Every finding on record at Chandler Therapy & Living Center LLC

Based on observation, record review, and interview, the facility failed to ensure prepared food items were labelled with preparation and use-by dates and food items were discarded after use-by date during 1 of 2 kitchen observations.The administrator identified 36 residents received nutrition from the kitchen.Findings:On 12/08/25 at 9:43 a.m., the following observations were made in the walk-in refrigerator located outside the building: a. a covered plastic pitcher labelled grape, 12/02/25,b. a covered plastic pitcher labelled noodles, 12/03/25,c. a covered plastic pitcher labelled unsweet, 12/06/25, and d. a covered plastic pitcher labelled oj, 12/07/25. On 12/08/25 at 9:48 a.m. a cardboard box was observed containing salad dressing packets with manufacturer use-by date of 9/25 in the dry storage area in the kitchen.An undated facility policy titled Date Marking and Food Safety, read in part, the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.An undated facility policy titled Date Marking for Food Safety, read in part, the discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest.On 12/08/25 at 9:44 a.m., the dietary manager stated they were not sure if the dates were prepared date or use-by date, but assumed the dates were the prepared date. On 12/08/25 at 9:50 a.m., the dietary manager stated they should have discarded and removed items that were expired from dry storage and placed in a trash receptacle.

Based on record review and interview, the facility failed to ensure residents were free from abuse for 1 (#31) of 2 sampled residents reviewed for abuse.The administrator identified 37 residents resided in the facility.Findings:An undated Abuse Policy and Procedure, read in part, We will endeavor to protect our occupants from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of resident property. It recognizes resident rights to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal regulation.An incident report form, dated 12/08/25, showed on 12/08/25 Res #31 made an allegation of verbal abuse against CNA #1. The report also showed CNA #1 was suspended pending an investigation.An annual assessment, dated 09/29/25, showed Res #31 had a BIMS (a test for cognition) of 11 which was indicative of moderately impaired cognition. The assessment showed Res #31 had diagnoses which included diabetes mellitus and anxiety disorder. On 12/08/25 at 2:19 p.m., Res #31 stated CNA #1 was verbally abusive to them earlier in the day. Res #31 stated they had not reported the abuse.On 12/08/25 at 2:25 p.m., Res #31's allegation of verbal abuse was reported to the administrator.On 12/10/25 at 12:10 p.m., CMA #5 stated they had reported CNA #1 in the past for verbal abuse and was not sure if it was investigated.On 12/10/25 at 12:20 p.m., CNA #4 stated they had reported CNA #1 in the past for verbal abuse and does not know if it was investigated. On 12/10/25 at 3:00 p.m., the administrator stated during the investigation CNA #1 resigned. They also stated the facility had substantiated the allegation of abuse and they were reporting their findings to the nurse aide registry.

Based on record review and interview, the facility filed to ensure allegations of abuse were reported to the OSDH for 1 (#21) of 2 sampled residents reviewed for abuse.The administrator identified 37 residents resided in the facility.Findings:An undated Abuse Policy and Procedure, read in part, All allegations of resident mistreatment, including neglect, physical abuse, mental abuse, sexual abuse, involuntary isolation, verbal abuse, injuries of unknown origin, and/or misappropriation of property, shall be promptly reported to the administrator and investigated by facility management. Administrator will immediately report the allegation to the Oklahoma State Department of Health and the local police.A quarterly assessment, dated 10/16/25, showed Res #21 had a BIMS score (a test for cognition) of 04, which was indicative of severe cognitive impairment. The assessment showed Res #21 had diagnoses which included anxiety and depression.An undated statement form, signed by CNA #4, showed Res #21 expressed suicidal thoughts and CNA #1 antagonized Res #21.An undated statement form, signed by CMA #5, showed Res #21 was yelling and CNA #1 was yelling back at Res #21.On 12/10/25 at 12:10 p.m., CMA #5 stated they witnessed CNA #1 shouting at Res #21 and wrote a statement about it and slid it under the administrator's door. On 12/10/25 at 3:15 p.m., CNA #4 stated on 10/04/25 they, along with CMA #1 and CMA #5, witnessed CNA #1 verbally abuse Res #21. CNA #4 stated the administrator was not in the building at the time of the incident, so they all wrote statements and slid them under the administrator's door. They stated the administrator was sent a text message to inform them of the situation.On 12/15/25 at 10:15 a.m., the administrator stated calling a resident names, cursing at a resident, or yelling at a resident, were all examples of verbal abuse. The administrator stated the incident involving Res #21 and CNA #1 was not reported to the OSDH or the local police.

Based on record review and interview, the facility failed to ensure an allegation of abuse was investigated for 1 (#21) of 2 sampled residents reviewed for abuse.The administrator identified 37 residents resided in the facility.Findings:An undated Abuse Policy and Procedure, read in part, The administrator or administrative designee will conduct an immediate investigation of all alleged or actual incidents of abuse, neglect, or misappropriation of property.A quarterly assessment, dated 10/16/25, showed Res #21 had a BIMS score (a test for cognition) of 04, which was indicative of severe cognitive impairment. The assessment showed Res #21 had diagnoses which included anxiety and depression.An undated statement form, signed by CNA #4, showed Res #21 expressed suicidal thoughts and CNA #1 antagonized Res #21.An undated statement form, signed by CMA #5, showed Res #21 was yelling and CNA #1 was yelling back at Res #21.On 12/10/25 at 12:10 p.m., CMA #5 stated they witnessed CNA #1 shout at Res #21 and wrote a statement about it and slid it under the administrator's door. On 12/10/25 at 3:15 p.m., CNA #4 stated on 10/04/25 they, along with CMA #1 and CMA #5, witnessed CNA #1 verbally abuse Res #21. CNA #4 stated the administrator was not in the building at the time of the incident, so they all wrote statements and slid them under the administrator's door. They stated the administrator was sent a text message to inform them of the situation.On 12/15/25 at 10:15 a.m., the administrator stated calling a resident names, cursing at a resident, or yelling at a resident were all examples of verbal abuse. The administrator stated the incident which involved Res #21 and CNA #1 was not investigated because they did not think it was verbal abuse.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for 1 (#6) of 4 sampled residents reviewed for medication administration. The administrator identified 37 residents resided in the facility.Findings:An undated medication administration policy showed residents should be identified by the photo in the medication administration record. The policy showed to follow the six rights of medication administration which included identifying the right resident.A quarterly assessment, dated 09/11/25, showed Res #6 had a BIMS score (a test for cognition) of 15 which was indicative of intact cognition. The assessment also showed Res #6 had diagnoses which included diabetes mellitus and anxiety disorder.An incident note, dated 09/25/25 at 11:44 a.m., showed Res #6 was given another resident's medication by mistake. The medications given in error were Lasix 20 mg (a diuretic), Colace 100 mg (a stool-softener), Mobic 7.5 mg (an anti-inflammatory), Prilosec 40mg (a proton pump inhibitor), Xanex 0.5 mg (an anti-anxiety medication), Cymbalta 30 mg (an anti-depressant medication), and oxycodone 10 mg (an opioid pain medication). On 12/15/25 at 9:05 a.m., CMA #2 stated residents should always be positively identified before medications were administered.On 12/15/25 at 9:25 a.m., CMA #1 stated on 09/25/25 they administered the wrong medication to Res #6 by mistake. On 12/15/25 at 9:45 a.m., the DON stated residents should always be identified before medication administration

Based on record review and interview, the facility failed to ensure a care plan was revised for 1 (#30) of 12 sampled residents reviewed for care plans.The administrator identified 37 residents resided in the facility. Findings: An undated medical diagnoses list showed Res #30 had diagnoses which included vascular dementia, bipolar, schizophrenia, muscle weakness, and abnormalities of gait. An undated incident list for Res #30 showed they had non-injury falls on 11/15/25, 11/24/25, 11/27/25, and 12/12/25. Res #30's record was reviewed, and the care plan had not been revised to show interventions after each fall. On 12/15/25 at 11:40 a.m., the DON stated the care plan should have been revised after each fall to show an intervention.

Based on observation and interview, the facility failed to have a licensed administrator for the management of the facility. The DON identified 32 residents resided in the facility. Findings: On 03/10/25 at 2:00 p.m. an entrance was made at the facility. There was no administrator present and there was no administrator license observed posted. On 03/10/25 at 2:02 p.m. the DON stated the administrator quit last Friday (03/07/25) and had not been replaced.

Based on record review and interview, the facility failed to ensure: a. menus were prepared in advanced for serving sizes and nutritional adequacy; and b. menus were reviewed by the dietitian for nutritional adequacy. The DON identified 32 residents who ate meals prepared by the kitchen. Findings: A handwritten dietary menu for the week of 03/09/25 through 03/15/25 was reviewed. The menu did not document serving sizes or therapeutic diets such as renal diets or diabetic diets for the residents. There was no documentation the menu was approved by the dietitian. On 03/11/25 at 12:00 p.m., dietary cook #2 stated the menus they followed did not document serving sizes, only the name of the item to serve. Dietary [NAME] #2 stated they just guessed how much to serve of each food item. On 03/11/25 at 12:15 p.m., the DM stated they were not certified and had been in the position for about a month and a half. The DM stated they had not had therapeutic menus with serving sizes reviewed by the dietitian since the change in food provider at the first of the year. The DM stated they were told by administration to use what was currently in the freezer and on the shelves. The DM stated they thought the menus had been reviewed by the dietitian, but they had not. On 03/11/25 at 12:45 p.m., the DM stated they would not know what to serve a resident a resident with a special diet such as a renal diet. The DM stated they would ask the nurse or the dietitian.

Based on record review and interview, the facility failed to ensure residents rights to participate in the development and implementation of their person-centered plan of care for 3 (#1, 2 and #4) of 3 sampled residents who were reviewed for care plan meetings in the last six months. The DON identified 32 residents resided in the facility. Findings: 1. Resident #1 had diagnoses which included orthopedic aftercare following surgical amputation, chronic pain, dependence on renal dialysis, major depressive disorder, and anxiety disorder. A multidisciplinary care plan conference summary, dated 09/04/24, showed the resident had a meeting with staff members regarding their stay at the facility. A discharge return anticipated, dated 02/08/25, showed the resident was independent for daily decision making and their mental status for short term memory was okay. On 03/10/25 at 5:45 p.m., Resident #1 stated they had not had care plan meeting. 41873 2. Resident #2 was admitted to the facility on [DATE] with diagnoses which included epilepsy and anoxic brain damage. A multidisciplinary care plan conference summary, dated 09/24/24, showed a care plan meeting was conducted with the resident. A quarterly assessment, dated 12/11/24, showed Resident #2's cognition was intact with a BIMS score of 15. A care plan conference summary, dated 12/17/24, showed a care plan meeting was conducted with the resident. On 03/10/25 at 5:20 p.m., Resident #2 reported they had not been having regular care plan meetings as required. 3. Resident #4 was admitted to the facility on [DATE] with diagnoses which included heart failure and bi-polar disorder. A care plan conference summary, dated 12/10/24, showed Resident #4 refused to attend the care plan conference and the facility would reschedule for a later date if the resident was willing. A quarterly assessment, dated 12/13/24, showed Resident #4's cognition was intact with a BIMS score of 15. On 03/11/25 at 10:30 a.m., Resident #4 reported they had not attended a care plan meeting since they had been admitted . On 03/13/25 at 11:14 a.m., the SSD stated the residents had one care plan meeting in the last year. The social services director stated care plan meetings should be conducted quarterly and annually. The SSD stated they had no documentation to show the meetings had been completed as required.

Based on record review and interview, the facility failed to ensure: a. a system was maintained to assure generally accepted accounting principles for each resident's personal funds account, and b. individual financial records were available to the residents through quarterly statements and upon request for 3 (#1, 2, and #4) of 3 sampled residents reviewed for personal funds accounts. The business office manager identified 18 residents with trust fund accounts. Findings: A policy titled Resident Right - Accounting and Records of Personal Funds, last reviewed 06/27/22, read in part,The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf .The individual financial record will be available to the resident through quarterly statements and upon request. 1. Resident #1 had diagnoses which included orthopedic aftercare following surgical amputation, chronic pain, dependence on renal dialysis, major depressive disorder, and anxiety disorder. A discharge return anticipated, dated 02/08/25, showed the resident was independent for daily decision making and their mental status for short term memory was ok. A trust account balance record, posting date 03/11/25, showed the balance for the resident's personal funds account. On 03/10/25 at 5:45 p.m., Resident #1 stated they had asked for the balance of their personal funds account and the facility had not provided the information. 41873 2. Resident #2 had diagnoses which included epilepsy and anoxic brain damage. A quarterly assessment, dated 12/11/24, showed Resident #2's cognition was intact with a BIMS score of 15. On 03/10/25 at 5:20 p.m., Resident #2 reported they had not received their part of the SSI payment for the last two months. A trust account balance record, posting date 03/11/25, showed the balance for the resident's personal funds account. 3. Resident #4 had diagnoses which included heart failure and bi-polar disorder. A quarterly assessment, dated 12/13/24, showed Resident #4's cognition was intact with a BIMS score of 15. On 03/11/25 at 7:50 a.m., Resident #4 reported they had not been getting their part of the SSI checks. The resident reported staff had stated they were trying to get the account balances corrected. A trust account balance record, posting date 03/11/25, showed the balance for the resident's personal funds account. On 03/11/25 at 1:38 p.m., the vice president of business administration reported trust funds had not been reconciled since June 2024. The vice president of business administration reported quarterly statements were last given out in April 2024.

