Every finding on record at Fairfax Behavioral Health & Memory Care Community

Based on record review and interview, the facility failed to access, monitor, and intervene for a change in condition for 1 (#1) of 3 sampled residents reviewed for quality of care.The administrator identified 50 residents who resided in the facility. Findings:A quarterly assessment, dated 11/17/25, showed Resident #1 was originally admitted on [DATE] with diagnoses which included stroke, congestive heart failure, hemiplegia and diabetes mellitus type II. The assessment showed Resident #1 was severely impaired in cognition and had unclear speech. The assessment showed Resident #1 required substantial assistance with all activities of daily living. There were no nurse progress notes documented for Resident #1 between 02/03/26 and 02/09/26.A treatment administration record for Resident #1, dated 02/09/26 at 7:44 a.m., showed the resident's finger stick blood sugar was 209.A blood pressure and pulse summary for Resident #1, dated 02/09/26 at 10:37 a.m., showed the resident's blood pressure was 130/84 and heart rate was 93 beats per minute.A staff schedule, dated 02/09/26, showed LPN #2 was responsible for Resident #1's care. No documentation was found in Resident #1's medical record showing LPN #2 had provided care to the resident on 02/09/26.A nurse progress note, dated 02/09/26 at 7:45 p.m., showed LPN #1 found Resident #1 lethargic and not responding to verbal or tactile stimuli. Resident #1's finger stick blood sugar was 334, their blood pressure was 108/57, and their pulse was 111. Resident #1 was sent to the emergency room for evaluation and treatment. A Change in Condition policy, revised 03/01/26, read in part, The facility shall promptly identify and respond to any change in a resident's condition. Changes in condition shall be assessed immediately, reported to the physician, reported to the resident's representative, documented thoroughly, and care planned appropriately. On 05/04/26 at 1:36 p.m., family member #1 stated they were notified Resident #1 was admitted to the hospital with a UTI after they were found unresponsive. Family member #1 stated Resident #1's mind wasn't there and the family had watched their health slowly decline. Family member #1 stated they believed Resident #1 had a small stroke while in the hospital. Family member #1 stated they were informed by an unidentified staff member that Resident #1 had not been checked on in four hours and nobody knew how long Resident #1 had been unresponsive.On 05/04/26 at 2:02 p.m., family member #2 stated they spoke to one of the nurses at the hospital and was informed the resident was septic from a UTI. On 05/04/26 at 2:40 p.m., the EMT stated on 02/09/26, they were dispatched for an unresponsive patient. The EMT stated when they arrived, shortly after 8:00 p.m., they observed LPN #1 getting out of their car and smoking a cigarette. The EMT stated when they entered Resident #1's room they observed Resident #1 lying flat on their back, alone in their room, barely breathing, and white as a ghost. The EMT stated they initially thought Resident #1 was dead. The EMT stated three staff members were observed at the nurse's station. The EMT stated CMA #1 told them Resident #1 had been like that since at least 4:00 p.m. The EMT stated LPN #1 told the EMTs they had arrived at 6:00 p.m. and had just assessed Resident #1. The EMT stated Resident #1 was one of their regulars.On 05/04/26 at 3:26 p.m., CMA #1 stated they arrived on shift at 3:00 p.m. CMA #1 stated between 4:00 p.m. and 5:00 p.m., they tried to assist Resident #1 with eating, but Resident #1 only managed to eat a couple bites because they kept gagging. CMA #1 stated Resident #1 did not answer or talk to them which was abnormal. CMA #1 stated they notified LPN #2 about their observations, but LPN #2 was new at the time and never laid eyes on [Resident #1]. CMA #1 stated they told LPN #1 about what was going on and asked LPN #1 to go lay eyes on [Resident #1]. CMA #1 stated LPN #1 informed them they would after they completed the evening blood sugar checks. CMA #1 stated LPN #1 called EMS after their observation and asked CMA #1 for a pulse oximeter to allow them to check Resident #1's oxygen levels. CMA #1 stated LPN #1 ran to their car looking for a pulse oximeter, and that was when the EMTs arrived. CMA #1 stated LPN #1 did not have time to smoke a cigarette in the short amount of time they went to their car to look for the pulse oximeter. CMA #1 stated the EMT was yelling at [LPN #1] about why no one was with [Resident #1]. CMA #1 stated I think the nurses should have acted like it was more important. CMA #1 stated when they last saw Resident #1 for the dinner meal, they were not unresponsive, but they were not responding appropriately. CMA #1 stated they did not know the facility protocol for leaving residents alone when they are preparing to be transferred to the hospital.On 05/04/26 at 3:58 p.m., CNA #1 stated when they fed lunch to Resident #1 on 02/09/26. CNA #1 stated the resident only took a couple of bites and was letting food roll out of their mouth. CNA #1 stated they notified LPN #2 Resident #1 was not eating.On 05/04/26 at 5:06 p.m., the ADON stated they were made aware Resident #1 was acting differently on 02/09/26. The ADON stated they went to speak with Resident #1 at approximately 1:00 p.m., and Resident #1 stated they were fine. The ADON stated documentation should have been completed about Resident #1's decline throughout the day. The ADON stated LPN #2 was the nurse responsible for Resident #1 and the ADON assumed LPN #2 was going to document Resident 1's condition. The ADON stated they did not know when Resident #1's decline began because the administration did not have a procedure in place to verify if charting was being completed or monitoring for resident changes in condition. The ADON stated an assessment should have been conducted right after a change in condition was identified. The ADON stated it should not have taken the nurse almost two hours to assess Resident #1 after the change in condition was identified.On 05/04/26 at 5:16 p.m., LPN #2 stated at the time of the incident, they were still new and Resident #1 was already naturally declining. LPN #2 stated they were notified around 4:00 p.m. that Resident #1 was not acting right. LPN #2 stated they assessed Resident #1's vital signs but did not recognize any change in condition from the previous day. LPN #2 stated they did not feel their assessment needed to be documented because there was nothing out of the ordinary and Resident #1 was stable. LPN #2 stated Resident #1 had not been eating well in the last few days. LPN #2 stated they did not feel Resident #1's condition warranted a call to the physician because they did not identify a change in condition.On 05/04/26 at 6:02 p.m., LPN #1 stated they arrived at work around 6:00 p.m. and received report. LPN #2 stated they had not been notified about any concerns with Resident #1. LPN #1 stated they reviewed documentation and started completing blood sugar checks. LPN #2 stated when they checked Resident #1's blood sugar at approximately 7:45 p.m., they noticed Resident #1 was not acting right. LPN #1 stated Resident #1 had an increased pulse rate, low blood pressure, and was pale which indicated something was wrong. LPN #1 stated they went to their car to look for a pulse oximeter after they called EMS. LPN #1 stated the EMT kept asking how long Resident #1 had been unresponsive. LPN #1 stated they had a two-hour time frame to check on their residents. LPN #1 stated they called and gave report to the hospital. LPN #1 stated after they identified Resident #1's change in condition, they were notified by CMA #1 that concerns about Resident #1's change in condition were raised earlier during the previous shift. LPN #1 stated they did not feel the situation was dire enough to have someone sit with Resident #1. They stated they didn't really have time to go chase somebody down. LPN #1 stated Resident #1's breathing was normal. LPN #1 stated they were aware of Resident #1's history of UTI's and that Resident #1 did not like liquids because they had to be thickened. LPN #1 stated I did not stop for a smoke break; I wasn't out there for more than a few seconds to look for a pulse oximeter. On 05/06/26 at 12:37 p.m., the director of nursing stated We are trying to educate the staff on how to appropriately chart and make sure observations are charted.

