Every finding on record at Cleveland Care and Rehab Center

Based on observation, record review, and interview, the facility failed to ensure a resident was provided physical assistance with toileting for 1 (#4) of 3 sampled resident reviewed for accident hazards.The DON identified 50 residents required assistance with toileting.Findings:On 08/03/26 at 9:14 a.m. videos recorded by the family of Resident #4 were reviewed. The videos showed the following:On 03/02/26 at 6:19 a.m., Resident #4 rose from a laying position to a sitting position and attempted to stand without success.On 03/02/26 at 6:23 a.m., the video began with Resident #4 sitting on the lower right of the bed next to the foot board. The resident had both hands on a red walker. In front of the walker, Unidentified Staff #1, wearing black pants and a light blue shirt, was observed with their back to the resident and moving a wheelchair toward the room's entry door. Nine seconds into the video, Unidentified Staff #1 exited the room. Thirteen seconds into the video the resident began to raise themself from the bed. Twenty-two seconds into the video the resident was standing while holding the walker and began to walk. Fifty-three seconds into the video, Unidentified Staff #2 entered the room. Unidentified Staff #2 was facing the resident who was still walking when they entered. Unidentified Staff #2 then turned toward the Resident #4's roommate and greeted them. The video ends with Unidentified Staff #3 disappearing behind the roommate's bed curtain and Resident #4 still walking toward the bathroom using the red walker.On 03/02/26 at 6:25 a.m., the video began with Resident #4 standing inside the unlit and dark bathroom. Eight seconds into the video, Unidentified staff #3 was observed coming from behind the bed curtain and departed the room. As Unidentified Staff #3 came from behind the curtain, Resident #4 was visible standing in the then lit bathroom door. At 49 seconds into the video the sound of a toilet seat being put down was heard and the resident was no longer visible. Resident #4's walker was visible in the bathroom. The video then ends.On 03/02/26 at 6:36 a.m., the video began with Resident #4 standing behind the red walker heading out of the bathroom. The resident remained inside the bathroom, and the walker was halfway through the bathroom doorway. When the video started, Resident #4 immediately began to fall backwards. At two seconds into the video, the resident is on the floor with the walker on top of them. At three seconds into the video, the resident can be heard yelling out Help. Five seconds into the video, Resident #4's roommate could be heard yelling out that Resident #4 had fell. Eight seconds into the video, Unidentified Staff #4 entered the room. At 12 seconds into the video, Unidentified Staff #4 entered the bathroom and removed the walker from on top of Resident #4. At 37 seconds into the video, Unidentified Staff #4 departed the room and could be heard calling for assistance. The video ends with Resident #4 still lying on the bathroom floor and no staff visible in the room.On 03/02/26 at 6:37 a.m., the video began with Resident #4 still on their back in the bathroom and no staff visible in the room. Fourteen seconds into the video, Unidentified Staff #4 re-entered the room with Unidentified Staff #5. Forty-six seconds into the video, Unidentified Staff #5 departed the room and re-entered at 50 seconds into the video. At 56 seconds into the video, two unidentified staff with the same clothing combinations as Unidentified Staff #1 and #3 enter the room.A policy titled Fall Management, dated 02/28/23, read in part, To provide an environment that remains as free of accidents as possible. The Facility will complete a Morse Fall Scale Evaluation on Residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize (sic) further Falls and/or reduce injuries.A fall risk evaluation, dated 02/20/26, showed Resident #4 was at risk for falls due to intermittent confusion, being chair bound, having poor vision, and predisposing diseases.An admission assessment, dated 02/27/26, showed Resident #4 had a BIMS (Brief Interview for Mental Status) score of 9 which indicated their cognition was moderately impaired. The assessment showed Resident #4 required substantial assistance (a staff member would provide more than half of the physical effort while lifting or holding the resident) for the following tasks:a. standing from a sitting position,b. getting on and off the toilet, andc. to walk 10 feet in a room, corridor, or similar space.On 08/03/26 at 1:38 p.m., the MDS (minimum data set) coordinator stated they recalled Resident #4 and had completed their admission assessment. They stated according to the assessment, Resident #4 required someone to assist them when walking, getting on and off the toilet. They stated staff should have stayed with the resident while they were in the bathroom.On 08/03/26 at 2:28 p.m., Registered Nurse #1 stated the day the resident fell in the bathroom on 03/02/26, a staff member should have taken them to the bathroom and stayed with them until they were back in bed.On 08/03/26 at 3:14 p.m., the director of nursing stated if there was a staff member with Resident #4 when they went to the bathroom on 03/02/26, they should have stayed with them.On 08/03/26 at 3:14 p.m., the administrator stated if the person in the video was a clinical person, they should have stayed with Resident #4 to assist the resident with toileting.

Based on record review and interview, the facility failed to ensure medication was administered as ordered by the physician for 1 (#44) of 1 resident sampled reviewed for medication administration. The regional director identified 58 residents resided in the facility. Findings:A physician order, dated 07/09/24, showed Nystatin Powder was to be applied to folds, abdomen, and neck topically every shift. A significant change assessment, dated 11/17/25, showed Resident #44 had diagnosis which included candidiasis of the skin and nails. The assessment showed Resident #44 had a BIMS of 15 and was cognitively intact for daily decision making.A review of the November 2025 medication administration record for the night shift, showed Resident #44 had not received Nystatin Powder on November 10, 11, 12, 13, 14, 17, 18, 19, 20, 21, 25, 26, 27 and 28.On 12/08/25 at 10:14 a.m., the ADON stated if the check box on the medication administration record was not checked the task had been completed then they assumed it was not done.

Based on observation, record review, and interview, the facility failed to evaluate a resident for vaping/e-cigarette use safely for 1 (#44) of 2 sampled residents reviewed for safe smoking. The regional director identified 58 residents resided in the facility. Findings: On 12/02/25 at 2:53 p.m., Resident #44 was observed in bed wearing oxygen with a nasal canula attached to an oxygen concentrator. There were three pink vape-e-cigarettes smoking devices observed on the resident's bedside table. On 12/04/25 at 11:02 a.m., Resident #44 was observed in bed wearing oxygen with a nasal canula attached to an oxygen concentrator. There were three pink vape-e-cigarettes smoking devices observed on the resident's bedside table. A facility policy titled Smoking Protocol, dated 10/25/22, did not show vaping/e-cigarettes was addressed in the policy to prevent accidents and hazards. Resident #44's Smoking Safety Evaluation, dated 11/05/25, showed the resident did not smoke. Resident #44's comprehensive assessment, dated 11/17/25, showed the resident was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease and hypoventilation syndrome. The assessment showed Resident #44's cognition was intact with a BIMS score of 15. The assessment showed Resident #44 required substantial to maximum assistance with bed mobility and was dependent for a bed transfers. The assessment showed the resident used supplemental oxygen and was not a tobacco user. On 12/02/25 at 2:23 p.m., Resident #44 stated they were bed bound and used supplemental oxygen continuously. Resident #44 stated they vaped e-cigarettes in their room and everybody, but the DON knew they vaped in their room. Resident #44 stated facility staff turned their heads because they could not go outside. On 12/04/25 at 11:02 a.m., Resident #44 stated the ADON told them they should not smoke in their room, but understood because the resident did not get out of bed. On 12/04/25 at 11:22 a.m., CNA #1 was asked to discuss Resident #44's smoking. CNA #1 stated Resident #44 used e-cigarette/vapes, had vapes/e-cigarettes on their bedside table, and did not like to get out of bed unless it was for a shower. CNA #1 stated Resident #44 had confided in them they vaped e-cigarettes in their room when nurses had asked them not to. On 12/04/25 at 11:34 a.m., the ADON was asked about Resident #44. The ADON stated Resident #44 was bed bound, used continuous supplemental oxygen, and was on hospice services. The ADON stated Resident #44 got out of bed for showers only and was a three to four person assist. The ADON stated Resident #44 used e-cigarettes/ vapes the resident had in their possession. The ADON stated Resident #44 hid under their blanket and used the e-cigarette/vape in their room. The ADON stated they did not include vaping/e-cigarettes on smoking assessments. On 12/04/25 at 11:43 a.m., the administrator stated vaping/e-cigarettes were not included in smoking assessment and smoking policy. The administrator stated residents were not allowed to use vapes/e-cigarettes inside the facility.

Based on observation, record review, and interview, the facility failed to ensure the head of bed was elevated for 1 (#5) of 1 resident reviewed for continuous tube feeding. The ADON identified two residents received tube feeding. Findings: On 12/03/25 at 8:43 a.m., Resident #5 was observed to receive continuous tube feeding without the head of their bed elevated. On 12/04/25 at 8:51 a.m., the head of bed for Resident #5 was observed to be flat and without elevation.On 12/04/25 at 12:25 p.m., the head of bed for Resident #5 was observed to be flat and without elevation. On 12/08/25 at 11:00 a.m., the head of bed for Resident #5 was observed to be flat and without elevation.A care plan, dated 08/08/25, showed Resident #5 had diagnoses which included severe protein calorie malnutrition and gastro-esophageal reflux disease.A significant change assessment, dated 11/21/25, showed Resident #5 had moderate cognitive impairment with a BIMS of 10.On 12/08/25 at 11:00 a.m., LPN #1 stated they had worked at the facility for one week and had not observed the head of Resident #5's bed to be elevated. On 12/08/25 at 11:15 a.m., Resident #5 stated they do not want the head of the bed elevated because they like to sleep a lot and cannot sleep if the head of the bed is elevated. 0n 12/08/25 at 2:22 p.m., the ADON stated Resident #5 should have the head of their bed elevated 45 degrees. They stated the resident could aspirate if it was not elevated. They stated the resident would put the head of the bed down if it were elevated. The ADON stated the resident had not been educated on the possible complications of not having the head of their bed elevated.

Based on observation, record review, and interview, the facility failed to ensure a resident's nebulizer and oxygen mask were bagged when not in use to prevent cross contamination for 1 (#4) of 16 sampled residents reviewed for infection control practices. The regional director identified 58 residents resided in the facility. Findings: On 12/03/25 at 2:47 p.m., Resident #4 was not in their room. Resident #4's nasal cannula was observed laying bedside in a recliner loose and not in a bag. Resident #4 nebulizers mask was bedside with a hose attached laying on a cart under the window and not in a bag. Resident #4's physician orders, dated 01/10/25, showed Resident #4 had orders for albuterol sulfate inhalation solution 2.5 milligrams/3 milliliter orally via a nebulizer. Resident #4's physician orders, dated 07/04/25, showed Resident #4 had orders for continuous oxygen at two liters via an oxygen concentrator. The orders showed to store tubing and mask in a dry protective cover when not in use. Resident #4's significant change assessment, dated 11/17/25, showed they were admitted on [DATE] with diagnoses which included congestive heart failure and anemia. The assessment showed Resident #4's cognition was moderately impaired with a BIMS score of 11. The assessment showed Resident #4 was dependent for transfers, used a wheelchair to ambulate, and used oxygen therapy. On 12/03/25 at 2:55 p.m., LPN #2 was asked about Resident #4's respiratory needs and orders. LPN #2 stated Resident #4 had orders for continuous oxygen and had routine breathing treatments. LPN #2 stated the nasal cannula was laying on the chair and should be hung on the machine. On 12/03/25 at 3:02 p.m., the ADON was asked to look in Resident #4's room and discuss the concern. The ADON stated the nasal cannula was laying on the recliner not in a bag and the nebulizer mask was laying bedside on a cart not in a bag. The ADON stated the nasal canula and nebulizer mask should be bagged when not in use. The ADON stated Resident #4 required staff assistance to transfer the resident and put on portable oxygen. The ADON stated staff should have bagged the nasal canula and the nebulizer mask for infection control to keep germs away.

Based on record review and interview, the facility failed to ensure a resident with an allergy to latex did not receive an indwelling latex urinary catheter for 1 (#1) of 1 sampled resident reviewed for a latex allergy.The administrator identified 54 residents resided in the facility. The DON identified one resident with a latex allergy.Findings:An Allergy tab, dated 03/05/25, showed Res #1 had an allergy to latex.A physician order, dated 03/08/25, showed to maintain an indwelling silicone urinary catheter and to change monthly on the 6th of each month.An admission assessment, dated 03/12/25, showed Res #1 had a brief interview for mental status score of 15 and was cognitively intact. The assessment showed Res #1 had an indwelling urinary catheter.A care plan, dated 03/18/25, showed Res #1 was allergic to latex. The care plan showed Res #1 would not receive medications and/or substances known to cause allergic reactions.A treatment administration record, dated 04/06/25, showed Res #1 had a new indwelling urinary catheter placed.A progress note, dated 04/09/25, showed Res #1's catheter was removed and replaced with a silicone catheter due to a latex allergy. The note showed Res #1 had some redness on the right thigh where the latex catheter tubing had been touching their leg. The note showed the physician was notified of the redness and orders were obtained to apply hydrocortisone cream (medication lotion/ointment) twice daily for seven days.On 08/18/25 at 2:00 p.m., Res #1 stated they were allergic to latex. They stated the facility had inserted a latex indwelling urinary catheter into them a few months ago which caused redness and irritation to their right leg. Res #1 stated the facility should have known better because their allergies had been listed in their medical record since they were admitted .On 08/20/25 at 11:36 a.m. the IP stated they had changed Res #1's catheter on 04/09/25 after noticing redness on Res #1's right thigh where the catheter tube was touching their skin. They stated the catheter was removed immediately once they realized it was latex and not silicone. The IP stated staff had inadvertently inserted a latex catheter. They stated the staff should have verified all allergies prior to the insertion of the catheter.On 08/20/25 at 12:46 p.m., the DON stated a urinary catheter containing latex was placed in error. They stated staff should have verified all allergies prior to the placement of the catheter.

On 04/03/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide a safe and orderly discharge for Resident #7. Resident #7 was discharged to a prepaid motel room located away from their community, leaving the resident without identification, financial means, or caregiver support. The facility did not provide the resident with a 30-day notice of intent to discharge, nor notify the Office of the Ombudsman or the State agency (OSDH) of the resident's anticipated discharge as required. Resident #7 was a direct admitted from the Department of Corrections to the facility on [DATE] with Medicaid pending for their pay source status and without state issued identification, birth certificate, or social security card. Resident #7 was discharged from the facility on 02/26/25 to a motel room in Tulsa without financial means, identification, or caregiver/community support. The resident returned from the community based motel to the facility on [DATE]. On 04/03/25 at 2:45 p.m., the Oklahoma State Department of Health (OSDH) determined the existence of a past non-compliance IJ. The facility self identified non-compliance and on 03/06/25 in-serviced all department heads on proper discharge/transfer policy. The facility initiated an Ad Hoc QAPI meeting on 03/06/25 with department heads in attendance. The Ad Hoc QAPI showed the following corrective measures: a. the immediate fix included an Ad Hoc on discharge practices with education provided to the department heads/SSD on discharge planning/notices/notifications. The facility reviewed their current discharge notices for accuracy and identified one discharge notice which was rescinded. The social security director was to send a monthly discharge notice to the office of the Ombudsman, b. the process included an audit once a week for discharges to ensure the appropriate discharge processes were followed. The regional director was to be notified of any new 30-day or emergency discharge notices so they may ensure accurate and timely notifications and a safe discharge was in place, c. systematic changes included education with the appropriate staff on the discharge policy and procedure. The regional director was to ensure the discharges were accurate, timely and to a safe discharge location. d. ongoing monitoring included a monthly review of discharges and any concerns were brought to QAPI, and e. the date of compliance on the Ad Hoc QAPI was 03/07/25. Based on record review and interview, the facility failed to: a. provide a safe and orderly discharge by providing the resident/representative a 30-day notice of intent to discharge; b. to provide education to resident/representative on the discharge plan to support resident care needs; and c. to plan/set-up/provide/educate resident/representative on community support and services to aide resident to maintain their independence in the community for 2 (#4 and #7) of 4 sampled residents whose clinical records were reviewed for the facility's discharge process. An Admission/Discharge To/From Report identified 14 residents who were discharged to the community between 01/01/25 and 03/28/25. Findings: A Discharge Summary and Plan Policy, dated 02/01/16, read in part, The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and [their] family and will contain, as a minimum: description of the resident's and family's preferences for care; a description of how the resident and family will access such services; a description of how the care should be coordinated if continuing treatment involves multiple caregivers; the identity of specific resident needs after discharge (i.e., personal care, sterile dressings, physical therapy, etc. [et cetera]); and a description of how the resident and family need to prepare for the discharge. The resident or representative (sponsor) should provide the facility with a minimum of seventy-two (72) hour notice of a discharge to assure that an adequate discharge plan can be developed. The Social Services Department will review the plan with the resident and family twenty-four (24) hours before the discharge is to take place. A copy of the post-discharge plan and summary will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records. 1. Resident #7 was admitted directly from the Department of Corrections, to the facility, on 07/01/24 with diagnoses which included morbid obesity, cirrhosis of the liver, anxiety, depression, bipolar disorder, pancytopenia, pacemaker, aortic (heart) valve insufficiency, and osteoarthritis of the knees. A quarterly assessment, dated 12/18/24, showed Resident #7 was cognitively intact (BIMS score 15), required supervision/touch assist with most activities of daily living utilizing their upper extremities, required substantial to maximal assistance with bathing/showering, partial to moderate assistance with personal hygiene and sit to stand. The assessment showed walking 10 feet was not attempted and the resident required supervision to touch assistance when they utilized their manual wheelchair. The assessment showed the resident was occasionally incontinent of urine and continent of bowel. The assessment showed frequent pain and shortness of breath with exertion. The assessment showed the resident weighed 336 pounds. A wound care physician's progress note, dated 02/24/25, showed the resident had a venous wound of the right shin measuring 8cm x 8cm x 0.2cm and a venous wound of the left leg measuring 10cm x 6cm x 0.1cm. The note showed the recommended treatment for both was Zinc ointment applied daily and tubular elastic applied daily for 30 days. A release of responsibility for discharge against medical advice form was signed by the resident and witness. Neither resident nor witness dated the form. A progress note, dated 02/26/25 at 3:23 p.m., showed the resident was discharged from the facility in stable condition with their personal belongings and medications. There was no documentation where the resident discharged to. There was no documentation of who the resident discharged with. The resident's clinical record was reviewed. There was no documentation the facility provided the resident with a 30-day notice of intent to discharge, no documentation the interdisciplinary team was involved or developed a discharge plan, no documentation of referrals for community support services such as home health, and no documentation the facility educated the resident or their caregiver in all aspects of resident care needs when discharged to the community. There was no documentation the physician was notified of the discharge. There was no physician's order for the discharge. There was no documentation of where the resident discharged to and no documentation of a caregiver involved in the discharge process. An admission assessment, dated 03/28/25, documented the resident was admitted from the community on 03/21/25. A care plan, updated 03/21/25, showed the resident had a deficit performing activities of daily living and required assistance with mobility due to debility and had limited range of motion due to osteoarthritis and morbid obesity. The care plan documented the resident used a wheelchair for mobility, transferred to/from wheelchair and bed via mechanical lift and two person assist, required assistance to turn and reposition themselves in bed, and was dependent on staff for dressing and personal hygiene. On 04/01/24 at 3:05 p.m., LPN #2 stated the facility had no say in the discharges that occurred on 02/26/25. The LPN stated Resident #7 discharged to a motel room in Tulsa without a caregiver or community support. On 04/01/25 at 3:45 p.m., SSD stated they were told by the former administrator to discharge Resident #7. The SSD stated the discharge did not follow the facility policy. The SSD stated they were told the resident had a paid motel room and they were to transport the resident to the motel in Tulsa. The SSD stated they did not set up home health or any other community resource for the resident and did not educate the resident on how to access community resources in Tulsa. The SSD stated they did not know who paid for the motel room. On 04/01/25 at 4:10 p.m., the DON stated all the staff were upset about the discharge. The DON stated the former administrator instructed them to discharge the resident, but did not know if they initiated the resident's discharge. The DON stated the resident's lack of a pay source was the reason for the discharge. The DON stated Resident #7 was admitted to the facility from the Oklahoma Department of Corrections and did not have any form of identification. The DON stated the resident had no way to identify themselves (no driver's license, social security card, or birth certificate) to obtain valid identification and file for coverage and service. The DON stated due to the lack of identification, the facility could not secure a pay source for Resident #7 (i.e. Medicaid). The DON stated Resident #7's discharge did not follow their policy. The DON stated all the staff were concerned about Resident #7 and regularly drove to Tulsa to check on the resident and help with financial needs. The DON stated this was done voluntarily by the staff and occurred on their own time and with their own money. The DON stated the facility did identify the discharge process as a problem, educated the department heads, and initiated steps to ensure the discharge policy was followed. On 04/01/25 at 5:10 p.m., the former administrator stated they were instructed by corporate Resident #7 received their 30-day notice and should be discharged on 02/26/25. The former administrator stated they later were informed the resident did not receive a 30-day notice. The former administrator stated the facility paid for the resident's motel room. On 04/02/25 at 9:15 a.m., Resident #7 stated on 02/25/25 they were approached by the evening nurse and asked if they still wished to move to Oklahoma City. Resident #7 stated they answered yes. The resident stated the nurse asked them to sign a form. The resident stated they were unable to read the form, but trusted the nurse so they signed it. Resident #7 stated they could just make out the word discharge toward the top of the form. The resident stated had asked social services for assistance finding a nursing home in the Oklahoma City area to move to and thought they were moving to a facility nearer to their family in Oklahoma City. Resident #7 stated their belongings were already loaded and they were headed out the facility door when staff first mentioned they were going to a motel room. The resident stated the staff informed them they were going to a motel room in Tulsa because they were unable to locate a motel in Oklahoma City that accepted a check as payment. The resident stated when they arrived, the facility staff paid for them a 30-day stay with the facility check. Resident #7 stated the motel was not handicapped accessible and they were unable to enter/exit their motel room without assistance because the wheelchair the facility provided was too big for the doorway. The resident stated they were concerned that if there was a fire or other disaster, they would not be able to get out of their motel room. Resident #7 stated they could not enter the bathroom because the wheelchair did not fit through the bathroom doorway and they were unable to walk. Resident #7 sustained themselves on microwavable meals such as canned ravioli and had to use a five-gallon bucket for their toileting needs. The resident stated their skin was scratched and irritated from using the bucket as a toilet. Resident #7 stated the lack of permanent housing and caregiver support to help with activities of daily living made them anxious. The resident stated they were concerned they would be homeless after their stay was up and they had no income or community resources to rely on. The resident stated they voiced their concerns and their increasing anxiety to a friend who contacted APS. The resident stated it was APS who informed them the facility would pick them up and return them to the facility. The resident stated they did not think the facility would have accepted them without the help of APS. 2. Resident #4 had diagnoses which included Meniere's disease, dementia, psychotic disturbance, mood disturbance, and anxiety. The resident's clinical record was reviewed. There was no documentation the facility provided the resident with a 30-day notice of intent to discharge and no documentation the interdisciplinary team was involved in the discharge plan. There was no documentation the physician was notified of the discharge. There was no physician's order for the discharge. A discharge planning review, dated 02/26/25, showed the family participated in the discharge planning and overall goal setting during the discharge process and established a discharge to the community as the overall goal. The discharge planning review showed the family was the primary source of all information and Resident #4 would live with family as their primary caregiver. A nurse's progress note, dated 02/26/25, showed the resident was discharged home with all personal belongings and medications. On 04/01/25 at 3:45 p.m., SSD stated they were told by the former administrator to discharge Resident #4. The SSD stated the discharge did not follow the facility policy. The SSD stated they transported Resident #4 to their family home. The SSD stated there were three family members at the family home and it was obvious they did not know the resident would be discharged . The SSD stated the family asked if the discharge was related to finances, but that they did not know the answer. The SSD stated they did set up home health for Resident #4 and reviewed the medication list with the family. On 04/01/25 at 4:10 p.m., the DON stated all the staff were upset about the discharge. The DON stated the former administrator instructed them to discharge the resident, but did not know if they initiated the resident's discharge. The DON stated the resident's reason for discharge was financial. The DON stated Resident #4's discharge did not follow their policy. The DON stated all the staff were concerned about the residents who were discharged on 02/26/25 and how those discharges were conducted. The DON stated the facility did identify the discharge process as a problem, educated the department heads, and initiated steps to ensure the discharge policy was followed. On 04/01/25 at 5:10 p.m., the former administrator stated they were instructed by corporate Resident #4 received their 30-day notice and should be discharged on 02/26/25. The former administrator stated they later were informed the resident/representative did not receive a 30-day notice.

