Every finding on record at Eastgate Village Care & Rehab Center

On 07/01/25, a past non-compliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the safety of residents at risk for elopement. On 06/19/25, Resident #1 eloped from the property through the front entrance at approximately 6:30 p.m. by following out a food delivery person. Resident #1 had a history of threatening to elope and wandering. The police found and returned Resident #1 to the facility at approximately 7:30 p.m. and reported Resident #1 was located in a field near the facility. Based on record review and interview, the facility failed to provide supervision to ensure the safety of a resident for 1 (#1) of 2 sampled residents reviewed with exit seeking behaviors. The DON identified one resident wandered. Findings: A care plan for Resident #1, initiated 08/06/24, showed a focus of the potential for elopement risk/wanderer with interventions which included: assess for elopement/wander risk, disguise exits, cover door knobs and handles, tape floor, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, observe for fatigue and weight loss, observe location frequently, document wandering behavior and attempt diversional interventions in behavior log, provide structured activities, toileting, waking inside and outside, reorientation strategies including signs, pictures, and memory boxes, and utilize wanderguard. A care plan for Resident #1, initiated 12/20/24, showed a focus of the risk for wandering/elopement was identified with interventions which included: clearly identify resident's room and bathroom, engage resident in purposeful activity, identify if there was a certain time of the day wandering/elopement attempts occurred, implement a scheduled toileting program, and implement a scheduled hydration. A progress note, dated 04/20/25, showed Resident #1 was verbally aggressive toward staff and had attempted and threatened to elope, and had kicked at windows and doors. A progress note, dated 04/27/25, showed Resident #1 walked up to the nurses station without their walker with a skin tear to their right forearm. The note showed the nurse went to the room of Resident #1 to find their wheelchair and observed the window open, blankets on the window sill, and the wheelchair was thrown out the window with the window screen on the ground next to the wheelchair. A progress note, dated 04/29/25, showed Resident #1 was at the front door with staff attempting to redirect the resident to turn around. A progress note, dated 05/03/25, showed Resident #1 was verbally aggressive and had stated they were leaving and no one could stop them. A re-admission after hospitalization elopement risk evaluation, dated 05/15/25, showed Resident #1 was at risk for elopement with a score of 4.0. A quarterly assessment, dated 05/21/25, showed Resident #1 had a brief interview for mental status score of 10 with diagnoses which included hypertension, heart failure, and dementia. A care plan for Resident #1, revised 06/20/25, showed a focus risk for wandering/elopement was identified with interventions which included: the resident would be transferred to a memory unit when the veterans administration sent the contract to the memory unit facility. Review of the facility elopement investigation, dated 06/20/25, showed an elopement risk audit for new admissions form, dated the week of 06/23/25 to 06/27/25. The audit form showed new admissions during the week and if an elopement risk audit was completed upon admission. The audit form showed four residents had admitted and an elopement risk evaluation was completed with scores of zero for all. The facility elopement investigation included the faxed ODH (Oklahoma Department of Health) Form 283, Incident Report Final and a word document which included the facility's investigation findings. The findings, read in part, Upon completion of investigation, the facility determined that the resident had eloped from the facility and was transferred to a veterans administration (VA) contract memory unit in [another city] for his safety. The investigation included an educational in-service record dated 06/20/25 and 06/22/25, titled elopement education. The in-service form showed signatures of all current staff. The investigation included a timeline of when and where Resident #1 was last seen. The timeline showed Resident #1 was last seen at 6:30 p.m. in the lobby. The investigation included elopement risk evaluations of all residents in the facility and a facility map indicating location of outside doors checked and the result. The facility investigation included a quality assurance and performance improvement (QAPI) meeting form dated 06/20/25 with signatures of meeting attendees and corrective action/steps taken immediately, process, systematic changes, ongoing monitoring, and date of compliance 06/20/25. On 07/01/25 at 11:20 a.m., the DON stated Resident #1 was gone approximately 35 to 40 minutes. They stated Resident #1 had walked across the dead end road in front of the facility, crossed over the loose fence to the neighbor's yard, and was sitting under their tree. The DON stated when Resident #1 returned they did a head-to-toe assessment and kept Resident #1 on one on one observation until they transferred to a memory care unit. The DON stated Resident #1 had a wanderguard on their wheelchair, but had taken their walker. The DON stated the representative of Resident #1 had recently brought in a walker and it did not have the wanderguard like the wheelchair.

Based on observation, record review, and interview, the facility failed to ensure a care plan was updated/revised for 1 (#1) of 18 sampled residents whose care plans were reviewed. The administrator identified 73 residents resided in the facility with 2 in the hospital. Findings: A Comprehensive Person Centered Care Plan policy, dated 01/2019, read in part, Each resident will have a person centered care plan to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Resident #1 had diagnoses which included cerebral palsy, ostomy status, and UTI. A care plan, revised 01/09/25, read in part, Potential for elopement risk/wander risk. An Elopement Evaluation, dated 12/23/24 at 11:18 p.m., showed an elopement score of 0.0. It showed no instance of elopement history and no wandering aimlessly. A nutrition note, dated 01/07/25 at 5:05 p.m., showed Resident #1 had noted history of cerebral palsy, quadriplegia with upper and lower extremity contractures. A progress note, dated 12/23/24 at 11:09 p.m., showed the resident arrived via ambulance to the facility and had cerebral palsy and quadriplegia with muscle contractures on all limbs. On 02/03/25 at 11:44 a.m., Resident #1 was observed in bed, eyes open, and no verbal response. They were observed moving their right arm and head only and did follow with their eyes. Their bilateral lower extremities were bent up towards their torso. On 02/05/25 at 2:00 p.m., the IP stated Resident #1 was not and had never been an elopement risk since being in the facility. On 02/05/25 at 2:02 p.m., the regional MDS consultant, ADON, and DON were present. The DON stated Resident #1 was bedbound and was not an elopement risk and used a mechanical lift with total care. They stated they received the resident with contractures, a catheter, a colostomy, and they were total care. The DON stated the care plan was not an accurate reflection of the resident.

Based on observation, record review, and interview, the facility failed to ensure proper infection control practices were utilized during transportation of linen to the soiled closet for 1 observation during review of infection control practices. The administrator identified the census of 73 in house with 2 in the hospital. Findings: A Handling linen/laundry policy, dated 07/2024, read in part, Linen/Laundry includes resident's personal clothing, linens, (i.e., sheets, blankets, pillows), towels, washcloths .Linen and laundry should be handled, transported, and sorted to prevent the spread of infection .1. Handling soiled linen/laundry .a. Gloves should be worn, and standard precautions followed. b. Bag soiled linen/laundry at point of collection before transporting. c. Bagged linen shall be placed in a leak proof container for transport to laundry facilities. On 02/06/25 at 12:20 p.m., housekeeper #1 was observed to carry white linen with red substance on it to the soiled utility room without being in a bag and without wearing gloves. They were asked what the policy and procedure was for transporting soiled linen. They stated they probably should have taken the barrel to transport it. They stated it was not soiled. Housekeeper #1 was asked where they got the linen from. They stated it was on B hall on a pillow on the couch. They were asked what was on it. They stated nothing. They were asked how they knew nothing was on it and it was not soiled. They stated they did not know. They went down the hall then returned to the soiled utility room and looked at the linen. They stated it was ketchup on it. They were asked if it had been put in a bag for transport. They had no response. They were then asked how should the linen have been transported. They stated in a bag. On 02/06/25 at 2:02 p.m., the DON was aware of findings and stated the staff member was new and were to be educated. On 02/06/25 at 2:28 p.m., the infection preventionist was asked if they were aware of the infection control concern with the linen. They stated they were aware and would address it as soon as they could.

