Every finding on record at The Oaks Healthcare Center

Based on record review and interview, the facility failed to coordinate care with a facility contracted hospice service provider for 1 (#1) of 3 sampled residents reviewed for cardiac code status. The administrator identified 10 residents received hospice services.Findings:A care plan note, dated 05/07/25, showed Resident #1 and a family member reviewed the resident's cardiac code status as a full code and declined to make any changes to the resident's cardiac code status. A care plan note, dated 07/23/25, showed Resident #1 and a family member reviewed the resident's cardiac code status as a full code and declined to make any changes to the resident's cardiac code status. A physician's order, dated 07/30/25, showed Resident #1 was admitted to hospice services effective 07/29/25.A care plan note, dated 08/13/25, read in part, Care Plan Meeting held today with the IDT team and no answer for scheduled care plan meeting with [family member's name withheld] via phone. [Resident #1's name withheld] is currently in a LTC bed and weights are stable at this time. Currently a Full Code status and no code status changes at this time d/t family not in attendance and resident can't cognitively make the decision. No issues or concerns noted. Continue POC [plan of care].A nurse's progress note, dated 08/24/25, showed Resident #1 was sluggish with audible secretions and the staff connected Resident #1 to 2 liters of oxygen. The note showed the facility arranged for the resident to be sent to the emergency room, contacted the contracted hospice provider, contacted the resident's primary care physician, and contacted the family member. The facility's Transfer and Referral Record, dated 08/24/25, showed Resident #1 was a Full Code and the reason for transfer to the hospital was shortness of breath and secretions. The hospital emergency room provider note, dated 08/24/25, showed Resident #1 was intubated, chemically sedated and paralyzed in route to the hospital by the emergency medical technicians. A nurse's progress note, dated 08/25/25, showed the facility staff contacted the physician and received an order to change the cardiac code status for Resident #1 from Full Code to Do Not Resuscitate [DNR]. The note showed the facility had a copy of the Do Not Resuscitate document signed by the guardian on 07/29/25. The note showed the facility added the signed Do Not Resuscitate document to the resident's electronic medical record. A code status audit, dated 08/26/25, showed an alphabetical list of all residents with their code status, confirmation of order for code status, and the resident's hospice provider, if applicable. An email correspondence, dated 08/26/25, showed the administrator summarized a meeting with the contracted hospice service provider for Resident #1. The email showed the meeting addressed four concerns: notification of new admits; DNR status; diagnoses for MDS update; and communication. The email showed the facility and hospice collaborated on a plan to prevent further issues. The plan included a nurse assigned to the facility to aid with consistency in communication; weekly meetings with hospice providers to review admissions, admission diagnoses for MDS; cardiac code status; and other resident concerns. The email showed the social service director made a central binder with each residents' cardiac code status and copies of their Do Not Resuscitate form and/or advanced directives. The email showed one hospice provider planned to provide access to hospice electronic medical records; all service providers were to provide new resident paperwork/orders/changes to the social service director; and the social service director communicated any new information / changes to the director of nursing and the medical director. On 09/11/25 at 4:40 p.m., the marketing representative for the contracted hospice service provider for Resident #1 stated they witnessed the cardiac code status change for Resident #1 from a Full Code status to a Do Not Resuscitate status and signed the document as one of two required witnesses to the document on 07/29/25. The marketing representative stated the document was signed by Resident #1's guardian at the guardian's home. The marketing representative stated they did not notify the facility of the change in Resident #1's code status and did not provide a copy of the signed Do Not Resuscitate document for Resident #1 to the facility. The marketing representative stated they were not sure how the hospice provider notified the facility of a change in a resident's code status but thought such documents were possibly faxed to the facility by the hospice provider's main office. On 09/11/25 at 4:22 p.m., MDS Coordinator #1 stated when a resident was admitted to hospice, the facility usually scheduled a new care plan meeting for the following Wednesday. MDS Coordinator #1 stated the floor nurses entered the order for hospice into the resident's clinical record. MDS Coordinator #1 stated if the terminal diagnosis was not entered as part of the hospice order, they contacted the contracted hospice provider to obtain the terminal diagnosis. MDS Coordinator #1 stated they did not ask about the resident's code status because it was usually placed in the resident's clinical record by the nursing staff and once there, MDS coordinator #1 updated the care plan. MDS Coordinator #1 stated they did not change the resident's code status until they had signed DNR or other signed documentation of the resident's change in code status. MDS Coordinator #1 stated Resident #1 did not participate in their last care plan meeting and the family did not answer the call for the scheduled care plan meeting. MDS Coordinator #1 stated without the family member's participation, they could not re-address the code status for Resident #1 and the contracted hospice provider had not provided the resident's updated Do Not Resuscitate signed by the guardian for Resident #1. On 09/11/25 at 6:55 p.m., the DON stated the contracted hospice provider typically informed the floor nurse that the resident was admitted to hospice and then the floor nurse would inform the DON. The DON stated generally the nurse from hospice brought a copy of the DNR and placed it in the resident's hospice book and gave another copy of the DNR paperwork to nurse. The DON stated the contracted hospice provider for Resident #1 failed to communicate the resident's admission to hospice until the following day and failed to inform and/or provide the facility with a copy of the DNR paperwork the guardian signed outside of the facility. The DON stated the issue was identified on 08/25/25 and they immediately audited all the hospice charts and confirmed with the contracted hospice providers that the facility had the correct code status, the documents to support their code status, and other pertinent paperwork. The DON stated, the facility started weekly meetings with their contracted hospice service providers to ensure both parties communicated resident care needs, reported changes in resident status/care, confirmed the resident's current code status, and ensured the resident's care plans and supporting documents all matched information and were up to date.

Based on observation, record review, and interview, the facility failed to serve food that was palatable and at a safe and appetizing temperature for the residents.The DON identified 103 residents received meals prepared by the kitchen and two residents received nutrition via percutaneous endoscopic gastrostomy tube. Findings:On 08/21/25 at 12:44 p.m., a meal test tray was obtained. The plate had turkey pot pie, salad, and a hot roll. The plate was not on a plate warmer and was covered with a lid. The turkey pot pie temped at 140 degrees F, the salad temped at 87.2 degrees F, and the hot roll temped at 94.3 degrees F. The salad was warm to taste, and the turkey pot pie and hot roll were not hot to taste.A resident/family council meeting document, dated 07/16/25, showed a resident stated the food was terrible and cold at mealtimes. A hot food temperature chart for August 2025 showed food temperature checks were not obtained for 08/01/25 through 08/07/25 and 08/17/25 through 08/19/25. Evening meal temperature checks were not obtained on 08/08/25 and 08/09/25. On 08/20/25 at 4:37 p.m., Resident #7 stated the food was served cold.On 08/20/25 at 3:55 p.m., Resident #1 stated they received their diet per physician order, but the food was cold. On 08/21/25 at 9:27 a.m., Resident #3 stated the food was always cold. On 08/21//25 at 11:45 a.m., Resident #4 stated the facility served to much starch for a diabetic diet and the food was always cold. On 08/21/25 at 3:00 p.m., the DM stated the reason a plate warmer was not used for the lunch meal on 08/21/25 was because the salad was a cold item to be served. The DM stated cold and hot food should not have been served on the same plate. The DM stated the food temperature chart had food temperatures missing and they would not know if the food was served at the correct temperature.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program during wound care for 2 (#2 and #3) of 3 sampled residents reviewed for enhanced barrier precautions. The DON identified 18 residents with wounds and 27 residents on enhanced barrier precautions. Findings:1.On 08/21/25 at 9:26 a.m., LPN #1 obtained supplies to perform wound care for Resident #2. LPN #1 donned a pair of gloves and a gown. LPN #1 positioned the resident for comfort and removed the current dressing. LPN #1 removed their gloves and exited the room to obtain more supplies. LPN #1 did not remove or change their gown when exiting and reentering the room. LPN #1 continued with the wound care. LPN #1 changed wound areas and needed more supplies. LPN #1 removed their gloves and exited the room again to obtain more supplies. Wearing the same gown, LPN #1 exited and reentered to room without changing their gown. An undated policy titled Enhanced Barrier Precautions Policy, read in part, An order for enhanced barrier precautions will be obtained for residents with any of the following: i. wounds .Make gowns and gloves available immediately near or outside of the resident's room.d. Position a trash can inside the resident room for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.An undated face sheet showed Resident #2 had diagnoses which included atherosclerosis of native arteries of the right leg with ulceration of calf, diabetes mellitus, and moderate protein-calorie malnutrition.A quarterly assessment, dated 07/31/25, showed Resident #2 had a brief interview for mental status score of 14 which indicated the resident's cognition was intact and a diabetic foot ulcer. A physician order, dated 08/19/25, showed Resident #2 was to have wound care to bilateral lower extremities every day shift every Tuesday. The order showed staff were to cleanse the wound with normal saline, pat dry, apply gentamicin (topical for skin infections), apply iodoform (antiseptic)to wound bed, and cover with a 4X4 gauze. The order showed staff was then to apply three-layers compression consisting of past gauze, rolled gauze, and self-adherent wrap. On 08/21/25 at 9:45 a.m., LPN #1 stated the process they knew was to remove and place their PPE in the barrel out in the hallway. 2.On 08/21/25 at 9:00 a.m., LPN #1 gathered supplies to compete wound care for Resident #3. There was no signage posted at the door regarding precautions or PPE available at the door. LPN #1 obtained gloves from their cart and entered the room with the wound supplies. LPN #1 was not wearing a gown. LPN #1 positioned the resident and removed the current dressing. LPN #1 changed their gloves and used alcohol-based hand gel. LPN #1 donned gloves and completed the wound care. LPN #1 did not wear a gown. An undated face sheet showed Resident #3 had diagnoses which included osteoarthritis, thrombocytopenia, severe protein-calorie malnutrition, and cerebral vascular disease. A physician order, dated 05/23/25, showed staff was to clean the left hip wound with normal saline or wound cleanser, pat dry, pack wound with iodoform, and cover with a bordered foam dressing daily and as needed. A significant change assessment, dated 08/10/25, showed Resident #3 was severely cognitively impaired and had one unstageable pressure ulcer. On 08/21/25 at 9:15 a.m., LPN #1 stated all residents with wounds should be on enhanced barrier precautions. LPN #1 stated they had forgot.

Based on observation, record review, and interview the facility failed to ensure a resident's dignity was maintained by providing clean clothes after meals for 1 (#72) and failed to ensure dignity with dining for 1 (#48) of 2 sampled residents reviewed for dignity. Corporate Nurse #1 identified 87 residents who resided in the facility. Findings: 1. Resident #72 had diagnoses which included dementia. On 02/20/25 at 4:02 p.m., the resident was observed in the dining room waiting to be served dinner wearing a black T-shirt with food debris on it. On 02/25/25 at 2:24 p.m., the resident was observed in the common area, in a chair, with food debris on their shirt and blanket. The quarterly assessment, dated 12/20/24, showed Resident #72 was severely impaired in cognition for daily decision making. On 02/25/25 at 3:15 p.m., LPN #3 stated resident #72 had been in the common area since just after lunch. They stated they did not know why the staff brought the resident out to the common area with food on them, but stated they should have cleaned them up. 35474 2. Resident #48 had diagnoses which included dementia. On 02/21/25 at 8:44 a.m., Resident #48 was observed being assisted with the noon meal in their room. CNA #1 was observed to stand while assisting the resident with their meal. The annual assessment, dated 01/30/25, showed Resident #48 was severely impaired in cognition for daily decision making. On 02/25/25 at 7:58 a.m., CNA #1 stated they preferred to stand when assisting residents with their meals in their rooms. On 02/25/25 at 10:30 a.m., LPN #1 stated they thought staff should sit when assisting residents with their meal but would need to check with their supervisor. On 02/25/25 at 10:38 a.m., the DON stated staff were to sit when assisting residents with their meals to maintain the residents' dignity. On 02/25/25 at 11:21 a.m., LPN #1 stated they had found out from their supervisor that staff should sit when assisting residents with their meal.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than five percent for one (#47) of four sampled residents who were observed to receive medications. The medication error rate was 6.9% The corporate nurse identified 87 residents who received medications from the facility. Findings: On 02/25/25 at 7:24 a.m., CMA #1 was observed to administer an albuterol sulfate hydrofluoroalkane inhalation aerosol 90 mcg per actuation. CMA #1 was observed to administer two puffs to Resident #47 without waiting one minute between puffs. CMA #1 was observed to administer aller-flo fluticasone 50 mcg/spray with 2 sprays to Resident #47 in each nostril. They administered one spray, then counted to three and administered another spray. Out of 29 opportunities two medication errors resulted in a medication error rate of 6.9% The undated manufacturer instructions for Albuterol sulfate hfa inhalation aerosol, read in part, Step 6. Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. If your healthcare provider has told you to use more sprays, wait 1 minute and shake the inhaler again. Repeat step 2 through step 6. An Administering Medications policy, revised April 2019, read in part, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the physician orders for Resident #47 showed an active order to administer aller-flo fluticasone 50 mcg/spray one spray both nostrils twice a day. On 02/25/25 at 11:51 a.m., the DON stated their expectation of staff during medication administration was to follow the five rights, stay with the resident until completed, use precautions and administer medications in the ordered way. They stated the CMA supervisor was responsible to educate and train the CMA staff. On 02/25/25 at 11:58 a.m., the CMA supervisor stated their expectation was the staff administer medications effectively. They stated CMA #1 was the only CMA they had not trained because CMA #1 was hired before they started at the facility. The CMA supervisor stated they monitored to ensure medications were administered correctly by watching during the medication administration from a distance.