Based on record review and interview, the facility failed to ensure a resident was permitted to return to the facility after they were hospitalized for 1 (#5) of 1 sampled resident reviewed for hospitalization. The DON identified 32 residents who resided in the facility. Findings: A policy titled Bed-Hold and Returns, revised [DATE], read in part, The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source .Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident: a. still requires the services provided by the facility; and b. is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. Resident #5 had diagnoses which included persistent mood disorder, bipolar disorder, major depressive disorder, morbid obesity, pressure ulcer, and chronic obstructive pulmonary disease. A discharge return not anticipated assessment, dated [DATE], showed no acute mental status change. A health status note, dated [DATE] at 11:15 p.m., showed the resident complained of chest pain and was transported to the hospital by ambulance. A health status note, dated [DATE] at 9:23 a.m., showed the resident returned to the facility by ambulance. A health status note, dated [DATE] at 6:16 a.m., showed the resident was transported to the hospital via emergency management services for abdominal pain. The resident's clinical record did not document a discharge summary or a progress note documenting the reason the resident was discharged from the facility. On [DATE] at 5:08 p.m., the DON stated they could not locate a 30 day discharge notice or a discharge summary for the resident. The DON stated they were not employed by the facility at the time of the resident's discharge and could not provide information or documentation regarding the resident's discharge. On [DATE] at 4:30 p.m., Resident #5 stated they were still in the hospital and had never received a 30 day discharge notice. The resident stated they received a telephone call from the facility who stated they would not be allowed to return to the facility. On [DATE] at 3:45 p.m., the DON stated they could not find documentation regarding if the resident's discharge was self or facility initiated.

Based on record review and interview, the facility failed to ensure a PASSAR level I assessment was completed before or on admission for 1 (#7) of 1 sampled resident reviewed for PASSAR. The DON identified 32 residents who resided in the facility. Findings: Resident #7 was admitted to the facility 02/03/25 with diagnoses which included chronic obstructive pulmonary disease, depression, and anxiety disorder. A review of the resident's clinical record was completed and no documentation regarding the completion of a PASSAR level I was found. On 03/13/25 at 3:46 p.m., the DON stated they could not locate documentation a PASSAR level I was completed for the resident. The DON stated it must have been missed.

Based on record review and interview, the facility failed to ensure a PRN order for an antianxiety medication had a 14 day stop date for one (#3) of three sampled residents reviewed for medications. The administrator identified 40 residents resided in the facility. Findings: Res #3 was admitted to the facility with diagnoses which included anxiety disorder, insomnia, unspecified dementia. A physician's order, dated 09/05/24, documented Xanax (benzodiazepine medication) Oral Tablet. Give 1 tablet by mouth every 8 hours for anxiety. The order did not document a stop date. On 10/11/24 at 2:02 p.m., the DON stated the medication should have had a stop date.

Based on record review and interview, the facility failed to follow physician's orders for one (#2) of three sampled residents reviewed for medications. The administrator identified 40 residents resided in the facility. Findings: Res #2 was admitted to the facility with diagnoses which included of anxiety disorder, hypertensive heart disease, and unspecified dementia. A physician's order, dated 08/07/24, documented to hold Ativan (benzodiazepine medication) for now and call if behaviors resume. A medication regimen review, dated August 2024, documented the resident was administered Lorazepam (Ativan) on 08/15/24 at 8 a.m. and 4 p.m., 08/16/24 at 8 a.m. and 4 p.m., 08/24/24 at 4 p.m., and 08/25/24 at 8 a.m. and 4 p.m. The resident's record did not contain documentation the order was resumed or the resident had any behaviors. On 10/11/24 at 2:02 p.m., the DON was shown the August 2024 medication administration record and asked if the facility had a physician's order to resume the lorazepam. They stated the medication hold probably fell off. The DON was unable to find an order to resume the lorazepam.

Based on record review and interview, the facility failed to ensure orders for dialysis and pre/post dialysis assessments were completed for three (#3, 22, and #27) of three sampled residents who were reviewed for dialysis. The DON identified three residents who received dialysis. Findings: The End-Stage Renal Disease, Care of a Resident with policy, dated September 2010, read in parts, .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . 1. Resident #3 had diagnoses which included end stage renal disease. The annual assessment, dated 05/14/24, documented the resident received dialysis and was cognitively intact for daily decision making. Review of the Dialysis Information forms, dated 07/01/24 through 07/31/24, revealed the following: a. The pre dialysis assessment did not document a weight two times out of 12 opportunities; b. The post dialysis assessment had been completed by dialysis staff, rather than facility staff, seven of 12 opportunities; and c. The clinical record did not contain any documentation, nor was documentation provided for pre/post dialysis assessments by the end of the survey, for five of 12 opportunities. Review of the Dialysis Information forms, dated 08/01/24 through 08/10/24, revealed the following: a. The post dialysis assessment had been completed by dialysis staff, rather than facility staff, for four of five opportunities; and b. The clinical record did not contain any documentation, nor was documentation provided for pre/post dialysis assessments by the end of the survey, for one of five opportunities. Review of the physician's orders in the electronic clinical record did not reveal an order for dialysis. On 08/11/24 at 12:04 p.m., Resident #3 stated the nurses at the facility obtained vital signs and their weight but did not assess the access site. 2. Resident #22 had diagnoses which included end stage renal disease. The admission assessment, dated 06/15/24 documented the resident received dialysis and was cognitively intact for daily decision making. Review of the Dialysis Information forms, dated 07/01/24 through 07/31/24, revealed the following: a. The pre dialysis assessment did not document a weight three times out of 13 opportunities; and b. The post dialysis assessment had been completed by dialysis staff, rather than facility staff, 10 times out of 13 opportunities. Review of the Dialysis Information forms, dated 08/01/24 through 08/10/24, revealed the following: a. The pre dialysis assessment did not contain a weight for four of five opportunities; and b. The post dialysis assessment had been completed by dialysis staff, rather than facility staff, for five of five opportunities. Review of the physician's orders in the electronic clinical record did not reveal an order for dialysis. On 08/11/24 at 12:20 p.m., Resident #22 stated they received dialysis three times a week on Tuesday, Thursday, and Saturday. The resident stated the scales had not been working so the staff had not obtained weights recently. They stated their access site was in their right upper chest and the facility staff did not assess the site, the dialysis nurses maintained it. 3. Resident #27 had diagnoses which included end stage renal disease. The quarterly assessment, dated 04/19/24, documented the resident received dialysis and was severely impaired in cognition for daily decision making. Review of the Dialysis Communication forms, dated 07/01/24 through 07/31/24, revealed the following: a. The pre dialysis assessment did not document a weight one time out of 13 opportunities; b. The post dialysis assessment had been completed by dialysis staff, rather than facility staff, eight times out of 13 opportunities; and c. The clinical record did not contain any documentation, nor was documentation provided for pre/post dialysis assessments by the end of the survey, for four of 13 opportunities. Review of the physician's orders in the electronic clinical record did not reveal an order for dialysis. On 08/13/24 at 10:51 a.m., RN #1 stated Resident #3 and Resident #22 had access to their right upper chest. They stated they obtained weights and vital signs before dialysis and assessed the dialysis access site after dialysis to ensure it was not bleeding. RN #1 stated they utilized the Dialysis Information form to document the pre dialysis assessment and the post dialysis assessment was completed by the nurse at the dialysis center. On 08/14/24 at 9:42 a.m., the DON stated they did not have a policy regarding dialysis assessments. They stated they coordinated with the dialysis center and followed physician's orders. The DON was asked how they followed physician's orders when there were no orders for dialysis documented in the electronic clinical record. They stated they had done what they could but needed to look into why there were no orders. On 08/13/24 at 2:06 p.m., LPN #1 stated they obtained vital signs and weights before and after dialysis for Resident #27. They stated if the access site appeared abnormal after dialysis they would document in the progress notes. On 08/13/24 at 2:27 p.m., the DON stated the charge nurses were to complete the communication/information forms. They stated the dialysis center conducted the post dialysis assessments and the charge nurses were to monitor for bleeding. They stated the nurses followed the standards of practice with dialysis assessments and only documented if something was abnormal. The DON stated there should have been orders for dialysis from the physician in the electronic clinical record.

Based on observation, record review, and interview, the facility failed to ensure the urinary drainage bag was positioned in a manner to maintain infection control for two (#92 and # 6) of two sampled residents who were reviewed for urinary catheters. The Resident Matrix documented two residents who had urinary catheters. Findings: An undated policy titled Catheter Care, Urinary, read in parts .Be sure the catheter tubing and drainage bag are kept off the floor . 1. Resident #6 had diagnoses which included pressure induced deep tissue damage of the right buttocks and the sacral region. On 08/13/24 at 2:00 p.m., Resident #6 was observed in bed with the urinary catheter bag on the floor. On 08/14/24 at 10:45 a.m., Resident #6 was observed in bed, lying on their left side. The urinary catheter bag was observed to be attached to the bed frame and resting on the floor. On 08/14/24 at 10:49 a.m., LPN #1 was observed to provide urinary catheter care for Resident #6. On 08/14/24 at 10:53 a.m., LPN #1 stated the catheter bag should not be on the floor and repositioned the bag. On 08/14/24 at 1:00 p.m., the adminsitrator stated they do not have a policy regarding positioning of a urinary catheter. 35474 2. Resident #92 had diagnoses which included acute kidney failure and sacral wound. The Physician Order, dated 07/15/24, documented to clean the indwelling urinary catheter twice daily. Review of the electronic clinical record did not reveal documentation of care twice daily for the indwelling urinary catheter. On 08/11/24 at 11:53 a.m., Resident #92 was observed in their wheel chair in their room. The bottom of the indwelling urinary catheter bag was observed to touch the floor. On 08/12/24 at 10:49 a.m., Resident #92 was observed, in their wheel chair, propelling down the hallway. The bottom of the catheter bag was observed to drag on the floor, under the wheel chair. On 08/12/24 at 11:36 a.m., Resident #92 stated the staff provided catheter care if the catheter was dirty but it did not happen very often. On 08/12/24 at 11:39 a.m., CNA #1 stated the CNAs and nurses performed indwelling urinary catheter care. CNA #1 reviewed the electronic clinical record and stated the CNAs did not document catheter care. They stated the nurses documented catheter care. On 08/12/24 at 11:48 a.m., RN #1 stated the CNAs were responsible to perform indwelling urinary catheter care for Resident #92. On 08/12/24 at 12:15 p.m., the DON stated the nurses and CNAs performed indwelling urinary catheter care. The DON stated the nurse documented on the treatment record and the aides documented under the task tab in the electronic clinical record. Documentation of catheter care for Resident #92 was requested from the DON. On 08/12/24 at 12:35 p.m., RN #1 stated they wanted to clarify that both the nurses and the CNAs performed indwelling urinary catheter care but they had not documented. On 08/14/24 at 10:10 a.m., CNA #2 stated indwelling urinary catheter bags were not to touch the floor. On 08/14/24 at 3:03 p.m., Resident #92 was observed to propel down the hallway in their wheel chair. The bottom of the catheter bag/dignity bag was observed to drag on the floor under the wheel chair.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed for four (#3, 27, and #92) of 14 sampled residents whose care plans were reviewed. The DON identified 40 residents who resided in the facility. Findings: The Care Plans, Comprehensive Person-Centered, dated December 2016, read in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. Resident #3 had diagnoses which included end stage renal disease. The annual assessment, dated 05/14/24, documented the resident received dialysis. Review of the electronic clinical record did not reveal a care plan had been developed to address end stage renal disease/dialysis with goals or interventions. On 08/13/24 at 8:32 a.m., CNA #1 stated Resident #3 was getting ready for dialysis. On 08/13/24 at 2:27 p.m., the DON reviewed the electronic clinical record and stated the previous care plan coordinator had not developed a care plan related to end stage renal disease/dialysis. The DON stated they had not had time to audit all of the care plans. 2. Resident #27 had a diagnoses of schizophrenia. The admission assessment, dated 01/19/24, documented the resident had a diagnoses of schizophrenia and received an antipsychotic medication routinely. The quarterly assessment, dated 04/19/24, documented the resident had a diagnoses of schizophrenia and received an antipsychotic medication routinely. Review of the electronic clinical record did not reveal a care plan had been developed to address the diagnoses of schizophrenia, treatment/interventions, or goals. On 08/14/24 at 2:54 p.m., the DON stated the care plan for Resident #27 needed updated to include schizophrenia and the use of antipsychotic medications. 3. Resident #92 had diagnoses which included acute kidney failure and sacral ulcer. On 08/12/24 at 11:36 a.m., Resident #92 was observed to have an indwelling urinary catheter. A physician order, dated 07/12/24, documented to change the indwelling urinary catheter every month and as needed. Review of the electronic clinical record did not reveal a care plan had been developed to address the use of an indwelling urinary catheter, goals, or interventions. On 08/12/24 at 12:17 p.m., the DON stated they had been completing and updating care plans for code status, falls, elopement risk, and hospice. The DON stated they had been completing care plans since the previous care plan coordinator had quit at the end of June/beginning of July. The DON stated no one had developed care plans related to the use of catheters.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed for three (#22, 27, and #92) of 12 sampled residents whose care plans were reviewed. The DON identified 40 residents who resided in the facility. Findings: The Care Plans - Baseline policy, dated December 2016, read in part, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . 1. Resident #22 had diagnoses which included congestive heart failure and end stage renal disease. The Baseline Care Plan, dated 06/10/24, in the electronic health record, was documented as In Progress and was blank. 2. Resident #27 had diagnoses which included schizophrenia and end stage renal disease. The Baseline Care Plan, dated 01/13/24, in the electronic health record, was documented as In Progress and was blank. 3. Resident #92 had diagnoses which included absence of left leg below the knee, absence of right foot, and schizoaffective disorder bipolar type. The Baseline Care Plan, dated 06/14/24, in the electronic health record, was documented as In Progress and was blank. On 08/14/24 at 12:55 p.m., the DON stated the baseline care plans were supposed to be done within 48 hours of admit by the admitting nurse. The DON stated they did not know why the baseline care plans were blank.