Based on observation, record review, and interview, the facility failed to ensure staff transferred a resident in a safe manner to prevent injury for 1 (#6) of 2 sampled residents reviewed for safe transfers.The DON identified 48 residents resided in the facility. Findings:On 02/03/26 at 1:14 p.m., Resident #6 was observed sitting in a wheelchair in their room with their left arm wrapped in an ace wrap and secured in an immobilized arm sling.A facility policy titled Policy and Procedure Resident Transfer and Safe Patient Handling, dated 11/01/23, read in part, It is the policy to ensure all resident transfers are performed using proper body mechanics, approved transfer techniques, and appropriate equipment in order to prevent injury to residents and staff and to promote resident dignity and mobility.A care plan for Resident #6, dated 10/02/25, showed the resident required moderate to maximum assistance of two staff members for toileting and incontinent care.An incident note for Resident #6, dated 11/30/25, showed the resident had a fall and was lowered to the bathroom floor by staff. The incident note showed Resident #6 was crying that their left wrist was hurt.A mobile x-ray report for Resident #6, dated 11/30/25, showed the resident had an x-ray taken of their left arm which showed an acute distal left arm fracture.A radiology results note for Resident #6, dated 11/30/25 showed resident was sent to the hospital for their left arm to be stabilized.A quarterly assessment for Resident #6, dated 01/08/26, showed the resident had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and required substantial maximum assistance with transfers. The assessment showed the resident had one fall with major injury. A progress note for Resident #6, dated 01/09/26, showed a CNA reported to a nurse they had heard a pop while assisting Resident #6 in the shower.A mobile x -ray report for Resident #6, dated 01/10/26, showed the resident had an acute distal fracture of the left humerus.A progress note for Resident #6, dated 01/10/26, showed was sent to the hospital for stabilization of the arm.On 02/03/26 at 1:15 p.m., Resident #6 stated they broke their wrist while CMA#1 was assisting them to the bathroom. Resident #6 stated they told CMA #1 they needed two people for assistance. Resident #6 stated they broke their left arm when two aides transferred them under their arm pits to get into a shower chair.On 02/03/26 at 3:18 p.m., CNA #1 stated they transferred residents by placing their forearms under the residents' arms. On 02/04/26 at 9:15 a.m., LPN #2 stated on 01/09/26 two CNAs transferred Resident #6 under the resident's arms. They stated the CNAs where transferring Resident #6 to a shower chair when they heard the resident's left shoulder pop.On 02/04/26 at 10:14 a.m., CNA #3 stated when they had attempted to transfer Resident #6 to a shower chair on 01/09/26, they transferred by putting their arms under the resident's arms. CNA #3 stated they heard a pop in Resident #6's left shoulder.On 02/05/26 at 10:32 a.m., CMA #1 stated they utilized a one-person transfer for Resident #6 on 11/30/25. They stated Resident #6 started to fall and used their left hand to break the fall. CMA #1 stated they did not know Resident #6 was a two-person transfer. On 02/05/26 at 11:49 a.m., the DON stated staff were to use gait belts and to not lift residents under their arms.

Based on observation, record review, and interview, the facility failed to ensure adequate supervision to prevent elopement for 1 (#2) of 2 sampled residents reviewed for elopements.The DON identified 48 residents resided in the facility.Findings:On 02/03/26 at 1:33 p.m., Resident #2 was observed walking up and down halls with CNA #5. They were unsteady on their feet and required hands on assistance to walk. CNA #5 attempted to redirect resident several times to sit in their broda chair without success. On 02/03/26 at 2:47 p.m., Resident #2 was observed sitting in their chair while CNA #5 was talking to them.On 02/04/26 at 9:48 a.m., Resident #2 was observed walking up and down halls with CNA #5.On 02/04/26 at 11:10 a.m., the park where Resident #2 was found during their elopement was observed to be approximately 50 yards from the facility's back door and on the other side of a small hill.A Policy and Procedure: Resident Elopement Prevention and Response, dated 11/01/23, read in part, It is the policy to protect residents from elopement.An admission assessment, dated 08/28/25, showed Resident #2 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia, delirium due to known psychological condition, and anxiety disorder. The assessment showed Resident #2 had a BIMS of 3, which indicated Resident #2 had severe cognitive dysfunction, and had a history of wandering. A care plan, dated 08/21/25, showed Resident #2 was an elopement risk. Interventions for risk of elopement were to provide structured activities and offer diversions.An Incident Report, dated 10/04/25, showed Resident #2 was noticed to be missing from the facility on 10/04/25 at 2:59 p.m. The resident was located by staff at a nearby park shortly after 3:11 p.m. and was visibly anxious.An incident note, dated 10/04/25, read in part, Order for Hydroxyzine (an anti-anxiety medication) 25mg PO [by mouth] every 6 hours for 48 hours then reassess with primary care provider. Resident continues on every 30 minute checks.A MAR dated October 2025 showed Resident #2 was given eight doses of Hydroxyzine 25mg every six hours for 48 hours and then it was discontinued due to anxiety resolution.A document titled, In-Service Educational Program, dated 10/04/25, showed all staff were educated regarding elopement prevention and procedures and an elopement drill was completed.A document titled, 30 Minute Check Log [Resident #2], dated 10/04/25 showed Resident #2 was placed on 30 minute visual checks by staff until 10/24/25.A document titled, Quality Assurance and Performance Improvement Committee Meeting, dated 10/27/25, showed quality assurance committee members met to discuss elopement prevention and response monitoring.An undated task created in Resident #2's electronic health record showed they are to be one-on-one with a staff member at all waking times.A review of time punches from 10/04/25 showed eight direct care staff were working at the time of Resident #2's elopement.On 02/03/26 at 2:48 p.m., CNA #5 stated interventions in place to prevent elopement for Resident #2 was that someone was with them, they give treats and snacks or something to fidget with to keep Resident #2 distracted.On 02/03/26 at 2:53 p.m., LPN #1 stated interventions in place to prevent elopement for Resident #2 was that a member of staff was to be with them during waking hours. They stated distraction with activity and toileting as needed were also interventions. LPN #1 stated the facility changed the code on the door and only staff had the code for entering and exiting.On 02/03/26 at 3:12 p.m., the DON was asked about Resident #2's elopement. They stated Resident #2 was off premises for approximately 12 minutes, found at the nearby park, and uninjured. They stated Resident #2 was then prescribed Hydroxyzine and placed on 30 minute visual checks. The DON stated an elopement drill and all staff in-service regarding elopement prevention and response was held.On 02/05/26 at 11:03 a.m., CNA #6 stated a staff member is with Resident #2 at all times except while sleeping and still on 30 minute visual checks while sleeping. CNA #6 stated residents at risk for elopement were discussed during ongoing in-services and no one had the door code except employees. CNA #6 stated staff was educated to check exit doors when near them, keep residents engaged in activity, and check all residents at least hourly.On 02/05/26 at 11:07 a.m., the dietary manager stated Resident #1 had a staff member with them at all times. They stated the facility door code changed and only staff had codes for entering and exiting. The dietary manager stated they had received an in-service training to prevent elopements and as part of that training they check exit doors whenever they were near them.

