Every finding on record at The Grand at Bethany Skilled Nursing and Therapy

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental illness to the OHCA for a level II PASARR evaluation for 1 (#4) of 1 sampled resident reviewed for PASARR.The ADON identified 110 residents resided in the facility. Findings:A level I PASARR, dated 03/22/16, showed Resident #4 had a primary diagnosis of cerebrovascular accident. The PASARR did not show Resident #4 had been diagnosed with a serious mental illness.An admission record, dated 03/11/25, showed Resident #4 was diagnosed with schizophrenia on 11/22/22.A quarterly assessment, dated 12/10/25, showed Resident #4 routinely received antipsychotic medication.A physician's order, dated 12/16/25, showed Resident #4 received olanzapine 2.5 mg (an antipsychotic medication) at bedtime. A review of Resident #4's health record did not show they were screened for a level II PASARR when they received the new diagnosis of schizophrenia on 11/22/22. On 01/05/26 at 12:10 p.m., corporate nurse #1 stated after Resident #4 was diagnosed with a serious mental illness the facility should have referred them for a level II evaluation.On 01/07/26 at 2:40 p.m., MDS coordinator #2 stated when a resident got a new diagnosis of a serious mental illness they should be referred to the OHCA for a level II screening.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed to include a hearing aid for 1 (#1) of 24 sampled residents reviewed for comprehensive care plans. The ADON identified 110 residents resided in the facility.Findings:On 12/30/25 at 12:02 p.m., Resident #1 was observed not wearing hearing aids.A Comprehensive Activity Assessment, dated 9/26/25, showed Resident #1's hearing in both the left and right ear was adequate when using hearing aids.A 5-day assessment, dated 09/27/25, showed Resident #1's cognition was moderately impaired with a BIMS score of 12. The assessment showed Resident #1 did not use hearing aids or other hearing appliances during the assessment.An admission assessment, dated 10/19/25, showed Resident #1 was wearing hearing aids and had minimal difficulty hearing during the assessment. The assessment showed Resident #1's cognition was moderately impaired with a BIMS score of 12. Resident #1's care plan, dated 11/05/25, did not have a focus, goal, and interventions to address hearing aids were used as an intervention to address the resident's communication problem and hearing deficit.Physician progress notes, dated 11/06/25 and 11/11/25, showed Resident #1 was hard of hearing, and used hearing aids for communication.On 12/30/25 at 12:02 p.m., Resident #1 stated they did not know where their hearing aids were at but would like staff to help find them.On 01/05/26 at 12:13 p.m., CMA #1 stated they were not aware Resident #1 had hearing aids.On 01/05/26 at 12:22 p.m., CMA #2 stated Resident #1 had hearing aids, glasses, and misplaced them sometimes. CMA #2 stated the hearing aids should be in the care plan.On 01/05/26 at 1:14 p.m., the ADON stated the hearing aids should be a part of the care plan.On 01/05/26 at 1:16 p.m., MDS coordinator #1 stated Resident #1's hearing aids were not in their care plan to address the resident's communication problem and hearing deficit. MDS Coordinator #1 stated hearing aids should be in the care plan, orders, and tasks.On 01/07/26 at 1:25 p.m., regional director #1 stated there was no care planning policy, and the facility followed the resident assessment instrument manual.

Based on record review and interview, the facility failed to ensure a care plan for vision had interventions included for orientation, education, and guidance about the facility for a blind resident for 1 (#17) of 1 sampled resident who's care plan was reviewed. The ADON identified 110 residents resided in the facility.Findings:An admission assessment, dated 11/04/25, showed Resident #17's vision was Severely impaired-no vision or sees only light, colors or shapes; eyes do not appear to follow objects.An undated care plan did not show how the staff assisted Resident #17 with mobility or guidance about the facility.On 12/30/25 at 2:00 p.m., Resident #17 stated they had not been shown how to get around the facility. They stated the staff did not assist them to and from the dining room. Resident #17 asked other residents to assist them and felt like the staff were not aware of the assistance they needed. On 12/30/25 at 2:04 p.m., Resident #17 stated their vision was all black and could not see anything. On 01/02/26 at 2:39 p.m., MDS coordinator #1 stated the resident would gain familiarity and independence about the facility by way of constant intervention. MDS Coordinator #1 stated the staff let the resident know their environment and helped them. They stated if the resident could not read the menu, the staff had to assist. They stated it was in the task list (a portion of the electronic medical record for the staff to refer to for the Resident needs), and it was on the care plan to assist with meals.On 01/02/26 at 2:46 p.m., MDS coordinator #1 stated they did not see any specifics about there being an intervention for how to assist Resident #17 and what they needed assistance with. MDS Coordinator #1 stated the care plan only showed to assist them. MDS Coordinator #1 stated they did not have a process in place for assisting blind residents. MDS Coordinator #1 stated they needed to start looking at that.

Based on record review and interview, the facility failed to perform an assessment before and after dialysis for 1 (#129) of 1 sampled resident reviewed for dialysis. The administrator identified seven residents received dialysis. Findings:A blank dialysis communication form was reviewed. The form consisted of two sections, section A and section B. The form showed the pre-dialysis section (section A) was to be completed by the nursing facility and sent with the resident to the dialysis unit. The form showed the post-dialysis section (section B) was to be completed by the dialysis facility's nursing staff and the form returned to the facility with the resident. The form did not provide a section for the facility to document their own post-dialysis assessment.A dialysis communication form, dated 10/15/25, showed the following: the resident's pre-dialysis weight was documented as taken on 10/13/25 and section B was empty of documentation. A dialysis communication form, dated 10/17/25, showed the following: the resident's pre-dialysis weight was documented as taken on 10/13/25; and the resident's pre-dialysis temperature, pulse, and respirations were documented as taken on 10/17/25 at 12:20 a.m. A dialysis communication form, dated 10/20/25, showed the following: the resident's pre-dialysis weight was documented as taken on 10/13/25; the resident's pre-dialysis temperature and respirations were documented as taken on 10/20/25 at 12:46 a.m.; and the resident's pre-dialysis blood pressure and pulse were documented as taken on 10/20/25 at 9:30 a.m. A dialysis communication form dated 10/22/25, showed the following: the resident's pre-dialysis weight was documented as taken on 10/13/25 and section B was empty of documentation. A dialysis communication form dated 10/24/25, showed the following: the resident's pre-dialysis weight was documented as taken on 10/13/25; the resident's pre-dialysis temperature, pulse, and respirations were documented as taken on 10/24/25 at 12:42 a.m.; and section B was empty of documentation. A dialysis communication form, dated 10/27/25, showed the following: the resident's pre-dialysis weight was documented as taken on 10/13/25; the resident's pre-dialysis pulse, temperature, and respirations were documented as taken on 10/27/25 at 06:05 a.m.; and the resident's pre-dialysis blood pressure was documented as taken on 10/27/25 at 9:17 a.m.A dialysis communication form dated 12/29/25, showed the following: the resident's pre-dialysis weight was documented as taken on 12/28/25 and section B was empty of documentation. A dialysis communication form dated 12/31/25, showed the following: there was no documentation for the resident's pre-dialysis assessment for the presence of a thrill, bruit, dialysis site examination, or peripheral pulses; the resident's pre-dialysis weight was dated as taken on 12/28/25; the resident's pre-dialysis blood pressure, pulse, temperature, and respirations were documented as taken on 12/31/25 at 12:07a.m.; and section B was empty of documentation. The clinical record was reviewed for the above dates. There was no documentation of when the resident left for dialysis or returned from on the above dates. There was no documentation of how the resident presented to the facility after dialysis (i.e. what were the resident's vital signs upon their return to the facility; what did the resident's dialysis port/fistula look or sound like upon their return; what the resident's pulses were like in their extremities; what was the condition of the resident's site dressing immediately upon their return; how did the resident behave upon return; and did the resident have any complaints) for the above dates. On 01/07/26 at 10:30 a.m., Resident #129 stated the facility staff performed a pre-dialysis assessment, but not a post-dialysis assessment. On 01/07/26 at 11:10 a.m., LPN #1 stated when a resident returned from dialysis, they documented into the electronic medical record, what the dialysis center staff wrote on the dialysis communication form for section B. LPN #1 stated they performed their own post dialysis assessment if the dialysis center failed to document anything on the dialysis communication form. LPN #1 stated they checked the dialysis site for bleeding during their shift, but did not perform an assessment. LPN #1 stated they did not check the thrill and/or bruit, or the resident's vital signs when the resident returned from dialysis. LPN #1 stated when they checked the resident for bleeding post-dialysis, they did not document it, they only charted what was written on the dialysis communication form by the dialysis center staff. On 01/07/26 at 11:30 a.m., LPN #2 stated Resident #129 returned from dialysis on their shift. LPN #2 stated they transcribed what the dialysis center staff wrote on the dialysis communication form for section B into the resident's electronic medical record. LPN #2 stated when they sent a resident to dialysis, they fill out the dialysis communication form, check the resident's dialysis fistula or port, obtain their vital signs, obtain their pre-dialysis weight, and document it on the dialysis communication form. LPN #2 stated the dialysis center staff checked the resident's pre-dialysis weight as well as their post-dialysis weight and obtained post dialysis vital signs. LPN #2 stated that information was written on the dialysis communication form by the dialysis nurse and then the facility nurse entered the written information into the resident's electronic medical record. LPN #2 stated they checked the resident's vital signs when the resident returned from dialysis to make sure the resident's vital signs were stable, but they did not document the vital signs taken nor perform an assessment, they just checked to see if the resident's vital signs were stable. LPN #2 reviewed the dialysis communication forms dated 12/31/25. LPN #2 stated they worked on 12/31/25 and were responsible for transcribing the dialysis communication form into the resident's electronic medical record, but must have forgotten to transcribe the information when Resident #129 returned from dialysis. On 01/07/26 at 12:40 p.m., the ADON stated the post dialysis assessment documentation was written by the dialysis center's staff and transcribed into the resident's electronic medical record by the facility charge nurse on shift when the resident returned from dialysis. The ADON stated any additional information, like medications given during or post dialysis, were transcribed as well. The ADON stated the nursing home staff should assess the resident upon their return but, did not have a place to document their assessment. The ADON stated the facility nurses just documented what the dialysis center wrote on their communication form and to the ADON's knowledge, did not document their own assessment. On 01/07/26 at 1:40 p.m., corporate nurse consultant #2 stated the facility nurses documented the post assessment information provided by the dialysis center and section B of the dialysis communication form was there to show the facility communicated with the dialysis centers. Corporate Nurse Consultant #2 stated the treatment sheet documented the nurse checked the resident's thrill/bruit every shift, observed the fistula site for signs and symptoms of trauma and/or infection every shift, and removed the fistula dressing four hours after dialysis treatment. Corporate nurse Consultant #2 stated the nursing staff did not document when the resident returned from dialysis, when the nurse checked the resident's thrill/bruit, when the nurse observed the fistula site for signs and symptoms of trauma and/or infection, what time the nurse removed the fistula dressing, nor what the resident's dressing/fistula site looked like when the nurse removed the dressing. Corporate Nurse Consultant #2 stated they did not know if the staff documented how the resident felt or acted/behaved upon return from dialysis.

Based on record review and interview, the facility failed to ensure a resident received care and services to prevent pressure ulcers from developing or worsening for 1 (#1) of 3 sampled residents reviewed for pressure ulcer treatment.The administrator reported 103 residents resided in the facility.Findings: Resident #1s monthly physician orders showed resident was admitted to facility on 12/17/24, with the following diagnoses: history of cardiac arrest resulting in anoxic brain damage, congestive heart failure, hypernatremia, acute respiratory failure with hypoxia, acute kidney injury, and PEG tube status. A skin assessment, dated 12/17/24, showed sacrum with redness and superficial breakdown and had treatment order: cleanse bilateral buttocks with normal saline solution, pat dry, apply Triad cream twice daily and as needed for 14 days for wound prevention. A skin assessment, dated 12/22/24, read in part, Shearing to sacrum, with treatment order in place for wound management, which documented resident has pillow in place underneath 1 side to offload pressure. [Resident #1's family member] confirmed understanding. Will continue to monitor and provide prevention as ordered.A wound care note titled Woundynamics, dated 12/23/24, read in part, stage III pressure injury pressure ulcer, and has received a status of unhealed. Wound measurements, 6cm X 11cm X 0.2cm and small amount of serosanguineous drainage noted. Apply triad cream BID cover wound with bordered foam 4X4.On 08/18/25 at 3:24 p.m., a telephone interview with Resident #1's family member was conducted. They reported Resident #1 obtained a bed sore while a resident at this facility. The family member reported the wound initially looked like a scratch from square fingernails. Resident #1's family member reported Resident #1 was not receiving enough water and was not turned and repositioned as needed. They stated when family visited, they would have to go find nurses to turn Resident #1. On 08/18/25 at 4:03 p.m., the DON reported Resident #1 was not skilled appropriately due to being total care with lots of edema. The DON reported addressing all of Resident #1's family member's concerns. The DON reported the nurse who documented the shearing may not have been as accurate as the wound care person when staging pressure wounds.

