Every finding on record at Cottonwood Creek Skilled Nursing & Therapy

Based on observation and interview the facility failed to ensure residents right to privacy in their rooms for 2 (#27 and #39) of 3 sampled residents observed for resident rights. The administrator identified 76 residents resided in the facility. A Essentials of Resident Rights policy, dated 2020, read in part, Each resident has the right to enjoy privacy in their room. Always knock before entering a room, and if the resident is able to respond, wait for a response. Knock even when the door is open and the resident can see you, or if the resident cannot respond to let them know you are there. 1. Resident #39 had diagnoses which included chronic obstructive pulmonary disease and type two diabetes mellitus with diabetic neuropathy. Resident #39's significant change assessment, dated 01/11/25, showed the resident required partial/moderate to total assistance with their ADLs. On 02/05/25 at 10:16 a.m., LPN #1 sanitized their hands and entered the resident's room to obtain a FSBS. LPN #1 did not knock prior to entering the resident's room. 2. Resident #27 had diagnoses which included chronic congestive heart failure and type two diabetes mellitus with diabetic neuropathy. Resident #27's admission assessment, dated 01/01/25, showed the resident required one to two person assistance with their ADLs. On 02/05/25 at 10:23 a.m., LPN #1 sanitized their hands and entered the resident's room to obtain a FSBS. LPN #1 did not knock prior to entering the resident's room. On 02/05/25 at 10:28 a.m., LPN #1 stated they stated the policy for ensuring privacy and dignity for residents was to knock prior to entering room. They stated they did not knock on the residents doors prior to entering.

Based on observation record review, and interview, the facility failed to follow their policy on insulin administration for 2 (#27 and #39) of 3 sampled residents reviewed for medication administration. The DON identified 20 residents residing in the facility received insulin. Findings: A Medication Administration-General Guidelines policy, dated 01/2022, read in part, The person who prepares the dose for administration is the person who administers the dose. 1. Resident #39 had diagnoses which included chronic obstructive pulmonary disease and type two diabetes mellitus with diabetic neuropathy. Resident #39's significant change assessment, dated 01/11/25, showed the resident required partial/moderate to total assistance with their ADLs. On 02/05/25 at 10:16 a.m., LPN #1 sanitized their hands and entered the resident's room to obtain a FSBS. The resident's FSBS was 174. LPN #2 drew 10 units of Lantus into the insulin syringe and 2 units of regular insulin into another insulin syringe. LPN #2 verified the insulins with LPN #1 then handed both syringes to LPN #1. LPN #1 administered both insulins to Resident #39. 2. Resident #27 had diagnoses which included chronic congestive heart failure and type two diabetes mellitus with diabetic neuropathy. Resident #27's admission assessment, dated 01/01/25, showed the resident required one to two person assistance with their ADLs. On 02/05/25 at 10:23 a.m., LPN #1 sanitized their hands and entered the resident's room to obtain a FSBS. The resident's FSBS was 234. LPN #2 dialed the Lantus insulin pen to 25 units and drew 6 units of aspart insulin. LPN #2 verified the insulins with LPN #1, then handed both syringes to LPN #1. LPN #1 administered both insulins to Resident #27. On 02/05/25 at 11:11 a.m., LPN #2 stated they had drawn the insulin and gave the syringes to LPN #1 to administer. On 02/05/25 at 11:14 a.m., LPN #1 stated LPN #2 had drawn the insulin into the syringes and handed the syringes to them. They stated the person preparing the insulin should be the one to administer the insulin. On 02/05/25 at 11:16 a.m., LPN #1 stated policy had not been followed. On 02/05/25 at 11:19 a.m., the DON reviewed the policy and stated the policy was not followed.

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered for 1 (#30) of 18 sampled residents reviewed for following physician orders. The administrator reported 76 residents resided in the facility. Findings: Resident #30 had diagnoses which include chronic obstructive pulmonary disease and congestive heart failure. A physician's order, dated 12/03/24, showed the resident was to receive oxygen at 2 liters per nasal cannula every day and night shift related to chronic obstructive pulmonary disease with acute exacerbation. On 02/06/25 at 9:57 a.m., the DON stated, If there is an order for oxygen, then it is the responsibility of the assigned nursing staff to keep the oxygen on the resident. On 02/03/25 at 1:36 p.m., Resident #30 was observed with their oxygen tank set to 2.5 liters per nasal cannula. The oxygen tubing was in the bag attached to the oxygen concentrator and not on the resident. On 02/03/25 at 1:40 p.m., advanced certified medication aide #2 stated they did not know if Resident #30 was supposed to wear their oxygen all of the time, but they would check with the nurse. On 02/03/25 at 1:43 p.m., LPN #2 stated it was supposed to be on, but it was not. They then put the oxygen on the resident and checked their oxygen saturation which was 93%. LPN #2 stated Resident #30 was up in their wheelchair earlier and they must have forgot to switch it over.

