Every finding on record at Choctaw Nation Nursing Home

Based on record review and interview, the facility failed to ensure there was RN coverage 8 hours/day, 7 days/week. The DON identified 27 residents resided in the facility. Findings: A PBJ Staffing Data Report, dated 01/01/25 through 03/31/25 [the second quarter of fiscal year 2025], showed the facility did not have RN coverage on 9 of the 90 days in that quarter. The dates identified on the PBJ report as not having RN coverage in January, February, and March 2025 were 01/06/25, 01/13/25, 01/14/25, 01/27/25, 02/03/25, 02/11/25, 02/12/25, 02/17/25, and 03/31/25. A facility document titled Time Detail Report, dated 01/01/25 through 03/31/25, showed there was not a registered nurse on duty on 01/06/25, 01/13/25, 01/14/25, 01/27/25, 02/03/25, 02/11/25, 02/12/25, 02/17/25, and 03/31/25. On 06/17/25 at 2:08 p.m., the regional director of operations #2 stated they had reviewed their staffing records and found the PBJ report for the facility, for the first quarter of 2025, was accurate. They stated the facility had not had an RN on duty on 01/06/25, 01/13/25, 01/14/25, 01/27/25, 02/03/25, 02/11/25, 02/12/25, 02/17/25, and 03/31/25.

Based on record review and interview, the facility failed to ensure a resident was not prescribed an antipsychotic medication for a diagnosis of Alzheimer's disease for 2 (#8 and #18) of 5 sampled residents reviewed for unnecessary medications. The ADON stated there were 6 residents prescribed antipsychotic medications at the facility. Findings: A facility policy titled Antipsychotic Medication Use, dated July 2022, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated. 1. A physician's medication order for Res #8, dated 06/02/25, showed the resident had an order for Quetiapine [an antipsychotic medication] 25 mg at bedtime for the diagnosis of unspecified dementia, mild, with other behavioral disturbance. On 06/17/25 at 3:49 p.m., the DON reviewed Res #8's order for Quetiapine and stated the resident was being administered and antipsychotic medication. They stated the resident did not have a diagnosis that was approved for the use of Quetiapine. They stated the resident had been admitted to the facility with that diagnosis for that medication. 2. A physician's medication order for Res #18, dated 08/14/24, showed the resident had an order for Quetiapine [an antipsychotic medication] 12.5 mg at bedtime for the diagnosis of Alzheimer's disease, unspecified. 06/17/25 at 11:35 a.m., the DON was asked to define what Quetiapine was and its uses. They stated it was a medication used for such things as hallucinations and had serious side effects. They stated it was used for specific mental health diagnoses and was not to be used for people diagnosed with dementia. They stated Res #18's order was supposed to have been changed. They stated Res #18 was taking Quetiapine because they take their belt off and try to hit people with it. They stated they did not know why the resident did that, but they would meet with the physician and pharmacist to see what would be appropriate for the resident.

Based on record review and interview, the facility failed to ensure quarterly assessments were completed in the required time frame for 4 (#6, 16, 18, and #20) of 5 sampled residents reviewed for MDS assessments. The administrator stated 27 residents at the facility required MDS assessments. Findings: A facility policy titled Resident Assessment Instrument, dated October 2010, read in part, The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; b. When there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve (12) months. 1. On 06/17/25 at 3:06 p.m., Res #6's EMR was reviewed for MDS assessments. In the MDS section of the record, a list of assessments and their status showed Res #6's quarterly assessment, dated 04/04/25, was still in progress. 2. On 06/17/25 at 3:37 p.m., Res #18's EMR was reviewed for MDS assessments. In the MDS section of the record, a list of assessments and their status showed Res #18's quarterly assessment, dated 04/15/25, was still in progress. 3. On 06/17/25 at 3:39 p.m., Res #16's EMR was reviewed for MDS assessments. In the MDS section of the record, a list of assessments and their status showed Res #16's quarterly assessment, dated 03/07/25, was still in progress. 4. On 06/17/25 at 3:47 p.m., Res #20's EMR was reviewed for MDS assessments. In the MDS section of the record, a list of assessments and their status showed Res #20's quarterly assessment, dated 04/20/25, was still in progress. On 06/18/25 at 8:50 a.m. the administrator stated the former MDS coordinator had quit suddenly, and the facility did not have another person trained to perform the duties of that office until about one week prior to this survey. They stated they were aware that the quarterly assessments for Res #6, 16, 18, and #20 were late and stated they would have them completed. On 06/18/25 at 8:53 a.m., the regional director of operations #1 stated the corporation had two MDS coordinators from two facilities quit about the same time, so they did not have anyone available to immediately come to this facility. They stated they have recently trained someone, and they will catch up on past due assessments.

