Every finding on record at First Shamrock Care Center

Based on record review and interview, the facility failed to ensure a resident with exit seeking behaviors had care plan interventions to address and prevent elopement for 1 (#19) of 3 sampled residents reviewed for accidents. Resident #19 eloped through a facility window. The administrator identified 16 residents at risk for elopement. On 04/28/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident with exit seeking behaviors had care plan interventions to address and prevent elopement resulting in Resident #19 eloping.On 04/28/26 at 6:43 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 04/28/26 at 6:53 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On 04/29/26 at 3:02 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Elopement policy and procedures reviewed and revised - signature 4.30.2026 at 12 PMResident #19 care plan was reviewed and revised at 9:36 pm and added new interventionsMedical Director notified IJ -7:50pmReviewed and updated elopement book - update 4.30.2026 12:55 pmAll resident's elopement observation updated - 9:35 pm, new residents elopement assessment completed on 37 residentsMedications reviewed with medical director no new orders - 8:00pm on resident # 19QAPI will monitor plan of removalFamily for resident #19 was notified at 8:03 pm for IJ/new interventions placedMaintenance walked parameter and checked all windows at 9:41pm for safety and will continue with daily monitoring for safety all residentsAll staff in serviced on elopement policy and procedures 7:15 pm in-service conducted by Administrator, corporate nurse consultant in-serviced the Administrator on elopement. A copy of the policy and procedures on elopement was placed on bulletin board for staff to review. Staff verbalized understanding of policy by question and answer and understood location of policy to review if any questions arise. Update inservice completed on missing employees 4.30.2026 12:55 pmAll residents' care plans were updated for elopement risk 9:50 pmReview and revised care plan policy and procedures and posted on bulletin boards 7:30pmMDS nurse in serviced over care plans policy and procedures 12:30 pm 04/29/26POR completed 04/30/2026 at 1:08 pm.On 04/30/26, the IJ was lifted when all components of the plan of removal had been verified as completed. Staff in various departments and shifts were interviewed regarding elopement policy and procedures and missing resident drill procedure. The MDS nurse was interviewed on the care plan policy and procedure for elopement risk residents. All staff interviewed were knowledgeable on the education and training provided. The plan of removal records including facility's elopement policy and procedure, elopement risk audit with updated care plans interventions, staff in-service with signatures to attest understanding of the training received, maintenance log for windows and door lock checks, posting of the elopement/care plan policy and procedure on the bulletin board, QAPI plan to monitor plan or removal, resident representative and provider notification were reviewed.The deficiency remained at a pattern with the potential for more than minimal harm that is not immediate jeopardy. Findings:A nursing admission assessment for Resident #19, dated 07/28/25, showed the resident wandered and their cognition was severely impaired.A wandering and elopement risk assessment for Resident #19, dated 07/28/25, showed four areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. The areas marked yes on the assessment were placement in the facility, history of wandering, confusion and disorientation, and dementia. A wandering and elopement risk assessment for Resident #19, dated 01/29/26, showed two areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. The areas marked yes on the assessment were placement in the facility, and dementia. A quarterly assessment for Resident #19, dated 01/29/26, showed the resident had memory problems. The assessment did not show Resident #19 wandered. An elopment care plan for Resident #19, initiated 03/21/26, showed the resident was at risk for elopement. The care plan showed the resident had diagnoses which included unspecified schizophrenia and unspecified dementia, unspecified severity, with agitation. There was no documentation to show the resident had a care plan for wandering and elopement risk prior to 03/21/26.A nursing note for Resident #19, dated 03/21/26 at 7:04 p.m., showed the resident was sitting in Dietary Aide #2's truck. Resident #19 informed Dietary Aide #2 they were looking for their underwear and had them in their hands. Resident #19 became agitated because they did not want to be at the facility.A combined initial and final state reportable, incident date 03/21/26, showed Resident #19 was observed sitting in an employee's vehicle. The report showed the resident was an elopement risk and Resident #19 exited through a window of an empty room. The report showed the window was secured and the resident was placed on one on one with a staff member.On 04/28/26 at 1:08 p.m., LPN #1 stated Resident #19 had occasional exit seeking behaviors since admission to the facility.On 04/28/26 at 1:11 p.m., LPN #1 stated Dietary Aide #2 brought the resident to them and informed them the resident was sitting in their truck on 03/21/26. They stated the truck was in the back of the facility.On 04/28/26 at 1:28 p.m., the DON stated they were not sure how to determine from the elopement assessment if the resident was at risk for elopement. They stated they were not sure what question #3-#7 was on the elopement assessment.On 04/28/26 at 3:05 p.m., CNA #2 stated Resident #19 had behaviors of wanting to get out of the facility prior to the elopement incident. On 04/28/26 at 3:10 p.m., CNA #1 stated Resident #19 had exit seeking behaviors prior to the elopement incident. They stated the resident would go to the exit door, attempt to put in codes, kick the door, and would set off the door alarms.On 04/28/26 at 5:17 p.m., MDS Coordinator #1 stated Resident #19's care plan did not have interventions for wandering. They stated the care plan should include wandering interventions if the wandering assessment showed the resident wandered.On 04/28/26 at 5:20 p.m., MDS Coordinator #1 stated they were not aware Resident #19 had exit seeking behaviors or tried to get out of the facility prior to the incident on 03/21/26.On 04/28/26 at 5:21 p.m., MDS Coordinator #1 stated they could have obtained information on resident behaviors from staff interviews.On 04/28/26 at 5:22 p.m., MDS Coordinator #1 stated staff interviews were not usually part of their process for care plan development or revision. They stated they may ask staff about medication refusal or activities of daily living. MDS Coordinator #1 stated if a resident had exit seeking behaviors, they should have care plan interventions.On 04/29/26 at 1:19 p.m., Dietary Aide #2 stated they were in the kitchen and looked out of the window and saw the resident had one foot inside the truck and another on the truck step. They stated they ran outside to the resident and brought them back inside. Dietary Aide #2 stated they informed the nurse the resident was in their truck. They stated it was around 7:00 p.m. because they were getting ready to leave for the day. Dietary Aide #2 stated the truck was parked behind the facility building close to the kitchen.On 04/29/26 at 1:23 p.m., Dietary Aide #2 stated they did not lock the truck, and the keys were in the truck in one of the compartments.

