Every finding on record at Cedarcrest Care Center

Based on record review and interview, the facility failed to ensure initial competencies were completed upon hire for 3 (CNA #5, CNA 10, and CNA #11) of 6 sampled employees reviewed for staff competencies.The DON identified 14 licensed staff members that should have initial competencies completed.Findings:1.The employee file for CNA #5 showed a hire date of 04/11/25 and a competency/skills checklist was not completed upon hire. 2. The employee file for CNA #10 showed a hire date of 12/02/25 and a competency/skills checklist was not completed upon hire.3. The employee file for CNA #11 showed a hire date of 09/25/25 and a competency/skills checklist was not completed upon hire.On 03/04/26 at 9:28 a.m., the business office manager stated there were no skills checklists/competencies for the requested files.On 03/04/26 at 11:03 a.m., the DON stated they should be doing initial skills competencies on staff and did not know why they were not completed.

Based on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours per day for 2 (Quarter 3 2024 and Quarter 4 2024) of 4 PBJ reports reviewed for RN coverage. The DON identified 60 residents resided in the facility. Findings: A PBJ Staffing Data Report, dated 04/01/24 through 06/30/24, showed during quarter three the facility did not have RN coverage for 04/15/24, 04/21/24, 04/27/24, 06/15/24, 06/22/24, or 06/23/24. A PBJ Staffing Data Report, dated 07/01/24 through 09/30/24, showed during quarter four the facility did not have RN coverage for 08/03/24, 08/04/24, 08/11/24, 09/28/24, or 09/29/24. On 05/22/25 at 10:40 a.m., the business office manager stated the facility did not have documentation of RN coverage for the above listed dates. On 05/22/25 at 11:48 a.m., the resident care coordinator stated if the scheduled RN called in for a shift they notified the DON and the administrator. They stated they reviewed the above listed dates and they did not have RN coverage for those dates. On 05/22/25 at 12:16 p.m., the DON stated they had reviewed the dates listed above for RN coverage. The DON stated the facility had not had an RN working on the above listed dates.

Based on observation and interview, the facility failed to ensure daily staffing was posted in a place which was readily accessible to residents and visitors for three (05/20/25, 05/21/25, and 05/22/25) of four days during the survey. The DON identified 60 residents resided in the facility. Findings: On 05/20/25 at 12:30 p.m., posted daily nurse staffing was not observed. On 05/22/25 at 11:53 a.m., posted daily nurse staffing was not observed. On 05/22/25 at 11:54 a.m., the DON stated they kept daily nurse staffing behind the two nurses stations at the facility. They stated they did not post the information in an area which was accessible to residents or visitors.

Based on record review and interview, the facility failed to ensure a facility-wide assessment had been completed annually. The DON identified 60 residents resided in the facility. Findings: A Facility-Wide Assessment showed the date of the assessment was 07/18/22. On 05/20/25 at 11:54 a.m., during the entrance conference, the facility assessment was requested from the DON and the resident care coordinator. On 05/22/25 at 12:22 p.m., the DON stated they had forgotten to provide the facility assessment and was not sure what the facility assessment was. On 05/22/25 at 12:28 p.m., the business office manager stated they would check with the administrator for an updated facility assessment. On 05/22/25 at 2:32 p.m., the administrator stated they did not know how often the facility-wide assessment was to be completed. The administrator stated they did not utilize the facility-wide assessment. On 05/22/25 at 2:37 p.m., the administrator stated they had checked with the business office manager and the last facility-wide assessment completed was the one provided to the survey team, dated 07/18/22.

Based on record review and interview, the facility failed to maintain a bond equal to or in excess of the resident trust account balance. The business office manager identified 23 residents with funds in the facility's resident trust fund. Findings: On 05/27/25, three months of bank statements for the residents' trust was reviewed. The bank statements showed February 2025's highest daily balance was $90,899.45, March 2025's highest daily balance was $97,788.97, and April 2025's highest balance was $109,822.58. On 05/27/25 at 5:20 p.m., the business office manager provided evidence of a surety bond in the amount of $10,000.00. On 05/27/25 at 5:20 p.m., the business office manager stated the bond did not cover the residents' trust balance.

Based on observation, record review, and interview, the facility failed to implement infection control measures for residents with medical devices for 3 (#17, #37 and #162) of 4 sampled residents observed for infection control. The roster matrix, dated 04/20/25, identified eight residents in the facility with catheters. Findings: Facility signage showed enhanced barrier precautions (EBP) were defined as wearing a gown and gloves. An undated facility policy titled Enhanced Barrier Precautions showed EBP was to be used for residents with indwelling medical devices and wounds when: a. dressinng or bathing, b. transferring, c. changing linens, d. assisting with toileting, e. accessing indwelling medical devices, f. providing wound care, and g. other high contact resident care activities. 1. On 05/22/25 at 9:25 a.m., peg site care was observed for Resident #37. LPN #1 donned gloves for care. They did not don a gown as required by EBP protocols. A quarterly MDS, dated [DATE], showed Resident #37 had a BIMS of 03 which was indicative of severe cognitive impairment and diagnosis which included Alzheimers disease. On 05/27/25 at 8:39 a.m., LPN #1 stated the resident was not on enhanced barrier precautions. They stated only gloves were required during care. On 05/27/25 at 11:51 a.m., the resident was observed in their room. Their catheter tubing was laying on the floor. On 05/27/25 at 12:11 p.m., the ADON stated catheter bags and tubing should not touch the floor. 2. On 05/27/25 at 8:48 a.m., Resident #17 was observed in the dining room. Their catheter tubing was resting on the floor. On 05/27/25 9:05 a.m., Resident #17 observed in their room. Their catheter tubing was on the floor underneath their wheelchair. A quarterly MDS, dated [DATE], showed Resident #17 had a BIMS score of 11 which was indicative of moderate cognative impairment and diagnosis which included urogenital implants. 3. On 05/20/25 at 2:33 p.m., Resident #162 was observed in bed. Their catheter bag was hanging on the bed with the catheter tubing resting on the floor. CNA #1 was observed to empty the catheter bag and leave the room. The catheter tubing was left resting on the floor mat. On 05/22/25 at 9:46 a.m., peg site care was observed for Resident #162. LPN #2 washed their hands and donned gloves. LPN #2 removed the old dressing, cleansed the site, and applied a new dressing. LPN #2 did not wear a gown during peg site care. On 05/27/25 at 9:15 a.m., Resident #162's catheter bag was observed hanging from the recliner with the tubing resting on the floor. On 05/27/25 at 1:44 p.m., CNA #1 stated they were to wash their hands before and after emptying the catheter bag, they wore gloves while they emptied it, and the tubing should not be touching the floor. A quarterly MDS, dated [DATE], showed Resident #162 had a BIMS of 2 which indicated severe impairment in daily decision making and had diagnosis which included nontraumatic intracerebral hemorrhage. On 05/27/25 at 4:47 p.m., resident care coordinator #1 stated the facility did not wear EBP for all care that involveed catheter care, wound care, or feeding tubes. They stated, Should we be? I feel like I just don't understand the EBP at all.

Based on record review and interview, the facility failed to inform a resident on psychotropic medications the risk, benefits, and alternative treatment options for 1 (#57) of 5 sampled residents whose clinical records were reviewed for unnecessary medications. The ADON identified 10 residents on psychotropic medications. Findings: A physician's order summary, dated May 2025, showed Resident #57 had orders for risperidone (an antipsychotic) 0.5mg twice daily, trazodone (an antidepressant)100mg every night, and lithium (a mood stabilizer) 150mg every night. Resident #57 had diagnoses which included paranoid schizophrenia, and unspecified mood [affective] disorder. The clinical record for Resident #57 was reviewed. There was no documentation the resident or the resident's representative was informed of the risks and benefits of the use of psychotropic medications, of the treatment alternatives/options, and the choice of treatment the resident preferred. On 05/22/25 at 3:29 p.m., the ADON stated Resident #57 did not have documentation they or their representative were informed of the risk and benefits of the psychotropic medications the resident was taking.

