MEDICAL CONDITION] occurred while the resident was ambulating. The fax documented the facility requested the physician to please advise. The fax was signed by the physician on [DATE] at 10:36 a.m. There was no other documentation by the physician. A nurse's note, dated [DATE] at 3:30 p.m., documented the resident had been in bed all day with a poor appetite noted. The nurse's note documented as the staff were assisting the resident up to get ready for supper, the resident had a 30 second [MEDICAL CONDITION] activity. The nurse's note documented the staff would continue to monitor for [MEDICAL CONDITION] activity and would pass the information on to the on-coming nurse in report. There was no documentation the physician or family were notified of the [MEDICAL CONDITION] activity. There were no further nurses' notes dated [DATE]. A nurse's note, dated [DATE] at 5:00 p.m., documented the resident had no [MEDICAL CONDITION] activity noted for the day, but had remained with a poor appetite and weakness was observed. There were no further nurses' notes dated [DATE]. A nurse's note, dated [DATE] at 3:45 p.m., documented a CNA reported the resident had [MEDICAL CONDITION] type activity and the nurse did notice twitching for about 20 seconds. The nurse's note documented the resident had no verbal response. The nurse's note documented the resident did respond to her name being called after about 10 more seconds. The nurse's note documented the resident was asked how she felt and the resident had a blank look. The nurse's note documented the resident did finally state that she was tired and asked the CNAs to leave her in the bed and let her rest. There was no documentation the physician or family was notified of the resident's [MEDICAL CONDITION] type activity. A nurse's note, dated [DATE] at 4:55 p.m., documented the resident was up in her wheel chair for her bath to be given. The nurse's note documented the resident was brought to the nurses' station area. The nurse's note documented the nurse observed the resident slump over to the right side. The nurse's note documented the resident was non-responsive to verbal or tactile stimuli, the resident's eyes were fixed and the respirations were slowed. The nurse's note documented the resident's pulse was 50, the blood pressure was ,[DATE], respirations were 16 and the 02 saturation was at 79%. The nurse's note documented the physician was called, EMS was called, and the resident's daughter was called, with no answer. The nurse's note documented a message was left for the resident's daughter to return the nursing home call. A hospital (name deleted) initial interview form, dated [DATE] at 3:17 p.m., documented the resident presented to the emergency department with the chief complaint of decreased level of consciousness, right sided weakness, and decreased 02 saturation. A hospital patient progress note, dated [DATE] at 10:00 p.m., documented, "Pt is actively dying, Pt is DNR. She is clenching her chest." A hospital patient progress note, dated [DATE] at 10:30 p.m., documented, "Son and daughter in law at bedside. Pt is having [MEDICAL CONDITION] activity. VS are poor with Cheyne-stokes respirations." A nursing facility nurse's note, dated [DATE] at 10:55 p.m., documented the facility contacted the emergency room with regards to the status of the resident. The nurse's note documented the nurse was informed by the ER that the resident had expired at 10:55 p.m. On [DATE] at 1:00 p.m., the DON was interviewed. The DON was asked what interventions should be provided if the facility was aware someone had a change in condition. The DON reported the facility should have notified the physician to get new orders. The DON reviewed the nurses' notes and stated, "My question is why the physician wasn't called." The DON reported if the resident experienced a [MEDICAL CONDITION] the nurse should have notified the physician or gotten orders from the physician on call. On [DATE] at 12:00 p.m., the physician was interviewed. The physician was asked if he had been notified of the resident's [MEDICAL CONDITION] type activity. The physician reported his notes documented he had spoken with LPN #1 on [DATE] and informed the nurse to watch the resident closely before starting any new medications. The physician was asked if he was aware of the [MEDICAL CONDITION] activities on [DATE] and prior to the resident being sent to theER on [DATE]. The physician stated, "No." The physician reported he had only been aware of the two [MEDICAL CONDITION] on [DATE]. The physician was asked if he had been notified of the incident on [DATE] and the [MEDICAL CONDITION] on [DATE] at 3:45 p.m. The physician was asked what his interventions would have been. The physician reported he would have admitted the resident to the hospital and ordered an EEG and a CT scan. b. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The injection sheet, dated ,[DATE], documented fingerstick blood sugar results ranging from 108 to 312. The injection sheet, dated ,[DATE], documented fingerstick blood sugar results ranging from 92 to 319. The injection sheet, dated ,[DATE], documented fingerstick blood sugar results ranging from 95 to 301. There was no documentation the physician had been notified of any fingerstick blood sugar results. On [DATE] at 3:30 p.m., the DON was asked to review the medical record for orders for fingerstick blood sugar results. The DON reviewed the policy for fingerstick blood sugar. The DON reported the policy did not document fingerstick blood sugar parameters. The DON stated, "The doctor has to order parameters." The DON reported the resident should have physician orders [REDACTED]. The DON reported the physician should be notified if fingerstick blood sugar results were abnormal. The DON reported he would notify the physician if the fingerstick blood sugar results were above 300. The DON reviewed the medical record and reported there were no parameters to report fingerstick blood sugar results.