Every finding on record at The Regency Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure infection control program guidelines were implemented for 2 (#79 and #108) of 19 residents sampled for infection control. The regional nurse consultant reported five residents in the facility had C. diff. Findings: 1. On 04/30/25 at 2:18 p.m., Res # 79's door was observed to have personal protective equipment and a contact precaution sign on the door . The resident was observed resting in bed with eyes closed. A biohazard trashcan and a biohazard bed linen container were observed placed by the door upon entry. On 05/01/25 at 11:20 a.m., Res #79 was observed resting in bed watching television. A facility policy titled Infection Control Program Guidelines for Clostridium Difficile (C Diff), dated 06/14/06, read in part Contract Controls for C. Diff. 1. Contact precautions are recommended to prevent transmission of C. Difficile in the health care setting (CDC [Centers for Disease Control and Prevention] information for healthcare providers July 22, 2005). 2. Place residents with C Diff in private rooms or consolidate them together with other residents who have been diagnosed with C Diff. 3. Use gloves and gowns for all resident contact. 4. Use disposable items and equipment when possible. 5. Continue these precautions until the diarrhea ceases. An undated medical diagnoses list for Res #79's showed the resident admitted with acute cystitis with hematuria. A review of the Res #79 s progress notes, dated 04/19/25 through 05/01/25, showed the resident had been on precautions for c-diff since 04/19/25. On 04/30/25 at 2:18 p.m., Res #79 reported feeling better than they did three days ago. The resident reported their appetite was coming back and they were not having bowel movements as often. On 05/01/25 at 11:20 a.m., Res #79 reported they had four roommates since they admitted . The resident was asked about their last roommate. Res #79 stated they were not here for very long. Res #79 was asked how long it had been since their last roommate. Res #79 reported about a week. 2. A review of the facility's admissions in the last 30 days showed Res #108 admitted on [DATE]. An undated medical diagnoses list for Res #108 showed diagnoses of dementia, dysphagia, and sever protein-calorie malnutrition. A Grievance Form, dated 04/23/25, showed Res #108 was placed in the room with Res #79 upon admission. On 05/01/25 at 12:02 p.m., the IP was asked what the policy was on a resident with/or suspected c-diff and a roommate. They reported they did not cohort residents with C. diff with a negative resident, They stated they isolated the positive resident. The IP was made aware of Res #79 and Res #108 being placed in the same room on 04/23/25. The IP was asked why a negative resident was placed with a positive resident. The IP reported they would have to check with the DON. On 05/01/25 at 12:22 p.m., the DON was asked if any resident should have been put in the room with Res #79. The DON reported maybe if they had c-diff also.

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for one (#46) of five sampled residents reviewed for medications. The DON identified 94 residents resided in the facility. Findings: Res #46 had diagnoses which included COVID-19. Physician orders, dated 12/21/23, documented ascorbic acid (antioxidant medication) give one gram by mouth two times a day for 14 days and decrease to 500 mg PO BID if stools loose; dexamethasone (steroid medication) 6 mg tablet one time a day for five days; and molnupiravir (anti-infective medication) 200 mg, give four capsules by mouth every 12 hours for five days. The December 2023 MAR documented ascorbic acid was held 10 out of 22 opportunities, dexamethozone was held four out of five opportunities, and molnupiravir was held four out of eight opportunities. On 01/03/24 at 1:59 p.m., corporate nurse consultant #1 and the DON were shown the December 2023 MAR for the medications and asked to provide documentation for the reason the medications were held. On 01/04/24 at 9:59 a.m., the DON stated there was no documented reason for the medications being held. They stated the medications were not administered as ordered.

Based on record review and interview, the facility failed to ensure a resident assessment was accurate for one (#58) of 24 sampled residents whose assessments were reviewed for accuracy. The DON reported 94 residents resided in the facility. Findings: Res #58 admitted to the facility with a diagnosis of asthma. A physician order, dated 09/17/23, documented resident to wear oxygen vis nasal cannula at 2 liters per minute to maintain oxygen saturation above 90%. A quarterly assessment, dated 12/15/23, did not include the resident required oxygen therapy. On 01/04/24 at 1:34 p.m., MDS #1 reported the assessment should have documented oxygen therapy.

Based on record review, observation, and interview, the facility failed to provide food that was palatable and at an appetizing temperature for the residents. The Resident Census and Conditions of Residents report, dated 08/28/23, documented 98 residents resided in the facility. Findings: The Resident Council Report, dated 08/17/23, documented the food was still cold when served on the resident halls. The Daily Hot Food Table Temperature Chart, dated 08/30/23, did not document food temperatures obtained for the lunch meal prior to serving. On 08/30/23 at 12:20 p.m., the dietary manager stated there was not enough hot plates to serve all the residents who ate in their rooms. The dietary manager stated the plates without hot plates are covered with plastic wrap and served as quick as possible. On 08/30/23 at 12:55 p.m., a sample meal tray was obtained. The food was not palatable to taste or temperature. On 08/30/23 at 1:29 p.m., Res #4 stated they ate lunch in the dining room and the food was hot. The resident stated when they ate meals in their room the food was usually cold. On 08/30/23 at 3:00 p.m., the dietary manager stated about 75% of facility residents ate meals in their rooms.

Based on record review and interview, the facility failed to ensure wound assessments were completed for one (#1) of four sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 08/28/23, documented 98 residents resided in the facility. Findings: Res #1 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of the lateral malleolus left fibula, history of falls, and pressure induced tissue damage of the back buttock and hip. The care plan, dated 01/09/23, documented the facility was to assess/record/monitor wound healing. The care plan documented to measure length, width, and depth of the wound where possible. The care plan documented to assess and document the status of the wound perimeter, wound bed, and healing progress. The plan documented to report improvements and declines to the physician. The admission assessment, dated 01/12/23, documented the resident was cognitively intact and had wounds. A skilled daily nurse note, dated 01/22/23, documented a focused assessment was completed for strengthening and monitoring related to the left ankle fracture and repair. The note documented moderate amount of edema, no open areas, appears scabbed, and red. The note did not document regarding drainage, measurements of surgical site/wound, or healing progress. The note was the only documentation found related to an assessment of the surgical wound. On 08/29/23, the DON reviewed the resident's clinical record. The DON stated the skilled note, dated 01/22/23, had the only wound assessment documentation regarding the resident's surgical site. The DON could not find a documented assessment regarding the staple removal from the surgical site. The DON stated the staff should have documented the procedure, appearance of the site, and how the resident tolerated the procedure. On 08/30/23, the DON stated the resident was in COVID isolation from 01/16/23 until the time she left the facility. The DON stated a wound assessment or a COVID assessment were completed, but not both. The DON reviewed the wound assessments completed and stated a surgical wound assessment was not present.

Based on record review, observation, and interview, the facility failed to ensure residents received physician prescribed diets for one (#2) of three residents sampled for physician prescribed specialty diets. The DON identified five residents who had a prescribed renal diet. Findings: Res #2 had diagnoses which included chronic kidney disease stage III and dependence on renal dialysis. A physician order, dated 11/08/22, documented the resident required a renal diet. A quarterly MDS, dated [DATE], documented the resident was cognitively intact and received a therapeutic diet. A Diet Spreadsheet Short Name Format menu was provided by the dietary manager. The menu for 03/16/23 documented the lib renal lunch was Salisbury beef, rice/noodles, buttered broccoli, bread choice, and dessert of the day. On 03/16/23 at 12:00 p.m., Res #2 was observed in her room seated in a wheelchair with a meal tray in front of them. The resident's plate was observed to contain mashed potatoes with brown gravy, a ground beef patty covered in brown gravy, and a bowl of steamed broccoli. A slice of white bread was observed in a bag on the tray. The resident stated they had eaten the dessert. The resident stated they had requested a different meal because they could not eat what was served. On 03/16/23 at 4:09 p.m., the dietary manager stated mashed potatoes were not part of a renal diet. She stated Res #2 should have been served rice or noodles instead.

Based on record review, observation, and interview, the facility failed to properly wear personal protective equipment to prevent the spread of infection. The Resident Census and Conditions of Residents documented 86 residents resided in the facility. Findings: A COVID-19 Guidelines for Employees, dated 10/02/22, documented signage will be placed at the entrances of facilities advising visitors and staff on COVID-19 precautions. On 02/06/23 at 10:28 a.m., a COVID-19 information sign was observed on the facility front entry door. The sign documented Masks are required if this building is in outbreak protocol or the county has a high community transmission rate. The COVID Data Tracker on the Centers for Disease Control and Prevention website documented the community transmission rate as High for Pottawatomie County during the survey observation period. On 02/06/23 at 10:30 a.m., the front desk receptionist #1 was observed not wearing a mask. On 02/06/23 at 10:44 a.m., LPN #2 was observed standing at the nurses' station with a surgical mask pulled down around the chin. The mask did not cover the nose or mouth. On 02/06/23 at 10:45 a.m., the front desk receptionist #1 was observed not wearing a mask. On 02/06/23 at 3:20 p.m., the infection preventionist stated all staff are required to wear a mask properly while in the facility, especially during direct resident care. On 02/07/23 at 7:35 a.m., the front desk receptionist #1 was observed not wearing a mask. On 02/07/23 at 7:36 a.m., LPN #2 was observed standing at a treatment cart in front of the nurses' station with a surgical mask pulled down around the chin. The mask did not cover the nose or mouth. On 02/08/23 at 9:04 a.m., the activity director was observed within approximately one foot of residents wearing a surgical mask that had been pulled down around the chin. The mask did not cover the nose or mouth. On 02/08/23 at 10:32 a.m., the activity director stated the facility required masks at all times but occasionally she pulls her mask down to communicate with residents. The activity director stated it is the rule of the building that all personnel wear a mask properly at all times. On 02/08/23 at 10:35 a.m., the activity director was observed pushing a resident in a wheel chair into the activity room with her mask pulled down under the chin. The mask did not cover the nose or mouth. On 02/08/23 at 10:40 a.m., the front desk receptionist #2 stated it is the receptionist's responsibility to wear a mask and make sure all staff and visitors wear masks when entering the building. On 02/08/23 at 10:50 a.m., the DON stated all staff should wear a mask at all times while in the building. She stated the mask should cover the nose and mouth at all times, especially if the staff member is providing direct resident care.

Based on observation and interview, the facility failed to ensure the kitchen was maintained, clean, and in good repair. The Resident Census and Condition of Residents reported 84 residents resided in the facility. Findings: On 02/01/23 at 925 a.m., during a tour of the kitchen the following observations were made: a. Ceiling lights were burned out and/or not working, b. An accumulation of lint on the ceiling around heat/air vents, c. An accumulation of white and black residue inside of the ice machine, d. Caulking was missing with gaps between the wall and the hand sinks, e. A wooden rolling pin stored on a shelf in the dish wash area had splits in the wood, f. Water leaking from the piping onto the floor below the two compartment sink, g. Sheet rock was cut out and there was a hole in the ceiling around the fire sprinkler in the cold cereal area, h. An accumulation of grease and food on the floor under the fryer and stove, i. An accumulation of grease on the fryer and stove, j. An accumulation of black residue on the table mounted can opener, and k. Paint was peeling off of doors. On 02/07/23 at 8:59 a.m., the DM was asked how the kitchen is kept clean and in good repair. The DM reported she did routine walk-throughs in the kitchen and staff did walk-throughs at 5:30 every morning.

Based on record review, observation, and interview, the facility failed to monitor for side effects and behaviors of psychotropic medications for one (#23) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 51 residents received psychotropic medications. Findings: Res #23 had diagnoses which included Parkinson's disease, rheumatoid arthritis, anxiety, and recurrent depressive disorder. A care plan, dated 11/21/21, documented to monitor and document the effectiveness and side effects of antidepressants such as dry mouth, dry eyes, constipation, urinary retention, and suicidal ideations every shift. Monitor, document, and report to the physician signs and/or symptoms of depression unaltered by antidepressant medications such as sad, irritable, crying, negative comments, and anxiety. A physician order, dated 12/9/22, documented to administer mirtazapine (an antidepressant medication) 15 mg daily at bedtime for appetite. A physician order, dated 12/10/22, documented to administer fluoxetine (an antidepressant medication) 20 mg daily for recurrent depressive disorder. A quarterly assessment, dated 01/20/23, documented the resident was cognitively intact, required extensive assistance with most ADLs, and received antidepressants. The December 2022 TAR, January 2023 TAR, and February 2023 TAR had no documentation of side effect or behavior monitoring for antidepressants. On 02/06/23 at 12:18 p.m., the DON stated side effect and behavior monitoring had not been documented on Res #23 from 12/08/22 until present but should have been.

Based on record review, observation, and interview, the facility failed to provide medications to residents per physician order for one (#17) of six residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 84 residents resided in the facility. Findings: A Nebulizer Treatment Therapy policy, revised 08/31/10, read in parts, .All employees of nursing .shall adhere to the guidelines set forth herein, when using a Nebulizer Machine .Observe patient and obtain vitals including heart rate, respiratory rate and auscultate for breath sounds .Instruct patient to take slow, deep breaths and on every 4th breath, hold it to the count of 5. This will facilitate deeper particle disposition of the medication .The medications will sometimes increase the heart rate or cause the patient to tremble. This is normal. If the patient's heart rate increased greater than 20 beats per minute discontinue the treatment immediately. Notify the nurse and physician. Don't forget to take the heart rate, respiratory rate, and auscultate for breath sounds after treatment. Obtain pulse oximeter readings both before and after treatment. Turn the nebulizer machine off and empty medication cup of any residual medication. Place nebulizer equipment in bag for future use when treatment is complete. Ask the patient to cough and document the results . Res #17 was admitted to the facility on [DATE] with diagnoses of morbid obesity, pulmonary heart disease, and hypertension. A significant change assessment, dated 01/19/23, documented the resident's cognition was intact. On 02/01/23 at 3:54 p.m., the resident was observed sitting in her room in a recliner with a nebulizer mask on her face with a treatment being administered. No staff were present in the room or in front of resident's door. Two staff members were observed down on the end of the hall and the resident could be heard coughing from the hall. On 02/01/23 at 3:57 p.m., the resident was observed sitting in her recliner in her room. A nebulizer mask was in place with a treatment being administered. On 02/01/23 at 3:59 p.m., LPN #1 was observed knocking on the resident's door and stated, Are you done? On 02/02/23 at 3:11 p.m., Res #17 was observed sitting in her recliner with HHN treatment via mask. She reported the nurse just started it. No staff were in the room with the resident. The resident reported the nurse checked her oxygen saturation before and it was 97%. The resident stated it took about 10 minutes for breathing treatment to be completed. The resident was asked if staff ever stayed in the room with her while she received her HHN treatment. She stated, No, they just come in and start it, then come back to stop it. On 02/02/23 at 4:22 p.m., LPN #1 was asked what the protocol was for administering breathing treatments. LPN #1 stated he set the resident up with the treatment and set a timer so he knows when to come back. He was asked if he stayed in the room while the breathing treatment was being administered. He stated if he had time he would. He was asked if the facility was short of staff. He stated he didn't think so. On 02/02/23 at 4:25 p.m., the DON was asked what the protocol was for administering breathing treatments. She stated she needed to ask the corporate nurse consultant. On 02/02/23 at 4:40 p.m., the DON provided the nebulizer treatment therapy policy and stated it did not specify anything about self administration. She was informed it was not about self administration, it was about the resident being administered meds and staff not being present throughout the process. She was made aware of the observations with resident.

Based on record review, observation, and interview, the facility failed to ensure resident care plans were reviewed and revised after falls for one (#23) of two residents reviewed for falls. The DON identified 103 resident falls during the previous six months. Findings: A Fall Awareness Program Policy, revised 11/27/17, documented to consider factors regarding a fall and develop the care plan using appropriate interventions after a fall occurs. Res #23 had diagnoses which included Parkinson's disease, rheumatoid arthritis, and arthropathy. An admission assessment, dated 08/17/21, documented the resident was cognitively intact, required supervision with transfer and ambulation, and had not fell prior to admission. A care plan, dated 09/29/21, documented Res #23 had the potential to fall related to gait and balance problems, weakness, and a history of falls. The care plan documented a goal of staff to evaluate all falls and intervene as needed to reduce the potential of significant injury. An incident report, dated 10/04/21, documented Res #23 was found in the floor. The resident stated the fall occurred from getting dizzy during transfer to the bed while using the bedside table for support. The resident had a raised hematoma to right forehead and was transferred to the hospital for evaluation. The intervention was for the resident to use the call light and utilizing the grab bar on the bed frame for stability. The care plan did not document an evaluation or the intervention of the 10/04/21 fall. An incident report, dated 02/28/22, documented Res #23 was found on the floor. The resident stated the fall occurred while trying to transfer. The resident had a bump on the back of their head. The report did not include an intervention for the fall. The care plan did not document an evaluation or the intervention for the 02/28/22 fall. An incident report, dated 03/29/22, documented Res #23 was found on the floor in front of the bed. The resident stated the fall occurred while getting out of bed. No injuries observed at time of incident. The intervention was for the resident to use the call light which was already used previouly. The care plan did not document an evaluation or the intervention for the 03/29/22 fall. An incident report, dated 05/11/22, documented Res #23 was found sitting on the floor. The resident stated he slid out of motorized wheelchair. No injuries observed at time of incident. The incident report did not include an intervention for the fall. The care plan did not document an evaluation and the intervention for the 05/11/22 fall. On 02/01/23 at 10:38 a.m., Res #23 was observed lying in bed. The resident stated he had fell several times in the last few months because he forgot to ask for help when getting up. On 02/06/23 at 1:59 p.m., the DON stated the falls that occurred on 02/28/22, 03/29/22, and 05/11/22 did not have an evaluation and interventions documented.

Based on record review, observation, and interview, the facility failed to ensure resident care plans were reviewed and revised after falls for one (#23) of two residents reviewed for falls. The DON identified 103 resident falls during the previous six months. Findings: A Fall Awareness Program Policy, revised 11/27/17, documented to consider factors regarding a fall and develop the care plan using appropriate interventions after a fall occurs. Res #23 had diagnoses which included Parkinson's disease, rheumatoid arthritis, and arthropathy. An admission assessment, dated 08/17/21, documented the resident was cognitively intact, required supervision with transfer and ambulation, and had not fell prior to admission. A care plan, dated 09/29/21, documented Res #23 had the potential to fall related to gait and balance problems, weakness, and a history of falls. The care plan documented a goal of staff to evaluate all falls and intervene as needed to reduce the potential of significant injury. An incident report, dated 10/04/21, documented Res #23 was found in the floor. The resident stated the fall occurred from getting dizzy during transfer to the bed while using the bedside table for support. The resident had a raised hematoma to right forehead and was transferred to the hospital for evaluation. The intervention was for the resident to use the call light and utilizing the grab bar on the bed frame for stability. The care plan did not document an evaluation or the intervention of the 10/04/21 fall. An incident report, dated 02/28/22, documented Res #23 was found on the floor. The resident stated the fall occurred while trying to transfer. The resident had a bump on the back of their head. The report did not include an intervention for the fall. The care plan did not document an evaluation or intervention for the 02/28/22 fall. An incident report, dated 03/29/22, documented Res #23 was found on the floor in front of the bed. The resident stated the fall occurred while getting out of bed. No injuries observed at time of incident. The intervention was for the resident to use the call light which was already used previouly. The care plan did not document an evaluation or intervention for the 03/29/22 fall. An incident report, dated 05/11/22, documented Res #23 was found sitting on the floor. The resident stated he slid out of motorized wheelchair. No injuries observed at time of incident. The incident report did not include an intervention for the fall. The care plan did not document an evaluation and intervention for the 05/11/22 fall. On 02/01/23 at 10:38 a.m., Res #23 was observed lying in bed. The resident stated he had fell several times in the last few months because he forgot to ask for help when getting up. On 02/06/23 at 1:59 p.m., the DON stated the falls that occurred on 10/04/21, 02/28/22, 03/29/22, and 05/11/22 did not have an evaluation and interventions documented on the care plan. She stated incident reports were completed but revision of the care plan was missed.

Based on observation and interview, the facility failed to provide a clean environment for one (#17) of three residents observed for environment. The Resident Census and Conditions of Residents form documented 84 residents resided in the facility. Findings: On 02/01/23 at 11:13 p.m., the resident's carpet in the room was observed to have small pieces of paper and food and dirt particles on the floor. On 02/02/23 at 12:14 p.m., the resident's carpet in room was observed to have small pieces of paper and food and dirt particles on the floor. On 02/06/23 at 1:30 p.m., the resident's carpet in room was observed to still have small pieces of paper and food and dirt particles on the floor. On 02/07/23 at 10:41 a.m., the maintenance/housekeeping/laundry supervisor was asked how often resident rooms are to be cleaned and vacuumed? He stated daily. The housekeeping supervisor and the administrator was informed of the resident's room not being vacuumed since start of survey, same pieces of paper, small food particles and dirt on floor.