Based on observation, record review, and interview, the facility failed to ensure residents were free from physical restraint for one (#41) of one residents observed for physical restraints. The ADON identified nine residents who utilized Broda chairs in the facility. Findings: On 05/21/25 at 1:18 p.m., Resident #41 was in a Broda chair (lounger style chair with head and foot support and the ability to sit upright or recline) positioned to run closely along the wall and with a pillar near the back of the Broda chair. The resident was facing a table which was positioned along the same wall, but was out of reach of the resident. The resident was in constant motion, wiggling in the chair, reaching outward toward other residents, and twisting their buttock in the seat of the Broda chair. The resident crossed their legs, placing the right leg over the left arm rest, and stretched the right leg out, flexing their toes back and forth as they extended their leg. The resident bounced their leg up and down before uncrossing their legs and repeating the motions. On 05/21/25 at 1:35 p.m., Resident #41 was in a Broda chair position closely along the wall and with a pillar to the back of the Broda chair. The wheels of the Broda chair were locked and not in reach of the resident. The table was pulled up close to the resident and covered the resident's legs and a portion of the arm rests of the Broda chair, confining the resident to a limited space. The resident was in constant motion, wiggling in the chair, twisting their buttock in the seat of the Broda chair, and reaching out toward other residents. Their movements were limited by the table and the resident was unable to push themselves away from the table due to the locked wheels. The resident extended the trunk and arms of their body over the left arm rest, reaching out toward the resident/staff nearest them. The resident could not cross their legs, throw their leg over the arm rest, nor twist their buttock to the same extent as they did when the table was not present. The resident voiced constant incoherent and repetitive chanting, often in a sing-song tone. On 05/21/25 at 1:56 p.m., Resident #41 was in a Broda chair position closely along the wall and with a pillar to the back of the Broda chair. The wheels of the Broda chair were locked and the locked wheels were not in reach of the resident. The table was pulled up close to the resident and covered the resident's legs and a portion of the arm rests of the Broda chair, confining the resident to a limited space. The resident was in constant motion, as they moved about the chair, but their movement was limited by the table and the chair's locked wheels. The resident extended the trunk and arms of their body over the left arm rest, reaching out toward the resident/staff nearest them. The resident could not cross their legs, throw their leg over the arm rest, nor twist their buttock to the same extent as they did when the table was not present. The resident voiced constant incoherent and repetitive chanting, often in a sing-song tone. On 05/21/25 at 3:08 p.m., Resident #41 was in the common area, in same corner/along the same wall with the back left wheel locked, the right rear side of the Broda chair blocked by the pillar, and table pushed up over the arm rests of the Broda chair and up to the resident. The resident had their arms positioned on top of the table. The resident's constant incoherent and repetitive chanting sounded calmer with the tone softer and cadence slower. The resident's legs were not in constant motion as with earlier observations, but the resident's motion was still limited by the locked wheels of the Broda chair, the pillar positioned behind the Broda chair, and the table positioned close to the resident. On 05/21/25 at 4:35 p.m., Resident #41 was still in the common area, in the same corner, along the same wall, with the back wheels locked and the table pushed up over the arm rests of the Broda chair. The resident chewed on their transfer sling, which the resident pulled partially out from under their left side. There were no staff present in the common area or in sight of the resident. After a few minutes, a CNA entered the common area and escorted another resident to the dining room, leaving the Resident #41 unsupervised while they chewed on their transfer sling. On 05/21/25 at 4:42 p.m., Resident #41 was observed in the dining room being assisted with their evening meal. On 05/22/25 at 8:50 a.m., Resident #41 was in the common room, in a Broda chair with the rear wheels locked, positioned closely beside a wall, with a pillar positioned behind the Broda chair, and a table pushed tightly over the arm rest of the Broda chair. The resident was in constant motion and moved about the chair, but their movement was limited by the table and chair's locked wheels. The resident voiced constant incoherent and repetitive chanting. On 05/22/25 at 9:50 a.m., Resident #41 was in the common room, in a Broda chair with the rear wheels locked, positioned closely beside a wall, with a pillar positioned behind the Broda chair, and a table pushed tightly over the arm rest of the Broda chair. The resident was in constant motion and moved about the chair, but their movement was limited by the table and chair's locked wheels. The resident was chewing on their transfer sling which the resident had pulled partially out from under their left side. On 05/22/25 at 4:00 p.m., Resident #41 was in the common room, in a Broda chair, with the rear wheels of the chair locked, the chair positioned closely beside a wall, with a pillar behind the back of the chair, and a table positioned in reach of the resident. The resident had both legs positioned on top of the table with their legs crossed. There were no staff present or in sight of the common room. On 05/27/25 at 8:42 a.m., Resident #41 was in the common room, in a Broda chair with the rear wheels locked, positioned closely beside a wall, with a pillar positioned behind the Broda chair, and a table pushed tightly over the arm rest of the Broda chair. The resident was in constant motion and moved about the chair, but their movement was limited by the table and locked wheels. The resident was chewing on their transfer sling which the resident had pulled partially out toward their left side until they were able to chew on the harness. On 05/27/25 at 1:30 p.m., Resident #41 was in the common room, in a Broda chair with the rear wheels locked, positioned closely beside a wall, with a pillar positioned behind the Broda chair, and a table pushed tightly over the arm rest of the Broda chair. The resident was antsy and moved about the chair, but their movement was limited by the table and locked wheels. The resident voiced constant incoherent and repetitive chanting. ON 05/27/25 at 3:07 p.m., Resident #41 was in the common room, in a Broda chair with the rear wheels locked, positioned closely beside a wall, with a pillar positioned behind the Broda chair, and a table pushed tightly over the arm rest of the Broda chair. The resident was antsy and moved about the chair, but their movement was limited by the table and locked wheels. The resident was chewing on their transfer sling which the resident had pulled partially out toward their left side until they were able to chew on the harness. Other residents in the common room were eating popcorn and playing BINGO. There was no food or fluids within reach of Resident #41. On 05/27/25 at 3:15 p.m., Resident #41 was in the common room in a Broda chair with the table pushed tight against the resident's chair and the rear wheels of the chair locked. On 05/27/25 at 3:30 p.m., LPN #2 pointed to a low metal and vinyl chair and stated that was a Broda Peddler. The Broda Peddler chair allowed for a resident's feet to touch the floor so the resident could pedal with their feet for mobility within the facility. The annual assessment, dated 04/21/25, showed the resident had diagnoses which included non-traumatic brain dysfunction, mood/affective disorder, anxiety, depression, and dementia. The assessment showed the resident was sometime understood by others and could sometimes understand others when they spoke and was severely impaired in daily decision making. The assessment showed the resident displayed inattention and an altered level of consciousness but did not display physical or verbal behaviors toward others. The assessment showed the resident did not reject care nor wander. The assessment showed the resident had no impairments in range of motion in their arms or legs and did not use a can/crutch, walker, wheelchair, or limb prosthesis. The assessment showed the resident received hospice services and was depended in activities of daily living. The assessment showed the resident was not restrained nor was a motion alarm used on the resident. The physician's order summary, dated 05/27/25, read in part, Broda Peddler for mobility and comfort. The physician's order summary showed the physician ordered the Broda Peddler on 08/26/24. On 05/27/25 at 3:15 p.m., CNA #2 stated it was someone on the day shift that positioned the table against the arm rests of Resident #41's Broda chair. CNA #2 stated they did not know what a Broda Peddler chair looked like and the resident had used this chair since moving to the hall they resided on. CNA #2 stated they thought the table was positioned again the resident's chair with the rear wheels of the chair locked to limit the resident's movement so the resident could not raise their leg over the side of the chair. CNA #2 stated in the past, the resident attempted to stand on the foot of the Broda chair. CNA #2 stated they thought this may have factored into why someone would position the table so close to the resident. CNA #2 stated the table and the locked wheels of the chair limited the residents movement so the resident would not attempt to get out of the chair and fall. On 05/27/25 at 3:30 p.m., LPN #2 stated Resident #41 transferred from the facility's locked unit. LPN #2 stated in the past, the resident was ambulatory, but now required the use of a lift to transfer. LPN #2 stated the resident grabbed at people and chewed on anything in reach, which included Styrofoam cups, the arm off of a baby doll, and their transfer sling. LPN #2 stated the resident had an order for a Broda Peddler. LPN #2 stated the resident transferred to them in the Broda chair they were in and thought the resident would do better in a Broda Peddler. LPN #2 looked at Resident #41 and stated the resident was restrained. LPN #2 stated the wheels of the Broda chair were locked, the chair was positioned with the pillar directly behind the chair, and the resident pushed up to the table. LPN #2 stated the resident's knees were in contact with the underside of the table. LPN #2 repeated the resident was restrained. LPN #2 stated they did not document the resident was restrained. On 05/27/25 at 3:45 p.m., the ADON exclaimed, Oh that's a restraint! The ADON stated it was obvious the restraint was restrained. The ADON stated the resident chewed on anything they could reach, including Styrofoam cups. The ADON stated the staff positioned the resident with the table to the arm rests of the resident's chair so the floor staff did not have to supervise the resident. On 05/27/25 at 4:05 p.m., the DON stated it sounded like the resident was restrained and not supervised. The DON stated the facility policy was not to restrain the residents. The DON stated the resident needed to return to the locked unit.

Based on record review and interview the facility failed to recognize and submit a report of abuse within 2 hours for 2 (#30 and #212) of 2 sampled residents reviewed for abuse. The DON identified 60 residents resided in the facility. Findings: A facility policy titled Abuse Prevention and Procedure, dated 04/07/25, read in part, all violations involving allegations of abuse, neglect, mistreatment, including injuries of unknown source, and misappropriation of resident property are to be reported immediately, but no more than two hours after the allegation was made. An initial incident report made to the OSDH, dated 03/13/25, showed an unwitnessed resident to resident incident that occurred on 03/12/25. The report showed Resident #30 was in Resident #212's room when staff heard a boom and found Resident #30 on the ground. Resident #30 was assessed for injuries and none were found. Resident #212 was sent out of the facility for a psychiatric evaluation. On 05/22/25 at 12:18 p.m. the resident care coordinator stated the facility needed to send a report of abuse within two hours of the incident. On 05/22/25 at 12:28 p.m. the DON stated they filed the incident report as soon as they were made aware of the incident. They stated the report was marked as reporting as certain injuries, but should have been marked as abuse because it involved a resident to resident altercation. The DON stated the incident should have been recognized as abuse and reported as abuse. The DON stated all incidences involving potential abuse should be reported to the OSDH within two hours.

Based on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation of the resident's stay and follow-up instructions was completed for 1 (#61) of 2 sampled residents who were reviewed for discharges. The DON identified one resident who had been discharged to another facility in the past three months. Findings: An admission assessment, dated 12/10/24, showed Resident #61 had a BIMS score of 07, which indicated the resident was moderately impaired in cognition for daily decision making and had a diagnosis of dementia. A nurse progress note, dated 03/07/25 at 2:38 p.m., showed the resident was discharged and paperwork had been sent to the receiving facility. A Discharge Summary, dated 03/07/25, showed Resident #61 had been discharged to another facility to live with their significant other. The discharge summary read in part, If discharged : Condition of Discharge, Follow-Up Instructions to Resident. This section of the form was blank. The discharge summary did not include a recapitulation of the resident's stay. On 05/22/25 at 2:54 p.m., the DON stated they did not know why the nurse had not documented a recapitulation of the resident's stay or follow up instructions. The DON stated they had reviewed the discharge summary and signed off on it, but had not noticed it was not completed with the required information.

Based on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 (#51) of 9 sampled residents who were reviewed for baseline care plans. The DON identified 60 residents resided in the facility. Findings: A significant change assessment, dated 05/14/25, showed Resident #51 had a diagnosis of diabetes mellitus, had a BIMS score of 11 which indicated the resident was moderately impaired in cognition for daily decision making, and had an original admission date of 04/04/24. Review of the electronic clinical record did not show a baseline care plan was developed for Resident #51. On 05/22/25 at 9:12 a.m., the resident care coordinator stated the nurses had not been completing baseline care plans. The resident care coordinator stated they had completed some baseline care plans for recent admissions. They stated there was not a baseline care plan developed for Resident #51. On 05/22/25 at 2:52 p.m., the DON stated they had not been monitoring to ensure baseline care plans had been completed within 48 hours of admission. They stated they had reviewed the electronic clinical record and a baseline care plan had not been developed for Resident #51.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed to include a restorative plan for 1 (#51) of 3 sampled residents whose care plans were reviewed. The DON identified 60 residents resided in the facility. Findings: On 05/22/25 at 8:53 a.m., Resident #51 was observed ambulating from the dining room using a walker. A physical therapy summary document showed skilled services were provided to Resident #51 from 03/03/25 to 04/01/25. A significant change MDS, dated [DATE], showed the resident had a BIMS score of 12 which indicated moderate cognitive impairment for daily decision making, and had diagnoses which included macular degeneration and dementia. A restorative progress note, dated 05/19/25 at 2:13 p.m., read in part, All walk program with assuasive device as tolerated Encouraged to walk in hallway more and resident has been doing some LE [left extremity] exercises at rail as tolerated and allowed has been refusing at times will continue to encourage Also encouraged to do UE [upper extremity] exercises with theraband. Current physician orders were reviewed and there were no current orders for restorative therapy were found. On 05/27/25 at 2:23 p.m., the DON stated the restorative aide got instructions on what to do from physical therapy. On 05/27/25 at 3:15 p.m., the care plan coordinator stated the aide did active and passive restorative care. They stated restorative care was not included in the care plan for any of the residents because the plan was so individualized. The care plan coordinator stated they guessed they should add restorative care to care plans. On 05/20/25 at 2:46 p.m., Resident #51 stated physical therapy used to work with them, but no longer did. On 05/27/25 at 2:08 p.m., Resident #51 stated they walked to the dining room every day and then the aide walked with them. Resident #51 stated the physical therapist used to work with them, but now the restorative aide worked with them. Resident #51 stated they would like to have therapy again. On 05/27/25 at 2:22 p.m., the restorative aide stated therapy had verbal communication on what was to be done with each resident. On 05/27/25 at 3:53 p.m., the DON stated Resident #51 did not have a restorative plan. They stated they had never seen a restorative plan for any resident. The DON stated they thought the physical therapy department handled all of that.

