Every finding on record at Beadles Nursing Home

On 01/14/26 at 4:00 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff were adequately trained for transportation of wheelchair bound residents.On 12/30/25, transporter #1 improperly secured Resident #20 in the transport vehicle, which resulted in the wheelchair being tipped over on its side when the driver swerved to miss another vehicle. Resident #20 sustained a fractured rib and moderate damage to the spleen which required admission to a hospital trauma center. The facility was unable to provide documentation of training or competency for securing wheelchairs in transport vehicles.On 01/14/26 at 3:38 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On 01/14/26 at 4:00 p.m., the administrator and DON were notified of the IJ situation and provided the IJ template.On 01/15/26 at 9:35 a.m., an acceptable plan of removal was received. The plan of removal, read in part, transport stopped 01/14/26 .a mandatory in-service and hands-on training for all staff assigned to resident transport. Training included correct wheelchair orientation in the vehicle, engaging wheelchair brakes, proper four-point tie-down attachment to wheelchair frame, proper strap tightening until no movement remains, application of separate occupant lap and shoulder belt, final tug test and visual verification before vehicle movement, procedure to follow if securement cannot be achieved. Each designated transporter completed a hands-on demonstration on the facility transport vehicle, the administrator and director of nursing completed and signed a competency validation checklist for each transporter.On 01/15/26 at 1:15 p.m., the immediacy was lifted, effective 01/14/26, after all components of the plan of removal were verified to be completed. In-services were reviewed, staff were interviewed to ensure training was completed and competency skills were reviewed. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure a resident in a wheelchair was free from accidents or injuries during transportation for 1 (#20) of 1 sampled resident reviewed for injury during transport.The administrator identified 45 residents resided in the facility.Findings: A quarterly assessment, dated 10/27/25, showed Resident #20 had a BIMS of 13 which indicated the resident's cognition was intact. The assessment showed Resident #20 was dependent for positioning and was wheelchair bound. A Transportation and Vehicle Use policy, dated 12/26/25, read in part, All drivers must complete: defensive driving training, wheelchair and mobility device securement training, resident safety and transfer training .facility transportation orientation, drivers must complete refresher training at least annually.Wheelchair and Seatbelt Securement: all residents must be secured before vehicle movement, wheelchair users must have wheelchair locked, four-point tie-down system secured and lap and shoulder belt applied .drivers must visually confirm securement before moving the vehicle. Employee files for transporter #1 and transporter #2 were reviewed and did not show documentation for staff regarding skills checks or training for properly transporting residents. A state reportable facility incident, dated 12/30/25, showed transporter #1 improperly secured Resident #20 in the transport vehicle, which resulted in the wheelchair being tipped over on its side when the driver swerved to miss another vehicle. Resident #20 had injuries requiring admission to the hospital trauma center with a fractured rib and moderate damage to the spleen. The facility was unable to provide documentation of training or competency for securing wheelchairs in transport vehicles. A nursing narrative note, dated 12/31/25, showed Resident #20 had a rib fracture and a grade 2 spleen injury. A significant change assessment, dated 01/12/26, showed Resident #20 had a BIMS of 12 which indicated they were moderately impaired for daily decision making. The assessment showed Resident #20 was dependent for positioning and was wheelchair bound. On 01/13/26 at 9:10 a.m., Resident #20 stated they were in an accident in the facility van where the wheelchair turned over while going to a doctor appointment in the city. Resident #20 stated they were going down the highway and swerved, the next thing they knew they were on the floor. Resident #20 stated they went to the hospital and stayed there a few days and returned home to the facility. Resident #20 stated they still had some pain and discomfort they took medications for. On 01/14/26 at 10:04 a.m., transporter #1 stated they placed Resident #20 in the van facing the front of the vehicle. They stated they strapped the wheelchair with the four-point strap system and placed the seatbelt around Resident #20. Transporter #1 stated they had training 15 years ago when they were hired for the position. Transporter #1 stated they had not had any training since. They stated the securing straps must not have been tight enough to hold the wheelchair in place. On 01/14/26 at 10:30 a.m., the DON stated transporter #1 did not secure the wheelchair in the van tightly enough. They stated the transportation staff had been scheduled for defensive driver training, but they have not completed it yet. The DON stated there was not an annual competency or training program for drivers. The DON stated the current drivers train the new ones when hired.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plan was developed for 1 (#14) of 23 sampled residents reviewed for care plans.The administrator identified 45 residents resided in the facility. Findings: On 01/12/26 at 12:54 p.m., Resident #14 was observed to be unable to hear what was being said. Hearing aides were observed on their table. A comprehensive care plan policy, dated 05/25/23, read in part, [NAME] Nursing Home will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth in the section on resident's rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. An admission assessment, dated 12/12/25, showed Resident #14 was admitted on [DATE]. The care planning decisions showed delirium, cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, falls, nutritional status, dental care, pressure ulcer, and psychotropic drug use. There was no care plan developed for the care areas within seven days of completion of the admission assessment for Resident #14 located in the clinical record. On 01/13/26 at 1:31 p.m., minimum data set coordinator #1 stated they missed completing the comprehensive care plan for Resident #14.

Based on observation, record review, and interview, the facility failed to identify a significant change for one (#42) of thirteen sampled residents assessments reviewed. The Resident Census and Conditions of Residents report, dated 06/28/23, documented the census was 49. Findings: Resident #42 had diagnoses which included, high blood pressure, chronic bronchitis, and dementia. A Quarterly Assessment, dated 03/17/23, documented Resident #42 had severe cognitive impairment, and needed limited assistance of one staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. A Quarterly Assessment, dated 06/17/23, documented Resident #42 had severe cognitive impairment and needed extensive assistance with the assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. There was no documentation in the clinical health record a significant change assessment had been completed when the resident had a significant decline in their activities of daily living. On 06/30/23 at 10:21 a.m., the MDS Coordinator was shown the MDS data from 03/17/23 and 06/17/23. They were asked why the resident had a decline in ADLs. They stated the resident had a UTI at the time. On 06/30/23 at 10:39 a.m., the MDS coordinator was asked if the MDS assessment, dated 06/17/23, accurately reflected the residents status. They stated, No. On 06/30/23 at 3:27 p.m., the MDS coordinator was asked when the significant change had been identified. They stated the system showed a significant change and flagged it as a potential change and I had chosen not to do it.

Based on observation, record review, and interview, the facility failed to ensure palatable food was served for one (#17) of six sampled residents reviewed for food services. The Resident Census and Conditions of Residents report, dated 06/28/23, documented the census was 49. LPN #1 identified all 49 residents received their meals from the kitchen. Findings: Resident #17 had diagnoses which included high blood pressure, diverticulitis of intestine, chronic kidney disease stage three, and major depressive disorder. A Physician Order, dated 05/13/19, documented Resident #17 was on a diverticulitis texture, regular consistency diet. A Quarterly Assessment, dated 04/25/23, documented Resident #17 had mild cognitive impairment. On 06/28/23 at 12:10 p.m., Resident #17 was asked how was the food. They stated, It's not any good, my hamburger was cold, and I couldn't hardly chew it. On 06/30/23 at 11:38 a.m., Resident #17 was observed in their room with a lunch meal of mashed potatoes with white gravy, chicken strips, apple pie, and cottage cheese. They were observed to be holding a chicken strip in their hand and were asked how the chicken strips tasted. They stated, They are hard, I can't hardly eat them. On 06/30/23 at 1:44 p.m., the CDM was asked if they'd had any complaints about the food. The CDM stated they were aware some residents did not care for the chicken strips that were being served, but had been unable to order the chicken strips that the residents preferred.