Based on observation, record review, and interview, the facility failed to provide a resident with a bed wide enough to allow the resident to reposition themselves and side rails/trapeze bar for the resident to use in positioning for 1 (#2) of 3 residents sampled for accommodation of needs. The alphabetical resident roster identified 56 residents resided in the facility. Findings: On 03/28/25 at 11:45 a.m., Resident #2 was observed in bed with the head of the bed up approximately 45 degrees. The resident was on an air mattress with approximately 4 inches from their hip to the edge of the air mattress on either side. There were no side rails or a trapeze bar present. A facility policy titled Quality of Life - Accommodation of Needs, dated 02/01/16, read in part, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being .The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Resident #2 was admitted on [DATE] with diagnoses which included paraplegia, anxiety, depression, and pressure ulcers. An admission assessment, dated 03/12/25, showed the resident was cognitively intact (BIMS 15), felt down, depressed, or hopeless, and was dependent on staff to roll left/right when lying on back or moving to/from sitting on the side of the bed. The assessment showed the resident was dependent on personal hygiene, lower body dressing, bathing, and toileting hygiene. The assessment showed the resident had four Stage 4 pressure ulcers. A care plan, dated 03/18/25, read in part, The resident has paraplegia r/t Spinal injury d/t MVA .Assist with ADLs [activities of daily living] and locomotion as required. Encourage resident to perform as much as possible of these activities .limited physical mobility d/t paraplegia r/t past MVA .Encourage resident to perform as much of upper body tasks as possible. On 03/28/25 at 11:45 a.m., Resident #2 stated their bed mobility was limited without side rails and a trapeze bar to grab. The resident stated they were accustomed to using side rails and a trapeze bar for bed mobility, but when they asked for side rails, the facility informed them the facility did not use side rails because they were a restraint. The resident stated they felt claustrophobic and restrained due to the bed's size and their lack of independent bed mobility. The resident stated without anything to hold onto, they were completely dependent on staff for bed mobility and feared falling from the edge of the bed every time they were repositioned. On 03/28/25 at 2:30 p.m., the DON stated the resident had requested full side rails on admission, but the facility policy did not allow for the use of full side rails. The DON stated the resident requested a trapeze bar a few days before, but they had not provided one yet. On 03/31/25 at 11:30 a.m., the DON stated they relied on their nursing staff and therapy department to inform them when an accommodation was needed. The DON stated they were unaware the resident's bed did not comfortably accommodate the resident.

Based on record review and interview, the facility failed to ensure a resident and/or resident's representative the right to participate in the development and implementation of their person-centered plan of care for 1 (#5) of 1 sampled resident reviewed for care plan meetings. The DON identified 52 residents resided in the facility. Findings: A Comprehensive Person-Centered Care Plan policy, dated 01/23/19, read in part, 3. The Interdisciplinary Team, along with the Resident and/or Resident Representative, will identify resident problems, needs, strengths, life history, preferences, and goals. 6. The Comprehensive Person Centered Care Plan can be revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change and annual assessments per the RAI manual. Resident #5 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease and kidney failure. Resident #5's clinical record was reviewed July 2024 through March 2025. There was no documentation to show Resident #5 and/or their representative participated in the development and implementation of their care plan. An annual MDS assessment, dated 01/29/25, showed Resident #5's cognition was intact with a brief interview for mental status score of 15. On 03/17/25 at 1:00 p.m., Resident #5 stated they had not had a care plan meeting, but would like to. They stated no one had discussed their plan of care with them. On 03/18/25 at 1:00 p.m., the director of nursing stated they depended on the MDS coordinator to tell them when care plan meetings were done, but they did not have a certain way they follow up on the meetings. On 03/18/25 at 1:30 p.m., the MDS coordinator stated they have not been doing care plan meetings because everyone says they are too busy, but they should be done quarterly.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 30 opportunities were observed with two errors. The total medication error rate was 6.67%. The DON identified 47 residents received medications in the facility. Findings: 1. Resident #14 had diagnoses which included rib fractures. The Physician's Orders, dated 02/02/24, documented Calcium 600mg by mouth daily for rib fracture. 2. Resident #32 had diagnoses which included cough and seasonal allergies. The Physician's Orders, dated 04/02/24, documented Geri-Tussin DM 10-100mg/5ml - give 10ml orally every four hours as needed for cough. On 04/03/24 at 8:48 a.m., CMA #1 was observed to administer Calcium 600mg plus vitamin D3 20mcg one tablet by mouth to Resident #14. On 04/03/24 at 3:23 p.m., CMA #2 was observed to administer 5ml of Geri-Tussin DM 10-100mg/5ml to Resident #32. On 04/04/24 at 9:51 a.m., CMA #1 stated they had not noticed the Calcium 600mg they had administered to Resident #14 included 20mcg of vitamin D3 and they should have administered Calcium 600mg. On 04/04/24 at 11:04 a.m., CMA #2 stated they thought the order for Geri-Tussin DM was for 5ml. They stated they should have administered 10ml of Geri-Tussin DM. On 04/04/24 at 11:59 a.m., the DON stated they randomly observed the CMAs during medication administration to observe to medication errors. The DON was informed of the medication error rate of 6.67%.

Based on observation, record review, and interview, the facility failed to ensure medications were dated when opened for three (300/400 hall medication cart, 200 hall treatment cart, and 400 hall treatment cart) of three medication/treatment carts observed. The DON identified five medication/treatment carts in the facility. Findings: 1. On 04/04/24 at 9:10 a.m., the 300/400 medication cart was observed with CMA #1. CMA #1 stated they were to date medications when they were opened. The following medications were observed to be open but not dated: a. Ketorolac eye drops for Resident #12. b. Imodium liquid 1mg/7.5ml house stock. c. Chloraseptic throat lozenges for Resident #22. On 04/04/24 at 9:11 a.m., the 200 hall treatment cart was observed with the ADON. The following medications were observed to be open but not dated: d. Breo Ellipta inhaler and icy hot cream for Resident #18. e. Levalbuterol nebulizer vials and nystatin cream for Resident #32. f. Anora inhaler for Resident #17. g. Spiriva inhaler for Resident #28. On 04/04/24 at 9:19 a.m., the 400 hall treatment cart was observed with the ADON. The following item was observed to be open but not dated: h. glucometer test strips On 04/04/24 at 9:23 a.m., the ADON stated they did not know why the opened medications had not been dated but they were to date medications when they were opened.

Based on record review and interview, the facility failed to implement a program designed to help prevent the development of Legionellosis. The administrator reported the census was 47. Findings: An undated facility policy titled Legionella Water Management Program, read in part, .Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella . The water management program includes the following elements . A detailed description and diagram of the water system . On 04/03/24 at 10:30 a.m., the maintenance director stated they did not have a detailed description and diagram of the water system.

Based on record review and interview, the facility failed to ensure residents on antipsychotic medications were assessed for tardive dyskinesia for three (#6, 18, and #19) of five residents who were reviewed for unnecessary medications. The DON identified eight residents who were ordered antipsychotic medications. Findings: The Monitoring of Anti-Psychotics policy, dated 2024, read in parts, .Upon initiation of antipsychotic medication therapy [or upon admission for new residents receiving anti-psychotics] and every three months thereafter, the Abnormal Involuntary Movement Scale [AIMS] or similar test is administered to the resident. The results, and actions taken in response to the results, are recorded in the residents medical record . 1. Resident #6 had diagnoses which included Schizoaffective disorder, Bipolar type. An AIMS assessment, dated 01/09/23, was completed in the electronic clinical record. Review of the clinical record did not reveal any AIMS assessments after 01/09/23. The annual assessment, dated 01/20/24, documented the resident was moderately impaired cognitively for daily decision making and received an antipsychotic medication on a routine basis. The Care Plan, dated 11/11/22, read in parts, ZYPREXA Altered Thought Processes AIMS SCALE. Quarterly AIMS Scale is required for residents receiving antipsychotic medication. Complete baseline AIMS Scale. Activate the recurring schedule for AIMS Scale quarterly . 42171 2. Resident #19 had diagnoses which included schizoaffective disorder and anxiety disorder. An AIMS assessment, dated 01/09/23, was completed in the electronic record. Review of the clinical record did not document any AIMS assessments had been completed after 01/09/23. A care plan, initiated 01/31/23, documented that AIMS scale assessments were to be completed quarterly for residents receiving antipsychotic medications. A physician's order, dated 02/22/23, documented the resident was receiving Ingrezza (a medication to treat tardive dyskinesia) 80 mg by mouth each day. A quarterly assessment, dated 02/29/24, documented the resident was severely impaired for daily decision making and received an antipsychotic medication on a routine basis. 35474 3. Resident #18 had diagnoses which included schizoaffective disorder. An AIMS assessment, dated 01/09/23, was completed in the electronic clinical record. Review of the clinical record did not reveal any AIMS assessments after 01/09/23. The quarterly assessment, dated 01/16/24, documented the resident was cognitively intact for daily decision making and received an antipsychotic medication on a routine basis. The Care Plan, revised 02/28/24, read in parts, .AIMS scale assessments are required at least quarterly on residents taking antipsychotic medications . A Physician's Order, dated 03/05/24, documented Austedo XR (a medication to treat tardive dyskinesia) 12mg by mouth daily related to drug induced subacute dyskinesia for seven days. A Physician's Order, dated 03/07/24, documented an order for Invega (an antipsychotic medication) 234mg/1.5ml inject every 28 days. On 04/02/24 at 11:13 a.m., the DON stated they thought AIMS assessments were documented on the MDS but would need to verify. On 04/02/24 at 11:19 a.m., the DON stated they did not conduct AIMS assessments anymore the charge nurses monitored behaviors and obtained consents for psychotropic medications. On 04/02/24 at 11:28 a.m., LPN #1 stated they observed for nausea, vomiting, diarrhea, and hallucinations when monitoring for tardive dyskinesia related to antipsychotic medication use. On 04/02/24 at 11:59 a.m., LPN #2 stated they assessed affect, clear speech, dizziness, nausea, observed the residents' movements, and headache when monitoring for tardive dyskinesia related to antipsychotic medication use.

Based on record review and interview, the facility failed to implement their abuse policy for one of five new employees reviewed for background checks. The Abuse Prevention policy, dated 10/21/2022 read in parts, . The facility will pre-screen all potential new employees and residents for a history of abusive behavior. A review of five new employees revealed one CNA #1 with no documented background check completed or in progress. On 04/03/24 at 03:47 p.m. the administrator stated they could not find a clearance letter for CNA#1. That apparently they never went to be fingerprinted. The CNA has been suspended and will not be allowed to work until final clearance has been received.

Based on record review and interview, the facility failed to ensure influenza vaccinations were offered for one (#41) of five residents reviewed for immunizations. The administrator reported the census was 47. Findings: An Influenza Vaccine policy, dated 04/28/22, read in part, .The opportunity to receive the influenza vaccine will be extended to all residents and employees. The facility will provide the pertinent information regarding the risks/ benefits of receiving the influenza vaccine .An individual is not required to receive the influenza vaccine .resident refusal will be documented . Resident #41 had diagnoses including dementia and hypertension. A review of resident #41's immunization records did not document the resident had received or been offered a flu vaccination. On 04/04/23 at 11:59 a.m., the DON stated there was no additional documentation for Resident #41 regarding immunizations.

Based on record review and interview, the facility failed to ensure COVID-19 vaccinations were offered for one (#41) of five residents reviewed for immunizations. The administrator reported the census was 47. Findings: An COVID Vaccine policy, revised 08/01/23, read in part, . The facility will offer the COVID Vaccine to employees/residents to assist in mitigating the spread of COVID-19 .COVID-19 Vaccinations will be offered to all residents/employees . Resident #41 had diagnoses including dementia and hypertension. A review of resident #41's immunization records did not document the resident had received or been offered a COVID-19 vaccination. On 04/04/23 at 11:59 a.m., the DON stated there was no additional documentation for Resident #41 regarding immunizations.

Based on observation and interview, the facility failed to employ a registered nurse as the full-time Director of Nursing. The DON identified 52 residents residing in the facility. Findings: On 12/04/23 at 12:33p.m., the DON stated they were a licensed practical nurse. On 12/04/23 at 2:05 p.m., the office placard which announced the office of the Director of Nursing was labeled with the name of the DON. On 12/06/23 at 12:20 p.m., the DON stated they signed their contract to accept the DON position on 09/14/23 and started on 09/18/23. The DON stated they employed registered nurses for at least eight hours every day in a supervisory position. On 12/06/23 at 12:25 p.m., the administrator stated they were aware of the regulation which required a registered nurse be employed in the position of DON.

Based on record review, observation, and interview, the facility failed to ensure the walls were clean and in good repair for two (#3 and #4) of four sampled residents and failed to ensure the common areas of the facility were safe, homelike, and maintained in good repair. The Resident Census and Conditions of Residents report, dated 03/28/23, documented 48 residents resided in the facility. Findings: The Maintenance policy, dated 04/14/03, read in parts, .The company believes that a clean, safe, well maintained facility is necessary to ensure a proper environment for our residents .The Administrator has direct responsibility for .Continuous and regular inspection of physical plant .Overseeing the development and implementation of scheduled repair, maintenance, or replacement of physical plant problem areas, i.e., scheduled painting of interior .The facility maintenance supervisor has direct responsibility for .Planning, scheduling, supervising, and participating in maintenance and repair such as .painting . On 03/28/23 at 1:28 p.m., the walls in the common area across from the nurses station had dark areas and peeling paint. The ledge between the hand rails and the wall had blackened debris on them. On 03/28/23 at 1:29 p.m., three 2 x 4 pieces of wood and sheet rock was observed stored in the common area of the facility. Four residents were observed sitting in the common area. Three out of the four residents were identified by staff as having cognitive impairments. On 03/28/23 at 4:30 p.m., the wall in Resident #4's room was observed with stains and white patches. Resident #4 was asked what was on the wall. They stated they did not know. Resident #4 stated the wall had been like that since they had moved to the facility. On 03/28/23 at 4:36 p.m., the tile floor in hall 200 was observed to be bubbled up and cracked. On 03/28/23 at 4:38 p.m., the wall on hall 200 was observed to have a white patch on the lower wall. On 03/28/23 at 7:41 p.m., the wall next to Resident #3's bed was observed to have paint missing and black areas on the wall. On 03/28/23 at 7:46 p.m., the maintenance supervisor observed the walls across from the nurses station. The maintenance supervisor stated the walls were discolored and had paint peeling from years of not being painted. The maintenance supervisor stated they did not know what was on the walls. The maintenance supervisor stated the 2 x 4s and sheetrock were in the common area because they were in the process of fixing the ceiling. The maintenance supervisor was asked if there was anywhere else the lumber and sheetrock could be stored. They stated no. The maintenance supervisor was asked about the tile on hall 200. They stated it looked like the tile was not put in properly. They were asked about the wall on hall 200. They stated they patched the wall and had not had time to paint. The maintenance supervisor was asked about Resident #5's wall. They stated they did not know what the brown stuff was on the wall. They stated the white patches on the wall was sheetrock mud. The maintenance supervisor stated the facility was in the process of remodeling the facility.

