Every finding on record at Beacon Ridge

Based on record review and interview, the facility failed to effectively manage pain for 1 (#3) of 1 sampled resident reviewed for pain management. The DON identified 55 residents resided in the facility.Findings: An admit form for Resident #3, dated 07/17/23, showed the resident had diagnoses which included cerebral palsy, migraines, and chronic pain. A physician's order for Resident #3, dated 10/12/24, showed Tylenol (an analgesic) oral tablet 325 mg, give two tablets orally every four hours as needed for pain. A care plan for Resident #3, dated 01/27/25 read in part, resident had chronic pain r/t [related to] cerebral palsy. Interventions included repositioning, administer in analgesia, evaluate the effectiveness of the pain interventions after medication is administered, monitor/document for side effects of pain medication, monitor/document for side effects of pain medication, monitor/record/report to nurse any s/sx [signs/symptoms] of non-verbal pain, observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM [range of motion], withdrawal or resistance to care. A quarterly assessment for Resident #3, dated 04/25/26, showed the resident was cognitively intact with a brief interview for mental status of 15. A physician's order for Resident #3, dated 04/01/26, showed Zanaflex (a muscle relaxer) oral capsule 2 mg, give two by mouth three times a day for muscle spasms. A physician's order, dated 05/21/26, showed Ultram (an analgesic) 50 mg, give 50 mg by mouth every eight hours as needed for pain. On 05/21/26 at 8:30 a.m., Resident #3 stated they were recently in the hospital for abdominal pain. Resident #3 stated they also had back pain which they had Tylenol, but it did not work. Resident #3 stated they did not know why there was nothing stronger ordered for pain. Resident #3 stated when they went to the hospital, they were given oxycodone (an opioid analgesic), and it helped. On 05/21/26 at 8:51 a.m., LPN #1 stated Resident #3 had Tylenol and Zanaflex ordered for pain. LPN #1 stated If Tylenol did not work the resident would ask to be sent to the hospital. LPN #1 stated the resident would be asked what their pain level was before taking pain medication. LPN #1 stated they asked Resident #3 what their pain level was after taking the pain medication and documented it on the resident's medication administration record. On 05/21/26 at 10:15 a.m., the DON stated on 11/10/25, 04/13/26, 04/22/26, and 05/13/26 Resident #3 was sent to the hospital for pain. The DON stated chronic pain was care planned, but the pain was not being effectively managed. The DON stated they did not know why Resident #3's pain was not being effectively managed, but they should have been on something stronger than Tylenol. On 05/22/26 at 10:00 a.m., Resident #3 stated they were having pain rated at an 8 out of 10 on the pain scale. Resident #3 stated the Tylenol did not help much, but repositioning to the left side relieved their pain. Resident #3 stated a pain of 3 out of 10 was acceptable. Resident #3 stated they would like to have oxycodone for the pain because it was effective. On 06/27/26 at 1:00 p.m., the medical director stated on 05/21/26, they ordered Ultram 50 mg every six hours for pain for Resident #3. The medical director stated if the Ultram did not relieve the pain, they would order something stronger. The medical director stated they did not know why something stronger had not been ordered previously.

Based on record review and interview, the facility failed to: a. give 30 days notice in writing of the resident's planned transfer/discharge to the resident/representative; b. send a copy of the notice of transfer/discharge to the ombudsman's office; c. provide the resident with a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which received such requests; d. provide information on how to obtain an appeal form; e. assist the resident in completing the form and submitting the appeal hearing request; f. provide the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities; and g. the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder for one (#1) of three sampled residents whose clinical records were reviewed for transfer/discharge requirements. The facility admission/discharge list documented four residents who were transferred to the hospital since 10/01/24. Findings: The facility policy, titled Transfer or Discharge, Facility-Initiated and dated October 2022, read in parts, Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility .When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility .Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care ombudsman .Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. If discharge is initiated by the facility after an emergency tranfers to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). If the facility does not permit a resident's return to the facility based on inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Notice of the Office of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and resident representative. If a resident chooses to appeal a discharge, the facility will not discharge residents while the appeal is pending. If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility. Resident #1 had diagnoses which included fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder. A nurse's progress note, dated 12/05/24, documented the resident was admitted to the facility from another nursing home, was pleasant, and was alert and oriented to person, place, time, and situation. The note documented the resident requested and received a tour of the facility. A nurses' progress note, dated 12/11/24, read in part, Call from [local hospital #1] on resident for information on why [they] went to the hospital. Resident refused treatment or to sign consent [for facility] to treat. Resident wanted to leave facility and no longer be here. Resident refusing care at this facility and has been aggressive both physically and sexually to staff. Resident assaulted staff by hitting [them] with a wooden sign. Resident is a danger to staff and other residents. Resident refusing care causes resident to be a danger to [themselves]. Nurse will relay message to the doctor. A nurse's note, dated 12/12/24, read in part, [Local ambulance service] brought [Resident #1] back to facility without report being called from [local hospital #1]. This facility has no right to treat [Resident #1] or make [Resident #1] stay as [Resident #1] expressed before leaving facility, Resident is a danger to staff and [themselves] as [themselves] has physically assaulted staff and refusing to consent to be treated poses a threat to [Resident #1's] health. Resident stated [they] wanted to go to [local hospital #2]. [Local ambulance service] called back and spoke with ADON and this nurse. Social worker at [local hospital #2] was notified by this nurse of situation with resident. Social worker stated [they] will call back after discussing situation with doctor and advised nurse this person usually goes to [satellite location for local hospital #2], not Tulsa. The nurse's note, dated 12/12/24, read in parts, Call back from Social Worker .[Social worker] wants to know if we will accept [Resident #1] back if [they] will sign consents and paperwork to treat at this facility. Informed social worker of inappropriate behavior, assaulting staff both physically and sexually, and assaulted [local ambulance service] staff when transferring, which is unlawful. Social worker will reach out to [their] DHS contact and would like to know if it is possible to send [Resident #1] back or if other arrangements need to be made. Informed SW I would send message to DON. Message sent to DON with phone number of SW. On 01/14/24 at 3:11 p.m., the ambulance service director was asked if the ambulance service transported Resident #1 on 12/11/24. The director stated the ambulance service transported the resident from hospital #1 back to the facility. The director stated it was a bitterly cold night and the resident was lightly clothed and strapped to a gurney. The director stated the facility staff refused to open the door and allow the resident and staff to enter the facility and discuss the situation. The director stated neither they nor the resident were informed of why the facility would not accept the resident back nor were they provided any paperwork from the facility. The director stated they had to transport the resident to another local hospital. On 01/24/25 at 3:15 p.m., LPN #1 stated when a resident was transferred/discharged to the hospital, the nurse was responsible for filling out the transfer packet. The LPN stated they read the forms to the resident before they were transferred, but the resident did not receive a copy of the forms and nothing was sent with the resident or ambulance personnel. The LPN stated the first form was a notice of transfer or discharge and documented where the resident was to transfer/discharge, the reason for the transfer or discharge, and the option for the resident to have their bed held. The LPN stated the second form was a check list of responsibilities for the nurse to complete prior to the resident's transfer/discharge. The LPN stated the third form was a certificate of medical necessity for emergency ambulance transport. The LPN stated the fourth, fifth, and sixth forms in the packet were not used. A review of the fourth form revealed it documented the resident had a right to appeal the decision to tranfers and provided the resident with an old address and contact information for the State Department of Health Long Term Care Division and the ombudsman's contact information. The fifth form was another facility check off list documenting the nurses' responsibilities with each resident transfer/discharge. The sixth form was another certificate of medical necessity to transport via ambulance. On 01/24/25 at 3:30 p.m., the social service director stated Resident #1 refused to sign the facility's consent to treat form and wished to go to a local company which worked directly with residents with intellectual disabilities. The social service director stated they had not contacted DHS Department of Developmental Disabilities nor contacted the local company to determine if a transfer was possible. The social service director stated they were not involved in the resident's transfer to the hospital and did not provide the resident with the discharge or bed-hold policy. On 01/24/25 at 3:45 p.m., the administrator stated Resident #1 did not want to live in the facility and instead wished to move to a local company that provided services to individuals with intellectual disabilities. The administrator stated the resident refused care and would not sign the facility's consent to treat form. The administrator denied contacting DHS and making a referral for services for a resident with intellectual disabilities nor contacting the local company which provided such services. The administrator was asked to provide documentation the facility assisted the resident with transferring to the local company for individuals with intellectual disabilities, documentation of the interventions attempted or used to encourage the resident's cooperation with care, what referrals were made on the resident's behalf, and who the facility contacted to help encourage the resident to cooperate with care (i.e. physician, psychiatric consult, ombudsman). The administrator reviewed the clinical record and stated there was no documentation to support any referrals were made or anyone was contacted/interventions changed to encourage the resident to cooperate with care. The administrator was asked to provide documentation the facility: a. provided the resident with a 30 days notice in writing of the resident's planned transfer/discharge to the resident/representative; b. sent a copy of the notice of transfer/discharge to the Ombudsman's office; c. provided the resident with a statement of the resident's appeal rights; d. provided information on how to obtain an appeal form; e. assisted the resident in completing the form and submitting the appeal hearing request; f. provided the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities; and g. provided the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. On 01/24/25 at 4:45 p.m., the administrator stated there was no such documentation in the resident's clinical record. The administrator stated they needed to in-service staff on the facility transfer/discharge/bed-hold policies and revise their transfer/discharge packets to ensure policies were followed and residents received the appropriate paperwork.