Based on observation, interviews and record review, it was determined the facility failed to prevent the spread of COVID-19 by allowing symptomatic staff members who had tested positive for COVID-19 to work during their isolation period. The facility identified 31 residents, who had not tested positive for COVID-19, resided in the facility. Findings: The Center for Disease Control (CDC) guidance titled,Criteria for Return to Work for Healthcare Personnel (HCP) with [DIAGNOSES REDACTED]-CoV-2 Infection (Interim Guidance), documented: .Symptom-based strategy for determining when HCP can return to work .HCP with mild to moderate illness who are not severely immunocompromised .At least 10 days have passed since symptoms first appeared and .At least 24 hours have passed since last fever without the use of fever-reducing medications and .Symptoms (e.g., cough, shortness of breath) have improved . An incident report form, dated 11/09/20, documented, Description of Incident .(Certified nursing assistant (CNA) #1) was tested for weekly testing of staff. tested via COVID-19 Ag ([MEDICATION NAME]) card and results were positive .(CNA #1) was sent to (hospital) for PCR (polymerase chain reaction) testing .(CNA #1) began running a fever on 11-10-20 with body aches and loss of taste and smell .(CNA #1) returned to work on 11/17/20 . A laboratory result document, dated 11/11/20, documented, CNA #1 .Collected .11/09/2020 .Test Name .[DIAGNOSES REDACTED]-CoV-2 .Out Of Range .DETECTED . An incident report form, dated 11/26/20, documented, .11/26/20 (licensed practical nurse (LPN) #1) c/o (complained of) body aches, cough, diarrhea, and lethargy. Was tested with Binax now covid-19 Ag card with positive results .Isolating at home . On 12/01/20 at 11:45 a.m., LPN #1 was observed working on the COVID-19 unit in the facility. At 12:15 p.m., the director of nurses (DON) was asked which nurses were currently working. She stated LPN #1 was on the COVID unit. At 1:40 p.m., the DON was asked what the policy was for allowing COVID positive staff to return to work. She stated after symptoms subsided for 72 hours. She was asked what the facility had done prior to LPN #1 returning back to work during her isolation period. She stated three other nurses and herself worked. She stated she tried to get other nurses to cover the shifts. She stated she looked at the CDC guidance. The DON and the administrator (admin) were asked if they called a staffing agency. They stated they had not. They were asked if the facility tried to send COVID positive residents to a different facility to help mitigate the staffing shortage. The admin stated they had. He was asked when was that. He stated when the residents first tested positive. He was asked if that was around 11/11/20. He stated it was. At 2:20 p.m., LPN #1 was interviewed over the phone. She was asked when did she test positive for COVID. She stated 11/26/20. She was asked when did her symptoms start and stop. She stated on the 26th she didn't have symptoms, on the 27th she was lethargic and had a slight cough, she didn't have symptoms on the 28th and she thinks she was lethargic on the 29th. She was asked if she had any symptoms yesterday or today. She stated she did not. At 3:05 p.m., CNA #1 was interviewed over the phone. She was asked when she tested positive for COVID. She stated 11/09/20. She was asked if she had symptoms. She stated she had a temperature of 99.2 on 11/10/20. She was asked when did she return to work. She stated she couldn't remember. She stated she was symptom free for 10 days before coming back to work. At 3:07 p.m., CNA #1 called back and stated the DON had texted her and stated she came back to work on 11/21/20. At 3:09 p.m., the admin was asked for CNA #1's time card from 11/07/20 through 11/28/20. At 3:35 p.m., the admin provided time card document. It documented, .11/16/2020 Clock In 06:30 AM Start Lunch 12:30 PM .End Lunch 01:00 PM Clock Out 07:15 PM .11/18/20 Clock In 07:00 AM Start Lunch 01:00 PM .End Lunch 01:30 PM Clock Out 07:15 PM . He was asked where did the CNA worked at on these dates. He stated it would have been the COVID hall. The DON and admin were notified of the above and acknowledged the findings.

Based on record review and interview, it was determined the facility failed to ensure assessments were completed accurately for 2 (#8 and #44) of 23 sampled residents whose assessments were reviewed. The inaccuracies were in regard to active [DIAGNOSES REDACTED]. Findings: 1, Resident #44 had [DIAGNOSES REDACTED]. The significant change in status assessment (SCSA) dated 02/08/18 documented the resident had clear speech, was understood, and understood others. The assessment documented she was severely impaired in cognition for daily decision making. The assessment documented she did not have a stage 1 or greater pressure ulcer. The same assessment documented the resident had an unhealed pressure ulcer at a stage 4. The care plan last reviewed/updated 02/13/18 documented the resident had a stage 4 pressure ulcer of the coccyx. The weekly wound observation tool dated 02/13/18 documented a stage 4 pressure ulcer of the coccyx. On 04/02/18 at 10:00 AM the assessment coordinator was asked to review the SCSA dated 02/08/18. After review, she was asked if the resident had a pressure ulcer. She stated, Yes. She was asked if the assessment was accurate in regard to pressure ulcer documentation. She stated, No. #2. Resident #8 had [DIAGNOSES REDACTED]. The annual assessment dated [DATE] documented the resident was severely cognitively impaired. The assessment documented the resident had received an antidepressant medication 7 of the 7 days prior to the assessment. The assessment did not identify depression as an active diagnosis. physician's orders [REDACTED]. On 03/29/18 at 11:00 a.m., the assessment coordinator, was asked to review physician's orders [REDACTED]. She was asked to review the assessment for active diagnoses. She was asked if depression was identified as an active diagnosis. After review she stated, No. She was asked if assessment was accurate in regard to the [DIAGNOSES REDACTED].

Based on record review, observation and interview, it was determined the facility failed to ensure a resident's privacy when a staff member took a video of the resident who had a urinary incontinence episode and posted it on social media. This affected 1 (#1) of 1 sampled residents whose right to privacy had been violated. Fifty-one residents resided in the facility. Findings: The facility's abuse policy, effective 10/01/99, documented: .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes .mental abuse including abuse facilitated or enable through the use of technology . The policy documented the definition of mistreatment as inappropriate treatment or exploitation of a resident. The facility's abuse policy and procedure included a social media policy, effective 12/14/16. The policy documented: .Employees are absolutely prohibited from using Social Media in any way that would violate HIPPA (Health Insurance Portability and Accountability Act) or otherwise disclose or compromise residents' PHI (protected health information) .DO NOT use Social Media to post, upload, send or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law .DO NOT use Social Media to post, upload, send or otherwise share or disclose the name of any resident (even if just the first name or nickname) without prior written permission of the resident or the resident's authorized agent as required by applicable law . The facility's abuse policy and procedure included an Abuse with Photos-Videos policy, effective 02/24/17. The policy documented: .Taking or distributing any photographs or video recordings of a resident or his/her private space without the resident's or designated representatives, written or verbal consent (unless directed by the courts or law enforcement officials), must not be done by employees .While residents may give consent for taking of photographs or videos, the use of those photographs must be consistent with the consent and cannot be demeaning or humiliating .All staff, contractors, volunteers and other caregivers will be educated about this policy ideally as part of their orientation prior to providing services to residents . A new employee packet document titled Federal Resident's Rights documented: .The Nursing Home Reform Law legally protects the following rights for nursing home residents .The Right To Privacy and Confidentiality, including the right to .Privacy in treatment and in the care of personal needs .The Right to Dignity, Respect, and Freedom, including the right to: Be treated with the fullest measure of consideration, respect, and dignity . The new employee packet also included an employee cell phone use policy which documented: .Employees may never use a cell phone or any other electronic device during direct resident care . Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 03/09/17, documented the resident had severe cognitive impairment; required extensive assistance or was dependent upon staff for all activities of daily living (ADLs); and was always incontinent of bladder and bowel. The care plan, last reviewed/revised 03/16/17, documented the resident had problems related to his dependence upon staff and family for all needs; ADL self-care deficit, and impaired cognition. The care plan addressed appropriate goals and interventions for the problems. A facility self reported incident to the Oklahoma State Department of Health, dated 03/29/17, documented certified nurse aide (CNA) #2 had reported to the director on nurses (DON) that she had been at a friend's house the evening of 03/28/17 and the friend received a Snapchat from CNA #1, who was working at the facility at the time. CNA #2's friend viewed the Snapchat and stated, Oh, look that man pissed himself. The report documented CNA #1 had been called into the DON's office and was questioned about the video. CNA #1 admitted she had taken a video of resident #1 and sent it to a male friend on a social media sight called Snapchat. The CNA stated she had put the following caption with the video: WTF (What the f***), (resident #1's first name). The report documented the local police had been notified and came to the facility to interview CNA #1. The report documented CNA #1 had been terminated on 03/29/17. CNA #1 had signed forms that she had received the residents' rights and the facility's cell phone policy on 01/08/17. On 04/04/17 at 9:10 a.m., during an interview with the administrator and the director of nurses (DON), the surveyor asked about the content of the video of resident #1. The DON stated the video (which no facility staff or law enforcement had seen) allegedly consisted of the resident's lap, legs, feet and the floor. The resident's pants were wet and a puddle of urine was on the floor by the resident. A caption with the video was: WTF, (resident #1's first name). At 11:30 a.m., the resident was observed in the dining area receiving assistance from his wife to eat. He was clean, well groomed and dressed appropriately. He was not interviewable due to his cognitive impairment. At 12:00 p.m., the resident's wife was interviewed and was asked if her husband had the cognitive ability to understand what had happened to him regarding the video being taken of him following an incontinent episode. She stated, No. She was asked how her husband might feel if he had the ability to understand what had happened. She stated her husband would be upset, maybe angry and embarrassed that he had urinated himself. She stated her husband was a private man. At 1:25 p.m., during an interview with the administrator, DON and the compliance officer, the surveyor asked if the incident of the video taken of resident #1's incontinence episode, posting it on Snapchat and including his first name in the caption violated the resident's right to privacy. The DON stated, Yes.