Based on observation, record review, and interview, the facility failed to:a. provide adequate supervision and a secure environment to prevent elopement for a resident with known exit seeking behaviors for 1 (#19). Resident #19 eloped through a facility window, andb. implement fall interventions for 1 (#3) of 3 sampled residents reviewed for accidents. An admission assessment for Resident #19, dated 07/28/25, showed the resident wandered and their cognition was severely impaired.A wandering and elopement risk assessment for Resident #19, dated 07/28/25, had four areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. The areas marked yes on the assessment were placement in the facility, history of wandering, confusion and disorientation, and dementia. A wandering and elopement risk assessment for Resident #19, dated 01/29/26, had two areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. he areas marked yes on the assessment were placement in the facility, and dementia. An elopement care plan for Resident #19, initiated 03/21/26, showed the resident was at risk for elopement. The care plan showed the resident had diagnoses which included unspecified schizophrenia and unspecified dementia, unspecified severity, with agitation. The care plan for Resident #19 did not show a concern for wandering and elopement risk prior to 03/21/26.A nursing note for Resident #19, dated 03/21/26 at 7:04 p.m., showed the resident was seated in a Dietary aide #2's truck. Resident #19 informed them they were looking for their underwear and had them in their hands. Resident #19 became agitated because they did not want to be at the facility.A combined initial and final state reportable form 283, with an incident date of 03/21/26, showed Resident #19 was observed to be seated in an employee's vehicle. The report showed the resident was an elopement risk and Resident #19 exited through a window of an empty room. The report showed the window was secured and the resident was placed on one on one with a staff member.On 04/28/26 at 1:53 p.m., the facility manager and the surveyor observed room [ROOM NUMBER] where Resident #19 exited the building. The window had a Plexi glass with a small, opened area along the vertical edge. The window could easily open when pushed gently. The door to the room was not locked.The facility manager identified 37 residents resided in the facility. The administrator identified 16 residents at risk for elopement.On 04/28/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide adequate supervision and a secure environment to prevent elopement for a resident with known exit seeking behaviors resulting in Resident #19 eloping.On 04/28/26 at 6:43 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 04/28/26 at 6:53 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On 04/29/26 at 3:02 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Elopement policy and procedures reviewed and revised -signature 4.30.2026 at 12 pm to ensure a safe environment and reasonable measures to prevent elopement and how to recognize areas of concern and how/who to report tooResident #19 care plan was reviewed and revised at 9:36 pm added new interventionsMedical Director notified IJ -7:50 pmReviewed and updated elopement book - update 4.30.2026 12:55 pmAll resident's elopement observation updated - 9:35 pm, new residents elopement assessment completed on 37 residents -complete elopement observation when due and determine if resident is an elopement risk through dx physical state, mental state, interviews and review of nursing notes, clinician recommendations, behaviors and then update care plan accordingly to riskMedications reviewed with medical director no new orders-8:00 pm on resident #19QAPI will monitor plan of removalFamily for resident # 19 was notified at 8:03 pm by SSD about IJ status and new interventions placedMaintenance walked parameter and checked all windows at 9:41pm for safety and will continue with daily monitoring for safety all residents - Maintenance will secure windows with screws to ensure windows do not operate. 4:15pm update maintenance written log and initialedAll staff in serviced on elopement policy and procedures 7:15 pm in-service conducted by Administrator, corporate nurse consultant in-serviced the Administrator on elopement. A copy of the policy and procedures on elopement was placed on bulletin board for staff to review. Staff verbalized understanding of policy by question and answer and understood location of policy to review if any questions arise. Update inservice completed on missing employees 4.30.2026 12:55 pmAll residents' care plans were updated for elopement risk 9:50pmReviewed care plan policy and procedures and posted on bulletin boards 12:55 pm. Educated MDS nurse on this policy and procedure 12:30 pmPOR completed on 04/30/2026 at 1:08pm.On 04/30/26, the IJ was lifted when all components of the plan of removal had been verified as completed. Staff in various departments and shifts were interviewed regarding elopement policy and procedures and missing resident drill procedure. The MDS nurse was interviewed on the care plan policy and procedure for elopement risk residents. All staff interviewed were knowledgeable on the education and training provided. The plan of removal records including facility's elopement policy and procedure, elopement risk audit with updated care plans, staff in-service with signatures to attest understanding of the training received, maintenance log for windows and door lock checks, posting of the elopement/care plan policy and procedure on the bulletin board, QAPI plan to monitor plan or removal, resident representative and provider notification were reviewed. Observation of secured windows was completed. room [ROOM NUMBER] was locked and not in use.The deficiency remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. Findings: 1. On 04/28/26 at 1:53 p.m., the facility manager and the surveyor observed room [ROOM NUMBER] where Resident #19 exited the building. The window had a Plexi glass with an open area along the vertical edge. The window could easily open when pushed gently. The door to the room was not locked. A nursing admission assessment for Resident #19, dated 07/28/25, showed the resident wandered and their cognition was severely impaired. A wandering and elopement risk assessment for Resident #19, dated 07/28/25, had four areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. The areas marked yes on the assessment were placement in the facility, history of wandering, confusion and disorientation, and dementia. A wandering and elopement risk assessment for Resident #19, dated 01/29/26, had two areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. The areas marked yes on the assessment were placement in the facility, and dementia. A quarterly assessment for Resident #19, dated 01/29/26, showed the resident had memory problems. An elopement care plan for Resident #19, initiated 03/21/26, showed the resident was at risk for elopement. The care plan showed the resident had diagnoses which included unspecified schizophrenia and unspecified dementia, unspecified severity, with agitation. The care plan did not show a concern for wandering and elopement risk prior to 03/21/26. A nursing note for Resident #19, dated 03/21/26 at 7:04 p.m., showed Resident #19 was sitting in a Dietary Aide #2's truck. Resident #19 informed Dietary Aide #2 they were looking for their underwear and had them in their hands. Resident #19 became agitated because they did not want to be at the facility. A combined initial and final State reportable, incident date 03/21/26, showed Resident #19 was observed sitting in an employee's vehicle. The report showed the resident was an elopement risk and Resident #19 exited through a window of an empty room. The report showed the window was secured and the resident was placed on one on one with a staff member. On 04/27/26 at 9:31 a.m., Resident #19 denied trying to leave the facility. They stated they would like to live in their own apartment. On 04/28/26 at 1:02 p.m., LPN #1 stated they cared for Resident #19 since they were admitted to the facility. They stated the resident went in and out of other rooms and was oriented to self. On 04/28/26 at 1:08 p.m., LPN #1 stated Resident #19 had occasional exit seeking behaviors since admission to the facility. On 04/28/26 at 1:11 p.m., LPN #1 stated the Dietary Aide #2 brought the resident to them and informed them the resident was sitting in their truck on 03/21/26. They stated the truck was in the back of the facility. LPN #1 stated the window had tape on it and must have come off. On 04/28/26 at 1:18 p.m., LPN #1 stated Resident #19 continued to have exit seeking behaviors after the elopement incident on 03/21/26. On 04/28/26 at 1:28 p.m., the DON stated they were not sure how to determine from the elopement assessment if the resident was at risk for elopement. They stated they were not sure what question #3-#7 was on the elopement assessment. On 04/28/26 at 1:44 p.m., the facility manager stated they did not have documentation to show in-service on elopement was provided to staff. On 04/28/26 at 1:46 p.m., the facility manager stated a review of the facility's video monitoring showed Resident #19 entered room [ROOM NUMBER] on the day of the incident. On 04/28/26 at 1:50 p.m., the facility manager stated residents could get out of the window in room [ROOM NUMBER] and any other windows in the facility. On 04/28/26 at 1:54 p.m., the administrator stated the window in room [ROOM NUMBER] was not secured and a resident could elope. On 04/28/26 at 2:57 p.m., the facility manager stated they no longer had the video footage of the Resident entering room [ROOM NUMBER]. They stated during the investigation the resident was seen on video electronic monitoring device entering room [ROOM NUMBER] around 6:30 p.m. and was found in the truck around 7:10 p.m. On 04/28/26 at 2:59 p.m., the facility manager stated at the time of the incident, the window in room [ROOM NUMBER] was Plexi glass taped with two boards. They stated after the incident they had secured the window with silicone tape. On 04/28/26 at 3:05 p.m., CNA #2 stated Resident #19 had behaviors of wanting to get out of the facility prior to 03/21/26. They stated after the incident, the resident would wait at the front door exit seeking and would go into rooms to see if the window was open. On 04/28/26 at 3:07 p.m., CNA #3 stated Resident #19 tried to leave the facility and had kicked the glass of the front door attempting to get out a week ago. They stated the resident tried to follow people out of the door. On 04/28/26 at 3:10 p.m., CNA #1 stated Resident #19 had exit seeking behaviors prior to the elopement incident. They stated the resident would go to the exit door, attempt to put in codes, kick the door, and would set off the door alarms. On 04/28/26 at 3:14 p.m., Hospitality Aide #1 stated they had seen Resident #19 at the front door exit seeking and tried to follow people out after the elopement incident. On 04/29/26 at 1:19 p.m., Dietary Aide #2 stated they were in the kitchen and looked out of the window and saw the resident had one foot inside the truck and another on the truck step. They stated they ran outside to the resident and brought them back inside. Dietary Aide #2 stated they informed the nurse the resident was in their truck. They stated it was around 7:00 p.m. because they were getting ready to leave for the day. Dietary Aide #2 stated the truck was parked behind the facility building close to the kitchen. On 04/29/26 at 1:23 p.m., Dietary Aide #2 stated they did not lock the truck and keys were in the truck in one of the compartments. On 04/29/26 at 1:33 p.m., Dietary Aide #2 stated they did not receive an in-service on elopement after the incident. 2. On 05/06/26 at 1:14 p.m., Resident #3 was observed to lie awake in a low positioned bed. No fall mat was observed in the room. Resident #3 was observed as unable to communicate well when greeted. On 05/06/26 at 1:25 p.m., CNA #5 was observed to enter the room of Resident #3 and locate the fall mat, when asked. CNA #5 was observed to look around the room several minutes, before they located the fall mat. The fall mat was found to be folded behind the resident's bed. Resident #3 was observed to be awake lying in bed during this time. An undated policy titled Falls and Fall Risk, Managing, read in part, The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. A quarterly assessment for Resident #3, dated 02/05/26, showed the resident required substantial/maximal assistance for lying to sitting on the side of the bed and to go from sitting to standing. The assessment showed the resident required supervision or touching assistance for walking. A progress note for Resident #3, dated 04/05/26, showed the resident had a fall incident at the facility and was found to lie on the floor adjacent to the bed with abrasions to the nose, right forehead, and right shoulder. A care plan for Resident #3, dated 04/05/26, showed the resident had a focus for being at risk for falls and had an intervention of a fall mat at the bedside in place. A fall observation document for Resident #3, dated 04/05/26, showed the resident had diagnoses which included vascular dementia with agitation, Alzheimer's disease, disorganized schizophrenia, restlessness and agitation, and expressive language disorder. The document showed the resident had a mental status/level of consciousness that was disoriented x3 (not oriented to person, place, and time) with diminished safety awareness. The document showed the current care plan needed to be continued to address Resident #3's needs. Resident #3 was given a fall risk score of 14, which indicated a high risk for falls. On 05/06/26 at 1:22 p.m., CNA #5 stated they had taken care of Resident #3 and the resident had interventions of a fall mat at bedside and lowered bed due to being a fall risk. On 05/06/26 at 1:27 p.m., CNA #5 stated the fall mat was not where it was supposed to be when they had entered the room of Resident #3 to help prevent future falls for the resident.

