Every finding on record at Anadarko Nursing & Rehab

Based on record review and interview, the facility failed to protect the resident's right to be free from sexual abuse for 1 (#2) of 3 sampled residents reviewed for sexual abuse. The director of nursing identified 73 residents resided in the facility.Findings: An undated policy titled Abuse Policy and Procedure, read in part, protect our occupants .sexual abuse .resident rights to be free from physical or mental abuse Resident To Resident Incidents .Assessment of risk .Upon admission to the facility, each person will be assessed through the MDS process to determine if they are a risk for abusing others .Care Plan .designed to prevent occurrences. An undated admission summary for Resident #1, showed the resident had diagnoses to include dementia and other sexual dysfunction. A physician order for Resident #1, dated 09/14/23, showed the resident was administered Provera (progestin hormone) 40 mg by mouth every day for sexual dysfunction. Provera use includes hypersexuality to lower testosterone levels and safely reduce libido or sexually inappropriate behaviors. A nurses note for Resident #1, dated 05/25/26, showed the resident was redirected and was on every 15-minute checks due to behaviors. A nurses note for Resident #1, dated 06/07/26, showed the resident was on observation and every 15-minute checks due to behaviors. A nurses note for Resident #1, dated 06/16/26, showed the resident continued on 15-minute behavior checks. A behavior monitoring sheet for Resident #1, dated 06/2026, showed the resident was monitored for wandering, yelling, and sexual behavior. Wandering was documented 16 out of 22 days with a total number of 67 observations of wandering. Yelling was documented two days out of 22 days with a total of three observations of yelling. Sexual behavior was documented nine days out of 22 days with a total number of 30 observations of sexual behavior. A final state reported incident form, dated 07/02/26, showed Resident #2 reported to charge nurse Resident #1 came into their room while they were sleeping and was rubbing their crotch over their clothes. Both Resident #2 and Resident #3 yelled at Resident #1 to get out of their room. Resident #1 was immediately placed on one-to-one observation by staff due to behaviors and remained on one-to-one monitoring. A nurses note for Resident #2, dated 07/02/26 at 12:32 a.m., showed Resident #2 came up to the nurse and stated, the new admission came in my room and was rubbing my crotch. A nurses note for Resident #1, dated 07/02/26, showed the nurse went to Resident #1's room and observed the resident touching themself under the blanket. The note showed the nurse told Resident #1 you cannot be going in other resident's rooms, and you cannot touch them. Resident #1 stated are you going to do it? Resident #1 pulled their right hand from under the covers and began rubbing their genital area. The note showed all residents' doors were closed and halls were monitored. The note showed the DON was notified of occurrence. A one-to-one monitoring form for Resident #1, dated 07/02/26 through 07/06/26, showed Resident #1 had been monitored until they were transferred to geriatric psychiatry. A quarterly assessment, dated 07/08/26, showed Resident #2 had a brief interview for mental status score of 15 which indicated intact cognition.On 07/14/26 at 12:06 p.m., Resident #2 stated they awoke to find Resident #1 standing over them. Resident #2 stated Resident #1 was fondling them over their clothes in their crotch area. Resident #2 stated they had been sexually assaulted before and was traumatized. Resident #2 stated they kicked Resident #1 in the chest and began yelling until Resident #1 left. Resident #2 stated they told the nurse and the nurse aide and they came immediately. Resident #2 stated the staff closed their door and moved Resident #1 to the other end of the building. They stated the staff placed Resident #1 on one-to-one monitoring.On 07/16/26 at 12:25 p.m., the transporter stated Resident #1 was talking dirty to the other transporter. The transporter stated Resident #1 wanted them to turn around to do something sexually to them. The transporter stated Resident #1 continued to speak inappropriately during the drive to the facility. The transporter stated Resident #1 stated they had money for a hotel for a threesome. The transporter stated they had reported Resident #1's behavior and conversations to the nurses' station, but they did not remember who was at the nurses' station. On 07/16/26 at 1:17 p.m., the ADON stated there was documentation Resident #1 had been monitored in May and June in the nurses notes. The ADON stated Resident #1 was being monitored for wandering, yelling, and sexual dysfunction. On 07/16/26 at 1:18 p.m., the DON stated they did not question the use of Provera. They stated other residents used the same medication. On 07/16/26 at 1:25 p.m., the ADON stated they had reviewed Resident #1's paperwork the other facility had faxed or emailed over to them before determining the resident would be admitted to their facility.

Based on record review and interview, the facility failed to ensure grievances were received and tracked by an identified grievance official per facility policy. The ADON identified 76 residents resided at the facility.Findings: Facility's grievance binder was reviewed. The binder contained several grievances filed by Resident #23 dated 01/07/26 and 03/19/26. The grievance dated 01/07/26 had no investigation reports attached.An undated policy titled, Grievance policy and procedure, read in part, the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and actions that will be taken to correct any identified problems.On 03/24/26 at 9:30 a.m., Resident #23 stated that they had filled out multiple grievances against a nursing staff member. Resident #23 stated they had not heard back from facility's administrative staff regarding the grievances.On 03-26-26 at 10:43 a.m., CNA #1 stated that nursing staff are required to take grievances as soon as they are written to the administrator.On 03-26-26 at 11:31 a.m., CNA #2 stated they thought grievances were being placed in the DON's office, but they were not sure. On 03-26-26 at 12:16 p.m., ADON stated that grievances were placed by staff all over the facility and do not get to the administrative staff immediately. ADON stated they assumed staff knew what to do with the grievances and that staff had not received in-service training for grievances.On 03-26-26 at 12:18 p.m., ADON, DON, and administrator stated they did not know about the grievance filed on 01-07-26 due to systemic grievance review failure.On 03/26/2026 at 4:10 p.m., LPN #1 stated that they had assisted Resident #23 with the grievance form dated 01-07-26. LPN #1 stated they had made two copies of the grievance form and slid it under the office doors of the administrator and ADON.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.The ADON identified 76 residents resided in the center.Findings:A Staffing Policy, dated 10/2023, read in part, RN must be on duty 8 hours a day 7 days a week. A PBJ Staffing Data Report, dated 03/20/26, showed the facility did not have RN coverage for quarter 1 of 2026. The dates identified were: a. 10/05/25,b. 10/12/25,c. 10/18/25,d. 10/19/25,e. 11/09/25,f. 11/15/25,g. 11/29/25,h. 11/30/25,i. 12/06/25,j. 12/07/25,k. 12/13/25, l. 12/14/25,m. 12/20/25,n. 12/21/25,o. 12/27/25, andp. 12/28/25. On 03/27/26 at 8:52 a.m., the business office manager stated the corporate human resource officer was responsible for inputting PBJ data and they confirmed the missing RN coverage from the PBJ report was accurate. On 03/27/26 at 8:57 a.m., the corporate human resource officer stated the RN hours listed as not covered for quarter 1 of 2026 were correct. There was no RN coverage for those dates. On 03/27/26 at 9:02 a.m., the DON stated they were aware of the missing RN hours for quarter 1 of 2026. They stated the facility had not had any missing RN hours since 12/28/25.

Based on record review and interview, the facility failed to;1 report an allegation of abuse to Oklahoma State Department of Health within two hours of discovery of the alleged abuse, and;2 immediately report an allegation of abuse to the local police, and;3 report an allegation of abuse to the Oklahoma Board of Nursing for 1 (#23) of 3 residents sampled for abuse allegations.The ADON identified 76 residents resided in the facility.Findings:An Abuse Policy Procedure, undated, read in part, All allegations of resident maltreatment, including neglect, physical abuse, mental abuse, sexual abuse, involuntary isolation, verbal abuse, injuries of unknown origin, and/or misappropriation of property, shall be promptly reported to administrator and investigated by facility management. Administrator will immediately report the allegation to the Oklahoma State Department of Health and local police. The following person or entities will be notified by facility personnel: state registry if perpetrator is known. When the allegation involves abuse or results in serious bodily injury you must report within 2 hours of notification of incident. A Grievance Form, dated 01/07/26, showed Resident #23 reported LPN #1 slugged them in the shoulder. Resident #23 stated they were, shaking like a leaf. A Grievance Form, dated 03/16/26, showed Resident #23 stated that LPN #1 told them to get my ass back on my own hall. Resident stated that they started crying after that. An employee disciplinary action form, dated 03/19/26, read in part, Due to several resident's concerns regarding your communication style . we are having a discussion today. This will stand as a reminder for [LPN #1] to ensure that all resident interactions are characterized by empathy, active listening, and professionalism. There were no signatures for this form. On 03/26/26 at 10:20 a.m., Resident #23 stated LPN #1 punched them in their left shoulder on 01/07/26 and then when the resident did not fall LPN #1 pushed their walker into them. Resident stated that they did not know until they had a dime-size bruise from the punch until they took a shower that same day. Resident #23 stated they sustained a dime-sized bruise to their left shoulder. Resident #23 stated they were fearful of LPN #1 and shook with fear and anger. They stated on 03/16/26 LPN #1 cussed at them and would not allow them access to a different hall in the facility. Resident #23 stated this made them upset and they cried all night. Resident #23 stated no one responded to their grievances until 03/25/26. On 03/26/26 at 12:14 p.m., the DON stated they were not aware of the abuse allegation from 01/07/26 until 03/25/25. They stated they had not reported the abuse allegations from 01/07/26 or 03/16/26 because they believed they had 48 hours after discovery to report the allegations. The DON stated they had not reported the allegation to OSDH or local police. On 03/30/26 at 11:57 a.m., the DON was asked for the notification of allegation of abuse that was sent to the Oklahoma Board of Nursing for LPN #1. They stated they had not sent it because they did not know they had to send it before the investigation was completed.

Based on observation, record review, and interview, the facility failed to ensure:a. left over food items were properly sealed, dated, and labeled, b. condiment containers were dated when opened, c. dried spillage were kept cleaned off the outside of the condiment containers,d. dishwasher sanitation was performed, e. dishes were air dried, and f. hand hygiene is practiced correctly,according to the standards of practice for 2 of 2 kitchen observations. The ADON identified 76 residents were served from the kitchen. Findings: 03/24/26 9:50 a.m., a tour of kitchen performed and the following were observed: a. an undated unlabeled bag of leftover pasta was observed to be in the refrigerator,b. an undated opened gallon container of mustard was observed to have dried spillage down the side onto the label,c. an undated opened gallon container of Ranch dressing with dried spillage down the side onto the label with the lid not secured properly,d. an open undated half package of sliced ham was observed to be in the refrigerator,e. stacked cups and plates were observed to have water droplets between them, and f. dietary aide #1 was observed to be tossing salad in a large bowl without wearing gloves. On 03/26/26 at 10:35 a.m., the following were observed: a. stacked cups and plates continued to have water droplets between them, b. an undated opened gallon container of mustard was observed to have dried spillage down the side onto the label,c. an undated opened gallon container of Ranch dressing with dried spillage down the side onto the label with the lid not secured properly,d. an undated unlabeled pitcher of white liquid observed to be in refrigerator. A facility policy, titled Kitchen Sanitation Policy revised 05/2023, read in part, Dishwashing machines must be operated using the following specifications: High-Temperature Heat sanitation or Low-Temperature Chemical sanitation.The policy also read in part, Food will be stored, handled, prepared and served so that risk of foodborne illness is minimized. On 03/24/26 at 10:10 a.m., the CDM stated the facility has not had the dietitian to visit in approximately a year, therefore no kitchen audits were available. The CDM also stated the dietary aide should have washed their hands and donned gloves when touching the food. On 03/24/26 at 1:00 p.m., the administrator stated they do not know who does kitchen audits since the dietitian does not come to building.

Based on observation, record review, and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for the residents.The ADON identified 76 residents resided in the facility. Findings:On 03/24/26 at 11:35 a.m., during facility tour, the following observations were made: 1. A folded bed sheet was observed to be tacked up over the window in rooms W4, W6, and W8,2. Room W6 was observed to be cluttered with items on the floor,3. Room W12B was observed to have clutter on the shelves and in the corners. The extra bed was not made up with linens. A TV was observed to be sitting on the floor. The room had an odor of urine, and4. Door facings and walls throughout the facility were observed to have chipped and peeled paint. 03/30/26 at 10:00 a.m., the following observations were made in the TV room::1. Baseboard ledges had dirt and dust build up, 2. A box fan guard had dust and dirt collected on one side, and3. The air return vent covers in the walls had dirt build up and were bent. 03/30/2026 at 10:39 a.m., Housekeeper #1 stated there was not a scheduled cleaning log or any type of check sheet. Housekeepers clean the fans when residents ask, and the base board were cleaned when they could. 03/30/2026 at 10:45 a.m., the ADON stated they were working on ordering new blinds.

Based on record review and interview, the facility failed to ensure a quarterly MDS assessment contained accurate information for 1 (#39) of 6 sampled residents reviewed for MDS accuracy.The ADON identified 76 residents resided in the facility.Findings:A diet order for Res #39, dated 05/06/25, showed the resident was ordered a low concentrate diet.A quarterly assessment, dated 02/11/26, showed Res #39 did not have a therapeutic diet as a nutritional approach.On 03/27/26 at 9:36 a.m., MDS Coordinator #1 stated Res #39's therapeutic diet had not been indicated in their 02/11/26 quarterly assessment. They stated the document should have indicated the resident had received a therapeutic diet.On 03/27/26 at 9:50 a.m., the DON stated it was their and the facility's expectation that all MDS assessments would always reflect the residents' condition and treatments at the time they are completed.

Based on observations, record reviews, and interviews, the facility failed to ensure food was served at a safe temperature for 1 (#38) of 6 sampled residents receiving pureed diets. The ADON identified 76 residents were served from the kitchen. Findings:On 03/26/26 at 12:26 p.m., Resident #38's lunch tray was observed to be sitting in front of them without anyone available to assist with the meal. The temperature of pureed chicken noodles was 91 degrees. On 03/26/26 at 12:31 p.m., LPN #1 was observed to be assisting Resident #38 with eating without rewarming or requesting new tray. A quarterly MDS dated [DATE] showed Resident #38 cognitive skills was severely impaired with diagnoses which included profound intellectual disabilities and aphasia. The MDS showed Resident #38 was dependent on staff for all ADL's. A care plan updated 01/02/26 showed Resident #38 required assistance with eating meals. On 03/26/26 at 12:26 p.m., LPN #1 stated they are not supposed to leave the tray in front of dependent residents until a staff member is sitting and waiting to help them eat. LPN #1 also stated they didn't know if it's an option to reheat residents' food. 03/30/26 at 09:15 a.m., the CDM stated the temperature of food being served should be 140 degrees. The CDM stated if the temp of the food falls below 140 degrees, the tray should be sent back to kitchen and a new tray served. They stated meal trays should not be placed in front of residents who require assistance until there is a CNA sitting at table waiting to help the resident. The CDM stated they witnessed the meal tray was set in front of Resident #38 during lunch on 03/26/26.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were used during supra pubic catheter care for 1 (#6) of 1 resident reviewed for catheter care. The ADON identified 1 resident had a catheter in the facility. Findings:On 03/25/26 at 2:46 p.m., LPN #1 was observed to be performing supra pubic catheter care on Resident #6. LPN #1 was observed to don gloves, but no gown was observed to be donned which was required for enhanced barrier precautions during catheter care. LPN #1 was also observed to perform the entire catheter care task for Resident #6 without changing their contaminated gloves. LPN #1 was observed to adjust Resident #6s clothes and replace over bed table back in position while wearing the same contaminated gloves.A facility policy titled, Catheter Care, Urinary with a revised date of 09/2014, read in part, the purpose of this procedure is to prevent catheter-associated urinary tract infections. Review the resident's care plan to assess for any special needs of the residentA quarterly MDS dated [DATE] showed Resident #6 was admitted to the facility on [DATE].and had a BIMS score of 15 indicating intact cognition. The MDS also showed diagnoses which included obstructed reflux uropathy, and multiple sclerosis.Resident #6's care plan updated 03/19/26 showed enhanced barrier precautions are required to prevent urinary infections.On 03/26/26 at 10:45 a.m., LPN #1 stated they forgot to put on a gown for enhanced barrier precautions. LPN #1 stated they were not sure of how many times or when gloves should be changed.

