Every finding on record at Baptist Village of Owasso

Based on observation, record review, and interview, the facility failed to ensure a resident did not fall from a mechanical lift during a transfer and failed to inspect the facility's mechanical lifts and slings as recommended by the manufacturer for 1 (#80) of 2 sampled residents reviewed for accident hazards The DON identified 21 residents who were routinely transferred by use of a mechanical lift. Findings: On 06/25/25 at 4:00 p.m., a mechanical lift sling the administrator identified as the one used with Res #80 when they slid out onto the floor on 06/16/25, was inspected by this surveyor. One of the blue colored loops on the sling had a cut or tear approximately ¾ inches in length from the edge and was approximately half the total width of the loop. Along the edges of the cut/tear, the material was evenly frayed with no loose fibers. There was no discoloration or other wear around the cut/tear. The remainder of the sling showed no signs of damage or wear. On 06/27/25 at 8:52 a.m., a visual and hands-on inspection of the facility's four mechanical lifts (including the one identified by the administrator as the one used when Res #80 fell) was completed by this surveyor. Each was clean, showed no signs of exterior damage, and did operate without any concerning noises or movements. An operator's manual for the brand of mechanical lifts the facility used, dated 12/2021, showed the slings used with the mechanical lifts must be inspected by a nurse or rehabilitation staff monthly for damage and excessive wear. The manual showed a permanent record of the monthly inspections should be kept by the facility and an inspection form was in the operator's manual. A facility policy titled Environmental Services Policy and Procedure, dated 02/20/24, read in part, BVC environmental team members will ensure that all necessary equipment is in working order and all necessary supplies are on hand. An admission MDS, dated [DATE], showed in Section C Res #80 had a BIMS score of 14 which indicated the resident's cognition was not impaired. The assessment showed in Section GG the resident was dependent on staff for transfers with the staff supplying all of the physical effort. A hospital imaging report, dated 06/16/25 at 11:41 a.m., showed Res #80 had a CT scan (a medical imaging procedure uses X-rays and computer technology to create detailed images of the body) performed. The report showed in the findings that the resident had a small subarachnoid hemorrhage (bleeding between the brain and the tissue that surround it). A progress note, dated 06/16/25 at 3:15 p.m., showed that on that date, Res #80 had been observed by LPN #1 to have been in a mechanical lift sling with their head laying on the leg of the lift and their legs still in the sling which was lifted above the floor. The note further described the sling having been broken on the upper right side. The note further showed the resident was transferred by ambulance to a hospital. A progress note, dated 06/17/25 at 11:34 a.m., showed LPN #3 had spoken to an ICU nurse at the hospital where Res #80 had been transferred. The note showed LPN #3 was told by the hospital ICU nurse Res #80 had a small brain bleed. On 06/24/25 at 10:00 a.m., Res #80 was asked if they had fallen recently. The resident stated they had fallen from a mechanical lift but could not recall the exact date. Res #80 was asked to describe the details of the fall. The resident stated they could not recall any details of the fall other than it was from a mechanical lift. Res #80 was asked what they were wearing. The resident stated they could not recall. Res #80 was asked to describe the staff's performance during that incident. The resident replied the staff had done a good job getting them to a hospital. Res #80 stated they were satisfied with their care and felt safe at the facility. On 06/25/25 at 3:39 p.m., the administrator stated the two CNA's who had been operating the mechanical lift when Res #80 had fallen were CNA #3 and CNA #4. The administrator stated the staff member who was responsible for ensuring the mechanical lift slings were in good condition and trained the staff on the use of the mechanical lifts was CNA #1. The administrator was asked about CNA #1's training related to the mechanical lifts. The administrator stated CNA #1 had read the operator's manual before instructing other staff. On 06/25/25 at 3:40 p.m., the DON stated they had observed and checked off on CNA #1's proficiency in the use of the lifts. On 06/27/25 at 9:47 a.m., CNA #4 was asked to describe what had occurred the day Res #80 had fallen during the transfer with the mechanical lift on 04/16/25. The CNA stated before using the sling, they had inspected it and had not seen the broken loop. CNA #4 stated when they placed the sling on the lift, they used the blue loops for the head and green loops for the bottom. The CNA stated once the resident was inside the sling, they lifted the resident from the bed and moved the lift to a position where they could lower the resident into a chair. CNA #4 stated it was at that time the resident had slid from the sling onto the floor. CNA #4 stated they then went to alert LPN #1 about the fall. The CNA stated the resident had been wearing pajamas made from very slick material and believed that was why the resident slid out of the sling. On 06/27/25 at 10:13 a.m., LPN #1 was asked to describe the events of Res #80's fall on 06/16/25. The LPN stated they had been called to Res #80's room by CNA #4 and when they entered, they observed Res #80 with their head on the ground and feet in the sling of the mechanical lift. LPN #1 stated when they entered the room, the sling was not connected to the lift on the end where the resident's head would been. The LPN stated they had assessed the resident and facilitated their transfer to a hospital. LPN #1 stated the resident was conscious during the time they were in the room. LPN #1 stated the hospital had found Res #80 had a brain bleed and the resident was in the ICU for a few days before returning to the facility. On 06/27/25 at 10:24 a.m., CNA #3 was asked to describe the events around Res #80 fall on 06/16/25. The CNA stated they had assisted CNA #4 transfer Res #80 from their bed to a chair. CNA #3 stated they were at the resident's feet and CNA #4 was on the resident's left side with one hand on the sling next to the resident's head and their other hand on the controls of the lift. The CNA stated the blue loops of the sling where the resident's head was and green loops where their feet were. CNA #3 stated when they maneuvered the lift from the bed toward the chair, they heard a popping sound and observed the resident slide from the sling headfirst. The CNA stated the resident's head ended up on the floor and their feet remained in the sling. CNA #3 stated the blue loop on the sling where CNA #4 had been holding it was found to have a break. CNA #3 was asked if any of the sling loops had come free of the lift. The CNA stated all the loops had remained attached to the lift when the resident had slid out of the sling. On 06/27/25 at 10:51 a.m., the maintenance supervisor stated Maintenance #1 was supposed to do monthly checks on the mechanical lifts, but they were not done in April 2025 or May 2025. On 06/27/25 at 11:00 a.m., Maintenance #1 was asked to describe their care of the mechanical lifts and slings. They stated there was a time when all of the mechanical lifts they used were rented and they believed they were not supposed to inspect those. Maintenance #1 stated they guess they were wrong about that. Maintenance #1 stated they did not inspect the mechanical lifts in April 2025 and May 2025 because they were rentals. They stated they knew the monthly inspections of the mechanical lifts and the slings were recommended by the manufacturer. Maintenance #1 stated they did not inspect the slings which were done by the nurses. They stated the sling used when Res #80 fell from the mechanical lift had been taken out of service that day and removed from the building. On 06/27/25 at 11:19 a.m., CNA #1 stated they had conducted inspections of the mechanical lift slings during the past year, but they had never documented those inspections. CNA #1 stated there was no documentation of sling inspections before June 2025.