Based on record review and interview, the facility failed to protect a resident's right to be free from physical abuse for 1 (#19) of 3 sampled residents reviewed for abuse. Resident #19 was physically abused by another resident. A review of an undated facility video monitoring showed Resident #20 attempted to grab a TV remote from the table where Resident #19 was. Resident #19 grabbed the remote and held onto it. Resident #20 continued attempts to take the remote from Resident #19 standing over them. Resident #19 asked Resident #20 several times not to touch it and to get away from them. Resident #19 was cussing at Resident #20 as they persisted at their approached. Resident #19 asked Resident #20 if they wanted their (curse word withheld) beat and stood up from their sitting position. Resident #20 responded, Yes, whip my [curse word withheld]. Resident #20 swung and hit Resident #19 on their face. CNA #4 stated from the dining area Hey stop it, both of you stop. CNA #4 was walking into the common area from the dining area with a cart. Resident #19 told Resident #20 to get away from them but Resident #20 moved closer to Resident #19 and Resident #19 took a couple steps back. Resident #20 punched Resident #19 several times on the face causing them to fall to the floor. CNA #4 was within view and called Resident #19 by their name.CNA #4 did not attempt to de-escalate the physical altercation between the two residents.A behavior care plan for Resident #19, initiated 08/05/25, showed the resident was at risk for verbal and physical behaviors. The care plan showed the resident had diagnoses which included unspecified schizophrenia and unspecified dementia, unspecified severity, with agitation.A nursing note for Resident #19, dated 03/31/26 at 8:42 p.m., showed the resident had a skin tear to the left bridge of their nose and left inner cheek. The note showed Resident #20 hit Resident #19 on their face.On 04/30/26 at 9:56 a.m., CNA #4 stated they had not received abuse in-service training after the incident on 03/31/26.On 04/30/26 at 2:09 p.m., the facility manager stated they reviewed video footage which showed CNA #4 continued to pass snacks after they witnessed the physical altercation and Resident #19 on the floor. The facility manager stated it took about 10 to 15 minutes before the nurse on duty was notified of the physical altercation between the residents.On 04/30/26 at 2:15 p.m., the facility manager stated they had not completed abuse in-service training for all staff after the incident.The facility manager identified 37 residents resided in the facility.On 04/30/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect a resident's right to be free from physical abuse resulting in Resident #19 sustaining facial injury to their face.On 04/30/26 at 2:55 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 04/30/26 at 3:17 p.m., the administrator was notified of the IJ situation and the IJ template was provided.05/01/26 at 3:52 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Medical Director notified of IJ F600 via electronic no new orders obtained 4.30.2026 3:34 PMNotified family member via phone call of IJ F600 of #19 4.30.2026 4:59 PMNotified family member via phone call of IJ F600 of #20 4.30.2026 5:10 PMAbuse and neglect clinical protocol reviewed 4.30.2026 4:13 PMMeasures for Abuse and neglect created for all staff on 4.30.2026 4:47 PMRevised on 5.1.2026 11:18 AMMeasures for Abuse and NeglectIe[sic] Resident on Resident, Resident on StaffScene safe observe environmentIf unable to intervene safely notify 911 for assistanceAttempt to safely intervene or stop an altercation verbal commandsIf unable to stop notify 911 for assistanceAttempt to deescalate verbally and notify other staff for assistanceAll staff regardless their title in the facility should attempt these measures and then ensure separation and nurse notification immediatelyStaff regardless their title in the facility will remain within viewing and listening distance and safely attempt to continue separation of individuals, if possible redirect from area and or redirect other residents also.Nurse will follow abuse and neglect clinical protocol.1:1 will be initiated for minimum of 72 hours and to restart if new altercation occurs.After 72 hour 1:1 monitoring is completed transition to initiating Q [every] 15 minute checks for minimum of 72 hoursNursing Home Abuse Prevention & Response Policy reviewed and revised 4.30.2026 4:50 PMIn service held with all staff on abuse and neglect clinical protocol, Nursing Home Abuse Prevention and Response Policy, and new measures for abuse and neglect abuse. Understanding with question and answer and acknowledgement of these items 4.30.2026 7:06 PMNursing Home Abuse Prevention and Response Policy, Abuse and neglect clinical protocol and measures for abuse and neglect abuse posted to bulletin board 4.30.2026 6:18 PMQAPI will monitor plan of removal 4.30.2026 5:30 PMSafe surveys completed for 5.1.2026 10:00 AMNew inservice for revised Measures for abuse and neglect, nursing home abuse prevention & response policy, and Abuse and Neglect - clinical protocol with all staff 5.1.2026 POR [plan of removal] completed 5.1.2026 1:31 PM.On 05/05/26, the IJ was lifted, effective 05/01/26, when all components of the plan of removal had been verified as completed. Staff in various departments and shifts were interviewed regarding facility measures for abuse and neglect, abuse policy, and clinical protocol. All staff were knowledgeable on the education and training provided. The plan of removal records including facility's measures for abuse, abuse and neglect policy and clinical protocol, staff in-service training, safe surveys, QAPI monitor plan of removal, and resident representatives' notifications were reviewed.The deficiency remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. Findings:A review of an undated facility video monitoring showed Resident #20 attempted to grab a TV remote from the table where Resident #19 was. Resident #19 grabbed the remote and held onto it. Resident #20 continued attempts to take the remote from Resident #19 standing over them. Resident #19 asked Resident #20 several times not to touch it and to get away from them. Resident #19 was cussing at Resident #20 as they persisted at their approached. Resident #19 asked Resident #20 if they wanted their (curse word withheld) beat and stood up from their sitting position. Resident #20 responded, Yes, whip my (curse word withheld). Resident #20 swung and hit Resident #19 on their face. CNA #4 stated from the dining area Hey Stop it, both of you stop. CNA #4 was walking into the common area from the dining area with a cart. Resident #19 told Resident #20 to get away from them but Resident #20 moved closer to Resident #19 and Resident #19 a couple steps back. Resident #20 hit Resident #19 several times on the face causing them to fall to the floor. CNA #4 within view and called Resident #19 by their name. CNA #4 did not attempt to deescalate the physical altercation between the two residents.1. A behavior care plan for Resident #19, initiated 08/05/25, showed the resident was at risk for verbal and physical behaviors. The care plan showed the resident had diagnoses which included unspecified schizophrenia and unspecified dementia, unspecified severity, with agitation.A quarterly assessment for Resident #19, dated 01/29/26, showed the resident had memory problems.A nursing note for Resident #19, dated 03/31/26 at 8:42 p.m., showed Resident #19 had a skin tear to the left bridge of their nose and left inner cheek. The note showed Resident #20 hit Resident #19 on their face and caused Resident #19 to fall.An initial State reportable form 283, dated 03/31/26, showed Resident #20 punched Resident #19 multiple times in the face and caused them to fall to the floor and they had a difficult time standing.On 04/30/26 at 9:48 a.m., CNA #4 stated they were in the dining room when they heard a verbal altercation between resident #19 and Resident #20. They stated they did not know what was said. CNA #4 stated when they came into the common area they saw Resident #19 swing at Resident #20. They instructed both residents to back away from each other and they did. CNA #4 stated they turned around to continue passing snacks. CNA #4 stated they heard a commotion behind them and next thing they saw was Resident #19 on the floor.On 04/30/26 at 9:56 a.m., CNA #4 stated they had not received abuse in-service training after the incident on 03/31/26.On 04/30/26 at 10:00 a.m., CNA #4 stated if they were to witness a resident-to-resident altercation, they were to separate them, make sure the residents were safe, report to the charge nurse, and provide a witness statement.On 04/30/26 at 10:01 a.m., CNA #4 stated they could have called another staff to lay eyes on the residents and ensure the residents were separated.On 04/30/26 at 2:09 p.m., the facility manager stated they reviewed video footage where CNA #4 continued to pass snacks after they witnessed the physical altercation and Resident #19 on the floor. The facility manager stated it took about 10 to 15 minutes before the nurse on duty was notified of the physical altercation between the residents.On 04/30/26 at 2:15 p.m., the facility manager stated they had not completed abuse in-service training for all staff after the incident.2. A quarterly assessment for Resident #20, dated 01/28/26, showed the resident had diagnoses which included anxiety and Huntington's disease. The assessment showed the resident's cognition was intact with a brief interview for mental status score of 14.On 04/27/26 at 9:46 a.m., Resident #20 stated they wanted the remote to change the channel on the TV and Resident #19 told them to, get the [curse word withheld] out. They stated they tried to grab the remote from the resident and Resident #19 hit them, so they hit Resident #19 back.