A past noncompliance Immediate Jeopardy (IJ) was determined to exist effective 11/13/24 related to the facility's failure to ensure a resident was free from accident hazards. The facility failed to safely secure Resident #1 in their wheelchair during transport which resulted in serious injury/harm. On 11/18/24 at 2:48 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance related to the facility's failure to safely secure a resident in a wheelchair during transport. The past noncompliance IJ was removed effective 11/14/24 after the facility put measures in place to prevent recurrence. On 11/14/24 the facility maintenance supervisor inspected the facility transport van to ensure all safety straps and harnesses were in working order and implemented monthly inspections to ensure proper working order, all drivers were inserviced on proper uses and placement of safety straps in the facility transport van and they will be inserviced quarterly, a QAPI improvement plan was initiated, and CNA #1 was suspended on 11/13/24 and then terminated on 11/14/24. On 11/18/24 at 11:55 a.m., the facilty's transport van was inspected. All harnesses and safety straps were observed to be in good repair with no issues. An IJ was identified from 11/13/24 through 11/14/24. Based on observation, record review, and interview, the facility failed to safely secure a resident in a wheelchair during transport for one (#1) of three sampled residents reviewed for safe transportation. Findings: An undated facility policy/job description titled Transportation Aide, read in part, Has completed a facility orientation on functioning facility transport vehicle and proper placement of straps for resident transport. The policy also read, At any point that it is discovered that any safety mechanism is not functioning properly that the maintenance/ administrator be notified immediately and transportation will be suspended until repairs are made. Resident #1 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, hypertensive heart disease, and dependence on renal dialysis. Resident #1's admission assessment, dated 10/15/24, documented Resident #1 was not cognitively impaired, ambulated with the assist of a wheelchair and required extensive assistance with ADLs. A facility Incident/Accident Report, dated 11/13/24 at 3:40 p.m., read in part, Reported to me by [CNA#1] that resident fell out of wheel chair in van during transport. Knot to back of head and upper back pain noted. Resident sent to ER. A Nurse's Note, dated 11/13/24 at 4:40 p.m., read in part, [CNA#1] transport called this nurse and stated that [they] had left the hospital with resident and was turning the corner when resident fell out of wheel chair. The document also read, [they] stated [Resident #1] had a knot on [their] head and c/o of upper back pain. The document also read, [name withheld] explained that [they] couldn't latch [them]. An Investigative Witness Statement, dated and signed by CNA #1 on 11/13/24, read in part, I didn't have the residents wheelchair secured, the back of the wheel chair was locked and [their] tires. I didn't lock the front because I thought I did lock them. When I went to step on the gas [they] went flying backwards and [they] hit the metal ramp. An intital Incident Report Form, dated 11/13/24 at 9:59 p.m., documented Resident #1 was being transported back to the facility from the hospital when the driver turned a corner, the resident fell out of their wheelchair. It documented the resident was transported to the ER then transported to [name of hospital withheld] for further evaluation. Resident #1's Emergency Department Note, dated 11/13/24 at 4:39 p.m., read in part, was in a transport van that apparently accelerated too quickly when [their] wheel chair tipped over backwards c/o head neck and upper spine pain. The note also read, there is a nondisplaced vertical linear fracture through the mid C6 vertebrae. The note documented Resident #1 was placed in a neck brace, given Tylenol and morphine for pain, and transferred to an acute care hospital. Resident #1's After Visit Summary, dated 11/13/24, documented Resident #1 was diagnosed with a closed nondisplaced fracture of the sixth cervical vertebrae and a closed head injury from a ground level fall. On 11/18/24 at 3:30 p.m., Resident #1 stated CNA #1 did not buckle their wheelchair in the front in the transport van correctly. They stated when CNA #1 accelerated from the traffic light they fell backwards hitting their head and neck on the ramp in the transport van. Resident #1 stated their family was called and told CNA #1 to take them to the ER. Resident #1 was observed wearing a cervical neck collar and stated they had pain in their neck and shoulders as a result of the accident. On 11/18/24 at 4:25 p.m., the ADON stated CNA #1 reported to the hospital they did not secure the resident in the van, but then they changed their story. The ADON stated CNA #1 reported a passerby and unidentified police helped sit the resident back into the chair and CNA #1 contacted the family which directed them to take the resident to the ER. On 11/18/24 at 4:30 pm., the administrator stated CNA #1 changed their story frequently. They stated the CNA admitted to not securing the residents wheelchair in the transport van correctly and should not have picked up the resident after the incident. The administrator stated CNA #1 was suspended immediately then terminated for the incident.

Based on record review and interview, the facility failed to ensure a resident was free from sexual abuse for one (#47) of five residents sampled for abuse. The administrator reported two allegations of sexual abuse. An Abuse Policy and Procedure policy, dated 07/23/21, read in part, We will endeavor to protect our occupants from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect .Sexual abuse includes sexual harassment, sexual coercion, or sexual assault. Resident #47 was admitted to the facility on [DATE] and had diagnoses which included schizophrenia, bipolar disorder, depression, rheumatoid arthritis, lupus, anxiety, and history of traumatic brain injury. An annual assessment for Resident #47, dated 08/13/24, documented the resident was cognitively intact. An OSDH incident report form, dated 11/01/24, documented Resident #47 reported to a dietary employee CNA #1 came to their room at approximately midnight on 11/01/24 during the 6:00 p.m. to 6:00 a.m. shift. The incident report documented the CNA exposed their genitals to the resident and made sexually explicit comments to the resident while requesting sexual favors. The report documented the CNA was immediately suspended and an investigation was conducted. A care plan for Resident #47, updated 11/04/24, documented the resident had behaviors which included attention seeking. The care plan documented the resident often fabricated stories against others. The care plan documented two staff members would provide care at all times and no employee would assist the resident without a female employee present. On 11/06/24 at 1:22 p.m., the administrator reported an allegation of sexual abuse involving Resident #47 and CNA #1 had been substantiated. The administrator reported the facility would be submitting their 5-day final report to the SA in the next day or two. The administrator reported they had interviewed other residents and staff members to ensure there were no other allegations against CNA #1. On 11/06/24 at 2:24 p.m., Resident #47 was interviewed in their room. The resident spoke freely about the incident and stated nothing like this had ever happened before. The resident reported CNA #1 had worked at the facility off and on for a couple of years and had never done anything to make the resident uncomfortable. The resident stated they felt safe and was not fearful of anything happening again and had no fear of being abused in any way. On 11/08/24 at 1:14 p.m., LPN #2 reported there had been recent staff in-services following the incident with Resident #47 and CNA #1. The LPN reported staff had been informed no male staff member should go into a female residents' room without a female staff member being present. The LPN reported they were attempting to have male CNAs care for male residents and female CNAs care for female residents. On 11/08/24 at 1:34 p.m., LPN #3 reported Resident #47's care plan had been updated to reflect changes in how care would be provided for this resident. The LPN reported they had implemented a two-person assist with all of Resident #47's care. On 11/12/24 at 11:26 a.m., the administrator reported Resident #47 initially reported the incident with CNA #1 to dietary aide #1. The administrator stated the resident waited until the dietary aide came on duty the following day to say anything. The administrator reported they were not sure why the resident reported the incident to the dietary aide and the dietary aide was not available for interview with the SA. The administrator reported CNA #1 was suspended as soon as the incident was reported and ultimately terminated.

Based on record review and interview, the facility failed to ensure a resident's power of attorney was notified of doctor appointments for one (#28) of two sampled residents reviewed for notifications. The administrator identified 79 residents resided in the facility. Findings: Resident #28 had diagnoses which included cardiac arrhythmia and hypertension. A comprehensive assessment, dated 08/27/24, documented Resident #28 had moderately impaired cognition. A progress note, dated 10/23/24, documented the resident was out of the facility for a doctor's appointment via the transport team. The progress note documented at 1:10 p.m., the resident returned to the facility and a follow up appointment had been made for December 5th at 8:30 a.m. The note documented social services was made aware. On 11/07/24 at 9:58 a.m., Resident #28's POA reported they were still having an issue with not being notified of all the resident's scheduled doctors appointments. On 11/12/24 at 12:22 p.m., Social Services reported residents family members were notified of their doctors appointments when the facility scheduled the appointments. Social Services reported Resident #28's POA was aware of scheduled doctor appointments. The social services staff reported notifications to the resident's POA had not been documented. On 11/12/24 at 12:30 p.m., LPN #1 reported residents family members were to be notified of doctors appointments, new orders, and changes in condition. The LPN reported Resident #28's POA was made aware of changes and doctors appointments. The LPN reported the POA was probably contacted on 10/23/24 with notification of a doctor's appointment scheduled for 12/05/24, but the LPN had failed to document the notification.

Based on record review and interview, the facility failed to refer residents with newly diagnosed mental illnesses to the OHCA and or LOCEU for a level II PASARR evaluation for one (#28) of three sampled residents reviewed for PASARR. The administrator identified 79 residents resided in the facility. Findings: A PASARR policy and procedure, dated 09/01/17, read in part, a new condition of intellectual disability or mental illness must be referred to the LOCEU by the nursing facility for determination of the need for the Level II assessment. Resident #28 was admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder on 06/27/17 and schizoaffective disorder on 08/04/21. A comprehensive assessment, dated 08/27/24, documented moderately impaired cognition. The assessment also documented the use of antianxiety medication. The level I PASARR screen completed on admission was unavailable in the resident's medical record. The Order Summary report, dated 11/07/24, documented the following medication: divalproex sodium (anticonvulsant medication) 125 mg for schizoaffective disorder and hydroxyzine pamoate (antihistamine medication) 25 mg for anxiety. On 11/12/24 at 10:41 a.m., the ADON reported not being able to locate the resident's PASARR completed on admission. The ADON reported being unaware if the anxiety disorder diagnosis given to the resident had been reported to the OHCA. The ADON reported the diagnosis of schizoaffective disorder was not reported to the OHCA. The ADON reported they had recently been made aware a new diagnosis of mental illness, not on the level I PASARR, needed to be reported to the OHCA.

Based on record review and interview, the facility failed to ensure a level I PASARR assessment was completed before or on admission for one (#9) of three sampled residents reviewed for PASARR. The administrator reported 79 residents resided in the facility. Findings: A PASARR policy and procedure, dated 09/01/17, read in part, the nursing facility must independently evaluate the Level I PASARR screen regardless of who completes the form and determine whether or not to admit an individual to the facility .nursing facilities which inappropriately admit a person without a PASARR screen are subject to recoupment of funds. Resident #9 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder and mood disorder. A comprehensive assessment, dated 10/08/24, documented the resident's cognition was intact. The assessment also documented antipsychotic and antidepressant medication use. An Order Summary report, dated 11/07/24, documented the following medication: donepezil hcl (cholinesterase medication) 5 mg for mood disorder, lamotrigine (phenyltriazine medication) 25 mg for mood disorder, riluzole (benzothiazole medication) 50 mg major depressive disorder, risperidone (antipsychotic medication) 1 mg for mood disorder, sertraline (antidepressant medication) hcl for major depressive disorder, and Vraylar (antipsychotic medication) 3 mg for mood disorder. On 11/07/24 at 3:43 p.m., the ADON reported a level I PASARR was not completed for Resident #9. They reported it was missed.

Based on observation and interview, the facility failed to ensure pureed foods were prepared in a manner to maintain flavor and nutritive value. The dietary manager reported five residents received a pureed diet. Findings: The Food and Nutrition Services policy, dated 10/01/2022, documented Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .Pureed food: Never use water to puree - must always add liquid/gravy/broth/sauce that adds nutritional/caloric value and complements the food being pureed . On 11/14/23 at 11:24 a.m., observation was made of a dietary staff member preparing pureed food for the noon meal. The dietary staff member put 6 servings of black eyed peas into the food processor to puree and added water to thin. The dietary manager put 6 servings of meat into the food processor and added water to thin. On 11/17/23 at 10:11 a.m., the dietary manager reported the dietary staff member that prepped the pureed food had used water to thin the black eyed peas and meat on 11/14/23. The dietary manager reported that water should not be used to thin pureed food. The dietary manager reported that black eyed peas should have been prepped with broth or juice from cooking to get pureed consistency. The dietary manager reported the meat should have been mixed with broth or gravy to puree.

Based on observation and interview, the facility failed to ensure staff practiced proper hand hygiene and food safety while serving food, drinks, and snacks to residents. The administrator reported 78 residents resided in the facility. Findings: The Food and Nutrition Services policy, dated 10/01/22, documented .Residents that are served meals or snacks outside of the dining room shall be covered to ensure that food or beverages are not contaminated . The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated 10/01/2023, documented Food and nutrition service employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness .Employees must wash their hands: after engaging in other activities the contaminate the hands .Antimicrobial hand gel cannot be used in place of handwashing in food service areas .However can be used in between passing trays during meal service in accordance with infection control practices .Gloves are considered single-use items and must be discarded after completing the task for which they are used . The use of disposable gloves does not substitute for proper handwashing . On 11/08/23 at 11:59 a.m., observation of the east side dining room was conducted. Staff members passing trays to residents in the east dinging room were observed wearing gloves while passing trays to residents, and retrieving condiments and drinks from the kitchenette area of the dining room. Staff members were observed setting up utensils and drinks for residents without changing gloves, washing hands or using hand gel between residents. Staff members were observed opening and closing the door of the kitchenette area with gloved hands, while not changing gloves before touching residents plates, cups or utensils. On 11/14/23 at 2:53 p.m., Dietary Staff #1 was observed pushing a cart down the hall wearing gloves while passing out fruit cups and a spoon to residents. Dietary Staff #1 was observed pulling a residents door closed with his gloved hand and pass out fruit cups and spoons to other residents without changing gloves and performing hand hygiene. The fruit cups that were being passed for residents in their rooms were not covered to prevent contamination. On 11/17/23 at 10:11 a.m., the dietary manager reported staff should not be wearing gloves in place of performing hand hygiene while passing food, drinks, and snacks to residents. The dietary manager reported if staff were going to wear gloves then the gloves should be changed between each resident. The dietary manager reported all food that was passed to residents down the hallways and in their rooms should be covered to prevent contamination.

Based on record review and interview, the facility failed to revise comprehensive care plans with new interventions after a fall with injury to prevent future falls for one (#31) of seven residents reviewed for falls. The Administrator reported 78 residents resided in the facility. Findings: The Care Plans, Comprehensive Person-Centered policy, dated 12/01/16, documented .The interdisciplinary team must review and update the care plan: When a desired outcome is not met; and at least quarterly, in conjunction with the required quarterly MDS assessment . Res #31 was admitted to the facility with diagnoses which included multiple sclerosis and paraplegia. A care plan, updated 01/19/23, read in part, .I have fallen in the past and I am at risk for other falls .Goal: I will be free from falls through the review date . Interventions: Nursing staff will use a lift pad when transferring me from surface to surface; Please ensure the lift if being used correctly to avoid injury .I am transferred using Hoyer lift x2 staff members .Nursing staff will monitor me during and between rounds .Ensure I am sitting in my Broda chair correctly and I am not sliding down/out. Reposition me as needed . A state reportable incident report documented Res #31 had a fall with injury on 07/16/23. The report documented Res #3's reclining wheelchair tipped over causing her to hit her forehead on the base of the bed frame in her room, resulting in a laceration to forehead. An MDS assessment, dated 09/26/23, documented Res #31's cognition was intact and was totally dependent on staff for ADLs. On 11/14/23 at 2:29 p.m., RN #1 reported a fall scene investigation should have been conducted to determine the cause of the fall and new interventions implemented to prevent future falls. RN #1 reported that Res #31's care plan had not been revised after the fall with injury on 07/16/23. RN #1 reported that resident #31's care plan should have been revised with new interventions to prevent further falls.

