Every finding on record at Pauls Valley Care Center

Based on record review and interview, the facility failed to ensure residents were free from injuries resulting in a fracture for 1 (#3) of 4 sampled residents reviewed for accidents.The DON identified 36 residents resided in the facility.Findings:An undated diagnoses report for Resident #3's showed Resident #3 was admitted on [DATE] with a diagnosis of morbid obesity (severe) due to excessive calories.A comprehensive assessment for Resident #3, dated 04/12/25, showed the resident was dependent upon staff for all transfers.A care plan for Resident #3's, revised on 10/04/25, showed Resident #3 required a mechanical lift with two staff assistance for transfers.A Combined Initial and Final incident report, dated 06/04/25, read in part, 06/04/25 1330 [1:30 p.m.], staff was transferring [Resident #3] post shower, using hoyer lift. Lift sling broke with resident in the air causing [them] to fall to floor. [They] maintained A/O status, states [they] did not hit [their] head, but did c/o 10/10 pain to right leg. Right leg was rotated inward, warm to touch. Interview with staff. There were 2 staff members assisting with Resident #3's care and present when sling broke. Inspection of sling showed loop that hooks onto mechanical [lift] tore. Disposed of this sling.A Follow up Information incident report, received on 06/09/25, read in part, Charge nurse spoke to [name withheld]. Resident #3 had surgery on 06/05/25 for Femur fracture.Review of investigation records showed no documentation for monitoring of slings for good repair.On 12/17/25 at 3:07 p.m., CMA #1 stated when they were transferring Resident #3, the bottom loops left side ripped apart and they slid out, they went to the floor and on the legs of the lift. On 12/17/25 at 3:11 p.m., CMA #2 stated two staff when using the lift always and they triple check the slings which we did. On 12/17/25 at 3:52 p.m., the administrator stated there was no documentation slings being monitored for frays or holes.

Based on record review and interview, the facility failed to ensure a resident was not involuntarily discharged during hospitalization for 1 (#40) of 3 sampled residents reviewed for discharge.The DON identified 36 residents resided in the facility. Findings:An undated facility Bed-Holds and Returns policy read in part, If a Medicaid resident exceeds the state bed-hold period, he or she will be permitted to return to the facility .provided that the resident .a. Requires services of the facility; and b. Is eligible for Medicare skilled nursing services or Medicaid nursing services .If the resident is transferred with the expectation that he or she will return, but it is determined that the resident cannot return or the resident exceeds the 30 days out of facility as noted in the facility that resident will be formally discharged . In event that occurs resident will have to request admission through the facility referral/admission process. The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided.An undated admission RECORD showed Resident #40 received long term care services and their primary payer was Medicaid.A discharge return anticipated resident assessment, dated 09/30/25, showed Resident #40 had an unplanned discharge to a short-term general hospital stay on 09/30/25. The assessment showed the resident had diagnoses which included recurrent unspecified major depressive disorder and anxiety. The assessment showed Resident #40's memory was OK and was independent in cognitive skills for daily decision making.A nursing note, dated 09/30/25, showed Resident #40 was vomiting and chilled and requested to go to the hospital. An order was received to transfer the resident with emergency medical services.A hospital Discharge summary, dated [DATE], showed the hospital sent the facility a referral on 10/30/25. The discharge summary showed the facility informed the hospital the resident was discharged from their facility. The discharge summary showed Resident #40 had completed their intravenous antibiotics on 11/01/25 and was ready for discharge to the facility on [DATE]. The discharge summary showed the facility involuntarily discharged the resident without a 30-day notice. The discharge summary showed the resident wanted to be transferred back to the facility and had reached out to the ombudsman for legal assistance.On 12/17/25 at 1:34 p.m., the DON stated the resident was transferred to the hospital on [DATE].On 12/17/25 at 1:35 p.m., the administrator stated Resident #40 was discharged from the facility on 10/31/25 because they were out of the facility for 30 days per facility policy.On 12/17/25 at 1:40 p.m., the DON stated the hospital reached out to the facility regarding the resident's return. They stated the resident was on an intravenous antibiotic infusion and required labs to monitor the trough and peak. They stated the facility did not have the ability to complete the required labs.On 12/17/25 at 1:44 p.m., the DON stated the hospital suggested for the resident to return to the facility after completion of the antibiotics. The DON stated they the informed the hospital the resident would be evaluated upon completion of the antibiotics.On 12/17/25 at 1:50 p.m., the administrator stated Resident #40 was not allowed to return to the facility after completion of the intravenous antibiotics.On 12/17/25 at 1:52 p.m., the administrator stated the hospital had sent a referral to the facility for Resident #40's return.On 12/17/25 at 1:54 p.m., the administrator stated they did not allow the resident to return to the facility based on their prior history. The administrator stated they felt like they could not meet Resident #40's needs.On 12/17/25 at 1:55 p.m., the administrator stated the facility could not meet the resident's psychosocial needs. They stated Resident #40 shared with them they had sued the facility previously and the facility filed bankruptcy and there was no money for the resident. The administrator stated the resident took that out on them and had not been able to make the resident happy. They stated the resident prided themselves on being mean to the staff.On 12/17/25 at 2:11 p.m., the administrator stated they had residents with similar needs as Resident #40. They stated those residents were compliant with behavioral services.On 12/17/25 at 3:30 p.m., the DON stated they could not locate documentation to show they had attempted to secure alternate placement for the resident.

Based on record review and interview, the facility failed to provide a:a. bed hold policy upon transfer;b. discharge notice to the resident and/or representative; andc. copy of the discharge notice to the ombudsman for 1 (#40) of 3 sampled residents reviewed for discharge.The DON identified 36 residents resided in the facility. Findings: An undated facility policy Bed-Holds and Returns, read in part, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Resident #40's discharge return anticipated resident assessment, dated 09/30/25, showed the resident had an unplanned discharge to a short-term general hospital stay on 09/30/25. The assessment showed the resident had diagnoses which included recurrent unspecified major depressive disorder and anxiety. The assessment showed Resident #40's memory was OK and was independent in cognitive skills for daily decision making. A nursing note, dated 09/30/25, showed Resident #40 was vomiting and chilled and requested to go to the hospital. An order was received to transfer the resident with emergency medical services. There was no documentation a bed-hold policy was provided to the resident. On 12/17/25 at 1:34 p.m., the DON stated the resident was transferred to the hospital on [DATE]. On 12/17/25 at 1:35 p.m., the administrator stated Resident #40 did not receive a bed-hold policy. They stated Resident #40 was discharged from the facility on 10/31/25 because they were out of the facility for 30 days per facility policy. On 12/17/25 at 1:50 p.m., the administrator was asked if a discharge notice was provided to the resident. They stated they provided residents with a bed-hold policy. On 12/17/25 at 3:37 p.m., the administrator stated they did not get an opportunity to provide the ombudsman with a discharge notice because Resident #40 had reached out to the ombudsman and the ombudsman contacted the facility. They stated their process was to mail out discharge notices to the ombudsman. On 12/18/25 at 3:39 p.m., the ombudsman stated they were not provided with a discharge notice for Resident #40.

Based on record review and interview, the facility failed to ensure comprehensive assessments were completed within 14 days for 1 (#3) of 12 sampled residents reviewed for comprehensive assessments.The DON identified 36 residents resided in the facility.Findings:An undated diagnoses report showed Resident #3 was admitted on [DATE].An annual assessment for Resident #3 showed an assessment reference date of 06/25/25. MDS Coordinator #1 and the DON signed the assessment as completed on 08/05/25.On 12/18/25 at 3:37 p.m. MDS coordinator #1 stated Resident #3's annual assessment, dated 06/25/25, was not completed or transmitted until 08/05/25. They stated it was not completed or transmitted timely. They stated the assessment should have been completed by the 14th day after the assessment reference date.

Based on record review and interview, the facility failed to ensure the initiation of a comprehensive nutrition care plan for 1 (#1) of 12 sampled residents reviewed for care plans.The DON identified 36 residents resided in the facility.Findings:An undated admission record for Resident #1 showed the resident admitted to the facility on [DATE] with diagnoses which included chronic kidney disease and diabetes mellitus.A care plan for Resident #1, initiated on 07/16/25, did not show Resident #1 had a nutritional care plan.On 12/16/25 at 1:04 p.m., MDS coordinator #1 stated care plans were to be completed within 21 days of admission and updated quarterly.On 12/16/25 at 1:05 p.m., MDS coordinator #1 stated care plans were updated with different things, falls, when resident has changes. They stated it was a bit complicated to keep up with both care plans and MDS assessments, but it was more complicated to keep up with care plans.On 12/16/25 at 1:10 p.m., MDS coordinator #1stated they did not see a nutritional care plan for Resident #1.

Based on record review and interview, the facility failed to complete and submit quarterly reviews of the minimum data set in the required timeframe's for eight (#3, 7, 11, 12, 14,16, 17, and #23) of 10 residents whose clinical records were reviewed for completion/submission of the resident assessments. The administrator identified 34 residents. Census: 34 Findings: The facility's MDS Completion and Submission Timeframe's policy, dated 10/01/10, read in part our facility will conduct and submit resident assessments in accordance with federal and state submission timeframe's . On 04/16/24 at 11:30 a.m., the corporate regional director documented the following as the last completed/submitted minimum data set assessments for the following residents: - a quarterly assessment dated [DATE] for Resident #3 - a quarterly assessment dated [DATE] for Resident #7. - an admission assessment dated [DATE] for Resident #11. - a significant change assessment dated [DATE] for Resident #12. - a quarterly assessment dated [DATE] for Resident #14. - a quarterly assessment dated [DATE] for Resident #16. - an admission assessment dated [DATE] for Resident #17. - a quarterly assessment dated [DATE] for Resident #23. On 04/17/24 at 10:10 a.m., the regional director stated the residents listed above did not have a complete/submitted minimum data set assessment in the last 120 days. The regional director stated they were aware of the delay but had not completed/submitted all residents' assessments that were delayed.

Based on observation, record review, and interview the facility failed to develop a comprehensive person-centered care plan for two (#1 and #80) of 12 residents reviewed for care plans. The facility failed to develop care plans related to: a) smoking for resident #1 and #80, and b) falls for one resident #80. The Administrator reported 34 residents resided in the facility. Findings: The facility's Care Plans - Comprehensive policy, dated 10/01/10, read in part An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Each residents comprehensive care plan is designed to: a. incorporate identified problems area; b. incorporate risk factors associated with identified problems . 1. Resident #1 had diagnoses which included paraplegia and neurological conditions. A smoking assessment, dated 05/16/23, documented resident #1 is a supervised smoker d/t inability to light cigarette and difficulty disposing of cigarette into receptacle. A smoking assessment, dated 04/01/24, documented resident #1 is a supervised smoker. On 04/16/24 at 5: 30 p.m., the resident was observed outside smoking with a staff member present. On 04/17/24 at 11:22 a.m., the DON reported smoking should have been included on resident #1's care plan and will get it updated. 2. Resident #80 had diagnoses which included hemiplegia and dementia. A. A smoking assessment, dated 02/23/24, documented resident #80 was safe to smoke unsupervised. An incident report, dated 02/27/24, documented resident #80 singed hair while lighting a cigarette. The incident report documented the resident was immediately placed on supervised smoking and all smoking items removed from his possession. A smoking assessment, dated 02/27/24, documented resident #80 resident was not safe to smoke unsupervised. Resident #80's care plan, dated 03/14/24, contained no documentation of smoking status. On 04/15/24 at 9:30 a.m., resident #80 was outside smoking with staff present. B. A fall risk assessment, dated 02/23/34, documented resident #80 was at risk for falls. A nurse's note, dated 02/23/24, documented resident #80 had a fall from wheelchair while attempting to transfer himself from his bed to his wheelchair. Resident #80 was instructed to call for assistance when trying to transfer. Resident #80's care plan, dated 03/14/24, contained no documentation of fall risk. On 04/15/23 at 9:43 resident # 80 was observed using a rolling walker to ambulate. A MDS assessment, dated 04/17/24, documented resident #80 had moderate cognitive impairment, required assistance with most activities of daily living, and used a wheelchair or walker to ambulate. On 04/17/24 at 11:22 a.m., the DON reported smoking and falls should have been included on resident #80's care plan.

Based on observation and interview, the facility failed to provide wound care in a manner to reduce the risk of infection or cross contamination for one (#17) of two residents observed for wound care. The director of nursing identified 4 residents with wounds. Resident census: 34 Findings: On 04/16/24 at 11:00 a.m., LPN #1 was observed to perform wound care on Res #17. The LPN washed hand and donned gloves. With gloved hands, the LPN borrowed an overbed table from the resident's roommate, removing the roommates personal possessions from the overbed table but not sanitizing the table. With the same gloves, the LPN opened and clear plastic shoe box shaped container, laying the lid on the inside facing up. With the same gloves, the LPN remove the contents needing for the dressing change and laid them atop the overbed table. With the same gloves, the LPN removed a positioning pillow from under the resident's hip/leg. One side of the pillow case appeared brown and wet with fecal incontinence. The LPN observed the condition of the pillow case and stated to the resident that after wound care, they would find the nurse aides to clean and freshly dress the resident. With the same gloves, the LPN folded and positioned the soiled pillow under the resident's right calf. With the same gloves, the LPN removed the old dressing from the resident's right foot, cleansed the wounds on the resident's right heel and toes with normal saline and gauze, applied the new dressing to each, wrapped the foot in kerlix, and secured the dressing with coban, all without changing gloves or sanitizing hands. When cleaning the wounds, LPN #1 swept across intact skin and wound beds alike, in a manner which had the potential to sweep bacteria from the resident's intact skin and onto the wound bed. On 04/16/24 at 11:15 a.m., LPN #1 stated they should sanitize their hands before donning gloves, change gloves when they were visibly soiled, and when moving from dirty task to a clean task. The LPN stated it was only after the dressing change did they recognize the potential cross contamination with touching the roommates personal belongings and using the roommates overbed table without sanitizing the surface; touching and using a soiled positioning pillow to prop the extremity for wound care; removing the old dressing, cleaning, applying, and securing the new dressing, all without further changing gloves and sanitizing hands. On 04/16/24 at 11:30 a.m., the DON stated LPN #1 was fairly new to the facility and they had not had the opportunity to observe the LPN perform wound care. The DON stated the LPN should sanitize hands and change gloves when the gloves were visibly soiled or when moving from a dirty task to a clean task.