Based on observation, record review, and interview, the facility failed to update care plan interventions after falls for 1 (#2) of 3 sampled residents reviewed for care plan interventions.The DON identified 48 residents resided in the facility. Findings:On 02/03/26 at 1:33 p.m., Resident #2 was observed walking up and down halls with CNA #5. The resident was unsteady on their feet and required hands on assistance to walk. CNA #5 attempted to redirect the resident several times to sit in their specialized wheelchair without success. On 02/03/26 at 2:47 p.m., Resident #2 was observed sitting in their chair while CNA #5 was talking to them.On 02/03/26 at 3:01 p.m., a sign posted in Resident #2's room, read in part, Use call light when needed.On 02/04/26 at 9:48 a.m., Resident #2 was observed walking up and down halls with CNA #5.A document titled Policy: Resident Falls and Prevention, dated 08/01/25, read in part, Interventions will be reflected in the resident's care plan and reviewed regularly .Update the care plan with revised or additional interventions.A care plan, dated 08/20/25, showed Resident #2 was at risk for falls related to weakness, impaired mobility, abnormal gait, and balance.An admission assessment, dated 08/28/25, showed Resident #2 was admitted to the facility on [DATE] with a diagnosis of non-Alzheimer's dementia. The assessment showed Resident #2 required supervision or touching assistance to walk 10 feet or more. The assessment showed Resident #2 had no history of falls.A review of the care plan showed a post fall intervention was added on 11/02/25 to provide frequent checks while they were in their room. The care plan had no additional interventions beyond 11/02/25.An incident note, dated 12/26/25, showed Resident #2 had a witnessed fall without injury. Interventions documented were to apply non-slip socks and obtain proper fitting shoes.An incident note, dated 01/01/26, showed Resident #2 had an unwitnessed fall which resulted in a skin tear to their right elbow. No interventions were documented.An incident note, dated 01/18/26, showed Resident #2 had an unwitnessed fall. No injuries or interventions were documented.An untitled document, dated 01/20/26, showed Resident #2 was seen in the emergency department for a fall. The document showed Resident #2 sustained a laceration of the face which was repaired by tissue glue. Resident #2 also sustained a bruise to the face and unspecified knee.An incident note, dated 01/21/26, showed Resident #2 was being monitored post fall. The note showed Resident #2 had bruising and swelling to their right eye.An incident note, dated 01/22/26, showed Resident #2 had an unwitnessed fall and the skin tear to their right elbow reopened. No interventions were documented.An incident note, dated 01/24/26, showed Resident #2 had an unwitnessed fall. No injuries or interventions were documented.An incident note, dated 01/28/26, showed Resident #2 had three unwitnessed falls. No injuries or interventions were documented.An incident note, dated 01/29/26, showed Resident #2 had an unwitnessed fall at 2:45 p.m. No injuries were documented. An intervention in place was to place resident in non-slip socks.An incident note, dated 01/29/26, showed Resident #2 had an unwitnessed fall at 4:33 p.m. with a skin tear and bruising to their right elbow. Intervention in place was to start Buspar (an anti-anxiety medication) 5mg twice daily for agitation.On 02/03/26, at 2:48 p.m., CNA #5 stated as a fall intervention a staff member would be with them around the clock. CNA #5 stated when Resident #2 became anxious or agitated, they would give snacks or treats as a distraction. CNA #5 was asked how they knew these were the interventions in place. They stated it was in the resident's electronic health record.On 02/03/26 at 2:59 p.m., LPN #5 stated fall interventions in place for Resident #2 were to take them to their room after meals, frequent toileting, non- slip socks, and use their chair when needed. LPN #5 was asked how they knew these were the interventions in place. They stated the interventions were posted in resident rooms, charts, or care plans.On 02/03/26 at 3:03 p.m., the DON stated care plans were reviewed and updated quarterly or with new physician orders and after every fall. The DON was asked to show interventions for Resident #2's falls after 11/02/25. They stated they could not show the interventions because they were not on the care plan. The DON was asked how staff knew what interventions were in place for residents. They stated progress notes in the electronic health record reflected the interventions. They were asked if the CNAs could see the progress notes. They stated, No, they can't. They receive the interventions verbally from the nurses.

Based on observation, record review, and interview, the facility failed to prevent resident-to-resident abuse for 2 (#33 and #45) of 4 sampled residents reviewed for abuse, which resulted in Resident #45 being hospitalized . The administrator reported four incidents of resident-to-resident abuse in the past 90 days. Findings: An undated policy titled Abuse By A Resident To Other Residents, read in part, In the case of abuse from one resident to another resident, any employee observing the abuse, shall immediately intervene in an effort to protect the resident. If there is an actual physical altercation, the employee shall immediately gain the assistance of another employee to assist in separating the residents involved by moving one resident away from the other. The residents will be geographically separated and supervised until both are calm and not a risk to harm themselves or others, or until it can be determined that the incident is isolated, and no threat or harm exists. 1. On 07/17/25 at 11:57 a.m., Resident #33 was observed in the dining room with their family member who was feeding the resident. A care plan for Resident #33, dated 06/04/25, showed the resident had diagnoses which included Alzheimer's disease, vascular dementia, peripheral vascular disease, anorexia, and acute kidney failure. A quarterly MDS assessment for Resident #33, dated 06/11/25, showed the resident had a BIMS of 01, which indicated the resident was severely cognitively impaired. On 07/17/25 at 12:05 p.m., Resident #33's family member reported the resident had been to a psychiatric facility twice and had gradually declined over the past couple of months. On 07/21/25 at 2:19 p.m., CMA #1 reported Resident #33 had been known to wander in the past and they were aware of the incident with Resident #45. CMA #1 reported they were not aware of Resident #33 being aggressive with any other resident and did not know of any other incidents of resident-to-resident abuse. 2. On 07/15/25 at 3:29 p.m., during the resident group meeting, Resident #45 reported they had been beat up approximately three weeks previously and required hospitalization. The resident did not indicate if the incident occurred with a staff member or another resident. A care plan for Resident #45, dated 03/07/25, showed the resident had alteration in musculoskeletal status related to compression fracture of the L1, L2, L4, and T12 [thoracic] vertebras. The care plan showed the resident had acute and chronic pain related to wedge compression fractures. A nursing incident note, dated 06/04/25 at 5:47 a.m., showed an unidentified certified nursing assistant alerted the nurse Resident #45 was on the floor and was being punched and kicked by another resident. The note showed upon entering Resident #45's room, the other resident had already left, and Resident #45 was attempting to get back into bed. The note showed there was no visible injury noted, but the resident complained of left hip pain rated 9/10. The note showed the resident was assisted back to bed. The note showed Resident #45 stated the other resident attempted to get into their bed and then began punching and kicking the resident. The note showed Resident #45 was transported to the emergency room for evaluation and treatment. An Oklahoma State Department of Health incident report, dated 06/04/25, showed an incident occurred between Resident #45 and Resident #33. The report showed staff was alerted to a commotion in Resident #45's room where they found the two residents in an altercation. The report showed the residents were immediately separated. The report showed after the residents were assessed, Resident #45 was transferred to the emergency room for evaluation and treatment related to complaints of hip pain. The report showed an investigation was conducted and it was determined Resident #33 entered Resident #45's room and attempted to get in the resident's bed. Upon seeing the bed was already occupied, Resident #33 began yelling at which time a physical altercation occurred. The report showed Resident #45 suffered a sacral fracture. The report investigation showed staff members and residents were interviewed on 06/04/25 regarding other potential incidents of abuse. The report showed Resident #33 was placed on 1:1 observation until the resident was sent out for evaluation. The report showed Resident #33 had a diagnosis of Alzheimer's disease with severely impaired cognition. A nursing note for Resident #45, dated 06/10/25 at 4:40 p.m., showed the resident arrived back at the facility from the hospital with diagnoses of L4, L5 and sacral fractures. A quarterly MDS assessment, dated 06/20/25, showed Resident #45 had diagnoses which included alcohol abuse, fracture of the lumbar vertebrae and sacrum, encephalopathy, depression, and anxiety. The assessment showed the resident required substantial assistance with most activities of daily living. The assessment showed the resident had a BIMS score of 15 which indicated the resident was cognitively intact. On 07/17/25 at 1:45 p.m., the DON provided documentation, dated 06/04/25, related to the incident investigation. The documentation showed two staff members, and four residents were interviewed at the time of the incident between Resident #45 and Resident #33. The DON provided documentation which showed staff assignments for providing 1:1 observation of Resident # 33. Nursing progress notes documented 1:1 observation was being conducted after the incident and prior to the resident being sent out for a psychiatric evaluation. On 07/17/25 at 1:50 p.m., the DON reported Resident #33 had returned to the facility following a psychiatric evaluation, had declined significantly since the incident with Resident #45, and was currently on hospice. The DON reported the resident no longer required close supervision or observation and was not a threat to other residents. The DON reported no other incidents of abuse involving Resident #33 either before or after the incident involving Resident #45. On 07/21/25 at 10:08 a.m., Resident #45 was interviewed in the facility common room. During the interview, the resident stood up independently from their wheelchair without difficulty. The resident reported they did not have much pain and was comfortable. The resident reported they were not fearful of any resident and voiced no concerns related to abuse.