Based on observation, record review, and interview, the facility failed to ensure resident assessments were accurate for 3 (#1, 52, and #60) of 18 sampled residents whose assessments were reviewed. The administrator identified 75 residents who resided in the facility. Findings: An MDS 3.0 policy, dated 04/2023, read in part, 2 The MDS Coordinator and/or IDT [interdisciplinary team] will use the following when completing the assessment as directed by the RAI User's Manual: Direct Observation, Communication with Residents, Family and Staff, Documentation in the Medical Record 3. MDS assessments will be completed per the 3.0 RAI User's Manual guidelines. 1. Resident #1 had diagnoses which included cerebral palsy, ostomy status, and UTI. A progress note, dated 12/23/24, at 10:09 p.m., showed the resident was alert, seemed to understand what was being said to them, and were laughing/smiling at jokes. A progress note, dated 12/25/24 at 2:47 p.m., showed the resident was pleasant, smiling, and nonverbal. A progress note, dated 12/26/24 at 7:39 p.m., showed the resident was able to communicate with their eyes. A progress note, dated 01/04/25 at 4:24 a.m., showed the resident was alert to stimuli. A progress note dated 01/05/25 at 3:05 a.m., documented resident was alert to stimuli but non verbal. A resident admission assessment, dated 01/05/25, had comatose marked as yes for B0100. On 02/03/25 at 11:44 a.m., Resident #1 was observed in bed, eyes open, and no verbal response. They were observed moving their right arm and heal only and did follow with their eyes. On 02/05/25 at 12:56 p.m., CNA #1 stated Resident #1 used their eyes to communicate by moving them left or right and up and down to say yes or no. They stated the resident laughed and they had heard them try to speak before. CNA #1 stated if the resident was awake they would respond. On 02/05/25 at 1:05 p.m., the regional MDS consultant stated in order to code comatose at B0100 on the MDS, the resident would have to not be reactive to painful stimuli or any stimuli. They stated B0100 was marked yes and they would have to look into it. The regional MDS consultant stated they were confident the coding of B0100 was a mistake. 35474 2. Resident #52 had diagnoses which included paroxysmal atrial fibrillation. The quarterly assessment, dated 01/15/25, showed Resident #52 had received an anticoagulant and antiplatelet medication during the seven day look back period. Review of the electronic clinical record did not show Resident #52 had received an anticoagulant or antiplatelet medication during the look back period. On 02/05/25 at 1:18 p.m., the regional MDS consultant reviewed the assessment and the electronic clinical record and stated Resident #52 was not on an anticoagulant or antiplatelet medication during the look back period for the assessment and the assessment was not accurately coded. 3. Resident #60 had diagnoses which included dementia. A physician's order, dated 08/19/24, showed the resident had an active order for Quetiapine (an antipsychotic medication) 200 mg at bedtime. The annual assessment, dated 12/18/24, showed the resident had not received an antipsychotic medication since the admission/entry/reentry, or the prior assessment, whichever was more recent. On 02/06/25 at 12:11 p.m., MDS coordinator #1 reviewed the electronic clinical record and stated the annual assessment did not accurately reflect Resident #60 had received an antipsychotic medication since the last admission/entry/reentry or prior assessment.

Based on record review and interview, the facility failed to notify a resident's representative/legal representative for treatment of a UTI for 1 (#1) of 1 sampled resident reviewed for notification of change. The administrator identified 73 residents resided in the facility with two in the hospital. Findings: Resident #1 had diagnoses which included cerebral palsy, ostomy status, and hyponatremia. On 02/03/25 at 3:11 p.m., Resident #1's legal representative stated they were not notified of the resident recently having a UTI until they called to check on the resident. A physician's order, dated 02/04/25, docuented Macrobid (an antibiotic) oral capsule 100 mg via peg-tube two times a day for UTI for 7 days. On 02/06/25 at 9:54 a.m., the ADON stated the process for a resident with a change in condition was to report to the proper parties (Medical director, family, DON, hospice if appropriate) and complete the form, and monitor for 72 hours or longer depending on doctor orders. They stated the form for change in condition was located in the electronic medical record under the forms tab. The ADON stated they were not able to produce documentation of notification for 02/04/24.

Based on observation, record review, and interview, the facility failed to ensure foods were dated when opened for 2 of 2 observations in the kitchen. The DON identified 72 residents who received nourishment from the kitchen. Findings: The Food Storage policy, dated 10/01/18, read in part, To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated.Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. On 02/03/25 at 10:46 a.m., an uncovered and undated bowl of ice cream, was observed in the stand up freezer. Six cups of undated milk were observed in the refrigerator. On 02/06/25 at 11:04 a.m., six small, clear containers with a pink/yellow substance in them were observed in the refrigerator. The containers were not observed to be dated. Two foam cups were observed in the refrigerator to be undated and unlabeled. On 02/06/25 at 11:10 a.m., dietary aide #1 stated the clear containers were snacks for residents who required a puree diet. Dietary Aide #1 stated they had prepared the snacks in the clear container earlier in the morning. They stated one foam cup had milk in it and they thought the other one contained coffee after smelling it. They stated they had seen the foam cup that had coffee in it on 02/05/25. On 02/06/25 at 11:13 a.m., the dietary manager stated staff were to label and date foods before they were placed in the refrigerator.

Based on observation, record review, and interview, the facility failed to ensure medications were secured for 2 (E hall medication cart, and B/C hall treatment cart) of 6 medication/treatment carts observed. The DON identified six medication/treatment carts were utilized in the facility. A Medication Storage in the Facility policy, dated 2021, read in part, Medication rooms, carts, and medication supplies are locked. On 02/04/25 at 3:40 p.m., an observation was made of an unlocked and unattended cart on E hall across from room E1. Inside the cart were resident medications. There was no staff near the cart nor on E hall at the time of observation. On 02/04/25 at 3:44 p.m., CMA #1 came from around the corner by the dining room to the cart and locked it. They stated the policy for medication storage was to lock the cart. They stated they went to get a laptop and forgot to lock it. On 02/06/25 at 3:36 p.m., the B/C hall treatment cart was observed to be unlocked by the nurses station. Two nurses had their back to it and CMA #2 was facing it from the nurses station. On 02/06/25 at 3:38 p.m., CMA #2 was observed to lock the cart. LPN #1 stated the protocol for medication/treatment carts was to be locked when not in use. They stated they guessed they did not lock it after loaning out a glucometer. On 02/06/25 at 3:42 p.m., the DON stated the protocol for medication/treatment cart storage and safety was they were supposed to keep the carts locked if they were not with them.

Based on record review and interview, the facility failed to ensure residents were weighed weekly for four weeks upon admit for 1 (#78) of 3 sampled residents who were reviewed for nutrition. The DON identified 75 residents who resided in the facility. Findings: The Weight and Hydration Management Practice Guidelines policy, dated February 2016, read in part, Weigh all residents upon admission and readmission, weekly for four weeks and then monthly or as indicated by physician orders and/or the medical status of the resident. Resident #78 had diagnoses which included dementia. The Care Plan, revised 11/01/24, read in part, Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Review of the clinical record showed the resident had been weighed on 11/04/24, 12/01/24, and 01/01/25. The electronic clinical record did not show weights had been obtained weekly for four weeks after admission on 10/28/24. On 02/06/25 at 4:15 p.m., the DON reviewed the electronic clinical record for Resident #78 and stated there was not a physician's order for the frequency of obtaining weights, so they had weighed monthly since admission to the facility. The DON stated they needed to review the facility's policy for weight monitoring. On 02/06/25 at 4:33 p.m., the DON stated they had just reviewed the policy regarding weight monitoring and should have obtained weights weekly for four weeks after admission for Resident #78.