Based on record review and interview, the facility failed to ensure assessments were transmitted within seven days of completion for two (#11 and #92) of 14 sampled residents whose assessments were reviewed. The DON identified 40 residents who resided in the facility. Findings: 1. Resident #11 had diagnoses which included diabetes. The MDS 3.0 NH Final Validation Report, dated 08/09/24 documented the following assessments had been submitted late: a. The annual assessment, dated 06/12/24; and b. The discharge return not anticipated, dated 07/03/24. 2. Resident #92 had diagnoses which included acute kidney failure and sacral ulcer. The MDS 3.0 NH Final Validation Report, dated 08/09/24 documented the admission assessment, dated 06/21/24, had been submitted late. On 08/14/24 at 10:47 a.m., the administrator stated the previous MDS coordinator has not transmitted MDS assessments timely. They stated they had not monitored MDS assessments to ensure they were transmitted timely but the previous DON had monitored.

Based on record review and interview, the facility failed to ensure an annual comprehensive assessment was completed within 14 days of the ARD for one (#11) of 14 sampled residents whose assessments were reviewed. The DON identified 40 residents who resided at the facility. Findings: Resident #11 had diagnoses which included diabetes. The annual assessment, dated 06/12/24, documented it had been completed on 06/28/24. The MDS 3.0 NH Final Validation Report, dated 08/09/24, documented the annual assessment, dated 06/12/24 was completed more than 14 days after the ARD date and was late. On 08/14/24 at 10:47 a.m., the administrator stated the previous MDS coordinator has not been completing MDS assessments timely. They stated they had not monitored MDS assessments to ensure they were completed timely but the previous DON had monitored.

Based on record review and interview, the facility failed to provide supervision to prevent elopement for one (#2) of three sampled residents reviewed for elopement, which resulted in hospitalization for rhabdomyolysis, acute kidney injury, and UTI. The administrator identified seven residents who were high risk for elopement. Findings: The facility's Elopement policy, revised 12/2007, documented staff should promptly report any resident who was suspected of being missing to the charge nurse or director of nursing, if an employee discovered a resident was missing from the facility premises they should determine if the resident was out on authorized leave or a pass, if not on authorized leave, initiate a search of the building and premises, if the resident was not located notify the administrator and the director of nursing, legal representative, and law enforcement. Resident #2 had diagnoses which included unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and bladder cancer. Resident #1's admission assessment, dated 05/10/24, documented the resident had severe cognitive impairment, was inattentive, had no behaviors of wandering, and was independent with ADLs. A document titled, Wandering Risk Scale, dated 05/20/24, documented Resident #2 had a low risk of elopement and to repeat the assessment in one month and quarterly. A document titled, Incident/Offense Report from the police department, dated 08/02/24, documented a missing person incident occurred on 08/02/24 at 12:00 p.m. The report documented On 08/02/24 at 6:48 p.m., a police officer was dispatched to the nursing center in reference to a missing resident. The report documented each staff member the officer spoke with gave a different time they had last seen Resident #2. The report documented at 8:30 p.m. a Silver Alert and a Be on the lookout was requested from Oklahoma Highway Patrol. The report documented sometime in the afternoon on 08/02/24 Resident #2 had been found by Oklahoma Highway Patrol and was taken to a rescue mission in Oklahoma City. The report also documented Resident #2 was located on 08/03/24 at a family member's house in Oklahoma City and it was not known how the resident had gotten there. A document titled, Incident Report Form, dated 08/02/24, documented Resident #2 could not be located on 08/02/24 when the CMA went to administer the resident their evening medications. The report documented Resident #1 was located at their families house in Oklahoma City. The DON and administrator transported Resident #1 to the local emergency room for evaluation on 08/03/24. Employee statements related to the incident documented the following: Employee #1 documented they changed Resident #2's urostomy appliance on 08/02/24 at 2:30 p.m. There was no documentation in the clinical record the care had been completed on 08/02/24 at 2:30 p.m. Employee #2 documented they had not seen Resident #2 for the entire evening shift on 08/02/24. Employee #3 documented they had taken Resident #2's tray to their room around 5:40 p.m. and the resident was not in their room, they looked in the resident's bathroom and in the hall and then went back to Resident #2's room around 15 minutes later to give the resident medication and still did not find Resident #2 in their room. Employee #4 documented they were on lunch break and saw Resident #2 go out the back door and sit down. The employee reported they continued to look at their phone and then went back inside and did not recall if Resident #2 was still outside when they went back in the building. Employee #5 documented at 5:45 p.m., a CMA asked them if they had seen Resident #2 and they stated they had not seen the resident, and they started searching for Resident #2 and notified the police. An undated document titled, Corrective Action: Plan of Removal, documented elopement risk assessments were conducted on all residents, signs posted on front door to alert visitors not to let anyone out, and all staff inserviced. The corrective action plan did not address how Resident #2 had been able to get out of the building. The corrective action plan did not have signatures from the QA committee. A document titled, ED Provider Notes, dated 08/03/24. documented the patient had dementia and a urostomy, had been missing from the skilled nursing facility for 24 hours. The note documented Resident #2 had walked an estimated 20 miles without food or water and was oriented to self only. A document titled, Physician Discharge Summary, dated 08/05/24 documented the resident was admitted to the hospital on 08/03/24 with a diagnoses of rhabdomyolysis (A breakdown of skeletal muscle due to direct or indirect muscle injury causes may include extreme muscle strain, heat stroke, and/or bacterial infection.), acute kidney injury, and urinary tract infection. On 08/09/24 at 3:16 p.m., Resident #2 stated they had lived at the facility for about six months. (The resident was admitted in May 2024.) Resident #2 stated they did not know the name of the facility or the name of the town where the facility was located. Resident #2 stated they had not gone to visit their family recently. On 08/09/24 at 5:27 p.m., CNA #1 stated they had been one of the CNAs assigned to Resident #2's hall on 08/02/24 on the evening shift. The CNA #1 stated they thought the resident was out on leave and had not informed anyone. The CNA #1 stated they had not seen Resident #2 at shift change, during supper or the entire shift, and did not recall if they had assisted any residents with smoking that day. CNA #1 stated they started looking for Resident #2 after supper. CNA #1 stated they thought Resident #2 had dementia. On 08/09/24 at 5:39 p.m., CMA #1 stated Resident #2 had dementia and needed cueing for ADLs and was not sure if the resident knew which town the nursing home was located. CMA #1 stated the last time they saw Resident #2 on 08/02/24 was around lunch time sometime between 12:00 p.m. and 12:30 p.m. On 08/09/24 at 5:57 p.m., LPN #1 stated they had discovered Resident #2 had been missing on 08/02/24. They stated it was around 4:30 p.m., on 08/02/24 when they were on that hall and thought the resident may have been out smoking. They stated around 5:00 or 5:30 p.m., they noticed Resident #2's evening meal tray in their room and knew the resident did not eat in their room. The LPN #1 stated they immediately started asking the staff if they had seen him and started looking for the resident. LPN #1 stated they had heard the resident may have been picked up by the highway patrol and taken to their family's house. LPN #1 stated the resident had a history of bladder cancer and after they found the resident they were admitted to the hospital for Rhabdomyolysis and dehydration. On 08/09/24 at 6:43 p.m., the DON stated they discussed QA related to Resident #2's elopement each morning. They stated they were reviewing new residents and any residents with new risks five times a week for five weeks. The DON stated they had started discussing it in the morning meetings but had not done it on 08/09/24 because they were off that morning. The DON was asked for the QAPI meeting and attendees. The QAPI meeting sign in sheet was not provided. On 08/09/24 at 7:00 p.m., the administrator stated they did not know how resident #2 had gotten out of the facility and did not know how the resident had gotten to their family's house. On 08/09/24 at 7:34 p.m., CNA #2 stated they had been told by the administrator and the DON, Resident #2 had left the building around 12:00 p.m. on 08/02/24 through the door to the smoking area by putting in the door code. On 08/09/24 at 8:08 p.m., the DON was asked if they had performed an elopement risk assessment one month after Resident #2 was admitted as stated on the elopement risk assessment. They stated they did not see one dated for one after admission in the computer. On 08/10/24 at 3:37 p.m., CNA #3 stated they had been working on 08/02/24 and had last seen Resident #2 around 12:00 p.m. CNA #3 stated they had heard Resident #3 had gotten out through the back door. CNA #3 was asked how it was determined the resident had left through the back door. They stated they looked at the cameras. On 08/10/24 at 3:53 p.m., RN #1 stated they had not been given specifics about the time Resident #2 had left the building. RN #1 stated if the staff had done on/off going shift rounds they would have discovered the resident was missing sooner. RN #1 stated they thought the resident had gone out to smoke and had left from there on 08/02/24. RN #1 stated some of the residents had the door code prior to this incident. On 08/10/24 at 4:01 p.m., CNA #4 stated the administrator had told them on Saturday 08/03/24, Resident #2 had gotten out through the back door to the smoking area around 12:00-12:30 p.m. On 08/10/24 at 4:27 p.m., residents were observed waiting in the back lobby to go to smoke. Two residents stated they used to have the code to go out to smoke, until a resident left. The residents identified the resident as Resident #2. On 08/10/24 at 5:06 p.m., the administrator was asked if they had determined how the resident had gotten out of the building. They stated they viewed the camera and saw Resident #2 go out the smoking door and they did not know if the resident came back in the building. The administrator stated they did not know how the resident got out of the door to the smoking area.

