Every finding on record at Callaway Nursing Home

Based on record review and interview, the facility failed to follow physician orders for administering medication for 1 (#2) of 4 sampled residents reviewed for following physician orders. The administrator identified 51 residents resided in the facility. Findings: Resident #2's hospital discharge papers, dated 08/21/25, showed the resident was diagnosed and treated for bacterial pneumonia during the hospital stay. A health status note, dated 08/21/25 6:24 p.m., showed Resident #2 was re-admitted to the facility on [DATE].The hospital discharge medication list, dated 08/21/25, showed the resident should had received the following new medications which had not been added to the resident's physician orders upon readmission to the facility: a. Albuterol (bronchodilator) 0.083 % Inhalation Solution, 3 milliliters HHN every 4 hours as needed;b. bumetanide (diuretic) AvPak, 0.5 mg orally twice daily;c. Cobenfy (antipsychotic) 125 mg-30 mg, one capsule orally twice daily;d. digoxin (used to strengthen the heart) 0.125 mg, 0.25 mg daily at noon;e. divalproex Sodium (anticonvulsant) AvPak 500 mg, extended release, 1500 mg orally daily;f. hydrochlorothiazide (diuretic) 25 mg, 25 mg orally daily;g. Klor-Con (potassium supplement) 20 meq, extended release, 40 meq orally twice daily;h. lacosamide (anticonvulsant) 200 mg, 200 mg orally twice daily;i. lactobacillus (bacteria to aide in digestion) 0.05 mg-0.05 mg, one tablet orally twice daily;j. Levalbuterol (bronchodilator) 1.25 mg, 1.25 mg HHN twice daily;k. magnesium Glycinate (magnesium supplement) 100 mg, 400 mg orally twice daily;l. midodrine HCL (antihypotensive) 5 mg, 2.5 mg orally three times daily;m. Miralax (laxative) 17 gram/1 dose oral powder for solution, orally twice daily;n. tamsulosin HCL (treatment of benign prostatic hyperplasia) 0.4 mg, 0.4 mg orally at bedtime;o. trospium Chloride (treatment of overactive bladder) 20 mg, 20 mg orally daily;p. clozapine (antipsychotic) had been changed from 50 mg, 3 tablets at bedtime to clozapine 25 mg at bedtime; andq. risperidone (antipsychotic) was changed from 3 mg, 2 tablets daily to risperidone 1 mg, give 3 mg daily.A health status note, dated 08/23/25 2:17 p.m., showed Resident #2's physician gave an order for the resident to be transferred to the emergency room due to respiratory concerns. On 10/27/25 at 1:10 p.m., the DON stated the medication additions to Resident #2's physician ordered medication list should have been added and given to the resident. The DON stated none of the above listed medications had been given as ordered by the physician upon Resident #2's readmission to the facility from the hospital on [DATE] until their discharge to the hospital again on 8/23/25.

On 05/02/25 at 10:52 a.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to effectively assess, monitor, and intervene for Resident #1's failure to have a bowel movement which likely caused the resident to be admitted to the hospital with a small bowel obstruction. On 05/02/25 at 11:14 a.m., the receiver, ADON and MDS coordinator were notified of the immediate jeopardy and provided the immediate jeopardy template. On 05/05/25 at 7:05 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Plan Of Removal 5/02/2025: 1. Systemic changes implemented: a. All residents with no bowel movement within the previous 3 days were immediately physically assessed and educated on the risks and benefits of proper hydration or lack of same for daily bowel movements. b. Physician notified and orders received for medication if applicable. c. Medications administered, as ordered. d. Continue to assess affected resident every 2 hours until bowel movement occurs. If no bowel movement within 24 hours of first medication administration, notify physician and send to emergency room for further evaluation. e. If bowel movement occurs within 72 hours, nurse will document bowel sounds and bowel movements, and update physician. 2. Process/Systems involved: a. Policy for Bowel Movement Monitoring was implemented on 5/2/2025. A copy of the policy is attached to this document as Exhibit A. b. CNAs will notify Charge Nurse if any resident does not have a bowel movement during their shift. Charge Nurse will document same on 24-hour report. Resident will be encouraged to hydrate more by Charge Nurse and CNAs. Charge Nurse will educate resident on importance of proper hydration and bowel movement. c. Charge Nurse will review PCC/POC dashboard at shift change and identify any residents who has not had a bowel movement within the previous 3 days. Charge Nurse will continue to assess affected resident every 2 hours until bowel movement occurs. If no bowel movement occurs within 24 hours of first medication administration notify physician and send to emergency room for further evaluation. d. PCC/POC dashboard to be discussed daily at Stand-up Meeting. DON and/or ADON will review PCC/POC Dashboard with Charge Nurse daily and track documentation for potential bowel issues. 3. Factors involved: POLICY - new policy attached as Exhibit 'A' PEOPLE: All Nurses, CMAs and CNAs were in serviced on new Bowel Movement Policy 4. Actions taken/Planned to be taken: a. All Nurses, CMAs, and CNAs were in serviced or will be in serviced On reporting process for residents with no bowel movements in previous 24 hours Staff in-serviced during shift change at 2 p.m. on 5/2/25, along with all agency staff in-serviced and acknowledged utilizing agency's communication app by 6:30 pm on 5/2/25. b. CNAs will notify Charge Nurse if any resident does not have a bowel movement during their shift. Charge Nurse will document same on 24-hour report. Resident will be encouraged to hydrate more by Charge Nurse and CNAs. Charge Nurse will educate resident on importance of proper hydration and bowel movement. c. Charge Nurse will review PCC/POC dashboard at shift change and identify any residents who has not had a bowel movement within the previous 3 days. Charge Nurse will continue to assess affected resident every 2 hours until bowel movement occurs. If no bowel movement occurs within 24 hours of first medication administration notify physician and send to emergency room for further evaluation. d. PCC/POC dashboard to be discussed daily at Stand-up Meeting. DON and/or ADON will review PCC/POC Dashboard with Charge Nurse daily and track documentation for potential bowel issues. e. Information to be reviewed during QAPI [quality assurance and performance improvement] meeting. 5. Date Action Taken 5/2/2025 6. Staff Education plan: Staff in-serviced on Bowel Movement Policy, reporting to Charge Nurses any resident who has had no Bowel Movement in their shift, and encouraging residents to hydrate properly. Nurses were in-serviced on educating residents on risks and benefits of proper hydration and bowel movements. All nursing staff in-serviced on proper documentation of bowel movements. Staff in-serviced during shift change at 2pm on 5/2/25, along with all agency staff in-serviced and acknowledged utilizing agency's communication app by 6:30 pm on 5/2/25. 7. Mode of education: Person to person in-service, as well as written materials available for review. 8. Monitoring of implemented actions: PCC/POC Dashboard will be monitored daily by Corporate Compliance Officer, Administrator, Director of Nurses and/or Assistant Director of Nurses to ensure Adherence to Bowel Movement Policy is occurring. PCC progress notes will be monitored daily by the Corporate Compliance Officer, Director of Nurses and/or Assistant Director. On 05/05/25 after interviews with facility staff and review of in-services, the immediacy was lifted, effective 05/02/25 at 6:30 p.m. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to assess, monitor, and intervene for a resident with no bowel movements to prevent a bowel obstruction for 1 (#1) of 3 sampled residents reviewed for bowel movements. The receiver reported 43 residents resided in the facility. Findings: A care plan, dated 07/31/24, showed Resident #1 had diagnoses of constipation. The care plan showed to check bowel sounds if no bowel movement for three days and notify physician for any further interventions. An annual assessment, dated 04/01/25, showed Resident #1's cognition was moderately impaired with a BIMS score of 09. The assessment showed the resident was always incontinent of bowel and required assistance from staff for activities of daily living. A bowel elimination record, dated 04/02/25 through 04/30/25, showed Resident #1 had no bowel movement on 04/22/25, 04/23/25, 04/24/25, 04/25/25, and 04/26/25. The record showed the resident had a medium sized bowel movement on 04/27/25. A progress note, dated 04/28/25 at 2:44 a.m., showed Resident #1 stated they felt nauseous. The note showed the resident had no further vomiting episodes. A progress note, dated 04/28/25 at 9:37 a.m., showed Resident #1 had vomited times two, a moderate amount, and chunks of food. The note showed Zofran (anti-nausea medication) was given and the nurse practitioner was notified. A progress note, dated 04/28/25 at 10:13 a.m., showed vomiting continued at that time. A progress note, dated 04/28/25 at 10:16 a.m., showed Resident #1's blood pressure was 128/100 and pulse was 110. The progress note showed complete blood count (CBC), urinalysis (UA), and comprehensive metabolic panel (CMP) was ordered by the nurse practitioner. A progress note, dated 04/28/25 at 1:10 p.m., showed a nurse aide reported to nurse Resident #1 was seen putting their finger down their throat making themselves vomit. A bowel elimination record, dated 04/28/25 and 04/29/25, showed no bowel movement. A progress note, dated 04/29/25 at 12:42 p.m., showed Resident #1 was transferred to the emergency room for self harm, altered mental status, and low blood pressure. A computed tomography (CT) of abdomen and pelvis without contrast exam, dated 04/29/25, showed marked fluid distention/dilation of the stomach and small bowel to rough area of transition in the anterior/central abdomen, suggestive of high-grade bowel obstruction. The exam showed a recommendation for surgical evaluation. An admission record/face sheet, dated 05/02/25, showed diagnoses which included cerebral palsy and intellectual disabilities. On 05/01/25 at 12:15 p.m., family member #1 reported family member #2 had been to the facility on [DATE] and Resident #1 would not eat and complained of their stomach hurting. On 05/01/25 at 2:45 p.m. CNA #1 reported Resident #1 usually had a hard time having bowel movements. CNA #1 reported if a resident asked for medication for constipation they would inform the nurse. CNA #1 also reported they should report no bowel movements for three days to the nurse. On 05/01/25 at 2:50 p.m., CMA #1 reported if the CNA reported a resident was having issues with constipation or if the resident asked for medication for constipation, and they had an order, it would be administered. CMA #1 reported no bowel movement for two days would warrant a need for medication. CMA #1 reported not having access to the electronic medical record to see residents' bowel movements. On 05/01/25 at 3:00 p.m., the ADON reported the electronic medical record should notify all staff if a resident had not had a bowel movement for three days. The ADON reported all staff were responsible for looking for this notification in the electronic medical record. The ADON reported the nurse should notify the CMA if the resident had no bowel movement for three days to give a PRN medication for constipation or contact the physician for an order. On 05/01/25 at 3:15 p.m., LPN #1 reported the electronic medical record notified the CNAs if the resident had not had a bowel movement for three days. LPN #1 reported an assessment should be done and bowel sounds listened if a resident was not having bowel movements. LPN #1 reported nurses were not alerted by the electronic medical record if residents had no bowel movements for three days unless a CNA reported it to them. On 05/01/25 at 3:45 p.m., the MDS coordinator reported a nurse assessment should have been completed for Resident #1 not having a bowel movement for five days and having vomiting. The MDS coordinator reported vomiting with no bowel movements could have been an indication of a small bowel obstruction. On 05/01/25 at 4:00 p.m., the ADON reported the facility had no policy for assessing and monitoring bowel movements. The ADON reported the start of the fourth day of no bowel movements would be when staff should start to intervene. The ADON reported Resident #1 should have had a nursing assessment done with their vomiting. The ADON reported no nursing assessment had been documented in Resident #1's record related to the vomiting or no bowel movement. On 05/02/25 at 9:46 a.m., family member #2 reported Resident #1 had been complaining of stomach pain since 04/27/25. Family Member #2 reported the nurse had been informed on 04/27/25 by the family the resident was complaining their stomach was hurting and would not eat. Family member #2 reported going to the facility on [DATE] around midnight because the facility had reported the resident was having behaviors of making self vomit and the physician had ordered physical restraints and a referral for an inpatient psych evaluation. Family Member #2 reported the resident was sitting by the nurses station and had been crying, was tired and asking to go to bed. Family Member #2 reported the resident had been admitted to the hospital with a small bowel obstruction and had not had surgical intervention at this time.