Based on record review and interview, the facility failed to ensure a care plan intervention for the creation and implementation of a behavioral flow sheet had been implemented for 1 (#60) 5 sampled residents who were reviewed for unnecessary medications. The DON identified 75 residents who resided in the facility. Findings: Resident #60 had diagnoses which included dementia, anxiety, and mood disorder. The Care Plan, dated 12/20/24, read in part, I am experiencing dementia, anxiety, and insomnia.BEHAVIOR MONITORING: Behavior monitoring is required for residents who take antipsychotic medications. Implement Behavior Monitoring Flowsheet. Review of the electronic clinical record did not show a behavior monitoring flowsheet had been implemented. On 02/06/25 at 10:04 a.m., LPN #2 stated they were unwarned of a behavioral flow sheet for Resident #60. On 02/06/25 at 11:48 a.m., the DON stated the behavioral monitoring for behaviors was documented on the nurses treatment record in the electronic clinical record. The DON reviewed the electronic clinical record for Resident #60 and stated they must have forgotten to put the behavioral monitoring on the treatment record. 35474

Based on record review and interview, the facility failed to provide a notice of bed hold to 2 (#1 and #80) of 2 sampled residents who were transferred to the hospital. The administrator identified 75 residents who resided in the facility. Findings: The Resident Bed Hold policy, read in part, The Facility will provide written information to the Resident and/or the Resident Representative regarding Bed Hold Policy prior to transferring a Resident to the hospital or Therapeutic Leave as required by State/Federal Guidelines. 1. Resident #80 had diagnoses which included dementia. The electronic clinical record showed the resident was discharged to the hospital on 09/20/24 and 10/31/24. The electronic clinical record did not show the resident and/or the resident representative had been provided a bed hold notice upon transfer to the hospital. On 02/04/25 at 3:23 p.m., the infection preventionist/charge nurse stated the BOM or human resources employee provided the notice of bed hold to residents and/or resident representatives upon transfer to the hospital. On 02/04/25 at 3:25 p.m., the BOM stated they provided the notice for bed holds to residents and/or resident representatives when they admitted to the facility. On 02/04/25 at 3:29 p.m., LPN #2 stated the BOM was responsible to provide a notice of bed hold upon transfer to the hospital. On 02/04/25 at 3:32 p.m., the DON stated they did not know where it was documented a resident and/or resident representative had been provided a notice of bed hold when they were transferred to the hospital, but the BOM was the person responsible to provide them. On 02/04/25 at 4:11 p.m., the DON stated they had not been providing notices of bed holds to residents and/or representatives. They stated they had found out the nursing department was responsible to provide the notices upon transfer to the hospital. 45583 2. Resident #1 had diagnoses which included cerebral palsy and ostomy status. A Discharge Summary, dated 12/31/24 at 3:50 p.m., showed the resident was sent to the hospital via ambulance. It showed the resident left the facility at 2:30 p.m. A nurses note, dated 01/04/25 at 4:24 p.m., showed Resident #1 readmitted to the facility from the hospital. There was no documentation of a bed hold policy being provided. On 02/05/25 at 4:03 p.m., the ADON was asked where the documentation for the bed hold was for when Resident #1 went to the hospital on 12/31/24. They stated they needed to ask as that was new to them and needed to ask someone. On 02/05/25 at 4:04 p.m., the DON stated they keep them in a folder at the nurses station. The DON provided a blank form and the arrived to the conversation. The DON stated they have them signed and put in the hard chart. The DON also stated, when residents were sent out they sent one copy with the emergency medical service and one copy to the hospital. When asked for Resident #1's bed hold provided, the DON stated, We do not have it and will from now on. The administrator was present and verified.

Based on record review and interview, the facility failed to ensure advance beneficiary notices were provided for 2 (#10 and #18) of 3 sampled residents who were reviewed for beneficiary notices. The Beneficiary Notice - Residents discharged Within the Last Six Months form documented four residents who were discharged to home with skilled days remaining in the last six months. Findings: 1. The form Beneficiary Notice-Residents discharged Within the Last Six Months showed Resident #10 was discharged from skilled services, had skilled days remaining, and stayed in the facility as a long term care resident after the discharge from skilled services. The SNF Beneficiary Protection Notification Review form showed Resident #10 was discharged from skilled services on 12/26/24 and the resident and/or resident representative had not been provided an ABN. 2. The form Beneficiary Notice-Residents discharged Within the Last Six Months showed Resident #18 was discharged from skilled services, had skilled days remaining, and stayed in the facility as a long term care resident after the discharge from skilled services. The SNF Beneficiary Protection Notification Review form showed Resident #18 was discharged from skilled services on 09/18/24 and the resident and/or resident representative had not been provided an ABN. On 02/06/25 at 10:27 a.m., the business office manager stated they were responsible to provide residents and/or resident representatives NOMNC and ABNs. They stated they typically provided an ABN for residents with Medicare and a NOMNC for residents who had an Health Maintenance Organization health plan. On 02/06/25 at 12:28 p.m., the administrator stated the business office manager was responsible to provide beneficiary notices upon discharge from skilled services.

Based on record review, observation, and interview, the facility failed to prepare and serve food for the residents in a sanitary manner. The administrator identified 82 residents who resided in the facility. Findings: A policy titled, PERSONAL ALLOWED IN THE DIETARY DEPARTMENT, read in part, .All unauthorized persons are to be discouraged from entering the Dietary Department .Everyone that enters the Dietary Department must wash their hands and wear a hair net. On 10/31/23 at 11:37 a.m., CNA #1 was observed assisting in the dining room with meal service. The CNA was observed assisting residents with positioning in their chairs and setting up three residents' meals without washing/sanitizing their hands. On 10/31/23 at 11:41 a.m., CNA #1 stated they did not wash/sanitize their hands between assisting each resident. The CNA state they should have wash/sanitized their hands between each resident assistance. On 10/31/23 at 11:46 a.m., CNA #2 was observed entering the kitchen area to obtain a glass of tea. The CNA was observed to not wash their hands and was not wearing a hair restraint. On 10/31/23 at 11:49 a.m., CNA #2 stated staff were allowed to enter the kitchen far enough to obtain glasses and tea. On 10/31/23 at 12:03 p.m., the DM stated staff have been allowed to obtain glasses and tea from the kitchen area. The dietary manager stated a chain should have been in place marking the areas of the kitchen were the staff were not allowed to pass. The dietary manager stated the area was part of the kitchen.

Based on observation and interview, the facility failed to serve food at an appetizing temperature for the residents. The administrator identified 82 residents who resided in the facility. Findings: 1. Res #55 was admitted with diagnoses which included fractured femur and pressure-induced deep tissue damage. The physician orders documented the resident was on a healthy heart diet and was encouraged to get out of bed for meals and activities. On 10/31/23 at 1:40 p.m., the resident stated the food was always cold. On 11/02/23 at 7:45 a.m., a sample tray was obtained. The eggs were 123 degrees Fahrenheit, the pancake was 99.7 degrees Fahrenheit, and the bacon was 96.5 degrees Fahrenheit. The food was observed to not have been warm to taste. On 11/02/23 at 11:20 a.m., the DM stated the hall trays were not served using hot plates or a hot box to transport the meals to the halls. 46909 2. Res #38 had diagnoses which included major depressive disorder, diabetes mellitus, chronic obstructive pulmonary disease, and abnormal weight loss. An annual assessment, dated 09/28/23, documented Res #38 was moderately impaired with cognition and required minimal assistance with ADLs. On 10/31/23 at 12:19 p.m., Res #38 stated the pancakes and eggs were always cold when they received them. 3. Res #70 was admitted to the facility with diagnoses of diabetes mellitus type II, depression, anxiety, and metabolic encephalopathy. An admission assessment, dated 10/10/23, documented Res #70 was cognitively intact and required minimal assistance with ADLs. On 10/31/23 at 12:33 p.m., Res #70 stated the food was always cold.