Based on record review and interview, the facility failed to ensure a resident who received an anticoagulant medication had an acceptable diagnosis/indication for the use of the medication for 1 (#56) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 76 residents who resided in the facility. Findings: Resident #56 had diagnoses which included anxiety, displaced closed fracture of left femur from 2023, and mild cognitive impairment. A physician's order, initiated 09/27/23, showed to give Eliquis (an anticoagulant) 2.5 milligram tablet by mouth twice daily related to displaced closed fracture of the left femur (this diagnosis was from 2023 and was never updated). On 02/05/25 at 12:08 p.m., the ADON stated a displaced closed fracture of the left femur was no longer an appropriate diagnosis for Eliquis to continue to be given. On 02/05/25 at 12:12 p.m., the DON stated checking the accuracy of diagnoses was a group job. They stated a displaced fracture from 2023 was not an appropriate diagnosis for Eliquis.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for 1 (#8) of 18 assessments verified for accuracy. The administrator identified 76 residents resided in the facility. Findings: Resident #8 had diagnoses which included end stage renal disease. A physician's order, dated 02/22/24, showed dialysis: schedule visits to dialysis on Monday, Wednesday, and Friday at 6:30 a.m. at Anadarko for now. A nurse progress note, dated 02/23/24, read in part, resident continues dialysis Monday Wednesday and Friday. Resident continues to have fistula to left arm. An admission assessment, dated 02/28/24, showed the resident was not going to dialysis. On 02/05/25 at 8:19 a.m., the MDS coordinator stated the admission assessment documented Resident #8 was not on dialysis, but they have been since they arrived at the facility. On 02/06/25 at 9:59 a.m., the DON stated, I would expect the MDS to accurately reflect the residents condition.

Based on record review and interview the facility failed to ensure the OHCA was notified of a new mental health diagnosis for 1 (#2) of 1 resident sampled for preadmission screening and resident review. The administrator reported 76 residents resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE]. On 06/30/23 the resident received a mental health diagnosis of delusional disorders. The resident's record did not contain documentation the OHCA was notified of the new mental health diagnosis. On 02/05/25 at 3:00 p.m., the ADON reported they did not notify the state.

Based on observation, record review, and interview, the facility failed to ensure call devices were within reach for four (#3, 32, 51, and #63) and failed to ensure a resident's preference to have a microwave in their room was accommodated for one (#19) of six sampled residents reviewed for accommodation of needs. The administrator identified 69 residents resided in the facility. 1. Res #19 had diagnoses which included GERD, constipation, vitamin deficiency, anemia, diverticulosis, and diabetes. A resident handbook, read in part, .For your safety, and because of fire and safety regulations, the following items may not be used in the facility: Extension cords Fans with protective grills large enough for fingers to reach blades Electric space heaters Electric heating pads (unless accompanied by doctor's orders) Electric blankets (unless accompanied by doctor's orders) Cut Christmas trees Burning incense or candles Smoking materials, except in designated areas, if available Area rugs without non-slip rubber backing . An annual MDS, dated [DATE], documented Res #19 was cognitively intact, had no behaviors, it was very important for the resident to take care of their personal belongings, and was independent with eating. On 12/12/23 at 10:44 a.m., Res #19 was observed in their room, seated in a wheelchair. The resident's room was observed clean and with minimal clutter. They stated they had a microwave for over [AGE] years. They stated the administrator informed them they would be getting a roommate and took their microwave from their room. They stated the microwave was placed in a common area. They stated they were informed the microwave was a fire hazard. They stated they had not burned food or themselves in the last [AGE] years of using the microwave in the facility. They stated the facility did not assess them for safety before removing the microwave, only stating it was a fire hazard. On 12/14/23 at 9:25 a.m., the DON stated they had no information regarding Res #19's microwave. They stated they had not assessed the resident for safety. On 12/14/23 at 9:28 a.m., the administrator stated they were unaware the resident had the microwave until they were going to place a roommate in the room. They stated they removed it since it was a fire hazard. They stated the resident had no known history of safety concerns related to the microwave. They stated personal microwaves were not something that was specifically addressed with the residents. On 12/14/23 at 10:55 a.m., the administrator stated the resident was not assessed for safety prior to the removal of the microwave. 47751 2. Res #3 was admitted to the facility on [DATE] with diagnoses including dementia, pressure induced deep tissue damage right heel, neuralgia, insomnia, polyneuropathy. An admission assessment, dated 04/14/23, documented the resident was severely impaired in cognition, was totally dependent on staff for all ADL's, was incontinent of bladder and bowel. A quarterly assessment, dated 09/27/23, documented the resident was severely impaired in cognition, was totally dependent on staff for all ADL's, was incontinent of bladder and bowel, and received anti-depressant and antipsychotic medication. On 12/12/23 at 8:46 a.m., Res #3's call light was observed in the floor underneath the head of their bed between the headboard and the wall. The resident was sitting in their recliner unable to reach their call light. On 12/13/23 at 6:54 a.m., Res #3's call light was observed in the floor underneath the head of their bed between the headboard and the wall. The resident was sitting in their recliner unable to reach their call light. 3. Res #32 was admitted to the facility on [DATE] with diagnoses including dementia, a fractured left elbow and left pubis, and a history of falling. An admission assessment, dated 06/20/23, documented the resident was moderately impaired in cognition, was dependent on staff for most all ADL's, and was incontinent of bladder and bowel. On 12/12/23 at 8:50 a.m., Res #32's call light was observed lying on their bed and the resident was sitting in their recliner unable to reach their call light. 4. Res #51 was admitted to the facility on [DATE] with diagnoses including anemia, chronic kidney disease, and dependence on renal dialysis. An admission assessment, dated 08/21/23, documented the resident's cognition was intact, required assistance from staff for most all ADL's. On 12/12/23 at 10:06 a.m., Res #51's call light was observed lying at the end of their bed on a bedside table. The resident was asked if they were able to reach their call light. They stated they were not. On 12/13/23 at 6:57 a.m., Res 51's call light was observed lying at the end of their bed on a bedside table. 5. Res #63 was admitted to the facility on [DATE] with diagnoses including dysphagia and hemiplegia following a stroke and attention to gastrostomy. An admission assessment, dated 09/17/23, documented the resident was severely impaired in cognition, was totally dependent on staff for all ADL's, and was incontinent of bladder and bowel. On 12/12/23 at 8:41 a.m., Res #63's call light was observed draped over a bedside table drawer at the foot of their bed. On 12/13/23 at 7:02 a.m., Res #63's call light was observed lying in the floor underneath their bed. On 12/13/23 at 7:05 a.m., CNA #1 was asked what the facility policy was for call light placement. They stated it should be within the resident's reach. They were asked if residents #3, 32, 51, and #63's call lights were within their reach. They stated they were not. On 12/13/23 at 7:08 a.m., LPN #3 was asked what the facility policy was for call light placement. They stated the call light is supposed to be within the residents' reach at all times. They were shown residents' #3, 32, 51, and #63's call light placement. They placed the call lights within each residents reach. On 12/13/23 at 9:40 a.m. the DON was made aware of residents' #3, 32, 51, and #63's call lights were observed to be outside of the residents' reach on two separate dates. They were asked what the facility policy was for call light placement. They stated call lights are to be within their reach at all times.