Based on record review and interview, the facility failed to follow physician orders for 1 (#4) of 13 sampled residents whose orders were reviewed.The administrator identified 48 residents resided in the facility. Findings: An admission assessment, dated 05/08/25, showed Resident #4 had diagnoses which include diabetes mellitus type 2 and acquired absence of right leg below the knee. The assessment showed Resident #4 had a BIMS score of 9, which indicated a moderate impairment of cognitive ability. A physician's order, dated 07/05/25, showed to cleanse the left great toe with normal saline, pat dry, apply Betadine (antiseptic) every shift and leave open to air two times a day for wound care.The TAR for July 2025 did not show any wound care completed for the left great toe as of 07/17/25. On 07/17/2025 at 1:34 p.m., Resident #4 stated no treatment was being done on their toe. On 07/17/2025 at 1:42 p.m. ADON #1 stated the order had been put in incorrectly and was triggering a task on the TAR. ADON #1 stated the wound care treatment was not being completed as ordered. On 07/17/2025 at 2:12 p.m., the DON stated the wound care had not been completed as ordered.

Based on observation, record review, and interview, the facility failed to follow the menu for 2 of 2 meal services observed.The administrator reported 48 residents received meals from the kitchen.Findings:On 07/16/25 at 11:28 a.m., cook #1 was observed to plate one portion of meatloaf, one scoop of mixed vegetables, one scoop of au gratin potatoes, and one brownie.On 07/16/25 at 11:45 a.m., cook #1 was observed to plate a pureed diet plate with one scoop of pureed meatloaf, one portion of pureed corn, one portion of pureed bowtie pasta, and one portion of banana pudding.No bread was served with either meal.A spring/summer menu, dated 07/16/25, showed the menu for the day was meatloaf, au gratin potatoes, vegetable blend of the day, bread of choice, and dessert of the day.On 07/16/25 at 11:50 a.m., cook #2 stated they use frozen pureed food, and they tried to keep the pureed menu similar to the regular menu.On 07/17/25 at 1:51 p.m., the DM stated they had forgotten to prepare bread for the lunch service on 07/16/25. They stated the pureed meal served on 07/16/25 did not follow the menu. The DM stated that instead of using the frozen pureed meals they could have pureed the meal they had prepared, but they did not.

Based on observation and interview, the facility failed to ensure food served from the kitchen was palatable and served at an appetizing temperature.The administrator reported 48 residents received meals from the kitchen.Findings:On 07/16/25 at 12:47 p.m., a test tray was delivered. The food was observed to not be hot, the meatloaf was dry and bland, the mixed vegetables were soggy, the potatoes were not well seasoned, and the brownie was undercooked. No bread was served with the meal.A quarterly assessment, dated 06/18/25, showed Res #7 had a BIMS score (a test of cognitive function) of 15, indicative of intact cognition.A quarterly assessment, dated 07/09/25, showed Res #55 had a BIMS score (a test of cognitive function) of 15, indicative of intact cognition.On 07/15/25 at 10:09 a.m., Res #7 stated the food was not hot when served in the room and it sometimes did not taste appealing.On 07/15/25 at 10:50 a.m., Res #55 stated the food was not good.On 07/15/25 at 3:30 p.m., during a resident council meeting, some residents in attendance voiced concerns regarding temperature and palatability of the food.On 07/17/25 at 1:51 p.m., the DM stated the facility tried to serve hot palatable food.

Based on observation and interview, the facility failed to ensure lids to bulk containers were not broken and beard guards were worn in the kitchen.The administrator reported 48 residents received meals from the kitchen.Findings:On 07/15/25 at 10:35 a.m., an initial tour of the kitchen was conducted. Dietary Aide #1 was observed washing dishes without wearing a beard guard. A bulk sugar container with a broken lid was also observed.On 07/17/25 at 1:51 p.m., the DM stated staff should wear hair restraints while in the kitchen, and the broken lid for the bulk sugar container should have been replaced.

Based on record review and interview, the facility failed to ensure side effect monitoring was completed for a resident receiving psychotropic medications for 1 (#40) of 5 sampled residents reviewed for unnecessary medications.The administrator reported the facility census was 48.Findings:A facility policy titled Management of Routine Antipsychotic Medications in Long-Term Care, dated 11/01/23, read in part, 3. Monitoring and Documentation -Nursing staff must document: -the resident's response to the medication. -Any side effects, including extrapyramidal symptoms or sedation.An admission record, dated 03/28/25, showed Res #40 had diagnoses which included delusional disorders and unspecified anxiety disorder.A care plan, revised 04/03/25, showed the resident received psychotropic medications and that Res #40 was to be monitored every shift for side effects of the medication.An admission assessment, dated 04/10/25, showed Res # 40 had a BIMS score (a test of cognition) of 15 which was indicative of intact cognition. The assessment also showed Res #40 was receiving an antipsychotic medication.A physician's order, dated 06/27/25, showed Res #40 was to receive 10 milligrams of haloperidol (an antipsychotic medication) daily at bedtime.A review of Res #40's TAR for June 2025 and July 2025 did not show side effect monitoring.On 07/17/25 at 2:31 p.m., the DON stated residents on antipsychotics should be monitored every shift for side effects and the documentation should be in the TAR. They also stated if it was not documented on the TAR, it was not done.

Based on record review and interview, the facility failed to transmit MDS assessment data within 14 days after completion of the resident assessment for 4 (#2, 19, 21, and #48) of 4 residents sampled for transmitting resident assessments. The administrator reported 48 residents resided in the facility. Findings: An MDS Assessments policy, dated 11/01/23, read in part, The facility will complete MDS assessments for all residents in accordance with CMS requirements .All assessments must be accurate, reflect the resident's status during the designated observation period, and be submitted electronically to the Quality Improvement and Evaluation System (QIES) within mandated timelines .Completed MDS assessments will be locked and submitted to the QIES ASAP system with 14 days. On 07/16/25 at 1:00 p.m., a review of MDS assessments for sampled residents was conducted. MDS assessments were not transmitted within 14 days as required for Resident #2, 19, 21, and #48. On 07/17/25 at 1:46 p.m., the DON provided batch transmittal forms dated 05/24/25 and 06/25/25. The forms showed the following: a. Resident #2 had a discharge return anticipated assessment completed on 05/31/25 and was transmitted on 06/25/25,b. Resident #19 had a quarterly assessment completed on 06/10/25 and was transmitted on 06/25/25,c. Resident #21 had a quarterly assessment completed on 05/24/25 and was transmitted on 06/25/25, andd. Resident #48 had a quarterly assessment completed on 04/21/25 and was transmitted on 05/24/25. On 07/16/25 at 4:42 p.m., the ADON/MDS coordinator reported they had recently taken responsibility of MDS assessments. The ADON/MDS coordinator reported they had another person helping, but they were still behind in getting the assessments completed and submitted in the timeframe required.

Based on record review and interview, the facility failed to ensure a care plan was developed to address the use of an indwelling urinary catheter for 1 (#40) of 13 sampled residents whose care plans were reviewed.The administrator reported two residents had an indwelling urinary catheter.Findings:A facility policy titled Care Plans, dated 11/01/23, read in part, Each resident will have an individualized care plan that is developed and maintained by the interdisciplinary team (IDT). The plan will address the resident's identified needs, strengths, goals and risks, and it will guide consistent, coordinated care delivery by all staff.An admission record, dated 03/28/25, showed Res #40 had diagnoses which included unspecified retention of urine and dementia.An admission assessment, dated 04/10/25, showed Res #40 had a BIMS (a test of cognition) of 15, which was indicative of intact cognition. A physician's order, dated 06/27/25, showed Res #40 had a size 16 French indwelling urinary catheter for a diagnosis of unspecified retention of urine.A review of Res #40's care plan did not show the use of an indwelling urinary catheter was addressed on the care plan.On 07/21/25 at 10:08 a.m., ADON #2 stated catheter use should be addressed on the resident's plan of care.On 07/21/25 at 2:50 p.m., the acting DON stated the use of a catheter should be included on the care plan and they were usure why Res #40's care plan did not include the use of a catheter.

