Every finding on record at Fairmont Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were used during wound care for 1 (#44) of 3 sampled residents reviewed for enhanced barrier precautions practices. The administrator identified eight residents who required enhanced barrier precautions during the provision of care. Findings:On 12/10/25 at 9:20 a.m., LPN #2 was observed performing wound care on Resident #44's right lower leg. LPN #2 was observed to don gloves and then performed the wound care. LPN #2 performed wound care without a gown. A facility policy titled Infection Control and Isolation Guideline, dated 07/2025, read in part, Enhanced barrier precautions apply to residents with: MDRO, wounds and/or indwelling medical devices, and refer to the use of gowns and gloves during high-contact care. High-contact resident care activities requiring gown and glove use, include dressing, providing hygiene, changing briefs, device care, urinary catheter care, feeding tube, wound care with any skin opening requiring a dressing. Physician orders, dated November 2025, showed Resident #44 was admitted on [DATE] with diagnoses which included rheumatoid arthritis and shearing to right lower leg with open wound. A care plan for Resident #44, updated 11/03/25, showed enhanced barrier precautions were required during the provision of care due to open wounds. On 12/10/25, at 10:15 a.m., LPN #2 was asked if they understood enhanced barrier precautions and was the procedure done correctly for incontinent care and wound care for Resident #44. LPN #2 replied they did everything right. On 12/10/25 at 1:44 p.m., the DON was asked how the staff were taught about enhanced barrier precautions during wound care. They stated they had routine training subjects and enhance barrier precautions was one of the subjects which was reviewed often.

Based on observation, record review, and interview, the facility failed to ensure the physician was notified of a change in weight for 1 (#75) of 19 sampled residents reviewed for change in weight.The DON identified 88 residents resided in the facility.Findings:On 12/08/25 at 1:15 p.m., Resident #75 was observed to have a continuous feeding pump connected to their feeding tube with formula running through the tube.A policy titled Weight List, revision date 10/21/09, read in part, Residents' weights are routinely and systematically monitored. All residents must be weighed weekly for four weeks upon admission.The resident's physician should be notified of any significant weight changes.A policy titled, Notification of Change, dated 06/2025, read in part, The facility will notify the resident, the resident's physician, and the resident's representative (if applicable) promptly when there is: A significant change in the resident's physical, mental, or psychosocial status. All notifications should be documented in the medical record.A Care Plan, dated 11/17/25, showed Resident #75 was to be weighed weekly for four weeks. The care plan, read in part, Monitor/record/report to MD s/sx of malnutrition: .significant weight loss 3lbs in 1 week.An admission assessment, dated 11/23/25, showed Resident #75 was admitted to the facility on [DATE] with diagnoses to include cerebrovascular accident, aphasia, hemiplegia, and malnutrition. The MDS showed Resident #75 was dependent on staff for all ADLs and required the use of a feeding tube.An undated weight record for Resident #75 showed:a. on 12/01/25 they weighed 169.8 pounds; and,b. on 12/08/25 they weighed 165.8 pounds.On 12/10/25 at 1:57 p.m., LPN #1 was asked to show where Resident #75's physician was notified of their weight loss. They stated, I know I didn't notify [name-deleted physician] about the 4 pound weight loss. LPN #1 was asked when the physician would need to be notified regarding weight loss for Resident #75. They stated they did not think there were parameters for notifying the physician of the resident's weight loss. LPN #1 was asked what the process was for notifying the physician of weight loss. They stated the ADONs monitored the weights and notified the charge nurse if the physician needed to be notified. On 12/10/25 at 2:02 p.m., the DON was asked what the facility's process was for identifying weight loss. They stated the facility would meet monthly and compare the weights. The DON was asked who was responsible for notifying the physician of weight loss. They stated, Typically the charge nurse. The DON stated any physician notification would be documented in the nurse's notes and if the documentation was not in a nurse's note then the physician was not notified.On 12/10/25 at 2:31 p.m., the DON was asked why Resident #75's physician wasn't notified of their 4 pound weight loss. They stated they just got off the phone with the physician to notify them and LPN #1 had also just notified the physician. The DON was asked if the physician had been notified of the weight loss prior to 12/10/25 and they stated no.

Based on observation, record review, and interview, the facility failed to implement comprehensive care plan interventions for:a. physician notification of weight loss for 1 (#75) of 19 sampled residents reviewed for care plans, andb. trauma informed care for 1 (#7) of 1 sampled resident reviewed for diagnosis of post-traumatic stress disorder. The DON identified 88 residents resided in the facility.Findings:1. Monthly physician's orders, dated December 2025, showed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease late onset, bipolar disorder with current episode manic severe with psychotic features, post-traumatic stress disorder, hallucinations and depression, feeding tube status, and dysphagia. A significant change assessment, dated 11/25/25, showed a BIMS score of 8 which indicated moderately impaired cognition, dependence on staff for ADL completion, and received nutrition through feeding tube due to refusing meals. A care plan for Resident #7, updated 12/06/25, showed impaired cognition related to dementia and Alzheimer's disease. Resident #7's care plan did not address post-traumatic stress disorder care. On 12/10/25 at 8:35 a.m., CMA #1 was asked why Resident #7 had diagnosis of post-traumatic stress disorder. They were unable to state why. On 12/10/25 at 8:40 a.m., the activity director was asked why Resident #7 had diagnosis of post-traumatic stress disorder. They were unable to answer. On 12/10/25 at 9:10 a.m., the activity director stated they had learned that Resident #7 had diagnosis of post-traumatic stress disorder due to while in the military in [NAME], Resident #7 stepped on a hidden explosive device which blew up, also resulting in a right leg amputation. On 12/10/25 at 1:35 p.m., the DON and administrator were asked if the care plans included trauma informed care and interventions for residents with diagnoses of post-traumatic stress disorder. They stated no. 2. On 12/08/25 at 1:15 p.m., Resident #75 was observed to have a continuous feeding pump connected to their feeding tube with formula running through the tube. A policy titled Weight List, revised 10/21/09, read in part, Residents' weights are routinely and systematically monitored. All residents must be weighed weekly for four weeks upon admission.The resident's physician should be notified of any significant weight changes. A policy titled Notification of Change, dated 06/2025, read in part, The facility will notify the resident, the resident's physician, and the resident's representative (if applicable) promptly when there is: A significant change in the resident's physical, mental, or psychosocial status.All notifications should be documented in the medical record. A Care Plan, dated 11/17/25, showed Resident #75 was to be weighed weekly for four weeks. The care plan read in part, Monitor/record/report to MD s/sx of malnutrition:.significant weight loss 3lbs in 1 week. An admission assessment, dated 11/23/25, showed Resident #75 was admitted to the facility on [DATE] with diagnoses to include cerebrovascular accident, aphasia, hemiplegia, and malnutrition. The assessment showed Resident #75 was dependent on staff for all ADLs and required the use of a feeding tube. An undated weight record for Resident #75 showed: a. on 12/01/25 a weight 169.8 pounds; and, b. on 12/08/25 they weighed 165.8 pounds. On 12/10/25 at 1:57 p.m., LPN #1 was asked to show where Resident #75's physician was notified of their weight loss. They stated, I know I didn't notify [physician] about the 4-pound weight loss. LPN #1 was asked when the physician would need to be notified regarding weight loss for Resident #75. They stated they did not think there were parameters for notifying the physician of the resident's weight loss. LPN #1 was asked what the process was for notifying the physician of weight loss. They stated the ADONs monitor the weights and notify the charge nurse if the physician needed to be notified. On 12/10/25 at 2:02 p.m., the DON was asked what the facility's process was for identifying weight loss. They stated the facility would meet monthly and compare the weights. The DON was asked who was responsible for notifying the physician of weight loss. They stated, Typically the charge nurse. The DON stated any physician notification would be documented in the nurse's notes and if the documentation was not in a nurse's note, then the physician was not notified. On 12/10/25 at 2:31 p.m., the DON was asked why Resident #75's physician wasn't notified of their 4-pound weight loss. They stated they just got off the phone with the physician to notify them and LPN #1 had also just notified the physician. The DON was asked if the physician had been notified of the weight loss prior to 12/10/25 and they stated no. The DON was asked if Resident #75's care plan was followed. They stated no.

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for trauma informed care for 1 (#7) of 1 sampled resident reviewed with diagnosis of post-traumatic stress disorder. The DON identified 88 residents resided in the facility. Findings:Resident #7's December 2025 physician orders showed they were admitted on [DATE] with diagnoses of post-traumatic stress disorder, hallucinations, and depression. A care plan for Resident #7, updated on 12/06/25, did not address trauma informed care for post-traumatic stress disorder. On 12/10/25 at 8:35 a.m., CMA #1 was asked why Resident #7 had diagnosis of post-traumatic stress disorder. They were unable to state why. On 12/10/25 at 8:40 a.m. the activity director was asked why Resident #7 had diagnosis of post-traumatic stress disorder. They were unable to answer. On 12/10/25 at 9:10 a.m., the activity director stated they had learned Resident #7 had diagnosis of post-traumatic stress disorder due to while in the military in Vietnam, Resident #7 stepped on a hidden explosive device which blew up, also resulted in a right leg amputation On 12/10/25 at 1:35 p.m., the DON and administrator were asked if care plans included trauma informed care and interventions for residents with diagnoses of post-traumatic stress disorder. They stated no.

Based on observation, record review and interview, the facility failed to:a. failed to prevent verbal and physical abuse for 2(#10 and #11) of 5 sampled residents for verbal and physical abuse andb. prevent sexual abuse for 1 (#3) of 2 sampled residents for sexual abuse.The administrator identified 89 residents resided in the facility.Findings:An undated facility policy titled Resident Abuse, Neglect, and Misappropriation of Property, read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse,. Ongoing abuse training will be provided to all employees throughout the year, which include: a. Appropriate interventions to deal with aggressive and/ or catastrophic reactions of residents. report the incident to the highest-ranking person working in the facility at the immediate time of the allegation. The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation. The licensed nurse should report his/her findings to the administrator and or physician as soon as possible after the assessment and receive instructions for notification of the residents' responsible party. The nurse should take immediate steps to protect the resident from further incident during this time. Such steps could include: Immediate assessment of the alleged victim and provisions. Of medical treatment as necessary; Evaluation of whether the alleged victim feels safe and if he/ she does not feel safe, taking immediate steps to protect the resident, such as room relocation and/or increased supervision.1.Resident #2's admission health record, showed Resident #2 was admitted on [DATE] and discharged on 07/07/25. The health record showed they had diagnosis which included chronic obstructive pulmonary disease, dependent on supplemental oxygen, and recurrent depressive disorders.Resident #2's care plan, revised 02/15/24, showed a focus for consensual relations. The focus read in part, [Resident #2] has chosen to have consensual sex/ relations with another resident. Interventions last revised on 10/28/24, included; knock and wait before entering the residents' room and inform of risk associated with sexual intercourse including STDs.Resident #2's quarterly assessment, dated 04/18/25, showed they had moderate cognitive impairments with a BIMS score of 11.A progress notes, dated 07/03/25, showed a focused assessment was completed due to a resident-to-resident event on 07/03/25 on Resident #2. The note showed, a staff member observed Resident #2 in the dining room with Resident #3 engaging in sexually inappropriate behaviors towards Resident #3. The note showed the residents were separated and Resident #3 reported to the nurse Resident #2 had placed Resident #3's hand on Resident #2's genital area.2. On 07/22/25 at 9:44 a.m., Resident #3 was observed ambulating in the hall independently wearing a purple gown and slippers. Resident #3 went to the nurses' station to request ice in their cup. A CNA filled the cup from a locked ice chest and Resident #3 was offered water or tea. Resident #3 refused and stated they wanted something else and ambulated independently to the dining room. Resident #3 changed their mind and filled their cup with tea in the common area. Resident #3's admission health record, dated 07/17/17, showed they were admitted with diagnoses which included hypertension, obesity, bipolar disorder, epilepsy, anxiety disorder, and major depressive disorder.Resident #3's annual assessment, dated 11/23/25, showed their cognition was fully intact with a BIMS score of 15. The assessment showed Resident #3 did not have any behaviors or rejection of care. The assessment also showed Resident #3 transferred and ambulated independently. The assessment showed Resident #3 had diagnoses which included schizophrenia, extrapyramidal and movement disorder, nausea, localized edema, obesity, and gastroparesis.Resident #3's care plan, dated 02/24/25, showed a focus of, Consensual Relations. The care plan interventions read in part, 05/2021 Resident reported that nonconsensual sexual relations had occurred between her and another resident. Later, residents stated that it was consensual but. That [they] has no desire for any further sexual contact. Resident is encouraged to notify staff if [they] changes [their] mind. Family, administration, and physician have been notified. Date initiated: 05/04/2022.An OSDH document titled, Incident report Form, dated 07/03/25, showed a revised final report was faxed to OSDH on 07/08/25 at 4:05 p.m. The report showed CMA #1 observed Resident #2 touching Resident #3 inappropriately. Resident #2 and Resident #3 were immediately separated, and Resident #2 was placed on 1 on 1 care and supervision. The report showed Resident #2 was assessed head to toe, the police, the physician, and family were notified. The report also showed, Resident #3 was transported to a facility [name withheld] for a sexual assault nurse examination (SANE). The report showed during an interview with police, Resident #3 reported Resident #2 touched them inappropriately and the touch was non-consensual. The report showed Resident #2 and Resident #3 had an on and off again relationship and Resident #3 did not want to have any contact with Resident #2. The report showed Resident #2 was sent out and admitted to the hospital where they were evaluated for appropriate placement and discharge. Resident #3's progress note, dated 07/04/25, showed Resident #3 returned from the hospital with the local police at 3:55 a.m. The note showed Resident #3 reported to the nurse they felt safe, and the hospital found DNA and a scratch inside their vagina. The note showed, Resident #3 returned to the facility with discharge paperwork from the SANE forensic program that Resident #3 should have an obstetrics and gynecology examination within 2 weeks, and human immunodeficiency virus (HIV) preventative should be started within seventy-two hours if it was recommended or wanted.Resident #3's progress note, dated 07/04/25 at 5:00 a.m., showed a medication aide observed a [Resident #2] seated at 6:00 p.m. in their wheelchair. The note showed Resident #3 was standing near Resident #2 and the aide observed Resident #3 put their fingers into [Resident #3's] vaginal area.Resident #3's progress note, dated 07/04/25 at 8:52 p.m., showed Resident #3 reported to the nurse they had a nightmare Resident #2 was looking for them. The note showed the nurse provided emotional support and reassurance and encouraged Resident #2 to express their feelings.3. On 07/23/25 at 10:40 a.m., Resident #6 was observed in bed and was pretending to be sleeping. Resident #6 would open their eyes and then close them and not speak or respond. Resident #6's admission health record, dated 02/16/22, showed they had diagnoses which included Alzheimer's disease with late onset, dementia, psychotic disturbance, mood disturbance, and anxiety. Resident #6's quarterly assessment, dated 05/28/25, showed their cognition was moderately impaired with a BIMS score of 12. The assessment did not show any rejection of care or behaviors directed at others. The assessment showed Resident #6 had lower extremity range of motion impairments, used a wheelchair to ambulate, was independent for ADL's, and required supervision for tub/shower transfers.Resident #6's care plan, last reviewed 06/12/25, showed Resident #6 had a focus for Mood. The care plan focus read in part, Mood [Resident #6] has a potential for mood problems due to diagnosis of other recurrent depressive disorders.Resident #6's progress note, dated 06/22/25, showed Resident #6 was observed in the dining room by direct care staff touching the top of Resident # 12's clothing and attempting to pull their clothes. Resident #6 was redirected to another table in the dining room.Resident #6's behavior note, dated 06/24/25 at 7:29 a.m., showed Resident #6 wheeled up to another resident in the dining room and was shaking their finger and yelling at Resident #10. Resident #6 was redirected to another table and told not to yell at other residents. The note showed, two minutes after Resident #6 was redirected, they started yelling at the same resident and had to be redirected. The note showed close monitoring continued.Resident #6's incident note, dated 06/24/25 at 2:13 p.m., showed a nurse observed Resident #6 approached another resident pointing their finger and yelling at them. The note documented multiple attempts were made to redirect Resident #6. The note showed, two hours later staff observed. Resident #6 approach Resident #10 and started pounding on Resident #10's face approximately 7 to 8 times. The residents were immediately separated and assigned one-on-one supervision. The note showed Resident #6 was sent to the hospital for evaluation.Resident #6's hospital discharge records, dated 06/25/25 through 07/01/25, showed they were admitted for aggression and agitation towards other residents, danger to others, and hitting people at the nursing home. There were no other interventions added to Resident #6's care plan for the Mood focus after the incidents on 06/24/25 and 07/20/25 to address concerns related to Resident #6's behaviors directed at other residents.4. On 07/23/25 at 3:14 p.m., Resident #10 was observed on the memory care unit in the common area seated on the couch. The resident was dressed appropriately for the time and setting and was smiling. Resident #10's admission health record showed they were admitted on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance and pressure ulcers of the right buttock.Resident #10's quarterly assessment, dated 06/01/25, showed their cognition was severely impaired with a BIMS score of 04. The assessment showed Resident #10 did not have any rejection of care or behaviors directed at others. The assessment showed Resident #10 transferred independently and required supervision for showers/baths, dressing, and personal hygiene.A OSDH document titled, Incident Report form, dated 06/24/25, showed an initial report was faxed to the OSDH on 06/24/25 at 4:45 p.m. The report showed direct care staff observed Resident #6 in an altercation with Resident #10. The report showed Resident #10 received scratches to the left side of their face and an open area on the left forearm. The report showed the residents were separated and neuro checks were initiated. The physician was notified, and Resident #6 was placed on one on one then sent to hospital for further evaluation.The OSDH Incident Report Form, dated 6/30/25 at 4:47 p.m., showed the allegation was unsubstantiated due to lack of evidence and cognition issues with both parties involved.Resident #10's incident report note, dated 6/24/25 at 2:26 p.m., showed a direct care staff observed another resident approach Resident #10 at approximately 9:00 a.m. pointing their finger and yelling. The note showed, two hours later, staff observed the same resident approach Resident #10 again and started pounding at [Resident #10] face with a closed fist seven to eight times. The note showed Resident #10 had a small scratch to the left cheek bone and a small skin tear to the left forearm, so first aid was administered.5. On 07/25/25 at 9:40 a.m., Resident #11 was observed in their room, in bed, lying on their side with a neck contracture and was watching television. Resident #11's admission health record showed they were admitted on [DATE] with diagnoses which included Huntington's disease, major depressive disorder, and Parkinsonism.Resident #11's quarterly assessment, dated 04/22/25, showed their cognition was moderately impaired with a BIMS score of 8. The assessment showed Resident #11 did not have any behaviors directed at others and did not reject care. The assessment showed Resident #11 required substantial to maximum assistance with toileting, showers/baths, and dressing. The assessment showed Resident #11 required substantial to maximum assistance for repositioning in bed and does not transfer for toileting.Resident #11's care plan, last reviewed 04/24/25, showed Resident #11 preferred to stay in their room, in their bed most of the time per their preferences. An Incident Report Form dated 07/20/25, showed the administrator was notified of the incident on 07/20/25 Resident #6 threw clear liquid from their cup towards Resident #11's side of the room. The report showed the allegation was unsubstantiated after an investigation due to no staff members interviewed supported the substantiation of abuse. The initial report was received by OSDH on 07/25/25 at 2:14 p.m.There was no documentation in Resident #11's health record regarding the incident on 07/20/25 when direct care staff witnessed Resident #6 throw water, juice, cups, and use verbal abuse while direct care was providing perineal care.On 07/17/25 at 3:33 p.m., CMA #1 stated, on 07/03/25 at around 4:00 p.m., they observed Resident #3 wearing a night gown in the dining room and Resident #2's hand was under the gown. They stated both residents were startled and were immediately separated. CMA #1 asked Resident #2 what was going on. CMA #1 stated, Resident #2 told the nurse, it won't happen again. CMA #1 stated Resident #3 was scared and asked if they were in trouble. CMA #1 stated the police were called and the nurse started an incident report. CMA #1 stated Resident #3 stated Resident #2 was trying to pay them ten dollars to do sexual acts and was unaware the touch was non-consensual.On 07/17/25 at 3:52 p.m., LPN #1 stated on 07/03/25, CMA #1 reported to them they observed Resident #2 with their hand in Resident #3's vaginal area. LPN #1 stated they made sure Resident #2 was one on one then went to assess Resident #3. LPN #1 stated Resident #3 reported Resident #2 put their fingers in their vagina without consent.On 07/17/25 at 4:15 p.m., RN #1 stated CMA #1 reported they observed Resident #2 in the dining room with their hand in Resident #3's vaginal area under their gown. RN #1 stated Resident #3 reported to them that Resident #2 touched their vagina and it was not consensual. RN #1 stated Resident #2 was one on one, the police came out, and Resident #3 was transferred to the hospital to be evaluated.On 07/21/25 at 9:11 a.m., the MDS coordinator #1 was asked about interventions in Resident #3's care plan after the rape/sexual assault allegation on 07/03/25 involving Resident #2 and Resident #3. They stated Resident #3 was having nightmares and they set up a psychological teleconference with a counseling service provider on 07/07/25 after the holiday. On 07/21/25 at 10:19 a.m., the administrator stated Resident #2 and Resident #3 were care planned for consensual sex and both residents received sex education, and they were both in agreement in February 2024. The administrator stated a BIMS score of 10 or higher was the threshold they used to measure which residents could consent.On 07/22/25 at 9:36 a.m., Resident #3 stated on 07/04/25 around 4:00 p.m., they were in the dining room seated when Resident #2 came to their table and stated, I want some pussy and tried to bribe them with, pop, candy, and money for sex. Resident #3 stated they told Resident #2, you ain't getting nothing from me. Resident #3 stated Resident #2 they were both seated at a table in the dining room with Resident #2 in a wheelchair on their left side. Resident #3 stated Resident #2 reached over and forced their legs open and put their finger in Resident #3's vagina while they were seated. Resident #3 stated they stood up and Resident #2 placed their hand under their night gown and put their fingers in their vagina. Resident #3 stated when they were standing, they were not wearing panties and CMA #1 observed them standing when Resident #2 had their fingers in their vagina. Resident #3 stated they did not want to be touched like that and was caught off guard by Resident #2. Resident #3 stated they were having nightmares since the incident.On 07/22/25 at 10:03 a.m., the DON stated they were notified on 07/03/25 by LPN #1 and they came to the facility within 30 minutes. Resident #2 was one on one and Resident #3 was in their room. The DON stated, Resident #3 reported Resident #2 touched their vagina without consent and Resident #2 stated Resident #3 placed their hand on Resident #3's leg then Resident #3 moved Resident #2s hand to their vagina.On 07/23/25 at 8:47 a.m., Resident #3 stated the nightmares were improving since the alleged sexual assault. On 07/23/25 at 12:44 p.m., the DON was asked about the unsubstantiated abuse findings on the final Incident Report Form dated 06/24/25 involving Resident #6 and Resident #10 on 06/24/25. The DON stated the nurse who was no longer employed entered the note, but their stories were not consistent. The DON stated they could not prove intent because the incident occurred on memory care and the residents had cognitive impairments.On 07/23/25 at 12:47 p.m., the administrator stated the unsubstantiated abuse allegation involving Resident #6 and Resident #10 was unsubstantiated because the staff charted what they did to get Resident #6 moved off the memory care unit and the nurse's story who was no longer employed was not consistent. On 07/23/25 at 1:47 p.m., the regional director of operations stated that there had to be willful intent to have abuse. They stated, regarding the incident on 06/24/24 between Resident #6 and Resident #10, there was no pain and a lack of evidence because the nurse never observed the hitting and their stories were inconsistent. They stated Resident #10 required nothing more than first aide.On 07/23/25 at 3:33 p.m., CMA #2 stated they witnessed Resident #6 attack Resident #10. They stated Resident #10 was sitting down and Resident #6 was in a wheelchair. Resident #6 was hitting Resident #10 with their right hand in the face and arms area. CMA #2 stated Resident #10 had their arms up trying to shield the hits. CMA #2 stated other staff helped break up the fight. CMA #2 stated they were interviewed by the DON and reported what they witnessed. They stated, Resident #10 had scratches on the face and arms and was scared at that time.On 07/23/25 at 3:42 p.m., the activities director was asked about the incident on 06/24/25 involving Resident #10 and Resident #6. They stated they did not witness the incident between Resident #6 and Resident #10. The activities director stated they heard screaming, helped separate Resident #6 and Resident #10, and one on one with Resident #6 until they left for the hospital to be evaluated.On 07/23/25 at 3:51 p.m., the DON was asked about staff interviews regarding the investigation of the incident on 06/24/25 between Resident #6 and Resident #10. They stated their entire investigation was documented on the OSDH final Incident Report Form, received on 6/30/25. They stated they could not recall what and who reported to them regarding the incident. The DON was asked about their abuse policy and their role as the DON regarding abuse allegations. They stated, I can't quote it off the top of my head.On 07/24/25 at 8:18 a.m., the activities director stated Resident #6 would become agitated and rant and [NAME] about other residents. The activities director stated, they heard about another incident on hall 200 where Resident #6 threw food at their roommate during perineal care after they returned from the hospital on [DATE].On 07/24/25 at 8:28 a.m., the ADON was asked what the policy was when a resident had aggression or was abusive towards another resident. The ADON stated after the residents were separated, they would investigate. They stated, after the investigation, they would discuss as a team intervention to be added to the care plan.On 07/24/25 at 11:40 a.m., MDS coordinator #1 was asked when care plans should be updated. They stated care plans should be updated quarterly, if there was an incident, diet changes, and a change in condition. They stated if there was an abuse incident involving resident to resident where there was an incident report, they would update the care plan with interventions the following day. MDS Coordinator #1 was asked to review Resident #6's care plan and asked when the care plan was updated after the incident on 06/24/25 involving Resident #6 and Resident #10 and the incident on 07/20/25 involving Resident #6 and Resident #11 on 07/20/25. The MDS Coordinator #1 stated the care plan for Resident #6 was updated on 07/24/25 because they were off on vacation and was not made aware of the incidents. They stated the care plan policy was not followed.On 07/24/25 at 12:03 p.m., the administrator stated they were not made aware of the incident on 07/20/25 involving Resident #6 and Resident #11. The administrator stated the abuse policy was not followed because it was not reported and investigated the same day it happened. The administrator was asked about Resident #6's care plan. They stated the care plan was not updated when it should have been. They stated the risk of Resident #6's care plan not being updated could cause staff to not be aware of what interventions were in place.On 07/24/25 at 3:32 p.m., RN #2 stated on 07/20/25, they heard Resident #11 yelling. When they responded, CNA #9 was coming out of Resident #6 and Resident #11's room and stated Resident #6 had thrown water and juice on Resident #11 during peri care. They stated Resident #6 was upset and yelling. They stated they attempted to calm Resident #6 and contacted Resident #6's family. They stated Resident #11's blanket was wet. RN #2 stated they did not assess Resident #11 after the incident, did not call family, and did not report because they did not think Resident #11 was harmed. They stated they did not follow the abuse policy by not reporting the incident immediately, they should have separated the residents, they should have assessed Resident #11 and documented it and notified the administrator immediately.On 07/25/25 at 9:40 a.m., Resident #11 was asked about the incident on 07/20/25 involving Resident #6 who was their roommate. They stated Resident #6 was angry and threw a pillow and water on them and was telling Resident #11 that they smelled bad while they were receiving perineal care. Resident #11 stated their face and blanket got wet.On 07/25/25 at 10:13 a.m., family representative #1 stated they were not notified of the incident on 07/20/25. They stated on 07/23/25, Resident #11 looked like they were down during a visit. They stated Resident #6's behaviors and sensitivity to smells were reported to nursing staff in January 2025 due to Resident #6 stuffing the bathroom doors with cardboard and paper in the cracks and admonishing visitors for using the toilet during visits with Resident #11.On 07/25/25 at 12:11 p.m., CNA #9 stated they were providing perineal care on 07/20/25, for Resident #11 who was bed fast. They stated Resident #6 was shouting at Resident #11 during perineal care that they smelled bad and wanted Resident #11 out of the room. CNA #9 stated Resident #6 made statements to Resident #11 daily during peritoneal care. The CNA stated they reported the verbal, physical, and mental abuse directed at Resident #11 from Resident #6 to RN #2 immediately. CNA #9 stated the actions of Resident #6 met the criteria for abuse and Resident #11 was angry about the incident. The CNA stated Resident #6 made those statements daily to Resident #11.