Based on observation, record review, and interview, the facility failed to provide the necessary ADL assistance to residents who were unable to carry out their own for one (#37) of four residents sampled for ADL assistance. The DON identified 82 residents who currently resided in the facility. Findings: Res #37 had diagnoses which included post traumatic stress disorder, unspecified chronic kidney disease, vascular dementia with mood disturbance, Parkinson's disease with dyskinesia with fluctuations, chronic obstructive pulmonary disease, and altered mental status. A annual assessment, dated 05/21/23, documented the resident was severely impaired with cognition and required moderate assistance with all ADLs. The assessment documented Res #37 was always incontinent of bladder and bowel. A quarterly assessment, dated 08/21/23, documented the resident was severely impaired with cognition and required extensive assistance with all ADLs. The assessment documented Res #37 was always incontinent of bladder and bowel. On 11/01/23 at 10:35 a.m., a blood stain was observed on the bed sheets of Res #37. On 11/02/23 at 10:34 a.m., the same blood stain was observed on the bed sheets of Res #37. A clean pad covering a wet brown ring with the odor of urine was observed on the bed of Res #37. On 11/02/23 at 12:47 p.m., CNA #1 stated they did not know how long the blood stain had been on the sheets of Res #37 and they did not know the resident's bed was wet and had a brown ring stain. They stated they only checked the pad and since it was not wet they did not check the bed linens. On 11/02/23 at 12:47 p.m., CNA #2 stated they only checked the pad and since the pad was dry they did not check under the pad where the bed was wet with urine. On 11/02/23 at 12:47 p.m., LPN #1 stated the bed checks were to have been completed every two hours. They stated the staff should have checked the resident and the bed sheets should have been changed.

Based on record review and interview, the facility failed to correctly complete a PASRR level l form and make a referral to the state mental health authority or state intellectual disability authority for one (#26) of three residents reviewed for PASRR. The administrator identified 82 residents resided in the facility. Findings: Res #26 was admitted on [DATE] with diagnoses which included post-traumatic stress disorder and psychotic disorder with delusion. A PASRR level l form, dated 07/26/19, did not document the resident had a diagnosis of serious mental illness. The form did not document a referral to the state mental health authority or state intellectual disability authority for the diagnosis of serious mental illness. A care plan, dated 07/28/21, documented the resident had a disturbed thought process. The care plan documented the resident was experiencing changes in sleep habits, loss of appetite, and inability to concentrate. On 11/06/23 at 1:39 p.m., the MDS coordinator reviewed the PASRR level l form for the resident. The coordinator stated the PASRR level l dated 07/26/19 was not correct. The coordinator stated the resident had a diagnosis of mental illness on admission and referral should have been made to the state mental health authority or state intellectual disability authority.

Based on record review and interview the facility failed to conduct a significant change assessment for one (#37) of 18 sampled residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 80 residents resided in the facility. Findings: 1. Res #37 had diagnoses which included post traumatic stress disorder, unspecified chronic kidney disease, vascular dementia with mood disturbance, Parkinson's disease with dyskinesia fluctuations, chronic obstructive pulmonary disease, and altered mental status. A annual assessment, dated 05/21/23, documented the resident was severely impaired with cognition and required moderate assistance with all ADLs. A quarterly assessment, dated 08/21/23, documented the resident was severly impaired with cognition and required extensive assistance with all ADLs. On 11/02/23 at 3:34 p.m., MDS Coordinator #1 stated there should have been a significant change on Res #37 instead of a quarterly assessment on 08/21/23.

Based on record review and interview, the facility failed to ensure comprehensive assessments were accurate for two (#35 and #75) of 19 sampled residents whose assessments were reviewed. The DON identified 82 residents who currently resided in the facility. Findings: Res #35 had diagnoses which included mild vascular dementia with other behavioral disturbances and Alzheimer's disease. A physician order, dated 06/27/23, documented the facility was to administer Seroquel (an antipsychotic medication) 25 mg two times a day for anxiety and yelling/screaming related to mild vascular dementia with other behavioral disturbances. A care plan, dated 06/27/23, documented the antipsychotic Seroquel was to have been administered for altered thought process. The care plan documented the resident experienced behaviors associated with dementia with behavioral outbursts such as yelling, screaming, repetitive verbalizations, and tearfulness. The care plan documented to administer medication as prescribed. A admission assessment, dated 07/04/23, documented the resident was severely impaired with cognition; had delirium of inattention and altered level of conscious; and required extensive to total assistance with ADLs. The assessment did not documented the resident was on an antipsychotic medication. The July 2023 MAR, documented the resident was to receive Seroquel twice a day and documented the resident received the Seroquel every morning and evening for the month of July. On 11/02/23 at 1:14 p.m., the DON stated Res #35 had been on an antipsychotic for a long time. On 11/03/23 at 9:42 a.m., the MDS coordinator stated the resident was on an antipsychotic medication and it had been missed on the assessment completed in July. 2. Res #75 had diagnoses which included end stage heart failure; acute kidney failure; and muscle wasting and atrophy. A physician order, dated 07/13/23, documented to admit Res #75 to hospice care. A significant change assessment, dated 07/13/23, documented the resident was severely impaired with cognition and required extensive to total assistance with ADLs. The assessment did not documented the resident life expectancy was six months or less and did not document the resident was to receive hospice care. A social service note, dated 07/27/23, documented the resident had a decline and was admitted to hospice care on 07/13/23. On 11/02/23 at 11:18 a.m., the MDS coordinator stated the resident had been admitted to hospice care. The MDS coordinator stated the significant change assessment did not document the resident's life expectancy and hospice care but should have.

Based on observation and interview, the facility failed to treat residents with dignity during meal service in the dining room. The administrator identified 50 residents who ate meals and were served in the dining room. Findings: On 10/31/23 at 11:33 a.m., a lunch service was observed in the dining room. Three residents were observed sitting at a table, two of the residents were served their meal, one resident was provided a drink, but not a meal. On 10/31/23 at 11:41 a.m., the resident who had not received a meal while sitting with the other residents was observed to have received their meal. One of the two residents who had received their meal prior was observed leaving the dining room. On 11/02/23 at 7:27 a.m., a breakfast service observed in the dining room. Two residents were observed sitting at a table together before the meal service had began and only one resident had received their meal. On 11/02/23 at 7:30 a.m., the resident who had not received their meal stated they were hungry. On 11/02/23 at 7:37 a.m., the resident who had not received their meal continued to wait for their meal to be received. On 11/03/23 at 11:10 a.m., Dietary Cook #1 stated they try to serve all residents sitting at the same table at the same time but does not always happen. The cook stated they should serve everyone sitting at the table at the same time.

Based on interview and record review, the facility failed to ensure residents' nutritional issues were supervised by a physician for one (#39) of one resident sampled for weight loss. The Resident Census and Conditions of Residents form documented 80 residents resided in the facility. Findings: Res #39 was admitted to the facility with diagnoses of metabolic encephalopathy, diabetes mellitus, cerebral infarction, and age-related physical debility. An EHR entry, dated 06/12/23, documented Res #39 had a weight of 178.6 lbs. A quarterly assessment, dated 08/03/23, documented the resident was moderately impaired with cognition and required minimal assistance with ADLs. The assessment documented the resident had experienced a significant weight loss. An EHR entry, dated 09/13/23, documented Res #39 had a weight of 166.0 lbs representing a 7% weight loss over three months. On 11/06/23 at 10:30 a.m., the DM stated Res #39 tried to take other residents' food and stated the resident was always hungry. On 11/06/23 at 10:44 a.m., the DON stated the physician was not notified of the significant weight loss but they would contact the physician.