Based on record review and interview, the facility failed to ensure a current copy of a resident's Do-Not-Resuscitate (DNR) consent was in the resident's medical record for one (#39) of three residents sampled for advance directives. The DON reported 26 residents, who resided in the facility, have DNR consents. Findings: Res #39 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, depressive disorders, and dysphasia. A care plan revision, dated 7/25/22, documented the resident had a DNR status. On 02/01/23 at 4:36 p.m., the resident's electronic health record was reviewed and documented the resident's status as DNR. The resident's paper chart was reviewed and no DNR consent form was located in resident's chart. On 02/03/23 at 11:20 a.m., the DON and administrator provided a signed DNR form, dated for 02/03/23. The DON reported that the resident had one but the facility was not able to find it so they had her sign another one.

Based on record review, observation, and interview, the facility failed to dress residents in their personal clothes per their wishes for one (#8) of one resident reviewed for dignity. The Resident Census and Conditions of Residents documented 86 residents resided in the facility. Findings: Res #8's care plan, dated 02/23/22, documented the resident has an ADL self-care deficit due to weakness and required two staff participation to dress. The resident's refusal to dress was not documented in the care plan. A quarterly assessment, dated 11/05/22, documented the resident had severe cognitive impairment, did not ambulate, and required extensive assistance with dressing. On 02/01/23 at 12:59 p.m., Res #8 was observed lying in bed wearing a cloth medical gown. The resident stated she would like to wear her own personal clothing but the staff always dressed her in a hospital gown because she spilt things a lot and the nurse aides don't want to change her clothes as often. Personal clothing with the resident's name printed on the labels was observed in Res #8's closet. On 02/02/23 at 12:09 p.m., Res #8 was observed lying in bed asleep wearing a cloth medical gown. On 02/03/23 at 10:30 a.m., Res #8 was observed lying in bed asleep wearing a cloth medical gown. On 02/03/23 at 10:31 a.m., CNA #1 stated the resident frequently refused to allow staff to dress her in personal clothes. She reported the resident's refusals were documented under tasks in the electronic health record. On 02/03/23 at 10:40 a.m., CNA #2 stated the resident refused to get dressed almost daily. She stated the resident's refusals were documented in the electronic health record. On 02/06/23 at 12:20 p.m., the ADON stated Res #8 refused to allow staff to assist with dressing often and the refusals should be documented in the electronic health record. She stated residents should always be dressed in their personal clothes per their wishes. No documentation of the resident's refusal to dress in personal clothes was found in the electronic health record. On 02/06/23 at 3:52 p.m., the DON stated there was no documentation of Res #8's refusals to dress in personal clothes in the electronic health record. She stated the resident had a tendency to refuse care but there was no proof of refusal documented in the care plan or the nurse aides' tasks in the electronic health record.

Based on record review, observation, and interview, the facility failed to change nebulizer tubing as ordered by the physician for one (#17) of one resident sampled for respiratory therapy. The Resident Census and Conditions of Residents documented 19 residents required respiratory therapy. Findings: Res #17 was admitted to the facility on [DATE] with diagnoses of morbid obesity, pulmonary heart disease, and hypertension. A quarterly assessment, dated 10/23/22, documented the resident had an intact cognition. A physician's order, dated 12/9/22 documented to change nebulizer tubing on the 1st and 15th of each month and as needed. On 02/01/23 at 11:13 a.m., a nebulizer machine was observed sitting on the residents table beside her recliner. The tubing for the nebulizer was dated 12/20/22. On 02/08/23 at 11:30 a.m., the DON was made aware of the date on the nebulizer tubing upon initial tour of the facility. The DON was asked if the tubing should have already been changed. She stated, Yes, we have trouble getting them to change the tubing like they are supposed to.

Based on record review and interview, the facility failed to prevent neglect for two (#1 and #2) of three residents sampled for neglect. a. Resident #1 was left on a bedpan in their bed for multiple hours resulting in the resident feeling neglected and embarrased. b. Resident #2 was left naked, cold, uncovered, and crying in their bed for multiple hours. The DON reported seven residents required assistance with activities of daily living. Findings: 1. Res #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial assessment, dated 06/20/22, documented Res #1 was cognitively intact and required assistance with activities of daily living. A care plan, dated 06/22/22, documented Res #1 required assistance of one staff member with toileting. On 06/28/22 at 11:40 a.m., Res #1 reported, approximately one week ago, the staff had left them on the bed pan for two to three hours. Res #1 stated the staff reported they had gotten busy and forgotten about them. Res #1 stated they felt neglected and embarrassed at the time. On 06/28/22 at 11:41 a.m., FM #1 reported Res #1 had informed them of the incident. FM #1 also reported they had informed the charge nurse. On 06/28/22 at 1:35 p.m., CNA #3 reported staff should stay with a resident while on the bed pan. On 06/28/22 at 1:45 p.m., RN #1 reported if the resident was placed on the bed pan staff should have checked on them within a few minutes. On 06/28/22 at 3:38 p.m., the DON reported being unaware of a resident being left on a bed pan. 2. Res #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial assessment, dated 06/08/22, documented Res #2 was cognitively intact and required extensive assistance with activities of daily living. A care plan, initiated on 06/09/22, read in parts personal hygiene 1 staff participation with personal hygiene On 06/28/22 at 12:42 p.m., FM #2 reported the staff had left Res #2 naked and uncovered for two hours or so. FM #2 stated the staff were preparing to bathe Res #2, undressed the resident, left the room, and did not leave a call light in reach. FM #2 stated Res #2 was scared and screaming for staff to help them. FM #2 stated they had informed the administrator of the incident. On 06/28/22 at 3:30 p.m., CNA #1 reported they were informed of the incident the next morning by CNA #2. On 06/28/22 at 3:32 p.m., CNA #2 reported on the night of the occurrence, at the beginning of the shift, they observed Res #2 in bed, crying, naked, and without any covering on them. CNA #2 reported Res #2 reported to them the staff were preparing to be give them a bed bath, left the room, and did not return. CNA #2 reported they had reported the occurrence to the charge nurse. On 06/28/22 at 3:40 p.m., the DON stated, I am unaware of any resident being naked and crying. On 06/28/22 at 3:45 p.m., the administrator reported they were unaware of the occurrence.

Based on record review and resident and staff interviews, it was determined the facility failed to ensure: ~ there was a system in place to reconcile controlled medications for one (#135) of two sampled residents reviewed for reconciliation of a controlled medication and ~ medications were administered as ordered for two (#28 and #133) of seven sampled residents reviewed for medication administration. The director of nursing (DON) identified 46 residents who had orders for narcotic pain medication, 21 residents who had orders for [MEDICATION(S)] and one resident who had orders for an intravenous antibiotic. Findings: 1. A med destruction and donation policy addendum, dated 11/07/17, documented, .Dced narcotics will be stored under double lock. Only the director of nursing and assistant director of nursing together will have access to medication destruction area. 'Medication destruction record' sheets will be with each narcotic. Count sheets for dced narcotics will be stored in a separate book away for the controlled medication .The DON will sign the count sheet when he/she receives the medication to insure the count is correct. The certified medication aide (CMA) or licensed practical nurse (LPN) who is surrendering the medication to the DON will also sign the count sheet . Resident #135 was admitted on [DATE] with diagnoses which included a fracture to his left femur and malignant neoplasm of bronchus or lungs. A packing slip, dated 06/12/20, documented the facility received 30 oxycodone 5 mg tabs for the resident. A narcotic record, dated 06/12/20, documented the facility received 30 oxycodone 5 mg tabs for the resident. The narcotic record also documented all thirty pills were given between 6/12/20 through 6/15/20. A packing slip, dated 06/15/20, documented the facility received 180 oxycodone 5 mg tabs for the resident. This made a total of 210 oxycodone 5 mg tabs received by the facility. A narcotic record, dated 06/15/20 at 11:28 a.m., documented oxycodone 5 mg two tabs had been taken out of stock, but refused by the resident. The MAR, dated 06//15/21 at 11:28 a.m., documented the oxycodone was given to the resident. There was no documentation the controlled medications were refused and discarded by the nurse and the medication aide. A narcotic record, dated 06/15/20, documented oxycodone 5 mg two tabs given at 11:42 AM, fourteen minutes later than the last entry. The MAR, dated 06/15/21 contained no documentation to indicate the medication given at 11:42 AM. There was no documentation these controlled medications were refused and discarded by the nurse and the medication aide. A narcotic record, dated 6/16/20, documented 120 oxycodone 5 mg tabs were received. The narcotic record did not show any medications were given out of the 120 oxycodone 5 mg tabs. There were no narcotic records to account for the additional 60 oxycodone tablets which were delivered on 06/15/20. An admission assessment, dated 06/17/20, documented the resident was cognitively intact, received routine and/or PRN pain medication. The assessment further documented the resident had occasional moderate pain and had received opioid medication. A medication release on leave of absence/discharge form, dated 06/17/20, documented the medications which were released with the resident. The form did not included the oxycodone 5 mg tablets. A discharge summary note, dated 06/19/20, documented all medications except narcotics had been discharged with the resident. The discharge summary documented the resident left the facility against medical advice (AMA). An undated medication destruction record, documented oxycodone 5 mg tabs with a total of 120 tablets remaining to destroy. The medication destruction record had large letters written with a pink highlighter which documented across the paper, went home with family. There was no documentation to indicate the oxycodone had been destroyed. The MAR, dated June 2020, documented the facility administered 39 oxycodone 5 mg tabs during the residents stay. This left 171 oxycodone 5 mg tablets unaccounted for. On 04/27/21 at 4:18 p.m., the director of nursing (DON) was asked if all 210 pills received were accounted for on the narcotics log. She said they were not accounted for, there must be a narcotic log missing. She then stated she could not locate a narcotic sheet to account for the additional 60 pills. She was asked for a destruction sheet for the 171 narcotics pills not accounted for. She said there was not a destruction sheet for the narcotics. The DON was made aware of the discrepancy between the narcotic log and the MAR. She was also made aware of the narcotics which were recorded as refused, not documented on the MAR, not signed by a witness and had no corresponding nurses notes. She agreed the records did not match. On 04/28/21 at 1:00 p.m., the medication destruction storage closet was observed. There were narcotic medications which were being held for destruction but could not be destroyed due to the narcotic log count sheet not being found. The DON said the pharmacist refused to destroy the medications without verification of the amount to be destroyed. On 04/28/21 at 1:10 p.m., the DON was asked if the medications being held for destruction should have a narcotic count log and should it be signed by a witness to ensure correct count. The DON said it should have a narcotic count record and it should be signed by two people. It should also have a destruction sheet attached to it for destruction. 2. Resident #28 had diagnoses which included [CONDITION(S)]. A physician's order, dated 12/16/20, documented, the resident was to receive [MEDICATION(S)] tablet 50 micrograms one time a day at 7:00 a.m. A quarterly resident assessment, dated 02/22/21, documented the resident's cognition was intact. On 04/19/21 at 10:15 a.m., the resident was asked if she received her medications as ordered. She stated she was supposed to get her [MEDICATION(S)] between 6:00 a.m. and 7:00 a.m. but she doesn't always get it. An April 2021 administration history report documented the resident's [MEDICATION(S)] was administered: ~ 04/20/21 at 8:07 a.m., ~ 04/22/21 at 8:53 a.m., ~ 04/23/21 at 8:16 a.m., ~ 04/24/21 at 10:57 a.m., and ~ 04/25/21 at 10:26 a.m On 04/26/21 at 2:00 PM, certified medication aide (CMA) #1 was asked to review the resident's [MEDICATION(S)] order. She was asked when the medication was to be administered. She stated the medication was due at 7:00 a.m. She stated the resident has to get her [MEDICATION(S)] at least 30 minutes before she eats. She stated the medication should be administered by 7:30 a.m. or 7:45 a.m. She was shown the above administration history report and acknowledged the findings. At 2:15 PM, the corporate registered nurse was asked what the policy was for administering medications. She stated they had an open medication pass which was a four hour window unless the order specified a time the medication was to be administered. She stated if the order specified a time the medication could be administered one hour before or one hour after. She was made aware of the above administration times for the resident's [MEDICATION(S)]. She acknowledged the findings. 3. Resident #133 had diagnoses which included chronic [CONDITION(S)] to the left ankle and foot. A physician's order, dated 10/12/20, documented the resident was to receive [MEDICATION(S)] solution reconstituted 3.375 grams intravenously every 6 hours. The October 2020 treatment administration record (TAR) documented the resident's [MEDICATION(S)] was to be administered intravenously at 2:00 a.m., 8:00 a.m., 2:00 p.m. and 8:00 p.m. There were blanks where the 2:00 a.m. dose was to be administered on 10/13, 10/14 and 10/15/20 and the 2:00 p.m. dose on 10/23/20. On 04/27/21 at 10:55 a.m., the corporate nurse was shown the TAR. She was asked what the blanks indicated. She stated it meant the medication was not administered.

Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene related to [CONDITION(S)] for two (#20 and #234) of three residents sampled for [CONDITION(S)]. The director of nursing (DON) identified 15 residents who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse note, dated 02/10/21, documented oxygen (O2) saturation 92 on room air, clear lung sounds, no shortness of breath (SOB), and mild [CONDITION(S)] noted to the left lower extremity. An admission assessment, dated 02/16/21, documented the resident was severely cognitively impaired, required extensive assistance with activities of daily living, did not walk, had shortness of breath with exertion, was 61 inches tall and weighed 129 pounds (lbs), and did not receive diuretic medication. A nurse note, dated 02/26/21, documented lungs clear to auscultation, no cough present, bilateral pitting [CONDITION(S)] +3 to lower legs and feet. The note did not document physician notification. A nurse progress note, dated 03/17/21, documented the resident continued antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented oxygen saturation was 90% and 1+ [CONDITION(S)] noted to bilateral feet. A skilled daily assessment, dated 04/13/21, documented the resident had +1 [CONDITION(S)]. A skilled daily assessment, dated 04/16/21, documented the resident had +1 [CONDITION(S)]. The electronic record documented the resident's weights as the following: 02/10/21 - 124.0 lbs 02/11/21 - 128.6 lbs 02/18/21 - 133.5 lbs 02/25/21 - 134.0 lbs 03/04/21 - 134.0 lbs 03/10/21 - 131.5 lbs 03/18/21 - 128.0 lbs 04/13/21 - 130.5 lbs The care plan, dated 02/16/21, documented the resident had hypertension and [CONDITION(S)] heart disease of native coronary artery without [CONDITION(S)] pectoris. The care plan documented to monitor for and document any [CONDITION(S)] and notify the physician. On 04/20/21 at 8:56 AM, licensed practical nurse (LPN) # 2 was asked if she would assess the resident's lower extremities related to [CONDITION(S)]. She assessed the resident as having +3 pitting [CONDITION(S)] in her ankles and top of feet. On 04/21/21 at 1:27 PM, LPN #3 who worked the resident's hall, was asked if the resident had [CONDITION(S)]. The LPN stated she did not know, had not checked for it. She said the certified nurse aides (CNAs) would let her know if they noticed any [CONDITION(S)]. She said it was normal for the resident to have expiratory wheezing. On 04/21/21 at 3:52 PM, the DON was asked to assess the resident's lower extremities for [CONDITION(S)]. She stated the resident's legs and feet were swollen. The DON stated there was +3 pitting [CONDITION(S)] around the ankle area and the swelling around her knees was not pitting [CONDITION(S)]. She stated the physician should be notified of any new or worsening [CONDITION(S)]. The DON was informed there were only five times the resident's [CONDITION(S)] was documented since her admit in February. 2. Resident #234 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 04/15/21, documented the resident was severely cognitively impaired, required assistance with activities of daily living, and did not receive a diuretic. A review of skilled nurse notes documented no swelling until 4/19/21. A physician note, dated 4/19/21, documented the resident had 1+ pitting [CONDITION(S)] bilateral mid-tibias. A skilled nurse note, dated 4/19/21, documented the resident was noted with 2 + pitting [CONDITION(S)]. A skilled nurse note, dated 04/20/21, documented no [CONDITION(S)] present. A skilled nurse noted, dated 04/21/21, documented no [CONDITION(S)] present. Skilled nurse notes, dated 04/22/21 through 04/25/21, documented three plus pitting [CONDITION(S)]. On 04/27/21 at 8:01 AM, certified nurse aide (CNA) #1 was asked to look at the resident's legs and feet. She was asked if the resident had swelling. She said they were swollen but not as bad as they were last week. She was asked if the aides were supposed to notify anyone if a resident had swelling. She said anytime there was new or worsening swelling identified the aides notified the nurse. On 04/27/21 at 9:20 AM, licensed practical nurse (LPN) #4 looked at the resident legs and feet and identified three plus pitting [CONDITION(S)]. The nurse was asked if this was normal or an increased amount of swelling. She said she felt like the resident had always had swelling but this was an increased amount. She was asked to review nurse notes. She was asked if the swelling was new what should the nurse do. She said the nurse should notify the physician, notify management, and talk to family and notify of change. She said she had not notified the physician about the increased swelling.