Based on observation, record review, and interview, the facility failed to store hazardous chemicals in a secure manner. The director of nursing identified one wandering resident who ambulated throughout the facility. Facility census: 34 Findings: The facility policy entitled Storage Areas, Maintenance, documented hazardous/harmful chemicals were to be stored as instructed on the labels of such products and in a locked storage area. The MSDS (Material Safety Data Sheet) for Virex II - 256 disinfectant documented the chemical was corrosive to eyes, nose, throat, and respiratory tract. The MSDS documented the chemical was combustible and was intended for commercial or industrial use only. It documented to keep the chemical out of reach of children. The MSDS for Good Sense Liquid Air Freshener documented the chemical caused serious eye irritation and not to breath in vapors, taste, or swallow the chemical. The MSDS for Spraybuff, an industrial cleaning chemical, documented the chemical may be harmful if swallowed, may cause eye, skin, and respiratory irritation, and to keep out of children. The MSDS for Bounce Back, a floor finish restorer, documented the chemical may be harmful if swallowed, may cause eye, skin, and respiratory irritation, and to keep out of children. The MSDS for Soft Scrub Cleanser with Bleach, documented the chemical may cause permenant damage to eyes, irritation or severe burns possible on skin, to contact the poison control center if ingested, and to remove from exposed area to fresh air and to contact the poison control center if inhaled. The MSDS for Clorox Clean-Up Cleaner with Bleach, documented the chemical causes serious eye irritation, to avoid contact with skin, and to keep out of reach of children and pets. On 04/14/24 at 4:00 p.m., the following chemicals were observed in the bathroom of an unsecured resident room located on the north hall and used for the storage of equipment: - Bounce Back (floor finisher restorer); - Spraybuff (water based shine maintainer); and, - Soft Scrub with Bleach (cleanser). On 04/14/24 at 4:12 p.m., in the unsecured shower room on the north hall, the following chemicals were observed: - Virex II 256 (disinfectant). On 04/14/24 at 4:18 p.m., in the unsecured hopper room on the south hall the following chemicals were observed: - Good Sense (air freshener), and - Clorox Clean-Up with Bleach (disinfectant cleanser). On 04/14/25 at 4:25 p.m., LPN #1 stated the staff were to lock up stored chemicals. On 04/14/24 at 5:00 p.m., the administrator was shown the above chemicals and their locations. The administrator stated chemicals were to be stored in a secured manner such as in a locked cabinet or locked room.

Based on observation and interview, the facility failed to maintain sanitary conditions in the kitchen. There was standing water in the kitchen, an active water leak from the three compartment sink, and broken/missing floor tiles. This had the potential to effect all residents. The administrator identified 34 residents resided in the facility. Findings: On 04/14/24 at 12:46 p.m., the kitchen was observed. There was an active water leak from under the three compartment sink. There were several saturated bath sheets and towels on the floor between the three compartment sink and the food prep table. There were several missing, cracked, and broken floor tiles observed. The back door was opened wide and there was no screen door present. On 04/14/24 at 12:50 p.m., cook #1 stated when they arrive each morning to start their shift, there was always standing water all through the kitchen that they would have to mop up before starting breakfast. The cook stated the leak from under the three compartment sink had been there awhile and maintenance had been notified. On 04/16/23 at 4:34 p.m., the kitchen was observed. There was an active water leak from under the three compartment sink. There were several saturated bath sheets and towels on the floor between the three compartment sink and the food prep table. There were several missing, cracked, and broken floor tiles observed. On 04/16/24 at 4:45 p.m., the dietary manager stated the leak under the three compartment sink and the subsequent standing water on the floor had been ongoing for some time. The dietary manager stated maintenance had been aware. On 04/16/24 at 5:30 p.m., the administrator stated the facility was without a maintenance person now. The administrator stated they were aware of the condition of the kitchen floor and there was a plan in place for the repairs.

Based on record review and interview the facility failed to ensure the resident's representative was included in discharge planning for one (#30) of three residents reviewed for discharges. The Administrator reported 34 residents resided in the facility. Finding: The facility's Resident/Family Participation - Assessment/Care Plans policy dated 12/01/2006, read in part The resident and his/her family, and/or legal representative, are invited to attend and participate in the resident's assessment and care planning conference .The social services director or designee is responsible for contacting the resident's family and maintaining records of such notices . 1. Resident #30 had diagnoses which included heart failure, respiratory failure, and diabetes mellitus. A care plan, dated 08/25/23, documented Discharge planning: Resident, family and staff are in agreement for discharge planning .Planned discharge date is 09/01/23 .Goal: able to return home with supportive services 09/01/23 .Intervention: Notify provider of concerns. Assist with obtaining community services. Assist in ordering discharge supplies .The care plan documented no evidence the care plan had been signed and a copy given to the resident or resident's representative. On 04/15/24 at 5:27 p.m., family member #1 reported being resident #30's power of attorney and was not included in the discharge care plan meeting. Family member #1 reported not being aware of the discharge date or plan until 48 hours before the resident's benefits ran out. On 04/17/24 at 5:16 p.m., the administrator reported the resident's representative family member #1 had not given them paperwork that she was the POA she just told them she was. The administrator reported family member #2 came to the facility to see the residents and was listed as a contact. The administrator reported family member #2 was present for the care plan meeting. The administrator reported family member #1 was contacted 48 hours before his skilled benefits ran out and informed family member #1 the resident could stay in the facility but would have to be private pay. Resident #30's medical record was reviewed by the surveyor on 04/18/24 and contained a signed durable power of attorney for family member #1, dated 09/29/22.

Based on record review and interview, the facility failed to electronically transmit MDS assessments, within 14 days after completion, for 11 (#1, 4, 5, 6, 9, 14, 19, 20, 22, 23, and #24) of 11 residents reviewed for resident assessments. The Resident Census and Conditions of Residents form documented 21 residents resided in the facility. Findings: On 03/10/23 at 10:19 a.m., the facility's regional consultant was interviewed regarding MDS resident assessments not being transmitted as required. The consultant reported they had recognized a problem with MDS assessments on 02/01/23. The consultant stated the facility previously did not have an RN in their system to sign off on MDS assessments, and they believed this was part of the issue with the assessments either not being transmitted or being transmitted late. On 03/10/23 at 11:16 a.m., the regional consultant provided a list of residents who were identified as having MDS assessments completed but not transmitted in the required timeframe. The consultant reported they had transmitted a batch of MDS assessments over the past couple of days and some of the assessments would now show they had been transmitted. Resident #1 had an Admission MDS Assessment completed on 12/15/22. The assessment was electronically signed by an RN on 12/28/22 but had not been transmitted. Resident #4 had an Admission MDS Assessment completed on 01/17/23. The assessment was electronically signed by an RN on 01/30/23 but had not been transmitted. Resident #5 had a Reentry MDS Assessment completed on 01/28/23. There was no RN signature and the assessment had not been transmitted. Resident #6 had an Admission MDS Assessment completed on 01/24/23. The assessment was electronically signed by an RN on 02/06/23 but had not been transmitted. Resident #9 had an Admission MDS Assessment completed on 12/28/22. The assessment was electronically signed by an RN on 01/10/23 but had not been transmitted. Resident #14 had an Admission MDS Assessment completed on 12/21/22. The assessment was electronically signed by an RN on 01/03/23 but had not been transmitted. Resident #19 had a Reentry MDS Assessment completed on 11/11/22. The assessment was electronically signed by an RN on 11/23/22 but had not been transmitted. Resident #20 was discharged from the facility on 01/27/23. The assessment was signed by an LPN on 02/02/23 but not signed by an RN and was not transmitted. Resident #22 had an Admission MDS Assessment completed on 11/24/22. The assessment was electronically signed by an RN on 11/30/22 but had not been transmitted. Resident #23 had an Admission MDS Assessment completed on 01/25/23. The assessment had not been signed or transmitted. Resident #24 had an Admission MDS Assessment completed on 01/26/23. The assessment was electronically signed by an RN on 02/08/23 but had not been transmitted. On 03/10/23 at 11:27 a.m., the regional consultant reported LPN #1 was responsible for completing the resident MDS assessments. The consultant stated that due to the facility not having an RN responsible for signing off on assessments for a period of time, LPN #1 held the assessments and did not transmit them in the required time.

Based on record review, observation, and interview, the facility failed to ensure: a. an Oxygen in Use sign was in place per the facility's policy and, b. oxygen tubing was labeled with date and initials when changed per professional nursing standards for two (#1 and #178) of two residents reviewed for oxygen therapy. The Resident Census and Conditions of Residents, dated 03/08/23, documented 21 residents resided in the facility. Findings: The facility Oxygen Administration policy, dated 04/01/22, read in parts, .Place an 'Oxygen in Use' sign on the outside of the room entrance door .Place an 'Oxygen in Use' sign in a designated place on or over the resident's bed . 1. Resident # 1's cognition was documented to be severely impaired and had a diagnoses of COPD. Admission Orders for resident #1, dated 02/22/23, read in part, .Check SpO2 every shift, if < 93% place on oxygen 3 lpm via nc . Resident #1's Care Plan, dated 02/22/23, read in parts, .The resident is receiving PRN oxygen therapy related to COPD .Goal: The resident will maintain SpO2 above 93% through the next review date .Change tubing per protocol .Administer oxygen therapy as ordered . A Nurse Note for resident #1, dated 02/22/23, read in part, .Resident returned via EMSA from OU Medical .SpO2 94% on 3L via NC . The Treatment Administration Record for resident #1, dated 03/01/23 through 03/09/23, documented no schedule to change oxygen tubing. On 03/08/23 at 09:59 a.m., resident #1 was observed in bed with oxygen in place at 3 lpm via nc. The resident's oxygen tubing was not labeled with initials and a date when it was put in place. No Oxygen in Use sign was present in the residents's room or on the resident's door. The resident was unsure if the tubing had been changed. On 03/09/23 10:11 a.m., the ADON reported oxygen tubing should be labeled with initials and date when the oxygen tubing was put in place or changed. and a plastic bag should be present to store the tubing when not in use for infection control prevention. The ADON reported the oxygen tubing should be changed weekly. On 03/10/23 at 1:30 p.m., the regional consultant reported oxygen tubing should be tabled with date and initials and Oxygen in Use signs in place for residents receiving oxygen therapy. 2. Resident #178 had diagnoses which included alcoholic hepatitis. Physician Orders for resident #178, dated 01/13/23, documented .Remove oxygen for 5 minutes, check SpO2 every shift, replace oxygen at 3 LPM via nc for SpO2 < 93% .Change and date all respiratory products: tubing/masks/equalizer/etc weekly on Sundays on 11-7 shift . An Admission Assessment for resident #178, dated 01/27/23, documented the resident was cognitively intact and had oxygen therapy while in the facility. A Care Plan for resident #178, dated 02/01/23, read in parts, .Receiving oxygen therapy .Change tubing per protocol .Administer oxygen therapy as ordered . On 03/08/23 at 10:30 a.m., resident #178 was observed in their room eating breakfast. The resident was not wearing oxygen and reported they wore it at night. An oxygen concentrator and portable oxygen bottle was in the resident's room. The resident's oxygen tubing was not labeled with initials and date of when the tubing was put in place. No Oxygen in Use sign was present on the door of the resident's room or inside the room. On 03/09/23 at 9:36 a.m., resident #178 reported their oxygen tubing had been changed since they were admitted but they did not remember when. On 03/09/23 10:11 a.m., the ADON reported oxygen tubing should be labeled with initials and dated when the oxygen tubing was put in use or changed, along with a plastic bag to store the tubing in when not in use for infection control prevention. The ADON reported the oxygen tubing should be changed weekly. On 03/10/23 at 1:30 p.m., the regional consultant reported the oxygen tubing should be tabled with date and initials and Oxygen in Use signs in place for residents receiving oxygen therapy

Based on record review and interview, the facility failed to designate a registered nurse to serve as the Director of Nursing on a full time basis. The Resident Census and Conditions of Residents form documented 21 residents resided in the facility. Findings: On 03/08/23 at 9:43 a.m., the Administrator reported she had been at the facility since 02/01/23 and the facility had not had a Director of Nursing during that time. The Administrator stated the new DON had just started working half-days and would be at the facility full-time beginning 03/13/23. The Administrator reported a corporate nurse had been coming in occasionally and offering assistance as needed but did not fulfill the duties of DON. On 03/10/23 at 10:26 a.m., the regional consultant reported the last full time DON had resigned on 01/01/23. The consultant reported there was no DON coverage from 01/01/23 until 03/06/23 when the new DON started part-time, and the DON would be full time effective 03/13/23. The consultant reported she had called to request a waiver but was under the impression she did not need a waiver as long as she had two RN's for full time RN coverage. The consultant was asked if either of the RN's had taken responsibility for the DON duties, and the consultant confirmed that neither RN had fulfilled the duties of DON.

Based on record review, observation, and interview, the facility failed to act upon a pharmacy recommendation, to consider a dose reduction of an antipsychotic medication, for one (#9) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 21 residents resided in the facility. Findings: A facility policy, Medication Regimen Reviews, revised May 2022, documented in parts, .Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physician .The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record . Resident #9 had diagnoses which included Bipolar disorder, dementia with behaviors, and anxiety. An Annual MDS Assessment, dated 09/28/22, documented the resident was cognitively intact. The assessment documented the resident received antipsychotics seven of seven days, antidepressants seven of seven days, antianxiety medications seven of seven days, and opioids seven of seven days previous. A Medication Regimen Review, dated 02/13/23, documented resident #9 was taking dual agent antipsychotic therapy which could be considered duplication of therapy/unnecessary medication. The pharmacist addressed Quetiapine (an antipsychotic medication) 200 mg twice daily, and Aripiprazole (an antipsychotic medication) 10 mg daily. The pharmacist documented, Might we gradually reduce and discontinue one of these agents or does the current course of therapy remain safe and appropriate? The MRR had not been addressed by the physician. A Care Plan, dated 02/23/23, documented the resident had mental illness and received antipsychotic medications related to behaviors. The care plan documented the resident received medication for anxiety and pharmacy consults would be conducted to review medications. On 03/09/23 at 1:44 p.m., resident #9 reported he thought he was doing well on his current medications. The resident stated he had undergone surgery recently and was feeling better. On 03/09/23 at 2:07 p.m., the ADON pulled monthly pharmacy consults for resident #9 and reviewed the most recent recommendations. The ADON stated the resident had been in and out of the hospital recently and didn't think the physician had made any recent changes. Upon further review, the ADON found a pharmacy consult, dated 02/13/23, which had not been delivered to the resident's physician. The ADON stated the facility process for resident #9's physician was to drop off recommendations and pick up orders from the physician's office. The ADON confirmed the pharmacy recommendation had not been delivered to the physician for consideration and stated a staff member would take it to his office immediately. The pharmacy consult had addressed Quetiapine 200 mg BID and Aripiprazole 10 mg daily, stating this was considered duplication of therapy/unnecessary medication, and asked if the physician might consider a gradual reduction or discontinuation all together of one of the medications. On 03/10/23 at 11:52 a.m., the Administrator was interviewed regarding the facility's policy for getting documentation, such as pharmacy consults/MRRs, to a physician. The Administrator was informed of the MRR which had not been delivered to the physician in a timely manner. Facility staff reported a folder was kept at the nurse's station but could not provide an exact process for ensuring documents were delivered to the physician's office on a regular basis and in a timely manner. The Administrator reported if other physicians visited the facility at least weekly, then documentation requiring a response or signature for resident #9's physician should be delivered to the physician's office at least weekly. The Administrator stated they would review the current process and make changes to ensure the physician received documents in a timely manner.