Based on record review and interview, the facility failed to provide the bed-hold policy to one (#1) of three sampled residents who were transferred to the hospital. The facility admission/discharge list documented four residents who were transferred to the hospital since 10/01/24. Findings: The facility policy, titled Bed-Holds and Returns and dated October 2022, read in parts, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice .notice 1: well in advance of any transfer (e.g. in the admission packet); and notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). Resident #1 had diagnoses which included fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder. A nurse's progress note, dated 12/05/24, documented the resident was admitted to the facility from another nursing home, was pleasant, and was alert and oriented to person, place, time, and situation. The note documented the resident requested and received a tour of the facility. A nurses' progress note, dated 12/11/24, read in part, Call from [local hospital #1] on resident for information on why [they] went to the hospital. Resident refused treatment or to sign consent to treat. Resident wanted to leave facility and no longer be here. Resident refusing care at this facility and has been aggressive both physically and sexually to staff. Resident assaulted staff by hitting [them] with a wooden sign. Resident is a danger to staff and other residents. Resident refusing care causes resident to be a danger to [themselves]. Nurse will relay message to the doctor. A nurse's note, dated 12/12/24, read in part, [Local ambulance service] brought [Resident #1] back to facility without report being called from [local hospital #1]. This facility has no right to treat [Resident #1] or make [Resident #1] stay as [Resident #1] expressed before leaving facility, Resident is a danger to staff and [themselves] as [themselves] has physically assaulted staff and refusing to consent to be treated poses a threat to [Resident #1's] health. Resident stated [they] wanted to go to [local hospital #2]. [Local ambulance service] called back and spoke with ADON and this nurse. Social worker at [local hospital #2] was notified by this nurse of situation with resident. Social worker stated [they] will call back after discussing situation with doctor and advised nurse this person usually goes to [satellite location for local hospital #2], not Tulsa. The nurse's note, dated 12/12/24, read in parts, Call back from Social Worker .[Social worker] wants to know if we will accept [Resident #1] back if [they] will sign consents and paperwork to treat at this facility. Informed social worker of inappropriate behavior, assaulting staff both physically and sexually, and assaulted [local ambulance service] staff when transferring, which is unlawful. Social worker will reach out to [their] DHS contact and would like to know if it is possible to send [Resident #1] back or if other arrangements need to be made. Informed SW I would send message to DON. Message sent to DON with phone number of SW. On 01/14/24 at 3:11 p.m., the ambulance service director was asked if the ambulance service transported Resident #1 on 12/11/24. The director stated the ambulance service transported the resident from hospital #1 back to the facility. The director stated it was a bitterly cold night and the resident was lightly clothed and strapped to a gurney. The director stated the facility staff refused to open the door and allow the resident and staff to enter the facility and discuss the situation. The director stated neither they nor the resident were informed of why the facility would not accept the resident back nor were they provided any paperwork from the facility. The director stated they had to transport the resident to another local hospital. On 01/24/25 at 3:15 p.m., LPN #1 stated when a resident was transferred/discharged to the hospital, the nurse was responsible for filling out the transfer packet. The LPN stated they read the forms to the resident before they were transferred, but the resident did not receive a copy of the forms and nothing was sent with the resident or ambulance personnel. The LPN stated the first form was a notice of transfer or discharge and documented where the resident was to transfer/discharge, the reason for the transfer or discharge, and the option for the resident to have their bed held. The LPN stated the second form was a check list for the nurse to complete prior to the resident's transfer/discharge. The LPN stated the third form was a certificate of medical necessity for emergency ambulance transport. The LPN stated the fourth, fifth, and sixth forms in the packet were not used. A review of the fourth form revealed it documented the resident had a right to appeal the decision to tranfers and provided the resident with an old address and contact information for the State Department of Health Long Term Care Division and the ombudsman's contact information. The fifth form was another facility check off list documenting the staffs responsibilities with each resident transfer/discharge. The sixth form was another certificate of medical necessity to transport via ambulance. On 01/24/25 at 3:30 p.m., the social service director stated Resident #1 refused to sign the facility's consent to treat form and wished to go to a local company which worked directly with residents with intellectual disabilities. The social service director stated they had not reach out to the local company to determine if a transfer was possible. The social service director stated they were not involved in the resident's transfer to the hospital and did not provide the resident with the discharge or bed-hold policy. The social service director stated they were new to the position and did not know they needed to chart in the clinical record. On 01/24/25 at 3:45 p.m., the administrator stated Resident #1 did not want to live here and instead wished to move in with a local company that provided services to individuals with intellectual disabilities. The administrator stated the resident refused care and would not sign the facility's consent to treat form. The administrator was asked to provide documentation the facility assisted the resident with transferring to the local company for individuals with intellectual disabilities, documentation of the interventions attempted or used to encourage the resident's cooperation with care, what referrals were made on the resident's behalf, and who the facility contacted to help encourage the resident to cooperate with care (i.e. physician, psychiatric consult, ombudsman). The administrator reviewed the clinical record and stated there was no documentation to support any referrals were made or anyone was contacted/interventions changed to encourage the resident to cooperate with care. The administrator was asked to provide copies of the discharge and bed-hold policies provided to Resident #1 and documentation the resident's representative, ombudsman, and the State LTC office were notified of the discharge. On 01/24/25 at 4:45 p.m., the administrator stated there was no documentation the resident received the proper policies nor of the ombudsman or State LTC office being notified of the discharge. The administrator stated they needed to in-service staff on the facility transfer/discharge/bed-hold policies and revise their transfer/discharge packets to ensure residents received the appropriate paperwork.