Based on record review and interview, the facility failed to ensure a resident was provided with a written letter of transfer prior to being transferred to a hospital for 1 (#3) of 2 sampled residents that were reviewed for hospitalizations and discharges. The DON stated 24 residents had been transferred to a hospital in the past 6 months. Findings: A facility policy titled Admissions, Transfers, and Discharges, dated October 2022, read in part, Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). A facility progress note, dated 01/12/25 at 12:45 p.m., showed the DON had assessed the vital signs of Res #3 and then sent the resident to an emergency room in the community. On 06/19/25 at 9:33 a.m., the DON was asked to explain the facility's process for sending someone to a hospital. They stated they gave clinical paperwork regarding the resident's condition and a copy of the bed hold policy. They were asked about written notices of transfer. They stated they were not aware that supplying a written notice of transfer was a requirement and had not given one to Res #3.

Based on record review and interview, the facility failed to ensure an annual assessment had been completed in the time frame required for 1 (#12) of 5 sampled residents reviewed for MDS assessments. The administrator stated 27 residents at the facility required MDS assessments. Findings: A facility policy titled Resident Assessment Instrument, dated October 2010, read in part, The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; b. When there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve (12) months. On 06/17/25 at 3:36 p.m., Res #12's EMR was reviewed for MDS assessments. In the MDS section, a list of assessments and their status showed Res #12's annual assessment, dated 04/15/25, was still in progress. On 06/18/25 at 8:50 a.m. the administrator stated the former MDS coordinator had quit suddenly, and the facility did not have another person trained to perform the duties of that office until about one week prior to this survey. They stated they understood Res #12's annual assessment had not been completed in the required time frame. On 06/18/25 at 8:53 a.m., the regional director of operations #1 stated the corporation had two MDS coordinators from two facilities quit about the same time, so they did not have anyone available to immediately come to this facility. They stated they have recently trained someone, and they will catch up on past due assessments including Res #12's annual assessment.

Based on observation, record review, and interview, the facility failed to follow infection control practices for enhanced barrier precautions for 1 (#29) of 1 sampled residents reviewed for enhanced barrier precautions. The DON identified three residents with enhanced barrier precautions. Findings: A facility policy titled Enhanced Barrier Precautions, revised March 2024, read in part, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. An undated face sheet showed resident #29 had diagnoses which included nondisplaced comminuted fracture of shaft of the right femur, encounter for attention to gastrostomy, dysphagia, aphasia, and acute respiratory infection. A physician order, dated 05/02/23, showed the resident was to receive enteral feeding tube site care twice a day. A physician order, dated 03/21/25, showed the resident was to receive Jevity 1.5 enteral feeding at 50 ml an hour. On 06/17/25 at 9:05 a.m., CMA #1 prepared medication for Resident #29 to be administered per PEG tube. The CMA approached the resident's room. A sign posted on the resident's door showed enhanced barrier precautions and the staff was to wear gloves and a gown when providing care for the PEG tube. The CMA entered the resident's room, washed their hands, and donned a pair of gloves. CMA #1 did not don a gown. The CMA positioned the resident for comfort, checked the PEG tube for placement and residual. CMA #1 was unable to infuse the water/medication per PEG tube. The CMA requested help from nursing staff. On 06/17/25 at 9:35 a.m., the DON entered the resident's room, washed their hands, and donned a pair of gloves and a gown to assist the CMA with the PEG tube medication administration. On 06/17/25 at 9:36 a.m., the CMA stated they knew gloves were required for the PEG tube medication administration, but did not know a gown was needed. On 06/17/25 10:26 a.m., the DON stated per the facility enhanced barrier precaution policy the CMA should have worn a gown when administering medication per the resident's PEG tube. The DON stated the CMA did not wear a gown and should have for the PEG tube medication administration.

Based on record review and interview, the facility failed to educate/offer the COVID-19 vaccination for 1 (#15) of 5 sampled residents who were reviewed for vaccinations. The administrator identified 27 residents who resided in the facility. Findings: A facility policy titled Vaccination of Residents, read in part, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated .Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations .Provision of such education shall be documented in the resident's medical record. An undated face sheet showed Resident #15 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction and an encounter for prophylactic measures. A facility form titled Preventive Health Care, showed Resident #15 did not receive the COVID-19 vaccine. On 06/18/25 at 4:09 p.m., the DON reviewed the immunization record for Resident #15. The DON stated COVID-19 vaccination education and a refusal consent form for the vaccination could not be provided.