Based on record review, observation, and interview, the facility failed to maintain their infection control program, by not performing hand hygiene and disinfecting the glucometer between residents when obtaining fingerstick glucose levels (FSBS) and administering insulin, for four (#7, 17, 16, and #4) of four residents reviewed for infection control and prevention. The Resident Census and Conditions of Residents documented 22 residents resided in the facility. Findings: The facility Handwashing/Hand Hygiene policy documented in parts .This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water .before and after direct contact with residents .before preparing or handling medications .before performing any non-surgical invasive procedure .after contact with a resident's intact skin .after contact with blood or bodily fluids . The facility Obtaining a Fingerstick Glucose Level policy documented in parts .The following equipment and supplies will be necessary when performing this procedure .soap and water .disinfected blood glucose meter (glucometer) .perform hand hygiene . On 08/16/22, from 3:58 p.m. to 4:20 p.m., the Director of Nursing (DON) was observed to obtain finger-stick blood glucose levels and administer insulin. The DON was not observed to wash her hands or perform hand hygiene of any type during the procedures. The DON was observed to use the same glucometer for each resident and the glucometer was not sanitized or cleaned in any way between each resident use. The following was observed as the DON went from resident to resident: Resident (Res) #7 was observed to receive a FSBS and required insulin coverage. Res #17 was observed to receive a FSBS and required insulin coverage. Res #16 was observed to receive a FSBS and required insulin coverage. Res #4 was observed to receive a FSBS and required insulin coverage. On 08/17/22 at 8:34 a.m., RN #1 reported the facility typically had the purple lid sani-wipes which were to be used to disinfect the glucometer between each resident use. The RN reported the facility had only one glucometer. On 08/17/22 at 2:42 p.m., the DON was interviewed regarding hand hygiene and disinfecting the glucometer. The DON stated she didn't work the floor very often. She stated it was brought to her attention she had not performed hand hygiene while obtaining finger-stick blood glucose levels and while administering insulin. She stated she didn't realize it at the time because she was distracted by one of the residents. The DON stated they usually had the sani-wipes available to clean the glucometer between each resident but she didn't think to do this. The DON stated everyone was expected to perform hand hygiene between resident contact when obtaining fingerstick blood glucose levels and/or administering insulin. On 08/18/22 at 8:38 a.m., the Administrator was interviewed regarding facility policy related to hand hygiene and disinfecting glucometers. The Administrator stated the DON should have performed hand hygiene between each resident contact and the glucometer should be disinfected between each resident use.

Based on record review and interview, the facility failed to electronically transmit resident assessments, within 14 days after completion, for three (#10, 11, and #15) of three residents sampled for resident assessments. The Resident Census and Conditions of Residents documented 22 residents resided in the facility. Findings: A facility policy, Electronic Transmission of the MDS, documented in part .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. On 08/17/22 at 3:40 p.m., the Minimum Data Set (MDS) coordinator provided a Final Validation Report, which documented the status of the electronic transmission of resident assessments. The Final Validation Report documented the assessment for Resident (Res) #10 was accepted, with a target date of 06/28/22. The report showed a submission date of 08/15/22, and documented, record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #11 was accepted, with a target date of 06/18/22. The report showed a submission date of 08/15/22, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #15 was accepted, with a target date of 07/05/22. The report showed a submission date of 08/15/22, and documented record submitted late: the submission date is more than 14 days. On 08/18/22 at 12:23 p.m., the Regional Manager reported when the MDS coordinator accessed the system on the previous day, she found the assessments to be completed and closed, but noted they had not been transmitted. She stated the assessments should have automatically transmitted when they were completed and closed. The Regional Manager stated she and the MDS coordinator had contacted their IT department to find out why the assessments had not transmitted as required and this would be corrected as soon as possible.

Based on record review, observation, and interview, it was determined the facility failed to provide baths/showers as scheduled for three (#1, 2, and #3) of three sampled residents. The Resident Census and Conditions of Residents form documented 23 residents lived in the facility. Findings: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 04/13/22, documented the resident was cognitively intact and required two person physical assist for bathing. The resident's ADL record for May 2022 documented the resident was to receive showers on Tuesday, Thursday, and Saturday. The resident's ADL record documented they went from 05/12/22 to 05/19/22 without a shower or bath. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An ADL care record for April of 2022 documented resident #2 did not receive two showers as scheduled. Resident #2 was documented receiving one shower from 04/16/22 to 04/24/22. A quarterly resident assessment dated [DATE], documented resident #2 was moderately cognitively impaired and required total assistance with bathing. An ADL care record for May of 2022 documented resident #2 did not receive four showers as scheduled. Resident #2 was documented receiving one shower from 05/21/22 to 05/29/22. An ADL care record for June of 2022 documented resident #2 did not receive one shower as scheduled. On 06/13/22 at 9:52 a.m., resident #2 reported to surveyors that they not had a shower since last Monday. On 06/13/22 at 2:20 p.m., resident #2 reported he had not received his shower scheduled for that day. Resident #2 reported he was scheduled for a shower on Monday, Wednesday, and Friday. 3. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual resident assessment, dated 04/17/22, documented the resident was cognitively intact and required extensive assistance with bathing. An ADL care record for April of 2022 documented resident #3 was to receive a shower on Tuesdays, Wednesdays, and Saturdays. No showers were documented on the weekend. An ADL care record for May of 2022 documented resident #3 received seven showers for the month. Resident #3 was documented as receiving one shower from 05/01/22 to 05/10/22 and one shower from 05/21/22 to 05/29/22. No showers were documented as given on weekends. An ADL care record for June of 2022 documented resident #3 did not receive two shower as scheduled. No showers were documented as given on weekends. On 6/13/22 at 10:14 a.m., resident #3 reported that she was not receiving her showers as scheduled. On 06/13/22, at 12:24 p.m., CNA #1 reported that showers were documented on the ADL record and a bath sheet. The CNA reported if a resident refused, they must ask three times throughout the day, and report the refusal to their supervising nurse. The refusal was documented on a refusal sheet. On 06/13/22 at 12:28 p.m., RN #1 reported that refusals were reported to the RN, and the RN then must talk to the resident and fill out a refusal sheet if they continue to refuse. The RN reported that a shower would be attempted on the resident's next scheduled shower day. On 06/14/22 at 10:45 a.m., the DON was asked about the documentation on the ADL care record. She reported that she did not know what the line through the date on the ADL care record indicated. On 06/14/22 at 11:00 a.m., CNA #2 reported that the line through the square on the ADL care record indicated that the task was not performed on that date.

Based on record review, observation, and interview, the facility failed to implement Centers for Disease Control and Prevention (CDC) guidelines for infection control procedures to prevent the transmission of COVID-19 and/or other infections. The facility failed to: a) wear personal protective equipment (PPE) per CDC guidance. b) ensure visitors were COVID-19 screened before entering the facility. The ''Resident Census and Conditions of Residents'' report identified 22 residents resided in the facility. Findings: The Visitation and Infection Control Policy read in parts, .Monitor employees prior to starting their shift for fever or respiratory symptoms .Signs should be posted throughout the facility describing ways to prevent the spread of germs .CDC's COVID-19 Situation Summary will be updated regularly as information becomes available . Signage posted in common areas and in resident halls documented Masks and Face Shields to be worn at all times when within 6 feet of another person staff and resident! No exceptions. On 03/17/22 at 5:00 a.m., the survey team approached the entrance to the facility. The coded unmanned door was opened by a resident. A staff member, not wearing a mask, approached and identified themselves as the director of nurses (DON). The survey team was escorted into the facility without being COVID-19 screened. At 5:04 a.m., licensed practical nurse (LPN) #1 was moving in and out of resident rooms providing resident care without wearing a mask. At 5:54 a.m., LPN #1 stated she was not wearing a mask because she was not around people. At 6:05 a.m., the DON stated she should have had a mask on this morning. The DON stated she forgot to screen the survey team when entering the building. She stated screening visitors at the door was not something she did routinely. The DON stated the resident who allowed the survey team to enter the building was not educated on the process of COVID-19 screening and should not be allowed to grant visitors access to the facility. At 6:10 a.m., certified nurse aide (CNA) #1 stated residents who know the access code to the door allow visitors and staff to enter. The CNA stated upon arrival to work she checked and documented her temperature then donned a mask. The CNA stated if she had a temperature the charge nurse was to be notified. At 7:10 a.m., registered nurse (RN)/charge nurse #1 obtained temperature checks and provided masks for two staff members entering the facility. The LPN stated the COVID-19 questionnaire on the table had not been completed by staff lately. The questionnaire was completed by visitors only at this time.