Based on record review and interview, the facility failed to ensure the form CMS - 10055 was provided to residents with accurate information for 3 (#81, 82, and #103) of 3 sampled residents reviewed for beneficiary notices. LPN #2 stated 44 residents had discharged from skilled services between 01/01/25 and 06/23/25. Findings: 1. An undated face sheet for Res #81 showed the resident was admitted to the facility on [DATE]. A form CMS-10055, dated 12/31/24, showed Res #81 was informed the last day of their skilled services would be 12/31/24. This was the date of their admission to the facility and the form did not provide the cost of the skilled services listed. 2. An undated face sheet for Res #82 showed the resident was admitted to the facility on [DATE]. A form CMS-10055, dated 03/25/25, showed Res #81 was informed the last day of their skilled service would be 03/25/25. This was the date of their admission to the facility and the form did not provide the cost of the skilled services listed. 3. An undated face sheet for Res #103 showed the resident was admitted to the facility on [DATE]. A form CMS-10055, dated 12/06/24, showed Res #103 was informed the last day of their skilled services would be 12/06/24 . This date was prior to their admission date to the facility and the form did not provide the cost of the skilled services listed. On 06/27/25 at 1:00 p.m., LPN #1 stated they were the staff member who reviewed form CMS-10055 with the residents. They were asked what the purpose of the form was. They stated the purpose of the form was to document what their insurance covered and what day the coverage would start. They were informed the document was to alert residents of the upcoming end of coverage for skilled services paid by Medicare and to inform them of the services and costs if they chose to continue those services after coverage had ended. LPN #1 stated they were unaware that was the purpose of the form. They stated they had filled out the form incorrectly by putting in the admission dates instead of ending dates and excluding the cost of services on the forms. On 06/27/25 at 1:17 p.m., the administrator stated the date on CMS-10055 was not for the beginning of services but the last covered date. The administrator stated the form was to inform the residents of costs and options for continuing those services if they chose to do so. The administrator stated the form was to allow residents to make good financial decisions.

Based on record review and interview, the facility failed to ensure a resident was not prescribed psychotropic medications for dementia for 1 (#69) of 5 sampled residents reviewed for unnecessary medications. The pharmacist stated 45 residents at the facility were prescribed antidepressant medications (antidepressants are psychotropic medications). Findings: A facility policy titled Baptist Village Communities Psychotropic Medication Policy and Procedure, dated 02/20/24, read in part, The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. A physician's order for Res #69, dated 05/15/25, showed the resident had been prescribed sertraline (psychotropic medication approved for the treatment of depression) 25 mg once daily for dementia. A medication administration record, dated 06/01/25 through 06/30/25, showed Res #69 had been administered one sertraline 25 mg tablet each day starting on 06/01/25 and ending on 06/25/25 for a total of 25 doses. On 06/25/25 at 9:16 a.m., the facility's contracted pharmacist was asked if sertraline had been approved for the treatment of dementia. They stated it had not been approved for dementia, and they were trying to stay away from using psychotropics for those with dementia. On 06/25/25 at 9:56 a.m., LPN #3 was asked why Res #69 had been prescribed sertraline. They stated the active diagnosis was dementia without behavioral disturbances. They were asked for what specific symptom had the resident been prescribed the medication. They stated they did not know, but the resident was seeing a contracted behavioral service. They were asked if sertraline was approved to treat dementia. They stated they did not know. On 06/25/25 at 10:16 a.m., NP #1 stated Res #69 was taking an antidepressant for dementia and those medications were not approved for dementia. They stated the resident did have signs of depression and was seeing a behavioral health group for that. On 06/25/25 at 10:03 a.m., the DON was asked if antidepressants or any psychotropic medication had been approved for the treatment of dementia. They stated they did not know off hand, but did know they were used for various mental health disorders.

Based on record review and interview, the facility failed to ensure discharge assessments were completed for 1 (#72) of 5 sampled residents reviewed for assessments. The administrator reported the facility census was 74. Findings: A discharge note, dated 02/22/25, showed Res #72 was discharged on 02/22/25. A face sheet, dated 06/25/25, showed Res #72 was admitted on [DATE]. The face sheet also showed the resident had diagnoses which included sepsis and anemia. A review of Res #72's health record did not show a discharge MDS had been completed. On 06/25/25 at 2:49 p.m., MDS coordinator #1 stated a discharge MDS had not been completed upon Res #72's discharge. They also stated they were unsure why the discharge MDS was not completed.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was updated after a resident had a fall that resulted in an injury for 1 (#69) of 18 sampled residents whose care plans were reviewed. The DON reported that 74 residents at the facility had care plans. Findings: A facility policy titled Comprehensive Care Plan Policy and Procedure, dated 02/20/24, read in part, The comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). It will be updated quarterly, annually, with significant change, or as needed/identifies as preference changes occur or health need warrants. Res #69's care plan, dated 09/17/24, was reviewed. The care plan had a problem of falls, with past falls listed as 10/17/24, 10/27/24, 11/10/24, 12/08/24, 12/19/24, and 01/17/25. There were no falls, goals for fall prevention, or correlated interventions after 01/17/25. An admission MDS assessment, dated 04/01/25, showed Res #69 had a diagnosis of dementia and a BIMS score of 5 which indicated the resident's cognition was severely impaired. The assessment further showed the resident required supervision to stand from a chair and moderate physical assistance to walk up to 10 feet. A progress note, dated 04/27/25 at 3:13 p.m., showed staff had witnessed Res #69 rise from their chair and started walking which resulted in the resident falling to the floor striking their left hip and shoulder. On 6/27/25 at 11:40 a.m., LPN #4 was asked to describe their process for creating and updating comprehensive care plans. LPN #4 stated they updated the care plan every three months. LPN #4 stated they had updated Res #69's care plan in March 2025. LPN #4 stated the care plan showed the last fall the resident had was in January 2025, but they did have a fall in April 2025. LPN #4 was asked why the fall in April was not listed. LPN #4 stated they had been waiting for an incident report that would have new interventions on it, but so far the incident report had not made it back to them. LPN #4 was asked how they had been getting the incident reports with the interventions. LPN #4 stated the former DON had a system in place where they would get the reports to them. LPN #4 stated it ended when the former DON stopped working at the facility. LPN #4 stated they did not create interventions and still depended on those coming to them from the incident reports. LPN #4 stated the fall that occurred in April 2025 and new interventions should have been entered into the care plan. On 06/27/25 at 12:49 p.m., the DON was asked to describe the process for updating care plans. They stated, giving falls as an example, the charge nurse would assess what had occurred and add new interventions as appropriate. The DON stated in the case of Res #69's fall in April 2025, the former DON's system for updating care plans had ended with their employment and Res #69's fall had been missed. They stated not updating a care plan of a fall with injury went against their current procedures.

