Every finding on record at Brentwood Extended Care & Rehab

Based on record review and interview, the facility failed to ensure the required PBJ staffing data was submitted to CMS for the second quarter of FY 2025. The administrator identified 55 residents resided in the facility.Findings: A PBJ Staffing Data Report, dated 01/01/25 through 03/31/25 (second quarter of FY 2025), showed the facility had not provided staffing data to CMS for the PBJ staffing data report for the quarter. On 07/31/25 at 11:00 a.m., the office manager stated the employee that handled submitting the PBJ staffing data to CMS no longer worked at the facility and that at the time they did not have anyone that was able to send the data. They stated they now have multiple employees can submit the staffing data.

Based on record review and interview, the facility failed to ensure the facility administrator was aware of the provisions and responsibilities of the facility abuse policy which resulted in a substandard investigation of an abuse allegation for 1 (#59) of 15 sampled residents reviewed for abuse.The administrator reported 55 residents resided in the facility.Findings:An undated policy titled Management of Suspected Abuse/Neglect, read in part, The facility staff, during employee orientation and through an ongoing training program, provides all employees with information regarding abuse and related reporting requirements, including prevention, intervention, and detection.A quarterly MDS assessment, dated 02/03/25, showed Res #59 had a BIMS score of 15 which indicated the resident's cognition was intact at the time of the assessment.An OOSDH incident form, incident date 05/07/25, showed the form was the initial report regarding an allegation of physical abuse that had been made regarding Res #59. The corresponding fax receipt showed OSDH had received the incident report on 05/08/25 at 8:59 a.m. Investigation documentation for the allegation of abuse toward Res #59 on 05/07/25, that was provided by the facility administrator on 07/31/25 was reviewed. The documents did not show interviews of staff or residents regarding the alleged abuse.On 07/31/25 at 12:26 p.m., the administrator was asked who conducted abuse investigations at the facility. They stated they did. They were asked if they had conducted the investigation regarding Res #59 that occurred on 05/07/25. They stated they had conducted that investigation. They were asked to provide all their documentation related to that investigation.On 07/31/25 at 2:23 p.m., the administrator was asked to describe the investigation they had conducted regarding the alleged abuse of Res #59 on 05/07/25. The administrator stated at the time of the investigation they were unaware of all the requirements of conducting an abuse investigation as they were new to the organization and had not been trained in the process at that time. They stated they had not conducted interviews with other residents or staff members to determine if they had information regarding that or other incidents. They stated they had not suspended or took other actions to prevent the accused perpetrator from contacting the resident during the investigation. They had not contacted OSDH in the required time frame and had not contacted the local law enforcement agency of the allegation. They stated they have since been trained and were aware of the process.

Based on record review and interview, the facility failed to ensure the OSDH was informed of an allegation of physical abuse by a staff member in the mandated time frame and the facility failed to contact the local law enforcement agency of an allegation of physical abuse by a staff member for 1 (#59) of 15 sampled resident reviewed for abuse.The administrator reported 55 residents resided in the facility.Findings:An undated policy titled Management of Suspected Abuse/Neglect, read in part, It is the policy of this facility, under the guidance of applicable laws, that any person having reasonable cause to believe that any person in a state of abuse, exploitation or neglect shall report the information to the Oklahoma Stated Department of Health and any additional regulatory agencies required by the allegation.A quarterly MDS assessment, dated 02/03/25, showed Res #59 had a BIMS score of 15 which indicated the resident's cognition was intact at the time of the assessment.An OSDH incident form, incident date 05/07/25, showed the form was the initial report regarding an allegation of abuse that had been made regarding Res #59. The corresponding fax receipt showed the OSDH had received the incident report on 05/08/25 at 8:59 a.m. The incident report showed on 05/07/25 the activities director was informed by Res #59 a staff member had slapped them, but did not provide a date of the alleged assault. The section of the incident form that indicated if law enforcement had been contacted and when, was blank.On 07/31/25 at 2:23 p.m., the administrator was asked regarding the allegation of physical abuse toward Res #59 if they had reported the allegations of abuse to the OSDH within the required two hours. They stated they had not because at the time of the report they had not yet been trained on conducting abuse investigations at the facility. They were asked if they had contacted any law enforcement agency regarding the allegation of abuse. They stated they had not because they were unaware of that requirement at that time.

Based on record review and interview, the facility failed to conduct a thorough investigation of an allegation of physical abuse for 1 (#59) of 15 sampled residents reviewed for abuse.The administrator reported 55 residents resided in the facility.Findings:An undated policy titled Management of Suspected Abuse/Neglect, read in part, The facility shall ensure, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect and mistreatment.A quarterly MDS assessment, dated 02/03/25, showed Res #59 had a BIMS score of 15 which indicated the resident's cognition was intact at the time of the assessment.An OSDH incident form, incident date 05/07/25, showed the form was the initial report regarding an allegation of abuse that had been made regarding Res #59. The corresponding fax receipt showed the OSDH had received the incident report on 05/08/25 at 8:59 a.m. The incident report showed on 05/07/25 the activities director was informed by Res #59 a staff member had slapped them, but did not provide a date of the alleged assault. Investigation documentation for the allegation of abuse toward Res #59 on 05/07/25, that was provided by the facility administrator on 07/31/25 was reviewed. The documents did not show interviews with staff or residents regarding the alleged abuse around the time of the allegation. There were interviews regarding the incident dated 07/25/25 included in the packet of investigation material the administrator had provided.On 07/31/25 at 2:23 p.m., the administrator was asked to describe the investigation they had conducted regarding the alleged abuse of Res #59 on 05/07/25. The administrator stated at the time of the investigation they were unaware of all the requirements of conducting an abuse investigation. They stated they were new to the organization and had not been trained in the abuse investigation process at that time. They stated their investigation of the incident did not include interviews with residents and staff members regarding the incident with Res #59 or possible concerns regarding the alleged perpetrator. They stated they have since been trained and were aware of the process.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for 1 (#6) of 2 sampled residents reviewed for assistance with activities of daily living.The administrator identified 55 residents resided in the facility.Findings:On 07/27/25 at 3:05 p.m., Res #6 was observed lying in bed. The resident's hair was kempt. No odors were observed.An undated policy titled Resident Bathing, read in part, Residents will be bathed on a schedule of 3x's weekly and as needed/requested, unless indicated otherwise.In the event that a resident refuses to bathe: the CNA and nurse is to document the refusal in the EMR [electronic medical record].Documentation of bathing must be complete and timely.An undated medical summary tab showed Res #6 was admitted with diagnoses which included dementia and transient cerebral ischemic attack.An undated electronic bathing tab showed Res #6 was to receive a bath/shower weekly on Tuesday and Friday.A quarterly assessment, dated 04/29/25, showed Res #6 had a BIMS score of 99 and was severely cognitively impaired. The assessment showed Res #6 was dependent with bathing.Bath sheets were reviewed for the last three months (May 2025 through July 2025) for Res #6. The bath sheets showed completed baths on 05/05/25, 05/13/25, 06/30/25, 07/20/25, 07/22/25, and 07/29/25.There was no documentation for May 2025 Res #6 received a bath/shower on 05/02/25 (Friday), 05/09/25 (Friday), 05/16/25 (Friday), 05/20/25 (Tuesday), 05/23/25 (Friday), 05/27/25 (Tuesday), and 05/30/25 (Friday).There was no documentation for June 2025 Res #6 received a bath/shower on 06/03/25 (Tuesday), 06/06/25 (Friday), 06/10/25 (Tuesday), 06/13/25 (Friday), 06/17/25 (Tuesday), 06/20/25 (Friday), 06/24/25 (Tuesday), and 06/27/25 (Friday).There was no documentation for July 2025 Res #6 received a bath/shower on 07/04/25 (Friday), 07/08/25 (Tuesday), 07/11/25 (Friday), 07/15/25 (Tuesday), and 07/25/25 (Friday).On 07/27/25 3:08 p.m., Res #6 stated they had not received a bath in a while. Res #6 stated they were not sure exactly which days of the week they were scheduled to receive baths, but felt bathing was not being completed as ordered.On 07/29/2025 at 9:32 a.m., the DON stated they expected all residents to be bathed at least twice weekly. The DON stated all completed baths are documented on a bath sheet. They stated if a resident had refused a bath, a refusal form should have been completed. The DON stated the bath refusal form should have been signed by the resident, CNA, and the charge nurse. On 07/29/25 at 2:11 p.m., CNA #1 stated all completed baths were documented on a bath sheet. They stated if a resident had refused a bath, then a refusal form would have been completed and given to charge nurse to place in the medical record.On 07/29/25 at 2:27 p.m., the DON stated no additional bath sheets or bath refusal forms could be located for Res #6. They stated there was no way to prove Res #6 was bathed more than six times in the last three months. The DON stated Res #6 should have been bathed at least twice weekly.

Based on record review and interview, the facility failed to ensure a resident's legal representative was notified of inappropriate sexual behavior for three (#1, 3 and #4) of four sampled residents reviewed for abuse. The administrator identified 52 residents resided in the facility. Findings: An undated Management of Suspected Abuse/Neglect policy, read in parts, The charge nurse should complete an incident report, being very precise about the incident .physician and family notification will occur at this time. 1. Resident #1 had diagnoses which included PVD and essential hypertension. An OSDH incident report, dated 12/01/24, documented Resident #1 was sexually inappropriate with multiple female residents (Resident #3 and Resident #4). The clinical health record did not contain documentation of family notification of the inappropriate sexual behavior. 2. Resident #3 had diagnoses which included anxiety disorder and depression. The clinical health record did not contain documentation of family notification after an allegation of inappropriate sexual behavior by Resident #1. 3. Resident #4 had diagnoses which included dementia and major depression disorder. The clinical health record did not contain documentation of family notification after an allegation of inappropriate sexual behavior by Resident #1. On 12/27/24 at 9:34 a.m., the administrator stated, The LPN did not feel it necessary to notify the family.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#1) of four sampled residents reviewed for abuse. The administrator identified 52 residents resided in the facility. Findings: An undated facility policy, Management of Suspected Abuse/Neglect, read in parts, The nursing facility resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents .Physical Abuse .Physical injury that results in substantial harm: to the person, or the genuine threat of substantial harm from physical injury to the person .Failure to make a reasonable effort to prevent an action by another person that results in physical injury. Resident #2 was admitted on [DATE] with diagnoses which included cerebrovascular accident and PVD. Resident #2's admission assessment, dated 09/09/24, documented their cognition was intact and they were dependent on staff for transfers. An Initial Incident Report OSDH form, dated 10/20/24 at 10:00 a.m., documented the resident reported to the nurse staff were rough with assisting them in bed. It documented staff told the resident you're gonna die in here. It was documented there was a red area noted to the resident's right upper arm. It documented the resident complained of pain 6/10 on a 0/10 scale. It was documented staff were suspended pending investigation. A Initial/Final Incident Report OSDH form, dated 10/24/24 at 8:16 a.m., documented the resident reported CNA #1 used a mechanical lift to transfer them and hurt their right upper arm. It documented the resident was alert and oriented times four, cooperative with care, and was wheelchair bound. It documented the resident had a history of CVA. It documented sit to stand with transfers or slide board. It documented CNA #1 was terminated and CNA #2 was suspended and educated on reporting suspected abuse. On 11/07/24, an in-service related to resident rights and abuse was conducted. On 12/26/24 at 10:52 a.m., Resident #2 stated CNA #1 purposefully put the straps on wrong and they had significant bruising. They stated CNA #1 was no longer in the facility. On 12/27/24 at 12:24 p.m., the administrator stated, I don't have documentation of QA being involved, no formal QA involvement. We discussed steps to be taken to prevent further incident. After review of the in-service logs, interviews with staff, documentation of monitoring and interviews with residents it was determined the facility had corrective action in place on 11/07/24.

Based on record review and interview, the facility failed to ensure the results of an abuse investigation were submitted to the SSA within five business days of the incident for one (#1) of four sampled residents reviewed for abuse. The administrator identified 52 residents resided in the facility. Findings: An undated facility policy titled Management of Suspected Abuse/Neglect, read in part, It is the policy of this facility, under the guidance of applicable laws, that any person having reasonable cause to believe that any person in a state of abuse .shall report the information to the Oklahoma State Department of Health. 1. Resident #1 had diagnoses which included PVD and Diabetes Mellitus type two. An Initial State Reportable Incident form, faxed on 12/01/24 at 4:19 p.m., documented an allegation of abuse/mistreatment. It documented (unknown) resident reported to (unknown) nurse, Resident #1 was sexually inappropriate with multiple female residents. It documented Resident #1 was placed on one on one supervision during investigation. There was no documentation the results of the investigation were submitted to the SSA. On 12/27/24 at 12:12 p.m., the administrator stated the policy for reporting abuse was to turn in an initial within two hours, remove the threat, call the police, and turn in a five day/final within five days. On 12/27/24 at 1:37 p.m., the administrator stated they did not think they had turned in a five day or final report. They stated they thought the DON had done it, but the DON did not. They stated, I'm just gonna be honest, it wasn't done.

Based on record review and interview, the facility failed to assess a resident after allegation of inappropriate sexual behavior for two (#3 and #4) of four sampled residents reviewed for abuse. The administrator identified 52 residents resided in the facility. Findings: An undated facility policy titled Management of Suspected Abuse/Neglect, read in part, A complete assessment of both the resident's should be done by the charge nurse. An Initial State Reportable Incident form, faxed on 12/01/24 at 4:19 p.m., documented an allegation of abuse/mistreatment. It documented (unknown) resident reported to (unknown) nurse, Resident #1 was sexually inappropriate with multiple female residents (Resident #3 and Resident #4). 1. Resident #3 had diagnoses which included anxiety disorder and depression. There was no documentation in the clinical record of Resident #3 being assessed after the sexual abuse allegation. On 12/27/24 at 10:35 a.m., LPN #1 reviewed the resident's clinical record for nurses notes and assessments. They were unable to locate nursing notes or assessments related to the sexual abuse. 2. Resident #4 had diagnoses which included dementia and major depression disorder. There was no documentation in the clinical record of Resident #4 being assessed after the sexual abuse allegation. On 12/27/24 at 12:14 p.m., the administrator stated if there was no documentation in the clinical record then the resident had not been assessed after the allegation of sexual abuse.