Based on record review, observations, and interview, the facility failed to ensure a comprehensive care plan was developed for three (#45, 46, and #63) of 21 residents whose care plans were reviewed. The Resident Census and Condition of Residents form documented 70 residents resided at the facility. Findings: 1. Resident #45 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 03/21/22, did not document a plan of care for resident (Res) #45 dementia care. On 04/20/22 at 3:24 p.m., the MDS nurse stated Res #45's admission MDS had triggered the need for a dementia plan. On 04/20/22 at 3:30 p.m., the DON stated Res #45's care plan should have included a plan of care for dementia. 2. Resident (Res) #63 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #63's admission assessment, dated 03/28/22, documented dementia and urinary catheter were triggered for a plan of care. A care plan, dated 03/28/22, did not document a plan of care for dementia or urinary catheter. On 04/21/22 at 8:40 a.m., the DON stated Res #63's care plan did not include a plan of care for dementia or the use of a urinary catheter. The DON stated it should have. 3. Resident (Res) #46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual resident assessment, dated 12/23/21, documented bed rails were not used for Res #46. On 04/19/22 at 1:23 p.m., Res #46's bed was observed with a full side rail up on one side. The bed for Res #46 was also equipped with a low air loss mattress. On 04/21/22 at 1:23 p.m., Res #46's plan of care did not document a plan of care related to the use of full side rails. On 04/21/22 at 2:31 p.m., the DON stated the facility did not have any full side rails and Res #46 should not have side rails of any kind as they would get hurt. The DON then viewed Res #46's room and stated they were unaware Res #46's bed had been equipped with full side rails. The DON stated Res #46 did not have a care plan for side rails.