Based on observation, record review, and interview, the facility failed to provide supervision to prevent falls and implement interventions to prevent falls for one (#16) of three sampled residents reviewed for falls which resulted in a fall with bruising to the left eye area, and a laceration above the left eye which required stitches. The Resident Census and Condition of Residents report, dated 08/24/23, documented 47 residents resided in the facility. Findings The facility's Fall Reduction Program policy, revised 03/29/23, read in parts, .All residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accident Care plans will be created and implemented based on the individual's risk factors to aid in prevention of falls . Resident #16 was admitted on [DATE] with diagnoses which included Parkinson's, repeated falls, altered mental status, adult failure to thrive, and chronic pain. A fall risk assessment, dated 07/31/23, documented Resident #16 had fallen prior to admission, had an impaired gait, overestimated or forgot limits, scored 75 on the fall risk scale which indicated high fall risk. The fall risk assessment documented 0-24 was an indication of low risk for falls, 25-44 was an indication of moderate risk for falls, and 45 or higher was an indication of high risk for falls. A baseline care plan, dated 07/31/23, documented Resident #16's primary health concerns included falls and had a goal to minimize falls. The care plan documented the resident was at risk for falls due to history of falls, unsteady gait, poor safety awareness, the goal was to have no injuries from falls and the following interventions were in place: provide clutter free environment, encourage resident to request assistance when attempting to transfer, call light within reach, appropriate footwear, and well lit environment. A nurse's note, dated 08/03/23 at 7:13 a.m., read in parts, .resident was crawling on the floor and ran into wheelchair hitting his head. Small raised area on forehead . A nurse's note, dated 08/03/23 at 7:15 a.m., read in part, .[Ambulance service] notified and arrived to take resident to ER . A nurse's note, dated 08/03/23 at 12:05 p.m., read in parts, .Res. returned to facility Discharge paperwork received .seen for fall against object .closed head injury . An incident report, dated 08/03/23 at 6:20 p.m., read in parts, .resident got up from chair and attempted to walk around and fell in front of the front door and hit [their] head . A nurse's note related to the incident, dated 08/03/23 at 6:22 p.m., read in parts, .CNA's reported patient was walking towards exit and fell from standing position, they said [they] hit [their] head really hard.Lump developing to back of head, patient reports head pain and neck pain, EMS activated . A nurse's note, dated 08/03/23 at 7:24 p.m., documented the resident had fallen by the front door and was sent to the ER via ambulance. Resident #16 was sent to the hospital two times on 08/03/23 related to falls. A nurse's note, dated 08/04/23 at 10:11 a.m., documented Resident #16 returned to the facility via ambulance. A nurse's note, dated 08/04/23 at 11:19 a.m., documented Resident #16 changed positions frequently from couch to floor to standing and walking unassisted and was unsafe to ambulate unassisted due to gait imbalance. A nurse's note, dated 08/04/23 at 6:49 p.m., documented Resident #16 had bruising to back of right thigh, bruising to forehead and back of head and had multiple falls. The note documented the resident put himself from the couch to the floor repeatedly. An incident report, dated 08/05/23 at 9:16 p.m., documented Resident #16 had an unwitnessed fall outside of the building. The note documented the nurse was called outside the building and observed Resident #16 lying face down on the ground, the staff would continue to assist and redirect. A nurse's note related to the incident, dated 08/05/23 at 3:11 a.m., documented Resident #16 was observed lying on the ground face down outside in front of the building. The note documented prior to the fall the resident was crawling on the floor across the common area. The note documented Resident #16 had some discoloration to their right thumb, no swelling, no pain, resident had been given all routine and as needed medications for anxiety, resident remains in common area for all staff to assist with care. An admission assessment, dated 08/06/23, documented Resident #16 had severe cognitive impairment, required extensive assistance from staff for bed mobility, transfers, and toilet use. The assessment documented the resident was frequently incontinent of bowel and bladder and had falls prior to admission and had two or more falls without injury since admission. The Fall care plan, dated 08/07/23, documented Resident #16 was at high risk for falls related to cognitive impairment, gait/balance problems, poor communication/comprehension, and unaware of safety needs. The care plan documented Resident #16 had the following falls: Two falls with minor injury on 08/03/23 and a third fall on 08/03/23 without injury, A non injury fall on 08/04/23, A fall with minor injury on 08/08/23, and one non injury fall on 08/08/23, A fall with minor injury on 08/09/23 and 08/10/23, A non-injury fall on 08/10/23 and 08/11/23, Two non-injury falls on 08/14/23, Two non-injury falls on 08/15/23, A non-injury fall on 08/17/23, and A fall with minor injury on 08/22/23. The interventions initiated on 08/07/23 read in parts, .Anticipate and meet the Resident's needs .Educate resident/family/caregivers about safety reminders .Review information on past falls and attempt to determine cause .remove any potential cause if possible .safe environment with even floors free from spills and or clutter .working and reachable call light .activities that minimize the potential for falls .evaluated .and supplied the appropriate adaptive equipment or devices as needed. There were no new interventions documented on the care plan after the falls which occurred on or after 08/08/23 through 08/17/23. An incident report, dated 08/08/23 at 5:18 a.m., documented Resident #16 got up off the couch in the common area tried to run and fell . An incident report, dated 08/08/23 at 7:27 a.m., documented Resident #16 was attempting to ambulate without assistance and fell sideways. A nurse's note, dated 08/08/23 at 4:18 p.m., documented Resident #16 constantly attempted to stand and ambulate unassisted and required assistance due to weakness, shuffling gait, leans forward walking, history of frequent falls, staff attempted to redirect resident with television, food beverages, with no success, resident crawled on floor, grabbed at other residents' wheelchairs and was not cooperative and was difficult to redirect. A nurse's note, dated 08/09/23 at 7:39 p.m., documented Resident #16 had a fall with a laceration noted to the left eyebrow with redness from eyebrow ridge to hair line, resident was sent to the ER and returned at 5:15 p.m. with dermabond to the laceration. The note documented Resident #16 was provided 1:1 staff supervision to prevent further falls. A emergency department note, dated 08/09/23, documented Resident #16 was seen in the ER for a fall with injury. The report documented Resident #16 fell off of the couch and sustained a laceration to the left eyebrow. An OSDH combined initial and final incident report, dated 08/09/23, documented the CNA reported Resident #16 fell on his head hard Charge nurse observed a laceration in left eyebrow with redness from eyebrow ridge up to hair line, resident sent to ER, and returned to the facility, placed on one to one supervision to prevent further injury, and the facility was purchasing a helmet to prevent further injuries related to bumping their head. A nurse's note and incident report, dated 08/10/23 at 8:07 a.m., documented the nurse was informed Resident #16 was laying on couch and staff heard a loud boom and patient was observed crawling on the floor, an abrasion was observed to the left knee, no other skin problems since last fall, resident was confused and uncooperative. A nurse's note and incident report, dated 08/11/23 at 8:05 p.m., documented Resident #16 got up off couch, used the furniture to hold on to walk, the cushion gave way and the resident landed on the floor. The resident was placed in a wheelchair and provided one to one supervision. An incident report, dated 08/14/23 at 2:46 p.m., documented a wound care nurse entered the building and witnessed Resident #16 fall. A nurse's note and incident report, dated 08/14/23 at 5:53 p.m., documented Resident #16 stood up and attempted to walk and fell backwards onto planter and hit their back against the window sill. An incident report, dated 08/15/23 at 4:15 p.m., documented the nurse was informed by a resident, Resident #16 had fallen and hit their head. A nurse's note, dated 08/15/23 at 8:12 p.m., documented the nurse was informed by a CMA, Resident #16 stood up and fell rolling onto their shoulder. A nurse's note, dated 08/15/23 at 8:38 p.m., documented Resident #16 was grabbing at other residents, punched a staff member then fell on the couch. The physician was notified and orders were given to send Resident #16 out to the hospital with an emergency discharge and to not take the resident back because the facility was not able to meet the resident's needs. A nurse's note, dated 08/16/23 at 10:10 p.m., documented the physician was notified Resident #16 returned to the facility. A nurse's note and incident report, dated 08/17/23, documented the nurse was notified by the CNAs, Resident #16 had fallen, the resident was observed on the floor on their right side, resident complained of pain to the right hip. A nurse's note, dated 08/22/23 at 1:50 a.m., documented Resident #16 had fallen and had a cut to their left brow area and was sent to the hospital via ambulance. A nurse's note, dated 08/22/23 at 4:27 a.m., documented Resident #16 returned from the hospital with sutures to left eyebrow area. An OSDH combined initial and final incident report, dated 08/22/23, documented Resident #16 had bumped their head on the floor causing a laceration above the left eye, Resident #16 received stitches above their left eyebrow, the plan of care would be followed with fall mat below resident. On 08/22/23 at 12:17 p.m., Resident #16 was observed on the couch in the common area with bruising to left eye and sutures to the left eyebrow. Resident #16 was observed with the fall mat in their mouth, staff assisting other residents in the common area were observed to redirect the resident asking them if they were hungry. Resident #16 was observed crawling on the floor under the table. Resident #16 was not wearing a helmet. A Care Plan for falls, updated 08/22/23, read in parts, .Resident needs to be constant supervision .Staff to redirect resident as much as possible . On 08/23/23 at 5:34 a.m., LPN #4 stated Resident #16 was provided 1:1 supervision while awake because the resident was constantly into everything. Resident #16 was observed lying on the couch. On 08/23/23 at 5:56 a.m., CNA #2 stated Resident #16 had fallen again around 1:50 a.m., on 08/22/23 and was sent to the hospital. CNA #2 stated they had been outside on break and the LPN had been out in their car at the time Resident #16 fell . On 08/23/23 at 3:22 p.m., Resident #16 was observed lying on the couch. The DON was asked what interventions were in place to prevent Resident #16 from falling. They stated the staff watched the resident, a fall mat was in place, and when Resident #16 was awake they provided 1:1 supervision and were trying to get the resident admitted to a psychiatric hospital. The DON was asked if they had purchased a helmet as documented on the incident report. They stated therapy was supposed to help with the purchase, they had not purchased a helmet at this time. On 08/24/23 at 12:00 p.m., Resident #16 was observed sitting on the couch in the common area with a staff member. Resident #16 was not wearing shoes or a helmet. On 08/24/23 at 5:09 p.m., LPN #3 was asked if the facility had a form they used to document when a resident was provided 1:1 supervision. They looked through the computer charting and stated no. An incident report, dated 08/26/23 at 10:37 a.m., read in parts, .Un-Witnessed .resident was sitting on couch in lobby, resident tried to stand up and was found on floor on [their] face on [their] knees. resident had a one on one at time but had not caught [them] in time to prevent .from falling .transport to hospital for assessment due to hitting .head . emergency room discharge paperwork, dated 08/26/23, documented Resident #16 was seen in the emergency room for fall and nasal fracture. The paperwork documented to follow up with physician. An OSDH combined initial and final incident report, dated 08/26/23, read in parts, .[Resident #16] was sitting in the lobby .had a nurse 1:1.[Resident #16] stood up and she was unable to catch [them] before [they] fell [their] face hit the floor .was transferred to [hospital] .[Resident #16] has a nasal fracture. [They] returned with no new orders. We will continue to follow care plan with mat below him as well as 1:1 and helmet . On 08/27/23 at 7:02 p.m., LPN #2 stated Resident #16 had fallen this weekend. LPN #2 stated the RN had been watching the resident and Resident #16 attempted to get up and fell . LPN #2 stated they sent Resident #16 to the hospital, they stated Resident #16 had a nasal fracture. On 08/27/23 at 7:44 p.m., Resident #16 was observed sitting on the couch with gait belt around their waist, and wearing yellow non-skid socks. There were no staff observed with the resident. Two staff members were observed on the North hall. CNA #5 was observed to return to the common area where Resident #16 was located. On 08/27/23 at 7:49 p.m., Resident #16 was observed on the floor in the common area yelling Help. Staff were observed with resident. They stated the resident was walking with staff and the resident buckled so they lowered him to the floor. Staff were observed assisting the resident up to the wheelchair. On 08/27/23 at 7:58 p.m., Resident #16 stood up, there were no staff within reach of the resident. CMA #1 ran to the resident to assist. On 08/27/23 at 8:50 p.m., Resident #16 was on the couch with fall mat in front of him. On 08/27/23 at 8:52 p.m., Resident #16 was observed in the common area getting up from the couch and ambulating unsteady without staff supervision. A staff member ran from the dining room to reach Resident #16. On 08/27/23 at 8:53 p.m., the DON was observed sitting on the couch in the common area with Resident #16. On 08/29/23 at 2:49 p.m., the DON stated Resident #16 was at risk for falls. The DON was asked about interventions put in place after Resident #16 had fallen. They stated the interventions which were documented on the care plan dated 08/07/23. The DON was asked if Resident #16 was on 1:1 supervision. They stated, Yes. The DON was asked if the staff documented the supervision. They stated in the nurse's notes. The DON was asked if Resident #16 had been provided 1:1 supervision on 08/22/23 when they had fallen. They stated, No. The DON stated they had purchased a bicycle helmet for Resident #16 to prevent head injury but the resident would not wear it.