On 05/20/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were protected from falls with major injury. Res #1 had a non-injury fall on 04/11/24. Record review and interview confirmed hourly checks were not documented as completed. Res #1 had a fall on 04/14/24 resulting in a broken neck. On 05/17/24, Res #1's call light was observed unplugged, and wrapped up on top of the dresser. Res #2 had a fall with minor injury on 04/20/24. No interventions were developed following the fall according to facility policy. Res #2 had a fall on 04/23/24 resulting in a broken back. The intervention for this fall was to move the resident closer to the nurse's station. As of 05/20/24, the two rooms closest to the nurse's station are occupied and Res #2 was unable to be moved closer than current room. No new interventions had been put in place. On 05/20/24 at 4:36 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to falls with major injury for Res #1 and Res #2. On 05/20/24 at 4:40 p.m., the administrator was notified of the IJ situation. On 05/21/24 at 9:40 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: 1. Placing all residents on Q 1 hr. checks relating to prevention of falls it will be documented on TAR's 2. Call light for Res #1 has been secured so it cannot be unplugged. 3. Resident #2 is currently in hospital but have relocated her room across from nurse station. 4. All staff has been in-serviced on new policy and procedure for fall prevention and falls. 5. All nurses have been in-serviced on development and implementation of fall interventions and updated fall procedure. 6. Every resident will have a new Fall Risk Assessment completed. Regarding #1 5/20/24 at 6:20 p.m. Regarding #2 was completed 5/20/24, all staff was in-serviced by 6PM, all came in person except those 5 on medical leave, we had 1 in California (her father was in a wreck), 5 had second jobs and could not leave, we facetimed each on safely and securely, we had around 20 employees that live 45 mins to an hour away and didn't have gas money to come back as tomorrow is payday .but myself and the DON divided and facetimed each of those employees over the IJ R/T FALLS . we developed a new fall protocol and went over it with ach one, the others who were able to come up we in-serviced and educated as well. We explained how we are going to do every hour checks on all residents and chart it. How we are going to do interventions and implement them with the guidance of the DON and MDS coordinator. Regarding #3 they were completed yesterday 5/20/24. The IJ was lifted, effective 05/20/24 at 6:20 p.m., when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm. Based on observation, record review, and interview, the facility failed to develop and implement interventions to prevent falls with major injury for two (#1 and #2) of four sampled residents reviewed for falls. The DON identified 51 residents resided in the facility. Findings: An undated facility fall policy, read in part, .Nurse to complete an Incident Report and initiate fall interventions for fall prevention . 1. Res #1 had diagnoses which included history of falls and multiple sclerosis. A progress note, dated 04/11/24 at 9:52 a.m., documented Res #1 had a fall without injury. A facility incident report, dated 04/11/24, documented steps to prevent recurrence of fall as resident to be placed on hourly checks for resident safety and fall prevention. A TAR for April 2024 documented no order for hourly checks. A progress note, dated 04/14/24 at 12:55 p.m., documented Res #1 had a fall and was sent to the emergency room for further evaluation. A progress note, dated 04/14/24 at 10:48 p.m., documented Res #1 returned from the hospital with a diagnosis of a cervical fracture to cervical vertebrae 2. A quarterly MDS, dated [DATE], documented Res #1 was cognitively intact, required supervision with toileting, moderate assistance with transfers, was independent with bed mobility, and had no behaviors. A care plan, reviewed 05/12/24, documented to keep the call light within reach of the resident. On 05/17/24 at 10:59 a.m., Res #1 was observed resting in their bed. The call light was observed removed from the wall and coiled on top of the dresser by the entrance to the room. Res #1 stated they could use the call light when it was within reach. On 05/17/24 at 11:23 a.m., there was no change to the call light in Res #1's room. On 05/17/24 at 11:30 a.m., CNA #4 stated Res #1 used their call light to get assistance. They stated there were no residents that were unable to use a call light. The CNA was asked to locate the resident's call light. The CNA located the call light on the dresser. They stated the resident would have to call out to get assistance. On 05/17/24 at 11:32 a.m., LPN #1 was asked to locate the resident's call light. They were able to locate the call light on the dresser. They stated they were unsure how it got there, but thought maintenance may have removed or replaced the call light. On 05/17/24 at 12:29 p.m., maintenance staff #1 stated they had made call light replacements over a month ago. They denied removal or adjustment to Res #1's call light. 2. Res #2 had diagnoses which included impulse disorder, depression, and insomnia. A quarterly MDS, dated [DATE], documented the resident was moderately impaired cognitively, had no behaviors, and required moderate assistance with ADLs. A progress note, dated 04/20/24 at 7:56 p.m., documented Res #2 had a fall and was sent to the emergency room for evaluation. A hospital after visit summary, dated 04/20/24, documented the resident sustained an abrasion and skin tear from the fall. There was no incident report related to the 04/20/24 fall. The care plan was not updated with an intervention following the 04/20/24 fall. A progress note, dated 04/23/24 at 10:23 a.m., documented Res #2 had a fall and was sent to the emergency room for evaluation. A progress note, dated 04/23/24 at 7:58 p.m., documented Res #2 returned from the hospital with a diagnosis of a compression fracture to the thoracic vertebrae 4-7. An incident report, dated 04/23/24, related to the fall documented an intervention to prevent recurrence as a room change closer to the nurses station. There was no additional documentation regarding the room change in the resident's chart. On 05/17/24 at 11:14 a.m., Res #2 was observed ambulating in the hall with a rolling walker with the assistance of one staff member. The resident declined interview. On 05/20/24 at 2:47 p.m., the administrator stated they were unable to locate an intervention documented related to the fall on 04/20/24. On 05/20/24 at 3:00 p.m., the administrator stated the resident was not moved because there was not a room available to move the resident to. They stated there was no documentation of a relevant intervention since the room change was not applicable.

Based on observation, record review, and interview, the facility failed to ensure: a. the floors were maintained in a safe manner; b. the window blinds, wall, and wheelchair was in good repair for one (#30) of eight sampled resident rooms observed; and c. the washing machines were in proper working order. The administrator identified 49 residents who resided in the facility. Findings: The facility's Maintenance Service policy, revised 12/2009, read in part, .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe operable manner at all times .Functions of maintenance personnel include .Maintaining the building in good repair and free from hazards . The facility's undated Work Orders, Maintenance policy, read in part, .In order to establish a priority of maintenance service, work orders must be filled out in the log book .It shall be the responsibility of employees to fill out the log book and identify the area of concern for repairs . The maintenance request log books were reviewed and revealed the floor, window blinds, wheelchair, and wall had not been documented as needing to be repaired. 1. On 03/18/24 at 12:55 p.m., the dining room was observed to have two missing tiles, the surface was uneven, the area was not blocked off to keep the residents from stepping on the uneven surface. The floor in the hall enterance to the resident care areas had cracked, loose, and missing tiles, the floor in the common area/dining area had loose, cracked, and missing tiles. The floor leading to the dining room, common area, smoking area and extending to the resident halls was observed to have uneven floor surfaces. On 03/20/24 at 11:26 a.m., maintenance #1 stated they tried to apply quick cement to level out the surfaces when the tile was broken or they would block off the area to avoid accidents. Maintenance #1 observed the tile in the dining rooms and the hall. Maintenance #1 stated the tile had been like that for approximately two to three months. They stated the uneven surfaces were a trip hazard for the residents. On 03/20/24 at 11:30 a.m., the administrator stated the whole floor needed to be replaced. 2. On 03/18/24 at 12:44 p.m., Res #30's room was observed to be missing sheetrock on the lower corner of the wall, the window blinds had broken slats hanging down, and the resident's wheelchair arm rests were torn and had the padding showing through. On 03/20/24 at 11:34 a.m., maintenance #1 stated the wall looked like the corner at the bottom of the wall had a piece missing. Maintenance #1 stated the window blinds covering the window were missing two slats, and the wheelchair arm rests needed to be replaced. They stated they were not aware of the broken window blinds or the missing sheetrock on the wall. They stated the staff were supposed to put maintenance requests in a log book. 43023 3. On 03/25/24 at 10:29 a.m., a tour of laundry room was conducted. The washer on the left was observed to have a blanket and a bucket observed on the floor under in front of the washer. The washer on the right was observed to have a bucket under the drainage pipe behind the washer. The bucket had a small amount of water in it. An area of drywall behind the washers was pushed in and broken The electric and water lines behind the washers and dryers have a moderate amount of dust on them. Laundry detergents stored behind the washers was sitting directly on the floor. There were two boxes and one basket observed stored directly on the ground under the clean hanging clothes. Several areas of tile in front of the washers and in between the washers and dryers is missing. On 03/25/24 at 10:35 a.m., laundry staff #1 reported the washer on the left has been leaking for at least a year and was not sure how long the other washer had been leaking. They reported the area behind the washers and dryers do not get cleaned.

Based on record review and interview, the facility failed to ensure quarterly resident assessments were completed within 14 days of the assessment reference date for two (#24 and #29) of four sampled residents whose resident assessments were reviewed. The administrator identified 49 residents who resided in the facility. Findings: 1. Res #24's quarterly resident assessment, dated 10/12/23, was not completed and signed until 11/09/23. 2. Res #29's quarterly resident assessment, dated 10/22/23, was not completed and signed until 11/28/23. On 03/21/24 at 1:12 p.m. the administrator reported the resident assessments should have been completed and signed within 14 days and could not explain why that was not done.

Based on record review and interview, the facility failed to ensure the PASARR for a resident with a mental health diagnosis was filled out correctly and referred to the OHCA for two (#18 and #41) of three sampled residents reviewed for PASARR evaluations. The Administrator identified 49 residents resided in the facility. Findings: 1. Res #18 admitted to the facility with diagnoses of major depressive disorder and anxiety. A PASARR level I, dated 03/04/20, did not document the resident had a mental health diagnosis. 2. Res #41 admitted to the facility with diagnoses of delusional disorders and major depressive disorder. A PASARR Level I, dated 06/14/21, did not document the resident had mental health diagnosis. On 03/22/24 at 8:30 a.m., the administrator reported mental health diagnosis should have been documented and OHCA should have been notified.

Based on observation, record review, and interview, the facility failed to ensure: a. baths were given as schedule for two (#15 and #16) of two sampled residents whose baths were reviewed; and b. assistance with eating was provided for one (#18) of one sampled resident who required assistance with eating. The administrator identified five residents who required assistance with eating and 47 residents who required assistance with bathing. Findings: 1. Res #15 had diagnoses which included chronic obstructive pulmonary disease, neuropathy, and rheumatoid arthritis. The Bathing Schedule documented Res #15 was to receive a shower on Mondays and Thursdays. There was no documentation Res #15 received a shower from 03/01/24 to 03/22/24. On 03/18/24 at 10:38 a.m., Res #15 complained they had not received a shower this month and reported they have gone three to four weeks without a shower before. On 03/22/24 at 11:30 a.m., MDS Coordinator #1 reported Res #15 frequently refused baths, but was not able to provide documentation regarding the refusals. The MDS Coordinator reported Res #15's noncompliance with bathing should have been care planned and wasn't. 03/22/24 at 1:15 p.m., the administrator reported Res #15 does refuse showers but those refusals should have been documented and were not. The administrator reported they did not offer another day or time to make up missed showers. The administrator reported if it is not documented then it is not done. 2. Res #16 had diagnoses which included Parkinson's disease, neuralgia, and pain. The Bathing schedule documented Res #16 was to receive a shower on Tuesdays and Fridays. Res #16 received a shower on 03/20/24. There was no documentation Res #16 received a shower from 03/01/24 through 03/22/24. On 03/19/24 at 9:44 a.m., Res #16 reported they do not receive shower on their scheduled days and has gone one to two weeks without a shower before. 03/22/24 at 1:15 p.m., the administrator reported Res #16 does refuse showers but those refusals should have been documented and were not. The administrator reported they did not offer to another day or time to make up missed showers. The administrator reported if it is not documented then it was not done. 36191 3. Resident #18 had diagnoses which included hemiplegia and hemiparesis following cerebrovascular disease An assessment, dated 01/09/24, documented Res #18's cognition was moderately impaired, required cues and supervision for decision making, had limited range of motion to the upper and lower extremity on one side, and required supervision or touching assistance for eating. A care plan for ADL, dated 01/15/24, read in part, .I need some help with ADL care .Set up all meal trays and encourage me to eat . On 03/20/24 at 11:14 a.m., Res #18 was observed sitting in dining room with lights off eating their meal with their right hand. There was no staff in dining room to assist or supervise the resident. On 03/20/24 at 11:15 a.m., a staff member walked through the dining room. The staff member asked Res #18 if their food was good. They did not turn on the lights or encourage the resident to use utensils to eat their food. On 03/20/24 at 11:16 a.m., a staff member walked through the dining area. The staff member did not cue Res #18 to use a spoon or fork to eat their meal and did not turn the lights on in the dining room. On 03/20/24 at 11:17 a.m., the administrator observed Res #18 in the dining room with the lights off. The administrator found a staff member and asked them to move the resident to a lighted area. On 03/20/24 at 11:18 a.m., Res #18 continued to eat ground meat, strawberry dessert, green beans, and mashed potatoes with their hands. On 03/20/24 at 11:23 a.m., Res #18 continued to eat their meal with their hands. On 03/20/24 at 11:24 a.m., CNA #2 brought another resident into the dining area and assisted them with their meal. Res #18 was observed to use their spoon to eat their dessert after CNA #2 sat at the dining room table. On 03/22/24 at 9:38 a.m., the administrator stated the staff had not provided Res #18 supervision during lunch on 03/20/24. They stated the staff should not have given the resident their tray and left.