Based on observation and interview, the facility failed to ensure an extended menu with portion sizes was available for use during one of one meal service observed.The facility manager identified 37 residents who received meal services from the kitchen. Findings:On 04/27/26 at 7:50 a.m., a facility extended menu was requested during entrance conference.On 05/05/26 at 8:23 a.m., [NAME] #1 was observed to put a 5-ounce scoop of scrambled eggs on two plates.On 05/05/26 at 8:27 a.m., [NAME] #1 was observed to put 4-ounce spoon of scrambled eggs on three plates.On 05/05/26 at 9:02 a.m., the administrator brought a box to the surveyors and was observed to shift through the paper items. There was no extended menu in the box.On 05/05/26 at 6:56 a.m., [NAME] #1 stated the breakfast menu was biscuit and gravy, hash brown, scrambled eggs, and cold cereal.On 05/05/26 at 8:28 a.m., [NAME] #1 stated the proper portion size should be 4-ounces of scrambled eggs.On 05/05/26 at 9:06 a.m., the administrator stated the facility did not have an extended menu at this time.On 05/05/26 at 10:07 a.m., [NAME] #2 stated they were not told about portion sizes for serving.On 05/06/26 at 2:36 p.m., the registered dietitian stated they were responsible for reviewing and signing off on the regular menu and not the creation of menus.

Based on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours seven days a week.The facility manager identified 37 residents resided in the facility. Findings: An RN coverage policy, reviewed 01/01/26, read in part, Nurse staffing in nursing homes has a substantial impact on the quality of care and outcomes that residents experience.Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week.The facility must designate a registered nurse (RN) to serve as the DON on a full-time basis. A Punch Audit Report, dated 11/01/25 through 04/26/26, showed no RN hours for 10/01/25 through 10/03/25 10/06/25 through 10/15/25, 10/18/25 through 10/19/25, 10/21/25, 10/25/25 through 10/26/25, 10/28/25, 11/01/25 through 11/02/25, 11/06/25 through 11/09/25, 11/13/25, 11/27/25, 12/04/25, 12/08/25, 12/11/25, 12/22/25, 12/25/25, and 12/31/25. On 04/29/26 at 10:08 a.m., the business office manager stated between October 1st and October 14th, the facility had no RN coverage. They stated there was no RN coverage on any of the above dates.On 04/30/26 at 9:56 a.m., the facility manager stated the facility was without a DON from 09/18/25 through 10/14/25.

Based on observation, record review, and interview, the facility failed to ensure residents had access to the grievance procedure.The facility manager identified 37 residents resided in the facility. Findings:On 04/28/26 at 10:12 a.m., both resident halls, both nurses' stations, and the main living area were observed. There was no information regarding the facility's grievance procedure or location of grievance forms. The grievance personnel information was posted.On 05/06/26 at 1:37 p.m., the facility grievance binder was reviewed. There were no grievances.A Grievance Policy, dated 11/28/16, read in part, The facility will provide a mechanism for filing a grievance/complaint without fear of retaliation and/or barriers of service; will provide residents, resident representatives and others information about the mechanisms and procedure to file a grievance.On 04/28/26 at 10:03 a.m., a confidential interview was held with the resident council group. The resident council group stated they did not know how to file a grievance.On 04/28/26 at 10:20 a.m., the administrator stated the grievance procedure was not posted at the moment.

Based observation and interview, the facility failed to post notice of the availability of past State survey results in areas of the facility that were prominent and accessible to the public.The facility manager identified 37 residents resided in the facility. Findings: On 04/28/26 at 10:12 a.m., both resident halls, both nurses' stations, and the main living area were observed. There was no posted information on where the past State survey results were located. On 04/28/26 at 10:15 a.m., the administrator showed the location of the past State survey results. The binder was to the right of the facility entrance door.On 04/28/26 at 10:03 a.m., a confidential interview was held with the resident council group. The resident council group stated they did not know where to locate past State survey results.On 04/28/26 at 10:16 a.m., the administrator stated a sign was posted to show location of past State survey results, but it was taken down by a resident. They stated they were not sure when it was removed by the resident.

Based on observation and interview, the facility failed to ensure contact information for filing a complaint with the State Agency was available to the residents.The facility manager identified 37 residents resided in the facility. Findings:On 04/28/26 at 10:12 a.m., both resident halls, both nurses' stations, and the main living area were observed. There was no information regarding filing a complaint with the State agency.On 04/28/26 at 10:03 a.m., a confidential interview was held with the resident council group. The resident council group was asked if they had been informed of their rights and given information on how to formally complain to the State about the care they were receiving. They stated, No.On 04/28/26 at 10:20 a.m., the administrator stated the information on how to formally file a complaint with the State Agency was not posted at this moment.

Based on record review and interview, the facility failed to ensure a resident was not administered a psychotropic medication without adequate indications for its use and received gradual dose reductions for 1 (#4) of 5 sampled residents reviewed for unnecessary medications.The RNC identified 28 residents were prescribed psychotropic medications. Findings: An undated EHR facesheet for Resident #4 showed the resident had diagnoses which included vascular dementia (severe) with psychotropic disturbances, depression, and an anxiety disorder due to known physiological condition. A facility policy titled Policy on Unnecessary Drugs, dated 01/01/99, read in part, All medications prescribed to residents must be based on an individual assessment of each resident's clinical condition, needs, and goals of care. Medications must be regularly reviewed to determine their continued necessity and appropriateness.A discontinued medication order, dated 02/17/25, showed Resident #4 had received an order for Invega Sustenna (an antipsychotic) 78 mg once a month for the first time for the diagnosis of vascular dementia (severe) with psychotic disturbances. There were no records found that this medication had been prescribed prior to this date. A quarterly assessment, dated 06/17/25, showed Resident #4 did not have potential indicators of psychosis which included hallucinations and delusions. The assessment showed the resident did not have a diagnosis of schizophrenia. The assessment showed Resident #4 received antipsychotics on a routine basis and a GDR was not attempted, because the physician documented it as clinically contraindicated. A medication regimen review document, dated 09/03/25, showed a GDR was requested by the pharmacist for Invega Sustenna 78mg once a month, but was not completed. Invega Sustenna is used primarily to manage schizophrenia and schizoaffective disorders. Resident #4's PMHNP responded, a reduction in the medication would likely worsen behavior.A nursing progress note, dated 10/08/25, showed Resident #4 had received new medication orders from their psychiatric provider for Invega Sustenna 156 mg once a month. Prior to this order, all previous Invega Sustenna orders were for 78 mg. A psychiatry services note, dated 11/03/25, showed Resident #4's mood was stable during the assessment and the resident's sporadic shouting during the day was correlated to pain. The note showed the resident had a diagnosis of schizophrenia and the treatment plan for the diagnosis included Invega Sustenna 156 mg/mL.There was no documentation found the resident had been assessed for schizophrenia prior to Resident #4's diagnosis and treatment.A nursing progress note, dated 11/10/25, showed Invega Sustenna had been administered to Resident #4's right deltoid. A physician's order, dated 11/10/25, showed Resident #4 had an active order for Invega Sustenna 156 mg/mL once a day on the 10th of the month. The medication order did not have an end date listed. The record showed the medication was given for the diagnosis of vascular dementia (severe) with psychotic disturbances. A medication administration record, dated 03/01/26 through 03/31/26, showed Resident #4 had been administered Invega Sustenna 156 mg/mL on the 10th of the month.A medication administration record, dated 04/01/26 through 04/30/26, showed Resident #4 had been administered Invega Sustenna 156 mg/mL on the 10th of the month.There was no documentation found that a gradual dose reduction had been attempted for Invega Sustenna any of the times it was prescribed. On 05/05/26 at 11:57 p.m., the PMHNP stated they did not diagnose Resident #4 with schizophrenia and followed through with the previous provider's orders. They stated they did not know who diagnosed Resident #4 with schizophrenia and the resident's behaviors had been stable for a while. The PMHNP stated vascular dementia with psychotic disturbance was not an appropriate diagnosis for the administration of Invega Sustenna and a diagnosis of schizophrenia would be required.On 05/05/26 at 1:08 p.m., CNA #5 stated Resident #4 had behaviors of hollering out loud and grinding teeth, but the behaviors did not happen often. CNA #5 stated the behaviors occurred when the resident needed something or was uncomfortable.On 05/05/26 at 1:24 p.m., the facility manager stated a comprehensive assessment was required for a psychotropic medication if a new provider took over care. They stated the medication Invega Sustenna should be used for treatment for the diagnosis the psychiatry services had prescribed it for, which was schizophrenia.On 05/05/26 at 2:02 p.m., the facility manager stated Resident #4's admission records did not have a diagnosis of schizophrenia and would have to see where it came from. The facility manager could not find documentation of a schizophrenia assessment completed for Resident #4.On 05/06/26 at 4:39 p.m., the medical director stated they did not know why Resident #4's EHR showed they were being prescribed Invega Sustenna for dementia and would have to discuss this with the psych provider. They stated they did not know if a GDR had been attempted for this medication or of any assessments done by any providers to diagnose Resident #4 with schizophrenia.