Based on observation, record review, and interview, the facility failed to conduct a thorough investigation after an allegation of abuse for 4 (#6,10,11, and #12) of 5 residents reviewed for abuse allegations.The administrator identified 89 residents resided in the facility.Findings:An undated facility policy titled Resident Abuse, Neglect, and Misappropriation of Property, read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse,. A member of the administrative staff will then conduct a thorough investigation of the incident/ allegation to obtain information about the incident and complete the ODH-283.1.On 07/23/25 at 10:40 a.m., Resident #6 was observed in bed and was pretending to be sleeping. Resident #6 would open their eyes and then close them and not speak or respond.Resident #6's admission health record, dated 02/16/22, showed they were admitted with diagnoses which included Alzheimer's disease with late onset, dementia, psychotic disturbance, mood disturbance, and anxiety. A quarterly assessment for Resident #6, dated 05/28/25, showed their cognition was moderately impaired with a BIMS score of 12. The assessment did not show any rejection of care or behaviors directed at others. The assessment showed Resident #6 had lower extremity range of motion impairments, used a wheelchair to ambulate, was independent for ADL's (activities of daily living), and required supervision for tub/shower transfers.Resident #6's progress note, dated 06/22/25, showed Resident #6 was observed in the dining room by direct care staff touching the top of Resident #12's clothing and attempting to pull their clothes. Resident #6 was redirected to another table in the dining room.Resident #6's behavior notes, dated 06/24/25 at 7:29 a.m., showed Resident #6 wheeled up to another resident in the dining room and was shaking their finger and yelling at a resident. Resident #6 was redirected to another table and told not to yell at other residents. Two minutes later, the note showed Resident #6 started yelling at the same resident and had to be redirected. The note showed close monitoring continued.Resident #6's incident note, dated 06/24/25 at 2:13 p.m., showed a nurse observed Resident #6 approach another resident, pointed their finger and yelled at them. The note showed multiple attempts made to redirect Resident #6. The note also documented, two hours later staff observed. Resident #6 approached the Resident #10 and started pounding on their face approximately seven to eight times. The residents were immediately separated and assigned one-on-one. The note showed Resident #6 was transported to the hospital to be evaluated. Resident #6's hospital discharge records, dated 06/25/25 through 07/01/25, showed they were admitted for aggression and agitation towards other residents, danger to others, and hitting people at the nursing home. 2.On 07/23/25 at 3:14 p.m., Resident #10 was observed on the memory care unit in the common area seated on the couch. The resident was dressed appropriately and smiling. Resident #10's admission health record showed they were admitted on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance and pressure ulcers of the right buttock.A quarterly assessment for Resident #10, dated 06/01/25, showed their cognition was severely impaired with a BIMS score of 04. The assessment showed Resident #10 did not have any rejection of care or behaviors directed at others. The assessment showed Resident #10 transferred independently and required supervision for showers/baths, dressing, and personal hygiene.An OSDH document titled, Incident Report Form, dated 06/24/25, showed an initial report was faxed to OSDH on 06/24/25 at 4:45 p.m. The report showed direct care staff observed Resident #6 in an altercation with Resident #10. The report showed Resident #10 received scratches on the left side of their face and an open area on their left forearm. The report showed the residents were separated, neuro checks were initiated, the physician was notified, and Resident #6 was placed on one on one supervision ,then sent to the hospital for further evaluation. The final report received at the OSDH on 06/30/25 at 4:47 p.m., showed the allegation was unsubstantiated due to lack of evidence and cognition issues with both parties involved.Resident #10's incident report note, dated 06/24/25 at 2:26 p.m., showed a direct care staff observed Resident #6 approach Resident #10 at approximately 9:00 a.m., pointed their finger and yelled. The note showed two hours later, staff observed the Resident #6 approach Resident #10 again and started pounding at Resident #10 face with a closed fist seven or eight times. The note showed Resident #10 had a small scratch to the left cheek bone and a small skin tear to the left forearm so first aid was administered.3.On 07/25/25 at 9:40 a.m., Resident #11 was observed in bed with a neck contracture watching television lying on their side.Resident #11's admission health record, dated 02/19/14, showed they were admitted with diagnoses which included Huntington's disease, major depressive disorder, and Parkinsonism.A quarterly assessment for Resident #11, dated 04/22/25, showed their cognition was moderately impaired with a BIMS score of 8. The assessment showed Resident #11 did not have any behaviors directed at others and did not reject care. The assessment showed Resident #11 required substantial to maximum assistance with toileting, showers/baths, and dressing. The assessment showed Resident #11 required substantial to maximum assistance for repositioning in bed and does not transfer for toileting.Resident #11's care plan, last reviewed 04/24/25, showed Resident #11 preferred to stay in their room, in their bed most of the time per their preferences. An Incident Report Form, dated 07/20/25, showed the administrator was notified of the incident on 07/20/25 by the state survey agency on 07/25/25, Resident #6 threw clear liquid from their cup towards the roommates' (Resident #11's) side of the room. The report showed the allegation was unsubstantiated after an investigation due to no staff members interviewed supported the substantiation of abuse. The initial report was received by the OSDH on 07/25/25 at 2:14 p.m.There was no documentation in Resident #11's health record regarding the incident on 07/20/25 when direct care staff witnessed Resident #6 throw water, juice, cups, and use verbal abuse at Resident #11 while direct care was providing perineal care.On 07/23/25 at 12:44 p.m., the DON was asked about the unsubstantiated findings on the final Incident Report Form, dated 06/24/25 and received at the OSDH on 06/30/25 involving Resident #6 and Resident #10. The DON stated the nurse who was no longer employed entered the note but their stories were not consistent. The DON stated they could not prove intent because the incident occurred on memory care, and the residents had cognitive impairments.On 07/23/25 at 12:47 p.m., the administrator stated the abuse allegation involving Resident #6 and Resident #10 was unsubstantiated because the staff charted what they did to get Resident #6 moved off the memory care unit and the nurses story who was no longer employed was not consistent. On 07/23/25 at 1:47 p.m., the regional director of operations stated there had to be willful intent to have abuse. They stated, regarding the incident on 06/24/24 between Resident #6 and Resident #10, there was no pain and a lack of evidence because the nurse never observed the hitting and their stories were inconsistent. They stated Resident #10 required nothing more than first aide.On 07/23/25 at 3:33 p.m., CMA #2 stated they witnessed Resident #6 attack Resident #10. They stated Resident #10 was sitting down and Resident #6 was in a wheelchair. Resident #6 was hitting Resident #10 with their right hand in the face and arms area. They stated Resident #10 had their arms up trying to shield the hits. They stated other staff helped break up the fight. CMA #2 stated they were interviewed by the DON and reported what they witnessed. They stated, Resident #10 had scratches on the face and arms and was scared at that time.On 07/23/25 at 3:42 p.m., the activities director was asked about the incident on 06/24/25 involving Resident # 10 and Resident #6. They stated they did not witness the incident but did hear screaming, helped separate the residents, and provided one on one with Resident #6 until they left for the hospital.On 07/23/25 at 3:51 p.m., the DON was asked about staff interviews regarding the investigation of the incident on 06/24/25 between Resident #6 and Resident #10. They stated their entire investigation was documented on the OSDH final Incident Report Form, received on 06/30/25. They stated they could not recall what and who reported to them regarding the incident. The DON was asked about their abuse policy and their role as the DON regarding abuse allegations. They stated, I can't quote it off the top of my head.On 07/24/25 at 8:18 a.m., the activities director stated Resident #6 was moved to memory care to prevent elopement. They stated Resident #6 would become agitated and rant and [NAME] about other residents. They stated, they heard about another incident on hall 200 where Resident #6 threw food at their roommate during perineal care after they returned from the hospital on [DATE].On 07/24/25 at 8:28 a.m., the ADON was asked what the policy was when a resident had aggression or was abusive towards another resident. The ADON stated that after the residents were separated, they would investigate.On 07/24/25 at 12:03 p.m., the administrator stated they were not made aware of the incident on 07/20/25 involving Resident #6 and Resident #11. The administrator stated they were not informed of the incident on 06/22/25 involving Resident #6 and Resident #12. The administrator stated they learned about the incident on 06/22/25 in the morning stand up on 06/23/25 and the nurse did not report the incident on 06/22/25. They stated the abuse policy was not followed because it was not reported and investigated.On 07/24/25 at 3:32 p.m., RN #2 stated on 07/20/25, they heard Resident #11 yelling. When they responded, CNA #9 was coming out of Resident #6 and Resident #11's room and stated Resident #6 had thrown water and juice at Resident #11 during perineal care. They stated Resident #6 was upset and yelling. RN #2 stated they attempted to calm Resident #6 and contacted Resident #6's family. RN #2 stated they did not think Resident #6 throwing water at Resident #11 was abuse. RN #2 stated Resident #11's blanket was wet. RN #2 stated they did not assess Resident #11 after the incident, did not call family, and did not report the incident to the abuse coordinator because Resident #11 complained about something being thrown at them. RN #2 stated Resident #11 did not say they were harmed. On 07/25/25 at 9:40 a.m., Resident #11 was asked about the incident on 07/20/25 involving Resident #6, who was their roommate. They stated Resident #6 was angry and threw a pillow and water on them and were telling them they smelled bad while they were receiving peritoneal care. Resident #11 stated their face and blanket got wet.On 07/25/25 at 11:08 a.m., the DON stated the abuse allegation on 06/22/25 involving Resident #6 and Resident #12 was not reported following their abuse policy, and they learned about it the following day on 06/23/25 in the morning stand up meeting.On 07/25/25 at 12:11 p.m., CNA #9 stated they were providing perineal care for Resident #11 who was bed fast on 07/20/25. They stated Resident #6 was shouting at Resident #11 during perineal care that Resident #11 smells bad and wanted Resident #11 out of the room. CNA #9 states that Resident #6 made statements to Resident #11 daily during perineal care. The CNA stated they reported the verbal, physical, and mental abuse directed at Resident #11 from Resident #6 to RN #2 immediately. CNA #9 stated the actions of Resident #6 met the criteria for abuse and Resident #11 was angry about the incident. The CNA stated Resident #6 made those statements daily to Resident #11.

Based on record review and interview, the facility failed to ensure a resident's care plan was updated after 3 incidents of Resident- Resident abuse allegations for #6 of 5 residents reviewed care plan interventions to prevent abuse. The administrator identified 89 residents resided in the facility.Findings:1.Resident #6's health record upon admission showed they were admitted on [DATE] with diagnoses which included Alzheimer's disease with late onset, dementia, psychotic disturbance, mood disturbance, and anxiety. Resident #6's quarterly assessment, dated 05/28/25, showed their cognition was moderately impaired with a BIMS score of 12. The assessment did not show any rejection of care or behaviors directed at others. The assessment showed Resident #6 had lower extremity range of motion impairments, used a wheelchair to ambulate, was independent for ADL's, and required supervision for tub/shower transfers.Resident #6's care plan, last reviewed 07/16/25, showed Resident #6 had a focus for Mood. The care plan focus read in part, Mood [Resident #6] has a potential for mood problems. Due to diagnosis of other recurrent depressive disorders. Date initiated 10/26/2022. Revision on :12/24/24. The care plan documented interventions for Mood read in part, Administer Abilify as ordered Date Initiated: 07/16/2025.An OSDH document titled Incident Report Form, dated 06/02/25, showed an initial incident of abuse report was faxed to OSDH on 06/24/25 at 4:49 p.m. The final report was dated 06/23/25, faxed to OSDH on 06/27/25 at 8:35 a.m The report showed the incident occurred on 06/23/25. The report showed direct care staff observed Resident # 6 touching Resident #12 on the leg. The report showed, the Residents were separated, police, family, and physician were notified, and staff members were interviewed.Resident #6's progress notes, dated 06/22/25, showed Resident #6 was observed in the dining room by direct care staff touching the top of Resident #12's clothing and attempting to pull their clothes. Resident #6 was redirected to another table in the dining room.Resident #6's behavior note, dated 06/24/25 at 7:29 a.m., showed Resident #6 wheeled up to another resident in the dining room and was shaking their finger and yelling at a resident. Resident #6 was redirected to another table and told not to yell at other residents. Two minutes later, the note showed Resident #6 started yelling at the same resident and had to be redirected. The note showed close monitoring continued.Resident #6's incident note, dated 06/24/25 at 2:13 p.m., showed a nurse observed Resident #6 approaching Resident #10 pointing their finger and yelling at them. The note documented multiple attempts were made to redirect Resident #6. The note documented, two hours later staff observed [Resident #6] approach Resident #10 and started pounding on [their] face approximately seven to eight times. The residents were immediately separated and assigned one-on-one, and Resident #6 left via stretcher with EMSA at 1:55 p.m. and was sent to the hospital for evaluation.A OSDH document titled Incident Report form, dated 06/24/25, showed an initial report was faxed to OSDH on 06/24/25 at 4:45 p.m. The report showed direct care staff observed Resident #6 in an altercation with Resident #10. The report showed Resident #10 received scratches to the left side of the face and an open area on the left forearm. The report showed the residents were separated and neuro checks were initiated, the physician was notified, and Resident #6 was placed on one on one then sent to hospital for further evaluation. Resident #6's hospital discharge records, dated 06/25/25 through 07/01/25, showed they were admitted for aggression and agitation towards other residents, danger to others, hitting people at the nursing home, and acute mental status change.Resident #6's progress note, dated 07/01/25, showed they were readmitted to the facility on [DATE].An Incident Report Form dated 07/20/25, showed the administrator was notified of the incident on 07/20/25 on 07/25/25 by the state surveyor agency Resident #6 threw clear liquid from their cup at Resident #11's side of the room. The report showed the allegation was unsubstantiated after an investigation due to no staff members interviewed supporting substantiation of abuse. The initial report was received by OSDH on 07/25/25 at 2:14 p.m.There were no other interventions added to Resident #6's care plan for the Mood focus after the incidents on 06/22/24,06/24/25, and 07/20/25 to address concerns related to Resident #6's behaviors directed at other residents.On 07/23/25 at 3:33 p.m., CMA #2 stated they witnessed Resident #6 attack Resident #10. They stated Resident #10 was sitting down and Resident #6 was in a wheelchair. CMA #2 stated Resident #6 was hitting resident #10 with their right hand in the face and arms area. CMA #2 stated Resident #10 had their arms up trying to shield the hits. CMA #2 stated other staff helped break up the fight. CMA #2 stated they were interviewed by the DON and reported what they witnessed. CMA #2 stated Resident #10 had scratches on the face and arms and was scared at that time.On 07/23/25 at 3:42 p.m., the activities director was asked about the incident on 06/24/25 involving Resident # 10 and Resident #6. The activities director stated they did not witness the incident but did hear screaming. The activities director helped separate the residents and provided one on one with Resident #6 until they left for the hospital.On 07/24/25 at 8:18 a.m., the activities director stated Resident #6 would become agitated and rant and [NAME] about other residents. They stated, they heard about another incident on hall 200 where Resident #6 threw food at their roommate during perineal care after they returned from the hospital on [DATE] after the incident on 06/24/25involving Resident #6 and Resident #10. On 07/24/25 at 8:28 a.m., the ADON was asked what the policy was when a resident had aggression or was abusive towards another resident. The ADON stated that after the residents were separated, they would investigate. They stated, after the investigation, they discuss as a team interventions to be added to the care plan.On 07/24/25 at 11:40 a.m., MDS coordinator #1 was asked when care plans should be updated. They stated care plans should be updated quarterly, if there was an incident, diet changes, and a change in condition. The MDS coordinator #1 stated if there was an abuse incident involving residents to residents where there was an incident report, they would update care plan with interventions the following day. The MDS coordinator #1 were asked to review Resident #6's care plan and asked when the care plan was updated after the incident involving Resident #6 and Resident #12 on 06/22/25, the incident on 06/24/25 involving Resident #6 and Resident #10, and the incident on 07/20/25 involving Resident #6 and Resident #10 on 07/20/25. The MDS Coordinator #1 stated the care plan for Resident #6 was updated on 07/24/25 because they were off on vacation and was not made aware of the incidents. They stated the care plan policy was not followed.On 07/24/25 at 12:03 p.m., the administrator stated they were not made aware of the incident on 07/20/25 involving Resident #6 and Resident #11. The administrator stated they were not informed of the incident on 06/22/25 involving Resident #6 and Resident #12. The administrator stated they learned about the incident on 06/22/25 in the morning stand up on 06/23/25 and the nurse did not report the incident on 06/22/25. They stated the abuse policy was not followed because it was not reported and investigated. The administrator was asked about Resident #6's care plan. They stated the care plan was not updated when it should have been. They stated the risk of Resident #6's care plan not being updated could cause staff to not be aware of what interventions were in place.On 07/24/25 at 12:19 p.m., the corporate nurse #1 stated that they did not have a policy for updating care plans and they go by the RAI manual.On 07/24/25 at 3:32 p.m., RN #2 stated on 07/20/25, they heard Resident #11 yelling. When they responded, CNA #9 was coming out of Resident #6 and Resident #11's room and stated Resident #6 had thrown water and juice on Resident #11 during peri care. They stated Resident #6 was upset and yelling. RN #2 stated they attempted to calm Resident #6 and contacted Resident #6's family. RN #2 stated Resident #10's blanket was wet. RN #2 stated they did not assess Resident #11 after the incident, did not call family, and did not report because they did not think Resident #11 was harmed. RN #2 stated they did not think another resident throwing water on another resident during perineal care was considered abuse. RN #2 stated they did not follow the abuse policy by not reporting the incident immediately, they should of separated the residents, they should have assessed Resident #11 and documented it and notified the administrator immediately.On 07/25/25 at 9:40 a.m., Resident #11 was asked about the incident on 07/20/25 involving Resident #6 who was their roommate. They stated Resident #6 was angry, threw a pillow and water on them, and was telling Resident #11 that they smelled bad while they were receiving perineal care. Resident #11 stated their face and blanket got wet.On 07/25/25 at 10:13 a.m., family representative #1 of Resident #11 stated they were not notified of the incident on 07/20/25. They stated on 07/23/25, Resident #11 looked like they were down during a visit. They stated that Resident #6's behaviors and sensitivity to smells were reported to nursing staff in January 2025 due to Resident #6 stuffing the bathroom doors with cardboard and paper in the cracks and admonishing visitors for using the toilet during visits with Resident #11.On 07/25/25 at 11:08 a.m., the DON stated that the abuse allegation on 06/22/25 involving resident #6 and Resident #12 was not reported following their abuse policy, and they learned about it the following day on 06/23/25 in the morning stand up meeting.On 07/25/25 at 12:11 p.m., CNA #9 stated they were providing perineal care for Resident #11 who was bed fast on 07/20/25. They stated Resident #6 was shouting at Resident #11 during perineal care that Resident #11 smells bad and wanted Resident #11 out of the room. CNA #9 states that Resident #6 makes statements to Resident #11 daily during perineal care. CNA #9 stated they reported the verbal, physical, and mental abuse directed at Resident #11 from Resident #6 to RN #2 immediately. CNA #9 stated the actions of Resident #6 met the criteria for abuse and Resident #11 was angry about the incident. CNA #9 stated Resident #6 made these statements daily to Resident #11.