Based on record review and interview, the facility failed to maintain personal funds in an interest-bearing account for all residents on the trust fund. The administrator stated there are 18 residents on the trust fund in the facility. Findings: On 01/25/23 at 1:30 p.m., no documentation of residents on the trust fund having had their personal funds maintained in an interest-bearing account could be found with record review. On 01/25/23 at 1:50 p.m., the BOM was asked if residents on the trust fund had their personal funds maintained in an interest-bearing account. She stated the facility had not maintained the residents' personal funds in an interest-bearing account since March 2022. She stated the facility had not noticed the discrepancy until a few days ago. She stated the administrator had recently contacted the bank to correct the problem but it had not been corrected yet. On 01/25/23 at 1:59 p.m., the administrator stated the facility had not maintained the residents' trust fund in an interest-bearing account since March 2022. She stated the facility had not noticed the discrepancy until a few days ago. The DON stated she was currently in communication with the bank to ensure the residents' accounts would receive interest as required in the future.

Based on record review and interview, the facility failed to provide quarterly financial statements to residents on the trust fund. The administrator stated there are 18 residents on the trust fund in the facility. Findings: On 01/25/23 at 1:30 p.m., no documentation of receipt of quarterly financial statements by residents on the trust fund could be found with record review. On 01/25/23 at 1:48 p.m., the BOM was asked if residents on the trust fund were provided with quarterly financial statements. She stated financial statements were only provided upon request and not routinely on a quarterly basis. She stated she was not aware the financial statements were to be provided quarterly. On 01/25/23 at 1:56 p.m., the administrator stated financial statements had not been provided quarterly to residents on the trust fund since the facility changed ownership in November of 2021, but they should have been provided.

On 09/15/17, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect a resident from abuse. At 5:12 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:14 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to protect a resident from abuse. On 09/15/17 at 7:54 p.m., an acceptable plan of removal was provided. The plan of removal documented, .FAILURE TO PROTECT RESIDENTS FROM ABUSE A. Employees will be educated on the facility Abuse Policy and Procedure on 9-15-17 before midnight. B. Quarterly in services will include signs of symptoms of burnout / excessive stress in staff and behavioral or physical changes in residents that could detect potential abuse. C. Any signs or symptoms of staff burnout/excessive stress in staff or changes that any staff may recognize with residents shall be reported to charge nurse immediately. D. Any staff member with a concern about another staff members behavior shall be ensure of confidentiality and protected from retaliation. The immediate jeopardy was removed on 09/15/17 at 11:45 p.m., when all components of the plan of removal were carried out. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interview and record review, it was determined the facility failed to protect a resident from abuse for one (#3) of three sampled residents who were reviewed for allegations of abuse. Resident #3 was found to have an estimated 12 wipes pushed up into his rectum. The facility identified 52 residents who resided at the facility. Findings: The facility's abuse policy and procedures, which was not dated, documented, .A licensee, nursing home administrator, or employee of a nursing home shall not physically, mentally, or emotionally abuse, or harmfully neglect a patient. Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment . Resident #3 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident's care plan, dated 11/14/14, documented the resident needed extensive assist with toilet use, the resident would use the toilet or bedpan as needed for episodes of incontinence, staff would assist him on the toilet or a bedpan every two hours and as needed, and may use an incontinent brief while out of bed and an incontinent pad in bed. A facility inservice on abuse and neglect, dated 07/21/17, documented a signature of certified nurse aide (CNA) #1 which indicated that he had attended the inservice. The resident's quarterly assessment, dated 07/28/17, documented the resident was severely cognitively impaired; required total dependence on staff for transfers, dressing, and bathing; and was always incontinent of bowel and bladder. An interdisciplinary progress note, dated 09/07/17 at 7:00 p.m., documented, This nurse called to pt's (patient's) room by 2x (times) CNAs (certified nurse aides). Pt had a BM (bowel movement) et (and) while providing peri-care CNA pulled rolled/twisted wipes from pt's rectum. (No) apparent injury noted. Redness to buttocks et rectum however pt has had diarrhea throughout the day. D/T (due to) incident pt was transported to ER (emergency room ) for eval (evaluation) et tx (treatment). Physician notified. Messages left (with) all contacts. (No) answer. An interdisciplinary progress note, dated 09/07/17 at 8:30 p.m., documented, Pt sent to (name deleted hospital) et then transferred to (name deleted hospital in name deleted town). Still unable to reach any family @ (at) this x (time). An Incident Report form, documented an allegation of abuse/mistreatment and the report was indicated it was the initial report. The report documented the incident date was 09/07/17 and documented, Adult wipes found in pt's rectum during peri-care (with) BM. (No) apparent injury obtained. Pt has had diarrhea throughout the day, redness noted. Investigation initiated, (with) inservice started (with) staff on duty. Employees suspended. Pt send to ER for eval. The report documented the local police were called on 09/07/17 at 7:40 p.m. This report was faxed to the Oklahoma State Department of Health (OSDH) on 09/07/17 at 11:40 p.m. An inservice training form, dated 09/11/17 with no time indicated, documented, .TOPIC use of wipes (with) BM (bowel movement) .Always ensure wipes are removed (after) pt care. Never put wipes into rectum. An Incident Report form documented it was an allegation of abuse/mistreatment and the report indicated it was the final report. The report documented the incident date was 09/07/17 and documented, Police have taken over investigation & informed us that we are not allowed to interview staff or possible suspects, therefore we are unable to complete at this time. Will send f/u (follow-up) info (information). When available. Res, admitted to (name deleted hospital). This report was faxed to OSDH on 09/08/17 at 12:57 p.m. The resident's hospital after care instructions, dated as printed on 09/08/17 at 11:11 a.m., documented, .FEARED CONDITION RULED-OUT (ADULT) .2. The condition you or your doctor were concerned about did not seem like a serious problem. Your doctor does not think you have a medical problem that needs treatment. This is based on your history and physical exam .Note: Our social workers have talked to your family and everyone involved feels comfortable sending you back at this point. Your workup her in the ER did not reveal any concerning abnormalities .CT (cat scan) - Abdomen = Normal. An interdisciplinary progress note, dated 09/08/17 at 1:00 p.m., documented the resident was readmitted back to the nursing facility. An inservice training form, dated 09/11/17 with no time indicated, documented, All prn (as needed) - meds (medications) - nurse must be informed prior to giving. All prn pain meds must be doc. (documented) on MAR (medication administration record) showing location & pain scale before & after administration. Nurses to assess & document findings of request for pain meds prn. A facility Investigative Report Follow Up, dated 09/13/17, documented, On September 07, 2017 we were notified of wipes being found in resident (name deleted resident #3's) rectum. Investigation initiated immediately with this nurse phoning Administrator, who phone the (name deleted) Police Department and began watching surveillance video, with the charge nurse assessing the resident finding redness to rectal area, no other injuries noted. I arrived at the facility to assist with the investigation. Statements were able to be obtained from the two aides who found the resident in this condition, before the police arrived. Attempted to contact (name deleted CNA #1) and to inform of suspension with investigation, but no response at that time. Attempted to interview resident with no response to questioning. An in-service was initiated on the use of wipes to always ensure wipes are removed after care and never to be put into rectum. Police informed us they would be assuming this incident as a criminal act and not to interview further staff or residents, that it is their investigation at this time. Resident was sent to (name deleted hospital) in Tulsa for evaluation. Report was submitted to OSDH, DHS (department of human services), Oklahoma Nurse Aide Registry and the Abuse Hotline, (name deleted physician) and family were notified by phone. CNA #1 returned my call and police instructed him to come to facility to question him. (Name deleted CNA #2) CNA who worked the shift with (name deleted CNA #1) brought him to visit Officer (name deleted Officer #1). While present she stated she made rounds and was with (name deleted CNA #1) all day. At that point Officer (name deleted Officer #1) asked me if she was suspended as well and I stated yes. On September 08, 2017 resident returned to facility with after care instructions stating feared condition ruled out, no treatment was needed and all tests were normal. On September 11, 2017 Administrator converted surveillance video onto thumb drive and provided to (name deleted) Police, Chief (name deleted), with a copy of staff names and phone numbers that had entered resident's room that day. Later that day, Chief of police with Administrator and informed of (name deleted CNA #1) confessing to resident abuse. Administrator inquired on suspended aide, (name deleted CNA #2's) statement to police and Chief informed him that she stated that (name deleted CNA #1) had told her on the way home from work and Chief asked her if she thought to inform the authorities or nursing home and she said no. Chief stated permission to complete our investigation. Resident's roommate and other residents were interviewed about abuse and none have been abused or seen any abuse to others. Staff and hospice caregivers that entered room were interviewed, none were aware of any abuse. Being permitted to continue with our investigation, we learned that the resident had experienced diarrhea and complaint of pain of buttocks. Medication had been given for both pain and diarrhea with an in service initiated to ensure nurse aware of any prn medication and assesses for need, with documentation in MAR (medication administration record) and nurses notes. On September 12, 2017 a new order was received to discontinue Broda chair use geri chair and [MEDICATION NAME] routinely for complaint of pain. With the confession of abuse from (name deleted CNA #1) and failure to report and protect by (name deleted CNA #2), both are substantiated and terminated from this facility. (Name deleted CNA #1) is in jail at this time . The report was signed by the administrator and the director of nursing. This report was faxed to OSDH on 09/13/17 at 1:37 p.m. On 09/15/17 at 1:10 p.m., the surveyor entered the building and asked for various items/information to start the investigation which included allegations of abuse, neglect, or misappropriation which had been investigated since the facility's last annual survey. After a tour of the facility and interviewing some residents the surveyor reviewed the facility's investigation of the above allegation of abuse. The facility's investigation included two pictures. One picture showed what appeared to be a resident's anal area with something whitish in color sticking out of a resident's anus. The object sticking out of the resident's anus was covered with what looked to be bowel movement (BM) except for a few small areas where the whitish color could be seen. The area around the resident's anus looked engorged. The resident's buttocks had BM on them. The other picture was of a resident's buttocks area that was red in various places. On 09/15/17 at 3:30 p.m., the administrator and director of nursing (DON) were interviewed. They were asked how many residents they had interviewed during their investigation. They named the three residents that had been interviewed during their investigation. The administrator and DON were asked, three residents during your investigation. They stated yes. The administrator and DON were asked if they had completed any inservices. They stated yes. The administrator stated that they had immediately started training on pericare for the use of wipes with a BM. They were asked if they had completed any other inservices. The DON stated on 09/11/17 they had done an inservice on prn medications. The DON stated those were the two inservices they had done at that point. The administrator and DON were asked if they had done an inservice related to abuse, neglect, and reporting abuse. They stated no. The DON stated no, because we did it timely, we reported it timely. The administrator and DON were asked if they had identified a problem with reporting. The administrator stated, No, I did not. The surveyor stated the facility's investigative report stated that CNA #1 told CNA #2 and CNA #2 failed to report it to the authorities and the nursing home. The administrator stated yes and stated CNA #2 had been terminated related to CNA #2's failure to report. The administrator was asked so you identified a failure to report. The administrator stated yes. The administrator was asked did you inservice related to failure to report. The administrator stated no. The DON asked should we have. The administrator stated, Yes, we will need to. On 09/15/17 at 3:48 p.m., the chief of police was asked what were the findings of their investigation of the abuse allegation of resident #3 and CNA #1. The police chief stated the CNA had confessed. He stated the wipes were 8 inches by 12 inches in size and they estimated 12 wipes were used. He stated he had the CNA show him, how he had put the wipes into the resident's rectum. The chief showed the surveyor how he had made his hand with his first finger and thumb into a circle. He stated the CNA roughly pushed into the open area of chief's hand. On 09/15/17 at 4:13 p.m., the administrator and DON returned to the surveyor and stated they had started to inservice staff members about reporting abuse. He stated staff were being told if anything was seen, suspected, or heard about to tell the charge nurse, administrator, or DON. The administrator was asked who took the pictures of the resident. The administrator stated that CNA #3 had. The administrator stated the facility had a social media policy. He stated he had seen a picture of the dirty wipes on the DON's phone. The administrator was asked when CNA #1 had left the faciity on [DATE]. He stated at 3:00 p.m., as the staff members had an inservice that day to attend. The administrator was asked what time CNA #1 had stopped providing residents care. He stated at 2:00 p.m. The administrator and DON were asked what time the resident had been found with the wipes in his rectum. They reviewed the investigation documentation and stated at 6:44 p.m. The administrator and DON were asked why were the wipes not found until 6:44 p.m. He reviewed the investigation documentation and stated CNA #4 had been in the resident's room at 3:00 p.m. He stated the resident was gotten up for dinner at 5:00 p.m. The administrator and DON were asked if the CNAs had gotten the nurse to see the wipes while they were still in the resident's rectum or did they just pull the wipes out. He stated he did not know, then he stated he thought the nurse (licensed practical nurse (LPN) #1) had told him she had seen it. The administrator and DON were asked if the resident's anal/buttocks area pictures were on CNA 3's personal cell phone. They stated yes. They were asked if they had the CNA delete the pictures. They stated, no the police wanted them. They were asked who the pictures had been sent to. They stated the pictures had been sent via text message from CNA #3 to the administrator and then the administrator sent them to the DON. On 09/15/17 at 6:39 p.m., CNA #3 was interviewed. The CNA was asked to tell the surveyor about the situation with resident #3 and the wipes. She stated when she took over the floor, CNA #1 had told her the resident had had diarrhea several times that day and he had put wipes by his bottom in his brief to take care of the diarrhea. She stated before the resident was gotten out of bed for dinner she had checked the resident's brief and he was not wet or dirty. She stated she did take pictures. The surveyor showed her the two pictures that were in the facility's investigation file and asked her if those were the pictures she had taken. She stated yes. CNA #3 was asked when she had notified the nurse. She stated as soon as she had seen what was going on with the resident. The CNA was asked if the nurse had seen the wipes in the resident's rectum. She stated, no she had slowly pulled it out. She stated it was covered in BM. She stated she thought it was BM. The CNA was asked if the resident had done anything while she pulled them out. She stated, no. She stated he did when she wiped him. She stated it was really red. The CNA was asked what the resident did when she wiped him. She stated he cinched his butt cheeks together and called out nurse, nurse. She was asked if nurse was all the resident could say. She stated, yes. CNA #3 was asked where the wipes were when she went to go get the nurse. She stated she had them in a trash bag. The CNA was asked if they had finished cleaning up the resident when she went to go get the nurse. She stated, no. The CNA was asked what she had told the nurse. She stated she had told the nurse that she thought there was something wrong with resident #3's bottom that she needed to see. The CNA was asked if the nurse came right then to see the resident. The CNA stated yes. The CNA was asked which nurse came to check the resident. She stated she thought it was LPN #1. CNA #3 was asked what the LPN had done. She stated the nurse came to the resident's room, checked the resident, looked at the wipes, and asked the resident if he was in any pain. The CNA was asked what the nurse did next. The CNA stated the nurse called the administrator and DON. The CNA was asked who had the wipes. She stated she did until someone working that night had accidentally thrown them away. She stated she had dug them out of the garbage to show the police. On 09/15/17 at 7:13 p.m., CNA #4 was asked to tell the surveyor about the incident related to resident #3. She stated she and CNA #3 had put the resident to bed after dinner. She stated they went to pull down his brief. She stated he was all dirty. She stated she could see one white spot then the resident looked like he started to have a BM and it (the wipes) started to come out. She stated CNA #3 started to carefully slowly pull it out. She stated she went to go get the nurse. She stated she was in shock. She stated, that was in his rectum. When asked she stated she was not in the resident's room when the nurse came into the resident's room. When asked she stated she did not know what the nurse did because she got busy. She stated she did see the DON and then the police came to the facility. She stated she had filled out a statement for the DON and the police. CNA #4 was asked what the resident did while the wipes were coming out. She stated he called out oh nurse and cinched his buttocks. The CNA was asked what the resident did while he was getting cleaned up. She stated he called out, oh nurse. On 09/15/17 at 7:59 p.m., LPN #1 was asked to tell the surveyor about the incident with resident #3. She stated it was rolled up like a tampon. She stated CNA #3 had to pull them out of his rectum. She stated she immediately left the room and called the DON. She stated the DON called the administrator and the administrator called the police. She stated the police came to the facility. She stated she and the DON started getting paperwork together and called the physician. She stated the police asked if the resident was getting an abdominal xray. She stated the resident was sent to the hospital. On 09/15/17 at 8:15 p.m., with LPN #1 the resident's buttocks and anal area was observed. The resident's anal area and buttocks were not red and had no open areas. On 09/19/17 at 4:17 p.m., a phone interview was conducted with CNA #3. The CNA was asked when she took a picture of the resident's buttocks and anal area. She stated before she touched it or anything, she took a picture. CNA #3 was asked why she took the pictures. She stated, Evidence.

