Every finding on record at Stilwell Nursing and Rehab

Based on record review and interview, the facility failed to ensure the estimated costs of services was included on form CMS-10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) for 3 (#37, 78, and #79) of 3 sampled residents reviewed for beneficiary notifications reviews. MDS Coordinator #1 stated there had been 28 discharges from Part A services in the past six months (09/01/24 through 04/01/25). Findings: A facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated September 2022, read in part, If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). 1. A document titled Form CMS-10055, dated 2024, showed Res #79 had signed the form on 10/28/24. The section of the document designated for the cost of skilled services the resident would be required to pay was blank. 2. A document titled Form CMS-10055, dated 2024, showed Res #78 had signed the form on 11/24/24. The section of the document designated for the cost of skilled services the resident would be required to pay was blank. 3. A document titled Form CMS-10055, dated 2024, showed Res #37's representative had signed the form on 01/29/25. The section of the document designated for the cost of skilled services the resident would be required to pay was blank. On 04/09/25 at 8:03 a.m., MDS coordinator #1 was asked the purpose for CMS form 10055. They stated it was to inform residents they were running out of Part A service coverage and to inform them of their rights to appeal the loss of coverage or to assume the costs themselves. They were asked to review the CMS-10055 forms for Residents #37, 78, and #79 and identify any missing information. They stated they did not see any. They were asked about the costs of services. They stated they were unaware of the need to put the costs of the services on the form. MDS Coordinator #1 stated they were still new at filling out the forms. They stated they were unaware if the facility had a policy and procedure for filling out the beneficiary notices. On 04/09/25 at 8:14 a.m., the DON stated the CMS-10055 purpose of the form was to inform residents of their rights to appeal the non-coverage and the type of services that would end along with their costs. After reviewing the CMS-10055 forms Res #39, 78, and Res #79 had signed, they stated the forms did not provide the cost of the skilled services. They stated the residents and their representatives needed that information to make their decision.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of infections for 1 (#40) of 3 sampled residents reviewed for wound care. The DON identified 12 residents received wound care. Findings: On 04/09/25 at 12:00 p.m., LPN #1 gathered supplies to complete wound care for the Res #40. LPN #1 donned a gown, mask, and a pair of gloves for the wound care. LPN #1 cleaned the resident's wounds to both lower extremities with wet gauze and disposed of the gauze in the trash container on the side of the treatment cart in the hall. LPN #1 did not change their gloves or wash their hands. LPN #1 applied calcium alginate (wound dressing) and a Kerlix (bandage roll) dressing to both lower legs and wrapped with Coban (a self-adherent wrap). LPN #1 removed their gown, mask, and gloves then placed them in a trash container on the side of the treatment cart in the hall. LPN #1 did not change their gloves or wash their hands during the wound care. A policy titled Wound Care, Revised October 2010, read in part, Wash and dry hands thoroughly .Put on exam gloves. Loosen tape and remove dressing .Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .Put on gloves .Pour liquid solutions directly on gauze sponges on their papers .Remove dry gauze. Apply treatments as indicated .Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into soiled laundry container. Remove disposable gloves and discard them into designated container. Wash and dry your hands thoroughly. An undated diagnoses list showed Res #40 had diagnoses which included congestive heart failure and pulmonary edema. Res #40's care plan, dated 07/05/24, showed the resident had potential/actual impairment to skin integrity related to fragile skin and impaired mobility. Res #40's quarterly assessment, dated 01/20/25, showed the resident was moderately impaired for decision making with a brief interview for mental status 12. The assessment showed the resident did not have pressure ulcers. A physician order, dated 04/04/25, showed the staff was to cleanse the right lower extremity of Res #40 with wound cleaner, pat dry, apply calcium alginate to the wound bed, cover with Kerlix, and wrap with Coban daily. On 04/09/25 at 12:10 p.m., LPN #1 stated they should change gloves and wash their hands before the wound care and after wound care. On 04/09/25 at 12:20 p.m., the DON stated LPN #1 should have changed their gloves and washed their hands between dirty and clean surfaces with wound care.