Based on observation, record review, and interview, the facility failed to ensure enteral feeding were labeled for 1 (#37) of 2 sampled residents who were reviewed for enteral tube feedings. The DON identified two residents had enteral tube feedings. Findings: On 05/21/25 at 11:29 a.m., Resident #51 was observed in bed. A feeding pump was observed with a bag of tan liquid and a bag of clear liquid infusing at 50 mls per hour. The bags were not observed to be labeled or dated. On 05/21/25 at 4:41 p.m., Resident #51 was observed to be assisted from the dining area to their room. The feeding pump was observed with a bag of tan liquid and a bag of clear liquid infusing at 50 mls per hour. The bags were not observed to be labeled or dated. On 05/22/25 at 8:05 a.m., Resident #51 was observed in bed. The feeding pump was observed with a bag of tan liquid and a bag of clear liquid infusing at 50 mls per hour. The bags were not observed to be labeled or dated. A feeding syringe, in a bag, dated 05/19/25, was observed hanging on the enteral feeding pump. On 05/22/25 at 9:28 a.m., LPN #1 observed the feeding pump and the two, unlabeled bags of liquid. They observed the feeding syringe, dated 05/19/25. The policy titled, Enteral Tube Feeding via Continuous Pump, dated December 2011, read in part, Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID [identification] and room number; b. Type of formula; c. Date and time formula was prepared; d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe); and g. Rate of administration (mL/hour). A physician order, dated 11/25/24, read in part, Give Isosource 1.5 at 50cc continous [sic] every shift for feeding. A physician order, dated 11/27/24, read in part, Change feeding /flush bags and syringe out with new set-up Q 24 hours.date, initial and mark time each change. A physician's order, dated 12/26/24, read in part, Free water bolus of 200cc Q 6 hours.programmed into pump every 6 hours for Water bolus. A quarterly assessment, dated 02/15/25, showed the resident had a BIMS score of 03, which indicated the resident was severely impaired in cognition for daily decision making, had an enteral feeding tube, and had a diagnosis of Alzheimer's disease. On 05/22/25 at 9:28 a.m., LPN #1 stated Resident #51 received Isosource at 50 mls per hour and a water flush. They stated they thought the night shift nurse had hung the bags at 6:00 a.m., but was not sure. They stated they were supposed label and date the enteral tube feeding formula and the water. LPN #1 stated the feeding syringe was dated 05/19/25 and needed to be replaced. On 05/22/25 at 9:32 a.m., the DON stated they were supposed to label the name of the formula/water, date and time it was hung, nurse's initials, and the rate of infusion on the bags. The DON stated the feeding tube syringe was dated 05/19/25 and needed to be discarded.

Based on record review and interview, the facility failed to ensure a clinical rationale from the physician was provided on a gradual dose reduction request for an antianxiety medication for 1 (#29) of 5 sampled residents who were reviewed for unnecessary medications. The DON identified eight residents were ordered an antianxiety medication. Findings: A Medication Regimen Review, dated 03/19/25, read in part, lorazepam [a benzodiazepine] 0.5mg bid [twice daily] lorazepam 0.5mg q 4 hours prn [as needed].Do you feel that this resident is stable enough to tolerate a trial reduction of either of the above medications at this time? If not, please provide your clinical rationale. The medication regimen review showed the physician had documented continue on the form. The medication regimen review did not show a documented clinical rationale to continue the medication. A quarterly assessment, dated 04/03/25, showed the resident had a BIMS score of 03 which indicated the resident was severely impaired in cognition for daily decision making, had a diagnosis of Alzheimer's disease, and received an antianxiety medication. A care plan, revised 05/06/25, showed the resident received an antianxiety medication. The care plan, read in part, Consult with pharmacy. MD [medical doctor] to consider dosage reduction when clinically appropriate. On 05/27/25 at 9:26 a.m., the DON stated they reviewed and discussed medication regimen reviews with the physician to ensure a clinical rationale was provided when necessary. They stated they had missed that one in reference to the medication regimen review, dated 03/19/25, for Resident #29. They stated they did not know why a clinical rationale had not been provided or discussed.

Based on record review and interview, the facility failed to thoroughly investigate an injury of unknown origin for 1 (#4) of 4 sampled residents reviewed for abuse. The assistant director of nursing reported 63 residents resided in the facility. Findings: An undated Abuse Prevention Policy and Procedure policy, read in part, an immediate investigation will be initiated into any allegation of abuse, neglect or misappropriation of resident property .1. The Director of Nursing/Wellness Director or designee will complete the investigation process and document the steps taken and the information obtained. Resident #4 had diagnoses which included Alzheimer's disease, dementia, anxiety, and delusional disorders. A quarterly minimum data set assessment, dated 12/22/24, showed the resident's brief interview for mental status score was 99, which indicated the resident could not participate in the interview. On 03/03/25 at 10:43 a.m., LPN #1 stated in October the nurse aides found Resident #4 with their top lip discolored and with bite marks underneath. LPN #1 stated, We don't know how it happened, it was not there the day before. We padded the wall in case they bumped their face on it, but it was not determined how it happened. LPN #1 stated family member #1 was notified and a report to OSDH [Oklahoma State Department of Health] was made. On 03/03/25 at 10:45 a.m., the DON stated the resident was found on the morning of 10/08/25 with a swollen and discolored top lip right at shift change. The DON stated, No body is taking ownership of it. If it was done by a mechanical lift it had to have been night shift because they get the resident up. I spoke with day shift, but did not document it and with the [name withheld], but I did not speak with night shift staff. I do not know what in services were done. There was not a skin assessment done during the investigation. On 03/03/25 at 12:30 p.m., the resident care coordinator stated it was not determined how the resident's lip was injured. They stated the DON was the abuse coordinator and was responsible for the investigations.

Based on record review and interview, the facility failed to provide an environment free of abuse. The facility daily census report identified 24 residents on the secured unit and 62 total residents. Findings: 1. Resident #1 had diagnoses which included Alzheimer's dementia. A behavior note, dated 01/20/24, documented Resident #1 was observed to push another resident to the floor. When asked why, Resident #1 replied that they deserved it. A behavior note, dated 01/27/24, documented Resident #1 pushed another resident who had wandered into Resident #1's room. When asked why, Resident #1 replied that it was the only way they would get the other resident out of their room. An incident note, dated 02/07/24, documented in part, .It was reported to this nurse, this res went into another res room last eve and had an altercation with another res .this res has a habit of going into the first room on left as [their] room is in the same place on a different hall .hard to redirect at times . A behavior note, dated 03/01/24, documented Resident #1 threw water on another resident and swung their arms and fists at staff. A progress note, dated 08/09/24 at 8:01 p.m., documented in part, .This nurse heard screaming from residents room. Upon arrival resident was seen choking another resident [Resident #2], laying in a supine position in room-mates bed. This nurse was able to separate aggressive resident and defuse situation. Resident was upset that another resident was in [their] room-mates bed . 2. Resident #2 had diagnoses which included a memory deficit following a cerebral infarction (stroke) and amnesia. An incident note, dated 08/09/24, documented in part, .This nurse heard screaming from another residents room. Upon arrival [Resident #2] was in another residents bed, laying in a supine position being choked by [Resident #1]. This nurse was able to pull resident to safety. [Resident #2] was purple colored w/ unsteady gait, and scratches on (L) [left] side of face and neck . An initial incident report, with an incident date of 08/09/24, documented it was faxed to the Oklahoma State Department of Health date of 08/10/24 at 12:31 p.m., and documented an incident of resident to resident abuse occurred on 08/09/24 between Resident #1 and Resident #2. On 08/22/24 at 12:50 p.m., LPN #1 stated on 02/08/24 they noticed scratches on a resident's arms and when asked, they pointed to Resident #1 and stated Resident #1 had entered the other resident's room and attacked them. LPN #1 stated they thought Resident #1 had wandered down the opposite hall and into a room they thought was theirs and attacked the other resident, thinking the other resident who actually resided in the room had intruded into their room. LPN #1 stated Resident #1 had more than a few instances of aggression which usually happened in the evening hours. LPN #1 stated Resident #1 was real protective of their roommate and had expressed that the roommate was their child. LPN #1 stated when Resident #1 saw Resident #2 was in the roommates bed, Resident #1 attacked Resident #2. LPN #1 stated when Resident #1 was aggressive, they tried to separate them from others and get them to relax in their recliner in their room and when Resident #1 was in the common room, the staff tried to keep the resident separated from others sitting in the chairs or on the couches. LPN #1 stated to help mitigate resident behaviors, they had organized activities scheduled for the day shift to keep residents busy but there were no organized activities scheduled for the evening shift. The LPN stated they did not know what interventions the evening shift used to mitigate resident to resident abuse. On 08/22/24 at 1:40 p.m., CMA #1 stated Resident #1 was aggressive with other residents, pushing them to the floor, tripping them, or otherwise physically attacking them. CMA #1 stated Resident #1 was better in the daytime hours but as the day continued would get more confused and agitated. The CMA stated to help any feelings of anxiety or agitation, they tried to keep all the residents engaged throughout the day with different activities. On 08/22/24 at 3:55 p.m., LPN #2 stated they were present when the resident to resident altercation occurred. The LPN stated they heard screaming and choking sounds coming from the hall and responded immediately by running down the hall where the sound originated. They stated it was a second choked scream which allowed them to find Resident #2 being choked by Resident #1. LPN #2 stated they immediately asked Resident #1 to stop and the resident complied. LPN #2 stated Resident #1 appeared to have a brief look of startlement as though they just realized what they were doing with their hands around the neck of Resident #2. LPN #2 stated they did not see Resident #2 wander into the other residents room or they would have redirected Resident #2 from wandering in there. On 08/22/24 at 4:00 p.m., CMA #2 stated the staff watched Resident #1 because the resident had tripped a number of other wandering residents as they past close to where Resident #1 sat and could get aggressive without warning or provocation. On 08/23/24 at 12:15 p.m., a family member for Resident #2 stated they had concerns about another resident choking their family member for wandering into a room and laying on the roommates bed. The family member stated they often see residents wandering in and out of other residents room and laying in one another's beds. They stated during many of their visits, they entered their family member's room only to find another resident laying in their family member's bed. The family member stated the staff were quick to respond but could not be everywhere. On 08/23/24 at 1:45 p.m., the DON was asked what was the root cause of the resident to resident abuse which occurred on 08/09/24. The DON stated Resident #2 wandered into the room of Resident #1 and layed down in the unoccupied bed of Resident #1's roommate. Resident #1 did not like Resident #2 being in the roommates bed and attacked. The DON stated the staff try to redirect residents who wander into other residents rooms and to keep the residents busy with activities. The DON said they were unsure if the evening shift had scheduled activities. The DON stated the current interventions had not kept Resident #2 from wandering into the room and being choked by Resident #1. 3. Resident #4 had diagnoses which included dementia with anxiety. A behavior note, dated 01/14/24 at 6:30 p.m., documented the resident started yelling, screaming, confronting, and attempting to pick fights with other residents. The note documented the resident required close observation for safety. A behavior note, dated 01/29/24 at 9:22 a.m., documented the resident would walk up to other residents and talk disrespectfully to them. A behavior note, dated 07/01/24 at 12:57 p.m., documented the resident walked up to another resident and struck them in the abdomen. The other resident then slapped Resident #4 twice in the face. A behavior note, dated 07/02/24 at 9:15 p.m., documented resident was yelling at other residents all shift and hitting staff when they attempted to help the resident. On 08/22/24 at 12:50 p.m., LPN #1 stated the staff watched Resident #4 closely because they were known to be verbally and physically aggressive toward other residents and staff, by cussing, screaming, grabbing, and hitting others without provocation. On 08/23/24 at 1:45 p.m., the DON was asked what the facility planned to do to extirpate abuse on the secured unit. The DON stated they had plans to remodel the unit and were looking at ways to make the environment more engaging and other ideas to reduce the wandering in and out of other residents' rooms. 4. Resident #3 had diagnoses which included dementia with other behavioral disturbances. An incident report, dated 08/16/24, documented on 08/15/24, CNA #1 was observed to repeatedly hit Resident #3 with a wet, soapy towel after the resident allegedly spit on CNA #1. A hand written note attached to the incident report, dated 08/19/24, documented CNA #3 entered the shower room and observed Resident #3 bleeding from their nose, cheek, and above an eye. The note documented when CNA #1 was asked what happened, CNA #1 responded in part, .[Resident #3] spit on me, you ain't think I beat [their] ass . On 08/21/24 at 2:30 p.m., CNA #2 stated they observed CNA #1 to antagonize Resident #3 by repeatedly flicking the resident's nose with their finger and making derogatory comments over and over about the resident's genitalia which agitated Resident #3 to the point the resident spat on CNA #1. CNA #2 stated after Resident #3 spat on CNA #1, CNA #1 grabbed a wet, soapy towel and continually snapped the towel toward the resident's face. CNA #2 stated they could see the resident's eyes were red and irritated from the soap and his nose was bleeding. CNA #1 stated they kept asking for CNA #1 to stop and let them assist the resident but CNA #1 continued until CNA #3 entered the shower room. CNA #2 stated they assisted Resident #3 with assistance from CNA #3 without further incidence. On 08/23/24 at 1:45 p.m., the DON stated to keep abuse from reoccurring, the facility would have two staff members assist Resident #3 with their shower.