Based on record review, observation, and interview, the facility failed to complete assessments and provide treatments for pressure ulcers for two (#1 and #3) of two residents reviewed for pressure ulcers. The ''Resident Census and Conditions of Residents'' report documented one resident with a pressure ulcer. Findings: The Pressure Ulcer/Skin Breakdown-Clinical Protocol read in part, .the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; . 1. Resident (Res) #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 01/23/22, documented to perform weekly skin assessments. A nurse admission assessment, dated 01/27/22, documented the resident had a decubitus ulcer to the buttock measuring 2.1 x 1.8 x 0.2 cm. A visit report, dated 01/27/22, documented a wound to the bilateral buttock with full thickness moisture associated skin damage (MASD) and status not closed. The report documented the wound measured 5.0 x 4.0 x 0.1 cm. A weekly pressure ulcer record, dated 01/27/22, documented the resident returned from the hospital with a worsened stage III wound to the left buttock measuring 6.4 x 4.4 x 0.2 cm. The weekly pressure ulcer records from 01/27/22 through 03/16/22 did not document the completion of two weekly skin assessments. The quarterly assessment, dated 01/30/22, documented the resident was independent with cognition and required total assistance with most activities of daily living. The assessment documented the resident did not have pressure ulcers and was incontinent of bowel and bladder. The TAR for March 2022 documented the resident was to have wound care to the left buttock daily. The TAR indicated two treatments had not been completed. A wound/skin record, dated 03/18/22, documented the resident had a resolving stage III measuring 1.2 x 0.1 x 0.1 cm and an area with MASD. The record documented no new or worsening areas. On 03/21/22 at 11:24 a.m., RN #1 completed wound care for the resident. The resident had three open skin areas. The RN stated the area to the left buttock and gluteal cleft was measured last week, but the area to the left upper leg was new. The RN could not provide the skin assessment completed the previous week. On 03/21/22 at 1:00 p.m., the DON reviewed the resident's clinical record and stated the resident had three skin assessments completed the same day with conflicting information. The DON stated there were missing weekly assessments and the completed assessments only documented one wound. 2. Res #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 02/01/22, documented the resident was cognitively independent and required extensive assistance with bed mobility. The assessment documented the resident did not have pressure ulcers. A physician order, dated 03/03/22, documented the resident was to receive collagen powder with triad cream to the right gluteal area daily. The March 2022 TAR indicated two treatments had not been provided. Three pressure ulcer assessments were not provided. On 03/21/22 at 11:06 a.m., the DON reviewed the resident's chart and stated she could not locate assessments completed by the wound nurse, physician assessments, or physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated there was missing and conflicting assessments and documentation regarding wounds for the resident. The DON stated it was confusing and difficult to determine the status of the resident's wound. On 03/21/22 at 11:46 a.m., the resident declined to allow observations of his wound at that time.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess and intervene in a timely manner to prevent severe weight loss for three residents who had severe weight loss. Resident #10 developed three pressure ulcers. One progressed to a Stage IV, merged with another pressure ulcer and was unstageable due to necrotic tissue. The wound became infected. On [DATE] the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 2:30 p.m., the administrator was notified of the IJ situation. At 5:16 p.m., an acceptable plan of removal was provided. The plan of removal was updated on [DATE]. The plan of removal documented: .On [DATE] Administrator/designee began an instant in-service with nursing and dietary staff on Policy and Procedures for assessing, monitoring and intervening for weight loss and nutritional status. Emphasis was laid on notifying the physician and the dietitian immediately a resident has weight loss, providing resident with physician ordered supplements and encouraging resident family to partake in getting resident weight back up. To be completed by [DATE]. @ 5:30 PM On, [DATE] DON/MDS Coordinator will begin chart review and identify residents that have the potential to be affected by this deficient practice. Care Plans will be reviewed and updated. All weight loses [sic] will be reported to the physician and the dietitian immediately for orders and recommendations. Completed by [DATE] @5:45 PM Beginning [DATE] Admin and nurse managers will conduct weekly at-risk meetings to monitor for weight loss. Findings will be reported to physician and dietitian immediately for further review and recommendations .All immediate actions will be completed by 5:45 PM [DATE] and monitoring to continue thereafter . The immediate jeopardy was removed on [DATE] at 10:40 a.m., when all components of the plan of removal had been carried out. The deficient practice remained at a pattern of actual harm. Based on record review and staff interview, it was determined the facility failed to identify and provide interventions to prevent severe weight loss for three (#10, #12, and #1) of three sampled residents reviewed for weight loss. Resident #10 developed a stage II pressure ulcer to the left inner buttock. The resident later developed a pressure ulcer to the right upper buttock that progressed to a Stage IV. Both wounds joined each other creating an unstageable pressure ulcer due to necrosis to the sacrum. The resident was identified with an infection in the wound. The facility reported 37 residents resided in the facility. Findings: A nutrition impaired/unplanned weight loss clinical protocol policy documented the threshold for significant unplanned and undesired weight loss would be based on the following criteria: a. 1 month - 5% weight loss considered significant; greater than 5% considered severe, b. 3 months - 7.5% weight loss considered significant; greater than 7.5% considered severe, c. 6 months - 10% weight loss considered significant; greater than 10% considered severe. The policy documented the physician and staff would closely monitor residents who had been identified as having impaired nutrition or risk for developing impaired nutrition. The policy documented monitoring may include evaluating the care plan to determine if interventions had been implemented and were effective in attaining established nutritional and weight goals. The policy documented monitoring may include observing for and reporting significant weight gain or loss. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated [DATE], documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented a goal was for the resident to have gradual weight gain of at least two pounds weekly. The care plan documented for the staff to monitor, record, and report to the physician signs and symptoms of malnutrition such as significant weight loss of greater than 5% in one month. The care plan documented for the staff to provide supplements as ordered such as Ensure or house supplement with meals. A dietary note, dated [DATE] at 3:38 p.m., documented the resident's initial assessment. The note documented the resident weighed 163 pounds. The note documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented the resident's intake was ,d+[DATE]%. The note documented for the staff to monitor intake and weights. An admission assessment, dated [DATE], documented the resident was severely impaired with cognition and required extensive assistance with activities of daily living. The assessment documented the resident was independent with eating. The assessment documented the resident was at risk for developing a pressure ulcer. The assessment documented the resident did not have a pressure ulcer upon admission. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident weighed 163 pounds. The assessment documented the resident required a nutrition or hydration intervention to manage skin problems. A nurse's note, dated [DATE] at 12:34 p.m., documented, Stage II pressure sore noted to L inner buttock measuring approx 3.5 x 3.0 x 0.1 cm. A nurse's note, dated [DATE], documented to change the resident's diet to pureed due to having no teeth. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound care physician's note, dated [DATE], documented a wound on the left heel. A nurse's note, dated [DATE] at 12:13 p.m., documented, Telemed with PCP, new orders for [MEDICATION(S)] BID x 10 days for infection, new dx (diagnosis) of L heel DTI (deep tissue injury), Stg IV to Right upper buttock, and failure to thrive . A dietary note, written by the Registered Dietician, dated [DATE], documented, Wt. [weight] 146# [pounds], down 17# past month. 10% weight loss past month. Recent hip replacement, as well as femur fx. [fracture]. Receives a Regular, Puree diet with intakes of ,d+[DATE]%,. Also receives Ensure with meals. Pressure areas present. Will follow weights for any needed interventions. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record contained no documentation the physician had been notified of the severe weight loss. The clinical record contained no documentation the care plan had been updated to reflect the severe weight loss. The clinical record contained no new interventions to prevent further weight loss. A wound care telemedicine follow up evaluation, dated [DATE], documented, .He has an unstageable (due to necrosis) sacrum for at least 1 days duration . The evaluation documented the size of the wound was 2.3 x 3.0 x 2.5 centimeters (cm). A monthly weight record, dated [DATE], documented the resident weighed 139.2 pounds. The clinical record contained no documentation the physician or dietitian had been notified regarding the continued weight loss. A wound care telemedicine follow up evaluation, dated [DATE], documented, .He has an unstageable (due to necrosis) sacrum for at least 5 days duration. There is moderate serous exudate . The evaluation documented the size of the wound was 9.0 x 10.0 x 4.0 cm. A wound evaluation management summary, dated [DATE], documented the wound to the sacrum was unstageable due to necrosis. The summary documented the wound size was 10.0 x 3.5 x 2.6. The resident expired on [DATE]. On [DATE] at 11:35 a.m., the director of nurses (DON) reported the physician should have been notified of the severe weight loss. The DON reported new interventions should have been put into place to prevent further weight loss. The DON reported the resident should have received the Ensure in [DATE] as ordered by the physician. On [DATE] at 11:50 a.m., the DON reported she printed a list of weights from the computer. She provided a list of weights. When asked about some of the resident's on the list who had significant weight loss, and why they had not been identified, she reported she was unsure of what she was looking at. 2. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nutrition care plan, initiated on [DATE], documented the resident had a potential nutritional problem related to history of being underweight. The care plan goal documented the resident would maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline, would have no signs or symptoms of malnutrition, and would consume at least 50% of at least two meals daily through review date. The care plan documented approaches which included: provide, serve diet as ordered, monitor intake and record each meal, and for the registered dietitian to evaluate and make diet change recommendations as needed. A weight summary, dated [DATE], documented the resident's weight was 179.1 pounds. A comprehensive assessment, dated [DATE], documented the resident was intact with cognition. The assessment documented the resident reported poor appetite or overeating two to six days of the 14 day look-back period. The assessment documented the resident was independent with eating. The assessment documented the resident weighed 179 pounds. The assessment documented the resident was on a therapeutic diet. A weight summary, dated [DATE], documented the resident's weight was 161.0 pounds. This documented an 18.1 pound weight loss for one month. The summary documented this was a 10.1% weight loss in a month. A dietary progress note, signed by the Registered Dietician, dated [DATE], documented the resident weighed 161 pounds, down 18 pounds in past month. The note documented ,d+[DATE]% meal intake. The note documented a recommended reweigh. The clinical record did not contain documentation that the resident was reweighed. A weight summary, dated [DATE], documented the resident's weight was 165, which indicated a 7.9% weight loss of 14.1 pounds in 90 days. A quarterly assessment, dated [DATE], documented the resident was intact with cognition. The assessment documented the resident was independent with eating. The assessment documented the resident weighed 162 pounds. The assessment documented the resident had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a physician prescribed weight loss regimen. A weight summary, dated [DATE], documented the resident weighed 161.6 pounds. A weight summary, dated [DATE], documented the resident weighed 147.0 pounds, which indicated a 9.0% weight loss of 14.6 pounds in one month, a 13% weight loss of 22 pounds in three months, and a 17.9% weight loss of 32.1 pounds within the past six months. On [DATE] at 11:35 a.m., the director of nurses (DON) reported the physician should have been notified of the severe weight loss. The DON reported new interventions should have been put into place to prevent further weight loss. The care plan contained no interventions to address the severe weight loss. 3. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated [DATE], documented the resident had potential for a nutritional problem related to Alzheimers disease and vitamin deficiency. The care plan documented for the staff to monitor, record, and report to the physician signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A monthly weight report, dated [DATE] through [DATE], documented the residents weight as follows: [DATE]- 170 lbs. [DATE]- 158.4 lbs. [DATE]- 150 lbs. [DATE]- 176 lbs. [DATE]- 160 lbs. [DATE]- 141.8 lbs. [DATE]- 138.2 lbs. A dietary note, dated [DATE], documented, Wt. 158# [pounds] (question last month's weight of 170#. Current weight is more in line with the weights of the past 3 months. Continues to receive a Regular diet with good meal intakes of ,d+[DATE]%. Will continue to follow weights for any needed interventions. This documented a one month severe weight loss of 11.6 pounds or 6.8%. The clinical record contained no documentation the physician was notified of the severe weight loss. The clinical record contained no documentation of new interventions to prevent further weight loss. An annual assessment, dated [DATE], documented the resident was moderately impaired with cognition and required assistance with activities of daily living. The assessment documented the resident required one staff member to assist with meals. The assessment documented the resident weighed 158 pounds. The assessment documented the resident required a mechanically altered and therapeutic diet. A dietary note, dated [DATE], documented, Wt. 150#, down 8# past month. 5% weight loss past month. Receives a Regular diet with good meal intakes of ,d+[DATE]%. Recommend give 60cc 2.0 qid [four times a day] with med pass. The weight record, dated [DATE], documented the resident weighed 176 pounds. The weight record, dated [DATE], documented the resident weighed 160 pounds. The record documented the resident had lost 16 pounds, a 9.1% severe weight loss in one month. A dietary note, dated [DATE], documented the resident weighed 160 pounds. The note documented the resident's meal intake was ,d+[DATE]%. The note documented to continue the same routine. The clinical record contained no documentation the physician was notified of the severe weight loss. The clinical record contained no documentation of new interventions to prevent further weight loss. An updated care plan, dated [DATE], documented the resident had potential for nutritional problem related to Alzheimer's disease and vitamin deficiency. The care plan documented for the staff to monitor, record, and report to the physician signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. A quarterly assessment dated [DATE], documented the resident was severely impaired with cognition and required assistance with activities of daily living. The assessment documented the resident required extensive assistance of one staff member with meals. The assessment documented the resident weighed 160 pounds. The assessment documented the resident required a mechanically altered diet. The weight record, dated [DATE], documented the resident weighed 141.8 lbs. This represented an 11.3% severe weight loss of 18.2 pounds in one month. The weight record, dated [DATE], documented the resident weighed 138.2 lbs. This represented an 13.6% severe weight loss of 21.8 pounds in one month. On [DATE] at 11:35 a.m., the director of nurses (DON) reported the physician should have been notified of the severe weight loss. The DON reported new interventions should have been put into place to prevent further weight loss.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent the development and worsening of pressure ulcers (PU's), to consistently and thoroughly assess the resident's skin, and to notify the physician and intervene in a timely manner for the PU's. The resident did not have weekly skin assessments conducted and developed a stage II pressure ulcer to the left inner buttock. The resident later developed a pressure ulcer to the right upper buttock that progressed to a Stage IV. Both wounds joined each other creating an unstageable pressure ulcer due to necrosis, to the sacrum. An infection was identified in the wound. On [DATE], the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 2:30 p.m., the administrator was notified of the IJ situation. At 5:16 p.m., an acceptable plan of removal was provided. The plan of removal was updated on [DATE]. The plan of removal documented: .On [DATE] Administrator/designee began an instant in-service with all nursing staff on Policy and Procedures for assessing, monitoring and intervening for pressure ulcers. Emphasis was made on how to identify skin breakdown, subsequent actions such as notifying the charge nurse immediately, who in turn notify the physician and the wound care physician immediately. DON was in serviced on weekly monitoring and making sure wound care physician's order and recommendations are strictly followed. To be completed by [DATE] @ 5:30 PM Facility QA from [DATE] till present for wound care and documentation will be reviewed and updated to represent new findings. Physician and wound care doctor will be notified immediately of all skin breakdown. Skin assessments to be completed on all residents [DATE] @5:00PM. All skin breakdown will be reported to the physician and the wound care doctor immediately. On, [DATE] DON/MDS Coordinator will begin chart review and identify residents that have the potential to be affected by this deficient practice. Care Plans will be reviewed and updated to be completed by [DATE] @ 5:45 PM. Findings will be reported to physician immediately for further review and recommendations DON will review the [name of company] wound care recommendations and orders and make sure they are adhered to. To be completed by [DATE] @ 5:45 PM Beginning [DATE], Admin and nurse managers will conduct weekly at-risk meetings to monitor for pressure ulcers. Findings will be reported to physician immediately for further review and recommendations. All immediate actions will be completed by 5:45 PM [DATE] and monitoring to continue thereafter . On [DATE] at 10:40 a.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at pattern level. On [DATE] and [DATE], interviews were conducted with the nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated an in-service was provided on [DATE] and [DATE]. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on staff interview and record review, it was determined the facility failed to provide treatment and services necessary to promote healing and to prevent the worsening of a pressure ulcer for one (#10) of five residents reviewed with pressure ulcers. The facility reported six residents required pressure wound treatment. The resident did not have weekly skin assessments conducted and developed a stage II pressure ulcer to the left inner buttock. The resident later developed a pressure ulcer to the right upper buttock that progressed to a Stage IV. Both wounds joined each other creating an unstageable pressure ulcer due to necrosis, to the sacrum. An infection was identified in the wound. Findings: A facility pressure ulcer/skin breakdown protocol, dated [DATE], documented the nurse shall describe and document/report a full assessment of the pressure sore including the location, stage, length, width, presence of exudates or necrotic tissue, pain assessment, mobility status, and current treatments. The protocol documented the physician would authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents if indicated for the type of skin alteration. The protocol documented the physician would help the staff review and modify the care plan as appropriate, especially when wounds were not healing as anticipated. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated [DATE], documented for the resident to receive a supplement of Ensure with meals. A care plan, dated [DATE], documented the resident had a right and left femur fracture and was at risk for skin breakdown. The care plan documented the resident had a protein calorie mal-nutrition diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented the resident had potential impairment to skin integrity related to fragile skin, surgical wound, malnutrition and decreased mobility. The care plan documented for the staff to monitor for skin changes. A care plan, dated [DATE], documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented a goal was for the resident to have gradual weight gain of at least two pounds weekly. The care plan documented for the staff to monitor, record, and report to the physician signs and symptoms of malnutrition such as significant weight loss of greater than 5% in one month. The care plan documented for the staff to provide supplements as ordered such as Ensure or house supplement with meals. The care plan contained no documentation regarding the pressure ulcer. An admission assessment, dated [DATE], documented the resident was severely impaired with cognition and required extensive assistance with activities of daily living. The assessment documented the resident was at risk for developing a pressure ulcer. The assessment documented the resident did not have a pressure ulcer upon admission. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident weighed 163 pounds. The assessment documented the resident required a pressure reducing device for his chair and his bed. The assessment documented the resident required a turning and or repositioning program. The assessment documented the resident required a nutrition or hydration intervention to manage skin problems. The assessment documented the resident was to receive physical therapy and occupational therapy. A nurse's note, dated [DATE] at 12:34 p.m., documented, Stage II pressure sore noted to L inner buttock measuring approx 3.5 x 3.0 x 0.1 cm. Barrier cream applied. Referral to Dr. [name deleted]. The clinical record contained no physician's order for the barrier cream. The clinical record contained no physician's order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The treatment administration record, dated February 2021, contained no treatments for the Stage II pressure ulcer. A physician's telephone order, dated [DATE], documented to cleanse wound to left (L) inner buttock with normal saline solution (NSS), pat dry, apply gauze island border one time a day. A wound care physician's note, dated [DATE], documented an initial wound evaluation and management summary. The note documented the chief complaint was a wound on the left heel. The physician's note documented recommendations for the resident to receive a multivitamin once daily, vitamin C 500 milligrams (mg) twice daily, and [MEDICATION(S)] [MEDICATION(S)] 220 mg once daily for 14 days. The physician's note contained no documentation regarding the pressure ulcer to the L inner buttock. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated [DATE] at 7:29 p.m., documented the wound care doctor was here. The note documented new orders had been received for treatment to the left heel and to continue current treatment to the buttocks at this time. A nurse's note, dated [DATE] at 12:13 p.m., documented, Telemed with PCP, new orders for [MEDICATION(S)] BID x 10 days for infection, new dx (diagnosis) of L heel DTI (deep tissue injury), Stg IV to Right upper buttock, and failure to thrive . A physician's telephone order, dated [DATE], documented to cleanse wound to right (R) upper buttock with NSS, pat dry, apply Santyl to wound bed, pack with [MEDICATION(S)], cover with calcium alginate, skin prep to peri-wound, secure with bordered gauze every day and as needed if soiled. The clinical record contained no documentation regarding the size or assessment of the pressure ulcer to the right upper buttock. A dietary note, written by the Registered Dietician, dated [DATE], documented, Wt. [weight] 146# [pounds], down 17# past month. 10% weight loss past month. Recent hip replacement, as well as femur fx. [fracture]. Receives a Regular, Puree diet with intakes of ,d+[DATE]%,. Also receives Ensure with meals. Pressure areas present. Will follow weights for any needed interventions. The clinical record contained no documentation the physician had been notified of the severe weight loss. The clinical record contained no documentation the care plan had been updated to reflect the severe weight loss. The clinical record contained no new interventions to prevent further weight loss. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record contained no documentation regarding the condition of the pressure ulcer to the left buttock or the right buttock. A monthly weight record, dated [DATE], documented the resident weighed 139.2 pounds. The clinical record contained no documentation the physician or dietitian had been notified regarding the continued weight loss. A wound care telemedicine follow up evaluation, dated [DATE], documented, .At the request of the referring provider .a thorough wound care assessment and evaluation was performed today. He has an unstageable (due to necrosis) sacrum for at least 1 days duration. There is moderate serous exudate . The evaluation documented the size of the wound was 2.3 x 3.0 x 2.5 centimeters (cm). The evaluation documented the treatment plan was to apply Santyl daily, Alginate calcium daily and cover with gauze island border. The evaluation documented recommendations for the resident to receive a multivitamin once daily, vitamin C 500 milligrams (mg) twice daily, and [MEDICATION(S)] [MEDICATION(S)] 220 mg once daily for 14 days. A wound care telemedicine follow up evaluation, dated [DATE], documented, .At the request of the referring provider .a thorough wound care assessment and evaluation was performed today. He has an unstageable (due to necrosis) sacrum for at least 5 days duration. There is moderate serous exudate . The evaluation documented the size of the wound was 9.0 x 10.0 x 4.0 cm. The evaluation documented the treatment plan was to start Dakins cleanses. Cleanse and scrub wound with Dakins solution, rinse completely with normal saline, pat dry, then apply Santyl daily, and cover with gauze island border. The evaluation documented recommendations for the resident to receive a multivitamin once daily, vitamin C 500 milligrams (mg) twice daily, and [MEDICATION(S)] [MEDICATION(S)] 220 mg once daily for 14 days. A wound evaluation management summary, dated [DATE], documented the wound to the sacrum was unstageable due to necrosis. The summary documented the wound size was 10.0 x 3.5 x 2.6. The summary documented the physician debrided the wound to remove the necrotic tissue and establish the margins of viable tissue. The evaluation documented recommendations for the resident to receive a multivitamin once daily, vitamin C 500 milligrams (mg) twice daily, and [MEDICATION(S)] [MEDICATION(S)] 220 mg once daily for 14 days. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A treatment administration record (TAR), dated [DATE], contained two blank spaces where treatments had not been completed on the wound to the left inner buttock. The TAR contained two blank spaces where treatments had not been completed on the wound to the sacrum. The TAR contained two blank spaces where treatments had not been completed for the wound on the upper right buttock. The resident expired on [DATE]. On [DATE] at 12:15 p.m., registered nurse (RN) #2 reported a certified nurse aide had informed her on [DATE] the resident had an open area to the resident's bottom. The RN reported the wound was a stage II. The RN reported she had administered barrier cream to the wound without a physician's order. The RN reported she had sent a text to the wound care physician but did not get a response. The RN reported she had not reported the wound to the primary care provider (PCP). The RN reported she should have notified the PCP. The RN reported the pressure ulcer to the left buttock and the right buttock became one wound. The RN reported wound assessments should have been documented in the progress notes. On [DATE] at 1:50 p.m., the director of nurses (DON) reported she was not sure why the RN put barrier cream on the wound. The DON reported the physician should have been notified and treatment orders obtained. The DON reported assessments of the wound should be documented in the progress notes. The DON stated, But it's not there. The DON reported the resident was on [MEDICATION(S)] for an infection to the wound. The DON reported the blank documentation should have been completed. She reported if it's not documented it's not done. On [DATE] at 3:00 p.m., the wound care physician reported the first she was aware of the wound to the buttocks was on [DATE]. The physician reported if it started out as two wounds it had became one wound when she first observed the wound. On [DATE] at 11:35 a.m., the director of nurses (DON) reported the physician should have been notified of the severe weight loss. The DON reported new interventions should have been put into place to prevent further weight loss. The DON reported the resident should have received the Ensure in [DATE] as ordered by the physician.