Based on record review and interviews, the facility failed to implement their abuse policy by not:a. conducting a complete and thorough investigation for 3 of 4 incidents reports reviewed for a complete and thorough investigation,b. add appropriate interventions to involved residents care plan after an abuse allegation for 1 (#6) of 5 residents reviewed for interventions after an abuse allegation,c. reporting to the OSDH within two hours of the allegation of abuse for 2 of 4 incidents reports reviewed for reporting to OSDH within two hours,d. notifying family and physician after an abuse allegation for 2 (#11 and #12) reviewed for notification after an abuse allegation, ande. assessing residents for signs of injury for 2 (#11 and #12) residents reviewed for assessment after an abuse allegation.The administrator identified 89 residents resided in the facility. Findings:An undated facility policy titled Resident Abuse, Neglect, and Misappropriation of Property, read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse,. Ongoing abuse training will be provided to all employees throughout the year, which include: a. Appropriate interventions to deal with aggressive and/ or catastrophic reactions of residents.report the incident to the highest ranking person working in the facility at the immediate time of the allegation. The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation. The licensed nurse should report his/her findings to the administrator and or physician as soon as possible after the assessment and receive instructions for notification of the residents' responsible party. The nurse should take immediate steps to protect the resident from further incident during this time. Such steps could include: Immediate assessment of the alleged victim and provisions. Of medical treatment as necessary; Evaluation of whether the alleged victim feels safe and if he/ she does not feel safe, taking immediate steps to protect the resident, such as room relocation and/or increased supervision. A member of the administrative staff will conduct A thorough investigation of the incident. Allegation to obtain information about the incident and complete the ODH-283.On 07/23/25 at 10:40 a.m., Resident #6 was observed in bed and was pretending to be sleeping. Resident #6 would open their eyes and then close them and not speak or respond.Resident #6's admission health record, dated 02/16/22, showed they were admitted with diagnoses which included Alzheimer's disease with late onset, dementia, psychotic disturbance, mood disturbance, and anxiety. A quarterly assessment for Resident #6, dated 05/28/25, showed their cognition was moderately impaired with a BIMS score of 12. The assessment did not show any rejection of care or behaviors directed at others. The assessment showed Resident #6 had lower extremity range of motion impairments, used a wheelchair to ambulate, was independent for ADL's, and required supervision for tub/shower transfers.Resident #6's care plan, last reviewed 06/12/25, showed Resident #6 had a focus for Mood. The care plan focus read in part, Mood [Resident #6] has a potential for mood problems. Due to diagnosis of other recurrent depressive disorders. Date initiated 10/26/2022. Revision on :12/24/24. There were no other interventions added to Resident #6's care plan for the Mood focus after the incidents on 06/22/24,06/24/25, and 07/20/25 to address concerns related to Resident #6's behaviors directed at other residents. Resident #6's behavior notes, dated 06/22/25, showed Resident #6 was observed in the dining room on the memory care unit by direct care staff touching the top of Resident # 12's clothing and attempting to pull Resident #12's clothes. Resident #6 was redirected to another table in the dining room.Resident #6's behavior notes, dated 06/24/25 at 7:29 a.m., showed Resident #6 wheeled up to another resident in the dining room and was shaking their finger and yelling at a resident. Resident #6 was redirected to another table and told not to yell at other residents. Two minutes later, the note showed Resident #6 started yelling at the same resident and had to be redirected. The note showed close monitoring continued.Resident #6's incident note, dated 06/24/25 at 2:13 p.m., showed a nurse observed Resident #6 approach another resident pointing their finger and yelling at them. The note documented multiple attempts were made to redirect Resident #6. The note documented, two hours later staff observed. Resident #6 approach Resident #10 and started pounding on their face approximately seven to eight times. The note showed the residents were immediately separated, assigned one-on-one and Resident #6 left via stretcher ambulance at 1:55 p.m.Resident #6's hospital discharge records, dated 06/25/25 through 07/01/25, showed they were admitted for aggression and agitation towards other residents, danger to others, and hitting people at the nursing home. On 07/24/25 at 8:18 a.m., the activities director stated Resident #6 was moved to memory care to prevent elopement. They stated Resident #6 would become agitated and rant and [NAME] about other residents. They stated, they heard about another incident on hall 200 where Resident #6 threw food at their roommate during perineal care after they returned from the hospital on [DATE].2. Resident #10's admission health record showed they were admitted on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance and pressure ulcers of the right buttock.A quarterly assessment for Resident #10, dated 06/01/25, showed their cognition was severely impaired with a BIMS score of 04. The assessment showed Resident #10 did not have any rejection of care or behaviors directed at others. The assessment showed Resident #10 transferred independently and required supervision for showers/baths, dressing, and personal hygiene.An OSDH document titled, Incident Report Form, dated 06/24/25, showed an initial report was faxed to OSDH on 06/24/25 at 4:45 p.m. The report showed direct care staff observed Resident #6 in an altercation with Resident #10. The report showed Resident #10 received scratches to the left side of their face and an open area on the left forearm. The report showed the residents were separated, neuro checks were initiated, the physician was notified, and Resident #6 was placed on one on one then sent to hospital for further evaluation. The final report received at the OSDH on 06/30/25 at 4:47 p.m., showed the allegation was unsubstantiated due to lack of evidence and cognition issues with both parties involved.Resident #10's incident report note, dated 6/24/25 at 2:26 p.m., showed a direct care staff observed another resident approach Resident #10 at approximately 9:00 a.m. pointing their finger and yelling. The note showed two hours later, staff observed the same resident approach Resident #10 again and started pounding at [Resident #10] face with a closed fist seven to eight times. The note showed Resident #10 had a small scratch to the left cheek bone and a small skin tear to the left forearm so first aid was administered.On 07/23/25 at 12:44 p.m., the DON was asked about the unsubstantiated findings on the final Incident Report Form dated 06/24/25 and received at OSDH on 06/30/25 involving Resident #6 and Resident #10. The DON stated the nurse who was no longer employed entered the note, but their stories were not consistent. The DON stated they could not prove intent because the incident occurred on memory care, and the residents had cognitive impairments.On 07/23/25 at 12:47 p.m., the administrator stated the abuse allegation involving Resident #6 and Resident #10 on 06/24/25 was unsubstantiated because the staff charted what they did to get Resident #6 moved off the memory care unit and the nurse's story, who was no longer employed, was not consistent. On 07/23/25 at 1:47 p.m., the regional director of operations stated there had to be willful intent to have abuse. They stated, regarding the incident on 06/24/24 between Resident #6 and Resident #10, there was no pain and a lack of evidence because the nurse never observed the hitting and their stories were inconsistent. They stated Resident #10 required nothing more than first aide.On 07/24/25 at 11:40 a.m., MDS coordinator #1 was asked when care plans should be updated. They stated care plans should be updated quarterly, if there was an incident, diet changes, and a change in condition. They stated if there was an abuse incident involving resident to resident where there was an incident report, they would update care plan with interventions the following day. They were asked to review Resident #6's care plan and asked when the care plan was updated after the incident involving Resident #6 and Resident #10. MDS Coordinator #1 stated the care plan for Resident #6 was updated on 07/24/25 because they were off on vacation and were not made aware of the incidents. They stated the policy was not followed for updating the care plan.3. On 07/25/25 at 9:40 a.m., Resident #11 was observed lying in bed watching television lying on their side. Resident #11's admission health record showed they were admitted on [DATE] with diagnoses which included Huntington's disease, major depressive disorder, and Parkinsonism.A quarterly assessment for Resident #11, dated 04/22/25, showed their cognition was moderately impaired with a BIMS score of 8. The assessment showed Resident #11 did not have any behaviors directed at others and did not reject care. The assessment showed Resident #11 required substantial to maximum assistance with toileting, showers/baths, and dressing. The assessment showed Resident #11 required substantial to maximum assistance for repositioning in bed and does not transfer for toileting.Resident #11's care plan, last reviewed 04/24/25, showed Resident #11 preferred to stay in their room, in their bed most of the time per their preferences. There was no documentation in Resident #11's health record regarding the incident on 07/20/25 when direct care staff witnessed Resident #6 throw water, juice, cups, and use verbal abuse at Resident #11 while direct care was providing perineal care.The progress notes did not document Resident #11 was assessed, the family and physician were notified, and the incident was reported to OSDH. An Incident Report Form, dated 07/20/25, showed the administrator was notified of the incident on 07/20/25 when Resident #6 threw clear liquid from their cup towards Resident #11's side of the room. The report showed the allegation was unsubstantiated after an investigation due to no staff members interviewed supported the substantiation of abuse. The initial report was received by OSDH on 07/25/25 at 2:14 p.m.On 07/24/25 at 11:40 a.m., MDS coordinator #1 was asked when care plans should be updated. They stated care plans should be updated quarterly, if there was an incident, diet changes, and a change in condition. They stated if there was an abuse incident involving resident to resident where there was an incident report, they would update care plan with interventions the following day. They were asked to review Resident #6's care plan and asked when the care plan was updated after the incident involving Resident #6 and Resident #11 on 07/20/25. MDS Coordinator #1 stated the care plan for Resident #6 was updated on 07/24/25 because they were off on vacation and were not made aware of the incidents. They stated the policy was not followed for updating the care plan.On 07/24/25 at 12:03 p.m., the administrator who was the abuse coordinator stated they were not made aware of the incident on 07/20/25 involving Resident #6 and Resident #11.On 07/24/25 at 3:32 p.m., RN #2 stated on 07/20/25, they heard Resident #11 yelling. When they responded, CNA #9 was coming out of Resident #6 and Resident #11's room and stated Resident #6 had thrown water and juice on Resident #11 during perineal care. They stated Resident #6 was upset and yelling. RN #2 stated they attempted to calm Resident #6 and contacted Resident #6's family. They stated Resident #10's blanket was wet. RN #2 stated they did not assess Resident #11 after the incident, did not call family, and did not report because they did not think Resident #11 was harmed. They stated they did not follow the abuse policy by not reporting the incident immediately, they should of separated the residents, they should have assessed Resident #11 and documented it and notified the administrator, the family and the physician.On 07/25/25 at 9:40 a.m., Resident #11 was asked about the incident on 07/20/25 involving Resident #6 who was their roommate. They stated Resident #6 was angry and threw a pillow and water on them and were telling them they smelled bad while they were receiving perineal care. Resident #11 stated their face and blanket got wet.On 07/25/25 at 10:13 a.m., a family representative of Resident #11 stated they were not notified of the incident on 07/20/25. They stated on 07/23/25, Resident #11 looked like they were down during a visit.On 07/25/25 at 11:08 a.m., the DON was asked to review progress notes for Resident #11 and was asked what was documented after the incident on 07/20/25 involving Resident #11 and Resident #6. The DON stated there was no documentation Resident #11's progress notes a family representative and Resident #11's physician was notified, and no documentation Resident #11 was assessed on 7/20/25 after the incident. On 07/25/25 at 12:11 p.m., CNA #9 stated they were providing perineal care on 07/20/25 for Resident #11 who was bed fast. They stated Resident #6 was shouting at Resident #11 during perineal care Resident #11 smelled bad and wanted Resident #11 out of the room. CNA #9 stated Resident #6 made statements to Resident #11 daily during perineal care. CNA #9 stated they reported the verbal, physical, and mental abuse directed at Resident #11 from Resident #6 to RN #2 immediately. CNA #9 stated the actions of Resident #6 met the criteria for abuse and Resident #11 was angry about the incident. The CNA stated Resident #6 made these statements daily to Resident #11.4. On 07/23/25 at 10:00 a.m., Resident #12 was observed on the memory care unit sitting in the common area. The resident was dressed appropriately, presented as happy and was smiling.Resident #12's admission health record, dated 01/23/24, showed they were admitted with diagnoses which included a history of falling, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A quarterly assessment for Resident #12, dated 12/09/24, showed their cognition was severely impaired due to staff reporting the resident could not complete the interview. The assessment did not show any behaviors affecting others. The assessment showed they required partial to moderate assistance for dressing, used a walker to ambulate, and was independent for chair to bed transfers.An OSDH document titled, Incident Report Form, dated 06/02/25, showed an initial incident of abuse report was faxed to OSDH on 06/24/25 at 4:49 p.m. The final report, dated 06/23/25, was faxed to OSDH on 06/27/25 at 8:35 a.m The report showed the incident occurred on 06/23/25. The report showed direct care staff observed Resident # 6 touching Resident #12 on the leg and pulling at their clothes. The report showed, the Residents were separated, police, family, and physician were notified, and staff members were interviewed.The incident was not reported to the abuse coordinator and a state reportable was not sent to the OSDH until 06/24/25 at 4:49 p.m.There was no documentation in Resident #12's health record of the incident on 06/22/25 and no documentation on 06/22/25, Resident #12 was assessed, the physician and the family was notified after the incident.On 07/23/25 at 3:33 p.m., CMA #2 stated they witnessed Resident #6 attack Resident #10. They stated Resident #10 was sitting down and Resident #6 was in a wheelchair. Resident #6 was hitting Resident #10 with their right hand in the face and arms area. They stated Resident #10 had their arms up trying to shield the hits. They stated other staff helped break up the fight. CMA #2 stated they were interviewed by the DON and reported what they witnessed. They stated Resident #10 had scratches on the face and arms and was scared at that time.On 07/23/25 at 3:42 p.m., the activities director was asked about the incident on 06/24/25 involving Resident #10 and Resident #6. They stated they did not witness the incident but did hear screaming, helped separate the residents, and provided one on one with Resident #6 until they left for the hospital.On 07/23/25 at 3:51 p.m., the DON was asked about staff interviews regarding the investigation of the incident on 06/24/25 between Resident #6 and Resident #10. They stated their entire investigation was documented on the OSDH final Incident Report Form, received on 6/30/25. They stated they could not recall what and who reported to them regarding the incident. The DON was asked about their abuse policy and their role as the DON regarding abuse allegations. They stated, I can't quote it off the top of my head.On 07/24/25 at 8:28 a.m., the ADON was asked what the policy was when a resident had aggression or was abusive towards another resident. The ADON stated after the residents were separated, they would investigate. The ADON stated, after the investigation, they discussed as a team, interventions to be added to the care plan.On 07/24/25 at 11:40 a.m., MDS coordinator #1 was asked when care plans should be updated. They stated care plans should be updated quarterly, if there was an incident, diet changes, and a change in condition. They stated if there was an abuse incident involving resident to resident where there was an incident report, they would update care plan with interventions the following day. They were asked to review Resident #6's care plan and asked when the care plan was updated after the incident involving Resident #6 and Resident #12 on 06/22/25. MDS Coordinator #1 stated the care plan for Resident #6 was updated on 07/24/25 because they were off on vacation and were not made aware of the incidents. They stated the policy was not followed for updating the care plan. On 07/24/25 at 12:03 p.m., the administrator stated they were not informed of the incident on 06/22/25 involving Resident #6 and Resident #12. The administrator stated they learned about the incident on 06/22/25 in the morning stand up on 06/23/25 and the nurse did not report the incident on 06/22/25. They stated the abuse policy was not followed because it was not reported timely and investigated. The administrator was asked about Resident #6's care plan. They stated the care plan was not updated when it should have been. They stated the risk of Resident #6's care plan not being updated could cause staff to not be aware of what interventions were in place.On 7/25/25 at 10:57 a.m., LPN #10 was asked about the incident on 06/22/25 where an allegation of resident-to-resident abuse was made and where it was documented Resident #12 was assessed after the incident. They stated they did not document the assessment of Resident #12 and did not notify the family and physician after the incident because they forgot.On 07/25/25 at 11:08 a.m., the DON stated the abuse allegation on 06/22/25 involving resident #6 and Resident #12 was not reported following their abuse policy, and they learned about it the following day on 06/23/25 in the morning stand up meeting. The DON was asked to review progress notes for Resident #12 and was asked what was documented after the incident on 06/22/25 involving Resident #6 and Resident #12. The DON stated there was no documentation Resident #12's family representative and physician were notified and there was documentation Resident #12 was assessed on 06/22/25 after the abuse incidents.

Based on observation, record review, and interview, the facility failed to ensure family representatives and physicians were notified after an abuse allegation for 2 (#11 and #12) of 5 sampled residents reviewed for notification of family representatives and physician.The administrator identified 89 residents resided in the facility.An undated facility policy titled Resident Abuse, Neglect, and Misappropriation of Property, read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse.The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation. The licensed nurse should report his/her findings to the administrator and or physician as soon as possible after the assessment and receive instructions for notification of the residents' responsible party. On 07/25/25 at 9:40 a.m., Resident #11 was observed in their bed, lying on their side, and had a neck contracture. Resident #11's admission health record, dated 02/19/24, showed they were admitted with diagnoses which included Huntington's disease, major depressive disorder, and Parkinsonism.Resident #11's quarterly assessment, dated 04/22/25, showed their cognition was moderately impaired with a BIMS score of 8. The assessment showed Resident #11 did not have any behaviors directed at others and did not reject care. The assessment showed Resident #11 required substantial to maximum assistance with toileting, showers/baths, and dressing. The assessment showed Resident #11 required substantial to maximum assistance for repositioning in bed and did not transfer for toileting.Resident #11's care plan, last reviewed 04/24/25, showed Resident #11 preferred to stay in their room, in their bed most of the time per their preferences. An Incident Report Form, dated 07/20/25, showed the administrator was notified of the incident on 07/25/25 by the state survey agency that Resident #6 threw clear liquid from their cup at Resident #11's side of the room on 07/20/25. The report showed the allegation was unsubstantiated after an investigation due to no staff members interviewed supported the substantiation of abuse. The initial report was received by the OSDH on 07/25/25 at 2:14 p.m.There was no documentation in Resident #11's health record the family and physician were notified after the incident on 07/20/25 when direct care staff witnessed Resident #6 throw water, juice, a cup, and used verbal abuse while direct care was providing perineal care for Resident #11.On 07/24/25 at 12:03 p.m., the administrator who was the abuse coordinator, stated they were not made aware of the incident on 07/20/25 involving Resident #6 and Resident #11.On 07/24/25 at 3:32 p.m., RN #2 stated on 07/20/25, they heard Resident #11 yelling. When they responded, CNA #9 was coming out of Resident #6 and Resident #11's room and stated Resident #6 had thrown water and juice on Resident #11 during perineal care. RN #2 stated Resident #6 was upset and yelling. RN #2 stated they attempted to calm Resident #6 and contacted Resident #6's family. They stated Resident #11's blanket was wet. RN #2 stated they did not notify Resident #11's family representative and did not notify the physician after the abuse allegation.On 07/25/25 at 9:40 a.m., Resident #11 was asked about the incident on 07/20/24. They stated Resident #6 threw a pillow and some water on them when they were receiving perineal care. Resident #11 was asked if their family representative was notified. Resident #11 stated, staff did not notify their family representative on 07/20/25.On 07/25/25 at 10:13 a.m., family representative #1 for Resident #11 stated they were not notified of the incident on 07/20/25.On 7/25/25 at 11:08 p.m., the DON was asked who should be notified after an abuse allegation. They stated staff should follow the chain of command, notify the charge nurse, nurse manager, the provider, and the family after the resident was assessed. The DON stated the notifications should be documented in the progress notes. The DON was asked to review the progress notes for Resident #11 and asked what was documented after the incident on 07/20/25 involving Resident #11 and Resident #6. The DON stated that there were no documentation Resident #11's family representative and physician were notified on 07/20/25. On 07/25/25 at 12:11 p.m., CNA #9 stated, Resident #6 returned from the hospital and was shouting at Resident #11. CNA #9 stated they were providing perineal care for Resident #11 when Resident #6 started yelling at Resident #11 they stink and wanted Resident #11 out of the room. CNA #9 stated, Resident #6 made these comments daily to Resident #11. CNA #9 stated they reported to RN #2 on 07/20/25. Resident #6 was yelling at Resident #11, threw water, apple juice, and a cup at Resident #11, Resident #11's blanket was wet. CNA #9 stated it was abuse because it happened frequently. 2. On 07/23/25 at 10:00 a.m., Resident #12 was observed on the memory care unit sitting in the common area. The resident was dressed in daytime clean clothes, presented as happy and was smiling. Resident #12's admission health record, dated 01/23/24, showed they were admitted with diagnoses which included a history of falling, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Resident #12's annual assessment, dated 12/09/24, showed their cognition was severely impaired due to staff reporting the resident could not complete the interview. The assessment did not show any behaviors affected others. The assessment showed Resident #12 required partial to moderate assistance for dressing, used a walker to ambulate, and was independent for chair to bed transfers.An OSDH document titled Incident Report Form, dated 06/02/25, showed an initial incident of abuse report was faxed to OSDH on 06/24/25 at 4:49 p.m. The final report was dated 06/23/25 and was faxed to the OSDH on 06/27/25 at 8:35 a.m The report showed the incident occurred on 06/23/25. The report showed direct care staff observed Resident #6 touching Resident #12 on the leg. The incident occurred on 06/22/25 and was not reported until 06/23/25.Resident #6's behavior note, dated 06/22/25, showed Resident #6 was observed by staff in the dining room, touching and pulling at Resident #12's clothing.There was no documentation in Resident #12's health record of the incident on 06/22/25. On 07/24/25 at 12:03 p.m., the administrator, who was the abuse coordinator, stated they were not informed of the incident on 06/22/25 involving Resident #6 and Resident #12. The administrator stated they learned about the incident on 06/22/25 involving Resident #6 and #12 in the morning stand up on 06/23/25 and the nurse did not report the incident on 06/22/25 to the abuse coordinator.On 7/25/25 at 10:57 a.m., LPN #10 was asked about the incident on 06/22/25 where an allegation of resident-to-resident abuse was made and where it was documented Resident #12 was assessed after the incident. They stated they did not document the assessment of Resident #12 after the incident because they forgot. On 7/25/25 at 11:08 p.m., the DON was asked who should be notified after an abuse allegation. The DON stated staff should follow the chain of command, notify the charge nurse, nurse manager, the provider, and the family, after the resident was assessed. The DON stated the notifications should be documented in the progress notes. The DON was asked to review progress notes for Resident #12 after the incident on 06/22/25 involving Resident #6 and Resident #12. The DON stated there was no documentation Resident #12's family and physician were notified on 06/22/25 after the abuse incidents.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#2) of four sampled residents reviewed for abuse. The administrator identified 24 residents resided in the ACU. Findings: An undated facility abuse policy, documented all employees would be in-serviced on abuse/reporting abuse during the orientation process following employment. The policy documented on-going abuse training would be provided to all employees throughout the year which include: appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. 1. Resident #1 had diagnoses which included Alzheimer's disease, dementia with other behavioral disturbance, and psychosis. Resident #1's care plan, revised on 12/06/24, documented the resident's cognition was moderately impaired. 2. Resident #2 had diagnoses which included dementia with other behavioral disturbance, psychosis, and anxiety. Resident #2's care plan, revised on 10/30/24, documented the resident's cognition was severely impaired. An Initial Incident Report OSDH form, received on 01/02/25 at 8:31 a.m., read in part, Resident [Resident #1] bit roommate Resident [Resident #2] on the arm. Focused assessment completed. skin tear to Resident [Resident #2] arm noted. No other injuries noted. [Name withheld] notified for both residents. Resident [Resident #1] family [name withheld] notified. Resident [Resident #2] family [name withheld] notified. OKCPD notified. Resident [Resident #1] sent to ER per physicians order for further evaluation. Appropriate staff members interviewed. Other residents in the area assessed. No further signs/allegations of abuse. A Final Incident Report OSDH form, received on 01/09/25 at 12:19 p.m., documented the facility completed an initial investigation by interviewing staff members, assessing other residents in the area, completing focused assessments on the residents, and an evaluation of their medications. The form documented Resident #1 was admitted to the hospital for further evaluation. The form documented Resident #2 was moved to another room on the unit and started on antibiotics. The form documented the facility updated both residents plan of care and educated appropriate staff members on the signs and symptoms of abuse. In-services were started on 01/01/25 and completed on 01/11/25. On 01/15/25 at 10:51 a.m., Resident #1 did not respond when spoken to. Resident #1 only became angry when spoken to as they were repeatedly asking how to get out of here. On 01/17/24 at 2:27 p.m., the administrator stated Resident #1 and Resident #2 were roommates at the time of the incident. They stated Resident #1 stated they owned the whole place and Resident #2 was in Resident #1's way. On 01/17/25 at 2:31 p.m., the administrator stated they were unable to interview residents on the ACU due to their cognition. On 01/17/25 at 2:44 p.m. the administrator stated a Quality Tip report was completed on 01/01/25 and those were discussed right after they were received.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#1) of four sampled residents reviewed for abuse. The administrator identified 105 residents resided in the facility. Findings: An undated Resident Abuse, Neglect, and Misappropriation of Property policy, read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse. It also read, If the alleged perpetrator is facility staff, removal of the alleged perpetrator's access to the alleged victim and other residents and assurance that ongoing safety and protection is provided for the alleged victim and other residents. Resident #1 had diagnoses which included major depression, respiratory failure, chronic kidney disease, and chronic obstructive pulmonary disease. Resident #1's care plan, initiated 07/03/23, documented the resident had behaviors of being combative towards staff, disruptive outbursts that affect the living environment, and an impatient nature. An Notification of Nurse Aide/Nontechnical Service Worker form, dated 08/31/24, documented CNA #1 had been suspended on 08/31/24. On 08/31/24, an in-service on an allegation of abuse was conducted. A Combined Initial and Final State Reportable Incident form, dated 09/03/24, documented an allegation of abuse/mistreatment. It was documented on 08/31/24 at 3:00 a.m., the police department was notified of an allegation of abuse made by Resident #1. It was documented CNA #1 had pulled their arm behind their back. It was documented CNA #1 was suspended pending investigation. It was documented the physician was notified and an order for a X-ray of the resident's right arm was received. It was documented family was notified. It was documented appropriate staff and other residents were interviewed. It was documented Resident #1 refused to be sent out for further evaluation. It was documented the resident was alert and oriented with episodes of confusion and the resident often became agitated and resisted ADL care. It was documented the facility had completed their investigation by interviewing Resident #1, other residents in the area, staff members, and by completing a focused assessment on the resident. It was documented the resident's medications, medical and incident history were evaluated. It was documented upon completion of the investigation, the facility was unable to substantiate the allegation of abuse. It was documented Resident #1 had become agitated when CNA #1 was unable to provide medication due to being a CNA. It was documented CNA #1 had informed the resident the nurse had to give medication. It was documented Resident #1 began to yell, scream, hit, and scratch CNA #1 on the arm. It was documented interviews and focus assessments with other residents, interviews with other staff members and CNA #1, yielded no further basis for the substantiation of the allegation. It was documented CNA #1 was reinstated. It was documented the facility updated the resident's care plan. It was documented the facility educated the family and staff members on the signs and symptoms of abuse, and on the policies and procedures for reporting allegations of abuse. On 09/06/24, an in-service on adequate staffing and leaving the hall unattended was conducted. An Notification of Nurse Aide/Nontechnical Service Worker form, dated 09/07/24, documented CNA #1 was terminated on 09/07/24. On 09/07/24, in-services on how to handle a combative resident, allegations of abuse, neglect, and misappropriation, and assess and intervene for pain management were conducted. The facility form titled Compliance Rounds, documented compliance rounds were made on 09/08/24. A Follow up Information State Reportable Incident, form faxed to OSDH on 09/11/24 at 4:00 p.m., documented X-ray results received on 08/31/24 revealed no acute fractures. It was documented Resident #1 complained of pain to their right arm and wrist on 09/07/24. It was documented the physician ordered a X-ray which revealed a mildly displaced oblique fracture of the distal ulna with soft tissue swelling and calcification distal to the ulna. It was documented the physician and family were notified. It was documented Resident #1 was sent to the ER for further evaluation. It was documented Resident #1 returned back to the facility with a splint to wrist/forearm area wrapped with ace wrap. There was a new order to follow up with orthopedic physician and for pain medication for breakthrough pain. It was documented CNA #1 was terminated. The facility form titled Compliance Rounds, documented compliance rounds were made on 09/18/24. Resident #1's quarterly assessment, dated 09/24/24, documented the resident was cognitively intact and required only supervision and touching assist with ADLs. The facility form titled Compliance Rounds, documented compliance rounds were made on 09/25/24. An IJ was identified from 08/31/24 to 09/07/24. The deficient practice remained at isolated level of a potential for harm. On 10/02/24 at 1:42 p.m., Resident #1 stated they started down the hall to ask for medicine and could not get anyone on the hall, so they went to hall 400. They stated this was after midnight and it was dark. They stated all of the sudden someone came up behind them and tried to dump them out of their wheelchair. They stated they scratched them to get them to stop. They stated they then bent their arm behind the back of their wheelchair. They stated when they go free they tried to throw a plate at them to get them to stop. They stated that is when they called 911. They stated the police officer told them they attacked the staff and they should think about moving out. They stated eight days later they put them in a cast. On 10/02/24 at 1:48 p.m., Resident #1 stated some of the staff were afraid of them. They stated the administrator gave them a number to call for care if they felt they needed to call 911. Resident #1 stated, They were hoping I would call and give them a chance to resolve issues before the police became involved. I called my [family member] and [they] were the one that told me to call 911. On 10/02/24 at 2:35 p.m., LPN #2 stated Resident #1 would get mad when staff had to take care of other residents. They stated when the resident wanted a pain pill they would start hitting the bedside table, but the behavior would stop as soon as the pill hit their tongue. LPN #2 stated they had not witnessed any abuse, but they have had a couple of in-services about abuse recently. On 10/02/24 at 2:47 p.m., the administrator stated they did an in-service the day the allegation was made. They stated they conducted interviews with residents and staff regarding abuse and who to report to. They were asked if the residents felt safe in the facility. They stated a lot happened between the two X-rays. They stated they had never had any issues with the staff member. They stated they terminated the staff member once they got the second X-ray which showed a fracture. They stated they conducted additional in-services and implemented quality assurance monitoring.

Based on record review and interview, the facility failed to implement a care plan for one (#5) of 7 sampled residents reviewed for care plans. The administrator identified 105 residents resided in the facility. Findings: Resident #5 was admitted on [DATE] with diagnoses which included encephalopathy, liver cell carcinoma, fusion of spine, and intracerbral hemorrhage. A care plan, initiated on 8/12/24, documented only that the resident was admitted . The care plan was not comprehensive. An admission MDS assessment, dated 08/15/24, documented Resident #5 had a BIMS score of 12 indicating moderate cognitive impairment. It was documented they were dependent upon staff for activities of daily living and were always incontinent of both bowel and bladder. On 10/03/24 at 11:17 a.m., MDS Coordinator #1 agreed the comprehensive care plan was not completed. They stated it should have been completed within 21 days of admission to facility. On 10/03/24 at 12:49 p.m., Corporate Nurse #1 stated they followed the RAI guidelines and agreed the comprehensive care plan should have been completed.

Based on observation, record review, and interview, the facility failed to ensure meal consumption percentages were documented on a resident who experienced significant weight loss for one (#2) of three sampled residents reviewed for nutrition and hydration. The ADON identified 107 residents who resided in the facility. Findings: Res #2 had diagnoses which included type II diabetes mellitus, acute kidney failure, and dementia. A care plan, dated 04/19/24, documented the resident was at risk for nutrition and hydration problems related to diabetes mellitus with hyperglycemia. An admission assessment, dated 05/06/24, documented the resident was moderately cognitively impaired, required setup assistance with eating, and had no weight loss or gain. A physician order, dated 07/03/24, documented cardiac/healthy heart diet, mechanical soft chopped meat texture with regular thin liquids consistency. Resident #2's Weight Summary documented: a. 250.1 pounds on 06/01/24, b. 218.0 pounds on 07/02/24, and c. 210.0 pounds on 07/27/24. There was no documentation of Resident #2's meal consumption amount in July 2024 for: a. breakfast on the 5th, 6th, 7th, 26th, or the 28th, b. lunch on the 5th, 6th, 7th, 26th, or the 28th, and c. dinner on the 31st. On 09/12/24 at 1:55 p.m., CNA #1 stated all meal percentages should be documented in the electronic record after the meal tray has been picked up. They stated there would not have been any way to know how much of the meal the resident consumed if the percentage was not documented. On 09/12/24 at 3:28 p.m., the DON stated Res #2's meal percentages had not been monitored and documented appropriately; and there was no way to ensure proper nutrition had been maintained. They stated every meal should have had the percentage consumed documented.