Based on observation, record review, and interview, the facility failed to ensure EBP were in place during catheter care for 1 (#73) of 2 sampled residents reviewed for indwelling urinary catheters. The DON reported 6 residents in the facility with indwelling urinary catheters. Findings: On 06/27/25 at 10:55 a.m., CNA #2 was observed providing catheter care to Res #73. The CNA was not observed to be wearing a gown. A sign was observed on the resident's door that showed the resident was on EBP. A facility policy titled Baptist Village Communities Policy and Procedure for Personal Protective Equipment Use to Prevent Spread of Multidrug-resistant Organisms, dated 02/20/24, read in part, For EBP, team members will employ targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. An admission assessment, dated 05/27/25, showed Res #73 had a BIMS score (a test for cognitive function) of 12, which was indicative of moderate cognitive impairment. The assessment showed Res #73 had an indwelling urinary catheter. On 06/24/25 at 9:20 a.m., Res #73 stated the staff usually did not wear gowns while providing care. On 06/27/25 at 11:10 a.m., CNA #2 stated they should have been wearing a gown while providing catheter care to Res #73. On 06/27/25 at 11:15 a.m., LPN #1 stated a gown should be worn while providing direct care to a resident on EBP. On 06/27/25 at 12:05 p.m., the DON stated a gown should be worn while providing catheter care.

On 03/06/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #1 from sexual abuse. On 03/01/25, Resident #1 reported to an unknown staff member that Resident #2 had touched their breast in the dining area on a previous day. During the investigation, Resident #2 admitted to touching Resident #1. The facility did not initiate ongoing protection for Resident #1 or other residents. Resident #1 was touched inappropriately by Resident #2 resulting in Resident #1 feeling anxious and unsafe. On 03/6/25 at 5:51 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. On 03/06/25 at 6:05 p.m., the administrator was notified of the immediate jeopardy situation. On 03/07/25 at 6:48 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal, read in part, Baptist Village of Owasso Plan of Removal for IJ Total number of residents potentially at risk are 75. Action to Remove Immediacy On March 6, 2025, resident #2 was placed on alert monitoring to ensure that [they] would have no interactions with resident #1. This alert monitoring is being documented by nursing team of resident #2 location every 15 minutes. DOHS and/or [their] designee will continually monitor documentation twice a day. All staff received in-service education on all aspects of the Abuse and neglect policy by 12:00pm 3/7/2025. This training was conducted by the Director of Health Services, or [their] designee, with confirmation. This plan of removal was completed by March 7, 2025, at 12:00pm. Action to Prevent Recurrence If resident #1 and resident #2 choose to eat in the dining room at the same time, a dining team member will continuously monitor both residents. Resident #2 was educated on unwanted inappropriate physical contact by Registered Nurse on 3/1/2025. The nursing team is documenting every 15 minutes on the whereabouts of Resident #2 on a resident tracking tool. DOHS and/or [their] designee are monitoring this documentation twice a day. A dining service team member is assigned to monitor both residents when in the dining room to prevent recurrence. Life Enrichment is documenting eyes on during activities. All cognitive female residents were interviewed to ensure they felt safe and were encouraged to always report unwanted advances. The staff were educated on signs that would indicate the possibility that a resident who is unable to been interviewed may have been abused. All new staff that are hired after 12:00pm on 3/7/2025 will receive the same education on all aspects of the Abuse and neglect policy. Resident # 2 has been counseled by Chaplain and DOHS on the inappropriateness of [their] actions. Resident acknowledged understanding. Resident # 2 expressed remorse for [their] actions. The administrator has been in conversation with Resident #2's POA [power of attorney] about possible discharge due to resident's inappropriate behavior. All staff did receive in-service education on all aspects of the Abuse and neglect policy including resident to resident abuse with an emphasis on inappropriate sexual behavior before 12:00pm on 3/7/2025. This training was conducted by the Director of Health Services, or [their] designee, with confirmation. This training will continue for any new hires. Monitoring implementation of Plan of Removal. All education, implementation, and monitoring of this plan of removal was completed by the Director of Health Services and the Care Coordinator and/or their designee. Emergency QAPI meeting was conducted on 3/7/25 @ 11:00 am to review protocols put into place. This plan will continue to be reviewed in the regulatory quarterly QAPI meetings. The IJ was lifted, effective 03/07/25 at 12:00 p.m., when all components of the plan of removal had been completed. Ten staff members in all departments from all shifts were interviewed regarding abuse as indicated in the plan of removal. Documentation for monitoring of Resident #2 was reviewed to ensure monitoring was in place and ongoing. The deficient practice remained at an isolated level with potential for more [NAME] minimal harm. Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 75 residents resided in the facility. Findings: On 03/06/25 at 12:00 p.m., Resident #1 and Resident #2 were observed in the dining area at different tables. Resident #2 was sitting at a table with residents of the opposite sex. Resident #1 was sitting alone. An abuse policy, dated 02/20/24, read in part, If the alleged perpetrator is a health center resident, The team member will immediately remove the perpetrator from the situation and another team member will stay with the alleged perpetrator and wait for further instruction from administration, if possible. 1. Resident #1 was admitted with diagnoses which included anxiety and dementia. An annual assessment, dated 02/05/25, showed Resident #1's cognition was moderately impaired with a BIMS score of 11 and used a walker with ambulation. An incident report to OSDH, dated 03/01/25, showed Resident #1 alleged Resident #2 had touched their breast and private parts on a previous day while in the dining room. The report showed the facility would monitor and keep the residents apart while in the dining area. 2. On 03/06/25 at 1:56 p.m., Resident #2 was observed in the dining area having a conversation with a resident of the opposite sex. Resident #2 was admitted with diagnoses which included congestive heart failure and pain. A quarterly assessment, dated 03/04/25, showed Resident #2 had a BIMS score of 15 and used a manual wheelchair for ambulation. On 03/06/25 at 12:35 p.m., the DON stated the staff were keeping an eye on the resident and keeping the two residents separated. The DON did not know how this was keeping the other residents safe. On 03/06/25 at 12:03 p.m., Resident #1 stated when Resident #2 touched them it made them mad and upset. Resident #1 stated they did not know what they would do if this happened again. On 03/06/25 at 1:45 p.m., LPN #1, LPN #2, CNA #1, CNA #2, and CNA #3, staff on the halls of Residents #1 and Resident #2, were asked if they had been given any recent instructions regarding these two residents. All replied, No. On 03/06/25 at 1:54 p.m., LPN #1, LPN #2, CNA#1, CNA#2, and CNA #3 were asked if they knew where Resident #2 was at that time. None of the staff were able to give the location of Resident #2. On 03/06/25 at 1:58 p.m., the DON stated the incident was abuse and they should have ensured continued monitoring of Resident #2. On 03/06/25 at 3:14 p.m., the administrator stated they had not done everything that they should have done regarding the abuse.

