Every finding on record at The Lodge At Brookline

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff cleaned and disinfected a multiuse glucometer between resident use for 2 (Resident #2 and Resident #23) of 3 residents observed for fingerstick blood sugar checks. The facility further failed to ensure staff stored respiratory equipment per the facility policy for 2 (Resident #2 and Resident #39) of 3 sampled residents reviewed for respiratory care.Findings included: 1. An undated facility policy titled, Glucometer Disinfection, indicated, Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent the transmission of blood borne diseases to resident and employees. Definitions: 'Cleaning' is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergent or enzymatic products. 'Disinfection' is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected, then the meter will not be used for multiple residents. 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA [Environmental Protection Agency] registered healthcare disinfectant wipe that is effective against HIV [human immunodeficiency virus], Hepatitis C and Hepatitis B virus. 4. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. An admission Record revealed the facility admitted Resident #23 on 07/21/2025. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with hyperglycemia and chronic viral hepatitis C. Resident #23's Order Summary Report, with active orders as of 07/10/2026, revealed an order dated 03/18/2026, for Humalog injection solution 100 units per milliliter, inject as per the sliding scale subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with hyperglycemia. An admission Record revealed the facility admitted Resident #2 on 02/13/2026. According to the admission Record, the resident had a medical history that included a diagnosis oftype 2 diabetes mellitus with diabetic neuropathy. Resident #2's Order Summary Report, with active orders as of 07/09/2026, revealed an order dated 02/13/2026, for insulin lispro subcutaneous solution pen injector 100 units per milliliter, inject as per the sliding scale subcutaneously three times a day related to type 2 diabetes mellitus. During medication administration observation on 07/07/2026 at 10:56 AM, Licensed Practical Nurse (LPN) #4 pricked a finger on Resident #23's right hand to perform a fingerstick blood sugar (FSBS) check. After completion of the FSBS for Resident #23, LPN #4 cleaned the multiuse glucometer with an alcohol wipe then proceeded to prick the right index finger of Resident #2 to perform a FSBS check at 10:58 AM. After completion of FSBS for Resident #2, LPN #4 did not clean and/or disinfect the multiuse glucometer. During an interview on 07/07/2026 at 1:35 PM, LPN #4 acknowledged cleaning the glucometer with an alcohol wipe was her usual practice and reported she believed an alcohol wipe was sufficient for disinfection.During an interview on 07/07/2026 at 1:56 PM, the Director of Nursing stated she expected nurses to clean the glucometer between each resident with approved germicidal wipes and not alcohol wipes. During an interview on 07/07/2026 at 5:13 PM, the Infection Preventionist stated his expectations for disinfection of the glucometer would be for the nurse to clean the glucometer with an approved EPA wipe to prevent cross contamination.During an interview on 07/08/2026 at 1:17 PM, the Medical Director (MD) stated there was a risk for cross contamination when staff used a shared glucometer. Per the MD, alcohol wipes were not effective in the disinfection of a glucometer for a resident diagnosed with Hepatitis C, and an EPA registered wipe must be used for disinfection. During an interview on 07/10/2026 at 8:05 AM, the Administrator state he expected staff to follow the facility policy for the disinfection of a shared glucometer. Per the Administrator, proper cleaning of a glucometer needed to be done for infection control purposes. 2. An undated facility policy titled, Nebulizer Therapy indicated, 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. An admission Record revealed the facility admitted Resident #39 on 01/29/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2026, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Resident #39's Care Plan Report included a focus area initiated 01/30/2026 and revised 02/02/2026, that indicated the resident was new to the facility. Interventions directed staff to administer nebulizer treatments as ordered (initiated 01/30/2026). Resident #39's Order Summary Report with active orders as of 07/06/2026, revealed an order dated 01/30/2026, for albuterol sulfate hydrofluoroalkane (HFA) inhalation aerosol solution 108 micrograms per actuation (mcg/act), two puffs inhale orally every six hours as needed for shortness of breath or wheezing; an order dated 06/02/2026, for sodium chloride inhalation nebulization solution 0.9%, one vial inhale orally by way of a nebulizer three times a day for nasal congestion; and an order dated 07/02/2026, for ipratropium-albuterol inhalation solution 0.5-2.5 milligrams per three milliliters, one vial inhale orally every six hour as needed for shortness of breath or wheezing. During an observation on 07/06/2026 at 12:24 PM, Resident #39's nebulizer mask was noted on the resident's bedside table and not stored in a bag. During an interview on 07/06/2026 at 11:15 AM, Licensed Practical Nurse (LPN) #2 stated after a resident was administered a nebulizer treatment, staff should clean the nebulizer mask and place the mask in a bag for storage. LPN #2 confirmed Resident #39's nebulizer mask was on the resident's bedside table and not stored in a bag. LPN #2 stated the outcome of not storing a nebulizer mask properly would be that the mask would get dirty, and bacteria could get in the mask and be spread to the resident. During an interview on 07/09/2026 at 9:58 AM, the Infection Preventionist (IP) stated that after a resident received a nebulizer treatment, their mask should be wiped down and placed in a bag when it was not in use. The IP stated the consequence of the mask not being stored properly was that the mask could be exposed to bacteria, which was an infection control risk. The IP stated his expectation for nebulizer mask storage was the staff should follow the procedure for correct storage. During an interview on 07/08/2026 at 1:48 PM, the Director of Nursing (DON) stated after a nebulizer treatment was finished, the mask was supposed to be rinsed, allowed to dry, then placed in a bag when not in use. The DON stated her expectation was the staff would follow the correct method for storage of the nebulizer masks. During an interview on 07/09/2026 at 10:06 AM, the Administrator stated he would expect the staff to follow facility policy regarding the storage of nebulizer masks.3. An undated facility policy titled, Nebulizer Therapy indicated, 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. An admission Record revealed the facility admitted Resident #2 on 02/13/2026. According to the admission Record, the resident had a medical history that included diagnoses of dependence on supplemental oxygen and chronic respiratory failure with hypoxia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/19/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received oxygen therapy. Resident #2's Care Plan Report included a focus area initiated 03/10/2026 and revised 06/19/2026, that indicated the resident had a diagnosis of chronic obstructive pulmonary disease (COPD) and required supplemental oxygen by way of a nasal canula to maintain adequate oxygen and to breathe easier. Interventions directed staff to administer the resident's breathing inhalers as ordered and to please keep the tubing and nebulizer mask in a bag up off the floor and change tubing weekly (initiated 03/10/2026). Resident #2's Order Summary Report, with active orders as 07/07/2026, revealed an order dated 02/13/2026, for budesonide inhalation suspension 0.5 milligram (mg) per 2 milliliter (mL), one vial inhale orally two times a day related to COPD and an order dated 02/13/2026, for ipratropium-albuterol inhalation solution 0.5-2.5 mg per 3 mL, one vial inhale orally every six hours as needed for shortness of breath. During an observation on 07/06/2026 at 2:05 PM, Resident #2's nebulizer mouthpiece was connected to the nebulizer and on top of a bag, uncovered on the resident's bedside table. During an interview on 07/07/2026 at 10:24 AM, the Director of Nursing (DON) stated that a nebulizer mouthpiece should be bagged after the nebulizing treatment was completed. During an interview on 07/08/2026 at 10:13 AM, Licensed Practical Nurse (LPN) #4 stated she worked on 07/06/2026 and administered Resident #2 their nebulizer treatment prior to breakfast. LPN #4 stated after she administered Resident #2's nebulizer treatment, she did not clean or place the nebulizer mouthpiece in a bag. During a telephone interview on 07/08/2026 at 12:02 PM, the Medical Director stated after a nebulizer treatment, the nebulizer mouthpiece must be sterilized and stored in a bag to keep it clean. During a follow-up interview on 07/09/2026 at 10:24 AM, the DON stated she expected nebulizer mouthpieces to be cleaned after use and stored in a plastic bag. During an interview on 07/09/2026 at 10:56 AM, the Administrator stated after the review of the facility's Nebulizer Therapy policy, the expectation was to rinse a nebulizer mouthpiece, allow the mouthpiece to dry, and place the nebulizer mouthpiece in a bag. During an interview on 07/10/2026 at 1:52 PM, the Infection Preventionist stated when respiratory equipment was not kept clean and bagged after use, there was a potential to introduce microorganisms into the nebulizer mouthpiece which could lead to a potential infection.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure each resident was adequately equipped with a call light at their bedside for 2 (Residents #31 and Resident #49) of 6 sampled residents reviewed for the environment. Findings included: An undated facility policy titled, Call Lights: Accessibility and Timely Response, indicated, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. The policy specified, 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. An admission Record revealed the facility admitted Resident #31 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of cerebrovascular disease, syncope and collapse, chronic obstructive pulmonary disease, hypertension, chronic pain syndrome, age-related osteoporosis, mixed incontinence, dizziness and giddiness, and unspecified fall. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #31 was independent with activities of daily living, occasionally incontinent of bladder, always continent of bowel, and had no falls. Resident #31's Care Plan Report included a focus area initiated [DATE], that indicated the resident was at moderate risk for falls related to being unaware of safety needs. Interventions directed the staff to be sure the resident's call light was within each and encourage the resident to use the call light for assistance as needed (initiated [DATE]). An admission Record revealed the facility admitted Resident #49 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction, type 2 diabetes mellitus, chronic respiratory failure with hypoxia, Alzheimer's disease, heart failure, urinary incontinence, hemiplegia and hemiparesis, essential tremor, weakness, and repeated falls. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], indicated Resident #49 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required supervision or touching assistance with eating, oral hygiene, personal hygiene, sit to lying, and lying to sitting on side of bed; partial/moderate assistance with upper body dressing; substantial/maximal assistance with toileting hygiene, lower body dressing, and putting on/taking off footwear; and dependent on staff for shower/bathe self, sit to stand, chair/bed-to-chair transfers, and toilet transfers. Per the MDS, Resident #49 was frequently incontinent of urine, always incontinent of bowel, and had no falls. Resident #49's Care Plan Report included a focus area initiated [DATE] and revised [DATE], that indicated the resident was at high risk for falls related to paralysis. Interventions directed the staff to be sure the resident's call light was within each and encourage the resident to use the call light for assistance as needed (initiated [DATE]). During a concurrent observation and interview on [DATE] at 11:15 AM, Resident #49 and Resident #31 were noted lying in their respective beds in their room. The surveyor noted there was only one call light in the residents' room. Resident #49 stated there was only one call light in the room they shared with Resident #31 and when they needed assistance from staff, they would ask Resident #31 to press the call light. During an interview on [DATE] at 1:22 PM, Certified Nursing Assistant (CNA) #1 stated she was assigned to and familiar with Resident #31 and Resident #49. CNA #1 acknowledged about a month ago (06/2026), Resident #49 informed her that there was only call light in the room they shared with Resident #31. CNA #1 stated she did not report the resident's concern about not having a call light to anyone and did not document the concern in the maintenance log book. CNA #1 stated each resident should have a means to call for help. CNA #1 stated maintenance should have been notified, but she forgot to inform them when she observed that each resident did not have a call light. During a concurrent interview and observation on [DATE] at 1:40 PM, the Maintenance Director stated when equipment was damaged, broken, or missing, staff should fill out a maintenance request sheet. The Maintenance Director stated when there was one resident in a room there should be one call light, but when there were two residents in a room, there was supposed to be two call lights, one for each resident. The Maintenance Director confirmed there was only one call light in the room shared by both Resident #31 and Resident #49. The Maintenance Director stated her expectation was that each resident should have their own call light to summon for staff assistance. The Maintenance Director stated it was her responsibility to ensure proper equipment was in each resident's room. The Maintenance Director stated no one informed her that there was only one call light in the room shared by both Resident #31 and Resident #49 and she had not been monitoring the call light system to ensure each resident had a functioning call light to call for assistance when needed. During a follow-up interview on [DATE] at 1:15 PM, Resident #49 and Resident #31 stated that since their admission ([DATE]) there had only been one call light in their room. Resident #31 stated having two call lights would be better as they would not have to worry about getting out of bed to get the call light from Resident #49. Resident #49 stated they would have to yell for help when Resident #31 had the call light, when Resident #31 was not in the room, or when the resident was asleep. Resident #49 stated there had been times when they needed incontinence care and did not have a call light to get assistance from staff. During an interview on [DATE] at 1:34 PM, the Director of Nursing (DON) stated she expected that when staff found a resident's call light unavailable, they should document the concern in the maintenance log book and inform either her or a nurse. The DON stated she expected there to be two call lights in a room shared by two residents. The DON stated the Maintenance Director was responsible for monitoring to ensure each resident had a call light. The DON stated Resident #31 and Resident #49 admitted to the facility on [DATE] and had been in the same room since their admission, and there should have been two call lights in the residents' room. The DON stated she was just informed by the Maintenance Director on [DATE] that Resident #31 and Resident #49 had only one call light in their room. During an interview on [DATE] at 8:15 AM, the Administrator stated he expected each resident to have a call light. The Administrator stated the Maintenance Director was responsible for ensuring there was a call light for each resident in their room. The Administrator stated that when staff noticed a missing call light, it should be documented in the maintenance log book and he or the Maintenance Director should be notified.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a physician's order for supplemental oxygen contained the liters per minute of supplement oxygen the resident should be administered for 1 (Resident #39) of 3 sampled residents reviewed for respiratory care.Findings included: An undated facility policy titled, Oxygen Administration, revealed, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy specified, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. An admission Record revealed the facility admitted Resident #39 on 01/29/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2026, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Resident #39's Care Plan Report included a focus area initiated 01/30/2026 and revised 02/02/2026, that indicated the resident was new to the facility. Interventions directed staff to administer oxygen therapy as ordered and monitor oxygen saturation levels as ordered (initiated 01/30/2026). Resident #39's Order Summary Report, with active orders as of 07/06/2026, revealed an order dated 05/21/2026 that specified May have oxygen to keep SpO2 [peripheral oxygen saturation] 88% or greater three times a day related to chronic obstructive pulmonary disease. The physician's order did not specify how many liters of supplemental oxygen the resident should be administered. During an observation on 07/06/2026 at 11:10 AM, the surveyor noted Resident #39 was receiving supplemental oxygen by way of a nasal cannula, and the supplemental oxygen concentrator was set at 2 liters per minute (LPM). During an interview on 07/06/2026 at 11:15 AM, Licensed Practical Nurse (LPN) #2 stated Resident #39 had orders for supplemental oxygen as needed so the resident's oxygen saturation level would not go below 88%. During a follow-up interview on 07/08/2026 at 1:02 PM, LPN #2 acknowledged Resident #39's physician orders did not specify how many LPM of supplemental oxygen the resident should be administered. LPN #2 stated it was up to the discretion of the resident's nurse to determine how many LPM of supplemental oxygen the resident was supposed to receive. During an interview on 07/08/2026 at 1:48 PM, the Director of Nursing stated her expectation was that supplemental oxygen should be administered per the physician's order. During an interview on 07/09/2026 at 10:06 AM, the Administrator stated he expected physician orders to be complete with all the information needed. During a telephone interview on 07/10/2026 at 10:29 AM, the Medical Director (MD) stated all orders for supplemental oxygen should include how many liters of supplemental oxygen the resident should receive. The MD stated he did not specifically remember Resident #39, but all residents who received supplemental oxygen should have orders that included how many liters of supplemental oxygen the resident should receive.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff did not stand over a resident during meal service for 1 (Resident #9) of 7 sampled residents reviewed for dining.Findings included: An undated facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, specified, Policy: It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. The policy specified, 5. All staff will be seated, if possible, while feeding a resident. An admission Record revealed the facility admitted Resident #9 on 02/04/2025. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2026, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required set-up or clean-up assistance with eating. Resident #9's Care Plan Report included a focus area initiated 02/13/2025, that indicated the resident needed assistance with daily care needs because they was forgetful and needed verbal reminders or assistance to meet their daily care needs. During an observation of the lunch meal service on 07/06/2026 at 12:12 PM, Licensed Practical Nurse (LPN) #4 stood next to Resident #9 and spooned yellow cake into the resident's mouth. LPN #4 was then observed to assist Resident #9 to a chair at a table, then stood over Resident #9 and spooned food into the resident's mouth. During an interview on 07/06/2026 at 12:21 PM, Speech Therapist #6 stated the proper way to provide feeding assistance to a resident was for staff to sit down with the resident while they provided assistance. During an interview on 07/06/2026 at 12:30 PM, LPN #4 stated staff should sit beside a resident when they provided feeding assistance. LPN #4 stated feeding assistance should not be provided to a resident while a resident was standing. LPN #4 acknowledged she provided feeding assistance to Resident #9 while the resident was standing and provided feeding assistance to the resident while she stood over the resident. During an interview on 07/08/2026 at 10:30 AM, Certified Nursing Assistant (CNA) #7 stated staff should sit down with a resident and never stand over a resident while providing feeding assistance. CNA #7 stated it did not look good, and it did not give a resident dignity when staff stood over a resident while they provided feeding assistance. During an interview on 07/08/2026 at 10:43 AM, the Dietary Supervisor stated facility staff should not provide feeding assistance to a resident while a resident stood and staff should sit with the resident and provide feeding assistance. During an interview on 07/09/2026 at 10:18 AM, the Director of Nursing stated the expectation was that staff should be seated at the resident's eye level while they provided feeding assistance. During an interview on 07/09/2026 at 10:53 AM, the Administrator stated the expectation was for staff to treat residents with dignity and sit beside residents while they provided feeding assistance.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a Resident #4 received timely CPR per the physician's order when the resident was found unresponsive and without vital signs. The resident was pronounced deceased by EMS.On [DATE] at 11:26 a.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On [DATE] at 11:43 a.m., the administrator and DON were notified of the existence of the IJ situation and was provided the IJ template. On [DATE] at 4:28 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, [DATE] 3:58pm1.The facility failed to initiate CPR immediately when a resident with a full code status was found without signs of life.2. All residents residing in the facility who are full code status are at risk.3. Staff are in-serviced on policy and procedure of Medical Emergency Response and educated on locations of Code Status Identifiers for all residents residing in the facility. Signs are placed throughout facility for quick identification of how to respond to a resident without signs of life. DON updated code status sheets on [DATE].4. Plan will be completed [DATE] by 5:00pm.5. Staff present in building on [DATE] are in-serviced. Staff not present in building are contacted by phone call to provide verbal in-service on [DATE] with written documentation of date and time of contact for in-service. Signage posted throughout facility on [DATE].6. Changes to Code Status Document will be discussed in morning meeting to include Code Status changes, room changes, new admits or discharges. PIP will be initiated [DATE] for monitoring during 3 months for any changes needed to the system and will be added to QAPI [quality assurance and performance improvement]. New employees will be educated on Medical Emergency Response Policy and Procedure. A PIP will be initiated for the RN supervisor, [name withheld], [DATE] and monitored for the next 3 months.7. Medical Emergency Response Policy and Procedure provided with oral in-service, Signage posted throughout facility for quick identification of how to respond to a resident without signs of life with oral in-service for explanation of signage, and verbal education of locations of Code Status Identifiers for all residents residing in the facility. 8. The facility failed to initiate CPR immediately when a resident with a full code status was found without signs of lifeOn [DATE] at 9:11 a.m., after all staff members had been in-serviced, staff CPR training was verified, residents code status was verified for accuracy, and performance improvement projects were initiated with ongoing auditing, the immediacy was lifted, effective [DATE] at 5:00 p.m. The deficient practice remained at an isolated level with the potential for more than minimal harm.Based on observation, record review, and interview, the facility failed to initiate CPR to an unresponsive resident with a full code status for 1 (#4) of 1 sampled resident reviewed for emergency basic life support to include CPR.The administrator identified 47 residents resided in the facility and 31 Residents had a full code status.Findings: On [DATE] at 6:38 a.m., laminated code response/instructions were observed posted on shower doors, above nurse carts, and in the dining room. A Cardiopulmonary Resuscitation (CPR) policy, with a copyright date of 2024, read in part, If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. in accordance with the resident's advance directives, or b. in the absence of advance directives or a Do Not Resuscitate order; and c. if the resident does not show obvious signs of clinical death (e.g. [for example] rigor mortis, dependent lividity, decapitation, transection, or decomposition). CPR certified staff will be available at all times.The employee who first witnesses or is the first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. CPR will continue unless: a. there is a DNR order in place. b. There are obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection, or decomposition). c. initiating CPR could cause injury or peril to the rescuer.This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS. A Physician's order, dated [DATE] at 8:47 p.m., showed the resident was a full code and was admitted on [DATE]. An admission assessment, dated [DATE], showed Resident #4 had diagnoses which included bladder cancer, stage 3 kidney disease, and absence of kidney. A Nurse Progress Note, dated [DATE] at 3:27 p.m., showed LPN #1 received report from the night shift nurse at 7:00 a.m., Resident #4 had been anxious and attempting to get out of bed all night and that pain medication had been given at 6:30 a.m. The note showed at 8:00 a.m., LPN #1 completed the initial assessment, and vital signs were within normal limits. The note showed Resident #4 appeared anxious and was requesting more pain medication. The note showed Resident #4 was repositioned and the bed was lowered to the floor for safety. The note showed at approximately 9:00 a.m., CNA #1 reported Resident #4 had refused to put on a gown. The note showed CNA #1 responded to the call light at 9:30 a.m. and Resident #4 was sitting up in bed complaining of feeling hot and still did not want a gown on. The note showed between 10:30 and 10:45 a.m., CNA #1 checked on Resident #4 again and the resident still refused a gown, but was sitting up in the bed. The note showed at 11:05 a.m., Resident #4's family member stepped into the hall and alerted CNA #1 Resident #4 was breathing weird. The note showed CNA #1 entered the room and found Resident #4 unresponsive, with one leg on the floor and one on the bed. The note showed CNA #1 called for help and LPN #1 and two other nurses, and three other CNA's responded. The note showed Resident #4 was not breathing and had no pulse. The note showed 911 was immediately called and CPR was initiated until EMS arrived and assumed CPR. The note showed EMS performed CPR for approximately 26 minutes and administered six rounds of epinephrine, when they pronounced Resident #4 dead at 12:03 p.m. The note showed the physician, administrator, and DON were notified. The note showed the resident's family member was assisted in notifying other family members, Resident #4 was put back into bed and cleaned up. The note showed the family was provided privacy and time to make arrangements. On [DATE] at 2:52 p.m., a phone interview was conducted with Resident #4's family member that was present during the incident. The family member stated Resident #4 was admitted on [DATE] at 6:20 p.m. The family member stated when they returned to the facility on [DATE] at 11:11 a.m., Resident #4 had both knees on the floor and was leaning to their right onto their lowered bed. The family member stated Resident #4's mouth and eyes were open, but they were not breathing. The family member stated they walked to the hall and told a nurse Resident #4 was not breathing. The family member stated CNA #1 walked into the room and back out and then within two minutes seven to eight staff arrived. The family member stated the staff picked Resident #4 off the floor and placed them into the bed where staff proceeded to clean Resident #4 up and make the bed. The family member stated when air came out of Resident #4, the staff then called 911, and moved Resident #4 to the floor and may have done three compressions before the fire department arrived. The family member stated it was probably seven to nine minutes before the staff called 911 after being aware the resident was not breathing. The family member stated, They did not do anything resuscitative all the way up until after they called 911. On [DATE] at 3:37 p.m., via a telephone interview, RN #1 stated LPN #1 and LPN #2 were the ones that responded. RN #1 stated, I was in the building, but was not aware of the situation. RN #1 stated they did not know anything about that resident. On [DATE] from 3:44 p.m. to 4:00 p.m., via a telephone interview, LPN #1 stated they had received report from night shift Resident #4 had been anxious. LPN #1 stated they did not have a lot of information, except the resident had been crying out in pain and was anxious during their assessment. LPN #1 stated they were in a different resident's room when CNAs were running towards Resident #4's room. LPN #1 stated CNA #1 had told them they were just in Resident #4's room [ROOM NUMBER] minutes prior to being called into the room by a family member. LPN #1 stated somebody was checking for a pulse or breathing, and when it was not found, the staff moved Resident #4 up into the bed and were cleaning the resident up. LPN #1 stated they thought it was weird Resident #4 did not have much bowel movement in their colostomy, but there was bowel movement coming from the rectum. LPN #1 stated One of the CNAs thought they heard a breath, so the supervisor (RN #1) instructed them to move Resident #4 to the floor. LPN #1 stated LPN #2 started CPR while they called 911. LPN #1 stated RN #1 was going to check for code status. LPN #1 stated they took over CPR for LPN #2, so that LPN #2 could go get the crash cart. LPN #1 stated CPR was continued until EMS arrived and took over. LPN #1 stated, I am not going to override my clinical nurse supervisor on when to start CPR, when they were asked why CPR was not initiated as soon as it was recognized there was no pulse or breathing. On [DATE] from 4:08 p.m. until 4:28 p.m., via a telephone interview, CNA #1 stated they had checked on and spoken with the resident when breakfast trays were dropped off, picked up, and at least twice while they were offering to assist Resident #4 to put on a gown. CNA #1 stated they had last observed Resident #4 sitting up in bed at approximately 10:55 a.m. CNA #1 stated they were coming out of a different resident's room when the family member told them Resident #4 was not breathing at approximately 11:05 a.m. CNA #1 stated they ran up the halls asking for a nurse. CNA #1 stated while the nurses were checking for vital signs, the CNAs put Resident #4 on the bed and put a gown, and a brief on Resident #4. CNA #1 stated, It felt like an eternity, but was probably four to five minutes before CPR was initiated. CNA #1 stated, while RN #1 was looking for the code status one of the CNAs thought they heard a breath, so when RN #1 returned, they were instructed to move the resident to the floor and initiate CPR. CNA #1 stated LPN #2 started CPR, but then LPN #1 took over compressions while LPN #2 went to get the crash cart. CNA #1 stated they did not remember when 911 was called, but it started quickly once they were told to start CPR. CNA #1 stated the electronic health record system could be logged into from their phones within 60 seconds if they have good wireless internet. On [DATE] at 8:39 a.m., CNA #4 stated resident code statuses were kept in a binder. They showed the surveyor the binder in the linen closet by room [ROOM NUMBER] that showed resident names with a red column for DNR and a green column for full code. They stated every hall had a binder. They stated the DON was responsible for entering the code status. They stated the nurse would probably be the person to determine when to initiate CPR on a resident. CNA #4 stated they had not been involved in a code and would try to help in any way. On [DATE] at 8:44 a.m., CNA #5 showed the surveyor a binder in the linen closet by room [ROOM NUMBER]. They stated it identified each resident’s code status. They stated the nurses put the information in. They stated if a resident appeared to not be breathing, they would get the nurse. CNA #5 stated when a resident dropped to the floor, if staff were right there, they could not leave the resident by themselves. They stated if the resident started turning a color, they would start CPR. They stated their role in a code was to make sure everyone was out of the way. On [DATE] at 8:49 a.m., CNA #6 stated if a resident appeared to not be breathing, they would get the nurse and call for help. They stated they guessed they could initiate CPR if needed. On [DATE] at 8:52 a.m., CNA #3 stated staff would check to see if a resident was unresponsive. They stated if they did not respond they would start CPR. They stated their role could vary from chest compressions or swapping out breathing depending on what the person running the code instructed them to do. On [DATE] at 8:55 a.m., ACMA #2 stated resident code statuses were located in the MAR. They stated if a resident was unconscious or lethargic with a slow response, not moving, or not responding when their name was called, they would notify the nurse before beginning CPR. They stated their role was to assist the nurse when needed during a code. On [DATE] at 9:01 a.m., ACMA #3 stated there was a code sheet in both the linen closet on the hall and in their MAR. They stated when a resident appeared to not be breathing, they would check for a pulse, check their oxygenation, and call for a nurse. They stated they believed the nurse decided when to initiate CPR. They stated they would assist the nurse in whatever they needed. On [DATE] at 9:05 a.m., ACMA #4 stated if a resident appeared to not be breathing, they would stay with the resident, get the nurse, look at the code book to make sure they were a full code, call 911, and complete CPR until the paramedics arrived. On [DATE] at 9:08 a.m., LPN #4 stated if a resident appeared to not be breathing, they would get their stethoscope, watch for their chest to rise and fall, if it did not, they would do a sternal rub. They stated if the resident continued to not respond, they would check their code status if they were not breathing. They stated if they were a full code, depending on the bed, they would either deflate the bed or pull the resident to the ground and start chest compressions while calling for help. On [DATE] at 9:13 a.m., RN #2 stated the DON was the person responsible for putting resident code statuses in. They stated if a resident appeared to not be breathing, they would check their airway, circulatory status, and heart rate. They stated they would call for help, call 911, and initiated CPR if they did not have a pulse. RN #2 stated they would likely be the person running the code. On [DATE] at 9:10 a.m., RN #1 was re-interviewed via telephone. RN #1 stated, They came to get me, [Resident #4] wasn't responding. I went down there, [their] [family member] was sitting by the bed. [Resident #4] was already gone. RN #1 stated when one of the CNAs heard spontaneous breathing they found the code status on the electronic health record and instructed staff to initiate CPR and call 911. On [DATE] at 9:25 a.m., the DON stated, CPR should be initiated when you find a resident with the absence of vital signs and you find out they are a full code. The DON stated, Staff should assume CPR is necessary unless there is a DNR on file. I put [Resident #4's] orders in, and I know [Resident #4] was a full code. The DON stated the RN #1 told them Resident #4 had an absence of vital signs and they stated yes when they asked if we were doing a full code. The DON stated, CPR should be initiated quickly within a couple minutes at the most and should be continued until someone says they are a DNR or EMS takes over. The DON stated they did an in-service and placed the code status of every resident on the insides of the closets, on the nurses' carts, crash cart book, and the electronic health record. The DON stated staff should be able to get logged into the electronic health record within 60 seconds usually, and it should not take more than three to four minutes to find a resident's code status. On [DATE] at 10:47 a.m., the administrator was present, while the DON stated the code status list was updated for any new admissions, changes in room, or code status. The DON stated the ADON and administrator had access and would be able to update the list if the DON was not available. The DON stated they had completed CPR in-service on the weekend of [DATE], and then again with the weekly staff the following Monday. The DON stated the inaccuracies of residents being listed, or incorrect room numbers being listed, were found by surveyors were because one resident had just recently passed, one was recently discharged , and two had just had their rooms changed. The DON stated they were planning on updating the code status sheet that day. On [DATE] at 7:29 a.m., CNA #2 stated they were CPR certified, but that they had not received in-service in the past two weeks. On [DATE] at 7:44 a.m., performance improvement projects in regard to CPR initiation, were provided to state surveyors. They had been initiated on [DATE]. On [DATE] at 8:35 a.m., the administrator stated all of the staff had now been in-serviced, except one of the staff members who was in the intensive care unit, but they would in-service them when and if they returned to work. The administrator also stated that CNA #2 had been in-serviced that morning at 8:32 a.m. On [DATE] at 8:49 a.m., the updated code status sheet was provided and verified to be accurate.

