Every finding on record at 24th Place

Based on record review and interview, the facility failed to ensure an RN was competent and possessed the necessary skills to provide care for 1 (#1) of 1 resident sampled for peg tubes.The DON identified one resident with a peg tube. Findings:A facility policy titled Enteral Tube Feeding via Syringe (Bolus), dated November 2018, read in part, Verify that there is a physician's order for this procedure.An undated medical diagnoses list showed Resident #1 had diagnoses which included esophagitis, dysphagia, and traumatic hemorrhage of cerebrum.An untitled document showed RN #1 completed their training on tube feeding on 07/10/25.Resident #1's treatment administration record, dated 10/01/25 to 10/31/25, showed Resident #1 had an order for Osomolite 1.5 cal oral liquid (nutritional supplement), give 237 ml via peg tube every four hours. RN #1 initialed the 8:00 a.m. dose as being provided as ordered.A physician's order, dated 10/10/25, showed Osmolite (enteral nutrition) 1.5 Cal oral liquid, give 237 ml via peg tube every four hours for nutrient, flush peg tube with 60 ml of water before and after feeding.A nurse's note, dated 10/13/25, read in part, This patient was fed this morning by peg tube as requested, at 10:00 a.m., and after about an hour the patient started coughing continually and throwing up, they aspirated on their food. After managing the situation for a while (raise the HOB, ensure patient is calm) this nurse [RN #1] texted the doctor at about midday and reported what happened, the Dr. advised the nurse [RN #1] to hold the midday feeding and monitor the patient. Dr. was notified at 11:48 a.m. that the Resident was given to much formula. At 1:34 p.m., Dr. [name withheld] ordered the Resident to be sent out to the ER for possible fluid overload and aspiration.A written statement, dated 10/13/25, showed LPN #1 was notified by a CNA Resident #1 was vomiting. LPN #1 had notified RN #1 of the resident's condition and then asked RN #1 how much they fed Resident #1 through their peg tube. RN #1 stated two bottles, LPN #1 told RN #1 the physician's order showed one bottle each feeding.An entry on Resident #1 treatment administration record, dated 10/14/25, read in part, One time chest x-ray d/t wet cough, and for precautions as resident was sent out yesterday to r/o overload aspiration pneumonia.A mobile x-ray report, dated 10/14/25, showed Resident #1 had left basilar pneumonia.On 12/01/25 at 2:06 p.m., the DON stated RN #1 did not follow the physician's order and fed Resident #1 two cans of formula instead of one.

Based on record review and interview, the facility failed to ensure physician's orders were followed for enteral feeding for 1 (#1) of 1 resident sampled for enteral feeding.The administrator identified 72 residents resided in the facility. Findings:On 12/01/25 at 10:30 a.m., Resident #1 was observed resting in bed with their eyes open.A facility policy titled Enteral Tube Feeding via Syringe (Bolus), dated November 2018, read in part, Verify that there is a physician's order for this procedure. Report complications promptly to the supervisor and the Attending Physician.An undated medical diagnoses list showed Resident #1 had diagnoses which included esophagitis, dysphagia, and traumatic hemorrhage of cerebrum.An untitled document showed RN #1 completed their training on tube feeding on 07/10/25.Resident #1's treatment administration record, dated 10/01/25 to 10/31/25, showed Resident #1 had an order for Osomolite 1.5 cal oral liquid (nutritional supplement), give 237 ml via peg tube every four hours. RN #1 initialed the 8:00 a.m. dose as being provided as ordered.A physician's order, dated 10/10/25, showed Osmolite (enteral nutrition) 1.5 Cal oral liquid, give 237 ml via peg tube every four hours for nutrient, flush peg tube with 60 ml of water before and after feeding.A nurse's note, dated 10/13/25, read in part, This patient was fed this morning by peg tube as requested, at 10:00 a.m., and after about an hour the patient started coughing continually and throwing up, they aspirated on their food. After managing the situation for a while (raise the HOB, ensure patient is calm) this nurse [RN #1] texted the doctor at about midday and reported what happened, the Dr. advised the nurse [RN #1] to hold the midday feeding and monitor the patient. Dr. was notified at 11:48 a.m. that the resident was given to much formula. At 1:34 p.m., Dr. [name withheld] ordered the resident to be sent out to the ER for possible fluid overload and aspiration.A written statement, dated 10/13/25, showed LPN #1 was notified by a CNA, Resident #1 was vomiting. LPN #1 had notified RN #1 of the resident's condition and then asked RN #1 how much they fed Resident #1 through their peg tube. RN #1 reported two bottles, LPN #1 told RN #1 the physician's order showed one bottle each feeding.A nurse's note, dated 10/13/25 at 5:47 p.m., showed Resident #1 returned to the facility with no new orders.A care plan, dated 10/13/25, showed Resident #1 had a nutritional problem related to dysphagia. The goal showed Resident #1 would have clear lungs and no signs and symptoms of aspiration. A care plan intervention showed Resident #1 was sent to the emergency room for possible fluid overload aspiration.A typed and signed statement by the DON, dated 10/13/25, read in part, I asked the residents nurse [RN #1] how much Osmolite [they] administered via PEG tube, to which [they] responded, 'two containers.' I asked the nurse if [they] knew that was double, to which [they] replied 'Yes'.An entry on Resident #1's treatment administration record, dated 10/14/25, read in part, One time chest x-ray d/t wet cough, and for precautions as resident was sent out yesterday to r/o overload aspiration pneumonia.A mobile x-ray report, dated 10/14/25, showed Resident #1 had left basilar pneumonia.A physician's order, dated 10/15/25, showed Cefdinir (an antibiotic) 300 mg via peg tube two times a day for seven days for aspirational pneumonia.An admission assessment, dated 10/17/25, showed Resident #1's cognition was intact with a brief interview for mental status of 14. The assessment showed Resident #1 had a peg tube being utilized for nutrition.On 12/01/25 at 10:30 a.m., Resident #1 stated the staff took good care of them. Resident #1 stated they did not have feedings through their peg tube anymore.On 12/01/25 at 2:06 p.m., the DON stated RN #1 did not follow the physician's order and fed Resident #1 two cans of formula instead of one.