Based on observation, record review, and interview, the facility failed to ensure medications were secured for 2 (300 hall and 400 hall) medication/treatment carts of 6 medication/treatment carts observed. The DON identified 6 medication/treatment carts in the facility. Findings: On 02/20/25 at 3:45 p.m., LPN #3 was observed to enter room [ROOM NUMBER]. The 300 hall medication/treatment cart was observed to be left unattended and unlocked for less than one minute. On 02/20/25 at 3:55 p.m., LPN #3 was observed to leave the 300 hall medication/treatment cart unattended and unlocked. On 02/20/25 at 3:56 p.m., LPN #7 was observed to lock the 300 hall medication/treatment cart. On 02/20/25 at 4:11 p.m., LPN #3 was observed to enter room [ROOM NUMBER]. The 300 hall medication/treatment cart was observed to be left unattended and unlocked. On 02/20/25 at 4:14 p.m., LPN #3 was observed to again enter room [ROOM NUMBER]. The 300 hall medication/treatment cart was observed to be left unattended and unlocked. On 02/20/25 at 4:20 p.m., LPN #3 was observed to enter room [ROOM NUMBER]. The 300 hall medication/treatment cart was observed to be left unattended and unlocked. On 02/20/25 at 4:25 p.m., LPN #3 was observed to again enter room [ROOM NUMBER]. The 300 hall medication/treatment cart was observed to be left unattended and unlocked. On 02/25/25 at 10:13 a.m., the 400 hall medication/treatment cart was observed to be unlocked and unattended on the 400 hall. The Security of Medication Cart policy, dated April 2007, read in part, The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. On 02/20/25 at 4:26 p.m., LPN #3 stated they locked the medication/treatment cart when they were finished on the hall and parked the cart by the nurses station. They stated they did not lock the cart when they would go from room to room. On 02/25/25 at 10:25 a.m., LPN #5 stated the medication/treatment carts were to be locked. On 02/25/25 at 11:34 a.m., the DON stated they randomly checked medication/treatment carts to ensure the staff had locked them when they were unattended. 41809

Based on observation, record review, and interview, the facility failed to ensure appropriate hand hygiene was practiced in the kitchen and failed to ensure food delivered to residents on the hall were covered for 1 (C hall) of 1 hall observed during the noon meal. The administrator reported the census was 87 and the facility map showed six halls residents resided on in the facility. Findings: 1. On 02/21/25 at 11:52 a.m., dietary aide #2 was observed to enter the kitchen, touch their pants with both hands, and begin working without washing their hands. On 02/21/25 at 11:53 a.m., the dietary manager was observed to put on gloves without washing their hands. On 02/21/25 at 12:01 p.m., dietary aide #1 was observed to enter the kitchen and to begin preparing meal trays without washing their hands. On 02/21/25 at 12:03 p.m., dietary aide #2 was observed to enter the kitchen, touch their pants with both hands, prepare a meal [NAME], exit the kitchen, serve the meal to a resident in the dining room, return to the kitchen, touch face with right hand, don gloves, prepare two turkey sandwiches, and then to remove the gloves without washing their hands. A facility policy Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised 10/2017, read in part, Employees must wash their hands .whenever entering or re-entering the kitchen .Antimicrobial hand gel cannot be used in place of handwashing in foodservice areas .use of disposable gloves does not substitute for proper handwashing. On 02/21/25 at 12:05 p.m., dietary aide #2 stated hands should be washed when re-entering the kitchen. On 02/21/25 at 2:39 p.m., the dietary manager stated staff should wash their hands when entering the kitchen and prior to serving food. 2. On 02/25/25 at 12:15 p.m., the cart with meal trays, for residents on the C hall, was delivered to the front of the hall by the dietary manager. On 02/25/25 at 12:22 p.m., staff were observed to deliver meal trays, from the cart, down the length of the hall. The cake was observed to be on a saucer and uncovered. On 02/25/25 at 12:35 p.m., cook #1 stated they placed the meal on plates with covers, but did not cover small bowls or saucers. On 02/25/25 at 12:39 p.m., the dietary manager stated they did not cover food items that were not on the main plate because the foods were covered by the cart. They stated staff were to push the cart down the hall to each room to deliver the trays rather than walk down the hall with the foods uncovered.

Based on observation, record review, and interview, the facility failed to: a. ensure proper PPE was utilized during care for EBP for 2 (#42 and #48) of 6 sampled residents who were reviewed for EBP; b. ensure clean laundry was transported in a manner to maintain infection control; c. implement a water management program to prevent the spread of waterborne pathogens; and d. maintain indwelling urinary catheters in a manner to prevent infection for 2 (#48 and #15) of 4 sampled residents reviewed for indwelling urinary catheters. Corporate Nurse #1 identified 16 residents with indwelling urinary catheters, 10 residents with wounds, and 87 residents who resided in the facility. Findings: 1. Resident #42 had diagnoses which included diabetes. On 02/24/25 at 1:42 p.m., LPN #2 was observed to provide wound care for Resident #42. LPN #2 was not observed to utilize a gown during wound care. EBP signage was not observed outside the resident's room. On 02/25/25 at 9:02 a.m., LPN #2 stated Resident #42 was on EBP, but they had forgotten to utilize a gown during wound care. 2. Resident #48 had diagnoses which included dementia. On 02/20/25 at 3:39 p.m., Resident #48 was observed by the nurses station in a wheel chair. The catheter bag and tubing was observed to be in contact with the floor. On 02/25/25 at 1:45 p.m., CNA #1 and CNA #2 were not observed to wear gowns during catheter care for Resident #48. EBP signage was not observed outside the resident's room. On 02/25/25 at 2:55 p.m., the catheter bag and tubing for Resident #48 was observed to be in contact with the floor. The Catheter Care, Urinary, policy, dated September 2014, read in part, Be sure the catheter tubing and drainage bag are kept off the floor. The care plan, revised 02/11/25, showed the resident had an indwelling urinary catheter and staff were to maintain EBP during high contact care activities. On 02/25/25 at 2:10 p.m., CNA #2 stated they were unaware of EBP for Resident #48 and did not utilize a gown during catheter care. On 02/25/25 at 2:15 p.m., the DON stated the charge nurses were responsible to place EBP signage on the residents' doors so staff knew to utilize PPE. 3. On 02/25/25 at 1:58 p.m., the clothing racks for clean clothes was observed in the laundry room. Covers for the clean laundry racks were not observed. The Laundry and Bedding, Soiled policy, dated October 2018, read in part, Clean linens protected from dust and soiling during transport and storage to ensure cleanliness. On 02/25/25 at 2:00 p.m., the laundry supervisor stated they did not cover the clothing on the laundry racks when they were transported to residents. They stated they did not have covers for the clothing racks. On 02/25/25 at 3:26 p.m., the administrator stated they did not cover clothing when it was transported to the residents. On 02/25/25 at 3:46 p.m., corporate nurse #1 stated the reference to linen in the facility's policy was interchangeable with clothing. They stated they did not cover residents' clothing when it was transported down the hallways but should to protect against soilage. 4. The Legionella Water Management Program policy, dated July 2017, read in parts, The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of legionnaire's disease.The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility .c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. On 02/25/25 at 3:20 p.m., the maintenance supervisor stated they had not assessed the facility for areas in the water system that could encourage the growth or spread of waterborne bacteria. On 02/25/25 at 3:25 p.m., the administrator stated they had not implemented the Legionella Water Management Program policy, but had started some classes about waterborne bacteria. 5. Resident #15 had diagnoses which included retention of urine and chronic kidney disease. On 02/20/25 at 4:04 p.m., Resident #15 was observed in their room, sitting in their wheel chair. The catheter bag and tubing were observed to hang under the wheel chair with the bag and tubing in contact with the floor. On 02/24/25 at 11:10 a.m., Resident #15 was observed in their room, sitting in their wheel chair. The catheter bag and tubing were observed to hang under the wheel chair with the bag and tubing in contact with the floor. On 02/25/25 at 8:47 a.m., Resident #15 was observed in their room, sitting in their wheel chair. The catheter bag and tubing were observed to hang under the wheel chair with the bag and tubing in contact with the floor. On 02/25/25 at 9:08 a.m., Resident #15 was observed to be pushed in their wheel chair by staff from their room, through the front lobby by the nurses station, down the 600 hall to the therapy room. The resident's catheter bag and tubing were observed to hang under the wheel chair and drag on floor. The quarterly assessment, dated 12/13/24, showed the resident had an indwelling urinary catheter. On 02/25/25 at 10:24 a.m. CNA #1 stated catheter bags and tubing were to be kept off the floor. On 02/25/25 at 10:26 a.m., LPN #1 stated catheter bags and tubing were to be kept off the floor. LPN #1 stated they did not know why the catheter bags and tubing were in contact with the floor. On 02/25/25 at 11:11 a.m., the DON stated the nurses were to monitor to ensure catheter bags and tubing were not in contact with the floor. 41809 46703

Based on record review and interview, the facility failed to ensure residents were provided education and offered the influenza and pneumococcal immunizations for 2 (#88 and #17) of 5 sampled residents who were reviewed for immunizations. The DON identified 87 residents who resided in the facility. Findings: 1. Resident #88 was admitted [DATE] and had diagnoses which included coronary artery disease. Review of the clinical record did not show the resident had been provided education or offered the influenza or pneumococcal immunization. 2. Resident #17 was admitted on [DATE] and had diagnoses which included diabetes mellitus. Review of the clinical record did not show the resident had been provided education or offered the influenza or pneumococcal immunization. On 02/25/25 at 5:24 p.m., corporate nurse #1/infection preventionist stated a previous infection preventionist had been responsible for educating and offering residents influenza and pneumococcal immunizations, but they could not locate documentation for Resident #88 or Resident #17.

Based on record review and interview, the facility failed to ensure residents were provided education and offered the COVID immunization for 4 (#17, 49, 78, #88) of 5 sampled residents who were reviewed for immunizations. The DON identified 87 residents who resided in the facility. Findings: 1. Resident #78 was admitted [DATE] and had diagnoses which included dementia. Review of the clinical record did not show the resident had been provided education or offered the COVID immunization. 2. Resident #88 was admitted [DATE] and had diagnoses which included coronary artery disease. Review of the clinical record did not show the resident had been provided education or offered the COVID immunization. 3. Resident #17 was admitted on [DATE] and had diagnoses which included diabetes mellitus. Review of the clinical record did not show the resident had been provided education or offered the COVID immunization. 4. Resident #49 was admitted [DATE] and had diagnoses which included diabetes mellitus. Review of the clinical record did not show the resident had been provided education or offered the COVID immunization. On 02/25/25 at 5:24 p.m., corporate nurse #1/infection preventionist stated a previous infection preventionist had been responsible for educating and offering residents COVID immunizations, but they could not locate documentation for Resident #78, 88, 17 or Resident #49.

Based on observation, record review, and interview the facility failed to assess a resident for self administration of medication for 1 (#35) of 1 sampled residents who was reviewed for self administration of medication. The DON identified 5 residents that self administered medication. Findings: Resident #35 had diagnoses which included chronic obstructive pulmonary disease. On 02/21/25 at 9:15 a.m., Resident #35 was observed at the bedside self administering Albuterol Sulfate HFA Aerosol Solution 108 (90 base) MCG/ACT. The Self Administration of Medications policy, dated December 2016, read in part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. In addition to general evaluation of decision making capacity the staff and practitioner will perform a more specific skill assessment. The annual assessment, dated 11/28/24, showed the resident was cognitively intact for daily decision making. On 02/26/25 at 8:30 a.m., LPN #5 reviewed the electronic clinical record and stated there was not an assessment for self administering an inhaler for Resident #35. They stated it was the nurses responsibility to perform an assessment to have medications at the bedside. The nurse stated they did not know why an assessment had not been completed. On 02/26/25 at 8:50 a.m., the DON stated the charge nurses were responsible to complete an assessment for residents to self administer medications. They stated the facility's policy for self administration of medications had not been followed for Resident #35.

