Every finding on record at The Living Center

Based on record review and interview, the facility failed to notify a resident's family member listed as the emergency contact and responsible party of a change in condition for 1 (#4) of 2 sampled residents reviewed for hospitalization . The administrator identified 19 residents resided in the facility. Findings: A policy titled Change in a Resident's Condition or Status, revised 05/2017, read in part, Our facility shall promptly notify the resident, [their] Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. [for example], changes in level of care, billing/payments, resident rights, etc. [and the rest/so forth]). A progress note, dated 02/25/25 at 7:09 p.m., read in part, res was in dining room for evening meal and noted to have gotten choked up on meal, res started coughing and face got reddened, res cont [continue] to cough for several minutes. no s/s [signs/symptoms] distress noted. res was assisted to room and o2 applied o2 sats [saturation] 80% with o2 in place, vital signs: 138/89-95-22-98.7. lungs noted to have wheezes to bilat upper and lower lobes bilat. prn [as needed] breathing tx [treatment] given with ineffective results. dr [name withheld] notified and new order received for two view cxr. call placed to [name withheld] imaging to notify of new order. Res notified of new order and res is own responsible party. A progress note, dated 02/25/25 at 7:43 p.m., read in part, received follow up call from dr [name withheld] to transfer res to [hospital name withheld] er. res refused to go at first then changed their mind and decided to go. call placed to [name withheld] ems [emergency medical services] for ambulance to transfer res to [hospital name withheld] ER at 1937 [7:37 p.m.]. don and administrator notified of res being transferred out to hospital. cxr order cancelled thru [name withheld] imaging. Vital signs: 142/98-88-98.3-22-80-89% with o2 in place. res is own responsible party and notified of ambulance being on way. Resident #4's quarterly resident assessment, dated 04/19/25, showed the resident had severe cognitive impairment with a brief interview for mental status of 03. A care plan, dated 04/22/25, showed the resident had diagnoses which included dementia in other diseases classified elsewhere, severe, with mood disturbance and other speech disturbances. There was no documentation to show representative #1 was only responsible for financial obligations and not the care of the resident. There was no documentation to show representative #1 should not be notified of changes in the resident's condition. On 05/05/25 at 1:21 p.m., representative #1 stated their only concern was the resident went to the hospital a long time ago and was not informed. The hospital was the one that called them. They stated they were not aware Resident #4 went to the hospital this year or last year. On 05/07/25 at 10:29 a.m., LPN #1 stated representative #1 was Resident #4's responsible party and emergency contact. They stated they contacted them when changes occurred. On 05/07/25 at 10:31 a.m., LPN #1 stated the resident could not hold a conversation. On 05/07/25 at 10:35 a.m., LPN #1 stated they believed representative #1 should have been notified of the hospital visit on 02/25/25. On 05/07/25 at 10:37 a.m., the DON stated the person listed on the face sheet as responsible party would be notified of a change in condition. On 05/07/25 at 10:40 a.m., the DON stated representative #1 was only responsible for finances and not the care of the resident, but they called them. On 05/07/25 at 10:45 a.m., the DON stated the resident's representative was not notified of the transfer to the hospital on 02/25/25. On 05/07/25 at 12:22 p.m., the administrator stated there was no documentation to show representative #1 was not responsible for the resident's care. They stated they should have been notified of changes in condition.

Based on observation, record review, and interview, the facility failed to ensure medications that were expired were removed from the refrigerator of the medication storage room. Census: 20 Findings: On [DATE] at 10:36 a.m., in the presence of LPN #1 and CMA #1, the refrigerator in the medication storage room was observed to contained two vials of opened tuberculin solution. One vial was dated as opened on [DATE], the second vial was dated as opened on [DATE]. LPN #1 stated the medication is outdated and should have been thrown away. CMA #1 stated our lists shows all vials should be used or destroyed in 45 days.

Based on record review and interviews, the facility failed to ensure RN coverage for eight consecutive hours, seven days a week for October, November, December 2022, and for January and February 2023. The Resident Census and Conditions of Residents, dated 02/09/23, documented 18 residents resided in the facility. Findings: The Schedule Sheet, for the nursing department, dated October 2022, documented an RN was not scheduled to work on 10/16, 22, 23, 29, and 30. The Schedule Sheet, for the nursing department, dated November 2022, documented an RN was not scheduled to work on 11/05, 06, 12, 13, 19, 20, and 26. The Schedule Sheet, for the nursing department, dated December 2022, documented an RN was not scheduled to work on 12/03, 04, 10, 11, 17, 18, 24, 25, and 31. The Schedule Sheet, for the nursing department, dated January 2023, documented an RN was not scheduled to work on 01/01, 07, 08, 14, 15, 21, 22, 28, and 29. The Schedule Sheet, for the nursing department, dated February 2023, documented an RN was not scheduled to work on 02/04, 05, 11, and 12. On 02/14/23 at 10:35 a.m., the Administrator and BOM were asked how many RN staff were currently employed. The Administrator stated only one, the RN/DON. They were asked what the facility was doing for weekend RN coverage. The Administrator stated, We haven't been. The Administrator and BOM were asked what was the last weekend to have RN coverage. The BOM stated the last day their weekend RN was paid was on 10/09/22. On 02/14/23 at 11:08 a.m., the DON was asked when was last time an RN provided weekend coverage. The DON stated the weekend RN last worked on 10/09/22 but the RN/DON provided RN coverage on 10/15/22. The DON stated there had not been an RN work on weekends after 10/15/22.

Based on record review and interview, the facility failed to have a system in place to monitor water management to identify and prevent water-borne illnesses to include Legionella. The Resident Census and Condition of Residents, dated 02/09/23, documented 18 residents resided in the facility. Findings: A Legionella Water Management Program policy, dated July 2017, read in parts, .prevention, detection and control of water-borne contaminants, including Legionella .facility has a water management program, which is overseen by the water management team .to identify areas in the water system where Legionella bacteria can grow and spread, and reduce the risk of legionnaire's disease . A Legionella Surveillance and Detection policy, dated July 2017, read in parts, .Legionnaire's disease will be included as part of our infection surveillance activities .Clinical staff will be trained on .signs and symptoms associated with pneumonia and Legionnaire's . On 02/14/23 at 11:20 a.m., the Administrator provided facility policies for Legionella surveillance and water management as requested during the entrance conference. The Administrator stated, We do have a policy but we are not doing what we should to ensure water safety.