Based on record review and interview, the facility failed to allow one (#1) of three sampled residents who were transferred to the hospital to return to the facility. The facility admission/discharge list documented four residents who were transferred to the hospital since 10/01/24. Findings: The facility policy, titled Transfer or Discharge, Facility-Initiated and dated October 2022, read in parts, Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility .When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility .If discharge is initiated by the facility after an emergency tranfers to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). If the facility does not permit a resident's return to the facility based on inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Notice of the Office of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and resident representative. If a resident chooses to appeal a discharge, the facility will not discharge residents while the appeal is pending. If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility. Resident #1 had diagnoses which included fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder. A nurse's progress note, dated 12/05/24, documented the resident was admitted to the facility from another nursing home, was pleasant, and was alert and oriented to person, place, time, and situation. The note documented the resident requested and received a tour of the facility. A nurses' progress note, dated 12/11/24, read in part, Call from [local hospital #1] on resident for information on why [they] went to the hospital. Resident refused treatment or to sign consent to treat. Resident wanted to leave facility and no longer be here. Resident refusing care at this facility and has been aggressive both physically and sexually to staff. Resident assaulted staff by hitting [them] with a wooden sign. Resident is a danger to staff and other residents. Resident refusing care causes resident to be a danger to [themselves]. Nurse will relay message to the doctor. A nurse's note, dated 12/12/24, read in part, [Local ambulance service] brought [Resident #1] back to facility without report being called from [local hospital 1]. This facility has no right to treat [Resident #1] or make [Resident #1] stay as [Resident #1] expressed before leaving facility, Resident is a danger to staff and [themselves] as [themselves] has physically assaulted staff and refusing to consent to be treated poses a threat to [Resident #1's] health. Resident stated [they] wanted to go to [local hospital #2]. [Local ambulance service] called back and spoke with ADON and this nurse. Social worker at [local hospital #2] was notified by this nurse of situation with resident. Social worker stated [they] will call back after discussing situation with doctor and advised nurse this person usually goes to [satellite location for local hospital #2], not Tulsa. The nurse's note, dated 12/12/24, read in parts, Call back from Social Worker .[Social worker] wants to know if we will accept [Resident #1] back if [they] will sign consents and paperwork to treat at this facility. Informed social worker of inappropriate behavior, assaulting staff both physically and sexually, and assaulted [local ambulance service] staff when transferring, which is unlawful. Social worker will reach out to [their] DHS contact and would like to know if it is possible to send [Resident #1] back or if other arrangements need to be made. Informed SW I would send message to DON. Message sent to DON with phone number of SW. On 01/24/25 at 3:15 p.m., LPN #1 stated when a resident was transferred/discharged to the hospital, the nurse was responsible for filling out the transfer packet. The LPN stated they read the forms to the resident before they were transferred, but the resident did not receive a copy of the forms and nothing was sent with the resident or ambulance personnel. The LPN stated the first form was a notice of transfer or discharge and documented where the resident was to transfer/discharge, the reason for the transfer or discharge, and the option for the resident to have their bed held. The LPN stated the second form was a check list for the nurse to complete prior to the resident's transfer/discharge. The LPN stated the third form was a certificate of medical necessity for emergency ambulance transport. The LPN stated the fourth, fifth, and sixth forms in the packet were not used. A review of the fourth form revealed it documented the resident's right to appeal the decision to tranfers and provided the resident with an old address and contact information for the State Department of Health Long Term Care Division and the ombudsman's contact information. The fifth form was another facility check off list documenting the staffs responsibilities with each resident transfer/discharge. The sixth form was another certificate of medical necessity to transport via ambulance. On 01/24/25 at 3:30 p.m., the social service director stated Resident #1 refused to sign the facility's consent to treat form and wished to go to a local company which worked directly with residents with intellectual disabilities. The social service director stated they had not reach out to the local company to determine if a transfer was possible nor contacted DHS. The social service director stated they were not involved in the resident's transfer to the hospital and did not provide the resident with the discharge or bed-hold policy. The social service director stated they were new to the position and did not know they were to chart in the resident's clinical records until after the resident had discharged . On 01/24/25 at 3:45 p.m., the administrator stated Resident #1 did not want to live in the facility and instead wished to move to a local company that provided services to individuals with intellectual disabilities. The administrator stated the resident refused care and would not sign the facility's consent to treat form. The administrator denied contacting DHS, making a referral for services for a resident with intellectual disabilities, nor contacting the local company which provided such services. The administrator was asked to provide documentation the facility followed their policies and provided the resident with the information to appeal his discharge, assisted the resident in obtaining the forms, and provided the resident with the appropriate contact information to appeal the decision with OSDH. The administrator was asked to provide documentation the resident/resident's representative, ombudsman, and the State LTC office were notified of the discharge and when the individual entities were notified. On 01/24/25 at 4:45 p.m., the administrator stated there was no such documentation in the resident's clinical record. The administrator stated they needed to in-service staff on the facility transfer/discharge/bed-hold policies and revise their transfer/discharge packets to ensure policies were followed and residents received the appropriate paperwork.

Based on record review and interview, the facility failed to ensure residents were offered the right to formulate an advanced directive for three (#7, 32, and #107) of six sampled residents reviewed for advance directives. The DON identified 57 residents resided in the facility. Findings: 1. Res #107 was admitted to the facility on [DATE]. Res #107's medical record did not contain an advanced directive or an advanced directive acknowledgement form. 2. Res #32 was admitted to the facility on [DATE]. Res #32's medical record did not contain an advanced directive or an advanced directive acknowledgement form. 3. Res #7 was admitted to the facility on [DATE]. Res #7's medical record did not contain an advanced directive or an advanced directive acknowledgement form. On 11/21/24 at 8:40 a.m., the corporate nurse stated the forms were not completed.

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of abuse. The DON identified 57 residents resided in the facility. Findings: A facility Abuse, Neglect, and Exploitation policy, dated 2024, read in part, An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. The policy also read 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, or exploitation, and/or mistreatment has occurred, the extent, and cause, and; 6. Providing complete and thorough documentation of the investigation. A facility reported incident, dated 10/04/24, documented an allegation of abuse. The report to OSDH did not include supplemental documentation regarding an investigation. On 11/19/24 at 10:34 a.m., the administrator stated they were responsible for investigations of abuse. They stated the investigation should include personal statements from and safe surveys. They stated there should have also been statements by those who were making the complaints/allegations. They stated inservices should be conducted with staff. Regarding the incident on 10/04/24, they stated they were unable to find the documentation of an investigation.

