Every finding on record at Colonial Manor II

Based on observation, record review, and interview, the facility failed to assess and monitor a resident before and after dialysis treatments for 1 (#4) of 1 sampled resident reviewed for dialysis.The administrator identified one resident required dialysis services. Findings: On 01/06/26 at 3:20 p.m., Resident #4 pulled up their sleeve and showed the dialysis shunt site on their left forearm to this surveyor. An undated policy titled Dialysis, showed nursing staff would monitor residents before and after dialysis, and dialysis access sites would be protected and observed for signs of infection or complications. The policy showed all dialysis-related care, observations, and communications would be documented in the resident's medical record. A care plan, dated 12/15/25, showed a goal to manage Resident #4's end-stage renal disease while attending dialysis on Tuesday, Thursday, and Saturday. The care plan showed to ensure the resident was safely transported to and from dialysis and the resident was encouraged to report any symptoms related to dialysis. Resident #4's admission assessment, dated 12/21/25, showed their cognition was intact with a BIMS score of 13. The assessment showed the resident received dialysis services. Resident #4's medical records showed no monitoring was conducted by a nurse before or after scheduled dialysis treatments on 12/16/25, 12/18/25, 12/20/25, 12/23/25, 12/26/25, 12/27/25, 12/30/25, 01/02/26, 01/03/26, and 01/06/26. On 01/05/26 at 12:29 p.m., Resident #4 stated they went to dialysis on Tuesday, Thursday, and Saturday. The resident stated a transportation company took her to dialysis during the week, and her family transported her on the weekend. On 01/06/26 at 3:20 p.m., Resident #4 stated the facility nurses did not look at their dialysis shunt site or assess them before or after dialysis. On 01/06/26 at 4:00 p.m., RN #1 stated they did not assess Resident #4 before or after dialysis unless the resident was not feeling well or if their blood pressure was abnormal. The RN reported the resident's dialysis shunt was assessed if there was a concern. On 01/06/26 at 4:45 p.m., the DON stated the nurse should assess the resident when the resident returned from dialysis and document the findings in the nurse's notes. The DON stated in-service training needed to be provided for staff related to the dialysis resident.

Based on observation, record review, and interview, the facility failed to ensure staff used enhanced barrier precautions during catheter care for 1 (#11) of 1 sampled resident reviewed for catheter care.The facility roster matrix showed four residents in the facility had urinary catheters. Findings:On 01/07/26 at 9:35 a.m., CNA #1 and CNA #2 were observed to provide urinary catheter care for Resident #11. The CNAs were observed to provide resident privacy, set up supplies, and don gloves. The CNAs were observed to provide catheter care without wearing a gown.An undated policy titled Enhanced Barrier Precautions, showed enhanced barrier precautions were needed for residents with a catheter to prevent the spread of infections, especially multidrug-resistant organisms in the facility. The policy showed gloves and gowns must be worn whenever touching the resident or their environment.A care plan, dated 12/05/25, showed Resident #11 had an indwelling catheter and was at risk for infection and complications related to catheter use and required enhanced barrier precautions to maintain safety and reduce infection transmission. The care plan showed the staff should consistently utilize gowns, gloves, and hand hygiene during high-contact care.A quarterly assessment, dated 12/20/25, showed Resident #11's cognition was severely impaired with a BIMS score of 03. The assessment showed the resident had an indwelling urinary catheter.A physician's order, dated 12/25/25, showed urinary catheter change to be performed monthly related to a diagnosis of urine retention.On 01/07/26 at 9:45 a.m., CNA #1 and CNA #2 stated they should have worn a gown during catheter care for enhanced barrier precautions.On 01/07/26 at 4:45 p.m., the ADON stated staff should have worn gowns and gloves when performing urinary catheter care.

Based on record review and interview, the facility failed to ensure the results of an abuse investigation were submitted to the state within five business days for one (#1) sampled resident reviewed for abuse. The administrator identified 39 residents resided in the facility. Findings: An undated facility policy titled Policy: for reporting neglect and/or abuse, read in part, 1. Purpose: The purpose of this policy is to establish guidelines for reporting incidents of abuse and neglect in a long-term care facility, in compliance with state and federal regulations. Resident #1 had diagnosis which included mental disorder and was wheelchair bound. An Initial State Reportable Incident form, faxed 07/22/24 at 12:30 p.m., documented an allegation of abuse/mistreatment. It documented CNA #2 notified CNA #1 that Resident #1 had picked up their pizza box. CNA #1 grabbed Resident #1's wheelchair and spun them around and yelled in their face, and then again aggressively spun them around and pushed them from the table while being gruff and yelling at them. It documented cameras were in use at the time and the family, resident's legal representative, and police were notified. It documented the resident was no longer in danger and CNA #1 was sent home and the incident was reported to the nurse aide registry. An Initial and Final Reportable Incident form, faxed 08/07/24 at 11:42 a.m., documented in the final report the police chief was notified and reviewed the cameras and information was passed on to the district attorney and neither party wanted to prosecute. It documented CNA #1 was terminated and reported to the nurse aide registry. On 10/15/24 at 10:56 a.m., the administrator was asked about the facility policy to report abuse. They stated if there was bodily injury they reported within two hours and this incident was not. They stated the incident was reported within 24 hours. They were asked if the final report was submitted to the state within five business days. They stated the one labeled initial and final was the final report, however, they did not fax it within five days and did not keep the fax confirmation.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported within 24 hours to OSDH of an incident of abuse for one (#1) of three sampled residents reviewed for allegations of abuse. The DON reported 38 residents resided in the facility. Findings: An incident report dated 06/03/24 at 2:57 p.m. CNA#1 reported alleged abuse occurred on 06/01/24. CNA #1did not report to LPN#1 until 06/02/24. On 06/06/24 at 4:15 p.m., CNA#1 stated the alleged abuse occurred on 06/02/24 at 6a.m. during the 11a.m.-7p.m. shift. The alleged abuse was reported on 06/02/24 11p.m. to 7a.m. shift to LPN #1 charge nurse. On 06/07/24 at 1:04 p.m., the Administrator reported CNA #1 witnessed an abuse on 06/01/24 and reported to LPN #1. On 06/02/24, the incident report was faxed on 06/03/24 at 2:57 p.m The 24 hours had exceeded.