Based on record review and interview, the facility failed to ensure notification was made to a resident's guardian for 1 (#15) of 1 resident reviewed for notification of change. The administrator identified 87 residents who resided at the facility. Findings: A Change in a Resident's Condition or Status policy, revised May 2017, read in part, Our facility shall promptly notify the resident, [their] Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .changes in level of care, billing/payments, resident rights. Resident #15 had diagnoses which included major depressive disorder, schizophrenia, and anxiety. A behavior note, dated 02/06/25 at 9:23 p.m., showed the nurse had overheard Resident #15 state they wanted to die to their roommate. A behavior note, dated 02/06/25 at 9:26 p.m., showed the nurse entered the room of Resident #15 and asked if they were okay. Resident #15 stated they wanted to be changed and put to bed. The note showed Resident #15 was frustrated about having to wait to be changed for bed. A behavior note, dated 02/06/25 9:41 p.m., showed a CNA approached LPN #3 and stated Resident #15 stated, [They] wishes [they] was dead and [they] didn't have to deal with this [expletive]. That [they] just wanted to die. A health status note, dated 02/06/25 at 9:50 p.m., showed emergency management services was notified per the physician, but Resident #15 declined to go for further evaluation. A health status note, dated 02/06/25 at 9:54 p.m., showed Resident #15 had declined a blood draw and urine sample and stated they were tired and they were speaking out of frustration and being agitated. Resident #15 stated they did not want any of their family notified of the situation. A health status note, dated 02/07/25 at 9:04 a.m., showed Resident #15 was previously on 1:1 due to their comment of wanting to die. The note showed LPN #4 spoke with Resident #15 and they reported they were just upset the day before and wanted to retract their statement. Resident #15 stated they had no plans or intentions of hurting themselves. A communication note, dated 02/07/25 at 10:18 a.m., showed the SSD consulted with Resident #15 and the resident expressed having thoughts of suicide, which appeared to be more a result of frustration. The note showed Resident #15 discussed their feelings and clarified they had no active plan to act on their thoughts. A health status note, dated 02/07/25 at 2:28 p.m., showed a call was placed to the physician to notify of recent behaviors, but had to leave a message. An outside physician visit note, dated 02/09/25 at 2:39 p.m., showed Resident #15 voiced no concerns or needs and to continue with current plan of care. On 02/25/25 at 8:36 a.m., the SSD stated Resident #15 was asked about suicidal ideations and they stated they had a thought about suicide a while back, but after speaking to Resident #15 they had said it out of frustration. On 02/26/25 at 10:06 a.m., LPN #4 stated the behavior of Resident #15 happened the day before it was reported to them. They stated Resident #15 told them they did not mean what was said about suicide and was frustrated from the situation. LPN #4 stated they had Resident #15 brought to the nurses station for one on one observation. LPN #4 stated they informed Resident #15 of the policy and why they were required to receive one on one. LPN #4 stated Resident #15 did not like being at the station and stated they would never again. LPN #4 stated they did not notify the guardian of the suicide statement because Resident #15 made their own decisions. They stated it had occurred on the previous shift and was passed on to them in report. LPN #4 stated if the previous shift had notified the guardian, it would have been documented in the progress notes. No documentation of notification to the guardian was located in the clinical record. On 02/26/25 at 12:50 p.m., LPN #3 stated they had heard Resident #15 was upset and mentioned something about wanting to die, and spoke with them. They stated they asked how the statement came about and Resident #15 reported they was aggravated because it was taking the aides too long to get to them. LPN #3 stated Resident #15 was very upset and aggravated and after telling them the consequences of their words, Resident #15 tried to take everything back and they did not want anybody notified. They stated they tried to notify family around 11:00 p.m. and there would be a progress note in the clinical record. No progress note regarding notification to the guardian was located in the clinical record. On 02/26/25 at 11:36 a.m., the corporate nurse stated Resident #15 was not their own person and had a guardian. The stated the guardian should have been informed, but they did not see any documentation they were notified.

Based on record review and interview, the facility failed to assess and monitor the dialysis port for 1 (#24) of 1 resident who was reviewed for dialysis services. The corporate nurse identified four residents who received dialysis services. Findings: A Hemodialysis Access Care policy, revised September 2010, read in part, Central catheters for hemodialysis are generally inserted in the neck, chest or groin area. This is not the preferred site for long-term placement. There is more risk of clotting and infection than with either fistulas or grafts. Central dialysis catheters are used for short term dialysis (less than three weeks) while [arteriovenous fistula] or [arteriovenous graft] is healing.Care of Central Dialysis Catheters 1. The central catheter site must be kept clean and dry at all times. Bathing and showering are not permitted with this device. 2. Catheter lumens should be capped and clamped when not in use. 3. Dialysis catheters should be marked for dialysis use only so they are not confused with central venous access devices. 4. Flushing, drawing blood or administering medications via central hemodialysis catheters require specialized training and/or certification of an [registered nurse]. Do not allow non-dialysis personnel to access the catheter. 5. Those caring for the catheter site must wear a mask and gloves when doing so. Dressing changes, if ordered, should be done using sterile technique. 6. Never pull or tug on the catheter. Do not use scissors near the catheter, .Documentation The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis. Resident #24 had diagnoses which included renal failure. A care plan for Resident #24, revised 11/21/24, showed hemodialysis related to renal failure and the resident was non-adherent to attending treatments as scheduled. Review of the December 2024, January 2025, and February 2025 treatment records showed no documentation of assessments for pre and post dialysis. Review of the progress notes for December 2024, January 2025, and February 2025 showed no documentation of assessments for pre and post dialysis. A quarterly assessment, dated 02/16/25, showed dialysis as a special treatment. On 02/21/25 8:48 a.m., Resident #24 stated their dialysis days were Tuesday, Thursday, and Saturday in the morning. They stated the facility sent papers back and forth in a book. Resident #24 stated the facility did not do anything before they left for dialysis or when they returned from dialysis. On 02/26/25 at 8:56 a.m., LPN #5 stated Resident #24 left for dialysis prior to their shift, but when they returned they reviewed the dialysis paper and put Resident #24 back in bed. They stated they monitored the central catheter by reviewing the document from the dialysis center for changes in kidney function, but it was not documented. LPN #5 stated they prevent infection and maintain patency of the dialysis catheter during showers by covering it the site with something waterproof. On 02/26/25 at 9:10 a.m., the corporate nurse stated dialysis residents were monitored in collaboration of care with the dialysis team, they communicate back and forth. They stated it was documented in a dialysis note in the clinical record. The corporate nurse stated the assessment/notes were not completed because the prior leadership missed entering that on the treatment administration record.

Based on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for 1 (#58) of 5 sampled residents whose labs were reviewed. Corporate Nurse #1 identified 75 residents who had physician's orders for labs. Findings: Resident #58 had diagnoses which included diabetes, hyperlipidemia (high cholesterol), congestive heart failure, and end stage renal disease. A physician's order, dated 06/03/24, showed the resident was to have labs which included a complete blood count, hemoglobin A1C, comprehensive metabolic panel, lipids, and a liver function test every 3 months. The September 2024 medication administration record showed the ordered labs were completed on 09/03/24 and were documented as completed by LPN #1. Review of the clinical record did not reveal the lab reports for September 2024. On 02/25/25 at 11:14 a.m., the DON stated lab orders were documented on the treatment record by the nurse when they were completed. On 02/25/25 at 11:22 a.m., LPN #1 stated they documented on the treatment record when labs were completed. LPN #1 reviewed the treatment record and stated they would look for the lab reports for September 2024. On 02/25/25 at 11:31 a.m., LPN #1 stated the ordered labs for September 2024 had not been completed for Resident #58 and they did not know why they had documented they were completed.

Based on record review and interview, the facility failed to ensure the facility did not initiate a discharge of a resident for the use of authorized electronic monitoring of the resident's room for one (#2) of one sampled resident whose facility initiated discharge was reviewed. The DON identified 107 residents who resided in the facility. Findings: The facility Transfer or Discharge Notice policy, dated March 2021, read in part, .2. Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. c. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare and Medicaid) a stay at the facility . 63 O.S. S 1-1956.2 of the [NAME] E. [NAME] Act (a section of the Nursing Home Care Act) amended and renumbered from 63 O.S. S 1-1953.2 by Laws in 2020 read in part, B. A nursing facility, assisted living center or continuum of care facility shall not refuse to admit an individual to residency in the facility or center and shall not remove a resident from a facility or center because of authorized electronic monitoring of a resident's room. Res #2 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's, dementia, cerebral infarction, stage three chronic kidney disease, [NAME] depressive disorder, and hypertension. The Notice of Involuntary Discharge of Resident for Res #2, dated 10/03/24, documented the reason for discharge was misuse of surveillance camera violating all residents' rights in the facility, and not being able to meet the resident's needs as documented by the attending physician. A nursing note, dated 10/14/24 at 10:26 a.m. documented Res #2's was transferred to another facility by their family. On 11/01/24 at 10:17 a.m. a family member of Res #2's reported the resident did have video surveillance with audio in their room, and did not have a roommate when they were served with a 30 day discharge notice. On 11/01/24 at 5:00 p.m., the DON reported the facility was able to meet the resident's needs, but the family was never satisfied with the care the resident received. The DON reported Res #2 did have video with audio surveillance in their room and the facility was concerned with the audio surveillance picking up conversations residents and staff members had in the halls. The DON reported they were not aware of the requirement regarding video surveillance and the discharge of a resident.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#2) of three sampled residents reviewed for abuse. The Administrator identified 101 residents resided in the facility. Findings: The Abuse Prevention Program policy, revised 12/16, read in part, Our residents have the right to be free from abuse .Protect our residents from abuse by anyone including .other residents. The Abuse and Neglect Clinical protocol policy, revised 03/18, read in part, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Resident #2 had diagnoses which included autistic disorder, hemiplegia and hemiparesis. Resident #2's annual resident assessment, dated 08/15/24, documented Resident #2 had severe cognitive impairment. A Combined Initial and Final State Reportable Incident form, dated 08/19/24, documented an allegation of abuse/mistreatment. It documented Resident #1 put their arm around Resident #2. Resident #2 had no apparent injuries. A Combined Initial and Final State Reportable Incident form, dated 08/19/24, documented all staff to be in-serviced on de-escalation of behavior technique and redirection. Dietary Aide #1's witness statement, dated 08/19/24, documented Resident #1 followed Resident #2 after dining services yelling at them. The witness statement documented Resident #1 put Resident #2 in a choke hold. Dietary Aide #2's witness statement, dated 08/19/24, documented Resident #1 was yelling and staring at Resident #2 during meal service for making noises. It documented Resident #1 stalked Resident #2 out of the dining room. The statement documented Resident #1 grabbed Resident #2 from behind by the neck and put them in a chokehold. Dietary Aide #3's witness statement, dated 08/19/24, documented Resident #1 was steadily staring and hollering at Resident #2 during meal service because of the noises Resident #2 was making while eating. The statement documented Resident #1 chased Resident #2 out of the dining room. It documented Resident #1 grabbed Resident #2 in a chokehold. An in-service, dated 08/19/24, documented resident to resident behaviors and de-escalation. It did not contain all staff signatures. On 08/22/24 at 11:07 a.m., CMA #1 stated they had not received an in-service on resident to resident behaviors and de-escalation. On 08/22/24 at 11:11 a.m., LPN #2 stated they had not received an in-service on resident to resident behaviors and de-escalation. On 08/22/24 at 11:13 a.m., LPN #1 stated they had not received an in-service on resident to resident behaviors and de-escalation. On 08/22/24 at 11:20 a.m., the Infection Preventionist stated they were responsible for conducting in-services. They stated all staff have not been in-serviced on resident to resident behaviors and de-escalation.

Based on record review and interview, the facility failed to provide a written summary/findings of a grievance investigation for a resident/resident representative for one (#1) of one sampled residents whose grievances were reviewed. The administrator identified 99 people who residedd in the facility Findings: The Filing Grievances/complaints procedure which is posted on a bullentin board in the common area by the nursing station, read in part, The resident, or person filing the grievance and/or compliant on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems .A written summary of the report will also be provided to the resident The Grievances/Complaints, Filing policy, revised April 2017, read in part, .The resident, or person filing the grievances and/or complaint on behalf of the resident, will be informed verbally and in writing of the findings of the investigation and the actions that will be taken to correct any identified problems . A Grievance/Complaint Report was completed for Res #1 on 05/30/24 in response to Res #1's POA filing a grievance. The documented resolution of grievance/complaint was a phone conversation with Res #1's POA. No written summary of the investigation with any corrective action taken was provided to Res #1's POA. A Grievance/Complaint Report was completed for Res #1 on 06/18/24 in response to Res #1's POA filing a grievance. The documented resolution of grievance/complaint was One-to-one discussion. No written summary of the investigaion with any corrective action taken was provided to Res #1's POA. On 07/10/24 at 2:05 p.m., Res #1's POA reported they had not received a written response to any grievance they have filed on behalf of Res #1. On 07/10/24 at 3:30 p.m., the administrator reported they did not provide a written summary of a grievance invstigation to Res #1's POA. The administrator reported they verbally followed up with Res #1's POA and felt that was an appropriate response.