Based on observation, record review and interview, the facility failed to ensure residents trust money in excess of $50 for medicaid recipient and $100 for all other residents was kept in a secured interest bearing account for five (#36, 33, 49, 14, and #9) of five sampled residents. The business office manger identified 36 current residents who had money in the trust account. Findings: The undated Resident Trust Policies and Procedures- Nursing Facilities, read in part, .Medicaid recipient petty cash .funds in excess of $50.00 must be deposited in an interest bearing account .Do not keep large sums of cash in the facility . 1. Resident #36 face sheet documented they were a recipient of veterans administration. Resident #36 petty cash ledger docuented they had $443.78 on hand in the safe located in the social service director's office. 2. Resident #33 face sheet documented they were a recipient of medicaid. Resident #33 petty cash ledger documented they had $75 on hand in the safe located in the social service director's office. 3. Resident #49 face sheet documented they were a recipient of medicaid. Resident #49 petty cash ledger documented they had $280.18 on hand in the safe located in the social service director's office. 4. Resident #14 face sheet documented they were a recipient of medicaid. Resident #14 petty cash ledger documented they had $320.00 on hand in the safe located in the social service director's office. 5. Resident #9 face sheet documented they were a recipient of medicaid. Resident #9 petty cash ledger documented they had $100.00 on hand in the safe located in the social service director's office. On 07/24/24 at 9:20 a.m., the social service director counted and confirmed the following money on hand in her safe for the following residents: Resident #36 had $441.42; Resident #9 had $80; Resident #14 had $320; Resident #49 had $280.18; and Resident #33 had $75. Resident #36 had a $2.36 discrepancy and Resident #9 had a $20 discrepancy from the petty cash ledger and money on hand. The social service director was asked about the excess cash in residents petty cash and they stated residents can have as much money on hand as they would like. On 07/24/24 at 11:30 a.m., the business office manager was asked about the limits of cash on hand for residents in the trust account. The business office manager stated the amount they can have on hand increased to $75. When asked about the large amounts of cash over the limits of $50 for medicaid recipients and $100 for all others, the business office manager stated they were not aware of the limits for all residents.

Based on record review and interview, the facility failed to ensure residents had access to their trust account money on nights and weekends for three (#34, 26, and #33) of three residents reviewed for access to their trust account money. The business office manager identified 36 current residents who had money in the trust account. Findings: The resident trust policy, read in part, .after business hours petty cash place cash in envelope .using the after hours petty cash form complete seal envelope .distributed funds should be signed out . On 07/23/24 at 9:40 a.m., Resident #34 stated they requested money the previous week and was not able to receive it. Resident #34 stated they never were able to get money if the administrator or social service director were not at the facility. They stated money was not able to be received on the weekends. On 07/23/24 at 10:35 a.m., Resident #36 stated they could not get money on the weekends. They stated they could only get money Monday through Friday when the administrator was in the facilty. On 07/24/24 at 11:30 a.m., Resident #33 stated they were not able to get money on the nights and weekends. On 07/24/24 at 8:33 a.m., the business office manager stated residents have access to their funds through the social service director who keeps the money in a safe in their office. The business office manager stated unless residents provided advance notice of needing funds over the weekend, the resident could not get the money. On 07/24/24 at 9:20 a.m., the social service director stated the administrator was the only other person who had access to residents funds. The social service director stated residents can only get money Monday through Friday unless advance notice was provided for the weekend. On 07/24/24 at 11:30 a.m., the administrator stated there was no current system in place for residents to get money on the weekend, or at nights, when they and the social service director were not present at the facility.

Based on observation, record review, and interview, the facility failed to ensure a resident had a physician order for O2 therapy for one (#206) of three sampled residents reviewed for respiratory care. Corporate Nurse Consultant #1 identified eight residents who had routine orders for O2 and four residents who had orders for PRN O2. Findings: Res #206 had diagnoses which included nicotine dependence, age related osteoporosis, and moderate protein calorie malnutrition. On 07/23/24 at 8:46 a.m., the resident was observed with O2 in place. The setting on the portable O2 tank was 2 LPM. There was no documentation the resident had a physician order for O2 therapy. On 07/23/24 at 9:15 a.m., LPN #1 was asked if the resident received O2 therapy. They stated the resident was admitted to the facility from the hospital with O2. They stated there was not a physician order.

Based on record review and interview. the facility failed to ensure dignity and respect was provided for one (#2) of three sampled residents reviewed for dignity. The Administrator identified the census was 106. Findings: Resident #2 had diagnoses which included Parkinson's, type two diabetes mellitus, and hypertensive crisis. An Admission/Readmission Skin Assessment, dated 08/22/23 at 10:33 p.m., documented Resident #2 had dry skin. There was no documentation of any other skin issues. A Brief Interview for Mental Status, dated 08/23/23 documented Resident #2 had moderate cognitive impairment. A Service Notification invoice, dated 08/23/23 at 10:28 a.m., read in parts, .Bedbug service today. Inspected room [Resident #2's] .for bedbug activity. Upon inspection of room .found bedbug activity in both patients beds .Found bedbugs on curtain . A Social Services Narrative Note, dated 08/23/23 at 11:52 a.m., read in parts, .[Resident #2] and [family member] .unhappy because someone told [the resident they] brought bed bugs in. They do not want to stay but want [another facility], that has private rooms .I tried to calm the situation but they made up their mind. Sent email to Administrator who was not in yet . On 11/13/23 at 2:48 p.m., Pest Control stated there was a 90 percent chance the bed bugs were there before the Resident #2 moved into that room. On 11/13/23 at 3:03 p.m., the Administrator stated the charge nurse reported Resident #2 had a bug on them. The Administrator stated [Resident #2] was given a shower and was transferred to another room. On 11/13/23 at 3:07 p.m., the Administrator stated that the bed bugs may have been there before Resident #2 was admitted to the room. On 11/13/23 at 3:09 p.m., the Administrator stated they were not aware how the resident felt regarding the bed bugs. On 11/14/23 at 1:14 p.m., the DON was shown the social services note and asked why Resident #2 left the facility. They stated the family was not happy when the resident admitted because bed bugs were found and the resident had to be moved to another room. On 11/14/23 at 2:15 p.m., the Administrator was asked when they were informed there were bed bugs in Resident #2's room. They stated facility staff notified them on on August 22 at 10:38 p.m. On 11/14/23 at 2:48 p.m., the Administrator was asked to review the social services note and asked if they were aware. They stated, No. They administrator was asked if the facility admitted Resident #3 and was able to meet their needs why did Resident #2 leave the facility. They stated it was in the social service documentation. 46653

Based on observation, record review and interview, the facility failed to ensure wound care was performed as ordered by the physician for one (#100) of one sampled resident reviewed for wound care. The Resident's Census and Conditions of Residents report, dated 06/28/23, documented 102 residents resided in the facility. Findings: Resident #100 had diagnoses which included acute kidney failure, ASHD, PVD, DM, and obesity. Physician orders, dated 06/02/23, documented staff were to clean all surgical staple sites with normal saline, pat dry, monitor for signs and symptoms infection. Notify physician every shift and as needed. The groin order documented to clean with normal saline, apply gauze and cover with abdominal pad and secure with tape every day and evening shift. A Skin/wound noted, dated 06/02/23 at 5:05 p.m., read in parts, .groin red .right medial shin staples surgical, right upper medial shin staples surgical, right upper medial shin staples surgical, right medial lower knee staples surgical, left inner knee staples surgical, right medial knee staples surgical, right lower thigh medial staple . There was no documentation of the description of the surgical sites. There were no notes for 06/03/23 or 06/04/23. A Progress Note Details report from wound care, dated 06/05/23, read in parts, .the old surgical incision was assessed and found to be draining large amount of purulent drainage. Order to send out back to surgeon given. A Nurse's Progress Note, dated 06/05/23 at 12:18 p.m., read in parts, .resident has multiple incisions with stapes to RLE and groin, the incision to right groin is draining purulent drainage, [resident] was seen by wound care and recommendations to send back to [named hospital ER] for evaluation . A Treatment Administration Record, dated 06/01/23 through 06/30/23, had no documentation for treatment completion for 06/03/23 and 06/04/23 for the right lower thigh medial, right medial knee, right medial lower knee, right upper medial shin, right upper medial shin, and groin right side. There was no documentation for treatment completion for 06/04/23 for the left inner knee. On 06/29/23 at 1:32 p.m., LPN #1 was asked the reason the resident sent to the hospital. They stated it was recommended by wound care due to the drainage from the incisions. They were asked what the blanks on the TAR meant. They stated that someone forgot to click on it or didn't do it. LPN #1 was asked to review the June 2023 TAR for any blanks for the surgical wounds. They acknowledged the blanks for the 3rd and 4th of June. They were asked if Resident #100 received their wound care treatments as ordered. They stated not according to the TAR but they would have to look at the notes. After looking at the notes, they did not see one. LPN #1 was asked what the policy was for treatment administration. They stated they were to be done as ordered unless the doctor stated otherwise and call the doctor if they refused. On 06/29/23 at 1:47 p.m., the DON was asked the reason Resident #100 went to the hospital. They stated for drainage from the incision to the right groin. They were asked what blanks on the TAR meant. They stated someone forgot to click it or it was not done. The DON was asked to review the June 2023 TAR for any blanks for the surgical wounds. They were asked if there were blanks, and what dates. They stated, Yes, on 6/3 and 6/4. They were asked if the resident received their wound care treatments as ordered. They stated, Can't say did or didn't. They were asked if there was any documentation that the resident received or did not receive their treatment. They stated, There is none. They stated, According to the documentation, no.

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program that kept the facility free of pests in the kitchen. The Census and Conditions of Residents report, dated 06/28/23, documented 102 residents resided in the facility. Findings: A Pest Control Policy, dated 10/24/08, read in parts, .It is the policy of this facility to maintain an effective pest control program so that the facility is free of pests and rodents .Control Measures- The best method is to practice scrupulous housekeeping so that the problem doesn't occur. Poor environment sanitation is one of the main causes of severe cockroach infestation . A Pest Control Service invoice, dated 06/13/23, documented the facility was treated for cockroaches in areas which included the kitchen. A Pest Control Service invoice, dated 06/28/23, documented the facility was treated for a target pest of cockroaches in areas which included the kitchen. On 06/28/23 at 7:51 a.m., there were three bugs observed in front of the three compartment sink in the kitchen. There were four dead bugs observed in the dry storage area. On 06/28/23 at 7:52 a.m., the CDM stated the bugs came from outside. They stated the bugs had just showed up the last couple of days. On 06/29/23 at 7:44 a.m., one large dead roach/bug was observed on the floor by the back door in the kitchen. One dead bug was observed under the table by the microwave. One dead bug was observed on the floor under the refrigerator on the west wall. One dead bug was observed in the clean pots and pans area. One dead bug was observed on the floor by the paper goods storage shelf. On 06/29/23 at 8:06 a.m., Cook #1 was asked to explain the bugs observed in the kitchen. They stated the bugs had just recently shown up from the rain. They stated they were water bugs. They stated they facility was sprayed last week and yesterday.

Based on record review and interview, the facility failed to ensure a comprehensive assessment was completed within 14 days after admission for one (#90) of 26 residents reviewed for timely assessments. The Resident Census and Conditions of Residents report, dated 06/28/23, documented 102 residents resided in the facility. Findings: Resident #90 admitted to the facility on [DATE] with diagnoses which included recurrent depressive disorder, fibromialgia, chronic kidney disease, COPD, and DM. A 5 day Resident assessment, dated 06/13/23, had a status of In Progress. An Admission Resident Assessment, dated 06/13/23, had a status of In Progress. On 06/29/23 at 10:59 a.m., MDS Coordinator #1 was asked what the facility's timeframe requirement was for completing the admission MDS assessment. They stated they were to be within eight days maximum, depending on what happened between that time. MDS Coordinator #1 was asked when resident #90's admission assessment was completed. They stated, It is completed, just needs to be reviewed by an RN as I am an LPN. They were asked what the in progress meant on the status. They stated it was still being worked on or under review. MDS Coordinator #1 was asked if the admission assessment had been completed timely per the RAI requirement. They stated, No.

Based on interview and record review, is was determined the facility failed to: ~ perform ongoing thorough skin assessments; ~ provide thorough catheter care; ~ identify a change in condition; and ~ notify the physician when a resident exhibited a change in condition for one (#1) of three sampled residents who were reviewed for catheter care. The resident was seen in a urology clinic on 02/13/19 and the posterior portion of the resident's penis was found to be completely eroded (filleted) from the tip of the penis to the base of the penis. It was open with a creamy discharge all over the area. The facility identified six residents who had indwelling urinary catheters. Findings: A Catheter Care policy, revised 04/05/13, documented, .Purpose: Maintain an open and draining catheter while reducing complication or risk of urinary tract or bladder infection from the use of catheters. Catheters are used to protect the skin or wound from urine .Procedure .Check for crust, abnormal drainage, or secretions .Avoid tugging or pulling on the catheter . An undated Skin and Wound Care Guidelines policy documented, .Purpose .To provide a systematic approach and monitoring process for skin integrity/pressure ulcer care .Objective .To maintain an optimal level of skin integrity .Skin Care .Inspect skin at least once a day . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's record documented the resident had an indwelling urinary catheter in place on admission to the facility. A care plan, dated 09/24/18, documented, .Focus .Urinary catheter .Goal .Will have minimal infections r/t catheter use, will have no acute complications r/t use .Interventions .Assess for s/s of infection .fever, AMS, pain at site .Notify MD and family for any change in status .Provide catheter care per orders .Resident (sic) has pain at times with catheter. It becomes blocked at times, Reposition catheter, Position to prevent pulling . A physician's orders [REDACTED].Change Foley Catheter every month on the 15th and prn every night shift on the 15th and ending on the 15th every month . A physician's orders [REDACTED].Foley Catheter Care every shift and prn with soap and water or disposable wipes as needed . A quarterly assessment, dated 12/01/19, documented the resident had a BIMS of 14, which indicated the resident had intact cognition. A hospital Urology Clinic Note, dated 12/27/18, documented, .returns today for follow up following .an attempt at UDY for [MEDICAL CONDITION] .He has had difficulty urinating since 07/2018. During that time frame he was found to be in retention and indwelling foley catheter was placed. He remains at Grace living center where his foley is being changed monthly. No trouble with the catheter. Last change was 12/20/18 .Physical Exam: .GU: Foley in place with clear, yellow urine .Assessment/Plan: .Discussed that the UDY were unsuccessful and that we were unable to assess his bladder environment. Offered another attempt at UDY. Patient declined. He is happy with his foley and monthly changes The TAR, dated 01/2019, documented Foley Catheter Care had been provided every shift per physician orders. A review of the record revealed no documentation of catheter concerns or penile skin breakdown for the month of January. There was no documentation of a leg stabilizer being in place for the resident's indwelling urinary catheter. A review of the record revealed no documentation of catheter concerns or penile skin breakdown from 02/01/19 through 02/11/19. There was no documentation of a leg stabilizer being in place for the resident's indwelling urinary catheter. A Skin/Wound note, dated 02/12/19 at 4:12 a.m., documented, .Focus assessment r/t skin assessment .Resident given routine pain medication, foley catheter care provide (sic) and urine is yellow and on (sic) s/s of infection noted. No other skin issues noted . A Skin/Wound note, dated 02/12/19 at 1:03 p.m., documented, .Focus assessment r/t skin assessment. Head to toe assessment complete. Treatment orders in place for previously identified skin breakdown. No new skin issues or breakdown noted . A Nurses Progress Note, dated 02/12/19 at 2:29 p.m., documented, .Focused assessment r/t skin assessment completed, pre-existing skin condition noted .No new skin issue at this time . A Skin/Wound note, dated 02/13/19 at 3:04 a.m., documented, .Focus assessment r/t skin assessment .Head to toe assessment complete .No new skin issues or breakdown noted . A hospital Urology clinic note, dated 02/13/19 at 9:30 a.m., documented, .Pt. was here just (MONTH) 27 with Resident as well as I performed UDS test [DATE] penis was fine during that visit pt. stated it has recently middle of (MONTH) to know that this happened. Pt. kept saying I know something is wrong, it's my body and it's not supposed to be like this . Pt. arrived for catheter change, he was stating that he (sic) 'something' is wrong he is leaking all from the side its ripped the Nurses at Grace Living center tell me its ok it will be fine, (resident #1) was saying , 'They don't use the stickers to hold the catheter I want some before I leave. I escorted (resident #1) to the catheter room assisted him on the table and pulled his pants down removed his diaper he was very guarded for his groin area and he stated he was sorry it just hurts really bad, upon my exam it was noted that the posterior part of pt.'s penis is completely eroded (filleted) from the tip of the penis to the base of the penis itis (sic) open and creamy discharge all over the area. Pt stated the bag hangs all the time and pulls and the Nurses at Grace Living Center won't do anything about it. I told the patient I want to get a provider to look at this I asked (PA's name deleted) to come see and he in turn went and got (physician's name deleted) .had agreed to see the patient today and try and schedule him for surgery to get a SPT tube. Patient is in total agreement with plan and ready to move forward to fix this, he is tired of the pain and mess pt. was very emotional . A Urology History and Physical note, dated 02/13/19, documented, .Chief complaint: urethral erosion 2/2 indwelling foley catheter. History of Present Illness: .h/o [MEDICAL CONDITION] that has been managed with indwelling foley catheter changed monthly. He has had difficulty urinating since 07/2018. During that time frame he was found to be in retention and indwelling foley catheter was placed. He remains at Grace Living center where his foley is changed monthly. He has had no trouble with the catheter and it was last changed in 02/09/2019. Patient was last seen by urology for UDY, however was unable to tolerate filling, so this procedure was not completed. It was noted at that time the patient's penis was normal in appearance. He returned to nurse cath clinic today for a catheter change here. He complained today of penile tenderness and pain and stated that he felt something was wrong with his catheter and penis because he has been leaking urine from all around the catheter . He reports the nurses at Grace Living Center have not been securing the catheter to his leg such that the foley drainage bag hangs all the time, pulling his catheter straight down. Upon exam today, the posterior portion of the patient's penis was noted to be completely eroded almost to the penoscrotal junction with creamy discharge over the area . Assessment: .presented today with extensive posterior urethral erosion .Principal admitting [DIAGNOSES REDACTED].Plan: -Discussed that patient needs a suprapubic catheter placed due to extensive posterior urethral erosion and need for indwelling catheter .Patient elected to proceed with suprapubic catheter placement . A Nurse's Progress Note, dated 02/13/19 at 1:05 p.m. documented, .Focused assessment r/t resident returning from doctors appointment. Resident has outpatient surgery on 3/15/2019 to place a suprapubic catheter .Foley catheter in place with leg stabilizer . There was no documentation to indicate the resident's primary physician had been notified of the resident's penile erosion. A Skin/Wound Note, dated 02/13/19 at 1:24 p.m. documented, .Focus assessment r/t skin assessment. Head to toe assessment complete .No new skin issues or breakdown noted . A Skin/Wound Note, date 02/13/19 at 5:35 p.m., documented, .Focus assessment r/t skin assessment. Elder with new venous stasis ulcer to right anterior lower leg area cover (sic) in black eschar, no drainage or odor .elder and (physician name deleted) updated of above . There was no documentation to show the resident's primary physician had been notified of the resident's penile erosion. A review of the record revealed no documentation of catheter concerns or penile skin breakdown from 02/14/19 through 02/20/19. The TAR, dated 02/2019, documented Foley Catheter Care had been provided every shift per physician orders [REDACTED]. A Skin/Wound Note, date 02/21/19 at 01:13 a.m., documented, .Focus assessment r/t skin assessment completed, pre-existing skin condition noted, treatment orders in place for toes and knees. No new skin breakdown noted at this time . A hospital Social Work Long Term Care Note, dated 02/21/19 at 9:30 a.m., documented, .Community Nursing Home Program Resident Follow-up Visit .Notes: On 2/15/19 at approximately 15:30 (3:30 p.m.), I called (previous DON name deleted), DON at The Fairmont Skilled Nursing and Therapy to advise her of the Urology Clinic notes that I just read. I read the following notes to (previous DON name deleted), RN DON verbatim. 'Pt arrived for catheter change, he was stating that he something is wrong he is leaking all from the side its ripped the Nurses at Grace Living center tell me its ok it will be fine, Mr. (resident #1) was saying, They don't use the stickers to hold the catheter I want some before I leave. I escorted Mr. (resident #1) to the catheter room assisted him on the table and pulled his pants down removed his diaper he was very guarded for his groin area and he stated he was sorry it just hurts really bad, upon my exam it was noted that the posterior part of pt.'s penis is completely eroded (filleted) from the tip of the penis to the base of the penis itis (sic) open and creamy discharge all over the area. Pt stated the bag hangs all the time and pulls and the Nurses at Grace Living Center won't do anything about it. I told the patient I want to get a provider to look at this I asked (PA name deleted) PA-C to come see and he in turn went and got Dr. (physician's name deleted). Dr. (physician's name deleted) had agreed to see the patient today and try and schedule him for surgery to get a SPT tube. Patient is in total agreement with plan and ready to move forward to fix this, he is tired of the pain and the mess pt. was very emotional. Pt did not get his catheter changed because (resident #1) stated they change his catheter at the nursing home. on 2/9/19 was when it was changed last. Catheter was not changed in the Urology clinic today.' . I asked that (previous DON name deleted) please look at the veteran's penis and ensure that wound care orders were in place and that he had a leg strap holding his Foley Catheter. (Previous DON name deleted) stated that she would and that she saw some Foley Straps being delivered to his hallway earlier. Myself and a colleague visited with the veteran on 2/21/19 at approximately 10:30 in his room during our scheduled NH oversight visit. The veteran stated that he was in pain and I asked the nurse to please asses (sic) his pain and please give him his ordered pain medication as soon as possible. We asked if we could examine the underside of his penis. The veteran said that would be okay. The veteran nearly jumped out of his bed when my colleague picked up his penis with a gloved hand to examine the underside of his penis. There was thick purulent drainage covering the veteran's scrotum. The underside of his penis appeared eroded (filleted) from the tip of the penis to the base of the penis. The veteran was in extreme pain. I discussed with the veteran at length that the best option to control his pain was to be seen at the VA ER and be assessed for admission to the hospital. The veteran agreed and verbalized that his left lower leg was extremely painful and that at some point the surgeons :wanted (sic) to amputate it (sic) He stated that he was ready now. At approximately 11:00 a.m., I immediately asked (previous DON name deleted) to arrange (emergency medical service name deleted) transport to the (hospital name deleted) ER for evaluation and possible admission for this veteran. (Previous DON name deleted) agreed and stated that she would. On 2/21/19, Per documentation review, there was no documentation regarding the veteran's penile wound. There were not any wound care orders in place. When I conversed with the veteran regarding his penile wound during the oversight nursing visit on 2/21/19, The veteran verbalized that he had been telling staff since (MONTH) 2019 that it hurt and he was in pain and that something was not right. He verbalized that staff would say, It will be okay and never checked out his concerns or assessed his penile area . RESIDENT SATISFACTION (Determined by asking Resident, family, and/or through staff observation): . Resident is satisfied with care he/she receives at the CNH (No) Comment: Please see notes above . QUALITY OF CARE (Determined by observation, MDS, and/or Medical Record Review): . Resident has maintained the same or improved level of physical function since the last visit . (No) . 03/18/2019 ADDENDUM .New note - late charting for 2/21/19- . After speaking with the veteran and assessing his penile wound on 2/21/19, I called my supervisor at the (hospital name deleted) to report my findings regarding the veteran's penile wound and that the DON was going to call (emergency medical service name deleted) to facilitate the veteran being transferred to the (hospital name deleted) for evaluation and treatment . During closeout on 2/21/19 with the Administrator and DON of The Fairmont Skilled Nursing and Therapy at approximately 1500 (3:00 p.m.), I spoke about my concerns regarding the veterans penile wound and the fact that I had notified the DON on 2/15/19 in the afternoon with a phone call regarding the veterans penile wound. There was no documentation or orders in place for the veteran's penile wound, until after our visit with the veteran on 2/21/19. I also verbalized what the veteran had stated regarding the penile wound, as well as there was documentation of catheter every shift and catheter changes documented on 1/15/19 and 2/15/19. The Administrator replied that she would conduct an investigation to determine what happened . A Skin/Wound Note, dated 02/21/19 at 10:54 a.m., documented, .Focus assessment r/t wound, elder penis shaft split open due to catheter pulling on penis. Foley stabilization device in place, new treatment (clean inferior penis shaft with dakins solutions 0.25% cover with alginate every day shift for trauma) .Elder stated that he is having less sensation to his lower extremities and would like to go ahead with plan for amputation. (Government agency name deleted) social worker in facility, and aware of elder wishes. Elder is own responsible party, elder and (physician's name deleted) updated of above . A nurse's note, dated 02/21/19 at 5:58 p.m., documented, .Focused assessment r/t patient c/o increased pain to left foot of 8/10 .Patient has been scheduled for left foot amputation, in need of supra pubic catheter. Patient transported to (hospital name deleted) by (emergency medical service name deleted) via stretcher in stable condition .(physicians name deleted) and DON notified . A hospital emergency room note, dated 02/21/19 at 6:38 p.m., documented, .Pt. presents per (emergency medical service name deleted) for eval of left foot pain .States pain is out of control now .Nursing home called earlier and said pt also had open wound to penis. Pt. scheduled to have supra-pubic cath placed in March. pt has foley in place at this time . A hospital Nursing Emergency Dept. Note, dated 02/21/19 at 10:26 p.m., documented, .Patient also endorsed an ulcer at the base of his penis which was also painful. patient was seen by urology on 2/13/2019 and plan for suprapubic catheter is in place. Urology was consulted by ER staff. Urology will be seeing the patient in the morning .Secondary Admitting Diagnoses: [REDACTED].Urethral ulcer at the base of the penis: -no obvious discharge however exam was extremely limited -on IV vanc and [MEDICATION NAME] -urology consulted, will evaluate in am . A picture taken at the hospital, dated 02/22/19, showed the resident's penis appeared eroded from the tip of the penis to the base on the posterior side. The resident's urethral opening was at the base of the penis. A hospital Discharge Summary, dated 03/01/19, documented, .SECONDARY [DIAGNOSES REDACTED].Proteus Mirabilis UTI .HOSPITAL COURSE: .During his hospital stay, the patient was evaluated by the Wound care nurse, Vascular Surgery, Urology .Patient gave consent so that pictures of his wounds could be taken 2/2 to presumed neglect by GLC. He did consent and pictures were obtained .Urology did .place a suprapubic catheter on 2/27 in their clinic under local anesthesia .CONDITION OF WOUND AFTER PR[NAME]EDURE .Penis eroded open from tip to base of penis. Foley cath inserted into opening at base of penis into urinary bladder. Splayed open area is pink (traumatic [DIAGNOSES REDACTED] from chronic use of catheter). Foley anchored to R thigh .RECOMMEND .Penile wound: for any open areas daily cleanse and apply hydrogel ointment . On 03/14/19 at 12:14 p.m., resident #1 was asked how his care had been at the facility. He stated, Not that good. He stated that he sometimes laid in pee and BM about 30 minutes to an hour. Resident #1 was asked if he had received regular catheter care. He stated, Not right. He stated they did some. He was asked how many times a day he had received catheter care. He stated once a day. He stated the staff cleaned it but they did not attach the catheter to his leg with a stabilizer. He stated they had not not told him what would happen if he did not have a stabilizer. Resident #1 was asked if had known he had a penile sore. He stated, Yes, but I didn't know how bad it had been. He stated he had said something to the staff but they had told him it would be OK. Resident #1 stated the tear on the penis was found on 02/13/19 at a Urology clinic visit. He stated they had been upset. Resident #1 was asked if the staff had done anything different with his catheter care when he returned to the facility after the Urology clinic visit. He stated the clinic had put a stabilizer on his catheter but the facility staff did not change their care. On 03/18/19 at 9:36 a.m., LPN #1 was asked how often catheter care was done. He stated every shift. He was asked where catheter care was documented. He stated, It should be on the TAR. LPN #1 was asked what was assessed during catheter care. He stated he looked at the skin, scrotum, upper thighs, for open areas and for changes from previous times. He stated he looked for drainage or anything out of normal. He was asked if he assessed for skin problems. He stated, Yes. LPN #1 was asked how he did catheter care. He stated he got the supplies ready, provided privacy, washed his hands, informed the resident what he was going to do, gloved, wiped down each side of the penis with a disposable wipe, washed hands, changed gloves, cleaned around the head of the penis with a disposable wipe then wiped the tubing and repeated with a new wipe if needed. LPN #1 was asked if he assessed the penis during catheter care. He stated, Yes. He was asked if he were doing catheter care per orders and a resident had a skin breakdown, would he observe that. He stated, Yes. LPN #1 was asked if he was familiar with resident #1. He stated, Yes. He was asked if resident #1 had had a catheter. He stated, Yes. He was asked what care had been provided. He stated, He should have been getting foley care every shift. LPN #1 was asked how often he had done skin assessments. He stated head to toe skin assessments one time per week and skin assessment with foley care every shift. LPN#1 was asked if he had ever observed any skin breakdown on the resident's penis. He stated, Not until he came back from the urology appointment on 2/13/19. He was asked what his assessment of the resident's penis was after he returned from the urology appointment. He stated, I saw that it was split. That the urethra was split down the shaft of the penis. I documented that he came back from the appointment and that he was going to need a suprapubic catheter. I did not document the condition of the penis. I did read the discharge instructions from the Urology clinic but I did not document the condition of the penis. LPN #1 was asked what his note on 02/13/19 documented. He read the notes from 02/13/19 from 1:05 p.m. and 1:24 p.m. He was asked if there had in fact been a skin breakdown. He stated, Yes. He was asked why he had not documented the skin breakdown. He stated, Really, I don't even know. I think I took it that it was documented in the discharge note. He stated since it had been in the discharge note he did not feel like he needed to re-document. LPN #1 was asked if there had been any new orders related to the penile wound. He stated, No he did not believe there had been any new orders from the Urology clinic. LPN #1 was asked if he had informed the resident's primary care physician of the penile wound. He stated, No. He was asked why not. He stated, I was focused on discharge from Urology. I should have notified (physician's name deleted.) LPN # 1 was asked when the resident's physician had been notified. He stated, (MONTH) 21. He was asked how many days that had been after the wound had been discovered. He stated, Seven or eight. He was asked if that was appropriate notification. He stated, No. LPN #1 was asked if anything had been done differently after discovery of the wound on 02/13/19. He stated, No. On 03/18/19 at 10:36 a.m., LPN #1 was asked if on 02/13/19 he had notified anyone of the resident's penile wound. He stated he had notified the wound care nurse. He was asked if he had documented that. He stated, No, I don't believe so. I think I notified him after I wrote my second note. On 03/18/19 at 11:28 a.m., the DON was asked was how often catheter care was done. She stated every shift. She was asked where catheter care was documented. She stated on the TARs. The DON was asked what was assessed during catheter care. She stated the penis and the scrotal area. She stated they look for something not normal. The DON was asked what training nurses received regarding catheter care and when. She stated, In nursing school. She was asked if they did anything after they came to the facility. She stated, It's basic. The DON was asked if the nurses did a skills check. She stated the facility did a skills check annually. She was asked if it included catheter care. She stated she thought it did. The DON was asked how she monitored to ensure that catheter care was being done. She stated they monitor for completion of the documentation. She was asked if they ever observed staff. She stated she could not answer for what the previous DON did. The DON was asked if she ever asked residents if their care was being done. She stated, I haven't asked them that. She stated she just asked them if they were receiving their care. The DON was asked if what nurses did as follow-up when a resident goes to their physician's appointments. She stated if they got orders, follow-up on the orders, document they had gone to the physicians and that should be in the chart. The DON was asked if she was familiar with resident #1. She stated, I have read his chart. She was asked if he had a catheter. She stated, Yes. The DON was asked if catheter care had been provided and how often. She stated, As far as documentation, I believe it was every shift. She reviewed the resident's TAR and stated it had been charted every shift in (MONTH) and February. She was asked if that care included an assessment of the skin. She stated, I would have to assume it would. You have to look at what you are cleaning. The DON was asked how often skin assessments were done. She stated weekly for people without wounds and daily for people with wounds. She was asked if skin assessments were done during resident baths or showers. She stated, Yes. The DON was asked if a resident had a skin problem would it be found if the three assessments were occurring. She stated if it was unusual it should have been found. The DON was asked if from 02/05/19 through 02/12/19 skin assessments and Foley care had been done for resident #1. She reviewed the resident's record. She then stated foley catheter had been done and wound notes/skin assessments had been done. The DON was asked if except for pressure ulcers previously identified before 02/05/19 had any new skin or catheter issues been identified. She stated, It doesn't appear so. The DON was asked if the resident had a Urology Clinic appointment on 02/13/19. She stated, Yes. She was asked what happened during that visit. She stated his penis was eroded. She was asked to what degree. She stated, From the tip to the base. The DON was asked when the resident returned to the facility what did the staff do. She reviewed the nurse's note for 02/13/19 at 1:05 p.m She stated that the resident was scheduled for outpatient surgery. She was asked if there was anything documented about the resident's penis. She stated, No. The DON was asked to review the note for 02/13/19 at 1:24 p.m. and was asked what was documented related to skin. She stated, No new issues or breakdown noted. She was asked if she would have expected something about the penis. She stated if it's not new and they are used to seeing that. She stated, I don't know how to answer that. I don't know what the nurse observed. The DON was asked to review the Urology Clinic note, dated 02/13/19, regarding the Urology clinic visit on 12/27/18. She stated everything was fine 12/27 and 12/10, penis was fine. She was asked if there had been a change in the penis between 12/27/18 and 02/13/19. She stated, Yes. The DON was asked if the nurse had documented the condition of the penis upon return from the clinic. She stated, No. She was asked if the resident's primary physician had been notified of the wound. She stated, No. The DON was asked if any new orders or change in treatments were received in regard to the wound/erosion. She stated, No, not any documented. The DON was asked when the next change in skin condition was documented after the resident's return on 02/13/19. She reviewed the resident's record for 02/13/19 at 5:35 p.m. She stated a venous stasis ulcer. She was asked if there had been a wound that had developed with eschar between 1:24 p.m and 5:35 p.m. She stated, I don't know how it could happen that quick. The DON was asked if the staff was performing accurate skin assessments. She stated it doesn't look accurate. The DON was asked if between 02/13/19 and 02/21/19 there had been any documentation regarding skin breakdown to the penis or wound care to the penis. She stated, No. The DON was asked when the first documentation of the wound to the penis. She stated on (MONTH) 21. She was asked how many days that had been after the wound had been identified. She stated, Eight. She was asked when the physician had been notified. She stated he had been notified on (MONTH) 21. The DON was asked how the wound had been brought to her attention. She stated, By the (hospital name deleted) nurse. They came for a visit on the twenty-first. That's when it came to my attention. The DON was asked if prior to 02/13/19 the facility had been aware that it had a skin assessment problem. She stated, Yes, we have outstanding deficiencies related to that right now. The DON was asked what had they had in place to help prevent this type of occurrence. She stated they had added a second wound nurse when they had received the previous deficiency. She stated they were doing daily assessments on (federal agency agency name deleted) patients. She stated they had added additional staff probably by the eighth of February. The DON was asked if the addition of staff had been effective. She stated, I can't say it was. On 03/18/19 at 1:01 p.m., the Administrator was asked what she had done when the federal agency representative had brought the concern with resident #1's penis to her attention. She stated she started interviewing the staff, checked what they had documented. She stated she was in the process of typing interviews to make it legible for you. The Administrator was asked if she had done anything else. She stated, No that was the majority of it to see if there was a change. The Administrator was asked what they determined. She stated the staff said it looked the same, there was no change, the catheter flushed good. She stated one CNA said it leaked quite a bit. She stated they never saw blood or increased pain. She stated one CNA said it looked different and she notified the nurse. The Administrator was asked if they had had a system of monitoring in place. She stated to make sure, they already had added a second wound nurse on the 7th or 8th of February. The Administrator stated the federal agency representative called the previous DON on 02/15/19. She was asked if the call had been documented. She stated no the call had been made to the previous DON's personal cell phone. The Administrator asked what the previous DON had done. She stated, We don't have documentation of anything. She was asked how she knew the federal agency representative had called the previous DON. She stated the federal agency representative told her. The Administrator stated the federal agency representative came in on the 2/20/19 and they exited on the 2/21/19. She stated, They were upset. That's when we sent him out.