Based on record review and interview, the facility failed to ensure that training was being provided for activities that contribute abuse/neglect, procedures for reporting incidents of abuse/neglect, and abuse prevention for one (#1) of one records records reviewed for abuse. The DON reported 38 residents reside in the facility. Findings: A Policy and Procedure: Training for Nurses and CNAs policy, undated, read in parts .Documentation will include dates and training, completion status, competency assessment results, and certificates of participation or completion .The Quality Assurance department will conduct periodic audits of training records to verify compliance with training . On 06/06/24 at 3:58 p.m., there was no documentation of CNA #1 of having abuse/neglect training of which includes reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property during CNA #1's orientation. On 06/07/24 at 1:06 p.m., the DON reported CNA #1 had no abuse/neglect training's completed during orientation.

Based on record review and interview, the facility failed to submit PBJ FY Quarter 1 2024 ([DATE]-[DATE]) for direct care staffing based on payroll data. The administrator reported 38 residents resided in the facility. Findings: On 05/29/24 at 4:30 p.m., the administrator was asked about the PBJ report for the first quarter of 2024 ([DATE] - [DATE]). They reported it was not submitted within the required time frame. On 05/31/24 at 2:58 p.m., the administrator was asked about the facility's PBJ policy. They reported the policy was to complete them quarterly.

Based on record review and interview, the facility failed to develop, implement a policy and procedure for monitoring Legionella. The DON reported 38 residents resided in the facility. Findings: On 05/31/24 at 9:25 a.m., the maintenance director was asked to submit a specific policy for measures to prevent the growth of Legionella. They did not provide any descriptions of the water systems for visible inspection and/or steps to prevent the growth of Legionella in a flow diagram. On 05/31/24 at 9:15 a.m., ADON/IP reported there had not been any cases of Legionella. On 05/31/24 at 9:45 a.m., the administrator and DON were asked to the submit policy and procedures to include diagrams to identify areas of potential outbreaks of Legionella. The administrator reported they did not have a policy and procedure related to Legionella. 41873

Based on record review and interview, the facility failed to ensure the resident assessment was transmitted within seven days of completion for one (#19) of one sampled resident reviewed for discharge assessments. The DON reported 38 residents resided in the facility. Findings: A Minimum Data Set (MDS), policy and procedure, not dated read in part, .Our facility is committed to ensuring the accurate and timely completion of the Minimum Data Set (MDS) for all residents, as required by federal and state regulations . On 05/30/24 at 9:30 a.m., the DON reviewed Res #19's MDS assessment. They reported there was a glitch in the system and the MDS coordinator did not receive a report that Res #19's MDS had not been submitted. They reported the MDS assessment was submitted yesterday. On 05/30/24 at 9:40 a.m., the DON notified the MDS coordinator on the phone via speaker. They reported they had a software issue with PCC. Reported they did not notice if it was on the report as accepted or rejected. They reported they modified the MDS because of the re-entry dates and transmitted the MDS yesterday. They reported they signed the MDS yesterday 05/29/24 at 11:15 p.m., and transmitted it.

Based on record review and interview, the facility failed to update the plan of care related to documented falls for two (#22 and #29) of five sampled residents reviewed for falls. The DON reported 38 residents resided in the facility. Findings: A Long Term Care Facility: Care Plan Policy and Procedure, not dated, read in part, .All residents will have a care plan that is resident-centered, addressing their medical, psychological, and social needs. Care plans will be developed, reviewed, and updated regularly in collaboration with residents, their families, and the interdisciplinary care team . Care interventions will be carried out as outlined in the care plan . A plan of care dated 12/12/23 through 06/12/23, documented, the resident is high risk for falls r/t Parkinson's disease. New Goal New Custom Goal: The resident will be free of falls through the review date. New Intervention: New Custom Intervention Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: morning exercises, walk to dine. Ensure that the resident is wearing appropriate footwear black non-skid tennis shoes when ambulating or mobilizing in w/c. Follow facility fall protocol. Pt evaluate and treat as ordered or RESIDENT SEEN [Name Withheld-Physician] ON THE EVENING OF 1-8-24 D/T RESIDENT STATING SHE HAD FALLEN AND GOTTEN HER SELF UP. BRUISE WITH A KNOT NOTED TO RIGHT HIP. ORDERED X-RAY OF R HIP AND L KNEE. RESIDENT SENT OUT FOR X-RAYS ON 1-9-24. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. A significant change assessment dated [DATE], documented, severe cognitive impairment, with partial/moderate assistance with some activities of daily living. Number of falls since admission or prior assessment - no Injury: two or more. Number of falls since admission or prior assessment - injury (except major): two or more. Number of falls since admission or prior assessment - major injury: none. Res #22 had 8 un-witnessed falls documented from 01/08/24 through 05/14/24. The reports document immediate action taken; however, did not list interventions put into place after the falls. Res #22's incident reports, dated 01/08/24, 01/15/24, 02/13/24, 03/21/24, 03/25/24, 04/01/24, 04/17/24, and 05/14/24. On 05/29/24 at 3:10 p.m., Res #22 was using a rolling walker in hallways. On 05/30/24 at 10:48 a.m., the DON was asked about the corresponding fall interventions for Res #22. They reported they would update the plan of care and RN #1 was good about doing that. On 05/30/24 at 11:01 a.m., the DON reported RN #1 had not updated the plan of care related to the corresponding falls and reported they would let them know. 41873 2. Resident #29 had diagnoses which included hemiplegia. A comprehensive assessment, dated 02/15/24, documented cognition was severely impaired. An incident note, dated 03/24/24, read in part .Upon entering the room resident #29 was observed lying on the floor, lying on their right side .Resident was assisted back to his recliner .The resident had a small-moderate amount of bright red blood from the back of head and two large hematoma's. A progress note, dated 03/24/24, read in part .Upon entering the room resident #29 was observed lying on the floor, lying on their right side .Resident was assisted back to his recliner .The resident had a small-moderate amount of bright red blood from back of his head and two large hematoma's .Resident transported to emergency room for evaluation and treatment . A care plan, updated 03/20/24, read in part Risk for falls .Assist resident with ambulation and transfers, utilizing therapy recommendations .Determine residents ability to transfer .Ensure call light is available to resident .If fall occurs, alert provider .If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol .If resident is a fall risk, initiate fall risk precautions .Review medications for drugs that increase the risk of falls .Utilize devices as appropriate to ensure safety. The care plan documented no updates related to falls after 03/20/24. A progress note, dated 03/24/24. read in part .Resident #29 returns with discharge paperwork, neuro checks ordered, laceration to head cleaned, triple antibiotic ointment applied, and orders to repeat three times a day, no other new ordered noted . On 05/31/24 at 10:28 a.m., ADON reported resident care plans should be updated with fall interventions after each fall. The ADON reported not all care plans had been updated with new interventions after each fall.