Based on record review and interview, the facility failed to report an allegation of abuse to OSDH for one (#3) of one sampled resident whose record was reviewed for abuse. The administrator identified 99 residents who resided in the facility. Findings: The Abuse Policy, undated, read in parts, All suspected abuse will be investigated and reported to the appropriate agencies. The Abuse Investigation and Reporting policy, revised July 2017, read in part, All alleged violations involving abuse .will be reported by the facility Administrator .to the State licensing/certification agency responsible for surveying/licensing the facility . On 04/12/24 an in-service was conducted on the facility's Abuse Policy for all facility staff. On 07/10/24 at 3:34 p.m. CNA #1 reported they heard a rumor about some inappropriate behavior between CNA #2 and Res #3. CNA #1 reported the incident occurred in April and had to do with CNA #1's breasts and Res #3, but did not provide any details. On 07/10/24 at 3:50 p.m., CNA #3 reported hearing the aides talk about a situation of inappropriate behavior involving CNA #2 and Res #3. CNA #3 reported they immediately reported the rumor to the administrator and the DON sometime in April. CNA #3 reported the incident was concerning Res #3 and CNA #2's breasts but did not provide any details. On 07/10/24 at 4:05 p.m., the DON reported the rumor regarding CNA #2 and Res #3 was brought to the attention of administration sometime in April. The DON reported the administrator looked into the situation at that time. On 07/10/24 at 4:30 p.m., the administrator reported a situation of inappropriate behavior involving CNA #2 their breasts and Res #3 was reported to them in April. The administrator reported they looked into the situation by questioning Res #3, CNA #2 and other employees and residents to determine if the situation was a rumor or an allegation. The administrator reported they did not turn in a report to OSDH because they weren't sure the situation was a true allegation of abuse versus just a rumor. The administrator reported they didn't feel their attempt to determine whether or not the inappropriate behavior was an allegation versus a rumor was a true investigation. The administrator reported they did in-service all facility staff on their abuse policy at the time the inappropriate behavior was reported to them.

Based on record review and interview, the facility failed to investigate an allegation of abuse for one (#3) of one sampled resident whose record was reviewed for abuse. The administrator identified 99 residents who resided in the facility. Findings: The Abuse Policy, undated, read in parts, All suspected abuse will be investigated and reported to the appropriate agencies. The Abuse Investigation and Reporting policy, revised July 2017, read in part, All reports of resident abuse .shall be promptly reported .and thoroughly investigated by facility management . The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, read in part, Identify and investigate all possible incidents of abuse . On 04/12/24 an in-service was conducted on the facility's Abuse Policy for all facility staff. There was no documented investigation regarding Res #3 and CNA #2. On 07/10/24 at 3:34 p.m. CNA #1 reported they heard a rumor about some inappropriate behavior between CNA #2 and Res #3. CNA #1 reported the incident occurred in April and had to do with CNA #1's breasts and Res #3, but did not provide any details. On 07/10/24 at 3:50 p.m., CNA #3 reported hearing the aides talk about a situation of inappropriate behavior involving CNA #2 and Res #3. CNA #3 reported they immediately reported the rumor to the administrator and the DON sometime in April. CNA #3 reported the incident was concerning Res #3 and CNA #2's breasts but did not provide any details. On 07/10/24 at 4:05 p.m., the DON reported the rumor regarding CNA #2 and Res #3 was brought to the attention of administration sometime in April. The DON reported the administrator looked into the situation of inappropriate behavior at that time. On 07/10/24 at 4:30 p.m., the administrator reported a situation of inappropriate behavior involving CNA #2 their breasts and Res #3 was reported to them in April. The administrator reported they looked into the situation by questioning Res #3, CNA #2 and other employees and residents to determine if the situation was a rumor or an allegation. The administrator reported they did not turn in a report to OSDH because they weren't sure the situation was a true allegation of abuse versus just a rumor. The administrator reported they didn't feel their attempt to determine whether or not the inappropriate behavior was an allegation versus a rumor was a true investigation. The administrator reported they did in-service all facility staff on their abuse policy at the time the inappropriate behavior was reported to them. The administrator reported they did not have any documentation regarding the situation of inappropriate behavior between Res #3 and CNA #2.

Based on record review and interview, the facility failed to ensure care plans were updated with physician's orders for one (#1) of six sampled residents whose physician's orders were reviewed. The administrator identified 99 residents who resided in the facility. Findings: Res #1 had diagnoses which included dementia and stage 3 chronic kidney disease. A physician's progress note from Urologic Specialist, faxed to the facility on [DATE], documented an order for the facility to ensure the resident is drinking water, No coke/tea. Res #1's care plan was not revised with the physician's order from Urologic Specialist On 07/11/24 at 11:05, the DON reported Res #1's care plan was noted updated with the order from Urologic Specialist. The DON was not sure why the order was overlooked.

Based on observation, interview, and record review, it was determined the facility failed to consult and/or notify residents' physicians and/or interested family members of changes in resident care and/or conditions for two (#12 and #13) of 21 sampled residents reviewed for physician notification. The facility failed to: a. notify the physician of a worsening pressure ulcer for resident #13. The facility identified nine residents with pressure ulcers. b. notify the physician regarding refusal of insulin, the refusal of capillary blood glucose (CBG) finger sticks, and refusal of meals for resident #12. The facility identified 21 residents who received CBGs. A hospital history and physical documented the resident was admitted to the hospital with [REDACTED]. Findings: The notification of changes policy provided by the facility documented the facility would immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly. 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 12/04/13, documented the resident understood others and was understood by others. The assessment documented the resident was intact with cognition skills for daily decision making. The assessment documented the resident had a poor appetite. The assessment documented the resident required assistance with all activities of daily living. The assessment documented the resident was at risk of developing a pressure ulcer. A care plan, dated 01/02/14, documented the resident was on bedrest for a [MEDICAL CONDITION]. The care plan documented the staff was to monitor/document/report as needed any changes or declines in function. The care plan documented the resident required skin inspection with each care episode or at least every shift. The care plan documented the staff was to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. The care plan documented to discuss with the resident/family/power of attorney any care concerns related to loss of independence or decline in function. A fax to the physician, dated 01/21/14, documented the resident had a facility acquired stage II pressure ulcer to the left buttocks. A nurse progress note, dated 01/21/14, documented a stage II to the left buttocks was found. The progress note documented the area measured 1.5 x 1 x 0.1. The progress note documented the stage II had no odor and had minimal serous-sanguineous drainage. The note documented the wound bed was 100% pink granulated tissue and the peri-wound was pink and blanchable. The progress note documented a treatment order was received for the stage II. A comprehensive assessment, dated 01/23/14, documented the resident understood others and was understood by others. The assessment documented the resident was moderately impaired with cognition skills for daily decision making. The assessment documented the resident had a poor appetite. The assessment documented the resident required assistance with all activities of daily living. The assessment documented the resident had one stage II pressure ulcer that was worsening. A nurse progress note, dated 01/28/14, documented the resident's wound to the left buttocks was unstageable measuring 4.5 x 2.9. The note documented the depth was unable to be determined. The note documented there was a moderate amount of serous-sanguineous drainage with no odor. The note documented a new treatment order was obtained. The note documented an order for [REDACTED]. A physician's orders [REDACTED]. The medical record was reviewed for documentation the physician had been notified the stage II had worsened from 01/21/14 to 01/28/14. There was no documentation the physician had been notified the stage II had deteriorated in the seven day period. There was no documentation the physician had been notified of the condition of the resident's skin from 01/28/14 to 02/10/14. On 02/10/14 at 2:50 p.m., the resident was observed in her room. The resident was observed in her bed on an air mattress. The resident was asked if she had any problems with her skin. The resident reported she did have a "sore" on her bottom. The resident was asked if the surveyor could observe the treatment when provided by the facility. The resident stated it was personal and she preferred no one observe the treatment. A nurse progress note, dated 02/11/14, documented the resident's daughter was notified and informed of the resident's weight loss and general condition. There was no documentation the family had been notified of the resident's weight loss or skin condition prior to 02/11/14. A nurse progress note, dated 02/11/14 at 12:48 p.m., documented the resident had an unstageable area to the coccyx that measured 6.3 x 3.7 with the depth unable to be determined. The note documented there was a strong odor noted with a moderate amount of purulent drainage. The note documented the wound bed was 75% necrotic tissue and 25% red beefy tissue. The note documented the peri-wound was reddened. A telephone order, dated 02/11/14 at 3:50 p.m., documented the resident was admitted to the services of physician #2. A history and physical from name deleted hospital, dated 02/11/14, documented the resident was admitted to the hospital with [REDACTED]. On 02/11/14 at 3:55 p.m., the director of nursing (DON) was interviewed regarding assessment of the resident's pressure ulcer. The DON reported the facility had aggressively been monitoring the area. The DON reported the resident had been started on house supplements. The DON reported the facility had been working aggressively for three weeks. The DON reported the resident was receiving [MEDICATION NAME]. The DON reported weekly skin assessments were completed by the nurse. On 02/12/14 at 2:55 p.m., the DON was asked if the pressure ulcer was unstageable when it was found. The DON stated, "No." The DON reported the resident was ambulatory until she developed a [MEDICAL CONDITION]. On 02/14/14 at 9:00 a.m., the director of DON was interviewed regarding skin assessments. The DON reported the assessments were completed weekly but were not scheduled on the same day each week. The DON reported the charge nurses on each hall were assigned a list of residents to assess weekly. On 02/14/14 at 10:30 a.m., an interview was conducted with physician #1. The physician was asked if the facility had notified him of the deterioration of the pressure ulcer from a stage II to an unstageable pressure ulcer during the seven day period. The physician reported the facility had contacted him daily about the resident's [MEDICAL CONDITION]. The physician reported the resident had changed doctors and the facility had probably called the other doctor. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A significant change assessment, dated 10/04/13, documented the resident's cognition was intact. The assessment documented the resident was on a therapeutic diet. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The resident's medical records, dated 11/18/13 to 02/14/14, contained documentation the resident refused physician ordered insulin 25 times. The resident's medical record contained documentation the resident refused physician ordered CBGs 17 times. The resident's medical record contained documentation "Refused" ten times on orders administration notes. The resident's medical record contained documentation the resident either refused a meal or ate a small amount of her meal eleven times when she refused to take insulin. A quarterly assessment, dated 12/30/13, documented the resident's cognition was intact. The assessment documented the resident was on a therapeutic diet. The care plan, updated on 2/12/14, documented the resident had a [DIAGNOSES REDACTED]. Interventions on the care plan documented diabetes medication as ordered by doctor. The care plan documented to educate the resident that compliance was essential to prevent complications of the disease. The care plan documented staff was to obtain fasting serum blood sugar as ordered by the physician. The care plan documented to identify areas of non-compliance or other difficulties in the resident's diabetic management; monitor/document/report, as needed, compliance with diet; and document any problems. The care plan documented staff was to notify the resident's medical doctor as needed for non compliance, refusing insulin, meals, etc. On 02/11/14 at 12:05 p.m., the resident was observed sitting in the dining room in her electric wheelchair. On 02/14/14 at 9:10 a.m., the director of nursing was asked for documentation of notification of the physician regarding the resident's refusal of insulin and CBGs. The DON reported documentation was inconsistent. On 2/15/14 at 3:15 p.m., the director of nursing was interviewed regarding notification of the physician regarding the resident's refusal of insulin and CBGs. The DON reported notification of the physician was not documented.