On 07/13/23, at 3:09 p.m. the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related to the facility failed to provide goods and services by ensuring adequate portions, options for extra food, and/or an alternative of equal nutritive value was offered to the residents in order to maintain optimal physical and psychosocial well being. On 07/13/23 at 3:15 p.m., the Administrator was notified of the existence of the immediate jeopardy. On 07/14/23 at 4:45 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 07/14/23 Residents of different faith like Muslim will be offered equal valued food options. Residents can choose to eat another item if they choose. If they choose a sandwich option, it will be documented in notes. Staff will have training for residents of different culture food preference, this will be done by the dietitian and/or dietary manager. Dietician will assist in creating an appropriate nutritional alternate meal for residents with specific religious or other diets. Food will be ordered accordingly in addition to all other food and snacks for the week. All dietary recommendations will be reviewed by doctor and accepted or rejected. Rejected recommendation will have explanation as to why rejected. All recommendations approved by physicians will be updated in their orders. Dietary cards will be updated by the dietary manager. Dietary recommendations are already being worked on by DON with some changes already made. Care plans will be updated when needed by MDS. Staff will be in service by 7/14/2023. If supplements are added to a resident's diet and they continue to refuse, this will be documented, and alternatives will be pursued. Care plans will reflect options tried. Weights will be monitored by Dietitian, DON, MDS and Administrator for all sufficient or sever loss or gain. The team will come up with a plan addressing the weight difference and how to prevent it and update the care plan. A Nutrition Report will be run bi-weekly to monitor weights. We are actively searching for a dietary manager. If one cannot be found within the next 30 days we will try and find someone who we can send to school for dietary manager. However, if this is not an option, oversight will continue to be completed by a department manger each meal. Positions for cook, aide, and dietary manager have been posted on indeed, social media, Oklahoma nursing network with little to no response. People who respond have no experience cooking or do not wish to cook. We will continue to search to fill the positions. A food service satisfaction survey will be completed by all residents monthly Starting 7/25/2023. On 07/17/23, after interviews, review of all in-services, and documentation, all components of the plan of removal had been completed and the immediacy was lifted effective 07/14/23 at 4:45 p.m. The deficient practice remained at a level of actual harm. Based on observation, record review, and interview, the facility failed to monitor nutritional status, identify significant/severe weight loss, and provide interventions for significant/severe weight loss for four (#30, 9, 14, and #98) of 11 sampled residents who were reviewed for nutrition. The Resident Census and Conditions for Residents form, signed by the DON, dated 07/06/23, documented 44 residents were provided meals from the kitchen and two residents had experienced a significant weight loss/gain. Findings: 1. Resident #30 had diagnoses which included Alzheimer's disease and stage three chronic kidney disease. The Dietary Profile, dated 01/26/23, documented the resident was Muslim, ate a regular diet, regular texture, and had an admission weight of 175 lbs. The admission assessment, dated 02/03/23, documented the resident was mildly impaired in cognition, required extensive assistance for all ADLs, and was totally dependent on staff for meals. Review of the weights in the clinical record documented the resident weighed: a. 02/08/23 - 171 lbs b. 02/12/23 - 165 lbs c. 03/04/23 - 122 lbs d. 04/27/23 - 117.6 lbs e. 05/17/23 - 114.4 lbs f. 06/15/23 - 117.4 lbs g. 07/11/23 - 118 lbs The resident's undated meal card documented they did not eat pork. A review of the facility menu revealed pork was served as the main entree for lunch or dinner for 14 of 28 meals. On 07/11/23 at 9:52 a.m., DA#1 stated they had worked in the dietary department for three weeks and had their food handlers license. They stated they had received training the first three days they worked from another employee before they had quit. DA #1 stated they asked what else they could cook if they did not have what was on the menu. They stated the administrator referred them to the corporate level employees. DA #1 stated yesterday (07/10/23) they were supposed to have sweet and sour pork but they did not thaw it out in time so they made country fried steak instead. They stated they had to ask somebody for the menu change to ensure they did not get into trouble. DA #1 stated if a resident did not like what was served they could offer them a peanut butter and jelly or grilled cheese sandwich, soup, chicken, or whatever they had in the freezer, refrigerator, or pantry that could be easily made. They stated one resident did not eat pork and when they had asked to substitute the pork for chicken they were informed by the corporate RDO to not make special meals. DA #1 was asked if they had snacks available for bedtime snacks. They stated they did not know but they usually did not have snack items available. They stated no one had informed them they were to provide bedtime snacks. They stated a staff member had bought snacks for the residents in the past. On 07/11/23 at 10:15 a.m., DA #2 stated they had been told they could not make Resident #30 a special meal when pork was on the menu. DA #2 stated they were told to provide the resident a grilled cheese sandwich. DA #2 stated they had been at the facility the past six days and Resident #30 had eaten a grilled cheese sandwich in place of the scheduled meal all six days. On 07/11/23 at 1:21 p.m., the dietitian stated an alternative menu should have variety. They stated a grilled cheese or peanut butter and jelly sandwich was not an acceptable substitution for an extended period of time. The dietician stated they made note of seven residents with a significant weight change (gain/loss) during their last visit. On 07/11/23 at 1:51 p.m., the DON was asked who was responsible to monitor residents for weight loss. They stated they and the dietitian monitored for weight loss. The DON was asked who was responsible to review the residents weights and meal percentages. They stated they were responsible. On 07/12/23 at 4:24 p.m., Physician #1 was asked about weight loss for Resident #30. They stated to review their progress notes for information regarding the resident's weight loss. The physician stated if the resident had advanced dementia, all they could do was assist the resident to eat and provide nutritional support. 41809 2. Resident #9 admitted with diagnoses which included anorexia, protein calorie malnutrition, obesity, and dysphagia. A facility Weights and Vitals Summary, dated 07/11/23, documented Resident #9 weighed: a. 06/02/23 - 205.3 lbs b. 07/10/23 - 175.6 lbs. These weights indicated a 29.7 pound/14.5% loss in five weeks. A review of physician orders for Resident #9 revealed no orders for supplements for weight loss. A Nutrition/Dietary note, dated 04/21/23 at 11:09 a.m., documented Resident #9 had a BMI of 36 and was obese and oral intake of food was 76-100%. The note read in part, .Resident lost weight since last month, which is positive, but overall patient gained weight (BMI 36). It is desirable that patient loses some weight. However, meal intake should be at least 50% 3X/day in order to meet nutritional needs. A Nutrition/Dietary note, dated 06/16/23 at 1:30 p.m., documented Resident #9 had a BMI of 35.10% with a recommendation to continue the current nutrition plan of care. A Nutrition/Dietary note had not yet been completed for July 2023. 3. Resident #14 had diagnoses which included diabetes mellitus and muscle wasting and atrophy. A physician order, dated 12/28/17, documented the resident was on a regular diet and to encourage PO intake for nutritional maintenance. The Dietary Profile, dated 12/28/17, did not document likes/dislikes in the designated section of the form for Resident #14. A Nutrition/Dietary Note, dated 04/21/23, documented the resident had a BMI of 39, weighed 246.8 pounds, ate 76-100% of meals with some refusals, would benefit from some weight loss, and to continue the plan of care. A Nutrition/Dietary Note, dated 05/18/23, documented the resident had a BMI of 39, weighed 247.0 pounds, ate 51-75% of meals with a lot of refusals, and to encourage PO intake to meet nutritional needs. A Nutrition/Dietary Note, dated 06/16/23, documented the resident had a BMI of 38, weighed 230 pounds, experienced an 8% weight loss in one month and a 10% weight loss in six months, intake of meals was fair, reweigh the resident and encourage PO intake, and the physician would be notified. Review of the facility's weights documented the resident weighed: a. 01/06/23 - 255.8 lbs b. 04/07/23 - 246.0 lbs c. 07/07/23 - 227.0 lbs. These weights indicated a 7.72% loss in three months from 04/07/23 to 07/07/23 and an 11.26% loss in six months from 01/06/23 to 07/07/23. Review of the clinical record did not reveal the physician had been notified of the weight loss for Resident #14. On 07/03/23 at 3:14 p.m., Resident #14 was asked if they had gained or lost weight recently. Resident #14 stated they used to weight approximately 262 pounds and now weighed approximately 222 pounds. They were asked what time frame they had lost weight. They stated in the past couple of months. Resident #14 stated they had needed to lose some weight in the past but they were not getting enough food to get filled up and was still hungry after meals. They stated they were told food cost had been an issue since March or April 2023. They stated they never knew what they will provide for a meal. They stated sometimes they received half of a piece of meat instead of a whole piece. Resident #14 stated the facility would run out of bread, milk, eggs, and sugar. On 07/11/23 at 11:48 a.m., Resident #14 was asked how they felt about their current weight. Resident #14 stated they had wanted to lose some weight but not like this. The resident stated they refused meals at times if they did not like what was served. They stated there was not always an alternative option so they would eat snacks they had in their room from family. They stated the facility served small portions like they were toddlers. The Care Plan, revised 07/12/23, read in part, .I am over my recommended BMI .06/08/18 .I would like to lose weight .Goal .I want to be adequately nourished .revision date 06/21/23 .I will voice satisfaction of intake through next review date .revision date 06/21/23 . The last revision for the interventions for the care plan were documented on 08/31/22. On 07/12/23 at 5:31 p.m., the DON was asked about the nutritional status for Resident #14. The DON stated the resident had been losing weight, the resident's family brought food at times, they did not usually eat breakfast, and refused meals at times. The DON was asked what interventions had been implemented to prevent significant/severe weight loss. They stated they would need to review the clinical record to determine if health shakes had been ordered for Resident #14. The DON was asked what options were available for the resident if they did not want the meal that was served. The DON stated they could get a sandwich or a salad as an alternative. On 07/12/23 at 6:16 p.m., the DON stated there were no dietary interventions in place for Resident #14 to prevent significant/severe weight loss but they would see if the physician wanted to order health shakes. The DON was asked why interventions had not been implemented and weight loss identified by the facility. They stated, There just wasn't because I didn't review them. On 07/12/23 at 7:12 p.m., the administrator was asked when the last dietary profile, to determine food preferences, had been completed for Resident #14. They stated the only dietary profile was completed upon admission in 2017. The administrator was asked how dietary options for alternative foods were made available to meet residents preferences. They stated the residents would notify the staff of what they wanted for their meal, they notified the residents of what they had available to make as an alternative, and the resident could choose. They were asked why the preference section on the dietary profile had not been completed in 2017. They stated the dietary manager was supposed to complete dietary preferences but the dietitian and charge nurses had been assisting since they did not have a current dietary manager. 4. Resident #98 had diagnoses which included diabetes and obesity. The Dietary Profile, dated 05/15/23, did not document likes/dislikes in the designated section of the form for Resident #98. Review of the facility's weights documented the resident weighed: a. 05/15/23 - 232 lbs (on admission) b. 06/27/23 - 211 lbs. These weights indicated a 9.05% weight loss from 05/15/23 to 06/27/23. The Dietician's Recommendations for Primary Care Provider form, dated 05/16/23, read in part, .CURRENT WEIGHT: 232 BMI: 33 .RECOMMENDATION: 1) Mens MVI 2) Magnesium malate 3) Omega-3 fish oil . The recommendation was not addressed by the physician until 07/12/23. The Nutrition/Dietary Note, dated 06/16/23, documented the June 2023 weight was pending and it was recommended the weight be recorded for Resident #98. The Care Plan, revised 06/26/23, read in parts, .has a nutritional problem or potential nutritional problem r/t obesity-high BMI .Goal .The resident will maintain adequate nutritional status .Interventions .Invite the resident to activities that promote additional intake .report to MD .significant weight loss: 3 lbs in 1 week, [greater than] 5% in one month, [greater than] 7.5% in 3 months, or [greater than] 10% in 6 months . On 07/12/23 at 5:34 p.m., the DON was asked what the nutritional status was for Resident #98. They stated the resident ate in the dining room and ate most of their meals. The DON was asked how they utilized the weights to determine if a resident had experienced a significant or severe weight loss. They stated the report from the electronic clinical record indicated if the residents had lost 5% or 10%. The DON stated, I guess we need to monitor the weights. The DON was asked what interventions had been implemented for weight loss for Resident #98. They stated they would need to review the clinical record to determine if the resident was ordered a house supplement. On 07/12/23 at 6:16 p.m., the DON stated there were no dietary interventions in place for Resident #98 to prevent significant/severe weight loss. On 07/12/23 at 6:54 p.m., the administrator was asked when residents were assessed for food preferences/likes and dislikes. They stated upon admission. They were asked why the food preferences were not documented for Resident #98 on the Dietary Profile. They stated they had attempted to obtain the residents food preferences when they were transporting him to the facility but the resident was not cooperative with the questions. The administrator stated they had not had time to interview the resident after admission to determine their food preferences.