Based on observation, record review and interview, the facility failed to ensure EBP were in place during wound care for 1 (#55) of 1 sampled resident reviewed for wound care.The Administrator reported one resident received routine wound care.Findings:On 07/17/25 at 9:30 a.m., ADON #1 was observed providing wound care to Res #55. ADON #1 was not observed to be wearing a gown. No signage was observed indicating Res #55 was on EBP.A facility policy titled Enhanced Barrier Precautions (EBP) Policy and Procedure, dated 11/01/23, read in part, [NAME] Behavioral Health & Memory Care Community shall implement Enhanced Barrier Precautions (EBP) for all residents known to be colonized or infected with MDROs [Multidrug-Resistant Organisms] and in accordance with CDC [Centers for Disease Control] guidance. This includes the use of personal protective equipment (PPE) for certain resident care activities even when residents are not in isolation or on contact precautions.An admission record, dated 04/08/25, showed Res #55 had diagnosis which included diabetes mellitus with foot ulcer.A quarterly assessment, dated 07/09/25, showed Res #55 had a BIMS score (a test for cognitive function) of 15 which was indicative of intact cognition. A physician's order, dated 07/16/25, read in part, WOUND CARE - Cleanse left great toe with NS [normal saline], pat dry, apply medihoney [gel wound and burn dressing] and dry dressing daily and PRN [as needed].On 07/15/25 at 1:00 p.m., Res #55 stated staff did not wear gowns while providing wound care.On 07/16/25 at 9:45 a.m., ADON #1 stated they did not use EBP during wound care.On 07/21/25 at 2:50 p.m., the acting DON stated they were not aware of the requirement to use EBP during wound care.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, homelike environment. The DON identified 49 residents resided in the facility. Findings: Observations of rooms on the 100 hall revealed the sinks did not have hot running water. On 10/16/24 at 2:00 p.m., Resident #4 stated they have not had hot water in their room for over a month. The resident stated they have arthritis in their hands and washing them in cold water causes pain. On 10/16/24 at 2:15 p.m., the maintenance supervisor stated the 100 hall has been without hot water due to a broken hot water tank. 10/16/24 at 2:44 p.m., the maintenance supervisor stated they had spoke with the administrator who told them they are to receive a government grant in March and that is when the hot water tank will be replaced. On 10/17/24 at 9:05 a.m., Resident #5 stated they have not had hot water in their room since they arrived on 09/05/24. On 10/17/24 at 9:06 a.m., Resident #6 stated they have not had hot water in their room for over a month. They stated it would be nice to have hot water for washing their hands and face.

Based on record review and interview, the facility failed to ensure resident were free from abuse for one (#1) of three residents sampled for abuse. The DON reported 49 residents resided in the facility. Findings: An undated facility policy titled Abuse By a Resident To Other Residents, read in parts .abuse as used in this policy shall refer to all forms of abuse including, but not limited to physical, verbal, sexual and psychological . Resident #1 had diagnoses which included dementia with a BIMS of 5 Resident #2 had diagnoses which included dementia with a BIMS of 11. On 10/08/24 at 3:00 p.m., Resident #2 was observed by staff sitting beside Resident #1's bed with their left hand on Resident #1's pubic area. A nurse's note dated, 10/08/24 at 5:29 p.m., documented Residents #1 and #2 were immediately separated. A head to toe assessment was performed on Resident #1 with no signs or symptoms of trauma or injury. The physician, family and [NAME] Police Department were notified. On 10/15/24 at 2:30 p.m., the DON stated resident #2 was moved to a male segregated area after the incident. They were put on 1:1 observation until they could be sent out for psychological evaluation. The facility is currently trying to place Resident #2 at a different facility. The DON stated staff received training on identifying and reporting abuse upon hire and periodically.

Based on observations, record review, and interview, the facility failed to ensure residents were free from abuse for one (#8) of four residents sampled for abuse. The director of nurses reported the census was 53. Findings: An undated facility policy, titled Abuse by a Resident to Other Residents, read in parts .Abuse as used in this policy shall refer to all forms of abuse including, but not limited to physical, verbal, sexual, and psychological . Resident #3 had diagnoses including diabetes mellitus and hypertension. Resident #8 had diagnoses including schizophrenia and convulsions. On 08/06/24 at 8:05 am, Res #3 was observed in the dining room propelling their wheelchair towards Res #8, who was seated in a wheelchair and stationary. Res #3 was shouting obscenities and threatening Res #8 with bodily harm. Res #3 was observed to bump their wheelchair into the leg of Res #8. The residents separated and Res #8 went out of the dining room to the nurse's desk. As Res #3 passed by Res #8 they were heard to yell more obscenities and threaten Res #8 again. A nurse note, dated 08/06/24 at 8:43 am, documented that Res #3 was in the dining room yelling at another resident and that they pushed their wheelchair into the other resident's foot. On 08/06/24 at 11:36 am, RN #2 stated that this type of behavior is common for Res #3. RN #2 was asked if the interaction between Res #3 and Res #8 was abusive they stated, I guess it was. On 08/06/24 at 12:45 am, the ADON stated that staff receive training on identifying and reporting abuse and neglect upon hire and periodically. They also stated that the interaction between Res #3 and Res #8 met the definition of abuse.

Based on record review and interview, the facility failed to ensure required interdisciplinary team members participated in the planning process of resident care plans for six (#5, 12, 16, 21, 26, and #36) of twelve residents reviewed for care plans. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: The facility Policy and Procedure Regarding Resident Care Plan, undated, read in part, The comprehensive care plan will be developed by the IDT which will include the attending physician, registered nurse with the responsibility for the resident, nurse aide with responsibility for the resident, dietary staff representative, the resident and/or resident representative if possible, and any other healthcare professional as identified by the resident's needs or as requested by the resident. 1. Resident #5 was admitted on [DATE]. 2. Resident #12 was admitted on [DATE]. 3. Resident #16 was admitted on [DATE]. 4. Resident #21 was admitted on [DATE]. 5. Resident #26 was admitted on [DATE]. 6. Resident #36 was admitted on [DATE]. A review of resident records (#5, 12, 16, 21, 26, and #36) found no documentation related to interdisciplinary team care plan meetings. On 06/06/24 at 12:35 p.m., the MDS Coordinator stated they were in charge of care plan meetings. They stated the meeting included the resident's representative and the resident as well if they are cognitive enough, and themselves. She stated the floor nurse, aid, dietary, social services director and DON should attend but do not. They stated the physician had never participated in the meetings or planning unless a concern was raised that required them to be contacted. They stated they had been doing the care plans at the facility since November 2023 and only had a handful of care plan meetings since starting. The MDS coordinator was given a list of resident names (#5, 12, 16, 21, 26, and #36) and asked to provide documentation care plan meeting had occurred. On 06/06/24 at 12:45 p.m., the DON stated they were the MDS Coordinator's supervisor and randomly checked their work. They stated the MDS Coordinator attended the care plan meetings with the resident and resident representative. The DON stated they attend the meetings when they are available and they believed the social services director attended. They stated the physician was made aware of what came up in the meetings so they could act on issues as required. They stated the care plan meetings should be documented. On 06/06/24 at 12:59 p.m., the MDS Coordinator stated there was no documentation for residents #5 and #12 that care plan meetings had occurred. They stated there were progress notes that family of residents #16, 21, 24, and #36 had been contacted. They stated they had never invited other care team members to the care plan meetings for the six reviewed residents. They stated they had no recollection of contacting the medical director of results from the six care plan meetings. On 06/07/24 at 11:01 a.m., the DON stated the care plan meetings should have occurred. They stated it was their expectation they would be done in the future and would create a system for ensuring that happened.

