Every finding on record at Beare Manor

Based on record review and interview, the facility failed to ensure a resident at risk for pressure ulcers was assessed and monitored to prevent pressure ulcers for 1 (#3) of 2 sampled residents reviewed for pressure ulcers.Resident #3 was admitted to the facility on [DATE] with a skin condition described as MASD with early pressure areas to the upper buttocks. On 07/13/26, Resident #3 was assessed and the wound located in the sacral area had declined to a stage 2 pressure ulcer. A note from the DON showed the wound should have been staged as a stage 3 pressure ulcer at that time. Weekly skin checks for Resident #3 showed an increase in the dimensions and an overall decline of the wound status. There was no documentation to show pressure ulcer treatment/precaution interventions had been implemented. There was no documentation to show the physician had been notified of the decline in the wound's status. On 08/05/26, Resident #3 was discharged to an emergency room for acute care. Resident #3 required surgical intervention for a stage 4 pressure ulcer on their sacrum and a stage 2 pressure ulcer on their genitalia.The administrator identified 34 residents resided in the facility. The DON identified no residents with pressure ulcers currently resided in the facility. On 08/13/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident at risk for pressure ulcers was assessed and monitored to prevent pressure ulcers. On 08/13/26 at 10:30 a.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 08/13/26 at 12:53 p.m., the administrator was notified of the IJ situation and the IJ template was provided. On 08/17/26 at 3:33 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Date of Completion: 8/13/2026PROBLEM IDENTIFIED: Facility failed to develop and implement a system to identify residents at risk for and worsening of pressure ulcers, monitor and report pressure ulcer changes to the physician.HOW CORRECTIVE ACTION WILLTAKE PLACE:8/13/2026 -In service nursing department which includes RN's, LPN's, CNA's and CMA's - That all changes in resident skin conditions will be immediately reported to the charge nurse/DON/Administrator who will then do a formal skin assessment and notify physician if needed. Upon admission admitting nurse will do the initial skin/wound care assessment and braden scale risk assessment. Admitting nurse is to obtain measurements upon admissions but do not stage.DON/RN will do head to toe skin assessment on all residents 8/13/2026, and will continue to do head to toe full body assessments twice weekly for three months. Provider will be notified today of any new skin issues found that provider was not already aware of, and treatment orders will be obtained and implemented. Residents family will be notified as well. DON/RN noted no declines after completing her head to toe assessments on all residents. Also no declines in any with wounds. Did not have to notify the provider of any changes to wounds. Documentation will be added in clinical record.RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED: All ResidentsMEASURE PUT INTO PLACE TO ENSURE THAT DEFICIENT PRACTICE WILL NOT REOCCUR AND HOW IT WILL BE MONITORED:When skin issues are reported DON will review charting to make sure provider has been notified, treatment order obtained, and that treatment has been implemented.Upon admission admitting nurse will do initial skin/wound assessment. Then DON/RN will continue to do weekly skin/wound assessments twice a week. DON/RN was doing skin/wound assessments once a week but now increased to twice a week x3 months. Braden scale risk assessment will be completed upon admission by admitting nurse as well as head to toe skin assessment to identify residents at risk. All new admits with any wound at any stage will be assessed by wound care NP at the next facility visit. Wounds will be staged in collaboration with RN/DON, Provider, and/or wound care NP. DON/ADMIN will review nurse documentation and new treatment orders daily for indication of new skin changes and ensure that provider has been notified.DON/ADMIN will review skin issues twice weekly in morning meeting to review skin assessments and monitor wound progress. Provider will be updated if wound status regresses to obtain more suitable treatment order. On 08/14/26, the immediate jeopardy was lifted when all components of the plan of removal had been verified as completed. Nursing staff were interviewed regarding immediate notification of resident skin conditions to the charge nurse, DON, or administrator who will then do a formal skin assessment and notify the physician if needed. Staff interviewed were knowledgeable on education and training provided. The plan of removal records including facility's pressure ulcer policy and procedure, head to toe assessment of all residents, provider notification of any new skin issues were reviewed. The staff in-service with signatures to attest understanding of the training received was also reviewed. The deficient practice remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. Findings: A record summary document for Resident #3, dated 08/18/26, showed the resident was admitted to the facility on [DATE] with the following diagnoses which included malnutrition, hypertension, hyperkalemia, aphasia, hyperlipidemia, cerebrovascular accident, transient ischemic attack or stroke, atrial fibrillation or other dysrhythmias A care plan for Resident #3, dated 07/10/26, did not show any care areas or interventions for prevention or care of pressure ulcers. The care plan showed the resident would be assisted with all actives of daily living including assistance with turning and repositioning every two hours and positioned with pillows for pressure relief. A care plan note, dated 08/03/26, showed the resident changed to full body lift. A skin check document for Resident #3, dated 07/10/26, showed the resident's skin was warm and dry to the touch with redness noted to the right heel. The document showed MASD early pressure areas to the right upper buttock with measurements to the top area measuring 1.5 CM x 1 CM and the bottom area measuring 1 CM x 1.2 CM. The surrounding skin was noted to be red. A pressure injury risk evaluation for Resident #3, dated 07/11/26, showed the resident had a risk evaluation score of 14 indicating moderate risk for pressure injury. A skin check document for Resident #3, dated 07/13/26, showed the measurement of 2.5 CM x 2.3 CM. The document showed the skin between the areas on the resident's buttocks was red and macerated and had became one area. The document showed the wound was staged as a 2 with a note added by the DON that read in part, Should have been Stage 3. The document was signed by the DON on 08/11/26 at 11:56 p.m. An admission assessment for Resident #3, dated 07/20/26, showed the resident had a BIMS summary score of 99 which indicated severe cognitive impairment. The assessment showed the resident was at risk for developing pressure ulcers The assessment showed no unhealed pressure ulcers/injures. The assessment showed the resident was impaired on both sides of their lower extremities and used a wheelchair for mobility. The assessment showed the resident required partial/moderate assistance to roll left and right in bed and required substantial/maximal assistance to sit, stand, and transfer. A skin check document for Resident #3, dated 07/20/26, showed a measurement of 2.7 CM x 2.5 CM. The note showed the area was a little larger than the previous week but some of the macerated skin had peeled off causing a change in the measurement. The document showed the stage of the pressure ulcer was a stage 2 with stage 3 circled in the description. The document was signed by the DON on 08/12/26 at 12:01 a.m.A skin check document for Resident #3, dated 07/27/26, showed a measurement of 2.7 CM x 2.6 CM with notes showing there was not much change in the resident's condition from the previous week. The document was signed by the DON on 08/12/26 at 12:04 a.m.A resident matrix, dated 08/02/26, showed Resident #3 had a facility acquired pressure ulcer.A skin check document for Resident #3, dated 08/03/26, showed a measurement of 2.8 CM x 3.2 CM. The document showed the resident would be referred to the wound care provider. The document was signed by the DON on 08/12/26 at 12:12 a.m.There was no documentation to show the wound care provider had evaluated Resident #3.A nurse progress note for Resident #3, dated 08/05/26 at 10:48 a.m., showed the resident was not responding to yes and no questions when asked and not making eye contact when spoken to. The resident's vitals showed to be B/P - 100/58, HR - 122, R - 23, and T- 97.3 with no signs of pain. The note showed the resident's family member had requested the resident be sent to the emergency room for evaluation. The note showed the resident was transferred to the hospital by ambulance.An Emergency Department Note, dated 08/05/26, read in part, presented to the emergency department secondary to acute on chronic altered mental status.nursing staff reports when obtaining urinalysis sample they noted that the patient had an infectious appearing genitalia.Exam performed and the patient was noted to have a cellulitic process with likely superimposed candidal balanoposthitis [yeast and inflammation of the genitalia]. There is significant erythema of the [genitalia] and the area that the nursing staff question to be packing was actually tissue that was sloughing off overlying a central [genital] ulceration.CT [computed tomography] abdomen pelvis wit IV [intravenous] contrast demonstrates soft tissue defect and subcutaneous air in the region of the gluteal crease with air extension into the soft tissue and surrounding rectum/anus. These findings are concerning for Fournier's gangrene.Patient is also rolled and does have a ecchymotic appearing sacral pressure ulcer.decision was made to transfer the patient to a higher level of care facility with urology capabilities.A hospital discharge plan for Resident #3, dated 08/05/26 at 3:40 p.m., showed the resident would be transferred to an acute care hospital with diagnoses which included Fournier's gangrene, sepsis, MODS (multiple organ disfunction syndrome), hyperosmolar hyperglycemic state (HHS), acute metabolic encephalopathy, a pressure ulcer of sacral region, acute hypernatremia, acute renal failure, atrial fibrillation with rapid ventricular response. The discharge plan showed the resident was in critical condition. A hospital operative report for Resident #3, dated 08/07/26, showed the resident had pre-operative diagnoses which included necrotizing soft tissue infection of sacral decubitus ulcer, stage 4 sacral pressure injury, and stage 2 scrotal pressure injury. The report showed excisional debridement of full thickness skin, subcutaneous tissue, muscle, and fascia measuring 10 CM X 6 CM X 2.5 CM of the sacral decubitus ulcer. The report showed negative pressure wound therapy was applied to the wound post procedure.On 08/11/26 at 5:44 p.m., the DON stated Resident #3 was assessed when they were admitted to the facility and there was no documentation of a wound or skin issue in the records provided by the transferring facility. On 08/12/26 at 10:33 a.m., the DON provided skin check reports for Resident #3 and stated they had incorrectly staged the resident's wound as a stage 2. The DON stated the resident's wound should have been staged as a stage 3 according to the description provided on the skin check document. The DON stated Resident #3's wounds were not assessed by a physician or wound care provider prior to discharge to the hospitalOn 08/12/26 at 11:11 a.m., the DON stated they made a wound care assessment referral to APRN #1 on 08/03/26 for Resident #3 to be assessed at their next visit on 08/07/26 but the resident was discharged to the ER on [DATE]. The DON stated the referral was made verbally and there was no documented referral method with the provider.On 08/12/26 at 2:19 p.m., Intensive Care Unit Charge Nurse #1 stated Resident #3 was admitted to the hospital with sepsis and had two surgical procedures for wound debridement for a sacral wound. On 08/13/26 at 12:08 p.m., the medical director stated they had not seen Resident #3's skin conditions, wounds, or pressure ulcer while the resident was in the facility. They stated they had ordered a treatment when the resident was admitted treating a skin issue, but it was not for a pressure ulcer.On 08/20/26 at 12:37 pm., the DON stated Resident #3 was treated for Fournier's gangrene while at the hospital, and that could not have been determined at the facility with any amount of assessment they could have provided. On 08/20/26 at 04:08 p.m., CNA #1 stated Resident #3 had some skin issues and some scabs on their genitalia. CNA #1 stated they would apply ointment to the areas every time they changed the resident. CNA #1 stated the medication was for diaper rash. CNA #1 stated the resident had no other wounds they were aware of. CNA #1 stated the area on the resident's genitalia was not a hard scab and was kind of healing.On 08/21/26 at 11:27 a.m., the MDS coordinator stated they recalled Resident #3 had received wound wash and a topical sulfa antibiotic on their bottom. The MDS coordinator stated they did not recall any treatment on the resident's sacrum. They stated they were unsure why skin assessments for Resident #3 indicated a wound was on resident's sacrum because they weren't aware of any redness on the resident's genitalia and bottom until the morning the resident was sent out. They stated, on 08/05/26, CNA #1 asked them to look at the resident's bottom, and it had gotten much worse. They stated the resident was not themselves and very lethargic and had to be transported to the hospital by ambulance. They stated they did not recall providing care to a scab on the resident's genitalia.A text from medical director, dated 08/24/26, showed in their opinion, the wound should never have been staged because it was not a pressure ulcer. On 08/25/26 at 10:13 a.m., the DON stated the skin check documentation reporting stage 2 was consistent with wound staging and assessment practices. The DON stated the documents were marked and the note was added indicating the wound should have been stage 3 because they knew there would be questions based on the descriptions listed on the skin assessment documents provided. They stated the descriptions on the documents were not consistent with skin assessment and staging practices.