On 07/13/23 at 3:09 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related to the facility failed to provide goods and services by ensuring adequate portions, options for extra food, and/or an alternative of equal nutritive value was offered to the residents in order to maintain optimal physical and psychosocial well being. On 07/13/23 at 3:09 p.m., the Administrator was notified of the existence of the immediate jeopardy. On 07/14/23 at 4:45 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 07/14/23 Menus will be reviewed by a dietitian and adjusted to meet dietary standards, as needed. RDO or Dietary Manager will place all food orders to ensure there is an adequate supply. If facility is out of a staple food item, it will purchased from a local supplier. RDO, RNC, RBOM, Dietary Manager, Administrator have the authority to purchase an food item needed from local supplier or food company as needed. RDO or Dietary Manager will order enough menu items for a minimum of five additional residents on top of current census and planned admissions for the week. Dietary Manager was hired on 07/14/2023. She has a start date of 07/18/2023. Dietary manager will receive training for certification. Residents of different faith like Muslim will be offered equal valued food options. They will be offered the meal of the day with a substitution of the meat they are unable to eat. [Resident] will be offered a substitute meat off of their preference list while STILL GETTING THE REGULAR PLATE OF FULL NUTRITIONAL VALUE. Residents have the right to eat another item if they choose. If they choose an alternate option, it will be documented in notes. Staff will have training for residents of different culture food preference, this will be done by the dietitian, and/or dietary manager, or other specified person. Dietary staff will have training on menus, serving sizes, altered diets, how to read the dietary meal cards, offering alternate choices, how to fortify foods, etc. This will ensure the quantity of food available for each meal is adequate and that residents have the opportunity to have additional food. Staff will start this training on the first day of employment, until they are trained and comfortable with doing the position on their own. Staff will have a book with the forms that will need for the kitchen. Policies, Resident dietary orders, material showing how to substitute foods in the same food group and how much is a portion, information on ideas to fortify food groups when needed, pureed, etc. They will be in-service on this book 7/14/2023 and when hired. The dietary book was completed on 07/13/23 using information provided by the dietician. Oversight of the meals will be completed each meal by a department manager who will be in the dining room overseeing food portions, palatability, and that the dietary department follows the proper menu created by the dietician to ensure that all residents are given the appropriate nutritional value. Oversight of basic dietary supplies will be completed by the dietary manager or other specified person twice a week and provided to the RDO who currently does the food order. Any supplies that are low will be reordered or picked up locally whichever is quickest. Snacks of nutritional value will be supplied nightly before bedtime. An option will be available to residents who are pureed, dietetic, etc. Dietary staff along with nursing staff [will be inserviced by 07/14/23] on getting the snack out and offering them. They will be in-serviced 7/14/2023. Resident Preference List will be done upon admission by social services during the admission process, quarterly, and annually by the dietitian, Dietary manager, or other specified person. Preferences will also be updated at QAPI meetings and weight meetings. Staff will complete updated preference lists for each resident on 07/14/2023. Dietary cards will be completed and/or updated with any new information or changes per new orders/ likes or dislikes. I have a form for diet preference for annual update and a form for new admissions. Care plans will be updated quarterly and as needed. Staff will be in-service, and we will start updating 7/14/2023. On 07/17/23 after interviews, review of all in-services, documentation, and all components of the plan of removal had been completed and the immediacy was lifted effective 07/14/23 at 4:45 p.m. The deficient practice remained at a level of actual harm. An undated form titled, Abuse Policy and Procedure, documented in part, .We will endeavor to protect our occupants from maltreatment, which means .neglect, physical abuse .It recognizes resident rights to be free from physical or mental abuse .1. General Policy. All allegations of resident maltreatment, including .neglect, abuse .shall be promptly reported to Administrator and investigated by the Facility management. Administrator will immediately report the allegation to the Oklahoma State Department of Health and the Local Police . Based on observation, record review, and interview, the facility failed to: 1. provide goods and services by ensuring adequate portions, options for extra food, and/or an alternative of equal nutritive value was offered to the residents in order to maintain optimal physical and psychosocial well being for nine (#132, 98, 85, 81, 84, 5, 4,14, and #30) of 11 residents who were sampled for nutrition. 2. ensure residents were free from resident to resident abuse for four (#8, 131, 31, and #32) of seven residents reviewed for abuse. The Resident Census and Conditions of Residents report documented 45 residents resided in the facility. Findings: 1. On 07/02/23 Resident #132 stated, The food situation is, we aren't getting enough food. When asked if they thought they had lost weight, they stated, Yes, I don't get enough food everyday. They stated there had been no snacks offered in the last month. On 07/10/23, DA #1 stated we are told how much to feed the residents. They stated if they served them more, they would get in trouble. The DA stated last Saturday nights dinner was ravioli and the serving size was not enough. On 07/10/23 at 12:07 p.m., residents were observed at the noon meal. The meal was observed to be an unmeasured scoop of turkey pot pie, six thin slices of zucchini, salad with no salad dressing, a cinnamon roll and a beverage. The servings of turkey pot pie were observed to be inconsistent, with servings ranging from approximately one half to one cup each. The Weekly Menu documented the meal was to consist of one cup of turkey pot pie with biscuit topping, one half cup of zucchini, one half cup of salad with dressing, one each cinnamon roll, and beverage of choice Residents stated they did not get enough food. When asked if they could ask for more, one resident stated, No, and they don't serve second servings. Resident #132 was observed to have eaten everything on their plate. Staff were observed to pick up the plate, then the resident left the table. Resident #132 stated they were not full. On 07/10/23 at 4:59 p.m., Resident #98 was asked if they recalled what they had for dinner the previous Saturday. They stated yes, ravioli and tomatoes and zucchini and tea, the serving size was too small. I was still hungry. On 07/11/23 at 10:11 a.m., DA #1 stated my alternative menu is whatever is available in the refrigerator that can be put together. I have not been instructed to make a snack tray ever. We don't get the supplies for that. On 07/12/23, the puree for the noon meal was observed. Service for the meal was also observed. The meal was observed to be an unmeasured portion of barbeque pulled pork, one quarter cup of breaded fried okra, one half cup of baked beans, fruit salad, a biscuit and a beverage. The staff were not observed to puree bread for the residents who received a puree diet. The Weekly Menu for the meal documented four ounces of pulled pork with barbeque sauce, one half cup of baked beans, three quarters cup breaded okra, one biscuit, one butter, one half cup of five cup salad, and beverage of choice. An undated meal card for Resident #30 documented they did not eat pork. A review of the facility menu revealed pork was served as the main entree for lunch or dinner for 14 of 28 meals. On 07/11/23 at 10:15 a.m., DA #2 stated they have been told they cannot make Resident #30 a special meal when pork is served. DA #2 stated they were told by corporate management to feed the resident a grilled cheese sandwich. They stated, I have been here six days and Resident #30 has eaten a grilled cheese sandwich every day. On 07/11/23 at 1:21 p.m., the dietitian stated an alternative menu should have variety. They stated a grilled cheese or peanut butter and jelly sandwich was not an acceptable substitution for an extended period of time. The dietician stated they made note of seven residents with a significant weight change (gain/loss) during their last visit. On 07/12/23 at 9:43 a.m., Resident #85 stated they doesn't like scrambled eggs. The resident stated they have asked several times for hard fried eggs but they keep sending scrambled. They stated this morning they didn't get enough to eat and were still hungry. The resident was asked if they had asked for more food. Resident #85 stated, no because they only bring enough for the people on the hall and they don't have extra. The resident was asked how this makes them feel. They stated it makes them mad, they think staff are lazy. The resident stated, it feels like they don't care that we are hungry. On 07/13/23 at 10:56 a.m., interviews were conducted with residents regarding portion sizes at meals. Resident #81 stated, I hate going to bed hungry It makes me mad and makes me want to leave. It makes me sad, if I'm not full I know others aren't full. That's wrong. They don't give us enough to get full. Resident #98 stated, It makes me feel terrible, but that's the way it is. Resident #84 stated most of the time we don't get enough food. We pay them enough money to buy us enough food. Makes me feel low down, that I'm not a person, That they don't care about me. On 07/12/23 at 12:30 p.m., Resident #5 stated, Lunch was good, but I didn't get enough to eat. I asked for more, but they ran out. Sometimes they have more but sometimes not. When they don't I just stay hungry until the next meal. I understand they don't have enough food. When asked how often do you get snacks, the resident replied, Not often. When asked if they received a snack last night, the resident stated, Yes. I was hungry, it was half of a peanut butter and jelly sandwich. They don't think about snacks for bedtime. I think the kitchen girls get busy and forget. On 07/12/23 at 12:55 p.m., Resident #4 stated the portion sizes are not enough to feed a bird. Everything they cook they burn and expect you to eat it. When asked if they receive second helpings, the resident stated, No, they say they don't have any more. He stated, it makes me mad. They take our money but won't put it back into the home for food or maintenance. On 07/13/23 at 11:06 a.m., Resident #14 stated when they asked for second helping at meals and are told there is not enough food, it makes them feel terrible. Especially when there are not snacks provided at night. 2. Resident #31 had diagnoses which included MERRF, (a multisystem mitochondrial syndrome characterized by progressive myoclonus and seizures). The resident is 5'11 and weighs 124 lbs. The resident is non ambulatory and uses a wheelchair. Resident #32 had diagnoses which included unspecified psychosis not due to a substance or known physiological condition, traumatic brain injury. schizophrenia unspecified, major depressive disorder, and anxiety disorder. The resident is ambulatory, can ambulate independent of assistance and occasionally uses a walker. A progress note, dated 05/19/23, documented Haldol Deconoate was not available and the pharmacy had been notified. A physician order, dated 05/21/23, documented to administer Haldol Decanoate 100 mg and 50 mg IM every 28 days. The MAR, dated May 2023, documented Haldol Decanoate was administered on 05/22/23. The MAR, dated June 2023, documented the medication was due but not administered on 06/19/23. A risk management report, date 6/28/23 documented resident #32 hit resident #31. The anger and hitting were not preceded by any other altercation. Resident #32 was removed from the area and was taken by the administrator to a nearby hospital for evaluation. A progress note for Resident #32, dated 06/28/23 at 2:18 p.m., documented staff reported an episode of physical aggression from the resident towards resident #31 and towards a CNA. The patient left the facility with the Administrator for transfer to psychiatric hospital at 2:15 p.m On 07/03/23 at 2:55 p.m., Resident #31 stated they were outside smoking around noon when Resident #32 jumped up suddenly and hit them on the head. Resident #31 stated they put their arms up to protect their head/face but Resident #32 continued punching them, approximately seven or eight times. They stated the incident happened suddenly. Resident #31 stated they had observed Resident #32 hit staff before. Resident #31 stated the incident made them feel uncomfortable and after the incident they would avoid where Resident #32 was if they were out of their room. On 07/06/23 at 11:47 a.m., CNA #2 recounted the incident of resident to resident abuse. They stated residents were outside smoking and they were there to supervise. CNA #2 stated Resident #32 was pounding on the door to get out to smoking area. They stated Resident #32 jumped up and started punching #31 over and over in the face during the smoke break. CNA #2 stated Resident #31 tried to defend/protect their face by putting their arms up but Resident #32 continued punching Resident #31. They stated they had attempted to verbally redirect Resident #32, placed their hand on the shoulder of Resident #32, but they continued to punch Resident #31. CNA #2 stated Resident #32 began punching them. CNA #2 they were struck in the shoulder, chest, jaw, and under their left eye resulting in bruising and a panic attack. CNA #2 stated Resident #32 had exhibited increased aggression a couple of weeks prior to the incident with Resident #31. They stated Resident #32 would become angry if it was not time for a smoke break and they desired to smoke. They stated the resident would become verbally loud and would curse at the staff. On 07/06/23 at 4:05 pm., RN #1 stated Resident #32 had an incident with staff and Resident #31 outside. More recently Resident #32 punched a staff member in the face. Resident #32 missed his Haldol once because it was not in the building. The nurse who was unable to give the dose, which is given once a month, did not convey it wasn't given. When asked how the staff keep residents safe, CNA# 1 stated, we try to keep staff around him. CNA #1 stated the staff tries to keep the resident's smoke breaks separate from other residents. That the separate breaks have been in place since the second time the resident hit someone. On 07/07/23 at 11:52 a.m., PMHNP #1. was asked what the importance was for a resident to receive the Haldol Deconoate as ordered by the physician. They stated it was very important to receive this medication as ordered by the physician. They were asked what effects were likely if a resident received their scheduled Haldol Deconoate nine to ten days late. They stated it could contribute to an increase in aggression, psychosis, and violence. On 07/07/23 at 2:32 p.m., the Administrator stated Resident #32 had not received their medication [Haldol Deconoate] in June and without that medication the resident became violent and assaulted staff and residents. They stated the day after the incident with Resident #31, Resident #32 was observed hitting and shaking the glass doors in the lobby. They stated staff moved the other residents out of the lobby for their safety. 41809 3. Resident #8 had diagnoses which included osteoporosis. A facility progress note, dated 05/19/23, documented Resident #131 was pacing the southwest hallway and pushed on the outer door, setting off the alarm. Resident #8 yelled at Resident #131 to leave the door alone. Resident #131 stepped, inside the room of Resident #8. Resident #8 yelled at Resident #131 to get out. Resident #131 started to leave the room, then stepped back into the room and grabbed the right arm of Resident #8, and mumbled something to Resident #8. The nurse intervened and told Resident #131 to leave the ladies alone and it was not Resident #131's room and to leave. Resident #131 was walked to the north side lobby and offered a drink. A facility progress note, dated 05/20/23, documented Resident #8 had returned from urgent care with their resident representative. The resident representative informed the facility, they had taken Resident #8 to urgent care and both lower arms were x-rayed. The progress note documented nothing was broken. An Orders Administration note, dated 05/20/23 at 7:12 p.m., documented Resident #8 received a tablet of Norco 5-325 mg for pain to both arms. The medication was effective. A Health Status note, dated, 05/20/23 at 7:57 p.m. ,documented Resident #8 was telling the nurse about the x-rays, and showing their forearms. The note documented the nurse noted bruising to the right forearm. A Health Status note, dated, 05/21/23 at 10:07 a.m., documented the resident representative informed the nurse that they were taking Resident #8 back to the urgent care due to the urgent care had informed them, there was a fracture to the right arm of Resident #8. A Health Status note, dated, 05/21/23 at 5:25 p.m., documented Resident #8 had returned to the facility wearing a short splint on their right wrist and forearm. The note documented Resident #8 was moving their fingers and arm easily. The note documented the resident representative of Resident #8 stated they had gone to the emergency room due to the fingers of Resident #8 felt numb. An Orders Administration note, dated 05/21/23 at 7:05 p.m., documented pain to the right arm of Resident #8. The note did not document a number on a pain scale. A Health Status note, dated, 05/23/23 at 8:24 a.m., documented the right arm of Resident #8 was wrapped with splints in place. The note documented Resident #8 complained of pain to the lower right forearm as 10 out 10. An Incident note, dated 05/24/23 at 5:35 p.m., documented an assessment was completed due to the incident with Resident #131. Resident #8 had went to the doctor and had the sling removed. The note documented bruising to the right arm of Resident #8. An Orders Administration note, dated 05/24/23 at 6:26 p.m., documented Resident #8 received a tablet of Norco 5-325 mg for pain to the right arm. The medication was documented as effective. A Health Status note, dated, 05/25/23 at 4:41 p.m., a documented bruising was noticeable to the right arm of Resident #8. An Orders Administration note, dated 05/25/23 at 8:10 p.m., documented Resident #8 received one tablet of Norco 5-325 mg for pain to the right arm. The medication was effective. An Orders Administration note, dated 05/28/23 at 6:13 p.m., documented Resident #8 was monitored for pain. The note documented Resident #8 had pain. The note did not document the level of pain on a pain scale. On 06/13/23 Resident #8 discharged from the facility with their resident representative. Resident #131 had diagnoses which included, dementia with psychotic disturbance, dementia with behavioral disturbance, and assaultive behavior. Review of the clinical record for Resident #131 revealed a comprehensive assessment had not been completed. Review of the clinical record for Resident #131 revealed a baseline care plan was completed on 04/21/23. No comprehensive care plan was completed in the clinical record. Review of progress notes for Resident #131, from 04/21/23 to 5/20/23, revealed Resident #131 hit, scratched, head butted, punched, cursed at, and twisted fingers of staff; picked up chairs and slammed them down on the floor in the lobby. Other documented behaviors of Resident #131 were; pacing, wandering, exiting the facility, urinating and defecating on the floors in public areas and in the presence of other residents, and refusing medications. Progress notes documented Resident #131 had required one on one supervision infrequently, for short periods of time. From 04/21/23 to 05/20/23, Resident #131 was documented to have received one on one supervision two days, on 04/23/23 and 05/03/23. No other documentation of one on one supervision was provided. Progress notes documented Resident #131 refused medications on seven days. Review of the May 2023 MAR, revealed Resident #131 refused medications, chlorpromazine HCL (an antipsychotic medication) 100 mg used for psychotic disturbance, five out of 19 opportunities in May, melatonin ( a sleep aide medication) 3 mg, five out of 19 opportunities, Depakote (an anticonvulsant medication) 125 mg used for dementia with behavioral disturbance, four out of nine opportunities, and Depakote sprinkles 125 mg used for dementia with behavioral disturbance, one time out of 32 opportunities. An Incident note, dated 05/02/23 at 5:45 p.m., documented Resident #131 was in the north lobby with several other residents and was standing behind another resident's wheelchair so they could not move. Resident #131 was asked to move twice and refused. Resident #131 punched Resident #133, who then returned a punch, hitting Resident #131. The note documented the residents were separated and Resident #131 was taken to the southwest lobby and assessed for injuries with no discolorations or marks noted. Resident #133 was counseled on behavior and assessed, no marks or discolorations were noted. No documentation was provided Resident #131 had been placed on one on one supervision. An Orders Administration note, dated 05/19/23 at 6:53 p.m., documented Resident #131 had walked up to a CMA and grabbed them by their stomach and wrist, drew back a fist and started to hit the CMA. When Resident #131 was told No, Resident #131 mumbled something angry and walked away. No documentation was provided that Resident #131 had been placed on one on one supervision. An Orders Administration note, dated 05/19/23 at 7:12 p.m., documented Resident #131 was pacing the hallway and went to the north lobby, walked up to a CMA, hit them in the side, walked to the north door, turned around, came back, and hit the CMA again on the other side. The note documented Resident #131 then went to the southwest lobby, took a resident's wheelchair and ran the wheelchair into the back of a nurse's legs several times. Resident #131 was told to return the wheelchair to where it came from, and Resident #131 cursed at the nurse twice, then put the wheelchair back. No documentation was provided that Resident #131 had been placed on one on one supervision. An Incident note, dated 05/19/23 at 8:10 p.m., documented Resident #131 was pacing in the southwest hallway and pushed on the outside door, setting off the alarm. Resident #8 yelled out to Resident #131 to leave the door alone. Resident #131 then stepped just inside the room of Resident #8. Resident #8 yelled at Resident #131 to get out of their room. Resident #131 started to leave, then stepped back into the room, grabbed Resident #8 by the hand, and mumbled something to Resident #8. The nurse told Resident #131 to leave the ladies alone and is was not Resident #131's room and to leave. Resident #131 left the room and was walked to the north lobby. No documentation was provided Resident #131 had been placed on one on one supervision. A Health Status note, dated 05/20/23 at 11:47 a.m., documented Resident #131 was discharged to another facility via the facility van, and accompanied by the DON and another staff. On 07/13/23 at 4:32 p.m., CNA #1 was asked if they had observed resident to resident abuse. They stated they had not personally seen it occur, but stated Resident #131 had grabbed a female resident by their hand/arm and shook it really hard. CNA #1 was asked how they were made aware of the incident. They stated Resident #8 told them it occurred. CNA #1 was asked if other residents had reported similar incidents with Resident #131. They stated residents had not reported it to them, but did state they did not trust Resident #131 not to hurt them, and if Resident #131 hit them, they would retaliate. CNA #1 stated, several residents reported to them they did not feel safe. CNA #1 was asked how they were made aware of the behaviors of Resident #131. They stated they were not made aware of Resident #131's history and behaviors. They stated they figured it out the hard way. CNA #1 was asked if they had received any special training for residents with assaultive behaviors. CNA #1 stated they received online training. They were asked what they learned from the training. They stated to maintain a calm environment, calm the resident, and to reapproach them later or offer them a snack. On 07/13/23 at 4:57 p.m., LPN #1 was asked what they knew about Resident #131 taking their medications. They stated Resident #131 did not take them very often. LPN #1 was asked what type of behaviors Resident #131 exhibited. They stated Resident #131 would curse, get in others faces, draw back and hit. LPN #1 stated Resident #131 would grab and shake others, and give mean looks. LPN #1 was asked how they managed the behaviors of Resident #131. They stated they could talk to the Resident #131 at times, and the resident could comprehend, and back off, but there were times Resident #131 would do what they wanted. LPN #1 stated Resident #131 scared the other residents. They were asked how they knew other residents were scared of Resident #131. They stated the other residents told them they were scared of Resident #131. LPN #1 was asked how they managed the violent behaviors of Resident #131. They stated they tried to keep a calm voice. LPN #1 stated sometimes they just had to turn around and walk away to give Resident #131 time to settle down. LPN #1 was asked if Resident #131 had hurt other residents. They stated they knew Resident #131 had grabbed a female resident. They stated the female resident had yelled at Resident #131 because they had come into their room, so Resident #131 turned around and went back into their room and grabbed their arm. LPN #1 was asked how they knew of the incident. They stated Resident #8 and their room mate had informed them. LPN #1 was asked how other residents were kept safe from Resident #131. They stated when they worked, Resident #131 was monitored all of the time. LPN #1 stated the nurses assigned a CNA to be one on one with Resident #131 when they could not keep eyes on Resident #131. They stated someone always had eyes on Resident #131. LPN #1 was asked who instructed them to conduct the one on one supervision. They stated no one had told them to provide one on one supervision, they had done that on their own. On 07/13/23 at 5:21 p.m., LPN #1 was asked who had provided one on one supervision at the time Resident #131 grabbed Resident #8. They stated nobody, the one on one supervision started after that event. LPN #1 was asked what the physician said about Resident #131 refusing medications. They stated the CMAs started crushing the medications and putting them in food they knew Resident #131 would eat, but the resident would still refuse. LPN #1 was asked if the physician was informed of those refusals. They stated, Yes. LPN #1 was asked what the physician's response was. They stated they did not know. On 07/13/23 at 5:29 p.m., the DON was asked if Resident #131 had refused their medications. They stated they did not know and would have to look. By the end of the survey, the DON had not provided a response. On 07/14/23 at 12:09 p.m., the DON, with two regional directors present, was asked who was responsible for reviewing admission referrals. They stated themselves, the RDO, and the BOM. The DON was asked who was responsible for the ultimate decision to admit or not. They stated the team as a whole made the decision. The DON was asked what factors were used to determine an admission. The RDO stated financial's, medical needs, personality, and background checks. The RDO was asked what type of training was provided for assaultive behavior. They stated de-escalation, agitation, and they had gone over personal space. The RDO was asked where the training had been documented. They stated the DON should have the in-service in their office. By the end of the survey, in-services had not been provided for assaultive behavior. The RDO was asked what interventions were put in place regarding aggressive behavior. They stated if someone displayed aggressive behavior, the resident was on one on one supervision for eight hours, then they titrated down to 15 minute intervals. They stated a medication review was completed and monitoring continued to ensure behaviors did not continue. The RDO was asked where one on one supervision was documented. They stated it was documented on flow sheets as well as progress notes.