Based on observation, record review, and staff interview, it was determined the facility to ensure the menu was followed and bread was served for one (the lunch meal service) of two meals observed. The facility identified 70 residents with diet orders who could receive bread. Findings: On 04/26/21 at 11:30 a.m., the lunch meal service was observed in the main dining room. There was no lunch menu posted. Dietary staff was not observed offering residents a bread choice with their meal. At 12:02 p.m., the diet spreadsheet for the lunch menu was reviewed. It documented residents who received a regular, no added salt, mechanical soft, low concentrated sweets, healthy heart or renal diet were to have received a bread choice of either a roll or slice of bread with their meal. At 2:40 p.m., the dietary manager was asked how staff knew what was to be served to the residents at each meal. He stated there were weekly menus on what was to be cooked and served. He was shown the menu which indicated residents were to have received bread with their lunch menu and he was made aware of the observations. He stated the residents didn't usually want the bread but they still should have been asked.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the failure of the facility to assess and monitor resident #3 following a change in condition related to level of consciousness. The existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 5:35 p.m., the administrator (ADM), the director of nursing (DON) and the corporate nurse were notified of the existence of the IJ. On [DATE] at 11:35 a.m., an acceptable plan of removal was received from the ADM. The plan of removal documented, 29 [DATE] PLAN OF REMOVAL FOR IJ R/T (related to) Failure to Assess, Monitor, and Intervene 1. All licensed nursing staff will be re-educated regarding the facility policy on assessment, monitoring and intervention of a change in condition and on following physician ordered directives related to a change in condition on a case by case basis by 11:59p.m. (sic) on [DATE] or prior to to returning to work at the facility. All licensed nursing staff will further be re-educated on documenting q (every) shift for [MEDICATION NAME] (sic) patch placement and adverse reactions by 11:59p.m. (sic) on [DATE]. 2. Residents identified as having a change in condition will be listed on communication board in PCC (Point Click Care software) along with the frequency of monitoring per facility policy or as directed by the physician. 3. DON and/or designee will audit nursing documentation and resident status following a significant error or change in condition daily in the Q2 (quality 2) meeting to ensure compliance. (Name Deleted), Administrator. On [DATE], four licensed practical nurses (LPNs) were interviewed. They were asked if they had been inserviced recently and what the inservice covered. All of the LPNs stated they had been inserviced recently about assessing, monitoring and intervening when residents had a change in condition, monitoring after a significant medication error or change in condition and physician notification. The IJ was removed on [DATE] at 11:59 p.m., after all components of the plan of removal had been carried out. The deficient practice remained at a level of harm, at a pattern. Based on record review and staff and family interviews, it was determined the facility failed to: ~ assess, monitor and intervene for a resident who experienced a change in level of consciousness following a significant medication error for one (#3) of seven sampled residents reviewed for assessing monitoring and intervening; and ~ assess and monitor a resident's [MEDICATION NAME] every shift for one (#1) of three sampled residents reviewed for [MEDICATION NAME]es. The facility identified 81 residents resided in the facility. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive resident assessment had not been completed prior to the resident's discharge on [DATE]. A comprehensive care plan had not been fully developed prior to the resident's discharge on [DATE]. A daily care plan, dated [DATE], documented the resident was continent, used a commode and had a [MEDICAL CONDITION] under the elimination section. It documented the resident was able to ambulate with the assistance of one staff member and required staff assistance with her wheelchair under the mobility section. It documented the resident was alert and oriented under the cognitive section. A physician's orders [REDACTED]. A hospice physician's orders [REDACTED].D/C (discontinue) Fentany (sic) patch .[MEDICATION NAME] CR (controlled release) 12 h (hour) (MS ([MEDICATION NAME]) Contin) 30 mg (milligram) tablet take (one) tab by mouth every 12 h . A physician's telephone order, dated [DATE], documented, .[MEDICATION NAME] Extended Release 30 MG ([MEDICATION NAME] ER (extended release)) Give 1 tablet by mouth every 12 hours related to OTHER CHRONIC PAIN . A physician's telephone order, dated [DATE], documented, .[MEDICATION NAME]-100 Patch 72 Hour 100 MCG(microgram)/HR (hour) ([MEDICATION NAME]) Apply 1 patch [MEDICATION NAME] one time a day every 3 day(s) related to OTHER CHRONIC PAIN .apply with [MEDICATION NAME] 37.5 mcg to (equal) 137.5mcg. D/C when [MEDICATION NAME]. and remove per schedule . A physician's telephone order, dated [DATE], documented, .[MEDICATION NAME] Patch 72 Hour 37.5 MCG/HR Apply 1 patch [MEDICATION NAME] one time a day every 3 day(s) related to OTHER CHRONIC PAIN .apply with 100 mcg patch to (equal) 137.5mcg. May D/C when [MEDICATION NAME]. and remove per schedule . An admission note, dated [DATE] at 1:00 p.m., documented, .Focused assessment r/t admission. Resident arrived via private vehicle with daughter accompanying her. Resident is coming from home admitted to LTC (long term care) and (hospice provider name deleted) under the care of (physician name deleted). Alert and oriented x(times)3. Wears glasses and has partial upper denture. Lungs CYS (unknown abbreviation) bilaterally. No open areas, redness noted to B/I (unknown abbreviation) buttocks and inner aspect of right foot, A & D (vitamin A and D ointment) applied. Noted with large hernia to right lower abdomen, daughter also reports hiatal hernia that is inoperable because is it (sic) to (sic) close to the heart and [MEDICAL CONDITION] to left lower abdomen. Noted with RLE (right lower extremity) ,[DATE] + (plus)[MEDICAL CONDITION]/ LLE (left lower extremity) 1 + [MEDICAL CONDITION]. Continent of B&B (bowel and bladder). Resident is one person assist d/t (due/to) general weakness and has a hx (history) of fall 3 weeks ago per daughter. Tab (brand name) alarm and call light placed within reach. VS (vital signs) 97.5-,[DATE]-[DATE]% on RA (room air). (Physician name deleted) on call for (physician name deleted) notified of admission with order clarification to D/C [MEDICATION NAME] and start [MEDICATION NAME] mg q 12 hours when medication arrives (per (physician name deleted) new script), DON (name deleted), pharmacy and daughter here and aware of admission. No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 1:00 p.m. to [DATE] at 10:26 p.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 10:26 p.m., documented, .Focused assessment r/t admission. Res (resident) in bed A & O (alert and oriented) x3 pupils equal round reactive to light, T (temperature) 98.7 p (pulse) 71 bp (blood pressure) ,[DATE] r (respirations) 16 spo2 (peripheral capillary oxygen saturation) 96% RA (room air), lungs clear bil. (bilaterally), bs (bowel sounds) positive x 4 quads (quadrants) [MEDICAL CONDITION] to bil lower extremities. Res denies discomfort. voided x3, makes needs known, res ate 50% of supper and drank 360 cc (cubic centimeters) of fluids. res appears to be adjusting well at this time, family at bedside, call light in reach, alarm in place . A nurse progress note, dated [DATE] at 3:45 a.m., documented, .Focused assessment r/t admission. Resident continues with monitoring r/t new admission to LTC. v/s 97XXX[DATE]-,[DATE]-97% @ (at) RA. Resident resting in bed. [MEDICAL CONDITION] in place and secure. Currently resting in bed with 0 (zero) c/o (complaints of) pain or discomfort. Call light in reach . No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 3:45 a.m., to [DATE] at 2:18 p.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 2:18 p.m., documented, .Focused assessment r/t admission. Resident A & O x3. T97.9 p56 bp ,[DATE] r18 spo2 96% RA, lungs CTA (clear to auscultation), bowel sounds positive x 4 quads [MEDICAL CONDITION] to bil lower extremities. Resident noted with decreased LOC (level of consciousness)/slow to respond with eyes open and VS stable, and will monitor d/t change in medication and will pass on to oncoming nurse. Daughter here and aware of situation, call light in reach, alarm in place. VS 97.9-,[DATE]-,[DATE]% (sic) on RA . A late entry nurse progress note, dated [DATE] at 2:20 p.m., documented, .Focused assessment r/t medication. (Physician name deleted) on call for (physician name deleted) notified that [MEDICATION NAME]es were not removed when [MEDICATION NAME] started but have since been removed. Will continue to monitor . No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 2:20 p.m. to [DATE] at 10:56 p.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 10:56 p.m., documented, .Focused assessment r/t admission. Resident A&Ox1, slow to respond, noted with increased lethargy this shift, skin color appears pale, LCTA (lungs clear to auscultation), BS active x 4, B/L (bilateral) LE (lower extremities) non-[MEDICAL CONDITION] noted, redness noted to coccyx A & D applied, redness noted to inner aspect of right foot, A & D applied, large hernia noted to right lower abdomen, [MEDICAL CONDITION] noted to left lower abdomen. Resident denies pain at this time. Daughter (name deleted) at bedside and aware of residents (sic) current condition. This nurse notified on call (physician name deleted) (on call for (physician name deleted)) of residents current condition and hospice status, received orders to notify hospice to come to facility and assess resident, no additional orders received. This nurse contacted (hospice name deleted) and informed of situation. (name deleted) LPN (licensed practical nurse) arrived to this facility @ 1900 (7 p.m.) and assessed resident, no orders received at this time, hospice nurse stated, Her vitals are stable, she is slow to respond but alert, she has no c/o pain, lets continue to monitor and call us back if any changes occur or you need anything else. Information passed on to on-coming nurse (name deleted) LPN. VS ,[DATE], T97.2, P53, R14, Spo2 97%RA . A discontinued physician's telephone order, dated [DATE] at 3:08 p.m., documented, .[MEDICATION NAME] Patch 72 Hour 37.5 MCG/HR Apply 1 patch [MEDICATION NAME] one time a day every 3 day(s) related to OTHER CHRONIC PAIN .apply with 100 mcg patch to (equal) 137.5mcg. May D/C when [MEDICATION NAME]. and remove per schedule .Discontinue Date / Reason .[MEDICATION NAME] . A discontinued physician's telephone order, dated [DATE] at 3:09 p.m., documented, .[MEDICATION NAME]-100 Patch 72 Hour 100 MCG/HR ([MEDICATION NAME]) Apply 1 patch [MEDICATION NAME] one time a day every 3 day(s) related to OTHER CHRONIC PAIN .apply with [MEDICATION NAME] 37.5 mcg to (equal) 137.5mcg. D/C when [MEDICATION NAME]. and remove per schedule .Discontinue Date / Reason .[MEDICATION NAME] . An admission note, dated [DATE] at 2:25 a.m., documented, .Focused assessment r/t admission. Resident continues with monitoring r/t new admission to LTC. v/s 98XXX[DATE]-,[DATE]-95%@RA. Resident resting in bed. [MEDICAL CONDITION] in place and secure. Currently resting in bed with 0 c/o pain or discomfort. Call light in reach . No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 2:25 a.m. to [DATE] at 2:28 p.m. was located in he resident's clinical record. A family/resident grievance form, dated [DATE], documented, .(name deleted), dtr (daughter), voices concern regarding 1) Medication Error R/T continued [MEDICATION NAME] Patch 2) change of hospice service 3) mother's condition .reported to team that her mother's cognition was not the same because she will not speak to her but in short answers. (DON name deleted) stated to Dtr that @ breakfast the resident was served by (DON name deleted) and she sat on the side of the bed and answered appropriately to any questions that were asked .She also stated she wont eat or drink for me, she just isn't the same. (DON name deleted) explained to the dtr that the incident was being investigated so that it did not occur again. Dtr stated I don't know why there was a change in her medication other than the hospice wouldn't cover it which makes me very upset because her (hospice agency prior to admission name deleted) was covering it.(quality manager staff name deleted) requested that she be able to go and see her mother to evaluate her. Dtr (name deleted) refused and stated No, she wants to be left alone. All team members stated to daughter that she would continue to be monitored and any changes in condition would be called to the physician for further orders. Dtr (name deleted) stated, My mother is not a social person. She doesn't talk to people very often and she doesn't like to socialize. That's why I really liked (hospice agency prior to admission name deleted) and wanted to keep them because she was used to them, but I understand using (facility contracted hospice name deleted).2pm Daughter left facility. Resident alert + speaks to writer in short sentences. is watching T.V. (television) Denies any c/o distress or pain No SOB (shortness of breath) or sedation observed.(DON name deleted) . A facility Medication Incident Report, dated [DATE], documented, .Resident (resident #3) .Physician (name deleted) Date of Incident [DATE] .Time of incident PM .What was physician's orders [REDACTED].O. (by mouth) Q (every) 12 (hour) .What was given? [MEDICATION NAME] Patch was not removed per order .Reason for Incident: Med (medication) aide gave 2 doses of [MEDICATION NAME] nurse found [MEDICATION NAME] Patch was still in place .What is the actual effect of the incident on the resident? Increased sedation, How was the incident discovered? Resident assessment due to increased sedation .By whom? (nurse's name deleted) .When? [DATE] @ (at) 14:20 .Who notified the physician? (nurse's name deleted) .When? [DATE] @ 14:20 .What precautions can you take to prevent similar incident? Inserviced nurses/cma (certified medication aides) on [MEDICATION NAME] Patch Destruction .Administrator (name deleted) .Signature of Individual Filling Out This Report (name deleted) .Signature: Nurse Involved In Incident (name deleted) .Signature: Director of Nursing (name deleted) .Spoke with (nurse,name deleted) Stated she was under the belief that the [MEDICATION NAME] Patch was to be left on until MS came in. Explained that is why she did not remove the patch @ that time . A facility In-Service Educational Program sheet, dated [DATE], documented, .Subject Of Discussion: [MEDICATION NAME] Patch Destruction Sheet .Scope Of Meeting - Resume: All nurses and CMA are to Remove [MEDICATION NAME] Patches together and fill out the correct Form (see attached) (symbol undetermined) is to cut/flush Patch . The form documented eleven staff signatures. The attached sheet, titled [MEDICATION NAME] PATCH COUNT/DESTRUCTION SHEET documented, PT. (patient) NAME .DR. (doctor) .PATCH STRENGTH .RX (prescription) # .AMT. (amount) REC'D (received) .AMT. ON HAND .NURSE APPLYING PATCH .DATE .NURSE DESTROYING PATCH .WITNESS .AMOUNT APPLIED .AMT REMAINING . A facility In-Service Educational Program sheet, dated [DATE], documented, .Subject Of Discussion: [MEDICATION NAME] Charting .Scope Of Meeting - Resume: All residents with [MEDICATION NAME] Patch orders will have documentation each shift regarding current placement, verification that the correct amount is in place, any side effects such as increased lethargy, redness or swelling at the site. All [MEDICATION NAME] will be placed on the nurse's treatment carts in the lock box and will have the nurses perform an on shift and off shift count every shift. This is not optional . The form documented eight staff nurse signatures. An active employee list was provided by the administrator. The list documented 16 active nurses (licensed practical nurses/registered nurses) were currently employed by the facility. The list documented 5 CMAs were currently employed by the facility. A nurse progress note, dated [DATE] at 2:28 p.m., documented, .Focused assessment r/t admission. Resident continues with monitoring r/t new admission to LTC. VS 97XXX[DATE]-,[DATE]-95%@RA. Resident resting in bed. [MEDICAL CONDITION] in place and secure. Denies any c/o pain or discomfort. Call light within reach. Resident still remains slow to respond but more alert and talkative at this time . A nurse progress note, dated [DATE] at 7:38 p.m., documented, .Focus assessment r/t admission to LTC. Resident resting in bed most of this shift, A&Ox1, slow to respond. [MEDICAL CONDITION] in place and secure. Resident denies pain or discomfort at this time. call light with in reach. VS ,[DATE], T97.3, P59, R15, Spo2 96%RA . A physician's telephone order, dated [DATE], documented, .[MEDICATION NAME]-50 Patch 72 Hour 50 MCG/HR ([MEDICATION NAME]) Apply 1 patch [MEDICATION NAME] one time a day related to OTHER CHRONIC PAIN .and remove per schedule . A [MEDICATION NAME] count/destruction sheet, dated [DATE], documented a nurse applied a 50 MCG/HR patch and destroyed a [MEDICATION NAME] which was signed as witnessed by another staff member. It documented one patch was applied and the amount remaining was four. No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 7:38 p.m. to [DATE] at 2:23 p.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 2:23 p.m., documented, .Focus assessment r/t admission to LTC. Resident resting in bed most of this shift, A&Ox1, slow to respond. [MEDICAL CONDITION] in place and secure. Resident denies pain or discomfort at this time. Restarted on [MEDICATION NAME] his (sic) shift, no s/s (signs/symptoms) adverse reaction noted at this tome (sic). Daughter (name deleted) spoken to and made aware of resident decreased po (by mouth) intake and requiring more assistance. (hospice name deleted) nurse here to see resident and new orders received for PRN (as needed) tylenol, daughter (name deleted) notified. Call light within reach. VS ,[DATE], T97.4, P60, R18, Spo2 94%RA . No documentation of the events surrounding the resident having been placed back on the [MEDICATION NAME] was located in the resident's clinical record. No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 2:23 p.m. to [DATE] at 10:45 a.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 10:45 a.m., documented, .Res resting in bed B/P was taken at this time B/P was ,[DATE] RR (respiratory rate) 34 P 57 O2 (oxygen) was 93% on 3 LPM (liters per minute) via NC (nasal cannula). Skin was warm and calmy (sic) to touch noted mottling to her feet and to her fingertips. Res was using her accessory muscles during respirations. This nurse notified hospice as well as daughter (name deleted) . A nurse progress note, dated [DATE] at 11:30 a.m., documented, .Daughter (name deleted) here at bedside with Res . A nurse progress note, dated [DATE] at 1:41 p.m., documented, .Res was noted to have no pulse no blood pressure and no heart rate. Hospice and family members at bedside. Hospice nurse notified funeral home as well as provider . The hospice provider death summary, dated [DATE], documented, .Received a call from facility. Upon arrival CN(charge nurse) (name deleted) reports pt (patient) with low bp and diaphoretic. This nurse walked in to (sic) pt's room to perform assessment, pt's daughter and family friend at bed. Pt without vital signs or respirations. This nurse called MD (medical doctor) (name deleted) and unable to reach. MD (name deleted) called and notified of pt without vital signs or respirations . No documentation of the resident having been assessed/monitored by facility nursing staff from [DATE] at 10:45 a.m. until the resident's death at 1:41 p.m. on [DATE] was located in the resident's clinical record. A [DATE] treatment administration record (TAR) documented a [MEDICATION NAME]-50 Patch 72 hour MCG/HR ([MEDICATION NAME]) was applied to the resident on [DATE] at 9:00 a.m. and was removed on [DATE] at 11:09 a.m. A [DATE] Medication Administration Record [REDACTED]. It documented the resident received one 4 mg tablet of [MEDICATION NAME] at 10:45 p.m on [DATE], at 11:26 a.m. on [DATE] and at 3:09 a.m. on [DATE]. The reason the medication was administered was not documented. No documentation was located in the resident's clinical record to explain the reason the resident was given their as needed [MEDICATION NAME], and whether the resident was experiencing nausea or vomiting or both. The [DATE] meal percentage report, documented on [DATE] the resident consumed 51% - 75% of her lunch and 26% - 50% of her dinner meal. On [DATE] the resident consumed 51% - 75% of her breakfast, lunch and dinner meals. On [DATE] the resident consumed 0 - 25% of her breakfast and dinner meals and consumed 0 - 25% of a meal replacement. She refused her lunch meal. On [DATE] the resident refused her breakfast meal. She consumed 26% - 50% of her lunch meal and 26% - 50% of a meal replacement. She consumed 0 - 25% of her dinner meal and 0 - 25% of a meal replacement. On [DATE] the resident refused her breakfast and lunch meal. She consumed 0 - 25% of her dinner meal and 0 - 25% of a meal replacement. On [DATE] the resident refused breakfast. On [DATE] at 8:50 a.m., while the survey team was conducting an environmental tour of the facility, the DON asked to speak in private to a survey team member. She stated she knew why the survey team was there and knew what it was about. She stated resident #3 was on a [MEDICATION NAME]/[MEDICATION NAME] when she admitted to the facility. She stated she believed the facility staff discontinued the patches and started the resident on [MEDICATION NAME] she believed that Saturday. She stated she believed the first dose of [MEDICATION NAME] was given Saturday night and another dose was given the following morning. She stated that was when the nurse discovered the [MEDICATION NAME]es were still on. She stated the resident was lethargic. She stated the resident's doctor was notified. She stated the staff were performing frequent checks on the resident. She stated when the hospice came out to the facility, they took the resident off of the [MEDICATION NAME]es and started the [MEDICATION NAME]. She stated she was unsure of why. The DON stated she conducted an investigation related to the medication error. She stated the nurse thought hospice wrote to discontinue the patch when the [MEDICATION NAME] came in. However the order was not followed. The DON stated she completed an inservice. She stated the facility was watching all three residents on [MEDICATION NAME]es and checked the patches every shift on a daily basis. She stated the facility also moved the [MEDICATION NAME]es from the medication carts to the treatment carts in order for the nurses to complete the monitoring. She stated the resident's daughter reported the resident was nonresponsive. She stated the resident spoke to staff. She stated the resident was upset the daughter put her in a nursing home. She stated the resident wouldn't eat, so the facility ordered supplements. She stated several days later the resident was speaking to the facility staff. She stated hospice had provided care to the resident. She stated the resident steadily declined several days after this. (No documentation was located in the resident's clinical record to reflect this.) She stated the facility completed a medication error and notified the physician about the patch having not been removed. At 9:14 a.m., a confidential family interview was conducted for resident #3. The family member was asked to describe the events surrounding their family members stay at the facility. He/She stated the family member was admitted to the facility because they required around the clock nursing care at home which was expensive. He/She stated the hospice provider whom the facility staff told them they had to use stated they would not cover the [MEDICATION NAME]/[MEDICATION NAME]es which his/her family member was on at home. They stated the hospice provider they had at home did cover the patches. They stated they had taken their loved one to their primary care physician and obtained a hard script for the [MEDICATION NAME] pills. They stated when their loved one was admitted to the facility they had two [MEDICATION NAME]/ [MEDICATION NAME]es on which had been placed the day prior to admission. He/She stated the admitting nurse was aware the resident had two [MEDICATION NAME]es in place on admission. He/She stated the admitting nurse stated they would confirm the physician's orders [REDACTED]. He/She stated the only reason the medication was changed from [MEDICATION NAME]es to the [MEDICATION NAME] pills was because the hospice would not cover the patches and it would have cost over $600 per month. He/She stated they believed that was what killed their loved one. They stated when they arrived at the facility the next morning, their loved one was lying on their back in bed choking on vomit and out of it. They stated when they asked what was wrong with their loved one the staff stated it could have been a result of transitioning to the nursing home. He/She stated they asked the nurse, Did you take those patches off? He/She stated the nurse never answered them. He/She stated then the nurse said they had removed the patches. The family asked when. The staff stated to the family they had just removed the patches and they were in the nurses' pocket. He/She stated they had told the nurse the resident was overdosed. He/She stated they were never able to have a conversation with the named resident again. They stated when the resident came into the facility she could verbalize her needs and even sign her own checks. He/She stated it all changed when the facility overdosed the resident. He/She stated, They pushed her over the edge. He/She stated the resident's physician who had been treating her for her blood disorder (her hospice diagnosis) , had stated the normal aging process would kill the resident before the disease process would. He/She stated it was around the following Monday the DON, ADM and a third person came in and assured him/her they were conducting an investigation related to the medication error. He/She asked them not to speak in front of the resident because it would upset them. He/She stated they all went into the hall. The family member pointed out the nurse who made the medication error and informed the staff the nurse never notified hospice on her shift. He/She stated the facility had never followed up with them on the findings of the investigation. He/She stated the facility admitted they overdosed her. He/She stated the day the resident died , they were called and informed the resident had experienced changes overnight. He/She stated when they arrived to the facility, the resident was guppy breathing. He/She stated they had read information about guppy breathing and mottling from the resident's prior hospice. He/She stated they removed the resident's covers and observed mottling on the resident's legs and a cut on her knee. He/She asked the nurse what had happened to the resident's knee. They stated they had no idea how the cut had happened. The family member stated the hospice provider did not arrive to the facility until after the resident had died . They stated when the resident was followed by a local hospice at home, the family could call them and they would be right out. They stated the hospice provider the facility used was located in Oklahoma City. The family member stated resident #3 had always said putting her in the nursing home was like Taking her to the pound. The family member stated, It's the worst mistake I ever made. At 12:26 p.m., the DON was asked for all documentation related to the monitoring for oversedation for resident #3 following the medication error. At 12:35 p.m., the DON stated she reviewed the notes. She stated the monitoring was in the progress note/nurse notes. She was asked to review the note on [DATE] at 2:18 p.m. which documented the resident had a decrease in level of consciousness, was slow to respond, would continue to monitor due to change in medication and would pass on to oncoming nurse. She was asked to review the late note on [DATE] at 2:20 p.m. which documented the physician was notified of the [MEDICATION NAME]es not being removed when the [MEDICATION NAME] was started, would continue to monitor. She was asked to review the next note which was completed at 10:56 p.m. She was asked if any monitoring related to the oversedation occurred between these notes. She stated no. The next note was in eight hours. She stated the staff probably charted every shift. At 1:10 p.m., the DON returned and began to explain resident #3's [MEDICATION NAME] was later restarted and the resident's [MEDICATION NAME] was discontinued. She stated the resident's decline was not from the [MEDICATION NAME]. She stated the resident was started back on a [MEDICATION NAME] because the resident's daughter did not want the [MEDICATION NAME] and wanted the resident put back on the [MEDICATION NAME]. The DON stated the resident's daughter stated the facility hospice provider would not cover the [MEDICATION NAME]. The DON stated it did not make sense why hospice wouldn't cover the [MEDICATION NAME]. She was asked if resident #3 was involved in a medication error involving the [MEDICATION NAME]es. She stated yes the [MEDICATION NAME] was left on and yes the resident did have increased lethargy. The DON was shown the facility progress/nurse notes where the resident admitted to the facility alert and oriented x 3 and after the medication error occurred, the resident's level of consciousness was alert and oriented x 1. She was shown where the documentation never reflected the resident's level of consciousness returned to her baseline after the medication error occurred. She stated the fact was the increased lethargy was because the resident had the [MEDICATION NAME] and the [MEDICATION NAME] together. The DON stated she had went in with the resident every morning and took her her breakfast. She stated the resident was eating after the medication error had occurred. She stated the resident did not really speak with people much. At 1:45 p.m., LPN #1 was interviewed. The corporate nurse and the ADM were present during the interview. LPN #1 was asked to describe the events surrounding the placement of the [MEDICATION NAME] 50 MCG/HR patch on [DATE] where the TAR documented the patch had been applied at 9:00 a.m. and removed at 11:09 a.m. She reviewed the TAR and stated she did apply the patch at 9:00 a.m. She stated she did not remember removing the patch that day. She stated she had to clarify the order and she believed when the order was clarified, the system put the patch was removed because a new order was generated. She was asked if the resident was admitted to the facility with [MEDICATION NAME]es on. She stated, She did 100 and 37.5. She stated the resident's daughter had brought in hard scripts from the physician for both [MEDICATION NAME] and [MEDICATION NAME]. LPN #1 stated she did not believe the physician wanted the resident on both medications. She stated she called and clarified with the physician the order was to discontinue the [MEDICATION NAME]es and start the [MEDICATION NAME] when it came in. LPN #1 was asked if she was present when the [MEDICATION NAME] arrived at the facility. She stated, No. She was asked to explain the events surrounding the [MEDICATION NAME] 50 MCG/HR