Based on record review and interview, the facility failed to complete quarterly MDS assessments timely for three (#13, 20, and #31) of five sampled residents reviewed for MDS assessment completion. The DON identified 57 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated October 2024, documented quarterly assessments must be completed no later than 14 calendar days after the ARD. 1. Res #13 had a quarterly MDS assessment with an ARD of 10/15/24. The assessment was not completed until 11/18/24. 2. Res #20 had a quarterly MDS assessment with an ARD of 10/15/24. The assessment was not completed until 11/18/24. 3. Res #31 had a quarterly MDS assessment with an ARD of 10/14/24. The assessment was not completed until 11/12/24. On 11/19/24 at 9:30 a.m., the MDS coordinator stated the facility had been without an MDS coordinator for about five months. They stated they were aware there was an issue with completion of MDS assessments.

Based on record review and interview, the facility failed to develop a comprehensive care plan for: a. diabetic monitoring for one (#5) of five sampled residents reviewed for unnecessary medications; b. ADLs for one (#47) of three sampled residents reviewed for ADLs; c. pressure ulcers for one (#17) of two sampled residents reviewed for pressure ulcers, and d. psychotropic medications and diagnosis of psychosis for one (#31) of five sampled residents reviewed for unnecessary medications. The DON identified 57 residents who resided in the facility. Findings: 1. Res #5 was admitted to the facility with diagnoses which included type II diabetes mellitus and atrial fibrillation. A physician order, dated 08/22/24, documented to administer insulin glargine 10 units subcutaneously at bedtime for type II diabetes mellitus. A physician order, dated 08/22/24, documented to obtain FSBS and administer insulin lispro per sliding scale before meals for type II diabetes mellitus. A physician order, dated 08/22/24, documented to administer metformin (hypoglycemic medication) 500 mg two tablets twice daily for type II diabetes mellitus. A physician order, dated 08/22/24, documented to administer apixaban (anticoagulant medication) 5 mg twice daily for atrial fibrillation. A physician order, dated 09/02/24, documented to monitor for signs/symptoms of bleeding. An admission assessment, dated 09/04/24, documented the resident was cognitively intact and received insulin, hypoglycemic medication, and anticoagulant medication. A care plan, reviewed 11/20/24, had no documentation of diabetic monitoring or anticoagulant therapy. On 11/20/24 at 12:01 p.m., the corporate nurse stated diabetic monitoring and anticoagulant therapy should have been documented on Res #5's care plan. 46387 2. Res #47 had diagnoses which included shortness of breath, weakness, and chronic kidney disease. A care plan, revised on 11/01/24, did not document ADLs. On 11/19/24 at 11:58 a.m., the MDS coordinator stated ADLs should be care planned. They were asked to review Res #47's care plan and stated they could not say ADLs were documented. 43023 3. Res #17 was admitted to the facility with diagnoses which included of chronic kidney disease, HTN, and chronic pain syndrome. A skin assessment, dated 11/11/24, documented a new open area to the sacrum. A review of the resident's record did not document a care plan had been developed for the pressure ulcer. 4. Res #31 admitted to the facility with diagnosis which included unspecified psychosis. A physician's order, dated 02/06/24, documented Risperdal (antipsychotic medication) 1 mg twice a day. A care plan, dated 11/03/24, contained no documentation for unspecified psychosis or antipsychotic medication therapy. On 11/20/24 at 12:06 p.m., the corporate nurse stated the psychosis diagnosis and the antipsychotic medication should have been care planned.

Based on observation, record review, and interview, the facility failed to: a. perform an entrapment risk assessment for four (#3, 5, 14, and #44); b. obtain a physician order for one (#3); d. obtain an informed consent for four (#3, 5, 14, and #44); and e. develop a care plan for side rail use for two (#3 and #14) of four sampled residents reviewed for accident hazards. The DON identified 13 residents whose beds were equipped with a bed rail of any type. Findings: An undated Proper Use of Bed Rails policy, read in parts, As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: medical diagnosis, behavioral symptoms, size and weight, sleep habits, medications, acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, cognition, communication, mobility, risk of falling .The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself .Informed consent from the resident or resident representative must be obtained prior to installation and use of bed rails .Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail .The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan .A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail. 1. Res #3 was admitted to the facility with diagnoses which included morbid obesity, muscle weakness, and reduced mobility. An admission assessment, dated 08/10/23, documented the resident was cognitively intact and required limited one person assistance with bed mobility and transfer. There was no documentation of an entrapment risk assessment, informed consent, or physician order for bed rails found in the medical record. There was no documentation of bed rail use in Res #3's care plan. On 11/18/24 at 11:52 a.m., Res #3 was observed lying in bed. Bilateral Halo bed rails were observed on the upper portion of the bed. Res #3 stated they used the rails to assist staff with turning them. 2. Res #5 was admitted to the facility with diagnoses which included weakness, pain, and insomnia. A care plan, dated 09/02/24, documented U rails on bed to assist with turning. An admission assessment, dated 09/04/24, documented the resident was cognitively intact, impaired on one side of upper body, and required substantial to maximum assistance with bed mobility. A physician order, dated 09/05/24, documented the resident could use bedside rails for positioning and mobility. The order documented 1/8 rails on both sides of the bed for positioning. There was no documentation of resident and/or representative informed consent for side rails found in the medical record. On 11/18/24 at 12:31 p.m., Res #5 was observed lying in bed. Bilateral half rails were observed on the upper portion of the bed. Res #5 stated the rails were utilized for positioning. 3. Res #44 was admitted to the facility with diagnoses which included muscle weakness, lack of coordination, and reduced mobility. An admission assessment, dated 10/04/21, documented the resident was cognitively intact and required extensive assistance with bed mobility. A care plan, dated 10/18/21, documented U rails on both sides of the bed to assist with positioning. A physician order, dated 11/23/21, document U rails times two for self-positioning. A bed rail entrapment risk assessment, dated 06/27/22, documented use of side rails. There was no documentation of an entrapment risk assessment since June 2022. There was no documentation of resident and/or representative informed consent for side rails found in the medical record. On 11/18/24 at 12:21 p.m., Res #44 was observed lying in bed. Bilateral U rails were observed on the upper portion of the bed. Res #44 stated the bed rails were used for turning in bed. On 11/19/24 11:00 a.m., LPN #1 stated a physician order was required prior to installation of all bed rails. LPN #1 stated they were not aware of informed consent, or a bed rail assessment having been required prior to the use of bed rails. On 11/19/24 at 11:39 a.m., the DON stated a physician order, entrapment risk assessment, and informed consent should have been completed prior to the use of bed rails for all residents in the facility. The DON stated entrapment risk assessments should have been completed quarterly and all residents with bed rails should have had the use of bed rails documented in their care plan. 43023 4. Res #14 was admitted to the facility with diagnoses which included muscle weakness and cerebral infarction. A quarterly assessment, dated 07/26/24, documented the resident's cognition was moderately intact and was dependent for all functional abilities. There was no documentation of an entrapment risk or informed consent. There was no documentation of bedrail use in Res #14's care plan. On 11/18/24 at 4:27 p.m., Res #14 was observed resting in bed with their eyes open. Half rails were observed on the upper portion of the bed. On 11/19/24 at 11:39 a.m., the DON stated a physician order, entrapment risk assessment, and informed consent should have been completed prior to the use of bed rails for all residents in the facility. The DON stated entrapment risk assessments should have been completed quarterly and all residents with bed rails should have had the use of bed rails documented in their care plan.