Based on observation, record review, and interview, the facility failed to assess for fall risk, update care plans related to falls, and educate staff related to resident falls for two (#1 and #11) of three residents who were reviewed for falls with major injury. Res #1 had a fall on 11/14/23 and sustained an abrasion to the head and on 12/07/23 Res #1 fell and sustained a closed head injury with a concussion. Res #11 had a fall on 04/28/23 and on 08/24/23 Res #11 had a fall resulting in a left femur fracture. No interventions were added or care plan updated after the falls for either resident. The administrator identified nine residents who have fallen in the last six months. Findings: A Falls - Evaluation and Prevention policy, dated 03/2015, read in part, .Residents should be evaluated for their fall risk: On admission/readmission to the facility, following a significant change in condition, quarterly, and following a fall .Upon admission, the nursing staff/interdisciplinary team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls, if possible, and avoid any injury related to falls .Following a fall, the following steps should be undertaken .Complete the Incident report .document the physician's orders and/or response .If the fall was un-witnessed, initiate the fall scene investigation including witness statements from staff and residents .Review all falls immediately following stand-up the next business day - have charts (computer) present for review of nurses note documentation and CP updating. Fall interventions are to be reviewed for appropriateness, to ensure that they are a new intervention, and to ensure that they have been implemented. The fall is to be logged on the incident report log by month, the fall is to be logged on the intervention to prevent reoccurrence log individualized for each resident within the facility . 1. Res #1 had diagnoses which included history of CVA with left hemiparesis/wheelchair bound, muscle wasting/atrophy, lack of coordination, and muscle weakness. Res #1's annual assessment, dated 01/31/24, documented Res #1 was severely cognitively impaired, non-ambulatory, dependent for transfers, and has impaired range of motion to upper and lower extremities to one side. Res #1's medical record did not include any fall risk assessments. Res #1's event report, dated 11/14/23, documented Res #1 fell and sustained an abrasion to their left forehead. Res #1's care plan was not updated with an intervention to prevent reoccurrence. Res #1's hospital paperwork, documented Res #1 fell on [DATE] and sustained a closed head injury with concussion and was hospitalized until 12/13/23. Res #1's care plan was not updated with an intervention to prevent reoccurrence. There was no event report for Res #1's fall on 12/07/23. There was no nursing note regarding Res #1's fall on 12/07/23. An initial report regarding Res #1's fall on 12/07/23 was completed and submitted to OSDH, but a final report was not completed or submitted. On 02/13/24 at 1:00 p.m., Res #1 was observed to be sitting in the hallway in their wheelchair. On 02/13/24 at 1:30 p.m., CMA #1 reported they didn't know of any fall interventions for Res #1. On 02/13/24 at 1:35 p.m., LPN #1 reported they weren't aware of any interventions for Res #1. On 02/13/24 at 1340: CNA #1 reported they weren't aware of any intervention to prevent falls for Res #1. On 02/14/24 at 8:45 a.m., the DON reported they had a falling star program. The DON reported Res #1 was not on the program and should be. The DON reported no one had stars on their assistive devices or at their doors because they didn't have any printed out and laminated. The DON reported the staff have no way to identify residents at risks for falls. The DON reported they could not explain why Res #1 didn't have an event report or nursing note regarding Res #1's fall on 12/07/23. DON reported the nurse should have completed an event report and documented the fall in the nursing notes. The DON denied using any logs as referenced in the facilities Fall - Prevention and Evaluation policy. 2. Res #11 had diagnoses which included left femur fracture, muscle wasting/atrophy, lack of coordination, difficulty walking, muscle weakness and cognitive communication deficit. Res #11's quarterly assessment, dated 11/21/23, documented Res #11 was severely cognitively impaired, required set up to partial assistance with self care, supervision to partial assistance with mobility and was independent with their wheelchair. Res #11's medical record did not include any fall risk assessments. Res #11's event report, dated 04/28/23 documented Res #11 slid to the floor in the shower room during a transfer. Res #11's care plan was not updated with an intervention to prevent reoccurrence. Res #11's event report, dated 08/24/23, documented Res #11 fell and was transferred to the local hospital. A review of Res #11's progress notes, dated 08/29/23, documented Res #11 sustained a left femur fracture that required surgical intervention from their fall on 08/24/23. Res #11's care plan was not updated with an intervention to prevent reoccurrence. On 02/13/24 at 1:00 p.m., Res #11 was observed to be in their room, in their wheelchair with visitor present. On 02/13/24 at 1:30 p.m., CMA #1 reported they didn't know of any fall interventions for Res #11. On 02/13/24 at 1:35 p.m., LPN #1 reported they weren't aware of any interventions for Res #11. On 02/13/24 at 1:40 p.m., CNA #1 reported they weren't aware of any intervention to prevent falls for Res #11. On 02/14/24 at 8:45 a.m., the DON reported they had a falling star program and Res #11 was on the program but did not have any stars on Res #11's assistive device or at their doors because they didn't have any printed out and laminated. The DON reported the staff have no way to identify resident at risks for falls. The DON denied using any logs as referenced in the facilities Fall - Prevention and Evaluation policy. On 02/14/24 at 2:59 p.m., the DON reported we have a great fall policy and program. We are not currently utilizing our fall policy/program and should be. The DON reported Res #1 and #11's care plans should have been updated with fall interventions after each fall to prevent future falls.