Based on record review and interview, the facility failed to ensure a resident was not physically restrained for 1 (#1) of 1 sampled resident reviewed for physical restraints. The administrator reported 43 residents resided in the facility. Findings: An undated facility policy titled Use of Restraints showed unless there was an actual emergency, a physical restraint would not be initiated until the need for such a restraint was discussed thoroughly with the resident and/or representative and written consent is obtained. The policy showed the resident, or resident representative has the right to refuse the use of a restraint. An annual assessment, dated 04/01/25, showed Resident #1's cognition was moderately impaired with a BIMS score of 09. The assessment showed limited range of motion to one side of upper extremity and staff asssistance required with activities of daily living. A progress note, dated 04/28/25 at 5:12 p.m., showed Resident #1 was sitting in their room and placed four fingers down their throat which caused them to vomit. The note showed while gagging, the resident continued to put their hand down their throat six times. A progress note, dated 04/28/25 at 5:29 p.m., showed the nurse practitioner ordered to send Resident #1 to an inpatient psych facility and for a wrist restraint. A progress note, dated 04/28/25 at 7:15 p.m., showed Resident #1 was sitting in front of the nurses station under supervision due to self harm. The note showed the resident had been screaming and yelling wanting to got back to their room. A progress note, dated 04/28/25 at 7:52 p.m., showed the restraint was removed and the nurse would continue to monitor the resident's behavior. A progress note, dated 04/28/25 at 8:08 p.m., showed the restraint was put back on because the resident continued to cause self harm and hitting/cussing staff members. A progress note, dated 04/28/25 at 8:23 p.m., showed Resident #1 was up in their wheelchair at the nurses station yelling and cussing staff members, wanting to go to their room, and needing a drink every minute. The note showed the resident stated they promised to not put their fingers down their throat again. A progress note, dated 04/28/25 at 8:38 p.m., showed the Resident #1 remained in a restraint due to multiple failed attempts to remove due to the resident causing harm to self and staff members. A progress note, dated 04/28/25 at 9:51 p.m., showed Resident #1 had the restraint removed at 9:30 p.m. and the resident promised not to cause harm to self or others. The note showed the resident was put to bed at approximately 9:44 p.m. and about seven minutes later the resident put their fingers down their throat which caused them to vomit all over themselves. The note showed the restraint was placed back on the resident. A progress note, dated 04/29/25 at 12:13 a.m., showed the restraint was removed and family present. The note showed shortly after the family member left the facility the resident put their hand down their throat and made themselves throw up. The note showed the restraint was put back on. An admission record/face sheet, dated 05/02/25, showed diagnoses which included cerebral palsy and intellectual disabilities. The admission record/face sheet showed family member #1 was the resident's responsible party/POA and emergency contact #1. On 05/01/25 at 1:56 p.m., the ADON reported the charge nurses working at the time the wrist restraint was used had been put on suspension pending an investigation. On 05/01/25 at 2:55 p.m., the MDS coordinator reported no restraints were to be used in the facility for any reason. The MDS coordinator reported not being aware what was used as a restraint due to the facility did not have any type of restraint in house. On 05/01/25 at 3:00 p.m., the administrator reported an investigation was ongoing related to the use of the restraints, staff involved had been suspended, and all staff had been in-serviced related to facility policy of no restraints. On 05/02/25 at 9:46 a.m., family member #2 reported when they arrived to the facility on [DATE] around midnight, the resident was sitting by the nurses station and the nurse was observed to remove something tied around the resident's right wrist. Family Member #2 reported the resident did not have use of their left arm. Family Member #2 reported the resident appeared to have been crying and was tired, and kept saying they wanted to go to sleep, but staff had tied their arm up and would not let their arm out. Family Member #2 reported the resident had been complaining of stomach pain since 04/27/25 and it was apparent the restraint caused them mental distress.

Based on record review and interview, the facility failed to ensure a resident's representative was notified of physical restraint use for 1 (#1) of 3 sampled residents reviewed for change in condition. The administrator reported 43 residents resided in the facility. Findings: An undated facility policy titled Notification of Changes showed the facility must immediately inform the resident representative when there was a significant change in the resident's physical, mental or psychosocial status. The policy showed the facility must immediately inform the resident's representative when a need to alter treatment significantly. An annual assessment, dated 04/01/25, showed Resident #1's cognition was moderately impaired with a BIMS score of 09. A progress note, dated 04/28/25 at 5:29 p.m., showed the nurse practitioner ordered to send Resident #1 to an inpatient psych facility and ordered a wrist restraint. A progress note, dated 04/28/25 at 6:31 p.m., showed Resident #1's family was notified of the resident's behaviors, order to send to an inpatient psych facility, and new order for a wrist restraint. An admission record/face sheet, dated 05/02/25, showed diagnoses which included cerebral palsy and intellectual disabilities. The admission record/face sheet showed family member #1 was the resident's responsible party/POA and emergency contact #1. On 05/01/25 at 12:15 p.m., family member #1 reported they had not been notified by the facility about the behaviors Resident #1 was having, the order for the wrist restraint, or the referral for the inpatient psych facility. On 05/01/25 at 1:56 p.m., the ADON reported the resident's representative/POA was not notified by the charge nurse related to the resident's behaviors, the order for the wrist restraint and the referral for inpatient psych facility. The ADON reported another family member was contacted, but not the POA. The ADON reported the resident's representative/POA should have been contacted.

Based on record review and interview, the facility failed to have a registered nurse to serve as full time DON. The administrator reported 44 residents resided in the facility. Findings: An undated facility policy titled Registered Nurse showed the facility would ensure a registered nurse was available for supervision in the facility. The policy showed the facility must designate a registered nurse to serve as the director of nursing on a full-time basis. On 04/21/25 at 2:30 p.m., during the entrance conference, the ADON reported the facility did not currently have a DON. The ADON reported the facility did not have an RN acting in the capacity of the DON. On 04/24/25 at 9:20 a.m., the administrator reported the DON resigned the previous week. On 04/28/25 at 2:35 p.m., the administrator reported the previous DON last worked on 04/14/25.

Based on record review and interview, the facility failed to inform and provide written information to the resident or their representative regarding an advance directive for 3 (#9, 18, and #38) of 3 sampled residents reviewed for advance directives. The administrator reported 44 residents resided in the facility. Findings: The facility did not provide an advance directive policy. 1. A physician order for Resident #9, dated 01/23/25, showed the resident was a full code status. A MDS assessment for Resident #9, dated 02/09/25, showed the resident was cognitively intact with a BIMS score of 15. The assessment showed the resident had diagnoses which include congestive heart failure, hypertension, renal insufficiency, diabetes mellitus, depression, and schizophrenia. A care plan for Resident #9, dated 02/09/25, showed the resident was a full code status and staff would follow the full code protocol. A review of Resident #9's hard chart and electronic medical record showed no documentation related to advance directive information. 2. A MDS assessment for Resident #18, dated 01/15/25, showed the resident was severely impaired of cognition with a BIMS score of 04. A physician order for Resident #18, dated 01/23/25, showed the resident was a full code status. A review of Resident #18's hard chart and electronic medical record showed no documentation related to advance directive information. 3. A physician order for Resident #38, dated 05/17/24, showed the resident was a full code status. A MDS assessment for Resident #38, dated 02/09/25, showed the resident was cognitively intact with a BIMS score of 15. The assessment showed the resident had diagnoses which included depression, type 2 diabetes mellitus, hypertension, schizophrenia, anxiety, bipolar disorder, and history of traumatic brain injury. A care plan for Resident #38, dated 02/10/25, showed the resident chose to be a full code status and staff would follow full code protocol. A review of Resident #38's hard chart and electronic medical record showed no documentation related to advance directive information. On 04/23/25 at 2:09 p.m., the BOM reported the facility did not address advance directives with newly admitted residents or their representative. The BOM reported they did not have anything in place to offer information or education to current residents. The BOM reported they had a section in the admission packet that addressed resident rights, but no specific information related to advance directives. 41873

Based on record review and interview, the facility failed to: a. perform weekly blood pressure checks as ordered for 1 (#32); and b. follow hold parameters on blood pressure medication for 1 (#31) of 2 sampled residents reviewed for following physician orders. The administrator reported 44 residents resided in the facility. Findings: The ADON reported there was no policy for following physician orders or medication administration and hold parameters. 1. A physician order for Resident #32, dated 05/30/24, showed to take and record the resident's blood pressure weekly on Mondays. A progress note for Resident #32, dated 11/20/24 at 1:52 p.m., showed the resident went to have surgery on their right eye. The note showed the resident's blood pressure was elevated and they were unable to do the surgery. The note showed the resident was sent to the emergency room for evaluation due to elevated blood pressure. A progress note for Resident #32, dated 11/20/24 at 5:54 p.m., showed the resident returned to the facility accompanied by a staff member. The note showed the resident had a new order for Prinivil (a blood pressure medication) 10 mg by mouth daily, and to take the resident's blood pressure twice daily and record for the primary care physician. A MDS assessment for Resident #32, dated 03/23/25, showed the resident had diagnoses which include type 2 diabetes mellitus, mood disorder, dementia, psychosis, and benign intracranial hypertension (high blood pressure). The assessment showed the resident was cognitively intact with a BIMS score of 15. A care plan for Resident #32, dated 04/22/25, showed the resident had hypertension. The care plan showed to administer medications as ordered and monitor for effectiveness and side effects. The care plan showed to monitor and record the blood pressure as ordered and to notify the physician of significant abnormalities. On 04/24/25 at 11:40 a.m., the MDS coordinator reported there was a gap in documentation from June 2024 to September 2024 for blood pressure monitoring, and then another gap from September 2024 to November 2024. The MDS coordinator reported it was about that time that the facility switched over to an electronic medical record. The MDS coordinator reported they were unable to find any documentation to show they were checking the resident's blood pressure weekly as ordered. 41873 2. A physician's order for Resident #31, dated 06/06/24, showed Carvedilol (a blood pressure medication) 3.125 mg, give one tablet orally two times a day for hypertension and hold if systolic blood pressure is less than 120. A significant change assessment for Resident #31, dated 03/10/25, showed Resident #31's cognition was moderately impaired with a BIMS score of 09. The assessment showed the resident had a diagnosis of hypertension. A medication administration record for Resident #31, dated 04/01/25 through 04/30/25, showed Resident #31's systolic blood pressure readings were less than 120 and Carvedilol was administered on: a. 04/01/25 at 7:00 a.m. - 114/72, b. 04/02/25 at 7:00 a.m. - 119/67, c. 04/02/25 at 6:00 p.m. - 114/69, d. 04/04/25 at 6:00 p.m. - 118/77, e. 04/06/25 at 6:00 p.m. - 115/68, f. 04/09/25 at 7:00 a.m. - 118/83, g. 04/13/25 at 7:00 a.m. - 100/77, h. 04/14/25 at 6:00 p.m. - 114/77, i. 04/17/25 at 6:00 p.m. - 117/75, j. 04/20/25 at 6:00 p.m. - 114/65, k. 04/25/25 at 7:00 a.m. - 118/70, l. 04/25/25 at 6:00 p.m. - 107/70, m. 04/26/25 at 7:00 a.m. - 113/66, n. 04/27/25 at 7:00 a.m. - 117/65, and o. 04/28/25 at 7:00 a.m. - 117/63. On 04/28/25 at 2:31 p.m., CMA #1 reported the dose of blood pressure medication (Carvedilol 3.125 mg) given by CMA #2 this morning should not have been administered since the blood pressure reading of 117/63 was not within the written parameters. On 04/28/25 at 2:32 p.m., the ADON reviewed Resident #31's medication administration record for April 2025 and reported the medication Carvedilol 3.125 mg should have been held and not given for all the systolic blood pressure readings under 120. The ADON reported that was not a normal parameter for blood pressure readings and will get a parameter clarification from the doctor.