Based on record review, observation and interview, it was determined the facility failed to ensure a resident's dignity was respected when a staff member took a video of a resident who had a urinary incontinence episode and posted it on social media. This affected 1 (#1) of 1 sampled residents whose dignity was disrespected. Fifty-one residents resided in the facility. Findings: The facility's abuse policy, effective 10/01/99, documented: .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes .mental abuse including abuse facilitated or enable through the use of technology. The policy documented the definition of mistreatment as inappropriate treatment or exploitation of a resident . The facility's abuse policy and procedure included a social media policy, effective 12/14/16. The policy documented: .Employees are absolutely prohibited from using Social Media in any way that would violate HIPPA (Health Insurance Portability and Accountability Act) or otherwise disclose or compromise residents' PHI (protected health information) .DO NOT use Social Media to post, upload, send or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law .DO NOT use Social Media to post, upload, send or otherwise share or disclose the name of any resident (even if just the first name or nickname) without prior written permission of the resident or the resident's authorized agent as required by applicable law . The facility's abuse policy and procedure included an Abuse with Photos-Videos policy, effective 02/24/17. The policy documented: .Taking or distributing any photographs or video recordings of a resident or his/her private space without the resident's or designated representatives, written or verbal consent (unless directed by the courts or law enforcement officials), must not be done by employees .While residents may give consent for taking of photographs or videos; the use of those photographs must be consistent with the consent and cannot be demeaning or humiliating .All staff, contractors, volunteers and other caregivers will be educated about this policy ideally as part of their orientation prior to providing services to residents . A new employee packet document titled Federal Resident's Rights documented: .The Nursing Home Reform Law legally protects the following rights for nursing home residents .The Right To Privacy and Confidentiality, including the right to .Privacy in treatment and in the care of personal needs .The Right to Dignity, Respect, and Freedom, including the right to: Be treated with the fullest measure of consideration, respect, and dignity . The new employee packet also included an employee cell phone use policy which documented: .Employees may never use a cell phone or any other electronic device during direct resident care . Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 03/09/17, documented the resident had severe cognitive impairment; required extensive assistance or was dependent upon staff for all activities of daily living (ADLs); and was always incontinent of bladder and bowel. The care plan, last reviewed/revised 03/16/17, documented the resident had problems related to his dependence upon staff and family for all needs; ADL self-care deficit, and impaired cognition. The care plan addressed appropriate goals and interventions for the problems. A facility self reported incident to the Oklahoma State Department of Health, dated 03/29/17, documented certified nurse aide (CNA) #2 had reported to the director on nurses (DON) that she had been at a friend's house the evening of 03/28/17 and the friend received a Snapchat from CNA #1, who was working at the facility at the time. CNA #2's friend looked at the Snapchat and stated, Oh, look that man pissed himself. The report documented CNA #1 had been called into the DON's office and was questioned about the video. CNA #1 admitted she had taken a video of resident #1 and sent it to a male friend on a social media sight called Snapchat. The CNA stated she had put the following caption with the video: WTF (What the f***), (resident #1's first name). The report documented the local police had been notified and came to the facility to interview CNA #1. The report documented CNA #1 had been terminated on 03/29/17. On 04/04/17 at 9:10 a.m., during an interview with the administrator and the DON, the surveyor asked about the content of the video of resident #1. The DON stated the video (which no facility staff or law enforcement had seen) allegedly consisted of the resident's lap, legs, feet and the floor. The resident's pants were wet and a puddle of urine was on the floor by the resident. A caption with the video was: WTF, (resident #1's first name). At 11:30 a.m., the resident was observed in the dining area receiving assistance from his wife to eat. He was clean, well groomed and dressed appropriately. He was not interviewable due to cognitive impairment. At 12:00 p.m., the resident's wife was interviewed and was asked if her husband had the cognitive ability to understand what had happened to him regarding the video being taken of him following an incontinent episode. She stated, No. She was asked how her husband might feel if he had the ability to understand what had happened. She stated her husband would be upset, maybe angry and embarrassed that he had urinated himself. She stated her husband was a private man. At 1:25 p.m., during an interview with the administrator, DON and the compliance officer, the surveyor asked if resident #1 had been treated in a dignified manner by CNA #1. The DON stated, No.

Based on record review, observation and interview, it was determined the facility failed ensure its abuse policy was implemented to protect a resident from mental abuse when a staff member took a video of the resident who had a urinary incontinence episode and posted it on social media. This affected 1 (#1) of 1 sampled residents who had been abused. Fifty-one residents resided in the facility. Findings: The facility's abuse policy, effective 10/01/99, documented: .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes .mental abuse including abuse facilitated or enable through the use of technology. The policy documented the definition of mistreatment as inappropriate treatment or exploitation of a resident . The facility's abuse policy and procedure included a social media policy, effective 12/14/16. The policy documented: .Employees are absolutely prohibited from using Social Media in any way that would violate HIPPA (Health Insurance Portability and Accountability Act) or otherwise disclose or compromise residents' PHI (protected health information) .DO NOT use Social Media to post, upload, send or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law .DO NOT use Social Media to post, upload, send or otherwise share or disclose the name of any resident (even if just the first name or nickname) without prior written permission of the resident or the resident's authorized agent as required by applicable law . The facility's abuse policy and procedure included an Abuse with Photos-Videos policy, effective 02/24/17. The policy documented: .Taking or distributing any photographs or video recordings of a resident or his/her private space without the resident's or designated representatives, written or verbal consent (unless directed by the courts or law enforcement officials), must not be done by employees .While residents may give consent for taking of photographs or videos, the use of those photographs must be consistent with the consent and cannot be demeaning or humiliating .All staff, contractors, volunteers and other caregivers will be educated about this policy ideally as part of their orientation prior to providing services to residents . A new employee packet document titled Federal Resident's Rights documented: .The Nursing Home Reform Law legally protects the following rights for nursing home residents .The Right To Privacy and Confidentiality, including the right to .Privacy in treatment and in the care of personal needs .The Right to Dignity, Respect, and Freedom, including the right to: Be treated with the fullest measure of consideration, respect, and dignity . The new employee packet also included an employee cell phone use policy which documented: .Employees may never use a cell phone or any other electronic device during direct resident care . Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 03/09/17, documented the resident had severe cognitive impairment; required extensive assistance or was dependent upon staff for all activities of daily living (ADLs); and was always incontinent of bladder and bowel. The care plan, last reviewed/revised 03/16/17, documented the resident had problems related to his dependence upon staff and family for all needs; ADL self-care deficit, and impaired cognition. The care plan addressed appropriate goals and interventions for the problems. A facility self reported incident to the Oklahoma State Department of Health, dated 03/29/17, documented certified nurse aide (CNA) #2 had reported to the director on nurses (DON) that she had been at a friend's house the evening of 03/28/17 and the friend received a Snapchat from CNA #1, who was working at the facility at the time. CNA #2's friend looked at the Snapchat and stated, Oh, look that man pissed himself. The report documented CNA #1 had been called into the DON's office and was questioned about the video. CNA #1 admitted she had taken a video of resident #1 and sent it to a male friend on a social media sight called Snapchat. The CNA stated she had put the following caption with the video: WTF (What the f***), (resident #1's first name). The report documented the local police had been notified and came to the facility to interview CNA #1. The report documented CNA #1 had been terminated on 03/29/17. On 04/04/17 at 9:10 a.m., during an interview with the administrator and the DON, the surveyor asked about the content of the video of resident #1. The DON stated the video (which no facility staff or law enforcement had seen) allegedly consisted of the resident's lap, legs, feet and the floor. The resident's pants were wet and a puddle of urine was on the floor by the resident. A caption with the video was: WTF, (resident #1's first name). At 10:35 a.m., the surveyor asked the DON if the facility staff had been inserviced on the social media policy or the Abuse with Photos-Videos policy, which were effective 12/14/16 and 02/24/17, respectfully. She stated the staff had not been inserviced on the new policies. However, she stated similar policies were reviewed with all new staff upon hire. At 11:30 a.m., the resident was observed in the dining area receiving assistance from his wife to eat. He was clean, well groomed and dressed appropriately. The resident was not interviewable due to cognitive impairment. At 12:00 p.m., the resident's wife was interviewed and was asked if her husband had the cognitive ability to understand what had happened to him regarding the video being taken of him following an incontinent episode. She stated, No. She was asked how her husband might feel if he had the ability to understand what had happened. She stated her husband would be upset, maybe angry and embarrassed that he had urinated himself. She stated her husband was a private man. At 1:25 p.m., during an interview with the administrator, DON and the compliance officer, the surveyor asked if the facility's abuse policy had been implemented to protect a resident from abuse. The compliance officer stated, The policy was implemented but the CNA did not follow it. CNA #1's personnel file was reviewed. She had signed forms that she had received the residents' rights and the facility's cell phone policy on 01/08/17.