Based on observation, interview, and record review, the facility failed to ensure care was coordinated with hospice to ensure resident's medications were available for administration for one (#100) of two residents reviewed for hospice. The administrator identified 13 residents who received hospice services. Findings: The undated,Hospice policy, read in part, .It shall be the policy .to remain responsible for primary care for all residents .staff will communicate and coordinate residents care with Hospice . The facility's Medication Ordering and Receiving from Pharmacy policy, dated 04/2018, read in part, .Reorder medication four days in advance of need .to assure an adequate supply is on hand . A document titled, Hospice-Skilled Nursing Facility Service Agreement, dated 03/18/24, read in part, .Coordination of Care .Hospice and Facility shall communicate with one another regularly and as needed for the Hospice Patient .to ensure that the needs of the Hospice Patient are met 24 hours per day . Res #100 was admitted to the facility on [DATE] with diagnoses which included COPD and chronic pain. Current physician's order, dated 03/19/24, documented to administer Albuterol Sulfate Inhalation Nebulization Solution Albuterol 2.5 mg/ml every six hours at 2:00 a.m., 8:00 a.m., 2:00 p.m., and 8:00 p.m. The orders documented to administer oxycodone-acetaminophen oral tablet 10-325 mg every four hours at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m. A nurse's note, dated 03/20/24 at 2:51 p.m., documented the nurse was notified by the staff that the resident was completely out of their Oxycodone/acetaminophen tablet 10-325 mg that was due every four hours routine. The note documented the nurse notified the hospice nurse. On 03/21/24 at 9:59 a.m., CMA #2 stated Res #100 had been out of their pain medication since yesterday at noon. On 03/21/24 at 10:05 a.m., Res #100 stated they were on hospice and had transferred from another nursing home. They stated their pain medication had been delivered to the wrong facility and they had not been administered a nebulizer treatment since they were admitted to the facility on [DATE]. On 03/21/24 at 10:15 a.m., the DON stated the pain medication was delivered to the wrong facility. The DON was asked if the resident had their nebulizer treatment. They stated they did not know. On 03/21/24 at 10:28 a.m., LPN #1 stated they could not find the Albuterol nebulizer inhalation medication. LPN #1 stated there had been a mix up with Res #100's medications. LPN #1 stated Res #100 had breathing treatments ordered but did not have the medication in the building to administer the breathing treatments. On 03/21/24 at 10:29 a.m., CMA#2 who was present during the interview with LPN #1 stated they had signed the nebulizer treatment out on the MAR in error. They stated the Albuterol nebulizer treatment had not been administered. On 03/21/24 at 10:39 a.m., LPN #1 looked for the Albuterol nebulizer inhalation medication in Res #100's room. They did not find any medication in the resident's room. Res #100 reported to LPN #1 they had not had a breathing treatment since they had been admitted to the facility on [DATE]. On 03/21/24 at 11:44 a.m., the hospice nurse stated when a resident was admitted to a facility they would have someone from the hospice company come and ensure the resident was settled in with all of their medications and belongings. The hospice nurse stated they were notified on 03/21/24, Res #100 did not have their nebulizer inhalation treatment medication. They stated they were notified Res #100 was out of their pain medication yesterday (03/20/24) at 2:56 p.m., after the last dose had been administered.

Based on observation, record review, and interview, the facility failed to ensure pain medication was administered as ordered for one (#100) of one sampled resident who was reviewed for pain management. The administrator identified 29 residents who received pain management. Findings: The facility's Medication Ordering and Receiving from Pharmacy policy, dated 04/2018, read in part, .Reorder medication four days in advance of need .to assure an adequate supply is on hand . A document titled, Hospice-Skilled Nursing Facility Service Agreement, dated 03/18/24, read in part, .Coordination of Care .Hospice and Facility shall communicate with one another regularly and as needed for the Hospice Patient .to ensure that the needs of the Hospice Patient are met 24 hours per day . Res #51 was admitted to the facility on [DATE] with diagnoses which included chronic pain and opioid dependence. A baseline care plan, dated 03/19/24, documented Res #30 had diagnoses of chronic pain issues. The care plan did not document interventions for chronic pain. A Controlled Drug Receipt form, dated 03/19/24, documented Res #30 was admitted to the facility with six oxycodone/acetaminophen 10-325 mg tablets. Res #30's clinical record did not contain a pain assessment completed by a nurse. Current physician's orders, dated 03/19/24, documented to administer oxycodone-acetaminophen 10-325 mg every four hours at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and at 8:00 p.m. On 03/21/24 at 9:59 a.m., CMA #2 stated Res #100 had been out of their pain medication since yesterday at noon. On 03/21/24 at 10:05 a.m., Res #100 was observed in bed. On 03/21/24 at 10:05 a.m., Res #100 stated their feet was killing them. They stated they had neuropathy and they were dealing with a lot of pain. Res #100 was asked to rate their pain on a scale of one-10 with 10 being the worst pain. They stated their pain level was a 10. Res #100 stated they were taking gabapentin and oxycodone for pain. They stated they had been out of their oxycodone pain medication since yesterday (03/20/24) at 12:00 p.m. They were asked if the pain was keeping them from doing anything. They stated Oh yes. Res #30 stated they usually took the pain medication and then were able to get up some. The resident was not administered their oxycodone-acetaminophen 10 mg on 03/20/24 at 4:00 p.m., 8:00 p.m., or on 03/21/24 at 12:00 a.m., 4:00 a.m., or 8:00 a.m. Res #30 was not administered five doses of their pain medication. On 03/21/24 at 10:15 a.m., the DON stated the pain medication was sent to the wrong nursing home. They stated the pain medication was on the way. On 03/21/24 at 11:22 a.m., Res # 100 stated after taking their oxycodone their pain level usually went down to a two, and every four hours their body would know it was time for more pain medication. On 03/21/24 at 11:24 a.m., CMA #2 was observed administering Res #100 their oxycodone for pain. On 03/21/24 at 11:24 a.m., CMA #2 stated the pain medication had just arrived at the facility. On 03/21/24 at 11:44 a.m., The hospice nurse stated they were notified Res #100 was out of their pain medication yesterday (03/20/24) at 2:56 p.m. On 03/21/24 at 12:14 p.m., administrator stated they expected to staff to reorder medication when the resident had two -three days supply left in the building. On 03/21/24 at 12:41 p.m., LPN #1 stated they had done a few of the required assessments for Res #100 when they were admitted . They stated they had not done a pain assessment and did not find one in the clinical record. LPN #1 stated the staff should perform a pain assessment for the residents on admission. LPN #1 stated the facility staff should have notified hospice at the time of admission to reorder the oxycodone.

Based on record review and interview, the facility failed to ensure insulin and/or blood pressure medication was administered per physician's orders for two (#31 and #46) of three sampled residents whose medication regime was reviewed. The administrator identified 49 residents who resided in the facility. Findings: The facility's Medication Administration-General Guidelines policy, revised 01/2018, read in part, .Medications are administered as prescribed .A triple check .is recommended .Check #1: Select the Medication- label, container and contents .compared against the medication administration record .Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR .Check #3: Complete the preparation of the dose and re-verify the label against the MAR . 1. Res #31 had diagnoses which included hypertension and diabetes. A physician's order, dated 06/27/23, read in part, Insulin Detemir subcutaneous 100u/ml, administer 20u subcutaneously at 7am and 4pm. HOLD IF FSBS <100 . A physician's order, dated 08/09/23, read in part, Metoprolol Succinate ER (an anti-hypertensive) .50mg, 1 tablet by mouth at am/HOLD FOR SBP LESS THAN 100 OR APICAL PULSE LESS THAN 60. The insulin administration/glucocheck record documented the following: On 01/05/24 at 4:42 p.m., Res #31's blood sugar was 97, 20u of Detemir was administered but should have been held. On 01/14/24 at 4:12 p.m., Res #31's blood sugar was 76, 20u of Detemir was administered but should have been held. On 01/25/24 at 4:11 p.m., Res #31's blood sugar was 86, 20u of Detemir was administered but should have been held. On 02/16/24 at 3:59 p.m., Res #31's blood sugar was 94, 20u of Detemir was administered but should have been held. The MAR for March 2024 documented the following: On 03/17/24 for the am/morning medication administration Metoprolol ER 50mg was held due to vital signs being too low. The vital sign flow sheet for 03/17/24, documented a blood pressure of 111/60 and a pulse of 67. On 03/20/24 at 2:00 p.m., the MDS Coordinator reported Res #31's insulin should have been held when their blood sugar was below 100. On 03/20/24 at 2:30 p.m., LPN #1 reported on 01/05/24 they should have held Res #31's insulin but didn't. LPN #1 reported they weren't sure why the administered the insulin and stated it was an error. On 03/20/24 at 2:45 p.m., CMA #1 reported Metoprolol should have been administered on 3/17/24. CMA #1 reported they aren't sure why they medication was held. 36191 2. Res #46 had diagnosis which included hypertension. Current physician's orders, dated 07/24/23, documented to administer Metoprolol Tartrate 25 mg one tablet by mouth three times a day, hold medication if systolic blood pressure was less than 100 or diastolic blood pressure was less than 60. On 03/19/24 at 8:33 a.m., CMA #2 obtained Res #46's blood pressure. The blood pressure reading was 106/52. CMA #2 reported the blood pressure to LPN #2. CMA #2 was told to give the Metoprolol. CMA #2 prepared the medication to be administered to Res #46. The medication label for the Metoprolol documented to hold the medication if the resident's systolic (top number of blood pressure reading) blood pressure was less than 100 or the diastolic (bottom number of the blood pressure reading) blood pressure was less than 60. On 03/19/24 at 8:44 CMA #2 verified they were going to administer the Metoprolol. The CMA was asked to verify the directions on the medication label. CMA #2 read the label and stated they were not supposed to administer the Metoprolol because the resident diastolic blood pressure was less than 60. On 03/19/24 at 10:35 a.m., CMA #2 stated they had not read the blood pressure parameters on label of the Metoprolol because they were nervous and did not see the hold directions in the computer.

Based on observation, record review, and interview, the facility failed to ensure: a. blood pressure machine was disinfected between residents for three (#14, 39, and #46) of three sampled residents who were observed during medication administration; b. soiled linens were not placed on the floor; c. nebulizer mouth piece was stored in a manner to prevent cross contamination for one (#100) of two sampled resident who had breathing treatments; d. a surveillance system was in place to identify infections and communicable diseases; and e. the buildings water system was assessed, monitored, and measures put in place to prevent the growth of Legionella and other opportunistic waterborne pathogens. The administrator identified 49 residents who resided in the facility and three residents who received nebulizer treatments. Findings: The facility's Specific Medication Administration procedure, revised 01/2018, read in part, Nebulizer .Rinse and disinfect the equipment according to manufacturer's recommendations .Wash pieces with warm soapy water daily. Rinse with hot water. Allow to air dry completely on paper towel .When equipment is completely dry, store in a plastic bag with the resident's name and the date on it . 1. On at 03/19/22 at 8:22 CMA #2 obtained Res #39's blood pressure using a wrist blood pressure monitoring device. The CMA placed the wrist blood pressure device on top of the medication cart without disinfecting the blood pressure cuff. On 03/19/24 at 8:33 a.m., CMA #2 obtained Res #46's blood pressure using the same wrist blood pressure monitoring device used on Res #39. The CMA did not disinfect the blood pressure cuff prior to or after obtaining Res #46's blood pressure. On 03/19/24 at 8:46 a.m., CMA #2 obtained Res #14's blood pressure using the same wrist blood pressure monitoring device used on Res #39 and Res #46. The CMA did not disinfect the blood pressure cuff prior to or after obtaining Res #14's blood pressure. On 03/19/24 at 10:35 a.m., CMA #2 stated they cleaned the blood pressure machine a couple of times a day with alcohol or bleach wipes. They stated they did not usually disinfect the blood pressure machine/cuff in between each resident. They stated they did not know they needed to disinfect the blood pressure machine/cuff in between each resident. 2. On 03/21/24 at 10:36 a.m., CNA #1 was observed in a resident room with the door open. There was a strong urine odor and soiled linen on the floor. On 03/21/24 at 10:37 a.m., CNA #1 stated they did not bring a big enough bag for the soiled linens. CNA #1 stated they were not supposed to put soiled linens on the floor. 3. On 03/21/24 at 10:39 a.m. Res #100's room was observed with LPN #1 a nebulizer mouth piece was sitting on top of the nebulizer machine. On 03/21/24 at 10:40 a.m., LPN #1 stated the nebulizer mouth piece should not have been stored on top of the nebulizer machine. They stated it should have been stored in a bag. 4. The tracking and trending infection control book was reviewed and revealed the facility had not tracked their infections or potential communicable diseases since December 2023. On 03/25/24 at 10:12 a.m., administrator stated they have not tracked the infections since December 2023. On 03/25/24 at 12:51 p.m., the IP stated in March three residents had clostridium difficile infection (A bacterium that causes diarrhea and inflammation of the colon requiring contact isolation.) and were on contact isolation. They were asked if they monitored the staff to ensure they were using the correct PPE and washing their hands with soap and water. They stated they talked about it in stand up. There was no documentation the residents infections or communicable diseases were tracked or monitored to ensure infection control measures were put in place. 5. On 03/25/24 at 11:02 a.m., the administrator stated the facility did not have a water Legionella prevention program. The administrator stated the maintenance personnel did not know anything about the water Legionella management program. No documentation was provided related to the facility's water system.

Based on record review and interview, the facility failed to have a system in place to assess residents for infections using standardized tools and criteria for the initiation of antibiotics. The administrator identified 49 residents resided in the facility. Findings: The facility's undated, Communication of Resident Condition and Treatment with Antimicrobial Orders, read in part, .when facility staff suspects a resident has an infection, the nurse should perform and appropriately document a comprehensive assessment of the resident using established and accepted assessment protocols. This assessment will determine if the resident's status meets minimum criteria for initiating antibiotics . The tracking and trending infection control book was reviewed and revealed the facility had not tracked antibiotic use since December 2023. An undated document, titled, Attention All Nurses, read in part, We are initiating a new tool to help with antibiotic stewardship .Please note that there are assessment forms for urinary tract infections, skin and soft tissue infections and respiratory infections. It is required that we fill out the assessment form, as well as the antibiotic/anti-infective order forms .when an infection is identified and/or antibiotics are prescribed . On 03/25/24 at 10:27 a.m., the IP stated they could not determine if an assessment tool had been utilized prior to the initiation of the antibiotics. On 03/25/24 at 12:51 p.m., the IP stated based on the information in the computer 13 residents were administered antibiotics in January 2024, 12 residents were administered antibiotics in February 2024, 15 residents were administered antibiotics in March 2024.

Based on record review and interview, the facility failed to provide a SNF ABN to one (#23) of three sampled residents whose beneficiary notices reviewed. The MDS Coordinator identified four residents who were discharged from skilled services with Medicare benefit days remaining. Findings: Res #23 was admitted to skilled services on 01/18/24 and discharged from skilled services on 02/21/24 and remained in the facility. A SNF Beneficiary Protection Notification Review documented an ABN was not provided to the resident. On 03/20/24 at 11:10 a.m., the MDS coordinator reported Res #23 was not provided an ABN form.