Based on record review and interview, the facility failed to ensure residents did not receive an antipsychotic medication, unless for a specific diagnosis condition for three (#37, 55, and #43) of five residents reviewed for unnecessary medications. The Administrator reported 79 residents resided in the facility. Findings: 1. Resident #37 admitted to the facility with diagnoses which included dementia, depression, and cognitive communication deficit. A physician's order, dated 02/05/24, documented Risperdal 0.25 mg tablet Hour Of Sleep for unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's electronic health record was reviewed and contained no documentation the resident had a diagnoses of psychotic disturbance/mood disorder. 2. Resident #55 admitted to the facility with diagnoses which included dementia, altered mental status, anxiety, and cognitive communication deficit. A physician order, dated 3/27/24, documented Quetiapine 25mg tablet 1/2 tablet every evening for unspecified dementia. The resident's electronic health record was reviewed and contained no documentation the resident had a diagnoses of psychotic disturbance/mood disorder or depression. 41220 3. Resident #43 admitted to the facility with diagnoses which included dementia, anxiety, and cognitive communication deficit. A physician's order, dated 03/27/24, documented Quentiapine 25 mg 0.5 tablets every evening for unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's electronic health record was reviewed and contained no documentation the resident had a diagnoses of psychotic disturbance/mood disorder. On 07/24/24 at 8:47 a.m., the DON and Corporate RN stated they would need to speak with the pharmacy consultant to determine if dementia was an appropriate diagnosis for the use of an antipsychotic medication. On 07/24/24 at 8:59 a.m., the pharmacy consultant reported dementia was not an appropriate diagnosis for the antipsychotic medications.

Based on record review and interview, the facility failed to ensure resident assessments for discharge were completed and submitted to CMS for two (#68 and #63) of 11 sampled residents who were reviewed for resident assessments. The administrator identified 79 residents who resided at the facility. Findings: 1. Resident #68 admitted with diagnoses which included acute and chronic respiratory failure, diabetes type II, and congestive heart failure. Review of the face sheet for Resident #68 revealed they had transferred to the hospital on [DATE] and expired at the hospital on [DATE]. On [DATE] at 11:42 a.m., a review of the assessment log for Resident #68 revealed a discharge assessment had not been completed/submitted. On [DATE] at 1:49 p.m., MDS Coordinator #1 stated Resident #68 had been sent to the hospital on [DATE] and expired on [DATE]. They stated the discharge assessment was missing from the log for Resident #68. MDS Coordinator #1 stated the assessment was missed because it was an unplanned discharge and was not written on their calendar. 2. Resident #63 was admitted with diagnoses which included malignant neoplasm of cervix, chronic kidney disease stage III, and type II diabetes. Review of the face sheet for Resident #63 revealed they discharged to the hospital on [DATE]. On [DATE] at 11:42 a.m., a review of the assessment log for Resident #63 revealed a discharge assessment had not been completed/submitted. On [DATE] at 1:49 p.m., MDS Coordinator #1 stated the discharge assessment for Resident #63 was not completed timely. On [DATE] at 2:03 p.m., MDS Coordinator #1 stated they had forgotten to put the discharge assessment in the system because it was an unplanned, hospital discharge.

Based on record review and interview, the facility failed to ensure coordination and certification of assessments for four (#23, 37, 42 and #73) of 11 sampled residents who were reviewed for assessments. The administrator identified 79 residents who resided at the facility. Findings: Review of the electronic clinical record, revealed Residents #23, 37, 42 and #73, were missing quarterly assessments, due to no signature from the RN. Resident #73 was missing a quarterly which required correction and to be opened by the RN. On 07/23/24 at 11:42 a.m., MDS Coordinator #1 stated the quarterly assessments required a signature from the RN before the assessments could be submitted. They stated Resident #74 had a rejected assessment for the mood miscalculation and required to be unlocked by the RN before the correction could be made. The MDS Coordinator stated they sent emails to the RN for signatures and when assessments required re-opening for correction.

Based on record review and interview, the facility failed to ensure assessments were accurate for one (#15) of one sampled resident reviewed for hospice services and four (#4, 6, 53, and #2) of four sampled residents whose assessments were reviewed for accuracy related to anticoagulant use. The Resident Census and Conditions of Residents report identified 15 residents who received hospice services. The consultant pharmacist identified 14 residents who received anticoagulant medications. Findings: 1. Resident #15 had diagnoses which included Parkinson's disease. A Written Certification, dated 05/05/23, documented the physician certified the resident was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. The significant change assessment, dated 05/08/23, documented the resident did not have an illness or condition that may lead to a life expectancy of six months or less. On 06/29/23 at 11:18 a.m., MDS coordinator #2 was asked where information was obtained to determine if a resident has an illness which may result in a life expectancy of six months or less. They stated they reviewed the history and physicals and the physician progress notes. They were asked why the significant change assessment, dated 05/05/23, had not been coded to indicate the resident had an illness or condition which may lead to a life expectancy of six months or less. They stated they did not know because that was the reason they had initiated the assessment. 2. Resident #4 had diagnoses which included history of venous thrombosis and embolism. The quarterly assessment, dated 05/26/23, documented the resident had received an anticoagulant medication seven days during the seven day look back period. Review of the May 2023 Medications record did not reveal documentation the resident was ordered or had received an anticoagulant medication. 3. Resident #6 had diagnoses which included congestive heart failure. The annual assessment, dated 05/14/23, documented the resident had received an anticoagulant medication seven days during the seven day look back period. Review of the May 2023 Medications record did not reveal documentation the resident was ordered or had received an anticoagulant medication. 4. Resident #53 had diagnoses which included atherosclerotic heart disease. The annual assessment, dated 05/30/23, documented the resident had received an anticoagulant medication seven days during the seven day look back period. Review of the May 2023 Medications record did not reveal documentation the resident was ordered or had received an anticoagulant medication. 5. Resident #2 had diagnoses which included chronic ischemic heart disease. The significant change assessment, dated 06/05/23, documented the resident had received an anticoagulant medication seven days during the seven day look back period. Review of the May 2023 Medications record did not reveal documentation the resident was ordered or had received an anticoagulant medication. Review of the June 2023 Medications record did not reveal documentation the resident was ordered or had received an anticoagulant medication. On 06/29/23 at 12:53 p.m., MDS coordinator #1 was asked what anticoagulant medication Resident #53 had received on the 05/30/23 annual assessment. They stated Plavix. They were asked why Plavix had been coded as an anticoagulant medication on the assessment. They stated Plavix. MDS coordinator #1 reviewed the drug classification for Plavix and stated they thought the medication was an anticoagulant not an antiplatelet medication when they had coded assessments for Resident #53 and Resident #2. MDS coordinator #1 was asked what anticoagulant medication Resident #4 had received on the 05/26/23 quarterly assessment. They stated they thought cilostazol was an anticoagulant medication. MDS coordinator #1 was asked what anticoagulant medication Resident #6 had received on the 05/14/23 annual assessment. They stated the resident had not received an anticoagulant medication during the look back period. They stated they had made a coding error.