Based on record review and interview, the facility failed to notify the attending physician/medical director of a decline in a resident's condition for 1 (#3) of 2 sampled residents reviewed for pressure ulcers.The administrator identified 34 residents resided in the facility. The DON identified no other residents in the facility had pressure ulcers. Findings:A policy titled Change in a Resident's Condition or Status, dated 02/2014, read in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). d. A significant change in the resident's physical/emotional/mental condition;. 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii). 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when:. b. There is a significant change in the resident's physical, mental, or psychosocial status.A skin check document for Resident #3, dated 07/13/26, showed the measurement of 2.5 CM x 2.3 CM with the note showing skin between the areas was red and macerated and now it had become one area. The note showed it was staged as a 2 on this skin check document with a note added indicating it should have been a Stage 3. The document was signed 08/11/26 at 11:56 p.m.A skin check document for Resident #3, dated 07/20/26, showed a measurement of 2.7 CM x 2.5 CM with the note showing the area was a little larger than the previous week but some of the macerated skin had peeled off causing a change in the measurement. A note on skin the check document showed the stage was a 2 with Stage 3 circled in the description. The document was signed 08/12/26 at 12:01 a.m.A skin check document for Resident #3, dated 07/27/26, showed a measurement of 2.7 CM x 2.6 CM with notes showing there was not much change from the previous week. The Stage 3 and description were circled. The document was signed 08/12/26 at 12:04 a.m.A skin check document for Resident #3, dated 08/03/26, showed a measurement of 2.8 CM x 3.2 CM and notes showed the area was larger than the previous week and the resident would be referred to the wound care provider. The document was signed 08/12/26 at 12:12 a.m.There was no documentation to show the physician/medical director had been notified of the change in condition of Resident #3's wound. On 08/12/26 at 11:11 a.m., the DON stated they made a wound care assessment referral to APRN #1, the wound care nurse, on 08/03/26 for Resident #3 to be assessed at their next visit on 08/07/26. The DON stated the referral was made verbally and there was no documented referral method with the provider. On 08/13/26 at 12:08 p.m., the medical director stated if the facility staff had a concern about a resident's wound, they would call for the wound care provider to assess and treat pressure ulcers that were Stage 2, or higher. The medical director stated they did not recall any communication with the facility staff concerning Resident #3's declining wound status.On 08/21/26 at 11:27 a.m., the MDS coordinator stated they made rounds with the medical director on 07/15/26 and had not asked the medical director to assess Resident #3's skin conditions. On 08/21/26 at 2:34 p.m., LPN #1 stated they did not recall contacting the medical director, other doctors or wound care concerning Resident #3's wounds but may have when the resident admitted to the facility. On 08/21/26 on 3:10 p.m., APRN #1 stated they had not assessed Resident #3 for wound care and denied they had received a referral to assess the resident. APRN #1 stated they did not recall being asked to assess Resident #3 for wound care.On 08/24/26 at 11:35 a.m., the administrator stated the charge nurse, or DON made rounds with the attending physicians and notified them of any issues or concerns they had for resident care. The administrator stated the DON should have notified the medical director or primary care provider when a skin assessment documented a change in the wound, or any other resident care decline occurred. The administrator stated the medical director, primary doctor, and the family should be notified when anything concerning a resident worsened.On 08/24/26 at 1:14 p.m., the medical director stated they were not notified about the increasing wound measurements documented on the skin check documents for Resident #3 and hoped the facility staff had called the wound care provider because they should have during that time. On 08/25/26 at 9:40 a.m., the DON stated no referrals were made to the wound care provider for Resident #3's wound because it was just skin peeling until 08/03/26 and Resident #3 had discharged from the facility on 08/05/26.

Based on record review and interview, the facility failed to ensure a comprehensive resident assessment was accurate for 1 (#3) of 3 sampled residents reviewed for accurate resident assessments. The administrator identified 34 residents resided in the facility. Findings:A policy titled Resident Assessment Instrument, dated 10/2010, read in part, 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care the allows the resident to reach his/her highest practicable level of functioning.A weight measurement for Resident #3, dated 07/10/26, showed a weight of 162 lbs.A skin check document for Resident #3, dated 07/10/26, showed the resident's skin was warm and dry to the touch with redness noted to the right heel, MASD early pressure areas to the right upper buttock with measurements to the top area 1.5 x 1 and the bottom area 1 x 1.2. The surrounding skin was noted to be red. A physician's order for Resident #3, dated 7/10/26, showed to cleanse areas to right buttock with wound wash, pat dry, and apply zinc twice daily and as needed for soilageA skin check document for Resident #3, dated 07/13/26, showed the measurement of 2.5 CM x 2.3 CM. The document showed the skin between the areas on the resident's buttocks was red and macerated and had become one area. The document showed the wound was staged as a 2 with a note added by the DON. The note, read in part, Should have been Stage 3. The document was signed by the DON on 08/11/26 at 11:56 p.m. A skin check document for Resident #3, dated 07/20/26, showed a measurement of 2.7 CM x 2.5 CM. The note showed the area was a little larger than the previous week but some of the macerated skin had peeled off causing a change in the measurement. The document showed the stage of the pressure ulcer was a Stage 2 with Stage 3 circled in the description. The document was signed by the DON on 08/12/26 at 12:01 a.m.An admission assessment for Resident #3, dated 07/20/26, showed the resident was at risk for developing pressure ulcers and showed no unhealed pressure ulcers/injures. The assessment showed the resident's weight was 172 lbs.On 08/20/26 at 12:10 p.m., the DON stated they were unsure why the weight entered in Resident #3's assessment was 172 lbs. They stated the resident's weight of 162 lbs. on 07/10/26 in their clinical record was correct. The DON stated they were unsure why the resident's assessment did not identify any wounds, skin issues, or pressure ulcers, although the assessment included a skin treatment. The DON stated the MDS coordinator was still new to the position.On 08/20/26 at 3:17 p.m., the administrator stated the assessment for Resident #3 should have identified the documented wounds, skin issues, and pressure ulcers. They stated the order for skin treatment was correct. The administrator stated the assessment listed Resident #3's weight as 172 lbs. was likely entered in error. The administrator stated the MDS coordinator was still learning their position.On 08/21/26 at 11:27 a.m., the MDS coordinator stated they did not recall why Resident #3's weight was listed as 172 lbs. in the assessment. The MDS coordinator stated they were unsure why the resident's assessment did not identify any skin issues, wounds, or pressure ulcers, although a treatment was noted.On 08/25/26 at 9:40 a.m., the DON stated Resident #3's weight of 172 lbs. entered on the assessment dated [DATE] was incorrect. They stated the weight documented on 07/10/26 of 162 lbs. in the resident's clinical record were correct.On 08/25/26 at 10:13 a.m., the DON stated Resident #3's skin issues and weights recorded in the clinical record were correct and they could not know what someone else entered on the assessment documentation.

Based on record review and interview, the facility failed to develop and/or implement comprehensive care plans for 2 (#1 and #3) of 3 sampled residents reviewed for care plans.The administrator identified 34 residents resided in the facility.Findings:A policy titled Care Plans - Comprehensive, dated 10/2010, read in part, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.1. A skin check document for Resident #3, dated 07/10/26, showed the resident's skin was warm and dry to the touch with redness noted to the right heel, MASD early pressure areas to the right upper buttock with measurements to the top area 1.5 x 1 and the bottom area 1 x 1.2. The surrounding skin was noted to be red. A physician's order for Resident #3, dated 7/10/26, showed to cleanse areas to right buttock with wound wash, pat dry, and apply zinc twice daily and as needed for soilage.A care plan for Resident #3, dated 07/10/26, did not show care areas for the resident's wound care.A skin check document for Resident #3, dated 07/13/26, showed the measurement of 2.5 CM x 2.3 CM. The document showed the skin between the areas on the resident's buttocks was red and macerated and had become one area. The document showed the wound was staged as a 2 with a note added by the DON. The note, read in part, Should have been Stage 3. The document was signed by the DON on 08/11/26 at 11:56 p.m. A skin check document for Resident #3, dated 07/20/26, showed a measurement of 2.7 CM x 2.5 CM. The note showed the area was a little larger than the previous week but some of the macerated skin had peeled off causing a change in the measurement. The document showed the stage of the pressure ulcer was a Stage 2 with Stage 3 circled in the description. The document was signed by the DON on 08/12/26 at 12:01 a.m.A skin check document for Resident #3, dated 07/27/26, showed a measurement of 2.7 CM x 2.6 CM with notes showing there was not much change in the resident's condition from the previous week. The document was signed by the DON on 08/12/26 at 12:04 a.m.A skin check document for Resident #3, dated 08/03/26, showed a measurement of 2.8 CM x 3.2 CM and notes showed the resident would be referred to the wound care provider. The document was signed by the DON on 08/12/26 at 12:12 a.m.On 08/18/26 at 12:36 p.m., the MDS coordinator stated Resident #3 should have had wound care in their care plans. They reviewed the resident's care plan and stated the resident's care plan had a care area for skin integrity but not one for wound care. On 08/18/26 at 12:40 p.m., the DON stated Resident #3 should have had wound care as part of their care plan. The DON stated the care plan should have included wound care.2. A record summary document for Resident #1, dated 08/20/26, showed the resident was admitted to the facility on [DATE] with diagnoses which included thyroid disorder, non-Alzheimer's dementia, anxiety disorder, hyperlipidemia, gastroesophageal reflux disease, hypertension, and diabetes mellitus.A care plan for Resident #1, dated 06/19/24, showed no care plan areas or interventions for wound care. A skin check document for Resident #1, dated 07/29/26, showed the resident had an area of scabbing consistent with a deep tissue injury to their left heel. A skin check document for Resident #1, dated 08/05/26, showed the resident had an area of scabbing consistent with a deep tissue injury to their left heel. On 08/18/26 at 12:36 p.m., the MDS coordinator stated they were unsure about updates needed to Resident #1's care plan and would discuss any needed updates with the DON.On 08/18/26 at 12:40 p.m., the DON stated the care plan for Resident #1 had not been updated to include wound care since the resident was shown to have had an area of scabbing consistent with a deep tissue injury to the left hill that was documented on skin check assessments dated 07/29/26 and 08/05/26.On 08/20/26 at 3:17 p.m., the administrator stated they were aware of missing information for Resident #1 and Resident #3 care plans and it would be addressed.