On 09/15/17, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy and procedure to prevent resident abuse. At 5:12 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:14 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to protect a resident from abuse. On 09/15/17 at 7:54 p.m., an acceptable plan of removal was provided. The plan of removal documented, .FAILURE TO IMPLEMENT POLICY AND PR(NAME)EDURES ON PREVENTING ABUSE A. Employees will be educated on the facility Abuse Policy and Procedure on 9-15-17 before midnight. B. A thorough investigation to include statements from all cognitive residents on abuse by midnight 9-15-17. B (C). Thorough reference checks on any new employees will be conducted. C (D). All employees will be interviewed 9-15-17 by midnight related to the substantiated allegation of abuse on 9-7-17. The immediate jeopardy was removed on 09/15/17 at 11:45 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on interview and record review, it was determined the facility failed to implement their abuse policy and procedure to: ~ prevent resident abuse for one (#3) of three sampled residents who were reviewed for allegations of abuse; ~ conduct a thorough investigation; ~ ensure staff members reported the allegation immediately; ~ report the allegation in a timely manner; and ~ failed to ensure pictures were not taken of a resident. Resident #3 was found to have an estimated 12 wipes pushed up into his rectum. The facility identified 52 residents who resided at the facility. Findings: The facility's abuse policy and procedures, which was not dated, documented, .A licensee, nursing home administrator, or employee of a nursing home shall not physically, mentally, or emotionally abuse, or harmfully neglect a patient. Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment . The facility must have evidence that all alleged violations are thoroughly investigated , and must prevent further potential abuse while the investigation is in progress . A licensee, nursing home administrator, or employee of a nursing home shall not physically, mentally, or emotionally abuse, or harmfully neglect a patient. A nursing home employee who becomes aware of an act prohibited by this section immediately shall report the matter to the nursing home Administrator of Nursing Director . Any employee who suspects or witnesses abuse or neglect toward a resident must report it to the facility administrator or his /her designee. The provider ensures that any suspected or alleged incidents of abuse and neglect are thoroughly, objectively and expeditiously investigated and substantiated incidents are reported to the state and local law enforcement and regulatory agencies as required. The facility's photography/video/audio recording policy, which was not dated, documented, There shall be NO picture taking, videotaping or audio recording of staff, residents, or property of (name deleted nursing facility) without approval from the Administrator. Resident #3 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident's care plan, dated 11/14/14, documented the resident needed extensive assist with toilet use, the resident would use the toilet or bedpan as needed for episodes of incontinence, staff would assist him on the toilet or a bedpan every two hours and as needed, and may use an incontinent brief while out of bed and an incontinent pad in bed. A facility inservice on abuse and neglect, dated 07/21/17, documented a signature of certified nurse aide (CNA) #1 which indicated that he had attended the inservice. The resident's quarterly assessment, dated 07/28/17, documented the resident was severely cognitively impaired; required total dependence on staff for transfers, dressing, and bathing; and was always incontinent of bowel and bladder. An interdisciplinary progress note, dated 09/07/17 at 7:00 p.m., documented, This nurse called to pt's (patient's) room by 2x (times) CNAs (certified nurse aides). Pt had a BM (bowel movement) et (and) while providing peri-care CNA pulled rolled/twisted wipes from pt's rectum. (No) apparent injury noted. Redness to buttocks et rectum however pt has had diarrhea throughout the day. D/T (due to) incident pt was transported to ER (emergency room ) for eval (evaluation) et tx (treatment). Physician notified. Messages left (with) all contacts. (No) answer. An interdisciplinary progress note, dated 09/07/17 at 8:30 p.m., documented, Pt sent to (name deleted hospital) et then transferred to (name deleted hospital in name deleted town). Still unable to reach any family @ (at) this x (time). An Incident Report form, documented it was an allegation of abuse/mistreatment and the report indicated it was the initial report. The report documented the incident date was 09/07/17 and documented, Adult wipes found in pt's rectum during peri-care (with) BM. (No) apparent injury obtained. Pt has had diarrhea throughout the day, redness noted. Investigation initiated, (with) inservice started (with) staff on duty. Employees suspended. Pt send to ER for eval. The report documented the local police were called on 09/07/17 at 7:40 p.m. This report was faxed to the Oklahoma State Department of Health (OSDH) on 09/07/17 at 11:40 p.m. An inservice training form, dated 09/11/17 with no time indicated, documented, .TOPIC use of wipes (with) BM (bowel movement) .Always ensure wipes are removed (after) pt care. Never put wipes into rectum. An Incident Report form documented it was an allegation of abuse/mistreatment and the report indicated it was the final report. The report documented the incident date was 09/07/17 and documented, Police have taken over investigation & informed us that we are not allowed to interview staff or possible suspects, therefore we are unable to complete at this time. Will send f/u (follow-up) info (information). When available. Res, admitted to (name deleted hospital). This report was faxed to OSDH on 09/08/17 at 12:57 p.m. The resident's hospital after care instructions, dated as printed on 09/08/17 at 11:11 a.m., documented, .FEARED CONDITION RULED-OUT (ADULT) .2. The condition you or your doctor were concerned about did not seem like a serious problem. Your doctor does not think you have a medical problem that needs treatment. This is based on your history and physical exam .Note: Our social workers have talked to your family and everyone involved feels comfortable sending you back at this point. Your workup her in the ER did not reveal any concerning abnormalities .CT (cat scan) - Abdomen = Normal. An interdisciplinary progress note, dated 09/08/17 at 1:00 p.m., documented the resident was readmitted back to the nursing facility. An inservice training form, dated 09/11/17 with no time indicated, documented, All prn (as needed) - meds (medications) - nurse must be informed prior to giving. All prn pain meds must be doc. (documented) on MAR (medication administration record) showing location & pain scale before & after administration. Nurses to assess & document findings of request for pain meds prn. A facility Investigative Report Follow Up, dated 09/13/17, documented, On September 07, 2017 we were notified of wipes being found in resident (name deleted resident #3's) rectum. Investigation initiated immediately with this nurse phoning Administrator, who phone the (name deleted) Police Department and began watching surveillance video, with the charge nurse assessing the resident finding redness to rectal area, no other injuries noted. I arrived at the facility to assist with the investigation. Statements were able to be obtained from the two aides who found the resident in this condition, before the police arrived. Attempted to contact (name deleted CNA #1) and to inform of suspension with investigation, but no response at that time. Attempted to interview resident with no response to questioning. An in-service was initiated on the use of wipes to always ensure wipes are removed after care and never to be put into rectum. Police informed us they would be assuming this incident as a criminal act and not to interview further staff or residents, that it is their investigation at this time. Resident was sent to (name deleted) in Tulsa for evaluation. Report was submitted to OSDH, DHS (department of human services), Oklahoma Nurse Aide Registry and the Abuse Hotline, (name deleted physician) and family were notified by phone. CNA #1 returned my call and police instructed him to come to facility to question him. (Name deleted CNA #2) CNA who worked the shift with (name deleted CNA #1) brought him to visit Officer (name deleted Officer #1). While present she stated she made rounds and was with (name deleted CNA #1) all day. At that point Officer (name deleted Officer #1) asked me if she was suspended as well and I stated yes. On September 08, 2017 resident returned to facility with after care instructions stating feared condition ruled out, no treatment was needed and all tests were normal. On September 11, 2017 Administrator converted surveillance video onto thumb drive and provided to (name deleted) Police, Chief (name deleted), with a copy of staff names and phone numbers that had entered resident's room that day. Later that day, Chief of police with Administrator and informed of (name deleted CNA #1) confessing to resident abuse. Administrator inquired on suspended aide, (name deleted CNA #2's) statement to police and Chief informed him that she stated that (name deleted CNA #1) had told her on the way home from work and Chief asked her if she thought to inform the authorities or nursing home and she said no. Chief stated permission to complete our investigation. Resident's roommate and other residents were interviewed about abuse and none have been abused or seen any abuse to others. Staff and hospice caregivers that entered room were interviewed, none were aware of any abuse. Being permitted to continue with our investigation, we learned that the resident had experienced diarrhea and complaint of pain of buttocks. Medication had been given for both pain and diarrhea with an in service initiated to ensure nurse aware of any prn medication and assesses for need, with documentation in MAR (medication administration record) and nurses notes. On September 12, 2017 a new order was received to discontinue Broda chair use geri chair and [MEDICATION NAME] routinely for complaint of pain. With the confession of abuse from (name deleted CNA #1) and failure to report and protect by (name deleted CNA #2), both are substantiated and terminated from this facility. (Name deleted CNA #1) is in jail at this time . The report was signed by the administrator and the director of nursing. This report was faxed to OSDH on 09/13/17 at 1:37 p.m. On 09/15/17 at 1:10 p.m., the surveyor entered the building and asked for various things to start the investigation which included allegations of abuse, neglect, or misappropriation which had been investigated since the facility's last annual survey. After a tour of the facility and interviewing some residents the surveyor reviewed the facility's investigation of the above allegation of abuse. The facility's investigation included two pictures. One picture showed what appeared to be a resident's anal area with something whitish in color sticking out of a resident's anus. The object sticking out of the resident's anus was covered with what looked to be bowel movement (BM) except for a few small areas where the whitish color could be seen. The area around the resident's anus looked engorged. The resident's buttocks had BM on them. The other picture was of a resident's buttocks area that was red in various places. On 09/15/17 at 3:30 p.m., the administrator and director of nursing (DON) were interviewed. They were asked how many residents they had interviewed during their investigation. They named the three residents that had been interviewed during their investigation. The administrator and DON were asked, three residents during your investigation. They stated yes. The administrator and DON were asked if they had completed any inservices. They stated yes. The administrator stated that they had immediately started training on pericare for the use of wipes with a BM. They were asked if they had completed any other inservices. The DON stated on 09/11/17 they had done an inservice on prn medications. The DON stated those were the two inservices they had done at that point. The administrator and DON were asked if they had done an inservice related to abuse, neglect, and reporting abuse. They stated no. The DON stated no, because we did it timely, we reported it timely. The administrator and DON were asked if they had identified a problem with reporting. The administrator stated, No, I did not. The surveyor stated the facility's investigative report stated that CNA #1 told CNA #2 and CNA #2 failed to report it to the authorities and the nursing home. The administrator stated yes and stated CNA #2 had been terminated related to CNA #2's failure to report. The administrator was asked so you identified a failure to report. The administrator stated yes. The administrator was asked did you inservice related to failure to report. The administrator stated no. The DON asked should we have. The administrator stated, Yes, we will need to. On 09/15/17 at 3:48 p.m., the chief of police was asked what were the findings of their investigation of the abuse allegation of resident #3 and CNA #1. The police chief stated the CNA had confessed. He stated the wipes were 8 inches by 12 inches in size and they estimated 12 wipes were used. He stated he had the CNA show him, how he had put the wipes into the resident's rectum. The chief showed the surveyor how he had made his hand with his first finger and thumb into a circle. He stated the CNA roughly pushed into the open area of chief's hand. On 09/15/17 at 4:13 p.m., the administrator and DON returned to the surveyor and stated they had started to inservice staff members about reporting abuse. He stated staff were being told if anything was seen, suspected, or heard about to tell the charge nurse, administrator, or DON. The administrator was asked who took the pictures of the resident. The administrator stated that CNA #3 had. The administrator stated the facility had a social media policy. He stated he had seen a picture of the dirty wipes on the DON's phone. The administrator was asked when CNA #1 had left the faciity on [DATE]. He stated at 3:00 p.m., as the staff members had an inservice that day to attend. The administrator was asked what time CNA #1 had stopped providing residents care. He stated at 2:00 p.m. The administrator and DON were asked what time the resident had been found with the wipes in his rectum. They reviewed the investigation documentation and stated at 6:44 p.m. The administrator and DON were asked why were the wipes not found until 6:44 p.m. He reviewed the investigation documentation and stated CNA #4 had been in the resident's room at 3:00 p.m. He stated the resident was gotten up for dinner at 5:00 p.m. The administrator and DON were asked if the CNAs had gotten the nurse to see the wipes while they were still in the resident's rectum or did they just pull the wipes out. He stated he did not know, then he stated he thought the nurse (licensed practical nurse (LPN) #1) had told him she had seen it. The administrator and DON were asked if the resident's anal/buttocks area pictures were on CNA 3's personal cell phone. They stated yes. They were asked if they had the CNA delete the pictures. They stated, no the police wanted them. They were asked who the pictures had been sent to. They stated the pictures had been sent via text message from CNA #3 to the administrator and then the administrator sent them to the DON. On 09/15/17 at 6:39 p.m., CNA #3 was interviewed. The CNA was asked to tell the surveyor about the situation with resident #3 and the wipes. She stated when she took over the floor, CNA #1 had told her the resident had had diarrhea several times that day and he had put wipes by his bottom in his brief to take care of the diarrhea. She stated before the resident was gotten out of bed for dinner she had checked the resident's brief and he was not wet or dirty. She stated she did take pictures. The surveyor showed her the two pictures that were in the facility's investigation file and asked her if those were the pictures she had taken. She stated yes. CNA #3 was asked when she had notified the nurse. She stated as soon as she had seen what was going on with the resident. The CNA was asked if the nurse had seen the wipes in the resident's rectum. She stated, no she had slowly pulled it out. She stated it was covered in BM. She stated she thought it was BM. The CNA was asked if the resident had done anything while she pulled them out. She stated, no. She stated he did when she wiped him. She stated it was really red. The CNA was asked what the resident did when she wiped him. She stated he cinched his butt cheeks together and called out nurse, nurse. She was asked if nurse was all the resident could say. She stated, yes. CNA #3 was asked where the wipes were when she went to go get the nurse. She stated she had them in a trash bag. The CNA was asked if they had finished cleaning up the resident when she went to go get the nurse. She stated, no. The CNA was asked what she had told the nurse. She stated she had told the nurse that she thought there was something wrong with resident #3's bottom that she needed to see. The CNA was asked if the nurse came right then to see the resident. The CNA stated yes. The CNA was asked which nurse came to check the resident. She stated she thought it was LPN #1. CNA #3 was asked what the LPN had done. She stated the nurse came to the resident's room, checked the resident, looked at the wipes, and asked the resident if he was in any pain. The CNA was asked what the nurse did next. The CNA stated the nurse called the administrator and DON. The CNA was asked who had the wipes. She stated she did until someone working that night had accidentally thrown them away. She stated she had dug them out of the garbage to show the police. On 09/15/17 at 7:13 p.m., CNA #4 was asked to tell the surveyor about the incident related to resident #3. She stated she and CNA #3 had put the resident to bed after dinner. She stated they went to pull down his brief. She stated he was all dirty. She stated she could see one white spot then the resident looked like he started to have a BM and it (the wipes) started to come out. She stated CNA #3 started to carefully slowly pull it out. She stated she went to go get the nurse. She stated she was in shock. She stated that was in his rectum. When asked she stated she was not in the resident's room when the nurse came into the resident's room. When asked she stated she did not know what the nurse did because she got busy. She stated she did see the DON and then the police came to the facility. She stated she had filled out a statement for the DON and the police. CNA #4 was asked what the resident did while the wipes were coming out. She stated he called out oh nurse and cinched his buttocks. The CNA was asked what the resident did while he was getting cleaned up. She stated he called out, oh nurse. On 09/15/17 at 7:59 p.m., LPN #1 was asked to tell the surveyor about the incident with resident #3. She stated it was rolled up like a tampon. She stated CNA #3 had to pull them out of his rectum. She stated she immediately left the room and called the DON. She stated the DON called the administrator and the administrator called the police. She stated the police came to the facility. She stated she and the DON started getting paperwork together and called the physician. She stated the police asked if the resident was getting an abdominal xray. She stated the resident was sent to the hospital. On 09/15/17 at 8:15 p.m., with LPN #1 the resident's buttocks and anal area was observed. The resident's anal area and buttocks were not red and had no open areas. On 09/19/17 at 1:52 p.m., the administrator was asked who took the two pictures of resident #3's buttocks and anal area. He stated he thought it was CNA #3. He stated he thought she had sent the pictures to him. He was asked who saw the pictures. He stated he had sent them to the DON. He stated he did not think he had sent them to anybody else. He was asked if anyone else had the pictures. He stated, not that he was aware of. The administrator was asked who normally takes pictures of the residents. He stated he was the only one that took the new residents' pictures for their medication administration record. He stated he emailed them to himself then deleted the pictures. He was asked what was his process for taking the residents' pictures. He stated he just takes a picture of the residents' face, on his phone, then sends it to his email, with no identifying information in the subject line. The administrator was asked how he was protecting resident #3's privacy with the two pictures of his buttocks and anal area on electronic devices. He stated he was gong to speak to the DON and CNA #3 about not sharing the pictures with anybody. The administrator was asked if he had spoken to them about not sharing or showing the pictures. He stated he had not. The administrator was asked if they had shown the pictures to anyone else. He stated not that he was aware of. The administrator was asked if LPN #1 had seen the pictures. He stated yes, probably. On 09/19/17 at 2:02 p.m., the DON was asked if she had received the pictures of resident #3's buttocks and anal area. She stated yes the administrator had sent them to her. The DON was asked where were the pictures. She stated on her work phone she stated the police told the administrator to keep the pictures as they may be needed. The DON was asked if her phone was purely a work phone. She stated yes. She was asked how the resident's privacy was being protected with the pictures on her phone. She stated with a code or her fingerprint. On 09/19/17 at 2:18 p.m., the administrator was asked if his phone that had the pictures of resident #3 was it a personal phone. He stated no it was a business phone and the business paid for the phone. The administrator was asked if he also used the phone for personal use. He stated yes he did. On 09/19/17 at 2:23 p.m., the DON was asked if she used her business phone for personal use. She stated yes. Then she stated she was not on Facebook and she had not posted it anywhere else. On 09/19/17 at 2:34 p.m., LPN #1 was asked if she had seen the pictures of resident #3's bottom. She stated yes on the DON's phone. The LPN was asked if the pictures had been sent to her. She stated no. She was asked if she had seen the pictures on CNA #3's phone. She stated no. On 09/19/17 at 4:17 p.m., a phone interview was conducted with CNA #3. The CNA was asked when she took a picture of the resident's buttocks and anal area. She stated before she touched it or anything, she took a picture. She stated she had deleted the pictures from her phone. She was asked when she deleted the pictures. She stated two to three days after she took them. The CNA was asked if she had went into her delete file on her phone and deleted the pictures from there. She stated no. She then stated she would have to. CNA #3 was asked if she had showed the pictures of the resident to anyone. She stated the DON, the investigators, and the police officers. She stated she had sent them to the administrator because she was asked to send them to him. She was asked how she sent the pictures to the administrator. She stated in a text message. She was asked if she showed anyone else the pictures. She stated no. She was asked if she sent the pictures to anyone else. She stated no. CNA #3 was asked why she took the pictures. She stated, Evidence. She was asked why did she not go get the nurse when you took the picture. She stated she did get the nurse. She was asked when did she go get the nurse. She stated after she took it (the wipes) out.