On [DATE], an IJ situation was determined to exist related to the facility's failure to provide oxygen as ordered by the physician. Resident #77 was found unresponsive and without oxygen on [DATE]. The resident expired in the facility. Resident #77 had a physician order for continuous oxygen at 2 liters per minute per nasal cannula. On [DATE] at 3:01 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 3:12 p.m., the administrator was notified of the IJ and provided the IJ template. On [DATE] at 12:33 p.m., an amended plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Immediate Plan Of RemovalFacility revied [sic] all patients with oxygen orders on 9-29-2025 by 5:00 p.m. to ensure appropriate physician orders are in place, pulse ox, oxygen saturation, and liters ordered per patients is monitored Q shift per policy, and documentation is completed in each resident Emar Q shift. All patients with prn oxygen will have pulse ox checked every shift and prn.All available Nursing staff will be in-serviced on 9-30-2025 by 6:00 p.m. over all patients that require oxygen. All unavailable employees will be removed from schedule and in-service completed on their return before starting a shift. All agency staff will be in-serviced when entering facility for a shift and in-service sent to agency management to complete with their employees that they may send to our facility.All available nursing staff will be in-serviced by [name withheld], RN and [name withheld], RN on 9-30-2025 by 6p.m. over Facility Oxygen administration policy ensuring that all residents with oxygen orders, have pulse ox monitored, oxygen saturation, and liters of oxygen per patient orders monitored Q shift per policy, and documentation is completed in each residents Emar Q shift. All residents with prn oxygen orders pulse ox will be monitored every shift and prn. All unavailable employees will be removed from schedule and in-service completed on their return before starting a shift. All agency staff will be in-serviced when entering facility before beginning a shift.All oxygen concentrators for patients with continuous and prn oxygen were audited on 9-29-2025 by 6:00 p.m. to ensure all are in working order and all hoses and machines are connected correctly.All oxygen concentrators for patients with continuous oxygen will be monitored per shift to ensure all are in working order and all hoses and machines are connected correctly. Monitoring check off sheets will be reviewed at stand up for any concerns. All patients with prn oxygen will have their concentrators checked weekly to ensure properly functioning and oxygen tubing is readily available.All available nursing staff will be in-serviced by [name withheld], RN and [name withheld], RN 9-30-2025 by 6 p.m. over the designated area for the facility crash cart in order to ensure they are able to locate it in a timely manner in an emergency situation. All unavailable employees will be removed from schedule and in-service completed on their return before starting a shift. All agency staff will be in-serviced when entering facility for a shift and in-service sent to agency management to complete with their employees that they may send to our facility.The IJ was lifted effective [DATE] at 6:00 p.m., after all components of the plan of removal were verified as corrected. Policy and procedure for oxygen was reviewed. Orders for oxygen were verified. Audits were verified. In-services were verified and staff communicated they had received in-service in regard to abuse. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed ensure:a. a resident received oxygen as ordered for 1 (#77); andb. a resident had an order for the use of oxygen for 1 (#31) of 2 sampled residents reviewed for respiratory care.The corporate nurse consultant identified two residents who received continuous oxygen resided in the facility. Findings: 1.An undated diagnoses report showed Resident #77 had diagnoses which included acute respiratory distress and chronic obstructive pulmonary obstruction. A care plan intervention, dated [DATE], read in part, Give oxygen therapy as ordered by the physician. A physician's order, dated [DATE], showed Resident #77 was to receive oxygen at 2 liters per nasal cannula continuous every shift. Resident #77's admission assessment, dated [DATE], showed Resident #77 required substantial/maximum assistance with repositioning and transfers and required the use of oxygen. A health status note, dated [DATE] at 3:30 p.m., read in part, Called to room by CNA, resident's Oxygen is unhooked and resident is cold, and blue, with no carotid pulse or respirations. Began Chest compressions x [times] 12 minutes until [ambulance service] arrived and took over. A health status note, dated [DATE] at 3:59 p.m., read in part, [ambulance service] and Paramedics called code. Resident is deceased . On [DATE] at 11:57 a.m., CNA #3 stated, As soon as I saw [Resident #77], was pale, [their] eyes were open and dried out. The oxygen hose was unplugged from the machine. [Resident #77] was dead as soon as I saw [them]. On [DATE] at 12:01 p.m., CNA #3 stated there was no in-service after Resident #77 was found unresponsive and pronounced deceased at the facility by the ambulance service. On [DATE] at 1:06 p.m., LPN #3 stated Resident #77 was found unresponsive. On [DATE] at 1:10 p.m., LPN #3 stated they initiated cardiopulmonary resuscitation and the ambulance service took over when they arrived. They stated it was a lengthy code and the ambulance service pronounced the resident deceased at the facility. On [DATE] at 1:23 p.m., corporate nurse consultant #1 stated the policy for monitoring residents with oxygen was to chart once a shift that they were on oxygen and chart their oxygen saturation. They stated staff were to check the tubing placement and ensure appropriate liters at least every shift. 2. On [DATE] at 8:57 a.m., Resident #31 was observed on 3 liters of oxygen via nasal cannula. An Oxygen Administration policy, revised 10/2010, read in part, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. A care plan, revised [DATE], showed Resident #31 had diagnoses which included acute respiratory failure with hypoxia and hypoxemia. The care plan showed to provide oxygen as ordered. Resident #31's annual resident assessment, dated [DATE], showed the resident's cognition was intact with a BIMS of 15. There was no documentation Resident #31 had an order for the use of oxygen. On [DATE] at 8:57 a.m., Resident #31 stated they were on oxygen for more than three months. They stated they were on 3 liters of oxygen. On [DATE] at 9:18 a.m., LPN #2 stated a physician's order was needed for oxygen administration. On [DATE] at 9:19 a.m., LPN #2 stated Resident #31 was on oxygen. On [DATE] at 9:22 a.m., LPN #2 stated Resident #31 did not have a physician's order for the use of oxygen. On [DATE] at 9:23 a.m., LPN #2 stated the resident was on three liters of oxygen. On [DATE] at 3:07 p.m., corporate nurse consultant #1 stated residents needed a physician's order for oxygen use.

Based on record review and interview, the facility failed to ensure fall interventions were initiated to prevent reoccurring falls for 1 (#10) of 2 sampled residents reviewed for falls.The administrator identified 74 residents resided in the facility. Findings: A review of March 2025 incidents showed Resident #10 had a non-injury fall on 03/07/25 and 03/17/25.Resident #10's fall risk assessment, dated 03/17/25, showed the resident had moderate risk for falls with a score of 9.An incident report, dated 03/19/25 at 9:00 p.m., read in part, Notified by staff that resident had a fall. Nursing assessment completed and observed with 5cmx5cm scalp hematoma. Neurological checks initiated and resident was assisted to bed. Resident states [gender withheld] was trying to close the curtain and lost [gender withheld] balance.Resident #10's fall risk assessment, dated 03/19/25, showed the resident had moderate risk for falls with a score of 13.There were no documented interventions to prevent falls or injuries related to the fall on 03/19/25.Resident #10's annual resident assessment, dated 03/20/25, showed the resident's cognition was intact with a BIMS of 15. The assessment showed the resident was independent with bed mobility, transfer, and walking at least 150 feet. The assessment showed the resident used a walker. The assessment showed the resident had two or more non major injury falls.An incident report, dated 04/04/25 at 11:10 p.m., read in part, Residents roommate yelled to notify nursing staff that [Resident #10] was in the floor. Upon entering the room Resident is witnessed sitting on floor beside roommates bed and electric W/C [wheelchair]. Resident complains of Left Hip and leg pain. Left leg is visible shortened by 2-3 inches and Left knee is turned inward to the right. [Resident #10] reports feeling like [gender withheld] hip did when [gender withheld] had surgery on it two years ago. [Resident #10] states I was trying to get back to my walker and I fell. The report showed the resident's walker was in their bathroom.A nursing note, dated 04/05/25 at 12:05 a.m., showed Resident #10 was sent to the emergency room.A hospital operative report, dated 04/05/25, showed a preoperative diagnosis of left distal femur supracondylar fracture.Resident #10's admission resident assessment, dated 04/18/25, showed the resident's cognition was intact with a BIMS of 15. The assessment showed the resident required partial to moderate assistance with bed mobility and transfer.An incident report, dated 04/19/25 at 6:15 p.m., showed Resident #10 had a non-injury fall. The report showed the resident slid off their wheelchair.On 09/23/25 at 12:51 p.m., Resident #10 stated they tripped over their roommate's wheelchair, fell and broke their left hip about four months ago.On 10/01/25 at 10:03 a.m., CNA #2 stated Resident #10 could transfer themselves into their wheelchair and used their walker during therapy.On 10/01/25 at 10:04 a.m., CNA #2 stated Resident #10's fall interventions were to encourage the resident to use the call light for assistance and wheelchair in reach.On 10/01/25 at 10:09 a.m., Resident #10 stated they had a fall while trying to adjust their privacy curtain because the roommate's television images reflected in theirs and closing the curtain helped.On 10/01/25 at 10:25 a.m., LPN #1 stated nurses initiated fall interventions after each fall. They stated they could discuss the fall in morning meeting and come up with fall interventions if unable to come up with interventions on their own.On 10/01/25 at 10:31 a.m., LPN #1 stated Resident #10 had multiple falls in the facility.On 10/01/25 at 10:36 a.m., LPN #1 stated the 03/19/25 fall report showed Resident #10 fell while trying to close their curtain. They stated it could either be the window curtain or the privacy curtain. They stated no interventions were documented on the resident's report or electronic health record to prevent future falls.On 10/01/25 at 10:42 a.m., LPN #1 stated the report should have specified what curtain and the interventions could have been to educate the staff on closing the resident's curtain, educate the resident on calling for assistance, and the use of call light.On 10/01/25 at 11:10 a.m., the chief nursing officer stated if a resident fell, staff were to do an incident report, implement immediate interventions, notify family, physician, administrator, and director of nursing. They stated they did a track and trending and if the resident had two or more falls in a month, they would complete a Five Why to find the root cause of the falls. They stated the nurses would implement interventions to prevent reoccurring falls. On 10/01/25 at 11:13 a.m., the chief nursing officer stated they could not locate any interventions related to the fall on 03/19/25.On 10/01/25 at 11:35 a.m., the chief nursing officer stated they could not locate documentation a Five Why was completed after the fall on 03/17/25 and on 04/19/25.