Based on record review and interview, the facility failed to ensure the skin condition of a resident and wound status was evaluated by a physician for 1 (#3) of 3 sampled residents reviewed for pressure ulcers.The administrator identified 34 residents resided in the facility. The DON identified no other residents in the facility had pressure ulcers. Findings:A policy titled Attending Physician Responsibilities, dated 04/2013, read in part, The Attending Physician shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the facility. 3. The Attending Physician will seek, provide and analyze information regarding the resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with regulations and care standards. 12. During visits, the Attending Physician will determine each resident's overall condition and the status of specific medical issues by seeing and evaluating the individual, speaking with staff (as needed) and (as indicated) with responsible parties/family, and reviewing relevant information. 20. The Attending Physician will perform accurate, timely and relevant medical assessments. 21. The Physician will verify and clarify symptoms, problems, and diagnoses, and will help establish a realistic prognosis and care goals. 23. In consultation with facility staff, the Physician will identify appropriate treatments and services, consistent with each individual's diagnosis, condition, prognosis, and wishes. 26. The Physician will respond to notifications of, and will assess and manage acute and significant changes in resident conditions.A skin check document for Resident #3, dated 07/13/26, showed the measurement of 2.5 CM x 2.3 CM. The document showed the skin between the areas on the resident's buttocks was red and macerated and had become one area. The document showed the wound was staged as a 2 with a note added by the DON. The note, read in part, Should have been Stage 3. The document was signed by the DON on 08/11/26 at 11:56 p.m. A physician's note by the attending physician/medical director for Resident #3, dated 07/15/26, did not show a pressure ulcer on the sacrum, or other skin issues on the genitalia and bottom as documented in the skin assessment completed by the DON on 07/13/26. The medical director's note showed to refer to the nurse's charting concerning the resident's skin.On 08/13/26 at 12:08 p.m., the medical director stated they recalled Resident #3's stated they did not see Resident #3's wounds or skin condition while the resident was in the facility. They stated they had discussed the situation with facility staff the previous day when they visited the facility. The medical director stated if the facility staff had a concern about a resident's wound, they would call the wound care provider to assess and treat pressure ulcers that were Stage 2, or higher. The medical director stated they did not require facility staff to obtain an order to consult another physician for treatment or a second opinion.On 08/20/26 at 12:10 p.m., the DON stated the medical director did not normally make notes concerning skin issues, wounds, or pressure ulcers during rounds and instead refered to nurses' notes and assessments in the clinical record. On 8/21/26 at 11:27 a.m., the MDS coordinator stated they had made rounds with the medical director after Resident #3 was admitted to the facility. The MDS coordinator stated the medical director did not assess the resident's skin condition or wounds at that time. They stated doctors would assess wounds if needed or requested but did not normally assess wounds as part of routine rounds.On 08/21/26 at 2:34 p.m., LPN #2 stated they did not recall making rounds with the medical director to assess Resident #3. They stated doctors would assess residents' skin conditions when staff informed them of an issue. LPN #2 stated they had not asked a doctor to assess any residents' skin condition that they recalled.On 08/21/26 at 3:10 p.m., APRN #1 stated when they were in the facility and staff wanted them to assess a resident, staff would provide them with a face sheet. They stated they liked to review whether residents were receiving enough protein, whether the physician ordered zinc, and other information, but staff provided most of the resident's information verbally. APRN #1 stated they provided the facility with documentation of their involvement but did not know how staff communicated that information to the attending physician or medical director.On 08/24/26 at 11:35 a.m., the administrator stated the charge nurse or DON made rounds with physicians and notified them of any issues or concerns with resident skin conditions, wounds or other resident care needs.On 08/24/26 at 1:14 p.m., the medical director stated the reason they referred the skin portion of the physician's note to see nurses charting was because any wounds that were staged as a 3 or greater went straight to a wound doctor. The medical director stated when a wound doctor was involved, they backed off to prevent issues from occurring. The medical director stated they asked nursing staff about wounds and then addressed the wounds based on that information. The medical director stated they did not roll every resident and look at every wound every week or look at every bottom to see if there were wounds. They said they looked at skin conditions and wounds when asked by nursing staff. The medical director stated they guessed there could be some caution from that.

Based on record review and interview, the facility failed to ensure the medical director:a. participated in QAPI meetings as part of the QAPI committee;b. reviewed and approved facility polices that directly affected resident care; andc. participated in the developing, updating, and reviewing the facility assessment. The administrator identified 34 residents resided in the facility. Findings:An undated document titled [NAME] Manor Quality Assurance Committee QAPI Committee showed the medical director was to be included as a quality assurance and assessment and QAPI committee member.A policy titled Medical Director, dated 04/2008, read in part, 2. The Medical Director is a licensed physician in this state and is responsible for:. d. Overseeing and helping develop and implement care-related polices and practices;. 3. Medical Director functions also include, but are not limited to:. d. Helping assure that the resident care plan accurately reflects the medical regimen; . e. Participating in staff meetings concerning infection control, quality assurance, pharmaceutical services, resident care policies, etc.;A policy titled Facility Assessment, dated 10/2018, read in part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during the day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. 1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. 2. The team responsible for conducting, reviewing and updating the facility assessment includes the following:. c. The medical director;. 10. The QAPI committee is responsible for reviewing facility and resident information quarterly to determine if a facility reassessment is warranted.A QAPI committee sign-in sheet, dated 01/08/26, showed the medical director did not sign the document as part of the QAPI committee. An annual review signature page for the facility QAPI program, revised 01/10/26, showed the facility administrator's signature. A document titled [NAME] Manor QAPI Plan, revised 01/10/26, read in part, The QAPI Committee will oversee the implantation of our QAPI Plan. The committee will meet monthly.A QAPI committee sign-in sheet, dated 04/02/26, showed the medical director did not sign the document as part of the QAPI committee. A facility assessment, dated 06/11/26, showed to have been completed or updated and reviewed with the quality assessment and assurance/QAPI committee on 06/11/26. There was no documentation to show the medical director had participated in developing, updating, and reviewing the facility assessment. A QAPI committee sign-in sheet, dated 07/16/26, showed the medical director did not sign the document as part of the QAPI committee. There was no documentation to show the medical director had reviewed facility policies annually. On 08/21/26 at 10:50 a.m., the administrator stated the medical director had not reviewed facility policies annually. On 08/24/26 at 1:14 p.m., the medical director stated they did not attend QAPI meetings at the facility. The medical director stated they were at the facility regularly and addressed issues and concerns without waiting until the next QAPI meeting.On 08/24/26 at 1:14 p.m., the medical director stated they did review facility polices but they had not formally sat down and read policies or signed off on them annually. They stated they did have input in policy changes and had been consulted concerning policies and procedures that affected the care provided to residents in the facility.On 08/24/26 at 3:55 p.m., the administrator stated the medical director was part of the QAPI committee but did not normally attend the QAPI committee meetings.On 08/24/26 at 3:55 p.m., the administrator stated the medical director had not reviewed the facility assessment. On 08/25/26 at 9:35 a.m., the administrator stated that facility policy required the medical director to approve and sign the facility assessment, but they had declined to sign it.