Based on observation and interview, the facility failed to ensure food for resident meals were stored in a safe and sanitary manner. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: On 02/06/24 at 5:11 a tour of the kitchen area was conducted. A large metal bowl, covered with foil and dated with 02/04, was observed to contain raw hamburger meat, diced peppers and onions, and dried bread cubes. An unlabeled resealable plastic container with lid was observed to contain what appeared to have been raw chicken wings in sauce. A resealable plastic container, with a label documenting tuna salad with a date of 02/03 was observed. The container of tuna salad appeared to have been served out of. An undated and opened container of Hormel Thick and Easy drink was observed on the top shelf of the refrigerator. This container documented to dispose of the drink 10 days after opening. A second container of thickened drink was observed to have been opened and was undated. This container documented to dispose of the container three days after opening. A resealable plastic container was observed to have a date of 01/15. The DM stated the container contents were turkey lunch meat they had taken out of the original package and placed in the container on 01/15. At that time, the DM stated they did not know what day the turkey lunch meat would expire. The DM stated they thought the facility could keep meats for seven days, deserts for five days, and eggs for three days. The DM stated they had opened the thickened drinks earlier in the day and were unaware the package documented how long the drinks could be kept after opening. The DM stated they were unaware potentially hazardous foods should have been disposed of specific hours of opening/preparing/and-or storing for later use depending on what the food was. The DM stated they were unaware raw meat should not have sliced onions and bread placed in the bowl and stored in the same container for future use in the refrigerator. The walk in freezer was observed to have a box of bacon on the floor of the freezer. The DM stated this was where the delivery person had placed the box. The upright freezer was observed and multiple resealable plastic bags of uncooked chicken was observed on shelves over packages of frozen vegetables. The DM stated they had not stored them this way and the meat should not have been over the vegetables. The upright refrigerator was observed to have multiple containers of single serve prepackaged pureed food. The containers were not labeled as to when they were placed in the refrigerator to thaw. The DM stated the packages were for the next day's pureed meals. On 02/08/24 at 12:14 p.m., the administrator and the corporate administrator were informed of the above and confirmed the above foods had not been stored in a safe and sanitary manner. The administrator stated the DM would be re-educated.

Based on record review and interview, the facility failed to ensure the information submitted on the PBJ was accurate. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: A document titled PBJ staffing Data Report, dated Quarter 1 2023 (October 1 - December 31) documented one date in November of 2023 with no documented RN hours and three days in December 2023 with no RN hours documented. The report documented the facility failed to have licensed nursing coverage 24 hours a day for eight days in October 2023, six days in November, and 10 days in December of 2024. On 02/13/24 at 1:34 p.m., the administrator provided documentation the facility had RN coverage for at least eight consecutive hours on the days in question. At that time, the administrator stated they did not know why the PBJ was incorrect. The administrator stated they felt it was a problem with the accounting/payroll service who entered the facility data. On 02/14/24 at 10:49 a.m., the administrator was asked to clarify the documentation they provided for proof of coverage by licensed nurses on a 24 hour basis. At that time, the administrator they and the corporate staff had discovered this was not the only home which had experienced a discrepancy with the PBJ. The administrator provided time cards for the months of October, November, and December, 2023 for licensed nursing staff and reviewed the clock in and outs of the licensed staff. All the dates on the PBJ which indicated no licensed nurse coverage had licensed nurses on duty 24 hours a day per the time cards. At that time, the corporate director of operations stated they had discovered several of their homes were experiencing errors on the data entry by the accounting/payroll service. The corporate director of operations stated they would get the issue corrected.

Based on record review and interview, the facility failed to ensure care plans were developed regarding medication for two (#11 and #19) and for skin lesions for one (#5) of fifteen residents whose care plans were reviewed. The administrator identified 25 residents who resided in the facility. Findings: 1. Res #11 had diagnoses which included dementia. A physician's order, dated 08/29/23, documented hydroxyzine 25mg 1/2 tablet twice a day. The comprehensive care plan for Res #11 did not include a care plan for use of a psychotropic (anti-anxiety) medication. On 02/14/24 at 2:57 p.m., the DON reported the medication should have been care planned. On 02/14/24 at 3:15 p.m., the MDS coordinator reported the anti-anxiety medication for Res #11 should have been care planned. 34945 2. Res #5 had diagnoses which included rash and other nonspecific skin eruption. An annual assessment, dated 09/11/23, documented Res #5 was severely impaired in cognition, required extensive to total assistance with most ADLs, and was at risk for pressure ulcers but did not have one at that time. Pressure ulcers triggered for care planning. A physician order, dated 12/22/23, documented the facility was to clean the area to the resident's right temple with normal saline and wound wash, pat the area dry, apply collagen particles, and cover the area with a band-aid daily. wound care orders: A five day PPS assessment, dated 12/25/23, documented Res #5 did was moderately impaired in cognitive skills for daily decision making and had an open lesion other than ulcers, rashes, or cuts. A care plan, last reviewed on 12/31/23, did not document a plan of care related to the skin lesion on the resident's right temple. On 02/13/24 at 11:07 a.m., wound care on the resident's wound on their right temple was observed as performed by LPN #1. At tat time, the LPN stated the wound was not pressure related but was an overgrowth of skin. The LPN stated the family and the resident's physician had decided not to do a surgical intervention due to the resident's age and general condition. On 02/13/24 at 12:37 p.m., MDS coordinator #1 reviewed the care plan for Res #5 and stated there was not a plan of care related to the lesion on the resident's right temple. The MDS coordinator stated there a care plan should have been developed regarding the skin lesion. 29358 Res #19 was admitted to the facility on [DATE] and had diagnoses which included amputation, A-fib, DVT, GERD, aphasia, dementia, and depression. An admission MDS assessment, dated 12/08/23, documented the resident was severely cognitively impaired, required moderate assist with ADLs, and received opioid medication. The pain portion of the MDS documented the resident received a PRN pain medication or was offered and declined. The assessment documented the pain interview should be conducted but was not documented. A physician order, dated 01/08/24, documented acetaminophen extra strength 500 mg every six hours as needed. A physician order, dated 01/09/24, documented hydrocodone-acetaminophen 7.5-325 mg every six hours as needed. There was no care plan for pain or the need for pain medication. On 02/12/24 at 4:20 p.m., Res #19 when asked about any pain issues, they stated their neck hurt. The resident was asked if they received pain medication. They stated sometimes they would take something. On 02/12/24 at 4:30 p.m., LPN #1 stated the resident hardly ever complained and if they said they were hurting, they wouldn't take medication for it. On 02/12/24 at 4:31 p.m., LPN #1 asked the resident about their pain and asked them to rate it. The resident stated his neck hurt and rated it as a seven on a scale of one to ten. The resident also stated they didn't want any thing for it. On 02/12/24 at 4:53 p.m., the MDS coordinator stated the MDS pain interview should have been completed. She stated there should be a care plan for pain, also.