On 08/21/12, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision to prevent accidents when resident #20, a resident with a history of seizures while smoking, was allowed to smoke unsupervised. From 04/26/12 through 07/20/12, the resident experienced seizures four times while smoking unsupervised. At 4:55 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the Immediate Jeopardy. At 4:57 p.m., the administrator and DON were informed of the Immediate Jeopardy and this placed the facility in an extended survey. At 8:31 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented, "5:08 pm Resident in question (resident #20) was not in the smoke room and smoke room was locked per posted times from 5 pm until 6 pm. All of resident's smoking materials are locked in the drawer at the nurses' station. A staff member designated by the charge nurse will provide supervision for her safety, due to seizure disorder, in designated smoking areas for residents. A new smoking assessment has been completed indicating resident does require supervision with her smoking. Resident will review and sign the entire assessment. A notation has been posted at nurses' station for resident to be supervised at all times while smoking. New assessments will be completed on all smokers by 2:00 pm 8/22/2012. Will be reviewed quarterly and as needed. Care plan on (resident #20) has been updated. Director of Nurses will give in-service to all staff 8/21/12." The inservice training sheet documented, "Date 8-21-12 Topic Supervising Residents who are at risk (safety) that smoke. Instructor (DON). We have residents with [DIAGNOSES REDACTED].#20), (resident #19), and (resident #6). (Resident #31) has dx - brain cancer, (resident #22) COPD, (resident #36) - CVA. We shall supervise (resident #20) due to her having seizures in designated smoking areas. Other residents that smoke include (resident #12), (resident #37), (resident #38), (residents #10 and #25), (resident #39), and (resident #24). Smoking is care planned and CP books are at nurses station. (Resident #31) only smokes with his family present (and) they supervise him. If any resident is observed having a change in their current status, it will be addressed immediately. It is our goal to maintain safety (and) the highest level of independence possible for all residents. Reviewed s/s of seizures, seizure standards, smoking policy (and) supervised smoking, also reviewed report changes to charge nurse who reports to DON (and) PCP." Review of the clinical records for residents #6 and #10 revealed the residents did not have a [DIAGNOSES REDACTED]. On 08/22/12 at 1:45 p.m., the Immediate Jeopardy in supervision to prevent accidents was removed after ensuring through observations and interviews that resident #20 was being supervised when smoking; that accurate smoking assessments had been completed for all residents who smoked; and that all staff had been inserviced regarding resident supervision while smoking and reporting changes in condition. The deficient practice remained at a level of the potential for more than minimal harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: A. Provide supervision to prevent accidents while smoking for one (#20) of one sampled resident who had an active history of having seizures while smoking. The facility identified one resident who had active [DIAGNOSES REDACTED]. B. Provide supervision, identify/implement interventions to aid in the prevention of falls, and attempt to identify the cause of falls for two (#1 and #16) of six sampled residents who were reviewed for falls. The facility identified 52 residents as being at risk for falls; and C. Provide supervision to prevent accidents for one (#4) of three sampled residents with physician orders [REDACTED]. The facility identified 14 residents as requiring a mechanically altered diet and five residents who required staff to feed them. Resident #4 was not one of the residents identified by the facility as requiring staff to feed him. Findings: The facility's undated standard on falls documented, "...This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. Each resident will be provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs...Residents will be reassessed for risk upon a decline or improvement which meets criteria for significant change in status and is not self-limiting, a significant change in functional status...A 'Falls Risk Assessment' score of 10 or above represents a high risk for falls and will require the development of a care plan with interventions implemented designed to prevent falls...When a resident sustains a fall, assessment will include investigation using the Post Incident Review record...to determine the probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall. The investigation and appropriate interventions will be initiated at the time of the fall and reviewed by Nursing Management following the next morning stand-up meeting...Residents who sustain a fall will have a care plan developed or the existing care plan updated at the time the incident occurs that includes the date the fall occurred, and measurable objectives and time frames. The care plan interventions will address those elements determined by investigation as probable causal factors that contributed to the fall..." The facility's policy and procedure on smoking, dated 06/12/06, documented, "...It is not our intent to establish a smoking policy based on moral judgments, nor to deny one group of residents and employees rights over another. The intent of this policy is to establish a fair and equitable smoking policy that is in the best interests of the residents, employees and the company alike..." The policy did not address smoking assessments for residents or supervision while smoking. The facility's undated standard on feeding a resident documented, "...Residents unable to feed themselves are fed by all properly trained nursing personnel...Position resident in proper body alignment for eating...Any eating problems are reported to the charge nurse and recorded in Interdisciplinary Notes..." 1. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 01/23/12, documented the resident was cognitively intact, felt tired or had little energy, was independent in mobility, transfers, locomotion, and activities of daily living. It was documented the resident had a [DIAGNOSES REDACTED]. A smoking assessment, dated 01/2012, documented the resident had [DIAGNOSES REDACTED]. It was not documented the resident had a [DIAGNOSES REDACTED]. It was documented the resident was safe to smoke unsupervised. A quarterly assessment, dated 04/24/12, documented the resident was cognitively intact, felt tired and had little energy, and was independent in mobility, transfers, locomotion, and activities of daily living. A nurse's note, dated 04/26/12 at 8:45 p.m., documented, "...Res in smoke room smoking. Started have (sic) seizure, lasted approx 2 minutes..." A nurse's note, dated 04/28/12 at 5:00 a.m., documented, "...(Up) in smoke room, smoking cigs. Voiced (no) c/o. (No) further seizure activity noted..." The resident's care plan, updated 05/01/12, documented a problem, "...is a smoker. Does not wish to quit..." The goal was, "...will remain free from injury r/t smoking over next 90 days..." Interventions were, "...1. May keep cigarettes/lighting material(s) on herself. At this time she has been keeping then (sic) at the nurses station...2. To smoke in desiginated (sic) smoking areas only. Observe for compliance daily...3. May smoke unattended...4. Observe for compliactions (sic) when smoking such as: burn holes in clothes, having difficulty lighting cigarette, tremors, tries to light the wrong end, drops cigarette, falls asleep...5. Nurse to assess if any complications observed when smoking to r/o any acute diseases. Notify PCP as warranted...6. Re-eval smoking assessment at least q 3 months and prn..." Another problem was, "...at risk for injury during seizures..." The goal was, "...will have no injuries..." Interventions included, "...Protected environment when having seizure..." A nurse's note, dated 06/21/12 at 2:00 p.m., documented, "...Res in smoke room. Started having tremors, unresponsive, pupils dilated...Put in w/c et assisted to bed..." At 2:10 p.m., it was documented, "...In bed siezures (sic) lasted approx 10 minutes..." A nurse's note, dated 07/10/12 at 5:20 a.m., documented, "...res (up) in smoke showing s/s of mild seizure activity lasting (approximately) 2 min..." A nurse's note, dated 07/20/12 at 9:15 p.m., documented, "...Res in smoke room. Res had a seizure lasted about 2 min. Res was oriented at first and talking normally...Pupils pin point. (Family member) called right after. She was talking about doing things tomorrow that aren't happening. Res forgot names. She was having a hard time communicating. Res zoned out and started trembling while on the phone..." A care plan update, dated 08/03/12, documented the smoking problem listed on the resident's care plan was changed. It was documented, "...Want to quit..." A care plan update, dated 08/12/12, documented, "...smoke patches ordered..." On 08/20/12 at approximately 1:30 p.m., the facility was noted to have a smoking room behind the nurses' station. There was a window between the smoking room and nurses' station. Residents were observed to be smoking, and there was no staff at the nurses' station. On 08/21/12 at approximately 11:50 p.m., a resident approached the surveyor and informed the surveyor that resident #20 had seizures while smoking in the smoking room. The resident stated he/she had to leave the smoking room and obtain help from a nurse when resident #20 had her last seizure in the smoking room. At 2:30 p.m., the DON was asked how the facility's smoking room was monitored. She stated, "Through the window." When asked who was responsible for monitoring the smoking room, the DON stated, "Any staff. The charge nurses know they are responsible." The DON was asked how it was determined a resident could smoke unsupervised. She stated the AD/SSD completed smoking assessments and the information was brought to the interdisciplinary meeting for agreement. The DON was asked how often smoking assessments were completed. She stated, "On admission and as needed if there are any changes." The DON was asked if resident #20 was an unsupervised smoker. She stated, "She doesn't smoke anymore. She's a nonsmoker now." The DON was asked when the resident quit smoking. She stated, "With the hospitalization she had on 8/3 (08/03/12). When she was readmitted , she didn't smoke after that." The DON was asked what the resident's [DIAGNOSES REDACTED]. The DON was asked if the resident had experienced any seizures while smoking in the smoking room. She stated, "She had some activity. They did get her out." The DON was asked if smoking unsupervised was an accident hazard for the resident. She stated, "Of course it could be." The DON stated the resident did not smoke any more. The DON was asked if the smoking room was monitored. She stated, "They (the staff) should be while it's open." The DON stated the facility did not staff a person specifically for monitoring the smoking room. At 4:20 p.m., resident #20 was observed smoking in the smoking room. There was no staff at the nurses station to monitor the residents in the smoking room. At 4:22 p.m., resident #20 was asked if she had just finished smoking. She stated, "Yes." A burn hole was noted on the front of the resident's blouse. The resident was asked if the hole was a burn hole. She stated, "Yes. It's an old shirt." The resident was observed to be wearing a medical alert bracelet. When asked what the bracelet was for, the resident stated it was because she was diabetic and had seizures. The resident was asked if she had quit smoking when she returned from the hospital on [DATE]. She stated, "I would quit for eight hours and then smoke for eight hours." The resident was asked if she had ever had a seizure while smoking. She stated, "Yes, but I didn't hurt myself." 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment, dated 05/11/12, documented the resident scored an eight. The form documented, "...A resident who scores a 10 or above is at high risk..." The form contained no documentation to show the resident's gait/balance while standing, walking, turning, or walking through doorway was assessed. The form documented the resident scored a two on assessment of predisposing diseases, identifying that resident had one - two of the predisposing diseases. The form listed predisposing conditions as Hypotension, Vertigo, CVA, Parkinson's disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis and Fractures. The resident's admitting [DIAGNOSES REDACTED]. The Fall Risk Assessment form data was incomplete, and the data did not reflect the resident's actual status as documented in the clinical record. An admission assessment, dated 05/21/12, documented the resident scored a 13 on the Brief Interview for mental status, indicating the resident was cognitively intact. The assessment documented the resident was independent with transfers, toilet use, personal hygiene, and utilized a wheelchair for mobility. The assessment documented that when moving from a seated to standing position, the resident was not steady, but was able to stabilize self. The admission assessment also documented the resident was not steady when moving on or off the toilet, but was able to stabilize self. The assessment documented resident was always continent of bowel and urine and believed she was capable of achieving increased independence. The assessment documented the resident required the physical assistance of one with bathing activity. A nurse's note, dated 05/22/12 on the 2 - 10 shift, documented, "...Answered Emergency Light in res bathroom, res sitting on floor next to stool states she slid off stool, noted S/T (approximately) .25 cm long on rt hand between 1st (and) 2nd knuckle AROM s difficulty or c/o assist (up) wt tol s diff or c/o assist to w/c. Cleansed s/t w wnd cleanser Band Aid applied instructed her to call for assist when transferring..." An Incident Report dated 05/22/12 documented, "...Cont. PT (and) OT (and) more frequent (checks) prn for assist (with) ADL's..." A nurse's note, dated 05/27/12 at 10:40 a.m., documented, "...Res found in floor bleeding from back of head access (sic) res no c/o pain at the back of head no neck or back pain sat res up cleaned back of head out (sic) hematoma (approximately) 3 x 3 (and) laceration (approximately) 1 cm long gapped open (approximately) .5 cm. Res stated was getting up from w/c fell backwards ice pack applied..." A nurse's note, dated 05/27/12 at 10:50 a.m., documented, "...Notified (ambulance service) for transport to ER...11:10 a.m., (Ambulance) left at this time..." An Incident Report dated 05/27/12, documented, "...Cont. to encourage assist c transfers. Keep call light in reach, neuro's initiated..." A nurse's note, dated 05/28/12 at 1:40 a.m., documented, "...Res back to facility in stable condition. Assisted to room via gurney to (lie down) in bed. Sutures (5) to back of head C/D/I...Cont. to observe. Neuro (checks) WNL..." The resident's care plan, dated 05/29/12, documented a problem, "...Resident needs some assistance with ADLS..." The goal was, "...Resident will perform all ADL care needs by herself by next review..." Approaches included, "...Maintain call light in easy reach when in room...Answer promptly. Staff to anticipate needs daily...Monitor frequently to see if resident may need assistance..." Another problem was, "...Resident non-ambulatory without assistance from staff...Currently working with physical therapy, and occupational therapy for strengthening..." The goal was, "...Resident will ambulate safely with assist of one for 300 feet by 06/30/12..." Approaches included, "...Use wheelchair for mobility needs...May use walker...Don't let resident walk unassisted...Verbally remind her if needed, to ask for assist when wanting to walk..." Another problem was, "...Has a fall history...Potential for further falls D/T weakness R/T past CVA, OA, Osteoporosis, Use of medications..." The goal was, "...Resident will remain free from serious injury falls while trying to prevent falls over the next 90 days..." Approaches included, "...Keep call light in easy reach...Answer promptly...Monitor for safe environment...Keep hallways/room free from clutter/obsticles (sic)...Observe at frequent intervals for safety/comfort...Assist with all transfers...Monitor for any changes in endurance, transfers...Alert nurse...Nurse assess, notify PCP as warranted...Use W/C for mobility...May walk with resident using a walker...Don't let her walk unassisted...Verbally remind if needed to ask for assist when wanting to walk..." A nurse's note, dated 05/31/12 at 05:30 a.m., documented, "...Res. had emergency light on in bathroom. Found Res. sitting upright on floor between w/c and toilet. States she was getting up to sit in w/c (and) missed w/c (and) sat on floor. Denies hitting head. States tailbone a little sore? (sic) (No) injury noted @ this time. Assisted back down in bed. Cont. to observe..." An Incident Report dated 05/31/12, documented, "...Remind resident to use call light for assist. Keep call light in reach..." A final Incident Report form, with a fax date of 06/01/12, documented measures implemented to prevent recurrence as, "...OT (and) PT will cont. Will monitor for use of non-skid socks or shoes when up in chair..." A nurse's note, dated 06/06/12 at 7:40 p.m., documented, "...Res. on floor in her room. ROM WNL. Skin intact. Red area to mid back..." An Incident report dated, 06/06/12, documented, "...Remind resident to use call light. May need personal alarm..." Review of the clinical record revealed no documentation of when a personal alarm was initiated. An Incident Report, dated 06/12/12 at 5:00 a.m., documented, "...Resident found sitting up, leaning against bed. Denies hitting head. States slid on floor while getting up to go to BR. Reddened area (mid-back) from leaning against rail. Utilize bed alarm - respond immediately if heard..." A nurse's note, dated 07/11/12 at 5:40 a.m., documented, "...Answered light and found resident sitting upright on floor beside bed. Res. states she was going to the B.R. (and) slid off side of bed. Denies hitting head. Bed Alarm was intact (and) sitting on bed? (sic) Assess done, has a (approximately) 4 cm skin tear to (left) forearm (and) 1 cm skin tear to (left) elbow...Steri-Strips applied to (left) forearm..." An Incident Report, dated 07/11/12, documented, "...Remind to use call light (and) wait for help. Monitor Q 2 (hours) (and) PRN for need of assist with transfers..." A nurse's note, dated 07/26/12 at 9:25 a.m., documented, "...Reported resident with skin tears to right arm (after) sitting on floor in BR. Areas approx 3 to 4 (inches). Cleansed, steri-strips applied. TAO et covered..." An Incident Report, dated 07/26/12, documented, "...CNA placed resident on toilet, res. needed to sit for a while. CNA gave res. light et asked her to use it when ready. Res. agreed. Call light on, CNA entered bathroom, res. sitting on floor. Denies hitting head. Has 2 large (unknown) skin tears left arm...ROM W (unknown) Denies pain. Counseled (sic) staff re: To not leave res. alone when on the toilet. Lab ordered (and) will monitor for Ortho. Hypotension..." A review of the clinical record revealed no documentation to show the resident's vital signs were monitored and recorded to assess for signs and symptoms of orthostatic hypotension. A nurse's note, dated 08/07/12 at 3:15 p.m., documented, "...Son was assisting resident to recliner. She slipped and slid to floor. Checked for injuries none noted..." An Incident Report, dated 08/07/12, documented, "... Son did not witness any bumping of the head...Cont. Alarm..." A nurse's note, dated 08/13/12 at 10:00 p.m., documented, "...Res. was in the restroom where she started to slid (sic) and hit her right leg on the w/c. Skin tear and swelling noted on right leg. Skin tear cleaned and wrapped (with) clean, dry dressing..." An Incident Report, dated 08/13/12, documented, ..."ST RLE Use caution c transfers..." Review of the resident's clinical record revealed no documentation to show the resident's plan of care was updated with new interventions to aid in the prevention of falls that occurred when the resident was attempting to transfer from 05/22/12 through 08/13/12. During this time the resident suffered eight falls, one resulting in a laceration to the head that required six sutures. There was no documentation to show the facility had attempted to determine the cause of the resident's falls. A nurse's note, dated 08/18/12 at 2:45 a.m., documented, "...Called to Res room by CNA Res noted on stomach on floor. A (and) O x 3 (No) head injury noted. Lg skin tear to (left) hand. Applied Steri-strips (after) cleansing with NS. Applied TAO, covered with sterile Telfa (and) wrapped c gauze...States she rolled OOB. Moved bed against wall (and) placed mat next to bed...Alarm sounding upon entering room..." An Incident Report, dated 08/18/12, documented, "...Res was sleeping in bed (and) rolled OOB. Denies hitting head. 6 cm skin tear noted to (left) hand, bruise noted to (left) shoulder...Personal alarm sounding...Placed bed against wall c fall mat on floor. Call light in reach. Bolster mattress placed..." On 08/23/12 at 4:30 p.m., resident #16 was observed with purple-colored bruising to her left posterior hand and left forearm. A gauze dressing covered the resident's left wrist area. Purple-colored bruising was also observed to the skin on the right upper arm, elbow, forearm and wrist areas. Two dry, scabbed areas were also present on the lateral aspect of resident's right forearm, approximately two - three inches below the elbow. Resident #16 reported, "...I have one (skin tear) on my leg too..." The resident's right lower leg was observed to have an area of purple-colored bruising over the anterior aspect, with a linear, dark-colored, dry scabbed area visible in center, approximately three and one half inches in length. There was not a non-skid mat in the resident's wheelchair. Resident #16 was asked if she had ever fallen since moving in at the facility. Resident #16 stated, "...Oh, I've had more than one..." The resident was asked why she had fallen, and she answered, "...Just clumsy I guess. It's happened three or four times since I've been here." Resident #16 was asked what had happened to her left hand and if it had happened with one of her falls. She replied, "Yes." The resident was asked, "Do you get dizzy when you fall?" She replied, "Not when I fall, but when I get up." On 08/24/12 at 3:40 p.m., CNA #9 was asked if the resident was able to go to the bathroom by herself when first admitted to the facility. CNA #9 reported supervision was utilized at first, but it was used more just for support. CNA #9 then stated the resident now required total assistance. CNA #9 was asked if the resident was at risk for falls. She answered, "Yes." CNA #9 was then asked what interventions were in place to prevent the resident from falling. She stated, "A mat, a non-skid pad in the wheel-chair this morning, and a personal alarm." The CNA was asked when the non-skid pad was placed in the wheelchair. She answered, "It was in there this morning I don't know when it came about." CNA #9 was asked when most of the resident's falls occurred. She answered, " When the resident tries to go to the bathroom by herself." CNA #9 was asked if the resident was on a toileting plan. She replied, "As in bowel and bladder, I'm not sure, but we try to take her Q 2 hours." CNA #9 was then asked if she always did take the resident every two hours. She stated, "No, but we always try, sometimes it's a little before, sometimes a little after." CNA #9 was asked how the resident's fall mat helped to prevent falls. She replied, "The mat made it so she's not hitting concrete." On 08/24/12 at 3:51 p.m., LPN #3 was asked if resident #16 was at risk for falls. She answered, "Yes, she's real unsteady on her feet." When asked what interventions were in place to prevent resident #16 from falling, LPN #3 stated, "Well, we walk with her. She has a wheel chair, not sure if she has a bolster mattress, or rails, but she would climb over them if she had them." On 08/24/12 at 3:15 p.m., LPN #7 was asked if resident #16 was at risk for falls. She replied, "Yes." LPN #7 was asked what interventions had been implemented to prevent the resident from falling. She replied, "Last time I got her a bolster mattress and a floor mat." LPN #7 was asked if resident #16 was on a toileting program. LPN #7 stated, "She's alert and oriented, and we just take her when she needs to go. If she gets restless, or tries to get up, we have that alarm on her." LPN #7 stated, "The last time she rolled over and fell from the bed." On 08/27/12 at 4:40 p.m., the DON was interviewed regarding interventions put in place to help prevent resident #16 from falling. The DON reported starting with the least restrictive interventions and stated, "Bed alarm, fall mat and bolster mattress." She stated, "Also, monitoring more frequently." The DON was asked when the non-skid pad was initiated to the resident's wheelchair, she replied, "I'm not sure." There may not be an order, but I'm hoping there is." The DON was asked how the facility identified residents who were at high risk for falls. She stated, "From the MDS, and fall risk assessments and the incident reports." The DON was asked if a fall risk assessment was completed when a resident at the facility was identified as having had repeated falls, and she replied, "Yes." The DON was asked if she had completed an updated Fall Risk assessment pertaining to resident #16, following her repeated falls. She answered, "No, I did not." The DON was asked, "Did you attempt to determine the cause of the resident's falls?" She stated, "No, I did not." The DON was asked how the facility communicated information after a resident at the facility sustained a fall. She answered, "I make a copy of the Incident Report, and make sure it's complete, then (MDS coordinator) get's a copy of it and she completes the MDS and careplan." The DON also reported the 24 hour nursing report was reviewed, changes were made to the care plan, and new interventions were documented. The DON was asked, "Do you have a fall prevention program in place here at the facility?" She stated, "No." The DON continued, " Well we have the written policy in the book over there. That's what we use." 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment for resident # 1, dated 07/18/12, documented the resident required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. The assessment documented the resident's balance during transfers was not steady, and he was only able to stabilize with human assistance. The assessment documented the resident had two or more falls since prior assessment with no injury and one fall with minor injury since last assessment. The quarterly assessment, dated 07/18/12, documented no occupational or physical therapy was performed with the resident for the assessed period. The care plan for resident #1, updated 08/01/12, documented, ..."Has fall (history.) Potential for further fall (due to) lower extremity weakness, poor safety awareness skills (due to) cognitive loss, use of medications..." The documented goal was for the resident to remain free from serious injury falls while trying to prevent falls over the next 90 days. The documented interventions included, "...keep call light in easy reach. Answer promptly. 8-1-12 (discontinued) PT & OT. (Restorative Aide) to work (with) (resident) per (physician) order. Restorative started 8-1-12...Keep frequently used items within easy reach...Monitor for safe environment. Keep hallways/room free from clutter/obsticles (sic)...Staff to anticipate/meet (resident) needs daily...Use w/c for mobility needs. Maintain non-skid pad in w/c. Do not leave (resident) alone in room when he's up in w/c...Use bed/chair alarm to alert staff when trying to get up unassisted...Check for incontinece (sic) at least (every) 2 hours. Change as warranted...Observe/monitor at frequent intervals for safty (sic)/comfort...Assist with ADL's only to extend (sic) needed...Be extra careful when in shower room. Keep (floor) as dry as possible...Use 2 person assist or mechanical lift for all transfers...Give meds as ordered..." A nurse's note, dated 09/15/11 at 4:45 p.m., documented, "...before transfer left room to get pillow. Arrived back resident sitting in floor in front of w/c..." A nurse's note, dated 09/28/11 at 3:15 p.m., documented, "...(resident) found sitting on floor in his room..." A nurse's note, dated 10/13/11 at 5:30 p.m., documented, "...spilt (sic) food tray, tried to get out of recliner, slipped in cottage cheese (and) fell to floor..." A nurse's note, dated 10/14/11 at 09:40 a.m., documented, "...resident (up) in lobby propelling self. Slid out of w/c onto floor..." A nurse's note, dated 10/16/11 at 9:15 a.m., documented, "...resident was found lying on floor next to bed...stated, 'I was on bed and slid to the floor'..." A nurse's note, dated 10/25/11 at 5:00 p.m., documented, "...Res was in room. CNA put him in w/chair, turned (and) walked away. Turned when res yelled (and) saw res fall to floor on buttocks..." A nurse's note, dated 11/03/11