Based on observation, record review, and interview, the facility failed to ensure: a. a resident was educated on the risks and benefits of using bedrails and obtained informed consent; b. bed frames and bed rails were inspected prior to the application of rails to the frame and use of bed rails by a resident; and c. alternatives to the use of bed rails were attempted prior to the use of bed rails for two (#12 and #36) of two sampled resident reviewed for bed rails. The DON reported eight residents had bed rails in use at the facility. Findings: When asked for the facility policy on the use of bed rails the DON offered the Policy and Procedure for the use of Alternative Measures to Restraints which was undated. The policy read in part, Positioning bars may be used by residents who request them as an aid to reposition in bed. Also, residents who are confused or disoriented to the point that they do not recognize the edge of the bed, but who would not attempt to climb over them, may use them to prevent falling from bed. 1. Resident #12 was admitted to the facility on [DATE] and had diagnoses which included vascular dementia, acquired absence of the right leg below the knee, and acquired absence of the left leg above the knee. 2. Resident #36 was admitted to the facility on [DATE] and had diagnoses which included dementia. A review of the medical records of Residents #12 and #36 did not find documentation of the residents having been education on the use of bed rails, that the beds had been inspected prior to the use of bed rails, or that alternatives to the use of bed rails had been tried prior to the use of bed rails. On 06/05/24 at 10:50 a.m., Resident #12's bed was observed to have positioning bars attached to both sides of their bed frame. The resident stated they used the positioning bars attached to the bed frame for positioning. They stated the bars had been attached since they were admitted . They did not recall having a discussion about the risks of using them or if they tried alternatives to the positioning bars. 06/06/24 at 10:15 a.m., the DON stated in regards to Resident #12, they were unable to find documentation that alternate interventions to bed rails had been attempted. They stated they were unable to provide documentation that bed frame and bed rail inspections had been performed. 06/06/24 at 11:47 a.m., Resident #36's bed was observed to have full bed rails attached to the frame of their bed. They stated the bed rails had been on the bed since they arrived at the facility. On 06/07/24 at 10:46 a.m., the DON stated, in regards to Residents #13 and #36, there had been no alternate interventions to the use of bed rails attempted prior to their use. They stated no documentation of bed frame or bed rail inspections having been done prior to the use of those bed rails and no documentation of informed consent for the rails were located. They stated they will correct their process for using bed rails at the facility.

Based on record review and interview, the facility failed to provide residents the opportunity to develop or refuse the creation of an advance directive or three (#15, 21 and #36) of five residents reviewed for advance directives. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: The facility Policy and Procedure for Residents Rights Regardign (sic) Advance Directives for Health Care & Mental Health Treatment, undated, read in part, Every competent person has a right to determine whether he/she will receive life sustaining treatment , who will make the decisions concerning their health care if they cannot and provide their wishes concerning organ donation. 1. Resident #15 was admitted to the facility on [DATE]. 2. Resident #21 was admitted to the facility on [DATE]. 3. Resident #36 was admitted to the facility on [DATE]. On 06/04/24 at 12:57 p.m., LPN #1 stated the advance directive form for Resident #15 was signed on 06/04/24. Resident #15 admitted on [DATE]. On 06/04/24 at 12:59 p.m., LPN #1 stated Residents #21 and #36 stated there was no documentation that either resident was offered an opportunity to develop and advance directive. They stated the facility had a document used in the admission process for that task. 06/07/24 at 12:45 p.m., the DON stated that during the admission process advance directives were to be completed during the admission process. They stated they expect the documents to be done thoroughly on admission or before.

Based on observation and interview, the facility failed to ensure residents who require assistance with dressing were not left unclothed in their rooms and resident catheter bags were covered while in public spaces for one (#12) of two residents reviewed for dignity. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: The facility's Policy and Procedure for Exercising of Rights policy, undated, read in part, The resident has a right to a dignified existence and the facility will protect and promote the rights of each resident. Resident #12 had diagnoses which included vascular dementia, acquired absence of right leg below the knee, and acquired absence of the left leg above the knee. On 06/03/24 at 2:19 p.m., upon entrance to Resident #12's room they were observed lying sideways on their bed nude from the waist down. They stated they could not reposition themselves or reach the call light to ask for assistance. They stated they they had returned from the hospital earlier and were not happy the staff left them there without clothes on. They stated they could not recall how long they had been in that stated but thought it was not too long. On 06/04/24 at 7:47 a.m., Resident #12 was observed eating in the dining room. Their catheter bag was uncovered and half full of urine. On 06/05/24 at 7:54 a.m., Resident #12 was observed sitting in a wheelchair located in the hallway outside of their room. Their catheter bag was uncovered and one third full of urine. On 06/05/24 at 8:27 a.m., Resident #12 was observed eating a meal in the dining room. Their catheter bag was uncovered and half full of urine. On 06/05/24 at 9:27 a.m., Resident #12 was observed sitting in a wheelchair located in the hallway outside of their room. Their catheter bag was uncovered and half full of urine. On 06/05/24 at 10:28 a.m., Resident #12 was observed in their room during wound care. LPN #2 stated the facility does have dignity covers for catheter bags and they would instruct and the aides to keep one on the resident's bag. On 06/05/24 at 11:57 a.m., Resident #12 was observed in the dining room with their catheter bag uncovered and full of urine. On 06/06/24 at 7:35 a.m. Resident #12 was observed in the dining room. Their catheter bag had a dignity bag covering it. 06/07/24 at 11:01 a.m., the DON stated all resident rights must be respected in all situations. They stated Resident #12 should not have been left alone without clothes on and their catheter bag should be covered at all times. They stated they have a good supply of catheter bag covers.

Based on observation, interview, and record review, it was determined the facility failed to implement interventions to prevent the development of an avoidable pressure ulcer for one (#41) of one sampled resident reviewed for pressure ulcers. This resulted in actual harm. The Resident Census and Condition of Residents documented no residents with pressure ulcers. Findings: Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 01/16/14, documented the skin integrity was impaired related to fragile skin. Interventions included to turn and reposition every two hours and as needed. The interventions to reposition every two hours for skin integrity documented on the care plan were not observed to have been implemented. A significant change assessment, dated 01/28/14, documented the resident's cognition was severely impaired. The assessment documented the resident was totally dependent on two staff members for bed mobility, transfers, and dressing. The assessment also documented the need for a pressure reducing device for the resident's bed and a turning and repositioning program. A Braden Scale assessment, dated 03/20/14, documented the resident was at moderate risk for the development of pressure ulcers. On 04/09/14 at 8:56 a.m., the resident was observed sitting in the front lobby in her wheelchair with no pressure relieving device in her wheelchair. At 9:45 a.m., the resident had repositioned her legs from a sitting position, to more of a reclining position. The resident had closed her eyes and had started to slump in her chair. At 9:49 a.m., CNA #5 stopped and repositioned the resident's legs. The CNA wheeled her to the activity room. The resident was left in her wheelchair in the activity room. The resident began to lean to the right and occasionally had her head back. There was no head rest on the wheelchair to support her head. Three recliners were available for the resident to sit in. At 10:04 a.m., CNA #5 and CNA #1 were observed lifting the resident into a recliner in the activity room. At 3:40 p.m., the resident was observed sitting in her wheelchair which did not have a pressure relieving device. At 3:48 p.m., the resident was observed being wheeled into the day room and left to sit in her wheelchair. There were three empty recliners available for the residents to sit in. On 04/10/14 at 6:45 a.m., the resident was observed in the dining room sitting at the assisted feeding table. At 7:15 a.m., resident #41 continued to sit at the table. No food or drinks had been provided. At 8:23 a.m., CNA #2 transferred the resident out of the dining room to the nurse's station and she continued to sit in her wheelchair with no pressure relieving device until 8:50 a.m. The resident sat in her wheelchair with no pressure relieving device for two hours. At 10:46 a.m., the resident was observed to be sitting in her wheelchair in her room. The wheelchair did not have a pressure relieving device in it. CNA #6 transferred the resident to the dining room in her wheelchair. On 04/10/14 at 3:30 p.m., the resident was observed to receive catheter care. During personal care, a blister, approximately 2 x 2 centimeters, was observed on the resident's right buttock. The center of the blister was observed to be pink in color and the outer edge was a darker color. At 4:13 p.m., the resident was observed sitting in the front area by the nurse's desk in her wheelchair which did not have a pressure relieving device. At 4:30 p.m., LPN #1 was asked if anyone had reported the resident's skin problems to her. She stated yes. She stated she had been told today about a stage 1 pressure ulcer. She was asked if she had observed the area. She stated yes. We just got one healed in the exact same spot. She was asked if she measured it. She stated it was approximately 3.5 x 2 centimeters. LPN #1 was asked about the daily routine for resident #41. She stated the resident usually gets up about 6:00 a.m. for breakfast. After breakfast the resident was moved to a recliner in the activity room, after lunch the resident was moved back to the recliner. If her husband was in the facility she is transferred to a recliner. If her husband goes home she was transferred to bed. She stated the resident was normally in a recliner with pillows. She stated the resident was generally up for 2.5 hours in the morning in her wheelchair, and was in her wheelchair about 3.5 hours per day. LPN #1 was asked if there was a pressure relieving device used in the resident's wheelchair. She stated yes, a pad. The pad was not observed to be in use. The LPN was asked if the resident currently had a pressure relieving device in her wheelchair. She stated no. At 5:52 p.m., MDS coordinator was asked what interventions had been implemented for the prevention of pressure ulcers. She stated the resident was placed in a recliner in the activity room versus leaving her in her wheelchair, she was to be repositioned, and toileted every two hours. The MDS coordinator was informed of the observations made of the resident sitting in her wheelchair with no pressure relieving device. She was asked if the interventions for the prevention of pressure ulcers for the resident were being implemented. She replied, "If you saw her sitting in her wheelchair by the nurse's station, then no." On 04/11/14 at 9:00 a.m., LPN #1 stated she had looked at the inches instead of centimeters and the pressure ulcer for resident #41 was actually 11 x 7 centimeters.