Based on record review and interview, the facility failed to prevent a significant medication error occurred when the incorrect dosage of medication was administered for multiple administrations of a prescribed corticosteroid (steroid) for one (#55) of four sampled residents whose medication administration records were reviewed. The ADON identified 57 residents resided in the facility. Findings: An undated Medication Errors policy, read in part, The facility shall ensure medications will be administered according to physician's orders .Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines .c. Frequency of Error: If an error is occurring repeatedly such as an omission of a resident's medication several times. Resident #55 had diagnoses that included adrenocortical insufficiency and hypothyroidism. A physician's order for Resident #55 documented they were to receive fludrocortisone (steroid) 0.1mg tab - 0.5mg (5 tabs) by mouth daily. The label on the blister pack for Resident #55's fludrocortisone 0.1mg tab documented the prescription was filled on 09/04/24 for 150 tabs. A notation on the label read in part, give 5 tablets by mouth daily. There were 71 tabs remaining from Resident #55's fludrocortisone prescription, filled 09/04/24 for 150 tabs. Only 79 pills had been given from the prescription that was issued on 09/04/24 (79 days ago). On 11/20/24 at 12:15 p.m., CMA #1 was asked how many tablets of fludrocortisone they had administered to Resident #55 during the morning medication pass. They stated one. CMA #1 was asked to read the notation on the fludrocortisone blister pack and stated, I did not notice that notation there. We have always given [Resident #55] one tab. Usually if the dose is more than one tab it is highlighted. On 11/20/24 at 3:30 p.m., the corp nurse was informed of the observations described above. They were asked how long Resident #55's fludrocortisone prescription, filled on 09/04/24 for 150 tabs, would have lasted if the resident had been given 5 tabs daily as ordered. They stated 30 days. The corp nurse was asked if the refill date on the fludrocortisone and the number of pills given from the prescription to date, were an indication that Resident #55 had received the medication as ordered from 09/04/24 to 11/20/24. They stated no and acknowledged a significant medication error had occurred. On 11/21/24 at 9:03 a.m., Pharm Tech verified the last refill of fludrocortisone 0.1mg tab - 150 tabs was sent to the facility on [DATE].

Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety and dishes were sanitized prior to use. The DON identified 57 residents resided in the facility and received services from the kitchen. Findings: An initial tour of the kitchen was conducted on 11/18/24 at 10:39 a.m. The following observations were made: a. an open bottle of nectar thickened water with lemon, dated open on 11/07/24. The label on the container documented to discard after 10 days of opening; b. an open bottle of nectar thickened orange juice, dated open 11/03/24. The label on the container documented to discard after 10 days of opening; c. an open bottle of honey thickened orange juice, not dated when opened; d. an open bottle of honey thickened milk, dated open on 11/07/24. The label on the container documented to discard after four days of opening; e. an open bottle of honey thickened orange juice, not dated when opened; and d. the walk in freezer door was observed with ice accumulation on the outside of the seal to the door. Upon opening the door icicles were observed hanging above the door frame. An accumulation of ice was on the inside of the door as well as ice was on the outside of boxes stored in the freezer. There was a layer of ice on the floor of the freezer and the back wall had ice hanging from the cooling fans. On 11/18/24 at 10:40 a.m. an initial test of dish machine sanitation was conducted. The chlorine strips had no reaction. On 11/18/24 at 10:44 a.m., a second test of dish machine sanitation was conducted with the same results. On 11/18/24 at 10:45 a.m., the DM stated the dish machine was tested daily for sanitation. The DM was observed performing a chlorine test with no reaction. They stated they would have to serve on paper and call the dish machine people. On 11/18/24 at 10:55 a.m., the DM was shown the walk in freezer and stated corporate had ordered the part, but it had not come in yet. On 11/18/24 at 10:57 a.m., the DM was shown the thickened liquids. They stated they should have been thrown out already.

Based on record review and interview, the facility failed to maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. The DON identified 57 residents who resided in the facility. Findings: A Legionella Water Management policy, revised September 2022, read in part, As part of the infection control prevention and control program, our facility has a water management program, which is overseen by the water management team .The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .The water management program includes the following elements: an interdisciplinary water management team, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situations that could lead to Legionella growth, specific measures used to control the introduction and/or spread of Legionella, and documentation of the program. No documentation regarding maintenance of a water management program was found from record review. On 11/20/24 at 11:24 a.m., the maintenance supervisor was asked to provide documentation of water management procedures. The maintenance supervisor stated they had never heard of a water management program to reduce the risk and growth of Legionella. They stated they had not monitored the water system for Legionella per the policy and had never been educated to perform this task. On 11/20/24 at 12:07 p.m., the corporate nurse stated the facility had not maintained a water management program.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four (#3, 5, 14, and #44) of four sampled residents reviewed for accident hazards. The DON identified 13 residents whose beds were equipped with a bed rail of any type. Findings: An undated Proper Use of Bed Rails policy, read in parts, If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails .The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible and ensuring that the bed's dimensions are appropriate for the resident .Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair .The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails. 1. Res #3 was admitted to the facility with diagnoses which included morbid obesity, muscle weakness, and reduced mobility. An admission assessment, dated 08/10/23, documented the resident was cognitively intact and required limited one person assistance with bed mobility and transfer. On 11/18/24 at 11:52 a.m., Res #3 was observed lying in bed. Bilateral Halo bed rails were observed on the upper portion of the bed. Res #3 stated they used the rails to assist staff with turning them. 2. Res #5 was admitted to the facility with diagnoses which included weakness, pain, and insomnia. A care plan, dated 09/02/24, documented U rails on the bed to assist with turning. An admission assessment, dated 09/04/24, documented the resident was cognitively intact, impaired on one side of upper body, and required substantial to maximum assistance with bed mobility. A physician order, dated 09/05/24, documented the resident could use bedside rails for positioning and mobility. The order documented 1/8 rails on both sides of the bed for positioning. On 11/18/24 at 12:31 p.m., Res #5 was observed lying in bed. Bilateral half rails were observed on the upper portion of the bed. Res #5 stated the rails were utilized for positioning. 3. Res #44 was admitted to the facility with diagnoses which included muscle weakness, lack of coordination, and reduced mobility. An admission assessment, dated 10/04/21, documented the resident was cognitively intact and required extensive assistance with bed mobility. A care plan, dated 10/18/21, documented U rails on both sides of the bed to assist with positioning. A physician order, dated 11/23/21, document U rails times two for self-positioning. A bed rail entrapment risk assessment, dated 06/27/22, documented use of side rails. On 11/18/24 at 12:21 p.m., Res #44 was observed lying in bed. Bilateral U rails were observed on the upper portion of the bed. Res #44 stated the bed rails were used for turning in bed. On 11/19/24 at 1:30 p.m., the DON was asked to provide documentation of regular bed rail inspections for all residents with bed rails. On 11/19/24 at 2:33 p.m., the DON stated the facility was not able to provide documentation of regular bed rail inspections and maintenance. 43023 4. Res #14 was admitted to the facility with diagnoses which included muscle weakness and cerebral infarction. A quarterly assessment, dated 07/26/24, documented the resident's cognition was moderately intact and was dependent for all functional abilities. On 11/18/24 at 4:27 p.m., Res #14 was observed resting in bed with their eyes open. Half rails were observed on the upper portion of the bed. On 11/19/24 at 1:30 p.m., the DON was asked to provide documentation of regular bed rail inspections for all residents with bed rails. On 11/19/24 at 2:33 p.m., the DON stated the facility was not able to provide documentation of regular bed rail inspections and maintenance.