Based on record review and interview, the facility failed to: a. provide an environment free from resident to resident abuse; and b. ensure staff accused of abuse did not have access to facility residents until the allegation was thoroughly investigated for one (Resident #3) of four residents reviewed for abuse investigation. The facility roster identified 62 residents. Findings: 1. Resident #1 had diagnoses which included Alzheimer's dementia. A behavior note, dated 01/20/24, documented Resident #1 was observed to push another resident to the floor. When asked why, Resident #1 replied that they deserved it. A behavior note, dated 01/27/24, documented Resident #1 pushed another resident who had wandered into Resident #1's room. When asked why, Resident #1 replied that it was the only way they would get the other resident out of their room. An incident note, dated 02/07/24, documented in part, .It was reported to this nurse, this res went into another res room last eve and had an altercation with another res .this res has a habit of going into the first room on left as [their] room is in the same place on a different hall .hard to redirect at times . A behavior note, dated 03/01/24, documented Resident #1 threw water on another resident and swung their arms and fists at staff. A progress note, dated 08/09/24 at 8:01 p.m., documented in part, .This nurse heard screaming from residents room. Upon arrival resident was seen choking another resident [Resident #2], laying in a supine position in room-mates bed. This nurse was able to separate aggressive resident and defuse situation. Resident was upset that another resident was in [their] room-mates bed . Resident #2 had diagnoses which included a memory deficit following a cerebral infarction (stroke) and amnesia. An incident note, dated 08/09/24, documented in part, .This nurse heard screaming from another residents room. Upon arrival [Resident #2] was in another residents bed, laying in a supine position being choked by [Resident #1]. This nurse was able to pull resident to safety. [Resident #2] was purple colored w/ unsteady gait, and scratches on (L) [left] side of face and neck . An initial incident report, with an incident date of 08/09/24, documented it was faxed to the Oklahoma State Department of Health date of 08/10/24 at 12:31 p.m., and documented an incident of resident to resident abuse occurred on 08/09/24 between Resident #1 and Resident #2. On 08/22/24 at 12:50 p.m., LPN #1 stated on 02/08/24 they noticed scratches on a resident's arms and when asked, they pointed to Resident #1 and stated Resident #1 had entered the other resident's room and attacked them. LPN #1 stated they thought Resident #1 had wandered down the opposite hall and into a room they thought was theirs and attacked the other resident, thinking the other resident who actually resided in the room had intruded into their room. LPN #1 stated Resident #1 had more than a few instances of aggression which usually happened in the evening hours. LPN #1 stated Resident #1 was real protective of their roommate and had expressed that the roommate was their child. LPN #1 stated when Resident #1 saw Resident #2 was in the roommates bed, Resident #1 attacked Resident #2. LPN #1 stated when Resident #1 was aggressive, they tried to separate them from others and get them to relax in their recliner in their room and when Resident #1 was in the common room, the staff tried to keep the resident separated from others sitting in the chairs or on the couches. LPN #1 stated to help mitigate resident behaviors, they had organized activities scheduled for the day shift to keep residents busy but there were no organized activities scheduled for the evening shift. The LPN stated they did not know what interventions the evening shift used to mitigate resident to resident abuse. On 08/22/24 at 1:40 p.m., CMA #1 stated Resident #1 was aggressive with other residents, pushing them to the floor, tripping them, or otherwise physically attacking them. CMA #1 stated Resident #1 was better in the daytime hours but as the day continued would get more confused and agitated. The CMA stated to help any feelings of anxiety or agitation, they tried to keep all the residents engaged throughout the day with different activities. On 08/22/24 at 3:55 p.m., LPN #2 stated they were present when the resident to resident altercation occurred. The LPN stated they heard screaming and choking sounds coming from the hall and responded immediately by running down the hall where the sound originated. They stated it was a second choked scream which allowed them to find Resident #2 being choked by Resident #1. LPN #2 stated they immediately asked Resident #1 to stop and the resident complied. LPN #2 stated Resident #1 appeared to have a brief look of statement as though they just realized what they were doing with their hands around the neck of Resident #2. LPN #2 stated they did not see Resident #2 wander into the other residents room or they would have redirected Resident #2 from wandering in there. On 08/22/24 at 4:00 p.m., CMA #2 stated the staff watched Resident #1 because the resident had tripped a number of other wandering residents as they past close to where Resident #1 sat and could get aggressive without warning or provocation. On 08/23/24 at 12:15 p.m., a family member for Resident #2 stated they had concerns about another resident choking their family member for wandering into a room and laying on the roommates bed. The family member stated they often see residents wandering in and out of other residents room and laying in one another's beds. They stated during many of their visits, they entered their family member's room only to find another resident laying in their family member's bed. The family member stated the staff were quick to respond but could not be everywhere. On 08/23/24 at 1:45 p.m., the DON was asked what was the root cause of the resident to resident abuse which occurred on 08/09/24. The DON stated Resident #2 wandered into the room of Resident #1 and laid down in the unoccupied bed of Resident #1's roommate. Resident #1 did not like Resident #2 being in the roommates bed and attacked. The DON stated the staff try to redirect residents who wander into other residents rooms and to keep the residents busy with activities. The DON said they were unsure if the evening shift had scheduled activities. The DON stated the current interventions had not kept Resident #2 from wandering into the room and being choked by Resident #1. 2. Resident #3 had diagnoses which included dementia with other behavioral disturbances. An incident report, dated 08/16/24, documented on 08/15/24, CNA #1 was observed to repeatedly hit Resident #3 with a wet, soapy towel after the resident allegedly spit on CNA #1. A hand written note attached to the incident report, dated 08/19/24, documented CNA #3 entered the shower room and observed Resident #3 bleeding from their nose, cheek, and above an eye. The note documented when CNA #1 was asked what happened, CNA #1 responded in part, .[Resident #3] spit on me, you ain't think I beat [their] ass . On 08/21/24 at 2:30 p.m., CNA #2 stated they observed CNA #1 to antagonize Resident #3 by repeatedly flicking the resident's nose with their finger and making derogatory comments over and over about the resident's genitalia which agitated Resident #3 to the point the resident spat on CNA #1. CNA #2 stated after Resident #3 spat on CNA #1, CNA #1 grabbed a wet, soapy towel and continually snapped the towel toward the resident's face. CNA #2 stated they could see the resident's eyes were red and irritated from the soap and his nose was bleeding. CNA #1 stated they kept asking for CNA #1 to stop and let them assist the resident but CNA #1 continued until CNA #3 entered the shower room. CNA #2 stated they assisted Resident #3 with assistance from CNA #3 without further incidence. On 08/23/24 at 1:45 p.m., the DON stated to keep abuse from reoccurring, the facility would have two staff members assist Resident #3 with their shower.