Based on observation, record review, and interview, the facility failed to investigate the cause of a fall and implement new interventions to prevent falls for one (#31) of seven residents reviewed for falls. The administrator reported 78 residents resided in the facility. Findings: The Assessing Falls and Their Causes policy, dated 10/01/10, documented .Residents must be assessed in a timely manner for potential causes of falls .Relevant environmental issues should be addressed promptly .Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident .The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found .When a resident falls, the following information should be recorded in the resident's medical record: Completion of a falls risk assessment. Appropriate interventions taken to prevent future falls . Res #31 was admitted to the facility with diagnoses which included multiple sclerosis and paraplegia. A care plan, updated 01/19/23, documented I have fallen in the past and I am at risk for other falls .Nursing staff will use a lift pad when transferring me from surface to surface; Please ensure the lift if being used correctly to avoid injury .I am transferred using Hoyer lift x2 staff members .Nursing staff will monitor me during and between rounds .Ensure I am sitting in my Broda chair correctly and I am not sliding down/out. Reposition me as needed. A state reportable incident report documented Res #31 had a fall with injury on 07/16/23. The report documented Res #31 had just been placed into her reclining wheelchair and while the CNA was returning the lift to the hallway the residents tipped over backwards causing her to hit her forehead on the base of the bed frame in her room. The report documented the fall resulted in a laceration to forehead. An MDS assessment, dated 09/26/23, documented Res #31's cognition was intact and was totally dependent on staff for ADLs. On 11/14/23 at 1:36 p.m., Res #31 reported that staff always use two staff and the mechanical lift when transferring her to her Broda chair from the bed. Res #31 reported that staff had already left the room when she fell out of her Broda chair and hit her head on 07/16/23. Res #31 reported the Broda chair had bars on the back to prevent it from falling backwards but it did not prevent the fall. On 11/14/23 at 2:29 p.m., RN #1 reported a fall scene investigation was not conducted for Res #31's fall on 07/16/23. RN #1 reported a fall scene investigation should have been conducted to determine the cause of the fall and new interventions implemented to prevent future falls.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide a physician-ordered therapeutic diet for Resident #2, which resulted in the resident choking and requiring emergency services. The facility failed to provide a mechanical soft diet, causing resident #2 to choke, become unresponsive, and require hospitalization . The resident had a physician's order for a mechanical soft/chopped diet. On [DATE], the resident was served coleslaw which had not been properly prepared per the physician order. The facility failed to provide a mechanical diet for texture according to the facility policy for therapeutic diets. The resident choked for approximately five minutes prior to becoming unresponsive and emergency medical services (EMS) documented suffocation/asphyxia. The resident was hospitalized for six days. The hospital discharge summary record documented a diagnosis of acute [CONDITION(S)] (damage that affects the brain) present upon arrival to the hospital, likely secondary to suspected aspiration pneumonia versus dysphagia with choking. An Elite Comprehensive Report for resident #2, from emergency medical services and dated [DATE] at 1:20 p.m., documented in parts .Complaint Unresponsive . [DATE] 1:25 p.m., . Patient Care Report .Staff met us at the rear entrance. The female staff member stated that the pt had choked on fish while eating lunch approximately 20 minutes prior to our arrival. She stated that they removed the obstruction from the pt's airway and he was breathing on his own: but has remained unresponsive to verbal stimulus since the event. They stated that the choking event lasted approximately 5 minutes total . As we approached the patient he was sitting upright in his wheelchair. His head was slumped down and snoring respirations were noted . The patient's airway was manually opened via head tilt chin lift. The airway remained open with manual stabilization. The snoring respiration subsided at this point.The patient was unresponsive and unable to follow commands. The PT's pupils were bilaterally pin point and unresponsive to light.His airway was patent and manually maintained throughout transport. Intermittently the patient would cough up small amounts of food with saliva and I would suction the foreign body from the PT's mouth.Clinical impression . Possible [CONDITION(S)] brain injury.No interventions improved patient's unresponsiveness . The patient was determined to be a priority 2 transport to {name deleted} hospital. The pt however never became alert or oriented. On [DATE] at 4:04 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 4:50 p.m., the Administrator and the corporate RN were notified of the IJ situation. On [DATE] at 4:17 p.m., an acceptable Plan of Removal was provided by the corporate RN and Administrator. It documented the following: Corrective Action: Plan of removal On, [DATE], All staff In-serviced on Facility Policy and Procedure Choking, [MEDICATION(S)] Maneuver, Preventing Choking, and completion of Incident reports. 1. All new hires will be educated on choking, [MEDICATION(S)] maneuver, and preventing choking. 2. Admin/designee will review new hire packets to ensure all training is completed. 3. Admin/designee will report any negative findings quarterly to Qapi On [DATE], all licensed RN/LPN In-serviced on Facility Policy and Procedure Documentation, Physician Notification. Completed by 8 p.m. [DATE] 1. All licensed new hires will be educated on Facility Policy and Procedure Documentation and Physician notification. 2. Don/designee will review all new hire packets to ensure all training is completed. 3. Don/designee will report any negative findings quarterly to Qapi On [DATE] Inservice provide to all dietary/nursing staff on Facility Policy and Procedure Therapeutic Diet. To be completed 6 p.m. [DATE]. 1. All new hires will be educated on the Facility Policy and Procedure Therapeutic Diet. 2. Dietary manager will review all new hire packets to ensure all training is completed. 3. Dietary manager will report any negative findings quarterly to Qapi 4. Observation of meal service will be conducted by dietary/nursing staff to ensure proper diets are being served per physician orders. On [DATE] Chart review of all 67 resident's dietary orders were reviewed and cross referenced with dietary cards to ensure physician ordered diets are followed. Completed by 10 a.m. [DATE] 1. Dietary manager/designee will observe meal service to ensure physician ordered diet is served daily X 3 weeks or until substantial compliance is achieved. 2. Dietary manager/designee will report any negative findings to DON at time of occurrence. 3 Dietary Manager/designee will report any negative findings quarterly to Qapi. On [DATE], interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The immediacy was lifted, effective [DATE] at 10:00 a.m., when all elements of the plan of removal had been implemented. The deficient practice remained at an isolated level with potential for harm to the resident. Based on record review, observation, and interview, it was determined the facility failed to ensure the therapeutic diet policy was implemented, and the emergency procedure for choking was followed, for one (#2) of five residents reviewed for therapeutic diets. The facility reported 13 residents with mechanical soft/ground diet orders (not including pureed). Findings: The facility Therapeutic Diets policy, dated [DATE], read in parts, .Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences.A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet . The facility's Emergency Procedure - Choking policy, dated [DATE], read in parts, .Conscious Resident -- Standing or Sitting 1. Ask the resident if he or she is choking . 2. Ask the resident to cough or speak if at all possible . 6. If the resident cannot cough, only then should abdominal thrusts be performed . .Unconscious Resident . 1. Ease the resident .to the floor. 4. Perform abdominal thrusts . 5. Perform the finger sweep maneuver to check for a foreign body . a. Keep the resident's face up . Documentation The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individuals who performed the procedure. 3. The exact time the choking began. 4. The exact time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The resident's response to the procedure. 8. The signature and title of the person recording the data. .Reporting 1. Report results promptly to the supervisor and the attending physician. 2. Notify the resident's personal physician of all assessment data, observations and results. 3. Report other information in accordance with facility policy and professional standard of practice. Resident #2 had diagnoses which included right-sided [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], hypertension and depression. The resident's Care Plan, dated [DATE] and revised on [DATE], read in parts .I have potential for nutritional problems because I have no teeth, .and communication problems. Intervention, I eat a soft mechanical chopped diet double portion with regular liquids.Nursing staff will monitor me while eating to ensure that I am having no difficulty chewing or swallowing my food . A plan of care for code status was revised on [DATE], read in parts .I have chosen to be full code status. Intervention, If I choke perform the [MEDICATION(S)] Maneuver and proceed with CPR as needed. The resident's monthly Physician's Order, dated [DATE] to [DATE], documented Soft mechanical chopped diet double portions regular liquids. A weekly menu, dated [DATE], in the lunch column documented: Fried Fish, French Fries, Creamy Coleslaw, Hushpuppies, Tarter Sauce, Lemon Pie. A nurse note for resident #2, dated [DATE] at 12:30 p.m., documented Resident in dinner [sic] room @ lunch eating choked on coleslaw and stopped breathing normal after choking sent out via ambulance -- [Name deleted] LPN. A Diet Sheet for resident #2, dated [DATE], documented the resident consumed 100% of his lunch meal. Resident #2's Treatment Record had no vital signs documented on [DATE] related to the choking incident. An emergency room Report for resident #2, dated [DATE] at 6:05 p.m., documented in parts .nursing home resident who presented with complaint of unresponsiveness. Reportedly patient choked on a fish for almost 5 minutes around 1 PM.since then he has become less responsive. Hospital records documented resident #2 remained in the hospital from [DATE] through [DATE]. The Hospital Discharge Summary, dated [DATE] at 10:49 a.m., documented Discharge DX: Acute [CONDITION(S)], present on admission (POA) likely secondary to suspected aspiration pneumonia versus dysphagia with choking. On [DATE] at 10:20 a.m., the dietary manager reported the resident's coleslaw had not been ground up per the therapeutic diet order. The dietary manager reported, we fixed it right then and made sure even if the food was chopped up it would still need to be ground up in the blender. The dietary manager reported a staff member had swept their finger through the resident's mouth but she couldn't remember if anyone had attempted a [MEDICATION(S)] maneuver on the resident. She reported the resident did become unresponsive. On [DATE] at 10:52 a.m., the corporate nurse reported they did not do an incident report and no one had attempted a [MEDICATION(S)] maneuver on the resident. On [DATE] at 11:30 a.m., the DON reported LPN #2 noticed the resident choking and reported it to the DON. The DON reported she went to the resident and attempted a finger sweep of the resident's mouth. The DON reported she continued this procedure the whole time. The DON stated she removed a hand-full of fish from the resident's mouth and stated, I couldn't believe how much fish I got out of him. The DON reported she did not think to attempt the [MEDICATION(S)] maneuver. The DON reviewed the choking policy and stated she did not follow the facility policy or the resident's care plan. On [DATE] at 12:45 p.m., the resident was observed in the dining room feeding himself. His food was observed to be mechanical soft ground. Staff members were observed in the dining room supervising residents while eating. On [DATE] at 10:10 a.m. LPN #2 reported she was supervising lunch in the dining room on [DATE]. She stated resident #2 was eating fish and coleslaw. The LPN stated she noticed the resident was choking on the coleslaw, went to check on him, and gave him a thrust to the back. The LPN stated some of the coleslaw came out, she removed the remainder of coleslaw from the resident's plate, a few minutes later the resident was coughing and choking on the fish. The LPN reported the coleslaw was regular slaw, not ground. The LPN stated the fish was fried and the crust was hard. The LPN reported the DON was coming around the corner so she got her attention. The LPN stated the resident was slumping down so she straightened him back up but he kept slumping over. The LPN stated the DON started doing a finger sweep and continued this procedure. The LPN stated she told the DON the resident should be sent out to the emergency room and the DON left to call for emergency services. The LPN stated she thought the resident aspirated on the coleslaw before he continued to eat the fish. On [DATE] at 4:00 p.m., the DON was interviewed and stated the resident's care plan for a therapeutic diet, as well as the choking policy, should have been followed.

Based on record review, observation, and interview, the facility failed to implement the resident's Care Plan, and perform a [MEDICATION(S)] maneuver when the resident choked, for one (#2) of 15 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 67 residents who resided in the facility. Findings: The facility's Emergency Procedure - Choking policy, dated [DATE], read in parts . Conscious Resident -- Standing or Sitting 1. Ask the resident if he or she is choking . 2. Ask the resident to cough or speak if at all possible . 6. If the resident cannot cough, only then should abdominal thrusts be performed . .Unconscious Resident 1. Ease the resident .to the floor. 4. Perform abdominal thrusts . 5. Perform the finger sweep maneuver to check for a foreign body . a. Keep the resident's face up Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, dated [DATE], read in parts .Care Plan Description, I have chosen to be full code status . Intervention, If I choke perform the [MEDICATION(S)] Maneuver and proceed with CPR as needed. A nurse note, dated [DATE] at 12:30 p.m., documented, Resident in dinner [sic] room @ lunch eating choked on coleslaw and stopped breathing normal after choking sent out via ambulance -- [Name deleted] LPN. There was no other documentation by facility staff related to this incident. An Elite Comprehensive Report for resident #2, from emergency medical services and dated [DATE] at 1:20 p.m., documented in parts .Complaint Unresponsive . [DATE] 13:25, .Patient Care Report .Staff met us at the rear entrance. The female staff member stated that the pt had choked on fish while eating lunch approximately 20 minutes prior to our arrival. She stated that they removed the obstruction from the pt's airway and he was breathing on his own: but has remained unresponsive to verbal stimulus since the event. They stated that the choking event lasted approximately 5 minutes total . As we approached the patient he was sitting upright in his wheelchair. His head was slumped down and snoring respirations were noted . The patient's airway was manually opened via head tilt chin lift. The airway remained open with manual stabilization. The snoring respiration subsided at this point.The patient was unresponsive and unable to follow commands. The PT's pupils were bilaterally pin point and unresponsive to light.His airway was patent and manually maintained throughout transport. Intermittently the patient would cough up small amounts of food with saliva and I would suction the foreign body from the PT's mouth.Clinical impression . Possible [CONDITION(S)] [CONDITION(S)].No interventions improved patient's unresponsiveness . The patient was determined to be a priority 2 transport to {name deleted} hospital. The pt however never became alert or oriented. An emergency room Report for resident #2, dated [DATE] at 6:05 p.m., documented in parts .nursing home resident who presented with complaint of unresponsiveness. Reportedly patient choked on a fish for almost 5 minutes around 1 PM.since then he has become less responsive. Hospital records documented resident #2 remained in the hospital from [DATE] through [DATE]. A Hospital Discharge Summary, dated [DATE] at 10:49 a.m., documented Discharge DX: Acute [CONDITION(S)], present on admission (POA) likely secondary to suspected aspiration pneumonia versus dysphagia with choking. On [DATE] at 10:20 a.m., the dietary manager reported a staff member had swept their finger through the resident's mouth but she couldn't remember if anyone had attempted a [MEDICATION(S)] maneuver on the resident. She reported the resident did become unresponsive. On [DATE] at 10:52 a.m., the corporate nurse reported they did not do an incident report and no one had attempted a [MEDICATION(S)] maneuver on the resident. On [DATE] at 11:30 a.m., the DON reported when the incident occurred, LPN #2 noticed the resident choking and reported it to the DON. The DON reported she went to the resident and attempted a finger sweep of the resident's mouth. The DON reported she continued this procedure the whole time. The DON stated she removed a hand-full of fish from the resident's mouth and stated, I couldn't believe how much fish I got out of him. The DON reported she did not think to attempt the [MEDICATION(S)] maneuver. The DON reviewed the choking policy and stated the facility policy was not followed and the resident's care plan was not implemented. On [DATE] at 12:45 p.m., the resident was observed in the dining room feeding himself. His food was observed to be mechanical soft ground. Staff members were observed in the dining room supervising residents while eating. On [DATE] at 10:10 a.m. LPN #2 reported she was supervising lunch in the dining room on [DATE]. She stated resident #2 was eating fish and coleslaw. The LPN stated she noticed the resident was choking on the coleslaw, went to check on him, and gave him a thrust to the back. The LPN reported the DON was coming around the corner so she got her attention. The LPN stated the resident was slumping down so she straightened him back up but he kept slumping over. The LPN stated the DON started doing a finger sweep and continued this procedure. The LPN stated she told the DON the resident should be sent out to the emergency room and the DON left to call for emergency services. On [DATE] at 4:00 p.m., the DON was interviewed and stated the resident's care plan and choking policy should have been followed.

Based on observation, interview and record review, it was determined the facility failed to: ~ put new interventions in place for fall prevention for one (#12) and, ~ put interventions in place for falls with major injuries for one (#39) of five residents whose records were reviewed for accidents. This resulted in harm due to the resident having a broken foot/ankle from one fall and a broken back from another fall. This had the potential to affect all 69 residents. Findings: The facility's policy for falls documented, Facility: Falls- Clinical Protocol, Assessment and Recognition . page 1, The physician will identify medical conditions affecting fall risk .(for example, increased fracture risk in someone with [MEDICAL CONDITION] .) . Page 2, Cause Identification, 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall . 1. Resident #39 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 04/04/17, documented the resident was not a fall risk. A nurse's note, dated 05/31/17, documented the resident stated, I was putting my dirty clothes in barrell (sic) and slipped Res (resident) unable to move L (left) leg with severe pain 10/10. N/O (new order) mobile x-ray to L hip. The x-ray, dated 05/31/17, documented Findings: Transcervical fracture with varius deformity and superior positioning of the distal femur in relation to the femoral head . A significant change, dated 06/09/17, documented the resident had no falls since admission. No fall risk assessment was found in the clinical record. A significant change assessment, dated 09/12/17, documented the resident was independent with all of her activities of daily living (ADL). No care plan was found in the clinical record prior to 10/31/17. An incident report, dated 10/31/17, documented the resident was in her room on her coccyx on the floor. A nurse's note, dated 11/01/17, documented N/O (new order) for X-ray to L (left) foot An x-ray report, dated 11/02/17, documented Impression: 1. Acute avulsion fracture fragments along the dorsal surface of the head of the talus . A quarterly assessment, dated 12/13/17, documented the resident was independent with all of her ADL's. An incident report, dated 01/17/18, documented the resident was getting up off the toilet in the bathroom and fell on to the floor. The resident complained of pain to her right hip, back, and shoulder. A nurse's note, dated 01/17/18, documented a new order for an x-ray to her back. An x-ray report, dated 01/18/18, documented .There is a wedge compression [MEDICAL CONDITION] vertebral body, . In addition, there is a probable mild wedge compression [MEDICAL CONDITION] vertebral body . A significant change assessment, dated 03/13/18, documented the resident's cognition was intact. She required extensive assistance with transfers, dressing, toilet use and personal hygiene. She was independent with eating. She was always incontinent of bowel and bladder. On 05/15/18 at 8:16 a.m., certified nurse aide (CNA) #8 was asked after the resident fell had the staff had to start helping her. She stated they had to help her after she fell and broke her hip, after she broke her foot and after she broke her back. All three times, we are still helping her. At 8:31 a.m., licensed practical nurse #5 was asked about this resident's falls, interventions and ADL care. She stated, After she broke her foot we were always helping her, we kept reminding her to use her call light when she needed help. We were afraid she was going to get hurt again and sure enough she fell again and broke her back. She was asked if there were any other interventions put in place other than reminding her to use her call light. She stated, No, I can't think of anything else except reminding her to use her call light. She was asked if any other interventions should have been put in place. She stated, Yes, I'm going to be honest, we should have put other things in place. At 1:23 p.m., CNA #4 was asked if the resident was independent after breaking her foot. She stated they had to use a bed pan for her and only got her up for meals. We did the same thing for her after she broke her hip and her back. At 2:47 p.m., the administrator was asked about the multiple falls the resident had and she was asked who would have been responsible for having done a root cause analysis. She stated, The director of nursing (DON) would be. At 3:50 p.m., the DON was asked about having done a root cause analysis for this resident's falls. She stated, I don't do the falls, the assistant director of nursing (ADON) does them. On 05/16/18 at 12:07 p.m., The ADON was asked who had done the root cause analysis for the falls. She stated, I don't know, maybe the DON does them. I only record the falls, that's it, I don't do a root cause analysis. At 2:16 p.m., the administrator was shown the above findings. She was in agreement a root cause analysis should have been done to have determined the underlying causes of the resident's falls and interventions should have been put in place to assist in the reduction of her falls. 2. Resident #12 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/11/18, documented the resident was cognitively intact . It documented he was independent with activities of daily living and had no range of motion limitation and was always continent of bowel and bladder. A care plan, dated 03/15/18, documented fall risk with interventions to have had his call light in reach, monitor his gait, and remind him not to get up if he was dizzy. The resident's clinical record documented the resident had 22 falls between 03/15/18 and 05/01/18. No new interventions were put in place for 18 of these falls. On 05/14/18 at 2:40 p.m., the assistant director of nursing was asked what new interventions were put in place after the resident's falls. She stated just to remind the resident to use the call light. She was asked if that intervention was an effective intervention for the resident. She stated it was not.