On 01/30/18, an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility to ensure a resident who wandered was not abused by other residents in the facility and to protect the residents who wandered from abuse when they continued to wander into other residents' rooms. Resident #3 who was a wanderer was observed by staff in the hallway with injuries to the face that included: Blood coming from his nose and face, a hematoma with laceration at the right brow, an abrasion on the right side of the bridge of the nose, epistaxis, a scrape in the inner corner of the left eye, an abrasion with hematoma on the left cheek bone, and there was a reddish undertone to the face. The Oklahoma State Department of Health was notified and verified the IJ situation. At 2:23 p.m., the administrator and the director of nursing were informed of the IJ regarding failure to protect a resident from resident to resident abuse. They were informed this placed the facility in an extended survey. At 2:37 p.m., an acceptable plan of removal was received from the administrator. The plan of Removal documented, 1-30-2018 Plan of Removal 1. Placed (Resident #3) and (Resident #74) on 1:1 @ 2:45 p.m., (They shall remain on 1:1 till (sic) relocated) Staff will sign & date time they come on & sign out. 2. Called both families explained situation that we could not meet their needs and that they would be getting 30- day notice. Called (name deleted) on 1-30-18 @ 2:04 p.m. Called (name deleted) on 1-30-18 @ 2:07 p.m. 3. Call Dr. (name deleted)@ 2:00 p.m., explain situation and ask for guidance he stated to call & fax (Facility name deleted) that it is a locked memory unit. 4. Called Emergency inservice for All Employees regarding reporting, resident to resident abuse, Recognizing & preventing & investigating abuse & wandering residents this inservice was given by (name deleted) VP of operations from 2:45 p.m. to 3:45 p.m. The IJ was removed on 01/30/18 at 4:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to ensure residents who wandered were not abused by other residents in the facility and to ensure the residents were protected from further abuse when the residents continued to wander into other residents' rooms for one (#3) of two sampled residents who wandered. The facility identified three residents who wandered. Resident #3 who was a wanderer was observed by staff in the hallway with injuries to the face that included: Blood coming from his nose and face, a hematoma with laceration at the right brow, an abrasion on the right side of the bridge of the nose, epistaxis, a scrape in the inner corner of the left eye, an abrasion with hematoma on the left cheek bone, and there was a reddish undertone to the face. Findings: An abuse prohibition policy, dated 12/19/16, documented, .Abuse includes any form of physical, verbal, or sexual abuse, involuntary seclusion, neglect, misappropriation of property, and corporal punishment .Management of suspected Abuse/Neglect .The nursing facility resident has the right to be free from verbal, sexual, physical, and mental abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .Abuse means the willful infliction of injury .with resulting physical harm, pain, or mental anguish Resident to Resident abuse .This facility prohibits mistreatment, neglect or abuse of residents .Physical abuse includes hitting, slapping, pinching, and kicking . Procedure for management of resident to resident abuse .In the event there is an allegation or incidents involving resident to resident abuse, the individuals involved in the abuse should be immediately separated by staff .The charge nurse should complete an incident report, being very precise about the incident and obtain statements from any witnesses to the incident .The incident report and statements must be completed before the end of the shift .Every effort should be made to redirect and keep the resident separated through activities and diversion .An investigation into what triggered the abuse shall be conducted by the DON with referrals made accordingly . Plan for prevention of abuse/neglect .Prevention: The facility shall prevent occurrence of abuse by reviewing specific incidents for lessons learned and policy amendments .Identify, correct and intervene in situations in which abuse .is more likely to occur. This includes an analysis of: .Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility; .The assessment, care planning and monitoring of residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with communication disorders .Identification: .The staff of this nursing facility shall take a proactive approach to identifying events and occurrences that may constitute or contribute to abuse. These are detailed more specifically in the management of suspected abuse/neglect policy .and include identifying events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse, and to determine the direction of the investigation .Protection: The facility shall protect individuals from abuse during investigation of all allegations of abuse, neglect, or mistreatment . Resident #3 had diagnoses that included [MEDICAL CONDITION], and unspecified dementia without behavioral disturbance. A significant change assessment, dated 04/25/17, documented the resident had short term and long term memory problems, wandering behavior occurred one to three days, required supervision with walking in room and corridor, and had diagnoses of [MEDICAL CONDITION] and Non-Alzheimer's dementia. A nurse's note, dated 11/25/17, documented, Resident was hit in the back of the neck by another resident. No apparent injury observed. Family was notified about incident and does not want to press charges at this time. Doctor and administration also notified. There was no incident report and no state reportable incident report provided for the resident to resident altercation. A nurse's note, dated 12/06/17, documented, At 0635 (6:35 a.m.) resident was observed ambulating the facility with blood coming from nose and face. Upon assessment, these injuries were noted: Hematoma with laceration at the right brow, abrasion on the right side of the bridge of the nose, epistaxis, scrape in the inner corner of the left eye & abrasion with hematoma at the left cheek bone. Also, there was a reddish undertone to the face. Neuro checks initiated .Resident did not appear to be in any pain .It is unknown at this time, the origin of injuries . An incident report, dated 12/06/17, documented, .Other location: Location unknown, Resident was observed with injuries on C-Hallway .Description of incident: Resident was observed at 0635 with injuries to face. Resident was last seen approx. 0605, when incontinent care was given and appeared normal with no injuries to face .Injury description: Right brow hematoma & laceration, bridge of nose: Right side abrasion, epistaxis, inner corner of left eye scrape, abrasion with hematoma at the left cheek bone .Level of Consciousness: Alert x 1, before & after incident . No state reportable incident report for this incident was provided. A quarterly assessment, dated 01/18/18, documented the resident had short term and long term memory problems was severely impaired with cognitive skills for daily decision making, wandering behavior occurred daily, was independent with walking in room and in corridor, and had no diagnoses documented. A wandering assessment, dated 01/18/18, documented, .History of wandering Yes. wander guard in place to alert staff when (name deleted) gets close to an exit door. Has wander guard in place . A care plan, updated on 01/19/18, documented, Problem: .wanders aimlessly about facility r/t impaired cognitive status .Goal: .will not leave facility unattended through review period .Approach: Nurse will assure wander guard is in place and in good working order .Staff will respond to wander guard alarm immediately .Redirect resident away from exit when he is close to one .Notes: 11/27/17 wandered into another resident's room. Yellow strap placed across doorway to deter (resident #3) from entering room . Problem: .is at risk for falls .ambulates about facility indpendently (sic) with a slow steady gait .Goal: .will have no injury related to fall through review period .Approach: .Staff to visually observe (resident #3) frequently throughout the day to ensure tha (sic) he is safe .Notes: 12/6/2017 (Resident #3) was noted ambulating about facility with a head injury. He is unable to communicate to staff what happened related to cognitive status. (Resident #3) will be visually observed for location and safety frequently . On 01/24/18 at 12:00 p.m., the resident was observed standing next to the table in the dining room. He was observed at random times throughout the day wandering by himself throughout the facility up and down the halls. A state reportable incident report, dated 01/28/18, documented, Resident(s)/Client(s) involved: (Resident #21); (Resident #3) .Incident type .Allegations of Abuse/Mistreatment .Physical harm .Description of Incident .(Resident #21) grabbed (Resident #3) by his wrist .Please include relevant history .(Resident #3) has history of wandering behavior and dementia. BIM scores for both residents is ZERO. Both residents sent out for psychiatric evaluation .Part C .For 5 day and final reports, please include a summary of the investigation .Muskogee Police Dept responded to seen (sic). Staff interviewed and statements collected from witnesses of incident, one of which includes resident, (name deleted #50). verbal report of what occurred. It was found that (Resident #3) cognitive level with wandering behaviors resulted in him entering (Resident #21) room where (Resident #21) grabbed (Resident #3) by his wrist and leading him out of the room. No trauma from incident. (Resident #3) has been placed on 1-on-1 constant observation to assure his safety and security within the facility. A nurse's note, dated 01/29/18, documented, Pt was sent today to (name deleted) behavior health unit for eval and possible admit,. pt difficult to re-direct at times. cont to wander into others rooms, upsets a lot of residents. uses the BR, where ever he is at the time, TV room, furniture, others rooms,. today another resident was seen putting his hands on (name deleted) wrists, and agressivly (sic) getting him out of his room, left at approx 6pm and was back by 9pm. the EMT stated he also didn't meet, the criteria for admitt (sic) at the hospital either. NO new orders. On 01/29/18 the resident was observed at random times throughout the day wandering throughout the facility up and down the halls. On 01/30/18 at 11:09 a.m., CNA #6 was asked if the resident wandered. She stated, Yes he does. She was asked if he wandered into other residents rooms. She stated, He does. She was asked if other residents ever attacked or hit him. She stated, It depends. They usually tell him to get out. I've never personally seen anyone hit him. She was asked what interventions were in place to protect him. She stated, Some residents have color guard bands across the doors and we try to redirect. At 11:16 a.m., LPN #2 was asked if the resident wandered. She stated, Yes. She was asked if the resident wandered into other residents rooms. She stated, Yes. She was asked if other residents had attacked or hit him. She stated, I've heard something happened over the weekend but I haven't witnessed any. She was asked if she had completed an incident report for the incident on 12/06/17. She stated, I believe I did. She was asked if she had completed a state reportable incident report. She stated, I personally did not. I don't do state reportable's. Usually the DON or administrator fills those out. The LPN was asked how she protected the resident. She stated, We have hourly checks. We lay eyes on him every hour. We invite him to activities. We have a wanderguard and at meal times we keep him in the dining room. At 11:20 a.m., CNA #7 was asked if the resident wandered. She stated, Yes. She was asked if the resident wandered into other residents rooms. She stated, No. At 11:22 a.m. CNA #1 was asked if the resident wandered. She stated, Yes, She was asked if the resident wandered into other residents rooms. She stated, Yes, but we keep an eye on him and we have yellow signs up. She was asked what interventions were in place to protect him. She stated, We give him stuff to do. Keep him busy. At 12:18 p.m., the DON asked if the LPN reported the incident on 12/06/17 to her. She stated, Yes. She was asked if she investigated to determine the cause of the injuries. She stated, We were unable to determine where he had gone. He is a wanderer. There were signs of foul play. It looked like he had been struck by somebody. The DON was asked if she reported this incident to the state. She stated, I didn't. I figured one was done She was asked if she normally completed the state reportable's. She stated, Yes. She was asked if she interviewed staff or residents. She stated, No. I didn't write anything down. She was asked what plans were in place to protect the resident. She stated, We try to keep eye on all our wanderers and we try to redirect them to their room, dining room or TV room. She was asked if the staff documented hourly checks. She stated, Not to my knowledge. At 12:28 p.m., the administrator was asked if they had completed a state reportable. She stated, If it's not there it wasn't done. She was asked if she had investigated the injury of unknown origin. She stated, We watched cameras. We were concerned (name deleted Resident #21) might have hurt him. We were able to narrow time down. It had to be in a room where no camera was. She was asked why no state reportable was completed. She stated, I thought we did. We couldn't determine what happened. The administrator was asked if a state reportable was completed for the resident to resident altercation with resident #19 on 11/25/17. She stated, If it's not in there, then it wasn't done. She was asked if she knows why it wasn't completed. She stated, No. The administrator and the DON were asked how they protected the resident from being injured. The administrator stated, We sent him to (name deleted) psych. They sent him back the same day. She also stated, He won't go in other rooms if the yellow strap is up. I've talked to activities about getting involved. They were asked why the resident's care plan did not address the resident wandering into other residents' rooms. No response was given. On 02/08/18 at 1:54 p.m., the administrator and DON were asked who was in charge of the abuse investigations. The administrator stated, (DON) and I both do them. They were asked why an incident report was not completed for the resident to resident altercation between resident #3 and resident #19. The administrator stated, We just didn't. The administrator was asked if she had done a thorough investigation related to the resident to resident altercation between resident #3 and esident #19. She stated, We could have done better I'm sure. She was asked if she had done a thorough investigation related to resident #3 injuries of unknown origin. She stated, Related to the state reportable, we should have.