Based on interview and record review, the facility failed to update care plans for two (#1 and #3) of four resident whose clinical records were reviewed for abuse. The facility daily census report identified 24 residents on the secured unit and 62 total residents. Findings: 1. Resident #1 had diagnoses which included Alzheimer's dementia. A progress note, dated 08/09/24 at 8:01 p.m., documented in part, .This nurse heard screaming from residents room. Upon arrival resident was seen choking another resident [Resident #2], laying in a supine position in room-mates bed. This nurse was able to separate aggressive resident and defuse situation. Resident was upset that another resident was in [their] room-mates bed . An incident note, dated 08/09/24, documented in part, .This nurse heard screaming from another residents room. Upon arrival [Resident #2] was in another residents bed, laying in a supine position being choked by [Resident #1]. This nurse was able to pull resident to safety. [Resident #2] was purple colored w/ unsteady gait, and scratches on (L) [left] side of face and neck . An initial incident report, with an incident date of 08/09/24, documented it was faxed to the Oklahoma State Department of Health date of 08/10/24 at 12:31 p.m., and documented an incident of resident to resident abuse occurred on 08/09/24 between Resident #1 and Resident #2. On 08/22/24 at 12:50 p.m., LPN #1 stated Resident #1 had more than a few instances of aggression which usually happened in the evening hours. LPN #1 stated Resident #1 was real protective of their roommate and had expressed that the roommate was their child. LPN #1 stated when Resident #1 saw Resident #2 was in the roommates bed, Resident #1 attacked Resident #2. LPN #1 stated when Resident #1 was aggressive, they tried to separate them from others and get them to relax in their recliner in their room and when Resident #1 was in the common room, the staff tried to keep the resident separated from others sitting in the chairs or on the couches. LPN #1 stated to help mitigate resident behaviors, they had organized activities scheduled for the day shift to keep residents busy but there were no organized activities scheduled for the evening shift. The LPN stated they did not know what interventions the evening shift used to mitigate resident to resident abuse. On 08/22/24 at 1:40 p.m., CMA #1 stated Resident #1 was aggressive with other residents, pushing them to the floor, tripping them, or otherwise physically attacking them. CMA #1 stated Resident #1 was better in the daytime hours but as the day continued would get more confused and agitated. The CMA stated to help any feelings of anxiety or agitation, they tried to keep all the residents engaged throughout the day with different activities. On 08/22/24 at 3:55 p.m., LPN #2 stated they were present when the resident to resident altercation occurred. The LPN stated they heard screaming and choking sounds coming from the hall and responded immediately by running down the hall where the sound originated. They stated it was a second choked scream which allowed them to find Resident #2 being choked by Resident #1. LPN #2 stated they immediately asked Resident #1 to stop and the resident complied. LPN #2 stated Resident #1 appeared to have a brief look of statement as though they just realized what they were doing with their hands around the neck of Resident #2. LPN #2 stated they did not see Resident #2 wander into the other residents room or they would have redirected Resident #2 from wandering in there. On 08/22/24 at 4:00 p.m., CMA #2 stated the staff watched Resident #1 because the resident had tripped a number of other wandering residents as they past close to where Resident #1 sat and could get aggressive without warning or provocation. On 08/23/24 at 12:15 p.m., a family member for Resident #2 stated they had concerns about another resident choking their family member for wandering into a room and laying on the roommates bed. The family member stated they often see residents wandering in and out of other residents room and laying in one another's beds. They stated during many of their visits, they entered their family member's room only to find another resident laying in their family member's bed. The family member stated the staff were quick to respond but could not be everywhere. On 08/23/24 at 1:45 p.m., the DON was asked what was the root cause of the resident to resident abuse which occurred on 08/09/24. The DON stated Resident #2 wandered into the room of Resident #1 and laid down in the unoccupied bed of Resident #1's roommate. Resident #1 did not like Resident #2 being in the roommates bed and attacked. The DON stated the staff try to redirect residents who wander into other residents rooms and to keep the residents busy with activities. The DON said they were unsure if the evening shift had scheduled activities. The DON stated the current interventions had not kept Resident #2 from wandering into the room and being choked by Resident #1. The DON said that other than frequent monitoring, they could not think of another intervention to reduce wandering or to stop the associated incidents of resident to resident abuse. 2. Resident #3 had diagnoses which included dementia with other behavioral disturbances. An incident report, dated 08/16/24, documented on 08/15/24, CNA #1 was observed to repeatedly hit Resident #3 with a wet, soapy towel after the resident allegedly spit on CNA #1. A hand written note attached to the incident report, dated 08/19/24, documented CNA #3 entered the shower room and observed Resident #3 bleeding from their nose, cheek, and above an eye. The note documented when CNA #1 was asked what happened, CNA #1 responded in part, .[Resident #3] spit on me, you ain't think I beat [their] ass . On 08/21/24 at 2:30 p.m., CNA #2 stated they observed CNA #1 to antagonize Resident #3 by repeatedly flicking the resident's nose with their finger and making derogatory comments over and over about the resident's genitalia which agitated Resident #3 to the point the resident spat on CNA #1. CNA #2 stated after Resident #3 spat on CNA #1, CNA #1 grabbed a wet, soapy towel and continually snapped the towel toward the resident's face. CNA #2 stated they could see the resident's eyes were red and irritated from the soap and his nose was bleeding. CNA #1 stated they kept asking for CNA #1 to stop and let them assist the resident but CNA #1 continued until CNA #3 entered the shower room. CNA #2 stated they assisted Resident #3 with assistance from CNA #3 without further incidence. On 08/23/24 at 1:45 p.m., the DON stated to keep abuse from reoccurring, the facility would have two staff members assist Resident #3 with their shower. The DON was asked what the root cause for the staff to resident abuse. The DON stated Resident #3 was known to spit on staff at times and the only intervention they could think of was to have two staff members present at all times when showering the resident. The DON was asked if there was two staff members present when the incident of abuse occurred. They stated at least two staff were present and possibly a third. The DON was asked if two staff members were present when the alleged abuse occurred, was the facility intervention to have two staff members present at all times when showering the resident an appropriate intervention. The DON stated no.

Based on record review and interview, the facility failed to implement their abuse policy related to the reporting of an allegation of abuse within two hours of staff knowledge of the incident to the Oklahoma State Department of Health and failed to report an allegation of verbal and physical abuse, by a certified nurse aide toward a resident, to the Nurse Aide Registry. The facility daily census report identified 24 residents on the secured unit and 62 total residents. Findings: An undated facility policy, titled Allegations of Abuse, documented in part, .All alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegation is made .Report the results of all investigations to: Oklahoma State Health Department, Department of Human Services, Ombudsman, Resident Representative/Family/POA, Physician, Licensing Boards, Police, Other appropriate agencies . Resident #3 had diagnoses which included dementia with other behavioral disturbances. An incident report with an incident dated of 08/15/24, was sent to OSDH and documented the facility received an allegation of staff to resident abuse on 08/16/24 but which occurred on 08/15/24. The incident report documented the physician, family, and APS were notified. An incident audit report, dated 08/19/24, documented an allegation of abuse was reported by staff that another staff member was observed hitting Resident #3 with a wet, soapy towel over and over again. The report documented the incident occurred on 08/15/24 but was not reported to administration until 08/16/24. On 08/20/24 at 1:35 p.m., the ADON stated on 08/16/24, a staff member reported it was a rumored CNA #1 had abused Resident #3 on 08/15/24. The ADON stated CNA #1 worked the day shift on 08/15/24 and 08/16/24. The ADON stated once they were able to confirm there were witnesses to the allegation, they suspended CNA #1 until they completed their investigation. On 08/21/24 at 2:30 p.m., CNA #2 stated they observed CNA #1 to antagonize Resident #3 by repeatedly flicking the resident's nose with their finger and making derogatory comments over and over about the resident's genitalia which agitated Resident #3 to the point the resident spat on CNA #1. CNA #2 stated after Resident #3 spat on CNA #1, CNA #1 grabbed a wet, soapy towel and continually snapped the towel toward the resident's face. CNA #2 stated they could see the resident's eyes were red and irritated from the soap and his nose was bleeding. CNA #1 stated they kept asking for CNA #1 to stop and let them assist the resident but CNA #1 continued until CNA #3 entered the shower room. CNA #2 stated they assisted Resident #3 with assistance from CNA #3 without further incidence. On 08/21/24 at 3:20 p.m., the DON stated they were not notified of the allegation of staff to resident abuse until 08/16/24, the day after the incident occurred. The DON stated they notified OSDH, APS, the police, physician, and family on 08/16/24. The DON was asked if the facility reported the incident to the Nurse Aide Registry. The DON stated they faxed the allegation to the Nurse Aide Registry from home. On 08/22/24 at 10:30 a.m., the DON stated the attempted fax to the Nurse Aide Register never completed and they resent the fax from the facility on 08/21/24.

Based on record review and interview, the facility failed to report an allegation of abuse, within two hours of staff knowledge of the incident,`to the Oklahoma State Department of Health and failed to report an allegation of verbal and physical abuse, by a certified nurse aide toward a resident, to the Nurse Aide Registry for one (Resident #3), and failed to take appropriate corrective action to extirpate the risk of abuse for three (#2 and #3) of four residents whose clinical records were reviewed for abuse. The facility roster identified 62 residents. Findings: An undated facility policy, titled Allegations of Abuse, documented in part, .All alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegation is made .Report the results of all investigations to: Oklahoma State Health Department, Department of Human Services, Ombudsman, Resident Representative/Family/POA, Physician, Licensing Boards, Police, Other appropriate agencies .If alleged violation is verified appropriate corrective action must be taken . Resident #1 had diagnoses which included Alzheimer's dementia. Resident #2 had diagnoses which included a memory deficit following a cerebral infarction (stroke) and amnesia. Resident #3 had diagnoses which included dementia with other behavioral disturbances. An incident note, dated 08/09/24, documented in part, .This nurse heard screaming from another residents room. Upon arrival [Resident #2] was in another residents bed, laying in a supine position being choked by [Resident #1]. This nurse was able to pull resident to safety. [Resident #2] was purple colored w/ unsteady gait, and scratches on (L) [left] side of face and neck . An initial incident report, with an incident date of 08/09/24, documented it was faxed to the Oklahoma State Department of Health date of 08/10/24 at 12:31 p.m., and documented an incident of resident to resident abuse occurred on 08/09/24 between Resident #1 and Resident #2. An incident report with an incident dated of 08/15/24, was sent to the Oklahoma State Department of Health and documented the facility received an allegation of staff to resident abuse on 08/16/24 but which occurred on 08/15/24. The incident report documented the alleged perpetrator was suspended. The incident report documented the physician, family, and APS were notified. An incident audit report, dated 08/19/24, documented an allegation of abuse was reported by staff that another staff member was observed hitting Resident #3 with a wet, soapy towel over and over again. The report documented the incident occurred on 08/15/24 but was not reported to administration until 08/16/24. On 08/20/24 at 1:35 p.m., the ADON stated on 08/16/24, a staff member reported it was a rumored CNA #1 had abused Resident #3 on 08/15/24. The ADON stated CNA #1 worked the day shift on 08/15/24 and 08/16/24. The ADON stated once they were able to confirm there were witnesses to the allegation, they suspended CNA #1 until they completed their investigation. On 08/21/24 at 2:30 p.m., CNA #2 stated they observed CNA #1 to antagonize Resident #3 by repeatedly flicking the resident's nose with their finger and making derogatory comments over and over about the resident's genitalia which agitated Resident #3 to the point the resident spat on CNA #1. CNA #2 stated after Resident #3 spat on CNA #1, CNA #1 grabbed a wet, soapy towel and continually snapped the towel toward the resident's face. CNA #2 stated they could see the resident's eyes were red and irritated from the soap and his nose was bleeding. CNA #1 stated they kept asking for CNA #1 to stop and let them assist the resident but CNA #1 continued until CNA #3 entered the shower room. CNA #2 stated they assisted Resident #3 with assistance from CNA #3 without further incidence. On 08/21/24 at 3:20 p.m., the DON stated they were not notified of the allegation of staff to resident abuse until 08/16/24, the day after the incident occurred. The DON stated they notified OSDH, APS, the police, physician, and family on 08/16/24. The DON was asked if the facility reported the incident to the Nurse Aide Registry. The DON stated they faxed the allegation to the Nurse Aide Registry from home. On 08/22/24 at 10:30 a.m., the DON stated the attempted fax to the Nurse Aide Registry never completed and they resent the fax from the facility on 08/21/24. On 08/22/24 at 3:55 p.m., LPN #2 stated they were present when the resident to resident altercation occurred. The LPN stated they heard screaming and choking sounds coming from the hall and responded immediately by running down the hall where the sound originated. They stated it was a second choked scream which allowed them to find Resident #2 being choked by Resident #1. LPN #2 stated they immediately asked Resident #1 to stop and the resident complied. LPN #2 stated Resident #1 appeared to have a brief look of statement as though they just realized what they were doing with their hands around the neck of Resident #2. LPN #2 stated they did not see Resident #2 wander into the other residents room or they would have redirected Resident #2 from wandering in there. On 08/23/24 at 1:45 p.m., the DON was asked what was the root cause of the resident to resident abuse which occurred on 08/09/24. The DON stated Resident #2 wandered into the room of Resident #1 and laid down in the unoccupied bed of Resident #1's roommate. Resident #1 did not like Resident #2 being in the roommates bed and attacked. The DON stated the staff try to redirect residents who wander into other residents rooms and to keep the residents busy with activities. The DON said they were unsure if the evening shift had scheduled activities. The DON stated the current interventions had not kept Resident #2 from wandering into the room and being choked by Resident #1. The DON said that other than frequent monitoring, they could not think of another intervention to reduce wandering or to stop the associated incidents of resident to resident abuse. The DON was asked what the root cause for the staff to resident abuse. The DON stated Resident #3 was known to spit on staff at times and the only intervention they could think of was to have two staff members present at all times when showering the resident. The DON was asked if there was two staff members present when the incident of abuse occurred. They stated at least two staff were present and possibly a third. The DON was asked if two staff members were present when the alleged abuse occurred, was the facility intervention to have two staff members present at all times when showering the resident an appropriate intervention. The DON stated no.