Based on observation, record review, and interview, the facility failed to ensure orders for PEG tube care were transcribed and completed for 2 (#6 and #7) of 2 sampled residents reviewed for PEG tube care.The administrator identified five residents had PEG tubes.Findings:1.On 07/09/25 at 12:33 p.m., Resident #6's peg site was observed to have no gauze around it, There was some dark residue around the PEG site entrance into the abdomen and the clamp appeared to have red droplets on it. An undated PEG Site Cleaning Policy and Procedure, read in part, To ensure the safe and effective care of residents with PEG tubes, LTC facility staff will follow standardized procedures for routine PEG site cleaning to prevent infection, skin breakdown, and complications. Purpose: To maintain cleanliness, promote healing, and prevent infections or irritation at the PEG insertion site. Scope: This policy applies to all licensed nursing staff responsible for the care of residents with a PEG tube. Frequency: Daily, after any leakage or soiling, as per physician or wound care recommendations. Supplies needed: clean gloves, mild soap or normal saline, gauze pads.There were no physician orders to clean or care for the PEG tube for Resident #6.A quarterly resident assessment, dated 06/20/25, showed Resident #6 was blind, had a BIMS of 8 (indicating moderately impaired cognition), had a PEG tube, and was dependent upon staff for all activities of daily living.On 07/09/25 at 1:31 p.m., the DON stated the PEG tube site did not look clean, there was dark matter at the site, and there was no gauze in place to keep the plastic ring from rubbing against Resident #6's skin. The DON stated PEG tube care should be done at least daily and more often if there was drainage.2. On 07/09/25 at 1:58 p.m., Resident #7's PEG tube site was observed to have a split gauze secured with tape around it with the 7-3 (indicating the shift) and 7/7/25 (indicating date) written in black marker on it. There were no physician orders to clean or care for the PEG tube for Resident #7.A quarterly resident assessment, dated 06/12/25, showed Resident #7 had a BIMS of 10 (indicating moderately impaired cognition), had a PEG tube, diagnosis which included chronic kidney disease stage 5, and was dependent on staff for all activities of daily living.On 07/09/25 at 2:03 p.m., the DON stated the PEG site had gauze around it labeled 7-3 and 7/7/25. The DON stated there was a dark residue under the gauze at the PEG site at the entrance to the abdomen of resident #7.On 07/10/25 at 8:58 a.m., LPN #4 stated the initials mean they did complete the care on that day by cleaning the site and tube with normal saline, but there was no new gauze, so LPN #4 left on the old gauze. They confirmed the initials on the treatment record did belong to them for the day shift on 07/07/25 and 07/08/25.