Based on record review and interview, the facility failed to have effective administration who utilized its resources effectively and efficiently to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. The facility administration failed to:a. provide adequate supervision and a secure environment to ensure residents at risk for elopement had not eloped for 1 (#19) of 16 sampled residents at risk for elopement. Resident #19 was at risk for wandering and elopement. The care plan for Resident #19 did not show a concern for wandering and elopement risk prior to 03/21/26. Dietary Aide #2 stated they found Resident #19 in their truck. A combined initial and final state reportable form 283, incident date of 03/21/26, showed Resident #19 was observed seated in an employee's vehicle. The report showed the resident was an elopement risk. The report showed Resident #19 exited through a window of an empty room. MDS Coordinator #1 stated they were not aware the resident had exit seeking behaviors.b. protect resident's right to be free from physical abuse for 1 (#19) of 3 sampled residents reviewed for abuse. A review of an undated facility video monitoring showed Resident #20 punched Resident #19 several times on the face causing them to fall to the floor. Resident #19 had facial injuries. CNA #4 did not attempt to de-escalate the physical altercation between the two residents. CNA #4 stated they had not received abuse in-service training after the incident on 03/31/26. The facility manager stated they reviewed video footage where CNA #4 continued to pass snacks after they witnessed the physical altercation and Resident #19 on the floor. The facility manager stated it took about 10 to 15 minutes before the nurse on duty was notified of the physical altercation between the residents. The facility manager stated they had not completed abuse in-service training for all staff after the incident.c. ensure an extended menu with portion sizes was available for use during one of one meal service observed. [NAME] #1 was observed to put a 5-ounce scoop of scrambled eggs on two plates and they changed the serving size to 4 ounce spoon of scrambled eggs on three plates. [NAME] #1 stated the proper portion size should be 4 ounces. [NAME] #2 stated they were not told about portion sizes for serving. The administrator stated the facility did not have an extended menu at this time.d. ensure RN coverage for 8 consecutive hours seven days a week. A Punch Audit Report, dated 11/01/25 through 04/26/26, showed no RN hours for 10/01/25 through 10/03/25 10/06/25 through 10/15/25, 10/18/25 through 10/19/25, 10/21/25, 10/25/25 through 10/26/25, 10/28/25, 11/01/25 through 11/02/25, 11/06/25 through 11/09/25, 11/13/25, 11/27/25, 12/04/25, 12/08/25, 12/11/25, 12/22/25, 12/25/25, and 12/31/25. The BOM stated between October 1st and October 14th, the facility had no RN coverage. They stated there was no RN coverage on any of the above dates.The facility manager identified 37 residents resided in the facility. Findings: Please refer to CMS form 2567 at F600, F689, F727, and F803 for evidence details. The Quality Assurance Improvement Plan policy, revised 07/28/25, read in part, Our purpose is to provide excellent quality resident/patient care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good resident/patient outcomes and perfections of patient care.The Administrator/Assistant Administrator ensures that the quality program is adequately resourced.On 05/06/26 at 3:58 p.m., the administrator stated they tried to be at the facility atleast 20 hours a week but occasionally did not meet the requirement due to having other facilities.On 05/06/26 at 4:07 p.m., the administrator was asked if there was a lack of oversight in the administration of their facility. They stated, Yes.

Based on record review and interview, the facility failed to ensure the medical director verified the appropriateness of an antipsychotic medication for 1 (#4) of 5 sampled residents reviewed for unnecessary medications.The facility manager identified 37 residents resided in the facility. Findings:A review of an undated EHR facesheet for Resident #4 showed the resident had diagnoses which included vascular dementia (severe) with psychotropic disturbances, depression, and an anxiety disorder due to known physiological condition. A physician's order, dated 11/10/25, showed Resident #4 had an active order for Invega Sustenna (antipsychotic medication) 156 mg/mL once a day on the 10th of the month. Invega Sustenna is used primarily to manage schizophrenia and schizoaffective disorders. The record showed the medication was prescribed for the diagnosis of vascular dementia (severe) with psychotic disturbances. A quarterly assessment, dated 06/17/25, showed Resident #4 did not have potential indicators of psychosis which included hallucinations and delusions. The assessment showed the resident did not have a diagnosis for schizophrenia. A psychiatry services note, dated 11/03/25, showed Resident #4 had a diagnosis of schizophrenia and the treatment plan for the diagnosis included Invega Sustenna 156 mg/mL. There was no documentation found the resident had been assessed for schizophrenia prior to Resident #4's diagnosis and treatment.On 05/05/26 at 11:57 p.m., the PMHNP stated they did not diagnose Resident #4 with schizophrenia and followed through with the previous provider's orders. They stated they did not know who diagnosed Resident #4 with schizophrenia and the resident's lashing out behaviors had been stable for a while. The PMHNP stated vascular dementia with psychotic disturbance was not an appropriate diagnosis for the administration of Invega Sustenna and a diagnosis of schizophrenia would be needed.On 05/06/26 at 4:39 p.m., the medical director stated they oversaw the medications the psych services were prescribing and appropriate medication was ordered for the diagnosis. They stated they went over the indications for the use of psychotropic medications for residents on a monthly basis. They stated they signed off on all medications for the facility. The medical director stated they did not know why Resident #4's EHR showed they were prescribed Invega Sustenna for dementia and would have to discuss with the psych provider. They stated they did not know the psych notes showed Resident #4 was prescribed Invega Sustenna for schizophrenia. The medical director stated they did not know where to find the psych notes for the facility's residents. They stated they did not know if a GDR had been attempted for this medication or of any assessments done by any providers to diagnose Resident #4 with schizophrenia. The medical director stated they did not recall the black box warning for Invega Sustenna because they did not usually prescribe this medication.

Based on record review and interview, the facility failed to ensure a clinical rationale from the physician was provided on a gradual dose reduction request for a antidepressant and an antipsychotic for 1 (#37) of 5 sampled residents who were reviewed for unnecessary medications.The facility manager identified 37 residents resided in the facility. Findings:A Policy on Unnecessary Drugs, dated 01/01/1999, read in part, To ensure that residents in the long-term care facility are prescribed medications based on their clinical needs, avoiding unnecessary drugs that could lead to adverse effects, interactions, or diminished quality of life.Criteria for Identifying Unnecessary Drugs: Lack of a documented clinical indication for the medication.Documentation will include the rationale for continuing, discontinuing, or adjusting any medication, as well as discussions with the resident or their representative.A significant change assessment, dated 11/06/25, showed Resident #37 was severely impaired in cognition for decision making, had diagnoses of dementia and psychotic disorder, and received an antidepressant and antipsychotic medication.A Medical Director Report, dated, 08/06/25 showed a gradual dose reduction request for haloperidol (an antipsychotic medication) 10 mg at bedtime and fluoxetine (an antidepressant medication) 20 mg once a day. The drug regimen review did not show a physician response to the gradual dose reduction request.An Expanded DRR [drug regimen review] report, dated 02/04/26, showed a gradual dose reduction request for haloperidol 10 mg at bedtime and fluoxetine 20 mg once a day. The drug regimen review did not show a physician response to the gradual dose reduction request.On 05/06/26 at 1:39 p.m., the regional nurse consultant stated the February and August gradual dose reduction requests had not been addressed by the medical director or by psychiatric services.

Based on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 (#4) of 12 sampled residents whose care plans were reviewed.The facility manager identified 37 residents resided in the facility. Findings: An undated policy titled Care Plans - Baseline, read in part, To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.A significant change assessment, dated 06/17/25, showed Resident #4 had diagnoses which included anxiety, vascular dementia (severe) with psychotropic disturbance, depression, acute and chronic respiratory failure with hypoxia, and an original admission date of 12/03/24, and a reentry date of 05/30/25.Review of the electronic health record did not show a baseline care plan was developed for Resident #4.On 05/05/26 at 1:24 p.m., the facility manager stated they could not find the baseline care plan for Resident #4, which meant there was not one for them.