On 06/27/19 at 12:03 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's system failure to ensure residents with known wandering behaviors did not elope from the facility. On 06/27/19 at 12:23 p.m., the OSDH verified an immediate jeopardy situation existed related to the facility's failure to ensure a resident with wandering behaviors had not eloped from the facility. On 06/27/19 at 12:55 p.m., the administrator (ADM) and director of nursing (DON) were informed of the IJ situation which consisted of substandard quality of care. On 06/27/19 at 4:35 p.m., the ADM and DON provided the plan of removal for the immediate jeopardy. The plan of removal was accepted and documented the following: Place identified resident 1:1 until another placement can be found. Update careplan to identify risk and interventions. Change the door code to front door. Identify other residents at risk for wandering/elopement. Careplan appropriate interventions to minimize elopement risk. Re-educate staff on the facility wandering and elopement policy when resident exits the facility unattended, they are to be placed 1:1 immediately until a proper intervention can be implemented. They are not to be taken off 1:1 until instructed by the Administrator to do so. Staff will also be re-educated on the requirement to notify the DON and administrator as well as document in the resident's chart. All staff will be re-educated prior to returning to work. Plan will be completed by 7:00 pm 06/27/19. The administrator and DON or designee will do the inservice. On 07/01/19 at 9:00 a.m., a tour of the facility was conducted. Interviews were conducted with staff members from the nursing department, housekeeping, dietary, and maintenance. Staff members were able to explain the in-service education provided regarding residents at risk for wandering. The staff members were able to discuss what their role was in reporting to the charge nurse when a resident attempted to leave the facility or a change of condition was observed with the residents. Licensed staff members were able to verbalize their responsibility in assessing, monitoring, intervention, and reporting when residents attempted to elope or were successful in elopement from the facility. On 07/01/19 at 4:30 p.m., the facility was informed the IJ was removed effective 06/28/19 at 12:00 p.m. The deficient practice remained at a potential for more than minimal harm at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to implement systems to ensure supervision to prevent elopement for one (#5) of three residents reviewed for elopement. The facility failed to: a) Implement their policies and procedures related to wandering. b) Thoroughly assess to determine the root causes of wandering behavior. c) Develop and implement a care plan to prevent elopement for the resident. Facility records documented the resident had two previous elopements and one the first afternoon of the survey. The facility identified three residents who were at risk for elopement. Findings: A wandering policy, dated (MONTH) 2008, documented, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctible (sic) risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. 7. Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 02/02/19 at 6:17 a.m., documented, Resident has been up most of the night running up and down the halls following staff pulling at them. When (sic) outside with another resident and we were not aware of this until we missed her not wandering around. Looked outside on patio and she was just putting out cigarette and started to step off of patio. Explained to all the other residents that they could not take her outside . A wandering risk assessment, dated 03/28/19, documented the resident was a high risk for wandering. The assessment documented the resident ambulated independently. The assessment documented the resident had a history of [REDACTED]. A quarterly assessment, dated 03/31/19, documented the resident was severely impaired with cognition and exhibited wandering behaviors daily. The assessment documented the resident was independent with activities of daily living. A care plan, updated on 04/19/19, documented the resident received anti-anxiety medications. The care plan documented for the staff to monitor and record behavior symptoms of pacing and wandering and document per facility policy. A nurse's note, dated 04/22/19 at 5:00 p.m., documented, Resident attempted to leave facility 3X this shift. Resident brought back into building no injuries noted. Resident brought back this AM by family and continues to have confusion and wandering halls attempting to open doors. A care plan, updated on 04/30/19, documented the resident had impaired cognitive function. The care plan documented the resident had been going into other residents' rooms. The care plan documented the resident needed supervision and assistance with all decision making. The care plan contained no documentation regarding wandering or elopement. On 06/26/19 at 9:45 a.m., the resident was observed at the nurses' office with a telephone in her hand. Certified medication aide (CMA) #1 came out from the medication room about the same time and assisted the resident to use the telephone. The CMA reported the resident wandered. On 06/26/19 at 9:54 a.m., the beauty shop was observed to be unlocked and unsupervised. There was a container of combs in a disinfectant solution on a shelf, five boxes of hair dye, and a bottle of Clorox mold and mildew spray on the top shelf. The Clorox bottle contained a warning label (may cause eye irritant). On 06/26/19 at 11:42 a.m., the resident was observed to push on the front door. Staff was observed to assist the resident away from the door. On 06/26/19 at 12:25 p.m., the resident was observed at the front door pushing buttons on the key pad. The administrative assistant stated, She is our wanderer. The administrative assistant reported the resident had gotten out of the building two or three times in the past. The administrative assistant reported the resident had exited through the administrator's office and out an open door on one occasion. On 06/26/19 at 2:30 p.m., another resident stated, You missed it. She (resident #5) got out the front door while you were gone. The resident reported someone had come into the building and the door had not locked. The resident reported the activity director ran outside to get her. On 06/26/19 at 2:50 p.m., the resident was observed following a staff member down the hall. The staff member was going out the hall door. The staff member called for another nurse to come and get the resident. Licensed practical nurse (LPN) #1 went down the hall and retrieved the resident. The LPN reported the resident had been exit seeking since early January. The LPN reported the resident would go into other resident rooms to get snacks and cigarettes. The LPN reported all of the staff were aware of the resident's exit seeking tendencies. On 06/26/19 at 2:51 p.m., the DON reported there were two residents who wandered into other resident rooms. On 06/26/19 at 2:55 p.m., all exit doors were observed to have no signs on the doors to alert visitors of exit seeking residents. On 06/26/19 at 2:58 p.m., certified nurse aide (CNA) #4 reported three (#5, #9 and #11) residents had been found to enter other resident rooms. The CNA reported the staff would redirect resident #5 away from the door. The CNA reported the resident had exited the facility that day and was found out on the front porch. The CNA reported the wandering behavior was supposed to be documented in the resident's care plan. The CNA reported she had not had time to look at the care plan because they had been so short staffed. The CNA reported there was usually one aide on each hall and one nurse on each hall. The CNA reported there had been times the resident was up wandering until 3:00 a.m. The CNA reported the beauty shop was usually locked due to chemicals kept in the room. On 06/26/19 at 3:06 p.m., laundry aide #1 reported the resident was a wanderer. The laundry aide reported the resident had gotten out of the facility several times. The laundry aide reported she had assisted other staff to bring the resident back into the facility. The laundry aide reported the resident had been known to enter other resident rooms. On 06/26/19 at 3:09 p.m., the resident was observed dragging the laundry cart down the hallway. On 06/26/19 at 3:11 p.m., registered nurse (RN) #1 reported the resident would go into other resident rooms. The RN reported the resident should have been one on one but was not. On 06/26/19 at 3:27 p.m., the DON reported she was not aware of the resident getting out of the front door that day. The DON reported the resident's exit seeking behavior should have been care planned. The DON reported the resident was not one on one. The DON reported each time the resident had exited the building documentation should have been completed. A nurse's note, dated 06/26/19 at 5:49 p.m., documented the resident had entered the code to the front door and went outside. The note documented staff brought the resident back inside the facility. The note documented the resident was placed on one on one observation. On 06/27/19 at 8:30 a.m., the resident was observed ambulating throughout the facility with a staff member following her. On 06/27/19 at 9:30 a.m., the activity director (AD) reported the previous day she had observed the front door move and when she looked up the resident was in the front courtyard. The AD reported she ran after the resident and assisted her back into the facility. The AD reported when the resident had visitors she became more restless. On 06/27/19 at 11:00 a.m., staff reported the resident had left the facility with a family member for the day. On 06/27/19 at 11:15 a.m., the administrative assistant reported she had observed the resident out her window the previous day. The administrative assistant reported the resident had exited the building at least five times previously. On 06/27/19 at 4:22 p.m., a family member reported an unknown staff member informed her the resident had been found in an unlocked car in front of the building a couple of months ago. The family member reported the facility had never notified them regarding the resident exiting the facility.