Based on observation, record review, and interview, the facility failed to ensure:a. urinary catheter care was completed as ordered for 1 (#7); andb. orders for urinary catheter care were transcribed and completed for 1 (#1) of 3 sampled residents reviewed for urinary catheters.The administrator identified three residents with urinary catheters resided in the facility.Findings:A catheter care policy, with a handwritten date of 02/07/25, read in part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care.Catheter care will be performed every shift and as needed by nursing personnel.1. A significant change resident assessment, dated 12/20/25, showed Resident #1 had an indwelling catheter, and diagnoses which included benign prostatic hyperplasia and viral hepatitis. A discontinued physician order, dated 01/28/25, showed staff were to provide catheter care to Resident #1 every shift related to neuromuscular dysfunction of the bladder.The February 2025 treatment administration record showed Resident #1's catheter care every shift was discontinued on 02/28/25.The March 2025 treatment administration record did not contain catheter care every shift for Resident #1.Resident #1's hospital records, dated 03/12/25, showed they admitted with a urinary tract infection associated with indwelling urethral catheter. The records showed the urinary catheter contained lots of sediment, was dark, and was changed upon admission to the hospital.Resident #1's after visit hospital summary showed the resident was hospitalized [DATE] through 03/17/25. The summary showed discharge instructions which included urinary catheter with routine care. Resident #1's orders did not show the catheter care was continued when the resident returned to the facility from the hospital.A quarterly resident assessment, dated 03/22/25, showed Resident #1 had an indwelling catheter.The April 2025 treatment administration record did not contain catheter care every shift for Resident #1.On 07/10/25 at 11:44 a.m., CNA #3 stated their only responsibility when a resident had a urinary catheter was to empty the bag and ensure nothing was leaking. They stated if it was leaking, they would notify the nurse. They stated they believed it was the nurse's responsibility to clean the catheter and provide care while a resident had an indwelling urinary catheter. They stated Resident #1 did have a urinary catheter while they were a resident at the facility.On 07/10/25 at 12:10 p.m., ACMA #1 stated they did not provide any urinary catheter care. They stated the nurse was responsible for providing care to a urinary catheter. They stated Resident #1 did have a urinary catheter while a resident.On 07/10/25 at 1:00 p.m., LPN #3 stated a urinary catheter being placed and not cleaned could contribute to a resident developing a UTI.On 07/10/25 at 1:01 p.m., LPN #3 stated every staff member was allowed to clean a urinary catheter. They stated the aides cleaned them when they gave a resident a shower or changed their brief. They stated they were allowed to clean around the catheter. On 07/10/25 at 1:02 p.m., LPN #3 stated where the information was documented was a good question. They stated there would be a spot on the MAR or TAR that would pop up on their end from time to time. They stated they believed their charting was to just monitor the output, not anything other than that. LPN #3 stated they were not a fan of urinary catheters because they believed they promoted UTIs. LPN #3 identified the last catheter care for Resident #1 was documented in February 2025. They stated when a resident returned from the hospital the DON, ADON, or administrator was responsible for ensuring the orders from the hospital were put in. On 07/10/25 at 1:10 p.m., LPN #3 stated they believed Resident #1 had a urinary catheter in March and April 2025. They reviewed the 03/12/25 hospital records and stated the records indicated Resident #1 was treated for a UTI. On 07/10/25 at 1:38 p.m., the administrator stated Resident #1 came back from the hospital on [DATE] and was also hospitalized [DATE] and returned to the facility on [DATE]. On 07/10/25 at 2:06 p.m., the DON stated decreased fluid intake, improper incontinent care, dietary intake, and general cleanliness were factors that could contribute to a resident developing a UTI. On 07/10/25 at 2:07 p.m., the DON stated when a resident had a urinary catheter, the nurses should provide catheter care as ordered by the physician. They stated it should be listed in the physician orders. The DON stated the floor staff who provided incontinent care should also be providing general catheter care such as cleaning the meatus around the catheter to ensure bacteria and stool did not get in there. They stated CNAs, CMAs, and nurses could all clean the catheter.On 07/10/25 at 2:09 p.m., the DON stated nurses documented catheter care in the treatment records. They stated Resident #1 did have a urinary catheter. On 07/10/25 at 2:10 p.m., the DON reviewed the after visit hospital note, dated 03/12/25 through 03/17/25, and stated, Foley catheter with routine care. The DON reviewed the hospital update, dated 03/12/25, and stated Resident #1 was treated for a UTI. On 07/10/25 at 2:18 p.m., the DON stated Resident #1's catheter care showed it was last completed on the TAR on 02/28/25. On 07/10/25 at 2:19 p.m., the DON stated they did not locate catheter care on the resident's March or April 2025 TAR. 2. On 07/09/25 at 1:58 p.m., Resident #7's suprapubic catheter site was observed to have a split gauze secured with tape around it with the 7-3 (indicating the shift) and 7/7/25 (indicating date) written in black marker on it. Dried red blood was observed in the abdominal fold below the gauze.A physician order, dated 02/17/25, showed suprapubic catheter care was to be done every shift.A quarterly resident assessment, dated 06/12/25, showed Resident #7 had a BIMS of 10 (indicating moderately impaired cognition), had an indwelling catheter, diagnosis which included chronic kidney disease stage 5, and was dependent on staff for all activities of daily living.The July 2025 treatment record for suprapubic catheter care every shift showed staff initials on 07/07/25 for day shift, evening shift, and night shift. The record also showed staff initials for 07/08/25 for day shift, evening shift, and night shift, indicating suprapubic catheter care had been done. The initials on 07/07/25 and 07/08/25 belonged to LPN #4.On 07/09/25 at 2:03 p.m., the DON stated the gauze around the suprapubic site was labeled 7-3 and 7/7/25, they also stated there was some serosanguinous drainage noted to Resident #7's abdominal fold and the gauze dressing. The DON stated the suprapubic catheter was pulled tight and was wrapped around the securement clamp on the resident's leg.On 07/09/25 at 2:30 p.m., ACMA # 4 stated the suprapubic catheter care was to be done by the nurses. They stated the initials on the day shift for both days belonged to LPN #4, but they were not working that day.On 07/10/25 at 8:55 a.m., the DON stated, I know catheter care is on the nurses treatment orders, and initials indicate that the care was provided. I know where you are going with this. I verified the treatment record was initialed on different shifts, by different nurses, but it did not appear the care was actually provided. I did check into it and in-serviced the staff about it.On 07/10/25 at 8:58 a.m., LPN #4 stated the initials meant they did complete the care on that day by cleaning the site and tube with normal saline, but there was no new gauze, so LPN #4 left on the old gauze. They confirmed the initials on the treatment record did belong to them for the day shift on 07/07/25 and 07/08/25.