Based on record review and interview, the facility failed to provide sufficient staff to ensure the highest practicable well-being of each resident. The administrator reported 44 residents resided in the facility. Findings: The PBJ Staffing Data Report, dated October 2024 through December 2024 showed no RN hours on 10/09, 10/10, 10/11, 10/14, 10/15, 10/16, 10/17, 10/18, 10/21, 10/22, 10/23, 10/24, 10/25, 10/26, 10/28, 10/29, 10/30, 10/31, 11/01, 11/02, 11/03, 11/04, 11/05, 11/06, 11/07, 11/08, 11/09, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, 11/29, 11/30, 12/01, 12/02, 12/03, 12/04, 12/05, 12/06, 12/07, 12/08, 12/09, 12/10, 12/11, 12/12, 12/13, 12/14, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, and 12/31. The PBJ Staffing Data Report dated October through December 2024, showed the facility failed to have licensed nursing coverage 24 hours/day on 10/11, 10/13, 10/20, 10/24, 10/25, 10/26, 10/28, 10/29, 10/30, 10/31, 11/01, 11/02, 11/03, 11/04, 11/05, 11/06, 11/07, 11/08, 11/09, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, 11/29, 11/30, 12/01, 12/02, 12/03, 12/04, 12/05, 12/06, 12/07, 12/08, 12/09, 12/10, 12/11, 12/12, 12/13, 12/14, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, and 12/31. The Quality of Care Monthly Report, dated January 2025, showed 15 day shifts, 14 evening shifts, and 10 night shifts with insufficient direct care staff for the reported resident census. The Quality of Care Monthly Report, dated February 2025, showed 21 day shifts, 7 evening shifts, and 10 night shifts with insufficient direct care staff for the reported resident census. The Quality of Care Monthly Report, dated March 2025, showed 10 day shifts, 4 evening shifts, and 15 night shifts with insufficient direct care staff for the reported resident census. On 04/24/25 at 9:10 a.m., CNA #1 reported they were agency staff and reported the aides did a lot of the cleaning and housekeeping tasks. CNA #1 reported housekeeping staff were usually in the building Monday through Friday, but the aides did not always know what hours housekeeping would be in the building, and they were also agency. CNA #1 reported the aides emptied trash, cleaned bathrooms, and tried to sweep the floors when they had time. CNA #1 stated sometimes they had to stop cleaning to take care of a resident. CNA #1 reported when the resident census was high enough, they had more aides, but occasionally there was only one CNA per hall if there were call-ins. On 04/24/25 at 9:20 a.m., the administrator was asked to provide documentation to show RN coverage. The administrator reported the facility used almost all agency staff and currently all of their CNAs, CMAs, and licensed nurses were agency staff. The administrator reported their agency staff hours were turned in and included in their staffing reports. The administrator reported the DON had resigned and last worked on 04/14/25. The administrator reported the ADON was full-time core staff and the MDS coordinator was shared with a sister facility. On 04/28/25 at 2:35 p.m., the administrator reported they had better RN coverage when the DON was still employed and named four RNs who signed up to work as needed. The administrator reported one of the RNs had recently dropped down to PRN only and it varied from week to week on when the RNs would cover shifts. The administrator reported they had a schedule out for the RNs to sign up, but they did not have any core staff RNs who covered specific shifts each week.

Based on record review and interview, the facility failed to ensure the physician provided a rationale when not agreeing with a gradual dose reduction recommendations made by the pharmacist for 4 (#3, 18, 21, and #31) of 5 sampled residents reviewed for unnecessary medications. The administrator reported 44 residents resided in the facility. Findings: An undated facility policy titled Gradual Dose Reduction showed a gradual dose reduction may be considered clinically contraindicated if the physician had documented the clinical rationale. 1. A care plan, dated 08/16/24, showed Resident #3 took tramadol (an opiate analgesic), Remeron (an antidepressant), Cymbalta/duloxetine (an antidepressant), and Abilify/aripiprazole (an antipsychotic) daily for diagnoses of pain and depression. The care plan showed to consult with pharmacy and the physician to consider dosage reduction when clinically appropriate. A pharmacist consult, dated 12/16/24, showed a recommendation for a trial dose reduction for one of the following medications: Abilify, Cymbalta, and Remeron. The pharmacist consult showed the physician disagreed with the recommendation on 02/28/25 and no rationale was provided by the physician for the reason. An annual assessment, dated 02/27/25, showed Resident #3's cognition was severly impaired with a BIMS score of 03. The assessment showed diagnosis of depression and usage of antipsychotic and antidepressant medications. 2. A care plan, dated 11/08/24, showed Resident #18 took Lexapro (an antidepressant) and Zypreza/olanzapine (an antipsychotic) daily for diagnoses of depression. The care plan showed to consult with pharmacy and the physician to consider dosage reduction when clinically appropriate. A pharmacist consult, dated 12/16/24, showed a recommendation for a trial dose reduction for the following meds: Lexapro 10 mg and Zyprexa 2.5 mg. The pharmacist consult showed on 02/28/25 the physician disagreed with the recommendation and no rationale was provided. An annual assessment, dated 01/15/25, showed Resident #18's cognition was severly impaired with a BIMS score of 04. The assessment showed diagnosis which included schizophrenia. 3. A care plan, dated 08/14/24, showed Resident #21 took Rexulti (an antipsychotic), trazodone (an antidepressant), Trintelix (an antidepressant), and Lamictal/lamotrigine (an anticonvulsant) daily for diagnoses of mood disorder, depression, and seizure disorder. The care plan showed to consult with pharmacy and the physician to consider dosage reduction when clinically appropriate. A pharmacist consult, dated 12/16/24, showed a recommendation for a trial dose reduction for the following meds: clonidine (blood pressure medication) 0.2 mg, Rexulti 2 mg, Trintellix 20 mg, Lamictal 150 mg, and riluzole (a benzothiazole) 50 mg. The pharmacist consult showed on 02/28/25 the physician disagreed with the recommendation and no rationale was provided. A quarterly assessment, dated 03/08/25, showed Resident #21's cognition was severly impaired with a BIMS score of 03. The assessment showed diagnoses which included Alzheimer's disease and depression. 4. A care plan, dated 08/05/24, showed Resident #31 took clozapine, Lexapro, Norco (a pain medication), Keppra (an anticonvulsant), lamotrigine, and lorazepam daily for diagnoses of schizophrenia, depression, pain, seizure disorder and anxiety. The care plan showed to consult with pharmacy and the physician to consider dosage reduction when clinically appropriate. A pharmacist's consult, dated 12/16/24, showed Resident #31 continued on the following meds: clozapine 100 mg, escitalopram 20 mg, lamotrigine 150 mg, riluzole 50 mg, and lorazepam (an anxiety medication) 0.5 mg. The pharmacist consult showed on 02/28/25 the physician disagreed with the recommendation and no rationale was provided. A significant change assessment, dated 03/10/25, showed Resident #31's cognition was moderately impaired with a BIMS score of 09. The assessment showed antipsychotic, antianxiety, antidepressant, and opioid medication use. The assessment showed diagnoses of anxiety, depression, psychotic disorder, and schizophrenia. On 04/28/25 at 11:58 a.m., the MDS coordinator reported the physician should give a rationale for why a dosage reduction recommended by the pharmacist was contraindicated when not agreeing with the recommendation. The MDS coordinator reported a rationale was not provided for Residents #3, 18, 21, and #31.

Based on record review and interview, the facility failed to develop a water management program for Legionella. The administrator reported 44 residents resided in the facility. Findings: A maintenance air and water temperature log, dated 04/22/25 through 04/25/25, showed no testing for Legionella had been conducted. On 04/23/25 at 10:00 a.m., the administrator provided an information packet for Legionella water management. The packet contained no policy. On 04/28/25 at 10:31 a.m., the maintenance supervisor reported they were hired in March 2025. They reported they were trying to organize paperwork for the facility, but stated they do not have a detailed diagram of the facility and do not have a water management program in place. They reported they have not been trained on Legionella but was given a packet of information. On 04/28/25 at 10:50 a.m., the administrator reported no Legionella water management policy was available.

Based on on record review and interview, the facility failed to ensure the antibiotic stewardship program was implemented for 3 (#3, 18, and #21) of 3 sampled residents reviewed for antibiotic use. The administrator reported 44 residents resided in the facility. Findings: An undated facility policy titled Antibiotic Stewardship showed to implement protocols to optimize the treatment of infections by ensuring residents who required an antibiotic were prescribed the appropriate antibiotic. The policy showed to assess residents for any infection using standardized tools and criteria. 1. A physician's order for Resident #3, dated 11/29/24, showed Bactrim double strength (an antibiotic) 800 mg -160 mg, give one tablet two times a day for an urinary tract infection. A physician's order for Resident #3, dated 02/27/25, showed Azithromycin (an antibiotic) 250 mg, give one tablet one time a day for a positive COVID test. An annual assessment for Resident #3, dated 02/27/25, showed antibiotic use for the resident. The assessment showed a diagnosis of dementia and the resident's cognition was severly impaired with a BIMS score of 03. 2. An annual assessment for Resident #18, dated 01/15/25, showed the resident's cognition was severely impaired with a BIMS score of 04. The assessment showed a diagnosis of Alzheimer's disease. A physician's order for Resident #18, dated 02/04/25, showed Azithromycin 250 mg, give two tablets by mouth one time a day for a positive COVID test, and give one tablet by mouth one time a day for four days. A physician's order for Resident #18, dated 04/17/25, showed Azithromycin 250 mg, give two tablets by mouth one time a day for infection, and give one tablet by mouth one time a day for four days. 3. A physician's order for Resident #21, dated 02/04/25, showed Azithromycin 250 mg, give two tablets by mouth one time a day for a positive COVID test on the first day, and give one tablet by mouth one time a day for four days. A quarterly assessment for Resident #21, dated 03/08/25, showed the resident's cognition was severely impaired with a BIMS score of 03. The assessment showed a diagnosis of Alzheimer's disease. A physician's order for Resident #21, dated 04/17/25, showed Azithromycin 250 mg, give 250 mg by mouth one time a day for infection for four days, and 500 mg for initial dose. On 4/28/25 at 11:46 a.m., the MDS coordinator reported the facility used the Loeb minimum criteria forms when initiating antibiotic therapy for residents. The MDS coordinator reported no forms were found for Residents #3, 18 and #21 or any other residents in the facility. The MDS coordinator reported the forms should have been completed and they did not know what the previous DON did with the forms or if they were used.