Based on record review and interview, the facility failed to ensure the medication was necessary to treat a specific condition indicated in the clinical record for three (#7, 14, and #31) of five residents reviewed for unnecessary medications. The DON reported 38 residents resided in the facility. Findings: An Antipsychotic Medication Policy and Procedure for Long-Term Care, not dated, read in part, .Assessment and Indication: Clinical Indication: Antipsychotic medications should only be prescribed for residents with a diagnosed psychiatric disorder (e.g., schizophrenia, bipolar disorder) or for the management of severe behavioral symptoms associated with dementia when other interventions have failed . A facility document titled, Psychosis/Schizophrenia/Behaviors, not dated, read in part, Antipsychotic's require specific diagnosis and behavior monitoring . Res #7's diagnosis included other recurrent depressive disorders, delusional disorders, generalized anxiety, and restlessness and agitation. 1. A physician's order as of 05/09/24 read in part, Ativan 0.5 mg give by mouth every 6 hours, order date 04/24/24 for agitation, Buspirone 15 mg give one tablet two times a day for dementia, order date 04/24/24, Klonopin 1 mg give one tablet by mouth two times a day for dementia, order date 05/20/24, Zoloft give 1.5 tablet by mouth once time a day, order date 11/11/22, give 1 1/2 tabs to =75 mg related to other recurrent depressive disorders, Zyprexa 10 mg give one tablet by mouth two times a day for dementia, order date 04/24/24. Refer to [Name Withheld-Psych Facility] order date 04/11/24 .Behaviors - Monitor for the following: (specify) itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusion, hallucinations, psychosis, aggression, refusing care . Behavioral charting for March 2024 consisted of 12 days, April 2024 consisted of 13 days, and May 2024 consisted of 7 days charted as Yes for behaviors. On 05/31/24 at 10:28 a.m., ADON was asked about medications administered for a diagnosis of dementia. They reported the pharmacist request appropriate diagnosis and they try to get them changed. They reported the pharmacist in-serviced them on what they could chart for what to be considered a behavior. They reported the residents were under the care of Geri psych facility and medications were prescribed from them. On 05/31/24 at 11:12 a.m., ADON provided antipsychotic policy and a Buspirone order with a diagnosis of anxiety not dementia. They reported they would need to change that. 41873 2. Resident #14 had diagnoses which included dementia. A comprehensive assessment, date 02/25/24, documented resident #14's cognition was severly impaired. A care plan, dated 02/15/24, read in part, The resident has a behavior problem (agitation/anxiety) related to dementia . Risperidone 0.5 mg one by mouth every night .The resident has impaired cognitive function/dementia or impaired thought processes related to Dementia. A pharmacist's monthly medication review, dated 04/08/24, documented no psychotic behaviors for risperidone reported. A physician order, dated 05/22/24, documented risperidone oral tablet 0.25 mg, give 1 tablet by mouth one time a day every other day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety until 06/05/24. 3. Resident #31 had diagnoses which included dementia. A pharmacist's monthly medication review, dated 03/08/24 , documented a recommendation to decrease risperidone from 05. mg to 0.25 mg for gradual dose reduction, will need a psych diagnoses, and psych behaviors monitored. A comprehensive assessment, dated 04/22/24, documented severly impaired cognition. A care plan, updated 04/29/24, read in part Behavior management: Resident seen Dr. [name removed] 03/12/24 due to pharmacy recommendation to decrease risperidone to 0.25 mg daily, physician agreed .The resident has impaired cognitive function/dementia or impaired thought process related to dementia .Administer mediations as ordered . A pharmacist's monthly medication review, dated 05/13/24, documented Finding no diagnoses or behaviors to justify the use of risperidone .Recommend a decrease to every other day for gradual dose reduction .On 05/21/24, a physician disagreed due to agitation is under control with this medication, no change at this time . On 05/31/24 at 10:28 a.m., ADON was asked about antipsychotic medications being administered for a diagnosis of dementia. The ADON reported the pharmacist had requested an appropriate diagnosis for antipsychotic medications from the physician [name removed] and the physician fails to respond. The ADON reported resident's #14 and #31 physician [name removed] preferred to use risperidone to control behaviors for residents with dementia.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to perform neuro checks as ordered by the physician, and to notify the physician with a change of condition per the facility's Neuro Checks Policy and Procedure. The resident passed away that night. On [DATE] at 1:05 a.m., Resident #43 had a fall and reported to the nurse he had hit his head and complained of pain all over. The resident was sent to the ER per physician orders. The hospital record documented the resident fell backwards and was complaining of a headache. The resident was given pain medication and sent back to the facility with orders to do neuro checks every two hours for 24 hours. The neuro check form documented neuro checks were completed every two hours until 7:30 p.m. The form had no neuro checks documented at 9:30 p.m. At 10:45 p.m., the resident started having behaviors. No neuro checks or vital signs were documented at that time and the physician was not notified of a change in condition. There were no 11:30 p.m. neuro checks documented. At 12:30 a.m., the aides found the resident unresponsive in his bed and reported to the nurse the resident was cold to the touch. The nurse checked for the resident's pulse with no return. The ARNP was notified, arrived at the facility, found no pulse or respirations, and notified the physician of the patient's death. An Emergency Department Note, dated [DATE], read in parts, .MD complaint: .fell backwards c/o headache . Neuro Cognition (Neuro): abnormal cognition . Thought process: Other thought process findings present . Additional Instructions: neuro checks q 2 hours . On [DATE] at 11:09 a.m., the Oklahoma State Department of Health was notified of the existence of a possible IJ situation. On [DATE] at 12:39 p.m., OSDH verified the existence of the IJ situation. On [DATE] at 1:00 p.m., the Administrator and the DON were notified of the IJ situation. On [DATE] at 4:47 p.m., an acceptable Plan of Removal was provided by the