Based on observation, record review, and interview, the facility failed to ensure resident records were accurate for 3 (#1, 6, and #7) of 3 sampled residents reviewed for accurate records.The administrator identified 47 residents resided in the facility.Findings:A charting and documentation policy, revised 07/2017, read in part, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.1.Resident #1's hospital records showed the resident was hospitalized [DATE] through 03/17/25.The March 2025 MAR showed Resident #1 was administered the following medications at the facility during the dates the resident was hospitalized :a. aricept 10 mg (a medication used to treat dementia) on the 13th, 15th and 16th;b. ferrous sulfate 325 mg (a supplement for low iron) on the 15th and 16th;c. megestrol acetate suspension 5 milliliters (appetite stimulant) on the 15th and 16th;d. protonix 40 mg (used to treat reflux) on the 15th and 16th;e. prozac 20 mg (used to treat depression) on the 15th and 16th;f. vitamin B12 1000 (a supplement) micrograms on the 15th and 16th;g. zinc sulfate 220 mg (a supplement) on the 15th and 16th;h. arginaid oral packet (a supplement) on the 13th, 15th, and 16th;i. oxycontin extended release 10 mg (a pain medication) on the 13th for a pain level of four, on the 15th for a pain level of 2, and the 16th for a pain level of 2 (the narcotic count records for this medication were reviewed and did not document any dispensing of this medication on these dates);j. gabapentin 300 mg (a pain medication) on the 13th, 15th and 16th;k. lithium 150 mg (a mood stabilizer) on the 13th, 15th, and 16th;l. midodrine 5 mg (a medication to treat low blood pressure) on the 15th and 16th with blood pressures documented; andm. Ativan 1 mg (an antianxiety medication) on the 15th and 16th.On 07/10/25 at 12:02 p.m., ACMA #1 stated they would ask their nurse if they had any questions and would double check information to ensure accurate documentation.On 07/10/25 at 12:04 p.m., ACMA #1 stated they had from 7:00 p.m. to 11:00 p.m. to administer medications on their shift. They stated once they administered the medications, they would select yes on the electronic record to document it was given.On 07/10/25 at 12:06 p.m., ACMA #1 stated there was an option to document hospitalized when a resident was hospitalized . They stated they did recall Resident #1 was hospitalized at times, but could not recall what month. (This staff member was not in the facility to review the above documented administration when the resident was hospitalized , but was one of the staff members who documented medications were administered).On 07/10/25 at 12:37 p.m., LPN #3 stated there really was no way of ensuring staff documented accurately. They stated when staff administered medications, they were to initial them as administered. They stated when staff administered breathing treatments or wound care, they would click yes as they completed it. They stated ultimately at the end of the day, they hoped everyone was honest.On 07/10/25 at 12:38 p.m., LPN #3 stated when a resident was hospitalized , staff can click hospitalized as the option. On 07/10/25 at 12:40 p.m., LPN #3 stated Resident #1 was hospitalized from [DATE] to 03/17/25. LPN #3 reviewed the medications initialed as given during this time and stated, I don't know. They stated the medication aides were who gave the resident their medications. They stated they were not sure why a staff member would document medications were given when the resident was in the hospital. On 07/10/25 at 1:34 p.m., the DON stated staff should be accurately documenting at the time they complete a task.On 07/10/25 at 1:36 p.m., the DON stated staff should pull up a medication, and initial it as administered in the electronic charting system at the time it was given. They stated their initials should print for who administered the medications.On 07/10/25 at 1:37 p.m., the DON stated there was a number six option on the legend to document when a resident was hospitalized on the MAR. They stated some staff chose a nine that meant see nurse's note and documented there the resident was hospitalized . On 07/10/25 at 1:38 p.m. the administrator stated Resident #1 went to the hospital on [DATE] and returned to the facility on [DATE]. The administrator and the DON were asked to review all of the above medications initialed as administered during Resident #1's hospitalization. The DON stated they did not have an explanation for staff documenting the medications were administered or the reason vital signs were recorded when the resident was not in the building. On 07/10/25 at 1:48 p.m., the administrator and DON reviewed the narcotic count record for Resident #1's oxycontin ER 10 mg and stated there were no pills signed out during this time. They stated they believed it was a documentation error. 2. On 07/09/25 at 12:33 p.m., Resident #6's peg site was observed to have no gauze around it, There was some dark residue around the PEG site entrance into the abdomen and the clamp appeared to have red droplets on it. An undated PEG Site Cleaning Policy and Procedure, read in part, To ensure the safe and effective care of residents with PEG tubes, LTC facility staff will follow standardized procedures for routine PEG site cleaning to prevent infection, skin breakdown, and complications. Purpose: To maintain cleanliness, promote healing, and prevent infections or irritation at the PEG insertion site. Scope: This policy applies to all licensed nursing staff responsible for the care of residents with a PEG tube. Frequency: Daily, after any leakage or soiling, as per physician or wound care recommendations. Supplies needed: clean gloves, mild soap or normal saline, gauze pads.There were no physician orders to clean or care for the PEG tube for Resident #6.A quarterly resident assessment, dated 06/20/25, showed Resident #6 was blind, had a BIMS of 8 (indicating moderately impaired cognition), had a PEG tube, and was dependent upon staff for all activities of daily living.On 07/09/25 at 1:31 p.m., the DON stated the PEG tube site did not look clean, there was dark matter at the site, and there was no gauze in place to keep the plastic ring from rubbing against Resident #6's skin. The DON stated PEG tube care should be done at least daily and more often if there was drainage.3. On 07/09/25 at 1:58 p.m., Resident #7's suprapubic catheter site was observed to have a split gauze secured with tape around it with the 7-3 (indicating the shift) and 7/7/25 (indicating date) written in black marker on it. Dried red blood was observed in the abdominal fold below the gauze. The PEG tube site was also observed to have a split gauze secured with tape around it with the 7-3 (indicating the shift) and 7/7/25 (indicating date) written in black marker on it. There were no physician orders to clean or care for the PEG tube for Resident #7.A physician order, dated 02/17/25, showed suprapubic catheter care was to be done every shift.A quarterly resident assessment, dated 06/12/25, showed that Resident #7 had a BIMS of 10 (indicating moderately impaired cognition), had an indwelling catheter and a PEG tube, diagnosis which included chronic kidney disease stage 5, and was dependent on staff for all activities of daily living.The July 2025 treatment record for suprapubic catheter care every shift showed staff initials on 07/07/25 for day shift, evening shift, and night shift. The record also showed staff initials for 07/08/25 for day shift, evening shift, and night shift, indicating suprapubic catheter care had been done. The initials on 07/07/25 and 07/08/25 belonged to LPN #4.On 07/09/25 at 2:03 p.m., the DON stated the gauze around the suprapubic site was labeled 7-3 and 7/7/25, they also stated there was some serosanguinous drainage noted to Resident #7's abdominal fold and the gauze dressing. The DON stated the suprapubic catheter was pulled tight and was wrapped around the securement clamp on the resident's leg. The DON also acknowledged the PEG site had gauze around it labeled 7-3 and 7/7/25. The DON stated there was a dark residue under the gauze at the PEG site at the entrance to the abdomen of Resident #7.On 07/09/25 at 2:30 p.m., ACMA #4 stated the suprapubic catheter care was to be done by the nurses. They stated the initials on the day shift for both days belonged to LPN #1, but that they were not working that day.On 07/10/25 at 8:55 a.m., the DON stated I know catheter care is on the nurses treatment orders, and initials indicate that the care was provided. I know where you are going with this. I verified the treatment record was initialed on different shifts, by different nurses, but it did not appear the care was actually provided. I did check into it and in-serviced the staff about it.On 07/10/25 at 8:58 a.m., LPN #4 stated the initials mean they did complete the care on that day by cleaning the site and tube with normal saline, but there was no new gauze, so LPN #4 left on the old gauze. They confirmed the initials on the treatment record did belong to them for the day shift on 07/07/25 and 07/08/25.