Based on observation and interview, the facility failed to ensure the most recent state survey results were readily accessible to residents, family members, and legal representatives of the residents.The administrator identified 74 residents resided in the facility. Findings: On 09/26/25 at 1:39 p.m., the information board observed at the facility entrance showed the current survey and past three years of state survey were available at the screening desk.The surveyor was unable to locate the past survey results at the screening desk.On 09/26/25 at 2:34 p.m., the resident council group stated the past survey results were located at the nurses' station.On 09/26/25 at 4:13 p.m., the administrator provided the past survey results binder from inside the nurses station. They stated residents were not allowed to enter the nurses station. The administrator stated the results should be on the nurses station counter for resident access.On 09/26/25 at 4:23 p.m., the administrator stated the binder did not contain results of the 2024 annual recertification survey.

Based on observation and interview, the facility failed to ensure contact information for filing a complaint with the State agency was available to the residents.The administrator identified 74 residents resided in the facility. Findings:On 09/26/25 at 4:08 p.m., the administrator and surveyor observed the information board. On 09/26/25 at 2:38 p.m., the resident council group stated the contact information for filing a complaint with the State agency was covered and not visible. They stated they wanted to contact the State agency a month ago, but could not. On 09/26/25 at 4:06 p.m., the administrator stated the information for filing a complaint with the State agency was posted at the information board by the facility entrance. On 09/26/25 at 4:08 p.m., the administrator stated the contact information on the form was not visible to residents.

Based on record review and interview, the facility failed to ensure residents and their representatives were invited to care plan meetings for 2 (#4 and #31) of 18 sampled residents whose care plans were reviewed.The administrator identified 74 residents resided in the facility. Findings:A Care Plans, Comprehensive Person-Centered policy, revised 03/2022, read in part, The resident is informed of his or her right to participate in his or her treatment, and provided advanced notice of care planning conferences .If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.1. On 09/26/25 at 3:24 p.m., the resident council group stated the facility did not invite residents or their representatives to care plan meetings.2. Resident #31's annual resident assessment, dated 08/28/25, showed the resident's cognition was intact with a BIMS of 15.A review of Resident #31's care plan from January 2025 to October 2025 showed the resident had three quarters of care plan review. There was no documentation the resident or their representatives were invited to care plan meetings for the three quarters. A care plan, revised 08/28/25, showed Resident #31 had diagnoses which included acute respiratory failure with hypoxia and hypoxemia.On 10/01/25 at 3:01 p.m., resident representative #1 stated they had not been invited, but representative #2 may have been invited to care plan meetings.On 10/01/25 at 3:06 p.m., resident representative #2 stated they had not been invited to care plan meetings and they had not attended any care plan meetings for Resident #31.On 10/01/25 at 3:11 p.m., Resident Representative #3 stated they had not been invited to care plan meetings and they had not attended any care plan meetings for Resident #31.3. Resident #4's quarterly resident assessment, dated 09/11/25, showed the resident's cognition was intact with a BIMS of 15.A care plan, revised 09/17/25, showed Resident #4 had diagnoses which included right eye blindness, left eye blindness, and end stage renal disease.A review of Resident #4's care plan from January 2025 to October 2025 showed the resident had three quarters of care plan review. There was no documentation the resident or representatives were invited to care plan meetings for the three quarters.On 09/30/25 at 8:35 p.m., MDS coordinator #1 stated they could not locate documentation that Resident #4 and Resident #31 or their representatives were invited to care plan meetings. They stated care plan meetings were completed quarterly.On 10/01/25 at 3:35 p.m., the social services director stated they sent out care plan meetings invite via mail to the resident's families. They stated they notify residents prior to the meeting and on the day of the care plan meeting. They stated the MDS coordinators could send them out but they rarely retain MDS coordinators so they send the invites out.On 10/01/25 at 3:39 p.m., the social services director stated they did not keep a copy of the invites they sent out to resident families.On 10/02/25 at 1:05 p.m., Resident #4 stated they were not invited to any care plan meeting. They stated they never attended a care plan meeting at the facility.

Based on observation, record review, and interview, the facility failed to follow the menu for mechanical soft portion size for 1 of 1 meal service observed.A Diet Type Report, dated 09/29/25, showed six residents received a mechanical soft diet. Findings:On 09/29/25 at 11:54 a.m., a #16 scoop (equivalent to 2 ounces) was observed on the grounded mechanical soft chicken pan.On 09/29/25 at 12:04 p.m., one #16 scoop of grounded chicken was put on a resident's plate.On 09/29/25 at 12:06 p.m., one #16 scoop of grounded chicken was put on a resident's plate.The PREPARATION OF FOODS policy, dated 07/2020, read in part, measured utensils are used to serve proportions as described on the menu.A 2025 Week 3 Day 16 menu showed to use a #8 scoop (equivalent to 4 ounces) to serve the grounded crunchy chicken ranch.On 09/26/25 at 3:26 p.m., a resident council group stated the meal portion sizes were either too large or too small.On 09/29/25 at 12:16 p.m., cook #1 stated they reviewed the serving sizes in the extended menu book prior to meal services.On 09/29/25 at 12:18 p.m., cook #1 stated they had used the wrong serving size for the mechanical soft chicken. They stated they should have used the #8 scoop.On 09/29/25 at 12:20 p.m., the dietary manager stated they followed portion sizes to prevent weight loss and ensure residents were full.

Based on record review and interview, the facility failed to ensure insulin was administered per physician's orders for 1 (#6) of 5 sampled residents reviewed for unnecessary medications.The administrator identified 74 residents resided in the facility.Findings: An Insulin Administration policy, revised 2014, read in part, To provide guidelines for the safe administration of insulin to residents with diabetes.Document the resident's blood glucose before intervention.Note blood sugar after each administration An undated Diagnosis Report, showed Resident #6 had diagnosis which included type II diabetes mellitus.Physician orders, dated 01/23/25, showed to administer insulin glargine 69 units one time a day and insulin glargine 72 units one time a day.An August 2025 MAR showed missed doses for:a. insulin glargine 69 units on 08/09/25, 08/10/25, and 08/13/25 andb. insulin glargine 72 units on 08/19/25.A September 2025 MAR showed missed doses for: a. insulin glargine 69 units on 09/02/25 and 09/05/25 andb. insulin glargine 72 units on 09/20/25.On 10/02/25 at 11:41 a.m., LPN #4 stated if there was a blank on the medication administration record it meant it was not given, not done. They stated Resident #6 did not receive insulin on the days above.

Based on observation, record review, and interview, the facility failed to ensure EBP and appropriate use of gloves was followed during catheter and perineal care for 1 (#7) of 1 sampled resident reviewed for urinary catheter use.The administrator identified 74 residents resided in the facility. Findings: On 10/01/25 at 3:51 p.m., EBP sign was observed by Resident #7's door and had instructions to wear a gown and gloves. Personal protective equipment supplies were in a storage drawer by the door. The supplies included gowns. On 10/01/25 at 3:53 p.m., CNA #1 was observed to don gloves, told the Resident #7 they would be performing catheter care, and adjusted the resident's bed.On 10/01/25 at 3:55 p.m., CNA #1 was observed to don new gloves and clean Resident #7's catheter. CNA #1 proceeded to clean the resident's groin.On 10/01/25 at 4:01 p.m., CNA #1 was observed to wash their hands, don new gloves, and retrieve a new brief and pad. CNA #1 rolled Resident #7 to their left side.On 10/01/25 at 4:04 p.m., CNA #1 was observed to clean Resident #7's anal area. There was a fecal smear on the brief and anal area.On 10/01/25 at 4:05 p.m., with the same gloves, CNA #1 was observed to put the new brief on Resident #7 and the pad under the resident. They discarded the dirty brief and pad in a plastic bag. CNA #1 adjusted the resident in bed and put the resident's shorts back on.On 10/01/25 at 4:08 p.m., with the same gloves, CNA #1 was observed to empty Resident #7's catheter bag. They proceeded to wash their hands.On 10/01/25 at 4:12 p.m., CNA #1 was observed to take the trash out.CNA #1 did not have a gown on during Resident #7's care. An undated order summary for Resident #7 showed the resident had diagnoses which included other specified disorders of bladder, benign prostatic hyperplasia without lower urinary tract symptoms, and cerebral palsy.A physician's order for Resident #7, dated 08/09/23, showed catheter care every shift and as needed. The order showed to ensure the catheter bag had a privacy bag on at all times.On 10/01/25 at 4:15 p.m., CNA #1 stated the resident was on enhanced barrier precautions. They stated EBP meant to use gloves and change them every time you touched dirty.On 10/01/25 at 4:17 p.m., CNA #1 stated a gown was not needed for EBP and they did not have a gown on during the care that was provided for Resident #7.On 10/01/25 at 4:22 p.m., CNA #1 stated they thought they changed their gloves after cleaning the fecal smear.On 10/01/25 at 4:23 p.m., CNA #1 observed the EBP sign posted and stated they should have worn a gown during the resident's care.On 10/02/25 at 1:41 p.m., corporate nurse consultant #1 stated gowns and gloves were to be used for catheter care due to EBP. They stated gloves were to be changed when going from dirty to clean.