Based on observation, record review, and interview, the facility failed to ensure menus were followed for one of one meal service observed. The DON identified 56 residents who received a diet with regular or mechanical soft texture. Findings: The summer to fall 2023 menu documented, on 12/12/23, residents were to have received bread of the day with their lunch meal. On 12/12/23 at 11:07 a.m., the lunch meal service was observed. Residents who received a diet with regular or mechanical soft texture did not receive the bread of the day. On 12/12/23 at 11:31 a.m., Dietary Cook #1 was asked if the residents received the bread of the day on their lunch trays. They stated they did not have bread to give the residents who had diets with regular or mechanical soft texture.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The DON identified 65 received services from the kitchen. Four resident received nutrition and hydration solely through a feeding tube. Findings: On 12/12/23 at 8:29 a.m., a tour of the kitchen was conducted. The following observations were made: a. material was peeling off of the ceiling in the dish wash area. There were brown water marks, b. ceiling lights were burned out and/or not working, c. the shields on the ceiling lights were cracked, d. there was an accumulation of black and white residue on the floor and walls in the dish wash area, e. there was an accumulation of lint on the return vent and lint was on the ceiling around the vent, f. material was hanging loose from the seams of the oven hoods, and g. there was an accumulation of food and dirt along the baseboards in the walk in cooler. On 12/13/23 at 10:06 a.m., the director of dietary operations was asked how staff ensured the kitchen was kept clean and maintained in good repair. They stated staff were to clean daily and maintenance concerns were to be reported to maintenance for repairs. They were shown the above observations.

Based on observation, record review, and interview, the facility failed to ensure tube feedings were administered timely for one (#53) of one sampled residents reviewed for tube feeding. The DON identified four residents received tube feedings. Findings: Res #53 had diagnoses which included dysphagia following cerebral infarction. A physician order, dated 03/22/23, documented to administer Isosource 1.5 enteral feeding six times per day at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. An annual MDS, dated [DATE], documented Res #53 was cognitively intact, received greater than 51% of total calories through tube feeding, and received greater than 501 ml of fluid intake per day by tube feeding. A physician order, dated 12/09/23, documented to administer Jevity 1.5 or Isosource 1.5 every six times per day at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. An EMAR administration details report documented Res #53's enteral feeding (tube feeding) was administered greater than one hour before or after the scheduled time eight of 48 opportunities from 12/01/23 to 12/08/23 and five of 25 opportunities from 12/09/23 to 12/13/23. On 12/12/23 at 1:17 p.m., Res #53 was observed seated in the recliner in their room. The resident's feeding tube was observed sticking out the bottom of their shirt. The resident stated they were not getting their feedings when they were supposed to. They stated it was sometimes an hour to an hour and a half late. They stated they had not lost any weight. On 12/14/23 at 9:20 a.m., the DON stated medications are due within an hour before or an hour after their scheduled time.