Based on record review, and interview, the facility failed to ensure care plans documented the need for residents with bed rails for three (#59, #53, and #2) of three sampled residents who were reviewed for bed rails. The administrator identified 65 residents who utilized bed rails. Findings: An undated document titled Bed Rail Policy, read in part, . 1. Resident Assessment . Before admission, prospective residents will be screened to help determine if care needs may necessitate specialized beds (e.g. bariatric equipment) or accessories (e.g. side rails) . Resident care plan will include the use of bed rails as evaluated . 1. Resident #59 had diagnoses which included muscle weakness. The Nursing Admission Evaluation Comprehensive assessment, dated 12/20/22, documented the resident utilized bed rails for bed mobility or transfer. The Care Plan, updated 06/20/23, did not document a care plan regarding side rails. The quarterly assessment, dated 06/20/23, documented the resident was severely impaired in cognition for daily decision making and was totally dependent on staff for bed mobility. Review of the clinical record did not reveal an assessment had been completed or a physician order had been obtained related to the use of bed rails. On 06/26/23 at 2:43 p.m., Resident #59 was observed in bed with half bed rails in the raised position on the right side of the bed which was not by the wall. On 06/28/23 at 3:35 p.m., Resident #59 was observed in bed with half bed rails in the raised position on both sides of the bed. 2. Resident #53 had diagnoses which included dementia. An annual assessment, dated 05/30/23, documented the resident was severely impaired in cognition for daily decision making and was totally dependent on staff for bed mobility. The Care Plan, dated 06/0623, did not document a care plan for the use of bed rails. Review of the clinical record did not reveal an assessment had been completed or a physician order had been obtained related to the use of bed rails. On 06/28/23 at 3:39 p.m., Resident #53 was observed in bed with half side rails in the raised position bilaterally. 3. Resident #2 had diagnoses which included dementia. A physician's order, dated 09/21/19, documented the resident was ordered bilateral side rails to assist in repositioning. The Care Plan, updated 05/31/23, did not document a care plan regarding side rails. The significant change assessment, dated 06/05/23, documented the resident was moderately impaired in cognition for daily decision making and required limited assistance of staff for bed mobility. Review of the clinical record did not reveal an assessment had been completed related to the use of bed rails. On 06/26/23 at 2:01 p.m., Resident #2 was observed in bed with half bed rails in the raised position bilaterally. 06/29/23 at 06:20 p.m., The MDS coordinator was asked why bed rails were not included in care plans. They stated they would check.

Based on observation, record review, and interview, the facility failed to ensure residents with bed rails were assessed for the use for three (#59, #53, and #2) of three sampled residents who were reviewed for bed rails. The administrator identified 65 residents who utilized bed rails. Findings: An undated document titled Bed Rail Policy, read in part, . 1. Resident Assessment .a. Before admission, prospective residents will be screened to help determine if care needs may necessitate specialized beds (e.g. bariatric equipment) or accessories (e.g. side rails). b. Upon admission, readmission or change of condition, residents will be screened to determine: 1) level of independence with bed mobility. 2) Bed comfort level 3) If the bed meets manufacturers recommendation and specifications pertaining to resident height and weight 4) Need for special equipment or accessories (e.g. side rails) c. Evaluate the resident to identify appropriate alternative prior to installing bed rails d. Evaluate the resident for risk of entrapment from bed rails prior to installation or use e. Bed rails will not be used when a resident cannot raise and lover them easily . 1. Resident #59 had diagnoses which included muscle weakness. The Nursing Admission Evaluation Comprehensive assessment, dated 12/20/22, documented the resident utilized bed rails for bed mobility or transfer. The Care Plan, updated 06/20/23, did not document a care plan regarding side rails. The quarterly assessment, dated 06/20/23, documented the resident was severely impaired in cognition for daily decision making and was totally dependent on staff for bed mobility. Review of the clinical record did not reveal an assessment had been completed or a physician order had been obtained related to the use of bed rails. On 06/26/23 at 2:43 p.m., Resident #59 was observed in bed with half bed rails in the raised position on the right side of the bed which was not by the wall. On 06/28/23 at 3:35 p.m., Resident #59 was observed in bed with half bed rails in the raised position on both sides of the bed. 2. Resident #53 had diagnoses which included dementia. An annual assessment, dated 05/30/23, documented the resident was severely impaired in cognition for daily decision making and was totally dependent on staff for bed mobility. The Care Plan, dated 06/0623, did not document a care plan for the use of bed rails. Review of the clinical record did not reveal an assessment had been completed or a physician order had been obtained related to the use of bed rails. On 06/28/23 at 3:39 p.m., Resident #53 was observed in bed with half side rails in the raised position bilaterally. 3. Resident #2 had diagnoses which included dementia. A physician's order, dated 09/21/19, documented the resident was ordered bilateral side rails to assist in repositioning. The Care Plan, updated 05/31/23, did not document a care plan regarding side rails. The significant change assessment, dated 06/05/23, documented the resident was moderately impaired in cognition for daily decision making and required limited assistance of staff for bed mobility. Review of the clinical record did not reveal an assessment had been completed related to the use of bed rails. On 06/26/23 at 2:01 p.m., Resident #2 was observed in bed with half bed rails in the raised position bilaterally. On 06/28/23 at 1:58 p.m., LPN #1 was asked why Resident #59, 53, and Resident #2 had side rails. They stated most of the residents who had side rails utilized them for repositioning. They were asked who was responsible to assess residents for the use of bed rails. LPN #1 stated they did not know. On 06/29/23 at 5:42 p.m., the DON was asked how often residents were assessed for the use of bed rails. They stated there was not a scheduled assessment for the use of bed rails.