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the failure of the facility to ensure residents were free of significant medication errors for resident #3 following a physician's orders [REDACTED]. The existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 5:35 p.m., the administrator (ADM), the director of nursing (DON) and the corporate nurse were notified of the existence of the IJ. On [DATE] at 12:10 p.m., an acceptable plan of removal was received from the ADM. The plan of removal documented, 29 [DATE] PLAN OF REMOVAL FOR IJ R/T (related to) SIGNIFICANT MED (MEDICATION) ERROR 1. All licensed nursing staff will be re-educated on removal of durageic (sic) patches per facility policy and on the facility policy for documentation following significant medication errors by 11:59 p.m. on [DATE] or prior to returning to work at the facility. 2. All CMAs (certified medication aides) were re-educated on [DATE] by 10:50a.m. (sic) regarding immediately notifying charge nurse of any medication errors. One CMA was unavailable and will be inserviced prior to returning to work at the facility. 3. All residents currently in the facility who have prescriptions for durageic (sic) patches will be assessed for signs of adverse effects and patches (sic) placement by a licensed nurse by 11:59p.m. (sic) on [DATE]. 4. DON and/or designee will audit removal/destruction log daily in Q2 (quality 2) meeting for compliance related to facility compliance. (Name Deleted), Administrator On [DATE], four licensed practical nurses (LPNs) were interviewed. They were asked if they had been inserviced recently and what the inservice covered. All of the LPNs stated they had been inserviced recently about [MEDICATION NAME] documentation, monitoring after a significant medication error or change in condition and physician notification. Two CMAs were interviewed. They were asked if they had been recently inserviced and what the inservice covered. Both of the CMAs stated they had been inserviced recently about reporting significant medication errors to a charge nurse. The IJ was removed on [DATE] at 10:45 a.m., after all components of the plan of removal had been carried out. The deficient practice remained at a level of harm, at a pattern. Based on record review and staff and family interviews, it was determined the facility failed to ensure a [MEDICATION NAME]/[MEDICATION NAME] was removed as ordered prior to the administration of two doses of [MEDICATION NAME] which resulted in a significant medication error for one (#3) of seven sampled residents reviewed for signifiant mediction errors. The facility identified three residents resided in the facility with orders for [MEDICATION NAME]/[MEDICATION NAME]es. The facilitly identified three residents with orders for [MEDICATION NAME]. The facility identified resident #3 as the only resident who had experienced a significant medication eror within the past three months. Findings: A medication error an adverse drug reaction reporting policy, revised [DATE], documented, .MISCELLANEOUS SPECIAL SITUATIONS 2. Medication Error and Adverse Drug Reaction Reporting Policy .Significant medication errors and adverse drug reactions are assessed, documented and reported as appropriate to the resident's attending physician, the Quality Assessment and Assurance Committee, the pharmacy and Food and Drug Administration MedWatch Program. Definitions .Adverse Dug Reaction: An undesirable or unintended harmful effect occurring as a result of a medication; an allergic reaction in a patient with no documented history of allergy to the medication. Significant .Medication errors and adverse drug reactions that .require discontinuing a medication or modifying the dose .result in cognitive deterioration or impairment are life threatening result in death Procedures .In the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to protect the resident's safety and welfare .The physician's orders [REDACTED].The incident is described on the shift change report to alert staff of the need to monitor the resident .The following information is documented in the resident's medical record and on the incident report: .Resident's condition for 24 or 72 hours or as directed .The consultant pharmacist reviews all medication error reports . 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive resident assessment had not been completed prior to the resident's discharge on [DATE]. A comprehensive care plan had not been fully developed prior to the resident's discharge on [DATE]. A daily care plan, dated [DATE], documented the resident was continent, used a commode and had a [MEDICAL CONDITION] under the elimination section. It documented the resident was able to ambulate with the assistance of one staff member and required staff assistance with her wheelchair under the mobility section. It documented the resident was alert and oriented under the cognitive section. A physician's orders [REDACTED]. A hospice physician's orders [REDACTED].D/C (discontinue) Fentany (sic) patch .[MEDICATION NAME] CR (controlled release) 12 h (hour) (MS ([MEDICATION NAME]) Contin) 30 mg (milligram) tablet take (one) tab by mouth every 12 h . A physician's telephone order, dated [DATE], documented, .[MEDICATION NAME] Extended Release 30 MG ([MEDICATION NAME] ER (extended release)) Give 1 tablet by mouth every 12 hours related to OTHER CHRONIC PAIN . A physician's telephone order, dated [DATE], documented, .[MEDICATION NAME]-100 Patch 72 Hour 100 MCG(microgram)/HR (hour) ([MEDICATION NAME]) Apply 1 patch [MEDICATION NAME] one time a day every 3 day(s) related to OTHER CHRONIC PAIN .apply with [MEDICATION NAME] 37.5 mcg to (equal) 137.5mcg. D/C when [MEDICATION NAME]. and remove per schedule . A physician's telephone order, dated [DATE], documented, .[MEDICATION NAME] Patch 72 Hour 37.5 MCG/HR Apply 1 patch [MEDICATION NAME] one time a day every 3 day(s) related to OTHER CHRONIC PAIN .apply with 100 mcg patch to (equal) 137.5mcg. May D/C when [MEDICATION NAME]. and remove per schedule . An admission note, dated [DATE] at 1:00 p.m., documented, .Focused assessment r/t admission. Resident arrived via private vehicle with daughter accompanying her. Resident is coming from home admitted to LTC (long term care) and (hospice provider name deleted) under the care of (physician name deleted). Alert and oriented x(times)3. Wears glasses and has partial upper denture. Lungs CYS (unknown abbreviation) bilaterally. No open areas, redness noted to B/I (unknown abbreviation) buttocks and inner aspect of right foot, A & D (vitamin A and D ointment) applied. Noted with large hernia to right lower abdomen, daughter also reports hiatal hernia that is inoperable because is it (sic) to (sic) close to the heart and [MEDICAL CONDITION] to left lower abdomen. Noted with RLE (right lower extremity) ,[DATE] + (plus)[MEDICAL CONDITION]/ LLE (left lower extremity) 1 + [MEDICAL CONDITION]. Continent of B&B (bowel and bladder). Resident is one person assist d/t (due/to) general weakness and has a hx (history) of fall 3 weeks ago per daughter. Tab (brand name) alarm and call light placed within reach. VS (vital signs) 97.5-,[DATE]-[DATE]% on RA (room air). (Physician name deleted) on call for (physician name deleted) notified of admission with order clarification to D/C [MEDICATION NAME] and start [MEDICATION NAME] mg q 12 hours when medication arrives (per (physician name deleted) new script), DON (name deleted), pharmacy and daughter here and aware of admission. No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 1:00 p.m. to [DATE] at 10:26 p.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 10:26 p.m., documented, .Focused assessment r/t admission. Res (resident) in bed A & O (alert and oriented) x3 pupils equal round reactive to light, T (temperature) 98.7 p (pulse) 71 bp (blood pressure) ,[DATE] r (respirations) 16 spo2 (peripheral capillary oxygen saturation) 96% RA (room air), lungs clear bil. (bilaterally), bs (bowel sounds) positive x 4 quads (quadrants) [MEDICAL CONDITION] to bil lower extremities. Res denies discomfort. voided x3, makes needs known, res ate 50% of supper and drank 360 cc (cubic centimeters) of fluids. res appears to be adjusting well at this time, family at bedside, call light in reach, alarm in place . A nurse progress note, dated [DATE] at 3:45 a.m., documented, .Focused assessment r/t admission. Resident continues with monitoring r/t new admission to LTC. v/s 97XXX[DATE]-,[DATE]-97% @ (at) RA. Resident resting in bed. [MEDICAL CONDITION] in place and secure. Currently resting in bed with 0 (zero) c/o (complaints of) pain or discomfort. Call light in reach . No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 3:45 a.m., to [DATE] at 2:18 p.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 2:18 p.m., documented, .Focused assessment r/t admission. Resident A & O x3. T97.9 p56 bp ,[DATE] r18 spo2 96% RA, lungs CTA (clear to auscultation), bowel sounds positive x 4 quads [MEDICAL CONDITION] to bil lower extremities. Resident noted with decreased LOC (level of consciousness)/slow to respond with eyes open and VS stable, and will monitor d/t change in medication and will pass on to oncoming nurse. Daughter here and aware of situation, call light in reach, alarm in place. VS 97.9-,[DATE]-,[DATE]% (sic) on RA . A late entry nurse progress note, dated [DATE] at 2:20 p.m., documented, .Focused assessment r/t medication. (Physician name deleted) on call for (physician name deleted) notified that [MEDICATION NAME]es were not removed when [MEDICATION NAME] started but have since been removed. Will continue to monitor . No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 2:20 p.m. to [DATE] at 10:56 p.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 10:56 p.m., documented, .Focused assessment r/t admission. Resident A&Ox1, slow to respond, noted with increased lethargy this shift, skin color appears pale, LCTA (lungs clear to auscultation), BS active x 4, B/L (bilateral) LE (lower extremities) non-[MEDICAL CONDITION] noted, redness noted to coccyx A & D applied, redness noted to inner aspect of right foot, A & D applied, large hernia noted to right lower abdomen, [MEDICAL CONDITION] noted to left lower abdomen. Resident denies pain at this time. Daughter (name deleted) at bedside and aware of residents (sic) current condition. This nurse notified on call (physician name deleted) (on call for (physician name deleted)) of residents current condition and hospice status, received orders to notify hospice to come to facility and assess resident, no additional orders received. This nurse contacted (hospice name deleted) and informed of situation. (name deleted) LPN (licensed practical nurse) arrived to this facility @ 1900 (7 p.m.) and assessed resident, no orders received at this time, hospice nurse stated, Her vitals are stable, she is slow to respond but alert, she has no c/o pain, lets continue to monitor and call us back if any changes occur or you need anything else. Information passed on to on-coming nurse (name deleted) LPN. VS ,[DATE], T97.2, P53, R14, Spo2 97%RA . A discontinued physician's telephone order, dated [DATE] at 3:08 p.m., documented, .[MEDICATION NAME] Patch 72 Hour 37.5 MCG/HR Apply 1 patch [MEDICATION NAME] one time a day every 3 day(s) related to OTHER CHRONIC PAIN .apply with 100 mcg patch to (equal) 137.5mcg. May D/C when [MEDICATION NAME]. and remove per schedule .Discontinue Date / Reason .[MEDICATION NAME] . A discontinued physician's telephone order, dated [DATE] at 3:09 p.m., documented, .[MEDICATION NAME]-100 Patch 72 Hour 100 MCG/HR ([MEDICATION NAME]) Apply 1 patch [MEDICATION NAME] one time a day every 3 day(s) related to OTHER CHRONIC PAIN .apply with [MEDICATION NAME] 37.5 mcg to (equal) 137.5mcg. D/C when [MEDICATION NAME]. and remove per schedule .Discontinue Date / Reason .[MEDICATION NAME] . An admission note, dated [DATE] at 2:25 a.m., documented, .Focused assessment r/t admission. Resident continues with monitoring r/t new admission to LTC. v/s 98XXX[DATE]-,[DATE]-95%@RA. Resident resting in bed. [MEDICAL CONDITION] in place and secure. Currently resting in bed with 0 c/o pain or discomfort. Call light in reach . No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 2:25 a.m. to [DATE] at 2:28 p.m. was located in he resident's clinical record. A family/resident grievance form, dated [DATE], documented, .(name deleted), dtr (daughter), voices concern regarding 1) Medication Error R/T continued [MEDICATION NAME] Patch 2) change of hospice service 3) mother's condition .reported to team that her mother's cognition was not the same because she will not speak to her but in short answers. (DON name deleted) stated to Dtr that @ breakfast the resident was served by (DON name deleted) and she sat on the side of the bed and answered appropriately to any questions that were asked .She also stated she wont eat or drink for me, she just isn't the same. (DON name deleted) explained to the dtr that the incident was being investigated so that it did not occur again. Dtr stated I don't know why there was a change in her medication other than the hospice wouldn't cover it which makes me very upset because her (hospice agency prior to admission name deleted) was covering it.(quality manager staff name deleted) requested that she be able to go and see her mother to evaluate her. Dtr (name deleted) refused and stated No, she wants to be left alone. All team members stated to daughter that she would continue to be monitored and any changes in condition would be called to the physician for further orders. Dtr (name deleted) stated, My mother is not a social person. She doesn't talk to people very often and she doesn't like to socialize. That's why I really liked (hospice agency prior to admission name deleted) and wanted to keep them because she was used to them, but I understand using (facility contracted hospice name deleted).2pm Daughter left facility. Resident alert + speaks to writer in short sentences. is watching T.V. (television) Denies any c/o distress or pain No SOB (shortness of breath) or sedation observed.(DON name deleted) . A facility Medication Incident Report, dated [DATE], documented, .Resident (resident #3) .Physician (name deleted) Date of Incident [DATE] .Time of incident PM .What was physician's orders [REDACTED].O. (by mouth) Q (every) 12 (hour) .What was given? [MEDICATION NAME] Patch was not removed per order .Reason for Incident: Med (medication) aide gave 2 doses of [MEDICATION NAME] nurse found [MEDICATION NAME] Patch was still in place .What is the actual effect of the incident on the resident? Increased sedation, How was the incident discovered? Resident assessment due to increased sedation .By whom? (nurse's name deleted) .When? [DATE] @ (at) 14:20 .Who notified the physician? (nurse's name deleted) .When? [DATE] @ 14:20 .What precautions can you take to prevent similar incident? Inserviced nurses/cma (certified medication aides) on [MEDICATION NAME] Patch Destruction .Administrator (name deleted) .Signature of Individual Filling Out This Report (name deleted) .Signature: Nurse Involved In Incident (name deleted) .Signature: Director of Nursing (name deleted) .Spoke with (nurse,name deleted) Stated she was under the belief that the [MEDICATION NAME] Patch was to be left on until MS came in. Explained that is why she did not remove the patch @ that time . A facility In-Service Educational Program sheet, dated [DATE], documented, .Subject Of Discussion: [MEDICATION NAME] Patch Destruction Sheet .Scope Of Meeting - Resume: All nurses and CMA are to Remove [MEDICATION NAME] Patches together and fill out the correct Form (see attached) (symbol undetermined) is to cut/flush Patch . The form documented eleven staff signatures. The attached sheet, titled [MEDICATION NAME] PATCH COUNT/DESTRUCTION SHEET documented, PT. (patient) NAME .DR. (doctor) .PATCH STRENGTH .RX (prescription) # .AMT. (amount) REC'D (received) .AMT. ON HAND .NURSE APPLYING PATCH .DATE .NURSE DESTROYING PATCH .WITNESS .AMOUNT APPLIED .AMT REMAINING . A facility In-Service Educational Program sheet, dated [DATE], documented, .Subject Of Discussion: [MEDICATION NAME] Charting .Scope Of Meeting - Resume: All residents with [MEDICATION NAME] Patch orders will have documentation each shift regarding current placement, verification that the correct amount is in place, any side effects such as increased lethargy, redness or swelling at the site. All [MEDICATION NAME] will be placed on the nurse's treatment carts in the lock box and will have the nurses perform an on shift and off shift count every shift. This is not optional . The form documented eight staff nurse signatures. An active employee list was provided by the administrator. The list documented 16 active nurses (licensed practical nurses/registered nurses) were currently employed by the facility. The list documented 5 CMAs were currently employed by the facility. A nurse progress note, dated [DATE] at 2:28 p.m., documented, .Focused assessment r/t admission. Resident continues with monitoring r/t new admission to LTC. VS 97XXX[DATE]-,[DATE]-95%@RA. Resident resting in bed. [MEDICAL CONDITION] in place and secure. Denies any c/o pain or discomfort. Call light within reach. Resident still remains slow to respond but more alert and talkative at this time . A nurse progress note, dated [DATE] at 7:38 p.m., documented, .Focus assessment r/t admission to LTC. Resident resting in bed most of this shift, A&Ox1, slow to respond. [MEDICAL CONDITION] in place and secure. Resident denies pain or discomfort at this time. call light with in reach. VS ,[DATE], T97.3, P59, R15, Spo2 96%RA . A physician's telephone order, dated [DATE], documented, .[MEDICATION NAME]-50 Patch 72 Hour 50 MCG/HR ([MEDICATION NAME]) Apply 1 patch [MEDICATION NAME] one time a day related to OTHER CHRONIC PAIN .and remove per schedule . A [MEDICATION NAME] count/destruction sheet, dated [DATE], documented a nurse applied a 50 MCG/HR patch and destroyed a [MEDICATION NAME] which was signed as witnessed by another staff member. It documented one patch was applied and the amount remaining was four. No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 7:38 p.m. to [DATE] at 2:23 p.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 2:23 p.m., documented, .Focus assessment r/t admission to LTC. Resident resting in bed most of this shift, A&Ox1, slow to respond. [MEDICAL CONDITION] in place and secure. Resident denies pain or discomfort at this time. Restarted on [MEDICATION NAME] his (sic) shift, no s/s (signs/symptoms) adverse reaction noted at this tome (sic). Daughter (name deleted) spoken to and made aware of resident decreased po (by mouth) intake and requiring more assistance. (hospice name deleted) nurse here to see resident and new orders received for PRN (as needed) tylenol, daughter (name deleted) notified. Call light within reach. VS ,[DATE], T97.4, P60, R18, Spo2 94%RA . No documentation of the events surrounding the resident having been placed back on the [MEDICATION NAME] was located in the resident's clinical record. No documentation of the resident having been assessed/monitored by facility staff from [DATE] at 2:23 p.m. to [DATE] at 10:45 a.m. was located in the resident's clinical record. A nurse progress note, dated [DATE] at 10:45 a.m., documented, .Res resting in bed B/P was taken at this time B/P was ,[DATE] RR (respiratory rate) 34 P 57 O2 (oxygen) was 93% on 3 LPM (liters per minute) via NC (nasal cannula). Skin was warm and calmy (sic) to touch noted mottling to her feet and to her fingertips. Res was using her accessory muscles during respirations. This nurse notified hospice as well as daughter (name deleted) . A nurse progress note, dated [DATE] at 11:30 a.m., documented, .Daughter (name deleted) here at bedside with Res . A nurse progress note, dated [DATE] at 1:41 p.m., documented, .Res was noted to have no pulse no blood pressure and no heart rate. Hospice and family members at bedside. Hospice nurse notified funeral home as well as provider . The hospice provider death summary, dated [DATE], documented, .Received a call from facility. Upon arrival CN(charge nurse) (name deleted) reports pt (patient) with low bp and diaphoretic. This nurse walked in to (sic) pt's room to perform assessment, pt's daughter and family friend at bed. Pt without vital signs or respirations. This nurse called MD (medical doctor) (name deleted) and unable to reach. MD (name deleted) called and notified of pt without vital signs or respirations . No documentation of the resident having been assessed/monitored by facility nursing staff from [DATE] at 10:45 a.m. until the resident's death at 1:41 p.m. on [DATE] was located in the resident's clinical record. A [DATE] treatment administration record (TAR) documented a [MEDICATION NAME]-50 Patch 72 hour MCG/HR ([MEDICATION NAME]) was applied to the resident on [DATE] at 9:00 a.m. and was removed on [DATE] at 11:09 a.m. A [DATE] Medication Administration Record [REDACTED]. It documented the resident received one 4 mg tablet of [MEDICATION NAME] at 10:45 p.m on [DATE], at 11:26 a.m. on [DATE] and at 3:09 a.m. on [DATE]. The reason the medication was administered was not documented. No documentation was located in the resident's clinical record to explain the reason the resident was given their as needed [MEDICATION NAME], and whether the resident was experiencing nausea or vomiting or both. The [DATE] meal percentage report, documented on [DATE] the resident consumed 51% - 75% of her lunch and 26% - 50% of her dinner meal. On [DATE] the resident consumed 51% - 75% of her breakfast, lunch and dinner meals. On [DATE] the resident consumed 0 - 25% of her breakfast and dinner meals and consumed 0 - 25% of a meal replacement. She refused her lunch meal. On [DATE] the resident refused her breakfast meal. She consumed 26% - 50% of her lunch meal and 26% - 50% of a meal replacement. She consumed 0 - 25% of her dinner meal and 0 - 25% of a meal replacement. On [DATE] the resident refused her breakfast and lunch meal. She consumed 0 - 25% of her dinner meal and 0 - 25% of a meal replacement. On [DATE] the resident refused breakfast. On [DATE] at 8:50 a.m., while the survey team was conducting an environmental tour of the facility, the DON asked to speak in private to a survey team member. She stated she knew why the survey team was there and knew what it was about. She stated resident #3 was on a [MEDICATION NAME]/[MEDICATION NAME] when she admitted to the facility. She stated she believed the facility staff discontinued the patches and started the resident on [MEDICATION NAME] she believed that Saturday. She stated she believed the first dose of [MEDICATION NAME] was given Saturday night and another dose was given the following morning. She stated that was when the nurse discovered the [MEDICATION NAME]es were still on. She stated the resident was lethargic. She stated the resident's doctor was notified. She stated the staff were performing frequent checks on the resident. She stated when the hospice came out to the facility, they took the resident off of the [MEDICATION NAME]es and started the [MEDICATION NAME]. She stated she was unsure of why. The DON stated she conducted an investigation related to the medication error. She stated the nurse thought hospice wrote to discontinue the patch when the [MEDICATION NAME] came in. However the order was not followed. The DON stated she completed an inservice. She stated the facility was watching all three residents on [MEDICATION NAME]es and checked the patches every shift on a daily basis. She stated the facility also moved the [MEDICATION NAME]es from the medication carts to the treatment carts in order for the nurses to complete the monitoring. She stated the resident's daughter reported the resident was nonresponsive. She stated the resident spoke to staff. She stated the resident was upset the daughter put her in a nursing home. She stated the resident wouldn't eat, so the facility ordered supplements. She stated several days later the resident was speaking to the facility staff. She stated hospice had provided care to the resident. She stated the resident steadily declined several days after this. (No documentation was located in the resident's clinical record to reflect this.) She stated the facility completed a medication error and notified the physician about the patch having not been removed. At 9:14 a.m., a confidential family interview was conducted for resident #3. The family member was asked to describe the events surrounding their family members stay at the facility. He/She stated the family member was admitted to the facility because they required around the clock nursing care at home which was expensive. He/She stated the hospice provider whom the facility staff told them they had to use stated they would not cover the [MEDICATION NAME]/[MEDICATION NAME]es which his/her family member was on at home. They stated the hospice provider they had at home did cover the patches. They stated they had taken their loved one to their primary care physician and obtained a hard script for the [MEDICATION NAME] pills. They stated when their loved one was admitted to the facility they had two [MEDICATION NAME]/ [MEDICATION NAME]es on which had been placed the day prior to admission. He/She stated the admitting nurse was aware the resident had two [MEDICATION NAME]es in place on admission. He/She stated the admitting nurse stated they would confirm the physician's orders [REDACTED]. He/She stated the only reason the medication was changed from [MEDICATION NAME]es to the [MEDICATION NAME] pills was because the hospice would not cover the patches and it would have cost over $600 per month. He/She stated they believed that was what killed their loved one. They stated when they arrived at the facility the next morning, their loved one was lying on their back in bed choking on vomit and out of it. They stated when they asked what was wrong with their loved one the staff stated it could have been a result of transitioning to the nursing home. He/She stated they asked the nurse, Did you take those patches off? He/She stated the nurse never answered them. He/She stated then the nurse said they had removed the patches. The family asked when. The staff stated to the family they had just removed the patches and they were in the nurses' pocket. He/She stated they had told the nurse the resident was overdosed. He/She stated they were never able to have a conversation with the named resident again. They stated when the resident came into the facility she could verbalize her needs and even sign her own checks. He/She stated it all changed when the facility overdosed the resident. He/She stated, They pushed her over the edge. He/She stated the resident's physician who had been treating her for her blood disorder (her hospice diagnosis) , had stated the normal aging process would kill the resident before the disease process would. He/She stated it was around the following Monday the DON, ADM and a third person came in and assured him/her they were conducting an investigation related to the medication error. He/She asked them not to speak in front of the resident because it would upset them. He/She stated they all went into the hall. The family member pointed out the nurse who made the medication error and informed the staff the nurse never notified hospice on her shift. He/She stated the facility had never followed up with them on the findings of the investigation. He/She stated the facility admitted they overdosed her. He/She stated the day the resident died , they were called and informed the resident had experienced changes overnight. He/She stated when they arrived to the facility, the resident was guppy breathing. He/She stated they had read information about guppy breathing and mottling from the resident's prior hospice. He/She stated they removed the resident's covers and observed mottling on the resident's legs and a cut on her knee. He/She asked the nurse what had happened to the resident's knee. They stated they had no idea how the cut had happened. The family member stated the hospice provider did not arrive to the facility until after the resident had died . They stated when the resident was followed by a local hospice at home, the family could call them and they would be right out. They stated the hospice provider the facility used was located in Oklahoma City. The family member stated resident #3 had always said putting her in the nursing home was like Taking her to the pound. The family member stated, It's the worst mistake I ever made. At 12:26 p.m., the DON was asked for all documentation related to the monitoring for oversedation for resident #3 following the medication error. At 12:35 p.m., the DON stated she reviewed the notes. She stated the monitoring was in the progress note/nurse notes. She was asked to review the note on [DATE] at 2:18 p.m. which documented the resident had a decrease in level of consciousness, was slow to respond, would continue to monitor due to change in medication and would pass on to oncoming nurse. She was asked to review the late note on [DATE] at 2:20 p.m. which documented the physician was notified of the [MEDICATION NAME]es not being removed when the [MEDICATION NAME] was started, would continue to monitor. She was asked to review the next note which was completed at 10:56 p.m. She was asked if any monitoring related to the oversedation occurred between these notes. She stated no. The next note was in eight hours. She stated the staff probably charted every shift. At 1:10 p.m., the DON returned and began to explain resident #3's [MEDICATION NAME] was later restarted and the resident's [MEDICATION NAME] was discontinued. She stated the resident's decline was not from the [MEDICATION NAME]. She stated the resident was started back on a [MEDICATION NAME] because the resident's daughter did not want the [MEDICATION NAME] and wanted the resident put back on the [MEDICATION NAME]. The DON stated the resident's daughter stated the facility hospice provider would not cover the [MEDICATION NAME]. The DON stated it did not make sense why hospice wouldn't cover the [MEDICATION NAME]. She was asked if resident #3 was involved in a medication error involving the [MEDICATION NAME]es. She stated yes the [MEDICATION NAME] was left on and yes the resident did have increased lethargy. The DON was shown the facility progress/nurse notes where the resident admitted to the facility alert and oriented x 3 and after the medication error occurred, the resident's level of consciousness was alert and oriented x 1. She was shown whe