Based on record review and interview, the facility failed to ensure residents were bathed when scheduled for three (#15, 17, and #80) of three residents who were reviewed for bathing. The administrator identified 25 resident who resided in the facility. Findings: 1. Res #15 had diagnoses which included Alzheimer's disease, difficulty walking, lack of coordination, muscle wasting/atrophy, and muscle weakness. A Bath Schedule, updated on 02/08/24, documented Res #15 is to receive a bath on Monday, Wednesday and Friday. The Nurse Assistant Daily Body Observation Form, read in part, .Complete during shower or bath for each resident scheduled . The January and February Nursing Assistant Daily Body Observation Form, and the Point of Care History, dated 01/15/24 - 02/14/24, were reviewed and documented Res #15 did not receive five baths in January and two baths in February. On 02/14/24 at 3:00 p.m., the DON reported the resident refused their showers. The DON reported the refusals were not documented in Res #15's progress notes or care plan. The DON reported no baths are scheduled on Sundays so they can make up baths that were not given during the week. The DON reported Res #15 didn't have any documented make-up baths. 34945 2. Res #17 had diagnoses which included Alzheimer's disease and candidiasis of skin and nail. A care plan, last reviewed on 12/31/23, documented the resident could dress themselves and needed assistance with personal hygiene and was to be showered by staff. The care plan documented the staff were to set up and assist the resident with showering, shaving, oral care, hair care, and nail care per the schedule and as needed. A quarterly assessment, dated 01/13/24, documented the resident was moderately impaired in daily decision making, required supervision with oral and toilet hygiene, and partial to moderate assistance with personal hygiene and bathing/showering. On 02/07/24 at 1:59 p.m., Res #17 was observed in their room. The resident had facial hair which was approximately 1/2 inch long and their hair appeared to be greasy and not combed. At that time, the resident was asked if they desired to have facial hair or would they want to have been clean shaven. The resident stated they preferred to be clean shaven. On 02/14/24 at 10:21 a.m., Res #17 was observed lying on their bed. The resident's clothing was soiled with food from the morning meal, their hair was greasy and uncombed, and the resident's facial hair was still present but appeared to have been shaved into the shape of a goatee and mustache. At that time, the resident was asked if they were trying to grow out their beard, they rubbed their chin and stated they needed a hair cut badly. Asked if they were talking about their beard or their hair, they replied they needed a hair cut. On 01/14/24 at 10:30 a.m., corporate nurse #1 provided a Point of Care History form, dated from 01/15/24 through 02/14/24, to review the frequency of the resident receiving baths/showers. The form documented the resident had received three baths/showers out of 11 opportunities during the previous 30 days. The corporate nurse confirmed the resident had not received the scheduled bath/shower per the documentation on the point of care history form. On 02/14/24 at 11:20 a.m., the DON provided the shower sheets they could find for Res #17. The DON stated Res #17 refused to shower frequently and they needed a shower as the resident smelled bad. The DON stated the staff were to fill out a shower form for each time the resident was to receive a shower and document it if the resident refused. They stated the nursing staff were to follow up and try to get the resident to shower. The DON provided five shower sheets for the previous 30 days and stated these were the only sheets they could find. They reviewed the sheets at that time and stated four of the sheets documented the resident had refused to shower. On 02/14/24 at 12:30 p.m., the DON confirmed the facility had not provided or attempted to provide Res #17 with their scheduled showers. They stated the resident was exceedingly modest and would not let most shower aides shower them. The DON stated the staff, including themselves, had fallen down on this resident's showers. The DON stated the staff had not been proactive in following up to attempt to shower resident. At that time, the DON was asked about the resident's desire to have a hair cut. They reported the facility did not have a barber or hair stylist. They stated if the resident wanted to have their hair cut, a family member would have to take them out of the facility to a barber or come in and cut their loved ones hair themselves. The DON stated if they did not have family willing to do this the resident could not have a hair cut. 3. Res #80 had diagnoses which included cerebral palsy. An admission assessment, dated 02/04/24, documented the resident was moderately impaired in cognition and was dependent on staff for self care. A care plan, dated 02/07/24, documented one to two staff members were to have provided assistance with bathing the resident three times weekly. On 02/07/24 at 1:50 p.m., Res #80 indicated they had not been shaved since their admission to the facility. The resident's facial hair was approximately 1/4 of an inch long. At that time a family member of the resident stated the resident always wanted to be clean shaven. When asked if the resident had told staff of their wishes the resident replied, Yes. On 02/13/24 at 11:30 a.m., the resident was observed in the living room area of the facility. The resident had visible facial hair. On 01/13/24 at 2:39 p.m., the resident was asked if they had received a shave since they were admitted to the facility. The resident confirmed they had been shaved one time. On 02/13/24 at 2:41 p.m., the shower book was reviewed and documented the resident had received a shower on 02/09/24. The shower book did not contain any other shower sheets for Res #80. At that time, corporate nurse #1 stated the shower sheets were scattered and the DON might have had more of them. On 02/13/24 at 2:42 p.m., the DON stated the resident should have been shaved on their shower day. At that time the DON observed the residents whiskers and confirmed with the resident they had only been shaved one time since admission. On 02/13/24 at 3:07 p.m., corporate nurse #1 provided the Point of Care History form for Res #80 documenting the showers the resident had received since admission. The form documented the resident had received three showers out of five scheduled opportunities. The corporate nurse stated there was not a task for shaving and it was to be done when the resident was showered. The corporate nurse confirmed the resident had not received their showers as scheduled.