Administrator. The Plan of Removal documented the following: Colonial Manor II Nursing Home IJ Plan of Correction: Immediacy will be removed by 1700 [5:00 p.m.] on [DATE]. Plan of Correction for Findings on Resident #43: To remove the immediacy of IJ the facility will do an in-service with all full time and part time RNs and LPNs to ensure they know the proper procedures to complete neuro checks according to Colonial Manor II Policy. Facility is also writing and adopting a policy outlining the procedures for receiving, charting, and following physician orders. RNs and LPNs will also be instructed on following Physician Order policy. The nurses attending the in-service will sign that they have understood and completed the training. This in-service will take place on [DATE] once the facility plan of correction is approved by the State Health Department. It is planned that the immediacy will be removed by 1700 [5:00 p.m.] on [DATE]. Currently we have a resident that is receiving neuro checks and neuro checks are being done as ordered. Agenda for In-Service to address Neuro Checks and Physician Orders Pass out copies of Neuro Check Policy and Procedure Pass out copies of Physician Order Policy. Read the policies and go over procedures for following Neuro Check Policy and Physician Orders State the importance of following policy fully. Allow nurses to ask questions to clarify that everyone is on the same page. Have nurses sign that they understand and will comply with the facilities Neuro Check Policy and that they will follow Physician orders fully. Follow up to ensure policy and procedures are being followed. Charting on neuro checks and physician orders will be monitored daily by DON, [name deleted], for a week starting [DATE] after the in-service on following physician orders and neuro checks is complete. After the initial first week of monitoring charting on neuro checks and physician orders is complete the DON and/or ADON, [name deleted], will monitor the charting weekly for three months. Once, the monthly monitoring is complete all the charting done on residents will be reviewed quarterly for any issues or problems and the findings will be addressed with the QA committee during QAPI meetings. On [DATE], observations were made of facility staff in the in-service meeting and interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The immediacy was lifted, effective [DATE] at 4:00 p.m., when all elements of the plan of removal had been implemented. The deficient practice remained at an isolated level with harm. Based on record review and interview, the facility failed to ensure neuro checks were completed per physician orders, and the physician was notified of a change in the resident's condition, for one (#43) of four residents reviewed for falls with neuro checks. The Resident Census and Conditions of Resident report, dated [DATE], documented 42 residents resided in the facility. Findings: Resident #43 had diagnoses which included right below the knee amputation, hypertension, depression, and cardiac pacemaker. An Annual Assessment, dated [DATE], documented the resident's cognition was intact. The Neuro Checks policy and procedure, dated ,d+[DATE], read in part, .5. Notify the resident's physician immediately of any abnormal Neuro Checks or any changes in the resident's condition. The Physician Order policy, dated ,d+[DATE], read in part, .6. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift by the RN or LPN. An Incident Note, dated [DATE] at 1:05 a.m., documented, called to residents room by CNA. Resident noted on floor next to bed. Koolaid and water noted on floor. Resident wet all over. Resident stated he tried to get out of bed and walk. Abrasion to left forearm noted. No blood or raised areas noted from head. Dressing to left leg noted on floor, resident stated he had taken dressing off before attempting to get out of bed. Resident states he did hit his head. C/O pain to all over. Vitals: ,d+[DATE]-,d+[DATE]- SAO2 =72% WITH O2 ON 3L N/C. [name deleted] ARNP called and updated. [name deleted] EMS called. Resident transported to [name deleded] for eval and treatment. A Health Status Note, dated [DATE] at 2:46 a.m., documented, [name deleted] called to update resident will be discharge and coming back to NH. Report given by [name deleted]. [name deleted] states resident received in ER 1000 mg of tylenol for pain. Xrays and CT scans are clear. No fracture or injuries noted from fall. New order received neuros ever 2 hours X 24 hours. Awaiting residents arrival via EMS. A Health Status Note, dated [DATE] at 3:23 a.m., documented, resident returned to facility via EMS. VSS; ,d+[DATE]-[DATE].4. SAO2 94%. New orders for neuros Q 2 hours X 24 hours. Neuros initiated and WNL. Resident in bed at this time. No C/O voiced. Resting OU closed. Call light in reach. A Nurses Note, dated [DATE] at 10:45 p.m., documented, Resident having behaviors this evening. Grabbed CNA by both arms and yelled, help me get out of here, help me, and making numerous other statements that made no sense. There was no documentation the physician was notified. An Alert Note, dated [DATE] at 00:30 a.m., [12:30 a.m.] read in parts, .Aides approached this nurse at nurses station and said that they found resident unresponsive in bed laying on his right side holding on to his bed side rail. They said resident was cold to the touch. This nurse went down to his room and checked for pulse with no return.ARNP notified of status .She is on her way to officially pronounce.DON and ADM notified. An Alert Note, dated [DATE] 12:45 a.m., read in part, .[name deleted] ARNP arrived at facility and pronounced resident has passed away. She also gave a 1x order for no CPR due to no signs of life. A Neuro Check report, dated [DATE], documented the resident received neuro checks starting at 3:30 a.m., every two hours until 7:30 p.m. There were no documented neuro checks at 9:30 p.m., at 10:45 p.m. when the resident was having behaviors, or at 11:30 p.m. The form documented at 12:30 a.m., Patient passed away. On [DATE] at 11:10 a.m., the Administrator reported, I was in shock when I heard the resident had passed away. On [DATE] at 3:50 p.m., LPN #1 stated, I left at 11:00 p.m. I did do his neuros, I just didn't get them documented. LPN #1 was asked what was done when the resident started having behaviors. She said, He usually had behaviors so I didn't think the behaviors he had the night he died was related to his neuro checks. On [DATE] at 5:15 p.m., the DON and ADON were asked if the resident usually had behaviors. The DON stated, He was just like you and me, he didn't have any behaviors. The ADON stated, He never had behaviors.