Based on observation, record review, and interview, the facility failed to ensure wound care treatments were completed as ordered for one (#3) of one sampled resident reviewed for pressure ulcers. The DON identified 12 residents with pressure ulcers in the facility. Findings: Res #3 had diagnoses including, dementia, neuralgia, and polyneuropathy An admission MDS assessment, dated 04/14/23, documented Res #3 was severely cognitively impaired. A physician order, dated 12/06/23, documented to perform wound care to the resident's right lateral heel by cleansing with normal saline, pat dry, and paint with betadine every day and night shift and PRN. The December 2023 TAR documented the treatment had not been completed twice daily on 12/9/23, 12/10/23, and 12/11/23. On 12/12/23 at 11:08 a.m., Res #3 was observed with a dressing dated 12/08/23 on their right foot. On 12/12/23 at 11:10 a.m., LPN #2 stated the dressing had not been changed according to the orders. On 12/12/23 at 2:10 p.m., the DON was made aware Res #3's treatment had not been performed since 12/08/23. They stated they had not been followed.

Based on record review, observation, and interview, the facility failed to provide sufficient staff to meet the needs of the residents. The Resident Census and Conditions of Residents report, documented 69 residents who resided in the facility. Findings: 1. On 11/14/22 at 12:40 p.m., Res #225 stated it takes forever for the call light to be answered. 2. On 11/14/22 at 1:15 p.m., Res #35 stated the call lights are not answered in a timely manner, and they are short handed. 3. On 11/14/22 at 12:13 p.m., Res #49 stated the call light was not working over the weekend. Res #49 pushed the call light at this time the light was on out side the resident's door. On 11/14/22 at 12:18 p.m., Res #49 stated staffing on weekends for the hall was one nurse, one CMA, and one CNA. On 11/14/22 at 12:58 p.m., no one had answered the call light for Res #49. On 11/14/22 at 1:01 p.m., housekeeping came in the room for the trash. The housekeeper did not ask the resident if she needed anything. On 11/14/22 at 1:03 p.m., the DON walked down the hall and past the resident room. When she came back down the hall she stopped and knocked on the door. A hospitality aide #1 was in the room, she stated she had just got in the room and had not turned off the light yet. The call light was not answered for 50 minutes for Res #49. On 11/18/22 at 11:52 a.m., the administrator stated 15 minutes would be an acceptable time for answering the call light. He stated 50 minutes was an excessive amount of time and should have been answered quicker. 4. On 11/14/22 at 12:00 p.m., Res #49 stated she had not had a shower in two weeks not even a bed bath. She stated her skin was flaking but she had no open wounds. The resident's bathing schedule was M-W-F. The bathing documentation in POC for the last 30 days from 10/20/22 through 11/16/22. Baths were not documented for October 24, 26, 28, and 31. The form documented the resident had refused a bath on 11/02/22 and 11/16/22. There was no bath or refusal documented for 11/14/22. On 11/18/22 at 7:36 a.m., CNA #1 stated it was very hard to get all the baths completed when you have seven to eight baths. She stated Res #49 took a long time and she is very particular. She stated even when changing the resident it takes a long time. She stated at one time the resident wanted to get up for a shower but was getting bed baths because of her knee. 5. On 11/14/22 at 2:59 p.m., Res #44 stated she did not receive ROM to her left side. The resident was observed on her back in the bed with her left arm on a pillow. The POC documented nursing rehab for passive ROM to BUE to hands, elbows and shoulders for two times for 10 repetitions by the RA as necessary. The documentation in the POC for ROM was reviewed for the last 30 days from 10/20/22 to 11/15/22. The resident received ROM six times during this period. On 11/16/22 at 4:02 p.m., MDS/care plan coordinator #1 stated Res #44 did not have a care plan for ROM and it should be care planned. She stated she had been out for three months because the facility had a staffing shortage and she had to work the floor. 6. On 11/14/22 at 12:01 p.m., Res #49 stated she had not received ROM. She stated her right hand was not able to open at all. Res #49 stated her 1st knuckle on thumb was locked. She stated the girls don't have the time because they don't have the staff to do ROM as far as she knew the shower aide had taken the restorative position but had been working other than restorative. The resident right hand was observed at this time. Res #49 was not able to move her thumb at the knuckle. The POC Tasks documented nursing rehab active and passive ROM to bilateral upper and bilateral lower extremities times 20 repetitions by RA as necessary. The ROM task revealed the resident had been offered ROM six times in the 30 day period from 10/20/22 to 11/15/22. Res #49 received ROM four times and refused ROM twice. On 11/16/22 at 1:52 p.m., RA #1 stated she worked in the facility as the restorative aide. She stated she discusses who is on the restorative program with ADON #1. RA #1 stated she goes in the POC system and it will have the residents on restorative listed and will know who to see that day. She stated some resident have M-W-F and other are T-TH. She stated the facility was short staffed and they pulled her to the floor to cover shifts. She stated she had worked 11 p.m. to 7 a.m. for a while.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM met the State requirement for DM. The Resident Census and Conditions of Residents report, dated 11/14/22, documented 69 residents resided in the facility. The corporate nurse consultant #1 identified three residents received nutrition and hydration solely through a feeding tube. Findings: An active employee list documented the DM had been employed at the facility since 01/15/14. There was no documentation the DM was certified as a dietary manager. On 11/14/22 at 9:50 a.m., the DM was asked if she was certified as a DM. She stated not yet. She was asked how long she had been the DM. She stated going on four years. On 11/15/22 at 2:31 p.m., the DON stated the DM transitioned into the dietary department as the DM on 09/03/19 according to what was documented in the computer.