Based on observation, interview and record review, it was determined the facility failed to ensure incontinent care was done, as needed, to prevent urinary tract infections [MEDICAL CONDITION] and moisture associated skin breakdown (MASB) for one (#3) of five residents whose records were reviewed for incontinence. This resulted in harm due to repeated UTI's and MASB. This had the potential to affect 36 residents who were incontinent of urine according to the resident census and conditions of residents form. Findings: The resident had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/19/18, documented the resident's cognition was intact. She required limited assistance (one person) with transfers, ambulation, dressing, hygiene/bathing, and bladder care. It documented the resident had moisture associated skin breakdown. On 04/17/18 at 1:00 p.m., the resident was observed to have still been in her bed. At 1:30 p.m., she was interviewed and asked why she was still in bed. She stated no one had come in to change her or get her up. She stated, I'm soaked from my stomach down. She stated, I'm embarrassed cause it stinks really bad. She pulled the cover back, her underwear had yellowish brown stains half way up them. The linen under her was soaking wet and her bedspread was wet. She stated, I'm left like this every morning. I even have sores between my legs from lying in this. The moisture associated skin breakdown area between her groin was observed. The area had a white, thinned out cream that had covered most of the area. There was an open skin area approximately 2 centimeters (cm) x 2 cm with surrounding reddish pink, irritated looking skin. She stated, I go at least 5 to 10 days without a shower. She stated, They write down that I'm getting them but I'm not. They say I refuse care but I don't, I just ask them to come back later and they never come back. On 04/18/18 at 9:30 a.m., certified nurse aide (CNA) #1 was asked about incontinent care for this resident. She stated she was working by herself and it took two people to get the resident up. A licensed practical nurse (LPN) was supposed to be helping her but was in the office. She was asked about this resident lying soaked in urine. She stated, It is not ok for her to be left lying like that. She stated she doesn't think anyone attended to her on the night shift because she was always soaked in the morning. She stated the resident refused care. She was asked if she refused care or if she asked them to come back later. She stated she asked her to come back later. She was asked if she had returned to the resident's room at a later time. She indicated, No, by shaking her head side to side. She was asked if she had taken that as she refused care. She nodded her head up and down and stated, Yes. At 2:45 p.m., LPN #1 who was supposed to have been helping CNA #1 was asked about incontinent care for the resident. She stated, She refuses to get up. She was asked if that was a reason to not change her or care for her. She stated, No. She was asked how often incontinent care was done. She stated every 2 hours. She was asked if she went into this resident's room at all this shift. She stated, No. At 3:45 p.m., the resident's roommate was interviewed and asked what she could tell about the resident's showers and incontinent care. She stated, She is always asking for a shower. They tell her they are short handed. She puts her light on every morning and sometimes they don't answer the light or they come in and say they'll get back to her and never come back. They just ignore/neglect her. At 3:48 p.m., the administrator was informed of the above findings. She was in agreement the resident should not have been left unattended all morning.

Based on observation, interview and record review, it was determined the facility failed to ensure incontinent care was done in a timely manner to prevent moisture associated skin break down (MASB) and urinary tract infections [MEDICAL CONDITION] for one (#3) of five residents whose records were reviewed for urinary tract infections. This resulted in harm due to repeated UTI's and MASB. This had the potential to effect 15 residents who required care for skin breakdown who resided in the facility. Findings: The resident had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/19/18, documented the resident's cognition was intact. She required limited assistance (one person) with transfers, ambulation, dressing, hygiene/bathing, and bladder care. It documented the resident had moisture associated skin breakdown. The resident's careplan for activities of daily living (ADL), dated 03/09/17, documented she required extensive assistance with her ADL's. On 04/17/18 at 1:00 p.m., the resident was observed to have still been in her bed with a strong lingering urine odor. At 1:30 p.m., She was interviewed and asked why she was still in bed. She stated no one had come in to change her or get her up. She stated, I'm soaked from my stomach down. She said I'm embarrassed cause it stinks really bad. She pulled the cover back, her underwear had yellowish, brown stains half way up them. The linen under her was soaking wet and her bedspread was wet. She stated, I'm left like this every morning. I even have sores between my legs from lying in this. The moisture associated skin breakdown area between her groin was observed. The area had a white, thinned out cream covering most of the area. There was an open skin area approximately 2 cm (centimeters) by 2 cm with surrounding reddish pink, irritated looking skin. She stated, I go at least 5 to 10 days without a shower. She stated the staff write down that she is getting them but she was not. They say I refuse care but I don't, I just ask them to come back later and they never come back. I am on my 8th round of antibiotics for urinary tract infections. The resident had a urinary tract infection [MEDICAL CONDITION] in (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), two in (MONTH) (YEAR), one in (MONTH) (YEAR) and one in (MONTH) (YEAR). Four of the UTI's had documented lower abdomen pain, increased burning/urination, strong foul odor, bladder spasms, and kidney and lower back pain. The resident's ADL sheet for (MONTH) (YEAR) documented the resident had a shower on January 2nd and hadn't documented another shower until (MONTH) 19th, with only one day documented refused on (MONTH) 16th. The (MONTH) (YEAR) and (MONTH) (YEAR) ADL sheets had documented showers every 2 to 4 days. The resident denied getting most of the documented showers. On 04/18/18 at 9:30 a.m., certified nurse aide (CNA) #1 was asked about incontinent care for this resident. She stated she was working by herself and it took two people to get the resident up. A licensed practical nurse (LPN) was supposed to be helping her but was in the office. She was asked about this resident lying soaked in urine. She stated, It is not ok for her to be left lying like that. She stated she doesn't think anyone attended to her on the night shift because she was always soaked in the morning. She stated the resident refused care. She was asked if she refused care or if she asked them to come back later. She stated she asked her to come back later. She was asked if she had returned to the resident's room at a later time. She indicated, No, by shaking her head side to side. She was asked if she had taken that as she refused care. She nodded her head up and down and stated, Yes. At 3:45 p.m., the resident's roommate was interviewed and asked what she could tell about the resident's showers and incontinent care. She stated, She is always asking for a shower. They tell her they are short handed. She puts her light on every morning and sometimes they don't answer the light or they come in and say they'll get back to her and never come back. They just ignore/neglect her. At 3:48 p.m., the administrator was informed of the numerous urinary tract infections and the moisture associated skin break down. She was in agreement the resident should not have been left unattended all morning.

Based on record review and interview, it was determined the facility failed to provide supervision to ensure a resident's safety on an outing outside of the facility for one (#1) of three residents who were reviewed for supervision. This caused harm to the resident. It resulted in the resident having been bitten by dogs, and having received treatment at a local emergency room . This had the potential to affect 53 residents which required supervision on outings outside of the facility as identified by the facility. Findings. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/20/17, documented the resident was moderately cognitively impaired. It documented the resident was independent with activities of daily living. A care plan, dated 11/20/17, documented the resident was not allowed on unsupervised outings. Interventions included outings by the resident would have been supervised by a staff or family member and the staff was to have frequently reminded the resident that she required supervision during an outing. A nurse's note, dated 12/06/17 at 7:00 p.m., documented, Resident left in dark to walk to store when nurse said it was dark and after curfew. Resident kept cursing and walked off and said call the cops that she didn't care. She stated we couldn't stop her. Resident returned after 40 minutes . A nurse's note, dated 12/15/17 at 10:00 a.m., documented, Was called out to porch on East hall by AN&R (Anadarko Nursing and Rehab) Staff to assess this resident. When this nurse approached the resident, a CNA (certified nurse aide) was holding a towel on the residents L (left) hand and L leg. Resident was crying and blood was noted on the ground under residents leg. resident brought into her room. DON (director of nursing) and this nurse washed wounds c (with) wound cleanse & put pressure dressing on wounds. EMTs were called @ this time. resident was transported to (hospital name deleted) for eval/tx (evaluation/treatment) by ambulance. physician notified. family notified. A nurse's note at 2:30 p.m. documented, resident returned to facility c daughter @ this time. new orders to clean & dress wounds as needed An incident report dated 12/15/17, documented the resident was found to have two bite marks and had been sent to a local hospital emergency room to be evaluated. On 01/02/18 at 1:34 p.m., the resident was asked about the incident on 12/15/17. She stated she had left the building to take a walk around the block. During her walk she stated she had been attacked by three dogs about a block from the facility. She stated the dogs had bitten her left hand and leg. She stated when she returned to the facility, certified nurse aide (CNA) #1 had assisted her. At 1:38 p.m., the resident's identified dog bite wounds were observed. The left hand was observed to have had a 2 centimeter (cm) scab. The resident's left leg was observed to have a 3 cm long by 1 cm wide puncture wound on top of her left calf and a 2 cm by 1 cm wound at the base of her left calf. Both leg wounds were observed to be pink in color and had no signs or symptoms of infection. The resident was asked if she had been supervised during her walk. She stated she had not been. At 1:45 p.m., CNA #1 was asked about the situation with the resident which had occurred on 12/15/17. She stated she had been on the porch on the east side of the building when the resident had been walking toward the building and she had blood on her. She stated she called for other staff assistance, obtained gloves and assisted the resident by holding pressure on her hand and leg wounds. She was asked if she knew what had caused the resident's injuries. She stated the resident had told her she went to take a walk and was attacked by some dogs. She was asked if anyone had been with the resident. She stated there had not been. At 2:38 p.m., the director of nurses was asked if the resident required supervision when she went on outings. She stated the resident required supervision. She was asked if the resident had ever been unsupervised during any outings. She stated she had been unsupervised on two occasions. At 3:50 p.m. licensed practical nurse (LPN) #1, who had written the nurse's note for 12/06/17, was asked what had occurred with the resident on that date. She stated the resident had walked out of the building while cursing at her. She was asked if she had attempted to prevent the resident from leaving. She stated she had asked the resident not to leave the facility and the resident left anyway and had stated she was her own boss. She stated no one had supervised the resident on the outing.