On 01/31/19, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to perform accurate and thorough skin assessments; consistently provide incontinent care for dependent residents; identify a change in condition; and notify the physicain of changes in condition. Resident #9 was sent to the hospital at the family members insistence and was found to have open draining wounds on his buttocks and back. The resident was found to be septic with altered mental status and was admitted to ICU. The resident required surgery for [REDACTED]. At 3:47 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:02 p.m., the administrator and the DON were notified of the IJ situation related to the facility's failures in caring for residents who were at risk for altered skin integrity. At 6:40 p.m., an acceptable plan of removal was provided. The plan of removal documented, The facility will ensure that a resident receives care to prevent skin breakdown and/or pressure ulcers and does not develop skin breakdown and/or pressure ulcers unless the clinical condition demonstrates that they were unavoidable; and a resident with skin breakdown and/or pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new skin breakdown and/or pressure ulcers from developing. 1) All residents will be assessed for any areas of skin breakdown, skin issues, and/or pressure ulcers by midnight on 01-31-19. The physicians' will be notified and appropriate treatment orders will be obtained for any new skin issues identified during the skin assessments. 2) If a resident refuses skin assessment, that resident's physician will be notified for further orders. 3) Facility wound care nurse will immediately be in-serviced by an RN on the skin and wound care guidelines. 4) All nursing staff will be in-serviced on the skin and wound care guidelines and instructed to report any skin issues to the charge nurse by midnight on 01-31-19. Any nursing staff not currently in the facility will be in-serviced before returning to work. 5) All licensed nursing staff will be in-serviced by midnight on 01-31-19 on the skin and wound care guidelines, instructed to re-attempt or have a different staff member attempt to assess, and if still unsuccessful to notify resident's physician if residents refuse assessments. Any licensed nursing staff not currently in the facility will be inserviced before returning to work. 6) New nursing staff members will be in-serviced prior to beginning their work on the floor. 7) The facility will ensure that incontinent residents are checked every 2 hours and provided incontinent care as needed. 8) All nursing staff will be in-serviced by midnight on the incontinent care guidelines and instructed to report any incontinent care refusals to the charge nurse. Any nursing staff not currently in the facility will be in-serviced before returning to work. 9) All licensed nursing staff will be inservices (sic) by midnight on the incontinent care guidelines and instructed to re-attempt or have a different staff member attempt to provide incontinent care upon incontinent care refusals, and if still unsuccessful to notify the physician. The immediate jeopardy was removed on 02/01/19 at 7:00 a.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on interview and record review, it was determined the facility failed to: ~ perform initial and ongoing thorough skin assessments; ~ provide consistent incontinent care for a dependent resident; ~ identify a change in condition; and ~ notify the physician when a resident exhibited a change in condition and when transferred to the hospital for one (#9) of three sampled residents who were reviewed for the care of dependent residents with a skin condition. Resident #9 was sent to the hospital at the family members insistence and was found to have open draining wounds on his buttocks and back. The resident was found to be septic with altered mental status and was admitted to ICU. The resident required surgery for [REDACTED]. This had the potential to affect all 112 residents who resided in the facility. Findings: A Skin and Wound Care Guidelines policy, revised 10/26/10, documented, .Objective .To maintain an optimal level of skin integrity and to promote optimum healing .using an individualized plan of care .Policy .All residents will be assessed weekly to determine factors that predispose the individual to risk of pressure ulcer formation .All residents regardless of Braden Score will be assessed on admission then on a weekly basis. Document this assessment on the Weekly Skin Evaluation sheet .A multidisciplinary plan of care will be implemented that reflects intervention strategies designed to alleviate, reduce, or minimize the negative effects of each resident's identified risk factors . Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission/Readmission Skin assessment, dated 01/04/19 at 6:32 p.m., documented, .Groin .Peritoneal (sic) [MEDICAL CONDITION] .Face .Reddness (sic) .Does the resident have pressure areas/open wounds? .No .Skin Goals and Interventions .Turn and reposition q2hrs and PRN . A Baseline Assessment and Care Plan, dated 01/04/19 at 6:40 p.m., did not address the integumentary (skin) system. A Braden Assessment for Predicting Pressure Sore Risk Form, dated 01/04/19 at 6:40 p.m., documented, .Score: 17 (moderate risk) .Sensory Perception .cannot always communicate discomfort or the need to be turned .OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities .Moisture .Occasionally Moist .requiring an extra linen change approximately once a day .Walks Occasionally .for very short distances .Spends majority of each shift in bed or chair .Makes frequent though slight changes in body or extremity position independently .Friction & Shear .Potential Problem .probably slides to some extent against sheets, chair .occasionally slides down . An admission note, dated 01/04/19 at 8:04 p.m., documented, .Incontinent of B&B .Reddness noted to face .Peritoneal (sic) [MEDICAL CONDITION] to groin .Needs assistance x1 person with ADLs . A physician's orders [REDACTED].Apply A&D ointment to peri area .every shift related to [MEDICAL CONDITION] .Clean area with soap and water, pat dry, apply A&D ointment, monitor s/s of infection. The TAR, dated 01/2019, documented the staff had applied the A&D ointment per the physician's orders [REDACTED].>A Nurse's Progress Note, dated 01/05/19 at 7:05 p.m., documented, .Wife .States patient has been incontinent of bowel and bladder and has required extensive assistance with ADL's . A Weekly Skin Evaluation, dated 01/08/19 at 8:39 a.m., documented, .New Skin Issues Identified .Yes .was order obtained .Yes . The assessment was electronically signed by LPN #4 on 01/08/19. A Skin/Wound Note, dated 01/08/19 at 8:41 a.m., documented, .cheek with light redness, no skin breakdown noted to head ears, scalp, and neck area. skin to back and front torso c/d/i. Redness noted to .groins, treatment order in place .braden score of 17, moderate risk for skin breakdown .incontinent at times .on (specialty) mattress, lotion after bathing, encourage fluids, moisture barrier after incontinent episodes and as needed . The ADL Task form, dated 01/2019, documented: ~ the first bath was given on 01/08/19 at 1:15 p.m.(four days after admission); and ~ n/a for 13, left blank for five, and refused for one of 45 opportunities for the number of times incontinent care had been provided each shift from 01/04/19 through 01/19/19 (16 days). From 01/13/19 to 01/19/19 (seven days) the resident had received incontinent care a total of 14 times, which is an average of two times per day or an average of once every twelve hours. The last four days the resident was in the facility he received incontinent care a total of five times, an average of once per day. From 01/16/19 at 4:23 p.m. through 01/18/19 at 12:52 p.m. (approx. 44.5 hr) the resident received no incontinent care. From 01/18/19 at 10:30 p.m. until the resident was transferred to the hospital on [DATE] at 1:07 p.m. (approx. 14.5 hr) the resident did not receive incontinent care. The last approximate 68.5 hr the resident was in the facility he received incontinent care a total of two times. The admission assessment, dated 01/11/19, documented the resident was independent in cognitive skills for daily decision making. He had not exhibited behavioral symptoms, rejection of care or wandering. He required extensive assistance with all ADLs except eating. He was frequently incontinent of bowel & bladder. He was at risk for developing pressure ulcers, however he had none at the time of the assessment. He did not have other ulcers, wounds and skin problems. A Braden Assessment for Predicting Pressure Sore Risk Form, dated 01/11/19 at 11:41 a.m., documented, .Score: 17 .Moisture .Occasionally Moist .requiring an extra linen change approximately once a day .Chairfast .Ability to walk severely limited or non-existent .must be assisted into chair or wheelchair .Makes frequent though slight changes in body or extremity position independently .Friction & Shear .Potential Problem .probably slides to some extent against sheets, chair .occasionally slides down . A Skilled Nurse's Note, dated 01/13/19 at 4:17 a.m., documented, .Skin Conditions .(left blank) . A Behavior Note, dated 01/13/19 at 9:00 a.m., documented, wondering the hall walking into different patients rooms, wearing only an open bath robe, no brief, exposing himself. PT stated he was only looking for the bathroom, educated to keep robe closed in hallway .Will continue to monitor. It was not documented the physician had been notified related to the behavior. A Monthly Summary, dated 01/13/19 at 10:09 p.m., documented, .Skin Turgor .Good .Skin Conditions .(left blank) .Urinary continence .Frequently incontinent .Bowel continence .Frequently incontinent .Briefs Worn .Worn at all times . A Skilled Nurse's Note, dated 01/15/19 at 7:59 a.m., documented, .Skin Conditions .(left blank) . A Skilled Nurse's Note, dated 01/16/19 at 2:09 a.m., documented, .Skin Conditions .(left blank) . A Weekly Skin Evaluation, dated 01/16/19 at 8:08 a.m., documented, Skin Assessment Complete? .No .reason .Refused . The assessment was electronically signed by LPN #4 on 01/21/19 (two days after the resident had been discharged ). A Skilled Nurse's Note, dated 01/17/19 at 3:38 a.m., documented, .Skin Conditions .(left blank) . A Physician's Progress Note, dated 01/17/19, documented, .Skin .denies new [MEDICAL CONDITION], rash, itching or yellowing of skin .No rashes or ulcers . A Skilled Nurse's Note, dated 01/18/19 at 2:37 a.m., documented, .Skin Conditions .(left blank) . A Braden Assessment for Predicting Pressure Sore Risk Form, dated 01/18/19 at 7:49 a.m., documented, .Score: 17 .Moisture .Occasionally Moist .requiring an extra linen change approximately once a day .Chairfast .Ability to walk severely limited or non-existent .must be assisted into chair or wheelchair .Mobility .Slightly Limited .Makes frequent though slight changes in body or extremity position independently .Friction & Shear .Potential Problem .probably slides to some extent against sheets, chair .occasionally slides down . A Skilled Nurse's Note, dated 01/19/19 at 1:00 a.m., documented, .Skin Conditions .(left blank) . A Behavior Note, dated 01/19/19 at 12:59 p.m., documented, .refusing care, CNA's notified this nurse PT refusing to let aids change wet sheets. PT stated NO, leave me alone and wrapped sheets around himself .Several staff members attempted, PT continued to refuse care. Wife notified. It was not documented the physician had been notified. A Nurse's Progress Note, dated 01/19/19 at 1:04 p.m., documented, .assessment r/t wife coming to nurse's station stating 'I'm sending him to be evaluated, (EMS company name deleted) is on the way', this nurse followed wife back to patient room asked if status had changed. Upon entering room PT found awake laying on right side wrapped in sheet, still refusing care. No change in status since previous evaluation. Wife began to take pictures. Respirations regular and even, Patient continued to denied (sic) pain, just stated he didn't want to get up. (EMS company name deleted) already called by wife, MAR & face sheet printed. It was not documented the physician had been notified. An Emergency Services Patient Care Report, dated 01/19/19 at 1:07 p.m., documented, .Patient has decubitus ulcer to lower back . A Nurse's Progress Note, dated 01/19/19 at 1:11 p.m., documented, Wife stated, I'm calling CPS (sic) on you, I called state on you, I called the head of the VA on you. He has had a withdraw (sic) of change in condition since Tuesday. He has bedsores all over his body. This nurse informed wife that staff has attempted multiple times today to change him and provide ADLs and resident has refused. This nurse offered to help with care of resident again while she was present and she said No. It was not documented the physician had been notified. It was not documented the staff had assessed the resident's skin condition. An Emergency Department Triage Note, dated 01/19/19 at 1:53 p.m., documented, .Subjective/Chief Complaint .Draining bed sores, fever, AMS .Objective .presents via ambulance from The Fairmont .d/t N/O of fever, AMS, and bedsores on his back and B/L GM that are draining purulent fluid .draining wounds to B/L gluteals and another that appears to be an abscess on the R side of his mid-back . An Emergency Department note, dated 01/19/19 at 1:58 p.m., documented, Physical Examination .SKIN: Has [MEDICAL CONDITION] on the back with 3 draining areas one on the back and 2 on the gluteal areas .Specimen .Collection Date: [DATE]@1439 (2:39 p,m.) .Lactic Acid 3.3 H (high) .(reference range) 0.7 - 2.1 .WBC 28.4 H .(reference range) 4.5 - 10.9 .Assessment:[MEDICAL CONDITION] .admitted to ICU service . An Emergency Department Note, dated 01/19/19 at 3:06 p.m., documented, Chief Complaint & History of present illness: .brought from the nursing home with c/o pus draining from the back and gluteal area, fever, confusion and not walking for 3 days as per his wife .mentions that he was in .his feces and was not cleaned .walking with support till 4 days ago .The wife says he had fever of 100.5 . A Nurses Progress Note, dated 01/21/19 at 9:13 a.m., documented, .assessment r/t discharge, (physician name deleted) notified of elder discharge to (hospital name deleted). A General Surgery Consult Note, dated 01/22/19 at 4:46 p.m., documented, .here from nursing home with gluteal [MEDICAL CONDITIONS] .Bp was in the 90s systolic, now improved to 110s .C/o pain to gluteal region, bilaterally. unknown when the [MEDICAL CONDITION] first began. Normally lives in nursing home but is reportedly receiving poor care with his incontinence . A Bacteriology Final Report, dated 01/23/19 at 4:07 p.m., documented, .Collection sample: Wound .Dermis .Final report .Staphylococcus Aureus .Moderate .PLEASE NOTE, THIS IS A [MEDICAL CONDITION]-RESISTANT STAPH AUREUS . A Wound Care Consult Note, dated 01/24/19 at 12:31 p.m., documented, .Wounds were present on admission .s/p I&D of bilateral gluteal abscess as of 1/23/19. Rt. Side peri wound area measures 6cm x 6cm the incision wound measures 1.5cm x .5cm. Lt. Side peri wound area measures 11cm x 12cm the incision wound Measures .2cm x 1cm. Bilateral gluteal tissue is 100% red. Pt. has a small 2cm x 2cm red blanchable spot on his left trochanter, and multiple scabbed areas of various sizes on his back .a small wound to the shaft of his penis that measures .2cm x .2cm etiology unknown. Pt. scrotum in 100% red blanchable irritated tissue most likely related to moisture related [MEDICAL CONDITION] . An Internal Medicine Inpatient Note, dated 01/24/19 at 2:32 p.m., documented, .presented from (nursing home) with concerns for new bedsores, altered mental status, and significant decline over 2 week period. His wife was frustrated at his conditions in the center as he had been sitting in his waste consistently .admitted for [MEDICAL CONDITION]ly secondary to [MEDICAL CONDITION]. In the MICU .On 1/22 he had an ultrasound of the soft tissue and an abscess was noted to the left gluteal tissue. General surgery was consulted for evaluation and slightly opened and packed bilateral gluteal regions. On 1/23 his altered mental status was significantly improved and he ambulated with his wife . A Discharge Instructions Note, dated 01/28/19 at 2:54 p.m., documented, Principal Discharge Diagnosis: [REDACTED].Chronic [MEDICAL CONDITION] . On 01/30/19 at 9:00 a.m., the resident's wife was asked if she had seen the wounds while the resident was in the facility. She stated, Yes. She was asked where the wounds were located. She stated there were four to five smaller wounds on the buttocks, which then grew together to form two larger wounds. She then stated they had to pack them and then cut into them to drain them at the hospital and the wounds were still draining. The wife was asked if the hospital had informed her what had caused the wounds. She stated, No. She then stated more than likely the dirty climate had caused them, that he was never clean. She stated she had taken pictures of dried feces on the bed the Wednesday (01/16/19) prior to his leaving the facility. She also stated his bed was saturated with urine which had dried out. She was asked if she had told the facility staff about the wounds. She stated, I don't know if I did or not. On 01/30/19 at 11:59 a.m., CNA #7 was asked where the aides documented the baths. She stated it was documented in the computer on the bath icon. She was asked if she assessed the skin during every bath. She stated she looked at each residents skin with every bath and she notified the nurse if she observed anything new. She was asked if they had a place to document the status of the residents' skin. She stated, No. She stated they would let the nurse know if they observed raw, red or irritated skin and the nurse would do an assessment of the resident. She was asked how she would know if the nurse failed to assess the residents' skin. She stated she would not know. CNA #7 was asked how often they provided incontinent care for the residents. She stated every two hours, the heavy wetters were changed every hour. She was asked where they documented incontinent care. She stated in the computer. She was asked if she documented incontinent care each time she completed it. She stated, No. She stated they documented how many times they had changed the resident on each shift. She was asked what they did if the resident refused care. She stated they came back in five minutes and tried again and if the resident still refused they notified their nurse. She was asked if they documented the refusal. She stated, Yes. CNA #7 was asked what they did if they noted skin breakdown during incontinent care. She stated, I notify my nurse. She was asked if she was providing incontinent care every two hours for a resident, would she be able to observe if the resident had new [MEDICAL CONDITION] to the groin, hips, legs, back or buttocks areas. She stated, Yes. She was asked if there was any way [MEDICAL CONDITION] in those areas could be missed while providing incontinent care. She stated, No. On 01/31/19 at 10:30 a.m., LPN #6 was asked why the resident was transferred to the hospital on [DATE]. He stated the resident's wife called the ambulance for him to be evaluated. He was asked what the resident's wife had stated was wrong with the resident. He stated she had said the resident had had a change in condition since that Tuesday and had bedsores all over his body. LPN #6 was asked what the staff had done when the wife reported this. He stated they sent him to the hospital. He was asked if the nurse had performed a skin assessment when the wife stated the resident had bedsores all over his body. He stated there was nothing documented in the notes related to a skin assessment. LPN #6 was asked if the resident required assistance with incontinent care. He stated, Yes. He was asked how often the staff had provided incontinent care for the resident. He stated every two hours and as needed. He was asked how often the resident's skin had been assessed. He stated the nurse aides would assess the skin every time they provided incontinent care and the nurse performed a weekly skin check. LPN #6 was asked what the results of the weekly skin assessments were. He stated the resident had refused the skin assessment on 01/16/19. He was asked when the skin assessment had been signed by the LPN. He stated, 1/21. He was asked why the skin assessment had been signed five days after the date of the assessment. He stated he did not know. He was asked if the skin assessments were supposed to be signed the date they were completed. He stated, I believe so. LPN #6 was asked if it was documented the resident had refused other care on 01/16/19. He stated, It doesn't appear so. He was asked what they did when a resident refused care. He stated they were supposed to try again. He was asked if the staff had attempted to perform the skin assessment after the refusal. He stated it was not documented. LPN #6 was asked if the resident had problems related to skin breakdown. He stated his skin was fairly good. He stated it was intact with redness to the groin and bottom. He was asked if the staff would be able to observe skin breakdown when they provided incontinent care. He stated, Yes. At 10:53 a.m., CNA #10 was asked if she had provided care for resident #9. She stated, Yes. She was asked how often she provided incontinent care for the resident. She stated every two hours, he required extensive assistance and he wore a brief. She was asked if she observed any problems with his skin. She stated, I didn't see anything. She was asked if she ever observed sores on his buttocks. She stated, No. At 11:04 a.m., the DON was asked when resident #9 was admitted to the facility. She stated on 01/04/19. She was asked how much assistance he had required with toileting and bathing. She stated it varied, sometimes he needed assistance and sometimes he did things on his own. She was asked how often the residents received baths. She stated three times a week. She was asked how soon after admission a resident should receive a bath. She stated within the first or second day. She was asked when the resident had received his first bath. She stated it looked like it was on 01/08/19. She was asked why it was four days before he had received a bath. She stated she did not know why. She was asked if it was documented he had refused a bath during the first four days. She stated, No. She was asked if the nurse aides assessed the residents skin during a bath. She stated, They look at it, yes. The DON was asked how often the resident received incontinent care. She stated he should have been checked every two hours and as needed. She stated, I do know he refused at times. She was asked how nurse aides documented incontinent care. She stated they documented in the ADLs. She stated they documented the number of times and if they performed incontinent care. She stated it was combined with turning and repositioning. She was asked if incontinent care had been provided every shift, would it be documented. She stated, It should be. The DON was asked what a blank space on the documentation represented. She stated that they did not document on those shifts. She was asked how many shifts were left blank for incontinent care during the resident's stay. She stated, Six. She was asked if it was not documented, was it done. She stated, The rules say no. She was asked what n/a would represent for the number of times incontinent care had been provided. She stated she would have to ask. She stated she might put n/a if he did not need assistance or he was repositioning himself. She stated she would have to ask the staff about their interpretation of using n/a. The DON was asked how they documented if a resident had refused incontinent care. She stated the RR was for when the resident refused. She was asked how many times it had been documented he had refused incontinent care. She stated, Once, on the 19th day shift. The DON was asked how often the residents had skin assessmentments. She stated the skin was assessed on admission, every week and as needed. She was asked who was responsible for skin assessments. She stated some of the skin assessments were done by the skin nurse and some by the floor nurse. The DON was asked when the resident's skin was first assessed. She stated on 01/04/19. She was asked what the findings were. She stated it was documented the resident had redness to the face, [MEDICAL CONDITION] to the groin area and no open areas. She was asked if they had treatment orders related to the skin. She stated they had an order on 01/05/19 for A&D to his peri area every shift. She was asked what the [DIAGNOSES REDACTED]. She stated, [MEDICAL CONDITION]. The DON was asked if they addressed the skin on the resident's baseline care plan. She stated, No, I don't see it. It's addressed in the admission assessment. She was asked if they admitted a resident with a skin [DIAGNOSES REDACTED]. She stated, We include it in the care plan, but not the baseline care plan. The DON was asked if his baseline care plan included an assessment of the skin with interventions. She stated, No, it did not. She was asked how the staff would be aware of his skin condition. She stated they would know about the order for the treatment. She was asked if the nurse's utilized the baseline care plan. She stated, They look at the orders. The DON was asked if the staff had applied the A & D ointment to the groin every shift per the order. She stated, Yes, they charted it every shift. She was asked if the staff would have observed any changes in his skin during the application of the ointment. She stated, Yes. She was asked if there had been any changes in his skin documented during his stay. She stated, No. The DON was asked when the weekly skin assessment, dated 01/16/19, had been signed by the LPN. She stated on 01/21/19. She was asked if the staff were supposed to sign the skin assessments on the day they had been completed. She stated, Normally they do. She was asked what the staff did when a resident refused a skin assessment, as documented on 01/16/19. She stated the staff should try again the same day or the next day. She was asked if it was documented they attempted to assess the skin a second time on 01/16/19. She stated, No. The DON was asked how the monthly assessment addressed the skin. She stated there was a section where they documented the skin assessment. She was asked what had been documented for the skin assessment dated [DATE]. She stated, It is not filled out on there. She was asked if the skin assessment was a thorough assessment for a resident with a [DIAGNOSES REDACTED]. The DON was asked if the skilled nursing notes, dated 01/13/19 and 01/15/19 - 01/18/19, included an assessment of the skin. She stated they did have a section for a skin assessment. She stated, But it was not filled out. She was asked if the skin assessment should be documented on the skilled nursing notes. She stated, Yes. She was asked what the resident's skin looked like on the dates of the skilled nursing notes. She stated, I don't know. The DON was asked what they did if a resident had a change in condition. She stated they notified the doctor and the family. She was asked if a resident was wandering the halls, going into other residents' rooms and exposing themselves to others, would that be considered a change of condition. She stated, Yes, but I don't know what his history was before. She was asked if the physician should have been notified when the resident exhibited this behavior. She stated, Yes. She was asked if the physician had been notified on 01/13/19 when the resident had exhibited this behavior. She stated, No, not on this nursing note, they did not. The DON was asked what happened with the resident on 01/19/19. She stated the resident's wife came in and told the staff she had called EMS and the resident went to the hospital. She was asked what the resident's wife had informed the staff related to his condition on that day. She read the nurse's note and stated, He has had a withdrawal (sic) of change in condition and bedsores all over his body. She was asked when the wife had stated the change of condition had started. She stated, She said Tuesday (01/15/19). The DON was asked what the staff had done when they received the information. She stated, They sent him out to the hospital. She was asked if the staff had assessed the resident's skin. She stated, No, they tried. She was asked if it had been documented the staff had attempted to assess his skin. She stated, No, it says at 12:59 that they tried to change him, but he wouldn't let them. She was asked what the resident's skin looked like when he was transferred to the hospital on [DATE]. She stated, They didn't know what it looked like because he was refusing. The DON was asked if they had documented an observation of the resident's skin the day prior to the transfer. She stated, No. She was asked when the last time the staff had documented they had observed the resident's skin. She stated the staff had been putting the ointment on his buttocks for [MEDICAL CONDITION], but the last skin assessment had been documented on 01/08/19 (11 days prior to discharge). She was asked what the condition of the resident was from 01/15/19 - 01/18/19. She stated they had documented vital signs on the skilled nursing notes. She was asked what they had documented in the progress notes for those dates. She stated, Just on the 15th, he refused his nicotine patch.