Based on observation, record review, and interview, the facility failed to provide a clean and homelike environment for the residents. The administrator reported 44 residents resided in the facility. Findings: On 04/21/25 at 2:15 p.m., a tour of the facility was conducted. Floors in the main lobby, hallways, dining room, and common areas were observed to have dirt and brown stains. A common area at the end of the womens hall was observed to have a fast-food sack of trash on the floor and the area smelled strongly of urine. In the same common area, a door was observed to have a plastic bag shoved into a hole where the door knob had previously been. On 04/24/25 at 8:18 a.m., the common area at the end of the womens hall was observed to still have the plastic bag shoved into the hole of the door where a door knob would be. [NAME] wrappers and a soiled brief/diaper was observed in the corner of the room beside a chair. The floor was noted with brown stains/spills. On 04/24/25 at 11:41 a.m., housekeeping staff were observed in the hallway of the womens hall near the common area. The brief/diaper and candy wrappers were observed to remain on the floor of the common area. On 04/24/25 at 12:40 p.m., the candy wrappers and brief/diaper were observed to remain in the back common area on the floor. On 04/28/25 at 12:49 p.m., candy wrappers and a crushed soda can were observed on the floor of the common area at the end of the womens hall. An undated facility policy titled, Cleaning of Common Areas, read in part, Ensure all common areas are clean and neat .All staff are responsible for seeing that the common areas are clean and neat .Any area will be cleaned if found to be dirty, even if it is not the scheduled day for cleaning that area. On 04/24/25 at 9:10 a.m., CNA #1 reported they were agency staff. CNA #1 reported the aides did a lot of the cleaning. CNA #1 reported housekeeping was in the facility Monday through Friday, but they never knew what hours they would be in the building, and reported the housekeeping staff were also agency. CNA #1 reported the aides emptied trash, cleaned bathrooms, and tried to sweep the floors when they had time. CNA #1 reported sometimes they had to stop cleaning to take care of a resident. On 04/24/25 at 11:52 a.m., housekeeping staff #1 reported they were normally in the building Monday through Friday, but hours varied. They reported they were normally not in the building over the weekend. Housekeeping Staff #1 reported they knew the floors looked bad and thought a floor stripper would be available in a couple of weeks. They reported their plan was to come in at 5:00 a.m. every day to strip the floors before residents were up walking around, and reported not being trained yet on using the stripper. Housekeeping staff #1 reported they thought some of the stains were a build-up of dirt or wax and thought the stripper would help with the stained areas. On 04/28/25 at 2:43 p.m., the administrator reported all housekeeping staff were contracted through an agency. The administrator reported there was no housekeeping staff on the weekends, but CNAs helped with housekeeping duties. The administrator reported all areas of the facility, including common areas, should be cleaned and trash picked up routinely.

Based on observation, record review, and interview, the facility failed to ensure residents received a shower as scheduled and requested for 1 (#9) of 1 sampled resident reviewed for activities of daily living assistance. The administrator reported 44 residents resided in the facility. Findings: On 04/22/25 at 12:05 p.m., Resident #9 was observed using a wet wipe to clean their body. An undated policy titled Shower/Tub Bath showed the purpose was to promote cleanliness and comfort, relax the resident, stimulate circulation, and facilitate observation of the residents's skin condition. A MDS assessment for Resident #9, dated 02/09/25, showed the resident was cognitively intact with a BIMS score of 15. The assessment showed the resident had diagnoses which included congestive heart failure, renal insufficiency, diabetes mellitus, depression, and schizophrenia. A progress note for Resident #9, dated 03/15/25 at 9:00 p.m., showed the resident refused a shower when asked by staff. The note showed the resident refused a shower before dinner as well. On 04/22/25 at 12:05 p.m., Resident #9 reported they were not a stinky person, but not having a shower made them feel yucky. Resident #9 reported they were supposed to get showers twice a week and reported they might get a shower every two weeks. Resident #9 reported they had complained several times and was told by staff they would get a shower scheduled. Resident #9 reported they had never been given a reason for the delay in showers, but stated they did not want to be scheduled at 8:00 p.m. when they were so tired. On 04/28/25 at 1:43 p.m., the ADON reported they were not aware of Resident #9 not getting showers as scheduled. On 04/28/25 at 1:44 p.m., the MDS coordinator reported on 03/15/25 it was documented Resident #9 refused their shower. The MDS coordinator reported they did keep shower sheets, but since the last DON left, they had not been able to find the shower sheets to show documentation of showers. On 04/28/25 at 2:09 p.m., CNA #2 reported Resident #9 did not refuse showers for them, but would not let some of the other staff give them a shower.

Based on record review and interview, the facility failed to designate a staff member to serve as the infection preventionist. The administrator reported 44 residents resided in the facility. Findings: An undated facility policy titled Infection Prevention and Control Program, read in part, The facility must establish an infection prevention and control program that must include .A system for preventing, identifying .and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment and following accepted national standards .'infection preventionist' .designated by the facility to be responsible for the infection prevention and control program. An undated staff roster showed no infection preventionist. On 04/21/25 at 2:23 p.m., the DON reported the facility was currently without an infection preventionist.

Based on record review and interview, the facility failed to ensure a refund was completed within 30 days from the resident's date of discharge for one (#8) of one sampled resident reviewed for timely refunds. The administrator identified one resident in the past six months who required a refund. Findings: A Resident Funds policy, not dated, documented in part, Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days of the resident's funds, and a final accounting of those funds, to the resident .in accordance with State law. A physician's order, dated 01/29/24, documented Resident #8 was to be discharged to another long term care facility. A progress note, dated 01/29/24 at 1:00 p.m., documented Resident #8 was transferred to another long term care facility via private car with their family member. Refund check #5426 in the amount of $328.00, dated 03/25/24, documented a refund for Resident #8 was made to the facility where the resident was transferred. Refund check #5422 in the amount of $1,024.00, dated 03/26/24, documented a refund for Resident #8 was made to the Social Security Administration. On 11/15/24 at 10:00 a.m., the administrator reported the business office manager no longer worked in the facility. The administrator reported they did not know why there was a delay in completing the refund for Resident #8.

Based on record review and interview, the facility failed to report allegations of abuse to the State Agency (OSDH) and other officials as required for two (#1 and #5) of two sampled residents reviewed for abuse. The administrator identified two allegations of abuse in the past 120 days. Findings: An undated Allegations of Abuse, Neglect, Exploitation or Mistreatment policy, read in part, Purpose: Ensure alleged violations related to mistreatment, exploitation, neglect, or abuse .the results of all investigations are thoroughly investigated and reported to the proper authorities within required time frames .reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Resident #1 had diagnoses which included Huntington's disease, depression, vascular dementia, mood disorder, and anxiety. A care plan for Resident #1, dated 07/22/24, documented the resident had a diagnosis of psychosis with physical aggression. The care plan documented the resident required assistance with activities of daily living. An MDS assessment for Resident #1, dated 09/18/24, documented the resident was severely impaired with cognition. A handwritten statement signed by CNA #1, dated 10/30/24, documented an incident in which the CNA entered Resident #1's room during routine rounds. The statement documented the resident had a bowel movement and became aggressive with the CNA while they were trying to clean and change the resident. The statement documented the nurse on duty witnessed the resident trying to kick the CNA and did not offer assistance. The statement documented Resident #1 put themselves on the floor while the CNA was changing their linens. The statement documented the CNA eventually got the resident back in bed, covered the resident, and continued their rounds. A typed statement by the previous BOM, dated 11/07/24, documented the BOM had notified the receiver on 10/31/24 of an allegation of abuse involving Resident #1 and CNA #1. The statement documented CNA #3 had reported the incident to the BOM due to feeling the incident was not being investigated. The statement documented the receiver requested the administrator speak to CNA #3 the following day. On 11/13/24 at 12:45 p.m., Resident #1 was observed lying in bed in their room with a blanket pulled over their head. The resident responded only with one word responses. The resident stated, yes, when asked if they were doing okay and stated, yes, when asked if staff treated them well. On 11/13/24 at 4:28 p.m., the ADON reported the night nurse reported an incident involving Resident #1 and CNA #1, in which the resident was found with scratches to their chest and neck area after the CNA had provided care. The ADON reported they assessed the resident and the administrator accompanied them to interview the resident. The ADON reported Resident #1 denied anyone had hurt them and it appeared the resident might have scratched themselves. The ADON reported they interviewed other residents, and none voiced complaints related to CNA #1, but there was no documentation of the interviews. The ADON stated they pulled the camera footage and did not see anything concerning with CNA #1's appearance or behavior following care provided to Resident #1. The ADON stated the charge nurse would normally initiate an incident report and if it was an abuse allegation, it would be reported to the State Agency, but they were not aware of an incident report being completed. On 11/14/24 at 5:30 a.m., CNA #3 reported they had observed scratch marks on Resident #1 after CNA #1 came out of the resident's room the morning of 10/31/24. The CNA stated they reported their concerns to the charge nurse on duty, an unnamed agency nurse. On 11/14/24 at 5:45 a.m., CNA #1 reported on the morning of the alleged incident with Resident #1, they had checked the resident and found them incontinent of a large bowel movement. The CNA stated the resident was being very combative and ended up putting themselves on the floor. The CNA reported they finally got the resident cleaned up and settled in bed, but received no assistance from other staff. The CNA reported staff made the allegation against them, but never offered to help the CNA with Resident #1. The CNA reported the incident happened on a Friday night shift and they were off until the following Wednesday. The CNA reported they gave their statement and talked with the administrator. A typed summary of the incident, without a date or signature, was provided by the administrator. The summary documented following the allegation of abuse, Resident #1 had been assessed for injuries and CNA #1 had been interviewed. The summary documented there were no witnesses to the incident and other residents were interviewed, but there was no documentation related to resident interviews. The summary documented a statement was never received from CNA #3. An incident report was not completed and the alleged allegation of abuse was not reported to OSDH or other required officials. 2. Resident #5 was admitted with diagnoses which included schizophrenia, peripheral vascular disease, Type 2 diabetes, bipolar disease, depression, and pain. A MDS assessment, dated 04/12/24, documented the resident was moderately impaired with cognition. A Grievance/Complaint Form, with a complaint date of 11/03/24, documented no resident's name, but was reported to be for Resident #5. The form documented the previous BOM took the complaint on 11/04/24, when the resident reported a CMA had cursed at the resident and almost hit them with the break room door. The form documented the administrator talked with the CMA and called the receiver for a phone interview with the CMA. The form documented the CMA was suspended for two days while an investigation was completed. A typed summary, signed by the administrator and dated 11/05/24, documented the administrator had received a complaint from a resident stating a CMA called them a derogatory term. The summary documented the administrator spoke with the CMA, reviewed cameras, and reviewed statements received from other employees. The summary documented the claim was unsubstantiated. There was no incident report and the allegation of abuse was not reported to OSDH or other required officials. On 11/14/24 at 1:30 p.m., Resident #5 reported CMA #1 was suspended for two days after the resident complained to the administrator the CMA had cursed at them. The resident was asked if they felt safe and they stated, Yes. On 11/15/24 at 11:20 a.m., the administrator reported they did not complete an incident report for the allegations of abuse. The administrator stated the incidents were not reported to OSDH or other required officials, as the administrator determined the allegations were unsubstantiated.