Based on record review and interview, the facility failed to ensure a binding arbitration agreement did not require mediation be held in a specific county of the state of Oklahoma for 1 (#45) of 3 sampled residents reviewed for binding arbitration agreements. The DON stated 76 residents at the facility were offered the opportunity to sign the facility's arbitration agreement. Findings: An undated facility document titled Mediation and Arbitration Agreement, read in part, It is understood and agreed by [blank line for resident's name] ('Resident' or 'Resident Authorized Representative') that in the event of any legal dispute, controversy, demand or claim that arises out of or related to the Admission Agreement or any service or health care provided by [NAME] Nursing Home (the 'Facility') to the Resident, such shall first be submitted to mediation, and not a lawsuit or resort to court process. Such mediation will be held in Tulsa County, Oklahoma in a place agreed to by the parties. A facility policy titled Binding Arbitration Agreements, dated November 2023, read in part, Residents (or representatives) are given the opportunity to suggest an arbitrator and a venue. If the facility disagrees with the resident's suggested arbitrator(s) and/or venue, the facility will document the reason and provide that documentation to the resident (or representative).Arbitration agreements provide for the selection of venue that is convenient to and suitably meets the needs of both parties. When selecting a venue for consideration, convenience for the resident (or representative) (sic) may be determined by his or her ability to get to the venue. An admission assessment for Res #45, dated 03/05/25, showed in Section C the resident had a BIMS score of 15 which indicated their cognition was intact. On 04/08/25 at 11:31 a.m., Res #45 was shown the binding arbitration agreement from their admission packet. They stated they had no recollection of signing the arbitration agreement, but agreed it was their signature. They stated they did not believe traveling to the required mediation site listed in the agreement would be convenient for them. On 04/09/25 at 08:20 a.m., the administrator was asked to review the facility's binding arbitration agreement and comment on any issues related to federal regulations. After looking at the arbitration agreement they stated the first paragraph mandated the arbitration occur in Tulsa County, Oklahoma and that did not meet the requirements. They stated they agreed the place for arbitration would be agreed upon by both parties. They stated they would have the part about arbitration being required to occur in Tulsa County removed from the current agreement. The administrator stated every resident was offered the opportunity to sign the current binding arbitration agreement.

Based on observation, record review, and interview, the facility failed to ensure there was a care plan intervention for tracheostomy self care for 1 (#60) of 1 sampled resident whose care plan was reviewed. The DON reported one resident with a tracheostomy resided at the facility. Findings: On 04/07/25 at 12:18 p.m., Resident #60 was observed to have a tracheostomy. A treatment administration record, dated 03/01/25 through 03/31/25, showed Resident #60 had diagnoses which included malignant neoplasm of the lung. Resident #60's care plan was reviewed. The care plan did not include self care for their tracheostomy. On 04/08/25 at 2:55 p.m., MDS coordinator #2 reviewed Resident #60's care plan. They stated Resident #60's self care of their tracheostomy was not care planned. They stated self care should have been added to their care plan. On 04/08/25 at 3:15 p.m., the DON stated Resident #60 performing self care for their tracheostomy should have been care planned.

Based on record review and interview, the facility failed to follow physician's orders for a diabetic for one (#17) of one sampled resident whose record was reviewed for insulin usage. The DON identified 24 residents who required insulin. Findings: Res #17 was admitted with diagnoses which included diabetes. A physician order, dated 04/11/23, read in part, Novolog Solution, inject as per sliding scale .for glucose over 450, recheck in 1 hour, if glucose is still above 401 call physician . The TAR for October 2023 was reviewed with the following findings: On 10/02/23 at 8:00 p.m., Res #17's blood sugar was 468. No documentation blood sugar was rechecked an hour later. On 10/03/23 at 6:00 a.m., Res #17's blood sugar was 571. No documentation blood sugar was rechecked an hour later. On 10/09/23 at 4:00 p.m., Res #17's blood sugar was 571. No documentation blood sugar was rechecked an hour later. On 10/10/23 at 11:00 a.m., Res #17's blood sugar was 500. No documentation blood sugar was rechecked an hour later. On 10/15/23 at 8:00 p.m., Res #17's blood sugar was 454. No documentation blood sugar was rechecked an hour later. On 10/29/23 at 8:00 p.m., Res #17's blood sugar was 470. No documentation blood sugar was rechecked an hour later. On 10/31/23 at 8:00 p.m., Res #17's blood sugar was 475. No documentation blood sugar was rechecked an hour later. The TAR for November 2023 was reviewed with the following findings: On 11/19/23 at 11:00 a.m., Res #17's blood sugar was 490. No documentation blood sugar was rechecked an hour later. On 11/22/23 at 4:00 p.m., Res #17's blood sugar was 524. No documentation blood sugar was rechecked an hour later. On 11/23/23 at 6:00 a.m., Res #17's blood sugar was 505. No documentation blood sugar was rechecked an hour later. On 12/13/23 at 10:40 a.m., the DON reported there was no documentation to show the nurses were rechecking Res #17's blood sugar as per physician's orders. The DON reported the physician's orders should have been followed and weren't.

Based on observation, record review, and interview, the facility failed to ensure food was palatable and at an appetizing temperature. The administrator identified 74 residents resided in the facility. Findings: 1. On 12/12/23 at 11:45 a.m., Res #24 stated they ate meals in their room. The resident stated the food was usually cold. On 12/12/23 at 9:03 a.m., Res #51 stated they ate in the dining room sometimes and sometimes in their room. The resident stated the food was always cold. 45913 2. On 12/13/23 at 1:24 p.m., a test tray was obtained as the last tray on Hall 6. The tray included black eyed peas with a temperature of 119 degrees; green beans at 111 degrees and did not taste seasoned; pork chop at 98 degrees which tasted lukewarm to cool; a roll at 109 degrees; and ice cream. On 12/14/23 at 11:35 a.m., CNA #1 reported the food was cold all the time and the residents complained of cold food. On 12/14/23 at 11:36 a.m., the DA reported the residents always complained of cold food. On 12/14/23 at 11:38 a.m., the DM stated. they had tried everything they could to help keep the food warm or hot and it still got cold. They stated the residents complained of cold food.

Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week. The administrator identified 74 residents who resided in the facility. Findings: A document titled, Time Care Report, documented an RN was not present in the building on the dates of 09/16/23 and 09/17/23 for the month of September. A document titled Time Care Report documented an RN was not present in the building on the dates of 10/08/23 for the month of October. A document titled Time Care Report documented an RN was not present in the building on the dates of 11/18/23, 11/19/23, 11/25/23, and 11/26/23 for the month of November. On 12/14/23 at 1:37 p.m., the DON stated they did have an RN in the facility every day for at least 8 hours per day. On 12/14/23 at 1:40 p.m., the administrator stated there was an RN in the facility every day. On 12/14/23 at 1:56 p.m., the BOM stated they were not aware that an RN was not here on certain days related to the corporate nurse never said anything about no RN coverage.

Based on observation and interview the facility failed to ensure trash cans were clean and in working order. The DON identified 73 residents who receive meals from the kitchen. Findings: On 12/11/23 at 9:30 a.m., there were three sensor trash cans in the kitchen. None of the trash cans were working and did not have foot pedals. All three trash can lids were covered with dried liquid, brown stains, and food debris. On 12/11/23 at 9:45, the DM reported the batteries in the trash cans were low and needed to be replaced. The DM reported the staff would have to raise the trash can lid with their hands to dispose of trash. The DM reported the trash cans were supposed to be cleaned on the weekend but they were not. On 12/13/23 at 11:45 a.m., the trash can beside the handwashing sink was covered in dried liquid and had food substances/debris on the outside lid, underneath the lid, and around the inside rim of the trash can. On 12/13/23 at 12:00 p.m., the DM reported the trash can beside the handwashing sink was not clean.

Based on record review and interview, the facility failed to update a comprehensive care plan when a resident developed a urinary tract infection for one (#54) of one sampled resident who was reviewed for an indwelling urinary catheter. The DON identified three residents who had an indwelling urinary catheter. Findings: Res #54 was admitted with an indwelling urinary catheter and had diagnoses which included neuromuscular dysfunction of the bladder and obstructive reflec uropathy. A review of the medical record showed Res #54 developed a urinary tract infection which was treated with antibiotics on the following dates: 07/14/23, 08/18/23, 09/22/23, and 09/28/23. The indwelling urinary catheter care plan for Res #54 did not address the resident's urinary tract infections. On 12/14/23 at 10:15 a.m., the DON reported the care plan should have been updated when Res #54 developed a urinary tract infection but it was not.

Based on record review and interview, it was determined the facility failed to ensure residents did not receive psychotropic medication, unless for a specific diagnosed condition, for one (#48) of five residents reviewed for unnecessary medication. The DON identified 17 residents who received psychotropic medication. Findings: Res #48 was admitted to the facility with diagnoses which included alcoholic cirrhosis of the liver, alcohol dependence with withdrawal, dementia, epilepsy, and hemiplegia and hemiparesis after non-traumatic intracranial hemorrhage. A physician order, dated 03/02/23, documented the resident was to receive Remeron (a antidepressant medication) 15 mg at bedtime for dementia. A physician order, dated 08/30/23, documented the resident was to receive Seroquel (a antipsychotic medication) 25 mg tablet with one 50 mg tablet totaling 75 mg three times a day for alcohol dependence with withdrawal and dementia. The quarterly assessment, dated 09/25/23, documented the resident was moderately impaired cognitively. The assessment documented the resident had a diagnosis of non-Alzheimer's dementia. The assessment did not document psychiatric/mood disorders for the resident. The assessment documented the resident received a antipsychotic and antidepressant medication seven times the last seven days. The care plan, dated 03/28/23, documented the resident used psychotropic medication related to behavior management. The staff were to educate the resident and/or family about risks, benefits, and the side effects of toxic symptoms. On 12/14/23 at 10:36 a.m., the DON stated the diagnoses identified for the use of the psychotropic medications was not appropriate.

Based on observation and interview, the facility failed to post the required information related to staffing and retain daily staffing information for the past 18 months. The administrator identified 74 residents who resided in the facility. Findings: On 12/11/23 at 10:30 a.m. and throughout the survey the staffing boards at both nursing stations did not include the facility name, census, and hours each employee worked. On 12/14/23 at 2:20 p.m., the DON reported they were not aware of the requirements regarding what information needed to be documented on the staffing board and did not retain the staffing information for 18 months.