Based on observation, record review, and interview, it was determined the facility failed to ensure residents maintained their highest levels of well-being for six (#1, #2, #3, #6, #9, and #10) of 12 residents reviewed levels of well-being. The facility failed to ensure: a) Pain was assessed prior to wound care for resident #6. During observation of wound care for the resident, the resident began stating, No, ma'am. No, ma'am. The resident was observed to make a facial grimace and pulled back into her recliner. The resident stated, It hurts. The LPN continued to cleanse the wound on right great toe which was red and swollen. The resident continued to pull back into her recliner and had a facial grimace. The DON identified eight residents who required wound treatments. b) A change in a wound treatment was addressed for resident #2. The DON identified eight residents who required treatments. c) Weekly weights were obtained per physician orders for resident #2. The DON identified six residents who required weekly weights be obtained. d) Proper procedures were followed in the performance of indwelling urinary catheter care for resident #1. The resident census and condition form documented two residents required indwelling urinary catheters. e) A swollen and reddened area was assessed and monitored for resident #9. f) Blood pressure parameters were documented for medication use for resident #10. g) A surgical site was assessed and monitored for resident #3. h) A peripheral IV site care was provided for resident #3. The resident census and condition form documented 45 residents in the facility. Findings: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order, dated 10/02/14, documented for the resident to receive Tylenol Extra Strength 500 mg as needed for pain. A care plan intervention, dated 02/12/15, documented for the staff to administer Tylenol Extra Strength one half hour before treatment or care. A quarterly assessment, dated 07/13/16, documented the resident was severely impaired in cognition with inattention and disorganized thinking, exhibited mild depression symptoms, and exhibited rejection of care on one to three days in the look back period. The quarterly assessment documented the resident exhibited no indicators of pain. The July 2016 flow sheet documented the resident exhibited no pain. The July 2016 nurses' notes contained no documentation of the resident experiencing pain. On 07/28/16 at 9:57 a.m., the resident was observed sitting in her recliner with her feet elevated. The resident exhibited no signs of distress. LPN #1 knocked on the resident's door, greeted the resident, and told the resident it was time for the resident's dressing change to her right toe. At that time, the LPN began removing the soiled dressing from the resident's right foot. The resident began stating, No, ma'am. No, ma'am. The resident was observed to make a facial grimace and pulled back into her recliner. The resident stated, It hurts. The LPN continued to cleanse the wound on right great toe which was red and swollen. The resident called out, No, ma'am. No, ma'am. The resident began to make repetitive consonant sounds without forming words. The resident continued to pull back into her recliner and had a facial grimace. On completion of the wound treatment, the LPN attempted to put a clean sock on the resident's right foot. The resident continued to repetitively state, No, ma'am. No, ma'am, while pulling her foot back from LPN. The LPN was in the process of putting a sock on the left foot when the resident pulled back her feet, saying, No more. The LPN stopped at resident's request. On 07/28/16 at 12:53 p.m., the DON was asked, if a resident expressed signs of pain during a treatment, should the staff stop treatment and provided pain medication to the resident before continuing with treatment. The DON reported yes. 2. Resident #2 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/19/16, documented the resident's cognition, depression symptoms, and behavioral symptoms were not assessed due to the resident having no discernable consciousness. The assessment documented the resident was totally dependent on staff for ADLs and had bilateral impairment of upper and lower extremities. The assessment documented the resident was incontinent of bowel and bladder function and had one unstageable pressure ulcer. a. A care plan, with an initial date of 03/09/15, documented the resident had a potential for pressure ulcer development related to the disease process, immobility, and incontinence of bowel. An intervention, dated 07/14/16, documented (physician's name deleted) saw the resident and for the staff to continue with the skin prep daily, dry protective dressing once daily, Hydrogel once daily, and to off load the wound. A wound care specialist evaluation, dated 07/21/16, documented, .He presents with a stage 4 pressure wound of the left heel 162 days duration. There is moderate serous exudate .Assessment & Plan Discontinue: Hydrogel - Once Daily -Continue: Skin Prep - Three Times per Week and PRN, Dry Protective Dressing - three Times per Week and PRN -Add: Calcium Alginate - Three Times per Week and PRN, Leptospermum honey - Three Times per Week and PRN .Electronically signed by (physician's name deleted) on 7/21/2016. A nurse's note, dated 07/21/16 at 1:39 a.m., documented the physician saw the resident and the wound treatment was changed. The resident's July 2016 treatment administration record (TAR) documented for the staff to cleanse the wound to left heel with normal saline, pat dry, place Calcium Alginate in wound bed, cover and wrap with roll gauze, and secure with tape BID. The change in treatment was not documented on the TAR. On 07/27/16 at 9:45 a.m., LPN #3 was observed to perform wound care for the resident. The LPN cleansed the wound with normal saline, patted dry with a 4X4 gauze, applied the Calcium Alginate, and applied the dry dressing to the wound. The LPN did not perform the wound treatment per the current physician's orders. On 07/27/16 at 10:15 a.m., the ADON, who had documented the change in treatment order in the nurses' notes, was asked why the resident's treatment had not been changed as ordered by the wound specialist. The ADON reported the medication had to be ordered and had not been received. At that time, the ADON was asked if the wound specialist was aware the treatment had not been performed as ordered. The ADON reported she had informed the wound specialist but had not documented she had contacted the physician. At that time, the ADON was asked if the change in treatment should have been documented on the TAR. The ADON reported the TAR should have been updated. On 08/01/16 at 9:30 a.m., the DON and the ADM were informed of the treatment not being followed. The ADM reported the issue would be addressed. b. A care plan, initiated on 03/09/15, documented the resident required tube feeding related to coma and was at risk for dehydration. A goal documented the resident would maintain adequate nutrition and hydration status as evidenced by stable weight, no signs and symptoms of malnutrition or dehydration. An intervention, dated 07/20/15, documented for the resident to have weekly weights completed on Mondays. A physician's order, dated 07/20/15, documented the resident was to have weekly weights obtained. The resident's electronic clinical record documented the following weights (in pounds) for 2016: 01/06/16: 127.4; 02/12/16: 125.0; 02/17/16 125.8; 04/05/16: 121.0; 05/10/16: 123.2; and 06/16/16: 126.4. A registered dietitian's progress note, dated 06/25/16 at 12:22 p.m., documented the resident's weight was 126 pounds. The dietitian's note documented the resident received Med Pass 2.0 60 ml TID and L-emental TID. The resident's clinical record documented the resident's weight was 121.4 pounds on 06/29/16 and on 07/04/16. The quarterly assessment, dated 07/19/16, documented the resident's weight as 122 pounds. The clinical record contained no other weights for July. On 07/27/16 at 2:40 p.m., the DON was asked for the resident's weekly weights. The DON reported the weights should be in the treatment book. On 07/27/16 at 2:50 p.m., LPN #2 was asked where the weekly weights would be documented. The LPN reported the CMA on the day shift obtained the weekly weights and documented on a form in the medication room. The LPN looked in the medication room and the documentation could not be located. On 07/28/16 at 10:55 a.m., the DON and the ADON were asked if the weekly weights were located. They reported the weights could not be located. On 08/01/16 at 9:30 a.m., the ADM and the DON were notified of the weekly weights not being obtained. The ADM reported the area would be addressed. On 08/01/16 at 11:00 a.m., the DON reported she had notified the physician the weekly weights were not obtained and the physician had discontinued the weekly weights. 3. A facility policy on urinary catheter care documented the staff was to cleanse and rinse the catheter from insertion site to approximately four inches outward and the catheter should be secured. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 10/30/15, documented the resident had an indwelling urinary catheter due to the [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/26/16, documented the resident was cognitively intact. The assessment documented the resident required one person limited assistance for bed mobility and personal hygiene. The assessment documented the resident had an indwelling urinary catheter. The July 2016 physician's orders documented the staff was to flush the resident's indwelling urinary catheter daily till clear and to provide catheter care every shift. On 07/27/16 at 10:40 a.m., LPN #1 was observed to provide the indwelling urinary catheter care and the daily catheter flush. The resident was positioned on her left side. During the instillation of the catheter flush solution, the LPN pulled the catheter tautly. The resident flinched and told the LPN to be more careful. The LPN was observed to cleanse the resident's groin areas and cleaned back toward the anal area away from the catheter site. The LPN did not clean the urinary catheter away from the insertion site. On 07/27/16 at 12:00 p.m., the DON was asked if she expected the staff to clean the catheter tubing away from the insertion site. The DON reported yes. The DON was asked if she expected the staff to secure the urinary catheter while handling to prevent the catheter from being pulled. The DON reported yes. 4. Resident #9 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 07/01/16, documented the resident was hard of hearing and could not be interviewed for cognitive abilities. The assessment documented the resident did not ambulate and required assistance with bathing. A nurse's note, dated 07/07/16 at 3:49 a.m., documented, .both legs are swollen and bright red, warm to touch . A nurse's note, dated 07/07/16 at 2:48 p.m., documented, resident was c/o rash on lower legs contacted Doctor (name deleted) and got order for mupirocin cream PRN. The July 2016 treatment administration record was reviewed. The record for the Mupirocin cream administration was blank from 07/07/16 until 07/26/16 with a note on 07/26/16 which documented, Dc'd 7/26/16 written across the record. A care plan, dated 07/19/16, documented the resident was at risk for altered skin status related to rash and other nonspecific skin eruption. Interventions included for the staff to administer treatments as ordered-Mupirocin 2% PRN, Aristocort Cream 0.1% PRN twice daily, and [MEDICATION NAME] cream 1% twice daily. The clinical record contained no further documentation of the condition of the resident's legs. On 08/01/16 at 9:40 a.m., LPN #4 was asked to see the resident's legs. The resident was observed lying in bed. The lower right leg was reddish in color. At that time, the LPN was asked to see if the Mupirocin cream was in the treatment cart. The Mupirocin was in the treatment cart. The tube containing the Mupirocin was full. The LPN was asked if the Mupirocin had been discontinued. She reported there was no physician's order to discontinue the medication. The LPN was shown the blank treatment record for July 2016. The LPN reported she thought the Mupirocin had been applied. On 08/01/16 at 11:55 a.m., the DON was notified of the Mupirocin not being administered as ordered. She reported she would check on it. 5. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order, dated 02/24/16, documented, Pindolol 10 MG Tablet By mouth-twice daily BID HTN. An admission assessment, dated 03/04/16, documented the resident was moderately impaired in cognition and required physical assistance in part of bathing. A nurse's note, dated 05/06/16 at 8:56 p.m., documented the resident's blood pressure was 95/60 and the resident's blood pressure medication was not administered. The nurse's note documented the resident's blood pressure would be repeated in one hour. A follow-up blood pressure was not documented. A nurse's note, dated 05/13/16 at 1:30 p.m., documented the resident's blood pressure was 97/55 and the blood pressure medication was not administered. A nurse's note, dated 06/05/16 at 9:19 p.m., documented the resident's blood pressure was 101/59 and the blood pressure medication was not administered. On 07/28/16 at 10:30 a.m., the ADON was interviewed. The ADON was asked how did the staff know when to hold a blood pressure medication and when to notify the physician of low blood pressure readings. The ADON reported there were blood pressure parameters for the staff to refer to. The ADON was asked where the blood pressure parameters were located. The ADON reported when a physician ordered a blood pressure medication, blood pressure parameters would be included in the physician's order. The ADON was asked to review the clinical record for the blood pressure parameters. The ADON reported the blood pressure parameters had not been included. The ADON reported the issue would be addressed. 6. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. A nurse's note, dated 04/28/16 at 8:00 p.m., a nurse's note documented the resident was yelling loudly. The resident stated, I was pushing on my knee and it broke. The nurse's note documented the resident was examined by the physician and ordered a mobile x-ray test. A nurse's note, dated 04/28/16 at 8:08 p.m., documented the physician was notified of the x-ray test results and ordered for the resident to be transferred to the emergency department. A nurse's note, dated 04/28/16 at 8:30 p.m., a nurse's note documented, Notified sisters husband of [MEDICAL CONDITION] said he would tell (name deleted). A nurse's note, dated 05/02/16 at 6:30 p.m., documented, Readmit to room . The clinical record did not contain assessment or monitoring of the resident's surgical site until 05/13/16 at 3:37 p.m. A nurse's note, dated 05/13/16 at 3:37 p.m., documented, Res (resident) back from Dr. appt, all staples removed except for the staples on the knee and there are to be removed in 3-4 days. New orders mobile Xrays Left femur. 2 views x-ray Left femur and 3 views x-ray right knee. The clinical record contained no assessment or monitoring of the surgical site until a nurse's note on 05/15/16 at 8:14 p.m. A nurse's note, dated 05/15/16 at 8:14 p.m., documented, 7 staples removed from left knee no redness or infection noted at this time. cleaned area with alcohol prep, applied steri strips x 3. The clinical record did not contain further assessment or monitoring of the resident's surgical site. A significant change assessment, dated 06/17/16, documented the resident was cognitively intact, did not ambulate, and required the assistance of two or more staff members for transfers. On 07/27/16 at 3:30 p.m., the DON was interviewed. The DON was asked when a resident returned to the facility after surgery, should the staff monitor and assess the surgical site. The DON reported yes. The DON was asked, after skin staples were removed from a surgical site, should staff monitor and assess the surgical for signs and symptoms of infection. The DON reported yes. The DON was asked when steri-strips were applied to a surgical incision after the removal of skin staples should staff monitor and document when the steri-strips are removed. The DON reported yes. b. A facility policy Central Venous Catheter Dressing Changes .Change transparent semi-permeable membrane dressings at least every 7 days and PRN (when wet, soiled, or not intact) . The policy documented the following information should be included in the resident's medical record: a. Date and time dressing was changed. b. Location and objective description of insertion site. c. Any complications, interventions that were done. A nurse's note, dated 07/07/16 at 12:45 p.m., documented the resident had left the facility for a PICC line placement. The clinical record contained no documentation the PICC line site was monitored and assessed upon the resident's return to the facility. A nurse's note, dated 07/10/16 at 10:15 p.m., documented the PICC line was intact and flushed easily. A nurse's note, dated 07/11/16 at 12:30 a.m., documented the PICC line was intact and flushed easily. A nurse's note, dated 07/11/16 at 8:50 p.m., documented the PICC line to the right upper arm was patent and flushed with saline and [MEDICATION NAME] after infusion of antibiotics. A nurse's note, dated 07/17/16 at 10:10 a.m., documented, cont with ABT IV cont picc line dressing C/D/I (clean dry and intact). On 07/25/16 at 3:30 p.m., the resident was observed lying in bed. The resident reported she was on IV antibiotics for an infection in her leg. The resident was observed to have an IV line in her right upper arm with no date on the IV dressing site. On 07/26/16 at 3:30 p.m., the DON was interviewed. The DON was asked should staff monitor and assess the PICC line site when a resident requires the use of a PICC line. The DON reported yes. At that time, the DON was asked when should a PICC line dressing be changed. The DON reported the dressing should be changed every seven days. The DON was asked where the documentation was located in the clinical record for the PICC line dressing change. The DON reported the dressing change documentation was in the nurses' notes or the TAR. The DON was notified no documentation was located in the nurses' notes or on the TAR where the PICC line dressing had been changed. The DON reported the issue would be addressed. c. A nurse's note, dated 07/12/16 at 6:32 a.m., documented the resident was transported to the hospital for surgery on her left hip at 5:00 a.m. and returned at 12:35 p.m. The clinical record did not contain documentation the left hip surgical site was monitored and assessed upon return to the facility. A nurse's note, dated 07/17/16 at 2:11 a.m., documented the resident's left hip dressing was clean, dry, and intact. The clinical record did not contain documentation the surgical site was monitored and assessed. On 07/27/16 at 8:40 a.m., wound care was observed to the resident's left leg. The resident's left hip was observed to have an open area with drainage on the dressing. On 07/27/16 at 3:30 p.m., the DON was interviewed. The DON was asked, when a resident returned to the facility after surgery, should the staff monitor and assess the surgical site. The DON reported yes.