Based on record review and interview, the facility failed to obtain lab tests as ordered by the physician for one (#11) of four residents whose lab orders and results were reviewed. The administrator identified 25 residents who resided in the facility. Findings: Res #11 had diagnoses which included atrial fibrillation and cerebral infarction. A Medication Regimen Review, dated 04/11/23, read in part, .The last INR available for review is from 03/01/23. Could we add monthly INR to the orders for this resident? . The physician marked, I agree with this recommendation. A progress note, dated 04/17/23 at 5:30 p.m., read in part, [Name withheld NP here reviewing pt's chart and talking with MDS coordinator concerning frequency of PT/INR. Order was changed to every two weeks until further notice. Order was written . There was no physician order written for every two week PT/INR's in the paper medical chart or the electronic health record. An Expanded DRR Report, dated 07/12/23, read in part, .INR is being drawn per progress notes (drawn on 7-3) but results are not available for review in chart. Please be sure to filed results in chart when possible . An Expended DRR Report, dated 09/13/23, read in part, .no recent INR results available for review .need to file results in chart when possible . A Medication Regimen Review, dated 11/07/23, read in part, .There is an INR ordered monthly but it does not appear that the lab is being drawn as ordered or at least the results are not being made available for review . There were no lab results in the paper medical chart or the electronic health record for August, October, November, or December 2023. On 02/14/24 at 3:11 p.m., the DON reported they didn't have a system to monitor the lab orders and lab results related to the Res #11's use of Coumadin (anticoagulant). The DON could not reconcile the lab orders for PT/INR with the lab results in Res #11's record. The DON was unable to provide additional lab results that may not have been filed in Res #11's record. The DON reported they had a hard time getting lab results. The DON reported the routine lab orders were not being followed because interim lab orders were being given and the nurses were writing those orders on the lab calendar but not writing a physician order regarding lab. The DON stated, Things aren't flowing well and we need to get better with tracking.