Surveyor: Ahlborn, Donna On 04/17/17, an immediate jeopardy (IJ) was determined to exist due to the facility's failure to have a system in place to properly supervise residents who were allowed to check themselves out to leave the facility. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 5:20 p.m., the administrator and the director of nurses (DON) were notified of the above IJ situation. At 7:21 p.m., an acceptable plan of removal (POR) was received. The IJ was removed on 04/18/17 at 8:50 p.m., when all components of the POR had been carried out. The deficient practice remained at a level of no actual harm, isolated, with a potential for more than minimal harm. The plan of removal documented: 1. Residents going on independent leave of absence have been identified. 04/17/17 6:30 p.m. 2. The Leave of Absence Policy and Procedure (LOA) is being revised and will include: Updated LOA form with destination and expected time of return. Resident/Responsible party will sign out with date and time. Medication while on pass, including when and how medication is to be taken. Specific time frame for notification of physician and responsible party, documentation of any changes in condition while on leave and residents response while on leave. Completed by 04/18/17 10 a.m. Residents going on unsupervised outings will be evaluated with Cognitive evaluation which includes the BIMS (brief interview for mental status). Careplans will be developed for unsupervised outings. Completed 04/19/17 by 9 p.m. 3. Identified resident will be educated on the revised Policy and LOA form by 04/18/17 10 a.m. 4. Identified residents PCP (primary care physician) will be notified and order obtained for -Continue unsupervised/independent outings. 5. Education will be provided to all staff on the revised - LOA Policy and supervision of residents. Completed 10 a.m. 04/18/17 6. The Leave of Absence Policy will be added to the Admission forms and Employee Orientation at hire. 7. A quality assurance (QA) Sub-Committee will be developed, meeting every week to monitor compliance with the LOA Policy and supervision of residents, reporting to the QA committee monthly to ensure compliance. 8. The Administrator and DON will receive education on the LOA Policy and supervision of residents, from the Corp. Director of Operations. Based on interview and record review, it was determined the facility failed to ensure: ~ residents who independently left the facility for short periods of time were supervised. Two residents left without signing themselves out, rented a motel and spent the night without staff attempting to find out where they were until the next day, for two (#1 and #2) of 5 residents whose records were reviewed for supervision. This had the potential to effect 24 residents who independently signed themselves out and, ~ residents were assessed and found to be safe to sign themselves out of the facility for five (#1, #2, #3, #4 and #5) of 5 residents whose records were reviewed for supervision. This had the potential to effect 24 residents who were not assessed and, ~ new interventions were implemented to prevent falls for one (#6) of one whose record was reviewed for falls. This had the potential to effect 13 residents identified at risk for falls. Findings: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/19/16, documented the resident's cognition was intact. She was independent with all of her activities of daily living. The clinical record documented there was an order for [REDACTED].(name deleted) an adult incompetent and a Kiowa Tribal Member, dated 8th day of March 2007 .for care, custody, and control of (name deleted), both medically and financially . The clinical record contained no careplan for this resident. The facility did not provide a careplan when asked. The Leave of Absence (LOA) log documented resident #1 had signed herself out on numerous occasions during 2016 and 2017. There was no documentation she had signed out on 04/03/17. The LOA sign out sheet titled: Release of Responsibility for leave of absence: documented, The undersigned party hereby accepts complete responsibility for the individual resident listed below while away from the Health Care Facility, and absolves the management of said care facility, its personnel, and the attending physician of responsibility of any ill effects in condition or accident that may happen while the resident is away . There was no documentation the guardian had been notified for any LOA. An assessment had not been completed to determine if she was able to safely leave the facility unattended. On 04/17/17 at 1:15 p.m., resident #1 was asked about leaving on 04/03/17 without signing out and not returning till 04/04/17. She stated she left with her boyfriend, resident #2, to go to a hotel. She stated she willingly left with him. I questioned him about not signing out and he said lets just sneak out, I'm going to be in trouble anyways so you will just be in trouble with me. I'm the one like a dummy that went along with it. She was asked if she knew why her boyfriend, resident #2, wanted to go to a hotel. She stated, I don't know why, we were only gone one night. The medication administration record (MAR) for resident #1 documented the resident was out of the facility (oof) on 04/03/17, for her 5:30 p.m., 6:00 p.m. and 10:00 p.m. medications. At 2:47 p.m., the director of nursing (DON) was interviewed and asked about resident #1 and her boyfriend (resident #2) leaving on 04/03/17. He stated, She leaves all the time, signs herself in and out. This time she was out all night and got a hotel with her boyfriend. The staff notified me between 12:30 a.m. and 1:00 a.m. that (name deleted) and (name deleted) were both missing and had not signed out. I had them wake up (resident #1's) friend and asked if she knew where (name deleted) had gone. (resident #1's friend) said that resident #1 had told her she was going out to get a hotel. We called the hotel the next morning and the social service director (SSD) went and picked her up. He was asked why had they waited until the next morning to look for the missing residents. He stated, one of the nurses told me we're not responsible for them after they leave. At 3:45 p.m., the administrator was interviewed and asked about resident #1 leaving on 04/03/17. She stated, she had received a call at 1:30 a.m. on 04/04/17, from the DON that two residents had gone to a hotel. They had not checked out or signed out. They had told another resident they were going to get a hotel. She stated, They leave the facility together all the time. I came to work the next morning on the 4th and started calling the hotels. She stated she asked the SSD to go to the hotel and she brought them back. She was asked if she knew what time they had left the facility. She stated, It was after 8:30 p.m. She was informed of what the MAR had documented on it. She was asked if an investigation had been completed. She stated, No, I didn't do an investigation. I didn't notify her guardian until the next day on the 5th. She stated the guardian had come to the facility and they had a meeting with the resident. The guardian said the resident is not allowed to leave without her permission. The facility staff were aware resident #1 was not in the facility at 5:30 p.m. on 04/03/17 and did not start looking for her until 04/04/17, after 6:00 a.m. 2. Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. An annual assessment, dated 08/19/16, documented the resident's cognition was intact and he was independent with all activities of daily living (ADL's). A care plan had not been developed in regard to him leaving the facility unattended. The medication administration record (MAR) documented he was out of the facility (oof) on 04/03/17, for his 6:00 p.m. medications. The Leave of Absence (LOA) log documented he had signed himself out on numerous occasions during 2016 and 2017. There was no documentation he had signed out on 04/03/17. An assessment had not been completed to determine if he was able to safely leave the facility unattended. On 04/17/17 at 2:12 p.m., the resident was asked why he had not signed out of the facility. He stated he just forgot. He was asked why he went out. He stated he had received his money from the tribe and he wanted to go out. He was asked when did he leave the facility. He stated, We left after lunch. Staff reported sometime between 12:30 a.m. and 1:00 a.m. on 04/04/17, to the DON, the resident and his girlfriend (resident #1), were not in the building. At 2:47 p.m., the DON was interviewed and asked about resident #2 and his girlfriend leaving on 04/03/17. He stated, He leaves all the time, signs himself in and out. This time he was out all night and got a hotel with his girlfriend. The staff notified me between 12:30 a.m. and 1:00 a.m. that (name deleted) and (name deleted) were both missing and had not signed out. I had them wake up (resident #1's) friend and ask if she knew where (name deleted) had gone. (resident #1's friend) said that resident #1 had told her she was going out to get a hotel with her boyfriend. We called the hotel the next morning and the social service director (SSD) went and picked the residents up. At 3:45 p.m., the administrator was interviewed and asked about resident #2 leaving on 04/03/17. She stated she had received a call at 1:30 a.m. on 04/04/17, from the DON that two residents had gone to a hotel. They had not checked out or signed out. They had told another resident they were going to get a hotel. She stated, They leave the facility together all the time. I came to work the next morning on the 4th and started calling the hotels. She stated she asked the SSD to go to the hotel and she brought them back. She was asked if she knew what time they had left the facility. She stated, It was after 8:30 p.m. She was informed of what the MAR had documented. She was asked if an investigation had been completed. She stated, No, I didn't do an investigation. The facility staff were aware resident #2 was not in the facility at 6:00 p.m. on 04/03/17 and did not start looking for him until 04/05/17, after 6:00 a.m. Surveyor: Naney, Christopher 3. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's care plan, dated 03/01/17 had not documented he was able to leave the facility unattended. The LOA form had not documented he had signed himself out. An assessment had not been completed to determine if he was able to safely leave the facility unattended. On 04/17/17 at 3:00 p.m., the resident was interviewed and asked if he was able to sign himself out of the facility. He stated he could sign himself out, but hadn't felt like it. 4. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A comprehensive assessment had not been completed for the resident. No care plan had been developed for the resident. The Leave of Absence (LOA) log documented he had signed himself out twice on 04/18/17. An assessment had not been completed to determine if he was able to safely leave the facility unattended. On 04/19/17 at 9:17 a.m., the resident was asked what type of assistance he needed with activities of daily living. He stated he did not need any, he did everything for himself. 5. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/21/16, documented the resident was cognitively intact. It documented the resident was independent with activities of daily living. A care plan had not been developed for the resident. The Leave of Absence (LOA) log documented resident #5 had signed herself out on numerous occasions during 2017 An assessment had not been completed to determine if she was able to safely leave the facility unattended. On 04/18/17 at 1:49 p.m., the DON was asked what the process was to determine if a resident would be safe to check themselves out of the facility. He stated they would assess a resident's cognition, activities of daily living level, and medical condition. He was asked if residents #1, #2, #3, #4 and #5 had an assessment completed to ensure they would be safe when they checked themselves out. He stated they did not. He was asked if the residents should have been allowed to check themselves out of the facility without being assessed. He stated they should not have been allowed to check themselves out. Surveyor: Bridges, Bobbi L. 6. Resident #6 was admitted with [DIAGNOSES REDACTED]. The resident's admission assessment, dated 10/11/16, documented the resident was moderately cognitively impaired, required assistance of one staff for toileting and hygiene, and supervision with eating. The assessment documented the resident had two falls since admission with no injury and two falls with injury. The care plan, dated 12/04/16, documented the resident was to be kept safe and free from injury. An Oklahoma State Department of Health incident report, dated 02/05/17, documented the resident was found on the floor with redness and bruising to his face. The record documented corrective measures to be implemented to prevent recurrence .Update fall risk assessment. Refer to PT (physical therapy) for evaluation with focus on safety, balance, gait training and transferring . . The corrective measures implemented on 03/09/17. A fall risk evaluation, dated 04/02/17, documented the resident had a high risk for falls. On 04/18/17 at 1:36 p.m., the DON was interviewed and asked if the measures of: Refer to PT (physical therapy) for evaluation with focus on safety, balance, gait training and transferring . were implemented from the incident report. He stated, No, it wasn't done.

On 03/30/15, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a thorough investigation was conducted following an allegation of sexual abuse for one (#1) of one sampled resident who had alleged sexual abuse. At 3:28 p.m., the existence of the IJ was verified with the Oklahoma Stated Department of Health (OSDH). At 3:40 p.m., the administrator, the director of nursing (DON) and the corporate nurse were notified of the existence of the IJ. At 4:25 p.m., an acceptable written plan of removal was received. The facility's plan for removal, dated 03/31/15 (sic), documented, "Plan of Removal... Administrator is being rein-serviced (sic) `on the abuse policy to include the proper investigation of staff and residents. 4:40 PM 3/30/2015 Current Staff today 3/30/2015 4:20PM at this time is being in-serviced on the abuse policy to include the reporting of any unusual actions noticed by them in the past 6 months also to include the full abuse policy to include the seven components. All staff will be in-serviced by 4:00 PM 3/31/2015 on the Abuse policy before returning to work. All staff will be interviewed in regards to any inappropriate action that may have been witnessed on any shift that could be considered inappropriate action or abuse to a resident. Statements will be taken in writing if anyone has witnessed any such actions. Staff will be interviewed in privacy of Administrator, Corporate Nurse or DON (Director of Nursing). This will be completed by 4:00PM on 3/31/2014 (sic) New employees will be in-serviced one on one by one of the following department supervisors DON, ADON or Administrator before being able to report for their job duties. Alert Residents will be interviewed by 4:00 PM 3/31/2015 in regard to ever feeling scared, threatened or abused by a staff member." On 03/31/15 beginning at 2:30 p.m., 12 staff members were interviewed. They all stated they had been inserviced on the abuse policy and were able to verbalize what to do if they suspected any resident abuse. They all stated they had written a statement about any knowledge of abuse in the past or present. Three residents were interviewed. They stated they had filled out a questionnaire regarding abuse on 03/30/15. At 3:10 p.m., the corporate nurse presented documentation that all staff had been inserviced by 3:00 p.m. The written statements by the staff about any knowledge of abuse were also presented. She stated a questionnaire had been completed by the cognitive residents and presented 23 completed questionnaires. The IJ was removed on 03/31/15 at 3:00 p.m. when all staff and residents had been interviewed and all staff had been inserviced on the abuse policy. The deficient practice remained at a pattern level with the potential for more than minimal harm. Based on record review and staff and resident interviews, it was determined the facility failed to ensure a thorough investigation had been conducted following an allegation of sexual abuse for one (#1) of one sampled resident who had alleged sexual abuse. The facility identified 37 residents resided in the facility. Findings: The policy, Abuse Investigation Protocol, documented, "...All reports of resident abuse, neglect, injuries of unknown source, resident-to-resident abuse and resident-to-staff abuse are promptly and thoroughly investigated by facility management... The individual conducting the investigation will, as a minimum... Interview other residents to whom the accused employee provides care or services to determine if they have complaints about the employee... Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee; and... Nursing care Policies and Procedures... To assist one in recognizing incidents of abuse the following definitions of abuse are provided... SEXUAL ABUSE is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault... Abuse Prevention Program... Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion... Our facility has developed policies and procedures to aid us in preventing abuse, neglect or mistreatment of [REDACTED]. The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident-to-resident abuse and resident-to-staff abuse... Timely and thorough investigations of all reports and allegations of abuse..." An OSDH Incident Report Form, dated 03/16/15, documented, "Resident came to my office this afternoon and told me that she had been having sex with a male employee for money. Employee has been suspended for investigation and until further notice..." An OSDH Incident Report Form, dated 03/19/15, documented, "The police approached me yesterday morning. While they were questioning (maintenance supervisor name) about the allegations of sex with resident (Resident's name) he told them that Lpn (licensed practical nurse #8 name) was having oral sex with (Resident #1 name) for money also. (LPN #8 name) was suspended for investigation and until further notice..." On 03/31/15 at 10:15 a.m., the corporate nurse was asked for the documentation of the investigation of the sexual abuse allegation by resident #1. At 12:40 p.m., the documentation was reviewed. No documentation was located where other residents had been interviewed. No documentation was located where other staff members had been interviewed. No documentation was located where the staff had been re-educated on the facility's abuse policy and protocol. At 1:30 p.m., the administrator was asked if she had any documentation of interviews with other residents. She stated she had not interviewed other residents because the two employees had been terminated and they were no longer a threat to the other residents. She was asked if she had interviewed any staff members. She stated she had talked with the department heads and a couple of the nurses about their knowledge of the incident. She was asked if she had documentation of these conversations. She stated, "No." She was asked how she could be sure no other residents or staff members were involved if she hadn't conducted other interviews. She stated they were all devastated by the incident and had decided since the two employees were gone, the residents were now protected. She was asked if other residents and staff members should have been interviewed. She stated, "Now that I look at it, yes." At 2:30 p.m., the employee files were reviewed. The file of LPN #8 contained eight handwritten reports from four female staff members documenting inappropriate verbal and physical sexual behaviors from LPN #8 directed toward them. The file of LPN #8 also contained a handwritten letter from a resident which documented, "Can you please talk to your night nurse (LPN #8 name) about talking nasty to his night aides. They shouldn't have to tolerate being talked to that way. I will continue to watch and see if he still does it. Thank you. Resident of the home." At 3:02 p.m., the business office manager was asked to locate the most current inservices on the abuse protocol. At 3:16 p.m., the DON stated the last inservices on abuse were on 03/31/14 and 12/15/14. She was asked if they had inserviced the staff on the abuse policy and protocols since the allegation on 03/16/15. She stated, "No." She stated abuse was scheduled for the inservice to be presented on 03/31/15.

On 03/30/15, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy to ensure a thorough investigation of an allegation of sexual abuse was conducted and to ensure the staff were re-educated on the abuse protocol after an allegation of sexual abuse for one (#1) of one sampled resident who alleged sexual abuse. At 3:28 p.m., the existence of the IJ was verified with the Oklahoma Stated Department of Health (OSDH). At 3:40 p.m., the administrator, the director of nursing (DON) and the corporate nurse were notified of the existence of the IJ. At 4:25 p.m., an acceptable written plan of removal was received. The facility's plan for removal, dated 03/31/15 (sic), documented, "Plan of Removal... Administrator is being rein-serviced (sic)on the abuse policy to include the proper investigation of staff and residents. 4:40 PM 3/30/2015 Current Staff today 3/30/2015 4:20PM at this time is being in-serviced on the abuse policy to include the reporting of any unusual actions noticed by them in the past 6 months also to include the full abuse policy to include the seven components. All staff will be in-serviced by 4:00 PM 3/31/2015 on the Abuse policy before returning to work. All staff will be interviewed in regards to any inappropriate action that may have been witnessed on any shift that could be considered inappropriate action or abuse to a resident. Statements will be taken in writing if anyone has witnessed any such actions. Staff will be interviewed in privacy of Administrator, Corporate Nurse or DON (Director of Nursing). This will be completed by 4:00PM on 3/31/2014 (sic) New employees will be in-serviced one on one by one of the following department supervisors DON, ADON or Administrator before being able to report for their job duties. Alert Residents will be interviewed by 4:00 PM 3/31/2015 in regard to ever feeling scared, threatened or abused by a staff member." On 03/31/15 beginning at 2:30 p.m., 12 staff members were interviewed. They all stated they had been inserviced on the abuse policy and were able to verbalize what to do if they suspected any resident abuse. They all stated they had written a statement about any knowledge of abuse in the past or present. Three residents were interviewed. They stated they had filled out a questionnaire regarding abuse on 03/30/15. At 3:10 p.m., the corporate nurse presented documentation that all staff had been inserviced by 3:00 p.m. The written statements by the staff about any knowledge of abuse were also presented. She stated a questionnaire had been completed by the cognitive residents and presented 23 completed questionnaires. The IJ was removed on 03/31/15 at 3:00 p.m. when all staff and residents had been interviewed and all staff had been inserviced on the abuse policy. The deficient practice remained at a pattern level with the potential for more than minimal harm. Based on record review and staff and resident interview, it was determined the facility failed to implement their abuse policy to ensure a thorough investigation of an allegation of sexual abuse was conducted and to ensure the staff were re-educated on the abuse protocol after an allegation of sexual abuse for one (#1) of one sampled resident who alleged sexual abuse. The facility identified 37 residents resided in the facility. Findings: The policy, Abuse Investigation Protocol, documented, "...All reports of resident abuse, neglect, injuries of unknown source, resident-to-resident abuse and resident-to-staff abuse are promptly and thoroughly investigated by facility management... The individual conducting the investigation will, as a minimum... Interview other residents to whom the accused employee provides care or services to determine if they have complaints about the employee... Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee; and... Nursing care Policies and Procedures... To assist one in recognizing incidents of abuse the following definitions of abuse are provided... SEXUAL ABUSE is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault... Abuse Prevention Program... Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion... Our facility has developed policies and procedures to aid us in preventing abuse, neglect or mistreatment of [REDACTED]. The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident-to-resident abuse and resident-to-staff abuse... Timely and thorough investigations of all reports and allegations of abuse..." An OSDH Incident Report Form, dated 03/16/15, documented, "Resident came to my office this afternoon and told me that she had been having sex with a male employee for money. Employee has been suspended for investigation and until further notice..." An OSDH Incident Report Form, dated 03/19/15, documented, "The police approached me yesterday morning. While they were questioning (maintenance supervisor name) about the allegations of sex with resident (Resident's name) he told them that Lpn (licensed practical nurse #8 name) was having oral sex with (Resident #1 name) for money also. (LPN #8 name) was suspended for investigation and until further notice..." On 03/31/15 at 10:15 a.m., the corporate nurse was asked for the documentation of the investigation of the sexual abuse allegation by resident #1. At 12:40 p.m., the documentation was reviewed. No documentation was located where other residents had been interviewed. No documentation was located where other staff members had been interviewed. No documentation was located where the staff had been re-educated on the facility's abuse policy and protocol. At 1:30 p.m., the administrator was asked if she had any documentation of interviews with other residents. She stated she had not interviewed other residents because the two employees had been terminated and they were no longer a threat to the other residents. She was asked if she had interviewed any staff members. She stated she had talked with the department heads and a couple of the nurses about their knowledge of the incident. She was asked if she had documentation of these conversations. She stated, "No." She was asked how she could be sure no other residents or staff members were involved if she hadn't conducted other interviews. She stated they were all devastated by the incident and had decided since the two employees were gone, the residents were now protected. She was asked if other residents and staff members should have been interviewed. She stated, "Now that I look at it, yes." At 2:30 p.m., the employee files were reviewed. The file of LPN #8 contained eight handwritten reports from four female staff members documenting inappropriate verbal and physical sexual behaviors from LPN #8 directed toward them. The file of LPN #8 also contained a handwritten letter from a resident which documented, "Can you please talk to your night nurse (LPN #8 name) about talking nasty to his night aides. They shouldn't have to tolerate being talked to that way. I will continue to watch and see if he still does it. Thank you. Resident of the home." At 3:02 p.m., the business office manager was asked to locate the most current inservices on the abuse protocol. At 3:16 p.m., the DON stated the last inservices on abuse were on 12/15/14 and 03/31/14. She was asked if they had inserviced the staff on the abuse policy and protocols since the allegation on 03/16/15. She stated, "No." She stated abuse was scheduled for the inservice to be presented on 03/31/15.