Based on record review and interview, it was determined the facility failed to conduct a thorough, written investigation of an incident of abuse. This affected 1 (#1) of 1 sampled residents for whom an allegation of abuse was alleged. The facility reported there had been no additional allegations of abuse since the previous survey. Fifty-one residents resided in the facility. Findings: The facility's abuse policy documented: .All allegations will be thoroughly investigated and the findings documented on the incident report form and/or in accordance to current state/federal regulations . A facility self reported incident to the Oklahoma State Department of Health, dated 03/29/17, documented certified nurse aide (CNA) #2 had reported to the director on nurses (DON) that she had been at a friend's house the evening of 03/28/17 and the friend received a Snapchat from CNA #1, who was working at the facility at the time. CNA #2's friend looked at the Snapchat and stated, Oh, look that man pissed himself. The report documented CNA #1 had been called into the DON's office and was questioned about the video. CNA #1 admitted she had taken a video of resident #1 and sent it to a male friend on a social media sight called Snapchat. The CNA stated she had put the following caption with the video: WTF (What the f***), (resident #1's first name). The report documented the local police had been notified and came to the facility to interview CNA #1. The report documented CNA #1 had been terminated on 03/29/17. On 04/04/17 at 9:10 a.m., during an interview with the administrator and the DON, the surveyor asked about the content of the video of resident #1. The DON stated the video (which no facility staff or law enforcement had seen) allegedly consisted of the resident's lap, legs, feet and the floor. The resident's pants were wet and a puddle of urine was on the floor by the resident. A caption with the video was: WTF, (resident #1's first name). On 04/04/17 at 11:27 a.m., the director of nurses (DON) was asked if the facility had completed a thorough, written investigation of the incident of abuse. The DON stated she had interviewed staff and other residents regarding the incident but had not documented the investigation.

Based on record review, observation and interview, it was determined the facility failed to protect a resident from mental abuse when a staff member took a video of a resident who had a urinary incontinence episode and posted it on social media. This affected 1 (#1) of 1 sampled residents who had been abused. Fifty-one residents resided in the facility. Findings: The facility's abuse policy, effective 10/01/99, documented: .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes .mental abuse including abuse facilitated or enable through the use of technology. The policy documented the definition of mistreatment as inappropriate treatment or exploitation of a resident . The facility's abuse policy and procedure included a social media policy, effective 12/14/16. The policy documented: .Employees are absolutely prohibited from using Social Media in any way that would violate HIPPA (Health Insurance Portability and Accountability Act) or otherwise disclose or compromise residents' PHI (protected health information) .DO NOT use Social Media to post, upload, send or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law .DO NOT use Social Media to post, upload, send or otherwise share or disclose the name of any resident (even if just the first name or nickname) without prior written permission of the resident or the resident's authorized agent as required by applicable law . The facility's abuse policy and procedure included an Abuse with Photos-Videos policy, effective 02/24/17. The policy documented: .Taking or distributing any photographs or video recordings of a resident or his/her private space without the resident's or designated representatives, written or verbal consent (unless directed by the courts or law enforcement officials), must not be done by employees .While residents may give consent for taking of photographs or videos, the use of those photographs must be consistent with the consent and cannot be demeaning or humiliating .All staff, contractors, volunteers and other caregivers will be educated about this policy ideally as part of their orientation prior to providing services to residents . A new employee packet document titled Federal Resident's Rights documented: .The Nursing Home Reform Law legally protects the following rights for nursing home residents .The Right To Privacy and Confidentiality, including the right to .Privacy in treatment and in the care of personal needs .The Right to Dignity, Respect, and Freedom, including the right to: Be treated with the fullest measure of consideration, respect, and dignity . The new employee packet also included an employee cell phone use policy which documented: .Employees may never use a cell phone or any other electronic device during direct resident care . Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 03/09/17, documented the resident had severe cognitive impairment; required extensive assistance or was dependent upon staff for all activities of daily living (ADLs); and was always incontinent of bladder and bowel. The care plan, last reviewed/revised 03/16/17, documented the resident had problems related to his dependence upon staff and family for all needs; ADL self-care deficit, and impaired cognition. The care plan addressed appropriate goals and interventions for the problems. A facility self reported incident to the Oklahoma State Department of Health, dated 03/29/17, documented certified nurse aide (CNA) #2 had reported to the director on nurses (DON) that she had been at a friend's house the evening of 03/28/17 and the friend received a Snapchat from CNA #1, who was working at the facility at the time. CNA #2's friend looked at the Snapchat and stated, Oh, look that man pissed himself. The report documented CNA #1 had been called into the DON's office and was questioned about the video. CNA #1 admitted she had taken a video of resident #1 and sent it to a male friend on a social media sight called Snapchat. The CNA stated she had put the following caption with the video: WTF (What the f***), (resident #1's first name). The report documented the local police had been notified and came to the facility to interview CNA #1. The report documented CNA #1 had been terminated on 03/29/17. On 04/04/17 at 9:10 a.m., during an interview with the administrator and the DON, the surveyor asked about the content of the video of resident #1. The DON stated the video (which no facility staff or law enforcement had seen) allegedly consisted of the resident's lap, legs, feet and the floor. The resident's pants were wet and a puddle of urine was on the floor by the resident. A caption with the video was: WTF, (resident #1's first name). At 10:35 a.m., the surveyor asked the DON if the facility staff had been inserviced on the social media policy or the Abuse with Photos-Videos policy, which were effective 12/14/16 and 02/24/17, respectfully. She stated the staff had not been inserviced on the new policies. However, she stated similar policies were reviewed with all new staff upon hire. At 11:30 a.m., the resident was observed in the dining area receiving assistance from his wife to eat. He was clean, well groomed and dressed appropriately. He was not interviewable due to his cognitive impairment. At 12:00 p.m., the resident's wife was interviewed and was asked if her husband had the cognitive ability to understand what had happened to him regarding the video being taken of him following an incontinent episode. She stated, No. She was asked how her husband might feel if he had the ability to understand what had happened. She stated her husband would be upset, maybe angry and embarrassed that he had urinated himself. She stated her husband was a private man. At 1:25 p.m., during an interview with the administrator, DON and the compliance officer, the surveyor asked if, based on the facility's abuse policy regarding abuse with photos/videos and the social media policy, the incident of the video taken of resident #1's incontinence episode, posting it on Snapchat and including his first name in the caption would be considered abuse. The DON stated, Yes. The compliance officer stated she did not think the facility failed the resident. She believed the CNA failed him.