Based on observation, interview, and record review, it was determined the facility failed to provide care to prevent the development and/or promote healing of pressure ulcers for three (#2, #4, and #13) of seven residents sampled for pressure ulcers. The facility failed to consistently and thoroughly assess, monitor, track, and document wound progression/deterioration for pressure ulcers. Resident #13 experienced pressure ulcer deterioration and a required hospitalization . A hospital admission history and physical documented the resident had a stage IV sacral decubitus that was infected. Resident #2 developed a pressure ulcer that was unstageable at the time it was identified by the facility. Resident #4 developed a pressure ulcer that was a stage II and draining at the time it was identified by the facility. The facility identified nine residents with a pressure ulcer. Findings: 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 12/04/13, documented the resident understood others and was understood by others. The assessment documented the resident was intact with cognition skills for daily decision making. The assessment documented the resident had a poor appetite. The assessment documented the resident required assistance with all activities of daily living. The assessment documented the resident was at risk of developing a pressure ulcer. A care plan, dated 01/02/14, documented the resident was on bedrest for a [MEDICAL CONDITION]. The care plan documented the staff was to monitor/document/report, as needed, any changes or declines in function. The care plan documented the resident required skin inspection with each care episode or at least every shift. The care plan documented the staff was to observe for redness, open areas, scratches, cuts, and bruises and report changes to the nurse. The care plan documented to discuss with resident/family/POA any concerns related to loss of independence or decline in function. The care plan had not been updated to reflect the resident's current skin condition. A skilled charting nurse note, dated 01/18/14, documented there were no new changes to the skin integrity noted. A fax to the physician, dated 01/21/14, documented the resident had a facility acquired stage II pressure ulcer to the left buttocks. A nurse progress note, dated 01/21/14, documented a stage II to the left buttocks was found. The progress note documented the area measured 1.5 x 1 x 0.1. The progress note documented the stage II had no odor and had minimal serous-sanguineous drainage. The note documented the wound bed was 100% pink granulated tissue and the peri-wound was pink and blanchable. The progress note documented a treatment order was received for the stage II. A comprehensive assessment, dated 01/23/14, documented the resident understood others and was understood by others. The assessment documented the resident was moderately impaired with cognition skills for daily decision making. The assessment documented the resident had a poor appetite. The assessment documented the resident required assistance with all activities of daily living. The assessment documented the resident had one stage II pressure ulcer that was worsening. A nurse progress note, dated 01/28/14, documented the resident's wound to the left buttocks was unstageable measuring 4.5 x 2.9. The note documented the depth was unable to be determined. The note documented there was a moderate amount of serous-sanguineous drainage with no odor. The note documented a new treatment order was obtained. The note documented an order for [REDACTED]. A physician's orders [REDACTED]. The medical record was reviewed for documentation the physician had been notified the stage II had worsened from 01/21/14 to 01/28/14. There was no documentation the physician had been notified the stage II had deteriorated in the seven day period. There was no documentation the physician had been notified of the condition of the resident's skin from 01/28/14 to 02/10/14. On 02/10/14 at 2:50 p.m., the resident was observed in her room. The resident was observed on her bed on an air mattress. The resident was asked if she had any problems with her skin. The resident reported she did have a "sore" on her bottom. The resident was asked if the surveyor could observe the treatment when provided by the facility. The resident stated it was personal and she preferred no one observe the treatment. A nurse progress note, dated 02/11/14 at 12:48 p.m., documented the resident had an unstageable area to the coccyx that measured 6.3 x 3.7 with the depth unable to be determined. The note documented there was a strong odor noted with a moderate amount of purulent drainage. The note documented the wound bed was 75% necrotic tissue and 25% red beefy tissue. The note documented the peri-wound was reddened. A telephone order, dated 02/11/14 at 3:50 p.m., documented the resident was admitted to the services of physician #2. A hospital history and physical, dated 02/11/14, documented the resident was admitted to the hospital with [REDACTED]. On 02/11/14 at 3:55 p.m., the DON was interviewed regarding assessment of the resident's pressure ulcer. The DON reported the facility had aggressively been monitoring the area. The DON reported the resident had been started on house supplements. The DON reported the facility had been working aggressively for three weeks. The DON reported the resident received [MEDICATION NAME]. The DON reported weekly skin assessments were completed by different charge nurses. On 02/12/14 at 2:55 p.m., the director of nursing (DON) was asked if the pressure ulcer was unstageable when it was found. The DON stated, "No." The DON reported the resident was ambulatory until she developed a [MEDICAL CONDITION]. On 02/14/14 at 9:00 a.m., the DON was interviewed regarding skin assessments. The DON reported the assessments were completed weekly but were not scheduled on the same day each week. The DON reported it depended on the nurse schedule what day the skin assessments were completed. The DON reported the skin assessments could be on different days because of the schedule. The DON reported it could be seven to nine days between skin assessments because of the nurses' schedules. The DON reported the charge nurses on each hall were assigned a list of residents to assess weekly. On 02/14/14 at 10:30 a.m., an interview was conducted with physician #1. The physician was asked if the facility had notified him of the deterioration of the pressure ulcer from a stage II to an unstageable pressure ulcer during the seven day period. The physician reported the facility had contacted him daily about the resident's [MEDICAL CONDITION]. The physician reported the resident had changed doctors and the facility had probably called the other doctor related to the pressure ulcer. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse note, dated 05/14/13 (7 - 3 shift), documented a new order to apply foam to the right coccyx and secure with tape every day and as needed. A treatment sheet, dated May 2013, documented to apply foam to the right coccyx and secure with tape every day and as needed, beginning 05/14/13. The treatment sheet, dated May 2013, documented the treatment was changed on 05/29/13. The order documented to cleanse the right coccyx with normal saline; apply [MEDICATION NAME] Ointment, hydrogel gauze, and foam; and secure with tape every day. A dietary progress note, dated 05/17/13, documented the resident had an unstageable wound to the coccyx. A significant change assessment, dated 06/24/13, documented the resident had long term and short term memory problems and required total assistance from staff for all activity of daily living needs. The assessment documented the resident had a facility acquired unstageable pressure ulcer. The care plan, dated 09/25/13 and updated on 12/29/13, documented the resident required total assistance with all aspects of care due to advanced dementia. The care plan documented the resident had a chronic pressure ulcer on the right side of the coccyx, with risk for complications due to nutritional status, mobility deficits, and incontinence. The care plan documented to follow the facility policies/protocols for the prevention/treatment of [REDACTED]. A quarterly assessment, dated 12/02/13, documented the resident had long term and short term memory problems and required total assistance from staff for all activity of daily living needs. The assessment documented the resident had a facility acquired stage IV pressure ulcer. On 02/11/14 at 11:20 a.m., the resident was observed during pressure ulcer treatment. Licensed practical nurse (LPN) #1 was observed to measure the pressure ulcer. The pressure ulcer measured 1.2 x .8 and .5 depth. On 02/11/14 at 3:10 p.m., the director of nursing (DON) was requested to provide documentation of weekly skin assessments prior to the new order regarding the unstageable pressure ulcer on 05/14/13. On 02/12/14 at 2:15 p.m., the DON was interviewed. The DON reported there was documentation missing and she would look for the documentation. On 02/13/14 at 3:35 p.m., the DON was interviewed. The DON reported she had brought all the skin assessments the facility had for the resident. The DON provided a weekly skin audit, dated 02/09/13, which documented the resident's skin was intact. The facility did not provide any other documentation of skin audits after 02/09/13 and prior to 05/14/13 that documented the resident's skin was intact. The DON reported having problems with the change over to the computer. The DON reported a staff had cleaned out papers and may have gotten rid of the skin assessments. The DON reported she could not find any more skin assessments for the resident prior to 05/14/13. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 07/11/13, documented the resident was severely impaired with skills for daily decision making ability. The assessment documented the resident had long and short term memory problems. The assessment documented the resident required extensive to total assistance for all activities of daily living. The assessment documented the resident was frequently incontinent of bladder and of bowel. The assessment documented the resident was totally dependent on staff for toileting. The assessment documented the resident had no impairment of upper or lower extremities. The care plan, dated 07/24/13, documented the resident required skin inspection with each personal care. The care plan documented for staff to observe for redness, open areas, scratches, and report any changes to the nurse. A quarterly assessment, dated 10/07/13, documented the resident was severely impaired with skills for daily decision making ability. The assessment documented the resident had long and short term memory problems. The assessment documented the resident required extensive assistance for all activities of daily living. The assessment documented the resident was frequently incontinent of bladder and bowel. The assessment documented the resident was totally dependent on staff for toileting. The assessment documented the resident had no impairment of upper or lower extremities. On 02/11/14 at 5:00 p.m., the resident was observed receiving wound care provided by LPN #1. The resident was positioned on her right side. The resident's left buttock was observed with an open area and drainage was observed down the entire length of the left buttock. The open area was observed inflamed and the surrounding tissue was observed excoriated. LPN #1 stated the facility had called the physician that morning for orders to treat the wound. The LPN stated the resident had a Stage III pressure ulcer in the same area recently but it had resolved. The LPN was asked how the facility assessed residents' skin to prevent pressure ulcers from occurring. The LPN stated charge nurses on different shifts were responsible for assessing residents' skin. The LPN was asked how the resident received an inflamed Stage II pressure ulcer before treatments and interventions were initiated. The LPN stated the resident was missed and someone should have observed the resident's pressure area before "today." The resident was observed on a regular mattress. An unidentified nurse-aide stated the resident had never been on an air or speciality mattress. On 02/14/14 at 9:10 a.m., the director of nurses (DON) was interviewed regarding skin assessments on the residents identified at high risk of development or a history or development of recurring pressure ulcers to prevent pressure ulcers. The DON stated charge nurses were suppose to do skin assessments on different shifts. The DON stated she could not find any consistent documentation on skin assessments. The resident's skin assessments in the electronic medical record documented, "No records."