Based on observation, record review, and interview, the facility failed to maintain a safe and homelike environment for the residents for 1 of 3 common areas observed. The administrator identified 78 residents resided in the facility. Findings:On 08/13/25 at 1:00 p.m., the following observations were made at the North end of hall one in the common area where residents participated in therapy, access to vending machines, and puzzle activities:a. a puzzle with a lamp was in progress on a table;b. two bags of dry sack concrete were stored on the floor blocking the pathway to the puzzle creating a trip hazard;c. a hospital bed with no sheets was stored and obscured the pathway to the resident puzzle activity;d. a broken recliner was stored and obscured the path to the resident puzzle;e. a wheelchair with an empty bucket and a bed grab bar around 4 feet in length was balanced across the arms of the wheelchair that was obscuring the path to the resident puzzle activity;f. a walking cane with 4 legs unattended in the pathway to the puzzle activity; andg. a red walker unattended in the pathway to the puzzle activity.A facility policy titled Homelike Environment, revised 02/2021, read in part, Resident are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include: a. clean, sanitary, and orderly environment.On 08/13/25 at 12:55 p.m., the maintenance supervisor was asked about the above observations. The maintenance supervisor stated the area was a resident accessible area. The maintenance supervisor stated the area was a fall hazard because the paths were not clear for the residents to access the puzzle activity that was ongoing. They stated the area did not facilitate a safe homelike environment. On 08/13/25 at 1:03 p.m., the DON was shown the above observations. The DON stated the area was a resident accessible area. The DON stated the area was a fall risk for residents due to the junk being stored. The DON stated the puzzle activity was not accessible. The DON stated the area was not a safe homelike environment because the pathways for residents were not clear. On 08/13/25 at 1:25 p.m., the administrator was shown the items including the sack concrete, the recliner, the bed, the wheelchair and bucket, the cane, the walker, and the bed rail which blocked the pathway to the resident's puzzle in the common were at the North end of hall one. The administrator stated the area was a resident accessible area and it was not a homelike safe environment. The administrator stated staff had been directed to not store items in the area, but continued to do so.

Based on record review and interview it was determined the facilty ensured residents were free of abuse for two (#1 and #3) of three residents reviewed for abuse. The administrator identified 70 residents resided in the facility. Findings: The facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, read in part, .Residents have the right to be free from abuse. neglect, misappropriation of resident property and exploitation. This includes but is not limited to .verbal, mental, sexual or physical abuse . Resident #1 interview questions forms, dated 11/27/24, read in part, .Question 1 have you been abused .by any staff working at the facility .[Certified Nurse Aide #5] said I couldn't keep my urinal because my arm was weak and I spilled it on my bed. He said I would have to go to the bathroom in the bed because I couldn't get up to go to the bathroom . an undated handwritten note, by the social service director, attached to Resident #1 interview questions form, read in part, [Resident #1] stated that [CNA #5] and a black aid who worked night was in the room. He took his urinal and would not give them back [Resident #1] told him does he feel like a big shot being mean to cripples . Resident #2 interview questions forms, dated 11/27/24, read in part, .Question 1 have you been abused .by any staff working at the facility .[Certified Nurse Aide #5] came in and grabbed the front of my diaper and then said I was checking to see if you were wet . Resident #3 interview questions forms, dated 11/27/24, read in part, .Question 1 have you been abused .by any staff working at the facility .yes. [Certified Nurse Aide #5] yelled at me from the door [Resident #1 last name]. I told him my name was Mrs he said he didn't have to all that because of a state law. It hurt my feelings . Question 2 have you observed any staff working at the facility be abusive .yes [CNA #5] to me . On 12/09/24 at 8:39 a.m., Resident #1 stated two weeks ago CNA #5 took my urinal and would not let me use it because it will spill on the bed. Resident #1 stated CNA #5 was then rough when changing him and cleaning him up and that was abusive the way they were treated. On 12/09/24 at 8:50 a.m., Resident #2, the roommate of Resident #1, stated they saw and heard CNA #5 mistreat their roommate. Resident #2 stated CNA #5 would not let Resident #1 have his urinal because urine would get all over the bed. On 12/09/24 at 1:25 p.m., Resident #3 stated CNA #5 was abusive to them when they came into the room calling them by their last name only. It was disrespectful and told CNA #5 it was. CNA #5 continued to disrespect me and that was abusive. On 12/09/24 at 11:55 a.m., the DON reviewed the investigation into the alleged abuse to Resident #1 and stated the allegation should have been confirmed as verbal abuse. They stated they had concerns of abuse because the way the aide spoke to Resident #1 and would not allow them to use the urinal. The DON then stated, You just can not take things away from a resident and the aide was very insensitive.

Based on observation, record review, and interview, the facility failed to ensure a resident's property was not misappropriated for one (#4) of four sampled residents reviewed for misappropriation. The administrator identified 76 residents resided in the facility. Findings: The facility Abuse and Neglect policy, revised 08/12/22, documented the facility would investigate all allegations of abuse, neglect, or misappropriation and analyze all occurrences of abuse during the next scheduled QA committee meeting. Res #4 had diagnoses which included MS. A quarterly MDS, dated [DATE], documented Res #4 was cognitively intact. A facility incident report, dated 09/13/24, documented Res #4's purse containing their wallet had been stolen from their safe while they were in the shower. An In-Service Training Report, dated 09/16/24 at 2:00 p.m., documented the facility provided training to staff over the facility abuse, neglect, and misappropriation policy. A final incident report, dated 09/19/24, documented the facility's investigation was substantiated and the CNA was terminated. The report documented the local police were notified and a plan of action was initiated to prevent recurrence. The report documented the plan of action included placing the resident's key to their safe in the possession of administration during showers. The report documented the codes to the doors were changed to prevent the CNA from re-entering the facility. On 10/11/24 at 10:29 a.m., Res #4 stated they had a credit card stolen from the lock box in their closet. They stated they kept the key to the box on a necklace, but took it off to shower. They stated a CNA had come into their room while they were showering and taken the key since they knew where Res #4 placed the key during showers. They stated the facility fired the employee and called the police to press charges. They denied any current concerns. On 10/11/24 at 3:00 p.m., the administrator stated they were alerted to the missing property on 09/13/24 when the activities staff was instructed to get the purse from the lock box in the closet for Res #4 and it was not there. They stated they immediately notified the police and the resident was able to determine a charge to their account was made at a gas station down the road. The administrator stated the facility contacted the gas station and was able to get a photo of the person who used the card. They stated the police confirmed it was the CNA who was accused of taking the purse. The administrator stated the CNA was terminated immediately. They stated they implemented the plan documented in the incident report and inserviced all staff on misappropriation and the abuse policy. The administrator stated they have followed up with the resident periodically to ensure they felt safe in the facility. A QA summary form, dated 10/14/24, documented the facility reviewed the incident regarding Res #4's misappropriated property. The form documented the plan to prevent recurrence and the facilities immediate actions following the allegation.