Based on observation and interview, the facility failed to ensure expired medications were removed from the medication storage room and from the medication cart. The Resident Census and Condition of Residents, dated 04/13/23, form documented 42 residents resided in the facility. Findings: On 04/13/23 at 9:00 a.m., during a tour of the medication room, two expired medications were observed. The medications included a bottle of Tums, for resident #36, with an expiration date of 7/22, and a bottle of Metformin 500 mg, in the Emergency Box, with an expiration date of 2/23. On 04/13/23 at 9:25 a.m., the medication cart was observed to have one expired medication, a bottle of Refresh eyes drops, for resident #7, expired 3/23. On 04/13/23 at 9:30 a.m., CMA #1 was asked how often staff checked for expired medications. The CMA stated, I haven't checked in about six months. On 04/13/23 at 10:00 a.m., the DON reported the pharmacist was supposed to be doing a check monthly for expired medications.

Based on record review, and interview, the facility failed to ensure a care plan was revised for fall interventions for one (#23) of four sampled residents reviewed for falls. The Administrator reported a facility census of 42 residents. Findings: Resident #23 was admitted with diagnoses which included hypertension and seizure disorder. A Quarterly MDS Assessment, dated 01/23/23, documented the resident was independent with ambulating and had two or more falls since admission. A nursing note, dated 12/01/22, documented the resident had a fall and was sent to the local hospital. The resident's seizure medication had been decreased. A nursing note, dated 12/01/22, documented the resident was moved to a room closer to the nurse's station .wheelchair in use. The resident was non-compliant with utilizing the call light for assistance. A nursing note, dated 12/01/22, documented a floor mat had been placed next to the bed in the lowest position .resident was found on the floor mat. A nursing note, dated 12/27/22, documented the resident's medication was adjusted and updated on the MAR. The resident continues with neuro checks at this time and was encouraged to use a walker or wheelchair, and wear his helmet. A nursing note, dated 12/27/22, documented the resident had a witnessed fall. The resident will not wear non-skid footwear properly and is non-compliant with safety. A nursing note, dated 12/29/22, documented interventions in place and resident is toileted frequently, every 30 minutes. The resident does have a helmet to wear for safety, but will not wear it. A revised Care Plan, dated 11/11/22, documented the resident was at moderate risk for falls and interventions included: anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it; and, the resident needs prompt response to all requests for assistance. On 04/14/23 at 8:38 a.m., the DON reported the resident had been educated and multiple fall interventions had been in place, but not updated on the resident's care plan.

Based on record review and interview, the facility failed to have a Registered Nurse on duty eight hours a day, seven days a week. The Resident Census and Condition of Residents form documented 37 residents resided in the facility. Findings: During the survey process, staffing schedules and reports were reviewed and documented inconsistent RN coverage, with no RN coverage on most weekend shifts. The staffing schedules for 4/17/22 through 04/30/22 documented no RN coverage for any weekend shifts. On 04/22/22 at 9:51 a.m., the ADON reported weekend shifts were currently being covered by LPN/Charge Nurses. The ADON stated there had been a waiver related to RN coverage sometime in the past but that had been a long time ago. The ADON reported there were a couple of RN's who picked up an occasional weekend shift but not on a regular basis. On 04/22/22 at 10:18 a.m., the Administrator and DON were interviewed regarding RN coverage. The DON reported she covered some weekend shifts as needed and the previous DON would occasionally cover a weekend shift. The DON stated for a period of time the facility was covered well on the weekends but for various reasons, the RN's were no longer available. The Administrator reported the facility had struggled with hiring RN's. He stated he had intended to get in touch with someone to inquire about a waiver related to RN coverage but had not started that process.