Based on record review and interview, the facility failed to inform a resident or their representative of the risk, benefits, and alternative treatment options prior to giving psychotropic medications for 1 (#4) of 5 sampled residents whose clinical records were reviewed for unnecessary medications.The RNC identified 28 residents were prescribed psychotropic medications. Findings:The undated clinical record facesheet showed Resident #4 had diagnoses which included vascular dementia (severe) with psychotic disturbance, depression, and an anxiety disorder due to known physiological condition (history of).The facility's medication consent form binder from 2025 was reviewed. A consent form dated 05/05/25 for clozapine 75 mg four times a day for Resident #4 was found. There was no other documentation the resident or the resident's representative had been informed of the risks and benefits of the use of other psychotropic medications, treatment alternatives/options, and the choice of treatment the resident preferred before receiving the psychotropic medications. A physician's order for Resident #4, dated 06/02/25, showed the resident was to receive clozapine (an antipsychotic) 75 mg four times a day.A physician's order for Resident #4, dated 06/17/25, showed the resident was to receive buspirone (an anxiolytic) 15 mg twice a day.A physician's order for Resident #4, dated 10/12/25, showed the resident was to receive citalopram (an antidepressant) 20 mg once a day.A physician's order for Resident #4, dated 11/10/25, showed the resident was to receive Invega Sustenna (an antipsychotic) 156 mg/mL once a day on the 10th of the month.A review of the nursing progress notes for Resident #4, from the past year, did not show Resident #4 or their representative had been informed about any psychotropic medications or treatment alternatives.On 05/05/26 at 11:09 a.m., the facility manager stated that if an antipsychotic consent form for a specific medication was not in the binder, then the facility did not have one for Resident #4.On 05/05/26 at 1:24 p.m., the facility manager stated if a resident or their representative were informed of the psychotropic medications or alternative treatments, then it would be in the nursing progress notes.

Based on observation and interview, the facility failed to ensure water was not utilized to puree foods for 1 of 1 breakfast meal observed.Cook #1 identified one resident on a pureed diet resided in the facility. Findings:On 05/05/26 at 7:54 a.m., [NAME] #1 was observed to place two hash brown patties in a blender. [NAME] #1 was observed to add an unmeasured amount of hot water to the blender and puree the hash browns.On 05/05/26 at 8:06 a.m., [NAME] #1 was observed to add a 5-ounce scoop of scrambled eggs to the blender. [NAME] #1 was observed to add an unmeasured amount of hot water to the blender and puree the scrambled eggs.On 05/05/26 at 8:12 a.m., [NAME] #1 was observed to place one and a half biscuit in a blender. [NAME] #1 was observed to add an unmeasured amount of hot water to the blender and puree the biscuits.On 05/05/26 at 7:56 a.m., [NAME] #1 stated they did not know how much water they added to the hash browns. They stated they just added water to food items until it was pureed.On 05/05/26 at 10:07 a.m., [NAME] #2 stated they used a half cup of hot water to puree food items. They stated if the puree became too thin, they added thickener.On 05/06/26 at 2:33 p.m., the registered dietitian stated staff were not supposed to use plain water for pureed foods.

Based on record review and interview, the facility failed to ensure residents were free from abuse for 2 (#1 and #5) of 6 sampled residents reviewed for abuse.The DON reported 44 residents resided in the facility.Findings:An undated facility policy titled Resident to Resident Abuse/Abuse Prohibition Policy read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and mistreatment.1.A care plan for Res #1, dated 08/10/24, showed Resident #1 had a problem with agitation and aggressive behavior. Approaches included to separate from stressful situations, persons or places, understand triggers, observe for signs of frustration and intervene early.Res #1's annual assessment, dated 07/24/25, showed the resident's cognition was severely impaired. The assessment showed the resident had diagnoses which included non-Alzheimer's dementia, schizophrenia, depression, and anxiety. The assessment showed the resident had delusions; verbal behavioral symptoms directed toward others daily which put the resident at significant risk for physical illness or injury.A progress note, dated 08/13/25 at 3:46 p.m., showed Res #1 was witnessed by staff running up to Res #5, jumping up and as Res #1 came back down hit Res #5 near the neck/shoulder/head area. Residents were separated immediately and assessed. Res #1 had no injuries, Res #5 had slight redness noted behind their left ear. The progress note showed the doctor and DON were notified of the incident. 2.Res #5's annual assessment, dated 06/26/25, showed the resident had a BIMS score of 9 which indicated their cognition was moderately impaired. The assessment showed the resident had diagnoses which included schizophrenia, depression, and anxiety.On 08/20/25 at 1:28 p.m., Res #5 stated they felt safe in the facility, but was worried Res #1 would hit them again.On 08/21/25 at 9:48 a.m., the DON stated they were not aware of the incident. They stated an incident report should have been completed and reported to the OSDH.On 08/21/25 at 1:38 p.m., the ADON reported Res #1 continues on every 15 minutes checks.

Based on record review and interview, the facility failed to ensure antipsychotic medications were administered as ordered for a serious mental illness for 1 (#1) of 6 sampled residents reviewed for behaviors.The DON reported 44 residents resided in the facility.Findings:An undated face sheet showed Res #1 had diagnoses which included disorganized schizophrenia, vascular dementia, major depressive disorder, and anxiety. A care plan, dated 08/10/24, showed Res #1 had a problem with psychotropic drug use, had an active diagnosis of schizophrenia and required anti psychotic medications. Interventions included the nurse would monitor and report side effects/behaviors to the physician.A physician order, dated 05/04/25, showed Uzedy (an antipsychotic) suspension 125mg/0.35ml; 1 injection subcutaneous once a day every 28 days for disorganized schizophrenia. A treatment administration record, dated 06/01/25 - 06/30/25, showed a missed injection on 06/01/25.An annual assessment, dated 07/24/25, documented Res #1s cognition was severely impaired. The assessment showed the resident had delusions; verbal behavioral symptoms directed toward others daily which put the resident at significant risk for physical illness or injury. The assessment showed the behaviors significantly interfered with the resident's participation in activities and social interactions.A mental health progress note, dated 08/04/25, read in part, Res #1's condition deteriorated significantly after nursing staff overlooked his monthly injection. Despite receiving the missed dose on July 22nd and being prescribed hydroxyzine [an antihistamine] 25mg every 6 hours as needed, the patient continued to exhibit physical aggressive behavior toward other residents. By July 28th, there was no improvement in the patient's condition. A 7-day course of Risperidone 0.5mg twice daily was initiated as a bridge to stabilize the patient and return them to their therapeutic levels.On 08/20/25 the ADON reported the injection was overlooked and they now have a board in their office to ensure it did not happen again.

Based on record review and interview, the facility failed to ensure a resident's care plan was updated to include an intervention related to aggressive behaviors for 1 (#1) of 6 sampled residents reviewed for care plans.The DON reported 44 residents resided in the facility.Findings: An undated resident face sheet showed Res #1 had diagnoses which included disorganized schizophrenia, expressive language disorder, restlessness and agitation.A care plan, initiated 08/10/24, showed Res #1 had agitation and aggressive behavior with no new interventions added to the care plan since 08/10/24.An annual assessment, dated 07/24/25, documented Res #1s cognition was severely impaired. The assessment showed the resident had delusions; verbal behavioral symptoms directed toward others daily which put the resident at significant risk for physical illness or injury. The assessment showed the behaviors significantly interfered with the resident's participation in activities and social interactions.A nurse note, dated 08/13/25 at 1:43 p.m., showed Res #1 was witnessed by staff running up behind Res #5, jumping up, and as Res #1 came back down, hit Res #5 near the neck/shoulder/head area. The residents were separated immediately and assessed. Res #5 denied pain but had slight redness behind left ear related to the incident. The doctor and DON were notified. Res #1 continued on every 15-minute checks.On 08/20/25 at 11:45 a.m., the ADON reported the care plan should have been reviewed/revised with new interventions added.

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of resident-to-resident abuse for 1 (#1) of 6 sampled residents reviewed for abuse.The DON reported 44 residents resided in the facility.Findings: An undated facility policy titled Resident to Resident Abuse/Abuse Prohibition Policy, read in part, Administrator or DON will initiate an immediate investigation of alleged abuse at the time of occurrence, and document findings. Investigation will continue for a minimum of 72 hours.An undated resident face sheet showed Res #1 had diagnoses which included disorganized schizophrenia, major depressive disorder, anxiety disorder, dissociative and conversion disorder.An annual assessment, dated 07/24/25, showed the Res #1's cognition was severely impaired.A nurse note, dated 08/13/25 at 1:43 p.m., showed Res #1 was witnessed by staff running up behind Res #5, jumping up, and as Res #1 came back down, hit Res #5 near the neck/shoulder/head area. The residents were separated immediately and assessed. Res #5 denied any pain but had slight redness behind the left ear related to this incident. The doctor and DON were notified. Res #1 continued on every 15-minute checks.On 08/20/25 at 11:45 a.m., the ADON reported the incident should have had a thorough investigation completed.