Based on record review and interviews, it was determined the facility failed to implement care and services to ensure residents' highest levels of well-being for one (#2) of three sampled residents reviewed for well-being. The facility failed to thoroughly assess and monitor resident #2 and failed to notify the resident's physician of changes in the resident's respiratory status and pulse rate. Resident #2 was hospitalized on [DATE], seven days after the first documentation of increased pulse rates. A facility nurse's progress note documented the resident had expired at the hospital on [DATE]. A hospital discharge summary documented the resident had a [DIAGNOSES REDACTED]. The business office staff reported 52 residents resided in the facility. Findings: Resident #2 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented the resident had shortness of breath related to exertion and air-borne allergens. Interventions included to administer the resident's medications as ordered, to monitor and document breathing patterns, to report abnormalities to the physician, such as respiratory depth changes, altered chest excursion, use of accessory muscles, pursed lip breathing or prolonged expiratory phase, and increased anteroposterior chest diameter. A physician's orders [REDACTED]. vial Order Date: [DATE] PRN (as needed)1 neb (nebulizer) vial per HHN (hand held nebulizer) TID (three times daily) PRN cough/congestion cough/congestion inhalent (sic) solution. A physician's orders [REDACTED]. A quarterly assessment, dated [DATE], documented the resident was cognitively intact, was independent with all ADLs with the exception of bathing, and was continent of bowel and bladder. The [DATE] medication administration records (MARs) were reviewed. Neither the [MEDICATION NAME] breathing treatment nor the [MEDICATION NAME] DM had been administered during the month of [DATE]. A nurse's progress note, dated [DATE] at 3:48 a.m., documented, PRN breathing treatment given. No other problems noted at this time. The clinical record contained no documentation the resident's respiratory status had been assessed before or after the treatment. The February 2016 MAR indicated [REDACTED]. The [MEDICATION NAME] DM had been administered once on [DATE] at 8:30 a.m. The clinical record contained no documentation of the resident's respiratory status on [DATE] or [DATE]. The clinical record contained no documentation the physician had been notified of the resident's change in respiratory status with the use of the breathing treatments and cough medication. A nurse's progress note, dated [DATE] at 1:56 p.m., documented, Resident has been coughing pretty hard and BP has been elevated. Resident is requesting a Dr's appointment or have physician come see her here. Sent physician a fax. A nurse's progress note, dated [DATE] at 6:28 p.m., documented, Dr (Name deleted) came by and seen resident this afternoon. V/S (vital signs) are ,[DATE] ,[DATE] 96% 98.2 N.O. (new order) CBC Friday am. The February 2016 MAR indicated [REDACTED]. A nurse's progress note, dated [DATE] at 2:25 a.m., documented, Resident requested a breathing treatment and cough medicine due to coughing and not being able to go to sleep. Breathing treatment and [MEDICATION NAME] dm given at 0100 (1:00 a.m.) . The February 2016 MAR indicated [REDACTED]. The clinical record contained no documentation the resident's respiratory status had been assessed or monitored again after the entry on [DATE] at 2:25 a.m. A nurse's progress note, dated [DATE] at 12:22 p.m., documented, Resident c/o (complained of) cough at 0900 (9:00 a.m.) this am and genralized pain was given [MEDICATION NAME] 50mg po and tussis dm 10cc. pain is better at this time was given [MEDICATION NAME] dm at 1200 (12:00 p.m.) for cont with cough 10cc. The clinical record contained no documentation the resident's respiratory status had been assessed or monitored before or after the entry on [DATE] at 12:22 p.m. The February 2016 MAR indicated [REDACTED]. A nurse's progress note, dated [DATE] at 6:18 a.m., documented, Resident requested a breathing treatment due to cough, give at 0100 (1:00 a.m.). She rested good after treatment. No inhalation treatments or administration of cough medication were documented for [DATE]. The clinical record contained no documentation the resident's respiratory status had been assessed or monitored again after the entry on [DATE] at 1:00 a.m. A nurse's progress note, dated [DATE] at 4:55 a.m., documented, Resident requested cough med (medication) and Br (breathing). Tx (treatment) d/t ongoing cough. Request granted, upon finishing br tx stated she felt better. The February 2016 MAR indicated [REDACTED]. The clinical record contained no documentation the resident's respiratory status had been assessed or monitored before or after the entry on [DATE] at 4:55 a.m. The February 2016 MAR indicated [REDACTED]. The clinical record contained no documentation the resident's respiratory status had been assessed or monitored on [DATE]. The clinical record contained no documentation the physician had been notified of the resident's continued cough or continued use of the [MEDICATION NAME] inhaler or [MEDICATION NAME] cough medicine. A nurse's progress note, dated [DATE] at 11:37 a.m., documented, Resident has been having elevated blood pressures and pulses in the AM since [DATE]. Resident also cont (continues) to complain of coughing and wheezing. Residents voice is very hoarse and raspy. No elevated temp noted. Faxed physician to inform him of residents status. Awaiting reply. A nurse's progress note, dated [DATE] at 12:30 p.m., documented, Spoke with physician, new orders noted. The February 2016 MAR indicated [REDACTED]. The clinical record contained no documentation the resident's respiratory status had been assessed or monitored [DATE] after 12:30 p.m. The February 2016 MAR indicated [REDACTED] [DATE] pulse 64, [DATE] pulse 68, [DATE] pulse 66, [DATE] pulse 123, [DATE] pulse 100, [DATE] pulse 123, [DATE] pulse 110, [DATE] pulse 117, [DATE] pulse 122, [DATE] pulse 123, and [DATE] pulse 138. The clinical record contained no documentation the physician had been notified of the high pulse rates. A nurse's progress note, dated [DATE] at 12:30 p.m., documented, 0830 (8:30 a.m.) Res out for CXR (chest xray) at (Name deleted) lab-1230, received call from Dr. (Name deleted), received order for res to be direct admit to (Name deleted) hosp. (hospital) with DX (diagnosis) of bi-lateral pneumonia-Res transported per Private vehicle accompanied by staff member. Placed call to (Name deleted) niece informing her of res,s status and transfer-all paperwork sent with res upon time of transfer. The February 2016 MAR indicated [REDACTED]. The clinical record contained no documentation the resident's respiratory status had been assessed or monitored on [DATE], before the resident was sent to the hospital. The chest xray report for [DATE] documented, CHEST-TWO-VIEW, [DATE] at 0848 (8:48 a.m.) hours INDICATION: Cough FINDINGS: Moderate cardiomegaly. Infiltrate is present in the right lung in the midlung field and right lower lobe. There also appears to be mild patchy infiltrate in the axillary aspect of the left lung. These changes have appeared compared to old exam. [DATE]. CONCLUSION: BILATERAL [MEDICATION NAME]. A nurse's progress note, dated [DATE] at 6:06 p.m., documented, Resident expired at 1650 (4:50 p.m.) while at hospital stay with (Hospital name deleted). The hospital discharge summary documented, Admitting Dx: Bilateral [MEDICATION NAME] Pneumonia .Discharge Dx: [MEDICAL CONDITION] (CPR with intubation x 25 mins-no response) Admission was requested by Dr. (Name deleted) yesterday for severe cough, fever, congestion and CXR showing cardiomegaly and [MEDICATION NAME]. Pt was admitted by Dr. (Name deleted). Cultures were done. She was started on [MEDICATION NAME]/[MEDICATION NAME] and [MEDICATION NAME] and [MEDICAL CONDITION] toilet . A hospital history and physical documented, admitted d [DATE] .CHIEF COMPLAINT: cough, fever HISTORY OF PRESENT ILLNESS: 78 Y/O (year old) female admitted from NH (nursing home) with bilateral [MEDICATION NAME] Pneumonia identified by X-ray per radiology. She has been having cough, fevers, dyspnea and night sweats .RESPIRATORY: Patient admits dyspnea, shortness of breath, wheezing, chest congestion, and non-productive cough. On [DATE] at 10:55 a.m., a family member was interviewed. The family member reported he/she had visited the resident on the evening of [DATE] around 4:00 p.m. The family member reported the resident was still in her pajamas and the staff reported the resident had not eaten since the day before. The family member reported the resident had a cough and he/she had told LPN #1, who was on duty, the resident needed to go to the hospital. The family member reported the LPN told him/her she would call the doctor. He/she reported an hour later he/she went to the LPN to see what the doctor had said. He/she reported the LPN had not called the doctor but she said she would do so. The family member reported he/she had called back to the facility at 9:00 p.m. and had talked to a CMA who did not know if the LPN had called the physician. The family member reported he/she had talked to the activity director on [DATE]. He/she reported the activity director had reported there was no documentation the physician had been contacted. A late entry, dated [DATE], in the nurse's progress notes by LPN #1 documented, ON [DATE] I charted can not find charting in the computer. Called Dr. (Name deleted) on [DATE] about Res condition and of niece (Name deleted) concerns. VS-WNL slight wheeze in lower R (right) lobe. Orders continue breathing TX and watch her. An attempt was made to contact LPN #1 by phone and a message was left on the phone. The LPN did not return the call. On [DATE] at 3:25 p.m., the resident's physician was interviewed. The physician reported he had no record or memory of a call by LPN #1 on [DATE]. At 3:35 p.m., the ADON was interviewed. She was asked if LPN #1 had notified the physician would the physician remember the call. The ADON reported the physician wrote everything down and would be aware if LPN #1 had contacted him. The ADON reported if he had not been called he would say so. She was asked if the resident's respiratory status should have been monitored closer. She stated, Yes. It should have been monitored closer. She was asked if the resident's change in condition should have been monitored closer. She stated, Yes.

Based on record review and interviews, it was determined the facility failed to notify the resident physician of changes in the resident's respiratory status and pulse rate for one (#2) of three sampled residents reviewed for physician notification. Resident #2 was hospitalized on [DATE], seven days after the first documentation of increased pulse rates. A facility nurse's progress note documented the resident had expired at the hospital on [DATE]. A hospital discharge summary documented the resident had a [DIAGNOSES REDACTED]. The business office staff reported 52 residents resided in the facility. Findings: Resident #2 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented the resident had shortness of breath related to exertion and air-borne allergens. Care plan interventions included to administer the resident's medications as ordered, to monitor and document breathing patterns, to report abnormalities to the physician, such as respiratory depth changes, altered chest excursion, use of accessory muscles, pursed lip breathing or prolonged expiratory phase, and increased anteroposterior chest diameter. A physician's orders [REDACTED]. vial Order Date: [DATE] PRN (as needed)1 neb (nebulizer) vial per HHN (hand held nebulizer) TID (three times daily) PRN cough/congestion cough/congestion inhalent solution. A physician's orders [REDACTED]. A quarterly assessment, dated [DATE], documented the resident was cognitively intact, was independent with all ADLs with the exception of bathing, and was continent of bowel and bladder. The [DATE] medication administration records (MARs) were reviewed. Neither the [MEDICATION NAME] breathing treatment nor the [MEDICATION NAME] DM had been administered during the month of [DATE]. A nurse's progress note, dated [DATE] at 3:48 a.m., documented, PRN breathing treatment given. No other problems noted at this time. The February 2016 MAR indicated [REDACTED]. The [MEDICATION NAME] DM had been administered once on [DATE] at 8:30 a.m. The clinical record contained no documentation of the resident's respiratory status on [DATE] or [DATE]. The clinical record contained no documentation the physician had been notified of the resident's change in respiratory status with the use of the breathing treatments and cough medication. A nurse's progress note, dated [DATE] at 1:56 p.m., documented, Resident has been coughing pretty hard and BP has been elevated. Resident is requesting a Dr's appointment or have physician come see her here. Sent physician a fax. A nurse's progress note, dated [DATE] at 6:28 p.m., documented, Dr (Name deleted) came by and seen resident this afternoon. V/S (vital signs) are ,[DATE] ,[DATE] 96% 98.2 N.O. CBC Friday am. The February 2016 MAR indicated [REDACTED]. A nurse's progress note, dated [DATE] at 2:25 a.m., documented, Resident requested a breathing treatment and cough medicine due to coughing and not being able to go to sleep. Breathing treatment and [MEDICATION NAME] dm given at 0100 (1:00 a.m.) . The February 2016 MAR indicated [REDACTED]. A nurse's progress note, dated [DATE] at 12:22 p.m., documented, Resident c/o (complained of) cough at 0900 (9:00 a.m.) this am and generalized pain was given [MEDICATION NAME] 50mg po and tussis dm 10cc. pain is better at this time was given [MEDICATION NAME] dm at 1200 (12:00 p.m.) for cont with cough 10cc. The February 2016 MAR indicated [REDACTED]. A nurse's progress note, dated [DATE] at 12:22 p.m., documented, Resident requested a breathing treatment due to cough, give at 0100 (1:00 a.m.). She rested good after treatment. No inhalation treatments or administration of cough medication was documented for [DATE]. A nurse's progress note, dated [DATE] at 4:55 a.m., documented, Resident requested cough med (medication) and Br (breathing). Tx (treatment) d/t ongoing cough. Request granted, upon finishing br tx stated she felt better. The February 2016 MAR indicated [REDACTED]. The February 2016 MAR indicated [REDACTED]. The clinical record contained no documentation the physician had been notified of the resident's continued cough or continued use of the [MEDICATION NAME] inhaler or [MEDICATION NAME] cough medicine. A nurse's progress note, dated [DATE] at 11:37 a.m., documented, Resident has been having elevated blood pressures and pulses in the AM since [DATE]. Resident also cont (continues) to complain of coughing and wheezing. Residents voice is very hoarse and raspy. No elevated temp noted. Faxed physician to inform him of residents status. Awaiting reply. A nurse's progress note, dated [DATE] at 12:30 p.m., documented, Spoke with physician, new orders noted. The February 2016 MAR indicated [REDACTED]. There was no documentation the resident's respiratory status had been assessed or monitored [DATE] after 12:30 p.m. The February 2016 MAR indicated [REDACTED] [DATE] pulse 64, [DATE] pulse 68, [DATE] pulse 66, [DATE] pulse 123, [DATE] pulse 100, [DATE] pulse 123, [DATE] pulse 110, [DATE] pulse 117, [DATE] pulse 122, [DATE] pulse 123, and [DATE] pulse 138. The clinical record contained no documentation the physician had been notified of the high pulse rates before [DATE]. A nurse's progress note, dated [DATE] at 12:30 p.m., documented, 0830 (8:30 a.m.) Res out for CXR (chest exray) at (Name deleted) lab-1230, received call from Dr. (Name deleted), received order for res to be direct admit to (Name deleted) hosp. (hospital) with DX (diagnoses) of bi-lateral pneumonia-Res transported per Private vehicle accompanied by staff member. Placed call to (Name deleted) niece informing her of res,s status and transfer-all paperwork sent with res upon time of transfer. The February 2016 MAR indicated [REDACTED]. The chest xray report, taken on [DATE], documented, CHEST-TWO-VIEW, [DATE] at 0848 (8:48 a.m.) hours INDICATION: Cough FINDINGS: Moderate cardiomegaly. Infiltrate is present in the right lung in the midlung field and right lower lobe. There also appears to be mild patchy infiltrate in the axillary aspect of the left lung. These changes have appeared compared to old exam. [DATE]. CONCLUSION: BILATERAL [MEDICATION NAME]. A nurse's progress note, dated [DATE] at 6:06 p.m., documented, Resident expired at 1650 (4:50 p.m.) while at hospital stay with (Hospital name deleted.) The hospital discharge summary documented, Admitting Dx: Bilateral [MEDICATION NAME] Pneumonia .Discharge Dx: [MEDICAL CONDITION] (CPR with intubation x 25 mins-no response) Admission was requested by Dr. (Name deleted) yesterday for severe cough, fever, congestion and CXR showing cardiomegaly and [MEDICATION NAME]. Pt was admitted by Dr. (Name deleted). Cultures were done. She was started on [MEDICATION NAME]/[MEDICATION NAME] and [MEDICATION NAME] and [MEDICAL CONDITION] toilet . A hospital history and physical documented, admitted d [DATE] .CHIEF COMPLAINT: cough, fever HISTORY OF PRESENT ILLNESS: 78 Y/O (year old) female admitted from NH (nursing home) with bilateral [MEDICATION NAME] Pneumonia identified by X-ray per radiology. She has been having cough, fevers, dyspnea and night sweats .RESPIRATORY: Patient admits dyspnea, shortness of breath, wheezing, chest congestion, and non-productive cough. On [DATE] at 10:55 a.m., a family member was interviewed. The family member reported he/she had visited the resident on the evening of [DATE] around 4:00 p.m. The family member reported the resident was still in her pajamas and the staff reported the resident had not eaten since the day before. The family member reported the resident had a cough and he/she had told LPN #1, who was on duty, the resident needed to go to the hospital. The family member reported the LPN told him/her she would call the doctor. He/she reported an hour later he/she went to the LPN to see what the doctor had said. He/she reported the LPN told the family member she had not called the doctor but she would do so. The family member reported he/she had called back to the facility at 9:00 p.m., and had talked to a CMA who did not know if the LPN had called the physician. The family member reported he/she had talked to the activity director on [DATE]. He/she reported the activity director had told her there was no documentation the physician had been contacted. A late entry, dated [DATE], in the nurses' progress notes documented, ON [DATE] I charted can not find charting in the computer. Called Dr. Moore on [DATE] about Res condition and of niece (Name deleted) concerns. VS-WNL slight wheeze in lower R (right) lobe. Orders continue breathing TX and watch her. An attempt was made to contact LPN #1 by phone. The LPN did not return the call. On [DATE] at 3:25 p.m., the resident's physician was interviewed. The physician reported he had no record or memory of a call by LPN #1 on [DATE]. On [DATE] at 3:35 p.m., the ADON was interviewed. She was asked if LPN #1 had notified the physician would the physician remember the call. The ADON reported the physician wrote everything down and would be aware if LPN #1 had contacted him. The ADON reported if he had not been called he would say so. The ADON was asked if the resident's respiratory status should have been reported to the physician in a timely manner. She stated, Yes. It should have been reported earlier. She was asked if the resident's change in condition should have been reported to the physician. She stated, Yes.