Based on record review and interview, the facility failed to thoroughly investigate allegations of abuse and report the results of the investigations for two (#1 and #5) of two residents reviewed for abuse. The administrator identified two allegations of abuse in the past 120 days. Findings: An undated Allegations of Abuse, Neglect, Exploitation or Mistreatment policy, read in part, Purpose: Ensure alleged violations related to mistreatment, exploitation, neglect, or abuse .the results of all investigations are thoroughly investigated and reported to the proper authorities within required time frames .reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Resident #1 had diagnoses which included Huntington's disease, depression, vascular dementia, mood disorder, and anxiety. A care plan for Resident #1, dated 07/22/24, documented the resident had a diagnosis of psychosis with physical aggression. The care plan documented the resident required assistance with activities of daily living. A MDS assessment for Resident #1, dated 09/18/24, documented the resident was severely impaired with cognition. A handwritten statement signed by CNA #1, dated 10/30/24, documented an incident in which the CNA entered Resident #1's room during routine rounds. The statement documented the resident had a bowel movement and became aggressive with the CNA while they were trying to clean and change the resident. The statement documented the nurse on duty witnessed the resident trying to kick the CNA and did not offer assistance. The statement documented Resident #1 put themselves on the floor while the CNA was changing the their linens. The statement documented the CNA eventually got the resident back in bed, covered the resident, and continued their rounds. A typed statement by the previous BOM, dated 11/07/24, documented the BOM had notified the receiver on 10/31/24 of an allegation of abuse involving Resident #1 and CNA #1. The statement documented CNA #3 had reported the incident to the BOM due to feeling the incident was not being investigated. The statement documented the receiver requested the administrator speak to CNA #3 the following day. On 11/13/24 at 4:28 p.m., the ADON reported the night nurse reported an incident involving Resident #1 and CNA #1, in which the resident was found with scratches to their chest and neck area after the CNA had provided care. The ADON reported they assessed the resident and the administrator accompanied them to interview the resident. The ADON reported Resident #1 denied anyone had hurt them and it appeared the resident might have scratched themselves. The ADON reported they interviewed other residents, and none voiced complaints related to CNA #1, but there was no documentation of the interviews. On 11/14/24 at 5:30 a.m., CNA #3 reported they had observed scratch marks on Resident #1 after CNA #1 came out of the resident's room the morning of 10/31/24. The CNA stated they reported their concerns to the charge nurse on duty, an unnamed agency nurse. On 11/14/24 at 5:45 a.m., CNA #1 reported on the morning of the alleged incident with Resident #1, they had checked the resident and found them incontinent of a large bowel movement. The CNA stated the resident was being very combative and ended up putting themselves on the floor. The CNA reported they finally got the resident cleaned up and settled in bed, but received no assistance from other staff. The CNA reported staff made the allegation against them, but never offered to help the CNA with Resident #1. The CNA reported the incident happened on a Friday night shift and they were off until the following Wednesday. The CNA reported they gave their statement and talked with the administrator. A typed summary of the incident, without a date or signature, was provided by the administrator. The summary documented that following the allegation of abuse, Resident #1 had been assessed for injuries and CNA #1 had been interviewed. The summary documented there were no witnesses to the incident and other residents were interviewed, but there was no documentation related to resident interviews. The summary documented a statement was never received from CNA #3. 2. Resident #5 was admitted with diagnoses which included schizophrenia, peripheral vascular disease, Type 2 diabetes, bipolar disease, depression, and pain. A MDS assessment, dated 04/12/24, documented the resident was moderately impaired with cognition. A Grievance/Complaint Form, with a complaint date of 11/03/24, documented no resident's name, but was reported to be for Resident #5. The form documented the previous BOM took the complaint on 11/04/24, when the resident reported a CMA had cursed at the resident and almost hit them with the break room door. The form documented the administrator talked with the CMA and called the receiver for a phone interview with the CMA. The form documented the CMA was suspended for two days while an investigation was completed. A typed summary, signed by the administrator and dated 11/05/24, documented the administrator had received a complaint from a resident stating a CMA called them a derogatory term. The summary documented the administrator spoke with the CMA, reviewed cameras, and reviewed statements received from other employees. There was no documentation related to interviews with other residents. The summary documented the claim was unsubstantiated. On 11/15/24 at 11:20 a.m., the administrator reported they did not complete an incident report or document all of their findings related to a thorough investigation of the allegations of abuse.

Based on record review and interview, the facility failed to electronically transmit completed MDS data to the CMS system within 14 days of completion. The administrator identifed 47 residents resided in the facility. Findings: An undated MDS policy, read in part, Policy Objectives .Maintain compliance with quality reporting requirements .Submit MDS data to the CMS database as required .Monitor submission compliance and address issues proactively .Submit MDS data to CMS via the Quality Improvement and Evaluation System within the required timeframes. On 11/13/24 at 4:00 p.m., review of MDS data documented MDS assessments were not submitted from 05/01/24 to 07/08/24. On 11/13/24 at 4:11 p.m., a phone interview was conducted with LPN #1. The LPN reported they had started working for the facility in July 2024 as the MDS coordinator. The LPN reported the facility was having difficulty transmitting MDS data and the issues had just recently been resolved. The LPN reported they were able to transmit a batch of approximately 200 MDS assessments on 10/08/24.

Based on record review and interview, the facility failed to have a registered nurse on duty for at least eight consecutive hours a day, seven days a week, and failed to have a director of nursing on a full time basis. The administrator identified 47 residents resided in the facility. Findings: An undated Registered Nurse policy, read in part, .Ensure that a Registered Nurse is available for supervision in the facility .Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .Except when waived, the facility must designate a registered nurse to serve as the director of nursing on a full-time basis. A review of staff time cards and schedules for August 2024 documented no RN or DON coverage on 08/01/24, 08/02, 08/05, 08/06, 08/07, 08/08, and 08/09/24. A review of staff time cards and schedules for September 2024 documented the DON worked 09/23/24, 09/24, 09/25, 09/26, 09/27, and 09/30/24. No other RN coverage was documented. A review of staff time cards and schedules for October 2024 documented the last day the DON worked was 10/09/24. There was no documentation of RN coverage for 10/11/24, 10/14, 10/15, 10/18, 10/21, 10/22, 10/23, 10/24, 10/25, 10/28, and 10/30/24. On 11/14/24 at 11:05 a.m., the ADON reported the facility had RN coverage on most weekends. The ADON was asked if the RN covered any of the DON responsibilities. They stated they did not think so. The ADON reported they were not aware of any staffing waivers. On 11/14/24 at 12:30 p.m., the administrator provided time card reports which documented the previous DON had last worked on 10/09/24. The administrator reported RN #1 worked most weekends and occasionally worked a night shift. The administrator reported RN #1 did not cover any DON responsibilities. The administrator reported they expected the new DON to start the following week.

Based on observation and interview, the facility failed to grant access to the EMR for the survey team. The administrator identified 47 residents resided in the facility. Findings: On 11/13/24 at 12:15 p.m., surveyors entered the facility to conduct complaint investigations. The administrator reported the facility utilized an EMR and staff members were observed to utilize the EMR. The administrator was informed surveyors would require access to the EMR for record review during the investigations. On 11/13/24 at 3:50 p.m., the administrator reported they were informed by the receiver their company did not provide access of the EMR to surveyors. The administrator was informed they were required to grant access to surveyors to avoid impeding the survey process. On 11/13/24 at 4:00 p.m., the receiver reported they did not grant access of the EMR to surveyors, but would print off any requested documentation. The receiver was informed they were required to grant access of the EMR to surveyors, but the receiver refused to comply.