Based on record review and interview, the facility failed to report allegations of abuse to the Oklahoma State Department of Health for 1 (#1) of 6 sampled residents reviewed for abuse.The DON reported 44 residents resided in the facility. Findings:An undated facility policy titled Resident to Resident Abuse/Abuse Prohibition Policy, read in part, Administrator or DON will initiate an immediate investigation of alleged abuse at the time of occurrence, and document findings. Investigation will continue for a minimum of 72 hours. The administrator and/or designee will notify the Oklahoma State Department of Health within 24 hours, by fax or telephone, of an actual abuse. A report of the incident shall be mailed/faxed to OSDH within 5 working days of the incident.An undated resident face sheet showed Res #1 had diagnoses which included disorganized schizophrenia, major depressive disorder, anxiety disorder, dissociative and conversion disorder.An annual assessment, dated 07/24/25, showed Res #1's cognition was severely impaired. The assessment showed the resident had delusions; verbal behavioral symptoms directed toward others daily which put the resident at significant risk for physical illness or injury. The assessment showed the behavior significantly interfered with the resident's participation in activities and social interactions.A nurse note, dated 08/13/25 at 1:43 p.m., showed Res #1 was witnessed by staff running up behind Res #5, jumping up, and as Res #1 came back down, hit Res #5 near the neck/shoulder/head area. Residents were separated immediately and assessed. Res #5 had no injuries related to this incident. The doctor and DON were notified. Res #1 continued on every 15-minute checks.On 08/20/25 at 11:45 a.m., the ADON reported the incident should have been reported to the Oklahoma State Department of Health. On 08/21/25 at 9:48 a.m., the DON reported they were not notified of the incident. The DON reported the incident should have been reported the OSDH.

On 12/16/21, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have an effective infection control program to prevent the spread of e-coli and other infectious diseases. Three residents in November '21 and 15 residents in December '21 were diagnosed with e-coli infections. The facility had four residents still on ABT for e-coli. Staff were not aware of any residents on transmission based precautions. Staff were not conducting proper hand hygiene or incontinent care and were not disposing of contaminated items properly. The facility did not have an IP and were not investigating causative factors, documenting surveillance of and implementing preventative measures to prevent the spread of e-coli and other infectious diseases. On 12/16/21, the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 4:08 p.m., the administrator was notified of the IJ situation. At 5:25 p.m., an acceptable plan of removal was provided. The plan of removal documented: In-servicing all staff prior to 1500 [3:00 p.m.] on 12/17/21. No one will be allowed to clock in before being in-serviced. A. Hand Hygiene. B. Incontinence care. C. Appropriate use of PPE. D. Standard and Respiratory isolation precautions. E. Handling of linens and trash. F. Change of shift communication. G. Isolation precaution notification on resident doors and staff educated. H. Infections will be documented and routine tracking and trending of infections will be performed to determine trends in the facility and preventative measures implemented as needed. I. All residents will be assessed for infections and a new infection surveillance log will be created. Residents will be put on isolation as needed. J. [DON], [MDS nurse], and [adm], will begin the CDC Infection Prevention Program. Also, [consultant IP], will oversee Infections Prevention until the time the class is complete. [Consultant IP] will approve the in-services to be conducted and will be available to consult with staff at [facility] as needed. On 12/20/21 at 3:00 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at a pattern. On 12/20/21, interviews were conducted with the nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced on 12/16/21 and 12/17/21. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on observation, record review and staff interviews, the facility failed to ensure they had an effective infection control program to prevent the transmission of infectious diseases. The facility failed to ensure: a. an IP on staff to implement and monitor an effective infection control program, b. standard and transmission based precautions were utilized with proper handwashing and incontinent care with residents with e-coli for two residents (#2 and #3) with e-coli and two residents (#4 and #6) without e-coli of four sampled residents reviewed for incontinent care, c. appropriate PPE was utilized when caring for residents with e-coli for two residents (#2 and #3), d. contaminated trash and linens were disposed of properly for two residents (#2 and #3), and e. infection control practices, investigate causative factors, document surveillance of and implement preventative measures to prevent the spread of e-coli and other infectious diseases. The administrator identified 35 residents resided in the facility and four residents were on ABT for e-coli. Findings: A November 2021 infection log documented three residents with e-coli in their urine. It documented the residents were on ABT and contact precautions. There was no documentation of causative factors, trends or measures implemented to prevent the spread of e-coli or other infectious diseases. An inservice sheet dated 11/25/21, read in part, subjects covered .Ecoli .outbreaks .handwashing .isolation . An inservice sheet dated 12/10/21, read in part, .Handwashing, E-coli .How to keep ecoli from spreading . The DON identified 14 residents were diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/15/21 at 10:30 a.m., the administrator was asked if they had any residents on transmission based precautions. She stated no. She stated they had outbreak of e-coli in the building, that about half of the residents had it, but all residents were off ABT. She stated they thought the cause of the outbreak was the city water. She was asked who their IP was. She stated it was her, but she hadn't taken her test yet. At 10:53 a.m., a three drawer chest with PPE was observed outside of resident #3's room. CMA #4 was asked if resident #3 was on transmission based precautions. She stated, No. We had e-coli outbreak, but that's all cleared up. At 11:19 a.m., the DON stated they had conducted urinalysis on all residents on 11/29/21 and 22 residents had UTis and 14 of the tests came back positive for e-coli. At 11:35 a.m., LPN #1 was asked if any residents were on isolation. She stated no. At 11:40 a.m., the administrator stated the DON had just informed her there were four residents on contact isolation for e-coli. 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A UA report, dated 11/24/21, documented the resident had a urinary tract infection with e-coli. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Take one capsule by mouth four times a day for 10 days. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Twice a day . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .capsule .Urinary tract infection .Twice A Day . A UA report, dated 12/10/21 documented the resident had a urinary tract infection with e-coli. On 12/15/21 at 12:03 p.m., CNA #6 was observed to enter resident #3's room to provide inconstant care. Resident #3 was on ABT for e-coli. There was a biohazard box with a yellow bag in it inside resident #3's room. CNA #6 donned gloves and provided appropriate incontinent care. She placed the soiled brief in the trash can and removed her gloves. CNA #6 stated, I think he was supposed to be on precautions for e-coli too, which is why the yellow linen bag. She then took the trash out of the room and placed it in the hall trash barrel. She did not don a gown prior to providing care to resident #3 and did not place the trash in a biohazard container in the resident's room. 2. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . At 12:15 p.m., CNA #6 and CNA #7 entered resident #4's room to provide incontinent care. Resident #4 was observed soiled with urine and feces. CNA #6 and CNA #7 donned gloves. CNA #7 rolled resident to her right side and used incontinent wipes to clean feces from resident #4's buttocks. While resident #4 was still on her right side, CNA #7 provided peri care. CNA #7 then wiped resident #4's buttocks again with an incontinent wipe. CNA #7 removed a soiled incontinent pad from under resident #6 and placed it on the floor. CNA #6 took a tube of barrier cream and squeezed some into CNA #7's right hand. CNA #7 put barrier cream on resident #4's buttocks. CNA #7 removed her right glove and put on a new glove. After putting a clean brief on resident #4, CNA #7 picked up the soiled linens from the floor and placed them in a trash bag. CNA #7 took an incontinent wipe and wiped off the resident's face with the same glove she picked up the soiled linens. CNA #7 removed her gloves, donned new gloves and both CNAs transferred resident #4 to her geri chair. Both CNAs removed their gloves. Resident #5 (roommate to resident #4) was observed in the same room sitting in a Broda chair. CNA #6 and #7 repositioned resident #5 in her chair and covered her with a blanket. Neither CNA #6 or #7 had washed their hands after providing care for resident #4 and before providing care to resident #5. Both CNA's washed their hands at the nurses' station hand sink after they left the resident's room. 3. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/15/21 at 1:45 p.m., CNA #6 and CNA #7 entered resident #6's room to provide incontinent care. Both CNA's donned gloves. CNA #7 provided peri care using incontinent wipes and what she stated was vinegar water in a plastic bottle. CNA #7 squirted the vinegar water on the wipes before using them. CNA #7 repeated this step several times. CNA #6 also assisted with providing peri care. CNA #7 removed her gloves, left the room to get linens from the linen cart, re-entered the room, closed the lid to the vinegar water with her left hand and then donned gloves. Resident #6 was rolled to her left side and CNA #6 took wipes, squirted vinegar water on them and wiped her buttocks. She repeated this twice. CNA #6 placed the package of incontinent wipes and the bottle with vinegar water on resident #6's bedside table. CNA #6 removed resident #6's nasal cannula from her nose and straightened the tubing and handed it back to the resident. CNA #6 placed the resident's call cord in reach, used the bed remote to adjust the bed height and handed the resident her comb before removing her gloves. CNA #7 removed her gloves and went out in the hall to get a sheet from the linen cart. CNA #7 re-entered the room and covered the resident with a sheet and blanket, used the bed remote to adjust the bed, gathered the trash and took it to the hall trash barrel. She then washed her hands at the nurses' station hand sink. CNA #6 was observed to use ABHR. 4. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A lab report dated 12/02/21, documented the resident had e-coli. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .tablet .Urinary tract infection .Twice A Day . A nurse progress note dated 12/03/21 at 5:56 p.m., read in part, Res [resident] placed on contact precautions. DX [diagnosis] ecoli [CONDITION(S)] [urinary tract infection]. On 12/15/21 at 2:16 p.m., CNA #6 and CNA #7 took the mechanical lift to the living room to transfer resident #2 to her wc. The resident had e-coli. Both CNA's donned gloves, transferred the resident to her wc, took her to her room and transferred her to her bed. There was an incontinent pad under the resident in the recliner that staff left in the recliner. CNA #7 removed her gloves, left the room, went to the nurses' station and got a package of incontinent wipes from a cabinet. The SS director handed the CNA a shirt for resident #2's roommate to put in the room. CNA #7 re-entered the room and donned gloves. CNA #7 used incontinent wipes and a bottle of vinegar water to provide peri care. She was observed to put both hands on the package of incontinent wipes to pull more out and provided care again. They rolled resident #2 to her side and removed the soiled brief and placed it in the trash can. CNa #7 used the incontinent wipes and vinegar water to wipe the resident's buttocks. CNA #6 took a tube of barrier cream from the resident's top drawer and put some on her right hand and wiped it onto the residents buttocks. She removed her right glove and donned a clean glove. CNA #6 took the tube of barrier cream and put some in her left hand a wiped it onto the residents groin area. CNa #6 removed her gloves and placed the tube of barrier cream on the resident's bedside table. CNA #7 removed her gloves, tied the bag of trash and placed it on the floor. CNA #6 opened the resident's door, reached out to a treatment cart and took a handful of gloves, placed them in her pocket and donned a pair. CNA #7 donned gloves and both CNA's used the mechanical lift to transfer the resident to her wc. Both CNA's removed their gloves. CNA #7 was observed to take the trash out to the hall trash barrel then used ABHR. They took resident #2 back to the living area to put her in the recliner but another resident was sitting there. They donned gloves and transferred the resident to another recliner. Both washed hands with soap and water at the nurses' station hand sink. At 3:20 p.m., CNA #6 was asked what the policy was for handwashing. She stated, In between resident rooms, if hands are dirty, if you've touched anything. She was asked what she would do if there were two residents in a room. She stated she would use ABHR. She was asked if staff should change gloves and use ABHR when going from dirty to clean during peri care. She stated yes. She was asked what PPE should be used when a resident is on contact isolation. She stated gowns, shoe covers, gloves and sometimes goggles. She was asked if any resident was currently on contact isolation. She stated, Don't think so. She was asked if staff should was their hands prior to touching resident's personal items. She stated yes. At 3:28 p.m., CNA #7 was asked the policy for providing incontinent care. She stated wash hands, use vinegar water and wipes, wipe front to back, roll the resident and wipe bottom top to bottom. She was asked the policy for hand washing. She stated to wash hand after every resident, when you touch anything dirty and before meals. She was asked if staff should change gloves, use ABHR and don clean gloves when going from dirty to clean. She stated yes. She was asked if staff should remove soiled gloves after providing incontinent care and wash hands prior to wiping a resident's face. She stated, Yes. She was asked if staff should wash hands between residents. She stated, Yes. She was asked if any residents were on contact isolation. She stated that resident #2 and #3 and maybe one other. She was asked what staff were instructed to do with soiled trash and linens if a resident was on contact isolation. She stated staff were to put soiled linens in the yellow biohazard bags and trash in the red biohazard bags. She stated they didn't have a red biohazard bag so she used the hall trash barrel. At 3:45 p.m., the DON and ADM was asked the policy for handwashing. The DON stated staff were to wash hands when entering a resident room, before and after resident care, if hands are dirty, use soap and water after gloving three times. They were asked if staff should wash hands between residents. The DON stated, Yes. The DON was asked the policy on incontinent care. She stated staff were to wash or sanitize hands before touching the resident, wipe front to back, an change gloves when going from dirty to clean. She was asked what PPE was to be utilized by staff if a resident was on contact isolation. She stated gloves, gowns and masks. She was asked how staff were informed when a resident was placed on contact isolation. She stated they were informed in shift report. She stated all nurses were aware of who was on contact isolation. The DON was asked if resident #3 was on contact isolation. She stated, Yes. She was asked if soiled trash and linens should be in biohazard containers. She stated, Yes. The DON and administrator were informed of the above observations. She stated, We're spreading it. On 12/16/21 at 12:23 p.m., the administrator stated she had been informed she could not be the IP because she was not a nurse, so they don't currently have an IP. At 1:08 p.m., the DON was asked who determined the outbreak and decided to get UA's on all residents. She stated she had spoken to the medical director. She was asked what they did after they determined further outbreak as a result of the facility wide UA results. She stated they started putting residents on ABT.