Based on record review and interview, the facility failed to administer medications as ordered as the physician for one (#11) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 11/14/22, documented 69 residents resided in the facility. Findings: Res #11 had diagnoses which included allergic rhinitis, GERD, and [CONDITION(S)]. Physician orders, dated 08/04/22, documented cetirizine HCL (antihistamine medication) 10 mg one time a day, [MEDICATION(S)] HCL (anticholinergic medication) 10 mg one time a day, and [MEDICATION(S)] (corticosteroid medication) 5 mg one time a day. The November 2022 MAR documented medication administration as 9's other/see nurse notes for the following: a. [MEDICATION(S)] at 7:00 a.m. - 11:00 a.m. on 11/07/22 through 11/09/22 b. centirizine HCL at 7:00 a.m. - 11:00 a.m. on 11/09/22, and c. [MEDICATION(S)] HCl at 8:00 a.m. and 2:00 p.m. on 11/10/22. Orders administration notes, dated 11/07/22 and 11/08/22, documented the facility was waiting on the resident's [MEDICATION(S)] to be sent by the pharmacy. Orders administration notes, dated 11/09/22, documented no indication for the reason cetirizine HCL and [MEDICATION(S)] was not administered. On 11/16/22 at 12:39 p.m., the DON was asked what a 9 indicated on the MAR. She stated other/see nurse note. She stated there should be a note. She was made aware the resident had three medications during the month of November coded as 9's. She was made aware nurse notes documented the facility was waiting for the resident's [MEDICATION(S)] to be delivered and there was no indication for the reason the other medications were not administered. She was asked how often medications were ordered. She stated medications could be ordered anytime. She stated the resident did have three medications she had to approve.

Based on record review, observation, and interview, the facility failed to ensure residents were free from unnecessary [CONDITION(S)] medications for one (#42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented 43 residents who received psychoactive medications. Findings: Res #42 had diagnoses which included recurrent depressive disorder, anxiety disorder, and [CONDITION(S)]. A physician order, dated 05/17/22, documented to administer [MEDICATION(S)] (an antianxiety medication) 10 mg TID for generalized anxiety disorder. A Pharmacist's Consult to Provider report, dated 08/09/22, documented Res #42 had orders for the following psych medications. [MEDICATION(S)] 100 mg 1 tab daily for ([CONDITION(S)]), [MEDICATION(S)] 20 mg 1 tab daily for ([CONDITION(S)]), [MEDICATION(S)] 10 mg 1 tab three times daily for (anxiety). Res #42 was due for a biannual reassessment of his psych regimen. Would you like to attempt to reduce any of the medications. If a reduction is clinically contraindicated please explain. The physician signed the MRR on the line that stated I would like to make the above changes and it was dated 08/12/22. The physician documented the resident continued to struggle, chronic depression at base line with the [MEDICATION(S)], no recent hallucinations. The physician documented a trial GDR reduction for [MEDICATION(S)] 7.5 mg one TID. A quarterly assessment, dated 08/13/22, documented the resident was cognitively intact and required extensive assistance in dressing, personal hygiene and bathing. The assessment documented the resident received antipsychotic medication and had a GDR contraindicated by the physician on 02/16/22. A review of the MAR for October and November 2022, documented Res #42 continued to receive [MEDICATION(S)] 10 mg TID. There was no documentation the facility had implemented the physicians order from 08/12/22 to reduce the [MEDICATION(S)] to 7.5 mg TID. On 11/15/22 at 9:44 a.m., Res #42 was observed sleeping on his bed in the dark room. On 11/15/22 at 4:20 p.m., the DON stated she noted the MRR on 08/17/22. She stated she missed that the physician wanted a reduction of the [MEDICATION(S)]. She stated the [MEDICATION(S)] had not been reduced. She stated she was surprised the pharmacist had missed it, also.