Based on record review, and interview, the facility failed to ensure residents with bed rails were regularly inspected for the use for three (#59, #53, and #2) of three sampled residents who were reviewed for bed rails. The administrator identified 65 residents who utilized bed rails. Findings: An undated document titled Bed Inspection Policy, read in part, . 2. Equipment Management and Environmental Services . b The environmental service department will conduct regular (prior to admission and quarterly thereafter) inspection of all bed frames, mattresses and bed rails as part of a regular environmental services program to identify areas of possible entrapment . 1. Resident #59 had diagnoses which included muscle weakness. The Nursing Admission Evaluation Comprehensive assessment, dated 12/20/22, documented the resident utilized bed rails for bed mobility or transfer. The Care Plan, updated 06/20/23, did not document a care plan regarding side rails. The quarterly assessment, dated 06/20/23, documented the resident was severely impaired in cognition for daily decision making and was totally dependent on staff for bed mobility. Review of the clinical record did not reveal an assessment had been completed or a physician order had been obtained related to the use of bed rails. On 06/26/23 at 2:43 p.m., Resident #59 was observed in bed with half bed rails in the raised position on the right side of the bed which was not by the wall. On 06/28/23 at 3:35 p.m., Resident #59 was observed in bed with half bed rails in the raised position on both sides of the bed. 2. Resident #53 had diagnoses which included dementia. An annual assessment, dated 05/30/23, documented the resident was severely impaired in cognition for daily decision making and was totally dependent on staff for bed mobility. The Care Plan, dated 06/0623, did not document a care plan for the use of bed rails. Review of the clinical record did not reveal an assessment had been completed or a physician order had been obtained related to the use of bed rails. On 06/28/23 at 3:39 p.m., Resident #53 was observed in bed with half side rails in the raised position bilaterally. 3. Resident #2 had diagnoses which included dementia. A physician's order, dated 09/21/19, documented the resident was ordered bilateral side rails to assist in repositioning. The Care Plan, updated 05/31/23, did not document a care plan regarding side rails. The significant change assessment, dated 06/05/23, documented the resident was moderately impaired in cognition for daily decision making and required limited assistance of staff for bed mobility. Review of the clinical record did not reveal an assessment had been completed related to the use of bed rails. On 06/26/23 at 2:01 p.m., Resident #2 was observed in bed with half bed rails in the raised position bilaterally. On 06/28/23 at 1:58 p.m., LPN #1 was asked why Resident #59, 53, and Resident #2 had side rails. They stated most of the residents who had side rails utilized them for repositioning. On 06/29/23 at 5:24 p.m., the maintenance supervisor was asked what their role was in relation to side rails. They stated I don't usually do much with them. Nothing is really implemented as far as maintenance goes. Almost everybody has them. If they tell me to take them off them I remove them.

Based on interview and record review, it was determined the facility failed to complete a discharge summary with a recapitulation of the resident's stay for two (#70 and #48) of three residents reviewed for discharge. The facility identified 47 residents had been discharged in the last three months. Findings: 1. Resident #70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented the resident was to continue with the plan of care and medications. The resident's medical record did not document a discharge summary signed by the physician. On 04/12/2021 at 2:49 p.m., the minimum data set (MDS) staff #1 stated a discharge summary was not completed for the resident. The MDS staff was unable to locate the signed discharge plan of care. The MDS staff stated they had never completed discharge summaries with a recapitulation of the resident's stay. On 04/13/2021 at 8:23 a.m., the corporate nurse stated it was the responsibility of the MDS staff to document a discharge summary. The nurse stated the staff had not been completing discharge summaries. 2. Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 03/04/21, documented the resident was cognitively intact for daily decision making and required limited assistance with activities of daily living (ADLs). A physician order, dated 03/23/21, documented the resident was discharging to home. The order documented the resident was to continue all current medications and treatments. The resident's medical record did not document a discharge summary signed by the physician. On 04/12/21 at 2:49 p.m., the MDS staff #1 stated a discharge summary was not completed for the resident. MDS staff #1 stated they never completed discharge summaries with a recapitulation of the resident's stay. On 04/13/21 at 8:23 a.m. the corporate nurses stated it was the responsibility of the MDS staff to document a discharge summary. The corporate nurse stated the staff had not been completing discharge summaries.

Based on observation and interview, it was determined the facility failed to ensure the staff wore hair covers correctly in the kitchen for 43 of 43 residents who ate food prepared in the kitchen. The facility identified 16 staff worked in the kitchen. Findings: On 04/07/21 at 11:05 a.m., the dietitian (RD) was observed in the kitchen. A large strand of hair was exposed from the hair net and dangling down her back. On 04/07/21 at 2:40 p.m., the RD and the kitchen general manager were interviewed regarding sanitation in the kitchen. They stated sanitary conditions were maintained in the kitchen by ensuring the staff wear hair nets. They stated all staff must don hair nets when they enter the kitchen. On 04/08/21, the RD was observed exiting the kitchen with a braided ponytail out of the hairnet.

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records for one (#69) of 13 sampled residents whose records were reviewed. The facility failed to accurately document the condition of the residents skin. The facility census and condition identified 44 resident resided in the facility. Findings: Resident #69 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged from the facility on 12/08/20. An admission five day assessment, dated 11/25/20, documented the resident was cognitively intact, did not have skin problems, required limited assistance with activities of daily living (ADLs), and did not have any falls since admission. The facility documented resident skin checks were completed on 12/04/20, 12/06/20, 12/07/20, and 12/08/20 with no skin issues noted. The assessment records documented the resident discharged from the facility on 12/08/20. On 04/12/21 at 12:48 p.m., licensed practical nurse (LPN) #1 stated on the day of discharge the resident had a bruise above the right eye. The nurse stated she asked the physician assistant (PA) to look at the resident's eye the day before discharge. On 04/13/21 at 8:32 a.m., LPN #1 stated on 12/07/20 was the first time discoloration around the resident's eye was noted. The LPN was unsure of the cause for the discoloration. The LPN stated she verbally reported the injury to the interim director of nurses (DON). The LPN stated she did not complete an incident report or document the discoloration in the assessment. On 04/13/21 at 9:38 a.m., the administrator provided a statement, dated 12/11/20, from the interim director of nurses (DON) regarding an investigation pertaining to the resident. The statement documented the interim DON spoke with the resident's family on 12/11/20. The family stated on 12/08/20 when the resident was discharged the family noticed a black and blue discoloration to the resident's right eye and the right side of the resident's nose was skinned up. The state incident reports from November 2020 to April 2021 were reviewed. No state reports were found for the named resident.

Based on interview and record review, it was determined the facility failed to report an allegation of an injury of unknown origin for one (#69) of 24 sampled residents whose records were reviewed. The facility failed to report within 24 hours an allegation regarding an injury of unknown origin to the administrator and state agencies. The facility identified there were no state incident reports submitted in the past six months. Findings: The facility abuse policy documented allegations regarding injury of unknown source were to be reported per Federal and State Law. The policy documented an investigation must be completed immediately to rule out abuse. The policy documented team members must always report any abuse or suspicions of abuse immediately to the administrator. Resident #69 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission five day assessment, dated 11/25/20, documented the resident was cognitively intact, did not document skin problems, required limited assistance with activities of daily living (ADLs), and had no falls since admission. A fall risk evaluation, dated 11/19/20, documented the resident was a high risk for falls. The care plan, dated 11/26/20, documented the resident was at risk for falls and documented interventions to prevent falls. A nurse assessment, dated 12/07/ 20, documented the resident's skin was intact with normal appearance. The assessment records documented the resident discharged from the facility on 12/08/20. On 04/09/21 at 1:20 p.m., the administrator was interviewed regarding notification of discoloration to the resident's eye area prior to discharge. The administrator stated she did not recall being informed of discoloration to the residents eye area prior to discharge. On 04/12/21 at 12:48 p.m., licensed practical nurse (LPN) #1 stated on the day of discharge the resident had a bruise above his right eye. The nurse stated she asked the physician assistant (PA) to look at the resident's eye the day before discharge. On 04/13/21 at 8:32 a.m., LPN #1 stated on 12/07/20 was the first time discoloration around the resident's eye was noted. The LPN was unsure of the cause for the discoloration. The LPN stated she verbally reported the injury to the interim director of nurses (DON). The LPN stated she did not document an incident report or document the assessment. On 04/13/21 at 9:38 a.m., the administrator provided a statement, dated 12/11/20, from the interim director of nurses (DON) regarding an investigation pertaining to the resident. The statement documented the interim DON spoke with the resident's family on 12/11/20. The family stated on 12/08/20 when the resident was discharged the family noticed a black and blue discoloration to the resident's right eye and the right side of the resident's nose was skinned up. On 04/13/21 at 9:44 a.m., a phone interview was conducted with the interim DON. The DON stated she was not made aware of possible injury to the resident's eye until 12/11/20. The DON stated she documented her investigation and gave it to the administrator. The facility incident reports were reviewed and did not document a state report for the resident related to an injury of unknown origin.