Based on observation, interview, and record review, it was determined the facility failed to: A. Recognize pain, develop and/or implement pain management interventions, and/or monitor the effectiveness of pain management interventions for two (#4 and #15) of eight sampled residents who were reviewed for pain. The facility's failure to manage pain resulted in actual harm for residents #4 and #15. The facility's Census and Conditions report identified 32 residents as being on a pain management program. The facility identified 27 residents as having physician orders [REDACTED]. B. Provide urinary catheter care in a manner to prevent infections for one (#1) of one sampled resident with a urinary catheter. The facility identified one resident as having a urinary catheter. Findings: The facility's undated standard on pain management documented, "...The resident's pain will be managed to assure that their quality of life and quality of care is achieved...When there is sufficient evidence...that the resident will experience pain, a pain management plan of care will be developed...The resident's physician will be involved in developing the plan of care for pain management...Monitor residents for pain, some things to look for are: verbals, body language, facial expressions, poor appetite, anger, and change in sleep patterns...Emphasize how important it is for all staff to report signs and symptoms of pain to Supervisor, Charge Nurse or DON..." The facility's undated standard on urinary catheter care documented, "...Wash hands before and after any manipulation of the catheter site and/or apparatus...Meatal care will be performed using soap and water each day by the nursing staff..." 1. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/05/12, documented the resident required assistance with activities of daily living and had not complained of pain in the five days prior to the assessment. The monthly physician orders [REDACTED]. MARs, dated 08/2012, documented the resident received his routine [MEDICATION NAME] 10 mg dose at 8:00 a.m., 4:00 p.m., and midnight. The resident's care plan, last updated 08/07/12, documented the resident received routine pain medication for chronic pain and had the potential for increased/uncontrolled pain. The documented interventions in the plan of care included, "... give routine pain med as ordered. Observe for effectiveness... Observe for s/s pain such as: change in behavior/mood, moans out, tearfulness, loss of appetite, resists care, restlessness, inappropriate behavior, etc. Give PRN pain med as ordered. Monitor for effectiveness. Notify doctor if med not effective or has increased use of PRN med for possible change in med regimen. If needed, give alternative pain mgmt therapy such as: diversional activity of choice, back rub, soothing music, watching tv, warm relaxing bath, talking with (resident)..." On 08/20/12 at 5:33 p.m., resident #15 was observed in the dining room during the evening meal. The resident's fists were clenched, his eyes shut, tears were on his face, and his body and facial muscles were tense and shaking. When asked what was wrong, the resident stated "sore tooth" and pointed to the lower right jaw line. LPN #5 was present and stated the resident frequently complained of oral pain and she would encourage and assist him with his meal. LPN #5 removed the resident's meal tray and returned with a plate of pureed food. The resident appeared apprehensive, and LPN #5 stated to the resident the food did not require chewing and continued to encourage the resident to eat. LPN #5 was asked if resident #15 had received any pain medication. LPN #5 stated the resident received his pain medication routinely and had received a dose just before dinner. LPN #5 did not ask the resident to describe and/or rate the pain, and no pain assessment was observed to be performed. There was no observation of any staff member performing an oral assessment of the resident or looking in the resident's mouth. Review of MARs, dated 08/20/12, revealed documentation to show the resident did not receive any as needed pain medication until 7:00 p.m. On 08/21/12, the resident received an as needed dose of [MEDICATION NAME] 10 mg at 12:30 p.m. On 08/21/12 at 5:20 p.m., resident #15 was observed in the dining room with a pureed meal tray. The resident ate one bite of food, tensed and shook with his upper body, grimaced and frowned before placing the utensil back down. When asked what was wrong, the resident stated his lower jaw "hurt real bad." The resident pointed to the lower right jaw line a little forward from the joint. LPN #4 was informed and stated it was too early to administer his as needed pain medicine as it had not been 2 hours since the resident received his routine dose of pain medicine. LPN #4 did not ask the resident to describe or rate his pain. She did not observe the resident's mouth. Review of the clinical record revealed no documentation to show the resident's increased pain level had been assessed. On 08/22/12 at 6:40 p.m., resident #15 was observed in his room. The resident complained of "real bad" jaw pain. The DON was in the hall and was informed of the resident's complaint. The DON entered the resident's room. The resident was in the bathroom and the DON assisted the resident back to bed. The DON asked the resident if he was hurting. The resident nodded his head "yes." The DON asked the resident how bad the pain was and the resident replied "awful." The resident was asked by the DON to rate his pain and he rated his pain at an eight out of ten. No assessment of the oral cavity was observed to be performed. Review of the clinical record revealed documentation to show the resident received an as needed dose of [MEDICATION NAME] 10 mg on 08/22/12 during the day shift. The specific time of administration was not documented nor was the pain assessment. On 08/22/12 at 6:40 p.m., LPN #4 was observed documenting an as needed dose of [MEDICATION NAME] 10 mg as administered on 08/21/12. LPN #4 was asked if the resident had received his as needed pain medication that evening. LPN #4 stated the resident had just received the dose. When asked why she documented the dose as given on the 08/21/12 and not 08/22/12, LPN #4 stated she wrote the date in error. LPN #4 was not observed to correct the date. On 08/23/12 at 10:15 a.m., resident #15 was observed in his room. The resident was asked how he felt. The resident complained of sharp, knife like pain in the lower right jaw forward from the joint and back from the canine. An observation of the oral cavity was performed. The resident's gum line appeared pink with no visible swelling or irritation observed. The right lower jaw line appeared edentulous, having teeth in the front of the jaw back to the second bicuspid on the right side. The second lower bicuspid appeared discolored around the base and exposed on the underside of the tooth from a receding gum line. There appeared to be a black hole near the bottom of the tooth. From the top, the tooth appeared discolored and gray in the center. On 08/23/12 at 3:20 p.m., resident #15 was observed lying down in bed. The resident's eyes were closed but opened when called by name. The resident was asked how he was doing. The resident replied, "Awful." When asked what was wrong, the resident pointed to the right side of his lower jaw and said, "Hurts bad." The resident then frowned deeply and furrowed his brow. On 08/23/12 at 3:30 p.m., LPN #7 was interviewed. The LPN stated she had administered as needed pain medication to resident #15 "around lunch time" for the past few days. The LPN stated the resident complained of pain at a ten out of ten. Upon her follow-up, the resident had stated the pain medication was ineffective. The LPN stated she had not reported the above information to anyone yet but was planning to leave a note for the DON. On 08/23/12 at 3:35 p.m., the day shift charge nurse, LPN #5, was interviewed. LPN #5 stated she had received a report of pain for resident #15 and she had been aware of the resident's complaint of pain at mealtime the last few days. LPN #5 was asked if an assessment had been performed to determine the possible cause of the jaw pain for resident #15. She stated she had looked inside the resident's mouth last week, and there had been no changes. LPN #5 stated the resident's pain "comes and goes" and this was "no different" from his usual complaints of jaw pain. She stated the resident's routine pain medication was effective for his pain and she had not informed the resident's physician because "... that is normal, that is (the resident). It's been going on since he came here. He's had four surgeries on his jaw for the pain." The surveyor asked for clarification as to whether the physician had been notified of the resident's pain. LPN #5 stated, "... I told (the physician) how (the resident) was when (the physician) was here yesterday." LPN #5 stated it was her routine to inform the physician of all the residents for whom he provided services but she did not chart she had notified the physician. LPN #5 stated the physician had no reason to chart because he did not see the resident that day. LPN #5 stated the resident was fine today. She stated she had just seen the resident up in his wheelchair and she had spoken with him briefly and he was not hurting. When asked if she had assessed the resident for pain, the LPN stated, "No, I did not ask him about his pain but he would have told me." On 8/23/12 at 4:00 p.m., the DON was interviewed. The DON was asked if she had been informed of the complaints of pain from resident #15. The DON stated she was aware of the pain from assisting the resident with his complaint of it at mealtime the prior day. The DON continued to explain that when she assisted the resident in his room, the resident had informed her the pain was in the lower jaw. The resident had opened his mouth and stuck out his tongue, moving it around and then saying "see." The DON stated she was unable to see into the mouth and did not perform an oral assessment. The DON was asked if she had informed the resident's primary care physician. The DON paused and then called to a nurse passing in the hall, "(LPN #5). Did you talk to (primary care physician) yesterday about (resident #15) jaw pain?" The LPN entered the room and answered, "Yes." The DON asked LPN #5 if she had charted the conversation with the primary care physician. The LPN answered no and repeated the answer from the interview on 08/23/12 at 3:35 p.m. The DON stated to LPN #5, "(resident #15)'s MAR indicated [REDACTED]. Let's call (the primary care physician) and see if he wants to do anything." The DON then stated she would perform an oral assessment. The DON knocked on the door for resident #15 and entered the room when greeted by the resident. The resident cooperated with the oral assessment, pointed to his lower jaw and rated his pain at an eight on a scale from one to ten (with one being very little pain and ten being extreme pain). The resident then stated the pain was "somewhat better" than earlier. The DON stated the resident had complained of upper jaw pain at times and asked the resident for confirmation. The resident stated, "Yes." The DON then asked the resident, "... the pain still there (in the upper jaw), right?" The resident stated, "No." The resident again pointed to his lower jaw. The DON was asked if this was a change in the resident's pain and the DON stated, "Yes." The DON looked in the resident's mouth with a flashlight and stated she observed a discolored tooth on the right side lower jaw. She described the tooth as discolored on the top, possibly from a filling, and on the bottom with a dark black ring and tunneling. She continued to state the bottom discoloration and tunneling may have been there but looked different now. The DON was unable to give further detail on how the tooth looked different. On 08/23/12 at 4:20 p.m., LPN #5 stated the resident's primary care physician had been informed of the resident's condition and usage of PRN pain medication. The LPN stated the physician increased the resident's routine pain medication. On 08/24/12 at 4:10 p.m., the administrator stated the facility contacted the resident's dentist. It was reported that the dentist stated the pain was not tooth pain but chronic jaw pain related to a history of oral surgeries. The administrator was asked if the dentist had been informed the resident was complaining of new pain. She stated she did not know because medical records personnel had been the person to speak with the dentist. On 08/24/12 at 4:50 p.m., the DON stated she had spoken with the resident's primary care physician and he planned to see the resident on Wednesday and adjust medication as needed for pain management. On 08/24/12 at 5:00 p.m., resident #15 was observed in bed. When asked how he was, the resident stated he was in pain. The resident stated the pain was very bad in his lower jaw. The resident pointed to the right side lower jaw line and frowned, furrowing his brow and mumbled, "It hurts real bad." The resident stated he had a history of [REDACTED]. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/02/12, documented rarely or never made himself understood, was totally dependent on staff for all aspects of care, was on a scheduled pain medication regimen, and received as needed pain medications. It was documented the resident made non-verbal sounds and facial expressions as indicators of pain, and the resident had experienced pain during the previous three to four days. A comprehensive care conference summary, dated 07/10/12, documented, "...no sign of pain at this (time)..." The resident's care plan, last updated 07/10/12, documented a problem, "...is bedbound. Potential for muscle spasms/discomfort..." The goal was, "...will be free from any muscle spasms/discomfort and kept as comfortable as possible during the next 90 days..." Approaches included, "...Assure...is in as good body alinement (sic) as possible...Give gentle ROM daily...Monitor/record any s/s of discomfort...Notify PCP of any increased use of PRN pain med for possible change in med regimen..." Another problem was, "...potential for pain..." The goal was, "...will be observed for pain, have relief from pain within 45 min of any acute onset of pain over next 90 days..." Approaches included, "...Observe for s/s pain such as...moans out, tearfulness...resists care, restlessness...Give PRN pain med as ordered...Notify doctor if med not effective or has increased use of PRN med..." Another problem was, "...incontinent of b/b..." The goal was, "...will be kept as clean/dry (and) odor free as possible w/ no skin breakdown/UTIs over the next 90 days..." Approaches included, "...Assure call pad is positioned correctly <under his shoulder> at all times...Keep HOB at lowest level possible...Assure...genitals are correctly positioned...Keep fresh water at bedside. Offer flds whenever assisting...with ADL care needs..." Physician orders, dated 08/2012, documented the resident was to receive [MEDICATION NAME], a pain medication, 7.5 mg one by mouth each day at 8:00 a.m., and [MEDICATION NAME], a muscle relaxant, 5 mg by mouth three times daily. It was also documented the resident was to receive [MEDICATION NAME] 960 mg liquid by mouth every six hours as needed for pain or 650 mg rectally every four hours as needed for pain. A pain evaluation, dated 08/08/12, documented the resident verbalized pain and had limited communication. It was documented the worst the resident's pain became was "hurts whole lot" and that the resident had repeated troubled calling out, loud moaning or groaning, or crying as negative vocalizations of pain. It was documented the resident's pain was relieved by medication, frequent position changes, and diversional activity. The conclusion was, "...Pain management intervention is necessary, refer to resident plan of care..." On 08/21/12 at 7:45 p.m., resident #4 was noted to be yelling out. LPN #4 stated, "He does that every time I give him his 2 cal. Should he be doing that?" LPN #8 entered the resident's room and asked him if was hot or cold. She did not ask him if he was in pain or if he needed to be repositioned. Review of the resident's medication administration sheets revealed no documentation to show the resident received any as needed pain medication at that time. On 08/22/12 at 2:53 p.m., CNAs #3 and #5 were observed performing incontinent care for the resident CNA #5 lowered the foot of the bed, and the resident grimaced. CNA #3 stated, "I know that's painful." During the provision of care, the resident was rolled from side to side. Tears were noted in the resident's eyes and he began moaning. CNA #3 was asked why the resident did not get out of the bed. She stated, "It hurts so bad now he doesn't get up any more." Review of the resident's medication administration sheets revealed no documentation to show the resident received any as needed pain medication at that time. On 08/23/12 at 6:42 a.m., CNA #8 and RA #1 were observed performing incontinent care for the resident. RA #1 was asked what the resident's restorative care consisted of. She stated she attempted to put wash cloths in the resident's hands but "he get mad at me a lot." RA #1 was asked why the resident got mad. She stated, "It probably does hurt. I barely touch his fingers and he moans." RA #1 was asked how she could tell the resident was in pain. She stated, "He screams out and lets us know." RA #1 and CNA #8 repositioned the resident to his left side. The resident moaned. The resident was rolled to his right side. The resident grimaced and squeezed his eyes. At 8:05 a.m., RA #1 was asked if the resident was scheduled for restorative services that day. She stated, "Yes." When asked if she was usually able to complete the restorative care, RA #1 stated, "Yes." She stated she usually worked with the resident every day by placing wash cloths in his hands. She stated, "He moves his arms himself. He gets very very mad when I put the wash cloths in." RA #1 was asked if she coordinated with the nurse prior to attempting restorative care so that the resident could be pre-medicated for pain. She stated, "No. The only thing they can give him is the Tylenol and they give it in the morning." RA #1 stated, "He can't have it again for four to six hours." RA #1 was asked if the resident had pain when she put the wash cloths in his hands. She stated, "Yes. He screams if he's hurting so much. I leave him alone if he does." RA #1 was asked if she had informed the nurse of the resident's pain during restorative care. She stated, "Yes. He's always done that." RA #1 was asked how often she completed restorative care for the resident. She stated, "Usually every day unless he's hollering." She stated, "It's better when I take the wash cloths out." On 08/23/12 at 8:34 a.m., RA #1 stated resident #4 had refused restorative care that day. She was asked why the resident refused. She stated, "Because it hurts." She stated, "He usually refuses." RA #1 was asked if the resident was pre-medicated for pain before restorative care was attempted. She stated, "She (the CMA) just gave him his Tylenol. I believe that's all he gets." Review of medication administration records, dated 08/23/12, revealed the resident had received his morning medications at 8:00 a.m., including [MEDICATION NAME] and [MEDICATION NAME] but no as needed pain medication. At 8:53 a.m., the resident was noted to be yelling out. CNA #8 went into the resident's room to check on him. She stated, "If he hollers out, he usually is wet or hurts." CNA #8 stated the resident's genitals needed to be repositioned. On 08/24/12 at 2:54 p.m., the resident was noted to be yelling out. LPN #4 checked on the resident and stated, "He's been hollering off and on since I've been here." She did not ask the resident if he was in pain or if he needed to be repositioned. At 3:20 p.m., the resident was noted to be yelling out. His door was closed, and his yelling was barely audible from the hallway. CNA #1 was asked why the resident's door was closed. She stated, "I don't know." The DON was asked why the resident's door was closed and if she could hear him from the hallway. The DON stated she did not know why the door was closed but she could hear him. The DON stated staff knew if the resident was yelling that he was either in pain or needed the room temperature adjusted. She stated the staff knew to go into the room and ask the resident what was wrong and make sure he did not need to be repositioned because his genitals were hurting or see if he needed pain medication. CNA #9 approached the DON and surveyor in the hall. The DON asked CNA #9 if she could hear the resident. She stated she had not heard the resident until it had been brought to her attention he was yelling. CNA #9 was asked by the DON what she would do if she heard the resident yelling. She stated she would go inform the nurse. The DON entered the resident's room and asked the resident if he was in pain. The resident acknowledged he was in pain and that his genitals needed to be repositioned. The resident's call light was clipped to the left side of the bed and was not under the resident's left shoulder. On 08/27/12 at 11:37 a.m., the DON was asked how often pain screenings were performed for the resident. She stated, "Monthly." When asked how often pain assessments were completed, the DON stated,"Evals are done on a monthly basis. There is a stack out there that have not been put in the chart." The DON was asked if the resident experienced pain. She stated,"He does verbalize at times that he does hurt." The DON was asked how staff determined if the resident was in pain. She stated, "They ask him." The DON was asked what caused the resident pain. She stated, "Positioning, being on his genitals." She stated the resident would complain of his head or stomach hurting. The DON was asked what staff was supposed to do if the resident was experiencing pain. She stated, "They should notify the nurse so the nurse could screen the pain." The DON was asked if movement of the resident's joints could cause him pain. She stated, "Yes." When asked why the resident was not pre-medicated with pain medication prior to attempting restorative care, the DON stated, "He is medicated with routine meds." She stated the resident's morning medications were given at 8:00 a.m. The DON was asked if the administration of the resident's morning medications was coordinated with his restorative care, the DON stated, "Not at this time." 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/18/12, documented the resident was cognitively moderately impaired, required extensive assistance with activities of daily living, required extensive assistance with personal hygiene, was totally dependent with toileting, was always incontinent of bowel and had a urinary catheter. The care plan, last updated 07/24/12, documented the resident had an indwelling urinary catheter and was not a candidate for removal. It was documented the resident had a history of [REDACTED]. The goal was for the resident to remain free from urinary tract infections and dehydration over the next 90 days. The documented interventions in the plan of care included for the facility to keep the catheter drainage bag in protective cover bag, maintain the drainage bag below the level of bladder, and perform catheter care every shift and as needed. On 08/22/12 at 3:40 p.m., CNA #2 was observed performing catheter care for resident #1. The resident was lying supine in bed with his legs spread slightly. Feces was observed on the inner right thigh of the resident. A sheet was present across the lower part of the resident's legs and the resident wore a shirt covering his torso. The resident's peri-area was exposed and a catheter was observed exiting the penis and ending with a catheter bag hanging on the right side of the resident's bed. Without washing or sanitizing her hands, CNA #2 donned gloves, wet one washcloth with cold water, and approached the resident. CNA #2 did not use any type of cleaning agent. CNA #2 verbally warned the resident that the washcloth was cold and wet. The CNA folded the washcloth in half and then over again. She then held the catheter near the entrance to the penis, wrapped the folded wet washcloth around the catheter at approximately two inches from the penis and drew the washcloth across the catheter, away from the penis and towards the catheter bag. The CNA stopped a few inches from the end of the catheter and wiped the washcloth towards the penis. The CNA continued the back and forth motion across the middle section of the catheter. She then pulled the wet washcloth from approximately an inch from the penis down the entire length of the catheter and drainage tube to the catheter bag with one directional stroke. CNA #2 then removed the washcloth from the tubing, folded the washcloth back the opposite direction, wrapped the washcloth around the catheter near the entrance to the penis and proceeded to move the washcloth back and forth along the catheter to the entrance to the penis and back again. She did not pull the foreskin back to clean the meatus. CNA #2 then removed the washcloth and stated she was done. CNA #2 did not dry the resident, provide bowel incontinent care, or secure the catheter tubing to prevent tugging. She placed the washcloth in a plastic bag and removed gloves before exiting the room. After the catheter care, the resident was asked permission for the surveyor to observe the resident's skin integrity by performing a skin assessment. The resident agreed and CNA #2 was followed to the hallway and requested for assistance in performing the skin assessment. Resident #1 remained in bed in the supine position with a sheet draped across the waist and legs and a shirt over the torso. The sheet was pulled back to expose the resident's peri-area and thighs. CNA #2 was asked what the discoloration was to the inner right thigh and replied, "That's bowel (movement)." The CNA informed the resident he needed to be cleaned up before dressing. The call light was utilized and CNA #10 answered. The two CNA's positioned the resident higher in bed. CNA #10 asked CNA #2 if she needed assistance with incontinent care. CNA #2 responded no but did ask the CNA #10 to gather two washcloths, a towel, and a pair of gloves. The CNA returned with the requested supplies. CNA #2 placed the washcloths in basin of the sink and started the water. She then moved the washcloths across the bottom of the wet sink in a circular pattern. CNA #2 gathered the washcloths and walked to the left side of the resident. CNA #2 positioned the resident's legs outward in a frog leg pattern and wiped the inner right thigh twice, then moved to the left thigh and wiped with the same washcloth. CNA #2 then assisted the resident onto his left side, facing her. With the second washcloth, CNA #2 reached over the resident and wiped the right cheek of the buttocks from thighs towards the coccyx and back again. The CNA then stated, "I'm done. That's it." The CNA assisted the resident back to the supine position, placed the washcloths in a plastic bag near the sink, and disposed of the soiled gloves. CNA #2 was asked if she had washed the resident's penis. She stated, "Oh, I wasn't doing incontinent care. I was just cleaning off the poop. I'll do that later." On 08/27/12 at 4:00 p.m., the DON was asked if annual evaluations and return demonstrations were completed for the CNAs. She stated, "No." She stated the facility did merit evaluations and not performance evaluations. On 08/27/12 at 4:55 p.m., CNA #2 was asked if any one at the facility had observed her performing her duties. She stated another aide had watched her at some time during her orientation. CNA #2 was asked if a nurse had ever observed her performing her duties. She stated, "(LPN #5) watched my hand washing and asked me about infection control." When asked if she had been observed performing incontinent care, CNA #2 stated, "No."