Based on observation and interview, the facility failed to ensure the kitchen was maintained clean and in good repair. The Resident Census and Conditions of Residents report, dated 11/14/22, documented 69 residents resided in the facility. The corporate nurse consultant #1 identified three residents received nutrition and hydration solely through a feeding tube. Findings: On 11/15/22 at 2:38 p.m., a tour of the kitchen was conducted. The following observations were made: a. light shields were cracked, b. the FRP board on the wall was not flush with the wall below the dish machine drain board, c. the stainless steel splash guard on the wall behind the spray nozzle sink was not flush with the wall in the dish wash area. There was an accumulation of black residue, d. material was peeling off of the metal/table support in the dish wash area. The metal was rusted, e. drywall tape was coming loose from the ceiling in the dish wash area, f. the metal on the spray nozzle hose located on the three compartment sink was missing and the rubber was exposed, g. the ceiling vent was missing near the three compartment sink, h. there was an accumulation of lint on the return vent and the ceiling area around the vent in the food preparation area, and i. the ceiling in the food preparation area was cracked, material was peeling and hanging loose, sheetrock was exposed, and there was a hole. On 11/15/22 at 2:58 p.m., the DM was asked how staff ensured the kitchen was kept clean and maintained in good repair. She stated they had an electronic system where they input work orders for maintenance to conduct repairs. She stated maintenance cleaned the ceiling vents and dietary cleaned the ceiling every two weeks, and more if needed. She was made aware of the above observations.

Based on record review, interview, and observation, it was determined the facility failed to ensure an Oklahoma Do Not Resuscitate (DNR) consent form was: a. available in the facility for a resident with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] b. dated when signed by the resident for one (#39) of 24 residents whose code status were reviewed. The Resident Census and Conditions of Residents report, documented 69 residents who resided in the facility. Findings: 1. Res #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An ''Advance Directive DNR Consent Admission Acknowledgment form, dated 10/25/10, documented the resident's name, social security number and medical records number at the top of the form. The form documented the resident did not have an Advanced Directive and did not have a DNR Consent.'' A physician order, dated 07/27/15, documented the resident's status was DNR. A court document, dated 11/26/16, granted [name removed], General Power of Attorney for all medical and surgical procedures. The care plan, dated 10/11/21, documented the resident was DNR status. The resident's medical records did not contain documentation of an Advance Directive or DNR consent. On 11/14/22, a red name plate was observed on the resident's door, indicating the resident had DNR status. On 11/14/22, the DON stated Res #14 did not have an Advanced Directive or DNR in the hard chart so she called the Power of Attorney and she came in and signed a Advance Directive and DNR consent form. 2. Res #39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 03/17/21, documented the resident's status was DNR. A quarterly assessment, dated 08/18/22, documented the resident was intact with cognition and required limited assistance with dressing, extensive assistance with personal hygiene and bathing, The resident was independent with most ADLs. The resident's care plan, documented the resident was DNR status. The resident's DNR form was signed but did not contain the date when it was signed. On 11/15/22 at 2:16 p.m., the DON stated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she dated the DNR the day the resident was admitted .