Based on observation, record review, and interview, the facility failed to ensure assessments were accurate for 2 (#1 and #3) of 2 sampled residents reviewed for accuracy of assessments. The DON identified 94 residents resided in the facility. Findings: 1. Resident #1's care plan, dated 02/07/25, showed they were admitted on [DATE] and discharged on [DATE] with diagnosis which included unspecified dementia, hypotension, syncope and collapse, and arteriosclerotic heart disease of native coronary artery without angina pectoris. Resident #1's admission assessment, dated 05/07/24, showed their cognition was moderately impaired for decision making with a BIMS score of 10. The assessment showed the resident was at risk for pressure ulcers/injuries and did not have one or more unhealed pressure ulcers upon admission and did not have any unhealed deep tissue injuries upon admission. Resident #1's discharge assessment, dated 03/08/25, showed the resident had one unstageable pressure ulcer/injury that were present upon admission/entry or reentry and two unstageable deep tissue injuries present upon admission or reentry. 2. On 04/23/25 at 3:13 p.m., Resident #3 was observed in bed and was edentulous (no natural teeth or tooth fragments). Resident #3's care plan, dated 04/09/25, showed they were admitted on [DATE] with diagnoses which included pressure ulcers and atherosclerosis. Resident #3's admission assessment, dated 05/22/24, showed their cognition was moderately impaired for decision making with a BIMS score of 12. The assessment showed the resident was not edentulous (no natural teeth or tooth fragments). Resident #3's quarterly assessment, dated 03/08/25, showed the resident did not have difficulty chewing. On 04/23/25 at 3:13 p.m., Resident #3 stated they had no natural teeth in their mouth, did not have dentures, and had difficulty chewing food. On 4/23/25 at 4:03 p.m., a family representative stated Resident #3 was admitted without natural teeth. On 04/24/25 at 11:07 a.m., the DON was shown Resident #3's admission assessment, dated 05/22/24. They were asked what section L documented. The DON stated section L was not accurate because the resident was admitted edentulous. On 04/24/25 at 11:54 a.m., the MDS coordinator was shown Resident #3's admission assessment, dated 05/22/24, section L. They were asked what was documented. They stated it showed Resident #3 was not edentulous. They stated the assessment was not accurate because the resident was edentulous upon admission. The MDS coordinator was showed resident #1's discharge assessment dated [DATE]. They stated the assessment was not accurate based upon it documented the resident had two unstageable deep tissue injuries present upon admission and one unstageable pressure/ulcer injury that was present upon admission.

Based on record review and interview, the facility failed to ensure appointments were scheduled for 1 (#1) of 3 sampled residents reviewed for appointments. ADON #1 identified 95 residents resided at the facility. Findings: A Procedural Visit note from a local eye specialty hospital, dated 10/15/24, showed to follow up in about four months (around 02/15/25). There was no documentation located in the resident's clinical record which showed the follow up appointment had been scheduled. Resident #1's annual assessment, dated 10/16/24, showed the resident's vision was highly impaired. The assessment showed the visual function care area was triggered related to the resident's diagnoses of glaucoma and macular degeneration. Resident #1's quarterly assessment, dated 01/07/25, showed the resident's vision was highly impaired. It showed the resident's brief score for mental illness was 15, which indicated the resident's cognition was intact. On 04/07/25 at 1:20 p.m., Resident #1 stated they had missed an eye appointment in February 2025. They stated they thought it was forgotten about, but they were not sure. On 04/08/25 at 1:54 p.m., ADON #3 stated they started making the residents' doctor's appointments around October 2024. They stated if the residents expressed the need to see a physician outside of the facility, they made the appointment for them and sat up transport. ADON #3 stated Resident #1's family member complained the resident had missed an eye appointment. ADON #3 stated when they called the eye specialty hospital, the hospital confirmed Resident #1 had missed an appointment in February 2025. ADON #3 was asked why Resident #1 had missed the appointment. They stated they were not sure but stated staff might not have communicated it.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff could identify a resident's code status in an emergency. Resident #1 became unresponsive while in the whirlpool tub and CPR was initiated before the resident's code status was confirmed. The resident had a DNR in place. On [DATE] at 5:56 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 6:09 p.m., the administrator and regional RN were notified of the IJ situation and provided the IJ template. On [DATE] at 5:29 p.m., the administrator was notified of an amended IJ template related to Resident #1's code status via telephone. On [DATE] at 5:49 p.m., an amended IJ template was provided to the administrator and the regional RN via email. On [DATE] at 11:03 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated [DATE], read in part, Plan of removal of IJ XXX[DATE] .The facility will observe resident's DNR code wishes.Removal Plans must include: . 1. How facility will ensure harm will not occur or recur; .In-service all staff regarding resident code status and proper procedure [DATE].Audit to verify all current residents' code status.Compliance rounds continued daily since ,d+[DATE].In-service all staff regarding resident code status and proper procedure [DATE]. 2. Date of implementation- planned implementation (actions do not need fully resolved prior to the survey team exiting the organization) XXX[DATE] . 3. Identify those recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and .Residents that have a valid DNR in place. 4. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.In-service all staff regarding resident code status and proper procedure on ,d+[DATE] and ,d+[DATE].Audit to verify all current residents' code status.The likelihood for serious harm to any resident no longer exists effective [DATE].QAPI meeting held to review .Root cause analysis of event.Plan of correction implemented on [DATE], and continued with compliance rounds and education through [DATE] at 8:00 p.m.The pan [sic] continues to be monitored by QA committee. The IJ was lifted, effective [DATE] at 8:00 p.m., when all components of the plan of removal had been completed. The deficiency remained at an isolated level with the potential for more than minimal harm. Based on observation, record review and interview, the facility failed to ensure the code status was verified before CPR was initiated for a resident who had become unresponsive in the whirlpool tub for 1 (#1) of 3 sampled residents reviewed for advanced directives. The administrator identified 114 residents resided in the facility. Findings: On [DATE] at 8:15 p.m., green and red color coded name plates were observed at each residents' door. The facility policy titled DNR, Advance Directives and End of Life Decisions, dated [DATE], read in part, It is the policy of the Facility to comply with a Resident's Advanced Directive and Do Not Resuscitate Consent.The facility should implement a procedure for identifying the DNR/code status for all resident in the facility .For example, the facilty could implement the following procedure .Residents with DNR Orders are identified by placing a red name plate on the door to the Resident's room. The original or a cop of the DNR Order will be placed in a red folder in the front of the Resident's chart .Residents with no DNR Order are identified by placing a green name plate on the door to the Resident's room. Resident #1 had diagnoses which included chronic obstructive pulmonary disease, hypertension, recurrent depressive disorder, diabetes with history of ketoacidosis with coma, transient ischemic attack, and cerebral infarction without residual deficits, dysphagia, and acute pylonephritis. A document titled OKLAHOMA DO NOT RESUSCITATE (DNR) Consent Form showed Resident #1 signed the consent on [DATE]. Resident #1's care plan, dated [DATE], read in part, [Resident #1] has a DNR.If [Resident #1] has no respirations or heartbeat, DO NOT START CPR. A physician's order, dated [DATE], showed the resident was a DNR. Resident #1's quarterly assessment, dated [DATE], showed the resident's BIMS was 15 which indicated the resident's cognition was intact. A nurse's progress note for Resident #1, dated [DATE] at 9:20 p.m., read in part, Staff alerted this nurse that res was unresponsive in the whirlpool. This nurse responded immediately, Res was sitting in whirlpool with head titled back and back was up against the whirlpool. Resident was lowered to the floor. No rise and fall of the chest, no pulse present, no response to chest rub. CPR was initiated chest compressions 30:2 given, and continued to be administered until [emergency medical service] arrived. [emergency medical service] arrived and took over code. Resident pronounced deceased at 2140 [9:40 p.m.] [Name withheld] on call for [physician name withheld] notified at this time. On [DATE] at 9:25 p.m., CNA #2 stated CNA #1 was in the hall and notified them Resident #1 was in the whirlpool and not breathing. CNA #2 stated they went to the whirlpool room, felt to see if Resident #1 had a pulse, did a sternal rub and chest compressions, while CMA #1 went to get LPN #1. CMA #2 stated when LPN #1 arrived they got Resident #1 out of the whirlpool tub and onto the floor and started doing chest compressions with no response from the resident. CNA #2 stated they had an in-service about not leaving residents in the whirlpool tub alone and could not remember any other in-service after this happened on [DATE]. The CNA did not state they had an in-service about CPR. On [DATE] at 9:40 p.m., CMA #1 was asked how they identified a resident's code status in an emergency. CMA #1 did not answer. They were asked what the red and green colors meant on the resident name plates on the doors. CMA #1 stated the green color indicated the resident could move a little bit and the red meant the resident needed help. They were asked what they would do if a resident's heart stopped or the resident quit breathing. CMA #1 stated they would check the resident's pulse and start CPR until they were told the resident was a DNR. CMA #1 stated Resident #1 was found unresponsive in the whirlpool tub on [DATE] by CNA #1. CMA#1 stated they assisted with getting the resident out of the whirlpool tub and the nurses started CPR right away. CMA #1 stated they did not know Resident #1 was a DNR at the time. On [DATE] at 1:39 p.m. LPN #1 stated CMA #1 was shouting that they needed to go to the whirlpool room. LPN #1 stated Resident #1 was sitting up in the whirlpool with water in the tub and they yelled at Resident #1 and rubbed the resident's chest and did not get a response. LPN #1 stated they started CPR because they did not know the resident was a DNR. LPN #1 stated later they were told by one of the supervisors they could look at the name plates by the residents door. LPN #1 stated the red name plate was for DNR and the green name plate was for a full code. On [DATE] at 1:59 p.m., the RN/regional nurse consultant stated Resident #1 had a DNR order. The regional nurse consultant stated the staff started CPR on the resident because they were in attendance when the resident became unresponsive. The regional nurse consultant stated they did not know who initiated CPR. On [DATE] at 3:45 p.m., the administrator stated they were not sure if the staff knew Resident #1 was a DNR. The administrator was asked if the staff should have known the resident's code status prior to starting CPR. The administrator stated one staff member did go to find out the resident's code status because this happened in the whirlpool room.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident was supervised while in the whirlpool. Resident #1 became unresponsive while in the whirlpool tub alone and was pronounced deceased at 9:40 p.m. On [DATE] at 5:56 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 6:09 p.m., the administrator and regional RN were notified of the IJ situation related to supervision in the whirlpool tub and provided the IJ template. On [DATE] at 5:29 p.m., the administrator was notified of an amended IJ template related to resident supervision while in the whirlpool via phone. On [DATE] at 5:49 p.m., an amended IJ template was provided to the administrator and the regional RN via email. On [DATE] at 11:03 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated [DATE], read in part, Plan of removal of IJ XXX[DATE] .The facility will monitor and keep resident's safe during bathing.Removal plans must include: . 1. How facility will ensure harm will not occur or recur; .Inservice all staff regarding Whirlpool Tub Bath policy and procedure [DATE] .Audit to verify all current resident's code status.Compliance rounds continued daily since ,d+[DATE].Inservice all staff regarding Whirlpool Tub Bath policy and procedure [DATE]. 2. Date of implementation- planned implementation (actions do not need fully resolved prior to the survey team exiting the organization); XXX[DATE] . 3. Identify those recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and .Residents that require assistance with bathing . 4. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.Inservice all staff regarding Whirlpool Tub Bath Policy and procedure on ,d+[DATE] and ,d+[DATE].The likelihood for serious harm to any resident no longer exists effective [DATE].QAPI meeting held to review .Root cause analysis of event.Plan of correction implemented on [DATE], and continued with compliance rounds and education through [DATE] at 8:00 p.m. The pan [sic] continues to be monitored by QA committee. The IJ was lifted, effective [DATE] at 8:00 p.m., when all components of the plan of removal had been completed. The deficiency remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure a resident was not left unsupervised while in the whirlpool tub for 1 (#1) of 3 sampled residents observed for supervision during bathing. The administrator identified 114 residents resided in the facility and no current residents utilized the whirlpool tub for baths. Findings: On [DATE] at 9:42 a.m., the whirlpool rooms on hall 300, 200, and the shower room on hall 100 were observed with the administrator. The emergency call systems in each whirlpool/shower room were activated and could be heard in the halls and at the nurses station on the hall the whirlpool or shower room was located. The staff responded immediately when the emergency lights were activated in the whirlpool and shower rooms. An undated facility policy titled Whilrpool [sic]Tub Bath, read in part, Assist the resident into the tub and remain with resident for safety. Resident #1 had diagnoses which included chronic obstructive pulmonary disease, hypertension, recurrent depressive disorder, diabetes with history of ketoacidosis with coma, transient ischemic attack, and cerebral infarction without residual deficits. Resident #1's ADL care plan, dated [DATE], showed the resident was at risk for ADL self care performance deficit and had the option of when to bathe, what kind of bath to take, with scheduled days suggested, but had the option to change if the resident chose to change the date and time. A document titled Course Completion History, dated [DATE] through [DATE], showed CNA #1 had been provided training related to Bathing without a Battle on [DATE]. There was no other training listed on the document related to supervision with showering or bathing in the whirlpool. Resident #1's quarterly assessment, dated [DATE], showed the resident's BIMS was 15 which indicated the resident's cognition was intact. The assessment showed they required set up or clean-up assistance with bathing/showering, and was independent with transferring in and out of the tub or shower. A nurse's progress note for Resident #1, dated [DATE] at 9:20 p.m., read in part, Staff alerted this nurse that res was unresponsive in the whirlpool. This nurse responded immediately, Res was sitting in whirlpool with head titled back and back was up against the whirlpool. Resident was lowered to the floor. No rise and fall of the chest, no pulse present, no response to chest rub. CPR was initiated chest compressions 30:2 given, and continued to be administered until [emergency medical service] arrived. [emergency medical service] arrived and took over code. Resident pronounced deceased at 2140 [9:40 p.m.] [Name withheld] on call for [physician name withheld] notified at this time. An undated statement from CNA #1 related to Resident #1 dying while in the whirlpool, read in part, took res to get whirlpool, got res in and relaxed and pulled privacy curtain to where could still see [Resident #1] and set timer for 25 minutes, talked w/[with] [Resident #1] until timer rang and res asked for ten more minutes, set timer for another ten minutes and kept talking-res got real quiet and could see [they] was w/ head slumped forward but not underwater. rushed to [them]. no response, rubbed chest and yelled no response, ran for help, saw [CMA #1] and [they] ran to get help while I continued to try to wake [Resident #1] [Resident #1] head was never underwater. On [DATE] at 8:33 p.m., CNA #5 stated Resident #1 was able to use the whirlpool unsupervised. On [DATE] at 8:57 p.m., employee #2 stated Resident #1 only required set up assistance with whirlpool baths and did not like the staff to stay in the whirlpool room with them. They stated CNA #1 took Resident #1 to the whirlpool room located on hall 300, assisted the resident to the whirlpool tub, closed the door and came out of the whirlpool room. Employee #1 stated CNA #1 was observed on hall 200 while Resident #1 was in the whirlpool tub. They stated CNA #1 set the timer for Resident #1 because they requested 10 more minutes in the whirlpool tub and the next thing they knew they were calling staff to go the whirlpool room. On [DATE] at 9:25 p.m., CNA #2 stated CNA #1 was in the hall and reported Resident #1 was not breathing. CNA #2 stated they went to the whirlpool room, felt for a pulse, did a sternal rub while the resident was in the whirlpool tub, assisted the other staff with getting Resident #1 out of the whirlpool tub. CNA #2 stated the facility had working emergency call lights in the whirlpool room. They were asked why CNA #2 had not activated the emergency call light. They stated they thought the CNA just panicked and went down the hall. On [DATE] at 10:15 a.m., Resident #4 stated they had been very close to Resident #1. Resident #4 stated Resident #1 went to take a whirlpool and passed away while in the whirlpool tub. Resident #4 stated Resident #1 had told them before the staff checked on them while they were in the whirlpool, but they did not stay in the whirlpool room with them. Resident #4 stated Resident #1 had been taking whirlpools without supervision for a long time. On [DATE] at 10:45 a.m., CNA #4 stated they had been assigned to hall 300 and observed CNA #1 walking on the halls while Resident #1 was in the whirlpool. CNA #4 stated they heard a muffled sound and stood up and looked down the hall and saw multiple staff running towards the whirlpool room. CNA #4 stated they observed staff lift Resident #1 out of the whirlpool and saw CNA #1 put their hand on their head, crying, and hollering. CNA #4 stated they heard CNA #1 state they were told Resident #1 could be in the whirlpool alone. CNA #4 stated they had told CNA #1 they should not have left Resident #1 in the whirlpool alone, that it was negligent homicide. On [DATE] at 11:34 a.m., CNA #1 stated they had put Resident #1 in the whirlpool tub and stayed in the room with the resident talking with them. CNA #1 stated the resident requested to stay in the whirlpool for 10 more minutes. CNA #1 stated the resident did not like for the staff to be in the whirlpool room, so they were outside of the door. CNA #1 stated when they came back in the whirlpool room the resident's face was a little under the water and was blue and the resident was laying slumped forward to the side. CNA #1 stated they pulled the resident up and ran out to get help. CNA #1 stated they forgot there was a call light in the whirlpool room. CNA #1 stated they were told Resident #1 only needed set up assistance for bathing. They stated the staff would set a timer, leave Resident #1 in the whirlpool tub, and go back and check on the resident. CNA #1 stated if they would have known they would not have left the resident in the whirlpool. On [DATE] at 1:38 p.m. LPN #1 was asked if they had an in-service recently related to the incident with Resident #1 on [DATE]. They stated they had answered the questions about what happened. LPN #1 they had not been told about supervision in the whirlpool after the incident with Resident #1. They stated they had been told about the name plates for code status. On [DATE] at 1:59 p.m., the RN/regional nurse consultant stated they conducted in-services concerning supervision in the whirlpool just to reiterate not to leave the residents alone in the whirlpool room. The regional nurse consultant stated Resident #1 was never left alone in the whirlpool room. They stated there were no exceptions to policy related to supervision in the whirlpool. The regional nurse consultant stated the staff were instructed to stay in whirlpool room with the resident even if the resident could bathe themselves. The regional nurse consultant stated the facility had privacy curtains in the shower and whirlpool rooms if the residents wanted privacy. The regional nurse consultant was asked if a QAPI meeting was held related to the incident. They stated they started compliance rounds on [DATE]. On [DATE] at 2:58 p.m., CNA #1 was asked about the statement they wrote which showed they were in the room with Resident #1 when they became unresponsive. CNA #1 stated they wrote that statement because they were afraid of going to jail because they were not in the whirlpool room with the resident. CNA #1 stated they had been outside the door of the whirlpool room for less than 10 minutes and CNA #4 was calling them a murderer and told them they were going to go to jail for killing Resident #1. On [DATE] at 11:44 a.m., CNA #9 stated they had their first in-service related to supervision in the whirlpool/shower on [DATE] at 5:30 a.m. and a second in-service on [DATE] at 7:00 p.m. On [DATE] at 5:33 p.m., CNA #1 stated they assisted Resident #1 into the whirlpool tub sometime between 8:00 p.m. and 8:30 p.m. On [DATE] at 6:35 p.m., CNA #2 stated when they first arrived to the whirlpool room on [DATE] Resident #1's color was beige yellowish, eyes were fixed, mouth was opened, and the resident was slumped back to the left side. CNA #2 stated they saw CNA #1 in the hall after supper, but was not sure what time that was or if Resident #1 was in the whirlpool when they saw CNA #1.