On [DATE] at 7:07 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy related to supervision during meals. The facility had no procedures in place for providing supervision during meals. On [DATE] at 5:00 p.m., a resident who had a physician's order for a pureed diet was given a sandwich and chips from another resident which resulted in the resident coughing. No staff were available to supervise or intervene during the meal service. At 7:35 p.m., the DON was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. On [DATE] at 1:18 p.m., the plan of removal was accepted by the OSDH. The plan of removal was as follows: IJ Plan of removal [DATE] [DATE] Dining room was set up at 7:00am [sic] this morning for breakfast. Residents who require monitoring during mealtime was at dining room and a CNA member was present during mealtime in dining area to watch for any eating concerns, like coughing, chocking [sic], trying to get other food, trying to eat foods not on diet, etc. Effective immediately staff assigned to mealtime in dining area are verbally in-serviced until written in-service is finished, then all facility staff will be in-services [sic]. Charge nurse will on the assignment sheet list the staff that will be assigned to monitor dining room area. Charge nurse will assign who will be passing out meal trays on the assignment sheets and they will monitor residents eating in their room. Charge nurse will assign a CPR certified staff member to monitor the residents during mealtime for concerns such as coughing, chocking [sic], trying to get others food, trying to eat foods not on diet, etc. Residents will be assessed to see if other [sic] are at risk. Speech therapy will be in to assess residents and recommendation on concerns will be expressed to DON. DON will then contact physician to inform them and see if they agree. DON will notify social services so that POA or guardians can be informed and approve or not. If POA or guardians approve then DON or designee will but [sic] orders into PPC [sic] and will give written notice to kitchen personal [sic], so diet can be updated. DON will notify MDS so that care plan can be updated. Staff will encourage resident to follow diet and explain the risk of choosing different diet. Staff will monitor them eating and make sure there are no issues while eating it, should issues arise staff will intervene and get nursing, if necessary, by yelling or asking the kitchen staff to get help. All staff will be in-services [sic] on the sign and symptoms of chocking [sic], and they will be posted in dining areas as reminders. If resident chooses to eat in their room staff will encourage then [sic] to come eat with others and the risk of eating alone, if they choose to eat in their room anyway staff assigned on the assignment sheet to pass out trays will go around to the rooms and check to make sure they not having issues. In-service [sic] All diet [sic] will be reviewed to ensure the correct diet is being served. Diet cards will be reviewed to ensure correct diets at this time. After speech therapy is done with assessments then doctors orders, diet cards and care plans will be updated with those changes. Families will be informed on the risk of the resident eating meals not prepared according to diet order. A note will be placed in the residents' notes. A letter is done and will be sent to all families. Care plans will be reviewed and updated if needed after speech therapy is finished with assessments. Policy on resident dining will be written and in-serviced to all staff. Policy on Food Brought in the Facility by the Family or Visitors has been updated to notify family of risk of not following diet. This will be done by [DATE] by 4:00pm.[sic] On [DATE] from 4:00 p.m., to 7:30 p.m., interviews were conducted with staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Staff were observed as they supervised residents during mealtime in the dining room and in the resident rooms. At 7:30 p.m., the DON and the administrator were notified the IJ was lifted effective [DATE] at 4:00 p.m. The deficient practice remained at a harm with one or a very limited number of residents affected. Based on record review, observation, and interview the facility failed to ensure: a. a resident with a physician's order for a modified diet was supervised during meals for one (#17) of three sampled residents who were on modified diets. The DON identified 20 residents who had physician orders for modified diets. The Resident Census and Conditions of Residents report, documented 29 residents required assistance with eating. b. a resident was assessed for the safety of bolsters on an air-mattress and the utilization of a Geri-chair for one (#14) of one sampled residents reviewed for the use of an air-bed with bolsters and a Geri-chair. The DON identified 12 residents utilized air-mattresses with bolsters and one resident that utilized a Geri-chair. This resulted in Resident #14 to sustain a hematoma due to a fall when climbing over the air-mattress bolsters. The DON stated 34 residents resided in the facility. An undated, facility policy for Food and Nutrition Services, read in parts, .It is the policy of the facility to ensure that facility staff supports the nutritional well being of the residents .The facility will employee sufficient staff .to carry out the functions of the food and nutrition service .The resident will receive and consume foods in the appropriate form .as prescribed by the physician .recieved a therapuetic diet when there is a nutritional problem . 1. Resident #17 had diagnoses which included dementia, dysphagia, and protein-calorie malnutrition. A physician's order, dated [DATE], read in parts, .Regular diet Pureed texture . A speech therapy evaluation, dated [DATE], documented a bedside swallowing evaluation was completed using mechanical soft textures and puree consistencies. The evaluation documented mechanical soft solids caused mild clinical s/s of dysphagia with oral phase impairments characterized by excessive mastication time. The evaluation read in parts, .Diet is changed to puree with thin liquid with distant supervision . A physician's progress note, dated [DATE], documented resident #17 had dysphagia, was tolerating a pureed diet well and to monitor and make adjustments to diet and eating habits as needed. Resident #17's quarterly Minimum Data Set (MDS) (Assessment tool used to identify resident care needs.), dated [DATE], documented the resident had severe cognitive impairment, and required supervision and set up help with meals. On [DATE] at 5:05 p.m., resident #17 was in the common area on the southwest side of the facility eating dinner with other residents. Resident #25 gave resident #17 half of a tuna fish sandwich. Resident #17 ate the sandwich. No staff members were in the dining room to intervene. Resident #17 had a pureed diet on the table. At 5:09 p.m., LPN #2 was observed near the nurses' station. The LPN identified the residents who were dining in the southwest dining area and then proceeded to the nurses' station. At 5:11 p.m., in the southwest dining area, three female residents and one male resident were observed eating unsupervised by staff. Resident #17 had a pureed meal in a Styrofoam container on the table. Resident #25 gave Resident #17 some Fritos chips, resident #17 ate the chips and coughed after eating the chips. No staff members were in the dining room supervising the residents. At 5:13 p.m., resident #17 coughed and held hand over mouth. LPN #2 stated staff were not required to stay in the dining room to monitor the residents during meals. LPN #2 stated resident #17 had an order for a pureed diet. LPN #2 was asked if residents on pureed diets needed to be observed during meals. LPN #2 stated , We probably should be sitting there with them. At 5:56 p.m., LPN #2 was sitting at the nurses station. LPN #2 stated the residents had the choice of eating in the main dining room, the southwest dining area or their rooms. LPN #2 was asked if the facility provided supervision in the dining areas during meal time. LPN #2 stated the facility did not assign anyone to supervise the dining room. LPN #2 was asked if a resident who had an order for a pureed diet should eat a sandwich. The LPN stated no, they could choke. On [DATE] at 12:26 p.m., the SLP stated resident #17 received speech therapy services upon admission. The SLP stated a swallow evaluation was completed on [DATE]. The SLP stated resident #17 was not able to tolerate a mechanical soft diet, a recommendation was made for a pureed diet, which was ordered by the physician. The SLP stated resident #17 was very malnourished and had significant weight loss upon admission. The SLP stated resident #17 did not have teeth, was not able to chew food, and was placed on a pureed diet and remained on a pureed diet. The SLP was asked what distant supervision during meals meant. The SLP stated resident #17 needed to eat in the common dining areas due to their cognition, need for assistance in opening packages, and needed cues and encouragement during meal times. The SLP stated resident #17 was at risk for choking. The SLP stated, When you cannot chew your food, you are at risk of choking. The SLP stated resident #17's swallowing problem was the inability to chew food small enough to swallow and this caused a choking hazard. The SLP stated resident #17's diet had not been upgraded to a mechanical soft diet and would not be able to be upgraded until another swallow evaluation was completed. On [DATE] at 6:58 p.m., the DON stated the current diet ordered for resident #17 was a pureed diet with regular liquids. The DON stated resident #17 did not have an order for finger foods. 2. Resident #14 had diagnoses to include: cognitive communication deficit; dementia; history of falling; muscle weakness/wasting/atrophy; and history of [CONDITION(S)]. An incident report dated [DATE] at 7:35 a.m., read in parts, .resident in the floor and his chair against the bed .small abrasion noted to left knee .Resident stated that he slid out of the chair . A progress note, dated [DATE] at 11:40 a.m., read in part, .Resident scooted down to foot of geri chair 3 x's .Resident continued to try and scoot out of geri chair . A care plan updated [DATE], read in part, .have bed bolster .Ensure bed is in low position and that my fall mat is beside my bed . A progress note, dated [DATE] at 00:15 a.m., read in parts, .Resident had pulled bolster off and had his feet on floor .Told him to please stay in the bed as he could fall and get hurt .bolster replaced . A progress note, dated [DATE] at 00:43 a.m., read in part, . Resident had pulled bolster off and had his feet on floor .bolster replaced . A progress note, dated [DATE] at 05:17 a.m., read in parts, .Told CNA that he wanted the bolster off his bed. When asked why, I don't want it. A progress note, dated [DATE] at 11:06 p.m., read in part, .Resident trying to crawl over the side of bed. Bolster placed on bed . A care plan updated [DATE], read in parts, .use a gerichair when I am out of bed for comfort/positioning .have bolsters on my bed . A progress note, dated [DATE] at 4:39 p.m., read in parts, .Trying to come out of bed. Had legs and buttocks laying bolster over and had feet on floor . A progress note, dated [DATE] at 9:09 a.m., read in parts, .observed resident sitting on floor with back against bed . A progress note, dated [DATE] at 4:29 p.m., read in parts, .Trying to throw his legs over the bolster. Explained to him that he had already fallen today. Repositioned, bolster secure . A progress note, dated [DATE] at 12:50 a.m., read in parts, .Has no complaint from fall .continue to try and get out of bed . An incident report, dated [DATE] at 7:56 a.m., read in parts, .res (sic) was on the floor .res (sic) back was leaning up against the bed, buttock on the floor mat in a sitting position . A progress note, dated [DATE] at 8:00 p.m., read in part, .bolster on and secured . A progress note, dated [DATE] at 9:00 a.m., read in parts, .res (sic) fell on to floor with noted right forehead hematoma .new order .may transport to ER . An Emergency Department Summary of Care, dated [DATE] at 10:23 a.m., read in parts, .had a contusion on the right side of his forehead, the top of the contusion was scraped and had some blood .fell out of his chair and hit his forehead . A progress note, dated [DATE] at 1:48 p.m., read in parts, .res (sic) returned to facility .noted at this time a skin tear to res (sic) right knee . A progress note, dated [DATE] at 8:57 p.m., read in parts, .Earlier this evening, found resident trying to get out of bed as he had his legs over the bolster .and was placed in his chair .taken to lobby. Non-skid piece under resident so that he couldn't scoot to edge of chair easily . An incident report, dated [DATE] at 9:00 a.m., read in parts, .res was on the floor .laying on his right side .beside his broda chair .noted hematoma to right side of forehead .res stated i thought i could walk . A progress note, dated [DATE] at 4:30 p.m., read in part, .Resident was trying to put his legs over the bolster and get out of bed . A progress note, dated [DATE] at 5:20 p.m., read in parts, .bolster on and secured for safety . A progress note, dated [DATE] at 1:13 p.m., read in parts, .Putting feet and legs over the bolster and on the floor .Explained he could fall. Bolster on and secure . A progress note, dated [DATE] at 1:26 a.m., read in parts, .Had legs over the bolster and feet on floor. Replaced back on the bed . An incident report, dated [DATE], at 5:00 p.m., read in parts, .found resident lying on the floor beside the bed .Bolster in place . A progress note, dated [DATE] at 6:48 a.m., read in parts, .cautioned resident about falling off bed has bolster in place . A quarterly assessment, dated [DATE], documented the resident had severe cognitive impairment for daily decision making; required extensive assistance for bed mobility; required total assistance for transfers; had impaired range of motion on one side of the upper body; was always incontinent of bowel and bladder; had experienced one fall since the prior assessment; and restraints/alarms were not in use. An incident report, dated [DATE] at 7:40 a.m., read in parts, .res [sic] was sitting upright on buttocks with his back leaning on the side of the bed .lifted res [sic] to bed .res [sic] stated 'I was getting up' . A progress note, dated [DATE] at 4:44 p.m., read in parts, .recent fall .bolster on and secure . A care plan, last updated [DATE], read in parts, .require assistance with my adl's .My ability to reposition myself in bed varies .roll side to side with no problem but cannot get myself back up if I slide down in bed .use a gerichair when I am out of bed for comfort/positioning .[DATE] I now use a Broda chair when out of bed and not in a gerichair .have bolsters on my bed . .history of [CONDITION(S)] .I will remain free from serious injury r/t falls .I depend on staff to anticipate my needs .Ensure my bed is in a low position .my bolsters and fall mat are in place .Staff to ensure foot rest is up on gerichair & chair is locked when I am in it .I have bed bolster(s) .Provide frequent visual checks for my comfort and safety . On [DATE] at 11:12 a.m., Resident #14 was observed seated in a reclined position in a Geri-chair in his room. His arms were tucked in with blanket, and his left foot was hanging down over the side of the foot rest, beside chair. On [DATE] at 3:15 p.m., Resident #14 was observed to be seated in a Geri-chair in the resident's room. Resident #14 had scooted/squirmed down toward the foot of the geri-chair. Resident #14 was positioned with buttocks on the elevated foot rests of the chair. Resident #14 continued to gradually scoot/squirm toward the foot of the Geri-chair. Surveyors notified staff and staff repositioned Resident #14. A progress note, dated [DATE] at 7:47 p.m., read in parts, .Tried to climb out of his chair. Pulled him up and told resident that he could fall if he kept scooting . On [DATE] at 11:28 a.m., Resident # 14 was observed in bed, wrapped in bedding, positioned slight side ways in bed. His head was off the pillow to the right/toward wall, both feet/legs dangling over bolster/bed to the left. No floor mat was in place. An unidentified laundry staff entered room, announce self, put away clean laundry, and left the room. At 11:31 a.m., CNA #1 entered room to assist the resident back into bed and provide care. The CNA was asked if the resident frequently climbed over the bolster/side of bed. She stated yes. CNA #1 was asked if the resident ever scooted out of the foot of his Geri-chair. The CNA stated the resident scoots down in the gerichair at times. On [DATE] at 9:28 a.m., CNA #2 was asked what was the reason Resident #14 utilized a Geri-chair. CNA #2 stated she did not know but was aware Resident #14 does scoot out of the Geri-chair and has fallen to the floor. CNA #2 was asked why the resident was placed in a Geri-chair. CNA #2 stated the resident was placed in a Geri-chair when the resident wanted to get out of bed. CNA #2 stated they had worked for several years and Resident #14 had always utilized a Geri-chair. CNA #2 was asked why the resident had an air-mattress with side bolsters. CNA #2 stated hospice provided the mattress with bolsters. CNA #2 was asked if the resident has ever attempted to come over the bolsters and possibly get up and/or had fallen. CNA #2 stated the resident frequently puts their feet and legs over the bolsters. The CNA stated she was not aware of any falls. At 9:40 a.m., CNA #3 was asked why Resident #14 was always seated in a Geri-chair. The CNA stated the chair was provided by hospice. CNA #3 was stated Resident #14 has scooted out of the Geri-chair and climbed over the bolsters on the air mattress. CNA #3 was asked why Resident #14 was on an air-mattress with bolsters. The CNA stated, Because the resident tries to get out of bed, he slips his legs out. The CNA denied awareness of the resident having falls from the air-mattress/bed. At 9:45 a.m., CMA #1 was asked why Resident #14 was in a Geri-chair. The CMA stated the Geri-chair was for safety, the resident did not balance well in a wheel-chair. CMA #1 was asked if Resident #14 had ever climbed or scooted out of the Geri-chair. The CMA stated yes but was not aware if the resident had fallen. CMA #1 was asked why Resident #14 had an air-mattress with bolsters. The CMA stated the bolsters were placed because the resident had thrown his legs out of the bed and they are to prevent the resident from falling to the floor. CMA #1 was asked if the resident had ever fallen when he climbed over the top of the bolsters. The CMA stated, Yes, but not sure when and has not been recently. At 9:50 a.m., the DON stated Resident #14 was placed in a Geri-chair for positioning. The DON was asked if the resident had ever scooted out of the chair. The DON stated, The Geri-chair is not a restraint because it does not prevent him from moving, it is more for positioning. The DON stated hospice provided the air-mattress and bolsters for comfort and due to increased risk for pressure ulcers. The DON stated the bolsters were not restraints because the resident had slid out of the bed. The DON was not aware of any injuries. The DON reviewed the progress notes regarding a fall on [DATE], and stated the resident had been to the emergency room after a fall from the bed that resulted in a hematoma on his forehead. The DON was asked if the resident had been assessed for the safest interventions regarding the Geri-chair and/or the air-mattress with bolsters. The DON stated there was nothing different put into place.