Based on observation, interview, and record review, it was determined the facility failed to implement interventions to aid in the prevention of injury with falls for one (#3) of six sampled residents who were reviewed for falls. Resident #3 suffered 16 falls from 01/2021 through 06/2021. The resident sustained three [CONDITION(S)]/abrasions and a fractured left hip. The facility reported 64 residents lived in the facility. Findings: The facility fall policy and procedure documented to evaluate resident's condition, assess for injuries, provide appropriate medical attention, and notify the physician and family. Resident #3 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, [CONDITION(S)], and resting tremors. A fall risk assessment, dated 08/13/20, documented the resident was a high risk for falls. An incident tracking log, dated August 2020, documented the resident had a fall on 08/12/20 and on 08/29/20. A fall risk assessment, dated 11/12/20, documented the resident was a high risk for falls. A significant change assessment, dated 12/09/20, documented the resident was severely impaired with cognition and was independent with tranfers and a.m bulation. The assessment documented the resident had no falls since the prior assessment. A care plan, dated 12/16/20, documented the resident was a high risk for falls and had a history of falls. The care plan documented a goal was for the resident to remain free of falls. The care plan documented the following interventions: Gather information on past falls and attempt to determine cause of falls. Anticipate and intervene to prevent future recurrence; Be sure call light is within reach and encourage to use it for assistance and respond promptly to request for staff assist; Anticipate and meet needs; Coordinate with appropriate staff to ensure safe environment; Evaluate for, supply adaptive or devices as needed. Reevaluate as needed for continued appropriateness and to ensure least restrictive device/restraint; Provide activities that minimize the potential for falls; Encourage activities that promote exercise, physical activity for strengthening and improved mobility; and ensure resident is wearing appropriate footwear (shoes, bedroom slippers, non-skid socks) when a.m bulating or in wheelchair. An incident tracking log, dated 01/10/21 at 2:15 p.m., documented the resident tipped his recliner over and hit his head. The log documented no injuries. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. An incident tracking log, dated 01/30/21 at 2:15 p.m., documented the resident tipped his recliner over and hit his head. The log documented an injury was swelling. The log documented first aid was administered. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. An incident tracking log, dated 02/15/21 at 11:30 p.m., documented the resident lost his balance and fell . The log documented the resident sustained an abrasion. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. A nurse's note, dated 03/07/21 at 11:00 a.m., documented the resident was a.m bulating in the hallway when another resident bumped into him causing him to fall. The note documented no injuries. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. A fall risk assessment, dated 03/08/21, documented the resident was a high risk for falls. A nurse's note, dated 03/17/21 at 9:30 p.m., documented the resident was found in the floor outside of his room in the hallway. The note documented no injuries noted. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. An incident tracking log, dated 03/20/21 at 11:30 p.m., documented the resident fell in the hallway. The log documented no injuries. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. A nurse's note, dated 04/04/21 at 5:15 a.m., documented, CNA's to room to get resident up for day. Noticed small at of blood on pillow then laceration to crown of head. Summond me to room @that time. Resident sitting in w/c dressed w approx 2 laceration to crown of head. Dried blood around site denies any pain. Neuro checks done. WNL. VS: 106/60-90-16-97. A nurse's note, dated 04/07/21 at 1:00 p.m., documented the resident was found lying on the floor in his room. Redness noted to forehead. Neuro checks started. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. A nurse's note, dated 04/15/21 at 5:20 p.m., documented the resident was found sitting on fall mat beside his bed. The note documented a light pink colored area to right lower back. The note documented no injuries noted. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. A nurse's note, dated 05/14/21 at 2:50 p.m., documented the resident was found in the floor in the front lobby. The note documented the resident had a small abrasion to the back of his head. The note documented neuro checks to be started. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. An incident tracking log, dated 05/18/21 at 9:10 a.m., documented the resident was found on the floor in the front lobby. The log documented the resident obtained an abrasion. A nurse's note, dated 05/18/21 at 10:45 p.m., documented the resident had a small abrasion to mid forehead. A nurse's note, dated 05/23/21 at 1:15 p.m., documented the resident was turning around in the hallway and sat down on the floor. The note documented the resident hit his left arm on the fire door causing a 2.5 x 0.1 abrasion to left outer hand and 4 x 4 centimeter abrasion to left elbow. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. A nurse's note, dated 05/26/21 at 9:36 p.m. documented the resident was found on the floor in his room. The note documented the resident sustained a laceration above his left eye. The note documented the resident was sent out to the local emergency room for evaluation. The note documented the resident was favoring his arm. The clinical record contained no new interventions to prevent further falls. The care plan had not been updated to included new interventions to prevent further falls. A fall risk assessment, dated 06/01/21, documented the resident was a high risk for falls. A quarterly assessment, dated 06/07/21, documented the resident was severely impaired with cognition, required limited assistance with transfers and a.m bulation. The assessment documented the resident had one fall with no injuries, two or more falls with injuries. The assessment documented the resident had no falls with major injuries. A nurse's note, dated 06/08/21 at 10:45 a.m., documented the resident was sitting in wheelchair in the front lobby and pushed himself away from the table and attempted to stand. The note documented the resident fell into the floor landing on his coccyx. The note documented no injuries noted. The note documented the resident was to be placed in a Broda chair to possibly alleviate pressure to left testicle. A nurse's note, dated 06/09/21 at 6:30 a.m., documented, Resident found sitting up Indian Style in front lobby in floor. Geri chair behind him has no apparent inj noted VS WNL assist resident into geri chair. leaned geri chair to reclining position. Informed staff to ensure resident to be the last one up for meals then taken directly back to bed . The clinical record contained no new interventions to prevent further falls. A care plan, updated 06/09/21, documented, .Resident must not be gotten up until very last to eat, then taken directly back to bed . A nurse's note, dated 06/22/21 at 1:00 p.m., documented to send resident to the local emergency room for a distended abdomen and emesis. A nurse's note, dated 06/22/21, documented, [Na.m e deleted] called reporting Res had a fractured hip, hospital [Na.m e deleted] was arranging for transport to a different hospital . A CT report of the abdomen and pelvis, dated 06/22/21, documented the resident had a comminuted displaced left intertrochanteric fracture. There was no documentation in the clinical record the facilty had increased supervision of the resident to aide in the prevention of further falls. On 06/21/21 at 9:32 a.m., the resident was observed sitting up in his geri chair with his eyes closed. On 06/22/21 at 8:09 a.m., the resident was observed sitting up in a Broda Chair in the front lobby. On 06/23/21 at 7:54 a.m., the resident was not in his room. LPN #1 reported the resident had been admitted to the hospital for a fractured hip. On 06/23/21 at 10:52 a.m., CNA #2 reported the resident was able to get up and walk around about a month or month and a half ago. The CNA reported something happened to him and he became unstable and fidgeting a lot. The CNA reported the resident could not transfer himself. The CNA reported the resident had a few falls but unsure when he last fell . The CNA reported staff was to provide 30 minute checks on the resident. The CNA reported the resident's door was to remain open. The CNA reported the resident required two staff to transfer and would utilize a lift at times. The CNA reported care plans were in the clinical record at the nurses station. The CNA then asked the nurses where she could find the care plans. On 06/23/21 at 11:12 a.m., CNA #1 reported the resident required a total lift for transfers. The CNA reported the resident's fall precautions were a fall mat and a Geri chair. The CNA reported the resident utilized the Geri chair because he had history of falls. The CNA reported the resident could standing when she came to work at the facility. The CNA reported the resident began having trouble standing on his own the last couple of weeks. The CNA reported there was an ADL book at the nurses station to determine what care was to be initiated. On 06/23/21 at 11:19 a.m., LPN #1 reported the resident was transferring on his own up until about a month ago. The LPN reported the resident required one staff to assist with transfers and bear weight. The LPN reported the resident had a procedure and things changed. The LPN reported the resident required the Broda chair due to the infection in the scrotal area. The LPN reported the resident had been a fall risk since admission. The LPN reported interventions to prevent falls included the use of a fall mat, checking the resident every two hours, and frequent incontinent care. On 06/23/21 at 2:05 p.m., RN #1 reported the care plan she had provided was the most current. The nurse reported the care plan should have been updated to include new interventions to prevent further falls.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (#1) of five residents reviewed for pressure ulcers received treatment and services necessary to promote healing and prevent infection of a pressure ulcer. The facility failed to notify the physician and coordinate care with physicians when the resident developed odor and drainage from a worsening, facility acquired, pressure ulcer. A hospital discharge summary for resident #1, dated 05/03/19, documented the resident had been admitted to the hospital for treatment of [REDACTED]. The discharge summary documented the wound was debrided with sharp debridement and calcaneus bone exposed. The discharge summary documented x-rays were positive for osteo[DIAGNOSES REDACTED] to the site. The discharge summary documented the resident would be discharged from acute care and admitted to swing bed services for continued wound care and intravenous (IV) antibiotic therapy. The facility reported five residents with pressure ulcers. Findings: A facility policy documented the skin care program would be interdisciplinary and would be developed and implemented using a team approach. The policy documented nursing would be responsible for identification of risk factors, identification of impaired skin integrity, and communication with the physician. The policy documented the physician or medical director would be responsible for ongoing treatment orders, participation in assessment, and re-evaluation of treatment orders as necessary. The policy documented in the event of altered skin integrity, nursing would provide and document notification to family and the physician. The policy documented minimal to moderate wound drainage with hues of yellow, green, or blue, usually indicated an infection. The policy documented if infection was suspected, the physician would be notified. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/25/18, documented the resident was moderately impaired with cognition. The assessment documented the resident required extensive to total assistance with transfers and bed mobility. The assessment documented the resident was at risk but had no pressure ulcers. A comprehensive assessment, dated 02/20/19, documented the resident was moderately impaired with cognition. The assessment documented the resident required extensive to total assistance with transfers and bed mobility. The assessment documented the resident had one stage II pressure ulcer. A care plan, updated 02/24/19, documented, Skin prep to left heel q (every) shift. A nurse note, dated 02/24/19, documented, L heel boggy. The note documented an offload boot was applied to the left heel and foot. A physician order, dated 02/24/19, documented skin prep to left heel q (every) shift. The order documented this was a telephone order received by physician #1 and signed by physician #2. A weekly wound tracking report, dated 03/06/19, documented the resident had developed a pressure ulcer to the left heel on 02/24/19. The report documented the wound measured 7 centimeters (cm) x 3 cm. The report documented the wound was unstageable with no odor or drainage. A weekly wound tracking report, dated 03/15/19, documented the left heel wound was unstageable and had an odor with no drainage. There was no documentation to indicate a physician was notified regarding the odor. A weekly wound tracking report, dated 03/28/19, documented the left heel wound was unstageable and had an odor with drainage. There was no documentation to indicate a physician was notified regarding the odor and drainage. A physician's orders [REDACTED]. The order documented to clean the left heel with normal saline, pat dry, apply calcium alginate, and cover with an adhesive dressing. The order documented a [DIAGNOSES REDACTED].#2. A doctor's progress note, dated 04/04/19 and signed by physician #1, documented the physician examined the resident for [MEDICAL CONDITION] of the right leg. The note documented the physician ordered [MEDICATION NAME] 100 milligrams (mg) twice a day for 10 days. The note did not address the left heel pressure ulcer. A physician's orders [REDACTED].#1, documented [MEDICATION NAME] 100 mg PO BID for 10 days. The order documented a [DIAGNOSES REDACTED]. A nurse note, dated 04/05/19 at 2:00 p.m., documented treatment to the left heel. The note documented, green, odorous drainage observed. The note did not document the physician was notified regarding the green, odorous drainage. A nurse note, dated 04/05/19 at 7:00 p.m., documented the resident was started on an antibiotic for [MEDICAL CONDITION]. A weekly wound tracking report, dated 04/11/19, documented the left heel wound was unstageable and had an odor with a moderate amount of drainage. The report did not document the physician was notified regarding the odor and drainage. A lab result, dated 04/16/19, documented the resident had a white blood cell (WBC) count of 10.3 (reference range 4.0 - 10.0). A nurse note, written on the lab result, documented the lab results were faxed with no new orders received. The note documented the antibiotic had been completed. A physician order, dated 04/18/19 and signed by physician #2, documented to discontinue the current wound treatment to the left heel. The order documented to clean the left heel with normal saline, pat dry, apply Santyl to the wound, then cover with calcium alginate, use a 4 x 4 gauze, and cover. The order documented, QOD (every other day), with a [DIAGNOSES REDACTED]. A nurse note, dated 04/18/19, documented, Treatment rec'd to left heel. Will start new treatment on 04-20-19. A treatment record, dated (MONTH) 2019, documented the new treatment for [REDACTED]. A weekly wound tracking report, dated 04/26/19, documented the left heel wound measured 4 cm x 4 cm x 0.3 cm, was unstageable, and had an odor with a moderate amount of drainage. The report did not document the physician was notified regarding the continued odor and drainage. A care plan, updated 04/30/19, documented the resident had a potential for skin breakdown or pressure ulcers related to a decrease in activities of daily living (ADL) function, debility, and incontinence. The care plan documented the resident required total care assistance with activities of daily living. The care plan documented pressure ulcer treatments to the resident's left heel and previous treatments to the left buttock. The care plan documented the resident was transferred to the local hospital emergency room for treatment and evaluation on 04/30/19. A hospital discharge summary, dated 05/03/19, documented resident #1 had been admitted to the hospital for treatment of [REDACTED]. The discharge summary documented the wound was debrided with sharp debridement and calcaneus bone exposed. The discharge summary documented x-rays were positive for osteo[DIAGNOSES REDACTED] to the site. The discharge summary documented the resident would be discharged from acute care and admitted to swing bed services for continued wound care and IV antibiotic therapy. On 05/15/19 at 3:00 p.m., licensed practical nurse (LPN) #1 reported the antibiotic prescribed for the resident was to treat [MEDICAL CONDITION] of the right leg. The LPN reported, to her knowledge, there was never an antibiotic ordered or culture obtained to treat the resident's pressure ulcer of the left heel. The LPN reported she initially found the drainage and foul odor to the left heel but did not notify the physician. The LPN reported she followed the chain of command and reported the drainage and foul odor to LPN #2 because she was in charge of wounds. LPN #1 was questioned about the treatment order received on 04/18/19 and started on 04/20/19. The LPN reported she wasn't sure why the treatment wasn't started the day it was ordered but possibly because the treatment was to be done every other day. The LPN reported it was her decision to start the new treatment two days later. The LPN confirmed she received the order from the physician. On 05/15/19 at 3:20 p.m., LPN #2 reported a different wound care nurse had provided wound care in (MONTH) 2019. The LPN reported, to her knowledge, the physician had not been notified of the drainage and foul odor to the left heel pressure ulcer. The LPN reported another nurse had asked her to look at the resident's [MEDICAL CONDITION] of the right leg, and she informed the nurse to contact the physician. The LPN reported she would expect the nurse who found the drainage and foul odor of the left heel to notify the physician. The LPN reported she was only responsible for measuring wounds on a weekly basis and was not in charge of wound care. The LPN reported the nurse who provided wound care and identified a problem would be expected to contact the physician. LPN #2 reported she assessed the resident's left heel on 04/18/19 and made the suggestion to LPN #1 to call the physician because the wound had not improved. LPN #2 reported the physician should have initially been notified on 03/28/19 when the wound was found to have a foul odor with drainage. On 05/15/19 at 3:45 p.m., the director of nursing (DON) reported the physician should have been notified when the resident's left heel pressure ulcer was found to have a foul odor with drainage. The DON reported the nurse who identified a change or worsening of the resident's wound should have notified the physician immediately. The DON was asked to review the physician progress notes [REDACTED]. The DON reported physician #1 would often agree with the nurse's suggestion in regard to wound treatment orders. The DON reported the physician would have examined the resident's wound if notified by staff of a worsening condition. On 05/15/19 at 5:15 p.m., physician #1 was interviewed by telephone. The physician reported he was familiar with the resident but could not remember for certain if he had examined the resident's left heel. The physician reported he would expect staff to contact him if a wound or pressure ulcer worsened significantly. The physician reported he would normally send a resident out to the wound clinic if indicated. On 05/15/19 at 5:45 p.m., physician #2 was interviewed by telephone. The physician reported he did not recall the resident's left heel pressure ulcer. The physician reported physician #1 would often see the residents in the facility. The physician was asked if he was ever made aware of the foul odor and drainage to the resident's left heel pressure ulcer. The physician reported he could not recall if he was notified and was uncertain of when he had last examined the resident.