Based on record review and interview, the facility failed to provide residents a binding arbitration agreement that informed the resident or their representative of their right not to sign the agreement as a condition of admission or continued care. The DON identified 67 residents resided in the facility and all residents had signed a binding arbitration agreement. Findings: 1. Resident #11 was admitted on [DATE]. A review of Resident #11's medical record documented a copy of a binding arbitration agreement signed by the Resident on 07/13/18. The agreement did not document the resident could be admitted to the facility without entering into the arbitration agreement. 2. Resident #51 was admitted on [DATE]. A review of Resident #51's medical record documented a copy of a binding arbitration agreement signed by the Resident on 03/31/22. The agreement did not document the resident could be admitted to the facility without entering into the arbitration agreement. 3. Resident #23 was admitted on [DATE]. A review of Resident #23's medical record documented a copy of a binding arbitration agreement signed by the Resident on 10/21/23. The agreement did not document the resident could be admitted to the facility without entering into the arbitration agreement. On 05/07/24 at 10:22 a.m., the Administrator stated the facility's arbitration agreement did not explicitly state that signing the arbitration agreement is voluntary and will not have any bearing on admission.

Based on record review, observation, and interview, the facility failed to ensure meals were served in a timely manner and frequency for four meal services and, for one of one Resident #3. The Don identified 67 residents resided in the facility. Findings: A undated Meal times documented, read in part .Breakfast 07:00-09:00 .Lunch 11:30-1:30p.m Dinner 5:00p.m.-7:00p.m . A Meal Times and Frequency policy, dated 02/27/21, read in part .1. in nursing facilities, there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day However, the individuals in the group must agree to this meal span and a nourishing snack must be served . a. Resident meals were not served in the 14 hour window. b. Resident #3 meal was not served according to posted meal times. On 05/05/24 at 9:30a.m., the cook stated we are working short staffed in the kitchen and meals are late. On 05/05/24 at 9:32a.m., a breakfast tray was served in the dining hall. On 05/05/24 at 1:41p.m., a lunch tray was served in the dining hall. On 05/05/24 at 1:27p.m., a lunch tray was served to Resident #3. On 05/08/24 at 8:31a.m., no breakfast tray was served. On 05/08/24 at 5:01p.m., a dinner tray was served in the dining hall. On 05/05/24 at 1:58p.m., the Social Services Director stated meals should be served at the times posted.

Based on observation and interview, the facility failed to store and label food items according with professional standards for food safety. The DON identified 67 residents resided in the facility. Findings: A undated Food Storage policy, read in part .All foods should be covered, labeled, and dated and routinely monitored to assure that foods(including leftovers) will be consumed by their safe use of dates, or frozen (where applicable), or discarded . On 05/07/24 at 11:06a.m., food items where found in the freezer undated and unlabeled. On 05/07/24 at 11:07a.m., LPN #1 identifed the unlabeled and undated the food items as rolls, biscuits and chicken patties. On 05/07/24 at 11:08a.m., the LPN #1 stated the rolls, biscuits and chicken patties should be dated and labeled. FACILITY Kitchen

Based on observation, record review, and interview, the facility failed to ensure a physician's order was in place for the use of a catheter for one (#51) of one sampled resident reviewed for catheter use. The DON identified that 13 residents had catheters in the facility. Findings: Resident #51 On 05/05/24 at 10:17 a.m., Resident #51 was observed to have a catheter. On 05/07/24 at 11:06 a.m., the Order Summary Report was reviewed for Resident #51, it had no physican order for a catheter. On 05/07/24 at 11:29 a.m., the DON stated that nurses are responsible for putting in physician orders. They stated we double check orders and note them, and put them into medical records. The DON stated they did not see an order for a catheter. On 05/08/24 at 3:51 p.m., the CNO stated the policy for using catheters was to have an appropriate diagnosis, have a physician's order and put it in the system before providing the cath care. The order should include the size and when to change the catheter.

Based on observation, record review, and interview the facility failed to ensure: a. adequate supervision was provided to prevent a fall for one (#7); and b. proper transferring techniques were used for one (#51) of three sampled residents reviewed for accident hazards. The Administrator identified 67 residents resided in the facility. 43 residents were dependent on staff for transfers. Findings: 1. Resident #7 had diagnosis which included Parkinson's Disease. A Falls and Fall Risk, Managing policy, revised March 2018, read in part, .5. If falling recurs after despite initial interventions, staff will implement additional or different intervention, or indicate why the current approach remains relevant . A Minimum Data Set, dated dated , 03/25/24, documented Resident # 7 Functional Assessment indicates they are a dependent resident for activities of daily living of which includes eating and transfers. On 05/05/24 at 1:27 p.m., Resident #7 was standing independently up from wheelchair and the wheel chair rolled back as resident attempted to sit back down. On 05/09/24 at 10:32 a.m., the DON stated Resident #7 should have been monitored. 2. Resident #51 had diagnoses which included Rheumatoid Arthritis. A Controlled Lift Policy, undated, read in part, .gait belt usage is mandatory for all resident handling with the exception of bed mobility and medical contraindications and is not needed with lifts . A Care Plan, revised 03/22/24, documented that Resident #51 required one or two staff member participation with transfers. On 05/05/24 at 10:34 a.m., CNA #1 attempted to put a gait belt around Resident #51, but the resident stated they were not comfortable with this. CNA #1 put their arms underneath Resident #51's arms, picked them up, turned and placed them into the bed. Resident #51's feet did not even touch the floor at all during the transfer. On 05/07/24 at 10:11 a.m., CNA #2 put their arms under Resident #51's arms and grabbed the back of their pants. CNA #2 lifted the resident pivoted and placed them in the bed. Resident #51's feet did not touch the floor during the transfer. On 05/07/24 at 10:17 a.m., CNA #2 stated the condition of the resident dictated how they would go about the transfer. They stated they would get a bear hug and pivot holding the back of the pants. They stated they were taught that a gait belt would be considered a restraint and they have never used them. CNA #2 stated a lift would be used if the chart or the nurse told them to. CNA #2 stated it was normal for Resident #51 to not bear weight during the transfer. On 05/07/24 at 10:21 a.m., the DON stated if a resident was unable to bear weight, a mechanical lift or a two person assist would be necessary dependent upon the residents preference to cause less pain and injury. They stated a gait belt should be used anytime a transfer is occurring without the use of a lift. 49701

Based on record review and interview, the facility failed to ensure resident assessments were accurately coded for two (#17 and #51) of 17 sampled residents reviewed for resident assessments. The Administrator identified 67 residents resided in the facility. Findings: 1. Resident #17 had diagnoses which included open left ankle wound and cerebral palsy. An Annual RAI assessment, dated 04/05/24, documented that Resident #17 had no pressure ulcers on question M0100A, there was a stage 3 present on question M0300C1. On 05/07/24 at 9:35 a.m., the MDS Coordinator stated question M0100A was answered incorrectly. 2. Resident #51 had diagnoses which included Rheumatoid Arthritis A Quarterly RAI assessment, dated 04/26/24, documented that Resident #51 had a stage 3 pressure ulcer that was present on admission and a stage 4 pressure ulcer. A Pressure Ulcer Skin Conditions form, dated 03/11/24, documented that Resident #51 had a sacral pressure wound that measured 1.21cm by 1.0cm by 0.1cm. That form did not document any staging. A Nurses Admission Assessment, dated 03/13/24, documented that Resident #51 had a sacral pressure wound that measured 1.2cm by 1.0cm by 0.1cm and documented it as unstageable. On 05/07/24 at 2:10 p.m., the MDS Coordinator stated they are unsure why stage 4 was documented on the MDS because it should not have been. They stated they documented the wound as a stage 3 after speaking to the wound care nurse. The MDS Coordinator stated present on admission means after returning from the hospital the wound had progressed to a stage 3. On 05/07/24 at 2:16 p.m., LPN #1 stated they called the wound care center and asked for staging on the day of the assessment which occurred on 04/26/24 and was not accurate staging to be documented for a 03/13/24 readmission from the hospital. On 05/08/24 at 3:51 p.m., the CNO stated the policy is for facilities to follow the RAI manual and assessments should be accurately completed.