Based on observation, interview, and facility policy review, the facility failed to ensure employees with facial hair wore a beard guard and/or hair net while in the kitchen. This had the potential to affect all 38 residents who received food from the kitchen.Findings included: A facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Samity Practices, dated12/2008, specified, Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The policy specified, 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. During a concurrent interview and observation of the kitchen on 06/03/2026 at 11:12 AM, the Maintenance Director entered the kitchen during the lunch meal. The Maintenance Director had facial hair and no dietary staff offered him a beard guard/hair net and he did not put one on. The Maintenance Director stated he had never been asked to put on a beard guard when he worked in the kitchen. During a concurrent interview and observation of the kitchen on 06/03/2026 at 11:15 AM, [NAME] #7 was observed prepping the dinner meal. [NAME] #7 had facial hair and was not wearing a covering over his facial hair. [NAME] #7 stated he recently grew a beard and had never been asked to wear a beard guard. During an interview on 06/03/2026 at 11:18 AM, the Dietary Manager (DM) stated she did not have any beard guards in stock and [NAME] #7 could have either worn a hair net or a face mask. During a follow-up interview on 06/03/2026 at 11:33 AM, the DM stated it was her expectation that beard guard supplies be kept in stock, but a hair net could also be used if a beard guard was not available. During an interview on 06/03/2026 at 11:48 AM, the Administrator stated it was the facility policy and expectation that anyone who entered the kitchen with facial hair wore a beard guard.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on interview, record review, document review, and facility policy review, the facility failed to ensure a certified nurse aide (CNA) immediately reported an allegation of suspected abuse to the Abuse Coordinator, Director of Nursing (DON) and/or the charge nurse for 1 (Resident #30) of 3 sampled residents reviewed for abuse. This deficiency represents non-compliance investigated under Complaint Number 3003056.Findings included: An undated facility policy titled, Abuse and/or Neglect, revealed, All healthcare workers are responsible for ensuring the safety of those under their care. It is the responsibility of our employees, facility consultants, attending physician, family members, and visitors to promptly report any incident or suspected incident of neglect or abuse, this also includes injuries of unknown source. The policy specified, Abuse is to be reported immediately to the abuse coordinator, the administrator in this case, if you can't get ahold of her let the DON or charge nurse know. A Mini Face Sheet indicated the facility admitted Resident #30 on 10/23/214. According to the Mini Face Sheet, the resident had a medical history that included a diagnosis of cellulitis. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/30/2026, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The facility Incident Report Form completed by the Administrator indicated an allegation of abuse/mistreatment that occurred on 04/28/2026 in which CNA reported while assisting another CNA transfer that CNA screamed at resident and pushed [resident] on the bed. DON/Admin. [Administrator] spoke with resident regarding incident. Resident is able to answer yes or no questions. Resident stated that CNA did not scream at [him/her] or push [him/her] on the bed. No injuries noted. Per the Incident Report Form, [CNA #2] and DON came in administrator office on 4/29 [2026] at 3:10pm the next day after [CNA #2] witness the abuse. Administrator and DON discussed with [CNA #2] that since she did not report abuse immediately that she is just as responsible. Our policy states that you have to report abuse immediately to your charge nurse/supervisor. Follow your chain of command. Both employees put on suspension following investigation. [CNA #2] for failure to report in a timely matter and [CNA #1] for suspected abuse. Part C: During investigation resident that was involved in incident was interviewed. DON/Administrator were notified by staff member CNA that another CAN was 'rude and rough' when putting resident to bed. DON/Administrator went and spoke with resident. Resident denied any staff member being mean, rude or rough with [him/her] by answering yes and no questions. The Incident Report Form indicated, Statement was obtained from [CNA #2] who witness the allegation of abuse. [CNA #2] stated she was assisting [CNA #1] transfer resident to bed and that [CNA #1] screamed at [Resident #30] telling [him/her] [he/she] can walk and stand up. Then she stated [CNA #1] then pushed [Resident #30] on to the bed. [CNA #2] said she told [CNA #1] she didn't need to talk to [the resident] that way. [CNA #2] also stated she reported it to the charge nurse that day. [CNA #2's] shift is 2p-10p Monday thru Friday. Obtained statements from both 6a-6p and 6p-6a charge nurses for that day. They both stated she [CNA #2] did not report any type of abuse to them. During a telephone interview on 06/02/2026 at 2:37 PM, CNA #2 stated there had been an incident where she witnessed what she considered to be abuse. According to CNA #2, CNA #1 stood Resident #30 up and kind of threw the resident on the bed. CNA #2 stated she immediately left the room and told Licensed Practical Nurse (LPN) #3, in the presence of CNA #4 and CNA #5. During a telephone interview on 06/02/2026 at 6:38 PM, CNA #4 stated she did not witness the incident, but was present when CNA #2 told LPN #3. During an interview on 06/03/2026 at 10:28 AM, LPN #3 stated no one had every reported an allegation of abuse to her. LPN #3 stated she did not remember any time that CNA #2 came to her and said anything about another CNA treating a resident rough or being rude. During an interview on 06/03/2026 at 3:37 PM, the DON stated CNAs should report allegations of abuse to their charge nurse, who was to immediately notify her or the Administrator. The DON stated she first learned of the incident involving Resident #30 on 04/29/2026, the day after the alleged incident occurred. According to the DON, CNA #2 told her that she did not report the incident to the day shift charge nurse, LPN #6, on 04/28/2026 because CNA #1 and LPN #6 were friends, so she reported the incident to LPN #3 later. The DON stated CNA #2 was adamant that no one else was around when she reported the alleged incident to LPN #3. The DON stated she expected the staff to report allegations of abuse immediately. During a telephone interview on 06/04/2026 at 8:18 AM, CNA #5 stated all she knew about the alleged incident was that CNA #2 told her that she saw a resident being jerked by the other CNA and handled roughly. CNA #5 stated she told CNA #2 that if she did not report the allegation, she was just as guilty. According to CNA #5, CNA #2 told her that she would report the alleged incident in the morning because it was late at night. CNA #5 stated she was not present and never witnessed CNA #2 report the alleged incident to LPN #3. During an interview on 06/04/2026 at 8:46 AM, the Administrator stated CNA #2 informed her and the DON of the alleged incident on 04/29/2026 at 3:10 PM. The Administrator stated she asked CNA #2 if she reported the alleged incident to the charge nurse, and CNA #2 stated she did not report it to the charge nurses. The facility implemented the below listed corrective actions once they became aware of the alleged incident: Once the DON and Administrator became aware of the allegations of abuse, they immediately suspended CNA #1 who was identified as the alleged perpetrator of abuse against Resident #30. They also suspended CNA #2 once they determined that she waited almost 24 hours to report allegations of abuse. During the facility investigation, interviewable residents were interviewed to determine if any other residents were affected or abused who were cared for by CNA #1. The facility also completed skin assessments on non-interviewable residents who were cared for by CNA #1 to ensure there were no unexplained bruises or injuries. Resident #30 was also interviewed by the DON and Administrator and a skin assessment completed to ensure there were no injuries. All staff were retrained on abuse and the importance of reporting abuse. Staff were interviewed to verify that they received retraining on abuse. This retraining was completed 05/04/2026 when the facility completed their investigation into the allegation of abuse. CNA #1 was placed on suspension once the allegations of abuse was reported and remained on suspension until the completion of the investigation. CNA #1 submitted her resignation on 05/04/2026; however, she returned to work at the facility on 05/15/2026. CNA #1 received re-orientation upon rehire on abuse and the importance of reporting abuse. CNA #2 was suspended at the beginning of the investigation for not reporting allegations of abuse and was ultimately terminated for not reporting allegations of abuse immediately. The facility addressed the reporting of abuse during their quality assurance performance improvement meeting and no further issues had been identified. After review and verification of the facility's corrective actions, to include the facility's investigation, staff education, and interviews with staff, the survey team determined the facility implemented the above corrective actions beginning 04/29/2026 through 05/04/2026, and during the survey, there was no identified concerns, therefore, past noncompliance was cited.

Based on record review and interview, the facility failed to submit accurate Registered Nurse staffing data to CMS for FY Quarter 2 2024. The DON identified 35 residents resided in the facility. Findings: A PBJ Staffing Data Report, for January 1, 2024 - March 31, 2024, documented the facility did not have RN hours for 01/02; 01/03; 01/04; 01/05; 01/08; 01/09; 01/09; 01/10; 01/11; 01/12; 01/15; 01/16; 01/17; 01/18; 01/19; 01/22; 01/23; 01/24; 01/25; 01/26; 01/29; 01/30; 01/31; 02/01; 02/02; 02/05; 02/06; 02/07; 02/08; 02/09; 02/12; 02/13; 02/14; 02/15; 02/16; 02/18; 02/19; 02/20; 02/21; 02/22; 02/23; 02/26; 02/27; 02/28; 02/29; 03/01; 03/04; 03/05; 03/06; 03/07; 03/08; 03/11; 03/12; 03/13; 03/14; 03/15; 03/16; 03/17; 03/18; 03/19; 03/20; 03/21; 03/22; 03/23; 03/24; 03/25; 03/26; 03/27; 03/28; and 03/29. On 07/23/24 at 3:48 p.m., the DON was asked if the facility had RN coverage on the days outlined on the PBJ Staffing Data Report. They stated all of the days listed for missing RN coverage were days the DON had worked, and the previous business office person failed to manually input them into the system before submitting the information to the state. The DON provided copies of the updated time reports. RN coverage was noted for each day designated on the [NAME] report. The DON was asked if accurate information had initially been submitted to the state? They stated no it was not.

Based on observation, record review, and interview, the facility failed to ensure: a. food items were labeled, dated and stored according to facility policy, b. proper freezer cleaning practices were followed to prevent the outbreak of foodborne illness, c. using adequate utensils for portion sizes for meals, d. maintain proper dishwasher temperature, and e, maintain infection control during wrapping of silverware. Findings: The DON reported all 35 residents that resided in the facility also received services from the kitchen. The facility's Food Receiving and Storage policy, dated 12/2008, read in part, Foods shall be received and stored in a manner that complied with safe food handling practices. The policy also read, Food Services, or other designated staff, will maintain clean food storage areas at all times. The policy also read, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). The facility's Cleaning Freezer document, undated, read in part, Remove all food from freezer to be defrosted and place in another freezer. The policy also read, Repeat this procedure as often as necessary. The facility's Kitchen Weights and Measures policy, dated 12/2008, read in part, Food Services staff will be trained in proper use of cooking ans serving measurements to maintain portion control. The policy also read, Cooks and Food Services staff will be trained in weights and measures, volume and weights, appropriate utensil use, and food can sizes. The policy also read, Serving utensils used. Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (e.g., color-coded) on utensils will be prominently displayed for reference. The facility's Washing Dishes document, undated, read in part, Dishwasher .(Wash 120 degrees F, Rinse 120 degrees F). On 07/22/24 at 3:15 p.m., during the initial tour of the kitchen the following observations were made: In refrigerator/freezer #2: a. one clear plastic container with yellow hinges with cheddar cheese inside with no date on the container. The cheese was not in its original container. b. two opened gallons of milk with no opened date. c. one opened half gallon of chocolate milk with no opened date. In refrigerator/freezer #1: a. one Ziploc bag of sliced cheese with no label or opened date. In refrigerator/freezer #3: a. one large pan of rice crispy bars covered with foil with no date or label. b. one pound cake in a plastic bag with no label or opened date. In the freezer in the dry storage area: a. two bags of opened frozen cookies with no label or opened date. b. observation of dietary aide #1 wrapping silverware on top of the deep freezer. The utensils were touching the surface of the freezer top with no barrier underneath. The freezer had debris on it. In freezer #5 observation made of the bottom of the freezer to be covered with ice and frozen red liquid underneath a shelf of frozen meat. On 07/22/24 at 3:34 p.m., the DM was asked what the policy and procedure was for refrigerator storage. They went to look. On 07/22/24 at 3:36 p.m., the DM stated the dishwasher temperature should reach 120 degrees. The DM stated it read 100 degrees and should be 120 degrees, then walked away. On 07/22/24 at 3:37 p.m., the dietary aide #1 stated if the dishwasher did not meat the right temperature then they would run it again. The dietary aide was observed to remove the dishes from the dishwasher and proceed to put them away. It was a large pot and two cups. On 07/22/24 at 3:39 p.m. the dietary aide #1 stated they could not say why they put the dishes up that were washed when the dishwasher was not at the correct temperature. On 07/22/24 at 3:41 p.m., the dishwasher temperature log was observed to have no temperatures documented for 7/20, 7/21, nor 7/22/2024. The dietary aide #1 stated the temperature log should be completed three times a day. They stated after looking at the log on the wall that the last date documented was the 19th. On 07/22/24 at 3:43 p.m., the DM ran the dishwasher again. The temperature reading was 105 and 100 degrees. On 07/22/24 at 3:44 p.m., the CDM informed staff to use paper until the dishwasher was fixed. On 07/22/24 at 3:45 p.m. the DM stated to use the 3 compartment sink for pots and pans. On 07/22/24 at 3:46 p.m., the CDM stated they were to check the dishwasher temperatures three times a day and the last date on the log was the 19th. On 07/22/24 at 3:48 p.m., the CDM stated the following of the identified concerns: a. the cheese had no date and the three milks had no date when opened. b. the pound cake had no date and stated the rice crispies had just been made that day but had no date or label. c. the wrapping of the cutlery should have been done on a clean surface and done in the dining room normally. d. no knowledge of when the cookies were place as there was no date. On 07/22/24 at 3:53 p.m., the CDM stated the freezers were to be cleansed once a month. They looked inside the freezer #5 and was asked if the freezer had been cleaned recently. They stated, No! They were asked if the policy and procedure were being followed. The CDM stated, no. On 07/22/24 at 4:07 p.m. the DM stated if dishes were washed in an under temp dishwasher, the staff were to re-wash them. On 07/22/24 at 4:10 p.m., there was a purple spoon/spatula in appearance, in the pureed main entree of shepherds pie. They had already served from the pan. On 07/22/24 at 4:12 p.m., the DM stated it was a one tablespoon. The removed it and stated should be a #12 which was a 1 1/2 cup and they did not have that so they were using a 1.5 scoop. On 07/22/24 at 4:15 p.m., the DM acknowledged the puree had already been served. On 07/22/24 at 4:41 p.m., the DON stated the portion sizes were on the wall and they did not have a policy. They were informed of the kitchen concerns.