Based on observation, record review, and interview, it was determined the facility failed to ensure a resident was free from unnecessary medications. This affected 1 (#7) of 11 sampled residents whose clinical records were reviewed for unnecessary medications. The unnecessary medication was in regard to an antidepressant. The census was 48. Findings: Resident #7 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was severely impaired in cognition and experienced minimal depression. The care plan last reviewed on 01/12/17 documented the resident received an antidepressant medication. Current physician's orders [REDACTED]. There was no documentation to indicate a gradual dose reduction (GDR) had been requested for the antidepressant medication during 2016. The resident was observed seated in his wheel chair and lying in his bed. The resident did not respond to the surveyor. On 02/23/17 at 1:15 p.m., the director of nurses was asked if a GDR had been requested for the antidepressant medication. She stated she would check. Upon return, she stated there was no GDR requested for [MEDICATION NAME] during 2016.

Based on observation, record review, and interview, it was determined the facility failed to ensure the care plan was followed. This affected 1 (#10) of 11 sampled residents whose clinical records were reviewed for following the care plan. The facility census was 48. Findings: Resident #10 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was severely impaired in cognition and required extensive assistance for most activities of daily living. The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident had experienced 2 or more falls with no injury since the prior assessment. An incident report dated 12/12/16 documented the resident had fallen in the bathroom. The report documented the resident experienced no injuries. The report documented predisposing physiological factors included confusion, gait imbalance, and impaired memory. A nurse's note dated 12/12/16 documented the resident had fallen in the bathroom and the resident was confused. The note documented the certified nurse aides (CNAs) were instructed to not leave the resident in the bathroom without assistance. An incident report dated 12/25/16 documented the resident was found on the floor by a CNA. The CNA reported she had left the resident on the commode with a call light. The report documented the resident had no observed injuries post incident. A nurse's note dated 12/25/16 documented the resident was found on the floor by a CNA who stated she left the resident on the commode with a call light. The note documented the following intervention: Do not leave resident alone in bathroom. The care plan revised on 01/20/17 documented the resident was a high risk for falls as she was unaware of safety needs and had confusion. An intervention initiated on 03/11/16 documented to offer or assist to toilet as scheduled and stay with resident until toileting was completed. An intervention initiated on 09/20/16 documented the resident was not to be left unattended on the toilet or commode. The resident was observed in a wheelchair in a common area where other residents and staff were present. She was pleasant during conversation and could answer some questions appropriately, but seemed to be confused at times. She was asked if she needed help to go to the bathroom. She stated, Yes. She was asked if staff stayed with her when she was in the bathroom. She stated sometimes they stayed with her or they would step outside the door. On 02/24/17 at 10:00 a.m., the director of nurses was shown the incident reports for 12/12/16, 12/25/16, and the care plan. She was asked if the care plan had been followed for not leaving the resident alone in the bathroom or on the commode. She reviewed the documents and stated, No. At 10:45 a.m., CNA #1 was asked if the resident could be left alone in the bathroom. She stated, they had to stay with the resident.

Based on observation, record review, and interview, it was determined the facility failed to ensure assessments accurately reflected the resident's status for 2 (#4 and #6) of 11 sampled residents whose clinical records were reviewed for accuracy. The inaccuracy was in regard to a [DIAGNOSES REDACTED]. 1. Resident #4 had [DIAGNOSES REDACTED]. The care plan dated 01/20/17 documented the resident was on a sedative/hypnotic. The staff were to administer the medication as ordered, evaluate the factors causing [MEDICAL CONDITION], and monitor for adverse effects of the medication. The quarterly assessment dated [DATE] documented the resident was independent in cognitive skills for daily decision making. The assessment documented the resident had received a hypnotic medication for 6 of the 7 days prior to the assessment. The assessment did not document the resident had a [DIAGNOSES REDACTED]. Monthly physician's orders [REDACTED]. On 02/23/17 at 12:20 p.m., the resident stated she had taken sleep medication for years. She stated she requested it at night when she needed it. She stated she had no problems with after-effects in the morning. The resident did not have an appearance of oversedation. She was alert and oriented. 2. Resident #6 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making. The assessment documented the resident had received a hypnotic medication 7 of the 7 days prior to the assessment. The assessment did not document the resident had a [DIAGNOSES REDACTED]. The care plan dated 01/19/17 documented the resident was on a sedative/hypnotic. The staff were to monitor for adverse effects of the medication. Monthly physician's orders [REDACTED]. On 02/21/17 at 11:30 a.m., the resident stated she was blind and had difficulty with sleeping. The resident did not appear oversedated and was alert/oriented. On 02/24/17 at 9:20 a.m., the assessment coordinator was asked if the [DIAGNOSES REDACTED]. She stated the [DIAGNOSES REDACTED].

Based on record review, and interview, it was determined the facility failed to ensure the clinical record was complete and accurate in regard to documentation of medication administration. This affected 1 (#6) of 7 residents whose clinical records were reviewed for medications. The facility census was 48. Findings: Resident #6 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making. The assessment documented the resident experienced no behaviors. The care plan dated 01/18/17 documented the resident was to be administered medications as ordered. The monthly physician's orders [REDACTED]. -[MEDICATION NAME] milligrams (mg) at bedtime, - D-[MEDICATION NAME] 1,000 mg three times daily, - Trazadone 100 mg at bedtime, - [MEDICATION NAME] 0.125 mg at bedtime, and - [MEDICATION NAME] 7.5 - 325 mg four times daily. The Medication Administration Record [REDACTED]. A review indicated the medications had been given and the medication count was correct. On 02/22/17 at 10:00 a.m., the director of nurses stated she believed the medications had been given, the person administering the medications that evening had been very busy, and probably had not documented the medications. She stated the facility had experienced computer problems for several weeks regarding the documentation of medications. She stated the record was incomplete without the documentation. At 10:10 a.m., certified medication aide #1 stated she had experienced computer problems lately. She stated that at times it was necessary to return at a later time to document the medications.

Based on observation, record review, and interview, it was determined the facility failed to ensure comprehensive care plans were developed for 1 (#1) of 12 sampled residents whose care plans were reviewed. The care plan was not comprehensive for weight loss. The facility census was 51. Findings: Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making. The assessment documented the resident required only supervision during meal time. The care plan last revised 11/25/15 documented the resident had a nutritional or potential nutritional problem. The goal was for the resident to maintain her weight and consume at least 50% of her meals. The staff were to explain the importance of eating to the resident and monitor the resident for signs of malnutrition. The staff were to provide and serve the diet as ordered. The care plan did not address the resident's weight loss. The weight records provided by the facility documented the following: 10/2015 - 109 pounds (lbs), 11/2015 - 99 lbs, for a significant weight loss of 9% in 30 days, 12/2015 - 101 lbs., 01/2015 - 91 lbs, for a severe weight loss of 10% in 30 days and 16% in 90 days. The record of meal intake provided by the facility documented the resident had consumed less than 51% of her meal 15 of 91 meals during 10/2015. The record documented the resident had consumed less than 51% of her meal 9 of 91 meals during 12/2015. The supplement documentation indicated the resident refused supplements when offered for less than 50% of the meal consumed. On 01/04/16 at 12:50 p.m., the resident was observed in the dining area. She was noted to feed herself without difficulty. An attempt was made to visit with the resident. She provided no coherent response to the questions. On 01/06/16 at 10:00 a.m., a family member stated the food was good at the facility, but the resident often refused to eat. At 10:50 a.m., certified nurse aide #1 (CNA) stated the resident was able to feed herself, but sometimes refused to eat. She stated the resident preferred to eat snacks and pickles. The CNA stated the resident was eating much better this week than she had in the past. At 12:00 p.m., the resident was observed in her recliner. She fed herself without difficulty or cueing. At 12:10 p.m., the assessment coordinator was shown the care plan and asked if it had been updated or revised to reflect the resident's weight loss. She reviewed the care plan and stated it had not. At 12:45 p.m., certified medication aide (CMA) #1 stated the resident usually ate well. She stated if the resident did not want to eat, nothing could change her mind. The CMA stated the resident mostly fed herself and refused to eat when assistance was provided.