Based on observation, record review and interview, it was determined the facility failed to: a) provide interventions according to the resident's needs to prevent the development of an avoidable stage 3 pressure ulcer for one resident (#5), b) identify the presence of a pressure ulcer prior to developing into a stage 3 and failed to identify the breakdown of the right heel for one resident (#5), c) provide interventions according to the resident's needs to prevent the development of an avoidable stage 2 pressure ulcer for one resident (#12), and d) provide interventions to prevent the worsening of a stage 3 pressure ulcer for one resident (#5) and the worsening of a stage 2 to a stage 3 pressure ulcer for one (#12) of six sampled residents with pressure ulcers. The facility's failure to provide interventions according to the residents' needs resulted in harm with the development and worsening of avoidable stage 3 pressure ulcers for two (#5 and #12) of six sampled residents with pressure ulcers. The facility identified nine residents with pressure ulcers. The facility also failed to: e) provide interventions to prevent the development of a stage one pressure ulcer; and accurately assess and identify the presence of a stage one pressure ulcer for one (#5) of six sampled residents with pressure ulcers. These deficient practices had the potential to affect 48 residents identified by the facility who were at high risk for the development of pressure ulcers. Findings: 1. Resident #5 was readmitted to the facility on [DATE] following hospitalization for surgical repair of a fracture to the left femur. Other [DIAGNOSES REDACTED]. The reentry assessment, dated 03/02/16, documented the resident displayed severe cognitive impairment and required extensive assistance of one to two persons with all activities of daily living, including bed mobility, transfers, personal hygiene and toileting. The assessment documented the resident had impaired range of motion to one side of the lower extremity and was at risk for the development of pressure ulcers, but had no pressure ulcers. The care plan, dated 01/21/15 and last updated on 03/29/16, documented the resident required assistance with activities of daily living related to weakness and a recent [MEDICAL CONDITION]. Interventions included staff was to assist the resident to reposition and turn in bed and perform weekly skin inspections. The care plan also documented the resident was incontinent of bladder, and staff were to check the resident every two hours and as required for incontinence. The admission summary progress note, dated 03/02/16, documented the resident returned to the facility with multiple bruises and scabs to wrists, elbows, forearms, feet and toes, and no pressure ulcers. The 'Braden Scale for Predicting Pressure Sore Risk', dated 03/02/16, documented the resident was high risk for the development of pressure ulcers. The assessment documented the resident's ability to respond to pressure-related discomfort was very limited; the degree to which skin was exposed to moisture was occasional; the degree of physical activity was limited to being confined to bed, and the resident was completely immobile with abilities to change and control body position. An initial plan of care, dated 03/02/16, documented interventions to include: ~ check every two hours for wetness and soiling of undergarments, ~ assist with turning and repositioning to meet the resident's needs and use pillows as needed to float heels and for positioning, ~ perform head to toe skin assessment and ~ keep skin clean and free from irritating substances and provide incontinent care as needed. On 03/08/16, a skin evaluation by licensed practical nurse (LPN) #2, documented no open areas/skin issues were noted and the resident continued to be at high risk for skin breakdown. A physician's orders [REDACTED]. There was no documentation of any changes to the resident's skin. On 03/15/16, the 'Braden Scale for Predicting Pressure Sore Risk' documented the resident remained at high risk for the development of pressure ulcers. The assessment documented the degree of physical activity was limited to being chairfast, and the resident's ability to change and control body position was very limited, meaning the resident made only slight changes in body position and was unable to make frequent or significant changes independently. On 03/17/16, a skin/wound progress note and 'Weekly Skin at Risk Evaluation' documented a skin evaluation was completed with no documentation of the presence of a pressure ulcer. On 03/18/16, a skin/wound progress note documented the presence of an open area to the coccyx, stage 3, with 75% pink/red granulation tissue and 25% slough, 2.0 centimeter (cm) length x 2.5 cm width x 0.3 cm depth with no drainage or odor. There was no prior documentation of altered skin integrity prior to the development of the stage 3 pressure ulcer. an order for [REDACTED]. On 03/25/15, a wound note documented the presence of an open area to the coccyx, stage 3, 2.5 cm length x 2.4 cm width x 0.3 cm depth with no drainage or odor. The length of the pressure ulcer had worsened from the prior week. On 04/04/16 at 4:15 p.m., the resident was observed sitting in a Geri chair in the living area outside the assisted dining room. The resident was observed to receive help with the evening meal at 5:30, continuing to sit in the Geri chair and without being repositioned. At 6:25 p.m., the resident was assisted to her room from the dining room, still seated in the Geri chair. At 7:15 p.m., the resident was assisted from the Geri chair to the bed utilizing a mechanical lift. CNAs (certified nurse aides) #1 and #3 removed the incontinent brief from the resident, which was observed to be heavily soiled with urine and feces. The lower edge of the dressing, which was intact over the coccyx, was soiled with feces. The resident's buttocks were observed to be dark pink. The CNAs did not notify the nurse of the soiled dressing. The CNAs cleansed the resident's soiled perineum and buttocks, applied a clean incontinent brief, repositioned the resident to her left side and adjusted the pillows and covers. The CNAs used the same gloves throughout the entire time. The CNAs were asked what care the resident had received since they had arrived at 3:00 p.m. They stated they had provided no care for the resident since arriving at 3:00 p.m. They stated the resident had been up in the Geri chair since noon to eat lunch in the dining room, and no staff had checked the resident for incontinence or provided any type of repositioning since that time. They stated the staff working prior had not had time to lay the resident down after lunch to provide any personal care or repositioning. They stated they had been busy assisting other residents with personal care and assisting residents up for the evening meal since arriving at 3:00 p.m. They stated they were aware the resident needed to be checked for incontinence and incontinent care provided every two hours, as well as repositioning the resident every one to two hours due the presence of a pressure ulcer on the coccyx. They were asked what care the resident needed. They stated the resident was incontinent of bowel and bladder, and unable to recognize or verbalize her needs, so she was to be checked for incontinence at least every two hours and incontinent care provided to keep her skin clean. They stated she needed to be repositioned from side to side every one to two hours, and heels were to be floated utilizing pillows so there was no pressure on the heels. They stated it was important to do these things so residents did not develop pressure ulcers. On 04/05/16, a skin/wound progress note documented the presence of an open area to the coccyx, stage 3, with 75% slough, 3.1 cm length x 2.6 cm width x 0.3 cm depth with no drainage or odor. The pressure ulcer had worsened, increasing in length and width from the prior week. The physician was notified of the worsening of the pressure ulcer and treatment orders changed to Santyl ointment (used for [MEDICATION NAME] slough in a wound) to be used daily and as needed. The resident's skin was observed on 04/05/16 at 10:45 a.m., with LPN #2 and CNAs #5 and #6. The pressure ulcer was observed to be the size as measured earlier in the day, as above. Heels were observed to be dark pink. The right heel was a darker pink with a purple color to the outer edge of the heel. There was no documentation of the discoloration to the heels in the resident's record or on the skin assessment that had been completed earlier in the day. At 2:30 p.m., LPN #2 was asked if she had observed the resident's heels as part of the skin assessment completed earlier in the day. She stated she had observed the heels, and although they were a darker pink, they had blanched. At 2:35 p.m., the surveyor and LPN #2 observed the resident's heels. The left heel was a dark pink color. The right heel was a darker pink with a purple color to the outer edge of the right heel. The LPN was asked if the discolored heels would be considered to be pressure related and she stated yes. She stated they should be considered as a stage one pressure ulcer to the right heel. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment and a weekly skin evaluation, dated 01/13/16, documented the resident had no pressure areas/open wounds. The care plan, initiated on 01/13/16, documented, .Focus .has Potential for skin breakdown and/or pressure ulcers r/t (related to) Braden <(less than) 18 . Goal .prevent any new breakdown, or reoccurrence of closed/resolved pressure ulcers . Interventions .Draw sheets to bed to reduce friction .encourage/assist in turning and repositioning every two hours .moisture barrier after each incontinence episode .Pressure relieving cushion in wheelchair or geri chair unless contraindicated .Use pillows while positioned in bed or a geri chair if applicable to reduce pressure to bony prominences . The admission assessment, dated 01/20/16, documented the resident had moderately impaired cognition, was frequently incontinent of urine, was always incontinent of bowel and required extensive two person assistance for bed mobility, transfers, toileting and hygiene. The assessment documented the resident was at risk for pressure ulcers, had no pressure ulcers, venous/arterial ulcers or other skin conditions at the time of admission. A wound assessment, dated 02/01/16, documented the resident had a stage 2 pressure ulcer to the right (rt) buttock with an onset date of 02/01/16. The wound measured 1 cm in length (L) x 0.4 cm in width (W) x < (less than) 0.2 cm in depth (D). The wound bed had pink/red granulation tissue present without drainage or odor present. Wound care orders were to apply Triad (a topical paste used for the treatment of [REDACTED]. The resident's care plan, updated 02/01/16, documented, .Focus .has a stage 3 pressure ulcer to her right buttocks near her coccyx . Goal .wound will not deteriorate, will be free from infection, and will show signs of healing . Interventions .keep skin clean and dry .lift sheet .low air loss mattress .pressure reducing cushion in w/c (wheelchair) .3/5/16- cleanse rt. buttock with NSS (normal sterile saline), pat dry, apply [MEDICATION NAME], cover with bordered foam dressing, change Q (every) day and prn (as needed) until resolved . A wound assessment, dated 02/08/16, documented the resident's pressure ulcer to the rt buttock had increased to a stage 3 which measured 1 cm L x 0.4 cm W x <0.2 cm D. The condition of the wound bed had worsened to include the presence of slough without drainage or odor. Wound care orders remained the same. The resident's care plan, dated 02/10/16, documented, .Focus .has an ADL Self Care Performance Deficit r/t right AKA, weakness, fatigue . Interventions .BED MOBILITY .requires X2 staff participation to reposition and turn in bed . On 02/13/16, the resident was sent to the emergency room for evaluation as per physician's orders [REDACTED]. A nursing readmission assessment, dated 02/15/16, documented the resident had an open area to the coccyx with no drainage. Wound assessments, dated 02/16/16 and 02/23/16, documented the resident's stage 3 pressure ulcer to the rt buttock had increased to 1 cm L x 1 cm W x <0.2cm D. The wound bed continued to have slough present without drainage or odor. Wound care orders changed to Magic Butt Paste to rt buttock every shift and Hydraguard cream to be left at bedside for application after each incontinent episode with the 02/16/16 assessment. A wound assessment, dated 03/04/16, documented the resident's stage 3 pressure ulcer to the rt buttock had increased to 1.3 cm L x 1.7 cm W x 0.1 cm D. The wound bed had pink/red granulation tissue present at that time without drainage or odor. Wound care orders were changed to cleanse with NSS, pat dry, apply [MEDICATION NAME] and cover with bordered foam pad. A wound assessment, dated 03/08/16, documented the resident's stage 3 pressure ulcer to the rt buttock measured 1.1 cm L x 1.5 cm W x 0.1 cm D. The wound bed continued to have pink/red granulation tissue present without drainage or odor. Wound care orders remained the same. A wound assessment, dated 03/18/16, documented the resident's stage 3 pressure ulcer to the rt buttock measured 1.1 cm L x 1.4 cm W x 0.1 cm D. The wound bed continued to have pink/red granulation tissue present without drainage or odor. Wound care orders remained the same. A wound assessment, dated 03/24/16, documented the resident's stage 3 pressure ulcer to the rt buttock had increased to 1.5 cm L x 1.4 cm W x 0.1 cm D. The wound bed continued to have pink/red granulation tissue present without drainage or odor. Wound care orders remained the same. A wound assessment, dated 03/31/16, documented the resident's stage 3 pressure ulcer to the rt buttock had increased to 2 cm L x 1.5 cm W x 0.1 cm D. The wound bed continued to have pink/red granulation tissue present without drainage or odor. Wound care orders remained the same. On 04/06/16, at 2:00 p.m., the resident had refused to allow the surveyor to observe her wound care. On 04/06/16 at 2:30 p.m., the director of nurses was asked about the resident's pressure ulcer. She stated it was facility acquired. On 04/06/16 at 2:55 p.m., CNA #3 was asked about the resident's care. The CNA stated staff assisted the resident with transfers from bed to recliner and to bedside commode. The CNA stated the resident would wipe herself. The CNA stated the resident would reposition herself in the bed and recliner to redistribute her weight. The resident was observed throughout the day on 04/06/16 sitting either in a wheelchair with her left leg/foot elevated on the recliner or sitting in the recliner with the left leg/foot resting on the extended footrest. The resident was not observed to reposition/redistribute her weight for any length of time.