Based on record review, observation, and interview, the facility failed to ensure a means to accurately measure and verify the amount of a liquid controlled drug on hand for four (#6, 15, 27, and #29) of six residents receiving a liquid controlled drug. The Director of Nursing identified 35 residents resided in the facility. There were six residents in the facility receiving a liquid controlled drug. Findings: A 'Controlled Substances' policy, effective date July 2015, read in part, .E. Accurate accountability of the inventory of all controlled drugs is maintained at all times . A 'Controlled Drug Receipt Record/Disposition Form' for Resident #15, read in parts, .Lorazepam Con 2mg/ml .Date Received 04/25/24 .Quantity Received 30.00 of 30.00 .Date 07/23/24 .Amount Left 29.25 . A 'Controlled Drug Receipt Record/Disposition Form' for Resident #27, read in parts, .Lorazepam Con 2mg/ml .Date Received 01/15/24 .Quantity Received 30.00 of 30.00 .Date 04/03/24 .Amount Left 29.25 . A 'Controlled Drug Receipt Record/Disposition Form' for Resident #6, read in parts, .Lorazepam Con 2mg/ml .Date Received 05/21/24 .Quantity Received 30.00 of 30.00 .Date 05/22/24 .Amount Left 29.25 . A 'Controlled Drug Receipt Record/Disposition Form' for Resident #29, read in parts, .Lorazepam Con 2mg/ml .Date Received 06/26/24 .Quantity Received 30.00 of 30.00 .Date 07/20/24 .Amount Left 27ml . On 07/24/24 at 11:20 a.m., this surveyor observed there were no markings on the 30ml Lorazepam Con 2mg/ml bottles to measure the amount of medication that exceeded 22mls. CMA #1 was asked to look at the medication bottles and confirm the amount of liquid Lorazepam Con 2mg/ml remaining in the bottles for Resident #6, #15, #27, and #29, without referring to the controlled drug sheet. They stated they could not. On 07/24/24 at 12:37 p.m., the DON was asked how the count for liquid narcotics was verified as accurate since there were no markings on the medication bottles between 22mls and 30mls. The DON acknowledged they could not verify the accuracy of the count and stated, The pharmacy would need to dispense it differently.

Based on record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for seven (#7, 10, 20, 21, 24, 26, and #30) of 12 sampled residents reviewed for advanced directives. The Director of Nursing identified 35 residents resided in the facility. Findings: 1. Resident #7 was admitted on [DATE]. Code Status: DNR 2. Resident #10 was admitted on [DATE]. Code Status: DNR 3. Resident #20 was admitted on [DATE]. Code Status: Resuscitate 4. Resident #21 was admitted on [DATE]. Code Status: Resuscitate 5. Resident #24 was admitted on [DATE]. Code Status: Resuscitate 6. Resident #26 was admitted on [DATE]. Code Status: Resuscitate 7. Resident #30 was admitted on [DATE]. Code Status: Resuscitate The clinical records for Resident #7, #10, #20, #21, #24, #26, and #30 did not document the residents and/or their representatives had or were offered the choice to formulate an advanced directive on admission nor thereafter. On 07/23/24 at 1:23 p.m., the DON acknowledged Resident #7, 10, 20, 21, 24, 26, and #30 did not have an established advanced directive nor did they have a signed acknowledgement saying it had been offered. 45583

Based on record review and interview, the facility failed to provide a binding arbitration agreement that informed the resident or their representative of their right to have the arbitration held at a venue that is convenient to both parties for sixteen (#6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34) of twenty-six residents with signed binding arbitration agreements. The DON identified 35 residents resided in the facility. There were 26 residents who had signed a binding arbitration agreement. Findings: The binding arbitration agreement did not contain a statement informing the resident or their representative of their right to have the arbitration at a neutral site that is convenient for both parties for Residents #6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34. On 07/25/24 at 3:54 p.m., the Administrator was asked to identify where in the binding arbitration agreement for Residents #6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34 did it state the resident or their representative had the right to have the arbitration held at a venue that was convenient to both parties. The Administrator reviewed the agreements and acknowledged they did not contain that necessary information.

Based on record review and interview, the facility failed to have a water management program in place to minimize the risk of Legionella and other opportunistic pathogens in building water systems reviewed for infection control. This had the potential to affect all residents. The DON identified 35 residents resided in the facility. A Legionnaires' Disease policy, dated 9/2019, read in part, Develop a water management strategies to reduce the risk of the growth and spread of Legionella if a risk assessment determines the facility to be at risk. 1. Complete a facility risk assessment of the water system. A map/diagram will be developed which will map out how the water enters and travels through the building. 2. Develop water management strategies for the facility's hot and cold water distribution system. 3. Document the water management program. Maintain record of the facility's activities and strategy to manage and maintain an efficient water system. 4. Prepare a facility description. A facility description should be written and include: location, age, uses/function, occupant population, visitor population. 5. Describe the facility's water system. The description should be written and include: general summary (how water enters and flows through the facility), uses of water, aerosol-generated devices, process flow diagram. The building diagram provided attached to the policy was blank and did not identify water flow. An Identifying Buildings at Increased Risk form, undated, documented if the answer to questions 1-4 were yes, then there should be a water management program for that building's hot and cold water distribution system. An X mark next to Yes for question#1 that stated Is your building a healthcare facility where patients stay overnight or does your building house or treat people who have chronic and acute medical problems or weakened immune systems. There was also a yes marked for question #2 for Does your building primarily house people older than [AGE] years (like a retirement [NAME] or assisted-living facility). An email, dated 11/02/2022 from CMS DNH Triage Team to a facility corporate representative per the DON. The email documented, Facilities must be able to demonstrate measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as having a documented water management program. It also documented, Facilities must also have an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. It also documented, Your water management program must at a minimum meet federal guidelines and any additional state requirements if applicable. On 07/24/24 at 8:52 a.m., the DON stated they were the IP for the facility. They stated they had not had any Legionellosis in the facility. The DON stated they needed to ask the administrator about the Legionella policy. They were asked if the maintenance would do it and they further stated would ask the administrator. On 07/24/24 at 10:30 a.m., the DON stated they did not follow the policy and procedure for Legionella but they were doing what was instructed and approved per their corporate which was who the email was sent to and who sent the documents to the facility. The DON verbalized they did not follow the policy they provided the survey team.

Based on record review and interview, the facility failed to provide a binding arbitration agreement that contained an acknowledgement the resident or their representative understood the agreement they were signing for sixteen (#6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34) of twenty-six residents with signed binding arbitration agreements. The DON identified 35 residents resided in the facility. There were 26 residents who had signed a binding arbitration agreement. Findings: The binding arbitration documentation did not contain an acknowledgement that the resident or their representative understoon the agreement for the following Residents #6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34. On 07/25/24 at 3:54 p.m., the Administrator was asked to identify where in the binding arbitration agreement for Residents #6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34 did it state the resident or their representative understood the agreement they were signing. The Administrator reviewed the agreements and acknowledged they did not contain that necessary information

Based on observation, record review, and interview, the facility failed to ensure care plans were developed and implemented for three (#8, 14 and #23) of three sampled residents with orders for a diuretic, opioid pain medications, anti-depressants, and anticoagulants. The MDS Coordinator identified three residents with orders for diuretics, eight residents with orders for opioid pain medications, 30 residents with orders for antidepressants, and six with orders for anticoagulants. Findings: 1. Res #8 was admitted with diagnoses which included chronic pain syndrome and depression. A care plan, last updated 12/13/22, did not contain documentation of Res #8's opioid pain medication or anti-depressant. A physician order, dated 03/01/23, documented to administer Cymbalta (an antidepressant) 30 mg daily. A physician's order, dated 05/08/23, documented to administer Oxycodone (an opioid pain medication) 5 mg twice daily. A quarterly assessment, dated 06/12/23, documented Res #8 had received the anti-depressant and pain medication for seven days of the seven day look back period. On 07/06/23 at 8:10 a.m., Res #8 was observed receiving the Cymbalta and Oxycodone. On 07/06/23 at 1:45 p.m., the MDS coordinator reported the anti-depressant and pain medication for Res #8 should have been care planned. 2. Res #14 was admitted with diagnoses which included hypertension and edema. A physician order, dated 03/23/23, documented to administer Lasix (a diuretic medication) 20 mg daily in the morning. A care plan, last updated 06/08/23, did not contain documentation of the diuretic/Lasix. A quarterly assessment, dated 06/29/23, documented Res #14 had received a diuretic for seven days of the seven day look back period. On 07/06/23 at 8:15 a.m., Res #14 was observed receiving Lasix 20 mg. On 07/06/23 at 1:45 p.m., the MDS coordinator reported the diuretic for Res #14 should have been care planned. 3. Res #23 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation and CVA. A physician order, dated 04/05/23, documented to administer warfarin (an anticoagulant) 4 mg daily. An admission assessment was completed on 04/12/23. A comprehensive care plan for Res #23 was not developed until 06/06/23. The care plan, dated 06/06/23, did not include a care plan for anticoagulant therapy. On 07/06/23 at 1:35 p.m., the MDS Coordinator reported there should have been a care plan for Res #23's anticoagulant therapy because warfarin use required monitoring. They stated the care plan for Res #23 was not developed in a timely manner.

Based on record review and interview, the facility failed to revise a care plan related to behaviors for one (#28) of one sampled resident reviewed for behaviors. The MDS coordinator identified 10 residents who refused medication and care. The Resident Census and Conditions of Residents, dated 07/03/23, documented a census of 39 residents. Findings: Res #28 was admitted with diagnoses which included depression, dementia, bipolar, delusional disorder and anxiety. A review of the nursing notes, dated 06/01/23 to 07/07/23, documented Res #28 refused medications 26 times, refused showers four times, and refused skin treatments twice. A Behavioral and Mental Health care plan, dated 03/08/22, did not document the resident's refusal of medications, showers and treatments. On 07/06/23 at 1:36 p.m., the MDS coordinator reported Res #28's behaviors of refusing medications, showers and treatments should have been care planned.