Based on record review and interview, the facility failed to ensure PICC/central line care was provided and the site was assessed for 1 (#1) of one sampled resident reviewed for PICC lines. The administrator identified no residents with PICC lines resided in the facility at the time of the survey.Findings:A central venous catheter care and dressing change policy, revised 03/2022, read in part, The purpose of this procedure it to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings.A physician's order is not needed for this procedure.Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised.Change the dressing if it becomes damp, loosened or visibly soiled and.at least every seven days.Assess central venous access devices with each infusion and at least daily.Resident #1's discharge hospital summary, dated 10/18/24, showed a tunneled PICC line was placed on 10/17/24.A hospital after visit summary, dated 10/08/24 through 10/18/24, showed Resident #1 was to start taking Unasyn (an antibiotic) three grams via intravenous piggyback route. There was no order located in Resident #1's orders for the care of the central line that was placed on 10/17/24.Resident #1's October 2024 MAR/TAR did not document central line care was provided.Resident #1's December 2024 MAR/TAR did not document central line care was provided.An interventional radiology note, dated 12/22/24, showed the removal of a tunneled single lumen powerline catheter for Resident #1.Nurse progress notes from the time the resident was readmitted to the facility on [DATE] until the central line was discontinued on 12/22/24 did not document the site was assessed daily, or the dressing to the insertion site was changed. On 07/10/25 at 12:06 p.m., ACMA #1 stated it was completely the nurse's responsibility to care for a resident with a PICC/central line. On 07/10/25 at 12:48 p.m., LPN #3 stated nurses took care of any medications or dressing changes with a PICC/central line.On 07/10/25 at 12:49 p.m., LPN #3 stated they would change the dressing every two weeks, unless it was leaking, soiled, or peeling around the edges. They stated where it was documented was a good question. They stated nowadays, they knew how to put it in a progress note. They stated during this time they were not familiar with the facility's charting system. LPN #3 stated they did not know if they were documenting it anywhere at the time. They stated unless someone put in a specific order to change the dressing, it would not populate an area to chart the dressing change was completed. On 07/10/25 at 12:52 p.m., LPN #3 stated they started in November 2024. They reviewed the November 2024 MAR/TAR and stated the only documentation related to Resident #1's PICC line was the heparin flush through 12/17/24. On 07/10/25 at 12:57 p.m., LPN #3 stated they did not see anything about a dressing change for November or December 2024.On 07/10/25 at 1:48 p.m., the DON stated the care for a PICC or central line was essentially the same. They stated staff would change the dressing once a week or as needed if it became loosened or soiled. They stated the line was flushed before and after medication administration with normal saline. They stated if the line did not receive a flush with medications, then staff would flush it once per shift. The DON stated the dressing changes should be on the nurse's treatment sheet.On 07/10/25 at 1:50 p.m., the administrator stated the PICC line was placed on 10/17/24 at the hospital. On 07/10/25 at 2:03 p.m., the DON stated there was a heparin flush order started on 10/17/24 through 12/17/24. They stated that was all they were seeing on the treatment record. The administrator stated they did not find anything charted in the notes. Neither the DON or the administrator were able to locate assessments of the central line site or dressing changes while the central line was in place. On 07/10/25 at 2:05 p.m., the DON stated the site should be assessed every shift.

Based on record review and interview, the facility failed to ensure a resident received their pain medication as ordered by the physician for 1 (#6) of 1 sampled residents reviewed for medications provided accurately.The administrator identified 47 residents resided in the facility. Findings:An Administering Medications policy, revised April 2019, read in part, Medications are administered in a safe and timely manner, and as prescribed.Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions.Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication.A Controlled Drug Receipt, dated 06/04/25, showed the facility received 56 tabs of oxycodone (an opioid) 10 mg tablets for Resident #6. The receipt also showed the last tablet was administered to Resident #6 on 07/01/25 at 9:30 p.m.A Controlled Drug Receipt, dated 07/04/25, showed oxycodone was not available in the facility for Resident #6 again until 07/04/25. The next dose administered was on 07/05/25 at 6:00 a.m.On 07/07/25 at 1:33 p.m., Resident #6 stated they put them on tramadol (an opioid) when they ran out of oxycodone, but the tramadol was like eating a tic tac. Resident #6 stated when the oxycodone ran out, they have had to wait three to four days before the medication was available for them again.On 07/10/25 at 11:56 a.m., LPN #4 stated staff were supposed to reorder medications when the number went into the blue area, indicating they had usually a few days of medication left. They stated they pushed a reorder button on the computer, but if they actually needed a physician signature, then they also had to fax to the physician, or tell the DON. LPN #4 stated they did fax it to the physician and told the DON, but was not sure when because they could not find a record of when that occurred. They stated they requested it a few days before the medication was completely out. They stated they remembered they had a hard time getting the hard script for the refill because the physician was out of the office at that time for the holiday.On 07/10/25 at 12:06 p.m., the DON stated the medications were supposed to be ordered when there was a four to five day supply left. They stated they sent an email on 07/01/25 to the physician's assistant because that was the first day they were made aware the medication needed to be refilled. The DON stated they did call the physician on 07/04/25 when they had still not received a response and the physician told them the assistant was out. and therefore, they had not received the request. The DON stated there should have been better communication between the facility and the physician. The DON stated it was not acceptable for Resident #6's narcotic to be unavailable to them.

Based on record review and interview, the facility failed to ensure interventions to promote pressure ulcer healing were implemented for 1 (#1) of 3 sampled residents reviewed for pressure ulcers.The administrator identified three residents with pressure ulcers resided in the facility.Findings:A wound care policy, revised 10/2010, read in part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Make the resident comfortable. Use supportive devices as instructed.An undated turning policy, read in part, To prevent pressure injuries, promote comfort, and maintain skin integrity by ensuring residents are turned and repositioned at appropriate intervals.All residents who are immobile, at risk for pressure ulcers, or require assistance will be turned and repositioned at a minimum of every two to three hours or as individually assessed and documented in the care plan. Position changes should be documented and communicated appropriately.Wound care provider visits notes, dated 02/06/25, 02/13/25, 02/20/25, 03/04/25, 03/11/25, 03/27/25, 04/01/25, 04/15/25, 04/22/25, and 04/29/25 showed interventions for wound care treatment that included turning Resident #1 every two hours using a foam wedge.Resident #1's February 2025 ADL records showed blanks for the task of turning and repositioning every two hours 63 out of 336 opportunities.Resident #1's March 2025 ADL records showed blanks for the task of turning and repositioning every two hours 93 out of 300 opportunities.A quarterly resident assessment, dated 03/22/25, showed Resident #1 had functional limitation in range of motion for bilateral upper and lower extremities. The assessment showed they required substantial/maximal assistance to roll left and right, had one stage three pressure ulcer, had four stage four pressure ulcers, and had one unstageable deep tissue injury. All wounds were present upon admission/entry or reentry. The assessment showed skin and ulcer/injury treatments which included a turning and repositioning program. The assessment showed Resident #1 had diagnoses which included pressure ulcer of sacral region stage four, pressure ulcer of right heel stage four, pressure-induced deep tissue damage of left heel, osteomyelitis, and viral hepatitis. Resident #1's April 2025 ADL records showed blanks for the task of turning and repositioning every two hours 146 out of 339 opportunities.Resident #1's care plan, revised 05/05/25, showed interventions for wounds which included the need for staff assistance with transfers and/or repositioning due to having limitations in mobility. Resident #1 no longer resided in the facility and their wounds were unable to be observed.On 07/10/25 at 11:46 a.m., CNA #3 stated staff turned residents every two hours to prevent pressure ulcer development. They stated Resident #1 at times would not allow staff to turn them due to being uncomfortable. They stated they would ask the resident how they could make them more comfortable.On 07/10/25 at 11:49 a.m., CNA #3 stated Resident #1 had wounds that were always covered.On 07/10/25 at 1:14 p.m., LPN #3 stated Resident #1 had wounds on their back side and knee. They stated the resident was contracted and paralyzed. They stated the resident could not roll or turn themselves. They stated the resident was turned every two hours to promote wound healing.On 07/10/25 at 2:24 p.m., the DON stated Resident #1 had several wounds with slow healing progression. The administrator stated the resident admitted to the facility with several wounds. On 07/10/25 at 2:27 p.m., the administrator stated Resident #1 was contracted, not mobile, and did not want to turn. The DON stated the resident was very resistive to turning. The DON stated staff repositioned the resident with pillows as much as they would allow staff to. On 07/10/25 at 2:29 p.m., the DON stated staff attempted to turn the resident at least every two hours. On 07/10/25 at 2:32 p.m., the DON stated with the blanks in the ADL documentation, they had no way to prove Resident #1 was turned every two hours.