Based on record review and interview the facility to monitor for side effects related to the use of a. an antidepressant medication for one (#10), and b. an anti-anxiety medication for one (#6) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Resident, dated 02/09/23, documented 13 residents were administered an antidepressant medication and four residents were administered an anti-anxiety medication. Findings: A Monitoring of Anti-Psychotics policy, dated 2022, read in parts, .When antipsychotic therapy is instituted, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions . 1. Resident #10 had diagnoses which included, Schizophrenia, depression, and increased aggression. A Significant Change Assessment, dated 12/07/22, documented the resident was cognitively impaired and had received seven days of an antidepressant medication. A Physician Order, dated 12/19/22, read in parts, .DULoxetine HCL Oral Capsule Delayed Release Sprinkle 60 MG .Give 1 capsule by mouth one time a day for depression . Resident #10 TAR's for December 2022, and January 2023, did not contain any documentation the resident had been monitored for side effects of related to the use of duloxetine. On 02/13/23 at 1:13 p.m., the DON was shown the TAR's for December 2022, and January 2023, and asked if Resident #10 had been monitored for side effects related to the use of duloxetine. The DON stated, there was only behavior monitoring. They were asked if Resident #10 should have been monitored for side effects for the use of duloxetine. They stated, yes. 2. Resident #6 had diagnoses which included, unspecified intracranial injury, dysphagia, and unspecified convulsions. A Physician Order, dated 10/22/21, read in parts, .clonazePAM Tablet 2 MG give one tablet via PEG-tube two times a day related to .UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION . Resident #6's TAR's for November 2022, December 2022, and January 2023 documented Resident #6 had received Clonazepam as directed but did not contain any documentation the resident had been monitored for side effects for the use of anti anxiety medication (Clonazepam). On 02/13/23 at 1:33 p.m., the DON was asked if Resident #6 had received Clonazepam. They stated yes, it was used for psychotic disorder. The DON was asked if Resident #6 should have ben monitored for side effects. They stated, yes.

Based on record review, observation and interview, the facility failed to ensure the dishwasher chemical testing for chlorine was 50-100 ppm to maintain dish sanitization. The Resident Census and Condition of Residents, dated 02/08/23, documented one resident received enteral nutrition and 18 residents resided in the facility. Findings: A Sanitization policy, revised October 2008, read in parts, .Dishwashing machine must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitization) .Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds . On 02/10/23 at 12:02 p.m., the dietary manager was observed to remove a chemical test strip from a clear container and perform a chemical test on the dishwasher machine. The chemical test strip did not change colors. On 02/10/23 at 12: 06 p.m., the dietary manager rechecked the dishwasher machine, using a testing strip from the clear container. The chemical test strip did not change colors, it remained yellow. The dietary manager stated it wasn't turning green according to the container. On 02/10/23 at 12:12 p.m., the dietary manager was asked if there had been any concerns with the dishwashing machine sanitization. They stated about three to four weeks ago there was a concern with the sanitizer not flowing. The contract company sent a maintenance man out and repaired the issue. The dietary manager was asked who had completed the testing this morning. They stated, I did and it wasn't working. They were asked how long had it not been testing correctly. They stated, About three days. On 02/10/23 at 12:40 p.m., the Administrator was asked if there had been any concerns with the dishwasher machine not meeting chemical levels. They stated, We had them come out about a month ago, and they replaced a hose and a new seal. The Administrator was asked if they were aware the sanitizer in the dishwashing machine was not reading to the level of 50-100 ppm. They stated, they were not aware. On 02/13/23 at 9:17 a.m., the Administrator approached and stated, the dietician was in the kitchen and they retested the dishwasher. The Administrator stated, staff had been using the wrong test strips.

Based on record review, observation and interview, the facility failed to ensure a garbage container near the food preparation table was covered with a lid. The Resident Census and Condition of Residents, dated 02/09/23, documented one resident received enteral nutrition and 18 residents resided in the facility. Findings: A Sanitization policy, revised October 2008, read in parts, .Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily . On 02/10/23 at 11:47 a.m., during meal service an uncovered trash can was observed between the steam table and the three compartment sink. On 02/10/23 at 12:40 p.m., the Administrator was asked if the trash cans should be covered in the kitchen area. They stated, the can should have been covered. On 02/13/23 at 5:07 p.m., an uncovered trash can was observed between the steam table and the three compartment sink. Cook #2 was asked what the policy was regarding the trash can being left uncovered. They stated, it shouldn't be uncovered.

Based on record review and interview, the facility failed to submit accurate data regarding direct care staffing information to CMS. The Resident Census and Condition of Residents, dated 02/09/23, documented 18 residents resided in the facility. Findings: A PBJ report for the fourth quarter of 2022, documented the facility failed to have adequate licensed nursing staff 24 hours a day for the following days: 07/03; 07/09; 07/10; 07/17; 07/23; 07/24; 07/30; 07/31; 08/06; 08/07; 08/13; 08/14; 08/20; 08/21; 08/27; 09/03; 09/04; 09/10; 09/17; 09/18; 09/24; and 09/25. The time sheets for the identified time, documented licensed nursing coverage. On 02/14/23 at 10:35 a.m., the Administrator and BOM were asked if there had ever been a time the facility did not have an LPN or an RN to provide licensed coverage for the 24 hour day. They stated there have not had any issues with having a licensed nurse in the building. The Administrator and BOM stated corporate staff enter the data into the system and do not know why the PBJ report would have documented the facility did not have licensed staffing 24 hours/day. They stated the PBJ report was not accurate.

Based on record review, observations, and interviews, the facility failed to ensure a care plan was revised to accurately reflect the smoking status for one (#17) of one sampled resident reviewed for smoking. The Administrator identified six residents who smoke that resided in the facility. Resident #17 had diagnoses to include hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. A Quarterly Assessment, dated 11/12/22, documented Resident #17 had moderate cognitive impairment. A Care Plan, dated 02/11/22, did not contain documentation Resident #17 chose to smoke, or a care plan initiated with interventions to ensure safety while smoking. On 02/09/23 at 10:45 a.m., Resident #17 was observed to be seated on the edge of their bed. An unused cigarette was on the over bed table next to the resident. On 02/10/23 at 11:09 a.m., Resident #17 was observed to gather in main dining area with other residents as they prepared to go into the courtyard to smoke. Each resident was provided a cigarette by CMA #1. An unidentified dietary staff escorted Resident #17 and the other residents into the courtyard, assisted to light each of the cigarettes, and remained with the residents while the residents smoked. On 02/10/23 at 11:25 a.m., The DON and LPN #2 were asked if Resident #17 had been assessed and care planned for safe smoking. The DON stated when Resident #17 was admitted from the hospital, the family told the resident they could not afford to smoke so the resident did not smoke for several months. The DON stated, the resident does not have a care plan for smoking. The DON was asked if the resident should have been assessed for the safety of smoking and a care plan put into place. The DON stated it should have been.

Based on record review and interview, the facility failed to ensure a baseline care plan had been completed within 48 hours of admission for one (#18) of one newly admitted residents. The Administrator identified one resident was admitted within the past 30 days. Findings: Resident #18 was admitted to the facility on [DATE], with a diagnosis to include chronic pain. A Baseline Care Plan, dated 02/01/23, documented the care plan was completed and locked on 02/01/23. The care plan documented the pain assessment portion had been completed on 02/01/23 at 6:37 p.m. On 02/13/23 at 12:52 p.m., the DON was asked when Resident #18's baseline care plan was completed. The DON stated Resident #18 had been admitted on [DATE] and the baseline care plan was locked on 02/01/23 but may have been completed and not locked prior to 02/01/23. On 02/13/23 at 3:32 p.m., the DON reported the baseline care plan was not completed until 02/01/23, and was not within the required 48 hours.