On 05/18/16, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to supervise one (#3) sampled resident who had eloped. At 4:42 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health. At 4:50 p.m., the administrator, director of nurses (DON), corporate nurse, and the social service director were informed of the existence of the IJ. At 6:25 p.m., the facility's plan of removal was accepted. The facility's plan of removal documented: Calloway Nursing Home Plan of Removal May 18th, 2016 All staff will be inserviced on elopement policy and procedure and missing resident policy and procedure by May 19th at 8 am. Communication forms will be implemented by 9:00 am on May 19th. All staff will be inserviced on using a symbol system to identify elopement risks by 3 pm on May 19th. All unavailable employees will not be allowed to return to work until they have been in serviced on all new policy and procedures to identify elopement risks. All new employees will be oriented on residents who are at risk for elopement effective immediately. Residents with the risk for elopement will be identified on ADL (activities of daily living) sheets and care plans by May 19th. Residents identified with elopement risks will be placed on one on one observation until above mentioned plan of removal is in place. Notice will be posted by at the (sic) doors to remind family members and visitors to not let a resident leave the building without identifying the resident. At 6:45 p.m., two additional residents, who were identified as elopement risks, were observed with a staff member providing one on one supervision. On 05/19/16 at 11:00 a.m., the facility inservice documentation was reviewed. It was documented that all but six of the forty-seven staff members had been inserviced regarding resident elopements. By 11:00 a.m., twelve staff members had been interviewed. They all verbalized knowledge of the inservice material. The entrances to the residents' rooms, who were identified as elopement risks, were observed to be identified with green circular symbols. Care plans and ADL sheets for residents who were at risk for elopement had been updated to include new assessments and/or interventions. On 05/19/16 at 11:00 a.m., the IJ was lifted when all components of the plan of removal had been verified. The deficient practice remained at a level of potential for more than minimal harm at a pattern. By 5:00 p.m., twenty-one staff members had been interviewed about the inservices. They verbalized knowledge of the inservice material. Based on record review, observation, and interview, it was determined the facility failed to provide supervision and consistent monitoring for three (#1, 2, and #3) of six sampled residents who had eloped from the facility. The facility identified no other residents who were at risk for elopement. Findings: The facility policy for elopement, no date provided, documented: Elopements . Policy Statement Nursing personnel must report and investigate all reports of missing residents. Policy Interpretation and Implementation 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Should an employee observe a resident leaving the premises, he/she should: a. Attempt to prevent the departure; b. Obtain assistance from other staff members in the immediate vicinity, if necessary; c. Instruct another staff member to inform the charge nurse or director of nursing services that a resident has left the the premises; and d. Be courteous in preventing the departure and in returning the resident to the facility 1. A history and physical from a local psychiatric hospital for resident #3, dated 04/11/16, documented the resident had been referred by Adult Protective Services (APS). The history and physical documented: .She (resident #3) currently lives at home with her son and daughter-in-law. Reports are that she has repeatedly refused the services offered to her and there are concerns that she is being exploited the patient did have methamphetamine in her system and the nursing staff asked her how she took that and she said she took it by mouth and her daughter-in-law gave it to her. Resident #3 was admitted to the facility on [DATE] at 12:45 p.m. with [DIAGNOSES REDACTED]. The facility's wander data collection tool, dated 04/19/16, documented the resident answered five questions with a yes response. The tool's scoring instructions documented three or more yes responses indicated the resident was a definite elopement risk. The back page of the tool had a hand written summarization which documented, Res (resident) is a new admission. Wants to go back home but realizes APS (adult protective services) must approve that. She stated she will stay here as long as needed. Under the hand written summary there were two response boxes. One documented the resident was not an elopement risk and the other documented the resident was an elopement risk. The director of nurses (DON) checked the box that documented the resident was not an elopement risk. The resident's care plan, dated 04/20/16, documented: Problem/Need (Resident) is going through an adjustment period and lifestyle change resulting from admission to nursing home Approaches Allow resident the opportunity to communicate feelings regarding attended activities. Evaluate favorite recreational activities and encourage involvement. Encourage ongoing family involvement. Invite family to attend special events, activities, and meals. Introduce to residents with similar background & (and) interest. Learn to recognize stressors which may be early warning signs of problem behavior. Provide as many situations as possible which give control over environment & care delivery. Spend time talking with resident. Encourage to express feelings about nursing home placement. Problem/Need (Resident) has a psychosocial well being problem related to: as evidenced by: admitted here under APS worker guardian. Not to have contact with son or his friend .per guardian Approaches Observe behavior and mood status. Attempt to determine potential causes of psychosocial problem. Meet with the resident as desired or at least (blank space) times weekly to allow him/her to discuss concerns, feelings. Help resident to identify positive coping skills and character traits and reinforce these. Invite to activities that promote a sense of control, self-determination. Allow resident choices in care, clothing, and activities daily. Administer medications as ordered and monitor for side effects. Arrange for behavioral health/psych (psychiatric) consults prn (as necessary). The clinical record contained no documentation a care plan and/or interventions had been developed to prevent the resident from eloping. A nurse's note, dated 04/20/16 at 4:45 p.m., documented a licensed practical nurse (LPN) had received a phone call from the resident's APS case worker. The note documented the case worker told the LPN he had received a call from the resident. The resident had informed him the facility had taken her off all of her medications and she wanted to leave the facility. The note further documented the case worker informed the LPN the resident was to have no contact with her son and daughter-in-law. The case worker also informed the LPN if the family showed up at the facility, they were to notify him and call the police. A nurse's note at 5:30 p.m. documented the resident told a staff member she wanted to return to her son's house. The clinical record contained no documentation of interventions having been initiated to prevent the resident from eloping after the resident expressed a desire to leave the facility. The resident's admission assessment, dated 04/27/16, documented the resident had entered the facility from a psychiatric hospital, made herself understood, and understood others. The resident had a cognition score of 12. This score indicated she was moderately impaired in cognition. The assessment documented the resident was independent with transfers, walking, locomotion, and toilet use. The assessment documented the resident used a walker for ambulation and had impaired range of motion on one side of her upper extremity. A nurse's note, dated 05/04/16 at 9:30 a.m., documented the resident stated she was starting to hallucinate and was hearing voices due to lack of sleep. The note documented the physician was notified. The clinical record contained no additional documentation the facility provided followed-up care regarding the resident's complaints of hallucinations, insomnia, or hearing of voices. A nurse's note at 10:00 a.m. documented the resident's daughter-in-law phoned the facility and informed them they would be arriving at the facility later in the day or early the next morning. The note documented the case worker was phoned and a message was left for him. A nurse's note, dated 05/05/16 at 9:30 a.m., documented the resident's case worker phoned the facility and requested to speak with the resident. The clinical record contained no documentation of the topic of the conversation. A nurse's note at 3:45 p.m. documented the resident's daughter-in-law phoned the facility and requested to speak with the resident. The daughter-in-law was informed that APS had instructed the facility to allow no contact between the resident and her family. The daughter-in-law was provided with the case worker's phone number. The note documented the daughter-in-law informed the facility the resident had written them a letter which requested them (the family) to call her. A nurse's note, dated 05/14/16 at 3:00 p.m., documented the resident was in the front lobby doorway with her belongings in a plastic bag. The resident was counseled and placed on visual checks every fifteen minutes. The clinical record contained documentation the resident was checked on every fifteen minutes from 05/14/16 at 3:00 p.m. through 05/16/16 at 3:00 p.m. A care plan update, dated 05/14/16, documented; Problem/Need (Resident) expressing desire to be released from the facility. Directed to speak c (with) her APS worker Approaches .Place on 15 min (minute) checks. A nurse's note, dated 05/16/16 at 3:00 p.m., documented the resident was missing from the facility. The note documented the facility had been unable to locate the resident and staff was looking for her. An incident report, dated 05/16/16 at 3:00 p.m., documented the resident was missing from the facility. The report documented the facility had been unable to locate the resident and they were still looking for her. The report documented the resident was last seen at 2:15 p.m. The report contained a handwritten statement, no time given, provided by certified medication aide (CMA) #1 which documented: I was driving down the road toward the park. I stopped at the stop sign by the (Local Hotel) when I saw what looked to be (Named Resident) walking up the road in front of me I asked her if she would come with me. She started yelling 'no' and kept walking I got on the phone and called (Facility) to tell them I had seen her and I would need assistance bring her back .By the time I made it back to where she had been walking, she was gone. The incident report contained a handwritten statement which had been provided by a business office employee which documented the resident had entered her office at 8:00 a.m. requesting to be discharged . The statement documented the office employee had explained to the resident she could not leave without the APS caseworker's permission. The statement documented the office employee asked the social service aide to take the resident to a phone to call the resident's caseworker. The report also contained another hand written statement which had been provided by the social service aide. The statement documented he had assisted the resident to speak to the caseworker by phone. The statement documented the social service worker stated the phone call had been placed about 9:20 a.m. The incident report contained a written statement provided by registered nurse (RN) #1 which documented the resident came out the front door with her at approximately 2:11 p.m. The statement documented the nurse stated the resident had always been allowed to exit the facility as desired. The report added the nurse stated the resident used her walker, was in a hurry, and she had cautioned the resident to slow down. A nurse's note, dated 05/16/16 at 3:15 p.m., documented the resident's case worker and local police department had been notified of the resident's elopement. A nurse's note at 6:15 p.m. documented a policeman phoned the facility and reported the resident had been seen at the resident's house in Durant, Oklahoma. The note documented the resident's daughter-in-law phoned the police, reported the resident's location, and told them the resident was aware the police were looking for her and so the resident took off. The note added the police were searching the neighborhood. On 05/18/16 at 10:15 a.m., three residents were observed sitting outside the facility in the porch and courtyard area without a staff member present. On 05/18/16 at 2:00 p.m., the DON was interviewed about the resident's elopement. She was asked if the resident had been allowed to go outside. She said, Yes. She was asked if the resident had been supervised while outside. She said, No, she would come and go on her own, she knew the door code. She stated the resident would go outside to read. She was asked if an elopement assessment had been conducted for the resident. She stated she would get it from her office. At 2:45 p.m., the DON provided the elopement assessment. She was asked to review the assessment and was asked if the resident's score indicated she was an elopement risk. She stated it did. The DON stated the resident should have been treated as an elopement risk. The DON was asked if the office employee or the social service aide had reported to the nursing staff on the morning of the 16th that the resident was requesting to be discharged from the facility. She stated they did not. She stated if they had reported it to her she might have done something different. The DON was asked to review the documentation for the every (Q) fifteen minute visual checks. She was asked if it documented the resident was in her room at 2:15 p.m., 2:30 p.m., and 3:00 p.m. on 05/16/16. She said, Yes. The DON was asked what time the resident was observed leaving the facility with RN#1. She stated just before 2:15 p.m. She was asked how it was possible the resident would have been observed in her room after she had been seen leaving the facility. She stated it was the first day on the job for certified nurse aide (CNA) #8, who was assigned to conduct the visual checks. The DON added when she interviewed CNA #8, he stated he had the resident confused with another resident and he had watched and documented on the wrong resident. The DON was asked if CNA #8 was working with a preceptor or working alone on his first day of work. She stated he was working alone because he had worked at the facility