On 01/30/18, an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility to ensure a resident who wandered was not abused by other residents in the facility and to protect the residents who wandered from abuse when they continued to wander into other residents' rooms. Resident #3 who was a wanderer was observed by staff in the hallway with injuries to the face that included: Blood coming from his nose and face, a hematoma with laceration at the right brow, an abrasion on the right side of the bridge of the nose, epistaxis, a scrape in the inner corner of the left eye, an abrasion with hematoma on the left cheek bone, and there was a reddish undertone to the face. The facility did not do a thorough investigation to determine the cause of the injuries, did not file the incident with the state, and did not protect the resident from abuse from other residents. The Oklahoma State Department of Health was notified and verified the IJ situation. At 2:23 p.m., the administrator and the director of nursing were informed of the IJ regarding failure to protect a resident from resident to resident altercations and failure to investigate abuse thoroughly for one resident who had experienced abuse from other residents. They were informed this placed the facility in an extended survey. At 2:37 p.m., an acceptable plan of removal was received from the administrator. The plan of Removal documented, 1-30-2018 Plan of Removal 1. Placed (Resident #3) and (Resident #74) on 1:1 @ 2:45 p.m., (They shall remain on 1:1 till (sic) relocated) Staff will sign & date time they come on & sign out. 2. Called both families explained situation that we could not meet their needs and that they would be getting 30- day notice. Called (name deleted) on 1-30-18 @ 2:04 p.m. Called (name deleted) on 1-30-18 @ 2:07 p.m. 3. Call Dr. (name deleted)@ 2:00 p.m., explain situation and ask for guidance he stated to call & fax (facility name deleted) that it is a locked memory unit. 4. Called Emergency inservice for All Employees regarding reporting, resident to resident abuse, Recognizing & preventing & investigating abuse & wandering residents this inservice was given by (name deleted) VP of operations from 2:45 p.m. to 3:45 p.m. The IJ was removed on 01/30/18 at 4:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review it was determined the facility failed to conduct thorough investigations for allegations of abuse/neglect for five (#3, #19, #21, #45, and #73) of five sampled residents who had allegations of abuse/neglect. This had the potential to affect all 73 residents who resided in the facility. Findings: An abuse prohibition policy, dated 12/19/16, documented, .Abuse includes any form of physical, verbal, or sexual abuse, involuntary seclusion, neglect, misappropriation of property, and corporal punishment .Management of suspected Abuse/Neglect .The nursing facility resident has the right to be free from verbal, sexual, physical, and mental abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .Abuse means the willful infliction of injury .with resulting physical harm, pain, or mental anguish Resident to Resident abuse .This facility prohibits mistreatment, neglect or abuse of residents .Physical abuse includes hitting, slapping, pinching, and kicking . Procedure for management of resident to resident abuse .In the event there is an allegation or incidents involving resident to resident abuse, the individuals involved in the abuse should be immediately separated by staff .The charge nurse should complete an incident report, being very precise about the incident and obtain statements from any witnesses to the incident .The incident report and statements must be completed before the end of the shift .Every effort should be made to redirect and keep the resident separated through activities and diversion .An investigation into what triggered the abuse shall be conducted by the DON with referrals made accordingly . Plan for prevention of abuse/neglect .Prevention: The facility shall prevent occurrence of abuse by reviewing specific incidents for lessons learned and policy amendments .Identify, correct and intervene in situations in which abuse .is more likely to occur. This includes an analysis of: .Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility; .The assessment, care planning and monitoring of residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with communication disorders .Identification: .The staff of this nursing facility shall take a proactive approach to identifying events and occurrences that may constitute or contribute to abuse. These are detailed more specifically in the management of suspected abuse/neglect policy .and include identifying events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse, and to determine the direction of the investigation .Protection: The facility shall protect individuals from abuse during investigation of all allegations of abuse, neglect, or mistreatment .Investigations: The facility shall ensure, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment .Report/Respond: The facility shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation . 1. Resident #3 had diagnoses that included [MEDICAL CONDITION], and unspecified dementia without behavioral disturbance. A significant change assessment, dated 04/25/17, documented the resident had short term and long term memory problems, wandering behavior occurred one to three days, required supervision with walking in room and corridor, and had diagnoses of [MEDICAL CONDITION] and Non-Alzheimer's dementia. A nurse's note, dated 11/25/17, documented, Resident was hit in the back of the neck by another resident. No apparent injury observed. Family was notified about incident and does not want to press charges at this time. Doctor and administration also notified. There was no incident report and no state reportable incident report provided for the resident to resident altercation. A nurse's note, dated 12/06/17, documented, At 0635 (6:35 a.m.) resident was observed ambulating the facility with blood coming from nose and face. Upon assessment, these injuries were noted: Hematoma with laceration at the right brow, abrasion on the right side of the bridge of the nose, epistaxis, scrape in the inner corner of the left eye & abrasion with hematoma at the left cheek bone. Also, there was a reddish undertone to the face. Neuro checks initiated .Resident did not appear to be in any pain .It is unknown at this time, the origin of injuries . An incident report, dated 12/06/17, documented, .Other location: Location unknown, Resident was observed with injuries on C-Hallway .Description of incident: Resident was observed at 0635 with injuries to face. Resident was last seen approx. 0605, when incontinent care was given and appeared normal with no injuries to face .Injury description: Right brow hematoma & laceration, bridge of nose: Right side abrasion, epistaxis, inner corner of left eye scrape, abrasion with hematoma at the left cheek bone .Level of Consciousness: Alert x 1, before & after incident . No state reportable incident report for this incident was provided. A quarterly assessment, dated 01/18/18, documented the resident had short term and long term memory problems was severely impaired with cognitive skills for daily decision making, wandering behavior occurred daily, was independent with walking in room and in corridor, and had no diagnoses documented. A wandering assessment, dated 01/18/18, documented, .History of wandering Yes. wander guard in place to alert staff when (name deleted) gets close to an exit door. Has wander guard in place . A care plan, updated on 01/19/18, documented, Problem: .wanders aimlessly about facility r/t impaired cognitive status .Goal: .will not leave facility unattended through review period .Approach: Nurse will assure wander guard is in place and in good working order .Staff will respond to wander guard alarm immediately .Redirect resident away from exit when he is close to one .Notes: 11/27/17 wandered into another resident's room. Yellow strap placed across doorway to deter (resident #3) from entering room . Problem: .is at risk for falls .ambulates about facility indpendently (sic) with a slow steady gait .Goal: .will have no injury related to fall through review period .Approach: .Staff to visually observe (resident #3) frequently throughout the day to ensure tha (sic) he is safe .Notes: 12/6/2017 (Resident #3) was noted ambulating about facility with a head injury. He is unable to communicate to staff what happened related to cognitive status. (Resident #3) will be visually observed for location and safety frequently . On 01/24/18 at 12:00 p.m., the resident was observed standing next to the table in the dining room. He was observed at random times throughout the day wandering by himself throughout the facility up and down the halls. A state reportable incident report, dated 01/28/18, documented, Resident(s)/Client(s) involved: (Resident #21); (Resident #3) .Incident type .Allegations of Abuse/Mistreatment .Physical harm .Description of Incident .(Resident #21) grabbed (Resident #3) by his wrist .Please include relevant history .(Resident #3) has history of wandering behavior and dementia. BIM scores for both residents is ZERO. Both residents sent out for psychiatric evaluation .Part C .For 5 day and final reports, please include a summary of the investigation .Muskogee Police Dept responded to seen (sic). Staff interviewed and statements collected from witnesses of incident, one of which includes resident, (name deleted #50). verbal report of what occurred. It was found that (Resident #3) cognitive level with wandering behaviors resulted in him entering (Resident #21) room where (Resident #21) grabbed (Resident #3) by his wrist and leading him out of the room. No trauma from incident. (Resident #3) has been placed on 1-on-1 constant observation to assure his safety and security within the facility. A nurse's note, dated 01/29/18, documented, Pt was sent today to (name deleted) behavior health unit for eval and possible admit,. pt difficult to re-direct at times. cont to wander into others rooms, upsets a lot of residents. uses the BR, where ever he is at the time, TV room, furniture, others rooms,. today another resident was seen putting his hands on (name deleted) wrists, and agressivly (sic) getting him out of his room, left at approx 6pm and was back by 9pm. the EMT stated he also didn't meet, the criteria for admitt (sic) at the hospital either. NO new orders. On 01/29/18 the resident was observed at random times throughout the day wandering throughout the facility up and down the halls. On 01/30/18 at 11:09 a.m., CNA #6 was asked if the resident wandered. She stated, Yes he does. She was asked if he wandered into other residents rooms. She stated, He does. She was asked if other residents ever attacked or hit him. She stated, It depends. They usually tell him to get out. I've never personally seen anyone hit him. She was asked what interventions were in place to protect him. She stated, Some residents have color guard bands across the doors and we try to redirect. At 11:16 a.m., LPN #2 was asked if the resident wandered. She stated, Yes. She was asked if the resident wandered into other residents rooms. She stated, Yes. She was asked if other residents had attacked or hit him. She stated, I've heard something happened over the weekend but I haven't witnessed any. She was asked if she had completed an incident report for the incident on 12/06/17. She stated, I believe I did. She was asked if she had completed a state reportable incident report. She stated, I personally did not. I don't do state reportable's. Usually the DON or administrator fills those out. The LPN was asked how she protected the resident. She stated, We have hourly checks. We lay eyes on him every hour. We invite him to activities. We have a wanderguard and at meal times we keep him in the dining room. At 11:20 a.m., CNA #7 was asked if the resident wandered. She stated, Yes. She was asked if the resident wandered into other residents rooms. She stated, No. At 11:22 a.m. CNA #1 was asked if the resident wandered. She stated, Yes, She was asked if the resident wandered into other residents rooms. She stated, Yes, but we keep an eye on him and we have yellow signs up. She was asked what interventions were in place to protect him. She stated, We give him stuff to do. Keep him busy. At 12:18 p.m., the DON asked if the LPN reported the incident on 12/06/17 to her. She stated, Yes. She was asked if she investigated to determine the cause of the injuries. She stated, We were unable to determine where he had gone. He is a wanderer. There were signs of foul play. It looked like he had been struck by somebody. The DON was asked if she reported this incident to the state. She stated, I didn't. I figured one was done She was asked if she normally completed the state reportable's. She stated, Yes. She was asked if she interviewed staff or residents. She stated, No. I didn't write anything down. She was asked what plans were in place to protect the resident. She stated, We try to keep eye on all our wanderers and we try to redirect them to their room, dining room or TV room. She was asked if the staff documented hourly checks. She stated, Not to my knowledge. At 12:28 p.m., the administrator was asked if they had completed a state reportable. She stated, If it's not there it wasn't done. She was asked if she had investigated the injury of unknown origin. She stated, We watched cameras. We were concerned (name deleted Resident #21) might have hurt him. We were able to narrow time down. It had to be in a room where no camera was. She was asked why no state reportable was completed. She stated, I thought we did. We couldn't determine what happened. The administrator was asked if a state reportable was completed for the resident to resident altercation with resident #19 on 11/25/17. She stated, If it's not in there, then it wasn't done. She was asked if she knows why it wasn't completed. She stated, No. The administrator and the DON were asked how they protected the resident from being injured. The administrator stated, We sent him to (name deleted) psych. They sent him back the same day. She also stated, He won't go in other rooms if the yellow strap is up. I've talked to activities about getting involved. They were asked why the resident's care plan did not address the resident wandering into other residents' rooms. No response was given. On 02/08/18 at 1:54 p.m., the administrator and DON were asked who was in charge of the abuse investigations. The administrator stated, (DON) and I both do them. They were asked why an incident report was not completed for the resident to resident altercation between resident #3 and resident #19. The administrator stated, We just didn't. The administrator was asked if she had done a thorough investigation related to the resident to resident altercation between resident #3 and esident #19. She stated, We could have done better I'm sure. She was asked if she had done a thorough investigation related to resident #3 injuries of unknown origin. She stated, Related to the state reportable, we should have. 2. Resident #19 had diagnoses that included paranoid [MEDICAL CONDITION], alcohol dependence, anxiety disorder, major [MEDICAL CONDITION], and [MEDICAL CONDITION] and [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] disease affecting left non-dominant side. An annual assessment, dated 06/01/17, documented the resident had a BIMS score of 15. This scored indicated the resident was cognitively intact with daily decision making. The assessment documented the resident had no behaviors, and required supervision with locomotion on and off the unit. An incident report, dated 11/25/17, documented, Reported by: Nurse found resident on the floor yelling for help .Description of incident: This nurse found resident laying on the floor next to his w/c. (name deleted) attacked another resident that had enter his room. He stated that he stood up and hit him in the back of the neck. (Name deleted) then fell on the floor landing on his L shoulder. Complaint of severe pain (level 9) to L shoulder and upper arm. Resident was very aggressive and angry with this nurse. Stating that he would attack the resident again if he entered his room. The resident that entered (name deleted) room is oriented x1. He often enters resident's rooms unaware of what he is doing .Incident type: Fighting .Injury Type: Major injury .Injury description: L shoulder possible dislocation. Ambulance called. Arrived at 4:40pm took resident to (name deleted) hospital . No state reportable incident report was completed for the resident to resident altercation between resident #19 and resident #3 or for the major injury to resident #19 left shoulder. A nurse's note, dated 11/26/17, documented, Closed Fracture of upper end of Left humerus. Resident has kept sling on. Tried to lay in bed for awhile. Got up and w/c is able to wheel self independently down the hall way. Spoke with resident about what happened yesterday that caused him to fall. He was able to verbalize that he hit another resident in the back of the neck for attempting to steal his nebulizer. Resident was no longer aggressive when asked about situation. Denied any pain sling helps minimize pain along with [MEDICATION NAME] 5mg Q6 hours. A quarterly assessment, dated 11/28/17, documented the resident had a BIMS score of 14. This score indicated the resident was cognitively intact with daily decision making. The assessment documented the resident had physical behavioral symptoms directed toward others one to three days, was independent with locomotion on and off the unit, and had diagnoses that included other fracture, anxiety, and [MEDICAL CONDITION]. A care plan, dated 11/30/17, documented, Problem: .at risk for aggressive behaviors r/t [MEDICAL CONDITION] .Goal: .will control his behaviors through review period .Approach: Monitor and document behaviors when/if they occur .if becomes aggressive or angry remove the cause or assist (name deleted) away from situation .Notes: 01/23/18 .Res has a yellow stop banner across door to aide in keeping other residents out .11/27/17 .hit another resident on 11/25/17, one on one supervison x 48 hrs . Problem: .at risk for falls related to left side paralysis secondary to late effect [MEDICAL CONDITION].Approach: .visually observe (name deleted) frequently to ensure that he is safe .Yellow strap in place across doorway to deter other residents from entering room .Notes: .11/27/17 .Another confused resident entered (name deleted) room, he stood up, swung at other resident, and lost his balance, fell to floor. Sent to ER and returned with a fracture to left arm .Yellow strap placed across doorway to deter other residents from entering (name deleted) room . On 01/30/17 at 12:28 p.m., the administrator was asked if a state reportable was completed for the resident to resident altercation with resident #19 on 11/25/17. She stated, If it's not in there, then it wasn't done. She was asked if she knew why it wasn't completed. She stated, No. On 02/08/18 at 1:54 p.m., the administrator and DON were asked who was in charge of the abuse investigations. The administrator stated, (DON) and I both do them. They were asked why they didn't interview residents during the investigation. The DON stated she was not in the practice of doing question and answers. They were asked why separate incident reports were not completed for the resident to resident altercation and the fractured shoulder. The administrator stated, We just didn't. The administrator was asked if she had done a thorough investigation related to the resident to resident altercation and fractured shoulder. She stated, We could have done better I'm sure. 3. Resident #21 had diagnoses that included [MEDICAL CONDITION], hypertension, and [MEDICAL CONDITION]. A quarterly assessment, dated 11/29/17, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with daily decision making. The assessment documented the resident had no behaviors, and required supervision for most of his activities of daily living. A state reportable incident report, dated 01/28/18, documented, Resident(s)/Client(s) involved: (Resident #21) ; (Resident #3) .Incident type: Allegations of Abuse/Mistreatment; Physical Harm .Part B: Description of Incident .(Resident #21) grabbed (Resident #3) by his wrist .Please include relevant resident history .(Resident #3) has history of wandering behavior and dementia. BIM scores for both residents is ZERO. Both residents sent out for psychiatric evaluation .Part C: For 5 day and final reports, please include a summary of the investigation .Police Dept responded to seen (sic). Staff interviewed and statements collected from witnesses of incident, one of which includes resident (#50) verbal report of what occurred. It was found that (Resident #3) cognitive level with wandering behaviors resulted in him entering (Resident #21) room where (Resident #21) grabbed (Resident #3) by his wrist and leading him out of the room. No trauma from incident No staff and resident interviews were provided related to the investigation. On 01/30/18 at 11:16 a.m., LPN #2 was asked if other residents had attacked or hit resident #3. She stated, I've heard something happened over the weekend but I haven't witnessed any. On 01/31/18 at 1:58 PM Resident # 21 Resident was asked if resident #3 had entered his room uninvited. He stated, A man kept coming in our room and my wife was in the bathroom That's not right. He was asked if he reported it to anyone. He stated, Yes, I reported to the admin and everything is taken care of. On 02/08/18 at 1:54 p.m., the administrator and DON were asked who was in charge of the abuse investigations. The administrator stated, (DON) and I both do them. They were asked why they didn't interview residents during the investigation. The DON stated she was not in the practice of doing question and answers. The administrator and DON were asked if they had done a thorough investigation related to the resident to resident altercation. The DON stated, Yes. 4. An incident report, dated 01/19/18, documented, Resident (name deleted-#73) reports to staff on 2/1/18 @ 8:35 am that in the evening on Friday (MONTH) 19, (YEAR) she went to resident (name deleted-#37) room to get coffee. She states he exposed his genitals to her and cursed at her when she was not interested in performing sexual activities with him. On 02/01/18 at 3:16 p.m., resident #73 was asked about the incident on 01/19/18. The resident stated, I went to his room and got coffee then he took it (privates) out. I just left. The resident was asked if she had told anyone what had happened. She stated, Yes, I told someone. She was asked what they did when she told them. She stated, They didn't do anything. At 3:45 p.m., CNA #1 was asked about the incident on 01/19/18 between resident #73 and resident #37. She stated, She (resident #73) was asking for coffee. (Resident #37) had coffee in his room and I told her to get some from him. I don't know what happened after that. She was asked if the resident had reported an incident to her regarding going to the resident's room for coffee. The CNA stated the resident had said something about him and his privates. She stated, I really wasn't paying any attention to her. The resident was also talking to her roommate and other people were around too. CNA #1 was asked if she had asked the resident any questions regarding what had happened. She stated, No, ma'am. The CNA was asked if she had reported the allegation to anyone. She stated, No. I didn't think it was any big deal. I didn't get in her business. The CNA was asked why she had not identified that as sexual abuse. She stated, I thought they were dating. I don't get in their business. The CNA was asked if she had attended the abuse inservice on 01/30/18. She stated, Yes. She was asked why she did not report the allegation then. She stated, I didn't think it was abuse. The CNA was asked if she should have reported the incident. She stated, Yes, I should have. At 4:00 p.m., resident #62 was asked if she was the resident's roommate and if she (resident #73) had told her about an incident with a male resident. She stated, Yes. She was asked if the resident was upset about the incident. She stated, Yes. At 4:45 p.m., the administrator was asked when the alleged incident between resident #73 and resident #37 had been reported to her. She stated, First thing this morning (02/01/18) around 8:35 a.m. On 02/08/18 at 1:53 p.m., the administrator was asked who was in charge of the abuse investigations. She stated, (DON) and I both do them. At 2:12 p.m., the administrator was asked if they had interviewed resident #73 regarding the sexual abuse allegation. She stated, Yes, in detail. The administrator was asked for the interview. No interview for the resident was provided. The administrator and the DON were asked if they had asked staff any questions regarding what had happened. The administrator stated, We asked if they had seen anything or him be inappropriate. I didn't write down any questions or answers. The DON stated, I just took notes and put on the incident report. They were asked why the staff's statements that were provided not dated. The administrator stated, I didn't know we were supposed to do that. The administrator and the DON were asked if during the investigation, when they received the CNA's statement, if they had asked the CNA any questions about the alleged incident. The administrator stated, She (resident) told us she asked him for a cup of coffee. They were asked if they had asked the CNA why she had not identified this as possible sexual abuse. The DON stated, I counseled her on identifying possible sexual abuse. The DON was asked for the documentation of the counseling. She stated, It was a verbal counsel. No written documentation was provided. The DON was asked if during the investigation the CNA had been asked why she had not reported the incident. The DON stated, No. The DON was asked if she had asked the CNA why she had not recognized or reported the incident after she had attended the abuse inservice on 01/30/18. The DON stated, No. The administrator and the DON were asked if they had done a thorough investigation. The DON stated, Yes. 5. An incident report, dated 01/30/18, documented, .01/30/2018 2:30:00PM reported by multiple staff members . Staff reported today during an in-service that this resident is being abusive and controlling to his wife. Staff states that he tells her when she can and can not eat, leave the room, visit with family, take showers, have a snack or drink, etc. Staff also states that when they attempt to talk to wife that this resident intervenes and will answer for her .Residents separated during investigation. Investigation initiated by administration . On 02/08/18 at 2:00 p.m., the DON was asked when they had started their abuse investigation. The DON stated, At the end of the inservice when it was reported. The administrator and the DON were asked if the abuse had been reported by three staff members. The DON stated, Yes. The administrator and the DON were asked if they had asked the staff when the abusive behaviors were first witnessed. The DON stated, No, I did not ask them. The administrator and the DON were informed there were no dates on the statements from two staff who reported the alleged abuse and no signatures from the person who received their statements. They were asked why. The DON stated, I'm not sure. The administrator and the DON were asked why the kitchen staff person who reported the incident had not been interviewed or a statement taken, during the investigation. The DON stated, She had left after the inservice. The administrator and the DON were asked if they had asked the witnesses why they had not reported the abusive behaviors when they first witnessed it or identified the behaviors as abuse. The DON stated, I asked the CNA's and they said because they were married. They were asked if they had reviewed the weight records and meal percentage records during the investigation to determine if the resident had experienced any weight loss. The DON and the administrator stated, No. The administrator and the DON were asked if they had interviewed residents during the investigation. The administrator stated, No. We felt odd regarding HIPP[NAME] The DON stated she was not in the practice of doing questions and answers. During the investigation did you ask what changes in behaviors the staff referred to in their statement. The DON stated, I don't recall that. The statement was read to the DON and the administrator. The DON stated, No. They were asked if they had done a thorough investigation. The DON stated, I feel like we did. 6. Resident #45 had diagnoses that that included convulsions, constipation, pain, [MEDICAL CONDITIONS] disease, anxiety disorder, heart failure, major [MEDICAL CONDITION], gastroesphageal reflux disease, hypertension, impulse disorder, intellectual disabilities, and vitamin deficiency. An annual assessment, dated 12/15/17, documented the resident had moderate difficulty hearing, speaker had to increase volume and speak distinctly, had no hearing aides, had adequate vision and wore glasses, had a BIMS score of seven, this score indicated the resident was severely impaired for daily decision making. The assessment documented the resident had inattention, had no behaviors, required extensive assistance for bed mobility, transfers, toileting, personal hygiene and was always incontinent of bowel and bladder. A care plan, dated 12/18/17, documented, .Problem: has a history of behavior problems related to care .becomes occasionaly (sic) becomes combative with staff . Goal: behaviors will not interfere with care . Approach: When (name deleted) becomes upset, do not challenge him. Remove him from the situation to a quiet area and allow him to verbalized (sic) his feelings. Attempt to assist (name deleted), but do not force him to do anything that is upsetting him. Document (name deleted) behaviors when they occur . An electronic nurses note, dated 01/10/18 at 4:13 a.m., documented: Very combative this shift with CNA during routine bed-checks, was able to redirect with several attempts will continue to monitor behavior . An incident report, (TRUNCATED)