Based on observation, record review, and interview, the facility failed to keep a urinary drainage bag off the floor to prevent infection for one (#54) of one sampled resident who was reviewed for an indwelling urinary catheter. The DON identified three residents who had indwelling urinary catheters. Findings: A Catheter Care, Urinary policy, last revised in September 2014, read in part, .Infection Control: .b. Be sure the catheter tubing and drainage bag are kept off the floor . Res #54 was admitted with an indwelling urinary catheter and diagnoses which included neuromuscular dysfunction of the bladder and obstructive reflux uropathy. On 12/11/23 at 11:45 a.m., Res #54's urinary drainage bag was on floor with the bedside table wheel on top of it. On 12/12/23 at 11:00 a.m., Res #54's urinary drainage bag was flat on floor underneath their bed. On 12/13/23 at 10:20 a.m., Res #54's urinary drainage bad was on the floor underneath bed. A progress note, dated 12/02/23 at 3:14 p.m., read in part, Foley catheter bag changed due to hole in the bag . A review of the medical record showed Res #54 developed a urinary tract infections, which was treated with antibiotics, on 07/14/23, 08/18/23, 09/22/23, and 09/28/23. On 12/13/23 at 10:25 a.m., Res #54 reported they tried to keep the drainage bag up off the floor but could not always lift the mattress to secure the drainage bag to the bed frame. Res #54 reported the staff did not consistently try to keep drainage bag up off the floor. On 12/14/23 at 10:15 a.m., the DON reported the staff should attempt to secure the drainage bag off the floor anytime it is on the floor to prevent infections.

Based on observation, record review, and interview, it was determined the facility failed to ensure the code status was identified and correct for one (#40) of five resident whose code status was reviewed. The administrator identified 74 residents who resided in the facility. Findings: Res #40 had diagnoses which included acute embolism and thrombosis or unspecified deep veins of left lower extremity, vascular dementia, Alzheimer's disease, and sarcopenia. On 06/07/23, a DNR was signed by the primary care physician. A significant change assessment, dated 06/09/23, documented the resident's cognitive skills were severely impaired and was dependent with ADLs. On 06/19/23, Res #40 was admitted to hospice. A physician order, dated 09/09/23, documented the resident's code status was DNR. On 12/11/23 at 10:55 a.m., an observation was made of a green sticker by resident's name on doorway, indicating the resident was a full code. On 12/13/23 at 2:30 p.m., CNA #3 stated the green sticker on the door meant the resident was a full code.

Based on record review and interview, the facility failed to notify OHCA of a new diagnoses of serious mental illness for two (#3 and #66) of three sampled residents whose PASARR records were reviewed. The DON identified 74 residents who residents in the facility. Findings: 1. Res #3 was admitted to the facility on [DATE] with diagnoses which included diabetes, atherosclerotic heart disease, hypertension, dementia, depression, and repeated falls. A PASARR I form, dated 01/09/23, documented the resident did not have a diagnosis of a serious mental illness. The EHR documented on 01/30/23 the resident received a diagnosis of major depressive disorder. On 12/13/23 at 3:04 p.m., the DON reviewed the resident's clinical record and stated a new diagnosis of serious mental illness was added to the resident's diagnoses list on 01/30/23. The DON stated a referral should have been made to the OHCA. 2. Res #66 was admitted on [DATE] with diagnoses which included depression and anxiety. A level I PASARR was completed on 04/26/23. On 08/28/23, Res #66 was diagnosed with bipolar disorder. There was no documentation OHCA was notified of Res #66's new diagnosis of bipolar disorder. On 12/14/23 at 8:00 a.m., the DON reported OHCA was not called when Res #66 was diagnosed with bipolar disorder and should have been.

Based on record review and interview, the facility failed to notify OHCA of a serious mental illness for one (#17) of three sampled resident whose Level I PASARR was reviewed. The administrator identified 74 resident who resided in the facility. Findings: Res #17 was admitted on [DATE] with diagnoses which included dementia, schizophrenia, bipolar disorder, and Parkinson's. A Level I PASARR was completed on 12/12/23, and OHCA was notified of Res #17's diagnoses of dementia and Parkinson's. There was no documentation to show OHCA was notified of Res #17's diagnoses of schizophrenia and bipolar disorder. On 12/14/23 at 10:15 a.m., the DON reported Res #17's diagnoses of schizophrenia and bipolar should have been communicated to OHCA and were not.

Based on record review, observation, and interview, the facility failed to follow the menu provided for one meal of five meals reviewed for menu accuracy. The Resident Census and Conditions of Residents form documented 67 residents ate meals from the menu. Findings: A Menu: [NAME] SS 2022 documented the evening meal for Sunday, 07/31/22, was garden vegetable soup, deli sandwich on bun, potato chips, sugar cookies and beverage of choice. On 07/31/22 at 4:30 p.m. meal trays were observed to contain baked macaroni and cheese with ham, buttered peas, and frosted gelatin poke cake. On 08/01/22 at 12:05 p.m. the RD reported the menu for 07/31/22 evening meal wasn't followed and should have been.