Based on observation, interview, and record review, it was determined the facility failed to: ~ Provide supervision to prevent accident hazards while utilizing a mechanical lift for one (#26) of two residents who were reviewed for accident hazards. Resident #26 slid out of a hoyer lift sling hitting her head and back. Resulting in the resident being sent to the emergency room where she recieved two staples to the backof her head. The facility identified 11 residents who utilized a mechanical lift, and; ~ Identify, develop, and implement appropriate interventions to aid in the prevention of accident hazards in a shower/bathroom for one (Memory Unit) of one shower/bathroom located on the Memory Unit. The facility identified 22 residents who resided on the Memory Unit and five of those residents identified as wanderers. Findings: A facility policy titled, Lifting machine, Using a Portable, documented, .The purpose of this procedure is to help lift residents using a manual lifting device .Two (2) nursing assistants will be required to perform the lift machines . 1. Resident #26 had [DIAGNOSES REDACTED]. A significant change assessemnt, dated 12/08/17, documented the resident was severely impaired in cognition and required extensive assistance with transfers. A quarterly assessment, dated 06/03/18, documented the resident was severely impaired in cognition and required extensive assistance with transfers. An inservice, dated 06/26/18, documented one of the topics discussed as, .Lifts and proper use of . A form 283 incident report, submitted to OSDH on 07/23/18, documented, .Nurse aide in the room attempting to transfer the resident from the bed to her chair. She lifted the resident up from the bed turning her around. (resident's name withheld) foot caught on the bed tipping her from the sling, she slid from the sling onto the floor landing on her back and her head striking the floor. It was found that the nurse aide had improperly positioned the resident in the sling creating potential for an incident, she also did not have another person assist her with the transfer. This nurse aide transferred this resident unassisted by Hoyer lift . The incident report was documented as being the final report. The form 283 incident report for the incident dated 07/22/18 was incorrectly dated as 05/22/18. The facimile cover sheet was dated 07/23/18 for the final incident report submission to OSDH. An undated Form 718, Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property, documented, .(CNA name withheld) was transferring a resident from the bed to a chair, using the Hoyer lift she did not ask for help and the resident slid from the sling landing on her back and striking her head on the floor. (Resident name withheld) was sent to ER where she recieved 2 staples to the back of her head. (CNA name withheld) will be terminated at this time due to not following facility protocol with lifts, and creating situation that led to injury of a resident . The Form 718 also documented the CNA was suspended and terminated on 07/23/18. A care plan, revised 07/25/18, documented, .Focus .(Resident name withheld) is at risk for further falls r/t needing staff assistance for transfers, dx of dementia, routine pain medication, and Poor communication/comprehension .07/22/18 .Fall laceration back of head, elbow . Interventions .07/22/18 .Reeducate staff on hoyer lift procedure and safety .04/23/17 .Provide (resident's name withheld) with 2 person assistance using hoyer lift with all transfers to and from bed, broda chair . Review of the facility's inservice records did not reveal an inservice had been provided to the staff regarding lift safety after the incident dated 07/22/18. On 07/31/18 at 9:14 a.m., CNA #6 was asked if she had received an inservice last week. She stated she did not attend inservice because she was working on the floor. She was asked how she found out what information had been presented during the inservice. She stated she asked another aide. She stated the aide told her they went over fire safety with the maintenance supervisor and watched a video about [MEDICAL CONDITION]. At 9:15 a.m., CNA #2 was asked if she had received an inservice recently. She stated she had not attended the last inservice because she was not yet receiving a pay check. She stated she had just completed orientation and training. She was asked what areas were covered during her orientation/training period. She stated she learned where paper work, such as the ADL books, were kept, she performed a shower with the training nurse aide, she dressed a resident, and assisted with dining for dependent residents. At 9:20 a.m., CNA #3 was asked if she had received inservice in the last two weeks. She stated she had received an inservice last week. She was asked what she had learned in the inservice. She stated they discussed QAPI, root cause analysis, broda chair positioning, falls, and fall mats. At 9:22 a.m., LPN #1 was asked if she had received inservice in the last two weeks. She stated yes, last week. She was asked what she had learned in the inservice. She stated they discussed orders, infections, antibiotics, medication times, and culture change. At 9:25 a.m., CNA #5 was asked if she had received an inservice last week. She stated she had attended one. She was asked what she had learned in the inservice. She stated they discussed fire drills, privacy, abuse, quality assessment, QAPI, and root cause analysis. On 07/31/18 at 12:03 p.m., the DON and adminsitrator was asked about the incident on 07/22/18 which resulted in the resident receiving two staples to the back of her head. The administrator stated they had terminated the CNA and educated staff during the QA/QAPI meeting. She stated they provided QA/QAPI meetings twice daily which included the nursing staff. She was asked who was responsible to educate the night shift staff members. She stated the charge nurses. She stated the weekend RN educated the weekend staff. She was asked where the education was documented. She stated it was on the QA/QAPI forms the faciltiy utilized. The DON stated they had done many inservices on lift use and safety. She was asked when the last inservice on lift use and lift safety had been completed. She stated at the inservice last week. The inservice was reviewed by the DON and she stated she forgot to add the lift use to the topic heading but they address lift use with every inservice. On 08/01/18 at 3:28 p.m., CNA #4 was asked what the procedure was when utilizing a mechanical lift. She stated they were to always have two staff members present and gently lift the resident for the transfer. She was asked what type of training she had received. She stated she was trained by a CNA and she knew how to utilize a mechanical lift. On 08/01/18 at 3:55 p.m., CNA #1 was asked what the procedure was when utilizing a mechanical lift. She stated there were to be two people in the room at all times. She was asked what type of training or inservice she had received regarding mechanical lift safety. She stated they would review the information in their daily meetings and at inservices. She was asked who provided the inservices and daily meeting information. She stated the DON, the administrator, or the MDS/care plan coordinator. On 08/01/18 at 6:09 p.m., the DON was asked how she ensured CNAs transferred residents safely when utilizing a mechanical lift to prevent accident hazards. She stated they constantly provided education and the staff knew two people were to be in attendance when utilizing a mechanical lift. She was asked who was reponsible to monitor the CNAs to ensure residents were transferred safely. She stated the charge nurses, the restorative aide, and ultimately it was herself as the DON. 2. On 07/31/18 at 9:16 a.m., the shower/bathroom on the Memory Unit was observed with the door open. Upon entering the room a shower stall was straight ahead. To the left of the shower stall was a sink with a soiled linen hamper between the sink and toilet stool. The linen hamper obstructed the usage of the toilet stool. A locked cabinet was above the toilet stool. A bottle of shampoo was observed on the grab bar in the shower stall. A container of deodorant and a used tube of Calmosystine Ointment was on the floor next to the toilet. The water in the toilet was yellow which appeared to be urine. No residents were observed entering the room. At 9:25 a.m., the surveyor returned to the shower/bathroom with LPN #2, charge nurse. The charge nurse was shown the linen cart in front of the toilet stool, the deodorant and ointment on the floor next to the toilet stool, and the shampoo in the shower. She was asked if the shower/bathroom door was kept unlocked. She stated, Yes. She was asked if residents on the Memory Unit utilized the toilet. She stated, Yes. She was asked if there were wanderers on the unit. She stated, Yes. She was asked where the shampoo, deodorant, and ointment were usually kept. She stated the items should be in the locked cabinet. She was asked if a resident entered to utilize the toilet and the linen cart was obstructing the usage what were the possibilities. She stated, It would be an accident hazard.