Based on record review and interview, the facility failed to document the required information regarding a transfer in a resident's medical record for one (#218) of one sampled resident reviewed for hospitalization . The Administrator identified 67 residents resided in the facility. Findings: A Transfer Form policy, dated 03/17, read in part, .Should it become necessary to transfer a resident from the facility, a transfer form will be executed and forwarded with the resident .The transfer form .will include .advanced directive information, all special instructions or precautions for ongoing care .any other documentation .to ensure a safe and effective transition of care . A Do Not Resuscitate Order policy, dated 03/21, read in part, .Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital . Resident #218 had diagnoses which included heart failure and COPD. A physician order, dated 06/19/23, documented DNR. A nursing note, dated 04/24/24 at 2:06 p.m., documented Resident #218 was clammy, cool to touch. Confused and unsteady. Resident #218 complained of being numb and abdominal pain. The Resident's blood pressure was 94/78. The doctor assessed the resident and ordered the Resident to be sent to the emergency room . Emergency medical services were called and the Resident's daughter was notified. The Resident was transferred out to the emergency room . There was no documentation Resident #218's DNR form, advanced directive, face sheet, and orders were sent with the Resident. On 05/07/24 at 2:37 p.m., RN #1 stated they were to document providing the emergency medical service with a copy of the resident's face sheet and orders. On 05/07/24 at 2:38 p.m., RN #1 stated they provided the emergency medical services with the Resident's medical information but did not document it. On 05/07/24 at 3:15 p.m., the DON stated they were to provide the transferring personnel a copy of the resident's face sheet, orders, DNR, and guardian ship or POA information. On 05/07/24 at 3:20 p.m., the DON stated there was no documentation the above information was sent with the resident.