Based on record review, observation, and interview, it was determined the facility failed to ensure a comprehensive care plan was developed to meet the residents' medical and nursing needs for three (#44, 49, and #61) of 19 sampled residents whose care plans were reviewed. The facility failed to: a. develop a care plan related to the smoking status for Res #61 and b. develop a care plan for restorative care and ROM for Res #44 and #49. The Resident Census and Conditions of Residents report, documented 69 residents who resided in the facility. Findings: 1. Res #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Smoking and Behavior Agreement, signed and dated 04/29/22, documented the resident would .acknowledge the importance of the facility smoking policy to my own safety or others resident and agree to comply with the terms and conditions of that policy, including but not limited to the following . An admission assessment, dated 05/05/22, documented the resident was cognitively intact, required extensive assistance with most ADLs, and utilized a wheelchair daily as a means to move on and off the unit, and no assistance after being seated in the wheelchair. On 05/13/22, the care plan addressed ADL self care, eating, locomotion, bed mobility, dressing, and diabetes. A smoking assessment/risk factor dated 10/07/22, documented the resident utilized smoking tobacco, was alert, and able to safely raise and lower cigarette from mouth to ash tray independently. A quarterly assessment, dated 10/22/22, documented the resident was cognitively intact, required extensive assistance with most ADLs, and utilized a wheelchair daily as a means to move on and off the unit, and no assistance after being seated in the wheelchair. On 11/14/22 at 12:50 p.m., the resident was interviewed and stated that she was allowed to go outside to smoke at any time of the day. On 11/18/22 at 7:56 a.m., the MDS coordinator #1 stated that the resident should have a care plan for smoking. The MDS coordinator #1 searched for a smoking care plan but then she stated the resident did not have one for smoking. 2. Res #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 09/24/22, documented the resident was intact with cognition and required extensive to total care with ADLs. The assessment documented impairment to upper and lower on one side. The assessment documented passive ROM was completed for one day. A care plan, last reviewed 10/03/22, documented to keep the residents's left arm up on a pillow while in bed as directed. The care plan did not document the resident was to receive ROM with restorative care. A physician order, dated 10/04/21, documented to place the left arm on a pillow every day and night shift for preventative. On 11/14/22 at 2:59 p.m., Res #44 stated she did not receive ROM to her left side. The resident was observed on her back in the bed with her left arm on a pillow. The POC documented nursing rehab for passive ROM to BUE to hands, elbows and shoulders two to ten repetitions by the RA as necessary. The documentation in the POC for ROM was reviewed for the last 30 days 10/20/22 to 11/15/22. The resident received ROM six times during this period. On 11/16/22 at 1:52 p.m., RA #1 stated she worked in the facility as the restorative aide. She stated she discussed who is on the restorative program with ADON #1. RA #1 stated she goes in the POC system and it will have the residents on restorative listed and will know who to see that day. She stated some resident have M-W-F and others are T-TH. She stated the facility was short staffed and they pulled her to the floor to cover shifts. She stated she had worked 11p.m. to 7a.m. for a while. On 11/16/22 at 2:15 p.m., ADON #1 stated there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON #1 stated she was not sure if the MDS coordinator put it on the care plan. She stated PT will recommend restorative when coming from skilled or if their mobility has gone down or after a fall. She stated residents can also request restorative. On 11/16/22 at 3:07 p.m., the DON stated the resident requested restorative so there was not a referral from therapy. She stated the resident should be getting ROM 2 to 3 times a week while on the restorative program. On 11/16/22 at 4:02 p.m., MDS/care plan coordinator #1 stated Res #44 did not have a care plan for ROM and it should be care planned. She stated she had been out for three months because the facility had a staffing shortage and she had to work the floor. 3. Res #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A grievance dated 4/7-4/13 documented the resident complained her hand was contracting. An annual assessment, dated 10/31/22, documented the resident was cognitively intact and required total assistance with ADLs. The assessment documented the resident had impairments upper and lower on both sides and did not have days documented for restorative care. The POC tasks, documented nursing rehab active and passive ROM to bilateral upper and bilateral lower extremities times 20 repetitions by RA as necessary. The ROM task revealed the resident had been offered ROM six times in the 30 day period from 10/20/22 to 11/15/22. Res #49 received ROM four times and refused ROM twice. A care plan, last revised 11/15/22, documented the resident had a decline in ADL performance related to MS. Res #49 required extensive to total assistant of one to two staff. The care plan did not contain restorative care with ROM. On 11/14/22 at 12:01 p.m., Res #49 stated she had no ROM. She stated her right hand was not able to open at all. Res #49 stated her 1st knuckle on thumb was locked. She stated the girls don't have the time because they don't have the staff to do ROM as far as she knew, the shower aide had taken the restorative position but had been working other than restorative. On 11/16/22 at 1:52 p.m., RA #1 stated she worked in the facility as the restorative aide. She stated she discussed who is on the restorative program with ADON #1. RA #1 stated she goes in the POC system and it will have the residents on restorative listed and will know who to see that day. She stated some resident have M-W-F and other are T- TH. She stated the facility was short staffed and they pulled her to the floor to cover shifts. She stated she had worked 11p.m. to 7a.m. for a while. On 11/16/22 at 2:15 p.m., ADON #1 stated there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON #1 stated she was not sure if the MDS coordinator puts it on the care plan. She stated PT will recommend restorative when coming from skilled or if their mobility has gone down or after a fall. She stated residents can also request restorative. On 11/16/22 at 3:07 p.m., the DON stated the resident requested restorative so there was not a referral from therapy. She stated the resident should be getting ROM 2 to 3 times a week while on the restorative program. On 11/16/22 at 4:02 p.m., MDS/care plan coordinator #1 stated Res #44 did not have a care plan for ROM and it should be care planned. She stated she had been out for three months because the facility had a staffing shortage and she had to work the floor.