An Immediate Jeopardy (IJ) situation was identified on 10/17/13 at 1:00 p.m., related to the facility's failure to follow the approved method for cooling and storing a cooked turkey breast to prevent the potential for food borne illness. On 10/17/13 at 1:20 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ. At 1:40 p.m., the administrator, the DON, the CDM, the dietary supervisor and the corporate nurse were notified of the IJ situation. At 4:00 p.m., a Plan of Removal (POR) was presented. The instructions for cooling hot foods was incorrect. The CDM was asked where they had obtained these instructions. She stated she had gotten them off the Internet at 'EHow." The administrator stated they had not been able to locate a policy on cooling foods in the facility manual. This POR was rejected. At 5:10 p.m., a POR was accepted. The POR documented : "...Plan of Removal for IJ... The turkey breast identified during the survey will not be served and has been placed in the trash. The pan the meat was sitting on has been sanitized along with the top of the storage chest. A substitute menu has been provided for the evening meal. The Substitutions have been verified with the regional dietician consultant (name and phone number). She has verified that this meets the correct nutritional requirements. This has been added to the substitute menu. Hot dogs, salad, baked beans and brownies. All dietary staff present has been in-serviced on the acceptable holding temperatures, preparation and handling of foods. Staff will be in-serviced before allowed to return to work. Inservice has been provided by the facility CDM. The staff responsible for the serving of the meat has been in-serviced and suspended for 3 days. 4:30 PM Revision of Plan of Removal Staff is being re-in-serviced on the proper way for cooling foods based on information from the SOM (State Operations Manual) Manual. Staff currently working in this evening in the kitchen have rein-serviced on this information. Remaining dietary staff have been in-serviced this evening between 4:30 PM and 5:00 PM per the telephone. Inservicing will be completed 5:15 PM" An inservice record, dated 10/17/13, documented, "...Cooling - read and asked if there were any questions. Read verbatim from the regulations page to each and every employee... Will leave a copy for each to look over and keep at the back of the kitchen by the schedules..." The regulations page, attached to the in-service, documented, "...Cooling...Cooked potentially hazardous foods that are subject to time and temperature control for safety are best cooled rapidly within 2 hours, from 135 to 70 degrees F, and within 4 more hours to the temperature of approximately 41 degrees F. The total time for cooling from 135 to 41 degrees F should not exceed 6 hours..." At 5:15 p.m., the administrator was informed the IJ had been removed. The deficient practice remained at a widespread level of no actual harm with the potential for more than minimal harm. Based on observation, record review and interview, it was determined the facility failed to ensure: ~ the approved method for cooling and storing a cooked turkey breast was followed to prevent the potential for food borne illness, ~ handwashing was not performed in a three compartment sink, which contained pitchers of tea and Kool-aid in the sink, next to the one used while washing hands, ~ food items were not served with unclean gloved hands ~ glassware, plateware and cookware was stacked dry, ~ kitchen surfaces and appliances were kept free from debris and kept in good repair, ~ expired foods were removed from the refrigerator, ~ expiration dates and 'best used by' dates could be identified by the dietary staff, ~ foods were labeled and dated, ~ food temps were taken prior to a meal service and ~ puree diets were properly prepared. The facility identified all 44 residents received nourishment from the kitchen. Findings: Cooling turkey: The facility's 'Guidelines for Proper Food Storage' documented, "...large quantities of food should be divided into smaller containers and shallow pans to allow thorough cooling..." On 10/17/13 at 11:10 a.m., a pan with a large foil wrapped meat was observed on top of a chest freezer in the storage room beside the kitchen. In the bottom of the pan was a liquid which was beginning to gel. The foil package containing the meat was very warm to the touch. At 1:00 p.m., the pan with the foil wrapped meat remained in the storage room on top of the chest freezer. The liquid in the pan had continued to gel. The foil wrapped meat remained warm to the touch. At 1:05 p.m., cook #1 was asked about the policy on cooling hot foods. He stated the policy was to let the food sit for 30 minutes to an hour. Cook #1 was asked what was cooling in the storage room. He stated it was a turkey breast for the turkey ala king for that night's dinner. He was asked what time he had removed the turkey breast from the oven. He stated he had removed the turkey breast at 6:00 a.m. He was asked if the turkey breast was fully cooked at that time. He stated, "Yes." He was asked what the temp of the turkey breast was at that time. He stated, "Um...185." At 1:10 p.m., the dietary supervisor was asked about the policy for cooling hot foods. She stated, " About one hour to an hour and a half, then put them in the frig." The dietary supervisor was asked about the plans for the turkey breast. She stated the turkey breast was to be cut up for the turkey ala king for that night's dinner. She was asked to obtain the temperature of the turkey breast. The dietary supervisor asked cook #1 to obtain the temperature of the breast. The temperature was 107.2F. The dietary manager was asked when the turkey was going to be cut up for the turkey ala king. She stated, "We'll scratch that and do something else." Handwashing/Gloves: On 10/15/13 at 8:30 a.m., an initial kitchen tour was conducted. Upon entering the kitchen, the dietary staff was asked where the handwashing sink was located. They pointed to the three compartment sink. Two pitchers of tea were observed brewing in the right compartment sink. Upon attempting to use the soap dispenser, there was no soap. Dietary aide #1 was asked about soap to wash their hands. After a moments hesitation, she stated, "Dishwashing soap. Do you need some?" She then went to the refuse sink and brought a bottle of dishwashing soap to the three compartment sink area. She then stepped out the kitchen door and asked someone to bring some hand soap to the kitchen. Upon reentering the kitchen she did not wash her hands. At 10:05 a.m., dietary aide #1 was observed washing her hands in the left compartment sink. A pitcher of Kool-aid, with no lid, was observed sitting in the middle compartment sink next to the compartment being used to wash her hands. At 12 noon, the meal service was observed. Cook #3 donned gloves and stated she was going to start on the hall trays. She was asked if she was going to temp the foods. She stated, "Oh yeah, I forgot." She was unable to locate any alcohol pads and left the kitchen area to obtain some. Upon reentering the kitchen, she did not wash her hands. At 12:25 p.m., cook #3 was serving up the west dining room trays. She was observed to leave the service area numerous times and then would return without washing her hands or changing her gloves. Cook #3 was observed removing slices of bread from the wrapper with her gloved hands and placing them on the plates. At 12:50 p.m., cook #3 was asked about the policy on handling bread. She stated she should have used tongs. East dining room: On 10/15/13, between 12:00 p.m. and 12:35 p.m., the following observations were made during the lunch meal service in the east dining room. ~ At 12:00 p.m., dietary aide #1, with gloved hands, prepared the first tray. The tray was covered with paper towels and taken down the east hall to a resident's room. ~ The dietary aide was observed handling pitchers of fluids, meal cards (plastic cards which documented the resident's diet, etc), preparing trays; then handling a tray with slices of bread in individual paper sleeves and removing the plastic wrap from the tray. ~ The dietary aide was observed handling the plates and bowls as she prepared the trays by placing her gloved thumb onto the plate or inside the bowl. ~ The dietary aide was observed handling soiled meal cards in between preparing the trays. She was observed handling shredded meat on one plate wearing the same soiled gloves she had started serving with, then she wiped her gloved hands off with paper towels and continued to serve the meal. ~ At 12:12 p.m., dietary aide #1 removed her gloves, washed her hands and applied a pair of clean gloves. She then picked up more soiled diet cards and continued to prepare more plates of food. While preparing the plates, she touched the serving area (countertop) of the steam table, cups and pieces of bread in individual paper sleeves. The dietary aide then wiped her gloved hands on a towel tucked in the front of her apron. The towel had been tucked into the front of her apron since the start of the meal service. The dietary aide prepared more plates of food. She again wiped her gloved hands on the towel tucked in her apron and retrieved salt packets for the trays. ~ At 12:20 p.m., the dietary aide, wearing the same soiled gloves, picked up a meat patty and placed it on a plate. She then took the towel out of her apron and wiped food spillage from the tray and other plates which had been set up on the steam table serving area. Wearing the same soiled gloves, she arranged a scoop of ground meat on a plate. She then removed her gloves, washed her hands and applied a clean pair of gloves. ~ At 12:25 p.m., all trays had been prepared and served. Dietary aide #1 removed her gloves and washed her hands. A resident requested another meat patty. The aide applied a pair of gloves and placed a meat patty on the plate. The aide's thumb was in the plate and not on the edge. A second resident requested another meat patty and more noodles. Again, the aide's thumb was was in the plate and the bowl, not on the edges. A third meat patty was served the same way. Dietary aide #1 removed her gloves, washed her hands and dried them again on the unclean towel tucked into the front of her apron. ~ At 12:30 p.m., the dietary aide applied another pair of gloves. She placed another meat patty on a plate and served it. The aide took the soiled towel from her apron and wiped down the metal three shelf cart where the tray of bread had been placed. She replaced the piece of plastic wrap over the tray of bread slices. She then preceded to clean up the serving area by wiping down the counter tops and the sink with the same soiled towel. Wearing the soiled gloves, dietary aide #1 rinsed out the coffee filter basket, placed a new pre-filled coffee filter in the basket and started the coffee machine. She wiped down the counter top in front of the microwave with the soiled towel. She removed her gloves and washed her hands. The aide then took the soiled towel and wiped down the metal cart (all shelves), the steam table serving area and the top of the sneeze guard, all of the cabinets and counter tops and the sink. The dietary aide dropped a meal card on the floor. She wiped it off with the soiled towel and placed it with the other meal cards on top of the steam table sneeze guard. Wares/Appliances: On 10/15/13 at 8:30 a.m., an initial kitchen tour was conducted. The following was observed: Kitchen: ~ cookware, glassware and plateware were stacked wet. At 9:00 a.m., cook #2 was asked what the policy was on stacking dishes while wet. She stated, "They should be stacked dry." ~ brownish gray debris on the industrial can opener blade, ~ brownish red debris was scattered throughout the interior microwave surfaces, ~ the metal wall beside the stove had grease splatters and drips of a brown dried liquid and ~ the attached shelf above the stove had a thick coating of grease and dust build-up which when scratched exposed a silver metal underneath. East dining room: ~ Resident water pitchers were stacked wet on a shelf in the dining room and ~ the ice deflector in the ice machine had a pink and brownish debris when wiped with a paper towel. Dietary aide #1 was shown the paper towel with the debris and stated, "I see it." Dry storage area: ~ A chocolate cake mix was spilt on the shelf. Office storage area: The facility's 'Guidelines for Proper Food Storage' documented, "...All exterior and interior materials should be rust-corrosion resistant. The doors should be well-constructed, with proper gaskets in place. The unit should have adequate insulation..." On 10/17/13 at 12:40 p.m., the freezers in the office storage room were inspected. The chest freezer on the left had a lid which would not shut completely. The lid had a large dent in the middle of the anterior edge which bent the outer edges up at an angle. The styrofoam insulation on the inside of the door was missing an approximately 3 inch by 12 inch area at the middle front of the door. The remaining styrofoam was cracked from edge to edge. The gasket had separated from the door across the entire left side. The center chest freezer had numerous scratched areas in which rust was observed on the interior walls. Foods labeled/expired: The facility's 'Guidelines for Proper Food Storage' documented, "...once food items are opened, they should be stored in moisture proof, air-type wraps. All storage areas should be kept clean..." On 10/15/13 at 8:30 a.m., an initial kitchen tour was conducted. The following was observed: Refrigerator: ~ 2 one gallon containers of pimento cheese spread with an expiration date of 10/02/13, ~ a large unopened bag of lettuce, dated 'use by 10/02/13, was turning brown and had a slimy appearance, ~ 1 one gallon container of tarter sauce with a 'best by' date of 09/10/13, ~ a bottle of cucumber ranch dressing with a 'best by' date of 08/27/12, ~ a pitcher of red thickened liquid which was not labeled or dated, ~ 2 one gallon containers of Ken's Ranch dressing displayed no expiration or 'best by' dates and ~ a large container of strawberries with mold observed on the walls of the container and on the strawberries. This container had no expiration or 'best by date' located on the container. Dry storage area: ~ numerous cans were undated, ~ numerous opened pasta bags were undated, ~ five opened cereal bags were not dated and were not placed in an airtight bag/container and ~ an opened chocolate cake mix package, dated 10/02/13, had spilled out onto the shelf. At 9:00 a.m., cook #2 was asked about the policy on dating and labeling foods. She stated they should be dated when they were delivered and should be labeled when placed in the refrigerator. She was handed a Ken's salad dressing container and asked if she could locate the expiration or the 'best by' date. After examining the container she stated she didn't see one. At 9:15 a.m., dietary aide #1 was asked if she knew how to tell if food items had expired. She stated to look at the expiration date. Dietary aide #1 was shown the expired food items. She stated, "They shouldn't be in the frig." She was shown the pitcher of thickened liquid and was asked what it was and when it had been placed in the refrigerator. She stated it was probably a juice from 10/14/13, but she would pour it out. She was handed a Ken's salad dressing container and asked if she could locate the expiration or the 'best by' date. After examining the container she stated she didn't know what the expiration date was. Food temps: The duty schedule for the A.M. cook documented, "...8:30 A.M. Prepare all meat for lunch, put on to cook. Prepare all frozen vegetables, put on to cook. Prepare all foods for all diets for lunch... 9:45 A.M. Prepare pureed foods 10:45 A.M. Set up steam table... 12:00 noon Take food temperatures Dip up food for dining room trays..." On 10/17/13 at 12 noon, the meal service was observed. Cook #3 donned gloves and stated she was going to start on the hall trays. She was asked if she was going to temp. the foods. She stated, "Oh yeah, I forgot." She was unable to locate any alcohol pads and left the kitchen area to obtain some. Upon reentering the kitchen, she proceeded to temp. the foods on the steamtable. The temps were as follows: ~ steak fritters - 151F ~ mixed vegetables - 169F ~ buttered noodles - 136F She then asked, "Is that all?" She was asked if she usually temped the ground meat or the pureed foods. She stated, "Sometimes." She then continued obtaining temps. They were as follows: ~ ground beef fritter - 162F ~ pureed noodles - 156F ~ pureed vegetables - did not temp ~ pureed beef fritters - 97.6F. She placed the pureed meat in the oven to reheat. She was asked about the policy for taking food temperatures. She stated everybody does it different. She stated she usually takes her temps when the foods come out of the oven. She was asked if they had a temperature log book. She stated, "Yes." and pointed at a notebook on a shelf above the three compartment sink. She did not write down the temps she had just taken. At 12:45 p.m., she removed the pureed meat from the oven. The temp was 175F. On 10/18/13 at 1:15 p.m., the temperature log book was reviewed. The temps recorded for the noon meal on 10/15/13 were documented: "...Meat/Main dish - 165 starch/potato - 135 vegetable - 154 puree meat - 154 Puree vegetable - 154 beverage - 35 coffee - 120..." Pureed foods: The menu for the pureed diet for the noon meal was: 4 ounces of pureed Salisbury Steak 4 ounces of noodles Romanoff 4 ounces steamed vegetables 3" x 2.5" serving of Red Velvet cake 1 cup beverage On 10/15/13 at 10:05 a.m., cook #2 was observed preparing the pureed vegetables. She stated there were four residents who received a pureed diet. She was observed to place five ladles of mixed vegetables in the blender and three scoops of the vegetable broth. She was asked what sized ladle she was using. She stated she didn't know, but this was the size she had been told to use when preparing the puree. After examining the ladle, she stated, "2 ounce." She stated she used five of the ladles because one of the residents received double portions. The puree was of a soupy consistency. She stated they were having beef fritters in place of the Salisbury steak because they did not have enough Salisbury Steak. She stated she would puree them when they were finished cooking. At 11:40 a.m., cook #2 was observed preparing the pureed noodles and the pureed meat. She placed six two ounce scoops of noodles in the blender and then poured in an unmeasured amount of cold milk. The puree was of a thick soup consistency. She placed four beef fritters and four slices of bread in the blender. She then poured in an unmeasured amount of cold milk. The puree was of a thick soup consistency. She was asked if the pureed foods always had the consistency of soup. She stated, "That's how they showed me."