Based on record review and interview, the facility failed to report an allegation of abuse to OSDH within two hours. The DON identified 57 residents resided in the facility. Findings: A facility Abuse, Neglect, and Exploitation policy, dated 2024, documented the facility was to report all allegations of abuse immediately, but no longer than two hours after the allegation was made. A facility reported incident, dated 10/16/24, documented an allegation of abuse regarding LPN #3. The incident report was not sent to OSDH until 10/17/24. On 11/19/24 at 11:58 a.m., the MDS coordinator stated the incident report should have been sent to OSDH within two hours, but was not.

Based on record review and interview, the facility failed to complete comprehensive MDS assessments within the required time frame for two (#15 and #109) of five sampled residents reviewed for MDS assessment completion. The DON identified 57 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated October 2024, documented a significant change MDS must be completed no later than the 14th calendar day after determination a significant change had occurred. The manual also documented an admission assessment must be completed no later than the 14th day of the resident's admission. 1. Res #15 had a significant change assessment with an ARD of 10/16/24, reflective of the determination date a significant change had occurred. The MDS was not completed and signed until 11/18/24. 2. Res #109 was admitted to the facility on [DATE]. A comprehensive MDS was not completed until 11/18/24. On 11/19/24 at 9:30 a.m., the MDS coordinator stated the facility had been without an MDS coordinator for about five months. They stated they were aware there was an issue with completion of MDS assessments.

Based on record review and interview, the facility failed to develop a baseline care plan within 48 hours of admission for one (#109) of five sampled residents reviewed for MDS completion. The DON identified 57 residents resided in the facility. Findings: Res #109 was admitted to the facility on [DATE]. On 11/18/24 there was no active care plan documented in the resident's chart. On 11/19/24 at 9:30 a.m., the MDS coordinator stated baseline care plans should be completed within 48 hours of admission. They stated the facility had been without a MDS coordinator for about five months. They stated they were aware there were some issues with care plans.

Based on observation, record review, and interview, the facility failed to review/revise a care plan for one (#17) of 15 sampled residents reviewed for care plans. The DON identified 57 residents resided in the facility. Findings: Res #17 was admitted to the facility with diagnoses which included chronic kidney disease, HTN, and chronic pain syndrome. A significant change assessment, dated 09/15/24, documented the resident was frequently incontinent of bladder and required partial to moderate assist with transfers. The assessment did not document the resident had an uindwelling catheter. A physician's order, dated 10/15/24, documented Hoyer lift with all transfers. On 11/18/24 at 11:40 a.m., Resident #17 was observed resting in bed with their eyes open. A catheter was observed draining to gravity at bedside. The resident's record was reviewed and the care plan had not been revised to document transfers with a lift or the catheter. On 11/20/24 at 12:03 p.m., the corporate nurse stated the care plan should have been revised to contain transfers with the lift and the catheter.

Based on observation, record review, and interview, the facilty failed to obtain a physician's order for a catheter for one (#17) of one sampled resident reviewed for catheters. The DON identified 57 residents resided in the facility. Findings: Res #17 admitted to the facility with diagnoses which included chronic kidney disease, HTN, and chronic pain syndrome. On 11/18/24 at 11:40 a.m., resident #17 was observed resting in bed with their eyes open. A catheter was observed draining to gravity at bedside. The resident's record was reviewed and did not contain a physician's order for a catheter. The resident's care plan was reviewed and did not document the resident's catheter. On 11/20/24 at 12:03 p.m., the corporate nurse stated a physician's order should have been obtained and the care plan for the catheter should have been developed.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 30 opportunities were observed with two errors. The total medication error rate was 6.67% related to incorrect doses of medication given to one (#55) of four sampled residents observed during the medication pass. The ADON identified 57 residents resided in the facility. Findings: An undated Medication Errors policy, read in part, The facility must ensure that it is free of medication error rates of 5% or greater. A physician's order for Resident #55 documented they were to receive fludrocortisone (steroid) 0.1mg tab - 0.5mg (5 tabs) by mouth daily and vitamin D3 25mg by mouth daily. A notation on the label of the blister pack for Resident #55's fludrocortisone 0.1mg tab read in part, give 5 tablets by mouth daily. The label on the blister pack for Resident #55's vitamin D3 read in part, vitamin D3 1,000 IU. On 11/20/24 at 10:24 a.m., CMA #1 was observed while administering medications to Resident #55. Medications administered by CMA #1 to Resident #55 by mouth included fludrocortisone 0.1mg tab - 1 tab and vitamin D3 1,000 IU cap - 1 cap. On 11/20/24 at 12:15 p.m., CMA #1 was asked how many tablets of fludrocortisone they had administered to Resident #55. They stated one. CMA #1 was asked to read the notation on the fludrocortisone blister pack and stated, I did not notice that notation there. We have always given [Resident #55] one tab. Usually if the dose is more than one tab it is highlighted. CMA #1 was asked to review Resident #55's order for vitamin D3 and if the dose given (1,000 IU) was equal to 25mg. They stated, I'll have to check with the nurse. On 11/20/24 at 12:25 p.m., LPN #1 was shown the blister pack for Resident #55's vitamin D3 and was asked if the dose of vitamin D3 given was equivalent to 25mg. They placed a call to the pharmacy and verified the dose was not equal to 25mg as ordered. LPN #1 was asked to review Resident #55's order for fludrocortisone and verified the dose given should have been 5 tabs. LPN #1 confirmed two medication errors had occurred. On 11/20/24 at 3:30 p.m., the corp nurse was informed of the observations described above and they acknowledged two medication errors had occurred.

Based on record review and interview, the facility failed to ensure the QAA committee met at least quarterly. The DON identified 57 residents resided in the facility. Findings: The QAA committee meetings were reviewed. The last QAA meeting documented was February of 2024. A QAA form, dated 08/22/24, documented a meeting was not completed in August 2024 due to the lack of a DON and staff. On 11/21/24 at 9:25 a.m., the interim administrator stated QAA meetings should have been completed quarterly. On 11/21/24 at 9:41 a.m., the interim administrator stated documentation of quarterly QAA meetings could not be located.