Based on observation, record review and interview, it was determined the facility failed to ensure one (#2) of two sampled residents with aggressive behaviors did not continue to physically and verbally abuse other residents The facility identified 82 residents as residing at the facility. This resulted in residents #1 and #3 staying in their rooms rather than face another altercation with resident #2. Findings: The facility policy for abuse documented, POLICY: it is the policy of this facility to maintain an abuse free environment. ABUSE: is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .VERBAL ABUSE is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms aimed to residents or their families or said within their hearing distance regardless of their age, ability to comprehend or disability. Examples of verbal abuse include but are not limited to: threats of harm: saying things to frighten a resident . PHYSICAL ABUSE including hitting, slapping, pinching, and kicking .PREVENTION: .Residents will be assessed, monitored, and a care plan will be established to direct care for residents with needs and behaviors which might lead to conflict or neglect, such as resident with a history of aggressive behaviors, residents with communication disorders, or those that require heavy nursing care and/or are totally dependent on staff for care .PROTECTION: residents who have been alleged to have been abused will be protected from harm during the investigation .ABUSE BY RESIDENT develop a care plan that included interventions to prevent the recurrence of such incidents, including the appropriate management of any underlying conditions such as acute [MEDICAL CONDITION] that may have caused or contributed to the problem; inform all staff involved in the are of the resident of the new care pan and to promptly report behavioral changes to the charge nurse . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/25/18, documented the resident's cognition was moderately impaired, had refusal of care for one to three days in the look back period and required limited assistance via a wheelchair for mobility. A nurse's note, dated 12/30/18 at 9:14 a.m. documented, observed this resident in the hallway ambulating in the hallway, gait and balance is unsteady, attempted to redirect him and he grab my arm and twist it and then to hit me with his fist, I called for someone to help and the other staff member help me to sit him in his w/c (wheelchair), resident used harsh verbal words while helping him . A nurse's note, dated 01/16/19 at 5:04 p.m., documented, Res. (resident) was informed by the CNA (certified nurse aide) that she was going to take him to the D.R. (dining room) for dinner, and became agitated and combative swinging at the CNA. at the time he slid out the w/c and fell on the floor , A care plan, dated 01/17/19, documented the resident had the potential to demonstrate physical behaviors; 01/17/19 resident hitting staff while trying to do incontinent care. The intervention documented the resident was educated on harming staff. A behavioral health note, dated 01/21/19, documented the chief complaint was resident feels frustrated/depressed with situation, health decline and having to be in a nursing home. The resident acknowledges he could get real upset' at times with a history of poor impulse control. Acute concerns documented the resident was refusing care/medications often with verbal agitation at times. Plan was to start [MEDICATION NAME] (an antidepressant) daily. A nurse's note, dated 01/25/19 at 3:30 p.m., documented, CNA states while she was placing some linen in the barrel this resident came behind her and hit her several times in the back and and (sic) when she began to go down the hall this resident began to be verbally abusive and curse. called and informed (name-deleted nurse practitioner) and then a call placed to (name-deleted staff from a behavioral health) . A nurse's note, dated 01/25/19 at 3:54 p.m. documented, SSD (social services director) notified by (name-deleted CNA) that patient (Resident #2) struck her with his fist several times. CNA reported to SSD that she had already notified the CNA of this encounter. SSD spoke with patient (Resident #2) who initially denied hitting (name deleted CNA) but then admitted that he did so. SSD let (Resident #2) know that in our facility we do not hit anyone and if he cannot follow these rules then we will have to assist him in finding another home. SSD let (Resident #2) know that we are always available to speak with him regarding any conflict that he is having with anyone, (Resident #2) verbalized understanding. An incident report, dated 01/25/19 at 3:30 p.m., documented as a CNA placed linens in a container in the hall, resident #2 came up behind her and punched her in the back several times. As she proceeded up the hall, the resident followed her and attempted to hit her again as he was cussing at her. The immediate action taken documented staff immediately offered him some food and drink and the physician was notified and received orders for behavioral health to see the resident. The care plan documented on 01/25/19 resident had a verbal and physical altercation two times with staff. The intervention documented to have a mental health evaluation. The care plan documented on 01/31/19 the resident had physical and verbal confrontation two times with a CNA. The intervention documented to reeducate the resident to not hit. A call was placed to a mental health group to evaluate. A nurse's note, dated 02/01/19 at 11:13 a.m. documented, This nurse interviewed resident r/t (related to) his behavior towards staff. Asked resident why he was acting out toward staff, hitting and cursing when cna's try to help. Resident state's at times I don't want them to leave me alone. The rule is that you need to take a bath as scheduled or when needed, or just say No I don't want a bath today, be nice, don't curse the help. He verbalize to this nurse that there will be no more hitting and cursing staff. He still hopes to go home with friend. (Name-deleted behavioral health) notified, to see resident for his aggressions and combativeness. ASAP (as soon as possible). A behavioral health note, dated 02/03/19, documented the chief complaint was agitated and restricted. The noted documented the resident was started on [MEDICATION NAME] on 01/19/19. Acute concerns documented increased agitation/combativeness and non compliant. The plan was to increase the [MEDICATION NAME] and begin [MEDICATION NAME] (a mood stabilizer). A behavioral health note, dated 02/13/19, documented the staff was requesting evaluation also made medication changes on 02/03/19. The note documented the resident stated he did not need or want any medication. The note continued to document the medications were reviewed in which the resident was refusing his [MEDICATION NAME] and his [MEDICATION NAME]. The resident had increased agitation and was refusing his medication. The plan was to continue to encourage medications. A nurse's note, dated 02/25/19 at 11:0 a.m., documented, Roommate was yelling for nurse. This resident yelled at him to shut up. The roommate is hard of hearing and could not hear him. (Resident #2) walked over to roommate's bed and yelled at him to shut up. He states I didn't hip (sic) him. This resident has been noted yelling to shut up to roommate before. Will more (sic) resident to another room trying to achieve a more compatible roommate . An incident report, dated 02/25/19 at 11:10 a.m. documented staff heard roommate yelling for a nurse. Resident #2 was observed to walk over to the resident and yelled at him to shut up. The immediate action taken documented the resident had been noted to yell at roommates in the past. The facility will change his room to separate the two residents. A nurse's note, dated 03/02/19 at 8:15 p.m., documented, Focused assessment r/t (related to) res (resident) hitting another resident on the right shoulder. res informed that he can not hit any residents or staff. res states understanding (Name-deleted administrator) talked to both resident about event. event witnessed by another in room [ROOM NUMBER]A .report event to (local police department) . An incident report dated 03/02/19 at 8:15 p.m., documented resident #2 wheeled himself up to resident #3 and hit him with a closed hand on the residents right shoulder. This was witnessed by another resident. A nurse's note, dated 03/03/19 at 12:43 p.m., documented, Resident continues on q(every) 15 min (minute) checks d/t (due to) aggressive behaviors. Resident found to be seeking certain resident out in hallway that he hit during on night shift. Resident stated to that resident that he is going to bust him in the mouth. Other resident scared and called police. (Resident #2) also aggressive to staff LPN (licensed practical nurse) when attempting to redirect (Resident #2). Before police arrived (Resident #2) went to his room and got in bed. Police questioned (Resident #2) and (Resident #2) acted like he didn't know what she was talking about and that he hasn't done anything. As soon as police left this nurse saw (Resident #2) back in his wheelchair peeking around the corner to see if they left. This nurse explained to (Resident #2) that he can not be aggressive to others and doing so could potentially cause him to have to find another place to live. (Resident #2) then said he thinks the other resident has a gun. I assured him that there was no gun. The immediate action taken documented the resident was informed that he can not hit residents or staff. A nurse's note, dated 03/18/19 at 11:29 a.m., documented, Res at nurse station cursing a nurse out and tried to knock her computer screen over. I intervened and he threw a pen at me. He finally sat back in W/C and left. A nurse's note, dated 03/20/19 at 11:46 p.m., documented, This resident standing beside female residents wheel-chair when watching TV in the front common area, reported by female that this resident hit her on her left upper arm several times with his fist, This nurse came to them when he was standing at her side, No contact seen by this nurse during this time. she stated he was punching her, he then raised his fist up in the air attempting to make a swing towards her. this nurse redirected him he then stop lowered his fist and sat down in his wheel-chair. Residents separated. This resident assessed for any type of injury, non were seen during assessment. spoke to (Resident #2) about what happened. He had no response about said behavior. Police called they came out spoke with (Resident #2), Nothing reported to this Nurse by them .Resident placed on q 15 min visual checks. An incident report, dated 03/20/19 at 11:30 p.m. documented (Resident #1) stated (Resident #2) hit her on her left arm. (Resident #2) raised his fist at her when she told the staff. The immediate action taken documented the resident was redirected to another area. A nurse's note, dated 03/25/19 at 1:21 p.m., documented, This resident made physical contact to another resident to the right shoulder. This resident propelled up to resident sitting at the back of the dining room. This resident said something to (Resident #3) and started punching him in the shoulder. The housekeeper standing near by stood between the two so this resident could not continue to make contact with (Resident #3). Staff surrounded this resident so other resident could leave the dining room area safely. This resident continued to stand from his chair with his fists clinched. Resident started propelling himself about facility . An incident report, dated 03/25/19 at 12:28 p.m. documented resident #2 made physical contact with another resident to the right shoulder. The resident propelled himself up to the resident who was sitting in the back of the dining room. The housekeeper stood between the two residents so the resident could not continue to make contact with resident #3. Other staff surrounded (Resident #2) so (Resident #3) could leave the dining room area. (Resident #2) continued to stand from his chair with his fists clinched. The immediate action taken was to monitor the resident. A nurse's note, dated 03/28/19 at 11:24 a.m., documented, this resident was propelling himself in the lobby and went toward another resident and had place his hand on another resident w/c and stated to the resident in the w/c icant (sic) stand your little[***]ass and don't want him around me. reeducated this resident that he cannot place his hand on another person chair and be in the space of any resident, he states he can do what he wants, this nurse began to move away from him and he told the CNA that he didn't like her because she was a red neck. A dietary note, dated 03/31/19 at at 12:52 p.m., documented, Noted [MEDICATION NAME] 1.5 per PT (peg tube) added to nutrition plan after initial assessment. He has behaviors and refused meds and tx (treatment) at times refused to go to (name deleted psychiatric hospital). It would be best if we could give supplemental [MEDICATION NAME]. Would refer behaviors to MD (medical doctor). A nurse's note, dated 04/12/19 at 3:55 p.m., documented, Resident has been harassing maintianence (sic) man this afternoon calling him ugly names and following him around. He was standing at the nurses station telling two nurses he didn't like him and he also pointed to ADM (administrator) office and said he didn't like that g--k either. I told him he didn't have to like them but he needed to keep his opinions to himself. he stated to us he was in a bad mood. He tried to stare at me and intimidate me. This nurse will call (name-deleted physician) and notify him of residents attitude. A nurse's note, dated 04/13/19 at 12:00 p.m., documented, At breakfast this morning this res was observed barely touching another res, (Resident #3) like he intended to poke him to (Resident #3) shoulder. Res placed on Q15 min checks per Administrator. Res spoken c (with) by another nurse about behaviors, res smirked and refused to be compliant and states he will cont (continue) doing what he already is. No changes seen rest of shift. At 6:51 p.m., a nurse's note documented, This nurse spoke with this resident regarding not touching a specific other resident and he stated I can't do that. Per Administrator - Tell this resident if it happens again he will deal with him and the police will be called. Administrator stated he has spoken with Social Services director regarding finding placement for this resident elsewhere. Spoke with this resident per administrator and no change. A care plan documented on 04/13/19 resident #2 touched another person. Interventions included to place resident on every 15 minute checks and provide education that he can not touch others. A nurse's note, dated 04/15/19 at 11:00 a.m., documented, Heard some yelling from resident (Resident #3), stating he hit me. The two residents were parked right next to the nurses station. (Resident #3) was charging his phone. (Resident #2) rolled up to him and was tapping him on the right arm with his fingers stating I aught to just [***] you up (Resident 32) was removed from area of the other resident. This nurse spoke to resident with SSD (name deleted) present. Educated resident that he could not touch another resident esp (especially) in a threatening way, nor could he make verbal threats toward him. Instructed (Resident #2) that police could be called. (Resident #2) did state he wanted to leave, stated he wanted to go home, stated he wanted to go somewhere else. An incident report, dated 04/15/19 at 11:00 a.m. documented the nurse was told resident #2 was observed to be verbally abusing (Resident #3) saying I should just f**k you up and tapping him on the arm. The immediate action taken documented both resident were separated from the same area. (Resident #2) had a one on one with the nurse to inform him his behavior was not accepted and he did not have to do that again. A care plan documented the resident made verbal threats to others. An intervention documented to explain to the resident it was not appropriate to threaten others. On 04/16/19 at 11:17 a.m., resident #1 was asked if there had been any resident that was mean or abusive toward her. She stated yes, there was a man than came from around the couch and hit me in the arm with his fist. She stated nothing had happened since that incident, but she decided it was better to just stay in her room and stay away from him. At 1:05 p.m., resident #3 was observed coming out of the dining room in his electric wheelchair. He stated he could like to talked to surveyors about a man that keeps putting his hand on him. The resident was asked if he was afraid of this resident. He stated, Yes I am. He stated he told the office he did not feel safe in the facility. He continued to state everytime the resident seen him, he would raise his fist up to him. At 1:46 p.m., resident #3 was asked if he felt like he had to stay in his room more. He stated yes, because everytime he would go to the lobby, resident #2 either points at him or puts his hands on him. It was very intimidating. At 2:45 p.m., certified medication aide (CMA) #1 was asked if she was aware of any residents who had behaviors to look for. She state no. Eight cognitive residents were asked if they had ever been abused or witnessed abuse to another resident. They stated no. At 4:10 p.m., the administrator was asked if he was aware of the behaviors for resident #2. He stated yes. He was asked if he was aware of the incident on 04/15/19. He stated yes. He was asked how did resident #2 get to resident#3. The administrator stated it was hard to redirect him when he was close by, they were not really focusing on resident #2 due to they were passing medications. The administrator was asked if he had talked with resident #3. He stated yes. He was asked if resident #3 voiced his concern of being afraid of resident #2. He stated yes. He was asked how he was protecting resident #3. He stated they were roommates and they separated. The administrator was asked if he was aware there were staff that were not aware of any behaviors from resident #2. He stated it was his responsibility to tell the charge nurses and they would let the CNAs know. He stated he was looking at a different placement for resident #3 as well as resident #2. He was asked what he informed staff regarding the behaviors for resident #2. He stated they discussed 15 minute checks, who needed to be watched more often and not to let those two residents get too close together. If something happens they should separate and make sure they are okay.