Based on record review, observation, and interview, the facility failed to ensure residents were free of accident hazards for one (#1) of three residents reviewed for transporting while in reclining wheelchairs. The Administrator reported five residents utilized reclining wheelchairs. Findings: An untitled and undated policy, read in parts, .To ensure that all residents are safe during transportation of using facility vehicle .All residents will be secured in their seats . On 03/14/23 at 2:20 p.m., Res #1 reported the brakes on their reclining wheelchair were broken. Res #1 reported when being transported in the facility van the reclining wheelchair was not secured. On 03/14/23 at 2:25 p.m., Res #1's reclining wheelchair was observed with the right brake missing and the left brake was broken. On 03/14/23 at 2:30 p.m., CNA #1 reported they had transported Res #1 to an appointment and the reclining wheelchair brakes were broken at the time. On 03/14/23 at 3:10 p.m., the Administrator observed Res #1's reclining wheelchair and reported the brakes were broken . The Administrator reported Res #1 should not have been transported with the broken brakes.

Based on record review and interview, the facility failed to ensure: a. annual skills competencies were completed for two (CNA #3 and LPN #2) of six employees whose personnel files were reviewed. b. skills competencies for new hires were completed for two (LPN #1 and RN #1) of six employees whose personnel files were reviewed. Findings: A CNA checklist for CNA #3, dated 01/06/21, was blank. A Nurse checklist for LPN #2, dated 03/19/21, was blank. A Nurse checklist for LPN #1, dated 05/01/22, was blank. On 06/02/22 at 10:30 a.m., the administrator verified the skills competencies were blank and reported they should have been completed upon hire and annually.

Based on record review, observation and interview, the facility failed to maintain an effective pest control program. The Resident Census and Conditions of Residents documented 31 residents received meals from the kitchen. Findings: On 05/31/22 at 9:10 a.m., during the intital tour of the kitchen, mouse droppings were observed: a. in the doorway between the kitchen and dining room. b. in the general storage room underneath a storage rack. c. in the corner of the chemical storage room. On 06/01/22 at 1:27 p.m., during a walk through of the kitchen, mouse droppings were observed: a. in the doorway between the kitchen and dining room. b. in the general storage room underneath a storage rack. c. on the floor of the chemical storage room. d. on the floor beside the food preparation table. e. behind the faucet in the janitor closet. f. on the floor of the broom closet. A Pro-[NAME] Pest Control invoice dated, 09/28/21, was provided by the facility. On 06/01/22 at 2:25 p.m., the administrator stated she had not allowed the pest control company inside the building due to Covid.

On 04/04/18, an immediate jeopardy (IJ) situation was determined to exist due to the failure of the facility to prevent abuse and protect a resident from abuse by a staff member who photographed resident #1 with a personal cellular (cell) phone and distributed it to another staff member who viewed and then showed the photo to other staff members. On 03/30/18 certified nurse aide (CNA) #1 used a personal cell phone to photograph resident #1 without her consent. The resident was naked in bed, awake, and looking at the camera. The resident's bedding hung off the side of the bed and on to the floor and the resident had experienced a bowel movement per the comment sent with the photograph. The CNA sent the photograph and comment in a text message to CNA #2 who showed the photo to other staff members. The staff members who viewed the photo did not report the incident to the director of nursing (DON), the facility administrator (adm), or to Oklahoma State Department of Health (OSDH) until 04/02/18. On 04/04/18 at 11:19 a.m., OSDH was notified and verified the IJ situation. On 04/04/18 at 11:25 a.m., the adm was notified an IJ existed related to the facility's failure to prevent and protect the resident from abuse. On 04/04/18 at 12:42 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented the following: Plan of Removal The Plan of Removal for correcting the Immediate Jeopardy Situation regarding Abuse of (name redacted, resident #1) is: - Staff (name redacted, CNA #1) responsible for taking the picture has been terminated. - Staff responsible for showing the picture to others (name redacted, CNA #2) is suspended at this time and will be terminated. - Nurses, who staff claim they reported incident to ((name redacted, licensed practical nurse (LPN) #1) and (name redacted, LPN #2)) are currently suspended and will be terminated. - Staff, who were shown the picture and did not report it until Monday, ((names redacted, CNA #3, housekeeper #2, housekeeper #3, and CNA #4)) will be terminated for failure to report abuse within the required time frame. - Remaining staff will be in-serviced on: - Abuse Prohibition Policy - Resident Rights - Social Media Policy - Staff will not be allowed to carry cell phones or other electronic devices in the building. - In-service will be held today (4/4/18) at 1 PM. - Any staff who does not attend will be in-serviced by phone by 3PM today. This plan of correction will be completed by 3 PM. On 04/05/18 at 9:55 a.m., the facility was notified the IJ was removed on 04/04/18 at 4:43 p.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from sexual abuse for one (#1) of four residents sampled for abuse and neglect. The facility failed to prevent a staff member from photographing a naked resident and distributing the photograph to another staff member who subsequently showed multiple staff members over the course of two days. The director of nursing (DON) identified 37 residents who resided in the facility. Findings: A facility policy on social media documented, Posting pictures, recordings, or names of any resident on social media is a violation of resident privacy and confidentiality and is grounds for immediate termination .Any other photos or recordings of residents are strictly prohibited. A facility policy on abuse prohibition documented, Abuse includes any form of physical, verbal, or sexual abuse, involuntary seclusion, neglect, misappropriation of property, and corporal punishment. If you have any concerns regarding these issues, you have the duty to contact us immediately through one or more of the following resources: The Administrator/Designee, DON, ADON, Charge Nurse. The policy documented one type of sexual abuse as Causing, permitting, encouraging, or allowing the photographing, filming, or depicting of the person, if the person knew or should have known, that the resulting photograph, film, or depiction was obscene or pornographic. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A significant change assessment, dated 12/01/17, documented the resident was moderately impaired with daily decision making. The assessment documented the resident required extensive assistance with most activities of daily living and did not walk. A quarterly assessment, dated 03/01/18, documented the resident was severely impaired in cognition. The assessment documented the resident required limited assistance with transfers, extensive assistance with dressing, hygiene, and toileting, and did not walk. An incident report form, submitted to OSDH as an initial report on 04/02/18 at 3:49 p.m., documented the DON was made aware of the photograph of resident #1 on 04/02/18 at 1:43 p.m. The incident report documented the facility had determined CNA #1 had photographed the resident on 03/30/18 and had sent the photo to CNA #2. The incident report documented CNA #2 showed the photo to other staff members. The incident report documented CNA #3 was shown the photo on 04/01/18 and reported it to licensed practical nurse (LPN) #1 on the same day. An undated handwritten statement, signed by CNA #2, documented she received a photo by text message of resident #1 on 03/30/18 at 11:43 p.m. The statement documented the resident was lying in her bed with the sheets and blankets hanging off her bed, covered with poop. The statement documented that on 03/31/18 she showed a co-worker the photo in an attempt to obtain advice on what to do. The statement documented the co-worker instructed her to inform the charge nurse. The statement documented the CNA told her charge nurse and was instructed to report the photo and incident to the DON when the DON returned to work. The statement documented the CNA showed the photo to LPN #2 and CNA #3. An undated handwritten statement, signed by CNA #3, documented CNA #2 had shown her a picture of the resident with no clothes on and a sheet beside her. The statement documented the photo was sent from CNA #1 and had a caption of in the middle of taking a (s***). The statement documented she told LPN #1 about the photo. The statement documented that on 04/02/18 she reported the incident and photo to the DON as soon as she got to work. A nurse note, dated 04/02/18 at 5:24 p.m., documented the resident was observed by the DON and another LPN and had no signs of trauma. A typed and signed statement from LPN #2, dated 04/02/18, documented the LPN had no knowledge of the photo or the incident surrounding the photo. The statement documented, apparently it was reported to admin that (name redacted) CNA (#1) had taken a naked pic of a res Friday night and was either showing it to some of the other aides or texting it to them or Snapchatting it to them. The statement documented she wasn't sure how they were passing it around. A handwritten statement from housekeeper #2, dated 04/03/18, documented she was shown a photo of resident #1 on Saturday, (MONTH) 30th, at 4:00 pm. The statement documented housekeeper #3 was right beside her, and CNA #2 and CNA #4 were sitting on the couch. The statement documented a conversation between CNA #2 and housekeeper #2 regarding CNA #1 who had quit. The statement documented the housekeeper was instructed by CNA #2 to come look at this message. The statement documented she observed a photo of the resident who was naked and looking at the camera with no blankets or covers on her. The statement documented the housekeeper told the others this was a big violation and needed to be reported. The statement documented she planned to report it on Monday (04/02/18). A handwritten statement from LPN #1, dated 04/03/18, documented the LPN was not on duty at the time the photo was taken. The statement documented the LPN denied seeing the photo but was told about the photo on 04/01/18. The statement documented she was told the photo had been sent to CNA #2. The statement documented the LPN was told CNA #2 had taken the photo to the DON. The statement documented the LPN thought the incident had been reported and did not report it herself. A handwritten statement from CNA #1, dated 04/03/18, documented, I took a picture as inside joke with my phone and sent it to a co-worker after taking and sending the photo I then deleted the photo. To my knowledge nobody else had seen the photo. Please give phone number to family so that I can appoleglse (sic) to them. On 04/04/18 at 8:55 a.m., the DON was asked what the facility had done to protect the resident and prevent the reoccurrence of abuse. The DON reported CNA #2 was suspended and CNA #1 had quit. She stated LPN #1 and LPN #2 had been suspended and reported to the Oklahoma Board of Nursing. She stated no cell phones were allowed on the floor and the facility had a mandatory in-service planned for 04/05/18. On 04/04/18 at 9:47 a.m., the adm was interviewed and reported she had been working at another facility and had called on 04/02/18 at approximately 2:00 p.m. to see if everything was OK. She stated she was asked by the front office manager if she had heard about the incident. The adm reported she was told CNA #1 had taken a naked photo of the resident and sent it to another staff member who was showing it around. She stated she reported it to the corporate nurse and was informed this was abuse and was instructed to go to the facility immediately and start the investigation and reporting process. She stated the police were notified and took a statement from CNA #2. The adm was asked what steps were put in place to protect the resident and to prevent reoccurrence of the abuse. She reported the facility planned to move the resident closer to the nursing station but had not done so as yet. The adm reported she suspended the two LPNs and CNA #2. She stated she planned on having an in-service for all the staff but had not done it yet. On 04/04/18 at 2:17 p.m., the resident was observed in her wheelchair in the living room area. The resident was clean, dressed, and showed no signs or symptoms of distress. An attempt was made to interview the resident but she was not able to form coherent sentences. When asked if she remembered a staff member taking a photo of her, she replied, No.