On 02/01/18 an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision with smoking for resident #40. Resident #40 was observed to smoke while wearing his oxygen at five liters per minute via nasal cannula. The resident stated he was not being supervised by staff during smoking and would wear his oxygen while smoking. At 9:41 a.m., The Oklahoma State Department of Health (OSDH) verified the existence of the Immediate Jeopardy situation. At 9:48 a.m., the administrator and the DON were informed of the Immediate Jeopardy regarding a resident who was smoking while wearing oxygen and was unsupervised during smoking with oxygen present on his wheelchair. They were informed that a plan of removal would be required. They were also informed that this placed the facility in an extended survey. The plan of removal, dated 02/01/18, was received on 02/01/18 at 12:07 p.m., from the administrator. The plan of removal documented, Plan of Removal for Supervision to Prevent Accidents 1. All smoking assessments will be done and updated to include the following: Identify smokers Identify smokers who use oxygen Identify smokers who are unsafe or safe to smoke independently 2. We will Care plan smokers in need of supervision to include what type of supervision is needed for each resident to smoke safely. Oxygen users will be transported from their room at smoking times in a wheelchair that does not contain an oxygen tank and escorted outside. They will be monitored by staff at all times to watch for potential distress. Residents that are high risk and not on oxygen will be monitored for safety throughout the smoking process, and proper disposal of the cigarette when smoking is complete. 3. An in-service will be held by (Name deleted) VP of operation with all employees educating them on our new smoking P&P to include the above information, where to identify high risk smokers, and importance of smoking safety. To be completed by 3pm on 2-1-18. To include: The smoking process Supervision of smokers and the lack there of that has been occurring Keeping residents safe while smoking To be posted at both nurses stations for staff to identify the high risk smokers HIGH RISK SMOKERS A HALL (Name deleted) - oxygen user (Name deleted) - oxygen user B HALL (Name deleted) - assist with lighting, appropriate disposal of butts D HALL (Name deleted) - burn prevention, appropriate disposal of butts (Name deleted) - oxygen user The Immediate Jeopardy (IJ) was removed on 02/01/18 at 2:54 p.m., after all the components of the plan of removal were completed. The deficient practice remained at a pattern level of no actual harm with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ provide supervision while smoking for a resident who required supervison to smoke and smoked while wearing oxygen for one (#40) of six sampled residents who smoked. Resident #40 had been assessed to require supervision while smoking, and ~ evaluate the resident's ability to smoke at least every three months as defined by their smoking policy and implement the resident's safety needs as defined in his care plan regarding smoking for one (#40) of six sampled residents who smoked. The facility identified eight residents who smoked. Findings: An undated smoking policy, documented, .No cigarettes or lighters are to be kept in resident rooms. Smoking is only permitted: a. In the facility's designated smoking area b. During the facility's designated smoking times . c. Under the supervision of a staff member . The supervising staff member will: .Supervise and maintain the safety of the residents during smoking . Complete a smoking assessment with every scheduled resident assessment and any significant change of condition . An undated oxygen policy, documented, .Notify the resident and family, and instruct them about oxygen use and the no smoking precaution .Place a No Smoking sign on the resident's door, and instruct staff members and visitors about the no smoking precaution . Resident #40 had [DIAGNOSES REDACTED]. A smoking assessment, dated 04/03/17, documented the resident had adequate recall memory and daily decision making skills, was not able to smoke safely, and did not comply with the smoking policy. The assessment documented the resident had been instructed on potential hazards of smoking with oxygen. There was no smoking assessment completed for July, (YEAR). A significant change assessment, dated 09/25/17, documented the resident had a BIMS score of 11. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required supervision and set up help with activities of daily living, used a wheelchair for mobility, and required oxygen therapy. A smoking assessment, dated 09/27/17, documented the resident had adequate recall memory and daily decision making skills, was not able to smoke safely, and did not comply with the smoking policy. The assessment documented the resident had been out to smoke several times without turning his oxygen off and needed supervision for safety. A five day assessment, dated 12/01/17, documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident was independent with activities of daily living, used a walker for mobility, and required oxygen therapy. A care plan, dated 12/01/17, documented, .Problem: .Smoking .Goal: .will smoke safely .wish to smoke and my decision to smoke will be respected .Nurse will assess quarterly and as needed my ability to smoke safely .Staff will observe my clothing and skin for signs of cigarette burns. I will be educated on smoking risk and hazards of smoking .Cessation aids that are available .I will be supervised for safe smoking . There was no smoking assessment completed for December, (YEAR). On 01/31/18, at 10:20 a.m., the resident was observed in the smoking area smoking with his oxygen tank on the back of his wheelchair and the nasal cannula in his nose. No staff was observed with the resident. At 11:35 a.m., the resident was observed in the hallway seated in his wheelchair by the exit door to the smoking area. There was an oxygen tank on the back of his wheelchair and he was wearing a nasal cannula. CNA #5 was observed to let him outside to the smoking area. She did not accompany the resident outside. The resident was observed to light a cigarette and start smoking. No staff was with him. The resident was asked if his oxygen was on. He stated Yes. He was asked if the oxygen was supposed to be on while he was smoking. He stated, No. The oxygen was observed to be on at five liters per minute. The resident stated he could turn it off. The resident turned around and turned off the oxygen. He turned the number on the tank from five to zero. He continued to wear the nasal cannula. He was asked if staff came out with him to smoke. He stated, No. He was asked what he normally did when he smoked. He stated he smoked alone and left the oxygen on. At that time the administrator came out to the smoking area and asked the resident if his oxygen was on. He stated it was off. The administrator apologized for interrupting the surveyor and resident's conversation and left. In the next one to two minutes a staff person came out and stood with the resident while he finished smoking. At 2:30 p.m., the resident was asked if staff supervised him while smoking. He stated they haven't lately. He stated he was supposed to leave the oxygen in his room and go out to smoke without it. He stated, I tell them I can't walk that far without it. On 02/02/18 at 11:25 a.m., The ADON was asked what the process was for obtaining cigarettes. She stated some residents kept their own and some did not. She was asked if resident #40 kept his own cigarettes. She stated, Yes. At 11:50 a.m., MDS coordinator #1 was asked about the smoking assessments. She stated she did some other assessments when the MDS assessments were due. She stated she didn't know why the other smoking assessments were not done. She stated she would have to check and see. She was asked how she did the smoking assessments. She stated she monitored the resident and watched them smoking and could see them smoking from her window in the MDS office. She was asked if she had seen the resident smoking with his oxygen on. She stated yes. She stated she had also worked the floor and had seen the resident outside smoking and he would give her the ok sign through the window which meant the oxygen was off. She stated she had told him in the past that the oxygen had to be turned off. She stated she told him he could hurt himself or others if not. She was asked if she had reported the resident being outside smoking with his oxygen on and not being supervised by staff. She stated, I'm sure I did but I may not have documented it. MDS coordinator #1 checked the missing smoking assessments and stated she did not know why they had not been completed. She stated all the nurses were doing assessments at different times and didn't know why they were not done. On 02/08/18 at 11:10 a.m., the administrator and the DON were asked why the smoking assessments had not been completed as scheduled. The administrator stated, It just got missed. They were asked if the care plan had been followed regarding smoking. They both stated no. The administrator and DON were asked if the resident should have been outside in the smoking area with his oxygen on. They both stated no. They were asked if the resident should have been supervised during smoking. They both stated yes.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services to maintain the highest practicable level of well-being for three (#4, #11, and #14) of 14 sampled residents reviewed for highest practicable well-being. Resident #4 verbalized unrelieved pain and was observed grimacing, moaning, and resisting care. Resident #11 verbalized unrelieved pain and was observed to moan and flinch with pain while the resident sat in the wheelchair. The facility failed to: a) completely assess the effectiveness of pain medications and implement measures to manage pain for residents #4 and #11. b) identify persistent breakthrough pain for residents #4 and #11. c) implement alternative pain relief interventions when pain medication was not effective for residents #4 and #11. d) obtain provider contracts for [MEDICAL TREATMENT] services which included the development and implementation of resident care plans and the specific form for information interchange between the [MEDICAL TREATMENT] facility and the nursing facility for residents #11 and #14. The facility identified two residents who received [MEDICAL TREATMENT] outside the facility. Findings: The facility policy for the pain management documented: 1. A comprehensive pain assessment must be completed on admission and monthly. A pain scale must be used to assess pain and pain must be rated by the resident. Assessment for the indicators of pain must be used for residents with cognitive or communication deficits. These indicators of pain included agitation, aggressive or defensive behaviors, grimacing, crying, frowning, protecting a body part, irritability, groaning, grunting, moaning, screaming, or yelling. 2. Chronic pain would be managed with around the clock pain medications and as needed medications for breakthrough pain for maximum relief of pain. 3. The nurse must notify the physician for changes in frequency and intensity of pain. 4. Non-medication relief measures included comfort food, companion, decreased stimulation, distraction, exercise, guided imagery, massage, music, relaxation, repositioning, spiritual activities, and television. 5. The resident's care plan should document the assessment of the resident's pain, treatment, and be individualized according to the resident's needs and preferences. The pain care plan must be updated when the resident's pain has changed in frequency or intensity. The care plan must be revised with new pain relief interventions when the previous interventions were not effective. 6. The nurse must document the resident's pain in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurse should document the non-medication interventions which were used. The pain monitoring flow sheet should document the resident's pain from each shift even if medication was not administered. 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive admission assessment, dated 03/26/13, documented the resident was moderately impaired for daily decision making and required moderate assistance with the activities of daily living. The assessment documented the resident experienced constant and severe pain. The assessment documented the resident received pain medications. The care plan, dated 04/04/13, documented the resident experienced pain and would have relief of pain within one hour of the implemented pain intervention for the next three months. The care plan documented the following pain interventions: assess frequently for pain, document what and where the pain was located, reposition for comfort, have the resident rest after the pain medication was given, document effectiveness of the pain medication, call the physician if the pain medication is not effective, complete a pain assessment monthly, and give all pain medication as ordered. The resident's monthly pain assessment, dated 04/09/13, documented the resident experienced pain daily. The pain assessment documented the resident's pain ranged from 2 to 10 on a pain scale of 0 to 10. Zero equals no pain and ten equals the most severe pain. The assessment documented the pain was located in the right hip, leg, and the right shoulder. The resident received [MEDICATION NAME] for pain. The assessment did not document the effectiveness of the medication. The assessment did not document alternative pain relief interventions specific for the resident. The monthly pain assessment, dated 05/02/13 documented the resident experienced pain less than daily and the resident's pain ranged from 2 to 10 on the pain scale of 0 out of 10. The assessment documented the pain was located in the upper and lower extremities. The monthly pain assessment, dated 06/04/13, documented the resident experienced pain daily and the resident's pain ranged from 0 to 10. The assessment documented the pain was located in the resident's legs and back. The physician's orders [REDACTED]. The prn Medication Administration Record, [REDACTED]. The MAR indicated [REDACTED]. The MAR, dated 06/2013, did not document the resident received routine pain medication. The nurses' notes, dated 06/01/13 through 06/18/13, documented the resident had no pain. The notes did not document the resident experienced pain or the required the administration of the prn pain medication. On 06/19/13 the notes documented the resident complained of pain, swelling, and warmth to the right leg. The notes stated an x-ray was ordered. On 06/23/13, the notes documented the resident was transported to the hospital for the evaluation of the right lower extremity. A [MEDICAL CONDITION] was diagnosed in the right leg. The resident was placed on a [MEDICAL CONDITION] medication. The resident's clinical record showed no documentation the resident was reevaluated for increased pain or the resident's need for additional pain medication. The monthly pain assessment, dated 07/01/13, documented the resident experienced pain less than daily and the resident's pain ranged from 0 to 10 on a scale of 0 to 10. The pain was located on the right side. The prn medication administration report, dated July 2013, documented the resident received [MEDICATION NAME] three times a day for one day, two times a day for six days, and one time a day for one day. There was one day the resident did not receive pain medication. The MAR indicated [REDACTED]. The MAR, dated 07/01/13 through 07/09/13, did not document the resident had an order for [REDACTED]. The nurse's notes, dated 07/01/13, documented the resident complained of increased pain to her right leg. The resident was transported to the hospital for re-evaluation. The resident's [MEDICAL CONDITION] medications were adjusted. The clinical record showed no documentation the resident's pain medication had been re-evaluated or increased. The resident's clinical record showed no documentation the resident was reevaluated for increased pain or the resident's need for additional pain medication. On 07/08/13 at 12:35 p.m., the resident was observed in bed eating lunch. The resident stated she had lived in the facility since March of 2013. The resident was grimacing and moaning. The resident stated it was difficult to eat due to the broken arm. The resident had difficulty scooping the food and bringing the fork to the mouth. The resident stated it was painful. The resident stated the pain was poorly controlled and she was not pain free. On 07/09/13 at 9:40 a.m., the resident was observed during pericare. The resident stated she was comfortable and pain free before pericare was performed. The resident grimaced, moaned, and resisted movement as pericare was performed. The resident told the certified nurse aides (CNA) to hurry up. The resident stated, "My knee hurts." The CNAs repositioned the resident without pillows when pericare was completed. On 07/09/13 at 4:30 p.m., the resident was observed resting in the bed, turned to the right side, and supported by pillows. The resident stated she had severe righted sided pain after the morning pericare. The resident stated she wanted pain medicine but it was too early for her next dose to be administered. The resident stated the pain lasted 20-25 minutes after the pericare was completed. On 07/10/13 at 10:00 a.m., the resident was interviewed regarding pain management. The resident stated she had experienced pain since her admission and the pain had worsened. The resident stated she has pain relief while lying on her back. The resident stated the pain medication helped relieve the pain but not completely. The resident stated she, "just suffered through it," when she had breakthrough pain. The resident stated the pain interfered with daily care and activities. She stated she does not want to do anything but to lie still and stay stationary. On 07/10/13 at 1:55 p.m., CNA #4 was interviewed regarding pain management interventions for the resident. The CNA stated the resident's pain was reported to the certified medication aide and the nurse. The CNA stated the alternative pain relief intervention was to reposition the resident. The CNA was not able to list other pain relief interventions. On 07/10/13 at 2:05 p.m., licensed practical nurse (LPN) #3 was interviewed regarding pain management. The LPN stated the resident was repositioned when the resident first complained about pain. A prn pain medication would be given for persistent pain. The LPN was asked what was done when the resident had breakthrough pain. The LPN stated there was not much that could be done. The LPN stated the resident had pain when turned to a side yet she had to be turned to prevent skin breakdown. The LPN was asked if the resident should have had pain relief even when turned to the side. The LPN stated the resident should have had pain relief when turned to the side. The LPN stated the physician had not been called regarding the resident's poor pain control and breakthrough pain. On 07/10/13 at 3:05 p.m., the director of nurses (DON) was interviewed regarding pain management. The DON stated a monthly pain screen was completed on the residents but no daily pain screen was completed. The DON stated there was no specific place to document the daily assessment of pain. The DON stated that pre and post medication assessments were to be completed and documented when a pain medication was given. The DON stated repositioning and the application of hot and cold packs were alternative pain interventions which could be utilized for persistent pain. The nurses were to call the physician for unrelieved pain. The DON stated the resident only had a prn order for pain medication and was not aware the resident's pain was not relieved. The DON was asked if the nurses had notified the physician of the resident's persistent pain. The DON stated the physician had not been called. The DON was asked if the resident's pain was being screened by the nurses daily. The DON stated the nurses probably did not screen the resident for pain daily. 2a. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive annual assessment, dated 03/22/13, documented the resident was independent with daily decision making and required minimal assistance with the activities of daily living. The assessment documented the resident had a diabetic ulcer to the foot, experienced pain, and received pain medications as needed. The care plan, dated 03/28/13, documented the resident experienced pain. The care plan documented the goal for the resident to have relief of pain within 45 minutes of receiving pain medication. The care plan documented reposition every two hours, apply heat/cold and place gel cushion in chair when up as interventions. The pain assessment for June 2013 documented the resident had pain daily. The pain assessment for July 2013 documented the resident had pain less than daily. The physician's orders [REDACTED]. The prn medication record for July 2013 documented the resident received pain medication on 07/09/13 and 07/10/13. The record documented the resident rated the pain at zero. On 07/11/13 at 3:30 p.m., the resident was observed and interviewed regarding pain management. The resident had returned from [MEDICAL TREATMENT] and was seated in her wheelchair in her room. The resident stated she experienced fatigue and lack of strength after [MEDICAL TREATMENT]. The resident grimaced, moaned, and flinched with pain to her foot three times during the interview. The resident stated she experienced pain in foot due to the diabetic ulcer. The resident rated the pain at nine to ten on the pain scale of 0 to 10. The resident stated the pain in the past had decrease to eight after the pain medication was received. The resident stated the prn non-narcotic pain medication was effective for only an hour. The resident stated she did not feel her pain medication was effective. The resident stated she had informed the nurse and the nurse advised her to speak with the physician. On 07/12/13 at 10:45 a.m., LPN #4 was interviewed regarding the resident's pain control. The LPN stated the resident rated the pain at two after pain medication was given. The LPN stated the resident would be repositioned, have heat/cold applied, or have meditation offered for breakthrough pain. The LPN stated the physician would be notified if the pain medication was not effective. The LPN stated she did not know the resident's prn pain medication was not effective. 2b. The resident's care plan, dated 03/28/13, documented the resident received a renal diet and received [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday every week. The provider contract for the resident's [MEDICAL TREATMENT] company was reviewed. The contract did not document an agreement for the specific form of communication which was to be used for the exchange of resident care information. On 07/11/13 at 3:30 p.m., the resident was observed and interviewed regarding [MEDICAL TREATMENT]. The resident had returned from [MEDICAL TREATMENT] and was seated in her wheelchair in her room. The resident stated she experienced fatigue, lack of strength, and required more assistance after [MEDICAL TREATMENT]. The resident stated the facility provided a sac lunch when she went to [MEDICAL TREATMENT]. The resident stated she did not take a facility communication report to or from [MEDICAL TREATMENT]. On 07/12/13 at 11:05 a.m., the assistant director of nurses (ADON) was interviewed regarding the resident's [MEDICAL TREATMENT]. The ADON was asked how the facility communicated with the [MEDICAL TREATMENT] provider. The ADON stated the facility did not utilize a communication sheet. The facility did not have a specific system in place to communicate with the [MEDICAL TREATMENT] providers. The ADON stated the [MEDICAL TREATMENT] facility would fax a medication change or call a report as needed. On 07/12/13 at 11:40 a.m., the administrator was interviewed regarding [MEDICAL TREATMENT] provider contracts. The administrator stated one of two [MEDICAL TREATMENT] providers did not provide contract agreements for the resident's [MEDICAL TREATMENT] care. The administrator was asked what system did the facility have in place to communicate with the [MEDICAL TREATMENT] providers.. The administrator stated there was no agreement with the [MEDICAL TREATMENT] providers for a specific system of the interchange regarding the residents. 3. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 06/24/13, documented the resident received [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday each week. The five day admission assessment, dated 06/28/13, documented the resident was moderately impaired for daily decision making and required moderate assistance with the activities of daily living. The assessment documented the resident received [MEDICAL TREATMENT]. The provider contract for the resident's [MEDICAL TREATMENT] company was requested. The staff was not able to locate the provider contract. On 07/12/13 at 11:40 a.m., the administrator was interviewed regarding [MEDICAL TREATMENT] provider contracts. The administrator stated one of two [MEDICAL TREATMENT] providers did not provide contract agreements for the resident's [MEDICAL TREATMENT] care. The administrator stated the facility did not have a contract for this resident's [MEDICAL TREATMENT] provider.