Based on record review, observation and interview, it was determined the facility failed to ensure the physician was notified of changes of condition for 2 (#1 and #5) of 7 sampled residents. The changes of condition were in regard to: a. 1 (#1) of 6 sampled residents whose clinical records were reviewed for dehydration. The facility had failed to notify the resident's physician regarding her decline in her ability to take fluids. The resident was taken to the hospital in a state of extreme dehydration and expired due to acute [MEDICAL CONDITION] secondary to dehydration. The facility's Roster/Sample matrix documented no residents had experienced dehydration. b. 2 (#1 and #5) of 6 sampled residents whose clinical records were reviewed for significant weight loss. The facility had failed to notify the resident #1's physician in regard to the resident's unplanned weight loss of 9.37% in less than 2 weeks and of her decline in her ability to take nourishment. The facility had failed to notify the physician of resident #5 regarding his desire to lose weight and of his significant weight loss of 8.2% in 3 months. The facility's Roster/Sample Matrix identified a total of 2 residents had experienced significant weight loss. c. 1 (#1) of 1 sampled residents whose systolic blood pressure readings were below the parameters set by the physician to hold antihypertensive medication. The low systolic blood pressure readings occurred 6 times before the physician was notified. d. 1 (#1) of 1 sampled residents who frequently refused physician-ordered medications. Ninety-two residents resided in the facility. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. The annual assessment, dated [DATE], documented the resident had severe cognitive impairment; was dependent upon staff for all activities of daily living; did not ambulate; was incontinent of bowel and bladder; and had not experienced significant weight loss during the 1 month and/or 6 months prior to the assessment. a. A "Hydration Risk Evaluation," dated [DATE], documented the resident's score was 16. A score of 8 or higher indicated the resident might be at risk for dehydration. The back of the evaluation, which documented whether the resident was/was not at risk for dehydration, whether interventions had been initiated/modified, whether physician's orders [REDACTED]. The care plan, dated [DATE], for resident #1, documented she had a problem related to "potential for dehydration and fluid/electrolyte imbalance (related to) advanced dementia (with) poor intake, dysphagia, recurrent (urinary tract infections)." The goal for the problem was "(resident) will show no signs of dehydration through next review date." Approaches included: "...intake and output as ordered...administer medications as per orders, monitoring for effectiveness and side effects, report to (doctor as needed)." The activities of daily living (ADL) flowsheet, dated ,[DATE], included a section where "Fluids Offered" were to be documented. The instructions were to "indicate the number of times fluids were offered and (milliliters) consumed." The documentation on the "Fluids Offered" from [DATE] through [DATE] was as follows: ,[DATE] shift - Fluids had been offered ,[DATE] times on 11 of 21 days. No fluids had been offered during the shift on 10 days. The number of milliliters taken by the resident during the shift each day was not documented. ,[DATE] shift - Fluids had been offered ,[DATE] times on 13 of 21 days. No fluids had been offered during the shift on 8 days. The number of milliliters taken by the resident during the shift each day was not documented. ,[DATE] shift - One hundred twenty milliliters was documented as consumed by the resident on 13 of 21 shifts. No fluids were consumed by the resident on 8 shifts. The facility's "Recording Percentage of Meals Consumed" policy and procedure documented: "..Meal Intake Sheet should be used to document percentage eaten each meal and (milliliters) of fluids consumed..." The meal intake sheet, dated ,[DATE], did not document any fluids had been consumed by the resident during any of 3 meals per day for the 21 days in August the resident was present in the facility. There was no documentation in the clinical record to indicate the resident's physician had been contacted regarding her decreased fluid intake. b. The care plan, dated [DATE], documented the resident had a problem related to nutrition and the "potential for (and starting to show significant) unplanned weight loss related to: dementia, poor intake, [MEDICAL CONDITION], diabetes-- power of attorney does not want to pursue hospice or feeding tube." The goal was as follows: "Weight loss will stabilize by next review date." Approaches included: "...Weigh as ordered and (as needed), notify physician...of any significant changes...nutritional supplement as ordered..." The "Weekly Weight Notes" for resident #1, written by minimum data set coordinator #1, documented the following: Week of [DATE] - 128 pounds. [DATE] - 116 pounds. "Shows weight loss of 12 (pounds). (Continue weekly) weights." [DATE] - 115 pounds. "(Down) 1 (pound). - (Continue weekly) weights. The 12 pound weight loss from the week of [DATE] to [DATE] represented a 9.37% severe weight loss in 1 week. There was no documentation in the clinical record to indicate the physician had been notified of the severe weight loss. The 13 pound weight loss from the week of [DATE] to [DATE] represented a 10.15% severe weight loss in 2 weeks. There was no documentation in the clinical record to indicate the physician had been notified of the severe weight loss. The facility's "Recording Percentage of Meals Consumed" policy and procedure documented: "Policy Nursing personnel are to observe and record the food consumption of each resident. Procedure 1. Nursing personnel shall be aware of the nutritional need of all or identified high risk residents and should daily record food intake. a. Meal Intake Sheet should be used to document percentage eaten each meal and (milliliters) of fluids consumed...d. Intake of 50% or less is poor and less than necessary requirements. Report to Dietary after 3 days. Refusal to eat, report immediately. e. Be sure to offer a substitute if 50% or less is eaten. Offer the alternate and if that is refused, offer a house supplement." The facility's "Feeding the Impaired Resident" policy/procedure documented: "...Alternate foods, readily available foods, or supplements, should be offered, consistent with the diet order, if the resident consumes less than half of the meal..." The "Food/Nourishment Intake Sheet," dated ,[DATE], documented the following for the dates of [DATE] through [DATE]: Breakfast - The resident had eaten 25% for 9 meals, 50% for 6 meals, 0% for 2 meals and 3 meals were blank. Lunch - The resident had eaten 25% for 6 meals, 50% for 7 meals and 75% for 4 meals. She had refused 2 meals and 2 meals were blank. Supper - The resident had eaten 25% for 3 meals, 50% for 3 meals, 75% for 2 meals, 100% for 3 meals, 0% for 3 meals and 6 meals were blank. There was no documentation on the "Food/Nourishment Intake Sheet" to indicate the resident was offered an alternate menu item or a meal replacement when she ate 50% or less of her diet for any meal during the month. There was no documentation on the "Food/Nourishment Intake Sheet" or anywhere else in the clinical record to indicate the resident was ever given a healthshake with her meal. There was no documentation in the clinical record to indicate the physician had been notified the resident had declined in her ability to eat. c. The care plan, dated [DATE], documented the resident had a problem related to hypertension. Approaches included to administer medications as ordered. The physician's orders [REDACTED]. The [MEDICATION NAME] was to be held if the resident's pulse was less than 60 or her systolic blood pressure was less than 100. Skilled nurses' notes documented the following blood pressures: [DATE] - night shift - ,[DATE] [DATE] - night shift - ,[DATE] [DATE] - evening shift - ,[DATE] [DATE] - evening shift - ,[DATE] [DATE] - day shift - ,[DATE] [DATE] - day shift - ,[DATE]. There was no documentation in the clinical record to indicate the physician had been notified of the resident's low blood pressure readings. d. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].): 1. [MEDICATION NAME] 5mg at 9 a.m. was refused 3 of 7 doses. 2. K-Dur 20meq at 8 a.m. was refused 2 of 7 doses. 3. [MEDICATION NAME] 20mg at 9 a.m. was refused 2 of 7 doses. 4. Xarelto 10mg at 8 a.m. was refused 2 of 6 doses. The MAR indicated [REDACTED] 5. [MEDICATION NAME] 15mg at 9 p.m. was refused for 7 of 7 doses. The MAR indicated [REDACTED] 6. [MEDICATION NAME] 40mg at 9 p.m. was refused for 8 of 8 doses. 7. [MEDICATION NAME] 325 (65)mg at 5:30 p.m. was refused 5 of 8 doses. 8. [MEDICATION NAME] 25mg at 8 a.m. was refused 3 of 7 doses. 9. [MEDICATION NAME] 25mg at 5:30 p.m. was refused 4 of 7 doses. The MAR indicated [REDACTED] There was no documentation in the clinical record to indicate the physician had been notified about the resident's frequent medication refusals in ,[DATE]. The MAR, dated ,[DATE], documented the resident refused medications as follows: 1. [MEDICATION NAME] 5mg at 9 a.m. was refused 4 of 21 doses. 2. K-Dur 20meq at 9 a.m. was refused 6 of 21 doses. 3. [MEDICATION NAME] 20mg at 9 a.m. was refused 5 of 21 doses. 4. Xarelto 10mg at 9 a.m. was refused 4 of 21 doses. The MAR indicated [REDACTED] 5. [MEDICATION NAME] 15mg at 9 p.m. was refused for 12 of 21 doses. 6. [MEDICATION NAME] 40mg at 9 p.m. was refused 12 of 21 doses. 7. [MEDICATION NAME] 325 (65)mg at 5:30 p.m. was refused 11 of 21 doses. 8. [MEDICATION NAME] 25mg at 9 a.m. was refused 7 of 21 doses. 9. [MEDICATION NAME] 25mg at 6 p.m. was refused 13 of 21 doses. There was no documentation in the clinical record to indicate the physician had been notified about the resident's frequent medication refusals in ,[DATE]. On [DATE] at 11:30 p.m., the surveyor asked licensed practical nurse #1 if resident #1 had been offered fluids routinely by staff. He stated the resident had been refusing food, fluids and medications. On [DATE] at 3:00 p.m., the surveyor reviewed the above findings with the director of nurses (DON) and asked if the resident's physician had been notified regarding the resident's low blood pressures and/or about her frequent refusal of medications. She reviewed the clinical record and stated, "I don't see anything where he was faxed." The DON stated the physician should have been notified regarding the resident's frequent medication refusals. On [DATE] at 4:40 p.m., the surveyor reviewed the above findings with the director of nurses (DON) and asked if the facility had notified the resident's physician regarding her severe weight loss and that she had declined in her ability to take food/fluids since [DATE]. The DON acknowledged the resident's physician had not been notified of the severe weight loss on [DATE] and should have been notified. The surveyor asked if the physician had been notified regarding the resident's decline in her ability to consume food and fluids. She stated there was no documentation in the clinical record to indicate the physician was aware the resident had not been eating or drinking. On [DATE] at 5:32 p.m., in a telephone interview, the surveyor asked the resident's physician if the facility had notified him regarding the resident's decline in her ability to take hydration/nutrition, the resident's blood pressure readings which were below the parameters set by the physician, and/or the resident's frequent medication refusals. The physician stated the facility had not notified him about any of the above changes of condition. The physician stated, "I was never told (the resident) wasn't eating or drinking. He stated he understood the resident was receiving the health shakes and was unaware the resident had experienced the significant weight loss in ,[DATE]. The physician stated he would have changed the resident's course of treatment had he known of the above changes in her condition. 2. Resident #5 had [DIAGNOSES REDACTED]. The facility's "Resident Weights" sheets documented the resident's weights were as follows: [DATE] - 245 pounds (admitted ) [DATE] - 233.4 pounds [DATE] - 227.2 pounds [DATE] - 224.8 pounds (an 8.2% significant weight loss in 3 months). A "Weekly Weight Note," dated [DATE], documented the resident had lost 8 pounds. The note documented the resident stated he was "trying to lose some weight." The care plan, dated [DATE], did not address the resident's desire to lose weight and/or his significant weight loss of 8.2% in the 3 months from [DATE] to [DATE]. The nutritional "Quarterly Review/Risk Assessment," dated [DATE], completed by the dietary manager, documented the resident had lost 8.2% in 3 months. A note, dated [DATE], written on the assessment by the consultant dietician, documented the resident had a significant 3 month weight loss. The note documented the resident was "trying to lose some (weight)." The quarterly assessment, dated [DATE], documented the resident had severe cognitive impairment; required supervision to perform activities of daily living; and had not experienced significant weight loss during the previous 1 month and/or 6 months. On [DATE] at 11:10 a.m., the resident stated he got "plenty" to eat and that he was trying to lose weight. He stated he was given "plenty" of fluids to drink. On [DATE] at 11:15 a.m., the surveyor asked the DON if the facility had notified the resident's physician of the resident's desire to lose weight and/or of his significant weight loss of 8.2% in the 3 months from [DATE] to [DATE]. She reviewed the clinical record and stated, "I don't see anything."

Based on record review and interview, it was determined the facility failed to prevent severe weight loss for 1 (#1) of 6 sampled residents whose clinical records were reviewed for weight loss. The facility failed to ensure: a. the resident's physician was notified of a severe weight loss of 9.37% in 1 week and of her decline in ability to eat. b. the resident's meal intake was monitored/recorded. c. the resident was served a healthshake with meals per consultant dietician's recommendation and the physician's orders [REDACTED]. The facility's Roster/Sample Matrix identified a total of 2 residents had experienced significant weight loss. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. The annual assessment, dated 07/31/12, documented the resident had severe cognitive impairment; was dependent upon staff for all activities of daily living; did not ambulate; was incontinent of bowel and bladder; and had not experienced significant weight loss during the 1 month and/or 6 months prior to the assessment. The care plan documented the resident had a problem related to nutrition and the "potential for (and starting to show significant) unplanned weight loss related to: dementia, poor intake, [MEDICAL CONDITION], diabetes -- power of attorney does not want to pursue hospice or feeding tube." The goal was as follows: "Weight loss will stabilize by next review date." Approaches included: "...Weigh as ordered and (as needed), notify physician...of any significant changes...nutritional supplement as ordered..." The "Weekly Weight Notes" for resident #1, written by minimum data set coordinator #1, documented the following: Week of 07/31/12 - 128 pounds. 08/07/12 - 116 pounds. "Shows weight loss of 12 (pounds). (Continue weekly) weights." 08/14/12 - 115 pounds. "(Down) 1 (pound). - (Continue weekly) weights. The 12 pound weight loss from the week of 07/31/12 to 08/07/12 represented a 9.37% severe weight loss in 1 week. There was no documentation in the clinical record to indicate the physician had been notified of the severe weight loss. A dietary progress note, dated 07/31/12, written by the consultant dietician, documented the resident weighed 130 pounds, which was a weight loss of 9.1% in 3 months. The note documented the resident had a recent hospitalization . An addendum to the note documented the dietician suggested the resident be given healthshakes with meals. A fax, dated 07/31/12, written to the resident's physician by the consultant dietician, documented the dietician's recommendation to reinstate healthshakes with meals for a significant 3 month weight loss. (The resident's weight had decreased from 143 pound on 03/01/12 to 130 pounds on 06/01/12. She had been hospitalized from [DATE] to 07/24/12, when she was readmitted to the facility.) A social services progress note, dated 08/2012, documented the social services director had discussed the resident's decline in eating with her power of attorney. A speech therapy weekly summary for the week of 07/29/12 to 08/04/12, included a note, dated 08/03/12, which documented: "...(Patient) continues to tolerate current diet well, although appetite remains poor-fair majority of meals. Oral cleaning (with) cues has improved...Continue (plan of care)." A speech therapy weekly summary for the week of 08/05/12 to 08/11/12, included a note, dated 08/10/12, which documented: "...Continues to require (maximum) encouragement for intake. Appetite seems to have decreased this period. Oral cleaning is worse this period. On 8/7/12 requiring finger sweep (secondary) to lethargy during intake...Continue (plan of care)." The 13 pound weight loss from the week of 07/31/12 to 08/14/12 represented a 10.15% severe weight loss in 2 weeks. There was no documentation in the clinical record to indicate the physician had been notified of the severe weight loss. A physician's telephone order, dated 08/16/12, documented the resident was to be served health shakes with meals for the [DIAGNOSES REDACTED].) A speech therapy weekly summary for the week of 08/12/12 to 08/18/12, included a note, dated 08/17/12, which documented: "...Appetite poor this period. Requires frequent attempts (at oral intake) by staff..." The facility's "Recording Percentage of Meals Consumed" policy and procedure documented: "Policy Nursing personnel are to observe and record the food consumption of each resident. Procedure 1. Nursing personnel shall be aware of the nutritional need of all or identified high risk residents and should daily record food intake. a. Meal Intake Sheet should be used to document percentage eaten each meal and (milliliters) of fluids consumed...d. Intake of 50% or less is poor and less than necessary requirements. Report to Dietary after 3 days. Refusal to eat, report immediately. e. Be sure to offer a substitute if 50% or less is eaten. Offer the alternate and if that is refused, offer a house supplement." The facility's "Feeding the Impaired Resident" policy/procedure documented: "...Alternate foods, readily available foods, or supplements, should be offered, consistent with the diet order, if the resident consumes less than half of the meal..." The "Food/Nourishment Intake Sheet," dated 08/2012, documented the resident's meal intake was as follows for the dates of 08/01/12 through 08/21/12: Breakfast - The resident had eaten 25% for 9 meals, 50% for 6 meals, 0% for 2 meals and 3 meals were blank. Lunch - The resident had eaten 25% for 6 meals, 50% for 7 meals and 75% for 4 meals. She had refused 2 meals and 2 meals were blank. Supper - The resident had eaten 25% for 3 meals, 50% for 3 meals, 75% for 2 meals, 100% for 3 meals, 0% for 3 meals and 6 meals were blank. There was no documentation on the "Food/Nourishment Intake Sheet" to indicate the resident was offered an alternate menu item or a meal replacement when she ate 50% or less of her diet for any meal during the month. There was no documentation on the "Food/Nourishment Intake Sheet" or anywhere else in the clinical record to indicate the resident was ever given a healthshake with her meal. On 08/27/12 at 11:30 p.m., the surveyor asked licensed practical nurse #1 if resident #1 had been offered fluids routinely by staff. He stated the resident had been refusing food, fluids and medications. On 08/28/12 at 4:40 p.m., the surveyor reviewed the above findings with the director of nurses (DON) and asked if the facility had notified the resident's physician regarding her severe weight loss and that she had declined in her ability to take food/fluids since 07/31/12. The DON acknowledged the resident's physician had not been notified of the severe weight loss on 08/07/12 and should have been notified. The surveyor asked if the physician had been notified regarding the resident's decline in her ability to consume food and fluids. She stated there was no documentation in the clinical record to indicate the physician was aware the resident had not been eating or drinking. On 08/28/12 at 5:32 p.m., in a telephone interview, the surveyor asked the resident's physician if the facility had notified him of the resident's decline in her ability to take food and drink fluids. He stated, "I was never informed the resident wasn't eating or drinking." He stated he would have changed her course of treatment had he known. The physician stated he was notified the resident had lost a significant amount of weight and had ordered a supplement to be served with meals. (The physician's telephone order for a supplement with meals was dated 08/16/12.) The physician stated he understood the resident was receiving the health shakes and was unaware the resident had experienced the significant weight loss in 08/2012.