Based on interview and record review, it was determined the facility failed to provide supervision to prevent resident to resident altercations for two (#1 and #2) of three sampled residents who were reviewed for aggressive behavior. Resident #2 had been involved in four incidents of being struck by another resident. Three of the incidents, including the most recent, involved resident #1. The last incident led to a head injury which required hospitalization . The resident died while in the hospital. The facility identified 30 residents with behavioral healthcare needs. Findings: 1. Resident #2 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A care plan, dated [DATE], documented, Focus .AT RISK FOR FALLS R/T MEDICATIONS .Goal .Staff will evaluate all falls and intervene as needed to reduce the potential of significant injury through the review date . A care plan, dated [DATE], documented the resident was at risk for injury of self and others due to behaviors and refusing care related to the [DIAGNOSES REDACTED]. Interventions included: ~ Administer medication as ordered. ~ Assess effectiveness of medications. ~ Assess for change in mood and behaviors. ~ Do not isolate resident. ~ Do not shout, or show impatience with resident. ~ If becomes violent or irrational staff to walk away and take appropriate steps per protocol to contain situation. ~ Labs as ordered. ~ Monitor behaviors every shift. ~ Notify MD and family of any change in status. ~ Offer activities of choice. ~ Provide calm environment. ~ Provide diversional activities as able. ~ Social Services/Activities to provide visits as needed. A quarterly assessment, dated [DATE], documented the resident had a BIMS of four, which indicated the resident was severely impaired in cognitive skills for daily decision making. A nurse's note, dated [DATE] at 12:22 p.m., documented, .assessment r/t resident to resident event on [DATE] at 1030 in the living room area .nurse heard screaming and ran to the living room area and saw another resident hit this resident in the forehead with a book .nurse immediately separated the two residents and did a head to toe assessment. This resident stated she did not know why the other resident hit her with the book. Another resident's family member saw the incident and stated this resident took another resident's list and pen, this resident refused to give it back when he asked for it, the other resident got a book and raised it at her and she still refused to give the list and pen back .Staff noted that this resident have had an increase in behavior towards other residents, taking things from them and yelling in their faces, staff noted this behavior for the past week .This resident is currently being monitored closely with 1 on 1 care with a medication review . A state reportable Incident Report Form, dated [DATE], documented, .(res #2) took .(res #1) paper from him .(res. #1) approached (res. #2) and attempted to get paper back. (Res #2) refused to give paper back. (Res. #1) hit (res. #2) on the forehead with a book. Elders seperated (sic). Focused assessments performed on both elders, No injuries noted .Medication review completed on (res. #2) and received order to increase previously decreased [MEDICATION NAME] back to original dose .Investigation initiated .(res#2) is alert to self only, has short and long term memory deficits .Elder has history of dementia .[MEDICAL CONDITION] .(res. #1) is alert and oriented to self with short and long term memory deficits due to dementia and history of mental illness .Elder has history of intellectual disabilities .mental disorders, mood disorder, [MEDICAL CONDITION], major [MEDICAL CONDITION] .Elder is anxious at times and difficult to redirect . The facility completed an initial investigation by interviewing the elders .staff member(s) .by completing a focused assessment on .(res#1) and (res. #2), evaluation of both elders medications, medical and incident history, chart and record review .OKC police notified .(res. #1) placed on 1:1, medication review was completed, and new orders started. The facility has updated both elders plan of care .The facility was unable to substantiate the allegations of abuse due to cognitive impairment of bothe (sic) elders involved . An update to the care plan for risk of injury, dated [DATE], documented, res/res, this elder took another elders property and wouldn't give it back another elder hit her with a book, medication review completed, medication adjusted. Date initiated: [DATE]. A Late Entry Incident note, dated [DATE] at 10:00 p.m., documented, .assessment r/t resident to resident event. At approx. 6:30 p.m., heard a loud slap sound & looked over & seen a female resident sitting back in her chair next to (res. #2) .(Res #2) reported that this female had hit her. (Res #2) was sitting @ the corner of the ACU lobby couch & the other female resident was sitting on a chair to the right side of (res. #2). Both residents were immediately separated. (Res #2) walked to her room & was assessed. The other involved female resident remained in the lobby & was place on 1:1 care. Observed a reddened area approx. 5x5 inches to the left side of (res. #2's) neck. The skin to this area was unopened with no swelling. (Res #2) reported she was hit one time @ this noted area .(Res. #2) was visibly calmer after approx. 15 minutes after she (sic) this event with this other lady resident. I asked what had happened, & (res. #2) said that the other female resident was sitting nearby & hit her .for no reason Police notified of resident to resident event . An update to the care plan for risk of injury, dated [DATE], documented, res/res another elder hit this elder. A Behavior Note, dated [DATE] at 9:48 a.m., documented, .assessment r/t behavior this resident noted with increase in agitation and combative behavior towards staff .staff tried to assist this resident to the bathroom for toileting. This resident stated she did not want to be change (sic) and began yelling at the staff .resident began to hit the CM[NAME] Redirecting this resident was difficult .Staff also stated they noted an increase in this resident yelling and trying to be aggressive with other resident's with staff being able to redirect before an altercation happens .staff will continue to monitor and anticipate any needs . An update to the care plan for risk of injury, dated [DATE], documented, bruise noted under chin. A nurse's note, dated [DATE] at 6:39 p.m., documented, .assessment r/t resident/resident incident .nurse observed male resident and this resident tugging on each others shirts and becoming aggressive. Male resident hit resident on the right side of her face. Resident then fell to the floor on her buttocks hitting her head on a chair. This nurse assessed resident started NEURO checks .Redness noted to right ear and slight redness behind right ear. Gums inside mouth appear to have been hit up against teeth. Blood noted .Resident assisted to room for full head to toe assessment .MD notified .DON notified . A state reportable Incident Report Form, dated [DATE], documented, Staff observed .(res. #1) and (res. #2) grabbing each others shirts. Staff attempted to separate (sic) and .(res.#1) hit .(res. #2) in the right chin with his right hand .(res.#2) fell and hit the back of her head on a chair. Elders seperated (sic). Focused assessments completed on both elders .(res #2) has raised area to head, laceration noted to right inside and out of lip, brusing (sic) noted to right chin .(res#1) placed on 1:1 and will reamin (sic) on 1:1 until out of facility .Investigation initiated .(res#2) is alert to self only, has short and long term memory deficits .Elder has history of dementia .[MEDICAL CONDITION] .(res. #1) is alert and oriented to self with short and long term memory deficits due to dementia and history of mental illness .has history of intellectual disabilities .mental disorders, mood disorder, [MEDICAL CONDITION], major [MEDICAL CONDITION] .is anxious at times and difficult to redirect The facility completed an initial investigation by interviewing the elders .staff member .by completing a focused assessment on .(res#1) and (res. #2). Evaluation of both elders medications, medical and incident history, chart and record review . police notified .(Res #1) sent out of facility for psych eval. The facility has updated both elders plan of care .The facility was unable to substantiate the allegations of abuse due to cognitive impairment of bothe (sic) elders involved . An update to the care plan for risk of injury, dated [DATE], documented, Res to Res. Resident was hit in the face by another resident. An update to the care plan for falls, dated [DATE], documented, Keep the residents separated from each other and resident to resident altercation resulting in a fall, A Quality Manager Progress Note, dated [DATE] at 10:45 a.m., documented, .QM focused assessment r/t incident on [DATE]. After interviewing staff, resident and performing a chart review, this nurse was told that this resident and another resident had an altercation, this resident was hit in the face by another resident in the unit causing this resident to fall to the floor and hit her head on the chair, residents were immediately separated and assessed, at the initial assessment this resident was observed with redness to the right ear and blood in mouth with a small abrasion .resident has purple bruising to the right side of her chin and a bruise to the top of the left hand .Interventions include but are not limited to, falling star program, assess resident's mobility and need for assistance, keep area consistently clear and clutter free, observe for dizziness and excessive fatigue, keep personal and frequently used items within reach, keep pathways clear clutter free and well lit, observe for risk factors contributing to fall risk, restorative nursing as needed. New intervention was immediately separating resident and to continue to keep them separated .Falling star and care plan updated . A nurse's note, dated [DATE] at 12:28 p.m., documented, Focused assessment r/t res to res event on [DATE] .noted small bruise to right side of abdomen, big purple bruise to left side of abdomen, purple bruise to right side of chin and neck, purple bruise to right and left upper chest. Resident stated pain to right back of head ,[DATE] . An Incident Note, dated [DATE] at 5:52 p.m., documented, .assessment r/t Res to Res event .Resident has been showing bossy' behaviors and trying to make resident's do what she wants them to do. Resident redirected by staff. Resident continues to pace around unit independently . An Incident Note, dated [DATE] at 1:24 p.m., documented, .Focused assessment r/t res to res event noted on [DATE] .Resident continue (sic) with bossy behavior and yelling at other residents, staff able to redirect resident . A Care Plan Note, dated [DATE] at 8:48 a.m., documented, .care plan meeting held on [DATE] with facility staff, no family present at meeting. Staff state that resident has shown a decrease in 'bossiness' of other residents recently . An Incident Note, dated [DATE] at 6:37 a.m., documented, .nurse at the nursing station and heard the resident asking .(res. #1) 'take off the bug.' This nurse immediately rushed to the dining room where the two resident (sic) were sitting at the this time. This nurse noted .(res. #1) slapped and pushed down .(res. #2) on the floor and she hit her head. This nurse noted blood on the floor. Immediately, separated the resident from getting to each other. Head to toe assessment completed. Pressure applied to right side head swollen with bleeding. Cleanse area with NS and pat dry. This nurse noted swollen to resident right elbow. BP-,[DATE], P-127 .Resident c/o feeling dizzy. Denies having pain @ ,[DATE]. Moves all extremities without difficulty. Neurological check initiated. Intervention: Notified (physician name deleted) on call and new order to send resident to ER for further evaluation .(Emergency Medical Services) at the facility and transported resident in a stretcher to (hospital name deleted) per resident choice. An Emergency Department provider note, dated [DATE] at 7:28 a.m., documented .Patient presents with .Fall .Med list from NH states 'long term use of anticoagulants.' Laceration posterior head 69 y.o. female with .dementia presents via EMS c/o headache s/p fall with head injury, no L[NAME] occurring PT[NAME] Pt. has a hx of dementia and is unsure about the mechanism of her fall. She does report that she hit the back of her head, but denies any L[NAME] .Pt does take [MEDICATION NAME] and ASA .Physical Exam: .Knot on R posterior scalp with some bleeding, no apparent laceration noted, no abrasion noted in the region .Medical Decision Making: .CT done showing ICH .will admit to neuro ICU .Clinical Impression .Final [DIAGNOSES REDACTED].Platelet inhibition due to [MEDICATION NAME] . A state reportable final Incident Report Form, dated [DATE], documented, .On [DATE] facility staff (LPN#7) observed .(res. #1) slapping and pushing resident (#2) to the ground. Focused assessment completed. Bleeding and swelling noted to the right side of head of (res. #2) .Resident (#1) placed on 1:1 with staff. (Res. #2) sent to ER . (Res.#1) is alert and oriented with short and long term memory deficits due to Dementia .Resident has a [DIAGNOSES REDACTED].[MEDICAL CONDITION], mental disorders .intellectual disabilities and [MEDICAL CONDITION] .gets anxious when someone gets in his space or touches him He actively moves around the unit .(Res. #2) is alert with confusion due to dementia .has [DIAGNOSES REDACTED].poor safety awareness due to dementia and [MEDICAL CONDITION] .The facility completed an initial investigation by interviewing the elders (res. #2) and (res. #1), and by interviewing the staf (sic) members i.e., by completing a focused assessment on the residents, an evaluation of their medication, medical and incident histories, chart and records reviews .No allegations/signs of abuse .police notified .(res. #1) placed on 1:1 .Upon completion of the investigation through staff (LPN #7) interview, the facility determined that .(res. #2) thought she saw a bug on .(res.#1) and the both elders .started to exchange words, then .(res.#1) slapped and pushed .(res#2) .(res #2) fell and hit her head .order to send to ER for further evaluation .(Res.#1) sent out of facility for inpatient psych .(Res. #1) is not returning to the facility .(Res. #2) remains in the hospital and interventions will be reevaluated upon return .The facility is unable to substantiate the allegation of abuse due to the cognitive impairments of the residents involved . A hospital significant event note, dated [DATE] at 12:42 a.m. documented, .House Officer Death Pronouncement Note Patient seen and evaluated .Time of death 0040 . A police department Crime Report form, dated [DATE] at 1:11 p.m., typed on [DATE] at 1:54 p.m., documented, .Victim: (res.#2) .Reporting per (RN #1) .Witness: (LPN #7) .Suspect: (res. #1) .Body of Report: I received a call to take a report by phone on an assault that occurred earlier today at The Fairmont Skilled Nursing Center. I spoke with (RN #1) who is an RN who works in the Alzheimers Center. (RN #1) said that this morning when he arrived at work, the cafeteria was covered in blood and the VI was being transported by (ambulance) for a head injury and possibly an injury to the right elbow. He was told by staff that the SU had assaulted the VI. The SU was isolated now and was waiting to be transferred to a psych unit. RP needed a report for that transfer. RP said the VI has [MEDICAL CONDITION] so severely she would not be aware of what happened or be able to decide to press charges .He advised VI was transported to (hospital name deleted) and learned that she would be admitted . I spoke to WI who is an LPN. She said she heard VI tell the SU that he had a bug on his clothes. SU got mad and slapped the VI. WI ran toward them but before she could reach them, SU had shoved the VI backward causing her to fall and hit her head on the floor. SU is also being treated for [REDACTED]. He has assaulted other patients in the past. I went to (hospital name deleted) and VI was still in the ER. Her nurse advised me that VI had a [MEDICAL CONDITION] and a brain bleed. She would be going to Neuro-ICU for a few days to be monitored . A police department Standard Supplement Report, dated [DATE] at 4:20 p.m., documented , .Interview with (LPN #7) .On [DATE] at 1620 (4:20 p.m.) hours, I interviewed (LPN #7) in regards to the homicide of (res. #2) . (LPN #7) advised she was on duty as an LPN this morning when the incident occurred between (res. #2) (victim) and (res. #1) (suspect). They were in the cafeteria area when she heard (res #2) speak to (res. #1). She advised (res #2) told (res. #1) to get the bug off you . (LPN #7) advised she was standing near the nurses station and could clearly see the victim and suspect. She saw the suspect turn to the victim and slap her with the back of his hand .in the same instance shoved the victim to the ground. (LPN #7) advised the victim hit her head as she fell to the ground. She called the two aides she had in the hallway so they could help the victim. She went back to the nurses station and called the head nurse. The head nurse authorized calling (Emergency Medical Services) and transporting the victim to (named) hospital. I asked (LPN #7) if the victim and suspect were both Alzheimers patients. (LPN #7) advised confirmed both were Alzheimers patients. She also advised this was the second incident between the victim and suspect. She does not know what occurred during that incident but has heard they have a history. I asked her what prompts the suspect to become angry. (LPN #7) says he likes to be left alone. It seems like when people talk to him it agitates the suspect. (LPN #7) advised the victims injury was to the right side of the head. She was bleeding from the wound and they applied some pressure to the wound. (LPN#7) advised the victim is on blood thinner and an aspirin per day so she will bleed allot (sic). (LPN #7) also advised she had some swelling on her right elbow. (LPN #7) was the person who called 911. 2. Resident #1 had [DIAGNOSES REDACTED]. The care plan, dated [DATE], documented, Focus (res. #1) HAS UNSPECIFIED [MEDICAL CONDITION], WITH BEHAVIORS BEING MONITORED EVERY SHIFT, RECEIVING ANTIPSYCHOTICS FOR MANAGEMENT OF BEHAVIORS (HITTING, PACING AND VANDALIZING PROPERTY (pulls up grass and flowers). (Res, #1) IS AT RISK FOR INJURIES TO SELF OR OTHERS AND DISRUPTING UNIT. AGITATED AT TIMES, LOUD AT TIMES .Goal .(Res. #1) WILL HAVE NO INJURIES TO SELF OR OTHERS, WILL HAVE NO ACUTE SIDE EFFECTS FROM MEDICATION USE OVER NEXT 90 DAYS. Interventions included: Monitor behaviors every shift Administer medication as ordered Monitor side effcts of medication Assess effectiveness of medications Labs as ordered Provide calm environment Offer activities of choice Do not shout, or show impatience with resident Contact Family if applicable Provide diversional activities as able Do not isolate resident If becomes violent or irrational staff to walk away and take appropriate steps per protocol to contain situation Social Services/Activities to provide visits as needed Assess for S/S of infection Assess for change in mood and behaviors Notify MD and family of any change in status An update to the care plan for [MEDICAL CONDITION], dated [DATE], documented, Likes to make lists of things he wants to buy and to have prices wrote down, he has persons other than himself write down the items and price. An update to the care plan for [MEDICAL CONDITION], dated [DATE], documented, Provide 1:1, redirection and or discuss his behaviors with him. A care plan, dated [DATE], documented, (res. #1) has potential to demonstrate physical behaviors gets in peoples personal space, reacts to others behaviors, episodes of pushing, hitting r/t Dementia, Poor impulse control .Goal .(Res. #1) will not harm self or others through the review date . Interventions included: Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Evaluate for side effects of medications Give the resident as many choices as possible about care and activities Monitor behaviors q shift and implement interventions as needed Notify Dr of danger to self and others. Psychiatric/Psychogeriatric consult as indicated. The resident likes to stand close to others in personal space, unaware of intrusion to others personal space, he reacts to actions of others. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, make sure he is in safe place away from other residents and walk calmly away, and approach later. A quarterly assessment, dated [DATE], documented the resident had a BIMS of three, which indicated the resident was severely impaired in cognitive skills for daily decision making. An Incident Note, dated [DATE] at 11:50 a.m., documented, Focused assessment r/t resident to resident event noted on [DATE] at 1030 in the living room area. This nurse heard screaming so I ran to the living room area where I see this resident hit another resident in the forehead with a book. This nurse immediately separated the two resident and did a head to toe assessment. This resident stated the other resident took his list and pen, he asked for it back but she would not give it back so he hit her with the book. A family member of another resident stated she saw the other resident with his paper and pen and she refuse to give it back after her (sic) asked for it and when he got the book and raised it at her she still would not give him the list and pen .Resident calmed down after getting his list back .Staff will continue to monitor and anticipate needs . An update to the care plan for [MEDICAL CONDITION], dated [DATE], documented, res/res no injuries, another elder took (resident #1's) list. An Incident Note, dated [DATE] at 11:52 a.m., focused assessment r/t res to res event on [DATE]. at approximately 10:45 AM- staff heard a loud noise in dining room, upon entering room this nurse observed resident standing up making a fist with his right hand, ask happen (sic), resident stated other female resident took his list of paper from him and he hit her on the head. both separated, resident place (sic) on 1:1 supervision, head to toe assessment completed no s/s of injury or bruises noted. this incident also witness (sic) by another male resident that is alert and oriented. MD, administrator., on call nurse .police .notified An Incident Note, dated [DATE] at 1:38 p.m., documented, .assessment r/t discharge. resident sent to (hospital name deleted) for psych eval/ resident continue on 1:1 supervision until (Emergency Medical Services) came and transported to ER .resident is alert and oriented, no s/s of behavior . An Incident Note, dated [DATE] at 7:28 p.m., documented, .Resident rec'd via (Emergency Medical Services) this PM at 1825 (6:25 p.m.). He came back with no new orders .Verified meds . No update to the care plan was documented. A Discharge Summary, dated [DATE] at 1:26 p.m., documented, .assessment r/t discharge from ACU to (hospital name deleted) .due to recent res to res event on [DATE] . An update to the care plan for behaviors, initiated on [DATE], documented, [DATE] res/res event, elder hit another elder. elder sent out of facility. A state reportable final Incident Report Form, dated [DATE], documented, .Facility staff observed resident (#1) strike (res. #3) in the head .(Res #1) placed on 1:1 with staff .(Res #1) with short and long term memory deficits due to dementia .Resident has dementia, intellectual disabilities, mental disorders .[MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident gets very anxious when someone takes his belongings .facility completed an initial investigation by interviewing staff .completing a focused assessments on the residents, an evaluation of their medication, medical and incident histories, chart and record reviews .Resident (#1) place on 1:1 with staff. Resident (#1) sent out for further evaluation. Upon completion of investigation, the facility believes the two residents, both with cognitive impairments, began to argue over a piece of paper and resident (#1) struck resident (#3) in the head but the facility is unable to substantiate the allegation of abuse due to cognitive impairments to the residents involved . Resident (#1) remains of out (sic) facility . An Admission Summary, dated [DATE] at 1:26 p.m., documented, .Focused assessment r/t readmission form (sic) (hospital name deleted) to ACU at 1245 .with dx of aggression/increased agitation .resident is calm and corporative (sic) .staff will continue to monitor and anticipate any needs . No updates/new interventions to the care plan were documented. An Incident Note, dated [DATE] at 5:39 p.m., documented, Focus assessment r/t Resident to resident event. This nurse observed resident and female resident tugging on each others shirts and becoming aggressive. Resident hit female resident punching female resident in the face with Right hand. Both residents were Yelling at each other. Staff separated residents. This resident placed on 1:1 .Cont. on 1:1 at this time .police notified. Resident easily redirected, however requires redirection multiple times . An Incident Note, dated [DATE] at 5:15 p.m., documented, Focused assessment r/t behaviors and discharge. At 1500 (3:00 p.m.), Resident was sitting in common area. No behaviors noted .At approximately 1630 (4:30 p.m.), resident picked up by (hospital name deleted) Transporters. Resident cooperative and entered van without any problems . An update to the care plan for behaviors, initiated on [DATE], documented, [DATE] Res to Res. Hit another resident in the face. A nurse's progress note, dated [DATE] at 3:11 p.m., documented, .assessment r/t readmission, elder readmitted back to facility .received verbal report from hospital, staff member stated that elder without any episode of agitation when at hospital .Resident happy to be back at facility . No updates/new interventions to the care plan were documented. An Incident Note, dated [DATE] at 6:37 a.m. documented, This nurse at the nursing station and heard (res. #2) asking (res. #1) 'take off the bug.' This nurse immediately rushed to the dining room where the two resident (sic) were sitting at this time. This nurse noted (res.#1) slapped and pushed down (res. #2) on the floor and she hit her head. This nurse noted spill of blood on the floor. This resident states 'she is trying to touch me. I do not like it here. I want to be the place I used to be before .' Separated the residents from getting to each other .Intervention in place to start one-on-one . An Incident Note, dated [DATE] at 6:34 p.m., documented, OKCPD notified @ approx 0900 .Spoke with resident on call .informed him of this resident to resident event. Nursing order received & noted to send to psych facility for eval & TX .continued 1:1 staff care until he left facility. Med Ride staff X1 came @ approx 8120 (sic) to transport .to (hospital name deleted). An update to the care plan for behaviors, initiated on [DATE], documented, [DATE] Res to res. Resident slapped and pushed down another resident. Resident to (hospital name deleted) psych facility. On [DATE] at 11:49 a.m., the DON was asked what interventions were put in place for residents demonstrating aggressive behavior. She stated, I think it would just depend. She stated sometimes they would separate them or there might be medication changes or they may send them out. She stated they would call the doctor to get orders from them and activities. She stated if it was aggressive behavior they would put the aggressor on 1:1 and call the doctor for further orders. The DON was asked how often care plans were updated. She stated they were updated everyday usually or as needed. The DON was asked if resident # 1 had a history of [REDACTED]. There has been an incident where he has pushed a resident down. The DON was asked what interventions had been put in place to monitor him. She stated, We sent him out to psych. We did some med changes on him. We brought him out here, (out of the unit) for activities and for meals. The DON was asked how many incidents of aggressive behavior had resident #1 been involved in from (MONTH) (YEAR) to (MONTH) 2019. She stated, I would have to look. I don't know. She stated she thought it was three. The DON was handed the incident reports for review. Then stated, Four. The DON was asked if resident #1's care plan had been reviewed and new interventions put in place after each incident. She stated, Yes. She was given resident #1's care plan to review and was asked again if the resident's care plan had been reviewed and new interventions put in place. She stated, I see those four listed on the care plan. The DON was asked if there were new interventions placed on the care plan regarding aggressive behaviors. She stated, On two of them, I see interventions. She stated she didn't see any new intervention on [DATE] and [DATE]. She stated she thought the resident had been sent out on [DATE]. The DON was asked if care plans were updated on readmission. She stated, Yes. She was asked if resident #1's care plan had been updated on his return. She stated, No. She was asked if it should have been. She stated, Yes. The DON was asked if any of the incidents involved the same resident. She stated, Yes. She stated, Three did. She was asked what resident was involved in the three incidents. She stated, (Resident #2 name deleted). The DON was asked if resident #2 had a history of [REDACTED]. She stated, Yes. She was asked what interventions had been put in place to help prevent inappropriate interactions with other residents. The DON reviewed the care plan and stated, We did do a medication adjustment for her on [DATE]. The DON was asked if there had been anything else. She stated, Then it says that we would attempt to keep them separate it was dated [DATE]. She was asked who was them. She stated resident #2 and resident #1. She then stated, That's all that I see. The DON was asked what staff had been working in the closed unit the morning of [DATE]. She stated LPN #7 and CNAs #8 and #9. She was asked who first became aware of the altercation between resident #1 and resident #2. She stated the residents had been in the dining room and LPN #7 heard resident #2 say something to the extent of there was something on resident #1's shirt. LPN #7 got up to see what they were doing. She saw resident #1 slap resident #2 and push her down. The DON stated this had happened between 6:30 a.m. and 7:00 a.m. She stated shift change was in the process of occurring. She stated when the