Based on observation, record review, and interview, it was determined the facility failed to provide care and services to maintain the highest practical for three (#2, #8, and #9) of ten sampled residents reviewed for highest well-being. The facility failed to have an agreement/arrangement with [MEDICAL TREATMENT] to include all aspects of the residents' [MEDICAL TREATMENT] care, including the development of the residents' care plans for resident #2, #8, and #9. The facility identified three residents who received [MEDICAL TREATMENT] services. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 12/06/12, documented the resident's cognition was intact. The assessment documented the resident required some assistance for activities of daily living (ADLs). The assessment documented the resident received [MEDICAL TREATMENT] services. The comprehensive care plan, dated 12/26/12, did not address the management of care related to [MEDICAL TREATMENT]. Documented communication from [MEDICAL TREATMENT] to the facility was provided for 06/13/13, 06/21/13, 07/12/13, and 08/08/13. The September 2013 monthly doctor's orders documented the resident went to [MEDICAL TREATMENT] three times per week. On 09/09/13 at 4:20 p.m., the resident was observed in her wheelchair in the dining room. The resident was alert and oriented and voiced no concerns about her care at the facility. The resident stated she went to [MEDICAL TREATMENT] three times per week. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A document titled chronic [MEDICAL TREATMENT] orders, dated 08/15/13, documented instructions related to the resident's weight, medications, labs, and vaccinations. The form documented the resident could receive the [MEDICATION NAME] every five years. The form documented the resident could be vaccinated but did not indicate if the resident had received the [MEDICATION NAME]. The admission assessment, dated 08/29/13, documented the resident's cognition was intact. The assessment documented the resident required assistance with ADLs. The assessment documented the resident received [MEDICAL TREATMENT] services. The monthly physician's orders [REDACTED]. The orders documented the port site should be monitored for bleeding or redness. A [MEDICAL TREATMENT] progress note, dated 09/10/13, documented a medication order and orders for nutritional supplement between meals. The comprehensive care plan, dated 09/05/13, documented the resident required a renal diet and went to [MEDICAL TREATMENT] Monday, Wednesday, and Friday. The care plan did not address the management of care related to [MEDICAL TREATMENT]. On 09/11/13 at 4:25 p.m., the resident was observed in the wheelchair in the lobby. The resident was alert and oriented and did not exhibit signs and symptoms of acute distress. The resident stated she had just returned from [MEDICAL TREATMENT]. 3. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan, dated 07/12/13, documented the resident went to [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday. The care plan did not address the management of care related to [MEDICAL TREATMENT]. The admission comprehensive assessment, dated 07/16/13, documented the resident's cognition was intact. The assessment documented the resident required assistance with ADLs. The assessment documented the resident received [MEDICAL TREATMENT] services. Documented communication from [MEDICAL TREATMENT] to the facility was provided for 07/09/13, 07/18/13, 08/08/13, 08/15/13, and 08/17/13. On 09/11/13 at 4:00 p.m., the resident was observed sitting the wheelchair in the dining room. The resident did not exhibit signs and symptoms of acute distress. On 09/11/13 at 5:30 p.m., the administrator was asked about the communication between the facility and the [MEDICAL TREATMENT] center. The administrator stated a communication form was sent with each resident going to [MEDICAL TREATMENT] at least once a week but the [MEDICAL TREATMENT] center did not return the form unless there was a change in the orders or resident's condition. The administrator was asked about the agreement between the facility and the [MEDICAL TREATMENT] center for management of care for the residents who received [MEDICAL TREATMENT] services. The administrator stated the [MEDICAL TREATMENT] center had not given the facility a written agreement related to the management of care for the residents receiving [MEDICAL TREATMENT]. The administrator stated the [MEDICAL TREATMENT] center stated they did not have a contract or agreement with any nursing home.