Based on record review and interview, it was determined the facility failed to provide sufficient fluid intake to prevent dehydration for 1 (#1) of 6 sampled residents whose clinical records were reviewed for hydration. The facility failed to monitor the resident's fluid intake and failed to notify the physician of her decline in her ability to take fluids. The facility's failure resulted in the resident being hospitalized with a [DIAGNOSES REDACTED]." The facility's Roster/Sample matrix documented no residents had experienced dehydration. Findings: Resident #1 had [DIAGNOSES REDACTED]. A hospital discharge summary, dated [DATE], by resident #1's physician, documented the resident's admitting [DIAGNOSES REDACTED]. The discharge summary documented the resident's discharge [DIAGNOSES REDACTED]. A "Hydration Risk Evaluation," dated [DATE], documented the resident's score was 16. A score of 8 or higher indicated the resident might be at risk for dehydration. The back of the evaluation which documented whether the resident was/was not at risk for dehydration, whether interventions had been initiated/modified, whether physician's orders [REDACTED]. The annual assessment, dated [DATE], documented the resident had severe cognitive impairment; was dependent upon staff for all activities of daily living; did not ambulate; and was incontinent of bowel and bladder. The care plan, dated [DATE], documented the resident had a problem related to "potential for dehydration and fluid/electrolyte imbalance (related to) advanced dementia (with) poor intake, dysphagia, recurrent (urinary tract infections)." The goal for the problem was "(resident) will show no signs of dehydration through next review date." Approaches included: "...intake and output as ordered...administer medications as per orders, monitoring for effectiveness and side effects, report to (doctor as needed)." The treatment sheet, dated ,[DATE], documented a physician's orders [REDACTED]." The order was dated [DATE]. The activities of daily living (ADL) flowsheet, dated ,[DATE], included a section where "Fluids Offered" were to be documented. The instructions were to "indicate the number of times fluids were offered and (milliliters) consumed." The documentation on the "Fluids Offered" from [DATE] through [DATE] was as follows: ,[DATE] shift - Fluids had been offered ,[DATE] times on 11 of 21 days. No fluids had been offered during the shift on 10 days. The number of milliliters taken by the resident during the shift each day was not documented. ,[DATE] shift - Fluids had been offered ,[DATE] times on 13 of 21 days. No fluids had been offered during the shift on 8 days. The number of milliliters taken by the resident during the shift each day was not documented. ,[DATE] shift - One hundred twenty milliliters was documented as consumed by the resident on 13 of 21 shifts. No fluids were consumed by the resident on 8 shifts. The facility's "Recording Percentage of Meals Consumed" policy and procedure documented: "..Meal Intake Sheet should be used to document percentage eaten each meal and (milliliters) of fluids consumed..." The meal intake sheet, dated ,[DATE], did not document any fluids had been consumed by the resident during any of 3 meals per day for the 21 days in August the resident was present in the facility. There was no documentation in the clinical record to indicate the resident's physician had been contacted regarding her decreased fluid intake. A nurse's note, dated [DATE] on the day shift, documented: "Upon (assessment patient) not as responsive as normal, skin tenting...called Dr. (name withheld) at (7:35 a.m.) orders given to send to ER. He thinks she might be dehydrated..." The hospital discharge summary, dated [DATE], documented the resident had been brought to the hospital and "found to have a (systolic) blood pressure in the 80s and was given a fluid [MEDICATION NAME] as she was extremely dehydrated." The discharge summary documented the resident had expired on [DATE] and the cause of her death was "severe dehydration and [MEDICAL CONDITION] as well as [MEDICAL CONDITION] and [MEDICAL CONDITION]." On [DATE] at 11:30 p.m., the surveyor asked licensed practical nurse #1 if resident #1 had been offered fluids routinely by staff. He stated the resident had been refusing food, fluids and medications. On [DATE] at 1:00 p.m., during an interview with the director of nurses (DON) and the administrator, the surveyor showed the resident's care plan pertaining to dehydration to the DON and asked if the the care plan was followed in regard to the documentation of intake and output. She stated, "Intake should have been monitored in more detail." On [DATE] at 4:40 p.m., the surveyor asked the DON if, because the resident had a history of [REDACTED]. The DON acknowledged the resident should have been monitored more closely. The surveyor asked if the physician had been notified regarding the resident's decline in ability to consume fluids. She stated there was no documentation in the clinical record to indicate the physician was aware the resident had not been eating or drinking. On [DATE] at 5:32 p.m., in a telephone interview, the surveyor asked the resident's physician if the facility had notified him of the resident's decline in her ability to drink fluids. He stated, "I was never informed the resident wasn't eating or drinking." He stated he would have changed her course of treatment had he known. He stated the resident's laboratory results indicated she was so severely dehydrated she could not have had any fluids for approximately 24 hours. On [DATE] at 6:25 p.m., the surveyor asked the speech language pathologist (SLP) about the resident's ability to take food and fluids. He stated the resident had done well to take food and fluids for the first 2 weeks after she was readmitted to the facility (on [DATE]). He stated she then needed more encouragement to eat and drink. The SLP stated the resident "ate like a bird" when he last saw her. (The most recent speech therapy note was dated [DATE], when the resident's speech therapy was discontinued.) On [DATE] at 12:35 p.m., the surveyor showed the resident's meal intake sheet and ADL flowsheet, both dated ,[DATE], to the DON and administrator and pointed out there was no fluid amount taken by the resident documented except by the night shift a few times. The administrator stated the milliliters of fluids needed to be "broke up" from the meals.

Based on record review, observation and interview, it was determined the facility failed to: a. obtain an ambulance to transport a resident who required emergency medical care to the hospital emergency room (ER) per the physician's orders [REDACTED]. b. provide report of the resident's condition by the facility charge nurse to the hospital ER staff so treatment could be initiated promptly. c. ensure facility transport staff provided pertinent information regarding the resident's status to the hospital ER staff. The 2 facility staff members delivered the resident to the admitting entrance of the hospital ER, gave transfer papers to the clerk and left. The facility's failures resulted in delayed treatment of [REDACTED]. The ER physician had to take time to call the facility to inquire about the resident's condition, history and reason for transport to ER. This affected 1 (#1) of 1 sampled residents who required transfer to a hospital emergency room . The facility's "Admissions/Discharges/Status Changes" log, dated [DATE], documented 19 residents had been transferred/discharged since [DATE]. d. The facility failed to ensure medications were administered according to physician's orders [REDACTED]. Ninety-two residents resided in the facility. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. The annual assessment, dated [DATE], documented the resident had severe cognitive impairment; was dependent upon staff for all activities of daily living; did not ambulate; and was incontinent of bowel and bladder. The care plan, dated [DATE], documented the resident had problems related to hypertension, cognitive status, bowel and bladder incontinence, nutrition, staff dependence for all activities of daily living, and potential for dehydration. Appropriate goals and approaches for the problems had been addressed in the care plan. A nurse's note, dated [DATE] on the day shift, documented: "Upon (assessment patient) not as responsive as normal, skin tenting...called Dr. (name withheld) at (7:35 a.m.) orders given to send to ER. He thinks she might be dehydrated...Out of facility at (8:00 a.m.) via Oaks van accompanied by 2 staff members...(Approximately) 9am (name withheld, hospital ER physician) called wanting to know how long (resident) had been like that. I told him, I found her that way on my morning (rounds). He said so you don't know how long she has been this way. I said No. He did say she had (left) sided facial drooping. I asked how she was doing. He said she is unresponsive not even responding to painful stimuli..." A facility "Transfer Record," dated [DATE], which was sent with facility staff and given to the ER admission clerk, documented the reason for the transfer was "skin tenting, not as responsive to stimuli as she is normal." The record documented the resident's vital signs on discharge were as follows: temperature - 97.4 (degrees Fahrenheit), pulse - 117, respirations - 28, blood pressure - ,[DATE]. On [DATE] at 10:52 a.m., the surveyor asked licensed practical nurse (LPN) #2, the charge nurse who transferred resident #1 to the hospital ER, why an ambulance was not called to transport resident #1 to the hospital ER. The LPN stated the resident was still responsive and could sit up in a wheelchair. On [DATE] at 11:15 a.m., CNA #1 was asked about the transfer of the resident in the facility van to the hospital ER. She stated CNA #2 had pushed the resident in her wheelchair into the waiting room as she started the admission process with the admitting clerk. The resident's power of attorney (POA) came in after they did to be with the resident. The ER nurse then pushed the resident back to the triage room. CNA #1 stated she told the POA they were leaving since she was there. The CNA stated it was the facility's policy to stay in the ER with a resident if the POA was not there. She stated if the POA was there, the nursing home staff could return to the facility. On [DATE] at 2:30 p.m. in a telephone interview, the surveyor asked resident #1's POA what she observed in the hospital ER when the resident was transferred on [DATE]. The POA stated she had been called by the facility to inform her the resident was being transferred the the ER. The POA stated she arrived at the hospital and observed the facility staff unload the resident from the facility van, push the resident into the ER, hand the hospital staff some papers and leave. On [DATE] at 2:35 p.m., the surveyor asked LPN #2 if she had called the ER staff to give report about the resident's condition. She stated she had not called report of the resident to the hospital ER staff. On [DATE] at 5:32 p.m. in a telephone interview, the surveyor asked the resident's physician about the transfer of resident #1 to the hospital ER per facility van. The physician stated he thought the resident should have been transferred to the hospital in an ambulance. He stated hospital staff had informed him of the transfer and the facility's failure to provide pertinent information regarding the resident's status to the ER staff. On [DATE] at 8:30 a.m., the hospital director of nurses (DON), whose office was in the emergency room , replayed the surveillance video of [DATE], the day the resident was received to the emergency room . The video documented the resident was pushed into the east side waiting room door at 8:06.18 a.m. by CNA #2, as CNA #1 held the door. The resident was covered from her neck down with a blanket and her head was tilted slightly to the right. CNA #2 exited the waiting room to the outside. CNA #1 then went to the door and retrieved paperwork from CNA #2. She stepped up to the admitting desk. The surveillance video documented the resident's POA and another woman entered the waiting room through the same door and bent down toward the resident. CNA #1 exited the waiting area through the east door at 8:08.22 a.m. The emergency room nurse was observed walking through the waiting room area to the east door, opened the door and then closed it. She then push the resident in her wheelchair into another doorway. The hospital DON stated, "The ER nurse was upset that day because she didn't get any report on the resident from the nurse at the nursing home or the two CNAs that dropped the resident off. The physician had to call the nursing home and get report on the resident to find out why she was there." On [DATE] at 12:35 p.m., the administrator and the DON were informed what the surveyors had observed on the surveillance video at the emergency room . The administrator stated, "They should have stayed with her till the nurse came out. Our nurse should have called report." On [DATE] at 12:55 p.m. in a telephone interview, the surveyor asked the ER RN if the resident's treatment in the ER had been delayed because the hospital staff did not know why the resident had been sent to the ER. She stated, "Yes." She stated she had not received report from the charge nurse at the nursing home and the resident had been brought to ER by the facility's private vehicle instead of an ambulance. The ER RN stated the nursing home staff had brought the resident into the ER through the admitting area instead of the ambulance bay where direct access to the ER nurse could have been obtained. The RN stated the resident was extremely hypotensive and venous access had to be obtained by the [MEDICATION NAME] vein. She stated because the resident was left in ER by nursing home staff and no report had been called in, the ER physician had to take time to call the nursing home to obtain pertinent information regarding the resident's current status and history. b. The care plan, dated [DATE], documented resident #1 had a problem related to hypertension. Approaches included to administer medications as ordered. physician's orders [REDACTED]. The [MEDICATION NAME] was to be held if the resident's pulse was less than 60 or her systolic blood pressure was less than 100. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The skilled nurses' note, dated [DATE], documented the resident's blood pressure was ,[DATE] on the day shift. There was no blood pressure documented for the evening shift. The MAR indicated [REDACTED]. There was no documentation to indicate the resident's blood pressure had been monitored following the administration of the morning [MEDICATION NAME] and [MEDICATION NAME] when her systolic blood pressure reading was below the parameters set by the physician to hold the medication and when the evening dose of [MEDICATION NAME] was administered. The daily skilled nurses notes, dated [DATE] on the day shift, documented the resident's blood pressure was ,[DATE]. The physician was notified and the resident was transferred to the hospital where she expired on [DATE]. On [DATE] at 3:00 p.m. in a interview with the DON, the surveyor reviewed the above findings regarding the administration of [MEDICATION NAME] and [MEDICATION NAME] when the resident's blood pressure readings were below the parameters set by the physician to hold the medication. The surveyor asked the DON if the medication had been administered according to physician's orders [REDACTED].