Based on interview and record review, it was determined the facility failed to provide care and services to ensure a resident's highest level of well being for one (#1) of three sampled residents observed to have sustained a fracture while in the facility. The facility failed to assess and intervene for resident #1 who had an injury of unknown origin; and failed to ensure hip precautions were followed for the resident who had a recent left [MEDICAL CONDITION]. This resulted in actual harm for resident #1 who sustained a right femoral intertrochanteric [MEDICAL CONDITION]. Findings: A facility policy, titled Fall Awareness Program, documented: "Purpose: The fall awareness program is designed to identify those residents who may be at risk for falls and injury. Policy: The fall risk assessment will be completed on all admissions, falls and significant changes. Falls and significant changes are reported to the Director of Nursing and the Quality Manager for review. Procedure: Evaluate Fall Risk Factors: 1. Review any health problems or conditions that can cause fall (cardiovascular, neuromuscular, orthopedic, perceptual, psychiatric). 2. Review medications (Antipsychotics, Antianxiety, Hypnotics, Antidepressants, Cardiovascular and Diuretics or other medications that potentially affect balance... 6. Review and investigate previous falls if able (time of day, last meal, usual or unusual activity, standing/walking, reaching, crowd of people, bowel or bladder urgency, glare or liquid on the floor, foreign objects, pattern of falls, medications given, vital signs taken and resident's usual pattern of interaction). 7. Complete Fall Risk Assessment and Pain Assessment Tools. 8. Upon completion of Fall Risk Assessment numeric scores of 25 or above, the resident is placed on Fall prevention Protocols." A facility policy, titled Admission, documented: "...After completing the admission exam, the nurse should verify the orders with the physician and order all medications and/or treatments from the pharmacy...The new resident will be monitored closely for the first 72 hours, every shift, to ensure familiarity of new surroundings and assessment of any problems." A facility policy, titled Policy: Nursing Documentation, documented: "Purpose: Nursing Documentation is complete, organized and addresses a resident's need, problems, capabilities, and limitations, as well as resident responses. Documentation also reflects changes in condition, care provided, and outcomes of interventions... Policy:..4. Accurately document the care provided to the resident and be at the time the care was given...11. Document the date and time the physician's orders [REDACTED]." The facility policy for Resident Abuse, Neglect and Misappropriation of Property did not address injuries of unknown origin. Reference Data: Posterior Hip precautions: Do not bend forward past 90 degrees. Do not cross your legs. Do not turn toes inward and do not twist. Do not turn knees inward or together. (www.AuroraHealthCare.org) Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Physician discharge instructions from the hospital, dated 03/28/14, documented "...Full weight bearing with posterior hip precautions. If you have any questions please call Dr. (name deleted) office (telephone number)." Review of the documentation revealed this physician's orders [REDACTED].#2). Further review of the resident's record revealed none of the nursing staff had reviewed the orders and clarified with the physician the interventions that were to be implemented for "Full weight bearing with posterior hip precautions" as ordered by the physician. Admission physician's orders [REDACTED]. ml injectable solution 40 mg subq q day, Tylenol 325 mg one tab po every 6 hours as needed for fever, [MEDICATION NAME] 10 mg po qd, [MEDICATION NAME] 17 gm po BID and [MEDICATION NAME] 50 mcg inh nasal spray one spray every day. physician's orders [REDACTED]." The same orders documented the resident fall assessment score was "50" and for a score of 25 or greater you must notify the physician and the family. The physician's admission orders [REDACTED]." The resident was placed on the facility Falling Star program, due to high risk for falls, with the following interventions documented: "Mobility 1 or 2 person assist (The following interventions had a check mark beside them) Call light within reach. Frequently used items within reach. Pathways clear, dry, clutter free & well lit. Lock wheelchair brakes before transfers. Appropriate non-skid footwear. Circle additional items below to increase safety..." Low Bed, Safety Fall Mat, and Frequent Visual Checks were circled. An Initial Plan Of Care, for the admitted [DATE], documented: "...#2 Falls Fall Score 50 (Score of 25 or more indicates at risk) 1. Assess resident's mobility and need for assist with transfers, toileting, ambulation. 2. Encourage resident to request assist with mobility, transfers, ambulation as needed. Call light in reach. 3. Keep pathways clear and free from clutter. 4. Keep area consistently clear and well lighted. 5. 1 person assist with transfers. 6. Observe for dizziness, excessive fatigue and unsteady gait. Encourage to rest as needed. 7. Call responsible party and physician to notify if at risk for falls. 8. Other chair alarm 9. Other safety mat; frequent visual checks... A form dated 03/28/14, titled MDS Range Of Motion, documented the resident had limitation on one side (L Hip) in range of motion that interferes with daily functioning or places the resident at risk of injury and partial loss of voluntary movement of the (L Hip) - resident is able to complete the required task but movements are slow, spastic, uncoordinated, rigid, choreiform, frozen, etc. on one or both sides. A form, dated 03/28/14 at 2:25 p.m., titled Resident - Data Collection (Initial Nursing Assessment) documented under Skin Condition "...Resident have bruises on her both hands, (R), (L) hip side, have 28 staples on (L) hip side, with no s/s of infection noted." A site diagram for skin condition documented the resident had areas to both elbows and the right and left sides of the hip. Functional status was documented as one person assist with transfers, partial weight bearing and ambulation with one person assist, wheelchair only, wheelchair/propels self." Bowel and Bladder Evaluation documented "Incont. of B & B...unaware of toileting needs due to Dementia." Psychological Aspects documented the resident answered questions reluctantly and was alert and oriented X 1." The nurse's note on the reverse side of the above form documented on 03/28/14 at 6:53 p.m., "Focused assessment r/t new admit... For (L) closed [MEDICAL CONDITION] is alert and oriented to person...Have 28 staples on (L) [MEDICAL CONDITION] bruises on her both hands, needs assistances when getting up...Moves (L) leg with assistance. (R) leg moves freely...MD notified and NO verified with medication..." No other fall prevention interventions were documented including the order for full weight bearing with posterior hip precautions.. A second nurse's note, dated 03/28/14 at 6:53 p.m., had been copied almost verbatim from the above note. The only deviations were: "...have bruises on her both hands, Hip (L) and needs assistance when getting up...(R) leg moves not freely..." A Skilled Daily Nurse's Note, dated 03/29/14 at 1:00 p.m., documented the resident was alert and disoriented to person, place and time (For both day and night shift) and was incontinent of bowel and bladder. The narrative portion of the same note documented, "...Staples to (L) hip CDI No swelling, redness or heat no drainage. Area has discoloration (R) of staples site red drk purple with yellow in center. Res holding area this am while in w/c c/o pain. [MEDICATION NAME] 7.5/325 mg one po given medication taken without diff. Res. able to stand bearing wt. on both legs with weakness. Slight [MEDICAL CONDITION] to (L) leg. Elev. while (arrow up) w/c slightly with foot pedal..." A nurse's note, dated 03/29/14 at 8:00 p.m., documented, "...Resident have (L) [MEDICAL CONDITION] with 28 staples have bruises (purple, redness on both hands and (L) hip) C/O pain, [MEDICATION NAME] 7.5/325 mg given...Resident tries to get up from wheelchair. Staff encourage this resident not to get up. Resident say OK..." There was no documentation of the wheelchair alarm in place. A Skilled Daily Nurse's Note, dated 03/30/14 at 9:00 a.m., documented the resident was alert and disoriented to person place and time for all 3 shifts (nights, days and evenings), was incontinent of urine and had decreased movement of the LLE. Bruises were documented for all shifts. The narrative portion of the note on the reverse side documented, "...Has not been cooperative with care. Has been hitting staff when assist with ADLS et pericare. (Arrow up) w/c with chair alarm (L) leg slightly elev with w/c pedal. (L) leg slight [MEDICAL CONDITION]. Pedal pulse present. (L) leg warm to touch. No s/s infec..." A nurse's note, dated 03/30/13 at 6:27 p.m., documented, "...Resident have (L) [MEDICAL CONDITION] with 28 staples, have bruises purple colors on both hands, redness on (L) hip. Resident uses wheelchair, propels around unit. C/O pain. 8 on a scale of 1-10. [MEDICATION NAME] 7.5/325 mg one po given. Resident refused to eat dinner..." A 5-day skilled assessment, dated 03/31/14, documented the resident was moderately impaired in cognitive skills for daily decision making and had no behaviors. She required extensive assist of one person for transfers, locomotion on and off the unit, dressing, personal hygiene and bathing. She had impairment in range of motion on both of the lower extremities. Balance was documented as not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and for surface to surface transfers (between bed and chair or wheelchair). She was frequently incontinent of bowel and bladder. She had pain frequently rated as an 8 (over the last 5 days) on a scale of 0-10. A nurse's note, dated 03/31/14 at 4:30 a.m., documented, "...(arrow down) in bed @ change of shift with CL in reach fall mat @ BS for prevention care. HOB (arrow up) X 45 (degrees) per client request PRN pain meds given @ (illegible) D/T c/o (L) hip pain with mod effect use of pillows for comfort measures. Staples @ outer (L) hip area intact without s/o infection noted skin appears to be closing well no drainage present...Discoloration @ (arrow down) (L) side R/T surgery..." A physical therapy note, dated 03/31/14, documented, "...Pt readily moves L LE on/off w/c footrest + lifted to don shoes. C/O (pain) R lat (lateral) hip c movmt (movement) of RLE to don shoes, lift for w/c mob (mobility) + standing. Discussed c nursing. Will hold gt (gait training) until x-ray R hip..." A physician's telephone order, dated 03/31/14 at 11:00 a.m., documented, "Xray (R) hip et leg D/T pain [MEDICATION NAME] 7.5/325 mg one po q 4 hours routine cont [MEDICATION NAME] 7.5/325 one po q 4 hours PRN pain." A physician's telephone order, dated 03/31/14 at 3:00 p.m., documented, "Send to (hospital name deleted) d/t poss fx." An x-ray report, dated 03/31/14, documented the resident had sustained a right femoral intertrochanteric [MEDICAL CONDITION]. A handwritten note on the Initial Plan of Care documented, "3/31/14 Hip Xray ordered on [DATE] (secondary to) decreased (arrow down) ROM (range of motion). Xray + (positive) for fx (fracture). Sent to ER. Elder to be moved closer to nurses station upon readmit." An OSDH Incident Report Form, documented on 03/31/14, the resident had certain injures and notifications were made to the physician and the family. The final report documented "Physical therapy notified nurse that elder complained of pain to right hip. PRN pain med given. Focus assessment completed on elder. No bruising swelling or heat noted to right hip and right leg. MD notified received order for xray. Xray complete positive for fracture to right hip. MD notified of xray results. Received order to go to ER. Family notified. Elder remains out of the facility." On 04/08/14 at 1:45 p.m., the surveyor asked the administrator to provide the facility policy and procedure to investigate injuries of unknown origin. At 2:20 p.m., the administrator stated "We don't have a policy. I thought we did but I was wrong." The surveyor asked the administrator to provide documentation of the investigation she had performed for the injury of unknown origin for resident #1 on 03/31/14. The administrator stated she had interviewed one LPN and two CNA's. The surveyor asked the administrator to provide documentation of the investigation. The administrator stated "I have it written down in notes somewhere I will have to find it." At 2:30 p.m., the surveyor asked the DON if she had interviewed anyone else regarding the injury of unknown origin on 03/31/14 for resident #1. She stated, "You mean other than who she (administrator) talked with, No." At 5:30 p.m., the surveyor asked CMA #2 if she had witnessed bruising to the resident's right hip or reported a fall. She stated, "I didn't provide any patient care, I only gave medicines. Her complaint was always generalized...I remember the right leg was slightly elevated with the foot pedal when she was up in the wheelchair. I remember she would try to get up...she had facial grimacing and would cry out when she had pain...I didn't witness a fall." At 6:10 p.m., LPN #2 was asked if the resident had full range of motion of her lower extremities when she performed the admission nursing assessment. She stated "She didn't move her right leg freely and she had a bruise on her right hip also, when I'm trying to do range of motion she told me 'No' on both sides." LPN #2 was asked if she knew the resident's weight bearing status. She stated "I did assessment with my knowledge and my skill, she couldn't stand at all, wouldn't bear weight at all." LPN #2 was asked if the resident had a physician's orders [REDACTED]. On 04/09/14 at 12:15 p.m., the administrator presented the surveyor with a piece of paper with the following handwritten documentation: "3-31-14 (Resident #1) Investigation Interviewed: (LPN #5) - no fall reported to him, unaware of any falls from (resident #1). (LPN #2) - no fall reported to her, unaware of any falls from (resident #1). (CMA #1) - doesn't know of any falls by (resident #1). (CMA #2) - doesn't know of any falls by (resident #1). Upon admission assessment showed bruising to both hips (left and right). (Resident #1) not able to fully move hip that did not have surgery. No falls reported to DON, QM, Admin. concerning (resident #1)." On 04/09/14 at 1:00 p.m., the administrator informed the surveyor she had just found out when speaking to one of the CNA's who cared for the resident, the resident had a fall which occurred on 03/28/14 on the 11-7 shift. The administrator stated CNA #2 informed her, she and LPN #2 found the resident on the floor next to her roommate's bed and assisted her back into her bed. At 2:05 p.m., the surveyor asked CNA #2 if she had assisted the resident back into bed after finding her on the floor on 03/28/14, and why she had not reported the incident. CNA#2 stated "The administrator did come to me today and ask me if I had any knowledge of how she (resident #1) fell or injured that right hip. That is when I told her, no-one had asked me about the right hip. (LPN #2) was told I found her on the floor and she helped me put her back into bed. The other aide was not on the unit at that time. I thought she reported it." At 2:10 p.m., the surveyor asked CMA #1 if she had witnessed the resident with bruising to her right hip or reported a fall. She stated, "The Monday she went out we went to stand her up and she grabbed the right hip, so we went and told LPN #3. We didn't let her stand, we eased her back down into the wheelchair." At 3:02 p.m., LPN #2 was asked if she had transcribed the physician's discharge order for full weight bearing status with posterior hip precautions to the admit orders or if she had clarified the order with the physician. She stated, "No I didn't see it so I didn't carry it over or clarify it with the physician." At 5:10 p.m., the surveyor asked CNA #5 if she had witnessed the resident with bruising to her right hip or reported a fall. She stated, "(Resident #1) was confused at times. She was in a lot of pain and would grab that right hip. I reported to both the LPN's on the 3-11 shift (LPN #2 and LPN #3). I am sure it was the right hip. If I lifted her leg two inches above the mattress, she would grab her right hip. I got adamant about it on Sunday and refused to get her out of bed." At 5:20 p.m., the surveyor asked LPN #3 if she had witnessed the resident with bruising to the right hip or reported a fall. She stated, "She had bruising to the right hip right before she left to go to the hospital, it was a faint yellow area bigger than your thumb. She had pain when she was moved. She moaned and cried." On 04/10/14 at 10:00 a.m., the administrator presented the surveyor with a typed form titled 'Hip Precautions' and stated they were in-servicing staff with the following documentation: "No crossing legs or ankles Do not bend too far forward or pull legs up past waist Avoid hip flexion greater than 90 degrees Feet 6 inches apart do not bring all the way together Hips should be higher than knees when sitting When lying in bed place pillows between knees No internal rotation of the foot Use log roll during bed mobility with pillow between legs Charge Nurses to ask Dr if you have any questions Nurse aides to ask charge nurse if you have any questions." Handwritten at the bottom of the page, "Placed in front of MARS (medication administration records), TARS (treatment administration records) & back of bathroom doors (employee)." At 3:10 p.m., the surveyor asked LPN #6 if she had witnessed the resident with bruising to her right hip or reported a fall. She stated, "On the 30th, during my initial assessment, I noticed she had faint bruising to the right hip, not old, not yellow or brown and it was silver dollar size. She had a fall mat, I don't know if she had a bed alarm."

On 03/04/14 at 9:00 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility to assess, monitor and intervene for Resident #1 after a low oxygen saturation of 78%. The Oklahoma State Department of Health was notified and verified the immediate Jeopardy situation. 03/04/14 the Administrator and the Director of Nursing were notified of the IJ situation. At 11:45 a.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "All residents requiring SaO2 will have a focused assessment related to oxygen saturation. If O2 saturation is below 90% appropriate interventions as per physician order [REDACTED]. 3-4-14 11:20 am All nurses will be in-services on recognizing signs and symptoms of illness and/or injury, appropriate assessment, monitoring and interventions. They will also be in-serviced on appropriate assessment, monitoring and interventions as per physician order [REDACTED]. 3-4-14 11:00 pm DON and designee will monitor oxygen saturation's daily for 30 days for appropriate interventions. Then random there after to ensure compliance. QA committee will monitor the effectiveness of the plan 3-4-14. On 03/04/14 at 3:00 p.m., thru 3:30 p.m., and 03/05/14 at 5:45 a.m., through 6:45 p.m., nursing staff from all shifts who attended the in-service were interviewed. They were knowledgeable in regard to assessment, monitoring and interventions of a resident with signs and symptoms of illness and/or injury, including decreased SaO2. On 03/04/14 at 11:00 p.m., the Immediate Jeopardy was removed after the staff had been in-serviced. The deficient practice remained at an isolated actual harm. Based on interview and clinical record review, it was determined the facility failed to ensure residents maintained their highest level of well-being for one (#1) of four sampled residents reviewed for changes in condition. The facility failed to thoroughly assess, monitor, and intervene for resident #1 after a decreased SaO2 of 78%. Resident #1 was admitted to the hospital with [REDACTED]. This had the potential to affect all 106 residents who resided in the facility. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, initiated 10/04/13 and last updated 01/13/14, documented, "...Problems/Needs... HTN, at risk for stroke and decreased cardiac output related to dx of HTN, [MEDICAL CONDITION] Approach...O2 2 LPM as needed for SOB, check O2 Sats Q shifts and prn..." A monthly physician's orders [REDACTED]...09/21/11 [MEDICATION NAME] per nebulizer Q 4 hrs prn dx: congestion...08/22/11 O2 2L/MIN PRN SOB...O2 SATS Q Shift..." A quarterly assessment, dated 01/03/14, documented the resident was independent in cognitive skills for daily decision making. She required supervision with transfers, bed mobility, ambulation locomotion, dressing, eating, hygiene and bathing. She had no functional limitations in range of motions and was frequently incontinent of bowel and bladder. A facility form, titled RESPIRATORY SHEETS, documented, "...from 02/01/14 thru: 02/28/14... [MEDICATION NAME] PER NEBULIZER Q 4HRS PRN DX: CONGESTION BI AT LUNGS..." There was no documentation any breathing treatment had been administered on 02/18/14 or 02/19/14. A nurse's note, dated 02/18/14 at 12:45 p.m., documented "...Focus assessment R/T res (up) to nurses station c/o SOB, coughing, lungs sound congested. O2sats fluctuating from 56% - 82% on R/A (room air). Res escorted to room. Assisted to bed O2 at 2L/nc prn placed on. O2 sats (up) 84% resident in bed resting quietly, (no) s/s of distress...(named physician) notified & given report. N.O...obtain CXR (chest x-ray)..." A nurse's note, dated 02/18/14 at 6:00 p.m., documented "focus assessment r/t (named x-ray company) at faciltiy..." A telephone order, dated 02/19/14 at 7:15 p.m., documented, "[MEDICATION NAME] 400 mg 1 Q day x 10 d for URI (upper respiratory infection)..." A facility form, titled Upper Respiratory Infection Charting, documented, "...Antibiotic: [MEDICATION NAME] 11-7 Shift Resident Temperature: 98.6 Adverse Reaction Yes (blank) No (checked) Cough: Yes (checked) No (blank) Productive Cough: (blank) Unproductive cough: (checked) Sputum Color: (blank) Consistency: (blank) Encouraged to Turn, Cough and Deep Breathe: Yes (blank) No (checked) Lung Sounds: congested Respirations Even and Unlabored:Yes (checked) Note: (blank) Nurses Signature (signed by LPN #3) Date:2/19/14..." A nurse's note, dated 02/19/14 at 3:30 a.m., documented, "...focus assess R/T N.O. new orders noted. Resting in bed c eyes closed. O2 Sats 78% O2 @ 2LPM N.C. Call light in reach..." A nurse's note, dated 02/19/14 at 8:30 a.m., documented, "...Focus Assess R/T called to residents room by CMA res (down) in bed c eyes closed unresponsive to verbal stimuli. Will open eyes to tactile stimulation. Res lungs congested. O2 (decreased) 67% c O2 at 2 lpm. B/P- 117/67 P - 99 R - 24 T - 98.9...N/O received to sent to (named hospital)..." A telephone order, dated 02/19/14 at 8:30 a.m., documented, "...send pt to (named hospital ER) for eval..." The resident returned to the facility on [DATE] from the hospital with a [DIAGNOSES REDACTED]. On 03/14/14 at 8:50 a.m., LPN #3 was asked what interventions were done with the O2 sats of 78% and where were they charted. She stated, "I got that. I had a CNA put a face mask on her and got her into the 90's. I usually put all my charting on the back of a report sheet. I left the mask on. We were in and out all night she was steady, no difficulty at all. I don't usually chart on the nurse's notes." At 8:55 a.m., LPN #3 was asked if she phoned the physician with the decreased O2 sats. She stated, "No, I just had the aide put the mask on because she's a mouth breather." The facility was unable to locate any documentation related to the decreased O2 sats or any interventions implemented. On 03/04/14 at 9:50 a.m., LPN #2 was asked at what time did he start the antibiotic ordered on [DATE]. He stated around 9:00 p.m. on the eighteenth. He was then asked what he received in report related to the resident experiencing decreased oxygenation saturation during the night. He stated, "I don't remember anything about low sats." LPN #2 was asked what the resident's condition was when he assumed care. He stated, "I had not seen her. Just got report she was down in bed and resting. I was in the dining room and the CMA called me to the room." On 03/05/14 at 5:30 a.m., CNA #2 who was on the resident's hall on 02/19/14 was asked to describe the events which took place when the O2 sats were 78%. She stated, "I don't remember exactly."