Based on record review and interview, it was determined the facility failed to notify the physician of a resident's pain status and condition following an emergency room visit for an acute exacerbation of pain for one (#7) of 10 sampled residents whose records were reviewed for physician notification. The Census and Conditions report, dated 10/15/13, documented 44 residents resided in the facility. Findings: Resident #7 had [DIAGNOSES REDACTED]. The quarterly resident assessment, dated 06/04/13, documented the resident was cognitively intact. She was independent with her ADLs and used a cane/crutch for ambulation. She had functional limitations with both her upper and lower extremities. She had experienced pain within the five days prior to the assessment which rated at it's worst a 10 on a 1-10 scale. It documented the pain was almost constant and interfered with her sleep and day-to-day activities. She had received routine and PRN pain medications. The comprehensive pain assessment, dated 06/09/13, documented the resident experienced "chronic pain all over 24/7." It was documented her pain medication was effective. The documented conclusion was "No new pain, intervention is not necessary. Re-assess quarterly or with onset of pain." The care plan dated 03/08/13, documented, "03/08/13...Problem...Resident @ risk for pain neck, back 06/04/13 Resident says pain is controlled to her comfort - But pain is always there. it is bearable with medications... Goal: Pain will be controlled to her comfort X next review Approach: 1. [MEDICATION NAME] 15 mg Bid [MEDICATION NAME] 10/325mg tid 2. Notify Physician if treatment not working... Problem...03/08/13 Resident is able to do most everything for self when not hurting 06/04/13 Resident moving slowly this am has swelling to rt. foot leg slight rt hand - ..." The care plan contained no non-pharmacological pain relief interventions. The August 2013 MARs documented the resident had received [MEDICATION NAME] mg every morning and 30 mg every night for pain and [MEDICATION NAME] 1 mg twice a day for anxiety prior to the exacerbation of pain on 08/10/13. She had no PRN pain medications ordered. The MAR indicated [REDACTED]. It documented she had received a dose on 08/10/13 at 6:15 p.m., on 08/11/13 at 9:00 p.m. and on 08/12/13 at 5:37 a.m. The nurse's notes, dated 08/04/13 through 08/10/13, documented the resident had not complained of back pain or discomfort during this period prior to the exacerbation of her pain. A nurse's note, dated 08/10/13, documented, "(3:30 p.m.) Pt c/o pain in lower back. Pt request Dr. be called for pain med adjustment. (Physician) called. New order received & noted. Pt given MS 15 mg P.O. 1 time dose for pain relief... (5:30 p.m.) Pt voided in toilet. I was called to Bath room. There appeared to be blood content in toilet water. Pt c/o lower back pain increasing. 8/10 at this time... (5:40 p.m.) (Physician) called. U.A. stat to be collected & taken to E.R. then results called to him... (5:55 p.m.) Pt daughter (name) called @ home. Notified of pt c/o and condition. (Daughter) concerned that more pain meds will be needed. (Daughter) asked to me to call (Physician) back and request muscle relaxer... (6:10 p.m.) (Physician) called with daughters request on reassessment of pt. Lower back pain persist. 10/10 @ this time. Pt unable to give urine specimen yet. Dr. canceled U.A. and recommended transfer to Local ER for full eval & Treat... (6:20 p.m.) Pt informed of Dr.s recommendation. Pt agreed to ER transfer. Pts daughter (name deleted) called. Notified of ER transfer. Daughter agreed that may be best at this time... (6:40 p.m.) (Emergency service) called for transfer... (7:00 p.m.) EMS here...Pt in stable condition at this time..." A nurse's note, dated 08/11/13, documented, " (12:20 a.m.) Res. returned from ER via POV (private owned vehicle) c daughter (Daughter's name). Report from (RN's name) @ (local hospital), res received [MEDICATION NAME] 25 mg IV, [MEDICATION NAME] 30 mg IV and [MEDICATION NAME] 10 mg po R/T [DIAGNOSES REDACTED]. (10:00 a.m.)[MEDICATION NAME] 5 mg not in facility d/t pharmacy being closed. [MEDICATION NAME] 1 mg administered according to previous order...Requesting staff go get the [MEDICATION NAME] ordered. Informed res pharmacy closed today, Rx will be filled tomorrow... (4:30 p.m.) Pt in bed...c/o Random shotting (sic) pain in L lower back c certain movements. No pain at this time or whenever lying still..." A nurse's note, dated 08/12/13, documented, " (1:00 p.m.) Awake, alert. Requesting '[MEDICATION NAME]'. Informed res. that MAR indicated I didn't ask for one @ 9", informed resident that I must follow documented times and administer within ordered intervals (5:37 a.m.) Res. (up) to BR. c/o back pain. Requesting "[MEDICATION NAME]" for pain. Attempted to inform resident that antiemetic not indicated for pain symptoms, but resident stated that she doesn't take medication "to get high". She denies nausea and vomiting @ present. Administered medication per resident request (9:00 a.m.) Refused [MEDICATION NAME] and [MEDICATION NAME] this am d/t "back hurts too bad to get up and go to bathroom" Requesting [MEDICATION NAME]. Explained Rx ordered and will be in facility this am..." A nurse's note, dated 08/13/13, documented, " (10:00 a.m.) Resident c/o back pain. Requesting replacement for [MEDICATION NAME]. States "it's not working. cont (continues) to ref (refuse) diuretics. PCP (primary care physician) notified. (No) N/O at this time..." A fax to the physician with the resident's name on it, dated 08/13/13 at 11:00 a.m., documented, "FYI (for your information): Res refusing diuretics ([MEDICATION NAME];[MEDICATION NAME]) X 3 days states "in too much pain to keep going to the bathroom." There was no documentation the physician had been requested to review the resident's care and recommend alternative pain relief interventions. A nurse's note, dated 08/14/13, documented, "(11:00 a.m.) Resident to Nurses station, states "I will be leaving around two to go to a Dr. in Lawton" Resident states "I have to get this pain under control" c/o back and neck pain. Offered ice packs this am. Resident refused. Resident states "I need more pain meds." Asked if she could get an extra dose of [MEDICATION NAME]. Explained to resident that this a routine med and can only be given at scheduled times. Resident upset but states she understands." A nurse's note, dated 08/15/13, documented, " (8:30 a.m.) Resident left for Dr. appt (appointment)... (4:00 p.m.) Returned to facility c n/o..." A physician's orders [REDACTED]. This would only allow the resident to take the Tylenol twice in one day. The August 2013 MAR indicated [REDACTED]. A nurse's note, dated 08/17/13 at 8:00 a.m., documented, "...Requesting [MEDICATION NAME] c morning meds from CMA. Explained by CMA that res has (no )order for [MEDICATION NAME]. Res does have order for Tylenol ES. CMA explained that routine pain meds would be given @ this time and if she felt she still...needed Tylenol later she would give it..." A nurse's note, dated 08/18/13 at 4:50 a.m., documented, "[MEDICATION NAME] (Tylenol ES) 500 mg ii tab administered at this time for c/o back pain..." A nurse's note, dated 08/21/13 at 3:00 p.m., documented, "...(Physician) here to see Res. N/O MSER ([MEDICATION NAME] sulfate extended release - MS Contin) 15 mg q 12 hr, [MEDICATION NAME] 10/325 tid. DC 30 mg MS to start on 08/22/13..." There was no other documentation in the nurses' notes of the resident complaining of back pain or discomfort since 08/21/13. The resident was observed numerous times throughout the survey. Her head was tilted to the right and slightly forward. Her neck was stiff, as if contractured, and she was only able to turn her head a few degrees without having to turn her whole upper body. Her posture was slightly stooped. Her gait was slow and guarded. She often used a cane for ambulation or utilized the hand rails when ambulating in the hall. At 3:15 p.m., resident #7 was interviewed. Upon entering the resident's room, she was observed in bed positioned on her left side watching TV. She slowly and guardedly sat up on the side of the bed, stood up, and walked to the TV to turn the volume down. She stated she was resting because her back was hurting. She was asked about her back pain. She stated she had been in a severe car accident and her neck had been fractured. She had undergone a fusion of the C3-5 vertebrae and now the other vertebrae were deteriorating which caused her severe pain in her neck and in her back. She stated several other bones were broken in the accident and they also caused her pain. She was asked to describe her pain. She stated it was hard to describe because the pain was often different on the opposite sides of her body. She stated the pain was often sharp and stabbing and sometimes it felt like bees were stinging her on one side of her body, while the other side would have sharp shooting pains. She stated the pain limited her activities. She stated she often did not want to eat or attend activities because she, "hurts so bad." She stated the pain often made her nauseated had to take a medication for the nausea when the pain was severe. She was asked if she remembered going to the emergency room in August with severe back pain. She stated, "Yes, they gave me some [MEDICATION NAME]." She stated she was having muscle spasms and the [MEDICATION NAME] had helped the pain a little, once she got it. At 3:00 p.m., the DON was shown the fax, dated 08/13/13 and the nurse's note dated 08/15/13. She was asked if she could locate any other documentation where the physician had been notified of the resident's pain or condition between returning from the emergency roiagnom on [DATE] and 08/21/13. After reviewing the clinical record, she stated, "No."

Based on record review and interview, it was determined the facility failed to assess, monitor and intervene during an acute exacerbation of pain for one (#7) of 10 sampled residents whose records were reviewed for pain management. The Census and Conditions report, dated 10/15/13, documented six residents were on a pain management program and 44 residents resided in the facility. Findings: Resident #7 had [DIAGNOSES REDACTED]. The quarterly resident assessment, dated 06/04/13, documented the resident was cognitively intact. She was independent with her ADLs and used a cane/crutch for ambulation. She had functional limitations with both her upper and lower extremities. She had experienced pain within the five days prior to the assessment which rated at it's worst a 10 on a 1-10 scale. The assessment documented the pain was almost constant and interfered with her sleep and day-to-day activities. She had received routine and PRN pain medications. The quarterly resident assessment, dated 09/04/13, documented the resident was cognitively intact. She was independent with her ADLs and used a cane/crutch for ambulation. She had functional limitations with both her upper and lower extremities. She had experienced pain within the five days prior to the assessment which rated at it's worst was a 10 on a 1-10 scale. The assessment documented the pain was almost constant and interfered with her sleep and day-to-day activities. She had received routine and PRN pain medications. The comprehensive pain assessment, dated 06/09/13, documented the resident experienced "chronic pain all over 24/7." It was documented her pain medication was effective. The documented conclusion was, "No new pain, intervention is not necessary. Re-assess quarterly or with onset of pain." The care plan, dated 03/08/13, documented, "03/08/13...Problem...Resident @ risk for pain neck, back 06/04/13 Resident says pain is controlled to her comfort - But pain is always there. it is bearable with medications.. 09/04/13 No changes - Pain still there #10 - stays in her room in Bed waiting on results from Doc in OKCity about her liver - wants on Somma (sic)... Goal: Pain will be controlled to her comfort X next review Approach: 1. [MEDICATION NAME] 15 mg Bid [MEDICATION NAME] 10/325mg tid 2. Notify Physician if treatment not working... Problem...03/08/13 Resident is able to do most everything for self when not hurting 06/04/13 Resident moving slowly this am has swelling to rt. foot leg slight rt hand - ... 09/03/13 She's moving slowly last few weeks But continues to do most everything for herself. uses cane gait slow unsteady..." The care plan contained no non-pharmacological pain relief interventions. The August 2013 MARs documented the resident had received [MEDICATION NAME] mg every morning and 30 mg every night for pain and [MEDICATION NAME] 1 mg twice a day for anxiety prior to the exacerbation of pain on 08/10/13. She had no PRN pain medications ordered. The MAR indicated [REDACTED]. It documented she had received a dose on 08/10/13 at 6:15 p.m., on 08/11/13 at 9:00 p.m. and on 08/12/13 at 5:37 a.m. The nurses' notes, dated 08/04/13 through 08/10/13, documented the resident had not complained of back pain or discomfort during the period prior to the exacerbation of her pain. A nurse's note, dated 08/10/13, documented, "(3:30 p.m.) Pt c/o pain in lower back. Pt request Dr. be called for pain med adjustment. (Physician) called. New order received & noted. Pt given MS 15 mg P.O. 1 time dose for pain relief... (5:30 p.m.) Pt voided in toilet. I was called to Bath room. There appeared to be blood content in toilet water. Pt c/o lower back pain increasing. 8/10 at this time... (5:40 p.m.) (Physician) called. U.A. stat to be collected & taken to E.R. then results called to him... (5:55 p.m.) Pt daughter (name) called @ home. Notified of pt c/o and condition. (Daughter) concerned that more pain meds will be needed. (Daughter) asked to me to call (Physician) back and request muscle relaxer... (6:10 p.m.) (Physician) called with daughters request on reassessment of pt. Lower back pain persist. 10/10 @ this time. Pt unable to give urine specimen yet. Dr. canceled U.A. and recommended transfer to Local ER for full eval & Treat... (6:20 p.m.) Pt informed of Dr.s recommendation. Pt agreed to ER transfer. Pts daughter (Name) called. Notified of ER transfer. Daughter agreed that may be best at this time... (6:40 p.m.) (Emergency service) called for transfer... (7:00 p.m.) EMS here...Pt in stable condition at this time..." A nurse's note, dated 08/11/13, documented, " (12:20 a.m.) Res. returned from ER via POV (private owned vehicle) c daughter (Name). Report from (RN's name) @ (Hospital), res received [MEDICATION NAME] 25 mg IV (intravenous), [MEDICATION NAME] 30 mg IV and [MEDICATION NAME] 10 mg po R/T (related to) [DIAGNOSES REDACTED]. (10:00 a.m.)[MEDICATION NAME] 5 mg not in facility d/t pharmacy being closed. [MEDICATION NAME] 1 mg administered according to previous order...Requesting staff go get the [MEDICATION NAME] ordered. Informed res pharmacy closed today, Rx will be filled tomorrow... (4:30 p.m.) Pt in bed...c/o Random shotting (sic) pain in L lower back c certain movements. No pain at this time or whenever lying still..." A nurse's note, dated 08/12/13, documented, " (1:00 p.m.) Awake, alert. Requesting '[MEDICATION NAME]'. Informed res. that MAR indicated I didn't ask for one @ 9", informed resident that I must follow documented times and administer within ordered intervals (5:37 a.m.) Res. (up) to BR. c/o back pain. Requesting "[MEDICATION NAME]" for pain. Attempted to inform resident that antiemetic not indicated for pain symptoms, but resident stated that she doesn't take medication "to get high". She denies nausea and vomiting @ present. Administered medication per resident request (9:00 a.m.) Refused [MEDICATION NAME] and [MEDICATION NAME] this am d/t "back hurts too bad to get up and go to bathroom" Requesting [MEDICATION NAME]. Explained Rx ordered and will be in facility this am..." A nurse's note, dated 08/13/13, documented, " (10:00 a.m.) Resident c/o back pain. Requesting replacement for [MEDICATION NAME]. States "it's not working. cont (continues) to ref (refuse) diuretics. PCP (primary care physician) notified. (No) N/O (new orders) at this time..." A fax to the physician with the resident's name on it, dated 08/13/13 at 11:00 a.m., documented, "FYI (for your information): Res refusing diuretics ([MEDICATION NAME]; [MEDICATION NAME]) X 3 days states "in too much pain to keep going to the bathroom." There was no documentation the physician had been notified of the failure of the facility to achieve pain relief for the resident and/or the need for additional interventions. A nurse's note, dated 08/14/13, documented, "(11:00 a.m.) Resident to Nurses station, states "I will be leaving around two to go to a Dr. in Lawton" Resident states "I have to get this pain under control" c/o back and neck pain. Offered ice packs this am. Resident refused. Resident states "I need more pain meds." Asked if she could get an extra dose of [MEDICATION NAME]. Explained to resident that this a routine med and can only be given at scheduled times. Resident upset but states she understands." A nurse's note, dated 08/15/13, documented, " (8:30 a.m.) Resident left for Dr. appt (appointment)... (4:00 p.m.) Returned to facility c n/o..." A physician's orders [REDACTED]. This would only allow the resident to take the Tylenol twice in one day. The August 2013 MAR indicated [REDACTED]. A nurse's note, dated 08/17/13 at 8:00 a.m., documented, "...Requesting [MEDICATION NAME] c morning meds from CMA. Explained by CMA that res has (no )order for [MEDICATION NAME]. Res does have order for Tylenol ES. CMA explained that routine pain meds would be given @ this time and if she felt she still...needed Tylenol later she would give it..." A nurse's note, dated 08/18/13 at 4:50 a.m., documented, "[MEDICATION NAME] (Tylenol ES) 500 mg ii tab administered at this time for c/o back pain..." A nurse's note, dated 08/21/13 at 3:00 p.m., documented, "...(Physician) here to see Res. N/O MSER ([MEDICATION NAME] sulfate extended release - MS Contin) 15 mg q 12 hr, [MEDICATION NAME] 10/325 tid. DC 30 mg MS to start on 08/22/13..." There was no further documentation in the nurse's notes of the resident complaining of back pain and/or discomfort since the physician's visit on 08/21/13. The resident was observed numerous times throughout the survey. Her head was tilted to the right and slightly forward. Her neck was stiff, as if contractured, and she was only able to turn her head a few degrees without having to turn her whole upper body. Her posture was slightly stooped. Her gait was slow and guarded. She often used a cane for ambulation or utilized the hand rails when ambulating in the hall. On 10/17/13 at 1:45 p.m., the administrator and the DON were asked if the facility had a pharmacy that would deliver emergency medications on a weekend or after hours. The DON stated, "Yes. (Pharmacist) at (Pharmacy) can be called for emergency medications." They were asked what they considered to be an emergency medication. The administrator stated that if a physician gave an order for [REDACTED]. At 2:40 p.m., the DON was asked how the emergency pharmacy worked. She stated they would usually deliver at least a one day supply of the medication when they were newly ordered. She was asked if the emergency pharmacy would fill emergency medications for residents who were not the pharmacies customers. She stated, "Yes." She was asked if the nurses were oriented on the availability of an emergency pharmacy which was available after hours and on weekends. She stated, "Yes." At 2:50 p.m., LPN #3 was asked what would she do if she received medication orders from a physician on the weekend. She stated she would send a fax to the pharmacy so they would know when they got in that there was an order for [REDACTED]. She was asked if the pharmacy would see the fax on a weekend. She stated, "Probably not." She was asked if this meant the resident would not receive the medication until Monday. She stated sometimes there was a pharmacist who, "out of the goodness of his heart" would sometimes get the medications on the weekends. She stated they had his phone number and she then obtained it from a notebook at the west nurse's station. After reviewing the notebook, she closed it without presenting the pharmacist number. She was asked who the pharmacist was. She gave the same name of the pharmacist the DON had stated at 1:45 p.m. At 3:05 p.m., LPN #4 was asked what she would do if she was working the weekend and received an order for [REDACTED]. She stated she thought the facility should be able to obtain medications on weekends, but didn't know where or how. At 3:15 p.m., the resident was interviewed. Upon entering the resident's room, she was observed in bed positioned on her left side watching TV. She slowly and guardedly sat up on the side of the bed, stood up, and walked to the TV to turn the volume down. She stated she was just resting because her back was hurting. She was asked about her back pain. She stated she was in a severe car accident and her neck had been fractured. She had undergone a fusion of the C3-5 vertebrae and now the other vertebrae were deteriorating which caused her severe pain in her neck and in her back. She stated several other bones were broken in the accident and they also caused her pain. She was asked to describe her pain. She stated it was hard to describe because the pain was often different on the opposite sides of her body. The pain was often sharp and stabbing; sometimes, it felt like bees were stinging her on one side of her body, while the other side would have sharp shooting pains. The resident stated the pain limited her activities. She stated she often did not want to eat or attend activities because she, "hurts so bad." She stated the pain often made her nauseated. She stated she had to take a medication for the nausea when the pain was severe. The resident was asked if she remembered going to the emergency room in August with severe back pain. She stated, "Yes, they gave me some [MEDICATION NAME]." She stated she was having muscle spasms and the [MEDICATION NAME] had helped the pain a little, once she got it. She was asked if the facility had given her an explanation why the [MEDICATION NAME] was not obtained until Monday. She stated the pharmacy's were not open on the weekend and the facility couldn't get the [MEDICATION NAME] until they opened on Monday. The resident was asked if she thought the pain could have been better controlled if she had received the [MEDICATION NAME] when it was ordered. She stated, "I'm not sure, but maybe it would have stopped the spasms sooner." She was asked if her pain was now controlled. She stated she always has pain, but it was now bearable. On 10/18/13 at 2:50 p.m., the DON was asked for the resident's monthly pain screens since December of 2012. At 3:00 p.m., the DON presented the monthly pain screens for January, February, March and April of 2013. She was asked if she had located any pain screens after April. She stated, "No." She was asked if a comprehensive pain assessment had been conducted after the resident returned from the emergency room . She stated, "Probably not." The DON was asked if she could locate any documentation where the pharmacy had been called on 08/11/13, to obtain the [MEDICATION NAME]. After reviewing the clinical record, she stated, "No." She was shown the fax, dated 08/13/13, and the nurse's note dated 08/15/13. She was asked if she could locate any other documentation where the physician had been notified of the residents pain and/or condition between returning from the emergency roiagnom on [DATE], and 08/21/13. After reviewing the clinical record, she stated, "No." The DON was asked to look at the care plan for pain. She was asked if she could locate any non-pharmacological pain management interventions. She stated, "No." She was asked if the pain care plan had been fully developed. She stated, "No."