Based on record review and interview, the facility failed to ensure residents were [NAME] from abuse and misappropriation for two (#1 and #2) of three sampled residents reviewed for abuse. The administrator identified 109 residents resided in the facility. Findings: The facility policy titled Resident Abuse, Neglect and Misappropriation of Property, last revised 01/01/22, read in parts, The resident has the right to be free from verbal, sexual, physical and mental abuse .the facilty will not tolerate mistreatment, neglect, or abuse of residents, including sexual or .misappropriation of property. 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral infraction, DM II; hyperlipidemia, cannabis use, anxiety, quadriplegia, and retention of urine. Resident #1's care plan, last revised 02/26/24, documented they had a decline in asssistance with daily living performance and required maximum asssistance with care. Resident #1's quarterly MDS assessment, dated 11/18/24, documented their cognition was intact with a brief interview for mental status score of 15. The assessment further documented Resident #1 had impairment to both sides of the upper and lower extremities and was dependent on staff for toileting, dressing, and personal hygiene. An incident report form to the OSDH, dated 01/02/25, read in parts, Resident [Resident #1] stated that [they] was sexually assaulted by a female staff member .also stated the same staff member stole [their] [name deleted drinks]. On 01/08/25 at 1:05 p.m., Resident #1 stated they had lived at the facility for six months and a staff member put their hands on their groin and stated, You know you want me. Resident #1 stated the aide also took their personal drinks from them and took them all of the time. Resident #1 stated when they confronted the aide about taking their drinks the aide stated, You know that I did. Resident #1 identified the aide as CNA #1. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia, COPD, recurrent depression, seizures, reflux, and hemiplegia affecting left side. Resident #2's quarterly MDS assessment, dated 12/16/24, documented their cognition was moderately impaired with a BIMS of 12. The assessment further documented Resident #2 had lower extremity deficits to both sides and impairment to one side of the upper extremity. It documented Resident #2 had no behaviors and did not resist care. Resident #2's care plan, last revised 12/26/24, documented they had impaired cognitive function and had a self-care performance deficit related to their disease process, limited mobility, and contractures to the left upper extremities. An incident report form to the OSDH, dated 01/02/25, documented Resident #2 alleged CNA #1 was rough during the provision of care and stole their personal drinks. On 01/08/25 at 2:40 p.m., Resident #2 stated CNA #1 was very rough and mean during care and stole their drinks from their room all of the time. On 01/09/25 at 10:30 a.m., the administrator stated they had two allegations on CNA #1 related to stealing and mistreatment and the aide was fired. The administrator stated it was abuse and was not tolerated in the facility. The administrator stated it was not right to touch a resident's groin area and say what they said and to take their personal property. A review of the in-service documentation related to the investigation documented the facility completed an all staff training on abuse, neglect, and misappropriation on 01/02/25. A review of the employee list and signatures indicated all employees had been in-serviced. There was documentation the facility interviewed other residents regarding abuse and misapplication on 01/02/25. Interviews with staff during all days of the survey indicated the had knowledge of the in-service education provided regarding the abuse and misapplication of Resident #1 and Resident #2. Staff demonstrated knowledge of identification and reporting and different types of abuse. The facility initiated a QA plan of improvement with monitoring on 01/02/25. The facility provided ongoing monitoring and interviews with residents for abuse.

Based on record review, and interview, the facility failed to ensure staff followed proper transfer technique to prevent accidents for one (#2) of three sampled residents reviewed for falls. The failure resulted in a fractured femur for Resident #2. The administrator identified 106 residents resided in the facility. Findings: A Fall Program policy, revised 05/2024, read in part, develop care plan using appropriate interventions. Resident #2 had diagnoses which incldued intracerebral hemorrhage, speech deficit, and convulsions. A care plan intervention, initiated 06/25/20, documented the resident needed the assistance of two staff for transfers. A progress note, dated 09/21/24 at 6:18 p.m., documented the resident was lowered to the floor during a transfer. It was documented the resident stated, Broke and pointed to their leg. It was documented a fracture was identified and the resident requested to be sent to the hospital. A progress note, dated 09/25/24 at 2:27 p.m., documented the resident returned from the hospital with 15 staples to their right hip and a dignosis of fracture of neck of right femur. On 10/07/24 at 3:00 p.m., an interview was attempted with Resident #2. When asked about ADL care they stated, You know, 1234567 yeah. Attempts were made to interview emergency contacts, but was unsuccessful in contacting emergency contact #1 and #2. On 10/08/24 at 12:23 p.m., CNA #2 was called, but the phone number was restricted. On 10/08/24 at 12:24 p.m., LPN #1 stated they questioned whether the break happened while being lowered to the floor. They stated they could not remember if there was enough staff on the hall to help the CNA with the transfer, but LPN #1 was not asked to help with the transfer. LPN #1 stated the staff have been in-serviced about falls and being lowered to the floor would be considered a fall. On 10/08/24 at 12:43 p.m., the administrator stated CNA #2 was transferred from a sister facility recently and had been through training on transfer procedures in June of 2024 at the sister facility. They stated CNA #2 did not look at the care plan to see how Resident #2 should have been transferred.

Based on record review and interview, the facility failed to ensure residents were free from abuse for two (#5 and #6) of four sampled residents reviewed for abuse. The administrator identified 106 residents resided in the facility. Findings: An undated Resident Abuse, Neglect, and Misappropriation of Property policy, read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse. The policy also read, If the alleged perpetrator is facility staff, removal of the alleged perpetrator's access to the alleged victim and other residents and assurance that ongoing safety and protection is provided for the alleged victim and other residents. 1. Resident #5 had diagnoses which included atrial fibrillation and anxiety. 2. Resident #5's significant change assessment, dated 08/26/24, documented the resident was severely cognitively impaired and was dependent with most ADLs. Resident #6 had diagnoses which included hemiplegia, bipolar, depression, anxiety, and spinal stenosis. Resident #6's significant change assessment, dated 08/17/24, documented the resident was cognitively intact, but was dependent with most ADLs. A Final State Reportable Incident form, dated 09/13/24, documented an allegation of abuse/mistreatment. It was documented on 09/13/24 at 3:40 p.m., the police department was notified of an allegation of abuse made by Resident #5 and Resident #6. It was documented CNA #1 had abused/handled them roughly. It was documented the physician and family were notified. It was documented involved staff and residents were interviewed, and focused assessments were performed on the residents. It was documented there were evaluations of their medications, medical and incident history. It was documented the facility updated the residents' care plans. It was documented CNA #1 was terminated the day of completion of the investigation. It was documented the facility provided in-service on abuse to staff. A Notification of Nurse Aide/Nontechnical Service Worker form, dated 09/13/24, documented that CNA #1 was terminated on 09/13/24. On 09/13/24, an in-service on abuse was conducted. The facility form titled Compliance Rounds documented compliance rounds were made on 09/13/24, 09/17/24, 09/23/24, 09/24/24, and 10/01/24. On 10/07/24 at 2:35 p.m., Resident #6 stated CNA #1 had been wiping them roughly and the CNA did not adjust when they complained to them it was painful. They stated they felt it was abusive and told the social worker about it. They stated the next thing they knew the police were at their door. On 10/07/24 at 2:55 p.m., an interview was attempted with Resident #5. They asked for a tissue and was instructed to push the call light. By the time the resident was able to push the call light, they had already forgotten what they needed. On 10/07/24 at 3:22 p.m., the administrator stated they did their investigation, substantiated the findings, terminated the employee, and began the process of in-servicing on abuse. They stated they also completed compliance rounds and made a performance improvement plan. They stated they QAPI committee had not had a meeting since the incident, but it was on the agenda for the next meeting.

Based on record review and interview, the facility failed to notify the physician when they held a routine insulin for one (#103) of five sampled residents reviewed for unnecessary medications. Regional Nurse Consultant #2 identified 32 residents who received insulin resided in the facility. Findings: A Resident's Family or Physician Notification of Change policy, dated 12/01/09, read in part, .The facility will inform the resident; consult with the resident's physician .of the following events .A significant change in the resident's physical, mental, or psychosocial status A need to alter treatment significantly . Resident #103 had diagnoses which included type two diabetes mellitus without complications. A Physician Order, dated 03/29/24, documented Tresiba Flextouch subcutaneous solution pen injector 200 unit/ml inject eight units subcutaneously one time a day related to type two diabetes mellitus without complications. The July 2024 Insulin record documented a 13 for the following Tresiba administrations on: a. 07/02/24 for a BS of 89; b. 07/03/24 for a BS of 77; and c. 07/05/24 for a BS of 82. The August 2024 Insulin record documented a 13 for the following Tresiba administrations on: a. 08/02/24 for a BS of 72; b. 08/06/24 for a BS of 74; c. 08/13/24 for a BS of 66; d. 08/15/24 for a BS of 79; and e. 08/21/24 for a BS of 72. The chart code for 13 documented Sliding Scale Insulin Not Required. There was no documentation the physician was notified when Resident #103's Tresiba insulin was held. On 08/30/24 at 10:12 a.m., LPN #3 stated a 13 code meant sliding scale insulin was not required. On 08/30/24 at 10:16 a.m., LPN #3 stated Resident #103's Tresiba order did not contain and parameters for holding the medication. On 08/30/24 at 10:21 a.m., LPN #3 stated they were unsure of the reason staff did not administer the scheduled Tresiba in July and August 2024. They stated they marked 13 because it was low and they didn't give the insulin. LPN #3 stated they would have notified the physician if they were going to hold insulin that did not have parameters to hold. On 08/30/24 at 10:26 a.m., LPN #3 stated staff would document in progress notes if they notified the physician when they held the Tresiba. LPN #3 reviewed Resident #103's progress notes and stated, I don't see anything. On 08/30/24 at 10:38 a.m., the DON stated staff would notify the nurse, the nurse would notify the physician and put in a note anytime a medication was held. On 08/30/24 at 10:38 a.m., the DON reviewed Resident #103's Tresiba order and stated there were no hold parameters in the order. On 08/30/24 at 10:41 a.m., the DON stated a 13 code meant the sliding scale insulin was not required. The DON reviewed the Tresiba administration for August 2024 and stated they did not see where the physician was notified when the Tresiba was held.