Based on observation, record review, and interview, the facility failed to ensure grievance forms were posted in the designated location per facility policy. The administrator identified 39 residents resided in the facility. Findings: On 11/26/24 at 2:20 p.m., a tour of the facility was conducted. Grievance information was posted at the entrance. It documented the grievance personnel, address, phone number, email, ombudsman's name and phone number, state survey agency phone number, and Adult Protective Services phone number. It documented the grievance forms could be found in a binder on the table in the front lobby. On 11/26/24 at 2:24 p.m., the front lobby table was observed with no grievance forms or binder. On 11/27/24 at 8:19 a.m., CNA #1 stated they did not know where the grievance forms were located. On 11/27/24 at 8:25 a.m., the social services director stated the forms were located in their office. They stated according to the grievance policy the forms should be on the table in the front lobby.

Based on record review and interview, the facility failed to ensure a MDS was coded accurately for one (#5) of six sampled residents whose MDS assessments were reviewed. The administrator identified 39 residents resided in the facility. They identified one resident received noninvasive ventilator services. Findings: Resident #5 had diagnoses which included amyotrophic lateral sclerosis. Resident #5's significant change in status resident assessment, dated 09/26/24, did not code Resident #5 received noninvasive ventilator services. On 11/26/24 at 2:56 p.m., a noninvasive ventilator was observed on Resident #5's bedside table. The device was off. On 11/27/24 at 11:04 a.m., Resident #5 stated they were admitted to the facility with a noninvasive ventilator. On 11/27/24 at 11:31 a.m., the DON stated Resident #5 had the noninvasive ventilator since admit. On 11/27/24 at 11:46 a.m., the DON stated they were responsible for completing care plans and MDS's. On 11/27/24 at 1:12 p.m., the DON stated they had looked at Resident #5's significant change in status MDS assessment and the noninvasive ventilator was not coded.

Based on record review and interview, the facility failed to ensure a resident's care plan included the use of a noninvasive ventilator for one (#5) of two sampled residents reviewed for respiratory services. The administrator identified 16 residents received respiratory services. Findings: The Noninvasive Ventilation policy, dated 2023, read in part, It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. Resident #5 had diagnoses which included amyotrophic lateral sclerosis. Resident #5's care plan, dated 10/02/24, did not document the use of a noninvasive ventilator. On 11/26/24 at 2:56 p.m., a noninvasive ventilator was observed on Resident #5's bedside table. The device was off. On 11/26/24 at 2:58 p.m., Resident #5 stated they used the noninvasive ventilator at bedtime. The resident stated they were admitted to the facility with the noninvasive ventilator. On 11/27/24 at 11:31 a.m., the DON stated Resident #5 had the noninvasive ventilator since admit. On 11/27/24 at 11:46 a.m., the DON stated they were responsible for completing care plans. They stated there was no care plan for the use of the noninvasive ventilator. They stated it should have been care planned.

Based on observation, record review, and interview, the facility failed to ensure a resident had a physician order for the use of a noninvasive ventilator for one (#5) of two sampled residents reviewed for respiratory services. The administrator identified 16 residents received respiratory services. Findings: The Noninvasive Ventilation policy, dated 2023, read in part, The facility will obtain an order for the use of a CPAP, BiPAP, AVAPS or [name withheld] device and settings from the practitioner. Resident #5 had diagnoses which included amyotrophic lateral sclerosis. On 11/26/24 at 2:56 p.m., a noninvasive ventilator was observed on Resident #5's bedside table. The device was off. On 11/26/24 at 2:58 p.m., Resident #5 stated they used the noninvasive ventilator at bedtime. The resident stated they were admitted to the facility with the noninvasive ventilator. On 11/27/24 at 11:31 a.m., the DON stated Resident #5 had the noninvasive ventilator since admit. A physician's order, dated 11/27/24, documented noninvasive ventilator on at night and off in the morning at bedtime related to amyotrophic lateral sclerosis. There was no physician order for the use and monitoring of the noninvasive ventilator prior to 11/26/24. On 11/27/24 at 11:40 a.m., the DON reviewed Resident #5's hospice record and electronic health records. They stated they could not locate a physician's order for the use and monitoring of the noninvasive ventilator prior to 11/26/24.

Based on observation and interview, the facility failed to ensure emergency call cord was available in a resident's bathroom for one (#2) of three sampled residents whose emergency bathroom call system was observed. The administrator identified 39 residents resided in the facility. Findings: The Call Lights: Accessibility and Timely Response policy, revised 10/21/24, read in part, The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. Resident #2 had diagnoses which included other abnormalities of gait and mobility. Resident #2's care plan for daily care, dated 10/01/24, documented the resident was able to use their call light to call for help. On 11/26/24 at 11:28 a.m., Resident #2 stated they fell in the bathroom and could not reach the emergency call system. On 11/26/24 at 11:31 a.m., Resident #2's bathroom had a red emergency switch by the side of the toilet. Resident #2 stated they had not been able to walk around and depended on a wheelchair for locomotion. A resident lying on the floor could not reach the switch on the wall. On 11/26/24 at 1:05 p.m., CNA #2 stated there was a call switch that had a string that a resident could use in the bathroom to call for help. On 11/26/24 at 1:06 p.m., CNA #2 stated Resident #2 can use their call light. On 11/26/24 at 1:13 p.m., CNA #2 observed the resident's bathroom. They stated the call switch did not have a string and a resident lying on the floor would not be able to reach the switch. On 11/26/24 at 1:18 p.m., the administrator stated the pull string in the bathroom should be on either side or in front of the toilet.

49701 Based on observation, record review, and interview, the facility failed to ensure: a. enhanced barrier precautions were utilized for two of two (#2 and #21) residents observed with indwelling devices and open wounds, b. infection control practices were adhered to after providing resident care. The Executive Director identified 43 residents resided in the facility. The Resident Matrix, dated 09/03/24, documented five residents that resided in the facility had gastric tubes, three of which had urinary catheters, and two also had pressure ulcers. Findings: A Standard Precautions policy, dated 9/2017, read in part, Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Place used disposable syringes and needles .and other sharp items in appropriate puncture-resistant containers located as close as practicable to the area in which the items were used . An Infection Prevention and Control Program policy, dated 1/2024, read in part, Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room . An Enhanced Barrier Precautions policy, dated 08/0724, read in part, enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The policy also read, a. all staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b. all staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. c. clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 1. Resident #2 had diagnoses that included gastrostomy, MRSA, Kidney Transplant Status, HIV, and quadriplegia. The quarterly MDS, dated [DATE], documented resident #2 was dependent on staff for all ADL's. They had a gastric tube, indwelling catheter, and one stage 3 pressure ulcer, two stage 4 pressure ulcers, and two unstageable pressure ulcers. On 09/03/24, upon the initial tour, it was observed that only one room had a sign indicating EBP were required. There were no PPE carts identified. On 09/04/24 at 2:15 p.m., RN #1 stated resident #2 had a gastric tube, indwelling catheter, and multiple open wounds. RN #1 Stated they were supposed to wear a gown, gloves, and a mask when administering medications or accessing indwelling devices. They stated the supplies usually stay on the carts or in the rooms. They stated there was no EBP sign on the door and no PPE available right now. 2. Resident #21 had diagnoses that included gastrostomy, pressure ulcer of sacral region stage 4, stage 4 right heel, osteomyelitis, and hepatitis C. The annual MDS, dated [DATE], documented resident #21 was dependent on staff for all ADL's. They had a gastric tube, indwelling catheter, and two stage 4 pressure ulcers. On 09/04/24 at 2:34 p.m., LPN #2 stated resident #21 is unable to get out of bed and requires a mechanical lift to transfer. They stated resident #21 has open wounds, an indwelling catheter, and a gastric tube. They stated they use universal precautions like hand washing. They stated they had not heard of enhanced barrier precautions. They stated gowns were kept on hall 300 and resident #21 was on hall 400. There was no EBP signage on the door. On 09/04/24 at 2:56 p.m., the Executive Director stated they were not surprised that some of the staff did not know what enhanced barrier protection meant because it was a newer policy. On 09/05/24 at 1:08 p.m., LPN #1 Was observed providing wound care to a resident without a gown on. On 09/05/24 at 1:23 p.m., LPN #1 Stated there was no EBP signage on the door. They stated they got a gown out but left it on the treatment cart outside the resident's door. On 09/04/24 at 8:43 a.m., LPN #4 was observed on hall 200 wearing gloves and with a glucometer in their hand, they walked past their cart to throw something in the trash outside of the kitchen, then walked back to their cart while removing the gloves. They stated they were coming from doing a finger stick blood sugar in the lobby on a resident. LPN #4 was asked what the infection control policy was. They stated they probably were not suppose to do the blood sugar in the lobby and should have taken them to their room. LPN #4 stated the concern with the gloves on in the hall was they could cross contaminate and they did not follow the policy. On 09/06/24 at 10:08 a.m., LPN #3 was observed walking from hall 400 to hall 300 with gloves on and linen in their right hand that was not in a bag. LPN #3 was asked if the linen was suppose to be in a bag. They stated they did not know the policy, then stated, Yes, it should be in a bag and not touching the floor and taken directly to the soiled utility room. They were observed to walk back to hall 400 and take the linen inside the soiled utility room.