Based on record review and interview, the facility failed to complete an annual performance review of nurse aides, and to provide regular in-service training. The Resident Census and Conditions of Residents form documented 37 residents resided in the facility. Findings: On [DATE] at 9:36 a.m., the assistant Administrator reported nurse aide annual re-training and/or competency skills performance reviews had not been completed. She stated the previous DON would not ensure these were completed but the new DON was working on getting this implemented. On [DATE] at 9:50 a.m., the Administrator reported he and the DON were working on organizing in-service training to ensure all required training was completed annually. The Administrator stated the DON had a plan for implementing annual nurse aide performance reviews. On [DATE] at 10:36 a.m., a file with in-service training was reviewed and documented various general in-services related to fire extinguishers, CPR training, teamwork and payroll, cell phone use, rounding on residents, and resident rights. The Administrator acknowledged the in-services did not meet all necessary requirements for nurse aide training.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 05/26/21 related to the facility's failure to provide adequate supervision to ensure a resident remained safe and free from elopement. The facility failed to provide adequate supervision to resident which resulted in him getting out of the facility unattended. The resident remained off the premises all night during a rain storm. On 06/17/21 at 3:05 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to provide adequate supervision to protect the resident and prevent elopement. Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received adequate supervision to prevent elopement for one (#1) of three sampled residents reviewed for elopement. Resident #1 had exited the facility unattended and remained off premises all night during a rain storm. The facility reported a resident census of 40. The facility reported no other incidents of resident elopement. Findings: Resident #1 had diagnoses which included dementia, congestive obstructive pulmonary disease, and anxiety. A quarterly assessment, dated 05/07/21, documented the resident's cognition was severely impaired and was independent with all activities of daily living. An incident report, dated 05/27/21, documented the resident eloped from the facility. The facility could not provide documentation to indicate the report had been faxed to the state agency (OSDH). The incident did not document the resident's representative or physician had been notified of the incident. The resident's current care plan, dated 05/07/21, had not been updated to address the incident of elopement on 05/26/21. On 06/17/21 at 10:00 a.m., the assistant director of nursing (ADON) reported the resident had left the building unobserved but was only missing for about 40 minutes. She reported the resident had gone to the bathroom and then went outside. The ADON reported the resident was found on the facility property on the back side of the alley. The ADON reported the police were called but stated staff found the resident right before the police arrived so a police report was not completed. On 06/17/21 at 10:50 a.m., an interview was conducted with the resident, two interpreters were present during the interview. The resident stated he wanted to go outside and tried to come back in but couldn't. The resident reported staff found him the next morning and brought him back in. The interpreters reported the resident kept repeating, God was watching over me. At 11:30 a.m., certified nurse aide (CNA) #5 reported when she arrived to work at 7:00 a.m. on 05/27/21, everyone was looking for the resident. She was asked where the resident was found. She stated staff all went outside and a dietary staff member found the resident between two houses across from the alley. The aide then stated the resident was on the ground next to a dog house, with a dog blanket covering him and a tin can covering his head. She was asked what the weather was like. She stated there had been [NAME] all night and the resident was drenched. She then added the resident was brought in and given a shower and provided breakfast. When asked if there was any injury she stated he had a scratch on his forehead. At 11:45 a.m., CNA #3 pointed to where the resident was found and stated the resident, looked really bad, and it had stormed and rained all night. At 11:50 a.m., the maintenance manager reported the house on the back side of the alley was not part of the facility property. He reported the alarm on the door was really a door chime, and as far as he knew it was not working at the time of the incident. At 11:55 a.m., the administrator (ADM) provided video from the facility security camera. The video showed on 05/26/21 at 10:58 p.m., the resident exited the facility through the back door on the north hall. The resident was observed through the glass door trying to open the door to get back inside but the door had locked behind him. At 1:00 p.m., the ADM reported the resident was first reported missing the following morning, 05/27/21, at approximately 6:40 a.m. and staff started to immediately look for him. He then added the police were called at 7:15 a.m. He was asked where the resident was found. He stated dietary staff found him across the alley between two homes. He was asked what he had done regarding the incident. He stated the LPN that was on duty was counseled on making rounds every two hours and he two CNA's working were provided with a verbal warning regarding rounding on the residents. He then added all nursing staff was in-serviced on 06/08/21 and 06/09/21 regarding elopement and making routine rounds. He then stated the door the resident had exited through had a new lock and alarm installed on 06/11/21. At 1:30 p.m., the ADM provided documentation to show all nursing staff had been in-serviced on 06/08/21 and 06/09/21. He also provided documentation to show a new lock/alarm system had been installed on 06/11/21. The ADM provided a documented account of the events that occurred the morning of 05/27/21 and everything the facility had implemented to prevent another elopement. Throughout the survey staff was interviewed regarding the in-services provided on 06/08/21 and 06/09/21 and all staff were knowledgeable on the topics covered during the in-service. At 2:15 p.m., licensed practical nurse (LPN) #1 reported she thought she had set the alarm the night of 05/26/21 but didn't really know how to work it. The LPN stated she was new to the facility and didn't receive any training on setting the alarm when hired. The LPN stated the other nurse who worked the night shift was also new and she didn't know how to set the alarm either.

Based on observation, interview, and record review, it was determined the facility failed to notify a family representative, and the residents' physician, of an elopement incident for one (#1) of three residents reviewed for notification. The facility reported 40 residents resided in the facility. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/07/21, documented the resident's cognition was severely impaired. The assessment documented the resident was independent with all activities of daily living. An incident report, dated 05/27/21, documented the resident eloped from the facility. The facility could not provide documentation to indicate the report had been faxed to the state agency (OSDH). The incident did not document the resident's representative or physician had been notified of the incident. On 06/17/21 at 10:50 a.m., two interpreters for the resident interpreted for him in an interview with the surveyor. The resident stated he wanted to go outside and tried to come back in but couldn't. The resident reported staff found him the next morning and brought him back in. The interpreters reported the resident kept repeating, God was watching over me. At 11:55 a.m., the administrator (ADM) provided video from the facility security camera. The video showed on 05/26/21 at 10:58 p.m., the resident exited the facility through the back door on the north hall. The resident was observed through the glass door trying to open the door to get back inside but the door had locked behind him. On 06/17/21 at 1:15 p.m., the director of nursing (DON) reported a family representative, as well as the resident's physician, should have been notified of the elopement incident which involved the resident remaining outside through the night.

Based on observation, interview, and record review, it was determined the facility failed to notify the state agency of an elopement incident for one (#1) of three residents reviewed for reporting. The facility reported 40 residents resided in the facility. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/07/21, documented the resident's cognition was severely impaired. The assessment documented the resident was independent with all activities of daily living. An incident report, dated 05/27/21, documented the resident eloped from the facility. The facility could not provide documentation to indicate the report had been faxed to the state agency (OSDH). On 06/17/21 at 10:30 a.m., the ADM reported, I filled out the form and gave it to my assistant to fax it in. At 10:35 a.m., the administrator's assistant reported, I don't know why it wasn't sent in. On 06/17/21 at 3:30 p.m., the director of nursing (DON) reported the incident should have been reported to the state agency.