Based on interview and record review, it was determined the facility failed to prevent reoccurring resident to resident abuse for six (#2, 3, 4, 6, 8 and #10) of six sampled residents whose records were reviewed for abuse. Residents stated they had pain and/or fear resulting from the incidents. This had the potential to affect all 39 residents who resided in the facility. Findings. An undated policy titled, Prevention - Abuse Prevention Program, documented, Our residents have the right to be free from abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Staff will have knowledge of all residents with a history of aggressive behavior, residents who wander into other resident's room, residents with communication disorders, and residents requiring extensive or total care . 1. A. Resident #6 had [DIAGNOSES REDACTED]. An admission assessment, dated 03/13/19, documented the resident was moderately impaired in cognition for daily decision making, was independent in activities of daily living, and had no behaviors. A behavior note, dated 03/13/19 at 12:48 a.m., documented the resident was yelling and cursing the nurse, banging on the front door glass, kicking the dining room doors, and knocked the exit sign off the ceiling. A psychiatric evaluation, dated 03/15/19, documented on the HPI (history of present illness) staff had reported the resident could be combative. The resident stated he experienced anger outbursts and his anger was out of control at times. The assessment documented, the described episodes of uncontrollable rages as Intermittent [MEDICAL CONDITION]. A care plan, dated 04/01/19, documented, .Focus area: problems making decision .forgetful .poor memory .need staff to help me and watch over me because I tend to make poor choices .get agitated or resist care at times . Goal: continue to attempt to make a simple daily decision with cues and supervision from staff .talk about my progress at my next care plan review . Interventions: Assist me to make routine daily decisions. Coach me through the process when my decisions are poor .give me verbal directions, verbal cues, reminders . Nurse and behavior notes from 04/20/19 through 04/23/19, documented the resident had behaviors which included pacing the halls, talking to himself, making inappropriate remarks, yelling and cursing at staff. The resident's sister had expressed concern that the behavior was becoming manic. A nurse note, dated 04/23/19 at 2:46 p.m., documented physical abuse between resident #6 and resident #3. Resident #6 grabbed resident #3's hand, squeezed and twisted his fingers. There was no documentation of how staff intervened after the incident. An investigative report, dated 04/23/19, documented resident #6 grabbed resident #3's hand during an activity. Both residents were interviewed by staff. One resident and one staff member were also interviewed after the incident. Both residents were assessed by the nurse, with no injury noted to either resident. Intervention included separating the residents for the rest of the day/night and monitoring resident #6's actions with other residents. The investigative report was signed by the administrator and dated 04/23/19. A state investigative form, dated 04/23/19, identified resident #3 as being physically abused and resident #6 as the abuser. There was no documentation of increased supervision related to the resident's aggressive behavior towards another resident. A behavior note, dated 04/23/19 at 6:01 p.m., documented, .threatening physical violence, throwing things .Told staff member 'I am going to kick your ass' .threw a plate in the floor .Intervention provided: Educated resident .Resident asked to leave the dining area while others finished their dinner .Resident went to his room . There was no documentation of increased supervision related to the resident's threatening behavior and no supervision was provided when the resident went to his room. On 05/08/19 at 10:23 a.m., resident #4 was asked if she was afraid of any residents. She stated yes, resident #6. On 05/08/19 at 11:54 a.m., resident #3 was asked if he had any pain after the incident with resident #6. He stated his fingers had hurt. On 05/09/19 at 8:35 a.m., CMA (certified medication aide) #2 was asked if she was familiar with resident #6. She stated yes, the day before he was transferred out of the facility he was blurting out inappropriate phrases which progressed to vulgar inappropriate statements to staff. She was asked if she had reported resident #6's behavior. She stated yes, she had reported it to LPN #1. She was asked if she was aware of the incident involving resident #6 and resident #3. She stated yes. She was asked what action was taken after the incident. She stated resident #6 was moved away from the activity table where the incident occurred. She was asked if the incident had been reported. She stated yes, it was reported to SS and the administrator. She stated they both spoke to resident #6. At 9:07 a.m., LPN #1 was asked if she was aware of any behaviors which involved resident #6. She stated she was aware of an incident involving resident #6 and #3. She stated resident #6 had grabbed resident #3's fingers. She was asked what action was taken following the incident. She stated she separated the residents, reported the incident to the administrator, and completed the state reportable form. She was asked how the staff protected residents from resident #6. She stated he was being monitored when he was in the hall. She was asked what interventions were implemented with aggressive residents. She stated talking to the resident and redirecting. On 05/09/19 at 12:25 p.m., the administrator was asked how the facility ensured residents #6 and #3 were separated following their altercations with other residents. She stated resident #6 was taken to the front of the facility and resident #3 stayed in the back of the facility. She was asked where the facility documented the supervision of residents #6 following the altercations with other residents. She stated there were no formal documentation or any tracking sheet. She was asked what the facility did to ensure other residents had not been assaulted by resident #6. She stated she interviewed witnesses to the incident. She was asked where that was documented. She stated it was not documented. She was asked how residents were protected to prevent further altercations from resident #6 after his assault on resident #3. She stated he was under observation. She was asked where the observations were documented for resident #6. She stated the staff had him under observation and saw him go into his room. B. A behavior note, dated 04/23/19 at 8:07 p.m., documented, .physical violence .Resident punched roommate in chest .Intervention .asked resident to leave from room while ADON (assistant director of nursing), Administrator notified .Intervention .leave facility to be evaluated . A nurse note, dated 04/23/19 at 8:08 p.m., documented an incident between resident #6 and resident #2. Both residents were interviewed. Resident #2 was examined by the nurse. The ADON, police, emergency medical services, and the resident's sister were contacted. Staff completed an EOD (emergency order of detention) and resident #6 was transported to a medical facility. A state investigative form, dated 04/23/19, identified resident #2 as being physically abused and resident #6 as the abuser. An investigation report, dated 04/24/19, documented resident #6 hit resident #2 in the chest. Both residents were interviewed by staff. No other interviews were conducted due to no other witnesses to the altercation. Resident #2 was assessed by the nurse with no injury noted. Intervention included separating the residents and transferring resident #6 to a medical facility for evaluation. The investigative report was signed by the administrator and dated 04/24/19. On 05/08/19 at 10:10 a.m., resident #2 was asked about the incident with his roommate. He stated his roommate (resident #6) had struck him twice in the upper and mid chest. He was asked what had happened prior to the roommate striking him. He stated nothing, the roommate had just came in and thought he was in his space and struck him. He was asked if he had experienced pain. He stated yes that it had lasted into the next day. He was asked if he had ever had any problems with his roommate prior to being struck. He stated no but he had told the SS (Social Services) director his roommate was not a good person. He was asked if he was afraid of the roommate returning to the facility. He stated yes. He stated he kept to himself and did not like trouble. On 05/09/19 at 8:55 a.m., LPN (licensed practical nurse) #2 was asked if she was aware of behaviors or incidents which involved resident #6. She stated she was aware of the incident which involved resident #6 and #2. She stated following the incident she had assessed resident #2 for injuries. She was asked if the incident had been reported. She stated she had reported the incident to the ADON. She was asked what action was taken following the incident. She stated resident #6 was transferred out of the facility. She was asked how the other residents were being protected prior to resident #6 being transferred out of the facility. She stated resident #6 was being observed by staff in the common area. On 05/09/19 at 12:25 p.m., the administrator was asked if other residents were interviewed following resident #6 altercation with resident #2. She stated there were no witnesses to interview. 2. A. Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 10/15/18, documented, .Focus: potential to demonstrate verbally abusive behaviors .ineffective coping skills, Poor impulse control .sometimes walk past someone in the hallway and just curse at them but really don't mean to be cursing at them . Goal: demonstrate effective coping skills . Interventions: Analyze the key times, places, circumstances, triggers that escalated my behaviors, and what de-escalates behavior and document . Psychiatrist will be consult (sic) be (sic) as needed for medication adjustment, LCSW (licensed clinical social worker) will be consulted if needed . Focus: potential to demonstrate physical behaviors r/t (related to) anger, poor impulse control . Goal: verbalize understanding of need to control physically aggressive behavior .demonstrate effective coping skills . Interventions: Assess and address for contributing sensory deficits . Document observed behavior and attempted interventions in behavior monitoring . The clinical record was reviewed and revealed documentation of ongoing behaviors from the day after admission. The resident had frequent behaviors which included cursing, yelling, throwing food, throwing dishware, urinating and defecating in public, grabbing, pushing, shoving, spitting, and slapping staff. A quarterly assessment, dated 03/03/19, documented the resident had the ability to make self-understood, had clear comprehension, and had physical and verbal behaviors including rejection of care. A psychiatric note, dated 04/19/19, documented staff had reported the resident as aggressive and hitting. The psychiatrist had assessed the resident as withdrawn, responding with one word answers, confused with behaviors of refusing medications and resisting care. The psychiatrist documented new orders for medication changes which included addition of an antipsychotic medication to be administered intramuscularly. A nurse note, dated 04/24/19 at 7:06 p.m., documented the resident was cursing at another resident after the other resident initiated a verbal confrontation, and resident #10 left the area after throwing a coffee cup. A behavior note, dated 04/26/19 at 11:45 a.m., documented, .physical abuse, verbal abuse, resisting care: Resident (#10) walking through hallways .telling everyone f . you!. (sic) .arguing with (resident #3). Residents were separated and (resident #10) was walked out of dining area .(Resident #3) started to leave dining area also and (resident #10) turned around and walked fast towards him and slapped him in his right shoulder .Intervention provided: Resident (#10) was initially redirected out of dining area. When resident (#10) turned around to go towards resident (#3) he was unable to be stopped before slapping other resident (#3). After incident resident (#10) was once again redirected to a different area .First redirection unsuccessful. Second redirection was successful . A state investigative form, dated 04/26/19, identified resident #3 as the reporting resident and resident #10 as the abuser. An investigation report, dated 04/27/19, documented a verbal and physical altercation between resident #10 and resident #3. Resident #10 slapped resident #3 on the shoulder. Both residents were interviewed. Three other residents and a staff member were also interviewed. Resident #3 was assessed by the nurse with no injury noted. Intervention included separating the residents and transferring resident #10 for further medical evaluation. The investigative report did not have a time the incident occurred and was signed by the administrator and dated 04/27/19. B. On 04/26/19 another incident involving resident #10 as the abuser to resident #4 occurred. A nurse note, dated 04/26/19 at 6:39 p.m., documented, .at approx. (approximately) 1630 (4:30 p.m.) .resident (#10) had a physical altercation with another resident (#4) .resident (#4) said that she and this resident (#10) were walking opposite in the dining room, as she passed resident (#10) he hit her in the left arm and then screamed 'F . you'! .Notified ADON, DON (director of nursing) and Administrator .Agreed that resident (#10) needed to be sent out for evaluation .resident had to be given something to calm him in order to get him to go with medics. Resident left facility at approx. (approximately) 1715 (5:15 p.m.) . A state investigative form, dated 04/26/19, identified resident #4 as the reporting resident and resident #10 as the abuser. An investigative report, dated 04/27/19, documented verbal and physical altercation between resident #10 and resident #4. Resident #4 was interviewed. Other residents and staff present in the room during the incident were also interviewed. Resident #4 was assessed by the nurse with no injury noted. Intervention included separating the residents, 1:1 staffing supervision for resident #10 while awaiting EMS (emergency medical services), and transport of resident #10 for further medical evaluation. The investigative report did not indicate a time the incident occurred and was signed by the administrator and dated 04/27/19. On 05/08/19 at 10:23 a.m., resident #4 was asked what she remembered of the incident with resident #10 on 04/26/19. She stated resident #10 passed by her in the dining room and would not move. She stated he did not punch her but pushed into her with his shoulder. She was asked if she had witnessed any other abuse situations with the resident. She stated no but had heard about them especially with the staff. She was asked if she was afraid of him. She stated she was. She was asked if she was afraid of any other resident. She stated yes, there was another one and she was concerned he could get violent. She named resident #6. C. On 04/26/19 another incident involving resident #10 as the abuser to resident #8 occurred on 04/26/19. A nurse note, dated 04/26/19, at 6:45 p.m., documented, .Resident (#8) reported to this nurse that while in the secondary dining room/activity room that another resident (resident #10) put his shoulder into the resident's arm when passing. Nurse assess (sic) this resident. No visible injuries, skin intact. No c/o (complaint of) pain . A state investigative form, dated 04/26/19, identified resident #8 as the reporting resident and resident #10 as the abuser. An investigative report, dated 04/27/19, documented a physical altercation between resident #10 and resident #8. Resident #10 pushed his shoulder into the arm of resident #8. Both residents were interviewed. Three residents and one staff member present during the incident were also interviewed. Resident #8 was assessed by the nurse with no injury noted. Intervention included separating the residents, and transferring resident #10 for further medical evaluation. The investigative report did not indicate a time the incident occurred and was signed by the administrator and dated 04/27/19. There was no documentation of increased supervision related to the resident's aggressive behavior towards another resident. On 05/08/19 at 12:40 p.m., resident # 8 was asked if he was afraid. He stated that he was not afraid of any residents but was afraid of the situation, who wouldn't be. On 05/08/19 at 4:30 p.m., CNA (certified nurse aide) #1 was asked if she was familiar with residents #10. She stated yes. She was asked if the resident had behaviors. She stated yes, he would push and shove. She was asked if the staff was instructed to do anything different following the resident to resident altercation. She stated she was not sure, she had not received any new instructions. She was asked what the protocol was if two residents were involved in an altercation. She stated they were separated, made sure they were safe, and the incident was reported. On 05/09/19 at 11:14 a.m., LPN #1 was asked what their policy was regarding documentation of resident to resident altercations. She stated a report was completed and faxed to the Oklahoma State Department of Health and DHS (department of human services). She stated the incident was documented in the nurse's notes, and the family and physician were notified. She was asked if supervision of the residents had been documented. She stated she had never documented when residents had been separated because staff just knew to monitor them. On 05/09/19 at 12:10 p.m., the Director of Clinical Services was asked what documentation was completed for a resident to resident altercation. She stated an incident report and the state reportable form were completed. She was asked where documentation of incidents were kept. She stated if a state reportable was completed then an incident report should have been completed and would be in the electronic medical record. She was informed that no incident reports had been completed regarding the incidents which involved residents #6 and #10's aggressive behaviors towards residents #2, #3, #4, and #8. She stated, it should have been. On 05/09/19 at 12:25 p.m., the administrator was asked where the facility documented the supervision of residents #6 and #10 following the altercations with other residents. She stated there were no formal documentation or any tracking sheet. She was asked what the facility did to ensure other residents had not been assaulted by resident #6. She stated she interviewed witnesses to the incident. She was asked where that was documented. She stated it was not documented. She was asked if other residents were interviewed following resident #6 altercation with resident #2. She stated there were no witnesses to interview. She was asked how residents were protected to prevent further altercations from resident #6 after his assault on resident #3. She stated he was under observation. She was asked where the observations were documented for resident #6. She stated the staff had him under observation and saw him go into his room. She was asked how the facility had protected resident #3 after being assaulted by resident #6 and #10. She stated, by keeping an eye on him. She was asked if other residents were interviewed, during the abuse investigations. She stated no, they were asked if they saw what happened, but were not asked if they had been abused.