Based on observation, interview, and record review, it was determined the facility failed to implement interventions to aid in the prevention of weight for one (#3) of four sampled residents who had experienced weight loss. This resulted in the actual harm of a 12.67% severe weight loss in three months for the resident. The facility's Census and Conditions report identified two residents as having a significant change in weight. Findings: Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A weight loss care plan, dated 04/04/12, documented, "...Has had wt loss. Potential for further wt loss d/t poor nutritional intake..." The goal was, "...Will have no further wt loss over the next 60 days..." Approaches included, "...Give diet as ordered. Encourage to eat at least 75% of meals...Dietary to screen for food likes/dislikes. Try to incorporate faviorte (sic) foods whenever possible...Record % of all meals...Offer replacement meal if <50% is consumed...Offer nourshing (sic) snacks between meals...Give supplements as ordered..." Review of the resident's clinical record revealed no documentation to show the resident's food likes and dislikes had been determined. Weight records, dated 05/12/12, documented the resident weighed 146 lbs. A nutritional assessment, dated 06/05/12 and signed by the RD/LD, documented, "...Weight: 136...Usual weight: 150...significant wt loss - 7.19 x 1 [MEDICAL CONDITION] noted with wt fluctuation...poor diet compliance...often angry and shouting, up in wheel chair..." A [MEDICAL CONDITION] risk assessment, dated 07/02/12, documented the resident scored an eight. The form documented, "...Total score above 10 represents HIGH RISK..." It was documented the resident was alert and oriented, had stable weight over the last three months, ate 75 - 100% of most meals, took snacks as offered, and had few food dislikes. A quarterly assessment, dated 07/02/12, documented the resident was severely cognitively impaired, rejected care, and had physical and verbal behavioral symptoms. It was documented the resident was independent in eating and had no weight loss. A nutritional assessment, dated 07/06/12 and signed by the RD/LD, documented the resident weighed 133 lbs and had a significant wt increase of 23/11% in three months, with a 10/5% increase in one year. Weight records, dated 07/12/12, documented the resident weighed 146 lbs. Weight records, dated 08/12/12, documented the resident weighed 127.5 lbs. This constituted an 18.5# or 12.67% weight loss in three months. On 08/20/12 at 6:17 p.m., the resident was observed lying in bed. Her meal tray was on her bedside table, and the resident had not ate. The resident was asked if she ate her dinner. She stated, "I didn't want anything." Review of the resident's meal percentage sheet revealed documentation to show the resident refused her meal. There was no documentation to show the resident was offered a supplement or replacement meal. On 08/21/12 at approximately 11:45 a.m., serving of the noon meal was observed. All residents who ate in the dining room were served, and all room trays were passed except to resident #3. A tray was not taken to resident #3. At approximately 12:30 p.m., dietary staff was asked if every one had been served. The DM stated, "Yes." The DM was asked why resident #3 did not receive a lunch tray. He stated it was because the resident was not on the list to receive a tray in her room. On 08/21/12 at 5:52 p.m., the resident was observed lying in bed. Her evening meal tray was on her bedside table, and the resident had not ate. The resident requested her tray be taken from her room. CMA #1 entered the resident's room and asked, "Do you want me to take your tray?" The resident stated, "Yes." CMA #1 picked up the tray and left the room. She did not offer the resident any other food or ask if there was something the resident wanted. At 5:53 p.m., CMA #1 was asked what she was supposed to do for the resident. She stated, "I will have to ask (LPN #6) and get a milk thing." At 5:55 p.m., LPN #3 saw CMA #1 with the resident's tray. She asked the CMA who the tray belonged to. The CMA stated, "(Resident #3)." LPN #3 took the tray, went to the resident's room, and asked the resident, "How come you didn't eat anything?" The resident made no reply. LPN #3 stated, "I've never seen her like this." She removed the tray and left the room. She did not offer the resident any other food. At 6:15 p.m., the resident was observed to have no food or drink in her room. On 08/22/12 at 2:18 p.m., LPN #5 was asked if resident #3 had lost weight. She stated, "Yes, she loses and gains." When asked what staff was supposed to do if the resident did not eat her meal or refused a meal, LPN #5 stated, "Offer her something else." Weight records, dated 08/22/12, documented the resident weighed 125.7 lbs. On 08/23/12 at 10:34 a.m., the DON was asked if the resident had experienced weight loss. She stated, "Yes." When asked what interventions had been put into place to aid in the prevention of weight loss for resident #3, the DON stated, "Offer her supplements, replacements. I have weekly weight sheets." The DON was asked what staff was supposed to do if the resident refused a meal. She stated, "Actually offer a replacement." The DON stated if the resident was adamant about refusing, staff was supposed to allow her to refuse and then offer something later. The DON was asked where the resident's food likes and dislikes were documented. She stated, "Dietary does the likes and dislikes. I do not see it under dietary." The DON was asked if the information should be in the resident's clinical record. She stated, "Yes." The DON was asked if she was aware the resident had not been served a noon meal tray on 08/21/12. She stated, "No." When asked if she was aware the staff was not offering the resident a supplement or replacement meal when the resident refused her tray, the DON stated, "No." The DON was asked if it had been reported to her the resident was refusing her meal trays. She stated, "No."

Based on observation, interview, and record review, it was determined the facility failed to provide pressure ulcer treatments for one (#26) of one sampled resident with pressure ulcers. This constituted actual harm for the resident. The facility identified one residents as having a pressure ulcer. Findings: The facility's undated standard on skin integrity documented, "...The skin integrity of residents is preserved through adequate nutrition and hydration, inspection of the skin condition...Those residents who score at risk for skin breakdown but do not have current skin breakdown will have a documented skin assessment each week...The Weekly Skin Condition Assessment record will be utilized to document assessment of all skin conditions including bruises, skin tears, rashes, stasis ulcers, etc...The physician, resident, and/or legal representative will be notified immediately of changes to the resident's skin...The physician will provide a treatment order specific to the skin issue of the resident...The treatment effectiveness will be evaluated each week and if ineffective will be changed after fourteen...days...The facility will have a skin team consisting of the Director of Nursing, Food Service Manager, Reimbursement Nurse Coordinator at minimum who will evaluate each wound each week and provide direction to charge nurses as to needed changes...Professional nursing staff will communicate changes in residents' skin condition through the Nursing Service Daily Report...A professional nurse will assess each wound weekly and will document the assessment on the Weekly skin Condition Assessment record..." Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's pressure ulcer risk assessment, completed on 03/20/12 and 06/22/12, documented a total score of 8 and above. This indicated the resident was at high risk for pressure sores. The resident was readmitted on [DATE] with end stage Alzheimer's and urosepsis. Re-admission orders [REDACTED]. A readmission nursing data collection tool, dated 07/31/12, documented the resident had two small open areas to the bilateral buttocks, a resolving skin tear to the right calf area, and multiple small bruises to the arms and legs. A re-admission assessment, dated 08/06/12, documented the resident had a stage I pressure ulcer. A pressure ulcer risk assessment, completed on 08/13/12 documented a the resident scored an eight. This indicated the resident was at high risk for a pressure ulcer. The resident's care plan, dated 08/15/12, documented the resident had a history of [REDACTED]. The care plan documented the resident had frail skin, needed lotion for the dry skin. The resident was to utilize geri arm sleeves to protect the resident's arms. The care plan had last been updated for a skin tear on 08/01/12. There was no documentation of a pressure ulcer on the updated care plan. The resident was readmitted on [DATE] with end stage [MEDICAL CONDITIONS], and pneumonia. A hospital discharge summary and orders, dated 08/15/12, contained no documentation of skin issues or treatments. The readmission nursing data collection tool, dated 08/15/12, documented the resident had had a skin tear noted to the left arm and it was cleansed and bandaged. The resident had [MEDICAL CONDITION]. There was no documentation of a pressure ulcer. A physician's progress note, dated 08/22/12, contained no documentation of a pressure ulcer. On 08/24/12 at 10:25 a.m., resident #26 was observed lying in bed. CNA #3 and LPN #1 rolled the resident to her left. Her incontinent pad was saturated with urine. LPN #1 stated, "I see it's soaked." CNA #3 was asked when the resident was repositioned last. She stated, "A while ago." A pressure ulcer, approximately 5 x 3 cms with a black center was noted to the resident's right buttock. LPN #1 left the resident's room and gathered treatment supplies and the treatment book. Review of the resident's treatment sheets revealed no documentation of treatment orders for the pressure ulcer. LPN #1 was asked if the resident had a treatment sheet that listed orders. He stated, "No. There wasn't a treatment sheet in the book for (resident #26). I had to grab a new one." At approximately 10:30 a.m., hospice aides #1 and #2 were asked if the pressure ulcer was new. Hospice aide #2 stated it had been reported to the nurse on 08/21/12. She stated, "It wasn't like that on Tuesday (08/21/12)." At 10:36 a.m., LPN #1 was asked to measure and describe the resident's pressure ulcer. The pressure ulcer was located on the middle portion of the right buttock. It consisted of a reddened area that measured 5 cms wide x 3 cms high. Inside the reddened area on the lower left quadrant was a black area that measured 3 cms wide x 2 cms high. A smaller open area, measuring .5 cm wide x 1 cm high was located below and to the left of the first pressure ulcer. Two areas of macerated appearing skin were observed on the resident's left buttock. LPN #1 stated, "It did not look that bad Wednesday. She had an order for [REDACTED]. He stated, "The nurses do." Review of the resident's clinical record revealed no documentation to show the physician had been notified of the pressure ulcer or that treatment orders had been obtained. At 3:01 p.m., LPN #2, the charge nurse, was asked if any one had reported to her any changes in condition, such as a change in skin condition. She stated LPN #1 had reported a "bed sore" on resident #26. LPN #2 was asked if it was a pressure ulcer. She stated, "It's not. It's kind of a dark area." LPN #2 was asked when the facility first became aware of the pressure ulcer. She stated, "Today. We notified hospice." LPN #2 was asked if the physician had been notified. She stated, "No. I figured (LPN #1) would do that." At 3:20 p.m., the DON was asked if the breakdown was a pressure ulcer. She stated, "I have not been in there to look at it myself." The DON was asked if the physician had been notified of the pressure ulcer. She stated, "I asked (LPN #2) to take care of that." The DON was asked if the pressure ulcer was new. She stated, "Yes." The DON was asked if she was aware the staff had been made aware of the pressure ulcer on 08/21/12. She stated, "No." The DON stated LPN #1 said the pressure ulcer was open. When asked if LPN #1 described or staged the pressure ulcer, the DON stated, "No." The DON stated, "She does have orders already for Lantaseptic. Not that that's gonna help an open area but it might." At 3:26 p.m., the DON was asked to review the resident's treatment sheets. When asked if she had an order for [REDACTED]." At 3:29 p.m., the DON was asked what conditions was Lantaseptic appropriate for. She stated, "Preventives and redness." The DON was made aware of the description of the resident's pressure ulcer. When asked if that was the description provided to her by the staff, the DON stated, "No." At 3:35 p.m., the DON was asked if the resident had skin breakdown when she came back to the facility on [DATE]. She stated, "I did not have the report that she had breakdown and I didn't do the head to toe." The DON was asked where the skin assessment from 08/15/12 was. She reviewed the resident's clinical record and stated, "I do not see an assessment." The DON stated skin tears and bruising were documented in the nurses' notes. The DON was asked when the facility first identified the pressure ulcer. She stated, "Today." When asked who identified the area, the DON stated, "(LPN #1) did while with the surveyor." The DON was asked when the physician was notified of the pressure ulcer. She stated, "As of right now, he has not been to my knowledge." The DON stated, "It stands to reason why there are no orders." The DON was asked why the staff applied Lantaseptic to the pressure ulcer. She stated, "I would like to ask them that too." The DON was asked how the facility identified residents at high risk for pressure ulcers. She stated, "Those that can't reposition themselves, incontinent." The DON was asked if the facility used an assessment form. She stated, "Yes." The DON was asked what was done with the data collected from the assessment form. She stated the data was taken to care plan meetings and the MDS Coordinator developed a care plan with interventions for prevention. The DON was asked how staff was informed if a resident was at high risk for pressure ulcers. She stated the temporary care plans in the ADL books showed if a person was at high risk, and the staff received report from the charge nurses. The DON was asked how often skin assessments were supposed to be completed. She stated, "Weekly." She stated if there was an open area, it should be documented in the treatment book weekly. The DON was asked if there was a skin assessment sheet for resident #26. She stated, "No." The DON was asked who was responsible for completing the weekly skin assessments. She stated, "(LPN #5)." The DON was asked if LPN #5 was completing the skin assessments. She stated, "I have July. I don't know where she is at with August yet." The DON was asked if the facility's process for monitoring skin was working. She stated, "No." When asked if she had identified a concern prior to learning of the pressure ulcer with resident #26, the DON stated, "Yes." The DON was asked what she had done once she identified the concern. She stated, "She (LPN #5) told me she was getting it, but she hasn't been on treatments (because she has been) being charge nurse."