Based on observation, interview, and record review, it was determined the facility failed to recognize pain, implement pain management interventions, and/or monitor the effectiveness of pain management interventions for 1 (#4) of 1 sampled resident with pain during pressure ulcer treatments. This constituted actual harm for the resident. Findings: An undated pain - clinical protocol policy documented, "...staff will identify individuals who have pain or who are at risk for having pain. a. This includes a review of known [DIAGNOSES REDACTED]. b. It also includes a review for any treatments that the resident currently is receiving for pain... c. Such assessments should occur...at any time pain is suspected... staff will establish goals of pain treatment..." Resident #4 had [DIAGNOSES REDACTED]. A physician's telephone order, dated 08/27/10, documented, "...May use [MEDICATION NAME] 7.5/0.3ml in place of tab form Res. unable to tolerate tab. 1 Apply entire Contents of syringe to inside of Wrist Bid for Pain 2 (and) PRN q 4 (hours) for pain..." A facility weekly note, dated 09/02/10, documented, "...nonverbal expressions of pain...Scale: 1-10 4 - 5 ..." A nurse's note, dated 09/26/10, documented, "...Tx to ishium (sic)...area is 5.25cm x 3.50cm x 2.50cm..." A facility pain evaluation, dated 09/30/10, documented, "...Does the resident have any diagnosis(es) which would give reason to believe he/she would be in pain? Yes If yes, describe cause and origin of pain: Chronic Pain, Decubitus...Nonverbal/noncognitive signs of pain...Frowning/scowling...Moaning...Fidgeting... Irritability..." A quarterly assessment, dated 08/10/10, documented the resident experienced moderate pain less than daily. A care plan, updated 08/17/10, was signed by the director of nursing. The care plan had no documentation of the resident's pain as a problem, no goal related to pain, and no approaches/interventions for pain. On 10/11/10 at 2:35 p.m., LPN #1 stated she was ready to do the pressure ulcer care for resident #4. LPN #1 stated, "She's the worst one (pressure ulcer) we have. She moans and moves when the treatment is done. She has topical [MEDICATION NAME] gel routinely and prn." LPN #1 was asked when the resident had received the [MEDICATION NAME] pain medication. She stated, "Don't know." The LPN continued with the wound treatment. The LPN sprayed wound wash into the open pressure ulcer. The resident grimaced, moaned and flinched. The LPN used 4x4 gauze to clean the outside of the pressure ulcer. The resident grimaced, moaned, and flinched. The LPN used 4x4 gauze to clean the inside of the pressure ulcer. The resident grimaced, moaned, and flinched repeatedly until the LPN stopped cleaning the pressure ulcer. The LPN squeezed [MEDICATION NAME] gel onto a 4x4 and placed the medication and 4x4 inside the pressure ulcer. The resident grimaced, moaned, and flinched repeatedly until the LPN completed placing the gauze inside the pressure ulcer. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's routine pain medication ([MEDICATION NAME]) was scheduled to be administered twice daily at 9 a.m. and 5 p.m. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The individual patient's narcotic record for [MEDICATION NAME] gel documented that the last dose received by the resident was the routine dose administered at 9 a.m. The resident had not received any prn doses. The resident exhibited multiple episodes of grimacing, moaning, and moving/flinching while the pressure ulcer treatment was being performed. On 10/11/10 at 3:30 p.m., LPN #1 was asked what she did to decrease the pain during wound care for resident #4. She stated that she cleaned very easy and gentle. LPN #1 was asked if the resident was given pain medication before the wound treatment. She stated, "I usually ask the CMA to give pain medication before the wound care. I should have ask her (CMA). I didn't today. I didn't know when I was going to do wound care." LPN #1 was asked if the resident grimaced, moaned, and moved/flinched every time pressure ulcer care was performed. She stated, "Pretty much every time." LPN #1 was asked how many days she had performed the resident's pressure ulcer care. She stated she had done the pressure ulcer care Saturday, Sunday, and today, Monday. LPN #1 was asked if the resident had grimaced, moaned, and moved/flinched each of the 3 days. LPN #1 stated, "Yes." The individual patient's narcotic record for [MEDICATION NAME] gel documented the resident had not received any prn doses of [MEDICATION NAME] on Saturday 10/09/10 or Sunday 10/10/10. LPN #1 was asked if the doctor had been notified regarding the resident's pain with pressure ulcer care. She stated, "No. I told the RN." LPN #1 was asked if she (LPN #1) could call the doctor. She stated, "Yes, but I couldn't get a hard script anyway." On 10/11/10 at 5:35 p.m., the DON was asked what the policy was for pain medication related to pressure ulcer care. She stated, "Give 1 hour prior to treatment." The DON was asked if the pain medication was being given 1 hour before the pressure ulcer treatment. She stated, "As far as I know. I would have to look at the treatment sheet." The DON was asked when pressure ulcer treatments were done. She stated, "Usually on 7-3 shift. The nurse knows when she is going to do the treatment and goes and tells the CMA to give med." The DON was asked how she monitored to see that the pain med is being given 1 hour before the treatment. She stated, "By asking. They're saying they're giving it before they (treatments) are being done." The DON was told of the pressure ulcer treatment observation and the resident's response. The DON was asked if she had observed the resident while a pressure ulcer treatment was performed. She stated, "I did the treatment on 2nd and 3rd shift. I think she was OK. Wasn't moaning."

Based on observation and interview, it was determined the facility failed to assure pressure ulcer treatments were conducted in a manner to prevent infection and cross contamination for 1 (#4) of 1 sampled resident. Findings: An undated facility policy titled Wound/Pressure Ulcer Care, documented, "...Clean technique will be used during all wound care, as well as following universal precautions...The Director of Nursing shall be made aware of all skin conditions and ensure treatments are carried out as prescribed to enhance healing." A physician's telephone order, dated 10/08/10, documented, "...Cleanse wound with wound cleanser - pat dry. Paint [MEDICATION NAME] Gel to wound base - apply gauze & cover...BID." Resident #4 had [DIAGNOSES REDACTED]. On 10/11/10 at 2:35 p.m., LPN #1 was observed performing a pressure ulcer treatment for [REDACTED]. LPN #1 had long hair that was hanging over her shoulder down the front of her uniform. The hair hung down to approximately her clavicle when she was upright. When she was bent forward, the hair was swinging freely over the work area. She washed her hands, set a flat metal pan on top of the treatment cart, and placed a sealed package of wound care supplies, a tube of medication, and a bottle of wound cleanser spray on the pan. She carried the pan into the resident's room and set the pan on the overbed table. She opened the package of wound care supplies and placed the tube of medication on the package next to the gauze. She laid extra gloves on the overbed table. She did not clean or sanitize the overbed table. She donned a pair of gloves, stepped over to the resident's bed, leaned over the resident, moved the blanket and sheet off the resident, reached down and while holding to the underpad at the resident's hip area, pulled up on the pad and turned the resident onto her right side. She ran her gloved fingers around the edges of the pressure ulcer dressing on the resident's left buttock. The LPN did not remove the contaminated gloves. The LPN then used both hands, reached up to the resident's face and repositioned the oxygen nasal canula into the resident's nares. She then removed the contaminated dressing and reached to the inside of the pressure ulcer to remove all dressings. The pressure ulcer had a foul odor and thick greenish slough. The LPN held the contaminated dressing in one gloved hand and used the other gloved hand to deglove and fold the contaminated dressing into the first glove. She carried the contaminated glove with the dressing to the trash can underneath the bathroom sink. She removed the other glove and washed her hands. She left the room, opened and looked in the drawers of the treatment cart, walked down the hall and returned with a lab specimen bag. She washed her hands and picked up and put on a pair of gloves from the overbed table. She picked up the wound cleanser spray and a 4x4 and sprayed the cleanser directly into and around the pressure ulcer. She used the 4x4 and rubbed the 4x4 around the inner edge and outside of the wound. She rubbed back and forth around the inner edge and outside of the pressure ulcer. She placed the contaminated 4x4 into the lab specimen bag. The bag was small and she touched the outside of the bag while placing the contaminated gauze inside the bag. The LPN's hair was over her shoulder and hanging freely over the resident. The LPN picked up another 4x4, sprayed the cleanser inside the pressure ulcer, cleaned around the inside of the pressure ulcer reaching into the pressure ulcer and cleaning. She placed the 4x4 in the lab specimen bag and touched the outside of the bag with the contaminated gloves and 4x4. She picked up another 4x4 and cleaned around the inside of the pressure ulcer, rubbing the areas of slough. She placed the contaminated 4x4 into the lab specimen bag and touched the outside of the bag with the contaminated gloves and 4x4. The LPN's hair was over her shoulder and hanging freely over the resident. The LPN did not wash her hands or change her gloves. She picked up the tube of [MEDICATION NAME] gel, removed the lid, and squeezed the medication onto a 4x4. She picked up the 4x4 and placed the medication and 4x4 into the pressure ulcer. She picked up the outer dressing and placed it over the pressure ulcer. She secured the clean dressing in place by rubbing across the dressing and around the edges with her contaminated gloved hands. The LPN's hair was over her shoulder and hanging freely over the resident. She did not wash her hands or change her gloves. She touched the resident's sheet and blanket, picked up the wound wash bottle and set it onto the metal pan. She removed her right glove, picked up the tube of medication with her left hand and placed the lid back on the tube with her right hand. She removed her left glove. She wadded up the papers from the metal pan and overbed table and the contaminated gloves. She attempted to stuff the papers and gloves into the lab specimen bag. They would not fit. Her hands were bare. She carried the lab specimen bag containing the contaminated 4x4s, the wadded paper, and the contaminated gloves to the bath room sink. She reached into the bathroom trash can and picked up the contaminated gloves and dressing she had removed from the wound. She carried the contaminated items and placed them in the trash bag on the side of the treatment cart. She washed her hands, returned to the overbed table, and picked up the contaminated metal pan containing the spray cleanser and the tube of medication. She carried the pan and set it on top of the treatment cart. She opened a drawer on the treatment cart and touched several items inside the cart. She picked up a Sani cloth and wiped the top of the pan 2 times and the bottom of the pan 2 times. She did not clean the complete surface of the top, bottom, and sides of the pan. She placed the pan inside the treatment cart. She used the same Sani cloth and wiped the spray bottle and the medication tube and placed them in the treatment cart. She used sanitizer on her hands. She did not clean or sanitize the overbed table or the top of the treatment cart. On 10/11/10 at 3:30 p.m., LPN #1 was asked how long she had been working at the facility. She stated since August 2010. LPN #1 was asked what orientation she had to the facility. She stated, "None. I was on the floor. It was really bad." LPN #1 was asked if she had been inserviced on pressure ulcer care. She stated, "No." LPN #1 was asked if someone had observed her for pressure ulcer dressing change proficiency. She stated, "No." LPN #1 was asked if she cleaned the metal pan sufficiently after the pressure ulcer care. She stated, "I thought so." LPN #1 was asked if she should have touched the resident's oxygen nasal canula with her gloved hands after touching the resident's skin around the pressure ulcer dressing and the bed sheet, underpad, and blanket. She stated, "No. Should not have touched the canula." LPN #1 was asked if she always used lab specimen bags for contaminated dressings. She stated, "No. There are usually red bags on the cart. There were no red bags on the cart today." LPN #1 was asked where her hair was while she performed wound care. She stated, "Hanging over my shoulder." LPN #1 was asked was her hair hanging over the pressure ulcer. She stated, "Yes". She was asked if her hair should have been hanging over the wound. She stated, "No." On 10/11/10 at 5:35 p.m., the DON was asked about resident #4's pressure ulcer. She stated, "I think it's gotten worse. Started to tunnel."