On 04/03/19 at 3:24 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to implement interventions for the prevention and worsening of pressure ulcers. At 3:30 p.m., the facility administrator and director of nursing (DON) were informed of the IJ situation related to the facility's failure to implement interventions for the prevention and worsening of pressure ulcers. A plan of removal for the IJ situation was requested. At 4:52 p.m., the administrator provided the surveyors with an acceptable plan of removal. The facility's plan of removal, documented the following: Plan for removal of IJ Cited resident no longer resides in the facility A resident review will be completed to identify those at risk for skin breakdown and the need for further interventions. Skin assessments will be done for all residents. Education will be completed to the nurses regarding admission assessments, wound measuring, wound identification, wound treatments, identifying those at risk, weekly skin assessments and interventions. Education will be provided to the nurse aides regarding notification of the nurse of any identified skin issues, repositioning and preventative interventions. Oncoming nursing staff will not work until education is complete. Completion date: 4/3 at 2330. On 04/04/19 at 9:00 a.m., the DON provided the surveyors with the staff in-service training record and the Braden Scale (a tool used to identify those at risk for developing pressure ulcers) completed for each resident. The skin assessments were requested for review. The DON stated they were working on them. On 04/04/19, interviews were conducted with a total of twelve staff, both nurses and nurse aides, who worked different shifts. The nurses and nurse aides verified they had been in-serviced regarding the components documented in the plan of removal and they understood the information provided. At 1:15 p.m., the chief operating officer (COO) provided the surveyors with the completed skin assessment for each resident. The final assessment had been completed at 11:15 a.m. At 4:00 p.m., the administrator, DON, COO, and corporate nurse were notified the IJ had been removed as of 04/04/19 at 11:15 a.m. The deficient practice remained at a level of actual harm, isolated. Based on observations, record review and interviews, it was determined the facility failed to implement interventions for the prevention of pressure ulcers and provide appropriate care and services to promote the healing of pressure ulcers for one (#2) of four sampled residents reviewed for pressure ulcers. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge summary, dated 02/18/19, documented the resident was discharged to the facility following treatment for [REDACTED]. A care plan, dated 02/18/19, documented the resident had the potential for pressure ulcer development related to diabetes mellitus. The staff was to check the skin weekly and document the results and follow the facility policies/protocols for the prevention/treatment of [REDACTED]. A nurse practitioner's progress report, dated 02/20/19, documented the resident had BLE wounds and scabs to bilateral feet. an order for [REDACTED]. A physician's orders [REDACTED]. The care plan was not updated to include interventions for the prevention of developing pressure ulcers. An admission assessment, dated 02/25/19, documented the resident's cognition was intact and he required extensive assistance from staff with bed mobility, transfers and dressing. The resident was incontinent and at risk for pressure ulcers. The assessment documented the resident had an unstageable ulcer and four venous ulcers. There was no documentation to indicate a skin assessment was completed from admission through 02/28/19. An initial wound evaluation and summary, dated 02/28/19, documented the resident was treated by the wound physician for venous wounds to the left posterior calf, right calf, left shin and right upper lateral calf. The wound to the right upper lateral calf was documented as unstageable and required surgical debridement (the removal of dead or damaged tissue). The summary also documented the resident had a shear wound of the left buttock which measured 7.6 x 0.9 x not measurable cm (centimeters) and an unstageable necrotic pressure ulcer to the sacrum which measure 9.3 x 4.1 x not measurable cm. There was no documentation to indicate the resident had wounds of the buttocks prior to the wound physician's report on 02/28/19. There was no documentation on the care plan to indicate the resident had wounds on the buttocks. The care plan was not updated to include new interventions to implement for the worsening of pressure ulcers. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A skin assessment, dated (MONTH) 2019, documented the resident had venous wounds to both calves and shear wounds to both buttocks. A hospital report, dated 03/13/19, documented the resident was admitted with complaints of abdominal pain and diarrhea. He was diagnosed with [REDACTED]. On 03/16/19 a surgical procedure was required to debride the sacral ulcer, including skin, tissue, muscle and bone. Findings from the procedure were documented to be stage IV sacral decubitus ulcer measuring 14 x 14 x 3 cm. A wound vac (a machine used to treat advanced pressure ulcers) was placed following the procedure. The resident was discharged from the hospital to a long term acute care facility on 03/25/19. His treatment required five more weeks of intravenous therapy (IV) antibiotics followed by one week of oral antibiotics and wound care. On 04/03/19 at 2:00 p.m., the DON was asked if the resident had skin assessments documented or interventions in place for the prevention of pressure ulcers. She stated RN #1 would know more. RN #1 stated the 28th was the first time she saw the pressure ulcers on the buttocks were identified. There was only one other skin assessment documented and it was in March. They should have been done.

Based on observation, interview, and record review, it was determined the facility failed to manage a resident's pain by providing pain medication timely for one (#58) of two sampled residents reviewed for pain management. Resident #58 had complained of pain five times before and during the provision of care which included a wound examination and treatment. The resident complained of pain a sixth time after the treatment was completed before receiving medication, 43 minutes after her first complaint. The facility identified 66 residents on a pain management program. Findings: A facility policy, titled Pain Assessment and Management, dated (MONTH) 2010, documented, . Pain management is a multidisciplinary care process that includes .Assessing the potential for pain .Effectively recognizing the presence of pain .Identifying the causes of pain .including .Skin/wound conditions: Pressure, venous, or arterial ulcers . A facility policy, titled Pain - Clinical Protocol, dated (MONTH) 2013, documented, .The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, would care, ambulation, or repositioning . A facility policy, titled Pressure Ulcer Treatment, dated (MONTH) 2014, documented, .Pressure ulcer treatment requires a comprehensive approach, including: Pain control . Resident #58 had [DIAGNOSES REDACTED]. A care plan, dated 06/19/18, documented the resident had chronic pain with interventions that included, to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A quarterly assessment, dated 09/26/18, documented the resident's cognition was intact, she required extensive assistance of one staff member for activities of daily living, had one stage three pressure ulcer and received pain medication as needed. The resident's active physician's orders [REDACTED]. A review of the Individual Narcotics Record revealed one tablet of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligrams) was dispensed on the following dates in November; 11/02/18 at 5:30 p.m., 11/03/18 at 9:30 a.m. and 7:30 p.m., 11/04/18 at 9:00 a.m., and 11/05/18 at 10:15 a.m. A review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed the only documented administration of [MEDICATION NAME]-[MEDICATION NAME] 5/325 from 11/01/18 through 11/05/18 was on 11/05/18 at 10:15 a.m. On 11/05/18 at 9:32 a.m., the wound physician entered the resident's room and asked how the resident was doing. The resident complained of pain. LPN (Licensed Practical Nurse) #1 and LPN #3 were present. The physician examined the resident's sacral and heel wounds, measuring the sacral wound at 2.5 cm (centimeters) x 1.4 cm, and the heel wound at 8.1 cm x 5.4 cm. The resident was repositioned on her left side and again complained of pain. During the examination, the resident stated she still had pain. The physician completed his examination and left the room. LPN #1 and LPN #3 discussed obtaining medication to treat the resident's pain. LPN #1 left the room. LPN #3 stated she needed to obtain wound care supplies. The resident stated she was uncomfortable. At 9:55 a.m., LPN #3 and CNA (Certified Nurse Aide) #3 entered the resident's room to provide wound care. The resident stated she wished the facility would give her pain medicine with a shot, it would kick in quicker. The CNA stated yes, it does work faster. At 10:05 a.m., LPN #3 was asked if the resident was pre medicated for pain prior to the wound care. She stated they told me they were going to provide medication to her. She was asked who 'they' were. She stated (LPN #1) told the certified medication aide (CMA) to pre-medicate and the CMA was a nurse. She was asked if she could verify the resident had received the medication. She stated she would go find out. The resident again asked if she could please have some pain medication. LPN #3 asked LPN #4 if she had administered pain medication to the resident. She stated no. LPN #3 stated no, it was a miscommunication, the resident was not administered any pain medication. At 10:09 a.m., the resident put on her call light. At 10:10 a.m., LPN #4 was asked when the last time the resident was provided any pain medication. She stated it was yesterday (11/04/18) at 9:00 a.m. LPN #4 answered the call light and asked the resident what she needed. The resident stated she would like some pain medication. The MAR, dated (MONTH) (YEAR), documented the resident was administered [MEDICATION NAME]-[MEDICATION NAME] 5/325 on 11/05/18 at 10:15 a.m. The resident had to wait 43 minutes after her first complaint of pain to receive the pain medication. The resident while waiting continued to have an examination and wound treatment while in her pain. At 10:16 a.m., the resident was asked if she had been asked what her pain level was prior to being given pain medication. She stated no, they never ask but they know it is bad. On 11/05/18 at 12:40 p.m., LPN #1 was asked if residents received pain medication prior to wound care. She stated there are some residents who are medicated prior to wound care. She was asked if Resident #58 received pain medication prior to wound care. She stated no, the resident really had not complained of pain during the wound doctor examination.