On 06/23/21, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to ensure residents received adequate supervision while smoking to prevent accidents. Resident #5 was admitted to the facility on [DATE] and was assessed to require supervision while smoking on 12/17/20. On 06/14/21, resident #5 went outside to smoke with his hospice aide. The resident and hospice aide failed to completely turn off his oxygen and remove the nasal cannula from his face. While smoking, his mustache, nose, beard and right eyebrow caught on fire, resulting in [CONDITION(S)] to his nose, cheek, and upper lip area. At 4:07 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:27 p.m., the administrator and director of nursing (DON) were notified of the IJ situation related to the facility's failure to ensure supervision while smoking to prevent accidents. On 06/24/21 at 10:28 a.m., an acceptable plan of removal was provided. The plan of removal documented, . 1) Smoking assessments were re-evaluated on the seven identified smokers in the facility on 06/23/21. 2) Care plans were updated to reflect each resident's level of smoking supervision on 06/23/21. 3) Three of seven smokers were identified as requiring supervised smoking. A supervised smoking list was updated and posted at the nurse station on 06/23/21. 4) Direct care staff were educated about the smoking safety procedure for residents who wear oxygen to include CN [charge nurse] delegating the supervision task. Additional inservices [sic] were conducted at 1800 [6:00 p.m.] (11 additional staff members) and 2330 [11:30 p.m.] (2 additional staff members) on 06/23/21. Online education was posted on the facility's communication board at 1745 [5:45 p.m.] 21 staff members signed in to the inservice online. 5) Smoking safety procedures were posted at the door to the designated smoking area, the nurse station on 06/23/21. 6) Staff who were not present for the mandatory inservice [sic] were messaged through the facility's communication board to complete the mandatory inservice [sic]. A self-study packet will be completed before the employee is placed back on the schedule. 7) The CN [charge nurse] each shift is responsible for designating supervision for the supervised smoking breaks. Supervision can be provided by a direct care staff member who has completed smoking safety training. Supervision is verbally designated when the direct care staff member checks out the smoking supplies at the nurse station. 8) The smoking material for the supervised smokers is kept at the nurse station. The designated supervisor will check out the smoking supplies when he/she takes the resident out to smoke. Supplies will be returned to the station when the smoke break is over. The Immediate Jeopardy was removed on 06/23/21 at 11:30 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to ensure adequate supervision for five (#1, #2, #3, #5, and #7) of six residents who were reviewed for smoking safety. The facility identified seven residents who smoked. Findings: The facility's policy on smoking safety, dated December 2018, documented, . Supervision (Considered an Unsafe Smoker) Requires a staff person or family member to light the cigarette and remain in attendance while the cigarette is burning. Cigarettes and smoking equipment will be kept at the nurses' station. Staff to monitor distribution of smoking materials during smoking sessions . If the resident/patient is on oxygen, please have staff assist with the removal of oxygen prior to leaving for the designated smoking area. Once the resident/patient has completed the smoking session, all smoking materials will be returned to the nurses' station. If oxygen was in place prior, the staff can assist in reapplying the oxygen at this time . 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included [MEDICATION(S)] dependence and [CONDITION(S)]. An annual assessment, dated 02/14/21, documented the resident did not use tobacco. A quarterly assessment, dated 04/23/21, documented no answer to the question on tobacco use. The resident's care plan, updated 06/24/20, documented the resident enjoyed smoking as an activity outside. A problem related to tobacco use was initiated on 02/16/21, and interventions included, . Educate resident/responsible party on facilities tobacco/smoking policy . orient resident to smoking times and procedures . The resident's smoking assessment, dated 09/17/20, documented the resident had no cognitive loss, visual deficits, or dexterity problem. It was documented the resident was to tell staff when he was to smoke and the facility needed to store the resident's smoking material. The resident's smoking assessments, dated 12/17/20 and 03/17/21, documented the resident had no cognitive loss, visual deficit or dexterity problem. It was documented the resident could light his own cigarette and required supervision. It was documented the resident's smoking materials did not need to be stored by the facility. A facility reported incident, dated 06/14/21, documented . Resident had went outside with hospice aide to smoke during visit. Resident had reached behind him to turn off oxygen, he lit cigarette and then there was a flame. Resident began extinguishing the flame with his hands. Mustach [sic] and eye brow on R [right] side of face singed. Scattered [CONDITION(S)] to nose, upper lip and L [left] cheek observed . Facility records documented the facility had 39 staff with nursing department responsibilities. Review of facility in-service records, dated 06/22/21, revealed documentation an inservice was conducted on smoking safety. The signatures of 16 direct care staff members attested they had attended the inservice. This meant 22 direct care staff were not inserviced. On 06/23/21 at 8:38 a.m., one staff and three residents were observed outside. Two residents were smoking, and one resident was observed coming into the building with the staff member. No staff were observed supervising the two smokers who remained outside. On 06/23/21 at 8:56 a.m., three residents (#2, #3, and #7) were observed outside smoking without supervision of staff. On 06/24/21 at 12:48 p.m., resident #5 was asked what had happened on 06/14/21. He stated I went out to smoke with my hospice aide, I turned it off [the oxygen] but when I did, it hung on the side of the bag that my oxygen tank was in and it did not close off and I didn't take off my cannula. I usually do. Anyway, I was almost done smoking when my face caught fire. He stated, I had the fire out before the hospice aide realized I had caught fire. He was asked if the hospice aide had checked to make sure the oxygen was off. He stated, Yeah, she looked at it and thought it was off too. He was asked if the hospice aide had reminded him to take off his cannula. He stated, No. The resident was asked what the facility did when the event happened. He stated, Now they keep my cigarettes and lighter at the desk, and someone has to go with me to smoke. I can't even light my own cigarette. He was asked about the oxygen. He stated, They turn it off and take my cannula off my face. On 06/23/21 at 9:04 a.m., certified nurse aide (CNA) #3, assigned to hall A, was asked if she had any smokers on her hall that required supervision. She stated one. She stated the staff were told to stay with them until the resident was ready to come in. She was asked if there was anything she was to do if the resident wore oxygen. She stated she was not told anything about that. She stated she did not attend the inservice the day before due to working the floor. On 06/23/21 at 9:48 a.m., licensed practical nurse (LPN) #1 stated she had not been inserviced but knew there was an inservice the day before. She was asked if she knew what the inservice was about. She stated no, that she was working the floor. On 06/23/21 at 10:25 a.m., certified nurse aide (CNA) #5 stated there were two smokers on her hall; none on oxygen and none that required supervision. She was asked when she had been inserviced on smoking safety. She stated six to eight months ago. She stated, I know there are some residents that need someone with them. On 06/23/21 at 3:15 p.m., the DON, administrator, and corporate nurse were asked if all staff had been inserviced on smoking safety on 06/22/21. The DON stated, Not yet, I started the inservices on 06/22/21 and was going to do another one today but you came in. She was asked if it was policy for all smokers to be supervised. She stated, Yes. The corporate nurse stated if the residents were assessed to require supervision. The DON was asked why residents were observed to be smoking unsupervised. She stated Well, some are independent. She was informed all the smoker evaluations were reviewed and all were assessed to require supervision. She stated, I believe all smokers should be supervised. She was informed what the facility policy documented as a supervised smoker. She was asked if the facility was following their policy. She stated, No. 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia, cancer, anxiety, and depression. An annual assessment, dated 12/11/10, documented the resident used tobacco. A quarterly assessment, dated 02/23/21, had no answer to the tobacco question documented. The resident's smoking assessment, dated 07/24/19, documented the resident required supervision while smoking. The resident's care plan, dated 05/19/21, documented a problem related to tobacco use. The goal was the resident would adhere to facility's tobacco and smoking policies. Interventions included to, . Educate resident/responsible party on facility's tobacco/smoking policy(s) . On 06/23/21 at 8:39 a.m., resident #1 was observed going outside to smoke. No staff were present. On 06/23/21 at 10:15 a.m., the resident was asked if he required supervision while smoking. He stated, No. He stated he smoked a couple times a day. He was asked if he had been educated about smoking safety. He stated, No. On 06/23/21 at 3:15 p.m., the DON was asked why residents were observed to be smoking unsupervised. She stated Well, some are independent. She was informed all the smoker evaluations were reviewed and all were assessed to require supervision. She stated, I believe all smokers should be supervised. She was informed what the facility policy documented as a supervised smoker. She was asked if the facility was following their policy. She stated, No. 3. Resident #2 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] and [MEDICATION(S)] dependence. The resident's care plan, updated 06/19/21, documented a problem related to tobacco use. The goal was the resident would adhere to the tobacco/smoking policies of the facility. Interventions included to educate resident or responsible party on the facility's tobacco smoking policy. The resident's smoking assessment, dated 06/02/21, documented the resident did not have cognitive loss, visual deficit, or a dexterity problem. It was documented the resident could light his own cigarette and did require supervision. It was documented the facility needed to store smoking materials. On 06/23/21 at 8:38 a.m., one staff and three residents were observed outside. Two residents were smoking and one resident was observed coming into the building with the staff member. No staff were observed to supervise the two smokers who remained outside. On 06/23/21 at 8:48 a.m. resident #2 was observed to obtain a cigarette from resident #3. The resident lit the cigarette and proceeded to smoke without supervision. On 06/23/21 at 9:54 a.m., the resident was asked if he was a supervised smoker. He stated, No. He was asked if he took his oxygen out with him to smoke. He stated Yes, but I don't wear it when I'm smoking. I turn it off. The DON was asked why residents were observed to be smoking unsupervised. She stated Well, some are independent. She was informed all the smoker evaluations were reviewed and all were assessed to require supervision. She stated, I believe all smokers should be supervised. She was informed what the facility policy documented as a supervised smoker. She was asked if the facility was following their policy. She stated, No. 4. Resident #3 was admitted to the facility on [DATE], with diagnoses that included osteomylelitis and diabetes. The resident's care plan, dated 05/03/21, documented a problem related to tobacco use. The goal was the resident would adhere to the tobacco smoking policies of the facility. Interventions included to educate the resident on the facility's tobacco smoking policy. The resident's smoking assessment, dated 04/29/21, documented the resident required supervision smoking. On 06/23/21 at 8:56 a.m., resident #3 was observed outside smoking without supervision of staff. On 06/23/21 at 1:10 p.m., the resident was observed outside smoking with no staff present. He was seated in his wheelchair. He was asked if he required supervision while smoking. He stated, No. He stated he came out to smoke at his leisure and did not need to leave his smoking material at the nurses' desk. On 06/23/21 at 3:15 p.m., the DON was asked why residents were observed to be smoking unsupervised. She stated Well, some are independent. She was informed all the smoker evaluations were reviewed and all were assessed to require supervision. She stated, I believe all smokers should be supervised. She was informed what the facility policy documented as a supervised smoker. She was asked if the facility was following their policy. She stated, No. 5. Resident #7 was admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)], anxiety, [MEDICATION(S)] dependence, and homonymous bilateral field defects, left (a condition in which a person sees only one side of the visual world of each eye). The resident's care plan, dated 04/17/20, documented, . Risk Prone Health Behavior, I choose to exercise my right to continue smoking although I am aware of the health risks it poses to me. Goal: I will be free from injury related to smoking. Interventions: Assess/monitor/document my ability to smoke independently upon admission and regularly thereafter. Routinely perform a smoking evaluation on all residents who request permission to smoke. Designate a smoking area for residents outside of the facility that provides non-combustible ashtrays, smoking aprons, fire extinguishers, supervised access to cigarettes and lighters and appropriate level of supervision . The resident's care plan documented a focus of Ineffective breathing Pattern/Risk: I have non-productive cough, wheezes, shortness of breath secondary to [MEDICATION(S)] dependence/smoking/[CONDITION(S)] [[CONDITION(S)]]/uri [upper respiratory infection] It documented an intervention to, . Resident is allowed to sit at gazebo without supervision for 30 minutes to smoke. His [sic] cigarettes and lighter are at the nurses station . The resident's smoking assessment, dated 06/06/21, documented the resident had no cognitive loss, visual deficit, or dexterity problem. On 06/23/21 at 8:15 a.m., the resident was observed outside smoking. On 06/23/21 at 8:27 a.m., the resident was observed coming into the building from a door at the end of B hall unassisted. She entered her room and shut the door. On 06/23/21 at 10:10 a.m., the resident was asked if she required supervision while smoking. She stated no. She stated she went out a couple times a day to smoke. She was asked if she was able to keep her cigarettes with her. She stated yes. She was asked if she had been educated by the facility on safe smoking practices. She stated no. On 06/23/21 at 3:15 p.m., the DON was asked why residents were observed to be smoking unsupervised. She stated Well, some are independent. She was informed all the smoker evaluations were reviewed and all were assessed to require supervision. She stated, I believe all smokers should be supervised. She was informed what the facility policy documented as a supervised smoker. She was asked if the facility was following their policy. She stated, No.