Based on record review, and interview, the facility failed notify the OHCA for a resident who received a new diagnosis of Schizophrenia for one (#10) of one sampled resident reviewed for PASRR's. The Resident Census and Conditions of Residents, dated 02/09/23, documented 11 residents had psychiatric diagnoses, and 18 residents resided in the facility. Findings: Resident #10 had diagnoses which included, Schizophrenia, increased aggression, hypertension and congestive heart failure. A State of Oklahoma Oklahoma Health Care Authority Nursing Facility Level of Care Assessment, dated 09/02/22, read in parts, .No Evidence of serious mental illness Diagnosis of serious mental illness .NO PASSRII (sic) NEEDED . A Physician Order, dated 09/22/22, read in parts, .ZyPREXA Oral Tablet 5 MG .Give 1 tablet by mouth in the evening related to Increased aggression . A Physician Order, dated 10/11/22, read in parts, .ZyPREXA Oral Tablet 5 MG .Give 2 tablet by mouth in the evening related to Increased aggression . A Significant Change Assessment, dated 12/07/22, documented the resident was cognitively impaired and had received seven days of an antipsychotic medication. A Physician Order, dated 12/16/22, read in parts, .ZyPREXA Oral Tablet 10 MG .Give 10 mg by mouth in the evening related to SCHIZOPHRENIA . The clinical health record did not document a level II PASRR had been completed after Resident #10 was diagnosed with Schizophrenia. A Physician Order, dated 02/03/22, read in parts, .ZyPREXA Oral Tablet 10 MG .Give 10 mg by mouth two times a day related to SCHIZOPHRENIA . On 02/13/23 at 12:55 p.m., the DON was asked who completed the PASRR'S. They stated, social services. On 02/13/23 at 3:53 p.m., SS was asked when Resident #10 was diagnosed with Schizophrenia, did the facility re-evaluate Resident #10 and contact the state to see if a Level II PASRR was required. They stated, No.

Based on record review and interview, the facility failed to monitor for side effects related to the use of an antipsychotic medication for one (#10) of five sampled residents reviewed for the use of unnecessary medications. The Resident Census and Condition of Residents, dated 02/09/23, documented 11 residents received antipsychotic medications, and 18 residents resided in the facility. Findings: A Monitoring of Anti-Psychotics, policy dated 2022, read in parts, .When antipsychotic therapy is instituted, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions . A Antipsychotic Medication Use policy, revised 12/16, read in parts, .Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician . Resident #10 had diagnoses which included, Schizophrenia, and increased aggression. A Physician Order, dated 09/22/22, read in parts, .ZyPREXA Oral Tablet 5 MG .Give 1 tablet by mouth in the evening related for Increased aggression . A Physician Order, dated 10/11/22, read in parts, .ZyPREXA Oral Tablet 5 MG .Give 2 tablet by mouth in the evening related to Increased aggression . Resident #10's TAR, dated November 2022, did not contain any documentation the resident had been monitored for side effects related to the use of Zyprexa. A Significant Change Assessment, dated 12/07/22, documented the resident was cognitively impaired, and had received seven days of an antipsychotic medication. A Physician Order, dated 12/16/22, read in parts, .ZyPREXA Oral Tablet 10 MG .Give 10 mg by mouth in the evening related to SCHIZOPHRENIA . Resident #10's TAR, dated December 2022, did not contain any documentation the resident had been monitored for side effects related to the use of Zyprexa. Resident #10's TAR, dated January 2023, did not contain any documentation the resident had been monitored for side effects related to the use of Zyprexa. A Physician Order, dated 02/03/22, read in parts, .ZyPREXA Oral Tablet 10 MG .Give 10 mg by mouth two times a day related to SCHIZOPHRENIA . On 02/13/23 at 1:13 p.m., the DON was shown the TAR's for November 2022, December 2022, and January 2023, and asked if Resident #10 had been monitored for side effects related to the use of Zyprexa. The DON stated, there was only behavior monitoring. They were asked if Resident #10 should have been monitored for side effects for the use of Zyprexa. They stated, yes.

Based on observation and interviews, the facility failed to ensure staff performed hand hygiene and sanitized the glucometer for two (#4 and #170) of two residents observed during finger stick blood sugar testing with a glucometer. The director of nurses identified four residents received finger stick blood sugar testing. Findings: On 11/02/21 at 11:17 a.m., LPN #2 was observed conducting a finger stick blood sugar reading on resident #4. LPN#2 did not clean the glucometer before or after use. She did not perform hand hygiene and did not change gloves according to standard of care practices. At 11:29 a.m., LPN #2 was asked the protocol for cleaning glucometers between residents. She said, night shift cleans glucometer. On 11/03/21 at 7:24 a.m., LPN #2 was observed conducting finger stick blood sugar reading on resident #170. LPN #2 did not perform hand hygiene and did not change gloves. At 7:29 a.m., LPN #2 was asked the protocol for hand hygiene when performing a finger stick blood sugar. She stated her hands were clean because she changed gloves and did not need to sanitize or performed hand hygiene between changing gloves.

Based on record review and interviews, the facility failed to ensure a psychoactive medication was gradually reduced and/or discontinued unless it was clinically contraindicated for one (#4) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 11/01/21, documented five residents received antianxiety medications. Findings: Resident #4 had diagnoses which included [CONDITION(S)] with behavioral disturbance. The current Order Summary Report, documented a physician's order with start date 06/08/21, read in part, [MEDICATION(S)] 0.5mg (milligram) give 1 (one) tablet by mouth every 8 (eight) hours as needed for Anxiety times 60 days and renew. A Medication Regimen Review report, dated 07/19/21, read in part, Dear [named physician] .As requested by [named facility], I have reviewed the resident chart for [named resident] on 07/19/21 in compliance with the CMS (Center for Medicaid/Medicare Services) regulations: Please respond to the following .Could we try a reduction for the [MEDICATION(S)] 0.5mg po (by mouth) Q (every) 8H (eight hours) PRN (as needed) anxiety? If no reduction wished please add rationale for PRN use or DC (discontinue) after 14 days therapy per State guidelines . The Medication Regimen Review report, dated 07/19/21, was signed on 07/28/21 by the physician. Hand written instructions on the document, read in part, Will Reduct (sic) [MEDICATION(S)] 0.5mg po to Q 12 hours prn anxiety. Rationale. On 11/03/21 at 3:19 p.m., the DON was asked to explain the requirements for as needed [CONDITION(S)] and antipsychotic medications. She stated they should be for 14 days only and discontinued. She was asked to review the Medication Regimen Review document dated 07/19/21 for Resident #4. She stated the medication regimen review was not followed through and the order was not updated.