Based on observation and interview, the facility failed to ensure medication carts were secured when not in use for three observations at random times throughout the survey on hall 400. The Executive Director identified 43 residents resided in the facility. Findings: A Medication Storage policy, dated 7/2024, read in part, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. On 09/03/24 at 12:42 p.m., an observation of the nurse cart on hall 400 was unlocked and unattended. There were medications, insulin, needles, etc located inside. On 09/03/24 at 12:44 p.m., LPN #1 was observed exiting a resident room. They stated the cart was not locked and the policy was to lock it when step away. On 09/04/24 at 7:59 a.m., LPN #1 was observed to walk away from the medication cart on hall 400 with medication cups in both hands. The cart was unlocked. On 09/04/24 at 8:01 a.m., LPN #1 returned to the cart and stated they did it again and it was not locked. On 09/06/24 at 9:39 a.m., an observation was made of a cart on hall 400 unattended and unlocked. The cart contained medication, insulin, needles, etc. On 09/06/24 at 9:41 a.m., LPN #3 returned to the cart and stated they were aware the cart was unlocked and they did not know the exact policy.

Based on observation and interview, the facility failed to ensure the appropriate dishwasher temperature and sanitization concentration levels were reached on a high temperature dishwasher. The ED identified 43 residents resided in the facility. Findings: A Dishwashing Machine Use policy, dated, 5/2024, read in parts, Dishwashing machines that use hot water to sanitize must maintain the following wash solution temperatures: c. 165 F for stationary rack, single temperature machines .Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 F, or less than: a. 165 F for stationary rack, single temperature machines. b. 180 F for all other machines. The policy also read, A supervisor will ensure the dishwashing machine is checked for proper concentrations of sanitizer solution (measured as parts-per-million[PPM] or ml/L) .The supervisor will check the calibration of the gauge weekly . On 09/04/24 at 10:38 a.m. during the follow up tour of the kitchen, the high temperature dishwasher was observed. Dietary Aide #1 was asked to run the dishwasher and to check the sanitizer. They were observed to have used the machine already and were to run it again. The wash temp was 162 degrees. On 09/04/24 at 10:46 a.m., the CDM stated with high temperature dishwasher not use sanitizer if the temperature reached 180 degrees. The machine was run again and read 167 degrees at the wash and 159 degrees at the rinse. There was no reaction on the sanitizer strip when tested . The CDM stated they were going to call maintenance to switch out the container but that it was not empty. On 09/04/24 at 10:49 a.m., the CDM ran the machine again. Wash temperature was 157 degrees and the rinse was 157 degrees. Ran again at wash and rinse at 156 degrees. On 09/04/24 at 10:40 a.m., maintenance had arrived and stated they did not hear the pump switch on and stated to call the company as they were not able to touch those. The CDM was to call. On 09/04/24 at 10:54 a.m., the CDM stated they called the appropriate companies to repair and will use the three compartment sink until repaired. On 09/04/24 at 12:26 p.m., observation made of the three compartment sink and appropriate temperature and sanitization.

Based on record review and interview, the facility failed to ensure residents were offered the choice to formulate an advanced directive for one (#44) of 12 sampled residents whose advance directive acknowledgements were reviewed. The Executive Director identified 43 residents resided in the facility. Findings: Resident #44 had diagnoses which included malignant neoplasm of the lungs and end stage renal disease. On 09/04/24 at 9:45 a.m., the ED was asked to locate the advanced directive acknowledgment. On 09/06/24 at 1:05 p.m., the ED was asked again to locate the advanced directive acknowledgement. They stated they were unable to locate the acknowledgement. They were asked for the policy. No policy was provided by the time of exit.

A past noncompliance immediate Jeopardy (IJ) situation was determined to exist effective [DATE] related to the facility's failure to immediately perform Cardio Pulmonary Resuscitation (CPR) on a Resident (Res) with full code status who was found not breathing and without a detectable heart beat. Res #42 was found by an unidentified Certified Nurse Aide (CNA) in bed and appeared not to be breathing. The unidentified CNA reported the findings to the Licensed Practical Nurse (LPN) immediately at approximately 6:00 a.m., who then assessed the resident and found him to have no signs of life. The LPN then notified the resident's family member, the administrator, the Director of Nursing (DON), and the Police. The LPN did not initiate CPR on Res #42 who had on file an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The fire department and EMSA were unable to revive Res #42. On [DATE] at 1:02 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facilities failure to ensure staff members initiated CPR on a resident who was deemed full code in the event a resident was found to be without a pulse or respirations. The past noncompliance IJ was removed, effective [DATE] at 3:00 p.m., after the facility put measures in place to prevent recurrence. A staff training of American Heart Association Basic Life Support was conducted on [DATE]. An additional in-service, dated [DATE] at 2:00 p.m. to 3:00 p.m., was conducted with the nursing staff regarding how to check Do Not Resuscitate (DNR) and full code status and when to perform CPR. On [DATE], interviews were conducted with facility staff and they voiced knowledge of what to do in an event a resident was found in cardio-pulmonary arrest. Based on interview and record review, the facility failed to provide basic life support, including CPR, to one (#42) of two residents sampled for closed record review due to death. The administrator identified 31 residents in the facility with full code status. Findings: An undated facility policy, titled Cardiopulmonary Resuscitation (CPR) read in parts If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: . In the absence of advance directives or a Do Not Resuscitate order; . Res #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Res #42's clinical record did not document a DNR form. A physician order, dated [DATE], documented Res #42 was a full code. A care plan, created on [DATE], read in parts Code status: I prefer to be a DNR, or I prefer to have CPR. I have an advanced directive that says it is empowered once 2 doctors determine I am incompetent to make my own decisions. I do not have an Advance Directive. An admission MDS assessment, dated [DATE], documented Res #42 was severely impaired in cognition, required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use, bathing, hygiene, and did not walk. The assessment documented Res #42 had shortness of breath when lying flat and during exertion, and utilized oxygen. A nurse note, dated [DATE] at 6:15 a.m., documented LPN #1 was notified at 6:00 a.m., that Res #42 was in bed and an unidentified CNA came to let her know that she did not think Res #42 was breathing. The note documented LPN #1 assessed Res #42 and his pupils were fixed and dilated and he had no pulse. The noted documented LPN #1 was unable to obtain a blood pressure on Res #42. The note documented LPN #1 notified a family member of Res #42 who stated they were on their way to the facility. The note documented LPN #1 notified the police, administrator, and the director of nursing. The note documented LPN had last visualized Res #42 at 5:15 a.m., when LPN #1 had put Res #42's oxygen cannula back in his nares. The note documented Res #42 was speaking at that time. The note did not document CPR had been initiated. The next nurse note entry, dated [DATE] at 6:53 a.m. by LPN #1, documented the fire department and EMSA had arrived to do CPR and Res #42's family member was at the bedside. The note documented the family member's statement of not attempting CPR on Res #42 and documented LPN #1 informing her that a DNR would have had to been signed and on file in the facility in order for the EMSA and fire department to not initiate CPR. A nurse note, dated [DATE] at 7:11 a.m., documented the fire department and EMSA were unable to revive Res #42 and the facility was waiting for the arrival of the medical examiner. On [DATE] at 5:15 p.m., the administrator was asked if the staff had initiated CPR for Res #42. The administrator stated she did not know as she was not in the building when Res #42 expired. When asked if the staff were CPR certified, the administrator stated the nurses were CPR knowledgeable but she did not know if they were all certified. On [DATE] at 5:32 p.m., the administrator provided documentation RN #1, who was working evening and night shift on [DATE], was CPR certified. On [DATE] at 8:29 a.m., a family member of Res #42 was interviewed and confirmed Res #42 did not have a DNR and was a full code. The family member stated they had received information on formulation of an advanced directive and DNR and had requested the facility assist them to complete the forms but had not done so before Res #42 had expired. [DATE] at 9:37 a.m., LPN #1 was interviewed and stated she was not assigned to care for Res #42 on the night shift of [DATE] onto [DATE], but had put his oxygen back on a few times during the night shift. LPN #1 stated at around 6:00 a.m. on [DATE], she heard a staff member yelling down the hall and went down to check on Res #42 then checked the chart and found was there was no DNR documented. LPN #1 stated she called the family member listed and was told by her/him they did not want Res #42 to be resuscitated as he would not want CPR. LPN #1 stated she told the family member they were required to start CPR since he did not have a DNR and he was a full code. LPN#1 stated she did not start CPR as she was trying to honor the family's request. LPN #1 stated CPR was not started until EMSA got to the facility and when the family member came in CPR was in progress. LPN #1 stated she knew the policy of the facility in the event of cardio-pulmonary arrest was to check the residents chart for code status and CPR was to be started if a DNR was not on file. LPN #1 stated she did not do that with Res #42. On [DATE] at 10:15 a.m., the social service (SS) director reported the family had told him the resident did have a DNR and advanced directive during the admission paperwork but did not have the documents with them. The SS director stated he told Res #42's family member the facility would be required to perform CPR on Res #42 if he experienced cardio-pulmonary arrest until a DNR on was on file with the facility. The SS director stated he made sure the family member understood this. On [DATE] at 11:05 a.m., the administrator stated the facility always asked for advanced directives and DNR's on admission and if they don't have one they are encouraged to complete one at that time. The administrator stated they are told if they had a DNR or advanced directives, they need to bring a copy to the facility as soon as possible as the resident will be resuscitated as a full code until the documents are in the building. The administrator stated she would contact the DON for additional information related to Res #42's cardio-pulmonary arrest. On [DATE] at 11:30 a.m., the administrator stated she spoke with the DON by phone and was told the BLS/CPR training and in-service in [DATE] were conducted due to the response of the facility staff when Res #42 experienced cardio-pulmonary arrest and subsequently expired.