in the past. She added he probably should not have been assigned to do the visual checks since he wasn't familiar with the residents. The DON was asked how the facility became aware of the resident's elopement. She stated a facility staff member had seen the resident about 3:00 p.m. near the park entrance and phoned the facility requesting help in retrieving the resident. She was asked if CNA #8 had reported the resident was missing at 2:15 p.m., would the facility have started looking for the resident immediately instead of 45 minutes later. She stated, Yes. On 05/18/16 at 3:15 p.m., a telephone interview was conducted with a supervisor of APS. She stated she was very familiar with the resident. She stated the resident had previous admissions to the psychiatric hospital for drug use. The supervisor added when the resident was taking drugs she would start having seizures and would need to be admitted to the hospital. The supervisor was asked if the resident had eloped before. She stated prior to this admission the resident had always had been her own power of attorney (POA). The supervisor added the resident had a history of [REDACTED]. The supervisor stated this was the first time the resident had been placed under APS guardianship. The supervisor stated the resident didn't have the authority to sign out AMA. On 05/18/16 at 3:30 p.m., RN #1 was interviewed about the resident's elopement. She was asked if she was aware of the results of the resident's elopement assessment. She stated she had not seen it and she didn't know anything about it. She was asked if she worked on Saturday the 14th. She stated she had. She was asked if she had been made aware the resident had attempted to leave the facility with her belongings. She stated the charge nurse had informed her of the elopement attempt. The RN was asked if she had been made aware the resident had been placed on Q fifteen minute visual checks. She stated she couldn't remember if she knew about the visual checks or not. The RN added the resident had always been allowed to go outside without supervision, so she just didn't think the resident was an elopement risk. The RN stated the resident had called APS herself and requested to be admitted , so she just didn't think the resident would leave. On 05/19/16 at 1:20 p.m., the social service aide was asked if he had informed anyone else the resident had requested to be discharged on the morning of May 16th. He stated he had not mentioned it to anyone. At 1:25 p.m., the office employee was asked if she had informed anyone else the resident was requesting to be discharged on the morning of May 16th. She stated she had not. On 05/24/16 at 10:30 a.m., the APS caseworker was contacted by phone to inquire about the status of the resident. He stated the resident had been located near a casino at a food distribution center in Durant the previous day. He added she had been admitted to a local psychiatric hospital. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual physical examination, dated 12/15/15, documented, Interval History: High risk for elopement .General findings: .Alert and oriented to name only .Ambulation: Self independently .Level of care needed: 24 hrs (hours) supervision and assistance . admission orders [REDACTED]. A form, titled 15 Minute Visual Checks On Residents and dated 12/15/16, had no documentation to indicate the resident had been checked on from 5:15 a.m. to 7:00 a.m. The care plan, dated 12/15/15 and last revised 02/22/16, documented, Problem/Need High Elopement risk d/t hx (history). 12/18/15 Confused wants to go home. 12/19/15 Packing bags. 12/20/15 Pushing on doors. 12/22/15 elope - across street in park o/ (no) injury. 1/31/16 resident found in park o/ injury - placed on 1:1 supervision. 2/22/16 On 15 min checks - all staff assist to identify location. Goal Resident will be in safe environment and maintain whereabouts by staff Resident/family will be made aware of sign out process Resident will be safe in her (sic) environment over the next 90 days. Approach .2) Monitor resident's whereabouts in the facility to ensure safe environment. 3) Remove resident from areas where there is overstimulation that agitates or confuses resident when wondering (sic) 8) elopement assessment. 9) redirect pacing visual checks as ordered. Date Reviewed 1/12/16 - Packing belongings - trying to head 'home.' Problem/Need (Resident) has behavioral problems related to Dx ([DIAGNOSES REDACTED]. 12/18/15 Problem/Need Increased confusion wants to 'go home.' Goals/Objectives (Resident) will experience a reduction in behavioral problems AEB (as evidenced by) decreased confusion, fear, aggression, anxiety, psychological problems, secrecy, or compulsive behaviors by review date. Approaches Evaluate reasons for behavioral problems. Elope risk/paces . Problem/Need Impulsive Behavior pacing . Goal Resident will be easily redirected by staff for the next 90 days. Resident will have fewer than 10 episodes of impulsive behaviors over the next 90 days. Approach .6) Monitor for increase in behaviors, and assess the cause .8) Try to identify causes of the impulsive behaviors, and eliminate. An admission comprehensive assessment, dated 12/16/15, documented the resident was oriented to name only, was forgetful, had a history of [REDACTED]. The assessment further documented the resident was independent with ambulation. Social Progress Notes, dated 12/21/15, documented, .Res (resident) is an elopement risk @ (at) this x (time). A form, titled 15 Minute Visual Checks On Residents, dated 12/21/16, had no documentation to indicate the resident had been checked on from 6:15 p.m. to 6:45 p.m. A form, titled 15 Minute Visual Checks On Residents, dated 12/22/16, documented the resident eloped from the facility at 12:45 p.m. A nurse's note, dated 12/22/15 at 12:45 p.m., documented, During Q15 (every 15) min (minute) checks res (resident) wasn't found in facility. Res found across street from facility walking in park. Res re-turned without further incident . A form, titled 15 Minute Visual Checks On Residents, dated 12/24/16, had no documentation to indicate the resident had been checked on from 5:15 a.m. to 7:00 a.m. A nurse's note, dated 12/24/15 at 4:30 p.m., documented, Res cont on Q15 min checks c/ no elopement attempts noted this evening. Res has paced facility and asked to go home. Q15 min visual checks continue. A form, titled 15 Minute Visual Checks On Residents, dated 12/29/16, had no documentation to indicate the resident had been checked on from 5:30 a.m. to 7:00 a.m. A Treatment Record for January 2016 documented, Check res q 15 min D/T elopement risk. A form, titled 15 Minute Visual Checks On Residents, dated 01/02/16, had no documentation to indicate the resident had been checked on from 4:00 p.m. to 6:45 a.m. A form, titled 15 Minute Visual Checks On Residents, dated 01/12/16, had no documentation to indicate the resident had been checked on from 4:15 a.m. to 7:00 a.m. A nurse's note, dated 01/12/16 at 7:15 a.m., documented, Res refusing to come to breakfast, found in room packing his belongings. After several minutes res encouraged and redirect to breakfast @ this time. Cont (continue) on Q15 min checks d/t elopement risk. A nurse's note, dated 01/12/16 at 6:30 p.m., documented, Res has been @ front door numerous times this shift trying to leave out c staff and visitors. Redirect throughout shift. A form, titled 15 Minute Visual Checks On Residents, dated 01/20/16, had no documentation to indicate the resident had been checked on from 5:30 a.m. to 7:00 a.m. A nurse's note, dated 01/31/16 at 2:55 p.m., documented, Received call from county dispatch park ranger returning resident from park. Resident last visualized in facility @ 1440 (2:40 p.m.) found in park at 1455 (2:55 p.m.) by park ranger. No injuries, resident stated he was walking and trying to return to facility .Placed on 1:1 (one to one) supervision until anxiety level decreases and no further talk of walking from facility. physician's orders [REDACTED]. A form, titled 15 Minute Visual Checks On Residents, dated 02/06/16, had no documentation to indicate the resident had been checked on at 7:00 a.m. A form, titled 15 Minute Visual Checks On Residents, dated 02/16/16, had no documentation to indicate the resident had been checked on from 6:45 a.m. to 7:00 a.m. 15 Minute Visual Checks On Residents forms for 02/01/16 through 02/05/16, 02/07/16 through 02/15/16, and 02/17/16 through 02/29/16 were not provided by the facility. A form, titled 15 Minute Visual Checks On Residents, dated 03/03/16, had no documentation to indicate the resident had been checked on from 6:15 a.m. to 7:00 a.m. A nurse's note, dated 03/09/16 at 1:00 p.m., documented, New orders to discharge res with meds (medications) and personal belongings 03/10/16. A nurse's note, dated 03/09/16 at 6:00 p.m., documented, Res has cont on Q15 min checks for elopement risk c no attempts noted. Wander guard bracelet remains in place to Rt (right) wrist. A nurse's note, dated 03/09/16 at 8:00 p.m., documented, Pacing - continues c wander guard wrist band. Cont on Q15 min cks (checks). No elopement attempts noted. physician's orders [REDACTED]. A Treatment Record for March 2016, documented, Check placement of wander guard bracelet to Rt wrist q shift. The order was dated 03/03/16. A Discharge Summary dated 03/16/16 documented, .Res was ambulatory, oriented to name .Res had a long history of elopement attempts and did have one elopement while here at this facility . 15 Minute Visual Checks On Residents forms for 03/01/16, 03/02/16, and 03/04/16 through 03/10/16 were not provided by the facility. On 05/18/16 at 2:10 p.m., an interview was conducted with the DON and RN #1 regarding the resident and his elopement from the facility prior to his discharge. They were asked where the resident went when discharged from the facility. RN #1 stated the resident was sent to (Name withheld) facility. She stated the facility had a secure unit with a secure outside area where the resident could wander around safely. They were asked about the resident's elopement from the facility. RN #1 stated the resident didn't get too far, one of the staff observed him standing at the entrance to the park and brought him back to the facility. They were asked if the facility was aware the resident was an elopement risk prior to his admission to the facility. RN #1 stated the resident had resided in the facility prior to this admission, so the facility was aware of the resident's elopement risk. They were asked what interventions the facility had put into place to prevent the resident from eloping from the facility. The DON stated they implemented visual checks every 15 minutes and later implemented an alarm bracelet. The DON was asked if the facility assessed the resident as an elopement risk. She stated, Yes. 3. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/22/16, documented the resident had short term memory problems, had moderately impaired cognitive skills for daily decision making, fluctuating inattention, disorganized thinking, wandered daily, and had delusions. The assessment documented the resident was independent with ambulation. The resident's care plan, dated 01/22/16 and revised on 04/28/16, documented, Problem/Need Resident deemed at risk for Wandering as evidenced by: New admission to facility Is ambulatory Resistant to being placed in longterm care facility Taking medication which may cause confusion/disorientation Dementia/Alzheimers Other: Specify Pacing/wander/elope risk Goal Will be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over next 90 days. Resident will not wander outside the facility for the next 90 days. Approach 1) Observe and document residents location q (every) 2hours. 2) Report any attempts to exit the facility to the IDT (interdisciplinary team), family & (and) MD (Medical Doctor) as indicated and record in the clinical record. Visual checks PRN as ordered q 15 min checks. Provide diversional act. (activity) PRN Walk to park c resident. Problem/Need 1/22/16 - Resident has an history of wandering and is an elope risk 1/30/16 - Increased elope risk - trying to get out 1/31/16 - elope noted - across st. (street) in park. Goal Resident will be in safe environment and maintain whereabouts by staff resident/family will be made aware of sign out process Resident will be safe in her environment over the next 90 days. Approach .2) Monitor resident's whereabouts in the facility to ensure safe environment. 3) Remove resident from areas where there is over stimulation that agitates or confuses resident when wandering 8) elopement assessment 9) walk c resident outside provide diversional act. of choice Visual checks as ordered. A facility Wander Data Collection Tool, dated 01/22/16, documented the resident answered seven questions with a yes response. The tool's scoring instructions documented three or more yes responses indicated the resident was a definite elopement risk. The back page of the tool had a hand written summarization which documented, Res (resident) is a new admit c (with) hx (history) of elopement attempts. Res does seem to watch the doorways freq (frequently). Does not verbally say he wants to go home. A nurse's note, dated 01/23/16 at 4:00 a.m., documented, res pacing facility this shift refused to go to bed this shift, no anxiety observed, q 15 checks in place c no elopement attempts noted . At 5:00 a.m. a nurse's note documented, res standing @ front door pushing and pulling on door, res redirected easily c improvement @ this time. A nurse's note, dated 01/26/16 at 2:45 p.m., documented, Res observed several times this shift @ doors trying to get out. Res saying he wants to go home. Reminded resident that he now lives here and showed res his room and belongings several times. Res continues on Q 15 min check d/t (due to) elopement risk. A nurse's note, dated 01/30/16 at 10:20 p.m., documented, Standing at front entrance, shaking the door, redirected to room for feet tx (treatment), easily. A nurse's note, dated 01/31/16 at 11:45 a.m., documented, Res not found in facility @ this time for Q 15 min checks. Res seen by staff through front doors across street in park @ this time. Staff went and got res. Res easily redirected back into facility. No injuries noted A nurse's note, dated 01/31/16 at 6:40 p.m., documented, Res kept in staff visual field since lunch; no attempts to leave facility A nurse's progress note, dated 02/20/16, documented the resident was oriented to name only, ambulated independently, did not interact with others, unhappy and isolated self, withdrawn, and had a problem behavior of high elopement risk with Q 15 minute checks. A Social Service Progress note, dated 02/22/16, documented, Res adjusting to facility but is an elopement risk @ this X (time). Res on 15 min visual checks. Staff helps by taking him outside when weather permits . A form, titled 15 Minute Visual Checks On Resident, dated 03/12/16, had n