On [DATE] at 8:05 p.m., the Oklahoma State Department of Health was notified of a potential immediate jeopardy situation related to: a. the facility's failure to have a system in place to identify residents' code status. b. the facility's failure to provide cardiopulmonary resuscitation (CPR). c. the facility's failure to provide access to outside medical care for resident #24 who was found without pulse and without respirations. The IJ situation was verified. On [DATE] at 8:15 p.m., the administrator, RN corporate chief operating officer (RN-COO), DON #1, and DON #2 were notified of the Immediate Jeopardy (IJ) situation beginning at 8:05 p.m. On [DATE] at 8:35 p.m., the administrator returned to the survey team with a verbal plan of removal which included the following: identification of all residents' code status, identification of all residents' charts with DNR stickers and code status, an audit of all physician's orders [REDACTED]. all staff would be inserviced on policy and procedure for situations where a resident would be found unresponsive, placement of a red heart at the head of the bed for all residents who were DNR, and care plans for all residents with a DNR status. The administrator was asked if that was already done. She stated yes, if there was no red heart at the head of the resident's bed then the resident was a full code. The administrator was asked who would monitor the interventions. The administrator stated the DON #1, DON #2, and the Quality Assurance (QA) committee. The administrator stated the in-services would begin "Tonight, prior to clocking on to shift" and prior to the present shift clocking out. She stated the facility would attempt to have all staff in-serviced by [DATE] at 8:00 a.m., when the last inservice would be offered. The administrator stated those staff members not in attendance would be in-serviced by phone if possible. On [DATE] at 9:15 p.m., the administrator told the surveyors that if any member of the staff was not able to be in-serviced they would be suspended and not be able to work until the staff member had been in-serviced on the facility's DNR policy. The administrator stated the in-service would be included in new employee orientation. The administrator, RN-COO, DON #1, and DON #2 were informed the IJ would not be lifted until all staff were in-serviced. They all voiced understanding. The facility team was notified the plan of removal had been accepted by the survey team. On [DATE] at 11:00 a.m., the plan of removal was discussed and the administrator, RN-COO, DON #1, and DON #2 discussed actions taken to meet the criteria of the plan of removal. All in-services with staff member signatures were presented to the surveyors. The facility team was instructed of the need to have the plan of removal in writing. On [DATE] at 11:20 a.m., the administrator brought the survey team a written plan of removal which documented the following: "PLAN OF REMOVAL All residents will have code status identified upon admission per physician order [REDACTED]. All resident's code status will be reflected on care plan... All residents will have chart marked with either DNR or FULL CODE STATUS STICKERS. All staff will (be) in-serviced upon hire orientation (sic) related to Code status identifier Sticker on Chart and red heart identifier that will be hung above DNR resident's bed to assure staff is aware who is a DNR. Red Heart above bed in frame means resident is a DNR Residents code status will be reviewed if readmission or status changes by DON/ADON Facility shall assign representative to monitor system to assure that all resident code status are correct and in place restorative / or designee.....(sic) Physician orders [REDACTED]. QA committee will review and monitor this system for continued compliance monthly. If staff finds a resident who is unresponsive they will identify Code status by sticker on chart or heart above bed or physician order [REDACTED]. Staff will be in-serviced quarterly to assure continued understanding of policy on code status and assure they are aware of indicators in facility. (Stickers on charts and hearts above beds mean resident are DNR.) List of DNR residents names will be provided to beauty shop, activities, dietary, therapy, laundry, and Administrator office for quick reference of code status of all residents keeping HIPPA guidelines in compliance. Hospice employees will be oriented to our code status policy before giving care to any resident in our facility." The plan of removal was signed by the administrator and RN-COO. On [DATE] at 9:15 p.m., the facility was informed the IJ was lifted as 9:08 a.m., that morning when the last staff member had been in-serviced. The deficiency remained at the level of actual harm that was not an immediate jeopardy with more than a very limited number of residents affected. Based on record review, observation, and interview, it was determined the facility failed to: a. Provide medical care and/or access to outside medical care as evidenced by the failure to initiate and provide CPR for one (#24) sampled resident. Resident #24 was found without pulse and without respirations and was not provided CPR or access to outside medical care. b. The facility failed to have a system in place to identify every resident's code status. Resident #24's clinical record did not identify whether the resident wanted to be resuscitated in the event of being found with no pulse and no respirations. This had the potential to effect 87 residents in the facility whose clinical record did not identify whether the resident's status choice was Full Code or DNR. The census on [DATE] was 110 residents and 23 of the clinical records identified the resident's choice as DNR. c. Correlate care between the [MEDICAL TREATMENT] unit and the facility in regards to the care provided by the [MEDICAL TREATMENT] unit. This had the potential to effect two (#7 and #12) of two sampled residents who received [MEDICAL TREATMENT]. There was no information on the residents' clinical record of the care the [MEDICAL TREATMENT] unit provided. Findings: During the review of the facility's in-services, the following policy was noted, with signatures of 33 staff members, dated [DATE]. "DNR DO NOT RESUSCITATE Federal Mandate to follow request of Resident on issue of: RESUSCITATE *OR* NOT Residents must be asked on admission by the nurse and an advanced directive form must be on chart and signed. IF REQUEST IS TO NOT BE RESUSCITATED PLEASE ASK RESIDENTS TO WEAR "BLUE BRACELET" THIS WILL BETTER ENABLE US TO FOLLOW THEIR REQUEST." 1. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet of the chart, which was called the Admission and Discharge Summary page, dated [DATE], did not address the resident's code status. The resident's initial social service history, dated [DATE], did not address the resident's code status. The resident's care plan, dated [DATE], did not address the resident's code status. The resident's admission assessment, dated [DATE], documented the resident had memory problems and was moderately impaired related to cognitive skills for daily decision-making. The assessment documented the resident required extensive assistance for all activities of daily living (ADLs). This assessment did not address the resident's advanced directives or code status. The physician's orders [REDACTED]. A nurse's note, dated [DATE] at 3:40 a.m., documented, "Resident noted (with) no resp (respirations), no v/s (vital signs.) Spoke (with) Dr (name deleted) who was on call - DNR per Dr (name deleted). (Family member - name deleted) notified of resident's passing away. (Family member - name deleted) wished for resident to be sent to (name-deleted) funeral home at this time." The nurse's note was signed by the LPN. The nurse's note did not document any other actions related to finding the resident with no respirations and no vital signs. A nurse's note, dated [DATE] ( with no entry time), documented the funeral home was notified. Resident #24's clinical record did not identify whether the resident wanted to be resuscitated in the event of being found with no pulse and no respirations. There was no evidence in the clinical record that the resident requested to be a Do Not Resuscitate. No where in resident #24's clinical record was code status addressed until the nurse's note, dated [DATE] at 3:40 a.m. A physician's orders [REDACTED]. . . " On [DATE] at 4:40 p.m., the director of nurses (DON) #2 was asked if the resident had a DNR in her clinical record. After looking through the clinical record, she pointed out the order on [DATE] that was written and noted at 4:00 a.m. It was pointed out to DON #2 that the resident had expired at 3:40 a.m. DON #2 was asked where in the nurses' notes did it document the care the resident received prior to her expiration. DON #2 looked through the chart for a prior DNR order and for documentation of the care the resident received just prior to having expired. DON #2 stated she couldn't find any additional information. On [DATE] at 5:40 p.m., the administrator was asked for the policy on what staff were to do if they found a resident unresponsive. The following documentation was provided. "When a licensed nurse discovers the signs of death... the following should occur: Review the resident's DNR orders; provide CPR as indicated by the resident's advance directive and clinical condition at time of discovery. . . ." Beginning at 5:47 p.m., on [DATE], the following staff were asked what the facility's policy was when a resident was found unresponsive. Their responses follow: Licensed practical nurse (LPN) #1 stated she would check for pulse and respiration, if the resident was not a DNR would begin CPR, and would have someone check the chart for DNR status. LPN #3 stated she would get someone to call the emergency services (EMS) and get vital signs. When asked how she would know if the resident was a DNR, she stated she would have someone get the chart. RN #5 stated she would check for respirations, vital signs, put oxygen on the resident, call for help, call the doctor, start CPR, and send the resident out. When asked how she would know if the resident was a DNR, she stated she would look at the chart. RN #3 stated she would do a quick assessment, start CPR, get help, call the doctor, and that the code status should be on the chart. LPN #2 stated he would look, listen, feel, then begin CPR, and call for the crash cart. When asked where he would find the DNR status, he stated on the chart. RN #6 stated she would find out if the resident was a DNR or a full code by going to the chart. She stated the resident should have a wrist band on. She was asked if the wrist band was not on the resident, what would she do then. She stated she would send someone to find out and that she would not leave the resident. RN #4 stated if a DNR was not readily accessible, she would initiate a full code. On [DATE] at 6:10 p.m., one of two attending physicians who took care of resident #24 was interviewed. During the interview, he agreed the facility should have a system in place to identity each resident's code status. On [DATE] at 6:20 p.m., a list of CPR certified staff was given to the survey team. On [DATE] at 6:24 p.m., DON #1 was asked what she would do if she walked in on a resident who was unresponsive. She stated she would immediately start CPR. She was asked what if the resident was a DNR. She stated that they (the facility) were talking about initiating a program so if a staff member was in a resident's room, the staff member would know what to do. On [DATE] at 6:30 p.m., DON #2 was asked what she would do if she walked in on a resident who was unresponsive. She stated she would treat them as a full code if the chart was not marked. On [DATE] at 12:30 p.m., the administrator, RN-COO, DON #1, and DON #2 were informed of the facility being in an Extended Survey related to Substandard Quality of Care. The administrator and RN-COO voiced understanding. On [DATE] beginning at 2:20 p.m., a minimum of 24 facility employees were asked about the in-services they had attended and the content of the in-services. The staff was able to tell the surveyors what the in-services consisted of, which was what the facility had placed in their plan of removal. On [DATE] at 3:30 p.m., all charts were identified with a blue sticker with FULL CODE or red sticker with DNR. All residents' rooms who were identified with DNR on their charts were observed to have an 8x10 framed red heart above the light located at the head of each resident's bed. On [DATE] beginning at 7:10 p.m., attempts were made to contact seven random staff members who worked the night shift. Three responses were received and the responses corresponded with the criteria documented in the plan of removal. The facility in-service book was reviewed for documentation of required in-services for direct care staff. No documentation of a cardiopulmonary resuscitation in-service during the last year was documented. On [DATE] at 7:50 p.m., DON #1 was interviewed regarding the missing in-service. DON #1 reviewed the in-service book and reported she could not find an in-service for cardiopulmonary resuscitation during the past year. 2. Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT]. The resident's admission assessment, dated [DATE], documented the resident had no memory problems and was independent related to cognitive skills with daily decision-making. The assessment documented the resident needed extensive assistance with ADLs. The resident's admission care plan documented the resident was on [MEDICAL TREATMENT] and the goals were to obtain lab work as ordered by the physician. During the review of the clinical record, a correlation between the [MEDICAL TREATMENT] clinic and the facility was not found. There were no records of reports from the clinic and no records of lab from the clinic in the facility's clinical record. On [DATE] at 3:25 p.m., the resident was observed sitting on the side of his bed eating a sandwich. On [DATE] at 4:30 p.m., the DON #2 was asked if the facility received reports from the [MEDICAL TREATMENT] clinic. She stated no, they used to but did not any more. The DON returned to the surveyor and stated she had talked to the [MEDICAL TREATMENT] clinic and they would return to sending the facility a report. DON #2 stated she had asked them why they were not sending the report any longer and they stated it was because the facility was not asking for one. 3. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented the resident had no memory problems and was independent with decision making skills. The care plan, dated [DATE], documented the resident experienced altered renal function related to end stage [MEDICAL CONDITION] and nephroti[DIAGNOSES REDACTED]. The care plan documented the resident required [MEDICAL TREATMENT] three times a week. The care plan did not address monitoring of the resident after [MEDICAL TREATMENT] appointments or the continuity of care between the [MEDICAL TREATMENT] staff and the facility. On [DATE] at 9:30 a.m., the resident was observed in her room. The resident reported the facility transported her to the [MEDICAL TREATMENT] unit three times a week. The medical record was reviewed for documentation of the resident's condition while at the [MEDICAL TREATMENT] unit. No documentation could be located. On [DATE] at 3:40 p.m., DON #1 was asked if the [MEDICAL TREATMENT] unit sent reports of the resident's condition to the facility following [MEDICAL TREATMENT] treatment. DON #1 reported she would find out. DON #1 stated, "Usually with [MEDICAL TREATMENT] patients they do." On [DATE] at 4:00 p.m., RN #5 was interviewed regarding monitoring of the resident's lab values during [MEDICAL TREATMENT] treatments. RN #5 reported the facility did not monitor the lab values from [MEDICAL TREATMENT] because the facility wasn't getting the reports from [MEDICAL TREATMENT]. On [DATE] at 5:05 p.m., DON #2 reported she had called the [MEDICAL TREATMENT] unit regarding reports of the resident's condition while at the [MEDICAL TREATMENT] unit. DON #2 reported the [MEDICAL TREATMENT] unit reported they obtained labs every visit. DON #2 reported the [MEDICAL TREATMENT] unit stated they had not sent the reports to the facility because the transport driver did not ask for the labs. DON #2 was asked if the facility had a policy for continuity of care between the [MEDICAL TREATMENT] unit and the facility. DON #2 reported the facility had reviewed the manuals and could not find a policy.