Based on observation, record review and interview, it was determined the facility failed to notify the physician of the increased severe pain for one (#5) of one sampled resident who demonstrated signs and symptoms of pain. This had the potential to affect 20 residents the facility identified with [DIAGNOSES REDACTED]. Findings: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 05/13/11 documented: "Focus: Acute /chronic pain R/T arthritis... Goals: ...voice/display a level comfort acceptable to the resident through next review date...will verbalize adequate relief of pain or ability to cope with incompletely relieved pain... Interventions:...Anticipate need for pain relief and respond immediately to complaint of pain...Monitor/document verbal and non-verbal s/sx of pain..Notify physician of needed changes in pain medications...Provide [MEDICATION NAME] as ordered...Evaluate the effectiveness of pain interventions q shift...Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain..." A significant change assessment dated [DATE], documented the resident experienced almost constant pain over the last 5 days, with the intensity of the worst pain over the last 5 days as very severe, horrible. The assessment documented pain limited day-to-day activities over the past 5 days. Restorative progress notes documented, "03/09/12...Resident often says she cant do it or it hurts too bad to move... 03/16/12...Resident often says restorative hurts her too bad to continue, and that anything we do hurts. Resident for the most part does not refuse to participate in restorative, but she often stops in the middle of it... 04/06/12...Resident still needs to quit in the middle because ROM hurts her to (sic) bad to continue... 04/11/12...Resident unable to participate today during restorative program due to pain..." A physician progress notes [REDACTED]. The April 2012, monthly physician's orders [REDACTED]. The April 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The Medication Administration Records for March 2012 and April 2012, documented the resident's pain level to be 10 each day on the day and evening shift. On 04/10/12 at 3:13 p.m., an interview was conducted with the resident. She was asked to describe and rate her pain on a scale of 0-10 with 10 being the worst. She stated her pain level was 10, and was a constant throbbing with occasional to frequent stabbing type sensation to her knees and legs. She stated she received pain medication 5 times daily. She stated the pain medication helped most of the time for a couple of hours before it became severe again. She stated the pain made it difficult for her to sleep well at night. She stated the nurses and physician were aware of her level of pain, and the physician had told her she would always have some pain due to her severe [MEDICAL CONDITION]. She stated she had talked to the physician about learning to live with the pain. She stated she also had some BenGay to help with the pain, and heat applied to her knees also helped. During the interview, the surveyor observed the resident make grimacing facial expressions and rub her knees and legs. Occasionally the resident's legs would move in a spastic manner. The resident's eyes began to tear occasionally. On 04/10/12 at 4:40 p.m., the surveyor asked LPN #2 about the resident's pain. The LPN stated the current medication regimen never completely relieved the resident's pain. The LPN stated the resident currently rated her pain level 10. The LPN stated the physician had not been notified of the current pain level, but the physician was aware the resident rated her pain 9-10 most of the time. On 04/11/12 at 8:40 a.m., the surveyor asked the resident about her pain. The resident stated the pain in her legs and knees was the worst it had ever been. She stated her pain level was 11 on a scale of 0-10. The resident was crying and rubbing her legs and knees. Her legs were frequently moving in a spastic manner. She stated she had not received her pain medication at 3:00 a.m., as was scheduled. She stated the constant severe pain prevented her from sleeping well, as well as going to activities she liked and walking as she had in the past. She stated a tolerable pain level for her would be 5 on a scale of 0-10. On 04/11/12 at 8:45 a.m., the surveyor asked LPN #3 about the resident's pain level. She stated the resident had rated her pain at 10 and had noticed the resident crying. She stated she had not notified the physician but had noticed the resident's pain seemed to be worse than it had previously been. She stated pain levels were assessed daily and the physician was to be notified if the resident was still complaining of pain after pain medication was given. She stated she was to notify the physician of the resident's pain level weekly which should have been done yesterday and had not notified him yet. She stated the resident's pain level was usually 10 on a scale of 0-10. She stated the resident always rated her pain 10. The surveyor asked the LPN if a 10 rating was something the physician should be notified about. She stated the physician should be notified of unrelieved and worsened pain. On 04/11/12 at 10:00 a.m., the surveyor asked the IDON about the resident's pain. The IDON stated when she arrived at the facility at 5:30 a.m., that morning the resident was crying and complaining of extremely bad pain to her knees and legs. She stated she had never seen the resident with such severe pain. She stated the pain medication scheduled to be given at 3:00 a.m., had not been signed out by the night nurse and the resident told her she did not get the scheduled medication at 3:00 a.m., so she had given the resident that dose at 5:30 a.m. She stated she gave the scheduled 6:00 a.m. dose at 8:30 a.m. She stated she had not yet contacted the physician regarding the resident's complaint of 'extremely bad' pain. On 04/11/12 at 3:15 p.m., the surveyor asked the resident's physician about the resident's pain and pain medication regimen. The physician stated he had worked closely with the resident and her family for several years for the treatment of [REDACTED]. He stated during that time multiple variations of pain medications had been tried for acceptable pain relief for the resident. He stated a multiple medication regimen for pain control that seemed to be acceptable to the resident had been discontinued in February 2012, due to a change in her condition which involved increased lethargy and a decrease in her level of consciousness. He stated at that time he discontinued all the medications for pain control except [MEDICATION NAME] because of the change in condition. He stated since that time the resident's condition improved and she had told him she was okay with the current medication regimen even though she rated her pain at 9-10. He stated in the past the staff had communicated with him weekly about the resident's level of pain and sedation level, but did not expect that now since her condition had stabilized. He stated he would still expect the staff to notify him of any significant changes of the resident's pain. He stated he ensured the resident's pain level was tolerable by communication with the resident, her family and the staff. He stated the facility had not contacted him with any significant changes of her pain level until today. A 'Pain Assessment and Management' policy dated October 2010 documented, "The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain...The pain management program is based on a facility-wide commitment to resident comfort..."Pain management" is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals...Pain management is a multidisciplinary care process that includes the following:...assessing the potential for pain...effectively recognizing the presence of pain...monitoring for the effectiveness of interventions...modifying approaches as necessary...Report the following information to the physician...Significant changes in the level of the resident's pain...prolonged, unrelieved pain despite care plan interventions..."

Based on observation, record review and interviews, it was determined the facility failed to evaluate the effectiveness of pain medication and provide pain management for the relief of severe pain for one (#5) sampled resident resulting in actual harm. 21 residents were interviewed regarding pain. This had the potential to affect 20 residents the facility identified as receiving pain medication. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 05/13/11, documented: "Focus: Acute /chronic pain R/T arthritis... Goals: ...voice/display a level comfort acceptable to the resident through next review date...will verbalize adequate relief of pain or ability to cope with incompletely relieved pain... Interventions:...Anticipate need for pain relief and respond immediately to complaint of pain...Monitor/document verbal and non-verbal s/sx of pain..Notify physician of needled changes in pain medications...Provide [MEDICATION NAME] as ordered...Evaluate the effectiveness of pain interventions q shift...Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain..." A quarterly assessment dated [DATE], documented the resident's functional status was independent with bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene. The resident used a walker for mobility. The assessment documented the resident experienced almost constant pain over the last 5 days. The resident described the intensity of the worst pain over the last 5 days was very severe, horrible. The assessment documented pain made it hard to sleep and night and limited day-to-day activities over the past 5 days. An updated intervention dated 01/27/12, documented, "resident will participate in restorative care to upper and lower extremities 5x's weekly x 60 days..." The resident was transferred to (name deleted hospital) emergency roiagnom on [DATE], due to a change in condition related to possible oversedation. A significant change assessment dated [DATE], documented the resident's functional status was totally dependent with bed mobility and transfers. Walking did not occur. Dressing, eating, toilet use and personal hygiene required extensive assistance. The assessment documented the resident experienced almost constant pain over the last 5 days. The resident described the intensity of the worst pain over the last 5 days was very severe, horrible. The assessment documented pain limited day-to-day activities over the past 5 days. A physician's progress note dated 03/29/12, documented, "She notes her pain is still significant, but is doing okay with pain control...Impression: Severe [MEDICAL CONDITION] with pain...Plan:...Monitor closely, we will make adjustments as needed..." Restorative progress notes documented, "03/09/12...Resident often says she cant do it or it hurts too bad to move... 03/16/12...Resident often says restorative hurts her too bad to continue, and that anything we do hurts. Resident for the most part does not refuse to participate in restorative, but she often stops in the middle of it... 04/06/12...Resident still needs to quit in the middle because ROM hurts her to bad to continue... 04/11/12...Resident unable to participate today during restorative program due to pain." The April 2012 monthly physician's orders [REDACTED].[REDACTED] The Medication Administration Records for March 2012 and April 2012, documented the resident's pain level to be 10 each day on the day and evening shift. On 04/10/12 at 3:13 p.m., an interview was conducted with the resident. She was asked to describe and rate her pain on a scale of 0-10 with 10 being the worst. She stated her pain level was 10, and was a constant throbbing with occasional to frequent stabbing type sensation to her knees and legs. She stated she received pain medication 5 times daily. She stated the pain medication helped most of the time for a couple of hours before it became severe again. She stated the pain made it difficult for her to sleep well at night. She stated the nurses and physician were aware of her level of pain, and the physician had told her she would always have some pain due to her severe [MEDICAL CONDITION]. She stated she had talked to the physician about learning to live with the pain. She stated she also had some BenGay to help with the pain, and heat applied to her knees also helped. During the interview, the surveyor observed the resident make grimacing facial expressions and rub her knees and legs. Occasionally the resident's legs would move in a spastic manner. The resident's eyes began to tear occasionally. On 04/10/12 at 4:40 p.m., the surveyor asked LPN #2 about the resident's pain. The LPN stated the current medication regime never completely relieved the resident's pain. The LPN stated the resident currently rated her pain level 10. He stated he had not notified the physician of the current pain level, but the physician was aware the resident rated her pain 9-10 most of the time. On 04/11/12 at 8:40 a.m., the surveyor asked the resident about her pain. The resident stated the pain in her legs and knees was the worst it had ever been. She stated her pain level was 11 on a scale of 0-10. The resident was crying and rubbing her legs and knees. Her legs were frequently moving in a spastic manner. She stated she had not received her pain medication at 3:00 a.m. as was scheduled. She stated the severe pain prevented her from sleeping well, as well as going to activities she liked and walking as she had in the past. She stated she wanted the pain to be at a tolerable level for her, which would be 5 on a scale of 0-10. On 04/11/12 at 8:45 a.m., the surveyor asked LPN # 3 about the resident's pain level. She stated the resident had rated her pain at 10 and had noticed the resident crying. She stated she had not notified the physician but had noticed the resident's pain seemed to be worse than it had previously been. She stated the resident always rated her pain 10. The surveyor asked the LPN if a 10 rating was something the physician should be notified about. The LPN state she had not notified the physician because the resident's pain was always rated 10. On 04/11/12 at 10:00 a.m., the surveyor asked the IDON about the administration of the resident's pain medication. The IDON stated when she arrived at the facility at 5:30 a.m. that morning the resident was crying and complaining of extremely bad pain to her knees and legs. She stated she had never seen the resident with such severe pain. She stated the pain medication scheduled to be given at 3:00 a.m. had not been signed out by the night nurse, so she had given the resident that dose at 5:30 a.m. She stated she gave the scheduled 6:00 a.m. dose at 8:30 a.m. She stated she had not yet contacted the physician regarding the resident's complaint of 'extremely bad' pain. On 04/11/12 at 3:15 p.m., the surveyor asked the physician about the resident's pain and pain medication regimen. The physician stated he had worked closely with the resident and her family for several years for the treatment of [REDACTED]. He stated during that time multiple variations of pain medications had been tried for acceptable relief for the resident. He stated when the resident became oversedated in February 2012 he had discontinued the multiple medication regimen that had been seemed to be acceptable. He stated since that time the resident had told him she was okay with the current medication regimen even though she rated her pain at 9-10. He stated in the past the staff had communicated with him weekly about the resident's level of pain and sedation level, but did not expect that now since her condition had stabilized. He stated he would still expect the staff to notify him of any significant changes of the resident's pain. He stated he ensured the resident's pain level was tolerable by communication with the resident, her family and the staff. He stated the facility had not contacted him with any significant changes. A 'Pain Assessment and Management' policy dated October 2010 documented, "The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain...The pain management program is based on a facility-wide commitment to resident comfort..."Pain management" is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals...Pain management is a multidisciplinary care process that includes the following:...assessing the potential for pain...effectively recognizing the presence of pain...monitoring for the effectiveness of interventions...modifying approaches as necessary...Report the following information to the physician...Significant changes in the level of the resident's pain...prolonged, unrelieved pain despite care plan interventions..." A facility policy titled 'Change in a Resident's Condition or Status' documented, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status...The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:...A significant change in the resident's physical/emotional/mental condition..."