Based on observation, interview, and record review, it was determined the facility failed to prevent a 14.4% severe weight loss in 6 months for 1 (#2) of 1 sampled residents with severe weight loss when they did not implement recommendations made by the registered dietician, did not offer the resident breakfast or a morning supplement, and made diet changes without a physician's orders [REDACTED]. The facility's Census and Conditions report identified 3 residents with an unplanned weight change. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 11/30/10, documented the resident was severely impaired in cognitive skills for daily decision making, had long and short term memory loss, was totally dependent on one person for eating, received a mechanically altered diet, and had no weight loss. It was documented the resident weighed 123 lbs. An undated dietary progress note, signed by the dietary manager for the month of November 2010, documented, "...Wants all her food in cups and thin to honey (liquids) to drink according to daughter..." The care plan, dated 12/06/10, documented a problem, "...Requires mechanically altered diet d/t swallowing difficulties, Alzheimer's dx...inability to feed self..." The goal was, "...will tolerate consistency of foods served without evidence of complaint or choking..." Approaches included, "...Assess response to diet and request order for any modification needed..." The care plan contained no documentation to show the resident did not like to eat breakfast or did not like to get up in the mornings. A physician's telephone order, dated 12/06/10, documented, "...Health shake/supplement (Ensure) 1 can with meds and 1 can with each meal..." A nutrition assessment, dated 12/17/10 and signed by the RD, documented, "...Wt 118#...Wt (down) 5# from admit wt. Was started on house supplements 6x/day. Usually refuses brkfast (sic). 0 - 25% other meals. Rec consider trial of appetite stimulant. Will follow and monitor nutritional status..." Review of the clinical record revealed no documentation to show the resident was offered house supplement 6 times per day. A nutritional recommendations sheet, dated 12/17/10 and signed by the RD, documented, "...Consider trial of [MEDICATION NAME] ES as appetite stimulant (intake poor)..." The form documented the physician agreed with the recommendation on 12/31/10, 14 days after the recommendation was made. A physician's telephone order, dated 12/29/10, documented, "...Clarification:...Health supp @ 10 am (and) 2 pm 4 oz..." There was no documentation to show what order was being clarified. Review of the clinical record revealed no documentation to show why the health supplement was only ordered for 10:00 a.m. and 2 p.m. An undated and unsigned dietary progress note for the month of December 2010, documented, "...Refuses to get up for breakfast. Gets H. supp ADA 4 oz at 10 (and) 2...drinks everything. No spoons - poor appetite - daughter brings food..." A dietary progress note, dated 01/09/11 and signed by the dietary manager, documented, "...Wt. 115#...Refuses breakfast...ADA House supp at 10 (and) 2..." A physician's telephone order, dated 01/10/11, documented, "...Stop thickening liquids...encourage drinking Ensure four times daily. (4 cans daily) x 8 oz each. Encourage snack after evening meal. Offer creamed soups twice daily such as tomato soup, mushroom, potato soup..." A dietary progress note, dated 01/29/11 and signed by the RD, documented, "...Wt 115#. (Down) 3#. Intake poor. (Family member) refused appetite stimulant...New order for Ensure 4x/day and offer creamed soups bid..." Review of the clinical record revealed no documentation to show the facility asked the family member about the use of an appetite stimulant or that the facility had provided education to the family member regarding the need and use of an appetite stimulant. There was no documentation to show the resident was offered 4 cans of Ensure per day. Meal intake records, dated January 2011, documented the resident refused breakfast 31 of 31 days. Vital sign records, dated 02/03/11, documented the resident weighed 111 lbs. The resident had weighed 123 lbs on 11/19/10. This constituted a 9.75% (12 lbs) severe weight loss in three months. A dietary progress note, dated 02/03/11 and signed by the dietary manager, documented, "...Feb wt. 111#. Cont to refuse breakfast. Poor appetite. Giving her soup, juices, milk, supplements, thin puree foods..." Meal intake records, dated February 2011, documented the resident refused breakfast 28 of 28 days. There was no documentation to show the resident was offered a bedtime snack 28 of 28 days or 4 cans of Ensure 28 of 28 days. A dietary progress note, dated 03/14/11 and signed by the dietary manager, documented, "...March wt 107#. Gets 8 oz ADA H. Supp at 10 (and) 2. Cont. to have poor appetite. Refuses 'Food' even thinned..." A physician's telephone order, dated 03/16/11, documented, "...D/C Ensure and 4 oz House supp at 10 am (and) 2 pm...(change) to 8 oz ADA house supp c meals at 10 am (and) 2 pm..." A dietary progress note, dated 03/31/11 and signed by the RD, documented, "...Wt 107#. Was 111# 2/11. Intake remains poor @ meals. Mainly drinks. Supplements were changed to 8 oz house ADA supplement c and between meals bid...Rec (increase) house ADA supplement to tid between and c meals..." A nutritional recommendation, dated 03/31/11 and signed by the RD, documented, "...Increase house ADA supplements between meal to tid. (Should get 6x/day c and between meals)..." The form documented the nurse practitioner agreed with the recommendation on 04/01/11. Review of the clinical record revealed no documentation to show the resident was offered the house supplement 6 times per day. Meal intake records, dated March 2011, documented the resident refused breakfast 30 of 31 days. There was no documentation to show the resident was offered a bedtime snack 31 of 31 days or between meal supplements 31 of 31 days. Monthly physician orders, dated April 2011, documented, "...8 oz ADA house supplement - by mouth twice daily at 10 am and at 2 pm..." The orders did not reflect the nurse practitioner approved dietary recommendation for the resident to receive the supplements 6 times per day. A dietary progress note, dated 04/18/11 and signed by the dietary manager, documented, "...April wt 103#. Gets 8 oz ADA H. Supp c meals 10 (and) 2. Fix soup c lunch (and) dinner. Refuses thined (sic) puree. Nothing by spoon only by glass..." A dietary progress note, dated 04/27/11 and signed by the RD, documented, "...Wt 103.5# (down) 3.5#. CDM reports only taking things from a glass - refuses to be spoon fed. Supplements were to be (increased) to 6x daily per previous rec...Does take some soup @ lunch and dinner. Rec make soup c half and half to help (increase) caloric intake..." A nutritional recommendation, dated 04/27/11 and signed by the RD, documented, "...Make soups c half and half to help (increase) calorie intake (wt (down))..." The form documented the nurse practitioner agreed with the recommendation on 04/29/11. Meal intake records, dated April 2011, documented the resident refused breakfast 30 of 30 days. There was no documentation to show the resident was offered a bedtime snack 30 of 30 days or between meal supplements 30 of 30 days. Vital sign records, dated 05/05/11, documented the resident weighed 105.5 lbs. The resident had weighed 123 lbs on 11/19/2010. This constituted a 14.2% (17.5 lbs) severe weight loss in 6 months. Monthly physician orders, dated May 2011, documented, "...8 oz ADA house supplement - by mouth twice daily at 10 am and at 2 pm..." The orders did not reflect the nurse practitioner approved dietary recommendation for the resident to receive the supplements 6 times per day. A physician's orders [REDACTED]. An undated dietary progress note, signed by the dietary manager for the month of May 2011, documented, "...May wt 105.5# Wt up a little. Cont to only take in fluids..." A dietary progress note, dated 05/24/11 and signed by the RD, documented, "...Wt 105.5# back (up) 2#...Has been refusing brkfast (sic). Drinks some supplements..." Meal intake records, dated May 2011, documented the resident refused breakfast 28 of 31 days. There was no documentation for 3 days. There was no documentation to show the resident was offered a bedtime snack 31 of 31 days or between meal supplements 30 of 30 days. Monthly physician orders, dated June 2011, documented, "...8 oz ADA house supplement - by mouth twice daily at 10 am and at 2 pm..." The orders did not reflect the nurse practitioner approved dietary recommendation for the resident to receive the supplements 6 times per day. A dietary progress note, dated 06/07/11 and signed by the dietary manager, documented, "...June wt 101#. Add half (and) half to soup for more calories. Not eatting (sic) food. Take in fluids only..." A dietary progress note, dated 06/21/11 and signed by the RD, documented, "...Wt 101# (down) 4.5#. Continues to refuse breakfast. Intake 25-100% of other meals. Does drink some supplements c meals...Rec 90 cc 2.0 cal tid c med pass..." A nutritional recommendation, dated 06/21/11 and signed by the RD, documented, "...90 cc 2.0 cal tid c med pass (wt (down), drinking only)..." The form documented the physician agreed with the recommendation on 06/24/11. A physician's telephone order, dated 06/24/11, documented, "...90 cc 2.0 cal tid c med pass..." Review of MARs, dated June 2011, documented the resident did not receive the 90 cc 2.0 cal with medication passes until 06/27/11. Meal intake records, dated June 2011, documented "Refuse Breakfast" across the form where daily breakfast percentages were to be recorded. There was no documentation to show the resident was offered breakfast 30 of 30 days, a bedtime snack 30 of 30 days, or between meal supplements 30 of 30 days. On 07/05/11 at 12:22 p.m., the resident was observed being wheeled into the dining room. The resident's geriatric chair was placed in the upright position, and the resident was placed at her table in the southwest corner of the assisted dining room. A glass of water, milk, and lemonade was observed in front of the resident. There was no food or supplement for the resident. At 12:42 p.m., the resident was still seated at her table, her eyes were closed, and there was still no food for her. At 1:08 p.m., the resident was still seated at her table without food. An empty glass was observed in the resident's lap, and a straw was hanging from her hair on the right side. At 1:09 p.m., a glass of red liquid was brought to the table and sat in front of the resident. Dietary Aide #1 was asked what was given to the resident. She stated, "Soup. I think something is wrong with her jaw." When asked how much liquid was in the glass, Dietary Aide #1 stated, "8 ounces." At 1:11 p.m., CNA #6 stirred the resident's soup and woke the resident. CNA #6 gave the resident two drinks of the soup. The resident then took the glass and began drinking the soup without assistance. At 1:18 p.m., the resident was finished with her soup. CNA #6 asked the resident, "You finished?" CNA #6 then offered the resident lemonade and milk. The resident refused. The resident was not offered any more soup or other type of food. At 1:19 p.m., CNA #6 asked the resident if she was full. The resident made no response. CNA #6 then asked CNA #3 what she was supposed to do. CNA #3 made no response. CNA #6 asked the resident, "Do you want a drink of milk before we leave?" The resident made no response. CNA #6 then removed the resident from the dining room. On 07/06/11 at 10:29 a.m., CNA #5, who was assigned to the resident, stated the resident did not "normally" eat breakfast. She stated, "She's not a morning person." CNA #5 was asked if the resident got up for breakfast. She stated, "No, she does not." When asked if the resident was offered any food in her room, CNA #5 stated, "I think they give her a supplement." CNA #5 was asked if she had offered the resident a supplement that morning (07/06/11). She stated, "No. Residents can't eat in their room." On 07/06/11 at 2:14 p.m., the RD, CDM, and DON were asked what the facility's policy was on handling dietary recommendations. The RD stated, "I fill out the rec sheet, it's given to the doctor, I leave the summary sheets with the DON. They're (the recommendations) saved for when (physician name withheld) comes in or they are faxed to him." The DON was asked how long it took to get the recommendations approved by the physician. She stated, "A week at the most. Two doctors come in weekly. As soon as they are signed, we note them and implement them." The DON and RD were asked why it took from 12/17/10 to 12/31/10, a period of 14 days, to get the recommendation for an appetite stimulant signed for the resident. The RD and DON stated, "It might have been the holidays." At 2:17 p.m., the RD was asked where the documentation was of the family member's refusal of the appetite stimulant and the education provided to the family of the need and use of an appetite stimulant. The RD stated, "I don't remember if there was documentation. The DON at that time presented me with that information." The RD and CDM were asked why the nutritional assessment dated [DATE] documented the resident was started on supplements 6 times per day but the physician's orders [REDACTED]. I don't know." The CDM was asked why the recommendation made on 03/31/11 to increase the resident's supplements to 6 times per day was not implemented. The CDM stated, "She gets them at lunch, dinner, 10, 2, and bedtime." The CDM was asked when the resident received the sixth supplement. She stated, "She is not getting it." When asked why the resident was not receiving the 6th supplement, the CDM stated, "She's not up." The CDM was asked if the supplement was taken to the resident's room in the mornings. She stated, "Nursing gives her the supplements." The CDM was asked if the resident was provided a supplement in the mornings. She stated, "No." The DON was asked why it took from 04/29/11 until 05/05/11 to implement adding half and half to the resident's soups. She stated, "I have no idea. It should have been right away." The CDM was asked why the resident received only soup at lunch on 07/05/11. She stated, "That's all she will eat. She is strictly a drinker. She doesn't do texture." When asked who made the decision to give the resident only soup, the CDM stated, "Between me and the family." The CDM was asked if a physician's orders [REDACTED]. She stated, "I thought he knew." The CDM was asked if the resident received only soup and supplement at the evening meal. She stated, "Yes." The DON was asked why the 90 cc 2.0 was not started until 06/27/11 when the physician signed the recommendation on 06/24/11. She stated, "I think they left it off the MAR. They didn't know what department was supposed to give it." The CDM was asked what other foods had been offered to the resident in liquid form. She stated, "All of them." When asked why the resident was not offered more soup after drinking all of her soup at lunch on 07/05/11, the CDM stated, "I didn't realize she wanted more." The DON was asked if the nursing staff was trained to ask residents if they wanted more food to eat. She stated, "No, they are not." The DON and CDM were asked why the resident sat in the dining room from 12:22 p.m. until 1:09 p.m., a total of 47 minutes, without any food. The DON stated, "It shouldn't have happened." The CDM was asked what kind of snack was offered to the resident at bedtime. She stated, "Right now, I haven't sent out anything, but I will." On 07/06/11 at 4:17 p.m., the administrator was asked if all residents had to eat in the dining room. She stated, "We have them come to the dining room." The administrator was asked if she was aware resident #2 was not being offered any breakfast or morning supplement in her room because it was the facility's policy to not allow residents to eat in their room. She stated, "No."