Based on record review and interview, the facility failed to implement and maintain an antibiotic stewardship program. The Resident Census and Conditions of Residents form documented 68 residents resided in the facility. Findings: The Antibiotic Stewardship policy, revised 12/16, read in parts, .the IP will monitor over time and report .measures of antibiotic use .antibiotic susceptibility patterns .and negative outcomes or events related to antibiotic use . The Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes policy, revised 12/16, read in parts, .Antibiotic usage and outcome data will be collected and documented .The data will be used to guide decisions for improvement of .facility-wide antibiotic stewardship. The Infection Control Summary forms from 01/22 to 05/22 contained no documentation. On 08/03/22 at 10:47 a.m., Corp RN #1 reported the IP had collected data on antibiotic use and resident infections, but the data had not been trended. She reported the IP had not been provided training on how to apply the data. On 08/03/22 at 11:00 a.m., the IP reported she had collected data on antibiotic use and had not utilized the data.

Based on record review, observation, and interview, the facility failed to prevent injury by assessing smoking safety for one (#14) of ten residents reviewed for smoking safety. The DON identified ten residents were smokers. Findings: A care plan, revised on 06/15/22, read in part, .Attendant to be with res when smoking . A nurse's note, dated 07/29/22, read in parts, .This nurse was given in report that this resident had a blister to her finger from smoking . Staff to monitor resident when she is smoking. A physician's order, dated 07/29/22, read in part, .BEHAVIORS - MONITOR FOR THE FOLLOWING: Resident has behaviors related to smoking such [sic] burning self. Document: .findings every day and night shift. A physician's order, dated 08/01/22, read in part, .clean right second finger with wound cleanser and pat dry, apply ATB [sic] and cover with bandage every day shift until resolved. An undated Smoking Policy - Resident, read in part, .A smoking risk assessment of a resident's cognitive ability, judgement, manual dexterity and mobility will be utilized to determine if a resident is deemed safe to smoke without supervision. The smoking risk assessment is done upon admission, annually, and more often if necessary. A Smoking Safety Screen, dated 08/02/22, read in parts, .had cognitive loss, smoked 5-10 cigarettes per day, in the morning, afternoon, and eve .Res cannot light own cigarette, res needs supervision, staff lights cigarette, facility needs to store lighter and cigarettes. all cigarette breaks are supervised by staff, safe to smoke with supervision. On 08/01/22 at 10:50 a.m., Res #14 was observed in the dining area with a bandage on their right second finger. On 08/02/22 at 8:25 a.m., Res #14 was observed in bed with a bandage on their right second finger. On 08/02/22 at 11:45 a.m., MDS coordinator #2 reported Res #14 had not had a Smoking Safety Screen completed prior to 08/02/22.

Based on record review, observation, and interview, the facility failed to update a care plan regarding smoking for one (#14) of ten residents reviewed for care plans. The DON reported the facility had ten residents who smoked. Findings: Res #14 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan last revised on 06/15/22, documented in part .Smoking attendant to be in smoke room at all times when resident is present. An assessment dated [DATE], documented Res #14 was moderately impaired with cognition. A nurse's note, dated 07/29/22, documented in parts .This nurse was given in report that this resident had a blister to her finger from smoking .Staff to monitor resident when she is smoking. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document: .findings every day and night shift. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/01/22 at 10:50 a.m., Res #14 was observed in the dining area with a bandage on their right second finger. On 08/02/22 at 8:25 a.m., Res #14 was observed in bed with a bandage on their right second finger. On 08/02/22 at 3:30 p.m., the DON reported Res #14's care plan should have been updated on 07/29/22 when the burn occurred, on 08/01/22 when orders were received for wound care, and on 08/02/22 when the Smoking Safety Assessment was done.