On 10/31/13 at 9:25 a.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent potentially hazardous chemicals from being ingested. The existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 9:35 a.m., the administrator, the corporate registered nurse (RN) and the corporate administrator were notified of the existence of the IJ. At 1:10 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: "Grace Living Centers NW 10th Street Plan of Removal 10-31-13 at 10:00am 1. A sweep of the building was conducted to remove any chemicals that may not be stored appropriately. 10:00am 2. All carts (housekeeping and treatment) have been checked for working keys and appropriate locking devices. 10:00am 3. All housekeeping staff have keys to the housekeeping carts. 10:30am 4. All carts that were identified as not locking have been stored behind locked doors by 10am. These carts have been repaired or replaced. 12:30pm. 5. Housekeeping staff and licensed nurses are being in-serviced to keep all carts locked when not in use. Housekeepers are to report to Housekeeping supervisor and/or administrator if they do not have a key to the housekeeping cart or if the cart is not locking appropriately. Licensed nurses are to report to DON and/or administrator if they don't have a key to the treatment cart or if the cart is not locking appropriately. In-services will be completed by 4pm today. 6. Random daily audits will be conducted by DON, administrator and/or designee for 30 days and findings will be reported to Quality Assurance committee. Quality Assurance committee will then determine further interventions if needed to insure compliance. 7. All staff will be in-serviced for chemical storage safety. We will have all staff in-serviced by midnight." On 11/01/13 at 2:25 p.m., the administrator was asked for the in-service presented for the chemical storage for the plan of removal. She presented copies of the in-service sign in sheet dated 10/31/13. The sign in sheet contained the copies of an in-service, dated 10/31/13, along with a list of employee signatures who attended the in-service. At 2:25 p.m., CMA #1 was interviewed. She was asked if she had had an in-service on 10/31/13. She stated she did. She was asked what it was about. She stated it was about keeping chemicals safe and locked up. She stated it was about proper storage of chemicals, who to notify, and if chemicals were found unattended and unsecured to secure it and notify the charge nurse. At 2:35 p.m., CNA #1 was interviewed. She was asked if she had had an in-service on 10/31/13. She stated she did. She was asked what it was about. She stated it was about proper use and storage of chemicals. She stated if any chemicals were found unsecured they were to be taken to the administrator. If a treatment cart or a housekeeping cart was left unlocked to yell for help and wait for someone to secure the chemicals. At 2:38 p.m., housekeeper #2 was interviewed. She was asked if she had had an in-service on 10/31/13. She stated she did. She was asked what the in-service was about. She stated they were to keep their housekeeping carts in view at all times, keep the cart locked when away from it, and keeping the chemicals in view and locked up. She was asked what to do if a chemical was found unsecured. She stated they were to take it to the administrator or the DON. She was asked where she kept her cart when she was not using it. She stated it was to be locked up in the soiled utility room. At 2:40 p.m., LPN #1 was interviewed. She was asked if she had had an in-service on 10/31/13. She stated she did. She was asked what it was about. She stated it was over chemical storage, what to do if unsecured chemicals were found and keeping the carts and doors locked. At 2:43 p.m., housekeeper #1 was interviewed. She was asked if she had an in-service on 10/31/13. She stated she had. She was asked what it was about. She stated they were to keep their carts secured, keeping all chemicals secured. She was asked what she was to do with her cart when she was in a resident's room. She stated they were to put the cart in front of the door, lock it and keep it in view at all times. She was asked where she was to store her cart when not in use. She stated she was to lock it up in the soiled utility room. At 2:55 p.m., the corporate RN and the corporate administrator were asked when the last staff member had been in-serviced. They stated the last staff member had been in-serviced on 10/31/13 at 6:15 p.m. The IJ was removed on 10/31/13 at 6:15 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, record reviews and interviews, it was determined the facility failed to provide supervision to prevent potentially hazardous chemicals from being ingested for one (#2) of three sampled residents. The facility identified 29 residents who were on the secured unit and wandered. Findings: Resident #2 had [DIAGNOSES REDACTED]. A significant change assessment, dated 07/22/13, documented the resident was severely impaired in cognitive skills for daily decision making. She was usually understood by others and usually understood others. She required limited assistance with transfers and ambulation. She used a walker to assist with ambulation. A care plan, dated 08/09/13, and last updated 10/21/13, documented, "...Res c bottle of cleaning product @ face c mouth open. Cleaning product dripped down side of face & down shirt. Resident assessed, 0 s/s of adverse effect, checked MSDS, gave 3 cups of water, showered & changed clothing, sent to ER for eval..." An incident report, dated 10/21/13 at 11:00 a.m., documented, "...Resident c bottle of cleaning product @ face c mouth open. Cleaning product dripping down side of residents face & down shirt. Resident assessed. 0 s/s of adverse effects. Drank 3 cups of water, skin rinsed then washed. Family & MD notified. Resident sent to ER for evaluation..." A nurse's note, dated 10/21/13 at 11:00 a.m., documented, "Focused assess r/t possible imbibement of cleaning products. Resident noted c bottle of cleaning product pointed @ face c mouth open. Cleaning product liquid dripped down face & shirt. Resident assessed. 0 s/s of dyspnea, [DIAGNOSES REDACTED] to skin or skin irritation. 0 irritation to mouth or oral mucosa. MSDS for stench and stain digestion reviewed. Resident assessed for s/s of allergic (illegible). Resident taken to shower room. Clothing removed skin flushed c water, then cleansed c soap. Resident given 3 cups of water to drink and finished 3 cups of water....Family notified. MD notified. Resident sent to (hospital name deleted) ER c copy of medication administration records treatment records, phys orders, lab, H & P, & transfer sheet c bed hold policy & face sheet. Resident taken to (hospital name deleted) ER accompanied by (ambulance company name deleted)." An environmental tour was conducted on 10/31/13 at 7:20 a.m., on the secured unit. A treatment cart was observed unsecured and unattended. An observation was made at 7:25 a.m., of a housekeepers cart outside a resident's room. The housekeeping cart had a bottle of hand sanitizer in the bucket on top of the cart. A bottle of 'One Step' cleaning solution was in front of the mop bucket. The housekeeping cart was unlocked. There were chemicals stored in the unlocked cart. A 'Material Safety Data Sheet' for the 'Betco One Step' cleanser documented, "...Section 3. Hazards Identification: Potential Acute Health Effects: Harmful if swallowed. Harmful if absorbed through the skin. Potential Chronic Health Effects: Severe over exposure may cause nervous system damage and kidney damage... Section 4. First Aid Measures:...Ingestion: NEVER give an unconscious person anything to ingest. Seek immediate medical attention. Contact a poison control center immediately for treatment advice. Do not induce vomiting unless instructed to do so be (sic) poison control center or doctor. Do not give anything by mouth to an unconscious person..." On 10/31/13 at 8:20 a.m., CNA #2 was interviewed. She was asked where the housekeeping carts were to be kept when the housekeepers were cleaning a resident's room. She stated the carts were kept outside the resident rooms when they were cleaning and in the locked room when they weren't using them. She was asked if she had ever heard of any residents who had obtained a chemical. She stated one of the residents had swallowed some and they sent her to the hospital. At 8:25 a.m., CNA #1 was interviewed. She was asked what the housekeepers did with their carts when they were cleaning a resident's room. She stated the housekeepers usually kept the carts by the room they were working in and they could keep an eye on the cart. She was asked if she had heard about any residents who had swallowed some chemical substance. She stated she had heard one of the residents had obtained a chemical substance and was sent to the hospital. She stated she had not been working when that happened. At 8:30 a.m., LPN #2 was interviewed. He was asked where chemicals were to be stored. He stated somewhere they could be monitored. He was asked if any residents had consumed any chemicals. He stated a resident had obtained a chemical. He stated first aid was required and she was sent to the hospital for evaluation. He was asked which resident had consumed the chemicals. He stated it was resident #2. He stated they were not sure if she had ingested any chemicals or not. On 10/31/13 at 8:40 a.m., a housekeepers cart was observed on hall 200. The housekeepers cart was observed with the door wide open. There were several bottles of cleaning chemicals observed inside. On top of the housekeepers cart there was liquid soap, and bottles of liquid deodorizer. An interview was conducted at 8:43 a.m., with housekeeper #2. She was asked what she did with her cart when she was in a resident's room cleaning. She stated she kept it right in front of her. She was asked when the cart was to be locked. She stated, "You're standing here and it was left open. I feel so bad." At 10:55 a.m., LPN #2 was asked what kind of chemical resident #2 had ingested. He stated he did not remember but it may have been some kind of floor stripper. At 1:10 p.m., the administrator was asked if the incident report regarding resident #2 had been reported to the OSDH. She stated it had not been reported.

Based on observation, clinical record review, review of policy and procedure, and staff interviews, it was determined the facility failed to assess, monitor and intervene for one (#26) of one sampled resident with bilateral lower [MEDICAL CONDITION]. This deficient practice resulted in actual harm to one resident who developed cellulitus of her bilateral lower extremities. This had the potential to affect 16 residents identified by the facility with lower extremity [MEDICAL CONDITION]. Findings: Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance from staff with transfers, dressing, toilet use, and bathing. She required supervision from staff with bed mobility and personal hygiene. She was continent of bowel and bladder. A care plan dated 06/21/13, documented, "...Problem at risk for skin breakdown Braden score 1, currently continent of bowel and bladder with DX of Alzheimer's dementia, anticipated decline... Goal Will have no skin breakdown x 90 days... Plan of Approach monitor skin daily with care for s/s of breakdown such as increased redness, excoriation, open areas..." A physician's telephone order dated 07/01/13, documented, "[MEDICATION NAME] 40 mg 1 po daily Dx 2+ [MEDICAL CONDITION]" A physician's telephone order dated 07/02/13, documented, "...Elevate legs (with) pillows while in bed dx [MEDICAL CONDITION]" A nurse's note dated 07/02/13, documented, "...currently skin (with) [MEDICAL CONDITION] +3 from upper L shin to dorsal foot..." A physician's telephone order dated 07/09/13, documented, "...Send to ER for eval per request of daughter..." A patient transfer form dated 07/09/13, documented, "...Chief complaint/reason for visit Swelling to lower extremities..." A hospital emergency room flow sheet dated 07/09/13 at 2:00 p.m., documented, "[MEDICAL CONDITION] amount (upper leg bilateral) 4+ severe/8 mm, dependent, pitting..." An ER report dated 07/09/13 at 2:23 p.m., documented, "...Musculosketal:...lower extremity: bilateral, distal. swelling, [DIAGNOSES REDACTED]..." A History and Physical dated 07/09/13 at 4:37 p.m., documented, "...admitted : 07/09/2013... Chief Complaint: Swollen leg... History of present illness:...The daughter tells me that she began having swelling in her legs in May. She tells me that despite numerous discussions with nursing home staff and being told they would get her some [MEDICATION NAME], no [MEDICATION NAME] was actually started until about the 2nd of July. Despite this, legs have gotten even more swollen and she asked them to send her to the emergency room . Her concern was that the legs have gotten so swollen they are turning red and they are leaking fluid... Review of Systems... Skin:...The legs have recently turned red. Again, they have been draining..." A hospital discharge summary dated 07/12/13, documented, "...Discharge Diagnosis: [REDACTED]. A physician's telephone order dated 07/12/13, documented, "[MEDICATION NAME] 100 mg po BID x 12 days. Dx: cellulitus..." A Telephone Admission/Readmission Order sheet dated 07/12/13, documented, "...[DIAGNOSES REDACTED]. On 07/25/13 at 7:00 a.m., LPN #1 was asked if she recalled when the resident was sent to the hospital a few weeks earlier. She stated, I recall when the daughter requested to send her to ER." She was then asked why her daughter wanted to send her to the ER. She stated, "She was talking about concerns with her legs." LPN #1 was asked what the concerns were. She stated, "They looked like they were swollen that day." She was then asked if anything else was going on with her that day. She stated, "No." She was asked if the resident's legs were swollen before the day she went out to the hospital. She stated, " I think she had maybe, not entirely sure. She wore pants a lot up until recently when her daughter started bringing dresses." She was asked where in the clinical record she would document the events leading up to her transfer to the hospital. She stated, "I would have documented. I probably started to document in the chart and got distracted and didn't go back." She was then asked who performed the skin assessments. She stated each nurse was assigned skin assessments. She stated, "They are in the treatment book." At 7:30 a.m., the DON was asked who was assigned weekly skin assessments. She stated, "Skin assessments depend on Braden. It must be 18 or less." At 7:50 a.m., the DON approached the survey team and stated, "In (named LPN #1) defense she called and told me the resident's legs were weeping. She probably just didn't chart." On 07/26/13 at 8:10 a.m., the wound care nurse was asked to describe the resident's [MEDICAL CONDITION] and how it progressed. She stated, "I did not see her leg after the second before she went to the hospital. When I was going to go down there to look the daughter had already had the nurse call EMSA." At 8:15 a.m., the DON was asked if the unit nurse assessed the [MEDICAL CONDITION] or just the wound care nurse. She stated, "Yes, the nurse assessed. It would be in the nurses' notes." She was then shown the clinical record and asked for the documentation related to the [MEDICAL CONDITION]. She could not find the documentation in the clinical record. She stated, "I would like to go look upstairs." No records were found.

Based on record review and staff interviews, it was determined the facility failed to ensure a resident who had recurring falls with injuries was provided with adequate supervision to prevent falls and had interventions in place to aid in the prevention of falls for one (#10) of 9 sampled residents who experienced falls in the facility. This deficient practice resulted in actual harm to resident #10 related to recurring falls with injuries. This had the potential to affect 63 residents identified by the facility who had falls in the last six months. Findings: A policy titled 'Fall policy', documented, "...The fall risk assessment will be completed on all admissions, readmission, falls, and significant changes... Falls and significant changes are reported to the Director of Nursing and the Quality Manager for review... Procedure: Evaluate Fall Risk Factors: 1. Review any health problems or conditions that can cause fall. (Cardiovascular, Neuromuscular, Orthopedic, perceptual, psychiatric)... 3. Review appliances and devices for possible problems as well as the resident's use of the appliance or device... 6. Review and investigate previous falls if able. (time of day, last meal, usual or unusual activity, standing/walking, reaching, crowd of people, bowel or bladder urgency, glare or liquid on the floor, foreign object, pattern of falls, medications given, vital signs taken, and resident's usual pattern of interaction)... Fall Awareness Protocol: (score 25 or above on fall risk assessment)... 7. Consider Rehabilitation Screen, if appropriate. 8. Institute bowel/bladder routine program, as appropriate..." Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's score on the Fall Risk assessment dated [DATE], was a 65 and on 05/01/13, her score was a 75. A score greater than ten indicated the resident was a high risk for falls and should be placed on the fall awareness program. The comprehensive assessment dated [DATE], documented the resident was sometimes able to make herself understood and rarely/never understood others. The resident required limited one person assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. She required supervision with one person assistance with walking on the unit and was independent with walking in her room. She required supervision set up assistance with locomotion on the unit and supervision one person assistance with locomotion off the unit. The assessment documented the resident was having falls with injury since admission. The CAAs (Care Area Assessment) dated 10/30/12, documented falls as a triggered care area and a fall score of 55. The care plan dated 07/18/13, documented, "...Problem/Needs: At risk for falls related to decreased cognition, paces, poor vision, poor safety judgment, history of previous hip fx... Goals/Objectives: Will have no to minimal injury with any falls x 90 days (Dx of osteoporosis risk of fractures) 4/29/13 Multiple falls this quarter 3 resulting in minor injury ... Approach: 05 11/06/12 FallR5 Check Elder often and provide care such as toileting, hydration, nutrition, rest and social interaction..." An incident report dated 01/30/13 at 5:30 p.m., documented, "...a resident informed CNA that a resident was on the floor. Elder sitting on floor with back against door jam... Injury to resident's back area." A new intervention was to place a chair alarm in wheelchair to notify staff when elder gets up. Neuro checks per policy. An incident report dated 02/04/13 at 8:00 p.m., documented, "...Elder was sitting in w/c. This nurse came out of a room & observed elder lying on floor face up c wheel chair at her head..." There was no injury documented. New intervention was to encourage elder to attend morning exercise class for strengthening. An incident report dated 02/28/13 at 12:30 a.m., documented, "...Resident observed coming out of rm, when she appeared to slip and fall- urine found on floor, L shoulder bruised sm. 1/2 cm s/t to L elbow first aid given c/o L shoulder hurting Bruise L forehead Hematoma L forehead..." No new interventions were documented for the prevention of falls. A nurse's note dated 02/28/13 at 12:30 a.m., documented, "...Dr. called orders to transfer to Deaconess hospital for eval & tx..." A hospital note dated 02/28/13, documented, "... Clinical Impression: SL6 02/28/2013 03:03 1. Fall 2. Contusion, Forehead 3. Ligamentous Sprain, Left Shoulder..." An incident report dated 03/26/13 at 5:40 p.m., documented, "...This nurse heard chair alarm, went to investigate and found Elder on her knees c arms on seat of recliner in another resident's room..." No injuries noted. The new intervention was to put elder to bed 30 minutes after dinner. An incident report dated 05/01/13 at 11:20 a.m., documented, "...This nurse investigated crying coming from down the hall, found res. lying on R side holding her head c the w/c on the floor behind her. ROM WNL for res. no bruising noted at this time large hematoma to R posterior side of her head..." The new intervention was to do visual checks every two hours. A nurse's note dated 05/01/13 at 12:50 p.m., documented, "...Res. AAOx1, self, attempting to awake. EMSA notified of event and they transported res. to Deaconess Hospital for eval & tx..." A discharge instructions sheet dated 05/01/13 at 3:16 p.m., documented, "...CONCUSSION WHAT IS A CONCUSSION? A concussion occurs when there is a rapid transient interruption in the normal function of the brain. This is often caused by trauma, such as a fall or blow, to the head..." An incident report dated 05/15/13 at 9:15 p.m., documented, "...Observed beside another resident's bed by a CNA. On assessment, bruises were noted to R back of the head & R shoulder..." New intervention was to xray shoulders and staff education. An incident report dated 06/13/13 at 9:35 a.m., documented, "...This nurse heard cry for help, elder sitting on bathroom floor c legs in room trying to get up, holding on to frame of door..." Injury documented on diagram to right mid back and right lower leg. No new interventions were documented for the prevention of falls. An incident report dated 06/14/13 at 1:00 p.m., documented, "...resident in another resident's room, attempted to stand up in a wheelchair, chair alarm alerted staff, resident fell on bottom in floor..." Injury documented on diagram to right mid back and right lower leg. New intervention was to engage in activity for redirection. An incident report dated 06/17/13 at 7:00 p.m., documented, ..."Res was in w/c & attempted to stand up by recliner-lost balance & held onto recliner then went to the floor..." No injury documented. No new interventions were documented for the prevention of falls. An incident report dated 06/21/13 at 9:30 p.m., documented "...Res attempted to transfer self from w/c to bed s assist, w/c alarm sounded. I went to res room as I entered resident slid down side of bed landing on coccyx and hitting arm on w/c..." Resident had skin tear to her left elbow. The new intervention was to continue with the chair alarm. An incident report dated 07/12/13 at 10:00 p.m., documented, "...Res fell to floor from W/C S/T L elbow o other injurys neuro (check mark) initiated..." New interventions were to continue with bed alarm, nonskid footwear and check alarms to ensure all are operational. An incident report dated 07/18/13 at 4:00 p.m., documented, "...Res on floor in room near bed..." No injury documented. No new interventions were documented for the prevention of falls. All incident reports listed above have corresponding nurses' notes with the same documentation. On 07/24/13 at 9:15 a.m., the DON was asked if new interventions were implemented with resident falls. She stated, "Yes." On 07/25/13 at 3:30 p.m., the ADON was asked if new interventions on the fall incident reports for the resident had been updated on the care plan. She stated, "No."

Based on record review, observation and staff interview, it was determined the facility failed to ensure services were provided to maintain a resident's ability to ambulate for one (#10) of 19 sampled residents whose clinical records were reviewed for maintenance of their ability to perform activities of daily living (ADLs). The deficient practice resulted in harm to the resident when the facility did not intervene as she declined from being independent with ambulation to becoming non-ambulatory. The Resident Census and Conditions of Residents documented six residents were independently ambulatory and 25 residents ambulated with assistance or an assistive device. Findings: A facility policy titled 'Restorative Nursing Phase 1' documented, "...Policy: It is the policy of Grace Living Center to provide restorative nursing services to promote the resident's ability to adapt and adjust to living as independently and safely as is possible. This concept actively focuses on maintaining optimal physical, mental and psychosocial functioning. Skill practice in such activities as walking and mobility, dressing and grooming, eating and swallowing, transferring, amputation care, and communication can maintain function in physical abilities and ADLs and prevent further impairment..." Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment dated [DATE], documented the resident had severe cognitive impairment and ambulated independently. The quarterly assessment dated [DATE], documented the resident had severe cognitive impairment and ambulated independently. The care plan updated 07/18/13, documented, "...Problem/Needs: At risk for falls related to decreased cognition, paces, poor vision, poor safety judgment, history of previous hip fx..." Goals/Objectives: Will have no to minimal injury with any falls x 90 days (Dx of [MEDICAL CONDITION] risk of fractures) 4/29/13 Multiple falls this quarter 3 resulting in minor injury ... Approach: 12 11/06/12 A Elder will pace, encourage frequent rest periods, redirect pacing behaviors..." On 07/24/13 at 4:30 p.m., the resident was observed sitting in her wheelchair at the dining room table in the ACU. At 4:57 p.m., the resident was observed leaving the dining room table in her wheelchair propelling it with her feet. At 5:00 p.m., the resident was observed in room [ROOM NUMBER] in her wheelchair. At 5:15 p.m., the resident was observed in the dining room area in her wheelchair. At 5:30 p.m., the resident was observed in the dining room area in her wheelchair at the table. At 5:35 p.m., the resident was observed in the dining room area in her wheelchair at the table eating a snack. At 5:45 p.m., the resident was observed in the dining room area in her wheelchair at the table. At 6:05 p.m., the resident was observed in the dining room area in her wheelchair at the table. On 07/25/13 at 7:30 a.m., the resident was observed in her wheelchair at the dining room table. At 8:00 a.m., the resident was observed in her wheelchair at the dining room table eating breakfast. At 8:15 a.m., the resident was observed in her wheelchair at the dining room table eating breakfast. At 8:25 a.m., the resident was observed propelling her wheelchair with her feet in the hall. On 07/24/13 at 2:40 p.m., LPN #1 was asked if the resident had ever been placed on a restorative program to help maintain her walking ability. She stated the resident had never been placed on a restorative program. On 07/25/13 at 8:40 a.m., an interview was conducted with the Restorative Aide. She was asked if the resident had ever been placed on a restorative program to help maintain her ambulation/walking. She stated the DON/nursing will tell her if a resident needs to be placed on the restorative program and then she will write a care plan. She stated the resident had not ever been on a restorative program. On 07/25/13 at 11:00 a.m., CNA #1 was asked if resident #10 was ambulating when she was admitted to the facility. She stated she was doing both. She stated she started using the wheelchair more after her falls and now she doesn't walk at all. At 11:55 a.m., the DON was asked if resident #10 was ambulating when she was admitted to the facility and when she started using her wheelchair for mobility. She stated she would have to review the chart and let this surveyor know. The DON never replied to the above question. At 12:00 p.m., MDS Coordinator #1 was asked if resident #10 was ambulating when she was admitted to the facility and when she started using a wheelchair for mobility. She stated she was ambulating independently when she was admitted to the facility. She stated at what point they put her in the wheelchair permanently she did not know. She was asked who "they" was. She stated, "The people in the unit, the nurses in the unit."