Based on observation, record review, and interview, it was determined the facility failed to ensure the refrigerated storage locked box for controlled medications was permanently affixed. The lock box contained controlled medications for 2 (#14 and #15) of 2 sampled residents whose controlled medications were stored in the refrigerator. The facility census was 51. Findings: On 01/05/16 at 1:49 p.m., the locked box which contained controlled medications was observed in the refrigerator. The box was not permanently attached to the refrigerator. On 01/05/16 at 1:50 p.m., licensed practical nurse (LPN) #1 was asked if the box was attached to the refrigerator. The LPN replied, No. Resident #14 had physician orders [REDACTED]. Resident #18 had physician orders [REDACTED]. On 01/07/16 at 10:10 a.m., an observation was made of the locked refrigerated box for controlled medications. The box contained controlled medications for residents #14 and #18. At 10:10 a.m., the director of nurses was informed of the above observations. She acknowledged the findings.

Based on observation, record review and interview, it was determined the facility failed to ensure new interventions were initiated after a fall for 1 (#5) of 5 sampled residents whose clinical records were reviewed for falls. The facility census was 50. Findings: Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The care plan dated 03/18/14 documented, "FALL RISK R/T (related to) POOR IMPULSE CONTROL AND BALANCE." The goal documented, "RISK OF FURTHER FALLS WILL BE MINIMIZED AS EVIDENCED IN NURSING DOCUMENTATION OF FREQUENCY OF FALLS." Interventions documented, "(1) FREQUENT STAFF MONITORING. (2) FLOOR MAT ALARM (3)TAB MONITOR/ALARM WHEN IN WHEELCHAIR (4) STAFF TO ASSIST WITH TRANSFERS WHEN OBSERVED ATTEMPTING TO TRANSFER SELF." A significant change assessment dated [DATE] documented the resident's cognition was moderately impaired. The assessment documented he required extensive assistance for most ADLs. The assessment also documented the resident had no falls since the prior assessment, received an antipsychotic medication on 7 of 7 days in the lookback period, received a hypnotic on 1 of the 7 days in the lookback period, and received an antibiotic 5 of the 7 days in the lookback period. An incident report dated 10/07/14 documented at 4:30 a.m., resident #5 was found sitting on the floor at his bedside. He complained of pain all over, in no specific area. The report documented no apparent injuries. The incident report contained no documentation the alarms had been used. The additional comments and/or steps taken to prevent recurrence documented to instruct the certified nurse aide (CNA) to make sure his alarms were on. An incident report dated 10/08/14 documented at 3:15 a.m., the resident was found sitting on the floor at his bedside, leaning to his left against his recliner. He complained of left shoulder pain. The report documented no apparent injuries. The incident report contained no documentation the alarms had been used. The additional comments and/or steps taken to prevent recurrence documented to remind the CNA to make sure his alarms were on. The CNA stated the resident would take the personal alarm off. An incident report dated 11/17/14 documented at 4:30 p.m., the resident was found on the floor. The resident stated the chair lifted up and he slid out of it. The report documented no apparent injuries. The incident report contained no documentation the alarms had been used. The additional comments and/or steps taken to prevent recurrence documented to monitor the resident more when in the chair and make sure the alarms were on. An incident report dated 11/23/14 documented at 5:30 p.m., the resident was found on the floor in front of his recliner trying to put himself in the chair. The report documented no apparent injuries. The incident report contained no documentation the alarms had been used. The additional comments and/or steps taken to prevent recurrence documented to remind the resident to call for help when needed. An incident report dated 12/30/14 documented at 6:25 a.m., the resident was found sitting on the floor at his bedside leaning to the left side. The report documented no apparent injuries. The incident report contained no documentation the alarms had been used. The additional comments and/or steps taken to prevent recurrence documented to remind the CNA to make sure the alarms were on. An incident report dated 01/20/15 documented at 5:45 a.m., the resident was found sitting on the floor at his bedside. The report documented no apparent injuries. The incident report contained no documentation the alarms had been used. The additional comments and/or steps taken to prevent recurrence documented to remind the CNA to make sure alarms were on. On 02/11/15 at 2:20 p.m., the director of nurses was asked about the falls. She was asked if the falls had been investigated, care planned, and new interventions implemented. She stated, "No."

Based on record review and interview, it was determined the facility failed to ensure a resident's complaints of pain were addressed in a timely manner for 1 (#5) of 5 sampled residents whose clinical records were reviewed for pain. The resident census and conditions of residents identified 14 residents on a pain management program. Findings: Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The care plan dated 03/18/14 documented the staff were to check for unmet needs of toileting or pain. A significant change assessment dated [DATE] documented the resident's cognition was moderately impaired. The assessment documented he required extensive assistance for most ADLs. The assessment also documented the resident had no falls since the prior assessment, received an antipsychotic medication on 7 of 7 days in the lookback period, received a hypnotic on 1 of the 7 days in the lookback period, and received an antibiotic 5 of the 7 days in the lookback period. The assessment documented the resident had frequent mild pain. A nurse's note dated 10/07/14 documented at 4:30 a.m., the resident was found sitting on the floor at his bedside. He complained of pain all over. The note documented that pain medication was administered. A nurse's note dated 10/08/14 documented at 3:15 a.m., the resident was found sitting on the floor by his bedside, leaning to his left against the recliner. He complained of left shoulder pain. The note documented pain medication was administered. A nurse's note dated 10/13/14 documented at 3:00 a.m., the resident received pain medication for complaints of pain all over. A nurse's note dated 10/14/14 documented the resident received pain medication for complaints of hip pain. A nurse's note dated 10/15/14 documented the resident received pain medication for complaints of pain all over. A nurse's note dated 10/22/14 documented at 5:30 a.m., documented the resident received pain medication for complaints of hip pain. A nurse's note dated 10/22/14 documented, "1230 - c/o (complained of) L (left) hip pain, states he feels like it is out of place...can't lift the L leg; Family is concerned et (and) would like to see about an x-ray; (Name-=deleted physician) notified via Fax." A nurse's note dated 10/23/14 documented, "130a (1:30 a.m.) Res (resident) rec'd (received) [MEDICATION NAME] 10/325 mg i (one) PO (by mouth) c/o (complaints of) hip/back pain." A nurse's note dated 10/23/14 documented, "11A (11:00 a.m.) Recd (received) N//O (new order) via fax from (Name-deleted physician) X-ray of L hip d/t (due to) hip pain. Sched (scheduled) for 10/24/14 at 11 AM. (Name-deleted family member) notified." A nurse's note dated 10/24/14 documented, "2p (2:00 p.m.) Results of hip X-ray - Prior left [MEDICAL CONDITION] with internal fixation. NO acute bony findings." On 02/11/15 at 2:30 p.m., the director of nurses was asked if it was acceptable for a resident with a prior history of a [MEDICAL CONDITION] and complaints of hip pain to wait 48 hours after a report of hip pain to obtain an x-ray. She stated, "No."