Based on observation, interview, and record review, it was determined the facility failed to implement their infection control program to prevent potential spreading of COVID-19 infection for all staff and residents. The facility failed to: ~maintain Centers for Disease Control (CDC) recommended infection control practices during observation of COVID-19 testing for two of two surveyors tested for COVID- 19 prior to entry to the facility. The administrator reported a census of 43 residents who resided in the facility and 73 staff members who were employed at the facility, and ~ consistently maintain CDC recommended infection control practices while delivering meals to five (#5, 6, 7, 8, 9, and #10) of 10 residents on the west unit who were observed receiving their meals during lunch. The facility identified 19 residents as receiving meal trays. Findings: The CDC guidance titled Performing Broad-Based Testing for [DIAGNOSES REDACTED]-CoV-2 in Congregate Settings, updated June 27, 2020, documented the following: Gown, N95 equivalent or higher-level respirator (or facemask if a respirator is not available), gloves, and eye protection are needed for staff collecting specimens or working within 6 feet of the person being tested . The CDC guidance titled Preparing for COVID 19 in Nursing Homes, updated November 20, 2020, documented the following: Reinforce adherence to standard IPC measures including hand hygiene and selection and correct use of personal protective equipment (PPE). Care must be taken to avoid touching the respirator, facemask, or eye protection . HCP should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others. 1. On 01/26/2021 at 9:15 a.m., two surveyors were screened for COVID-19 by the Director of Nursing (DON) upon entry to the facility. The DON wore only a N-95 mask and gloves when performing the COVID-19 tests. The DON performed one test, and before removing her gloves, washing, or sanitizing her hands, she obtained the second test kit from the box containing the kits. She then doffed her gloves, placed them on the table, sanitized her hands, donned gloves, and performed the second test. She then gathered the used testing kits and trash and left the testing area. On 01/26/2021 at 9:42 a.m., the DON stated the lobby area was where she tested the staff. She said the residents are tested in their rooms. She said normally she would have wax paper down to lay the COVID-19 tests on. She stated she had not been wearing gowns when testing staff. 2. On 01/26/2021 at 11:06 a.m., the noon meal service was observed. Without washing or sanitizing her hands, certified nurse aide (CNA) #1 was observed to don gloves, make two cups of ice, and deliver them to resident #10. She then removed her gloves, touched her hair, held the resident's hand, touched her hair again, and then poured water into one of the cups of ice. CNA #1 then retrieved gloves from her pocket, donned a glove on her right hand, touched her mask with her left hand, poured tea in a cup, and delivered the drink to resident #5. After leaving the room, CNA #1 removed her gloves, and without washing or sanitizing her hands, retrieved another pair of gloves from a personal protective equipment (PPE) station in the hall, placed gloves on both hands, donned a gown, and put goggles on the top of her head. She then assisted resident #6 with a drink. CNA #1 removed her PPE in the resident's trash bag, removed the trash bag from the room, and placed trash bag on the floor of the hopper room. She then washed her hands. CNA #1 touched her hair, removed her mask, and took a drink of fluids from a container at the nurses' station. Without washing or sanitizing her hands, CNA #1 then placed her mask back on, retrieved gloves from her pocket, and donned them. She then made a thickened drink and placed it on a table in the lobby. She donned a gown, took the goggles off her head and placed them over her eyes, and assisted resident #6 with a drink. On 01/26/2021 at 11:29 a.m., CNA #1 stated she was unable to use hand sanitizer, so she should have washed her hands between residents. On 01/26/2021 at 11:37 a.m., CNA #2 donned gloves and delivered a meal tray to resident #8. The CNA touched the door of the resident's room with gloved hands. She then returned to the meal cart, and without changing her gloves or washing or sanitizing her hands, retrieved a meal tray from the counter at the nurses' station, and delivered the meal to resident #7. She knocked on the door, set the meal up for the resident, and closed the door. The CNA then removed her gloves and washed her hands. On 01/26/2021 at 5:29 p.m., the administrator stated gloves did not take the place of hand hygiene during meal pass. She stated when you touched something dirty with gloves on, the gloves should be removed and hand hygiene performed.

Based on interview and record review, it was determined the facility failed to ensure care plans were developed and implemented for three (#78, #81, and #83) of five sampled residents who were reviewed for behaviors/antipsychotic medications. The facility identifed 17 residents received antipsychotic medications. Findings: A facility policy, titled [MEDICAL CONDITION] Medication Policy and Procedure for Residents with Dementia, documented, .[MEDICAL CONDITION] medications include: anti anxiety/hypnotic, antipsychotic and antidepressant classes of drugs .Nursing .Will monitor for the presence of target behaviors on a daily basis charting by exception ( .charting only when the behaviors are present) .May develop behavioral care plans . 1. Resident #83 had [DIAGNOSES REDACTED]. A physician's telephone order, dated 08/03/18, documented, .Increase [MEDICATION NAME] to 2mg PO daily .BPSD . The care plan, dated 08/22/18, did not include the resident exhibited behaviors or the use of the antipsychotic medication, [MEDICATION NAME], as a focused area with a goal and specific interventions to implement for the use of the antipsychotic medication, [MEDICATION NAME]. On 12/18/18 at 11:30 a.m., the care plan coordinators were asked why there was not a care plan for the behaviors/antipsychotic medication. Care plan coordinator #1 stated she would have to check the care plan but did not think the behavior/use of antipsychotic medication was on the care plan as a problem/focus area. At 3:00 p.m., care plan coordinator #1 stated there was a lack of communication between staff and the care plan had not been developed/implemented regarding behaviors/antipsychotic medications as a problem/focus area. 2. Resident #81 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 25mg 2 tabs po TID BPSD . The behavior monitoring sheets for the months of September, October, November, and (MONTH) (YEAR) did not address the specific targeted behaviors that were to be monitored and did not address the interventions to implement when a behavior was exhibited. There was no behavior monitoring care plan to address the specific targeted behaviors or the interventions to be implemented when a behavior was exhibited. On 12/18/18 at 11:34 a.m., the DON and care plan coordinator #1 were asked if there was a behavior care plan to address the specific targeted behaviors for the use of the antipsychotic medication, [MEDICATION NAME], and the interventions to be implemented when a behavior was exhibited. At 2:03 p.m., the DON brought in some care plans. She was asked if they had a behavior care plan to address the specific targeted behaviors for the use of the antipsychotic medication. She stated, No. The care plan coordinator was asked if there was a behavior care plan. She stated, I thought I did. 3. Resident #78 had [DIAGNOSES REDACTED]. The monthly physician orders, dated (MONTH) (YEAR), documented, .[MEDICATION NAME] 0.25 mg tablet (1 tab) oral hour of sleep .Major [MEDICAL CONDITION], single episode . There was no behavior care plan, to address the specific targeted behaviors for the use of the antipsychotic medication, [MEDICATION NAME] and the interventions to implement if the behavior occurred. On 12/18/18 at 11:56 a.m., the DON was asked what specific targeted behaviors the staff were monitoring. She stated, I don't know. Care plan coordinator #1 was asked what non pharmacological interventions were in place for the antipsychotic medication, [MEDICATION NAME]. She stated, I'll have to look. She was asked why the care plan did not address behaviors for the use of the antipsychotic medication, [MEDICATION NAME]. She stated, I'll have to look. It may be under a different problem. At 2:45 p.m., documentation was received from the DON and care plan coordinators. The behavior care plan was not provided. At 3:11 p.m., care plan coordinator #1 was asked why the behaviors were not care planned. She responded, I thought I had done it.