On 12/18/13, an Immediate Jeopardy situation was determined to exist in regard to the facility's failure to follow their policy and procedure for contact isolation for E-coli with ESBL. There was a lack of tracking and trending of infections for the months of October and November 2013. The CNAs were observed not utilizing moisture barrier gowns while providing personal care for infected residents with ESBL. Residents diagnosed with [REDACTED]. Residents infected with E-coli ESBL were allowed to go to the dining room and into public areas of the facility. Families and or visitors were not informed of the need for contact isolation during visits with residents diagnosed with [REDACTED]. There was a lack of training for personal care staff, related to contact isolation, mode of transmission and precautions to be taken to contain the infection. On 12/18/13 at 6:47 p.m., the Oklahoma State Department of Health was notified and the Immediate Jeopardy situation was verified. At 6:50 p.m., the Administrator and the DON were informed of the IJ situation. On 12/18/13 at 8:15 p.m., the plan of removal was accepted. The plan of removal documented the following: "Plan of correction of removal of IJ: Identification of necessary isolation and procedures- DON/ADON will review labs daily to ensure residents with identifiable organisms are identified and if indicated, appropriate isolation precaution will be initiated. Residents will be cohabited (sic) with those identified with same organisms or will be placed in a private room if necessary. Depending on the identified organism, residents will be isolated to their room until the organism is resolved. Signs are placed outside of door on those residents identified as requiring isolation. These signs will direct all staff, visitors, or any contracted health care workers to contact charge nurse before entering room to ensure they utilize appropriate personal protective equipment. Staff will immediately be in-serviced when resident is placed on isolation, identifying the type of isolation and the source of infection. Sign-off sheets will be utilized each time a new infection is found to be present to ensure staff know what they are dealing with and that they are following the appropriate, indicated precaution. Staff is also trained upon hire regarding infection control to include all forms of isolation and procedure to follow for identified infections. Tracking & Trending- Each month DON/ADON will track organisms, type of infections, location of infections (hallways, etc) and identify shifts assigned to the hallways. This data will be utilized as a tool to determine any additional training necessary and to assist staff with controlling and preventing the further spread of infection." The facility provided an 'Inservice Training Report', dated 12/18/13. The inservice documented, "Meeting held in: all facility. Subject: All staff inserviced on current infections requiring isolation precautions to residents in facility, proper PPE to use. PPE is now located outside of room, signs are posted on doors if isolation precautions used to speak c charge nurse, if there are any questions." On 12/19/13 at 9:45 a.m., facility staff were interviewed regarding the above inservice and their knowledge related to contact isolation and the use of PPEs. Each of the staff verbalized understanding of the infection, isolation and the use of PPEs. The facility's policy/procedure titled 'Isolation of Resident' documented, "It is the objective of this facility to prevent the spread of infection. The facility shall use, but is not limited to, the following equipment: 1. Private room 2. Handwashing facilities 3. Gown, mask, gloves 4. Food trays (all disposable equipment) 5. Housekeeping supplies 6. Bio-hazard containers for linen, meal trays and other disposable items. Procedure: 1. Before implementing isolation procedures, the categories of isolation should be checked for specific instructions. 2. Explain isolation procedures and purpose to resident. 3. It is absolutely essential to wash hands upon entering and leaving the isolation room. Hands are considered contaminated if they touch the resident, or anything in the resident's room 4. A clean mask must be worn (when required) and discarded into the proper container after use. Mask must cover the mouth and nose and should not be dropped from the face and put on again. 5. A clean gown must be worn when entering the room and discarded into the proper container after use. To remove gown, untie strings, pull gown off and fold outside of gown inward rolling the gown into a bundle. With contact isolation gown only necessary when possibility of contact with source of infection to prevent uniform contamination. 6. Soiled linen is placed in a clean bag in the contaminated area, that bag is closed tightly and placed into a closed isolation container clearly marked as CONTAMINATED." The IJ situation was removed on 12/19/13 at 9:45 a.m., after all the staff had been inserviced on infection control and isolation precautions. The deficient practice remained widespread at a level of no actual harm with potential for more than minimal harm. Based on record review, observation and staff interview, it was determined the facility failed to maintain an infection control program to prevent the spread of infections for 46 of 46 residents who lived at the facility. The facility failed to: a) Ensure tracking and trending of infections was completed for the months of October and November 2013. b) Ensure the facility policy and procedure was followed for contact isolation, by using moisture barrier gowns for two (#1 and #2) of two sampled residents with E-coli ESBL observed receiving incontinent care. c) Ensure residents with E-coli ESBL were not co-horted with residents that did not have ESBL for three (#4, 5 and #6) of three sampled residents without [DIAGNOSES REDACTED]. d) Ensure residents with E-coli ESBL were not allowed to go to the dining room and into public areas while being contagious for two (#2 and #3) of three sampled residents with [DIAGNOSES REDACTED]. e) Ensure families and or visitors were informed of the need for contact isolation during visits with residents diagnosed with [REDACTED].#3) of three sampled residents with E-coli ESBL. f) Ensure facility staff were trained on contact isolation, mode of transmission of the infections and precautions to take to contain the infection for three (#1, 2 and #3) of three sampled residents with E-coli ESBL. g) Ensure cross contamination did not occur during observed incontinent care between one (#2) resident with ESBL and one (#4) resident without ESBL. The DON verifed 46 residents resided in the facility. Findings: 1. On 12/18/13 at 2:15 p.m., the DON was asked for the facility's tracking and trending log for infections. At 2:30 p.m., the DON presented a notebook containing the tracking and trending of infections. The book did not contain any documentation for the months of October 2013, and November 2013. At 2:45 p.m., the DON was asked about the October and November 2013, tracking and trending. The DON reported the ADON had been responsible for the tracking and trending, but was no longer employed by the facility. The DON then reported the tracking and trending had not been completed for the months of October 2013 or November 2013. 2. Resident #1 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A significant change assessment, dated 10/22/13, documented the resident had moderately impaired cognition, required extensive assistance from staff with bed mobility, transferring between surfaces and ADL care, was not ambulatory and was frequently incontinent of bowel and bladder. On 12/09/13, a laboratory UA documented, "Escherichia Coli (ESBL)." A handwritten note on the bottom of the report documented, "[MEDICATION NAME] 500 mg qd X 7 days." On 12/10/13, a care plan documented, "I have a UTI... Goal- my UTI will be resolved p abt is complete... Approach- Adm [MEDICATION NAME] 500 mg 1 po q day X's 7 day. Monitor q shift for effectiveness & adverse reactions. Re check UA 72 hrs p abt is complete..." On 12/18/13 at 2:30 p.m., during an initial tour of the facility a cardboard box lined with a red biohazard bag was observed in the resident's bathroom. No isolation sign was observed on the door at that time. At 2:45 p.m., CNA #1 and CNA #3 were interviewed. The CNAs were observed providing resident care on the hall where the resident resided. The CNAs were asked if any residents on that hall were on isolation precautions. The CNA identified resident #1. The CNA was asked why the resident was on isolation. They reported they had no idea. No PPE equipment was observed in the room or in the hallway at this time. At 4:30 p.m., CNA# 3 and CNA #4 were observed providing incontinent care for the resident. The resident was observed to be soiled from urine. The CNAs were observed to turn the resident onto her right side and cleaned her buttocks with pre-wet cloths. The CNA then turned the resident onto her back and cleaned her perineal area with the pre-wet cloths. The CNAs were observed to wear gloves during the care, but did not wear moisture barrier gowns. The CNAs' outer clothes were touching the covers to the resident's bed. There were no moisture barrier gowns observed in the resident's room or in the hallway available for the staff or visitors to put on before entering the resident's bedroom. 3. Resident #5 was the roommate with resident #1. Resident #5's [DIAGNOSES REDACTED]. An annual assessment, dated 11/03/13, documented the resident had severely impaired cognition, was totally dependent on staff for bed mobility, all ADL care and was always incontinent of bowel and bladder. The resident's medical record was reviewed. The record did not contain documentation or lab results of the resident having E-coli with ESBL. On 12/18/13 at 2:45 p.m., the resident was observed lying in her bed. CMA #1 was observed administering a gastrostomy feeding to the resident. 4. The [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/11/13, documented the resident as severely cognitively impaired, requiring total assistance with transferring, dressing, eating, hygiene, and bathing, and was incontinent of both bowel and bladder. A laboratory report, dated 12/11/13, documented, "E-coli ESBL" present in the urine of the resident. A physician's telephone order, dated 12/11/13, documented, "Cipro 500 mg po QD x 10 days for [DIAGNOSES REDACTED]. The care plan, updated 12/11/13, documented the resident had a UTI. Approaches included, "[MEDICATION NAME] mg po BID x 7 days, monitor for effectiveness and adverse reaction, observe contact precautions. Recheck UA 72 hours after ABT is complete." A physician's telephone order, dated 12/13/13, documented, "Bactrim 15cc po BID x 10 days for [DIAGNOSES REDACTED]. On 12/13/13, the care plan was updated and documented, "Administer Bactrim 15cc po BID x 10 days. Monitor Q shift for effectiveness and adverse reactions and recheck UA 72 hours after ABT is complete." On 12/18/13, at 2:45 p.m., observation was made of the resident's room. There was a large biohazard box with a red liner in the room. The resident was not in the room at that time. There was no isolation notice posted on the door of the resident's room. There were no gowns or gloves outside the room available for use by the staff and/or visitors. At 3:10 p.m., CNA #1 was interviewed and asked why there was a red biohazard box in the resident's room. The CNA reported resident #1 was on isolation precautions. CNA #1 was asked if there were gloves and gowns inside the room available for staff use. The CNA reported the staff had not been using gowns when giving care to the resident. She further reported there were usually gloves in the room and the CNAs try to carry some gloves in their pockets. The CNA was asked how all the CNAs would know if a resident was on isolation precautions. She reported the CNAs watch for red bags in the rooms which tell them the resident is on isolation precautions. CNA #1 was then asked if the nurses verbally inform them (the CNAs) if a resident is on isolation. The CNA stated, "No, we just try to watch for the red bags." At 3:20 p.m., CNA #2 was interviewed. She reported she had just assisted the resident to the BSC. The CNA was asked if she wore a gown when providing care to the resident. The CNA reported she never wore a gown. She stated, "I figure if I needed to wear a gown, the nurses would tell me." At 4:45 p.m., CNA #1 brought the resident back to her room. Observation was made of incontinent care given to the resident by CNA #1 and CNA #2. Both CNAs wore gloves during the procedure. Neither CNA wore a gown. While providing the incontinent care, both CNA #1 and CNA #2 were observed to repeatedly touch the resident's bed linens with their legs. At 5:45 p.m., LPN #1 was interviewed. She reported resident #1 was on isolation due to a urinary tract infection. When asked what organism was present in the resident's urine, the LPN reported she was not certain. She further reported the resident was on contact isolation to make certain the infection was not spread. The LPN was then asked if the staff wore gowns when providing care to the resident. The LPN reported gowns were worn by the staff if there was a chance of being splashed with urine. LPN #1 was then asked how the CNAs find out a resident had been placed on isolation. She reported the CNAs coming on for a shift make rounds with other CNAs who are leaving the facility after working their shift. While making rounds, the CNAs see the red bags in the room of any resident who is on isolation. The LPN was then asked how the staff informs visitors if a resident is on isolation. She reported she was not certain. LPN #1 reported she had worked at the facility for about four months. She was asked if an isolation notice had ever been posted on any door of a resident on isolation precautions since she had started working there. The LPN reported she could not remember ever seeing an isolation notice posted on anyone's door. 5. Resident #4 was the roommate of resident #2. Resident #2 had been diagnosed with [REDACTED]. The [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/16/13, documented the resident as having severely impaired cognition, required extensive assistance with ADLs, and was frequently incontinent of bowel and bladder. A laboratory report, dated 11/12/13, documented the presence of E-coli ESBL. A physician's telephone order, dated 11/15/13, documented, "[MEDICATION NAME] 80 mg IM daily x 5 days." A laboratory report, dated 11/22/13, documented a UA was completed and had been negative for any bacteria. A care plan, updated 12/11/13, documented the presence of a UTI. The approaches included administer, "Cipro 500 mg po BID x 7 days, monitor for effectiveness and adverse reactions, observe contact precautions, and recheck UA 72 hours after ABT is complete." The care plan was again updated on 12/13/13. The approaches documented, "Administer Bactrim 15cc po BID x 10 days, monitor Q shift for effectiveness and adverse reaction, and recheck UA 72 hours after ABT is complete." On 12/18/13, at 5:00 p.m., the resident was observed being brought back to her room by CNA #2. On 12/18/13 at 5:10 p.m., an observation was made of incontinent care provided by CNA #1 and CNA #2. Both of the CNAs wore gloves while giving the resident care, but neither of the CNAs wore moisture barrier gowns. During the procedure, the resident's clothing was pulled down to her knees in order to provide incontinent care. CNA #2 was observed to turn the resident onto her left side, close to the edge of her bed. The resident's bare skin on her abdomen, perineal area, and upper legs were observed to touch the front of the CNA #2's uniform. 6. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/27/13, documented the resident had moderately impaired cognition, required limited assistance with bed mobility and transferring between surfaces, required extensive assistance with dressing and hygiene and was frequently incontinent of bowel and bladder. A laboratory report, dated 12/09/13, documented, "Escherichia Coli (ESBL)". A handwritten note on the bottom of the report documented, "Bactrim DS..." A care plan, dated 12/09/13, documented, "I have a UTI. Goal- My UTI will be resolved p abt is completed. Approach- Administer Bactrim DS 1 po BID X's 10 days...re check UA 72 hrs p abt is complete." On 12/18/13 at 3:30 p.m., the initial tour of the facility was conducted. At that time, a cardboard box lined with a red biohazard bag was observed in the resident's room. At that time, no sign was observed on the door to the resident's room related to isolation or precautions needed to be taken. The resident was not in the room at the time of the observation. At 4:10 p.m., the resident was observed sitting in the lobby. At 7:30 p.m., the resident was observed sitting in a W/C, in the dining room. On 12/18/13 at 3:10 p.m., CNA #1 was interviewed and asked why there was a red biohazard box in the resident's room. The CNA reported resident #1 was on isolation. The CNA was asked if she knew why the resident was on isolation. The CNA reported she did not know. At 4:10 p.m., CNA #1 was interviewed. The CNA was asked if the resident was incontinent. The CNA reported the resident was usually continent, but had episodes of incontinence. 7. Resident #6 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #6 was the roommate of resident #3. On 10/25/13, a quarterly assessment documented the resident had moderately impaired cognition, required limited assistance with bed mobility and transferring between surfaces, was continent of bowel and frequently incontinent of bladder. The resident's medical record was reviewed. The record did not contain laboratory reports of the resident being infected with E-coli ESBL. On 12/18/13 at 5:00 p.m., the resident was observed in her room lying in her bed. On 12/18/13 at 5:15 p.m., CNA #5 was interviewed. The CNA reported she had just assisted the resident with toileting. On 12/18/13 at 5:45 p.m., the DON was interviewed. The DON was asked which residents in the facility had contagious infections. The DON reported the facility had four residents at the current time with E-coli ESBL and one resident with MRSA. The DON was asked what the facility's policy and procedure was for containing the infections. She reported all the residents had been placed on contact isolation. The DON was then asked to explain contact isolation. She reported the staff were to wear gloves while providing care for the residents. She further reported the staff were to wear moisture barrier gowns when providing care. She also reported the facility was to use paper plates with those residents and place incontinent briefs on the resident if the resident would be leaving their room. She also reported all these resident's garbage and soiled linens were to be placed in a red biohazard bag. The DON was asked if it was appropriate to co-hort a resident with ESBL with a resident not having ESBL. She stated, "It is probably not a good thing. We will take care if it." The DON was asked how the facility informed family or visitors of the need for contact isolation when visiting the residents. She reported they had been advised by their attorney not to place isolation signs on the doors to the resident's rooms, related to confidentiality. The DON was asked how the staff were trained on isolation precautions and informed of modes of transmission to isolate. She reported the facility had been advised not tell the CNAs about the infections. She further reported the staff had been trained to recognize a resident on isolation by the red biohazard boxes placed in a resident's room. The DON was asked how long the resident's were to remain on ESBL isolation. She reported 72 hours after the resident completes the antibiotic the facility obtains a repeat UA and if it is negative then isolation is discontinued.