Based on record review and interview, the facility failed to revise a resident's care plan for four (#10, 62, 82 and #103) of 27 sampled residents reviewed for care plans. The Administrator identified 117 residents resided in the facility. Findings: 1. Resident #103 had diagnoses which included cerebral infarction and transient alteration of awareness. Resident #103's Care Plan was initiated on 03/29/24 and had a next review date of 06/27/24. The care plan had not been updated with the quarterly resident assessment. The care plan documented the resident had a urinary tract infection, and was receiving skilled nursing and therapy. Resident #103 had a Quarterly Resident assessment dated [DATE]. On 08/28/24 at 9:43 a.m., Regional Nurse Consultant #2 was asked to verify the surveyor was looking at the latest care plan for Resident #103. They stated it was the right care plan, but it looked like it hadn't been updated because it was showing overdue. On 08/28/24 at 9:56 a.m., MDS Coordinator #1 stated they were new to the facility, however they had been in an MDS role since around 2018. On 08/28/24 at 9:58 a.m., MDS Coordinator #1 stated they updated care plans with significant changes in their function. They stated they would have corporate look over MDS information when they had a question. On 08/28/24 at 9:59 a.m., MDS Coordinator #1 stated they would look through every new order and every discontinued order every day. They stated if they were made aware of anything that changed with a resident, they would update the care plan right then. On 08/28/24 at 10:00 a.m., MDS Coordinator #1 and MDS Coordinator #2 reviewed Resident #103's record and stated the last care plan documented the next review was 06/27/24. On 08/28/24 at 10:02 a.m., MDS Coordinator #2 stated the resident was not receiving skilled services and the care plan documented the resident was receiving skilled services. MDS Coordinator #2 stated Resident #103 did not have a urinary tract infection and the care plan documented they did. 45462 2. Resident #10 had diagnoses that included Alzheimer's disease, age-related osteoporosis and rheumatoid arthritis. A 'Fall Risk Assessment', dated 07/03/24, documented Resident #10 was at high risk for falls. A 'Care Plan' for Resident #10 documented the following interventions related to falls: concave mattress 07/16/20 and when resident is in bed, keep bed in lowest position 10/05/17. On 08/26/24 at 10:02 a.m., Resident #10 was observed in bed with bed in high position. On 08/28/24 at 6:30 a.m., Resident #10 was observed in bed asleep with bed in high position. 3. Resident #62 had diagnoses that included morbid (severe) obesity and major depressive disorder A 'Fall Risk Assessment', dated 06/09/24, documented Resident #62 was at high risk for falls. A 'Care Plan' for Resident #62 documented the following interventions related to falls: bed in low position when in bed 11/22/23 and follow facility fall protocol 02/10/23. On 08/26/24 at 10:51 a.m., Resident #62 was observed in bed with bed in high position. On 08/28/24 at 6:33 a.m., Resident #62 was observed in bed asleep with bed in high position. 4. Resident #82 had diagnoses that included acute kidney failure. A 'Fall Risk Assessment', dated 08/20/24, documented Resident #82 was at high risk for falls. A 'Care Plan' for Resident #82 documented the following interventions related to falls: 2/04/24 ensure [Resident #82] is in a comfortable position in center of bed and fall mat at bedside 02/04/24 and when [Resident #82] is in bed, keep bed in lowest position 05/29/24. On 08/26/24 at 10:20 a.m., Resident #82 was observed in bed with bed at medium height. A fall mat was observed folded and standing beside their cupboard. On 08/27/24 at 9:16 a.m., Resident #82 was observed in bed with bed at medium height. A fall mat was observed folded up on the side of cupboard. On 08/28/24 at 6:42 a.m., CNA #4 was asked if the care plans had been followed for Resident #10, Resident #62, or Resident #82. They stated these residents did not like their beds in the low position and they would complain if staff tried to put them there. CNA #4 was asked if these complaints had been reported to anyone. They stated yes, the nurses and the administrator are aware. On 08/28/24 at 6:43 a.m., the Administrator reported they were aware of the residents refusing to have their beds put in the low position and acknowledged that care plan updates should have been done.

Based on observation and interview, the facility failed to ensure snacks were offered to all residents in the facility for one of one snack observation. Regional Nurse Consultant #1 identified 115 residents who received services from the kitchen resided in the facility. Findings: On 08/28/24 at 2:00 p.m., the Resident Council Group stated the facility had snacks out, but you have to go get them. They stated if residents asked for snacks they would receive them, but staff did not pass snacks. They stated snacks were available at 7:00 p.m. and at 7:00 a.m. On 08/28/24 at 6:30 p.m., snacks were observed being placed at the nurses' station on Hall 100. On 08/28/24 at 6:31 p.m., Dietary Aide #1 delivered a bucket of ice with various snacks in it to the nurses' station located on Hall 200. On 08/28/24 at 6:43 p.m., the snack container was observed on the lower counter of the nurses' station on Hall 200. On 08/28/24 at 6:48 p.m., LPN #4 was observed taking two bags of Doritos into room [ROOM NUMBER]. On 08/28/24 at 6:52 p.m., a second container of snacks was observed on the bottom shelf of the white hydration cart on Hall 200. The container had various items including cheese-its, crackers, applesauce, and soda. On 08/28/24 at 7:22 p.m., the Housekeeping Supervisor was observed offering two residents at the nurses' station on Hall 200 a snack. On 08/28/24 at 7:44 p.m., CNA #2 was observed pushing the hydration cart with snacks on it down hall 200 and began offering ice/water to the residents. On 08/28/24 at 7:44 p.m., CMA #4 picked up the snacks on Hall 100 and carried them behind the nurses' station. On 08/28/24 at 8:10 p.m., CMA #4 was observed opening a package of peanut butter crackers for Resident #2 on Hall 100. On 08/28/24 at 8:18 p.m., the Admission Coordinator joined CNA #2 and began offering ice/water to the residents on Hall 200. On 08/28/24 at 8:37 p.m., both residents in room [ROOM NUMBER] asked CNA #2 for a snack, they exited the room, walked up to the nurses' station and obtained two peanut butter crackers and two graham crackers and took them to room [ROOM NUMBER]. On 08/28/24 at 8:42 p.m., the residents in the last room on Hall 200 were offered water/ice by the Admission Coordinator. Staff were observed going from room to room on Hall 200 from 7:44 p.m. through 8:43 p.m. offering ice/water to each resident. Staff did not offer snacks to each of the residents. The only residents observed to receive a snack were those who asked for it themselves. On 08/28/24 at 8:43 p.m., CNA #2 stated staff usually passed ice water on each shift to keep residents hydrated. On 08/28/24 at 8:44 p.m., CNA #2 stated staff put out snacks on the 7:00 a.m. to 3:00 p.m. shift and the 3:00 p.m. to 11:00 p.m. shift. They stated most of the residents would go up and ask for the snacks, or staff would offer them after supper. On 08/28/24 at 8:46 p.m., CNA #2 stated they should have offered residents snacks when they were passing water. The CNA acknowledged there was a bucket of snacks on the cart that contained apple sauce, jello, water bottles, cheese-its, pudding, and graham crackers. Hall 100 was observed for the passing of snacks from 6:30 p.m. through 8:48 p.m. Staff were not observed going room to room offering snacks to all residents on the hall. On 08/28/24 at 8:49 p.m., CNA #1 stated staff usually brought snacks at seven, but most residents had snacks in their rooms because family brought them. On 08/28/24 at 8:50 p.m., CNA #1 stated some resident would come up and ask for snacks. On 08/28/24 at 8:51 p.m., CNA #1 stated they would ask residents when they were in their room if they wanted a snack. On 08/28/24 at 8:51 a.m., the Administrator stated the facility always had snacks available. They stated snacks were put out every shift. They stated most of the residents would cruise by and get them themselves. They stated a few of the residents would hit their call lights if they knew snacks were out and staff would offer them as they went to resident rooms. The Administrator stated there was not a set snack pass at the facility. They stated snacks were out all the time on the water cart. On 08/28/24 at 8:52 p.m., CNA #1 stated they had not obtained snacks from the nurses' station to pass to the residents.

Based on record review, observation, and interview, the facility failed to ensure medications were properly labeled and stored in one medication room (Hall 200) and two nurse medication carts (Hall 200 and Hall 300) of two sampled medication rooms and five sampled medication carts reviewed for medication storage and handling. The administrator identified 117 residents resided in the facility. Findings: A 'Medication Storage in the Facility- Storage of Medications' policy, effective January 2022, read in parts, .All medications are maintained within the temperature ranges noted .Refrigerated 36 [degrees] F to 46 [degrees] F .Controlled-substances that require refrigeration are stored within a locked box within the refrigerator . A 'Preparation and General Guidelines- Vials and Ampules of Injectable Medications' policy, effective January 2022, read in parts, .USP<797> guidelines recommend discarding multidose vials .at 28 days after opened. The date opened and the triggered expiration date should be recorded on a label for such purpose affixed to the vial . A 'Disposal of Medications and Medication-Related Supplies- Discontinued Medications' policy, effective January 2022, read in parts, .Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue . On 08/29/24 at 11:25 a.m., the medication room on Hall 200 was reviewed with CMA #1 and LPN #3. These were my findings: a. There was no lock on the refrigerator. b. The lock box inside refrigerator was locked, but when opened controlled medications that were supposed to be inside were not there. c. Medication for a resident who expired on 06/26/24 was still in the refrigerator. d. A box of arformoterol inh soln with exp date on rx label 11/18/23 and exp date on actual packets 07/2024 was still in the refrigerator. e. A large container of various types of insulin pens for multiple residents was in refrigerator some used and some new had the following used flexpens inside: 1. Resident #82 insulin aspart flexpen- 1/2 full no open date and no discard date on pen. 2. Resident #79 Tresiba flexpen- 1/2 full no open date and no discard date on pen. 3. Resident #25 Novolin R flexpen- 1/4 full no open date and no discard date on pen. On 08/29/24 at 11:29 a.m., CMA #1 was asked the facility policy for discarding discontinued and/or expired medications. They stated the medications should have been removed from the refrigerator and given to the DON to discard. On 08/29/24 at 11:30 a.m., LPN #3 was asked where the contents of the refrigerator lock box were. They stated they had taken all the controlled drugs out when they arrived this am to count them, and they were currently still on the medication cart on the hall. When asked if they were supposed to remain refrigerated, LPN #3 stated yes. LPN #3 was asked the policy for opening and storing insulin? They stated it should be dated when opened and discarded after 30 days. LPN #3 acknowledged this was not done. On 08/29/24 at 11:45 a.m., the nurse's medication/treatment cart on Hall 200 was reviewed with LPN #3. These were my findings: a. Opened insulin flexpens and vials currently in use on the medication cart included: b. Resident #69 insulin glargine-yfgn soln flexpen & insulin aspart 10ml multiple dose vial no open date and no discard date on pen nor on vial. c. Resident #103 Novolog flexpen & insulin degludec flexpen no open date and no discard date on pens. d. Resident #25 basaglar flexpen & Novolin R flexpen no open date and no discard date on pens. e. Resident #81 Lantus 10ml multiple dose vial no open date and no discard date on vial. On 08/29/24 at 1:26 p.m., the nurse's medication/treatment cart on Hall 300 was reviewed with LPN #2. These were my findings: Medication for the following discharged residents was still on the medication cart: a. Unnamed Resident #1 discharged [DATE] b. Unnamed Resident #2 discharged [DATE] c. Unnamed Resident #3 discharged [DATE] On 08/29/24 at 1:27 p.m., LPN #2 was asked the policy for handling medications after a resident is discharged . They stated the medication should be removed from the medication cart and given to the DON for disposal. LPN #2 acknowledged this was not done. On 08/29/24 at 3:24 p.m., the DON was made aware of the findings for the medication room on Hall 200, the nurses medication/treatment cart on Hall 200, the nurses medication/treatment cart on Hall 300, as outlined above. The DON reported facility policy dictated that medications are to be keep refrigerated as indicated on the RX label, open insulin pens and vials were to be labeled with the date first used and discarded after 30 days, and discontinued and expired medications were to be immediately pulled off the medication cart and given to the DON to discard unless it was being sent home with the resident. The DON acknowledged facility policy had not been followed.