Based on observation, record review, and interview, it was determined the facility failed to ensure residents were free from unnecessary medications for 3 (#5, 10, and #11) of 7 sampled residents whose clinical records were reviewed for unnecessary medications. The unnecessary medications were in regard to antianxiety and antipsychotic medications. The facility's resident census and conditions of residents identified 17 residents received antianxiety medication and 10 residents received antipsychotic medication. Findings: 1. Resident #11 has [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. A significant change is status assessment dated [DATE] documented the resident was cognitively intact and independent with most activities of daily living (ADLs). The assessment documented the resident experienced other behavioral symptoms not directed toward others and had received an antianxiety medication 7 of the 7 days prior to the assessment. The care plan last reviewed 01/07/15 documented the resident experienced sign/symptoms (s/s) of anxiety as evidenced by pacing to exhaustion, repetitive health concerns, and inability to rest. The care plan documented approaches as redirect the focus from self by providing diversional activity, assess for any physical cause of discomfort, pain, toileting needs, hunger, thirst, and assess environment for any apparent irritants. A nurse's note dated 01/08/15 documented, "...Nurse went in and assessed resident found her to be very restless, repeating questions and stating she was sick and needed to see (doctor). Nurse told her (doctor name deleted) had been out to see her...(Doctor name deleted) notified of behaviors, refusing to eat supper or take a drink of (water due to) being restless...(doctor name deleted) called nurse and gave (new order) [MEDICATION NAME] 0.5 milligrams (by mouth every 4 hours as needed for) anxiety." The behavior monitoring record dated 01/2015 documented the resident had exhibited numerous episodes of s/s of anxiety on 01/08/15 and 01/09/15. Non-pharmacological interventions had been attempted and were non-effective. There was no documentation of s/s of anxiety exhibited prior to 01/08/15. The nurse's medication notes dated 01/2015 documented the following: 01/08/15 - 5:00 p.m. - [MEDICATION NAME] administered, 01/09/15 - 7:30 a.m. - [MEDICATION NAME] administered, 01/09/15 - 3:45 p.m. - [MEDICATION NAME] administered, and 01/11/15 - 9:00 a.m. - [MEDICATION NAME] administered. The nurse's medication notes documented 4 doses of the as needed (PRN) [MEDICATION NAME] had been administered from 01/08/15 through 01/11/15. A nurse's note dated 01/12/15 documented, "Faxed (doctor name deleted) (regarding increased) anxiety (and) that the PRN doses of [MEDICATION NAME] have been effective. (received new order) [MEDICATION NAME] 0.5 mg (by mouth twice a day)." The Medication Administration Record [REDACTED]. The resident was observed during the survey participating in numerous activities and in the independent dining room. She was pleasant and answered questions appropriately. On 02/12/15 at 11:15 a.m., the director of nurses (DON) was shown the Medication Administration Record [REDACTED]. She reviewed the information and stated, "No." 2. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. The care plan dated 09/17/14 documented the resident had aggressive behaviors and at times they were assaultive behaviors. Interventions were to discontinue care if the resident was resistive and notify and the charge nurse. Additional interventions were to remove the resident from the area when he was inappropriate, watch body language, and facial expressions when approaching the resident. Another care plan dated 09/17/14 documented the use of an antipsychotic medication. A goal documented the behaviors would be managed on the lowest dose possible and the resident would not have an increase in medication use for 90 days. Interventions included to administer medications as ordered, monitor and document responses to medications, and evaluate for dose reduction as indicated. A significant change assessment dated [DATE] documented the resident's cognition was severely impaired. The assessment documented he had fluctuating disorganized thinking and required extensive assistance with most ADLs. The assessment documented the resident received an antipsychotic, antianxiety, and hypnotic medication for 7 of 7 days of the lookback period. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The current monthly physician's orders [REDACTED].**use chemical restraint form** order date of 06/10/2014, [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg po bid (twice daily) prn for episode mood disorder **do chemical restraint**** order date of 09/29/14". A nurse's note dated 01/02/15 documented, "10:30 p.m., Resident pacing, up (and) down, attempting to hit staff when being help. resident refused to go to bed. Resident roaming DR (dining room) getting up (and) down out of w/c (wheelchair). [MEDICATION NAME] 1 mg given for anxiety." A nurse's note dated 01/09/15 documented, "1110 A (11:10 a.m.) - Res (resident) has been very restless, wheeling around bumping into other residents w/c's. Agitating other residents combative (with) staff. 1:1 visit (and) Re-Direct attempts unsuccessful. (No) c/o (complaints of) pain. [MEDICATION NAME] 1 mg given po for (increased) anxiety / aggression." A nurse's note dated 01/09/15 documented, "1210P (12:10 p.m.). [MEDICATION NAME] eff (effective) AEB (as evidenced by) (not) combative (not) aggressive. (Name-deleted physician) notified et (and) (Name-deleted friend) notified. Ref (refused) V/S (vital signs)." A nurse's note dated 01/09/15 documented, "1P (1:00 p.m.) DON (director of nurses) (Name-deleted) contacted (Name-deleted physician) RE (regarding) (increased) behaviors et (and) what has been tried in the past, et that the cons (consultant) pharm (pharmacist) recommended ADD ([MEDICAL CONDITION]) med (medication) like [MEDICATION NAME]. (Name-deleted physician) said not that he would rather try something else. And ordered [MEDICATION NAME] 10 mg i/i (one) PO BID. (Name-deleted friend) notified. A nurse's note dated 01/12/15 documented, "3:30p (3:30 p.m.) (Name-deleted staff) tried to help resident to w/c after he had stood up and pulled tab alarm out. Resident took fist and punched her in nose. Resident given supper to distract from getting up." "4 pm (4:00 p.m.) Resident ate supper and started getting up. Nurse went to assist him back to chair Resident reared arm back to hit Nurse. Nurse asked resident what he needed, wanted to walk. Nurse helping him walk, (Name-deleted) CNA (certified nurse aide) took over. resident tried to hit CNA, CNA helped resident to walk, refused to sit in chair,refused to be cleaned." "4:30 p (4:30 p.m.) [MEDICATION NAME] 1 mg given for anxiety." "5 pm (5:00 p.m.) [MEDICATION NAME] eff AEB (no) c/o of anxiety, resident refused vitals signs, (Name-deleted friend) notified and (Name-deleted physician) notified." A nurse's note dated 01/13/15 documented, "1a (1:00 a.m.) Res awake restless, keeps attempting to stand et threatens to hit staff when they are trying to keep him from falling, anxious, agitated et resistive to care. Rec'd (received) [MEDICATION NAME] 1 mg i PO for anxiety." "2a (2:00 a.m.) [MEDICATION NAME] eff AEB resting in bed. (no) further anxiety observed @ x (time). VS refused x 3." A nurse's note dated 01/19/15 documented, "4p (4:00 p.m.) Resident going up to female resident began rubbing on her arm up and down. female resident asked him to quit. resident continued to rub on her arm, female resident stated resident was hurting her. Removed female resident and took her down North. Resident pacing walking up and down hall staff assisting him to wc and walker. resident bringing fists up to hit staff." "4:15p (4:15 p.m.) [MEDICATION NAME] 1 mg po given for (increased) anxiety." "4:45p (4:45 p.m.) Resident received meal and sit @ card table away from other residents. Resident ate 1/2 of meal then Nurse tried to be assist him c (with) meal, resident leaned back fist to hit her. Nurse stepping away and another Nurse took over. Resident taken for walk down hall resident talking about car and leaving, trying to go in in other residents room. Resident refusing care, offered drink and taken to bathroom." "5pm (5:00 p.m.) Resident continue to hit @ staff and resisting care. [MEDICATION NAME] 0.5 mg given for agatition (sic)." "6p (6:00 p.m.) Refusing vital signs, resident going up and down hall, opening doors, went into male residents room hitting male resident foot c walker accidentally and hitting walker against other walker, asked resident to leave the room. resident leaning back fist to hit Nurse and went to hit her c walker, roll into her. Nurse asked for assistance to remove resident from room. Shoved Nurse into wall. resident walked to room. hitting @ staff. Sit on bed in room." "6:30 pm (6:30 p.m.) Resident in DR (dining