Based on observation, record review, and interview, it was determined the facility failed to: a) assess pain with a change in condition, b) provide interventions to manage pain when skin care/treatments were provided and c) coordinate pain management with hospice when interventions for pain relief were ineffective for one (#79) of one resident sampled for pain. The facility's 'Resident Census and Conditions of Residents' report dated 07/28/15, documented 90 residents were on a pain management program. Findings: Resident #79 had [DIAGNOSES REDACTED]. A care plan dated 10/16/13 documented the resident had experienced pain in the past. A goal documented, .will not be limited by pain . Interventions included, Address c/o (complaints of) pain promptly .assess effectiveness of pain medication .ongoing assissment (sic) of pain status . A quarterly assessment, dated 03/23/15, documented the resident was cognitively intact, did not receive scheduled pain medication, and did receive pain medication as needed (prn). The assessment documented the resident had occasional pain that did not effect or limit function and was rated as 5 on a scale of 0-10. The clinical record documented the resident was treated with antibiotic therapy for urinary tract infections four times from 02/06/15 to 05/26/15 and developed candidiasis. A nurse's note, dated 05/04/15 at 2:15 p.m., documented the resident had mouth pain and swelling to lips. The note documented the resident's physician was notified and a new order for [MEDICATION NAME] swish and swallow (S/S) was obtained due to (d/t) a yeast buildup. A nurse's note, dated 05/08/15 at 11:29 p.m., documented the resident refused one dose of [MEDICATION NAME] S/S d/t the medication burned her lips. A nurse's note, dated 05/11/15 at 3:21 p.m., documented the resident's lower lip was swollen, tender and sore. The note added the resident ate only applesauce for breakfast and lunch. The clinical record contained no documentation the pain was assessed. A nurse's note, dated 05/12/15 at 2:11 p.m., documented the resident's lips were chapped and the resident stated she would like to eat regular food without her mouth hurting. The note added the resident had unsuccessfully attempted to eat toast. The clinical record contained no documentation the pain was assessed. A nurse's note, dated 05/14/15 at 12:37 p.m., documented the resident's mouth continued to be sore. The resident was not able to eat well d/t mouth pain. The note documented the resident's lips had blisters with a green discharge and scabs covering the top and bottom edges. The physician's office was notified. A physician's progress note, dated 05/14/15, documented the facility had contacted his office requesting the physician phone the facility. The note documented the facility informed his office the resident had been on [MEDICATION NAME] mouth wash for nine days. The resident's lips were blistered with a green discharge, swollen, and she was having a hard time eating. A nurse's note, dated 05/15/15 at 1:50 p.m., documented the [MEDICATION NAME] S/S was discontinued and [MEDICATION NAME] (an antifungal medication) 200 mg for seven days was started. The note documented the resident's mouth remained tender and her dentures were left out. The clinical record contained no documentation the pain was assessed. A nurse's note, dated 05/17/15 at 11:30 p.m., documented the resident's mouth remained tender. The note documented the resident had refused water. At 12:05 p.m., a nurse's note documented the resident complained of her buttocks and coccyx burning. The note documented the resident had numerous open areas to her buttocks that were bleeding. The note documented anti-fungal medication had been applied to the resident's buttocks per physician's orders [REDACTED].>The clinical record contained no documentation the pain was assessed. A physician's progress note, dated 05/28/15, documented the resident had been seen in his office for a visit. The note documented the resident had a wound on her coccyx that was being addressed and complained that she was in pain. The note documented the resident had an order for [REDACTED]. There was no documentation the facility educated the family about the positive benefits of pain medication for the relief of pain, nor was the resident assessed for pain. A hospice report, dated 06/01/15, documented the resident was becoming weaker, was less conversant, was not eating much, had recurrent UTIs, and was in a lot of pain. There was no documentation the facility staff had comprehensively assessed the resident's pain. The clinical record documented an indwelling catheter was placed on 06/02/15, per the physician's orders [REDACTED].>A comprehensive pain assessment completed on 06/16/15 at 3:21 p.m. documented the resident had a pressure ulcer to the right buttocks, had pain now and in the past few months and the pain occurred daily. The assessment documented the pain, comes and goes and the description by the resident was documented as, I just hurt. The pain intensity was rated per facial expressions of pain at 3-4 on a scale of 0-10. The assessment documented current pain medication was [MEDICATION NAME] 5/325 milligrams every four hours prn, aspercream prn and [MEDICATION NAME] 325 milligrams two tabs every eight hours prn. The assessment documented the amount of relief provided was 3 on a scale of 1-10 with 0 as complete relief and 10 as no relief. A nurse's note, dated 06/29/15 at 2:00 p.m., documented complaints of bladder pain. A nurse's note at 11:23 p.m., documented the resident had been administered Tylenol for pain at 5:10 p.m. It was not effective so [MEDICATION NAME] 5/325 was administered at 6:15 p.m., which was effective. A nurse's note, at 9:15 p.m., documented the resident pulled her catheter out with the bulb intact. A hospice note, dated 07/01/15 at 9:30 p.m., documented the resident said, I don't want the catheter put back in. It isn't good for you, it pulls, and it hurts. The clinical record contained no documentation the resident's pain level, d/t the pain caused by the catheter, had been reassessed. On 07/30/15 at 12:44 p.m., staff member #14 was asked about the resident's catheter. The staff stated, although it was ordered by the physician, the resident would pull it out because she stated it hurt. On 07/31/15 at 3:00 p.m., peri-care, wound care, and catheter care were observed. When the resident was informed the care was going to be provided she stated, Be very careful because it hurts down there. The resident had not been offered pain medication prior to the care or when she first complained of pain. The skin on the resident's right groin was bright red. The labia and vaginal area was bright red, shiny, and had a few raised areas. The resident complained of pain every time the areas were touched. The clinical record contained no documentation the resident's pain level, d/t to the excoriated skin, had been assessed. After the care was provided, staff member #15, asked the resident if she wanted a pain pill. The resident said, It just hurts so bad and it takes so long for the pills to work. On 08/03/15 at 10:25 a.m., the resident was sitting in her recliner, with her call light observed to be on. She was complaining of pain, stating the catheter hurt. She stated, It really hurts. The resident was interviewed about her pain. She was asked to rate her pain between 1 to 10. She stated she didn't know it just hurt. Within a minute, staff member #16, entered the room. The resident stated the catheter hurt so bad. The resident asked the nurse if the catheter was still in. The nurse asked the resident if she had taken a pain pill that morning. The resident stated she had not. The staff member observed the placement of the catheter and stated it was still in. At 10:34 a.m., after the staff member administered [MEDICATION NAME] 5/325 she suggested to the resident that she take her pain medication more often. The resident said, They don't tell me when I can have a pain pill. The resident said, I'm afraid the catheter will come out again, it hurts so bad when it comes out. The staff stated that she would see if the resident could have a routine pain medication. It was observed the staff nurse did not assess or ask the resident to rate her pain. The staff nurse was asked how often the resident was assessed for pain. She stated the resident was assessed for pain with each contact. She was asked if she had asked the resident to rate her pain. She stated she looked for non-verbal and verbal cues. The staff nurse stated she didn't ask the resident to rate her pain, because the resident always complained that she was, Hurting, hurting. She was asked if the resident's current pain management routine was effective. She stated she thought it was when she took her pain pills. She added the resident's pain could get out of control at times, and would probably be more effectively controlled with the administration of a routine pain medication. She stated she had sometimes observed the resident in the dining room or lobby and could tell she was hurting. She stated the administration of one or two routine pain pills would probably help. The staff member was asked whose responsibility it was to assess the resident's pain. She stated the hospice nurse regulated her pain medication. At 11:05 a.m., the staff member was asked if anyone had discussed the residents increased pain with the hospice nurse. She stated she didn't think so. Staff member #17, stated pericare and catheter care were painful for the resident, but she also complained of pain during other times too. She was asked if the resident was offered something for pain before care was provided. She stated she was. On 08/03/15 at 11:00 a.m., staff member #1, was asked who was responsible for assessing the residents for pain. She stated the nurses and CNAs. She was asked if an assessment had been conducted to determine if the resident required a change in her pain medication. She stated she did not see one. She was asked if the nurses were responsible for discussing the resident's pain with the hospice nurse. She stated hospice and the facility nurses should be communicating with each other.

Based on observation, record review, and interview, it was determined the facility failed to ensure justification for the use of: a) multiple antibiotics for the treatment of [REDACTED].#79), and b) an antibiotic treatment of [REDACTED].#68) of six residents, who were reviewed for unnecessary medications. The facility's infection control log documented 28 residents received antibiotics for urinary tract infections (UTIs) from May 2015 through July 2015. Findings: 1. Resident #79 had [DIAGNOSES REDACTED]. A physician's progress note, dated 01/27/15, documented the resident had a history of [REDACTED]. There were no signs and symptoms of a UTI documented in the clinical record from 01/28/15 to 02/06/15 which would have warranted the use of an antibiotic. A urinalysis (UA) lab report, dated 02/04/15, documented: ~ appearance turbid, ~ protein 1+, ~ blood 3+, ~ bacteria 3+ and ~ greater than 100,000 Escherichia coli (E-Coli). A nurse's note, dated 02/06/15 at 12:42 a.m., documented the resident's physician received the faxed lab results and [MEDICATION NAME](oral antibiotic) 500 milligrams (mg) two times a day for ten days for treatment of [REDACTED]. A quarterly assessment, dated 03/23/15, documented the resident was cognitively intact. The assessment also documented the resident required extensive assistance while walking in her room and the corridor. The resident required limited assistance with eating. She was frequently incontinent of bladder and weighed 144 pounds (lbs). A urinalysis lab result, dated 04/12/15, documented : ~ appearance turbid, ~ protein 2+, ~ blood 3+, ~ [MEDICATION NAME] positive, ~ bacteria 3 +, ~ greater than 100,000 gram negative rods, ~ greater than 100,000 E-Coli, and ~ the culture was positive for Extended-Spectrum Beta-Lactamase (ESBL). The clinical record documented no additional nurses' notes regarding the urinalysis results until, 04/14/15 at 12:50 a.m. The note documented, Focused assessment r/t (related to) new medication. UA faxed to Dr (Name deleted) and office called. Dr. (name deleted) returned call giving new order for [MEDICATION NAME] (an antibiotic) 100 mg 1 po (by mouth) x (times) 10 days. A nurse's note, dated 04/14/15 at 2:20 p.m., documented, assessment r/t antibiotic for UTI. The initial dose was given at this time. The resident had voiced no complaints this morning. The note documented the resident denied dysuria and fluids were encouraged. A nurse's note, dated 04/20/15 at 2:27 p.m., documented the resident continued on antibiotic therapy. The resident was afebrile with a temperature of 98.1 degrees Fahrenheit (F). The note documented the resident denied discomfort and urgency with urination. A nurse's note, dated 04/21/15 at 2:07 a.m., documented the resident's temp was 98 degrees F. A nurse's note, dated 04/21/15 at 11:26 a.m., documented there were no reports of discomfort or urgency with urination and urine was yellow and free from odors. A nurse's note, dated 04/22/15 at 12:45 p.m., documented the antibiotic was completed. The note documented the resident was lethargic/disoriented with a poor appetite and poor fluid intake. The resident's temperature was 98.5 degrees. The note added the urine was concentrated with large amounts of sediment. The note documented a message was left at the resident's physician's office. There was no further documentation the resident continued with lethargy/confusion, abnormal temperature, complaints of urinary pain/urgency or abnormal appearance of urine during the next four days from 04/22/15 and 04/26/15. A urinalysis lab result, dated 04/25/15, documented: ~ protein 2+, ~ blood 2 +, ~ bacteria 1 +, ~ greater than 100,000 E-Coli, and ~ ESBL. A nurse's note, dated 04/26/15 at 12:23 a.m., documented the resident's physician was notified of the UA and culture/sensitivity results. The physician was also informed the lab results were positive for ESBL in the resident's urine. The physician issued a new order for ertapenem (an antibiotic) 1 gram IM (intramuscular) for 10 days. The note documented the resident's temperature as 99 degrees F. A nurse's note, at 3:43 a.m., documented the resident was afebrile, temperature was 97.3 F. The note further documented the resident did not complain of pain when voiding and .Ertapenem injection to start this a.m. A care plan problem, updated on 04/27/15, documented the resident had a urinary tract infection. The care plan goal was documented, .urinary tract infection will resolve without complications. Interventions documented included, .Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. A care plan problem, updated on 05/02/15, documented the resident had thrush. The care plan goal was documented, .WILL BE FREE OF ORAL DISCOMFORT AS WOULD PREVENT ENJOYMENT OF MEALS QD (every day) X (times) 14 DAYS. Interventions documented included, .REPORT TO CN (charge nurse)/PCP (primary care physician) IF SX (symptoms) PERSIST OR WORSEN . A nurse's note, dated 05/03/15 at 06:02 (no a.m or p.m.) documented the resident continued with antibiotic injections. The note added the resident was especially irritable and demanding tonight. At 1:56 p.m., the record documented the resident's temperature was 99.6 F. A nurse's note, dated 05/04/15 at 11:09 a.m., documented the resident was afebrile with a temperature of 97.8 F. A nurse's note, at 2:15 p.m., documented the resident had mouth pain and swelling to lips. The note documented the resident's physician was notified and a new order for [MEDICATION NAME] swish and swallow (S/S) was obtained due to (d/t) a yeast buildup. A nurse's note, dated 05/08/15 at 11:29 p.m., documented the resident refused one dose of [MEDICATION NAME] S/S d/t the medication burned her lips. A nurse's note, dated 05/09/15 at 1:58 p.m., documented the resident's lips appeared chapped and dry. The note documented the resident had refused lunch and fluids. The note added the resident complained of seeing a small child drowned in her room. An additional note documented the resident refused dinner. The clinical record contained no documentation the physician had been notified or that the resident's worsening oral condition had been assessed. A nurse's note, dated 05/11/15 at 3:21 p.m., documented the resident's lower lip was swollen, tender and sore. The note added the resident ate only applesauce for breakfast and lunch. The clinical record contained no documentation the physician had been notified or that the resident's worsening oral condition had been assessed. A nurse's note, dated 05/12/15 at 2:11 p.m., documented the resident's lips were chapped and the resident stated she would like to eat regular food without her mouth hurting. The note added the resident had unsuccessfully attempted to eat toast. The clinical record contained no documentation the physician had been notified or the resident's worsening oral condition had been assessed. A nurse's note, dated 05/14/15 at 12:37 p.m., documented the resident's mouth continued to be sore. The resident was not able to eat well d/t mouth pain. The note documented the resident's lips had blisters with a green discharge and scabs covering the top and bottom edges. The physician's office was notified. A physician's progress note, dated 05/14/15, documented the facility had contacted his office requesting the physician phone the facility. The note documented the facility informed his office the resident had been on [MEDICATION NAME] mouth wash for nine days, the resident's lips were swollen/blistered with a green discharge and she was having a hard time eating. A nurse's note, dated 05/15/15 at 1:50 p.m., documented the [MEDICATION NAME] S/S was discontinued and [MEDICATION NAME] (an antifungal medication) 200 mg for seven days was started. The note documented the resident's mouth remained tender and her dentures were left out. A nurse's note, dated 05/16/15 at 11:56 p.m., documented a UA was collected. The resident had complained of pain while urinating and pain in her hip. The resident's temp was documented as 99.4 F. The clinical record, dated between 05/16/15 at 11:56 p.m., and 05/27/15 at 3:26 p.m., contained no additional documentation of the resident exhibiting signs or symptoms of a UTI which would have required the use of an antibiotic. A nurse's note, dated 05/17/15 at 11:30 p.m., documented the resident's mouth remained tender. The note documented the resident had refused water. At 12:05 p.m., a nurse's note documented the resident complained of her buttocks and coccyx burning. The note documented the resident had numerous open areas to her buttocks that were bleeding. The note documented anti-fungal medication had been applied to the resident's buttocks per physician's orders [REDACTED].>A care plan problem, updated on 05/18/15, documented the resident had a urinary tract infection. The care plan goal was documented, .urinary tract infection will resolve without complications. Interventions documented included, .Monitor/document/report to MD PRN for s/sx (signs/symptoms) of UTI. A nurse's note, dated 05/20/15 at 4:49 a.m., documented the resident stated she had no pain or discomfort during urination. The nurses' notes for 05/20/15, documented the resident's temperature was 98.1 degrees F at 2:58 p.m., and 97.9 degrees F at 6:22 p.m. A urinalysis lab result, dated 05/21/15, documented : ~ appearance turbid, ~ protein 2+, ~ [MEDICATION NAME] positive, ~ blood 3 +, ~ bacteria 4 +, ~ greater than 100,000 E-Coli, ~ greater than 100,000 gram negative rods, and ~ ESBL. A nurse's note, dated 05/26/15 at 1:41 p.m., documented the physician's office was contacted and a new order was obtained for [MEDICATION NAME] (an oral antibiotic) 100 mg two times a day for 10 days. A nurse's note, dated 05/27/15 at 3:26 p.m., documented the [MEDICATION NAME] was started. The resident's temperature was documented as 98.7 degrees F. At 7:13 p.m., a nurse's progress note documented the resident's temperature was 98.3 degrees F and the resident had no complaints of pain or burning upon voiding. A physician's progress note, dated 05/28/15, documented the resident had been seen in his office for a visit. The note documented the resident had a very resistant organism growing in her urine culture and was currently receiving [MEDICATION NAME]. The note also documented the physician did not think any medication would make the problem any better. The note added the resident had received injections of ertapenem and apparently developed quite a yeast infection of her mouth and throat. The note added the resident had trouble wearing dentures. 2. Resident #68 had [DIAGNOSES REDACTED]. A progress note, dated 04/16/15, documented staff was to obtain a urinalysis with culture and sensitivity (C & S) for the resident. There was no documentation the resident was experiencing any symptoms of a UTI. A progress note, dated 04/18/15 at 3:40 a.m., documented the resident's temperature was 97.7 degrees Fahrenheit. The C & S results dated 04/18/15, documented the presence of greater than or equal to 100,000 Escherichia coli bacteria. A physician's orders [REDACTED]. No documentation of symptoms was found in the clinical record to support the use of antibiotics for the UTI. On 08/03/15 at 3:30 p.m., staff #1 was unable to locate any documentation of symptoms for the use of the antibiotic. On 07/31/15 at 10:30 a.m., staff #1 was asked about treatment of [REDACTED]. She stated she was unable to verify symptoms if they were not documented.