Based on record review and resident and staff interviews, the facility failed to ensure treatment and care practices were in place for two (#15 and #170) of two sampled residents reviewed for indwelling urinary catheter. The Resident Census and Conditions of Residents report, dated 11/01/21, documented two residents with indwelling urinary catheter. Findings: 1. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 10/21/21, documented the resident was cognitively intact with decision making and had an indwelling catheter. The resident's Care Plan report, revised 11/02/21, read in part, Resident is at risk for complications from usage of s/p (suprapubic) catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) .Assess for and record any changes .Change catheter per facility policy/physician order .provided catheter care Q (every) shift per policy . The medical electronic record documented no physician's orders for treatment and care practices of the indwelling catheter. On 11/02/21 at 10:55 a.m., Resident #15 stated she had the surgically placed catheter prior to admission to facility. On 11/03/21 at 2:50 p.m., LPN #1 was asked what size catheter the resident would require in the event it needed to be replaced. She stated she could not locate a physician's order. She was asked if she could show where catheter care was documented. She replied, I can't find it. 2. Resident #170 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission MDS, dated [DATE], documented the resident had an indwelling catheter. The Progress Note, dated 10/27/21, read in part, Resident emptied her cath (catheter) while taking a shower, so only 100 cc (cubic centimeter) out to measure this shift. The medical electronic record documented no physician orders for treatment and care practices of the indwelling catheter. There was no physician order to assess, monitor and provide care for indwelling catheter. The resident's Care Plan report, revised 11/01/21, read in part, [named resident] is at risk for [CONDITION(S)] (urinary tract infection) r/t (related to) use of urinary catheter .Check resident frequently and provide incontinence care as needed . On 11/02/21 at 2:34 p.m., Resident #170 stated she had indwelling catheter prior to admission to facility. On 11/03/21 at 3:04 p.m., the DON was asked what the procedure was for a resident with an indwelling catheter. She stated the nursing staff would provide care and treatment according to the physician orders. She stated catheter care was provided every shift and as needed, monitor drainage bag was below waist level, monitor tubing was not kinked, change catheter as ordered, monitor and report abnormalities to physician, and document care and treatment. The DON was asked how the nursing staff would know what size of indwelling catheter to use if the catheter needed to be replaced. She stated the nurse should be able to know the size from the physician order. She reviewed the resident's electronic medical records and stated, There is no order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation and interview, it was determined the facility failed to ensure two expired house stock medications had been removed from the current stock in one of one medication storage room. The facility identified 27 residents who resided in the facility. Findings: On [DATE] at 9:27 a.m., the medication storage room was observed with ACMA #1. Two bottles of [MEDICATION NAME] with an expiration date of ,[DATE] were on the shelf labeled house stock. ACMA #1 stated the medications were expired and should not have been with their current supply.

Based on record review and interview, it was determined the facility failed to ensure daily RN coverage was provided for eight consecutive hours for two of 14 days reviewed in February 2020. The facility identified 27 residents who resided in the facility. Findings: Review of the facility staffing hours from 02/03/20 through 02/16/20 documented the following: ~ on 02/11/20, the DON worked 7.0 hours. There was no other RN coverage documented on this day; and ~ on 02/15/20, RN #1 worked from 12:00 a.m. until 6:10 a.m. and the DON had worked 5.71 hours. The hours worked by the RN and DON were not consecutive. On 02/26/20 at 1:56 p.m., the DON stated she was aware an RN was required to have been on duty daily for eight consecutive hours. She stated this had not occurred on 02/11/20 or 02/15/20.

Based on record review and interview, it was determined the facility failed to complete a significant change assessment for one (#27) of one sampled resident who had a change in condition. The facility identified 27 residents who resided in the facility. Findings: Resident #27 was admitted to hospice services on 01/07/20. A quarterly assessment, dated 02/11/20, documented the resident received hospice services. No significant change assessment was found in the electronic clinical record. On 02/25/20 at 5:30 p.m., LPN #2 stated a significant change assessment should have been completed within 14 days of being admitted to hospice.

Based on record review and interview, it was determined the facility failed to provide Advanced Beneficiary Notices to skilled nursing residents who had discharged within the previous six months for three (#17, #79, #80) of three sampled residents who were reviewed for liability and appeal notices. The facility identified 6 residents who had discharged within the last six months from skilled nursing. Findings: Three ABN's for discharged residents from Medicare skilled nursing were reviewed to ensure they had been provided and signed for residents #17, #79, and #80. The facility provided one ABN form for resident #79 which had not been signed. They were unable to provide the ABN forms for resident #17 and #80. On 02/26/20 at 10:24 a.m., the corporate representative stated the notices should have been done.

Based on record review and interview, it was determined the facility failed to ensure the code status was accurate for two (#11 and #15) of two sampled residents who were reviewed for advance directives. The facility identified 27 residents who resided in the facility. Findings: 1. Resident #11 had [DIAGNOSES REDACTED]. The clinical record included a DNR form, signed by the resident on [DATE]. The monthly physician's orders [REDACTED].full code . On [DATE] at 3:05 p.m., the clinical record was observed with a DNR sticker on the front of the chart. At 3:07 p.m., a green dot sticker was observed on the name plate next to the resident's door. On [DATE] at 10:46 a.m., CNA #1 was asked how she became aware of the code status for a resident. She stated the code status was on the ADL record in the computer and they had a green dot for full code or a red dot for DNR on the name plate next to the resident's door. She stated the resident had a green dot on his name plate so he was a full code. She looked in the computer and stated the code status was not in the ADL section for the resident. At 10:51 a.m., LPN #1 was asked how they determined a resident's code status. She stated if the resident had a DNR, they filed the form in the front of the hard chart, placed a red dot on the name plate on the door, placed a DNR sticker on the outside of the chart and wrote a physician's orders [REDACTED].>LPN #1 was asked what the code status was for the resident. She stated, Full code. She was asked to look in the resident's chart for his code status. She stated, It has a DNR sticker on the chart. She turned to the front of the chart and stated, He has a DNR in here, he had to have signed that later. LPN #1 was asked what the physician's orders [REDACTED]. She stated, Full code. LPN #1 was asked if the resident's code status was accurate. She stated, No, because he has a signed DNR. 2. Resident #15 had [DIAGNOSES REDACTED]. The clinical record included a DNR form, signed by the physician on [DATE]. The monthly physician's orders [REDACTED].CPR . On [DATE] at 3:49 p.m., a DNR sticker was observed on the outside of the chart. At 3:56 p.m., a green dot sticker was observed on the name plate next to the resident's door. On [DATE] at 10:59 a.m., LPN #1 stated the resident's code status was full code. She then looked at the clinical record and stated the resident had a signed DNR form. She stated his code status was not accurate because the orders documented CPR. At 11:02 a.m., the DON stated the resident should have a physician's orders [REDACTED].

Based on observation, record review, and interview, the facility failed to ensure a resident's safety for 1 (#2) of 3 sampled residents whose clinical records were reviewed for safety. The resident fell from her wheelchair, sustained a head injury and required medical intervention at the hospital. The facility census was 39. Findings: Resident #2 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was severely impaired in cognition. The assessment documented the resident had no falls since the last assessment. The assessment documented the resident was totally dependent for activities of daily living. The current physician's orders [REDACTED]. The resident leaned forward in her wheelchair. The care plan last reviewed 07/01/16 documented the resident was at risk for falls related to being unaware of safety needs. The care plan documented the resident was to use a safety vest to prevent falling forward from her wheelchair. The staff was to ensure the resident was positioned correctly with proper body alignment and was to release the safety vest every 2 hours. A nurse's note dated 07/16/16 documented the resident was found on the floor with the left side of her head cut open. The note documented the resident fell forward from her wheelchair and for some reason the vest came untied. An incident report dated 07/16/16 documented the resident's safety vest was most likely not tied correctly at the time of the fall. There was no documentation of an investigation to determine the cause of the fall. The resident was observed several times during the investigation as she rested in a low bed with a fall mat beside the bed. She had constant unpurposeful movements of all extremities. She did not answer any questions. The staff member who reported the fall was no longer available for interview. Certified nurse aide (CNA) #1 stated she had been shown how to apply the safety vest when she was hired. CNA #2 stated she had been shown how to apply the safety vest on hire. Licensed practical nurse #1 stated the facility had provided inservices on safety specific to residents safety. On 07/21/16 the director of nurses was shown the incident report and asked why she felt the safety vest was most likely not tied correctly at the time of the fall. She stated the nurse told her it wasn't tied correctly. She was asked if an investigation had been completed. She stated she had only talked to the nurse on duty. She was asked if she had investigated the fall. She stated, No.