On 12/18/13, an Immediate Jeopardy situation was determined to exist in regard to the facility's failure to follow their policy and procedure for contact isolation for E-coli with ESBL. There was a lack of tracking and trending of infections for the months of October and November 2013. The CNAs were observed not utilizing moisture barrier gowns while providing personal care for infected residents with ESBL. Residents diagnosed with [REDACTED]. Residents infected with E-coli ESBL were allowed to go to the dining room and into public areas of the facility. Families and or visitors were not informed of the need for contact isolation during visits with residents diagnosed with [REDACTED]. There was a lack of training for personal care staff, related to contact isolation, mode of transmission and precautions to be taken to contain the infection. On 12/18/13 at 6:47 p.m., the Oklahoma State Department of Health was notified and the Immediate Jeopardy situation was verified. At 6:50 p.m., the Administrator and the DON were informed of the IJ situation. On 12/18/13 at 8:15 p.m., the plan of removal was accepted. The plan of removal documented the following: "Plan of correction of removal of IJ: Identification of necessary isolation and procedures- DON/ADON will review labs daily to ensure residents with identifiable organisms are identified and if indicated, appropriate isolation precaution will be initiated. Residents will be cohabited (sic) with those identified with same organisms or will be placed in a private room if necessary. Depending on the identified organism, residents will be isolated to their room until the organism is resolved. Signs are placed outside of door on those residents identified as requiring isolation. These signs will direct all staff, visitors, or any contracted health care workers to contact charge nurse before entering room to ensure they utilize appropriate personal protective equipment. Staff will immediately be in-serviced when resident is placed on isolation, identifying the type of isolation and the source of infection. Sign-off sheets will be utilized each time a new infection is found to be present to ensure staff know what they are dealing with and that they are following the appropriate, indicated precaution. Staff is also trained upon hire regarding infection control to include all forms of isolation and procedure to follow for identified infections. Tracking & Trending- Each month DON/ADON will track organisms, type of infections, location of infections (hallways, etc) and identify shifts assigned to the hallways. This data will be utilized as a tool to determine any additional training necessary and to assist staff with controlling and preventing the further spread of infection." The facility provided an 'Inservice Training Report', dated 12/18/13. The inservice documented, "Meeting held in: all facility. Subject: All staff inserviced on current infections requiring isolation precautions to residents in facility, proper PPE to use. PPE is now located outside of room, signs are posted on doors if isolation precautions used to speak c charge nurse, if there are any questions." On 12/19/13 at 9:45 a.m., facility staff were interviewed regarding the above inservice and their knowledge related to contact isolation and the use of PPEs. Each of the staff verbalized understanding of the infection, isolation and the use of PPEs. The facility's policy/procedure titled 'Isolation of Resident' documented, "It is the objective of this facility to prevent the spread of infection. The facility shall use, but is not limited to, the following equipment: 1. Private room 2. Handwashing facilities 3. Gown, mask, gloves 4. Food trays (all disposable equipment) 5. Housekeeping supplies 6. Bio-hazard containers for linen, meal trays and other disposable items. Procedure: 1. Before implementing isolation procedures, the categories of isolation should be checked for specific instructions. 2. Explain isolation procedures and purpose to resident. 3. It is absolutely essential to wash hands upon entering and leaving the isolation room. Hands are considered contaminated if they touch the resident, or anything in the resident's room 4. A clean mask must be worn (when required) and discarded into the proper container after use. Mask must cover the mouth and nose and should not be dropped from the face and put on again. 5. A clean gown must be worn when entering the room and discarded into the proper container after use. To remove gown, untie strings, pull gown off and fold outside of gown inward rolling the gown into a bundle. With contact isolation gown only necessary when possibility of contact with source of infection to prevent uniform contamination. 6. Soiled linen is placed in a clean bag in the contaminated area, that bag is closed tightly and placed into a closed isolation container clearly marked as CONTAMINATED." The IJ situation was removed on 12/19/13 at 9:45 a.m., after all the staff had been inserviced on infection control and isolation precautions. The deficient practice remained widespread at a level of no actual harm with potential for more than minimal harm. Based on record review, observation and staff interview, it was determined the facility failed to ensure the facility was administered to effectively attain and/or maintain resident levels of well-being for 46 of 46 residents. The facility failed to maintain an infection control program to prevent the spread of infections for the 46 residents who lived at the facility. The facility failed to: a) Ensure tracking and trending of infections was completed for the months of October and November 2013. b) Ensure the facility policy and procedure was followed for contact isolation, by using moisture barrier gowns for two (#1 and #2) of two sampled residents with E-coli ESBL observed receiving incontinent care. c) Ensure residents with E-coli ESBL were not co-horted with residents that did not have ESBL for three (#4, 5 and #6) of three sampled residents without [DIAGNOSES REDACTED]. d) Ensure residents with E-coli ESBL were not allowed to go to the dining room and into public areas while being contagious for two (#2 and #3) of three sampled residents with [DIAGNOSES REDACTED]. e) Ensure families and or visitors were informed of the need for contact isolation during visits with residents diagnosed with [REDACTED].#3) of three sampled residents with E-coli ESBL. f) Ensure facility staff were trained on contact isolation, mode of transmission of the infections and precautions to take to contain the infection for three (#1, 2 and #3) of three sampled residents with E-coli ESBL. g) Ensure cross contamination did not occur during observed incontinent care between one (#2) resident with ESBL and one (#4) resident without ESBL. The DON verified 46 residents resided in the facility. Please refer to F 441 for detailed investigative information.