Based on record review and interview, the facility failed to administer medication as ordered for two (#37 and #103) of five sampled residents reviewed for unnecessary medications. The Administrator identified 117 residents resided in the facility. Regional Nurse Consultant #2 identified 32 residents who received insulin resided in the facility. Findings: A Preparation for Medication Administration policy, revised 12/01/12, read in part, .Medications are administered as prescribed in accordance with good nursing principals and practices .Medications are administered within 60 minutes of scheduled time .unless otherwise specified by the prescriber .The resident's MAR is initialed by the person administering the medication . 1. Resident #103 had diagnoses which included type two diabetes mellitus without complications. A Physician Order, dated 03/29/24, documented Tresiba Flextouch subcutaneous solution pen injector 200 unit/ml inject eight units subcutaneously one time a day related to type two diabetes mellitus without complications. A Physician Order, dated 05/23/24, documented Novolog flexpen subcutaneous solution pen injector 100 unit/ml inject 20 units subcutaneously two times a day related to type two diabetes mellitus. It documented do not give if glucose reading is less than 125. The July 2024 Insulin record documented a 13 for the following Tresiba administrations on: a. 07/02/24 for a BS of 89; b. 07/03/24 for a BS of 77; and c. 07/05/24 for a BS of 82. The chart code for 13 documented Sliding Scale Insulin Not Required. The July 2024 Insulin record documented Novolog insulin was administered at 8:00 a.m. on the following dates: a. 07/02/24 for a BS of 84; b. 07/03/24 for a BS of 112; c. 07/09/24 for a BS 108; d. 07/10/24 for a BS of 108; e. 07/11/24 for a BS of 111; f. 07/12/24 for a BS of 112; g. 07/22/24 for a BS of 112; and h. 07/31/24 for a BS of 81. The August 2024 Insulin record documented a 13 for the following Tresiba administrations on: a. 08/02/24 for a BS of 72; b. 08/06/24 for a BS of 74; c. 08/13/24 for a BS of 66; d. 08/15/24 for a BS of 79; and e. 08/21/24 for a BS of 72. The chart code for 13 documented Sliding Scale Insulin Not Required. The August 2024 Insulin record documented Novolog insulin was administered at 8:00 a.m. on the following dates: a. 08/01/24 for a BS of 98; b. 08/08/24 for a BS of 110; c. 08/09/24 for a BS of 111; d. 08/12/24 for a BS of 81; e. 08/16/24 for a BS of 114; f. 08/20/24 for a BS of 86; g. 08/21/24 for a BS of 87; and h. 08/26/24 for a BS of 86. There was no documentation a hold order was obtained when Resident #103's Tresiba insulin was held. On 08/30/24 at 10:09 a.m., LPN #3 stated staff were to look at the MAR, check the medication three times, make sure it was the right time, right resident, and right medication before administering medications to residents. They stated staff were to ensure the resident took all of their medications while in the residents' room. On 08/30/24 at 10:12 a.m., LPN #3 stated a 13 code meant sliding scale insulin was not required. On 08/30/24 at 10:15 a.m., LPN #3 stated hopefully staff would let them know if they were holding a medication. They stated there would need to be a reason they were holding it. On 08/30/24 at 10:16 a.m., LPN #3 stated Resident #103's Tresiba order did not contain and parameters for holding the medication. They stated the Novolog had orders to hold if the glucose reading was less than 125. On 08/30/24 at 10:18 a.m., LPN #3 reviewed Resident #103's Novolog administration and stated, That would be me. They stated they clicked it off as administered. They stated they know they didn't give it at the time. They stated they waited until the resident ate breakfast and would recheck the BS and give the insulin. LPN #103 did not produce additional BS documentation for the resident for the above administrations of Novolog insulin. On 08/30/24 at 10:21 a.m., LPN #3 stated they were unsure of the reason staff did not administer the scheduled Tresiba in July and August 2024. They stated they marked 13 because it was low and they didn't give the insulin. LPN #3 stated they would have notified the physician if they were going to hold insulin that did not have parameters to hold. On 08/30/24 at 10:26 a.m., LPN #3 stated staff would document in progress notes if they notified the physician when they held the Tresiba. LPN #3 reviewed Resident #103's progress notes and stated, I don't see anything. On 08/30/24 at 10:38 a.m., the DON stated staff would notify the nurse, the nurse would notify the physician and put in a note anytime a medication was held. On 08/30/24 at 10:38 a.m., the DON reviewed Resident #103's Tresiba order and stated there were no hold parameters in the order. They stated the Novolog documented do not give if BS was below 125. On 08/30/24 at 10:41 a.m., the DON stated a 13 code meant the sliding scale insulin was not required. The DON reviewed the Tresiba administration for August 2024 and stated they did not see where the physician was notified when the Tresiba was held. On 08/30/24 at 10:43 a.m., the DON stated they did not have any knowledge of staff administering Novolog outside of ordered parameters. 45462 2. Resident #37 had diagnoses that included Stage 3 CKD and infection of amputation stump, left lower extremity. A 'physician's order', dated 08/01/24, documented Resident #37 was to receive meropenem 1 GM reconstituted in 50ml of sodium chloride and administered intravenously every 12 hours for 30 days. The August 2024 MAR documented Resident #37 was to receive meropenem 1 GM reconstituted in 50ml of sodium chloride via IV at 9 a.m. and at 9 p.m. On 08/28/24 at 6:50 a.m., LPN #1 was observed starting meropenem 1gm/50ml 0.9% sodium chloride at 100ml/hour via PICC line for Resident #37. LPN #1 was asked why the medication was being administered 3 hours before the scheduled administration time. LPN #1 stated he was administering the medication early because the resident had to leave the facility for an appointment this morning. There was no order in Resident #37's clinical record for a change or adjustment in administration time. On 08/28/24 at 9:30 a.m., a review of Resident #37's August MAR had documentation meropenem 1gm/50ml 0.9% sodium chloride at 100ml/hour via PICC line was administered 08/28/24 at 8:23 a.m. by LPN #2. On 08/28/24 at 10:30 a.m., LPN #2 was asked if they had administered Resident #37's IV antibiotic this am. They stated no, the night nurse gave it around 7 a.m. When asked if facility policy allowed for signing medications given by someone else, LPN #2 stated no it did not. On 08/28/24 at 10:41 a.m., the DON was asked the facility policy on giving medications outside of scheduled times written on the MAR. They reported the facility had a 1 hour before and 1 hour after window in which to give the medication if it was scheduled for a specific time. The DON was asked the procedure if a medication had to be administered outside of the 1 hour before or 1 hour after timeframe. They stated the nurse would need to notify the physician to obtain a one-time order to give the medication outside of the established timeframe. The DON was asked the facility policy on signing for medications you did not give. They stated that was against facility policy, only the person who gave it can sign. The DON was informed of the observations detailed above and they acknowledged the staff who hung the medication and the staff that signed the MAR did not follow facility policy for administering medications as ordered.

Based on observation, record review and interview, the facility failed to ensure residents received bathing assistance as scheduled for three (#1, 60, and #103) of four sampled residents reviewed for ADLs. The Administrator identified 117 residents resided in the facility. Findings: A Showers policy, dated 10/01/01, read in part, .Showering is important because it gets rid of surface dirt, eliminates body odors, stimulates circulation and gives you the opportunity to inspect the skin for any abnormalities or breakdown . 1. Resident #1 had diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. A Quarterly Resident Assessment, dated 05/21/24, documented Resident #1's cognition was severely impaired for cognitive skills for daily decision making. It documented the resident had functional limitation in range of motion on both sides for upper and lower extremities. It documented the resident was dependent for the task of shower/bath. A Hall 200 Bath Schedule, undated, documented Resident #1's bathing schedule was Monday, Wednesday, Friday on the 7:00 a.m. to 3:00 p.m. shift. Resident #1's bathing records for June 2024 was blank on the 14th. Resident #1's bathing record for July 2024 was blank for the 5th, 8th, 17th, 24th, and 29th. Resident #1's bathing record for August 2024 was blank for the 2nd and the 19th. The facility also utilized shower sheets for documentation of bathing. There were no shower sheets provided for the above missed dates. On 08/26/24 at 1:44 p.m., Family Member #1 stated the facility was too short handed to provide bathing assistance to Resident #1. They stated the resident was scheduled to receive a bath/shower on Monday, Wednesday, and Friday. They stated the issue was ongoing. On 08/26/24 at 2:12 p.m., Family Member #2 stated sometimes the facility was good at bathing their loved one and sometimes they were not. On 08/30/24 at 12:08 p.m., Resident #1 was observed being wheeled down to their room by CNA #6. The resident's hair was observed to be wet. On 08/30/24 at 12:09 p.m., CNA #6 stated Resident #1 was able to wash their face in the shower, but staff did everything else. On 08/30/24 at 12:11 p.m., CNA #6 stated today was the resident's shower day. They stated the resident's scheduled days were Monday, Wednesday, and Friday on the 7:00 a.m. to 3:00 p.m. shift. On 08/30/24 at 12:12 p.m., CNA #6 stated they had not identified any concerns with the resident receiving bathing assistance as scheduled. On 08/30/24 at 12:37 p.m., the DON stated Resident #1 was total dependence of one staff member for the task of bathing. They stated the resident was scheduled to receive bathing assistance on Monday, Wednesday, and Friday on the 7:00 a.m. to 3:00 p.m. shift. The DON reviewed the above bathing records and stated the resident did not receive bathing assistance as scheduled. 2. Resident #103 had diagnoses which included cerebral infarction and transient alteration of awareness. A Quarterly Resident Assessment, dated 06/28/24, documented Resident #103's cognition was intact and they required substantial/maximal assistance for the task of shower/bath. A Hall 200 Bath Schedule, undated, documented Resident #103's bathing schedule was Tuesday, Thursday, Saturday on the 3:00 p.m. to 11:00 p.m. shift. Resident #103's bathing record for June 2024 documented a blank on the 8th. Resident #103's bathing record for July 2024 documented blanks for the 11th, 23rd, 25th, and the 27th. Resident #103's bathing record for August 2024 documented blanks for the 3rd, 8th, 10th, 13th, 17th, 24th, and the 27th. The facility also utilized shower sheets for documentation of bathing. There were no shower sheets provided for the above missed dates. On 08/26/24 at 11:56 a.m., Family Member #3 approached the surveyor and stated it had been days since Resident #103 was bathed. On 08/26/24 at 11:57 a.m., Resident #103 stated it had been well over a week since they had been bathed last. They stated they were scheduled to be bathed in the evening every other day. They stated it took one staff member to bathe them. They stated, That's my main complaint is not having regular showers. The resident was observed with disheveled hair. They stated, It's just nasty. They stated they didn't know how the facility could get by with no showers what so ever. On 08/29/24 at 8:56 a.m., CNA #4 stated Resident #103 required limited assistance for bathing. They stated the resident liked to do their upper body themselves, and staff would do their legs, back, feet, and bottom. On 08/29/24 at 8:58 a.m., CNA #4 stated they allowed residents to do what they could for bathing and then assisted them as needed. They stated there was a bathing schedule for the hall. On 08/29/24 at 9:01 a.m., CNA #4 reviewed the bathing schedule and stated Resident #103 was scheduled on Tuesday, Thursday, and Saturday on the 3:00 p.m. to 11:00 p.m. shift. CNA #4 stated they worked all shifts and were unaware of any bathing concerns with the resident. On 08/30/24 at 10:30 a.m., the DON stated staff were to follow resident bathing preferences. They stated residents were able to choose what shift and what days they preferred to be bathed. They stated if a resident refused to bathe, they have them sign a shower sheet. On 08/30/24 at 10:36 a.m., the DON and Regional Nurse Consultant #2 reviewed the bathing records for June, July and August 2024 and stated the resident did not receive their bath/shower as scheduled. 48344 3. Resident #60 had diagnoses which included age-related osteoporosis without current pathological fracture. Resident #60's quarterly resident assessment, dated 06/05/24, documented Resident #60's cognition was intact and they were dependent on another person for bathing. A Documentation Survey Report v2, dated August 2024, documented Resident #60's bathing schedule was Monday, Wednesday, and Friday. The report documented the Resident had not received a bath, six out of 12 opportunities. The report documented blanks for 08/02/24, 08/05/24, 08/21/24, 08/23/24, 08/26/24, and 08/28/24. On 08/26/24 at 10:16 a.m., Resident #60 stated their bath schedule was Monday, Wednesday, and Friday. They stated they did not get their baths as scheduled. They sometimes get a bath once a week. On 09/03/24 at 9:21 a.m., CNA #7 stated baths given and refusals were documented on the shower sheets and electronic health record. On 09/03/24 at 9:23 a.m., CNA #7 stated the blanks on the August survey report meant the baths were not documented. On 09/03/24 at 9:24 a.m., LPN #3 stated bath refusals were documented in the progress notes. There was no documentation Resident #60 refused baths in the progress notes. On 09/03/24 at 10:22 a.m., the ADON stated baths were to be documented on the shower sheets, and the electronic health record. All refusals were to be documented on the residents' progress notes. On 09/03/24 at 10:24 a.m., the ADON stated the blanks meant the baths were not given.

Based on record review and interview, the facility failed to implement fall interventions for three (#10, 62, and #82) of four sampled residents reviewed for accidents. The Administrator identified 117 residents resided in the facility. Findings: 1. Resident #10 had diagnoses that included Alzheimer's disease, age-related osteoporosis and rheumatoid arthritis. A 'Fall Risk Assessment', dated 07/03/24, documented Resident #10 was at high risk for falls. A 'Care Plan' for Resident #10 documented the following interventions related to falls: concave mattress 07/16/20 and when resident is in bed, keep bed in lowest position 10/05/17. On 08/26/24 at 10:02 a.m., Resident #10 was observed in bed with bed in high position. On 08/28/24 at 6:30 a.m., Resident #10 was observed in bed asleep with bed in high position. On 08/28/24 at 6:40 a.m., the Administrator and CNA #4 were taken to Resident #10's room and asked if bed was in low position. CNA #4 and the Administrator stated no. 2. Resident #62 had diagnoses that included morbid (severe) obesity and major depressive disorder A 'Fall Risk Assessment', dated 06/09/24, documented Resident #62 was at high risk for falls. A 'Care Plan' for Resident #62 documented the following interventions related to falls: bed in low position when in bed 11/22/23 and follow facility fall protocol 02/10/23. On 08/26/24 at 10:51 a.m., Resident #62 was observed in bed with bed in high position. On 08/28/24 at 6:33 a.m., Resident #62 was observed in bed asleep with bed in high position. On 08/28/24 at 6:41 a.m., the Administrator and CNA #4 were taken to Resident #62's room and asked if bed was in low position. CNA #4 and the Administrator stated no. 3. Resident #82 had diagnoses that included acute kidney failure. A 'Fall Risk Assessment', dated 08/20/24, documented Resident #82 was at high risk for falls. A 'Care Plan' for Resident #82 documented the following interventions related to falls: 2/4/24 ensure [Resident #82] is in a comfortable position in center of bed and fall mat at bedside 02/04/24 and when [Resident #82] is in bed, keep bed in lowest position 05/29/24. On 08/26/24 at 10:20 a.m., Resident #82 was observed in bed with bed at medium height. A fall mat was observed folded and standing beside their cupboard. On 08/27/24 at 9:16 a.m., Resident #82 was observed in bed with bed at medium height. A fall mat was observed folded up on the side of cupboard. On 08/28/24 at 6:42 a.m., the Administrator and CNA #4 were taken to Resident #82's room and asked if the bed was in low position. CNA #4 and the Administrator stated no. On 08/28/24 at 6:45 a.m., the Administrator was asked if the care plans had been implemented for Resident #10, Resident #62, and Resident #82. They stated no.