Based on record review and interview, it was determined the facility failed to provide residents with beneficiary notices for one (#20) of three sampled residents for beneficiary notices. The Discharge Summary Report documented 39 residents had been discharged in the past six months. Findings: A SNF Beneficiary Protection Notification Review for Res #20, dated 03/11/22 read in parts, .Medicare Part A Skilled Services Episode Start Date: 02/01/22 .Last covered day of Part A Services 03/11/22 .The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted The document showed Res #20 was neither provided a SNF ABN, nor a NOMNC. The document did not contain explanation why the forms were not provided. On 08/02/22 at 1:45 p.m., MDS #2 reported Res #20 had not been provided a beneficiary notice.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist, related to the failure of the facility to initiate CPR for two residents and failure to have a system in place to identify a resident's advanced directive/code status. The Oklahoma State Department of Health was notified and verified the IJ situation. At 4:52 p.m., the administrator, the director of nursing, and the corporate RN were informed of the IJ regarding failure to initiate CPR for two residents who had experienced [MEDICAL CONDITION] and failure to have a system in place to identify a resident's advance directive/code status. They were informed this placed the facility in an extended survey. At 6:03 p.m., an acceptable plan of removal was received from the administrator, the DON, and the corporate RN. The plan of removal documented: Plan of Removal Immediate Jeopardy Stilwell [DATE] 1) System initiated to immediately identify residents code status at bedside. A dot will be placed beside the resident name plate. Red dot will indicate Do Not Resuscitate (DNR) and Green dot will indicate Full Code. 2) List with resident's code status will be removed from the crash carts immediately by ADON. 3) Off-line computer back-up Face Sheet will be updated by 8:00pm on [DATE] with resident's documented code status by the QAPI RN. 4) Dots will be placed on residents rooms indicating documented code status by QAPI RN and ADON by 8:00pm on [DATE]. 5) Computer software will be updated with resident's documented code status by ADON by 9:00pm on [DATE]. 6) Director of Nursing will educate all staff on: a. Cardiopulmonary Resuscitation (CPR) Policy b. Identifying resident's code status at bedside with dot system and c. Computer and back-up offline system for identifying residents code status 7) Director of Nursing will educate all licensed nursing staff: a. Identifying residents who are Full Code and initiate CPR immediately when [MEDICAL CONDITION] occurs. b. Cardiopulmonary Resuscitation (CPR) Policy c. Identifying residents code status at bedside and computer and computer back-up identification system 8) Staff Education timeline by Director of Nursing: a. 3pm to 11pm staff will be educated by 7:00 pm b. 7am to 3pm staff will be called in and educated at 7:00pm c. 11 pm staff will be educated when coming on shift. d. All staff education will be completed by 11:59pm on [DATE]. An Addendum to the Plan of Removal Immediate Jeopardy Stilwell [DATE] 11:55pm, documented, (Name deleted), LPN = (name deleted) is currently in the hospital on medical leave as of [DATE] for a minimum of 30 days and will be educated by Director of Nurses before returning to work when medically cleared. (Name deleted), Housekeeping = (Name deleted) is currently on Medical Leave as of [DATE] until medically cleared. (Name deleted) will be educated by Director of Nurses before returning to work when cleared medically. (Name deleted), C.N.A. = Director of Nurses (Name deleted) spoke with (Name deleted) on [DATE] at 7:51pm and (Name deleted) states she is at (Name deleted) Hospital Tulsa with child who is in ICU. (Name deleted) is scheduled to return to work by Saturday [DATE] at 3pm and will be educated by Director of Nurses before returning to work. On [DATE] staff were interviewed regarding education of the CPR policy, code status identification with dots, and offline face sheet book, observations were made regarding the dots indicating code status, and the face sheet book was observed to be complete regarding residents' code status. The IJ was removed on [DATE] at 10:03 a.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on clinical record review and staff interviews, it was determined the facility failed to: ~ perform CPR and notify EMS for two (#92 and #13) of three sampled residents whose deaths had occurred within 30 days of admission to the facility; ~identify advance directives or code status for two (#92 and #13) of three residents whose deaths had occurred within 30 days of admission to the facility; and ~ failed to have a system in place to identify a resident's code status for two (#92 and #13) of three sampled residents whose death had occurred in the facility within 30 days of admission. The resident census and condition report documented 65 residents resided in the facility. Findings: An undated Cardiopulmonary Resuscitation (CPR) Policy, documented, Subject: Cardiopulmonary Resuscitation (CPR) Purpose: To provide guidance to staff regarding initiation of Cardiopulmonary Resuscitation (CPR) according to resident individualized advanced directives. Procedure: 1) Provide written information to residents about their rights to make decisions about medical care, including the resident's right to formulate advance directives at the time of admission with the resident's choice to initiate CPR or forego CPR in a medical emergency. 2) Staff should initiate CPR when [MEDICAL CONDITION] occurs for residents who: a. Have requested CPR in their advance directives b. Have not formulated an advanced directive c. Who do not have a valid Do Not Resuscitate (DNR) order d. Or do not show AHA signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) 3) When [MEDICAL CONDITION] occurs staff: a. Immediately call 911 and activate the EMS system b. Provide basic life support including initiation of CPR in accordance with resident's advance directives or in the absence directives or absence of DNR order. c. Continue CPR until the arrival of EMS. 4) CPR-certified staff will be available at all times to provide CPR when needed. 1. Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No Oklahoma Do-Not-Resuscitate (DNR) Consent Form was signed by the resident prior to admission or after admission. No advance directive indicating the resident's preference was documented. A care plan, dated [DATE], documented the resident was a full code. An admission assessment, dated [DATE], documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact for daily decision making. The assessment documented the resident required extensive assistance with activities of daily living, had a [MEDICATION NAME], was occasionally incontinent of bowel, [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITION], and artificial openings of the urinary tract. The assessment documented the resident had shortness of breath or trouble breathing with exertion, received oxygen therapy, had no documented prognosis of life expectancy of less than six months documented by the physician, had received occupational and physical therapy, and wanted to return to the community. A life support levels of care document, dated [DATE], documented the resident had signed he wanted, .Level 1 Every means of maintaining life available in this facility will be initiated. In the event of cardiac or [MEDICAL CONDITION] collapse, manual CPR will be initiated and the resident will be sent to the hospital immediately .I Do Want CPR Performed . A progress note, dated [DATE], documented, (resident's name deleted) (Full Code) .at 0230 was called to residents (sic) room by CNA, states resident is unresponsive. Upon entering room resident was noted to be pale in color. Resident was noted without resp or heart rate. Pupils fixed and dilated. Skin warm and dry. Call placed to Dr. (name deleted) at 0235, states to call time of death at 0235. At 0243 informed Admin (name deleted) and DON (name deleted) . No CPR was initiated by the staff prior to calling the doctor, the administrator, and the DON. On [DATE] at 2:46 p.m., CNA # 9 was asked what she would do if she came upon an unresponsive resident. She stated, I would notify the charge nurse. She was asked how she would know the resident's code status. She stated, There was no visible way of knowing but the nurses should know. At 2:48 p.m., CMA #3 was asked what she would do if she came upon an unresponsive resident. She stated, I'd contact the charge nurse. She was asked how she was awaare of what a resident's code status should be. She stated, It's on the Medication Administration Record [REDACTED] At 2:53 p.m., CNA #11 was asked what she would do if she came upon an unresponsive resident. She stated, I'd check the resident's vitals, contact the charge nurse and DON immediately, we carry walkie-talkies to get someone there quickly. She was asked how she knew what a resident's code status should be. She stated, There use to be a notification on the back of the resident's closet door, but nothing now. At 2:56 p.m., CNA #12 was asked what she would do if she came upon an unresponsive resident. She stated, I would check for a pulse and notify the charge nurse. She was asked how she knew what a resident's code status should be. She stated, It's on the computer and some resident's I know their code status. At 3:00 p.m., CNA #7 was asked what she would do if she came upon an unresponsive resident. She stated, I'd call the nurse on the radio. She was asked how she knew what a resident's code status should be. She stated, I'd have to look at the resident's chart or ask the nurse. At 3:03 p.m., CNA #8 was asked what she would do if she came upon an unresponsive resident. She stated, Call a code as documented on the back of my name badge. She looked at her badge and pointed to a code blue. She was asked how she knew what a resident's code status should be. She stated, Should be on the resident's care plan. At 3:10 p.m., LPN #5 was asked what she would do if she came upon an unresponsive resident. She stated, I would check vital signs and attempt to get a response. She was asked how she knew what a resident's code status should be. She stated, If no response, contact someone via walkie-talkie to check resident's status and to bring crash cart. Then start CPR immediately if resident is a full code. At 3:12 p.m., CNA #6 was asked what she would do if she came upon an unresponsive resident. She stated, I would contact the charge nurse by walkie-talkie. She was asked how she knew what a resident's code status should be. She stated, I think it is on the resident's ADL sheet. At 3:25 p.m., LPN #5 was asked how she knew what a resident's code status should be. She stated there was a list on the crash cart with the residents' name and was highlighted with those residents' who had a DNR status. The list was reviewed and was last updated on [DATE]. She was asked how often the list was updated and by whom. She stated, It was updated by the ADON periodically with new admissions. She was asked if the facility had new admissions since the list was last updated. She reviewed the list and stated, Yes, there had been new admissions and the list had not been updated since [DATE]. On [DATE] at 4:30 p.m., the DON and corporate nurse were asked about what occurred when a resident was found unresponsive and without signs of life. The DON stated if the resident was listed as a full code the nurse should have gotten the emergency cart to the room and attempted to resuscitate the resident. She stated we have two nurses at all times and the other nurse should have assisted with 911 activation and physician notification. She was asked how the staff knew who was a DNR or a full code. She stated on the computer and they had a book that has face sheets of the residents kept up front. She was asked how often it was updated. She stated with new admits and changes, and any changes to the face sheet. She stated the computer was updated as they got them. On [DATE] at 2:25 p.m., the DON was asked what system was in place to identify the residents' code status. The DON stated The social service director or the administrative assistant filled out the paperwork with the resident's code status and hand it over to the nurses. The nurses would update the orders and the administrative assistant would update the face sheet in the face sheet book and the face sheet in the computer. The DON was asked why the facility had not followed their CPR policy when a resident was found unresponsive. She stated, I do not have an answer. The DON was asked why the list on the crash cart had not been updated to include residents admitted after [DATE]. She stated, I don't have an answer, the list wasn't suppose to be there. The DON was asked why the computer had not been updated with the residents' current code status. She stated, System failure, is all I know. The DON was asked why the two charge nurses had not followed the facility policy regarding performing CPR for a full code resident. She stated, The nurse thought the resident was absent of vital signs and had no sign of life. The DON was asked why the charge nurses had called the doctor before calling emergency 911. The DON stated, The nurses should have started CPR first, designate someone to call 911, and then call the doctor. The DON was asked if the system for maintaining accurate code status for the residents was complete and accurate. She stated, The system was not working. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's admission orders [REDACTED].Code Status: Full Code . An undated Oklahoma do-not-resuscitate (DNR) consent form, documented the resident had written the letter X on the signature line of the form. The social services director had documented, Mr. (name deleted) stated he wants to be a DNR I explained both choices to him witnessed by (names deleted). The social services director also witnessed the resident sign with the letter X on an information of medical rights form and an authorization for use or disclosure of protected health information form. Both of the forms were dated [DATE]. A care plan, dated [DATE], documented the resident's code status was full code. An admission assessment, dated [DATE], documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. Monthly physician's orders [REDACTED].Code Status: Full Code . A nurse's note, dated [DATE], documented, Entered res room at 4:20 (a.m.) to do FSBS and res had no V/S. Immediately called Dr. (name deleted) and received order to not do CPR .Waiting notification of family to find out what funeral home to send body to. On [DATE] at 2:50 p.m., CNA #13 was asked how they identified a resident's code status. She stated the code status was listed next to the resident's name in the computer. She was asked how a resident's code status was identified if the computers were not working properly. She stated there was a book at the desk with a list of the residents and their code status. At 3:15 p.m., LPN #2 was asked how they identified a resident's code status. She stated on the computer/electronic record and printed out information at the front nursing station. She stated they were also listed in a book on the emergency cart. At 3:20 p.m., the social services director was asked about the advance directive/do not resuscitate form signed by the resident. She stated the resident was blind and had signed the form with an X. She was asked if the resident was cognitively intact to sign the form. She stated yes. She stated she had two other witnesses in the room and they all observed the resident sign the form after it was explained to him and he agreed to it. She was asked why the form was not dated. She stated she must have forgot to date the form. She stated the form was signed on [DATE] with the other admission forms. The SSD was asked why the electronic record was not updated to reflect the resident was not a full code after he signed the form and did not want to be resuscitated. She stated she was a new employee then and had not notified the DON and business manager to change the code status in the electronic record. She stated she should have copied the forms and dispersed them to the appropriate staff. On [DATE] at 4:30 p.m., the DON and corporate nurse were asked about what occurred when a resident was found unresponsive and without signs of life. The DON stated if the resident was listed as a full code the nurse should have gotten the emergency cart to the room and attempted to resuscitate the resident. She stated we have two nurses at all times and the other nurse should have assisted with 911 activation and physician notification. She was asked how the staff knew who was a DNR or a full code. She stated on the computer and they had a book that has face sheets of the residents kept up front. She was asked how often it was updated. She stated with new admits and changes, and any changes to the face sheet. She stated the computer was updated as they got them. She stated she had talked to the nurse regarding her failure to follow appropriate protocol/policy in an emergency situation when a resident was listed as a full code and resuscitation should have been initiated. The Front Hall Book with the resident's face sheets, which identified the resident's code status, was reviewed. Information for three current residents, #39, 59, and #200, were not in the book. On [DATE] at 12:24 p.m., the DON and corporate nurse were asked why the resident's code status information was not correct in the electronic record. The DON stated she did not know without reviewing the record. The corporate nurse stated, A communication breakdown. The DON was asked if the resident's code status should have been accurate on the care plan. She stated it should have been accurate and she would have to review the resident's record to be more clear on what had occurred. No further information was provided. At 1:37 p.m., MDS/care plan coordinator #1 was asked if the resident's code status should be accurately addressed on the care plan. She stated she did not get a copy of any information regarding the resident's code status and had not addressed it on the care plan. On [DATE] at 2:25 p.m., the DON was asked what system was in place to identify the residents' code status. The DON stated The social service director or the administrative assistant filled out the paperwork with the resident's code status and hand it over to the nurses. The nurses would update the orders and the administrative assistant would update the face sheet in the face sheet book and the face sheet in the computer. The DON was asked what system was in place to identify a resident's code status if the computers are not working. She stated, The face sheet book. The DON was asked what training or education had been done since the facility transitioned from a hard clinical record to an electronic record regarding identification of a resident's code status. She stated, We showed them where the code status was located on the face sheets and demonstrated where the code status was documented on the computer. The DON was asked why the facility had not followed their CPR policy when a resident was found unresponsive. She stated, I do not have an answer. The DON was asked why the list on the crash cart had not been updated to include residents admitted after [DATE]. She stated, I don't have an answer, the list wasn't suppose to be there. The DON was asked why the computer had not been updated with the residents' current code status. She stated, System failure, is all I know. The DON was asked why the two charge nurses had not followed the facility policy regarding performing CPR for a full code resident. She stated, The nurse thought the resident was absent of vital signs and had no sign of life. The DON was asked why the charge nurses had called the doctor before calling emergency 911. The DON stated, The nurses should have started CPR first, designate someone to call 911, and then call the doctor. The DON was asked if the system for maintaining accurate code status for the residents was complete and accurate. She stated, The system was not working.