Based on observation, interview, and record review, it was determined the facility failed to investigate an allegation of abuse, protect the resident after an allegation of abuse, and failed to report the alleged abuse to proper authorities for 1 (#1) of 5 sampled residents. This had the likelihood to affect all residents who resided in the facility. This constituted an Immediate Jeopardy situation. Findings: Facility Policies & Procedures for Abuse The undated Abuse Policy and Procedure documented: "...The facility must report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation...The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress... The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with state law within 5 working days of the incident... A nursing home employee who becomes aware of an act prohibited by this section immediately shall report the matter to the nursing home administrator or nursing director. A nursing home administrator or nursing director who becomes aware of an act prohibited by this section immediately shall report the matter by telephone to the Oklahoma State Health Department... Protecting the rights and well-being of residents and staff...protect the rights of the victims...protect the resident from service interruption... Resident protection: separate from abuser...possible room or staffing change... Report and investigate: any employee who suspects or witnesses abuse or neglect toward a resident must report it to facility administration or his/her designee. The provider ensures that any suspected or alleged incidents of abuse and neglect are thoroughly, objectively and expeditiously investigated... Facilitating proper reporting and conducting timely and effective investigations: immediate, organized, systematic, adequate, thorough and objective response to reports of actual or suspected abuse and neglect...Conduct internal investigations and comply with external requirements. Complete and thorough documentation...Determine interventions to prevent further injury. Report to state, local and law enforcement agencies as required.... Components of an internal investigation: An initial evaluation and interview. A clinical history, if needed...A psychosocial evaluation, if needed. Interviews with potential witnesses... Initial evaluation and interview: all involved persons should be identified. Arrange a thorough evaluation as soon as possible. Conduct the interview with the alleged victim in a private setting free from any intimidating factors... Document results of interviews accurately and using the individual's own words... State of Oklahoma clarification on reporting: Both state and federal law require that suspected or alleged abuse...of resident be immediately reported by an employee to the administrator of the facility; And state law requires the administrator or DON or Charge nurse to report findings in (sic) immediately to the Oklahoma State Health Department. Federal law requires that the results of the investigation be reported to the administrator or his/her representative within 5 days of the incident... Two levels of response: immediate corrective action plan. Internal review of investigative findings..." An incident report policy and procedure, dated 06/27/06, "...It is a policy of this company to complete an incident report for every accident or incident involving a resident, visitor and employee. Every incident/accident will be thoroughly investigated within twenty-four (24) hours...The State guidelines will be followed for reporting purposes..." Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/09/10, documented the resident was moderately impaired in cognitive skills for daily decision making, was not verbally or physically abusive, and did not exhibit socially inappropriate or disruptive behavioral symptoms. It was documented the resident was frequently incontinent of bladder and usually continent of bowel. A nurse's note, dated 10/11/10 at 5:00 p.m., documented, "...res came to d/room yelling she hit her head on doorway, when asked how, stated a CNA slapped her. When asked again what happened said hit her head on doorway. DON notified & fam & phy. L eye brow has sm. tiny open spot cleansed & bandaide (sic) applied R eye outer corner has fading bruise. No other redness or marks noted..." An incident/accident report, dated 10/11/10 at 5:00 p.m. documented, "...Resident's condition before incident was normal...equipment involved...w/chair, door?..Res. said she hit the door way then said she was slapped by CNA, then hit door way...indicate on diagram location of injury: 1 above left eye 2 small bruise on right temple..." An attachment to the incident report, dated 10/11/10 and untimed, documented, "...On 10/11/10 at 1715 (5:15 p.m.), I received a call stating resident upset with having used all her toilet paper was using sheets on bed to wipe with, on the toilet. I was back in the facility by 1730 (5:30 p.m.) and found resident in her room...Another staff member (CMA #3) present stating to resident (CNA #3) slapped you, didn't she? Resident stated yes...Resident noted to have no redness to face, though bandaid placed over right temple with minute red spot....LPN #3 stated she had heard employee calling for help coming from resident's room. Resident was calmed easily and employee ended shift and left facility while I was present." The attachment was signed by the DON. Review of the incident report book revealed no documentation to show the incident was reported to the Oklahoma State Department of Health. A nurse's note, dated 10/12/10 at 8:00 a.m., documented, "...discoloration noted to L eye corner..." A nurse's note, dated 10/12/10 at 3:00 p.m., documented, "...res has discoloration noted to L outer edge of eye & R\eye has old bruise..." On 10/14/10 at 1:22 p.m., resident #1 was asked what happened to her eyes. She stated, "The aide hit me in the eye." She was asked who she told of the incident. She replied, "I told everyone I saw." At 1:28 p.m., CNA #3 was observed on hall 100, the resident's hall. At 1:30 p.m., the DON was asked if she was working on any state reportable incidents that were not in the incident book. The DON stated, "No, everything is in the book." At 3:05 p.m., the housekeeping supervisor was asked if resident #1 told her about the incident of alleged abuse. She stated, "She told me an employee smacked her." She was asked if she reported the incident to anyone. She stated, "LPN #1. She said she would talk to her." The housekeeping supervisor was asked if the charge nurse reported or investigated the incident. She replied, "Not that I know of. I don't know." At 3:36 p.m., CNA #2 was asked if she knew about the incident of alleged abuse between a staff member and resident #1. She stated, "Yes." She was asked if she reported it to anyone. She stated, "No." When asked why, she stated, "Because the nurse and administrator already knew about it. Everyone I guess should have heard it because she was upset and telling everyone." At 3:46 p.m., LPN #1 was asked if she recalled the incident with resident #1. She stated, "I recall the incident. No one reported it to me. I went into the resident's room on Tuesday (10/12/10) and the resident told me. It had already been told to me by other staff. I wondered if it had really happened. I asked her what happened to her eyes." LPN #1 was asked if she reported the incident of alleged abuse. She replied, "No, I didn't know who to report it to. The DON said she was going to keep the staff and just keep her away from the resident. She (resident #1) told everyone the story. Her story never changed. She gets some things wrong but she is alert and oriented and knows whats going on." At 4:07 p.m., LPN #3 was asked if a resident had reported an allegation of abuse. She stated, "Yeah, resident #1 did." She was asked if she reported the allegation. She replied, "Oh yes, I reported it to my DON." LPN #3 was asked what the resident had told her. She stated, "She (resident #1) said she (CNA #3) slapped her." She was asked what she did to protect the resident. LPN #3 stated, "The aide came off the hall, and she was put on another hall, and she went home at 7:00 p.m. I can't quote the exact time; that is an approximate time. I did the incident report on it." She was asked if the facility had training regarding when allegations of abuse are to be reported. She stated, "We had an inservice on abuse." On 10/14/10 at 4:40 p.m., the DON was asked if she had done a thorough investigation of the allegation of abuse. The DON stated, "Yes." She was asked if she had documented the investigation. She stated, "I talked to the staff but I didn't document it. There were no witnesses." The DON was asked if she talked to resident #1 about the allegation of abuse. She stated, "Yes." She was asked if she documented the interview. She replied, "I didn't document it." The DON was asked if she interviewed any other residents during her investigation. She stated, "No." The DON was asked what she had done to protect the resident. She stated, "The aide left the building. I told the resident she would not be taking care of her anymore." She was asked if she had reported the allegation of abuse. The DON stated, "No, I did not substantiate any abuse. I spoke with the administrator and she told me I didn't have to report it to the State." At 5:07 p.m., CNA #3 was asked how long she had worked at the facility. She stated, "I came back a month ago." She was asked how resident #1 received the knot on her head. CNA #3 stated, "I don't know." CNA #3 was asked what she had done the rest of the shift. She stated, "I stayed away from her, wrote a report, served dinner, and went home at 7." When asked if resident #1 was with her at any time during the rest of her shift, CNA #3 replied, "Yes, she was on one side of the nursing station and I was on the other side." She was asked if she had been on hall 100 (resident #1's hall). She stated, "Yes, I answered call lights." CNA #3 was asked if resident #1 was in the dining room when she served dinner. She stated, "Yes." CNA #3 was asked if anyone told her to stay away from resident #1. She stated, "No." Immediate Jeopardy Identified On 10/14/10, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to protect a resident following an allegation of abuse and thoroughly investigate the allegation of abuse for 1 (#1) of 5 sampled residents. At 5:33 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ. At 6:22 p.m., the administrator and the DON were informed of the IJ regarding the facility's failure to protect a resident following an allegation of abuse and thoroughly investigate the allegation of abuse. They were informed this placed the facility in an extended survey. Facility Plan of Removal for Immediate Jeopardy At 7:10 p.m., the facility submitted an acceptable plan of removal, which documented: "Immediate steps taken to remove immediate jeopardy of resident's allegation of abuse: 6:26 p.m. Certified Nurse Aide removed from building immediately and not to return to work until thorough investigation completed to protect residents. 7:12 p.m. An initial report sent to state regarding allegations of abuse 7:45 p.m. Ongoing investigation began to include statements from staff working the shift that allegations occurred on. 7:45 p.m. Staff addressed and in-serviced on Abuse Policy and Procedures on 2-10 shift and to report to charge nurse and residents will be protected immediately by removing any person that the allegation was made against. All Staff are being contacted for mandated in-service on abuse. In-service began with staff on 10/15/10 at 7:45 a.m. and concluded at 2:12 p.m." Immediacy Removed The IJ was removed on 10/15/10 at 2:12 p.m., when all employees had been inserviced regarding protecting residents after allegations of abuse and the facility's abuse policy and procedure, and the alleged perpetrator had been removed from the building until a thorough investigation could be completed. Staff were interviewed on 10/15/10 in regard to their knowledge of the in-service; to ensure their understanding of allegations of abuse, signs of abuse, and the importance of reporting all allegations of abuse. The deficient practice remained at a widespread level with a potential for more than minimal harm.

Based on observation, interview, and record review, it was determined the facility failed to follow and implement their policy and procedure to investigate an allegation of abuse, protect the resident after an allegation of abuse, and report the alleged abuse to proper authorities for 1 (#1) of 5 sampled residents. This had the likelihood to affect all residents who resided in the facility. This constituted an Immediate Jeopardy situation. Findings: Facility Policies & Procedures for Abuse The undated Abuse Policy and Procedure documented, "...The facility must report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation...The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress... The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with state law within 5 working days of the incident... A nursing home employee who becomes aware of an act prohibited by this section immediately shall report the matter to the nursing home administrator or nursing director. A nursing home administrator or nursing director who becomes aware of an act prohibited by this section immediately shall report the matter by telephone to the Oklahoma State Health Department... Protecting the rights and well-being of residents and staff...protect the rights of the victims...protect the resident from service interruption... Resident protection: separate from abuser...possible room or staffing change... Report and investigate: any employee who suspects or witnesses abuse or neglect toward a resident must report it to facility administration or his/her designee. The provider ensures that any suspected or alleged incidents of abuse and neglect are thoroughly, objectively and expeditiously investigated... Facilitating proper reporting and conducting timely and effective investigations: immediate, organized, systematic, adequate, thorough and objective response to reports of actual or suspected abuse and neglect...Conduct internal investigations and comply with external requirements. Complete and thorough documentation...Determine interventions to prevent further injury. Report to state, local and law enforcement agencies as required.... Components of an internal investigation: An initial evaluation and interview. A clinical history, if needed...A psychosocial evaluation, if needed. Interviews with potential witnesses... Initial evaluation and interview: all involved persons should be identified. Arrange a thorough evaluation as soon as possible. Conduct the interview with the alleged victim in a private setting free from any intimidating factors... Document results of interviews accurately and using the individual's own words... State of Oklahoma clarification on reporting: Both state and federal law require that suspected or alleged abuse...of resident be immediately reported by an employee to the administrator of the facility; And state law requires the administrator or DON or Charge nurse to report findings in (sic) immediately to the Oklahoma State Health Department. Federal law requires that the results of the investigation be reported to the administrator or his/her representative within 5 days of the incident... Two levels of response: immediate corrective action plan. Internal review of investigative findings..." An incident report policy and procedure, dated 06/27/06, "...It is a policy of this company to complete an incident report for every accident or incident involving a resident, visitor and employee. Every incident/accident will be thoroughly investigated within twenty-four (24) hours...The State guidelines will be followed for reporting purposes..." Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/09/10, documented the resident was moderately impaired in cognitive skills for daily decision making, was not verbally or physically abusive, and did not exhibit socially inappropriate or disruptive behavioral symptoms. It was documented the resident was frequently incontinent of bladder and usually continent of bowel. A nurse's note, dated 10/11/10 at 5:00 p.m., documented, "...res came to d/room yelling she hit her head on doorway, when asked how, stated a CNA slapped her. When asked again what happened said hit her head on doorway. DON notified & fam & phy. L eye brow has sm. tiny open spot cleansed & bandaide (sic) applied R eye outer corner has fading bruise. No other redness or marks noted..." An incident/accident report, dated 10/11/10 at 5:00 p.m. documented, "...Resident's condition before incident was normal...equipment involved...w/chair, door?..Res. said she hit the door way then said she was slapped by CNA, then hit door way...indicate on diagram location of injury: 1 above left eye 2 small bruise on right temple..." An attachment to the incident report, dated 10/11/10 and untimed, documented, "...On 10/11/10 at 1715 (5:15 p.m.), I received a call stating resident upset with having used all her toilet paper was using sheets on bed to wipe with, on the toilet. I was back in the facility by 1730 (5:30 p.m.) and found resident in her room...Another staff member (CMA #3) present stating to resident (CNA #3) slapped you, didn't she? Resident stated yes...Resident noted to have no redness to face, though bandaid placed over right temple with minute red spot....LPN #3 stated she had heard employee calling for help coming from resident's room. Resident was calmed easily and employee ended shift and left facility while I was present." The attachment was signed by the DON. Review of the incident report book revealed no documentation to show the incident was reported to the Oklahoma State Department of Health. A nurse's note, dated 10/12/10 at 8:00 a.m., documented, "...discoloration noted to L eye corner..." A nurse's note, dated 10/12/10 at 3:00 p.m., documented, "...res has discoloration noted to L outer edge of eye & R\eye has old bruise..." On 10/14/10 at 1:22 p.m., resident #1 was asked what happened to her eyes. She stated, "The aide hit me in the eye." She was asked who she told of the incident. She replied, "I told everyone I saw." At 1:28 p.m., CNA #3 was observed on hall 100, the resident's hall. At 1:30 p.m., the DON was asked if she was working on any state reportable incidents that were not in the incident book. The DON stated, "No, everything is in the book." At 3:05 p.m., the housekeeping supervisor was asked if resident #1 told her about the incident of alleged abuse. She stated, "She told me an employee smacked her." She was asked if she reported the incident to anyone. She stated, "LPN #1. She said she would talk to her." The housekeeping supervisor was asked if the charge nurse reported or investigated the incident. She replied, "Not that I know of. I don't know." At 3:36 p.m., CNA #2 was asked if she knew about the incident of alleged abuse between a staff member and resident #1. She stated, "Yes." She was asked if she reported it to anyone. She stated, "No." When asked why, she stated, "Because the nurse and administrator already knew about it. Everyone I guess should have heard it because she was upset and telling everyone." At 3:46 p.m., LPN #1 was asked if she recalled the incident with resident #1. She stated, "I recall the incident. No one reported it to me. I went into the resident's room on Tuesday (10/12/10) and the resident told me. It had already been told to me by other staff. I wondered if it had really happened. I asked her what happened to her eyes." LPN #1 was asked if she reported the incident of alleged abuse. She replied, "No, I didn't know who to report it to. The DON said she was going to keep the staff and just keep her away from the resident. She (resident #1) told everyone the story. Her story never changed. She gets some things wrong but she is alert and oriented and knows whats going on." At 4:07 p.m., LPN #3 was asked if a resident had reported an allegation of abuse. She stated, "Yeah, resident #1 did." She was asked if she reported the allegation. She replied, "Oh yes, I reported it to my DON." LPN #3 was asked what the resident had told her. She stated, "She (resident #1) said she (CNA #3) slapped her." She was asked what she did to protect the resident. LPN #3 stated, "The aide came off the hall, and she was put on another hall, and she went home at 7:00 p.m. I can't quote the exact time; that is an approximate time. I did the incident report on it." She was asked if the facility had training regarding when allegations of abuse are to be reported. She stated, "We had an inservice on abuse." On 10/14/10 at 4:40 p.m., the DON was asked if she had done a thorough investigation of the allegation of abuse. The DON stated, "Yes." She was asked if she had documented the investigation. She stated, "I talked to the staff but I didn't document it. There were no witnesses." The DON was asked if she talked to resident #1 about the allegation of abuse. She stated, "Yes." She was asked if she documented the interview. She replied, "I didn't document it." The DON was asked if she interviewed any other residents during her investigation. She stated, "No." The DON was asked what she had done to protect the resident. She stated, "The aide left the building. I told the resident she would not be taking care of her anymore." She was asked if she had reported the allegation of abuse. The DON stated, "No, I did not substantiate any abuse. I spoke with the administrator and she told me I didn't have to report it to the State." At 5:07 p.m., CNA #3 was asked how long she had worked at the facility. She stated, "I came back a month ago." She was asked how resident #1 received the knot on her head. CNA #3 stated, "I don't know." CNA#3 was asked what she had done the rest of the shift. She stated, "I stayed away from her, wrote a report, served dinner, and went home at 7." When asked if resident #1 was with her at any time during the rest of her shift, CNA #3 replied, "Yes, she was on one side of the nursing station and I was on the other side." She was asked if she had been on hall 100 (resident #1's hall). She stated, "Yes, I answered call lights." CNA #3 was asked if resident #1 was in the dining room when she served dinner. She stated, "Yes." CNA #3 was asked if anyone told her to stay away from resident #1. She stated, "No." Immediate Jeopardy Identified On 10/14/10, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to protect a resident following an allegation of abuse and thoroughly investigate the allegation of abuse for 1 (#1) of 5 sampled residents. At 5:33 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ. At 6:22 p.m., the administrator and the DON were informed of the IJ regarding the facility's failure to protect a resident following an allegation of abuse and thoroughly investigate the allegation of abuse. This placed the facility in an extended survey. Facility Plan of Removal for Immediate Jeopardy At 7:10 p.m., the facility submitted an acceptable plan of removal which documented: "Immediate steps taken to remove immediate jeopardy of resident's allegation of abuse: 6:26 p.m. Certified Nurse Aide removed from building immediately and not to return to work until thorough investigation completed to protect residents. 7:12 p.m. An initial report sent to state regarding allegations of abuse 7:45 p.m. Ongoing investigation began to include statements from staff working the shift that allegations occurred on. 7:45 p.m. Staff addressed and in-serviced on Abuse Policy and Procedures on 2-10 shift and to report to charge nurse and residents will be protected immediately by removing any person that the allegation was made against. All Staff are being contacted for mandated in-service on abuse. In-service began with staff on 10/15/10 at 7:45 a.m. and concluded at 2:12 p.m." Immediacy Removed The IJ was removed on 10/15/10 at 2:12 p.m., when all employees had been inserviced regarding protecting residents after allegations of abuse and the facility's abuse policy and procedure, and the alleged perpetrator had been removed from the building until a thorough investigation could be completed. Staff were interviewed on 10/15/10 in regard to their knowledge of the in-service; to ensure their understanding of allegations of abuse, signs of abuse, and the importance of reporting all allegations of abuse. The deficient practice remained at a widespread level with a potential for more than minimal harm.