Based on record review and interview, the facility failed to ensure: a. an Advance Directive DNR Consent Admission Acknowledgement form was complete for two (#10 and #69) of 32 sampled residents reviewed for Advance Directives. b. the DNR order was properly executed for one (#77) of 32 sampled residents reviewed for Advance Directives. The DON identified 117 residents resided in the facility. Findings: A DNR, Advance Directives and End of Life Decisions Policy, revised [DATE], read in part, .It is the policy of this Facility to comply with a Resident's Advanced Directive and Do Not Resuscitate Consent .Upon admission the Facility will ask every new Resident and/or the Resident's Representative, if the Resident has a written advance directive, Durable Power of Attorney for Health Care, DNR Consent, or related form .If the Resident has one .the Facility should request a copy be brought to the Facility .it cannot act upon any document until a copy has been provided to the Facility .Advanced Directives .To be valid, the Directive must be signed in the presence of two witnesses who are [AGE] years old and who will not inherit from the resident .cardiopulmonary resuscitation (CPR) should be administered to a Resident .unless the Resident has a properly executed DNR order . The Oklahoma Do-Not-Resuscitate (DNR) Consent form, read in part, Signature of Representative (Limited to an attorney-in-fact for health care decisions acting under the Durable Power of Attorney Act, a health care proxy acting under the Oklahoma Rights of the Terminally Ill or Persistently unconscious Act, or a guardian of the person appointed under the Oklahoma Guardianship and Conservatorship Act) . 1. Resident #69 had diagnoses which included aphasia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. A Quarterly Resident Assessment, dated [DATE], documented Resident #69's cognition was intact. An Advanced Directive DNR Consent form for Resident #69, undated, documented a check next to I currently Have and Advance Directive and I currently Have a DNR Consent. The form documented a check next to A copy of my advanced directive and/or DNR has been given to the facility. The form was not dated or signed by anyone. On [DATE] at 8:54 a.m., there was no advanced directive for Resident #69 observed in their hard chart or their electronic chart. On [DATE] at 9:07 a.m., the Admissions Coordinator stated residents who had an Advance Directive usually would provide it to the facility upon admission. They stated each resident received information on Advance Directive with their admission paperwork. They stated if the resident had one, the facility would request a copy. They stated a copy of it would be scanned into their file. They stated they scanned it under the MR record. They stated staff would have to have a nurse manager to access the record, and it would be in the resident's chart. On [DATE] at 9:13 a.m., the Admissions Coordinator stated an Advance Directive was mainly residents' wishes. On [DATE] at 9:14 a.m., the Administrator stated the facility was switching to electronic medical records. They stated a copy of the residents' Advance Directives were provided at the time they admitted to the facility. They stated it would go in the resident's paper chart and get scanned into the electronic record. The Administrator stated it should be uploaded under documents. On [DATE] at 9:19 a.m., the Administrator stated the consent form documented the resident had an Advance Directive and had a DNR, but the DNR had been revoked. On [DATE] at 9:20 a.m., the Administrator stated they did not know the reason the Advance Directive DNR consent form for Resident #69 was not signed. They stated they were unable to locate the resident's Advance Directive under documents in the electronic record. The Administrator accessed Resident #69's Advance Directive under a MR Program. 45462 2. Resident #10 had diagnoses that included Alzheimer's and age-related osteoporosis. A Quarterly Resident Assessment, dated [DATE], documented Resident #10's cognition was intact. An Advanced Directive DNR Consent Admission Acknowledgement form for Resident #10, documented a check next to I currently DO NOT have an Advance Directive and I currently DO NOT have a DNR Consent. The form was not dated or signed by anyone. On [DATE] at 8:56 a.m., the DON was asked if there was a signed copy of the Advanced Directive DNR Consent Admission Acknowledgement form. The DON checked the medical record in EHR and it was also blank. The DON was asked if the Advanced Directive had been offered to Resident #10 on admission. They stated they could not be sure. 3. Resident #77 had diagnoses that included atherosclerotic heart disease. A Quarterly Resident Assessment, dated [DATE], documented Resident #77's cognition was intact. A 'physician's order', dated [DATE], documented Resident #77's code status as DNR. The Facesheet in the EHR and documentation on Resident #77's physical chart listed Resident #77's code status as DNR. An Oklahoma Do-Not-Resuscitate (DNR) Consent form for Resident #77, was signed by resident's spouse. The form was not dated or witnessed by anyone. There was no POA, health care proxy, nor guardianship paperwork for Resident #77's spouse in their electronic record. On [DATE] at 8:56 a.m., the DON was asked the code status for Resident #77. They stated Resident #77 was a DNR. The DON was asked if there was a completed copy of the Oklahoma DNR Consent form on file for Resident #77. The DON checked the electronic medical record and stated the DNR had been signed by the spouse. The DON was asked if the DNR Consent form was dated or witnessed. They stated no. The DON was asked if an incomplete DNR Consent form was considered valid. They stated no. When asked if there was a signed POA, health care proxy, or guardianship paperwork for Resident #77's spouse in their medical record, the DON reviewed the record and stated no. The DON was asked if Resident #77 had a properly executed DNR order. They stated no Resident #77 should be a full code.

Based on observations, interviews, and record reviews, it was determined the facility failed to assess, monitor and intervene timely for a resident with changes in condition for one (#3) of one sampled resident reviewed with a change in condition. There was a delayed notification of the physician when the resident's condition worsened. The physician ordered antidiarrheal medication, which was not administered as ordered and the resident's skin started breaking down. The physician ordered labs, which were never obtained. The resident's condition worsened and the physician ordered a diuretic medication, which took over 7 hours to administer. Also, records documented a lack of fluid intake monitoring during the time the resident experienced loose stools. On [DATE] at 12:58 a.m. the resident expired in the facility. The DON (director of nurses) identified 106 residents resided in the facility. Findings: A facility policy titled, Resident's Rights and Confidentiality, documented: .we recognize the importance of protecting and promoting the rights of all its residents .responsibility to protect and promote the rights of each resident, including the following .the right to receive adequate and appropriate health care . A facility policy titled, Hydration Risk Assessment, documented: .the facility will provide care, as specified in the resident's overall plan of care, that is designed to reduce risk factors and ensure adequate fluid intake .keep fluids next to the resident at all times or assisting or cuing the resident to drink . A facility policy titled, Preparation For Medication Administration, documented: .Medications are administered in accordance with written orders of the attending physician. A facility policy titled, Resident's Family or Physician Notification of Change Guideline, documented: .The facility will inform the resident; consult with the resident's physician .of the following events .A significant change in the resident's physical, mental, or psychosocial status .deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications .A need to alter treatment significantly . Resident #3 had [DIAGNOSES REDACTED]. An admission note, dated [DATE] at 9:00 p.m., documented, .resident continent of bowel and bladder . A baseline assessment, dated [DATE], documented the resident was alert, friendly, quiet, and cooperative. The resident was identified as a potential hydration risk. Interventions included monitoring the resident for signs/symptoms of decreased output, poor skin turgor, low grade temperature and thirst. Interventions also included keeping fluids at the bedside and within reach of the resident and encouraging the resident to drink. A physician's orders [REDACTED].CBC (complete blood count), CMP (comprehensive metabolic panel) weekly x 2 (two times), then EOW (every other week) on Tue (Tuesdays) . The repeated lab was scheduled to be drawn next on [DATE]. A bowel movement task flowsheet, dated [DATE] at 10:10 a.m., documented a change in the consistency of the resident's bowel movements to loose/diarrhea. This change of condition eventually progressed to multiple, persistent loose stools with incontinence daily. There was no documentation the physician had been notified of this change in condition. A bowel movement task flowsheet, dated [DATE], documented the resident had multiple episodes of diarrhea during the day (7:00 a.m. to 3:00 p.m.) and evening (3:00 p.m. to 11:00 p.m.) shifts. An admission assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making. He required extensive assistance of two staff members with bed mobility, transfers and toilet use. He was admitted for skilled services after an acute hospital stay. He was occasionally incontinent of bowel and bladder with less than seven episodes of incontinence in the last seven days. No moisture associated skin damage was documented on his left buttock or gluteal crease. He did not have a condition or chronic disease that resulted in a life expectancy of less than six months. A care plan dated, [DATE], documented, .(Named resident) is at risk for fluid imbalance r/t (related to) [MEDICAL CONDITION], cardiovascular issues and diuretic use .Monitor and document intake and output as per facility policy .Monitor/document bowel sounds and frequency of BM (bowel movement): provide medication per order .Notify Physician if: Persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours .Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated .Recommended daily fluid intake: 2356 ml (milliliter) .monitor/document/report to MD PRN (as needed) .agitation .loose stools .assist with incontinent care/Turning and repositioning Q2 hrs (every two hours) and as needed .Keep skin clean and dry .Obtain and monitor Lab/diagnostic work as ordered .Administer [MEDICATION NAME] ([MEDICATION NAME], an antidiuretic) as ordered .Encourage adequate fluid intake to help liquefy secretions .Give medications as ordered. A bowel movement task flowsheet, dated [DATE] through [DATE], documented the resident had multiple episodes of diarrhea during the day and evening shifts. A physician's orders [REDACTED]. Two tablets were given on [DATE] at 1:12 p.m. This order was given five days after the resident began experiencing multiple episodes of loose stools daily. A skilled daily nurse's note, dated [DATE] at 1:42 p.m., documented, .Bowel & (and)Bladder .Bowel incontinence .Diarrhea .Alert .Oriented to .Person .Place .Time .short tempered .easily annoyed . A nurse's progress note, dated [DATE] at 2:24 p.m., documented, Resident c/o (complained of) diarrhea that has gone on for a few days. A bowel movement task flowsheet, dated [DATE] at 8:33 p.m., documented the resident had an episode of diarrhea. The MAR (medication administration record) documented the resident was not given an additional dose of the [MEDICATION NAME] ordered every six hours as needed. The MAR indicated [REDACTED] The amount eaten task sheet, dated [DATE], documented the resident refused the evening meal. A bowel movement task flowsheet, dated [DATE], documented the resident had episodes of diarrhea on the day and evening shifts. The MAR indicated [REDACTED]. The amount eaten task sheet, dated [DATE], documented the resident refused the first two meals of the day. On [DATE], there was no documentation the second ordered lab sample had been collected for the ordered CBC and CMP. From [DATE] through [DATE], records reviewed were inconsistent for documentation of the frequency of the resident's incontinent episodes. Task flow sheets were reviewed for bowel incontinence, urinary incontinence and incontinent care. Twenty-one discrepancies of incontinent episodes were noted for lack of documentation. Only the minimum number of incontinent loose stools could be determined during each shift from the documentation. This affected the staff's ability to accurately assess the resident's current condition and recognize the need for physician notification and the implementation of interventions to address the resident's persistent episodes of loose stools. On [DATE] at 8:09 a.m., the resident was observed sitting in his bed with approximately three inches of loose brown liquid stool enclosed between his upper thighs. The room smelled strongly of bowel movement, and the top sheet covering the resident had an approximately three inch watery brown stain above the resident's upper thighs. The resident said, I need water. There was no water or other fluids for hydration observed in the resident's room and within his reach. At 8:48 a.m., CNA #3 (certified nurse aide) entered the room and said, You are covered (with bowel movement). She stated she had requested medication for his diarrhea more than once and asked the resident if he had been given anything. He said, No. She stated the resident was completely soaked and had not been changed all night. The resident said, I've been laying in pee and (explicit term for bowel movement) all night. CNA #3 was asked what made her think the resident had not been changed during the night. She stated it was not the first time the resident had been found in this condition after the night shift. During incontinent care two pink areas were observed on the resident's skin. One pink area was of an irregular shape about one square inch in area on the left buttock. The lower margin of the area was bright red. Additionally, an approximately one inch extension was noted in the crease of the gluteal fold. This area was noted to be bright red. A progress note, dated [DATE] at 2:08 p.m., documented, pt (patient) /family expressing a desire to go back to ER (emergency room ) rt (related to) congestion and sob (shortness of breath), pt/family feels like he may have pneumonia again, on observation pt noted w (with) labored abdominal breathing, lungs coarse with rhonchi . At 2:11 p.m., the resident's skin was observed during incontinent care with the wound care nurse. She described the pink areas as new areas of excoriation due to moisture. At 2:22 p.m., family members of the resident were interviewed. They stated the resident had not been getting the antidiarrheal medication he needed. They stated it took two or three days for him to get his medication. They stated the resident had told them his call light was not being answered on the weekend, and he had been in poop all weekend. They stated nights were the problem. Family member #2 stated the family was there to take the resident back to the hospital. He stated the resident was still not getting the care he needed. He stated they were afraid the resident had pneumonia. He stated the resident had recently started to refuse meals due to nausea. The MAR, dated [DATE], did not document any dose of the PRN antidiarrheal medication was provided to the resident for his persistent loose stools during the day shift. At 3:40 p.m., the resident stated he asked for diarrhea medication when people came to his room. He said, But they should know I needed it, too, when I'm having diarrhea in my bed and on the bedpan. A chest x-ray report, dated [DATE] at 3:42 p.m., documented the resident had central [MEDICAL CONDITION] venous congestion without overt [MEDICAL CONDITIONS] and no focal pneumonia evident by frontal view. A handwritten note documented the physician was notified of the results and ordered [MEDICATION NAME] (a diuretic) 80 mg times one dose. A physician's orders [REDACTED]. The amount eaten task sheet, dated [DATE] at 8:03 p.m., documented the resident refused all meals. There was no documentation in the resident's record the physician was notified the resident had been refusing meals since [DATE]. There was no documentation the resident's fluid intake and output were monitored since admission to the facility. A MAR, dated [DATE] at 10:45 p.m., documented 80 mg (milligrams) of [MEDICATION NAME] had been given intramuscularly. The medication had been administered over seven hours after it had been ordered by the physician when he was notified of the chest x-ray results. Observation of the emergency medicines and review of records documented a supply of [MEDICATION NAME] had been available in the emergency medication supply for immediate use. There was no further documentation the resident was assessed and monitored following the resident's change in respiratory status on [DATE] at 2:08 p.m. when the resident had been assessed with [REDACTED]. A late entry nurse's progress note, dated [DATE] at 3:04 a.m., documented at 12:18 a.m. the resident experienced respiratory distress. EMSA (emergency services) were called and CPR (cardiopulmonary resuscitation) was started. EMSA arrived a few minutes later and continued CPR for about one hour. Three doses of [MEDICATION NAME] (a medication to attempt to restart the heart) were given. At 12:58 a.m., the resident was pronounced dead. On [DATE] at 12:25 p.m., physician #1 was asked when he was first notified the resident was having loose stools. He stated he did not know, but once he was notified he ordered an antidiarrheal medication. He was asked if he realized the PRN antidiarrheal medication was not being given. He was surprised to learn this and said, They weren't? He was asked how it was known the resident was getting the proper amount of fluids, and he stated fluids were being monitored (they weren't). On [DATE] at 8:05 a.m., the DON was asked if the resident's second ordered CBC and CMP labs had been collected. The DON answered, No. The DON was asked what was expected from staff if a resident had a change in condition. She stated the doctor should be called, the change should be documented and the change should be reported to oncoming staff. The DON was asked what she expected staff to do when a resident changed from having formed stools to loose stools. She stated the staff was expected to call the doctor and get something for diarrhea. The DON was asked how the facility would know the resident was not dehydrated considering he had multiple loose stools. The DON stated they would have fluid at the bedside, push fluids, monitor for signs and symptoms of dehydration and call the doctor if needed. The DON was asked where was documentation of the resident's fluid intake. She stated there was none. The DON was asked if there was a policy for Intake and Output. She stated, No. At 9:18 a.m., the nurse practitioner was asked what she expected from staff when a resident experienced a change in condition. She stated she expected to be informed of the change so she could address the issue. She was asked if she expected to be informed of a change in consistency of a resident's stools. She said, Yes. She was asked when she was made aware the resident was experiencing loose stools. She stated she became aware on [DATE], but she was unsure of the time. She stated, once she knew about the loose stools, she gave an order for [REDACTED].>She was asked if she was aware that his antidiarrheal medication had not been given per orders. She stated, she was not. She stated she expected a medication to be given when she wrote an order. She stated it was important for the medication to be given as ordered, otherwise the resident's condition would progress and the resident might not recover. When asked, she stated diarrhea could lead to skin breakdown and dehydration. She was asked if the resident was likely to become dehydrated because of his persistent diarrhea. She stated because of the resident's medical conditions he walked a fine line between dehydration and fluid overload. She stated it was staff's responsibility to determine the number of stools a resident was having, the frequency of stools, and the consistency of stools and to report changes promptly. She stated his food and fluid intake would be important to know so he could be treated appropriately. She stated she had not been notified the resident had refused meals. She stated lab results would be important to help monitor for fluid balance. She acknowledged the physician ordered a steroid and a diuretic. She was asked if the administration of the medications were important to the resident's health. She stated if the medications were not given the resident could continue to decline and this could contribute to his death. On [DATE] at 3:00 p.m., the facility administrator was notified the facility failed to assess, monitor, and intervene for a resident who had a changes in condition. He acknowledged the concerns.