Based on record review, observation, and interview, the facility failed to ensure a resident with limited ROM received services to increase, maintain, or prevent further decline in ROM for three (#44, 49, and #61) of three residents reviewed for limited ROM. The Resident Census and Conditions of Residents report, documented 45 residents who had contractures. Findings: 1. Res #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 09/24/22, documented the resident was intact with cognition and required extensive to total care with ADLs. The assessment documented impairments to upper and lower on one side. The assessment documented ROM passive one day. A physician order, dated 10/04/21, documented to place the left arm on a pillow every day and night shift for preventative. A care plan, last reviewed 10/03/22, documented to keep the residents's left arm up on a pillow while in bed as directed. The care plan did not document the resident was to receive ROM with restorative care. On 11/14/22 at 2:59 p.m., Res #44 stated she did not receive ROM to her left side. The resident was observed on her back in the bed with her left arm on a pillow. Documented in the POC -nursing rehab for passive ROM to BUE to hands, elbows and shoulders two to ten repetitions by the RA as necessary. The documentation in the POC for ROM was reviewed for the last 30 days, 10/20/22 to 11/15/22. The resident received ROM six times during this period. On 11/16/22 at 1:52 p.m., RA #1 stated she worked in the facility as the restorative aide. She stated she discussed who is on the restorative program with ADON #1. RA #1 stated she goes in the POC system and it will have the residents on restorative listed and will know who to see that day. She stated some resident have M-W-F and other are T- TH. She stated the facility was short staffed and they pulled her to the floor to cover shifts. She stated she had worked 11p.m. to 7a.m. for a while. On 11/16/22 at 2:15 p.m., ADON #1 stated there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON #1 stated she was not sure if the MDS coordinator puts it on the care plan. She stated PT will recommend restorative when coming from skilled or if their mobility has gone down or after a fall. She stated residents can also request restorative. On 11/16/22 at 3:07 p.m., the DON stated the resident requested restorative so there was not a referral from therapy. She stated the resident should be getting ROM 2 to 3 times a week while on the restorative program. On 11/16/22 at 4:02 p.m., MDS/care plan coordinator #1 stated Res #44 did not have a care plan for ROM and it should be care planned. She stated she had been out for three months because the facility had a staffing shortage and she had to work the floor. 2. Res #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A grievance form, dated 4/7 - 4/13 (no year), documented the resident complained her hand was contracting. An annual assessment, dated 10/31/22, documented the resident was cognitively intact and required total assistance with ADLs. The assessment documented impairment in upper and lower extremities on both sides and no hours for restorative. The POC Tasks documented nursing rehab active and passive ROM to bilateral upper and bilateral lower extremities ties 20 repetitions by RA as necessary. The ROM task revealed the resident had been offered ROM six times in the 30 day period from 10/20/22 to 11/15/22. Res #49 received ROM four times and refused ROM twice. A care plan, last revised 11/15/22, documented the resident had a decline in ADL performance related to MS. Res #49 required extensive to total assistant of one to two staff. The care plan did not contain restorative care with ROM. On 11/14/22 at 12:01 p.m., Res #49 stated she had not received ROM. She stated her right hand was not able to open at all. Res #49 stated her 1st knuckle on thumb was locked. She stated the girls don't have the time because they don't have the staff to do ROM as far as she knew the shower aide had taken the restorative position but had been working other than restorative. The resident right hand was observed at this time. Res #49 was not able to move her thumb at the knuckle. On 11/16/22 at 1:52 p.m., RA #1 stated she worked in the facility as the restorative aide. She stated she discusses who is on the restorative program with ADON #1. RA #1 stated she goes in the POC system and it will have the residents on restorative listed and will know who to see that day. She stated some resident have M-W-F and other are T- TH. She stated the facility was short staffed and they pulled her to the floor to cover shifts. She stated she had worked 11p.m. to 7a.m. for a while. On 11/16/22 at 2:15 p.m., ADON #1 stated there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON #1 stated she was not sure if the MDS coordinator puts it on the care plan. She stated PT will recommend restorative when coming from skilled or if their mobility has gone down or after a fall. She stated residents can also request restorative. On 11/16/22 at 3:07 p.m., the DON stated the resident requested restorative so there was not a referral from therapy. She stated the resident should be getting ROM 2 to 3 times a week while on the restorative program. On 11/16/22 at 4:02 p.m., MDS/care plan coordinator #1 stated Res #44 did not have a care plan for ROM and it should be care planned. She stated she had been out for three months because the facility had a staffing shortage and she had to work the floor. 3. Res #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 06/09/22, documented physical therapy to screen the resident for a restorative program. A physician order, dated 06/16/22, documented orders for active ROM, includng getting up in wheel-chair with lift and then do two times ten repetitions to BLE. A quarterly assessment, dated 10/22/22, documented the resident was cognitively intact, required extensive assistance with ADLS, and had impairment on both sides of the lower extremities. The assessment documented the resident utilized a wheelchair daily as a means to move on and off the unit with no assistance after being seated in the wheelchair. The care plan did not address restorative services. On 11/17/22 at 11:37 a.m., CNA #2 stated she will make the resident do as much as possible but there is no type of restorative program that the resident is on and no place to document that the resident is getting restorative. On 11/17/22 at 11:40 a.m., MDS coordinator #1 stated the resident does have a PT order date 06/09/22 to screen the resident for restorative. On 11/17/22 at 11:50 a.m., RA #1 stated she had not performed any restorative activities for the resident. On 11/17/22 at 12:29 p.m., ADON #1 stated the facility put the resident on the restorative program but at that time they did not have a restorative aide available.

Based on record review and interview, the facility failed to ensure assessments accurately reflected the resident's status for one (#11) of 19 sampled residents reviewed for MDS accuracy. The Resident Census and Conditions of Residents report, dated 11/14/22, documented 69 residents resided in the facility. Findings: Res #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 08/04/22, documented [MEDICATION(S)] (an antipsychotic medication) prefilled syringe 120 mg subcutaneously one time a day starting on the 5th and ending on the 5th every month. The August 2022 injection record documented [MEDICATION(S)] was administered on 08/05/22. An annual resident assessment, dated 08/10/22, documented no antipsychotics were received during the last seven days or since admission/entry or the prior assessment. The September 2022 injection record documented [MEDICATION(S)] was administered on 09/05/22. A quarterly resident assessment, dated 09/27/22, documented no antipsychotics were received since the prior assessment. On 11/16/22 at 2:30 p.m., MDS coordinator #1 was asked if the resident had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked to review the resident's annual and quarterly assessments for MDS accuracy. She stated the assessments were not correct. She stated the assessments should have been coded as antipsychotics were received.