Based on observation, interview, and record review, it was determined the facility failed to cook unpasteurized eggs to a safe temperature for 4 (#13, #14, #15, and #16) of 4 sampled residents who received soft cooked unpasteurized eggs. This had the potential to affect 9 facility residents who received unpasteurized soft cooked eggs. Findings: The facility's policies and procedures for food handling guidelines included the following: "Fresh shell eggs that are not pasteurized are used only for hard cooked, fried or hard poached eggs and must be cooked for immediate service to a minimum internal temperature of 145 (degrees) F (Fahrenheit) for 15 seconds." 1. Resident #16 had a birthdate of 04/25/35 and was admitted on [DATE] with [DIAGNOSES REDACTED]. On 12/08/10 at 7:29 a.m., resident #16 was observed to have two soft poached eggs on her plate. The yolks were liquid and had ran onto the plate. The resident was asked how long she had her plate. She stated she had just gotten it. The resident was taking her sausage link and dipping it into the egg yolk. At that time chef #1 was asked if the soft cooked eggs were unpasteurized. He stated yes because that was all they had. The surveyor told the chef at that time to replace the soft cooked eggs with hard cooked eggs. The two soft cooked eggs on her plate were checked and found to be 75 degrees F. There were five soft cooked poached eggs still in the pans that had just been pulled from the steam table. The temperature of the eggs were 81 degrees F at that time. 2. Resident #13, [AGE] years old, was readmitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. The vital sign and weight flow sheet documented the resident weighed 186 pounds on 10/19/10. The November 2010 treatment administration record documented the resident's weight to be 159 pounds on 11/29/10. A nursing note, dated 11/30/10 at 10:00 p.m., documented the resident had a deep congested cough and was ordered an antibiotic by the physician. On 12/08/10 at 7:29 a.m., the resident was observed at the dining room table. A soft fried egg yolk was on her plate. At 12/08/10 at 7:25 a.m., chef #1 was asked if he knew the required temperature and length of time to hard cook an unpasteurized egg. He stated he could not recall. The chef was asked how he usually cooked the unpasteurized eggs. He stated he usually cooked them medium to hard, but would cook them hard in the future. The chef was asked if he took the temperature of the eggs before serving them. He stated that he had and the temperature was 197 degrees Fahrenheit. At that time the trayline temperature record was reviewed. The poached eggs were documented to be 197 degrees Fahrenheit. 3. Resident #15 had a birthdate of 11/06/21 and was admitted on [DATE] with [DIAGNOSES REDACTED]. On 12/08/10 at 7:45 a.m., the resident was observed in the assistive dining room. The resident had been served 2 soft poached eggs and was in the process of eating the eggs. At this time, the surveyor requested the resident's tray to be replaced with hard cooked eggs. 4. Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 12/08/10 at 8:00 a.m., the resident was in her room with her breakfast tray. The resident had 2 soft poached eggs on her plate. The resident had only taken a few bites of the whites of the eggs. Immediate Jeopardy Identified On 12/08/10, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to hard cook unpasteurized eggs to the required 145 degrees Fahrenheit for 15 seconds. The Oklahoma State Department of Health (OSDH) verified the existence of the Immediate Jeopardy at 9:04 a.m. regarding the unsafe cooking of unpasteurized eggs. At 9:10 a.m., the facility's Administrator was informed of the existence of the Immediate Jeopardy. At 10:45 a.m., the facility submitted a plan of removal. The Plan of Removal documented: "Problem: Unpasteurized eggs, not fully cooked to 145 degrees were served to 5 residents. Plan of Correction: To immediately correct this situation in order to prevent potential for serious illness, all unpasteurized eggs were immediately disposed of. Pasteurized eggs will be obtain (sic) today 12/08/2010. Dining Service Staff members will undergo extensive training on purchasing eggs, storing eggs, cooking eggs, and serving eggs at 1300 hours today 12/08/2010. All 5 residents will be monitored for the next 48 hours for signs and symptoms of abdominal pain, colicky abdominal pain, nausea, vomiting, diarrhea, bloody diarrhea, or fever. None of the 5 residents currently exhibit any symptoms of adverse reaction to eating the eggs. Registered Dietician, and Dietary Manager will monitor weekly to ensure only pasteurized eggs are purchased for future use. Nutritional Service Policy on food handling guidelines has now been amended to say that Baptist Village of Owasso will only purchase pasteurized shell eggs." At 10:54 a.m., the Immediate Jeopardy plan of removal was accepted. Immediate Jeopardy Removed On 12/08/10 at 2:00 p.m., the Immediate Jeopardy was removed, although the deficient practice remained at no actual harm with potential for more than minimal harm for more than a very limited number of residents. It was observed the facility had removed all unpasteurized eggs from the facility and had obtained pasteurized whole shell eggs to use for fried and poached eggs. Inservice related to the safe cooking and holding temperatures of eggs was completed by all dietary staff. Monitoring tools were put in place for each resident who had been served soft cooked unpasteurized eggs. The facility's policy and procedure was amended to ensure only pasteurized whole shell eggs would be purchased. On 12/09/10 at 1:30 p.m., an interview was conducted with the Certified Dietary Manager (CDM) regarding the trayline temperature record having documentation of the soft cooked poached eggs as 197 degrees Fahrenheit. The CDM stated he had determined the chef had taken the temperature of the egg white instead of the egg yolk. The CDM stated the egg white was thin and the thermometer probe probably touched the bottom of the cooking pan.