Based on observations, interviews, and record reviews, it was determined the facility failed to ensure residents were not neglected and care was provided timely for three (#3, 9 and #10) of six sampled residents reviewed for neglect. For resident #3, there was a delayed notification of the physician when the resident's condition worsened. The physician ordered antidiarrheal medication, which was not administered as ordered and the resident's skin started breaking down. The physician ordered labs, which were never obtained. The resident's condition worsened and the physician ordered a diuretic medication, which took over 7 hours to administer. Also, records documented a lack of fluid intake monitoring during the time the resident experienced loose stools. On [DATE] at 12:58 a.m. the resident expired in the facility. The DON (director of nurses) identified 106 residents resided in the facility. Findings: A facility policy titled, Administrative Policy and Procedures Resident Abuse, Neglect and Misappropriation of Property, documented: .The resident has the right to be free from verbal .physical .and mental abuse .and involuntary seclusion. The facility will not tolerate mistreatment, neglect, or abuse of residents. .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs .when a resident receives a lack of care in one or more areas . 1. Resident #3 had [DIAGNOSES REDACTED]. An admission note, dated [DATE] at 9:00 p.m., documented, .Resident is .continent of bowel and bladder . A baseline assessment, dated [DATE], documented the resident was alert. Interventions included keeping fluids at the bedside and within reach of the resident and encouraging the resident to drink. A physician's orders [REDACTED].CBC (complete blood count), CMP (comprehensive metabolic panel) weekly x 2 (two times), then EOW (every other week) on Tue (Tuesdays) . The second CBC and CMP were expected to be collected on [DATE]. A skin/wound note, dated [DATE] at 5:47 p.m., documented, .Buttocks have no redness . A bowel movement task flowsheet, dated [DATE] at 10:10 a.m., documented a change in the consistency of the resident's bowel movements to loose/diarrhea. A bowel movement task flowsheet, dated [DATE], documented the resident had multiple episodes of diarrhea during the day (7:00 a.m. to 3:00 p.m.) and evening (3:00 p.m. to 11:00 p.m.) shifts. An admission assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making. He required extensive assistance of two staff members with bed mobility, transfers and toilet use. He was occasionally incontinent of bowel and bladder with less than seven episodes of incontinence in the last seven days. No moisture associated skin damage was documented on his left buttock or gluteal crease. He did not have a condition or chronic disease that resulted in a life expectancy of less than six months. A care plan dated, [DATE], documented, .(Named resident) is at risk for fluid imbalance . Monitor and document intake and output as per facility policy .Monitor/document bowel sounds and frequency of BM (bowel movement): provide medication per order . Obtain and monitor lab/diagnostic work as ordered .Recommended daily fluid intake: 2356 ml (milliliter) .skin integrity .assist with incontinent care/Turning and repositioning Q2 hrs (every two hours) and as needed .Keep skin clean and dry .Obtain and monitor Lab/diagnostic work as ordered .(Named resident) is incontinent at times and requires assistance with toileting .check as required for incontinence. Wash, rinse and dry perineum .(Named resident) requires assistance with ADL (activities of daily living) tasks r/t (related to) decreased mobility .Toileting .requires extensive assistance .Check nail .and clean .as necessary .Alteration in cardiovascular status .Administer [MEDICATION NAME] ([MEDICATION NAME], an antidiuretic) as ordered .Potential for cough/congestion .Encourage adequate fluid intake to help liquefy secretions .Give medications as ordered . A bowel movement task flowsheet, dated [DATE] through [DATE], documented the resident had multiple episodes of diarrhea during the day and evening shifts. A physician's orders [REDACTED]. Two tablets were administered on [DATE] at 1:12 p.m. This order was given five days after the resident began experiencing multiple episodes of loose stools daily. There was no documentation the physician had knowledge of the resident's continued persistent episodes of loose stools prior to receipt of the order. A skilled daily nurse's note, dated [DATE] at 1:42 p.m., documented, .Bowel incontinence .Diarrhea .Alert .Oriented to .Person .Place .Time . A nurse's progress note, dated [DATE] at 2:24 p.m., documented, Resident c/o (complained of) diarrhea that has gone on 'for a few days'. A bowel movement task flowsheet, dated [DATE] at 8:33 p.m., documented the resident had an episode of diarrhea. The MAR (medication administration record) documented the resident was not given an additional dose of the [MEDICATION NAME] ordered every six hours as needed. The MAR indicated [REDACTED] A bowel movement task flowsheet, dated [DATE], documented the resident had episodes of diarrhea on the day and evening shifts. The MAR indicated [REDACTED]. On [DATE], there was no documentation the second set of lab samples had been collected for the ordered CBC and CMP. On [DATE] at 8:09 a.m., the resident was observed sitting in his bed with approximately three inches of loose brown liquid stool enclosed between his upper thighs. The room smelled strongly of bowel movement, and the top sheet covering the resident had an approximately three inch watery brown stain above the resident's upper thighs. The resident's fingernails were noted to have about two millimeters of a brown substance under each fingernail. The resident said, I need water. There was no water or other fluids for hydration observed in the resident's room and within his reach. Between 8:09 a.m. and 8:48 a.m., the resident's room was observed. A strong odor of bowel movement was present outside the resident's doorway to his room. Several staff members were observed to enter and exit the resident's room and walk by his doorway. No staff members were observed to provide care or request assistance with the provision of incontinence care for the resident until a CNA #3 (certified nurse aide) entered the resident's room. At 8:48 a.m., CNA #3 entered the room and said, You are covered (with bowel movement). She stated she had requested medication for his diarrhea more than once and asked the resident if he had been given anything. He said, No. She stated the resident was completely soaked and had not been changed all night. The resident said, I've been laying in pee and (explicit term for bowel movement) all night. CNA #3 was asked what made her think the resident had not been changed during the night. She stated it was not the first time the resident had been found in this condition after the night shift. The resident stated he told the administrator he was not being provided incontinent care at night and he was often left sitting in liquid stool, but nothing gets done. During incontinent care two pink areas were observed on the resident's skin. One pink area was of an irregular shape about one square inch in area on the left buttock. The lower margin of the area was bright red. Additionally, an approximately one inch extension was noted in the crease of the gluteal fold. This area was noted to be bright red. The resident's care had to be interrupted to allow the resident to sit on the bed pan for diarrhea. A progress note, dated [DATE] at 2:08 p.m., documented, pt (patient) /family expressing a desire to go back to ER (emergency room ) rt (related to) congestion and sob (shortness of breath), pt/family feels like he may have pneumonia again, on observation pt noted w (with) labored abdominal breathing, lungs coarse with rhonchi . At 2:11 p.m., the resident's skin was observed during incontinent care with the wound care nurse. She described the pink areas as new areas of excoriation due to moisture. The resident's care had to be interrupted to allow the resident to sit on the bed pan for diarrhea. A skin/wound note, dated [DATE] at 2:18 p.m., documented, Skin assessment completed and noted two areas of excoriation. One was to left buttock and other to gluteal crease .Resident with loose stool noted . At 2:22 p.m., family members of the resident were interviewed. They stated they met with the administrator and DON on Monday, [DATE]. They stated the resident had not been getting the antidiarrheal medication he needed. They stated it took two or three days for him to get his medication. They stated the resident told them his call light had not been answered on the weekend timely, and he had been in poop all weekend. They stated nights were the problem. Family member #1 stated they had a meeting with the administrator and DON on Monday and were told a meeting would be held with the night shift to get it straightened out. Family member #2 stated the family was there to take the resident back to the hospital. They stated the resident was still not getting the care he needed. He stated they were afraid the resident had pneumonia. He stated the resident had also begun to refuse meals due to nausea. Family member #3 stated the facility should have been taking care of the diarrhea. She stated people should not take this job if they don't want to take care of people. At 2:46 p.m., the DON was asked if the resident or family had expressed concerns of neglect. The DON stated the family reported the resident had to wait for 30 minutes for help after using his call light. She stated the family said the resident had diarrhea. She stated after the conversation with the family a medication was ordered for diarrhea. She also stated two staff members, who worked on the weekend, were called and educated about answering call lights and providing incontinent care. She was asked if there was documentation of these calls to the staff, and the DON said, No. She was asked if she considered this neglect, and the DON stated she did not consider this neglect as it only happened one time and the resident finally received care. She stated incontinent care should be provided every two hours and as needed. The MAR, dated [DATE], did not document any doses of the PRN (as needed) antidiarrheal medication were provided to the resident for his persistent loose stools during the day shift. At 3:40 p.m., the resident was asked if his call light was answered during the night. He stated at night call lights were not answered. He stated he would ring the call light and then wait. He stated he fell asleep in bowel movement and woke up in it. He stated when he sat in bowel movement it hurt and stung. He stated he asked for diarrhea medication when people came to his room. He said, But they should know I needed it, too, when I'm having diarrhea in my bed and on the bedpan. A chest x-ray report, dated [DATE] at 3:42 p.m., documented the resident had central [MEDICAL CONDITION] venous congestion without overt [MEDICAL CONDITIONS] and no focal pneumonia evident by frontal view. A handwritten note documented the physician was notified of the results and ordered [MEDICATION NAME] (a diuretic) 80 mg (milligrams) times one dose. A skilled daily nurse's note, dated [DATE] at 4:31 p.m., documented, .Bowel & Bladder .Bowel incontinence .Diarrhea .Alert .Oriented to .Person .Place .Time . A physician's orders [REDACTED]. A MAR, dated [DATE] at 10:45 p.m., documented 80 mg of [MEDICATION NAME] had been given intramuscularly. The medication had been administered over seven hours after it had been ordered by the physician when he was notified of the chest x-ray results. Observation of the emergency medications and review of records documented a supply of [MEDICATION NAME] had been available in the emergency medication supply for immediate use. On review of records, there was no further documentation the resident had been assessed and monitored following the resident's change in respiratory status at 2:08 p.m. A late entry nurse's progress note, dated [DATE] at 3:04 a.m., documented at 12:18 a.m. the resident experienced respiratory distress. EMSA (emergency services) were called and CPR (cardiopulmonary resuscitation) was started. EMSA arrived a few minutes later and continued CPR for about one hour. Three doses of [MEDICATION NAME] (a medication to attempt to restart the heart) were given. At 12:58 a.m., the resident was pronounced dead. On [DATE] at 12:25 p.m., physician #1 was asked .if he realized the antidiarrheal medication he ordered was not being given. He was surprised to learn this and said, They weren't? At 2:59 p.m., CMA #1 (certified medication aide) was asked if the night shift did their job. She stated the nightshift was awful with a few exceptions. She stated it sometimes looked like nothing had been done on nights when she got to work in the morning. She stated when she got to work some night staff would be on their phones even though things were a mess. She stated she often did patient care and residents would be found in bowel movement when she started her shift. On [DATE] at 8:05 a.m., the DON was asked if the resident's second ordered CBC and CMP labs had been collected. The DON answered, No. The DON was asked what she expected staff to do when a resident changed from having formed stools to loose stools. She stated the staff were expected to call the doctor and get something for diarrhea. The DON was asked how the facility would know the resident was not dehydrated considering he had multiple loose stools. The DON stated they would have fluid at the bedside, push fluids, monitor for signs and symptoms of dehydration and call the doctor if needed. The DON was asked where was documentation of the resident's fluid intake. She stated, there was none. The DON further stated the resident had been going to the dining room for his meals, but since the diarrhea started he had been staying in his room. At 9:18 a.m., the nurse practitioner was asked if she was aware the antidiarrheal medication had not been given as ordered. She stated she was not. She stated she expected a medication to be given when she wrote an order. She stated it was important for the medication to be given as ordered, otherwise the resident's condition would progress and the resident might not recover. When asked, she stated diarrhea could lead to skin breakdown and dehydration. She was asked if the resident was likely to become dehydrated because of his persistent diarrhea. She stated because of the resident's medical conditions he walked a fine line between dehydration and fluid overload. She stated, his food and fluid intake would be important to know so he could be treated appropriately. She stated she had not been notified the resident had refused meals. She stated lab results would be important to help monitor for fluid balance. She acknowledged the physician ordered a steroid and a diuretic. She was asked if the administration of the medications were important to the resident's health. She stated if the medications were not given the resident could continue to decline and this could contribute to his death. On [DATE] at 3:00 p.m., the facility administrator stated it was alleged the resident was not provided necessary incontinent care. He was notified the resident and his family had reported the resident was not provided incontinent care for an entire weekend on [DATE] and no investigation was completed into the allegations. A surveyor observed the resident sitting in pooling liquid feces on the morning of [DATE] and the resident reported he had not been provided care all night. A staff member reported the resident had been found sitting in pooling liquid feces before and had reported he had not received care. The resident reported his buttocks were often burning due to sitting in liquid feces for prolonged periods of time without care. He reported he was thirsty and there was no available water or other fluids at his bedside, and he was unable to leave his room due to persistent untreated diarrhea. The administrator acknowledged the concerns. 2. Resident #9 had [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented the resident had bladder incontinence related to an overactive bladder. Interventions included: use of adult briefs, check the resident as required for incontinence, wash rinse and dry perineum, and change clothing as needed after incontinent episodes. A care plan, dated [DATE], documented the resident had an ADL (activities of daily living) performance deficit related to weakness. Interventions included: limited to extensive assistance of one to two staff with transfers. A care plan, dated [DATE], documented the resident had bowel incontinence. Interventions included: assist resident to toilet and provide pericare after each incontinent episode. A quarterly assessment, dated [DATE], documented the resident was cognitively alert in daily decision making skills. She had no behaviors of rejection of care. She was frequently incontinent of bowel and always incontinent of bladder. She required limited assistance from staff with bed mobility, dressing and hygiene. A task flow sheet, dated [DATE] through [DATE], documented, .encourage and assist with incontinent care .q (every) 2 hours and as needed . The flow sheet documented incontinent care was not provided on the 11:00 p.m. to 7:00 a.m. shift on [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 8:38 a.m., the resident was observed lying in her bed. There was a strong urine odor detected in the resident's room. She stated she had been wet with urine since 4:00 a.m. She stated she used her call light to ask staff to provide her incontinent care. They responded and stated they would return, but never did. She stated she was brought her breakfast tray before 8:00 a.m. and she informed the morning staff she was wet and staff replied they would return. She said, I'm still wet since 4:00 a.m. She said, I always wear briefs it's my choice because I do not want to lay in urine up to my back. My skin gets easily irritated and I am sitting here still wet. The resident's top sheet was observed with a circular wet spot and her gown was rolled up above her waist. The resident was wearing a white adult brief with a dark yellow color in the groin area extending upward towards her abdomen. At 9:06 a.m., CNA #2 was observed exiting the resident's room holding a plastic bag with a soiled brief. At 9:17 a.m., CNA #2 stated she started her shift at 7:00 a.m. She was asked when was the last time she provided the resident's incontinent care. She stated she had just provided incontinent care for the resident for the first time since her shift started. She stated she did not know when the night shift had last provided the resident's incontinent care. At 9:58 a.m., CNA # 10 stated she started her shift at 7:00 a.m. She stated she had provided the resident her breakfast tray at 7:45 a.m. She stated she had not checked the resident for incontinence since she started her shift. 3. Resident #10 had [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented the resident had bladder incontinence related to an overactive bladder. Interventions included: use of adult briefs when up out of bed for dignity, check the resident frequently for incontinence, and provide care after each episode. A care plan, dated [DATE], documented the resident had limited physical mobility and required assistance of staff with toileting and transfers. An admission assessment, dated [DATE], documented the resident was cognitively alert in skills for daily decision making. He required extensive assistance from staff with transfers and toileting. He was occasionally incontinent of bladder and frequently incontinent of bowel. There were no behaviors of refusal of care documented. At 9:50 a.m., resident #10 stated he was not able to get out of bed without staff assistance. He stated he could utilize the restroom for his toileting needs if staff provided him with assistance to the commode. He said, Most of the time I have to wait a long time, especially at night. He stated the facility staff have told him to go ahead and go #2 (bowel movement) in my brief. He then stated the facility staff have stated, I can do #1 (urinate) at least two times before they change me. He stated he routinely wakes up around 5:00 to 6:00 a.m. and the night shift often tells him to use the bathroom in his brief if he cannot wait for assistance. He stated this was often stated to him at 6:00 a.m. He said, I didn't like to go in my brief. He stated it embarrassed him to use the bathroom in his brief. On [DATE] at 3:00 p.m., the facility administrator was notified of the concerns related to dignity due to the facility's failure to ensure residents were provided timely assistance with incontinent care and toileting. He acknowledged the concerns. On [DATE] at 3:00 p.m., the facility administrator was notified of the concerns related to neglect. He acknowledged the concerns.