Based on observation, clinical record and policy/procedure review, and staff and resident interview, it was determined the facility failed to ensure qualified and capable nursing staff were available 24 hours a day to: a. physically respond to medical emergencies for two (#10 and #11) of two sampled residents with medical emergencies. b. provide two-person assistance to five (#1, 8, 9, 13 and #15) of five sampled residents who required two-person assistance with activities of daily living. This had the liklihood to affect five residents identified by the facility who needed two-person assistance; and c. administer prn pain medication when necessary for one (#12) of one sampled resident who was administered pain medication by an unlicensed person. These deficient practices were determined to result in an immediate jeopardy situation and had the likelihood to affect all residents who resided in the facility. Findings: 1. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/27/11, documented the resident was severely impaired in cognitive skills for daily decision-making and needed extensive assistance with activities of daily living. A care plan, dated 04/28/11, documented, "... I am risk for [MEDICAL CONDITION] D/T my [MEDICAL CONDITION] disorder... Approach: Fax the physician to notify them of any [MEDICAL CONDITION] activity unless the [MEDICAL CONDITION] is prolonged, ten minutes or over, then the physician is to be called... Place me on my side during a [MEDICAL CONDITION] to prevent aspiration... Do not restrain me if I have a [MEDICAL CONDITION] Maintain a patent airway until I am fully awake after I have a [MEDICAL CONDITION] Protect my head during a [MEDICAL CONDITION] Give me my medication as ordered..." A nurse's note, dated 06/05/11 at 4:15 p.m. and written by LPN #1, documented, "(Resident) had some [MEDICAL CONDITION] activity [MEDICATION NAME] 9 minutes - (pulse) 88 - Will monitor... 4:45 (p.m.) Continuing to have short [MEDICAL CONDITION] notified (doctor name deleted)... Order to transfer pt via ambulance... 5 (p.m.) ambulance here. Pt. transferred..." A nurse's note, dated 12/31/11 at 7:00 p.m. and written by LPN #1, documented, "Having some [MEDICAL CONDITION] activity. Unsteady on feet & jerking about - acts as if she wants to just walk..." On 01/11/12 at 2:00 p.m., LPN #1 was observed sitting at the nurse's station. She had a rolling walker nearby. She stated the walker was hers. She was observed having difficulty standing and walking short distances at the nurse's station. She supported herself on the desk as she tried to move. She was asked if she was the charge nurse for the shift. She stated she was. The daily staff deployment form, dated 01/11/12, documented LPN #1 was working the 2 p.m. to 10 p.m. shift with one CMA and one CNA. At 3:00 p.m., the DON was asked if LPN #1 was physically able to assist residents and staff in an emergency. She stated she hadn't really thought about that. She was asked if she had received any complaints from staff about the LPN's performance. She stated she was aware of some issues. She was asked if any action had been taken. She stated, "No." On 01/12/12 at 2:00 p.m., CNA #4 was asked if he had ever been expected to perform care for residents that should be performed by a licensed nurse. He stated approximately two weeks prior, he saw the resident have a grand mal [MEDICAL CONDITION] in her room. He stated he yelled out to LPN #1, who was sitting at the nurse's station, for assistance. He stated the nurse never came to assist him, and instead, CMA #3 came to the room and helped him lift the resident to the bed. He stated he and the CMA tried to keep the resident from hitting her head on the wall near the bed, as she continued to have a [MEDICAL CONDITION]. He stated they had not been directed by LPN #1 to do anything else for the resident during the [MEDICAL CONDITION]. He stated he and CMA #3 waited until the resident stopped seizing, then placed the resident in a wheelchair, and took her to the nurse's station. He stated LPN #1 then directed the CMA to take the resident's vital signs. He was asked why they brought the resident out to the nurse's station. He stated, "So the nurse could check her out. The nurse couldn't stand up and walk to the resident." He was asked if he was concerned about the residents' care and safety when LPN #1 was the charge nurse. He stated he was worried everyday there would be an emergency and LPN #1 would not be able to assist him with the residents. He stated he brought up his concerns at a recent staff meeting with the DON. He stated he was worried about an emergency that required evacuation of the residents because he didn't think he could get everyone out by himself. At 2:30 p.m., LPN #1 was observed as she entered the surveyor's work room. She used a rolling walker to ambulate. Her gait was slow and deliberate. She had difficulty turning to sit in a recliner. She was asked about her physical limitations. She stated she no longer drove a car because she could not operate the accelerator and the brake correctly with her foot. She stated she had been using a rolling walker for about a year after she had both hips replaced and also had extensive back surgery. She stated that she just turned [AGE] years old and was proud that she still worked as a nurse. She was asked if she was physically able to assist the residents. She stated, "I'm not gonna say they always get turned and pulled up in bed the way they should. I can't really do that. But otherwise, yes." She was asked what shifts she normally worked at the facility. She stated she worked all shifts and never turned down a request by the DON to cover a shift. She stated she usually worked more than 40 hours a week and sometimes worked 12 or 16 hour shifts. She stated she worked mostly evening and night shifts, but also worked day shifts when asked. She was asked how many staff worked with her on the evening shift. She stated one CMA and one CNA worked with her on that shift. She stated on the night shift, she worked alone with one CNA. At 3:57 p.m., CMA #3 was asked about the resident's [MEDICAL CONDITION] on 12/31/11. She stated CNA #4 was assisting the resident with incontinent care in her room when the resident had a [MEDICAL CONDITION]. She stated the CNA yelled out to LPN #1 for assistance. Instead of going to the CNA's assistance, the LPN called out for her (CMA #3) to go assist the CNA. She stated LPN #1 never left the desk while they were assisting the resident during the [MEDICAL CONDITION]. She further stated the resident continued to seize for about three to four minutes after she was placed on the bed. She and CNA #4 stayed with the resident until she stopped seizing. They placed the resident in a wheelchair and took her to the nurse's station so LPN #1 could check the resident's condition. She stated the LPN never left the nurse's station and instead instructed CMA #3 to obtain vital signs. She stated the nurse provided no other care to the resident. 2. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, last updated on 08/11/11, documented, "... I take [MEDICAL CONDITION] medications... Approach... Monitor for any adverse effects from the medication (i.e. tiredness...) Review:... (resident) is on [MEDICATION NAME] 0.25 mg BID, [MEDICATION NAME] 30 mg at 8 (p.m.), [MEDICATION NAME] 1 mg q HS, [MEDICATION NAME] 25 mg BID..." A quarterly assessment, dated 11/01/11, did not document the resident's cognitive status. It documented the resident needed limited assistance with activities of daily living. A nurse's note, dated 12/17/11 at 7:40 p.m., documented, "... Pt. sent via ambulance to (hospital name deleted) emergency room became unresponsive after supper. V.S. B/P 105/64, P 77, R 22, T 97. Worked with pt. O2 - water on face & everything. Could not arouse. Called (doctor name deleted) called order to send to E.R...." A facility resident transfer form, dated 12/17/11, documented the resident's vital signs, DNR status and allergies [REDACTED]. An ambulance patient information form, dated 12/17/11, and completed by LPN #1, documented no treatment prior to arrival of the ambulance. An ambulance patient care record, dated 12/17/11, completed by the EMS personnel documented the resident's oxygen saturation level was low at 89% and oxygen was provided. The form also documented the resident's pulse was low at 56 beats per minute. The narrative portion of the record documented, "...Called to the above location for an unresponsive PT. Upon our arrival PT was found lying in bed. Nursing staff stated that after dinner PT was sitting in a recliner and just went unresponsive. They were not able to awake PT. PT would not open eyes or would not talk. PT would move arms. Pupils were pinpoint. FSBS was checked. IV was started and PT was placed on the cardiac monitor. PT was monitored during transport with vitals..." On 01/12/12 at 3:57 p.m., CMA #3 was asked what happened the evening the resident became unresponsive. She stated CNA #4 noticed the resident was unresponsive when he tried to assist him out of a recliner in the lobby. She further stated LPN #1 was at the nurse's station and was within sight of the resident. CMA #3 stated the LPN yelled out at her to come check the resident. The LPN did not leave the nurse's station. CMA #3 stated she took the resident's vital signs and told the LPN the resident's oxygen saturation was in the 80's. She stated the LPN instructed her and the CNA to take the resident to his bed. CMA #3 stated the resident was not responsive and could not sit upright unassisted, but they placed him in a wheelchair, tried to hold him up the best way they could, and took him to his room. She stated they lifted him into the bed and returned to the nurse's station to ask LPN #1 if they should put oxygen on the resident. The LPN said, "OK." CMA #3 stated she was not instructed if the resident should have oxygen by a mask or by nasal cannula, and was not instructed on how much oxygen should be delivered per minute. She stated she just did the best she could. She stated the LPN never came to the resident's room to assess or assist the resident or the staff as they provided care. She stated the LPN completed paperwork at the nurse's station and called an ambulance. The CMA was asked if she was concerned about the residents' care and safety when LPN #1 was acting as the charge nurse. She stated, "I'm very concerned. I've gone up the chain of command and told them (charge nurses and administration) about the problems with her care." 3. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, last updated on 04/25/11, documented the resident needed assistance with all ADLs. An annual assessment, dated 10/18/11, documented the resident was severely impaired in cognitive skills for daily decision-making and needed extensive two-person assistance with transfers. 4. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 03/26/11, documented the resident was severely impaired in cognitive skills for daily decision-making and was totally dependent on staff for all activities of daily living. A care plan, last updated on 06/26/11, documented the resident was unable to ambulate and was totally dependent on staff for transfers. 5. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 02/10/11, documented the resident was severely impaired in cognitive skills for daily decision-making and was totally dependent on staff for all activities of daily living. A care plan, last updated on 08/14/11, documented the resident needed assistance with all activities of daily living, including assistance with changing positions. 6. Resident #13 was admitted with [DIAGNOSES REDACTED]. An annual assessment, dated 12/20/11, documented the resident's cognition was moderately impaired. The assessment also documented the resident required two person assistance with transfers, ambulation, dressing, toileting, personal hygiene, and bathing. A care plan, last updated on 02/24/11, documented the resident required assistance with all activities of daily living. 7. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 11/04/11, documented the resident's cognition was severely impaired for daily decision making. The assessment also documented the resident was totally dependent on staff for all activities of daily living. A care plan, last updated on 11/04/11, documented the resident was totally dependent on two staff for transfers. On 01/12/12 at 4:30 p.m., CNA #5 was asked about her experience working with LPN #1 on the night shift. She stated, "She cannot do patient care. I do all the care myself, even the heavy lifting." She was asked if the LPN was physically able to care for the residents. She stated, "No. I'm worried about the residents' well-being all the time." She stated, "If there was a fire in this place, I'd just have to do the best I could by myself, because she cannot help me." She was asked if the LPN assisted her with the residents who needed two staff for care. She stated she did not. She was asked if the LPN ever requested she perform tasks that a nurse should perform. She stated, "Yes. Like check on the residents for her. She doesn't check on any residents except resident #8. She sees him because he gets a tube feeding. She just tells me what to look for when I check on them." 8. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 12/31/11, documented the resident was cognitively intact and had occasional mild pain and was on a scheduled pain medication regimen and PRN pain medication. There was no care plan addressing the resident's pain found in the resident's clinical record. A monthly physician's orders [REDACTED]. Facility staff daily deployment sheets, dated 11/16/11, 12/07/11 and 01/07/12 documented LPN #1 and CNA #5 were the only staff working on the 10 p.m. to the 6 a.m. shift on those dates. A Controlled Drug Administration Record, dated 11/17/11, 12/08/11 and 01/08/12, documented LPN #1 signed out [MEDICATION NAME] 5/325 mg po at 3:00 a.m. On 01/11/12 at 3:00 p.m., the DON was asked if she had any reports the LPN directed a CNA to administer a narcotic to a resident on the night shift. She stated she was aware. She stated she had talked to the LPN about it. She stated the LPN admitted she had done it because she was having difficulty walking. She stated the LPN would only ask a person she could trust to give the medicine. The DON was asked if she had any reports of LPN #1 sleeping on the night shift. She stated she had. The DON was asked how many night shifts per week the LPN worked. She stated, "One or two per week." She was asked if there had been any action taken by the facility for the issue of sleeping during a shift. She stated there had not. On 01/12/12 at 4:35 p.m., CNA #5 was asked if LPN #1 ever asked her to do a licensed nurse's task. She stated, "Every night that I work with her, she asks me to give the resident his 3:00 a.m. pain medication. I do it because she can't walk, and he shouldn't have to get up in pain to come to the nurse's station to get it." She was asked if the LPN ever slept during the night shift. She stated the nurse sometimes slept on a couch in the lobby with her foot elevated. At 5:15 p.m., resident #12 was asked who gave him his 3:00 a.m. pain medication. He stated CNA #5 did. He was asked if LPN #1 ever gave him his night time pain medication. He said, "No." At 5:22 p.m., the OSDH was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to ensure capable nursing services were provided to the residents 24 hours a day according to acceptable standards of care. The facility failed to provide capable nursing services to respond to medical emergencies, to provide care to residents who required two staff, and to ensure only licensed or certified staff administered medications. At 5:27 p.m., the facility's corporate officers and the acting administrator were notified of the immediate jeopardy situation related to the facility's failure to provide capable nursing services 24 hours a day by nursing staff who could respond to medical emergencies, provide care to residents who needed two staff members to provide care, and failed to ensure there were licensed or certified staff to administer medications. At 9:00 p.m., the facility submitted an acceptable Plan of Removal. The Immediate Jeopardy Plan of Removal, dated 01/12/12, documented, "... 1. Assessment-monitoring-interventions (Pedagogy) Education of Licensed Nurses to 495 Oklahoma Nurse Practice act expectations and responsibility Reference Material - Policy of Facility Reference and educational of standers (sic) from 675 Oklahoma State Department of Health and Federal Regulations Perry and Potter 7th Edition assessment-monitoring-interventions common practice guide lines Teaching of line staff including but limited to CNA's and CMA's as to non delegateable tasks Guest Speaker (doctor name deleted) on Expectations of Staff in reference to assessment-monitoring-interventions and his availability for service as Medical Director. 2. Capable Nursing Staff / Physically Capable Nursing Staff Review of Physical Requirements of Job/Position Acknowledgment of Abilities to practice and function Review of 495 Oklahoma Nurse Practice Act Guest Speaker (name deleted) on topic of job requirements Reference and educational of standers (sic) from 675 Oklahoma State Department of Health Perry and Potter 7th Edition assessment-monitoring-interventions common practice guide lines delegation and non-delegation abilities 3. Follow up (nurse name deleted) LPN fully relieved of duty on 01/12/12 Skills check list will be done of staff upon hire and annually. Current staff will have skills check list redone by 1 pm 01/13/2012 DON relieved of duty as of 01/12/12 Interim DON (name deleted) Placed in-position 01/12/12 Daily review and monitoring of nurses assessment, monitor and intervention nursing skills along with nursing staff capability and physical capability will be done by DON or designee until confident practice achieved then continued prn with report to QA committee All staff in-serviced by 11:59 pm 01/12/2012 either in person or by phone. Anyone not inserviced will not work the floor until such education is completed..." On 01/13/12 at 11:50 a.m., the immediate jeopardy situation was removed. The deficient practice remained at a widespread level with a potential for more than minimal harm.