Based on observation, record review, and interview, it was determined the facility failed to assess a decline in oral intake due to candidiasis and provide interventions for one (#79) of one sampled resident with weight loss. The resident experienced a severe weight loss of 21 pounds, which was a 14.8% loss, during one month. The facility Resident Census and Conditions of Residents, dated 07/28/15, identified fifteen residents with unplanned significant weight loss/gain. Findings: Resident #79 had [DIAGNOSES REDACTED]. The resident's nutritional care plan, dated 10/16/13, documented; .Give consistency of food that is easy to eat and swallow.Weigh as scheduled, repot (sic) abnormal findings to charge nurse/PCP (primary care physician). The clinical record documented the resident was treated with antibiotic therapy for urinary tract infections four times from 02/06/15 to 05/26/15 and developed candidiasis. A physician's orders [REDACTED]. A quarterly assessment, dated 03/23/15, documented the resident was cognitively intact. The assessment also documented the resident required limited assistance with eating. She weighed 144 pounds (lbs). A nurse's note, dated 04/26/15 at 2:15 p.m., documented the resident had mouth pain and swelling to lips. The note documented the resident's physician was notified and a new order for [MEDICATION NAME] swish and swallow (S/S) was obtained due to (d/t) a yeast buildup. A nurse's note, dated 05/08/15 at 11:29 p.m., documented the resident refused one dose of [MEDICATION NAME] S/S d/t the medication burned her lips. A nurse's note, dated 05/09/15 at 1:58 p.m., documented the resident's lips appeared chapped and dry. The note documented the resident had refused lunch and fluids. An additional note documented the resident refused dinner. The clinical record contained no documentation the physician had been notified or the resident's worsening oral condition had been assessed. A nurse's note, dated 05/11/15 at 3:21 p.m., documented the resident's lower lip was swollen, tender and sore. The note added the resident ate only applesauce for breakfast and lunch. The clinical record contained no documentation the physician had been notified or that the resident's worsening oral condition had been assessed. The clinical record contained no documentation a dietary consultation had been obtained to provide the resident with foods with a consistency she could consume without causing oral pain. A nurse's note, dated 05/12/15 at 2:11 p.m., documented the resident's lips were chapped and the resident stated she would like to eat regular food without her mouth hurting. The note added the resident had unsuccessfully attempted to eat toast. The clinical record contained no documentation the physician had been notified or the resident's worsening oral condition had been assessed. A nurse's note, dated 05/14/15 at 12:37 p.m., documented the resident's mouth continued to be sore. The resident was not able to eat well due to mouth pain. The note documented the resident's lips had blisters with a green discharge and scabs covering the top and bottom edges. The physician's office was notified. A physician's progress note, dated 05/14/15 with no time given, documented the facility had contacted his office requesting the physician phone the facility. The note documented the facility informed his office the resident had been on [MEDICATION NAME] mouth wash for nine days. The resident's lips were blistered with a green discharge, swollen, and she was having a hard time eating. The clinical record contained no documentation the dietary manager was notified of the resident's inability to consume her regular diet. A nurse's note, dated 05/15/15 at 1:50 p.m., documented the [MEDICATION NAME] S/S was discontinued and [MEDICATION NAME] (an antifungal medication) 200 mg for seven days was started. The note documented the resident's mouth remained tender and her dentures were left out. A nurse's note, dated 05/17/15 at 11:30 p.m., documented the resident's mouth remained tender and the resident had refused water. A physician's progress note, dated 05/28/15, documented the resident had been seen in his office for a visit. The note documented the resident was currently receiving [MEDICATION NAME]. The note documented the resident had received injections of ertapenem and apparently developed quite a yeast infection of her mouth and throat. The note added the resident had trouble wearing dentures. The note also documented the resident appeared weaker and much sicker than at any time in the past and was to the point where hospice was appropriate. A hospice report, dated 06/01/15, documented the resident was becoming weaker, was not eating much and was in a lot of pain. There was no documentation the facility staff had comprehensively assessed the resident's oral pain and her inability to eat. The clinical record documented the resident's weight was 141 lbs on 05/02/15 and one month later, on 06/02/15, the residents's weight was 120 lbs. The resident experienced a severe weight loss in one month of 21 lbs, which was 14.8% loss. The significant change assessment, dated 06/17/15, documented the resident was moderately impaired in cognition, required extensive assistance with eating and weighed 120 lbs. A Nutritional Progress Note, dated 06/17/15 at 1:57 p.m., documented the resident had a 14.8% weight loss between 05/02/15 and 06/03/15. The note documented the resident's meal intake was frequently less than 50%. Prior to the nutritional progress note, there was no documentation the facility assessed the resident's declining oral intake. The clinical record documented the resident weighed 134.8 pounds on 07/27/15, after the candidiasis had begun to resolve. On 07/30/15 at 8:00 a.m., and 07/31/15 at 1:02 p.m., the resident was observed eating in the dining room. She was eating a regular diet without difficulty. On 07/31/15 at 10:30 a.m., staff #1 was asked about the resident's weight loss. She stated the facility thought the resident's weight had been recorded inaccurately. She was asked if the resident had been reweighed to confirm inaccuracy. She said stated no.

Based on observation, record review, and interview, it was determined the facility failed to evaluate the continued need of an indwelling urinary catheter that had no justification for it's use, for one (#79) of one sampled resident with an indwelling urinary catheter. This caused harm to the resident due to increased pain caused from the catheter. The facility's 'Resident Census and Conditions of Residents' report dated 07/28/15, documented nine residents used indwelling urinary catheters. Findings: Resident #79 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/23/15, documented the resident was cognitively intact. The assessment also documented the resident required extensive assistance while walking in her room and the corridor. The resident required limited assistance with eating. She was frequently incontinent of bladder and weighed 144 pounds (lbs). A telephone order from the resident's physician, dated 06/02/15 at 10:57 a.m., documented to place a Foley catheter (indwelling urinary catheter) for [MEDICAL CONDITION] and wound care. A nurse's note, dated 06/02/15 at 2:03 p.m., documented a hospice nurse inserted a Foley catheter for skin integrity. A physician's telephone order, dated 06/16/15 at 10:43 p.m., documented to apply Triad cream to bilateral groin areas for redness and irritation two times a day. The significant change assessment, dated 06/17/15, documented the resident was moderately impaired in cognition. The MDS documented required extensive assistance with eating and weighed 120 lbs. A nurse's note, dated 06/17/15 at 3:26 p.m., documented to continue Triad under breasts, right buttocks, and groin. A nurse's note, dated 06/24/15 at 5:00 p.m., documented the physician had issued a new order for bladder training for 48 hours. The resident's Foley tubing was to be clamped for fifteen minutes every two hours. At the end of the 48 hours the Foley was to be removed. A nurse's note, dated 06/26/15 at 5:00 p.m., documented the Foley catheter was removed. A nurse's note, dated 06/29/15 at 2:00 p.m., documented the resident complained of bladder pain. The note documented the hospice nurse inserted an indwelling Foley catheter due to the resident's complaint of bladder pain. The clinical record contained no documentation the resident's complaints of bladder pain had been evaluated to determine if inserting a catheter was the only option. A nurse's note at 11:23 p.m., documented the resident had been administered [MEDICATION NAME] 5/325 (a pain medication) at 6:15 p.m., which had relieved the resident's pain. A nurse's note, dated 07/01/15 at 2:16 p.m., documented redness remained in the resident's bilateral groin. A nurse's note, at 9:15 p.m., documented the resident pulled her catheter out with the bulb intact. A hospice note, dated 07/01/15 at 9:30 p.m., documented the resident said, I don't want the catheter put back in. It isn't good for you, it pulls, and it hurts. The clinical record contained no documentation the resident's pain level, d/t the pain caused by the catheter, had been reassessed. The nurses' notes, dated from 07/01/15 at 9:15 a.m., to 07/02/15 at 4:10 p.m., contained no documentation the resident had complained of urine burning her skin while the catheter was out. The clinical record also did not contain documentation the resident had open areas on her bottom or [MEDICAL CONDITION], which would have warranted the use of a Foley catheter. A hospice note, dated 07/02/15 at 10:35 a.m., documented the resident continued to refuse to allow placement of the Foley catheter. The note documented the staff had reported the resident had voided a large amount of urine. The note documented the resident had no open areas to the buttocks. A nurse's note, dated 07/02/15 at 11:45 p.m., documented the hospice nurse had seen the resident, the resident had two incontinent episodes, and was resting without distress. A hospice note, at 3:15 p.m., documented the resident's physician had been contacted and the resident had agreed to allow placement of the Foley catheter. A hospice note, at 4:10 p.m., documented the Foley catheter was placed and the urine was cloudy then bloody. The clinical record contained no documentation the resident had been fully assessed of the need for a catheter, when the resident stated she did not want a catheter. A nurse's note, dated 07/26/15 at 3:26 p.m., documented the resident's catheter was leaking urine on the resident's clothing. The catheter was changed. A hospice note, dated 07/27/15 at 2:05 p.m., documented the catheter was replaced d/t the catheter was out. The note documented the resident voided a large amount prior to catheter insertion. The note did not contain documentation the resident had complained of her skin burning when the resident voided the large amount of urine. A nurse's note, date 07/29/15 at 3:51 p.m., documented hospice reported the Foley was observed out while bathing the resident. The Foley was replaced by the hospice nurse. On 07/30/15 at 12:44 p.m., staff member #14 was asked why the resident had a catheter. She stated the hospice physician wanted her to have it for [MEDICAL CONDITION]. The staff stated the resident would pull it out because the resident stated it hurt. The staff member was asked if the tubing had been secured. She stated it had not. The clinical record contained no documentation the resident had [MEDICAL CONDITION]. There was no documentation of post voiding urine levels having been obtained. On 07/30/15 at 1:22 p.m., staff member #1, and staff member #4, were asked to review the resident's care plan. They were asked if a care plan had been developed for the resident's use of a catheter. They stated no. They were asked why the resident had a catheter. They stated for retention and wound care. At 2:52 p.m., the resident was asked if she knew why she had a Foley catheter. She stated she didn't know why she had it. She stated, she had been told she had to have it. She added, she didn't want it because it hurt and burned all the time. The resident was asked if she had trouble emptying her bladder before the catheter was placed. She stated she didn't think so. She stated, the catheter hurt right now. On 07/31/15 at 3:00 p.m., peri-care, wound care, and catheter care were observed. The catheter bag contained about 300 milliliters (mls) of dark amber/brownish urine. It was observed the resident's catheter tubing had not been attached to the resident's leg. On 08/03/15 at 10:25 a.m., the resident was sitting in her recliner, with her call light observed to be on. She was complaining of pain, stating the catheter hurt. She said, It really hurts. The resident was interviewed about her pain. She was asked to rate her pain between 1 to 10. She stated she didn't know it just hurt. Within a minute, staff member #16, entered the room. The resident stated the catheter hurt so bad. The resident asked the nurse if the catheter was still in, because it really hurt. The nurse asked the resident if she had taken a pain pill that morning. The resident stated she had not. The staff member checked the placement of the catheter and stated it was still in. The nurse was asked when the tubing had been secured. She stated a few days ago. At 10:34 a.m., after the staff member administered the medication, The staff member suggested to the resident that she take her pain medication more often. The resident said, They don't tell me when I can have a pain pill. I'm afraid the catheter will come out again, it hurts so bad when it comes out. The LPN stated that she would see if the resident could have a routine pain medication.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident did not develop a stage III pressure ulcer for one (#2) of three sampled residents, who were reviewed for pressure ulcers. The facility failed to: a. consistently assess skin integrity, b. implement measures to prevent the development of pressure ulcers by ensuring interventions were implemented, and c. ensure the physician was notified to obtain treatment interventions before ten days had elapsed between the time the pressure ulcer was identified and the physician was notified. After ten days, the pressure ulcer had increased in size and depth to a stage III pressure ulcer. The facility Census and Condition of Residents Report dated 07/28/15, documented four residents were receiving treatments for pressure ulcer wounds. Findings: A facility policy 'Skin and Wound Care Guidelines' documented, Purpose; To provide a systematic approach and monitoring process for skin integrity/pressure ulcer care. To prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and developing interventions. To promote healing of pressure ulcers. Objective: To maintain an optimal level of skin integrity and to promote optimum healing of pressure ulcers using an individualized plan of care. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. An initial admission skin/wound assessment, dated 06/03/15, documented, focused assessment r/t (related to) skin. this nurse finished skin assessment. no skin breakdown noted at this time. The note was signed by staff member #11. A care plan dated 06/04/15, documented, Focus (Resident) has Potential for skin breakdown r/t Braden <18. Goal; To prevent any new breakdown, or reoccurrence of closed/resolved pressures ulcers. Interventions; Document change in position and/or turning on ADL (activities of daily living) sheets with a goal time of every 2 hrs (hours) depending on activity participation, meals, and ADL's. Draw sheets to bed to reduce friction. A comprehensive admission assessment, dated 06/10/15, documented the resident did not have any type of pressure ulcers, wounds and/or any other skin problems. The assessment further documented the resident required extensive assistance from one staff person for bed mobility, transfers, dressing, toilet use and personal hygiene. Weekly skin/wound assessments dated 06/04/15, 06/11/15, and 06/18/15, all documented the resident exhibited, No skin breakdown. There was no skin assessment for 13 days from 06/18/15 through 06/30/15. A hospice facility note,dated 06/30/15, documented, .I saw two shearing point. both to the right inner coccyx about 2 in (inch) above anus. scant amount of bleeding from both. both dime size at this time. called nurse in to show her, and was reassured that cream would be applied. The same note documented, Physical\Skin\Incision/Wound Site location:Right inner coccyx Type: shearing Healing: other: new Wound Measurement: length in centimeters: dime size Incision/Wound Tissue Observed: Pink Surrounding Tissue: Other: red Wound Margins: Tunneling absent Drain Site and Type: None Drainage: Serous Drainage Amount: Small Dressing Changed this Visit: No There was no documentation the physician was notified of the presence of the wound and no treatments were provided to the newly identified open area to the coccyx. A comprehensive significant change assessment, dated 07/06/15, documented the resident now required extensive assistance from two persons, for bed mobility, and one person assistance for transfers, dressing, eating, toileting, and personal hygiene. A facility nurses' noted dated 07/09/15, documented, Focused assessment r/t skin. The resident has a stage III 2.0 x 1.9 cm (centimeters) with pink granulation in the middle of wound bed and dark slough around the edges. daugter (sic) (name withheld) called and updated. call placed to hospice spoke with (name withheld) who stated the (name withheld) would get a hold of this nurse. (name withheld) also stated that hospice doesn't do aggressive txs. (treatments) Dr. ((name withheld) notified. A physician's telephone order was obtained on 07/09/15 at 1:47 p.m., which was 10 days after the open area was identified by staff, documented, Duoderm to Coccyx one time a day every 3 day (s) for STAGE III CLEANSE BEFORE APPLYING DUODERM. A facility skin/wound note, dated 07/17/15, documented, focus assessment r/t skin. tx changed by hospice nurse. new orders noted to apply [MEDICATION NAME] cover with aseptic dressing secure with tape change daily. stage III 3.0 x 6.0 cm with 100% yellow slough with normal skin surrounding . A facility skin/wound note, dated 07/24/15, documented, focused assessment r/t skin. will continue the tx to stage III on coccyx 3.0 x 6.0 (cm) with 100% yellowish, gray, slough with normal skin surrounding. resident is on low air loss mattress, pillows for repositioning, resident has poor appitie (sic) . A facility nurses' note, dated 07/25/15, documented, Focused assessment related to wound to coccyx. Slough that had previously been attached to the left portion of the wound has now detached at this time. Portion of detachment is approximately 3 cm to 4 (sic) wide with allowing visibility within the wound that tunneling is present measurements not done at this time due to resident pain. Wound nurse notified of status of wound and daughter notified of change in wound . On 07/29/15 at 08:30 a.m., the resident was observed in bed with family at the bedside. She was observed to be in a supine position with the head of the bed at an approximate 45 degree angle. She was observed to be awake, alert and able to answer questions appropriately. Three hours later, at 11:30 a.m., the resident was observed to be in the same position, supine with the head of the bed up. The same family member remained at the bedside. Two hours and twenty minutes later, at 1:50 p.m., the resident was observed sleeping in bed. The head of the bed was lower at approximately 30 degrees and she remained in the same supine position. The same family member was at the bedside. Three hours and twenty minutes later, at 5:10 p.m., the resident was again observed in a supine position. The same family member remained at the bedside. The family member was asked when the resident was last repositioned. She stated she had not been repositioned. She was asked if the staff had attempted to reposition the resident. She stated they had not. She was then asked if the resident had refused to be repositioned. She stated, No. No one has asked. A facility skin/wound note, dated 07/30/15, documented, focused assessment r/t skin. will continue tx to stage III on coccyx of 5.0 cm x 6.0 cm x 2.0 cm with .her wound bed. the wound bed has 60% grayish slough from 11:00 to 5:00 oclock (sic) which the wound edges are attached from 6:00 to 10:00 the wound has no slough and the depth is 2.0 cm and the wound base is red beefy granulation . On 07/30/15 at 6:15 p.m., staff #11 and staff #1 were interviewed and asked to review the clinical records pertaining to the findings of the pressure ulcer. Staff #11 was asked what interventions were in place to prevent the resident from developing any type of pressure ulcers. She stated the resident was to be turned and repositioned every two hours, had a low air loss mattress on her bed, and a medicated cream was to have been applied to her coccyx area daily. She was asked about the documentation for the administration for the preventive cream and the turning and repositioning. She stated it should be on the treatment record (TAR) and activities of daily living record. She was asked how often the resident's skin was assessed. She stated weekly skin assessments were completed. The skin/wound nurses' notes, treatment records, and activities of daily records for the months of 6/15 and 7/15, were reviewed. There was no documentation on the monthly activity of daily living records the resident had been repositioned every two hours. There was no documentation on the June and July 2015 treatment records a medicated cream had been applied from 06/30/15 through 07/09/15. Facility nurses notes were reviewed from admission through 07/31/15. There was no documentation the resident had been repositioned every two hours. Staff#1 was asked when the physician was notified of the new pressure ulcer identified by staff on 06/30/15. She stated the physician was first notified and orders were first obtained for the treatment of [REDACTED]. On 08/04/15 at 9:30 a.m., an interview was conducted with staff #12, who provided care for the resident. She was asked how she cared for the resident. She stated the resident was to be turned and repositioned every two hours. She stated the resident was to be checked for incontinence every two hours and care provided at that time if needed, and was to be assisted with her meals. She stated the care provided was documented on the activities of daily living records. There was no documentation on the June and July 2015 monthly activity of daily living records the resident had been repositioned every two hours.

Based on interview and record review, it was determined the facility failed to ensure: a. the physician was notified of a stage III pressure ulcer for one (#2) of three sampled residents who were reviewed for pressure ulcers. This resulted in harm, and b. the physician was notified of negative urinalysis results before five days for one (#79) of five residents who were reviewed for unnecessary medications. The facility Resident Census and Conditions of Residents report dated 07/28/15, documented four residents were receiving treatments for pressure ulcers and four were receiving antibiotics. Findings: A facility policy documented, The facility will inform the resident; consult with the resident's physician; and if known, notify the residents's legal representative or interested family member of the following events: (B) A significant change in the resident's physical, mental, or psychosocial status. (i.e. a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) . 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive admission assessment dated [DATE], documented the resident was severely impaired in cognition, but able to make needs known. The assessment documented the resident had no types of ulcers, wounds and/or skin problems. A (name deleted) hospice note dated 06/30/15, documented, .I saw two shearing point. both to the right inner coccyx about 2 in (inch) above anus. scant amount of bleeding from both. both dime size at this time. called nurse in to show her, and was reassured that cream would be applied. The same note further documented, Physical\Skin\Incision/Wound Site location:Right inner coccyx Type: shearing Healing: other: new Wound Measurement: length in centimeters: dime size Incision/Wound Tissue Observed: Pink Surrounding Tissue: Other: red Wound Margins: Tunneling absent Drain Site and Type: None Drainage: Serous Drainage Amount: Small Dressing Changed this Visit: No A facility nurses' note dated 07/09/15, documented, Focused assessment r/t (related to) skin. The resident has a stage III 2.0 (centimeters) x 1.9 cm with pink granulation in the middle of wound bed and dark slough around the edges. daugter (sic) (name withheld) called and updated. call placed to hospice spoke with (name withheld) who stated the (name withheld) would get a hold of this nurse. (name withheld) also stated that hospice doesn't do aggressive txs. (treatments) Dr. (name withheld) notified. A physicians telephone order, dated 07/09/15 at 1:47 p.m., documented, Duoderm to Coccyx one time a day every 3 day (s) for STAGE III CLEANSE BEFORE APPLYING DUODERM. The order was signed by staff member #11. On 07/30/15 at 4:15 p.m., staff member #11 and staff member #1, were interviewed and asked to review the clinical records pertaining to the findings of the pressure ulcer. After reviewing the nurses' notes and the hospice notes, they were asked to show where the physician had been notified of the pressure ulcer found on 06/30/15. No documentation was found to show the physician had been notified. Staff member #1 was asked if the physician should have been notified of the presence of the open area identified on 06/30/15. She stated Without a doubt he should have been. 2. Resident #79 was admitted to the facility with [DIAGNOSES REDACTED]. A urinalysis lab result, dated 05/21/15, documented : ~ appearance turbid, ~ protein 2+, ~ [MEDICATION NAME] positive, ~ blood 3 +, ~ bacteria 4 +, ~ greater than 100,000 E-Coli, ~ greater than 100,000 gram negative rods, and ~ ESBL (extended-spectrum Beta-Lactamase), a bacteria. A nurse's note, dated 05/26/15 at 1:41 p.m., documented the physician's office was contacted and a new order was obtained for [MEDICATION NAME], an antibiotic,100 milligrams (mg) two times a day for 10 days. The clinical record documented the physician was not notified of the negative urinalysis results for five days.