Based on review of clinical records, review of policy and procedures, and staff interviews, it was determined the facility failed to assess, monitor, and intervene in the management of constipation for three (#2, 3, and #5) of four sampled residents with constipation. Resident #2 was admitted to the hospital. A hospital [MEDICATION NAME] report documented the resident had a fecal impaction. This had the potential to affect 47 residents identified by the facility who had prn laxatives ordered. Findings: A facility policy, titled "Policy and Procedures on Constipation," documented, "1. Staff will record on the ADL sheet every shift the frequency and size of each resident's bowel movement (Small, Medium, and Large) 2. CMA will monitor ADL sheets on a daily basis 3. Any resident that does not have a bowel movement for 3 consecutive days will receive a laxative as per their specific physician's orders [REDACTED]. 5. Results of a PRN laxative will be documented on the Medication Administration Record and ADL sheets." 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 12/23/10, documented, "Problem: Potential for constipation r/t hx of dx of constipation Goal: (Resident) will be free of nausea/vomiting r/t constipation problems Approach: (1) Encourage fl. intake with meals and med pass and times in between (2) Offer pruine (sic) juice prn (3) Notify charge nurse if (Resident) c/o nausea/vomiting (4) Monitor and record all BM.S (5) Medicate as ordered [MEDICATION NAME], mom (6) Impaction checks q other day." A significant change assessment, dated 12/21/2010, documented the resident's cognitive status was "severely impaired." The assessment documented the resident was totally dependent on staff for ADLs. The monthly physician's orders [REDACTED]. "...Impaction check every other day on 10-6 shift... [MEDICATION NAME] 10g/15ml syrup IE [MEDICATION NAME] 30cc (20gm) by mouth every day (dx. constipation)... Milk of Magnesia 400mg/5ml oral...30ml by mouth every morning (dx. constipation)... Milk of Magnesia 400/5ml oral...30 ml by mouth daily as needed for constipation." The October 2010 MARS documented no prn Milk of Magnesia (MOM) was given. The October 2010 ADL Sheet documented no bowel movements (BMs) for the time period between 10/03/10 - 10/09/10 for a total of seven days and between 10/22/10 - 10/28/10 for a total of seven days. The November 2010 MARS documented one prn dose of MOM was given on 11/22/10. The November 2010 ADL Sheet documented no BMs for the time period between 11/01/10 - 11/07/10 for a total of six days and between 11/14/10 - 11/25/10 for a total of 12 days. The December 2010 MARS documented one prn dose of MOM was given on 12/15/10. The December 2010 ADL sheet documented no BMs for the time period between 12/01/10 - 12/05/10 for a total of five days, between 12/11/10 - 12/15/10 for a total of five days, and between 12/17/10 - 12/25/10 for a total of nine days. The January 2011 MARS documented no prn MOM was given. The facility was unable to provide an ADL sheet for the first two weeks of January 2011 for review. A nurse's note, dated 01/09/11 at 11:00 p.m., documented, "Resident (with) N&V at this time, emesis yellow in color, previous shift reported N&V x3, had 3 lg BM's today, [MEDICATION NAME] supp (1) Per R at this time, (no) stool felt, negative for impaction at this time..." A nurse's note, dated 01/10/11 at 6:00 a.m., documented, "Resident lying on his bed, around 5:30 a.m. 6:00 a.m., I was notified by CNA about resident c/o nausea. Resident had a brown large emesis...negative for impaction...family and Dr. were notified about resident change of status..." At 1:50 p.m., a nurse's note, documented, "...Resident had a medium brown emesis...resident sister was in the room and stated 'I want him to go to the hospital...' EMSA was called..." A History and Physical record from the hospital, dated 01/10/11, documented, "...The patient apparently was able to eat on Saturday without much difficulty. Today, he became nauseous and had multiple episodes emesis. He was brought to the emergency room where he was vomiting outright fecal material. The patient was admitted in March of 2010 with similar presentation with severe urinary tract infection and bowel obstruction that was managed conservatively. In the emergency room , the patient had a CT scan which was consistent with another small-bowel obstruction..." A hospital [MEDICATION NAME] consultation, dated 01/12/11, documented,... "The patient may have had small bowel obstruction, but my current clinical impression is of obstipation...There is a large amount of very hard, solid fecal material in the rectal vault... A hospital progress note, dated 01/13/11, documented,..."Assessment: 1. Possible small bowel obstruction secondary to obstipation and a fecal impaction..." 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A annual assessment, dated 07/11/2010, documented the resident was moderately impaired in cognitive skills for daily decision making. The assessment documented the resident required limited assistance with dressing, toilet use, and personal hygiene. The monthly physician's orders [REDACTED]...2 tabs by mouth every day as needed for constipation..." The November 2010 MARS documented [MEDICATION NAME] 5 mg tab was given on 11/20/10, 11/21/10, 11/22/10, 11/27/10, and 11/30/10. The November 2010 ADL Sheet documented no BMs for the time period between 11/01/10 - 11/04/10 for a total of four days and 11/06/10 - 11/10/10 for a total of five days. The December 2010 MARS documented [MEDICATION NAME] 5mg tab was given on 12/19/10, 12/25/10, and 12/27/10. The December 2010 ADL sheet documented no BMs for the time period between 12/07/10 - 12/12/10 for a total of six days. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's August 2010 monthly physician's orders [REDACTED]. "...04/05/[MEDICATION NAME] 5mg (milligrams)...2 tabs (tablets) (10mg) by mouth daily as needed for constipation... 04/02/[MEDICATION NAME] Sodium 100mg...1 cap (capsule) by mouth daily as needed for constipation... 11/23/01...Milk of Magnesia...30 cc (cubic centimeters) by mouth daily as needed for constipation..." The resident's August 2010 Activities of Daily Living (ADL) flowsheet documented no bowel movement on 08/01/11 through 08/03/11 (three days), and from 08/04/11 day shift through 08/09/11 night shift (five days). The resident's August 2010 Medication Administration Record (MAR) did not document any prn laxatives had been given the entire month. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The resident's readmission orders [MEDICATION NAME] ([MEDICATION NAME]) tabs 2 po qd prn (as needed)..." The resident's September 2010 ADL flowsheet documented no bowel movement from 09/17/10 evening shift until 09/22/10 day shift (five days). The resident's September 2010 MAR did not document any prn laxatives had been given. The resident's December 2010 ADL flowsheet documented no bowel movement from 12/04/10 day shift until 12/08/10 evening shift (four days), and from 12/11/10 evening shift until 12/17/10 evening shift (six days). The resident's December 2010 MAR did not document any prn laxatives had been given the entire month. On 01/30/11 at 2:45 p.m., CNA #1 was asked how long a resident should go without having a BM before reporting it to the nurse. She stated, "At least two days, if they haven't had one I report it to the nurse." At 2:50 p.m., NA #1 was asked how long a resident should go without having a BM before reporting it to the nurse. She stated, "I'm not sure how many days you should go. Maybe after the third day." At 2:55 p.m., CNA #2 was asked how long a resident should go without having a BM before reporting it to the nurse. She stated, "I would report it to the nurse after three days. It depends on the person maybe sooner." At 3:05 p.m., CMA #1 was asked how long a resident should go without having a BM before reporting it to the nurse. He stated, "Usually three days and the girls let me know and I give them a laxative or the nurse tells me to give them a laxative." At 3:15 p.m., LPN #1 was asked when she would expect the CNAs to report if a resident had not had a BM. She stated, "If they haven't had a BM in three days we would give them their PRN laxatives or call the physician to get an order for [REDACTED]. At 3:30 p.m., LPN #2 was asked when she would expect the CNAs to report if a resident had not had a BM. She stated, "They are supposed to report after three days. Then we give them a laxative." At 6:00 p.m., the DON was asked about the facility policy for CNAs to report when a resident had not had a BM. She stated, "The CMA should be checking the ADL sheets and asking the CNAs and getting with the nurse because the laxatives are PRN. She further stated that is why the facility needed to be accurately documenting the BMs. The DON stated, "If they aren't having BMs, it needs to be followed up on." The DON was asked about the resident's December ADL sheet which showed the resident had gone nine days without a BM. She stated, "Yes I see, bad. I would have expected someone to report it and be monitoring it." She further stated it should have been taken care of.