Based on observation, clinical record review and staff interview, it was determined the facility failed to ensure a capable licensed nurse assessed, monitored and intervened in the residents' change in condition for two (#10 and #11) of eight sampled residents who had a change in condition. This deficient practice was determined to result in immediate jeopardy and had the likelihood to affect all residents who resided in the facility. Findings: 1. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 04/28/11, documented, "... I am at risk for [MEDICAL CONDITION] D/T my [MEDICAL CONDITION] disorder... Approach: Fax the physician to notify them of any [MEDICAL CONDITION] activity unless the [MEDICAL CONDITION] is prolonged, ten minutes or over, then the physician is to be called... Place me on my side during a [MEDICAL CONDITION] to prevent aspiration... Do not restrain me if I have a [MEDICAL CONDITION] Maintain a patent airway until I am fully awake after I have a [MEDICAL CONDITION] Protect my head during a [MEDICAL CONDITION] Give me my medication as ordered..." The May 2011 monthly physician's orders [REDACTED]. Call the DR for prolonged [MEDICAL CONDITION] activity of 10 minutes and he will decide whether to administer or not..." A nurse's note, dated 06/05/11 at 4:15 p.m., documented, "(Resident) had some [MEDICAL CONDITION] activity [MEDICATION NAME] 9 minutes - (pulse) 88 - Will monitor... 4:45 (p.m.) Continuing to have short [MEDICAL CONDITION] notified (doctor name deleted)... Order to transfer pt via ambulance... 5 (p.m.) ambulance here. Pt. transferred..." The clinical record did not include any further information about the assessment of the resident, nursing interventions provided, and how the resident was monitored. A facility resident transfer form, dated 06/05/11, documented the only vital sign recorded was a pulse rate of 88. There was no other pertinent information about the resident's medical history or current condition recorded on the form. There was no documentation of nursing interventions performed prior to the resident's transfer to the hospital. An ambulance service patient information form, dated 06/05/11, and completed by LPN #1, documented, "... Current Vital Signs: Time 4:30 p.m. B/P (none documented) Pulse: 88 Resp: (none documented) Temp: (none documented)... Treatment prior to arrival of (ambulance): (none documented)... Please "X" Appropriate condition:... Altered LOC (level of consciousness): (not marked)... Destination: (not documented)... " An ambulance service patient care record, dated 06/05/11, documented the emergency responders monitored the resident's vital signs and oxygen saturation level, applied oxygen to the resident, started an IV, and gave [MEDICATION NAME] to help control the [MEDICAL CONDITION]. The form's narrative documented, "... responded to scene in reference to pt with recurrent [MEDICAL CONDITION] history of same. 3 witnessed [MEDICAL CONDITION] by (nursing home) staff. Pt. moved to cot and secured and suffered another grand mal [MEDICAL CONDITION]. FSBS 260... (oxygen) at 4 lpm. 2 mg [MEDICATION NAME] IV. VS as listed. Pt. [MEDICAL CONDITION] stopped. Pt. transferred to (hospital emergency room )..." A quarterly assessment, dated 10/27/11, documented the resident was severely impaired in cognitive skills for daily decision-making and needed extensive assistance with activities of daily living. A nurse's note, dated 12/31/11 at 7:00 p.m., documented, "Having some [MEDICAL CONDITION] activity. Unsteady on feet & jerking about - acts as if she wants to just walk..." There was no other information in the nurse's note that described the [MEDICAL CONDITION] activity, how long it lasted, what monitoring was performed or what nursing interventions were provided for the resident. On 01/11/12 at 2:00 p.m., LPN #1 was observed sitting at the nurse's station. She had a rolling walker nearby. She stated the walker was hers. She was observed having difficulty standing and walking short distances around the nurse's station. She supported herself on the desk as she tried to move. She was asked if she was the charge nurse for the shift. She stated she was. At 3:00 p.m., the DON was asked if LPN #1 was able to assist residents and staff in an emergency. She stated she hadn't really thought about that. She was asked if she received any complaints from staff about the LPN's performance. She stated she was aware of some issues. She was asked if any action had been taken. She stated, "No." On 01/12/12 at 2:00 p.m., CNA #4 was asked if he had ever been expected to perform care for residents that should be performed by a licensed nurse. He stated approximately two weeks prior, (12/31/11) he saw the resident have a grand mal [MEDICAL CONDITION] in her room. He stated he yelled out to LPN #1 for assistance. He stated the nurse never came to assist him, and instead, CMA #3 came to the room and helped him lift the resident to the bed. He stated he and the CMA just tried to keep the resident from hitting her head on the wall near the bed, as she continued to have a [MEDICAL CONDITION]. He stated he was not directed by LPN #1 to do anything else for the resident during the [MEDICAL CONDITION]. He stated he and CMA #3 waited until the resident stopped seizing, placed her in a wheelchair and took her to the nurse's station. He stated LPN #1 then asked the CMA to take the resident's vital signs. He was asked why they brought the resident out to the nurse's station. He stated, "So the nurse could check her out. The nurse couldn't stand up and walk to the resident." He was asked if he was concerned about the residents' care and safety when LPN #1 was the charge nurse. He stated he was worried everyday there would be an emergency and the LPN could not assist him with the residents. He stated he brought up his concerns at a recent staff meeting with the DON. At 2:30 p.m., LPN #1 was observed as she entered the surveyor's work room. She used a rolling walker to ambulate. Her gait was slow and deliberate. She had difficulty turning to sit in a recliner. She was asked about her physical limitations. She stated she no longer drove a car because she could not operate the accelerator and the brake correctly with her foot. She stated she had been using a rolling walker for about a year because she had both hips replaced and had extensive back surgery. She stated that she just turned [AGE] years old and was proud that she still worked as a nurse. She was asked what shifts she normally worked at the facility. She stated she worked all shifts and never turned down a request by the DON to cover a shift. She stated she usually worked more than full time hours and sometimes worked 12 or 16 hour shifts. She stated she worked mostly evening and night shifts. She was asked how many staff worked with her on the evening shift. She stated one CMA and one CNA worked with her on that shift. She stated on the night shift, she worked alone with one CNA. She was asked if she was physically able to assist the residents. She stated, "I'm not gonna say they always get turned and pulled up in bed the way they should. I can't really do that. But otherwise, yes." She was asked about the resident's [MEDICAL CONDITION]. She stated she cared for the resident in the facility lobby. She stated, "I got her situated. She was OK." She did not provide any other details about the event. At 3:57 p.m., CMA #3 was asked about the resident's [MEDICAL CONDITION] on 12/31/11. She stated CNA #4 was assisting the resident with incontinent care in her room when the resident had a [MEDICAL CONDITION]. She stated the CNA yelled out to LPN #1 for assistance. Instead of going to the CNA's assistance, the LPN called out for her (CMA #3) to go assist the CNA. She stated LPN #1 never left the desk while they were assisting the resident during the [MEDICAL CONDITION]. She further stated the resident continued to seize for about three to four minutes after she was placed on the bed. She and CNA #4 stayed with the resident until she stopped seizing. They placed the resident in a wheelchair and took her to the nurse's station so LPN #1 could check the resident's condition. She stated the LPN never left the nurse's station and instead instructed CMA #3 to obtain vital signs. She stated the nurse provided no other care to the resident. 2. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, last updated on 08/11/11, documented, "... I take [MEDICAL CONDITION] medications... Approach... Monitor for any adverse effects from the medication (i.e. tiredness...) Review:... (resident) is on [MEDICATION NAME] 0.25 mg BID, [MEDICATION NAME] 30 mg at 8 (p.m.), [MEDICATION NAME] 1 mg q HS, [MEDICATION NAME] 25 mg BID..." A quarterly assessment, dated 11/01/11, did not document the resident's cognitive status. It documented the resident needed limited assistance with activities of daily living. A nurse's note, dated 12/17/11 at 7:40 p.m., documented, "... Pt. sent via ambulance to (hospital name deleted) emergency room became unresponsive after supper. V.S. B/P 105/64 P 77 R 22 T 97. Worked with pt. O2 - water on face & everything. Could not arouse. Called (doctor name deleted) called order to send to E.R...." A facility resident transfer form, dated 12/17/11, documented the resident's vital signs, DNR status and allergies [REDACTED]. An ambulance patient information form, dated 12/17/11 and completed by LPN #1, documented no treatment prior to arrival of the ambulance. An ambulance patient care record, dated 12/17/11, documented the resident's oxygen saturation level was low at 89% and oxygen was provided. The form also documented the resident's pulse was low at 56 beats per minute. The narrative portion of the record documented, "...Called to the above location for an unresponsive PT. Upon our arrival PT was found lying in bed. Nursing staff stated that after dinner PT was sitting in a recliner and just went unresponsive. They were not able to awake PT. PT would not open eyes or would not talk. PT would move arms. Pupils were pinpoint. FSBS was checked. IV was started and PT was placed on the cardiac monitor. PT was monitored during transport with vitals..." On 01/12/12 at 3:57 p.m., CMA #3 was asked what happened the evening the resident became unresponsive. She stated CNA #4 noticed the resident was unresponsive when he tried to assist him out of a recliner in the lobby. LPN #1 was at the nurse's station and was within sight of the resident. CMA #3 stated the LPN yelled out at her to come check the resident. The LPN did not leave the nurse's station. CMA #3 stated she took the resident's vital signs and told the LPN the resident's oxygen saturation was in the 80s. She stated the LPN instructed her and the CNA to take the resident to his bed. CMA #3 stated the resident was not responsive and could not sit upright unassisted, but they placed him in a wheelchair, tried to hold him up the best way they could, and took him to his room. She stated they lifted him into the bed and returned to the nurse's station to ask LPN #1 if they should put oxygen on the resident. The LPN said, "OK." CMA #3 stated she was not instructed if the resident should have oxygen by a mask or by nasal cannula, and was not instructed on how much oxygen should be delivered per minute. She stated she just did the best she could. She stated the LPN never came to the resident's room to assess or assist the resident or the staff as they provided care. She stated the LPN completed paperwork at the nurse's station and called an ambulance. The CMA was asked if she was concerned about the residents' care and safety when LPN #1 was acting as the charge nurse. She stated, "I'm very concerned. I've gone up the chain of command and told them about the problems with her care." At 4:30 p.m., CNA #5 was asked about her experience working with LPN #1 on the night shift. She stated, "She cannot do patient care. I do all the care myself, even the heavy lifting." She was asked if the LPN was physically able to care for the residents. She stated, "No. I'm worried about the residents' well-being all the time." She was asked if the LPN ever requested she perform tasks that a nurse should perform. She stated, "Yes. Like check on the residents for her. She doesn't check on any residents. She just tells me what to look for when I check on them." At 5:22 p.m., the OSDH was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to assess the residents' condition, failure to adequately monitor the residents' status and intervene according to standards of care when the residents had significant changes in condition. At 5:27 p.m., the facility's corporate officers and the acting administrator were notified of the immediate jeopardy situation related to the facility's failure to assess, monitor and intervene for a change in condition for residents #10 and #11. They were notified the immediate jeopardy indicated a substandard quality of care. At 9:00 p.m., the facility submitted an acceptable Plan of Removal. The Immediate Jeopardy Plan of Removal, dated 01/12/12, documented, "... 1. Assessment-monitoring-interventions (Pedagogy) Education of Licensed Nurses to 495 Oklahoma Nurse Practice act expectations and responsibility Reference Material - Policy of Facility Reference and educational of standers (sic) from 675 Oklahoma State Department of Health and Federal Regulations Perry and Potter 7th Edition assessment-monitoring-interventions common practice guide lines Teaching of line staff including but limited to CNA's and CMA's as to non delegateable tasks Guest Speaker (doctor name deleted) on Expectations of Staff in reference to assessment-monitoring-interventions and his availability for service as Medical Director. 2. Capable Nursing Staff / Physically Capable Nursing Staff Review of Physical Requirements of Job/Position Acknowledgment of Abilities to practice and function Review of 495 Oklahoma Nurse Practice Act Guest Speaker (name deleted) on topic of job requirements Reference and educational of standers (sic) from 675 Oklahoma State Department of Health Perry and Potter 7th Edition assessment-monitoring-interventions common practice guide lines delegation and non-delegation abilities 3. Follow up (nurse name deleted) LPN fully relieved of duty on 01/12/12 Skills check list will be done of staff upon hire and annually. Current staff will have skills check list redone by 1 pm 01/13/2012 DON relieved of duty as of 01/12/12 Interim DON (name deleted) Placed in-position 01/12/12 Daily review and monitoring of nurses assessment, monitor and intervention nursing skills along with nursing staff capability and physical capability will be done by DON or designee until confident practice achieved then continued prn with report to QA committee All staff in-serviced by 11:59 pm 01/12/2012 either in person or by phone. Anyone not inserviced will not work the floor until such education is completed..." On 01/13/12 at 11:50 a.m., the immediate jeopardy situation was removed. The deficient practice remained at a pattern level with a potential for more than minimal harm.