room), going to residents and picking up things and pushing walker around trying to stand up and walk. Resident offered drinks. Refused vital signs." "7pm (7:00 p.m.) Resident attempting to walk down hall c staff trying to stand up. staff @ stand by assist. Threatening to hit staff went to hit Nurse staff member had to assist him to wc to prevent him from falling Refused vitals." "7:30 (7:30 p.m.) Resident continues to (increase) agatition and trying to stand up and walk refusing staff assistance to help him walk refusing snacks and vital signs." "7:40 (7:40 p.m.) (Name-deleted physician) called about agatiton and (increase) anxiety. Reported behaviors of hitting and pacing, resistive to care. Rec N/O (new order) [MEDICATION NAME] (increase) 2 mg po q (every) 6 (hours) PRN and [MEDICATION NAME] (increased) 1 mg to BID PRN and [MEDICATION NAME] 2 mg IM (intramuscular) x 1. (Name-deleted pharmacy) called and ordered med." "8pm (8:00 p.m.) Resident relaxed and let staff put him to bed resting c ou (both eyes) closed resp even and unlabored. (no) c/o of pain (no) s/s (signs or symptoms) of agatation or anxiety." A nurse's note dated 01/20/15 documented, "3:30 pm Resident began pacing getting up and down from wc. Resident asked if he wanted to walk. Resident said NO, resident refusing to allow Nurse to put gait belt on him to steady him. Resident threatened to hit Nurse d/t (due to) Nurse trying to get him to sit down. Offered supper. Resident agreed. Resident given [MEDICATION NAME] 1 mg for agatition. Resident spit med out, wasted that med and repeated med." "430 p (4:30 p.m.) Resident ate supper and taken to the BR (bathroom). Resident walked down hall getting up (and) down moving from wc to walker." "5:30 pm Resident sitting in w/c when staff tried to take vital signs began raising arm and becomes resistive to care. (Name-deleted staff) faxed (Name-deleted physician) and reported behavior of resident asking for order for generations. (Name-deleted physician) faxed back for Generations and to obtain lab (laboratory) work in AM - (Name -deleted friend) notified about generations and about [MEDICATION NAME] usage." "6:30 pm Resident sitting in w/c offered fluids and offered to take him BR, refused, pacing, walking c walker, staff given 1-1 care." "7:20 p (7:20 p.m.) Resident having symptoms of (increase) anxiety. trying to go in residents rooms refusing to care, pacing, standing up and down. [MEDICATION NAME] 2 mg given." "7:45 pm Resident sitting in wc quietly, (no) pacing relaxing." "8 pm (8:00 p.m.) Resident sitting in w/c c eyes closed [MEDICATION NAME] eff AEB (no) s/s of anxiety." A nurse's note dated 01/22/15 documented, "4 pm (4:00 p.m.) [MEDICATION NAME] 1 mg given for behaviors refusing care, starting to pace getting agatited @ staff and residents, refused vitals." A nurse's note dated 01/22/15 documented, "(Name-deleted physician) faxed about resident having symptoms of pain. Asking if could put him on [MEDICATION NAME] 5/325 i/i tab (tablet) po 12N / 8pm routine and [MEDICATION NAME] 5 pm. (Name-deleted physician) faxed N/O Yes to Both request med ordered." A nurse's note dated 01/22/15 documented, "6 pm (6:00 p.m.) [MEDICATION NAME] eff AEB resident still getting up but calmer not aggitated toward staff." A nurse's note dated 01/23/15 documented, "635 am (6:35 a.m.) Res having (increase) agitation, attempting to try to get him to sit down in his w/c for appx (approximately) 5 min (minutes) uncooperative et refusing to sit even though very unsteady et hanging onto east med cart. res became combative when assisted to sit in w/c et hit CNA 3 times in fast punches. Res was separated from CNA et told that was inappropriate behavior." "7A (7:00 a.m.) Resident tore up napkin that had been twisted up, resistive to care trying to stand up and walk. Resident (increase) agatition, fed breakfast. [MEDICATION NAME] 1 mg given for (increase) agitation." "8AM (8:00 a.m.) Resident wheeling self around in DR, resident grabbing @ other resident w/c and walkers - refused vitals." "9 AM (9:00 a.m.) Resident talking to female resident, vital signs refused but calmer. [MEDICATION NAME] eff, (Name-deleted friend) notified." "2PM (2:00 p.m.) (Name-deleted physician) here for rounds, reported behaviors and [MEDICATION NAME] usage. Rec N/O for [MEDICATION NAME] 0.5 mg po TID (three times daily routine) The MAR for January 2015 documented the resident received [MEDICATION NAME] 1 mg on 01/19/15 at 5:30 p.m., 01/20/15 at 4:00 p.m., 01/22/15 at 4:00 p.m., and 01/23/15 at 7:00 a.m. for anxiety. On 02/12/15 at 3:45 p.m., the DON was asked to review the documentation provided in the nurses notes related to the use of [MEDICATION NAME]. She was asked if the administration of [MEDICATION NAME] (an anti-anxiety medication), with documentation of being effective four times from 01/01/15 through 01/19/15, would indicate the need to initiate the [MEDICATION NAME] (an anti-anxiety medication) 10 mg twice daily routine. She stated, "No, according to the documentation, it doesn't look like we gave the [MEDICATION NAME] a chance to work first." 3. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] documented the resident's cognition was moderately impaired. The assessment documented he required extensive assistance of one staff member for transfers, dressing, personal hygiene, and bathing. The assessment documented the resident received an antipsychotic medication on 7 of 7 days on the look back period and received a hypnotic on one of the 7 days in the lookback period. The care plan dated 03/18/14 documented, "Problem: DISRUPTIVE BEHAVIORS." A goal documented, "WILL EXPERIENCE A REDUCTION IN ANXIETY AS EVIDENCED BY DECREASED EPISODES OF RESTLESSNESS AND REPETITIVE REQUESTS." Interventions were documented as, "(1) REDIRECT RESIDENT WHEN ANXIOUS (2) CHECK FOR UNMET NEED OF TOILETING OR PAIN (3) ENGAGE IN 1:1 ACTIVITY (4) CHECK FOR ELEVATED BLOOD PRESSURE WHEN RESIDENT IS ANXIOUS." Another care plan dated 03/18/14 documented, "[MEDICAL CONDITION] MEDICATION: [MEDICATION NAME] USED DAILY FOR CONTROL OF [MEDICAL CONDITION]." A goal documented, "WILL SHOW IMPROVED BEHAVIOR AS EVIDENCED BY FEWER THAN 4 EPISODES DAILY OF DISRUPTIVE BEHAVIORS IN 90 DAYS." Interventions were documented as, "(1) MONITOR RESIDENT FOR SIDE EFFECTS, ESPECIALLY LETHARGY (2) OBSERVE FOR SIDE EFFECTS OF [MEDICAL CONDITION] MEDICATION (3) Q (EVERY) SHIFT BEHAVIOR MONITORING REPORT FREQUENCY OF DISRUPTIVE BEHAVIORS TO NURSE (4) AIMS TESTING, BASELINE & QUARTERLY (5) ASSESS FOR NEED OF GRADUAL DOSE REDUCTION OF ANTIPSYCHOTIC DRUG." The behavior monitoring sheets for October, November, December 2014, January, and February 2015 documented the behavioral symptom to monitor was repetitive questions/ health complaints. There was no documentation to indicate the behavior had occurred. On 02/11/14 at 1:45 p.m., certified medication aide (CMA) #1 was asked if the resident had any behaviors the staff were to monitor for. She stated not that she was aware of. The CMA stated sometimes he would yell out 'hey girl'. She was asked how she would be informed of this information. She stated eventually somebody would say something to let the staff know. At 1:55 p.m., certified nurse aide (CNA) #1 was asked if the resident had any behaviors the staff were to monitor for. She stated no, he was really nice and cooperative. At 2:10 p.m., licensed practical nurse (LPN) #2 was asked if the resident had any behaviors the staff were to monitor for. She stated he just liked attention and when he wanted it, he wanted it now. She stated he would flag you down and yell out if you did not attend to him pretty quick. She was asked if repetitive questions and health complaints would be indication to be on an antipsychotic medication. She stated she did not think that would be an appropriate reason. She was asked where she would document her findings if behaviors were to occur. She stated in the nurses notes and on the behavior sheet. At 2:20 p.m., the director of nurses (DON) was asked about the administration of the [MEDICATION NAME]. She stated he was admitted to the facility with that medication and he was doing good because he was not having any behaviors. She was shown the behavior monitoring sheets. She was asked if repetitive questions and health concerns were appropriate targeted behaviors and would be a reason to administer an antipsychotic medication. She stated no, but delusions should be included. The DON provided an informed consent for the use of a [MEDICAL CONDITION] medication for resident #5. It documented the symptoms to look for were agitation and delusions. She stated he was having them quite often. She was asked what non-pharmacological interventions were attempted. She stated the staff member at the front had a daughter that came after school and read to him. His wife came every night to eat supper with him and they went outside. She was asked if this was documented on the care plan. She stated it was not.