Based on resident and staff interviews, it was determined the facility failed to ensure residents received mail delivery on Saturday. The facility census was 40. Findings: On 04/27/21 at 1:47 p.m., a resident group interview, with six alert and oriented residents, was conducted. The residents reported they did not receive mail on Saturdays. The facility offices were closed and there was no one to go to the post office and obtain the mail for the residents. They stated the mail is delivered with Monday's mail. At 1:51 p.m., the administrator was asked if the local post office sent mail out on Saturday. He stated the window at the post office is open for business. He was asked if the residents received any mail from the post office on Saturday. He stated, Not at this time.

Based on observation, record review and interview, it was determined the facility failed to ensure visual privacy for: ~resident that was partially dressed left in his room then propelling self in the hallway, and ~transferred from a wheelchair in the hallway to a shower chair inside the bathing room. This affected one (#16) of two residents observed for assistance with care. The facility's Resident Census and Condition of Residents identified 11 residents required assistance with transfers and 12 residents were totally dependent of staff for transfers. The facility census was 40. Findings: Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly assessment, dated 02/17/21, documented the resident had severe cognitive impairment for daily decision making, required limited assistance of one staff for transfers, dressing, toileting, and hygiene, and did not walk in his room or hallway. The resident care plan, last updated 02/17/21, did not address the resident's need for assistance in transfers, dressing, toileting, or hygiene. On 04/28/21 at 9:07 a.m., resident #16 was observed in his room, seated in a wheelchair. The resident was partially dressed, wearing a tank style T-shirt, one house shoe, and incontinent protection. The door between the resident room and hallway was opened. The privacy curtain was not pulled closed, exposing the resident into the hallway. At 9:25 a.m., the resident remained in his room. He was dressed as before with the exception of a crochet afghan in his lap. The resident entered into the hallway. CNA #1 approached the resident and redirected him back into his room, telling him he was to wait for his shower. The resident remained partially dressed and the door into the hall was opened. At 9:31 a.m., the resident remained partially dressed with lap robe across his upper legs, as he propelled himself down the hallway. The resident stopped at the end of the hall, in front of a full glass door to the street. At 9:50 a.m., resident # 16 was approached by CNA #1. The CNA assisted the resident to place his wheelchair in front of the shower/bathing room door. She removed the afghan from the resident and assisted him to transfer into a shower chair inside shower room. The resident was exposed to the hallway wearing his T-shirt and incontinent protection only. The door remained open due to the wheelchair blocking the ability to close the door. The staff pushed the shower chair into the shower stall prior to attempting to close the door to the hallway. CNA #1 was asked if there was a reason the resident was transferred from the hallway into the shower, allowing him to be exposed. She stated there was not always enough room to close the door prior to transfers if a resident required assistance with transfers. The CNA was asked if a privacy curtain was every utilized for privacy. She stated the bathing room being used did not have a privacy curtain and the other shower area was out of order. The CNA was asked if a resident required transfer assistance, did the staff ever utilize a free-standing privacy curtain/barrier to provide privacy and prevent exposure while disrobing/transfer assistance into the shower chair. She stated, no. On 04/28/21 at 4:12 p.m., the DON and administrator were informed of the observations. The DON stated the resident should not have been exposed to the hallway while not fully clothed and staff should not transfer residents in the hallway.

Based on record review and interview, it was determined the facility failed to ensure qualified staff accompanied a resident during transport to an appointment in the facility van for one of one (#1) resident reviewed for transportation by the facility. The resident's wheelchair wheels were not locked. The resident fell out onto the ground and sustained a cervical fracture. This had the potential to affect all 38 residents residing in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A care plan dated [DATE], documented the problem was, At risk for falls. The Goal was, Will be free of falls X 90 days. The approaches were, Encourage the resident to rest every afternoon, Encourage safety precautions, Monitor for signs of agitation . The quarterly assessment, dated [DATE], documented the resident required extensive assistance with transfers. A nurse's note, dated [DATE] at 1:00 p.m., documented the resident was going to an out of town appointment for a pacemaker check. The town was approximately 35 miles away. An incident report form, dated [DATE], documented the facility was transferring the resident from the facility to an out of town appointment in the facility van, accompanied by the maintenance supervisor who was also a certified nursing assistant (CNA) and one van driver (who had no certifications or licenses in regard to resident care) .She was unloaded from the van by both staff members and taken into the clinic by the van driver, while the other staff member staff member (sic) stayed with the other resident. When coming out to reload (resident's name) the van driver had her stationary by the van and turned to open the van door. During the process, (resident's name) wheelchair rolled. Van driver had not set the wheelchair brakes. (CNA) seen the wheelchair roll, but neither were able to stop the roll. (Resident's name) wheelchair hit the border of a decorated area that was spread with mulch. (Resident's name) did come out of the wheelchair and landed in the mulch. (Resident) was checked by CNA (name withheld) and the only injury found was a small scratch to (resident's name) nose. There was no bleeding or other signs of injury. (Resident's name) was talking and responding to him. Staff placed (Resident) back in her wheelchair and called the facility stating what had occurred. Administrator and RND (registered nurse director) left immediately to get resident. We arrived in approximately 30 minutes and (resident) was sitting in her wheelchair in the van which was running with the heater for warmth. She was alert, answered no to pain, pupils were round .RND stayed with (resident) and rode back in van with her. Approximately ,[DATE] minutes on the road, (resident) said her head hurt. RND contacted resident's physician with details of the incident and now the complaint of headache. Physician instructed for us to bring her to ER (emergency room ) . (Resident) was assessed in the ER, a C-T (computed tomography) scan and labs were obtained. Results were negative and (resident) was returned to the facility with orders for neuro checks . The next morning (resident) did eat breakfast and lunch in bed .was receiving Tylenol (pain reliever) for headache. Facility called nurse practitioner who came to the facility and re-assessed (resident). Stated to continue Tylenol for pain and resume normal activities on [DATE] and if (resident's) condition did not improve test will be redone. Later that evening (resident's) pain worsened and she was sent back to the ER for evaluation where she was found to have a fracture to her cervical spine . .(Van driver) stated that he forgot to lock the wheelchair . .Maintenance/CNA stated he was stunned and honestly did what he thought best at the time for the resident . A nurse's note, dated [DATE] at 4:30 p.m., documented the resident was taken to the emergency room in the town the facility was located in per the physician's orders [REDACTED]. A nurse's note, at 5:10 p.m., documented the resident was returned to the facility from the emergency room with orders to follow up with her physician the following Monday. A nurse's note, dated [DATE] at 6:00 p.m., documented the resident was in excruciating pain with facial grimacing and moaning. A physician's orders [REDACTED]. A hospital radiology report from a computed tomography (CT) scan dated [DATE], at 9:22 p.m., documented the resident had a Type III odontoid fracture with dorsal angulation, bilateral C1 (cervical spine) posterior arch fractures, and a left C1 [MEDICATION NAME] process fracture. The resident never left the hospital and expired on [DATE]. On [DATE] at 11:30 a.m., the administrator stated the resident had been accompanied to her pacemaker check appointment in another town by the facility's maintenance man, who was also a certified nursing assistant and the bus driver, who had no certifications or licenses in regard to resident care. She was in agreement the resident had not been accompanied to her out of town appointment in the facility van with the appropriate/adequate staff to provide assistance and care for her. The resident's death certificate dated [DATE], documented the immediate cause of death was, Complications of cervical spine fractures.