Based on record review and interview, it was determined the facility failed to provide adequate supervision to prevent a fall, with injury, for one (#1) of three sampled residents whose records were reviewed for falls. This resulted in an actual harm for resident #1, who sustained a subdural hematoma and facial fractures as a result of the fall. Findings: A nurse's note, dated 06/26/15 at 10:58 p.m., documented the resident was admitted to the facility at 5:45 p.m., from a local hospital. The note documented the resident was alert and only oriented to himself. The note also documented the resident was incontinent of bowel and bladder with weakness to upper and lower extremities. These notes were signed by registered nurse (RN) #1. A facility fall assessment, dated 06/26/15, documented the resident had a score of 40. A score above 25 indicated the resident was a fall risk. An admission assessment dated [DATE], documented the resident was not ambulatory and used a wheelchair. A care plan, dated 06/26/15, documented interventions which included: 1. The resident was to be monitored for adjustment issues. 2. Provide 24 hour reality orientation as needed. 3. Assess the resident's mobility and need for assist transfers, toileting, and ambulation. 4. Encourage the resident to request assistance with mobility, transfers, and ambulation as needed. Keep the call light within reach. 5. Prompt to toilet every two hours. 6. Check every two hours for wetness and soiling of clothing. The care plan did not reflect the resident's status. The resident was not toileted and was not ambulatory. The clinical record contained no documentation the resident had been checked at a minimum of every two hours or more often as needed. A nurse's note, dated 06/27/15 at 10:12 a.m., documented at 9:19 a.m., the nurse was called to the resident's room by one of the hall aides. The resident had been found on the floor next to his bed. The note documented there was blood on the floor from the resident's head. The note also documented the physician's nurse practitioner was notified and a new order was received to transport the resident to a local hospital for evaluation. The resident was transferred at 9:45 a.m., to a local hospital. These notes were signed by registered nurse (RN) #1. The hospital report of the computerized tomography scan (CT scan) of the resident's head, dated 06/27/15, documented: 1. The resident had small foci of subdural/subarachnoid hemorrhage along the left convexity, 2. Nondisplaced fractures of the left maxillary sinus and zygomatic arch, and 3. Soft tissue swelling on the left scalp. The resident passed away on 07/04/15, while a patient in the hospital. The death certificate, dated 07/22/15, documented the cause of death was acute subdural hematoma due to blunt force trauma secondary to a fall. On 09/02/15 at 3:00 p.m., RN #1 was asked to review the clinical record of the named resident. The RN was asked if there was any additional information documented. She stated there was no additional documentation. On 09/05/15 at 9:30 a.m., two registered nurses (#1 and #2), who worked on the skilled unit, were asked if there was a policy, in place for supervising new admissions. They stated no official policy, but they checked on all the residents every 30 minutes to an hour. They were asked where that would be documented. They stated they could chart it anywhere, but there was no required place to chart those observations. They stated they could document it in the body of their notes. The clinical record contained no documentation the resident had been monitored every thirty minutes.

Based on observation, record review and interviews, it was determined the facility failed to implement interventions to prevent a decline in range of motion for one (#7) of six sampled residents whose records were reviewed for range of motion. The facility identified 12 residents with contractures. This resulted in actual harm for the resident. This had the potential to affect twelve residents identified by the facility who had contractures. Findings: Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A resident data collection form and a minimum data set (MDS) range of motion form, dated 10/05/12, documented the resident had contractures to the lower extremities. A restorative progress note, dated 10/10/12, documented the resident continued to have problem with her legs and needed to continue to work with restorative. Restorative progress notes, dated 10/19/12 and 10/26/12, documented the resident refused group exercise due to leg spasms. The restorative progress notes did not indicate range of motion was performed on the upper extremities. An MDS range of motion form, dated 01/14/13, documented the resident had contractures to her bilateral lower extremities. A significant change assessment, dated 03/28/13, documented the resident was able to be understood by others, was able to understand others and her cognition was moderately impaired. The assessment documented functional limitation in range of motion on both sides of her lower extremities. There were no days documented in which restorative therapy was utilized. A nurse's note, dated 04/07/13, documented, "...She is unable to open her fists w/o (without) crying out in pain..." There was no documentation in the clinical record to indicate the resident had a decreased range of motion in the right hand. The care plan, dated 04/08/13, did not address the contracture of the right hand. Monthly summaries, dated 05/15/13, 05/25/13 and 06/27/13, documented the resident had contractures of the right hand and both legs. An MDS range of motion form, dated 08/15/13, documented the resident had limitation to the arm and hand on one side of the body which interfered with daily functioning or placed the resident at risk for injury. The quarterly assessment dated [DATE], documented the resident was able to be understood and was able to understand others; her cognition was severely impaired. There was a limitation in range of motion on both sides of the lower extremities. There were no days documented in which restorative therapy was utilized. An MDS range of motion form, dated 09/21/13, documented the resident had limitation in range of motion to bilateral lower extremities. A resident data collection form, dated 10/08/13, documented the resident had contractures of the right legs and right hand. An MDS range of motion form, dated 10/08/13, documented the resident had contractures of the legs and to the right hand. On 11/20/13 at 9:15 a.m., the resident was observed with a contracture to the right hand. She was asked if she could open her right hand. The resident raised her right hand and attempted to open it but was unsuccessful. She was asked if she had full range of motion to the right hand when she was admitted to the facility. She stated, "Yes." She was asked if restorative had ever worked with her hand to prevent the contracture. She stated, "No." On 11/21/13 at 10:25 a.m., licensed practical nurse (LPN) #2 was asked if the resident had a contracture. She stated she was not sure. The surveyor and LPN #2 went to the resident's room. The resident had a paper towel folded in her right hand. She stated she put it in there to keep her hand separated. After looking at the resident's hand, the LPN stated the resident's right had was contracted. Registered nurse (RN) #1 entered the room and was asked about the contracture. She stated she thought hospice had ordered a splint a couple of months ago. The LPN was asked for documentation of the contracture and the placement of the splint. After reviewing the clinical record, she stated she could not find documentation. On 11/22/13 at 9:05 a.m., the director of nurses (DON) was asked who was responsible to identify residents at risk for the development of contractures or decrease in range of motion. She stated it was a collaboration of all the nurses. The DON stated when a decrease in range of motion or development of a contracture was identified, a plan of care was initiated and evaluated on a monthly basis. The DON was asked how residents were referred to the restorative program. She stated any staff could refer a resident to the program. She stated there were now three restorative aides working seven days a week, and they sometimes worked as certified nurse aides when needed on the halls. She was asked for documentation to show interventions implemented to prevent the development of the resident's contracture, before it was identified in April 2013. There was no documentation provided to show the facility had developed or implemented interventions to prevent the contracture.