Based on observation, interview, and record review, it was determined the facility failed to: ~ implement interventions to aid in the prevention of injury with falls for one (#66) of three sampled residents who were reviewed for falls. The resident suffered three falls from rolling out of the bed within ten hours. The resident sustained a [CONDITION(S)], a fractured clavicle, and fractures to the left superior and inferior pubic rami. The facility identified ten residents who had falls with injury; and ~ provide an environment free of accident hazards for one (#11) of one sampled resident who was reviewed for wandering. The facility identified five residents as wanderers. Findings: The facility's standard statement related to accidents and incidents, dated 12/2018, docoumented, . Should an accident/incident occur, the facility strives to prevent such an occurrence from happening again . 1. Resident #66 was admitted to the facility on [DATE] with diagnoses that included dementia and other mental disorders. A fall evaluation, dated 01/17/21, documented the resident was at high risk for falls. It was documented the resident did not recall three out of four of the following: current season, that she was in a nursing home, the location of her room, or staff names/faces. The resident's care plan, dated 02/26/15 and last revised 02/09/21, documented the resident was at high risk for falls related to diagnoses of gait/balance problems, dementia, and incontinence. The goal was the resident would remain free of serious injury related to falls. Interventions included to keep the call light within reach, floor free from clutter, remind to ask for assistance with transfers, non-skid socks, room well lit, bed in low position at night. An annual assessment, dated 02/09/21, documented the resident was severely impaired in cognitive skills; required extensive assistance of staff for bed mobility and locomotion; was incontinent of bowel and bladder; and had one fall without injury since the last assessment. An initial incident note, dated 03/19/21 at 10:59 p.m., documented, . Describe occurrence in resident's words: I rolled off the bed. Describe scene as observed by staff: Resident was next to bed on the floor on her back, bed lowest position. Said she did not hurt anywhere and did not hit her head. Factors that could have contributed to incident (wet floor, resident incontinent @ time of incident): none apparent, appears she rolled off bed. What safety interventions were in place at the time of the occurrence: bed lowest position. call light in reach. nonskid socks on. Were safety devices in use and functional: yes. New interventions added at time of incident to prevent re-occurrence: assisted back to bed, brief changed, reminded to ask for help to reposition, gave water . Describe resident injuries.: none apparent Describe pain and location. : says none . A post fall investigation report, dated 03/19/21, documented the resident's bed was locked and in the lowest position, her call light was within reach, and that the resident had shoes and socks on. It was also documented staff was reminded to prop the resident with pillows and to check frequently. Review of the resident's clinical record and facility incident reports reveal no documentation any new interventions were identified and implemented after the fall. There was no documentation fall mats were in use or put into use after the fall to help prevent injury in case of another fall. A health status note, dated 03/20/21 at 6:14 a.m., documented, . Resident noted on floor laying on her back without redness or bruising . Resident assessed and picked up placed in bed incontinent care provided. Resident denies pain or discomfort . A health status note, dated 03/20/21 at 6:25 p.m., documented, . Called [family member] notified her of fall . Review of the resident's clinical record and facility incident reports reveal no documentation any new interventions were identified and implemented after the fall. There was no documentation fall mats were in use or put into use after the fall to help prevent injury in case of another fall. A health status note, dated 03/20/21 at 8:43 a.m., documented, . Text: Res [resident] noted to be laying on her floor in between bed and wall. Laceration to R/temple. 2 pressure dressings applied and held by nurse . until EMS [Emergency Medical Services] arrived. Left facility at @ 0830 via ems stretcher . An initial incident note, dated 03/20/21 at 8:47 a.m., documented, . Describe occurrence in resident's words: Unable to verbalize. Describe scene as observed by staff: Res noted to be laying on her right side in between bed and wall in her room. Factors that could have contributed to incident . Poor trunk control, unsteady gait, res confused per usual status. What safety interventions were in place at the time of the occurrence: Bed in lowest locked position, room well lit, call light within reach, staff present on hall. Were safety devices in use and functional: yes . An accident/incident final disposition report, dated 03/20/21, documented, . When res returns from hospital res will be put in a low bed c [with] fall mat . A hospital pelvic x-ray report, dated 03/20/21 at 9:44 a.m., documented, . acute fractures suspected at the left superior and inferior pubic rami . A hospital chest CT scan report, dated 03/20/21 at 2:07 p.m., documented, . Nondisplaced fracture of the distal right clavicle . A health status note, dated 03/23/21 at 6:28 p.m., documented, . Resident just arrived back . Knot on top of right forehead has stitches. Is red and a little swollen. Also has a knot to the back of the head. Bed lowest position . Family pushed the bed against the wall . On 05/25/21 at 2:07 p.m., licensed practical nurse (LPN) #1 stated the resident was not alert and oriented and would not have known how to use her call light. On 05/25/21 at 2:09 p.m., the director of nursing (DON) stated the resident was not alert and oriented and would not have know how to use her call light. The DON was asked what interventions had been put into place after the resident rolled out of the bed on 03/19/21. She stated the resident had remained in a locked, low bed and had fall mats in place. She stated staff had been on the hall, and the resident would have been checked at least every two hours. The DON was asked where it was documented the resident had fall mats in place, as neither the resident's care plan, clinical record, or facility incident reports addressed the use of fall mats. She stated, I don't see where it is documented. The DON was asked what interventions were put into place after the resident rolled out of the bed on 03/20/21 at 6:14 a.m. She stated the resident's family came and sat with her at that time. The DON was asked where it was documented the family came at that time. She stated, It's not. The DON stated the resident suffered another fall after the fall at 6:14 a.m. She stated the resident sustained injuries with one of the falls. She stated the resident had suffered a laceration to her head and some fractures. The DON stated the resident would have had fall mats in place after being placed in a low bed. She was asked to provide the documentation the resident had fall mats in place. On 05/25/21 at 4:00 p.m., the DON, administrator, and corporate administrator reported the facility had been unable to find any documentation fall mats had been in use for the resident. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, [CONDITION(S)] with delusions, amnesia, mood disorder, [CONDITION(S)], vascular dementia, anxiety, and disorientation. A progress note, dated 01/16/21 at 12:43 p.m., documented, . resident at nurses station getting into a box of gloves that had been behind desk. This nurse went to get box of gloves. Resident then snatched face mask off of this nurse and refused to let it go. Was able to get mask back. Resident still up trying to get to things behind desk. Will continue to monitor . A progress note, dated 04/07/21 at 4:37 p.m., documented, . resident in lobby ambulating . Was a little combative when taking her vitals, trying to pull away, but calmed quickly afterwards. Was at the nurses desk fumbling through everything and walked to the dining room . A quarterly assessment, dated 04/30/21, documented the resident was severely cognitively impaired. It was documented the resident wandered daily on seven of the seven preceding days. A progress note, dated 05/03/21 at 6:22 p.m., documented, . resident in lobby being rather combative. Biting at anyone who attempts to get close to her . Refuses to be helped . She has also been in the dining room taking knives/ forks off of the tables and attempting to use them to hurt people. Will not listen to instruction. Also is taking things that are not hers, such as items from nurses desk and hiding them. Finally allowed me to give her as snack and drink but will not stop roaming the facility . The resident's care plan, dated 05/12/21, documented, . provide me a safe/calm environment that is free from environmental hazards. Reorient me/remind me when I get confused and disoriented to who I am, who you are, where we are and what we are doing. This will help me feel safe and reorient me to person/time/place. Eliminate/minimize hazards in the environment . On 05/18/21 at 9:56 a.m., licensed practical nurse (LPN) #1 stated staff are to redirect the resident. On 05/18/21 at 10:51 a.m., the resident was observed wandering down B hall. The resident stood in the doorway of room B16 and then wandered into the sun room. At 10:52 a.m., the resident wandered in front of an unattended medication cart located on B hall. The resident was observed looking on top of the medication cart. Acetaminophen, [MEDICATION(S)], and aspirin bottles were observed on top of the unattended medication cart. Certified medication aide (CMA) #1 was in room B16. The CMA did not have a visual path to the medication cart. CMA #1 exited room B16 while the resident was standing in front of the cart. The CMA walked past the resident and the medication cart and entered another room. The medications remained unattended on top of the medication cart. The resident then wandered down the hall. CMA #1 exited the room, returned to the medication cart, and placed the medications into the cart. On 05/18/21 at 1:59 p.m., the resident was observed looking in a notebook at the nurses' station. On 05/18/21 at 2:14 p.m., the housekeeping supervisor was observed walking the resident off of A hall. On 05/18/21 at 2:37 p.m., the resident was observed with a staff member leading her back to her room. The staff member was attempting to redirect the resident. On 05/25/21 at 2:49 p.m., CMA #2 stated when a medication cart was left unattended, the medication cart must be locked, with all medications locked inside the cart, and with no resident information showing. On 05/25/21 at 2:54 p.m., the director of nursing (DON) stated the medication cart should have been locked, and all medications put away if the cart was unattended. The DON stated medications should not be left on top of an unattended medication cart, no matter what kind of medication it was.