Based on observation, interview and record review, it was determined the facility failed to provide incontinent care in a dignified manner for three (# 1, 3 and #7) of five sampled residents observed who received assistance. This resulted in psychological harm to resident #7. This had the potential to affect 18 other residents identified by the facility who required assistance with incontinent care. Findings: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident had a BIMS score of 15 which meant she was cognitively intact. The resident was continent of bowel and bladder and required extensive assistance with all ADL's. The resident's balance during transition was unsteady and required assistance to stabilize while moving, turning, moving on and off toilet and surface-to-surface transfers. She had an impairment on her right side secondary to a [MEDICAL CONDITION]. A Care Plan dated 04/10/13, documented, "Problem: My stroke left me with right side (sic) paralysis....I require extensive assist with most of my ADL's... Goal: I want to feel good about myself...Approaches: I will ask for BRP's, please extend or provide incontinent care with good peri-care q 2 hrs and prn..." The care plan had another approach which documented the resident was occasionally incontinent. On 07/11/13 at 1:30 p.m., an interview was conducted with the resident in her room. She was aphasic and pointed to a computer in her room and a communication book as her methods to communicate. She was asked if she needed to communicate some information, she nodded her head up and down. She verbalized unintelligible sounds. When asked if she could write her information in the computer; she nodded her head up and down. She communicated the following; "3-11 shift do not respond to the light. They wait 3-4 hours to answer light. 7-3 wait an hour to answer light in the morning when I want to get up and go to the bathroom." According to the resident, the only time she was incontinent was when the staff did not answer her call light. The resident was asked if she had ever soiled or wet herself while waiting on staff to answer her light. She nodded her head up and down. When the resident was asked how it made her feel to soil and wet herself waiting on staff, she covered her face with her left hand and started crying in sobs. A family member present during the interview stated the resident had previously mentioned this to her on several occasions. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment was completed on 06/13/13, and documented the residents BIMS to be a two (moderately impaired). The resident required extensive assistance with all aspects of ADL's; was always incontinent of both bowel and bladder; had both upper and lower extremity impairments and had to be placed in a wheelchair for mobility. A Care Plan dated 03/25/13, documented, "Problem: I am incontinent of bowel and bladder...Goal: I want my skin to remain ulcer free ... Approaches: Please provide incontinent care every 2 hrs and prn, perform good peri-care, insure that I am clean, dry, odor free..." On 07/10/13 and 07/11/13, the resident was observed in the common area in front of the television. On 07/11/13, the resident was observed sitting in chair at 10:00 a.m. He was observed on 15-30 minute observations until 12:30 p.m. During the observation time, the resident was not turned and repositioned nor was his brief changed. On 07/11/13 at 2:25 p.m., an interview was conducted with Resident #3's spouse. She reported that on 07/10/13, the resident's brief was changed at approximately 3:30 p.m. She stated she timed the brief before she went home. The wife returned at approximately 9:45 p.m. and found the resident in the same brief saturated and overflowing into his clothes. The brief on the resident when she returned still had the 3:30 p.m. time. She stated when the resident was wet and/or soiled, he started crying and hollering. 3. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive annual assessment dated [DATE], documented the resident to have a BIMS of two which indicated moderate cognitive impairment. The documentation on ADL care indicated the resident required extensive assistance in all ADL's to include bed mobility, dressing, eating, toilet use and personal hygiene. A Care Plan dated 05/06/13, documented: "Problem:..I require extensive to total dependent assist for my ADL's...Goals: I want to feel good about myself... Approaches: I require extensive 2 person assist with my toileting. I am frequently incontinent of urine and occasionally incontinent of bowel. I wear adult briefs... Please offer BRP's/provide incontinent care q-2 hrs and prn..." On 07/11/13 at 10:05 a.m., resident #1 was observed to be sitting in a recliner in her room leaning to the right side of her chair. At 10:30 a.m., the resident was observed to be sitting in the same position, in her recliner leaning to the right side of her chair. At 11:00 a.m., the resident was observed to be in the same position. At 12:00 p.m., the resident continued in the same position. At 12:30 p.m., the resident was observed to be in the recliner propped up with a pillow. The daughter was in the room and stated she had propped her up because she was going to feed her. At 1:45 p.m., over three hours after the first observation, the resident was given incontinent care by CNA #2. The CNA rolled the soiled brief under the resident. She then wiped the resident's front side, starting from the sides and then down the middle. There were large amounts of urine and feces observed in the vaginal area. The resident was turned onto her left side and the CNA wiped the buttocks first and then down the gluteal cleft and gluteal folds. The resident's skin was excoriated. There was old, dried stool present in the gluteal cleft and gluteal folds. The resident was observed to have dried stool from the peri-area down to her knees, on both legs, front and back sides. On 07/11/13 at 5:20 p.m., an interview was conducted with the DON about residents lying in the same position for over three hours without repositioning or toileting/incontinent care. She stated, "We get there as soon as we can."