Based on record review and interview, it was determined the facility failed to utilize a wheelchair safely and failed to provide adequate supervision while the resident was being transported in the wheelchair. The resident's wheelchair wheels were not locked and the resident fell out onto the ground. This resulted in a cervical spine fracture for one of one (#1) resident reviewed for accidents. This had the potential to affect 10 residents who utilized a wheelchair for mobility according to the administrator. Findings: Resident #1 had [DIAGNOSES REDACTED]. A care plan dated [DATE], documented the problem was, At risk for falls. The Goal was, Will be free of falls X 90 days. The approaches were, Encourage the resident to rest every afternoon, Encourage safety precautions, Monitor for signs of agitation . The quarterly assessment, dated [DATE], documented the resident required extensive assistance with transfers. A nurse's note, dated [DATE] at 1:00 p.m., documented the resident was going to an out of town appointment for a pacemaker check. The town was approximately 35 miles away. An incident report form, dated [DATE], documented the facility was transferring the resident from the facility to an out of town appointment in the facility van, accompanied by the maintenance supervisor who was also a certified nursing assistant (CNA) and one van driver (who had no certifications or licenses in regard to resident care) .She was unloaded from the van by both staff members and taken into the clinic by the van driver, while the other staff member staff member (sic) stayed with the other resident. When coming out to reload (resident's name) the van driver had her stationary by the van and turned to open the van door. During the process, (resident's name) wheelchair rolled. Van driver had not set the wheelchair brakes. (CNA) seen the wheelchair roll, but neither were able to stop the roll. (Resident's name) wheelchair hit the border of a decorated area that was spread with mulch. (Resident's name) did come out of the wheelchair and landed in the mulch. (Resident) was checked by CNA (name withheld) and the only injury found was a small scratch to (resident's name) nose. There was no bleeding or other signs of injury. (Resident's name) was talking and responding to him. Staff placed (Resident) back in her wheelchair and called the facility stating what had occurred. Administrator and RND (registered nurse director) left immediately to get resident. We arrived in approximately 30 minutes and (resident) was sitting in her wheelchair in the van which was running with the heater for warmth. She was alert, answered no to pain, pupils were round .RND stayed with (resident) and rode back in van with her. Approximately ,[DATE] minutes on the road, (resident) said her head hurt. RND contacted resident's physician with details of the incident and now the complaint of headache. Physician instructed for us to bring her to ER (emergency room ) . (Resident) was assessed in the ER, a C-T (computed tomography) scan and labs were obtained. Results were negative and (resident) was returned to the facility with orders for neuro checks . The next morning (resident) did eat breakfast and lunch in bed .was receiving Tylenol (pain reliever) for headache. Facility called nurse practitioner who came to the facility and re-assessed (resident). Stated to continue Tylenol for pain and resume normal activities on [DATE] and if (resident's) condition did not improve test will be redone. Later that evening (resident's) pain worsened and she was sent back to the ER for evaluation where she was found to have a fracture to her cervical spine . .(Van driver) stated that he forgot to lock the wheelchair . .Maintenance/CNA stated he was stunned and honestly did what he thought best at the time for the resident . A nurse's note, dated [DATE] at 4:30 p.m., documented the resident was taken to the emergency room in the town the facility was located in per the physician's orders [REDACTED]. A nurse's note, at 5:10 p.m., documented the resident was returned to the facility from the emergency room with orders to follow up with her physician the following Monday. A nurse's note, dated [DATE] at 6:00 p.m., documented the resident was in excruciating pain with facial grimacing and moaning. A physician's orders [REDACTED]. A hospital radiology report from a CT scan dated [DATE], at 9:22 p.m., documented the resident had a Type III odontoid fracture with dorsal angulation, bilateral C1 (cervical spine) posterior arch fractures, and a left C1 transverse process fracture. The resident never left the hospital and expired on [DATE]. On [DATE] at 11:30 a.m., the administrator stated the bus driver had stated he forgot to lock the wheelchair and was in agreement the wheelchair breaks should have been locked. She was in agreement the resident had not been supervised. The resident's death certificate dated [DATE], documented the immediate cause of death was, Complications of cervical spine fractures.