On 02/05/13, an immediate jeopardy (IJ) situation was determined to exist regarding the facility's failure to protect the residents from accident/hazards by the use of open containers of chemicals stored on an unsecured and unsupervised housekeeping cart. The Oklahoma State Department of Health (OSDH) verified the existence of the IJ at 2:55 p.m., regarding the facility's failure to prevent accident/hazards related to unsecured and unsupervised chemicals stored on the housekeeping cart. At 3:00 p.m., the administrator and DON were notified of the IJ situation related to unsecured and unsupervised chemicals stored on the housekeeping cart and of the resulting partial extended survey. At 4:50 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: "Plan Of Removal 2.3.2013 This is the plan of removal for the alleged IJ declared at approximately 3:00 pm on 2.5.2013 regarding housekeeping chemicals that were unsecured on a housekeeping cart. Two bottles of cleaning agent and a spray can were separated from the cart. The cleaning bottles did not have a closing lid. On 2.5.2013 at 3:10pm, the facility provided inservice training to the housekeeping supervisor and two housekeepers on duty that anytime a chemical is missing from the cart, the charge nurse, DON and/or the Administrator is to be notified immediately to begin an all search for the missing item. The facility employs two other part time weekend housekeepers. One of the two was informed of the training by telephone at 3:30 pm by the housekeeping supervisor. The second housekeeper does not have a phone. The supervisor went to her house to provide training and the employee was not home. This employee called the facility at 3:55 pm and was provided inservice training by the Administrator. All facility housekeeping staff have received inservice training On 2.5.2013 at approximately 3:20pm, the maintenance supervisor applied a hasp and padlock to the cart with a door and housekeepers have been provided a key. The maintenance supervisor is currently applying a door to the cart and a lock and key to the cart that does not have a door. This cart will be operational before it is returned to the building for use. All chemicals on the cart shall be stored within the locked cabinet and shall be locked at all times. The cart without the door will not be used until a door can be added that locks, or the cart will be replaced with one that has a door that can be locked. Until such time that the door can be repaired or the cart replaced, the cart will be removed from the building until it is operational. The broken lids have been replaced on the two bottles of cleaner. All other bottles were checked and lids were replaced. Additionally, all nurses, cma's and cna's currently on duty have received inservice training as to the above. All staff not on duty will be called and provided this training over the phone by 11:59 pm on 2.5.2013. Any staff that cannot be reached by telephone will receive training prior to their next scheduled shift, as they report to duty. The Administrator, Maintenance Supervisor and Housekeeping Supervisor, evening charge nurse, night charge nurse, weekend charge nurse will provide a visual check of the carts at least every two hours to ensure the chemicals are in the cabinets and locked." An inservice record, dated 02/05/13 from 3:10 p.m. to 3:55p.m., documented, "Notify Charge Nurse, Administrator and/or DON immediately if (sic) any missing chemicals from cart to do an all search to locate chemical. Do not use cart that cannot be locked. Lock all chemicals on cart. Lock cart at all times." The inservice was provided to the housekeeping personnel and the housekeeping supervisor. An inservice record, dated 02/05/13 and 02/06/13, documented, "Reviewed Plan of Removal and Inservice on Chemicals on Carts." The inservice was for nursing staff and was signed by CNAs, CMAs, LPNs, and RNs. The last employee was inserviced on 02/06/13 at 8:50 a.m. On 02/06/13, five interviews were conducted with staff from housekeeping and nursing departments. All five staff stated they had received an inservice on storage of chemicals and what to do if a chemical was missing from the cart. All five staff stated the chemicals were to remain locked on the housekeeping cart when not in use. The staff continued to state that if a chemical was missing, it was to immediately be reported to the charge nurse, administrator, and/or DON and an immediate search begun to find the missing chemical. On 02/06/13 at 8:50 a.m., the IJ was removed when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with the likelihood of more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to: a. Properly supervise and secure cleaning chemicals located on 1 of 2 housekeeping carts used for the cleaning of resident rooms and common areas. This had the potential to effect 19 of the residents who were identified on the census and condition as cognitively impaired. b. Ensure residents did not elope from the facility for two (#5 and #6) of two sampled residents who have attempted to leave the facility through unlocked door. The facility identified two residents who were elopement risks. Findings: 1. An undated facility policy, titled Labeling of Hazardous Chemicals, documented, "It shall be our policy that every container of hazardous chemicals located at this facility is labeled, tagged or marked with the following information: The identity of the hazardous chemical contained therein; Appropriate hazard warning. All labels or forms of warning will be legible, in English, and prominently displayed on the container or readily available in the work area, if used on that particular shift. In the event that personal protective equipment is suggested, this suggestion will either affixed on the container, displayed on a sign posted in the area, or documented in the form of a symbol or by naming the specific equipment to be used. Employees who might be required to wear personal protective equipment shall be trained in the proper method and usage of any such equipment prior to doing any task requiring this equipment to be worn. this (sic) training will be conducted by the department's supervisor who is responsible for the area or task that the equipment is to be used in. The maintenance supervisor will have overall responsibility for insuring hat (sic) all hazardous chemicals containers are labelled in accordance with this policy and procedure." On 02/05/13 at 2:25 p.m., a housekeeping cart was observed in front of a resident room on hall #2. The housekeeper was in the resident room with her back to the cart. On the top of the cart was an open container of a blue colored cleaning solution and a toilet bowl brush pushed into a large drinking cup with a handle. There was no identifiable label on the cup and the body of the bottle was wrapped with blue tape. An aerosol spray container was also located on the top of the cart and was labeled SparSan Q Disinfectant Deodorant (Linen Clean Fragrance). The warning label documented, "Causes substantial but temporary eye injury. Do not get in eyes or on clothing. Wear safety glasses or face shield. Thoroughly wash hands after using and before eating, drinking, chewing gum, using tobacco, or using the toilet.... If in eyes: Hold eye open and rinse slowly and gently with water for 15-20 minutes...If swallowed: Immediately call a poison control center or doctor for treatment advice. Have person sip glass of water if able to swallow. Do not induce vomiting unless told to do so by a poison control center or doctor. Do not give anything by mouth to an unconscious person. Have the product container label with you when calling a poison control center or doctor or going for treatment. Note to physician: Probable mucosal damage may contraindicate the use of gastric lavage..." At 2:30 p.m., the housekeeping cart was observed outside another resident room on hall #2. Housekeeper #1 was observed in the room with her back to the cart. A bottle of NABC disinfectant bathroom cleaner was observed on the shelf of the cart. The shelf was approximately two feet off the floor, open with no visible way to secure content, and within easy reach of a resident in a wheelchair. The bottle of NABC cleaner was removed from the cart. The bottle was observed to be open with a broken pour spout cap with opening on top of the bottle. There was blue tape wrapped around the body of the bottle. The blue tape was removed to reveal the content label. The Precautionary statements located on the bottle documented, "...Hazards to Humans and Domestic