Based on observation, interview, and record review, it was determined the facility failed to store and prepare food under sanitary conditions for 91 residents who received nutrition and fluid from the kitchen. Mouse droppings and/or urine trails were observed in the food preparation and food storage areas of the facility kitchen. This deficient practice had the potential to infect the residents who received nutrition and fluid from the kitchen with diseases directly transmitted by rodents. The facility census and condition report identified 95 residents resided in the facility. Four residents received nutrition and fluid via tube feedings. Findings: A facility policy for kitchen cleaning procedures did not include the cleaning and sanitation of rodent waste. The policy did not include the cleaning and sanitation of cabinets and pull out drawers. The policy did not include the cleaning and sanitation of the area under the can racks. A facility policy for kitchen cleaning documented all food service personnel were responsible for cleaning and sanitizing all areas of the kitchen. The policy for kitchen floor cleaning documented the kitchen would be mopped using a sanitizing solution. The policy for kitchen cleaning documented all equipment would be cleaned and sanitized before use. A facility policy for dry storage of food documented foods should be stored at least six inches off of the floor and two feet from the wall. On 04/23/12 at 2:05 p.m., surveyors entered the kitchen area to complete the initial tour. Cook #1 was identified as being the person in charge during initial tour. On 04/23/12 at 2:10 p.m., a clear plastic container holding serving utensils was observed under the kitchen sink next to cleaning supplies. Rodent droppings were observed under the kitchen sink at the back of the cabinet, along the side of the cabinet, and along the side of the plastic container located under the cabinet. On the top shelf of the wooden cabinet to the right of the kitchen sink beside the steam table, two boxes of vanilla cookies were observed in unsealed opened boxes. On the lower shelf of the wooden cabinet were two undated bowls of dry cereal. The cereal was visible between the unsealed lid and the top of the bowl. Cook #1 was interviewed regarding the bowls of dry cereal in the cabinet. Cook #1 stated the bowls should have been covered and dated. On the top shelf of the wooden cabinet above the bowls of cereal was an unsealed package of raisins with no documentation of the opened date. Cook #1 stated she was not sure when the box of raisins was opened. On 04/23/12 at 2:15 p.m. in the last drawer of the wooden cabinet next to the steam table, there were two opened packages of single serve saltine crackers and one unopened package of single serve graham crackers in the back of the pull out drawer. There were multiple rodent droppings observed in the back left corner of the pull out cabinet. The serving scoops were laying in the drawer with the rodent droppings and crackers. In the next pull out drawer, there were rodent droppings along the back of the drawer. Serving scoops were observed in this drawer. On 04/23/12 at 2:20 p.m., the dietary manager (DM) stated this was not a new problem. She stated the pest control company had been here several times the past year. On 04/23/12 at 2:35 p.m., the storage racks located in the room with the freezers and refrigerators were observed to have an undated bag of opened croutons and an undated box of opened bacon bits with a Styrofoam cup laying inside the bacon bits on the second shelf. Under the storage rack behind the white freezer and under the can rack, there were rodent droppings, pieces of paper trash, and croutons observed along the wall and in the corner of the storage rack. On 04/23/12 at 2:40 p.m., a large bag containing multiple heads of cabbage was observed laying on the floor. The DM stated food items are not supposed to be laying on the floor. On 04/23/12 at 2:45 p.m., the stainless steel refrigerator was observed to have the following undated items in the refrigerator: one gallon of opened milk, one half gallon of opened buttermilk, a container of sliced cucumbers, a container of cut tomatoes, a container of grated cheese, a container of croutons, a large container of lettuce with brown pieces of lettuce in the container, a container of ham, a container of cooked / sliced eggs, and a container of sliced peaches. The top shelf of the stainless steel refrigerator was observed to have a large container filled 43 small plastic containers filled with a mixed brown food item. The DM was interviewed regarding the content of the plastic containers. The DM stated they were benecal pudding. She stated there was one resident who consumed four of them a day. The DM was asked if these containers were labeled or dated. The DM stated they were not. On 04/23/12 at 2:50 p.m., the DM was asked who was responsible for cleaning the kitchen and storage areas. The DM stated the kitchen staff was responsible for cleaning the kitchen and storage areas. A dietary daily cleaning schedule for March and April 2012 were reviewed with the dietary manager. The DM stated there were several days with no documentation that cleaning had been completed by kitchen staff. The DM was asked about the completion of the tasks listed on the cleaning schedule. The DM stated it looked like the tasks had not been done as listed on the cleaning schedule. The DM was asked if the kitchen and storage areas were clean as required by facility policy and the daily cleaning schedule. The DM stated the kitchen and storage areas were not clean. A dietary check list and sanitization survey from the dietary consultant documented the form would be completed at least monthly. The dietary manager (DM) was interviewed regarding the results of the previous monthly checks recommended by the dietary consultant. The DM stated they had not been completed. On 04/23/12 at 3:05 p.m., the coffee station which held coffee condiments was observed to have trash pieces and food particles in each separate compartment. On 04/23/12 at 3:10 p.m., the ice cream machine was observed to have an open, undated package of oreo cookie crumb ice cream topping laying under the machine. IMMEDIATE JEOPARDY IDENTIFIED On 04/23/12 at 3:30 p.m., an Immediate Jeopardy (IJ) situation was identified in kitchen sanitation. The facility failed to ensure the kitchen was free from mouse droppings and urine trails and sanitary conditions were maintained. On 04/23/12 at 3:55 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ in kitchen sanitation. On 04/23/12 at 4:00 p.m., the administrator was notified of the IJ in kitchen sanitation which placed the facility in an extended survey. FACILITY PLAN OF REMOVAL FOR IMMEDIACY On 04/23/12 at 4:55 p.m., an acceptable plan of removal of the immediacy was received from the administrator. The plan of removal was as follows: "All drawers will be broken down and completely sanitized with hot soapy water then cleaned with water and 50 ppm clorox. All utensils and liners will be sanitized, and not placed in drawers until drawers are sanitized. Can racks will be removed, cleaned with hot soapy water then sanitized with 50 ppm Clorox as well as floor underneath can racks. Staff will be inserviced and retrained in Sanitation 04/24/12. Dietary manager and administrator will continue to investigate and follow through to assure the situation will not occur again. They will document weekly the results of their findings and address it to the QA meeting. Any opened food will be destroyed. Complete kitchen shall be sanitized completely by 04/23/12. Administrator will notify (name deleted company) and rebait." IMMEDIACY REMOVED On 04/24/12 at 9:05 a.m., the black light was used to observe the previously identified areas contaminated with rodent droppings and urine. On 04/24/12 at 9:05 a.m., the registered dietician was interviewed regarding the inservice scheduled for 04/24/12. The pest control invoices from 06/01/11 to 03/17/12 documented service had been provided for rodent activity. Staff interviews were conducted on 04/24/12 and 04/25/12 in regard to their knowledge of the inservice, to ensure their understanding in the procedures for maintaining a clean and sanitary kitchen, and procedures for reporting the presence of rodent or pest activity. The IJ was removed effective 04/25/12 at 9:30 a.m., after observations were conducted in the kitchen, inservice documentation was provided to the survey team, and staff interviews were conducted. The deficient practice remained at a widespread level of no actual harm with potential for more than minimal harm.