Based on observation, record review, and interview, the facility failed to ensure menus were followed and residents who received altered textured diets were served the same foods as the residents who received the regular diet. The DON identified two residents who received a puree diet. Findings: An undated facility policy, titled Meal Substitution, read in part, .Menu substitutions must provide equal nutritive value and must not be excessive .1. Substitutions or changes shall be noted in the menu substitution book with the reason, date, and what was substituted indicated .3. Substitutions shall be of equal nutritive value to the original menu items, i.e.: .b. Protein source for another protein source c. Vitamin A source for another Vitamin A source d. Vitamin C source for another Vitamin C source e. Caloric value shall be equivalent 4. Substitutions shall be made in an emergency situation only and not for the convenience of the department . A menu, titled Fall/Winter 2023-2024, documented the kitchen was to serve eight ounces of turkey and dressing casserole for the regular diet, and two #8 scoops of pureed turkey and dressing for the pureed diet along with two ounces of poultry gravy. The menu documented the residents were to receive broccoli, a dinner roll, and a frosted pumpkin bar. On 02/06/24 at 5:11 p.m., the kitchen was observed during the evening meal service. The DM stated the meal consisted of Beef [NAME], a bread stick, and ice cream, along with a drink of choice. The DM stated the residents who received pureed meals were to receive prepackaged pureed food identified by the DM as consisting of pureed pork, vegetables, and a dessert. When asked if this was the meal the menu had scheduled the DM stated the menu documented the residents were to have received a meal of turkey with dressing, broccoli, dinner roll, and a pumpkin bar. When asked why they had not prepared the menu as documented the DM stated the residents liked variety. The DM was asked if they had discussed the menu change with the dietitian, the DM stated the dietitian had told them they could substitute meals as long as the nutrition was equivalent with the scheduled menu. The DM was asked if the they had prepared a vegetable to serve with the substituted meal and they confirmed they had not prepared any vegetables. A slotted spoon was observed in the pan of beef [NAME]. The DM was asked what amount they had served the residents the DM stated they had used a #4 scoop. The DM stated the #4 scoop had fallen on the floor and they had to use the slotted spoon to finish the service. The DM was asked what size the menu documented for the serving size of Beef [NAME], the DM stated there were papers somewhere in the kitchen which told how much to serve but they would have to find them. In the upright refrigerator in the kitchen area, multiple containers of pre-packaged pureed food was observed. At that time, the DM stated the packages had been placed there to thaw for the next days pureed meal service. On 02/08/24 at 12:14 p.m., the observation of the meals provided to the regular and pureed diet residents were reviewed with the administrator and the corporate administrator. They confirmed the DM should have followed the menu and the pureed meals were to have been the same as the regular diet meals.

Based on observation, record review, and interview, the facility failed to ensure written standards for infection control were followed to prevent the spread of infection when passing meal trays and when providing incontinent care for dependent residents. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: An undated facility policy, titled PERINEAL CARE, read in part, .1. Observe standard universal precautions or other infection control standards as approved by appropriate facility committee . An undated facility policy, titled Policies and Practices - Infection Control Policy Statement, read in part, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent ad [sic] manage transmission of disease and infections .4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where are [sic] how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. 1. On 02/06/24 at 5:30 p.m., the evening meal service in the dining room was observed. RN #1 was observed while assisting an unidentified resident to eat. The RN was then observed to use their cane and walk to another resident, bend over and grab the resident's wheelchair but the rail under the seat to move the resident closer to the table. The RN was observed to then open and set up the resident's meal, retrieve a clothing protector, and encourage the resident to start eating. The RN was then observed to set up other resident meals. The RN was then observed to return to the first resident and start assisting the resident to eat again. The RN was not observed to perform hand hygiene at anytime during this observation. On 02/07/24 at 12:00 p.m., the hall trays were observed while being passed by CNA #1. The CNA was observed moving from a resident room to resident room, adjusting the overbed tables, clearing trash from the tables, assisting the residents to sit up for the meal, moved garbage cans, moved wheelchairs and geri chairs, and then opening meal trays, silverware, and drinks for approximately nine residents. The CNA was observed to go to the linen cart for a towel to place on the 10th resident and sat down at the resident's bedside to assist the resident to eat. The staff member was not observed to perform hand hygiene throughout this observation. On 02/07/24 at 1:33 p.m., CNA #1 stated they had not performed hand hygiene at all during the passing of hall trays. The CNA stated they should have performed hand hygiene between each resident and after touching anything that may have been contaminated. On 02/08/24 at 12:19 p.m., the administrator stated the staff should always perform hand hygiene between residents and between touching dirty and clean when passing trays and assisting residents to eat. 2. On 02/07/24 at 1:21 p.m., CNA #1 was observed providing incontinent care for Res #3. The CNA was observed to use a wash cloth, they had used to wipe feces from the resident's bottom, to wipe the residents vagina. Feces was visible on the wash cloth. The CNA was observed to not remove their gloves or perform hand hygiene between wiping the feces and urine from the resident and repositioning the resident and covering the resident with their sheets and blanket. The CNA was then observed to offer the resident a drink while still wearing the soiled gloves. At that time, the CNA was interviewed and confirmed they did used the same washcloth to clean feces from the resident's bottom to clean the resident's vagina. The CNA stated they had not brought enough washcloths in as they did not realize the resident had been incontinent of stool. The CNA was asked if they performed hand hygiene in a manner to prevent cross contamination and they stated they had washed their hands when they entered the room but not between dirty and clean and confirmed they should have. On 02/08/24 at 12:27 p.m., the DON stated the CNA should have doffed their gloves and washed their hands between dirty and clean and should have not wiped the resident's vaginal area with a cloth they had used to clean feces off the resident's bottom.

Based on record review and interview, the facility failed to include QAPI program mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: An undated facility document, titled QAPI Plan, read in entirety, QAPI will be held Quarterly and or as needed for identified issues. On 02/14/24 at 4:06 p.m., the administrator stated the facility had not implemented QAPI training for the staff.