Animals. CAUTION. Causes moderate eye irritation. Harmful if absorbed through the skin. Avoid contact with eyes, skin, or clothing. Wash thoroughly with soap and water after handling...Have the product container or label with you when calling a poison control center or doctor, or going for treatment...KEEP OUT OF REACH OF CHILDREN..." At 2:35 p.m., the housekeeping cart was observed outside the visitor bathroom. Housekeeper #1 was observed to be out of view of the housekeeping cart. The surveyor removed an aerosol spray can of SparSan Q Disinfectant Deodorant spray from the top of the cart. At 2:45 p.m., the housekeeping cart was observed outside a resident room on hall #3. Housekeeper #1 was observed to enter the resident room and the door close. The surveyor removed a cup containing an open bottle of NABC and a toilet brush from the top of the cart. The body of the bottle was wrapped in blue tape. The blue tape was removed to reveal the content label. At 3:00 p.m., the administrator, DON, and head of maintenance were shown the open containers of cleaning chemicals. At 3:05 p.m., the housekeeping cart was observed with the administrator, DON, maintenance person, and housekeeper #1 and #2. The housekeeping cart was observed to have a door missing and exposed shelves with cleaning solutions and supplies easily accessible from the one side of the cart. The other side had a door with no working lock. Housekeeper #1 was asked if she had noticed the missing chemicals. The housekeeper stated she had and had notified her coworker. The housekeeper nodded toward housekeeper #2 in the room. Housekeeper #1 was asked if she had notified anyone else of the missing chemicals. The housekeeper stated, "No." Housekeeper #2 was asked if she had notified anyone of the missing chemicals. The housekeeper stated she had only learned of the missing chemicals about five minutes ago, just before coming into the room, and had not had an opportunity to tell anyone. At 3:45 p.m., housekeeper #1 was interviewed. Housekeeper #1 was asked why the caps on bottles of NABC cleaner were broken. The housekeeper stated the facility refilled the bottle from a dispenser and over time the caps had broken. The housekeeper pointed to a dispenser located on the wall. Housekeeper #1 was why the label area of the bottle was covered with blue tape. The housekeeper stated the bottles were slippery and the tape was used to help with gripping the bottle. Housekeeper #1 was asked why there was a bottle of NABC and a toilet bowl brush in a large cup kept on top of the housekeeping cart. The housekeeper stated she would store the bottle of cleaner and brush in the cup to keep it from dripping on clean surfaces. Housekeeper #1 was asked how she secured chemicals on the housekeeping cart. The housekeeper stated she did not have a door on one side and there was not a lock on the other side of the cart for securely storing chemicals. The housekeeper continued to state she knew the residents and none had taken anything from the carts. Housekeeper #1 was asked if there were any confused residents in the facility. The housekeeper state, "Yes." The housekeeper was asked if the chemicals on her cart were within reach of a resident in a wheelchair. The housekeeper stated, "Yes." 2. Resident #5 had current [DIAGNOSES REDACTED]. An incident report, dated 11/27/12, documented, "...Initial description of incident: Resident (#5) was standing at nurses desk @ 1615 (4:15 p.m.), asking staff to call her daughter, there was no answer when staff attempted to call daughter. Resident stated "I need a ride home". Staff attempted to redirect and reorient her that this is where she lives. At 1630 (4:30 p.m.) staff went to the front porch and noticed her going up the road, she was approximately 1 block from facility...no injuries were noted...We have instructed all staff if she appears to be wandering to keep a close watch on her, redirect her with an activity, or assign someone to set with her while she is on the front porch. All other exits to facility are armed with an alarm..." An initial assessment, dated 01/13/13, documented the resident had a BIMS score of nine. This score indicated the resident was moderately impaired for daily decision making. The assessment documented the resident was independent with mobility and had a psychiatric/mood disorder of anxiety and depression. On 02/04/13 at 3:51 p.m., the door to the outside smoking area was observed unlocked and without a wander guard. The smoking area was not a secured area and was adjacent to a field and a large wooded area. At 4:00 p.m., the resident was observed with a wander guard on her left wrist. On 02/05/13 at 9:00 a.m., the administrator was asked how many residents wandered. She stated only resident #5, and she had a wander guard on. She was asked about the door that led to the smoking area that was unlocked. She stated, "She only tries to go out through the front door." She was asked since she had eloped from the front door was there the potential for her to elope out another unlocked door. She stated, "She hasn't done that. She is to have a person with her when she is on the porch. She got out once but only got as far as the parking lot." At 10:08 a.m., housekeeping staff #2 was asked if residents wandered in the facility. She stated, "Resident #5." At 10:15 a.m., CNA #8 was asked if the facility had residents that wandered. She stated, "Resident #5 and #6." She was asked if all the outside doors at the facility had alarms. She stated, "They don't work." At 10:20 a.m., LPN #3 was asked if the facility had residents that wandered. She stated, "Resident #5." At 10:30 a.m., the door on hall three was opened and no alarm sounded in the hall or at the nurses' desk. On 02/06/13 at 1:25 p.m., the administrator and DON were asked how many residents resided in the facility that wandered. The administrator stated, "Two." She was asked what interventions were instituted when resident #5 eloped. She stated, "We ordered a wander guard for the front door." She was asked what was the plan for the other two unlocked door to the outside. She stated, "There is a key pad on one of the doors but it is not used. It is the wrong key pad for that door. The alarms were not working on the doors when I came and haven't been on since." The administrator and DON were informed of the incident report on 11/27/12 that documented the resident eloped, was a block away, and one of the interventions was that all exits to facility were armed with an alarm. The administrator stated, "I did not know that." 3. Resident #6 had current [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/09/12, documented the resident had a BIMS score of four. This score indicated the resident was severely impaired for daily decision making. The assessment documented the resident had disorganized thinking at times, rejected care, was independent for locomotion, and had an anxiety disorder and depression. The care plan, dated 12/09/12, failed to address the behaviors of the attempted elopement. On 02/05/13, CNA #8 was asked if the facility had any residents who wandered. She stated, "Yes." She was asked if any resident had attempted to leave the facility. She stated, "Yes, resident #6 (name withheld) had attempted to go out the front door and the door on hall three. They all have alarms on them." At 10:15 a.m., CNA #8 was asked if the facility had any residents that wandered. She stated resident #6. She stated resident #6 tried to go out the front door and tried to go out the door on the other hall. She was asked if all the outside doors at the facility had alarms. She stated, "They don't work." She was asked if any resident had eloped off of the property. She stated resident #6 got as far as the ramp past the front porch. At 10:20 a.m., LPN #3 was asked if the facility had any residents that wandered. She stated, "Resident #5 (name withheld) tries to go out the front door and tried to go out the door on the other hall." She was asked if she had gotten outside. She stated, "She got out the front door one time and got as far as the ramp past the porch." The resident's room was observed at the end of the hall next to the outside door on hall three. On 02/06/13 at 1:25 p.m., the administrator was asked if it was reported to her that the resident had attempted to exit through an outside door, and on another occasion had exited the front door and was found on the ramp past the porch. She stated, "No." She was asked what interventions were put in place to keep the resident safe from elopement. No comment was made.