On [DATE] at 3:00 p.m., an Immediate Jeopardy (IJ) situation was identified related to the failure of the facility to provide immediate cardiopulmonary resuscitation (CPR) to a resident who had requested to be on full code status. At 3:10 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 3:35 p.m., the facility administrator and the director of nursing (DON) were notified of the existence of an IJ pertaining to the failure of the staff to provide CPR to an unresponsive resident with a full code status. At 6:20 p.m., the plan of removal was received and accepted. The facility's Plan of Removal documented: "Each active resident chart was reviewed and updated on this date, [DATE], by 5:30 p.m. for current CPR status and current Health Care Power of Attorney (POA) status. Patient information sheets were updated in each MAR (medication administration record), TAR (treatment administration record)and ADL (activities of daily living) book to reflect each residents code status and Power of Attorney status by 6:00 p.m. All red stickers formerly used in patient rooms to identify status were removed by 5:30 p.m. Each licensed nurse, except for two who do not have telephone access, employed by the facility was educated in person or by telephone on where to identify code status and POA status of a resident by 6:30 p.m. At that time all nurses were further educated that only a resident, physician, or Healthcare Power of Attorney can alter a code status. Education included protocol for initiating CPR immediately when necessary and appropriate. The two nurses unavailable by telephone will receive inservice education before returning to work. All staff currently in the facility were educated in person by 7:00 p.m. regarding protocol for obtaining help for an unresponsive resident including using emergency call cords in the resident room or restroom and staying with the resident until a nurse arrives. All employees will receive inservice education covering this information and sign acknowledgement prior to working their next scheduled shift. To ensure compliance in this area and prevent recurrence of the deficient practice the Social Service Director will update the patient information sheets in the MAR, TAR and ADL book to reflect any changes in Power of Attorney upon receiving new legal documentation. The Director of Nursing or designee will update the patient information sheets in the MAR, TAR and ADL book to reflect a change in code status upon receiving a physicians order or signed DNR (do not resuscitate). At least once each month the DON or designee will review each MAR, TAR and ADL sheet with the resident chart to ensure status remains accurate. The DON or designee will record findings of monthly audit and report to the QA committee for review for continued effectiveness." On [DATE] at 9:40 a.m., the administrator was asked if the nursing staff had been inserviced on interventions for residents with a full code status. He stated all licensed nurses, except two without a phone, had been inserviced either in person or by phone by 5:30 p.m. on [DATE]. He stated all other personnel had been inserviced over the weekend or would be inserviced prior to returning to work. He stated no one would be allowed to return to work without having been inserviced. Documentation of the inservices was presented. Staff members from numerous departments were interviewed to verify the inservices had taken place. On [DATE] at 11:45 a.m., the administrator and DON were informed the IJ was removed as of [DATE] at 7:00 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to ensure staff initiated CPR (cardiopulmonary resuscitation) for one (#1) unresponsive resident of two sampled resident's, who had a full code status and had expired in the facility. The facility identified 57 residents with a full code status. Findings: The facility's policy, 'General Guidelines For Emergency Care', documented, "BASIC RESPONSIBILITY: LICENSED NURSE PURPOSE 1. To provide emergency care to a resident in need of urgent service. 2. To prevent complications... PROCEDURE ...If resident's condition has changed, call attending physician and report changes and nursing observations. Provide emergency care as necessary... Always take, report and record vital signs when a resident's condition has changed... If a resident expires, initiate CPR unless ordered otherwise. Call paramedics. Call the attending physician and resident's family or responsible party... Record details and exact time of condition change of resident, initiation of emergency procedure and resident's response to emergency care..." The facility's policy, 'Condition Change, of the Resident', documented, "BASIC RESPONSIBILITY: LICENSED NURSE... PURPOSE To observe, record and report any condition change to the attending physician so proper treatment will be implemented... PROCEDURE After all resident falls, injuries or changes in physical or mental function, monitor the following: ...Take vital signs and include temperature... Observe for dyspnea or variations in respirations (irregular)... Have someone stay with the resident while the nurse is calling the attending physician..." Resident #1 had [DIAGNOSES REDACTED]. A history and physical, dated [DATE], documented the resident had a history of [REDACTED]. The resident was alert and oriented to person, time, and place. His initial care plan, dated [DATE], documented he was alert and used a walker and/or a wheelchair for ambulation. He was on a regular diet and required supervision for eating. He was admitted to the facility on [DATE] and expired on [DATE]. No resident assessment had been obtained. The resident's personal information sheet, dated [DATE], documented he was his own power of attorney. The physician's admission orders [REDACTED]. A nurse's note, dated [DATE] at 1:00 p.m., documented the family informed the facility the resident had frequency of urination and dribbling of urine. At 2:15 p.m., a nurse's note documented the resident was catherized for post voiding residual. He had 400 milliliters of urine in his bladder. The catheter was left in place. This note documented the resident was coughing during the procedure. His lungs were auscultated. Licensed practical nurse (LPN) #1 documented she was unable to hear the lower lung sounds due to the resident not being able to breath deeply. At that time no further assessment was conducted as to why the resident was coughing and not breathing deeply. At 6:40 p.m., a nurse's note documented a certified nurse aide (CNA) reported to the charge nurse (LPN #2) the resident had something in his throat but he was unable to cough. LPN #2 documented when she entered the room the resident was sitting up in bed. His respirations sounded wet. His color was pale, he had no blood pressure, and his oxygen saturation was 58% (a normal range for oxygen saturation is between 90% and 100%.). The LPN left the room to get an oxygen concentrator and phone the physician. When she returned the resident had no respirations or vital signs. LPN #2 documented in the notes the wife said, "It's too late, there is nothing you can do, he's gone." The clinical record documented LPN #2 left the resident alone with a family member. She did not pull the emergency call light to summon help for a resident who was in distress. The clinical record contained no documentation that CPR was initiated for the nonresponsive resident, even though he had a full code status. The incident report filed with the state health department on [DATE], documented the charge nurse was called to the resident's room. It was reported to her that the resident needed to cough but was unable to cough. The resident's respirations sounded wet and his oxygen saturation was 58%. She left the room to get an oxygen concentrator and phone the physician. When she returned to the room she found the resident without vital signs or respirations. She further documented she was going to start CPR but the resident's wife refused to allow her to start CPR. On [DATE] at 11:00 a.m., the resident's granddaughter was interviewed. She stated her father phoned her from the facility around noon on [DATE]. He reported to her that the resident was urinating frequently, dribbling, and coughing. She stated she phoned the facility and suggested the resident had [MEDICAL CONDITION]. He might need a urine analysis and a catheter. She stated she asked them if he had something caught in his throat. She asked if he might need suctioning. She was asked if the family had been discussing having the resident placed on do not resuscitate status. She stated they had not, they were discussing taking him home with home health. At 11:10 a.m., the son was interviewed. He stated he asked the nurse about his father's cough after the nurse placed his father's catheter. The nurse (LPN #1) listened to his father's lungs and told him the lungs were clear. He stated he told her the lungs were not the problem. The problem was that something was stuck in his father's throat. He stated his father repeatedly told everyone something was stuck in his throat and he could not cough it up. The son stated he told the nurse the resident needed suctioning. He was asked if the family had been discussing having the resident placed on do not resuscitate status. He stated they had not. At 1:40 p.m., LPN #2 was interviewed. She was asked to tell us about the incident concerning the resident's death. She stated a CNA reported to her that the resident was choking. She entered his room to see what was going on. He was turning white. I hollered for the nurse at the front desk but she couldn't hear me. I pulled the call light at the bedside. He was gasping for air. She said the wife was yelling, "He's not breathing. He's not breathing." She was asked if she did an assessment. She said she did but she didn't write it down. She knew he was in distress. She took his O2 (oxygen) saturation level and assessed his lungs. She adjusted his head up, incase he had something stuck in his throat. There was an oxygen concentrator in the room but no tubing. She left the room and yelled at a nurse to get some tubing. No one was in the hall because it was dinner time and everyone was in the dining room. She stated that when she returned to the resident's room his daughter was there. She stated she started to put the head of his bed down but his wife began yelling, "Don't put his head down. He is dying, just leave him alone. He is not breathing now. You can do no more for him." LPN #2 was asked who had the authority to countermand a resident's wish to be resuscitated. She stated she thought the family did. At 2:00 p.m., LPN#1 was interviewed. She was asked if the son had discussed his father's inability to cough up whatever was caught in his throat. She stated he told me he was coughing. She was asked why she had listened to the resident's lungs. She stated he must have been coughing while I was in there. I asked the resident to take deep breaths, he couldn't take a deep breath. I couldn't hear anything. She was asked who had the authority to over ride a cognitively intact resident's wish to receive CPR. She said, "I'm not sure, I think the family can, you just have to know the resident. If the family is in the room and they ask me to stop or not do it, I might not do it." At 2:25 p.m., the administrator and director of nurses (DON) were interviewed. They were both asked who had the authority to countermand a resident's wish to receive CPR. They both stated the resident, the medical power of authority (POA), or the physician. They were both asked if the family had the authority to override a resident's wish to receive CPR when the resident was his own POA. They both said. "No." The DON was asked if the resident should have been left alone. She said, "No." She was asked if CPR should have been initiated. She stated she would expect the nurse to remain with the resident, start preparing for CPR, and pull the emergency call light. She stated the room had two emergency call lights. On [DATE] at 2:15 p.m., the resident's wife was interviewed. She was asked if she told the staff not to perform CPR. She said, "No." She stated the nurse didn't come back for several minutes and when she did come back, he was already dead. She said when the nurse first came in he was making gurgling sounds. She told me she was going to get some tubing, maybe for suction or oxygen. The facility discharge summary dated [DATE], documented the cause of death as respiratory arrest. An assessment was not conducted at 2:15 p.m., when no lung sounds were heard in the lower lung fields and the resident was complaining of being unable to clear his throat. At 6:40 p.m., the resident was left unattended when it was determined he was in distress. No emergency action, including CPR, was initiated for the resident who had requested to be a full code status.

On 11/29/11, an Immediate Jeopardy (IJ) was determined to exist in regard to the facility's failure to follow aspiration precautions for resident #12 who was documented to be at high risk for aspiration and a high risk for aspiration pneumonia. On 11/29/11 at 9:05 a.m., the Oklahoma State Department of Health confirmed an immediate jeopardy existed. At 9:10 a.m., the DON and ADM were notified of the IJ situation which constituted substandard quality of care. On 11/29/11 at 10:36 a.m., an acceptable plan of removal was received from the ADM. The plan of removal documented the following: "The resident had a head to toe assessment completed 11/29/11 at 10:00 a.m., with no signs and symptoms of respiratory distress at this time. The facility obtained an order for [REDACTED]. X-ray will be obtained by 11:30 (a.m.). Speech Language Pathologist (SLP) educated through small group inservices all Certified Nurse Aides and licensed nurses currently at work regarding proper techniques for assisting residents with swallowing problems with meals. Physical Therapy educated all Certified Nurse Aides and licensed nurses on appropriate positioning of residents during feeding or intake. These inservices were completed 11/29/2011 at 10:30 a.m. SLP will screen the identified resident for appropriateness of diet on this date by 12:00 (p.m.). All residents who eat in their rooms were reviewed for risk of aspiration. The reviews were completed 11/29/2011 at 10:00 a.m. To ensure compliance in this area and prevent recurrence of the deficient practice all CNAs and nurses employed by the facility will be inserviced on proper techniques for feeding or assisting residents with swallowing problems and appropriate positioning during intake by 11/30/2011 at 3:00 p.m. All clinical staff will be educated upon orientation to the facility and quarterly. A licensed nurse will be present in the dining room during meals. DON or designee will monitor the dining room at random during all three meals at least three times each week for eight weeks and then at random to ensure continued compliance. The results of dining room monitoring will be reviewed monthly by the QAA committee for continued effectiveness." The immediate jeopardy was removed on 11/29/11 at 4:20 p.m., after it was determined all facility staff had been inserviced and understood the correct procedures to follow for residents with aspiration precautions. The deficiency remained at a level of no actual harm with potential for more than minimal harm, at a pattern. Based on observation, record review, and interviews, it was determined the facility failed to follow aspiration precautions for a resident with a known history of aspiration pneumonia and a high risk for aspiration for one (#12) of five sampled residents. This resulted in an immediate jeopardy situation. The DON identified seven residents who were at risk for aspiration and/or aspiration pneumonia. The facility also failed to implement safety measures to prevent accidental falls for one (#3) of one sampled resident who utilized incontinent pads as a rug, on the floor by her bed. No additional residents were identified as using incontinent pads as rugs. Findings: A document titled "Assisted Feeding: The How and How Not's" provided by the DON as the facility policy for aspiration precautions, documented, "...Assistance with feeding: awake and alert, positioning- always feed/administer meds with pt at 90 (degrees), give small bites and sips, frequently check for residue in the mouth, cue pt if necessary...follow all precautions/postures put in place by ST..." A history and physical dated 06/22/10, documented, "History of present illness: (Resident #12) is a patient known to me with severe advanced dementia...She had an episode of aspiration yesterday with respiratory distress and hypoxemia....Impression: Clinical picture most suggestive of acute aspiration pneumonia..." A physician's progress note dated 12/29/10, documented, "...Recent dysphagia, aspiration pneumonia, just finished her Levaquin." A care plan written on 06/25/10 and last updated 06/30/11, documented, "Problem: Actual and potential for aspiration resident has potential for aspiration R/T: not chewing food completely and too large portions @ a time. Goals: resident will safely consume food and fluids with minimized risk of aspiration through NRD. Approaches: Follow-up speech screen or eval if indicated. Thin liquids at all times. Observe resident for signs and symptoms of aspiration (i.e. choking on foods and fluids, shortness of breath, wheezing, elevated temp, gurgling, etc.) coughing, runny nose, watery eyes, monitor for appetite, weight loss, and texture tolerance during meals, serve pureed diet ordered. Feed assisted dining room alternate small bites/ sips @ a time slowly, sit up right for all po intake. Aspiration precautions..." Physician's progress notes dated 02/23/11 and 04/20/11, documented, "...History of dysphagia, aspiration pneumonia." A speech language pathologist clinical evaluation for swallow, dated 05/03/11, documented, "...reason for referral: patient reportedly having increase in coughing/choking during meals (per nursing report). Pertinent medical and surgical information/precautions: Alzheimers disease, aspiration pneumonia 6/22/10...swallowing ability: fair, resident or staff complaints of dysphagia: coughing or choking on foods or liquids. History of coughing/choking/pneumonia: Pt had aspiration pneumonia June 2010. Test administered: Clinical bedside swallow evaluation. Cognition: comments: severe deficit. Swallowing: 50% (mod Sev Impairment) patient presents with severe oral dysphagia characterized by inability to form a cohesive bolus, delayed AP transit, and delayed swallow initiation. Patient has difficulty managing secretions at times. Patient also presents probable pharyngeal dysphagia characterized by delayed swallow onset. decreased laryngeal elevation, occasional and intermittent significant coughing episodes. AT RISK FOR ASPIRATION: yes. DYSPHAGIA EVALUATION RECOMMENDED: YES. NUTRITION SOURCE: Oral. DIET LEVEL: Nectar Liquid & Pureed VOLITIONAL SWALLOW: Unable. DIET LEVEL APPROPRIATE FOR ORAL MOTOR SKILLS: Yes. TIME TO INITIATE: 5 SWALLOWING OBSERVATIONS: Coughing & Delayed swallow & Multiple swallowing attempts & Poor bolus control & Reduced laryngeal excursion REASON FOR REFERRAL: Patient referred for ST evaluation 2 (secondary) increased coughing with PO intake. EVALUATION SUMMARY: Patient presents with severe oral dysphagia and probable pharyngeal dysphagia. At this time, feel that patient is not a good candidate for MBS d/t poor cognitive status/inability to follow commands. Also do not feel that alternative means nutrition/hydration appropriate, as patient is with advanced Alzheimer's disease. Recommended patient continue with pureed diet with honey thick liquids. Patient should be up at 90 (degree)) for all PO intake, fully awake and alert. ST will remain available for consult." An annual assessment dated [DATE], documented the resident was severely impaired in decision making, was totally dependent on staff for eating and positioning. The assessment also documented the resident held food or residual food in her mouth and cheeks after meals, and coughed or choked during meals or when swallowing medications. The CAA dated 06/20/11, documented, "Review of indicators of nutritional status analysis of findings: Combined care plan for nutrition and dental. (Resident) is on a pureed diet and has been noted to hold food in mouth/cheeks and to cough at times during meals...care plan consideration: proceed to care plan with goals of staff continuing to feed (Resident) at all meals. staff will continue to allow (Resident) adequate time to eat...referral to another discipline: No referrals at this time. Recently referred to speech therapy." A physician's progress note dated 06/22/11, documented, "...History of dysphagia, aspiration pneumonia." Physician's progress notes dated 08/24/11 and 10/26/11, documented, "...2. History of aspiration pneumonia. 3. Dysphagia." The November 2011, monthly physician's orders [REDACTED]. A significant change assessment dated [DATE], documented the resident had long and short term memory problems, was severely impaired in cognitive skills for daily decision making, was totally dependent on staff for eating and positioning. The assessment also documented the resident held food or residual food in her mouth and cheeks after meals, and coughed or choked during meals or when swallowing medications. The CAA dated 11/17/11, documented, "Analysis of findings: (Resident #12) requires a mechanically altered diet d/t difficulty swallowing...care plan considerations: will care plan for risk. Refer to the care plan for interventions." On 11/28/11 at 1:20 p.m., the resident was observed in the assisted dining room being assisted with her meal. The resident was in a geri-chair, which was reclined back to an approximate 20 degree angle. The aide assisting the resident was standing over her the resident while feeding her. The resident was not in an upright position. On 11/29/11 from 7:50 a.m. through 8:30 a.m., the resident was observed receiving assistance with her morning meal. The resident was in a geri-chair, which was reclined back to an approximate 20 degree angle. CNA #7 was observed assisting the resident with her meal. The CNA was observed standing over the resident while providing the assistance, placing the food in the resident's mouth. The restorative aide entered the dining room and took over feeding the resident. CNA #7 left the room. While the restorative aide was assisting the resident, the resident remained at approximately 20 degrees. The resident's face turned red, and she gasped for air. LPN #1 was summoned over to the resident who then began to cough hard. 15 seconds lapsed from the time the resident's face turned red until she was able to cough. The resident continued to be assisted while at positioned at approximately 20 degrees. The resident continued to cough during the meal assistance. The resident remained at an approximate 20 degree angle throughout the meal service. An interview was conducted on 11/29/11 at 9:12 a.m., with the restorative aide. She was asked what level of assistance the resident required during meals. She stated, "Total feeding assistance." She was asked what position the resident should be in during meals. She stated, "In an upright position, so she doesn't choke." She was asked why the resident was reclined back during the meal assistance. She stated, "The charge nurse said it was because she would slide out of the chair." She was asked if the resident had problems with choking. She stated, "Every now and then she will choke. She choked this morning." She was asked who all assisted the resident with the morning meal. She stated, "(CNA #7) also assisted the resident the same way." An interview was conducted with LPN #1 on 11/29/11 at 2:15 p.m., regarding the resident's positioning and aspiration risk. She was asked what her responsibilities were during meals. She stated, "I supervise to make sure no one chokes, check alarms, and oxygen." She was asked about the resident's position at an approximate 20 degree angle during the meal. She stated, "She slides down if the back is up all the way. I thought that it would be all right to be like that." An interview was conducted on 12/02/11 at 9:55 a.m., with the DON regarding the resident's aspiration risk. She was asked if the resident's care plan was being followed for aspiration precautions. She stated, "The care plan was not being followed." She was asked what the facility policy was for following care plans. She stated, "They should be followed at all times." She was asked how often she would monitor the meal assistance in the dining room. She stated, "I would check in and make sure everything would look right, but would rely on the charge nurse assigned in the room to fully monitor the meal service." She was asked to describe how aides should be positioned while assisting residents' with their meals. She stated, "At least one aide should be seated behind the table assisting the residents. If more than one aide was assisting residents at the table then they could be seated next to the resident." She then stated, "They shouldn't be standing." Incontinent pads on floor: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident was independent with transfers and ambulation, had bilateral range of motion deficits to the upper and lower extremities, was unsteady moving from a seated to a standing position, moving on and off the toilet, and transferring between the bed and chair. During the initial tour of the facility on 11/28/11 at 8:30 a.m., resident #3 was observed to have two large incontinent pads lying on the floor next to her bed. When she was asked about the incontinent pads, she stated, "I want to protect the floor." On 11/29/11 at 8:05 a.m., two large incontinent pads were observed on the floor by the resident's bed. The resident stated she used them as "rugs." CMA #1 was asked if a rug with a rubberized edge might be a safer choice for the resident. She stated, "Yes. We have spoken with the family about getting some rugs, but they haven't." On 12/01/11 at 10:00 a.m., the DON was interviewed regarding the incontinent pads by the bed of resident #3. The DON stated, "She chooses to do that, that is her choice." When the DON was asked about the potential for falls related to the use of the pads on the floor, she stated, "I guess we can see if we have anything we can use instead of letting her use the pads."