Based on record review and interview, it was determined the facility failed to obtain an ER physician ordered pain medication within 34 hours for one (#7) of 11 sampled residents whose records were reviewed for pain management. The Census and Conditions report, dated 10/15/13, documented six residents were on a pain management program and 44 residents resided in the facility. Findings: Resident #7 had [DIAGNOSES REDACTED]. The care plan dated 03/08/13, documented, "03/08/13...Problem...Resident @ risk for pain neck, back 06/04/13 Resident says pain is controlled to her comfort - But pain is always there. it is bearable with medications... Goal: Pain will be controlled to her comfort X next review Approach: 1. MS Contin ER 15 mg Bid Percocet 10/325mg tid 2. Notify Physician if treatment not working..." The quarterly resident assessment, dated 06/04/13, documented the resident was cognitively intact. She was independent with her ADLs and used a cane/crutch for ambulation. She had functional limitations with both her upper and lower extremities. She had experienced pain within the five days prior to the assessment which rated at it's worst a 10 on a 1-10 scale. It documented the pain was almost constant and interfered with her sleep and day-to-day activities. She had received routine and PRN pain medications. The comprehensive pain assessment, dated 06/09/13, documented the resident experienced "chronic pain all over 24/7." It was documented her pain medication was effective. The documented conclusion was "No new pain, intervention is not necessary. Re-assess quarterly or with onset of pain." The August 2013 MARs documented the resident had received MS Contin 15 mg every morning and 30 mg every night for pain and Xanax 1 mg twice a day for anxiety prior to the exacerbation of pain on 08/10/13. She had no PRN pain medications ordered. The MAR indicated [REDACTED]. It documented she had received a dose on 08/10/13 at 6:15 p.m., on 08/11/13 at 9:00 p.m. and on 08/12/13 at 5:37 a.m. The nurses' notes, dated 08/04/13 through 08/10/13, documented the resident had not complained of back pain or discomfort during this period prior to the exacerbation of her pain. A nurse's note, dated 08/10/13, documented, "(3:30 p.m.) Pt c/o pain in lower back. Pt request Dr. be called for pain med adjustment. (Physician) called. New order received & noted. Pt given MS 15 mg P.O. 1 time dose for pain relief... (5:30 p.m.) Pt voided in toilet. I was called to Bath room. There appeared to be blood content in toilet water. Pt c/o lower back pain increasing. 8/10 at this time... (5:40 p.m.) (Physician) called. U.A. stat to be collected & taken to E.R. then results called to him... (5:55 p.m.) Pt daughter (name) called @ home. Notified of pt c/o and condition. (Daughter) concerned that more pain meds will be needed. (Daughter) asked to me to call (Physician) back and request muscle relaxer... (6:10 p.m.) (Physician) called with daughters request on reassessment of pt. Lower back pain persist. 10/10 @ this time. Pt unable to give urine specimen yet. Dr. canceled U.A. and recommended transfer to Local ER for full eval & Treat... (6:20 p.m.) Pt informed of Dr.s recommendation. Pt agreed to ER transfer. Pts daughter (name) called. Notified of ER transfer. Daughter agreed that may be best at this time... (6:40 p.m.) (Emergency service) called for transfer... (7:00 p.m.) EMS here...Pt in stable condition at this time..." A nurse's note, dated 08/11/13, documented, " (12:20 a.m.) Res. returned from ER via POV (private owned vehicle) c daughter (name). Report from (RN's name) @ (local hospital initials), res received Demerol 25 mg IV (intravenous), Toradol 30 mg IV and Valium 10 mg po R/T (related to) [DIAGNOSES REDACTED]. (10:00 a.m.)...Valium 5 mg not in facility d/t pharmacy being closed. Xanax 1 mg administered according to previous order...Requesting staff go get the Valium ordered. Informed res pharmacy closed today, Rx will be filled tomorrow... (4:30 p.m.) Pt in bed...c/o Random shotting (sic) pain in L lower back c certain movements. No pain at this time or whenever lying still..." A nurse's note, dated 08/12/13, documented, " (1:00 p.m.) Awake, alert. Requesting 'phenergan'. Informed res. that MAR indicated I didn't ask for one @ 9", informed resident that I must follow documented times and administer within ordered intervals (5:37 a.m.) Res. (up) to BR. c/o back pain. Requesting "phenergan" for pain. Attempted to inform resident that antiemetic not indicated for pain symptoms, but resident stated that she doesn't take medication "to get high". She denies nausea and vomiting @ present. Administered medication per resident request (9:00 a.m.) Refused Lasix and Aldactone this am d/t "back hurts too bad to get up and go to bathroom" Requesting Valium. Explained Rx ordered and will be in facility this am..." A nurse's note, dated 08/13/13, documented, " (10:00 a.m.) Resident c/o back pain. Requesting replacement for Valium. States "it's not working. cont (continues) to ref (refuse) diuretics. PCP (primary care physician) notified. (No) N/O (new orders) at this time..." A fax to the physician with the resident's name on it, dated 08/13/13 at 11:00 a.m., documented, "FYI (for your information): Res refusing diuretics (Lasix; Aldactone) X 3 days states "in too much pain to keep going to the bathroom." There was no documentation the physician had reviewed the resident's care and recommend alternative pain relief interventions. A nurse's note, dated 08/14/13, documented, "(11:00 a.m.) Resident to Nurses station, states "I will be leaving around two to go to a Dr. in Lawton" Resident states "I have to get this pain under control" c/o back and neck pain. Offered ice packs this am. Resident refused. Resident states "I need more pain meds." Asked if she could get an extra dose of Morphine. Explained to resident that this a routine med and can only be given at scheduled times. Resident upset but states she understands." A nurse's note, dated 08/15/13, documented, " (8:30 a.m.) Resident left for Dr. appt (appointment)... (4:00 p.m.) Returned to facility c n/o..." A physician's orders [REDACTED]. This would only allow the resident to take the Tylenol twice in one day. The August 2013 MAR indicated [REDACTED]. A nurse's note, dated 08/17/13 at 8:00 a.m., documented, "...Requesting Percocet c morning meds from CMA. Explained by CMA that res has (no )order for Percocet. Res does have order for Tylenol ES. CMA explained that routine pain meds would be given @ this time and if she felt she still...needed Tylenol later she would give it..." A nurse's note, dated 08/18/13 at 4:50 a.m., documented, "...Acetaminophen (Tylenol ES) 500 mg ii tab administered at this time for c/o back pain..." A nurse's note, dated 08/21/13 at 3:00 p.m., documented, "...(Physician) here to see Res. N/O MSER (morphine sulfate extended release - MS Contin) 15 mg q 12 hr, percocet 10/325 tid. DC 30 mg MS to start on 08/22/13..." There has been no further documentation in the nurse's notes of the resident complaining of back pain or discomfort since 08/21/13. The resident was observed numerous times throughout the survey. Her head was tilted to the right and slightly forward. Her neck was stiff, as if contractured, and she was only able to turn her head a few degrees without having to turn her whole upper body. Her posture was slightly stooped. Her gait was slow and guarded. She often used a cane for ambulation or utilized the hand rails when ambulating in the hall. On 10/17/13 at 1:45 p.m., the administrator and the DON were asked if the facility had a pharmacy that would deliver emergency medications on a weekend or after hours. The DON stated, "Yes. (Pharmacist) at (Pharmacy) can be called for emergency medications." They were asked what they considered to be an emergency medication. The administrator stated that if a physician gave an order for [REDACTED]. At 2:40 p.m., the DON was asked how the emergency pharmacy worked. She stated they would usually deliver at least a one day supply of the medication when they were newly ordered. She was asked if the emergency pharmacy would fill emergency medications for residents who were not the pharmacy's customers. She stated, "Yes." She was asked if the nurses were oriented on the availability of an emergency pharmacy which was available after hours and on weekends. She stated, "Yes." At 2:50 p.m., LPN #3 was asked what would she do if she received medication orders from a physician on the weekend. She stated she would send a fax to the pharmacy so they would know when they got in that there was an order for [REDACTED]. She was asked if the pharmacy would see the fax on a weekend. She stated, "Probably not." She was asked if this meant the resident would not receive the medication until Monday. She stated sometimes there was a pharmacist who, "out of the goodness of his heart" would sometimes get the medications on the weekends. She stated they had his phone number in a notebook on the west nurse's station. After reviewing the notebook, she closed it without presenting the pharmacist number. She was asked who the pharmacist was. She gave the same name of the pharmacist the DON had stated at 1:45 p.m. At 3:05 p.m., LPN #4 was asked what she would do if she was working the weekend and received an order for [REDACTED]. but didn't know where or how. At 3:15 p.m., the resident was interviewed. Upon entering the resident's room, she was observed in bed positioned on her left side watching TV. She slowly and guardedly sat up on the side of the bed, stood up, and walked to the TV to turn the volume down. She stated she was resting because her back was hurting. She was asked about her back pain. She stated she was in a severe car accident and her neck had been fractured. She had undergone a fusion of the C3-5 vertebrae and now the other vertebrae were deteriorating which caused her severe pain in her neck and in her back. She stated several other bones were broken in the accident and they also caused her pain. She was asked to describe her pain. She stated it was hard to describe because the pain was often different on the opposite sides of he body. The pain was often sharp and stabbing; sometimes it felt like bees were stinging her on one side of her body, while the other side would have sharp shooting pains. She stated the pain limited her activities. She stated she often did not want to eat or attend activities because she, "hurts so bad." She stated the pain often made her nauseated. She stated she had to take a medication for the nausea when the pain was severe. She was asked if she remembered going to the emergency room in August with severe back pain. She stated, "Yes, they gave me some Valium." She stated she was having muscle spasms and the Valium had helped the pain a little, once she got it. She was asked if the facility had given her an explanation why the Valium was not obtained until Monday. She stated the pharmacys were not open on the weekend and the facility couldn't get the Valium until they opened on Monday. She was asked if she thought the pain could have been better controlled if she had received the Valium when it was ordered. She stated, "I'm not sure, but maybe it would have stopped the spasms sooner." She was asked if her pain was now controlled. She stated she always had pain, but it was now bearable. On 10/18/13 at 2:50 p.m., the DON was asked for the resident monthly pain screens since December of 2012. At 3:00 p.m., the DON was asked if she could locate any documentation where the pharmacy had been called on 08/11/13, to obtain the Valium. After reviewing the clinical record, she stated, "No."

Based on observation, record review and interview, it was determined the facility administration failed to identify system failures: ~ in dietary which resulted in an IJ situation with the improper cooling of meats and had the potential to harm all 44 residents who resided in the facility, ~ in providing care which would allow a resident to attain or maintain their highest practicable well-being following an acute exacerbation of pain for one (#7) of 10 sampled residents whose records were reviewed for pain management and resulted in actual harm, ~ in notification of the physician of a resident's pain status and condition following an acute exacerbation of pain which required an emergency room visit for one (#7) of 10 residents whose records were reviewed for physician notification and resulted in actual harm and ~ in pharmacy services for not providing a physician's orders [REDACTED]. The Census and Conditions report, dated 10/15/13, documented 44 residents resided in the facility. Findings: It was determined the facility failed to ensure the approved method for cooling and storing a cooked turkey breast was followed to prevent the potential for food borne illness. See F371 for details. It was determined the facility failed to assess, monitor and intervene during an acute exacerbation of pain for one (#7) of 10 sampled residents whose records were reviewed for pain management. See F309 for details. It was determined the facility failed to obtain an ER physician ordered pain medication within 34 hours for one (#7) of 10 sampled residents whose records were reviewed for pain management. See F425 for details. It was determined the facility failed to notify the physician of a resident's pain status and condition following an emergency room visit for an acute exacerbation of pain for one (#7) of 10 sampled residents whose records were reviewed for physician notification. See F157 for details.