Based on record review and interview, the facility failed to ensure the staff were provided with behavioral health training consistent with the requirements and as determined by the facility assessment. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: The facility assessment was reviewed and did not document behavioral training for the staff based on the diagnoses documented in the assessment. On 02/14/24 at 4:39 p.m., the administrator stated the ombudsman came in to discuss dementia care with the staff. The administrator stated they had discussed behavioral care needs with staff but did not have any formal training documented based on the facility assessment and resident diagnoses.

Based on record review and interview, the facility failed to ensure a DNR form was signed by a resident representative with the authority to make medical decisions for residents for one (#5) of 16 residents whose records were reviewed for advanced directives. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: Res #5 had diagnoses which included aphasia, dysphagia, conversion disorder with seizures, and cognitive communication deficit. An Oklahoma Do-Not-Resuscitate (DNR) Consent Form, dated 07/15/17, documented a signature of a representative for Res #5. A five day PPS assessment, dated 12/25/23, documented the resident was moderately impaired in cognitive skills for daily decision making. A review of the resident's documents did not reveal the resident had assigned a representative as a health care proxy or POA. On 02/08/24 at 11:41 a.m., the administrator stated they had contacted the representative who signed the DNR and confirmed with them they had not been delegated as a proxy or POA for Res #5. The administrator stated the facility would contact the resident's physician as the resident could no longer make decisions for themselves.

Based on record review and interview, the facility failed to ensure ABN notices were provided for two (#11 and #13) of three residents who had been discharged from skilled services and had benefit days remaining. The facility identified five residents who had been discharged from skilled services with benefit days remaining in the previous six months. Findings: Res #11 had been discharged from skilled nursing services on 12/05/23 with benefit days remaining and had remained in the facility. The facility did not provide the resident or resident representative with an ABN notice. Res #13 had been discharged from skilled nursing services on 01/11/24 with benefit days remaining and had remained in the facility. The facility did not provide the resident or resident representative with an ABN notice. On 02/14/24 at 11:12 a.m., the MDS coordinator, the staff member assigned to provide ABN and NOMNC letters and notices to residents who received skilled services, stated they did not know what an ABN notice was. On 02/14/24 at 11:13 a.m., corporate nurse #1 confirmed Res #11 and #13 had not received their ABN notices. The corporate nurse stated the facility should have provided an ABN notice prior to the resident discharge from skilled services.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported within two hours to OSDH for one (#7) of six residents whose records were reviewed. The administrator identified 25 residents who resided in the facility. Findings: A review of Res #7's incident report form and investigative notes, documented an incident of verbal abuse was witnessed by staff members on 04/30/23 at approximately 5:30 p.m. The incident was not reported to OSDH until 05/01/23 at 1:17 p.m On 02/14/24 at 4:55 p.m., the administrator reported an allegation of abuse should be reported within two hours. The administrator reported an initial incident report should have been sent in when an allegation was made, but the charge nurse at the time was new and not aware of the requirements. The administrator reported the nurse who did the combined initial and final incident report should have sent OSDH an initial incident report immediately and then worked on the investigation and completed a final incident report to OSDH within the required timeframe.

Based on record review, observation, and interview, it was determined the facility failed to ensure pain was assessed, medication was given prior to treatment, and pain was care planned for one (#1) of ten sampled residents. Resident #1 exhibited pain during a wound treatment. This had the potential to affect one resident identified by the facility who required a pressure sore treatment. Findings: A policy, dated 01/05, documented all residents would be assessed using a pain intensity scale upon admission, quarterly, and with any change of condition. The policy documented to consider the resident's description and observations of the resident's physical and behavioral responses. A physician's orders [REDACTED]. An annual assessment, dated 11/05/10, documented the resident had short and long term memory problems and was severely impaired with daily decision making skills. The assessment documented the resident required total assistance with all ADLs. The assessment documented the resident could not express needs. The pain assessment was blank. The care plan, dated 11/05/10, did not document a problem or interventions related to the residents pain. During record review, the monthly summary was reviewed. The pain assessment was crossed through with a single line signifying it had not been completed on all pain assessments. On 11/30/10 at 3:00 p.m., the resident was observed during a treatment on one stage IV decubitus ulcer and two, stage II ulcers. Licensed practical nurse (LPN) #1 cleansed the wound using normal saline and guaze dressing. The resident winced in pain each time the LPN cleansed an area. The LPN was interviewed regarding pre-medicating the resident prior to treatment. The LPN stated the resident was not medicated prior to the treatment. The LPN stated if the resident asked for pain medication, they would administer it. On 12/02/10 at 2:20 p.m., the DON was interviewed regarding the resident's pain and the care plan. The DON stated she had completed the treatment on 11/27/10 and had not observed any pain. The DON stated the pain was assessed on the monthly summary. The DON stated she didn't realize it hadn't been care planned. On 12/02/10 at 4:30 p.m., the nurse consultant stated she had reviewed the medication administration records (MARs) for November 2010. The nurse consultant stated the resident had not received any pain medication for the entire month.