On 04/29/14, an Immediate Jeopardy (IJ) situation was determined to exist due to unsecured hazardous chemicals and razors located in the unlocked shower rooms on two (North and South) of two halls. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 11:50 a.m., the Administrator and the DON were informed of the IJ situation related to the unsecured chemicals and razors. The Administrator presented an acceptable plan of removal which was dated 04/29/14 and timed 1:00 p.m. The plan of removal documented: "Plan of Removal April 29, 2014 Chemicals immediately removed from the shower room along with razors that was present. Door was locked and key was secured at nurses station 12:00 PM. All other areas where chemicals and hazardous materials may be located have been checked and are secure 12:30 PM. Chemicals and hazardous materials will be in the shower room in a locked cabinet. Inservice will be completed by 3:00 pm April 29, 2014 by (DON) of all current employees regarding securing of chemicals and hazardous materials in shower rooms and other areas where chemicals may be present. Monitoring will be completed by Charge Nurses, Director of Nursing, Maint. Supervisor and Administrative Assistant. Monitoring will be completed hourly and documented on a clip board at nurses station for 5 days and then daily xs 4 weeks." On 04/29/14 at 4:10 p.m., the immediate jeopardy situation was removed after all of the staff had been in-serviced on securing and monitoring hazardous chemicals. The deficient practice remained at no actual harm with potential for more than minimal harm, at a pattern. Based on observation, interview and record review, it was determined the facility failed to ensure potentially hazardous chemicals and razors were properly secured for three (#1, #8 and #9) of three sampled residents identified by the facility as wanderers and with cognitive impairment. A total of three residents were identified by the facility as wanderers with cognitive impairments. Findings: A facility policy, titled 'Wandering or Missing Resident', documented: "Policy: The facility will provide supervision to promote a safe environment for residents at risk for injury due to wandering or elopement behaviors. Key Points: 1) Wandering behavior is characterized as 'aimless' - appears to have no purpose 2) Wandering exhibited by residents who are cognitively impaired can put the resident at risk for harm 3) The resident who exhibits aimless movement may 'wander' off the nursing unit, into other resident's space, out of the building, or off the facility property... .... The potential for harm to the resident who wanders or elopes increases with the extent of cognitive impairment..." On 04/29/14 at 9:20 a.m., the shower room on the north hall of the facility was observed with the door ajar. The shower room door had splintered wood at the top of the door near the door frame. The door was swollen and would not completely close. The following observations were made inside the shower room: ~ Two spray bottles half full of a yellow liquid (with worn off labels on the front) hanging from a metal bar at shoulder level, ~ Two gallon bottles of 'Derma-Cen Shampoo/body wash; one with the lid off, sitting on the floor, labeled "For External Use Only," ~ Five razors sitting on a shelf, and ~ Three cans of shaving cream with the label directions, "Keep Out of Reach of Children." At 10:00 a.m., the maintenance man was asked if he could identify the yellow liquid in the spray bottles in the north hall shower. He identified the solution as 'Auto-Chlor Room Sense 200', with the label directions "Keep Out of Reach of Children - Corrosive - Hazardous to Humans and Domestic Animals - Danger, Disinfectant Cleaner." He stated, "This is what is in the bottles." At 10:45 a.m., the DON was asked to identify any residents in the facility who wandered and who had cognitive impairment. She stated "(Resident #1, resident #8 and resident #9) are and all three can drink by themselves. (Resident #1) wanders in and out of others rooms and could open a bottle by herself." At 10:50 a.m., the north shower hall door was observed to be open, ajar and unlocked. 04/29/14 at 10:55 a.m., LPN #1 was asked if the door to the north shower hall would close. She stated, "You have to slam it shut and you can lock it." She was asked how long the door had been difficult to close and she stated, "Two weeks maybe." At 11:15 a.m., the north shower hall door was observed to be open and ajar. At 11:20 a.m., the south shower hall door was observed to be unlocked. ~ Razors were in a basket located on top of a dresser shelf. ~ A sharps container, with multiple razors inside, was in a bucket on the floor and was open on the top on one side. ~ A gallon bottle of Derma-Care Shampoo/Body Wash labeled "For External Use Only" was also located on top of the dresser shelf. 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/18/14, documented the resident was severely impaired in cognitive skills for daily decision making and inattention and disorganized thinking behaviors were continuously present and did not fluctuate. He had verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others which occurred daily. He required extensive assistance of one person for dressing and was totally dependent for personal hygiene and bathing. He was independent in transfers and ambulation. A care plan for the resident, documented "...Problem: Cognitive Loss: As my Dementia progresses, I forget after 5 minutes what staff has told me. I have lost the ability to make safe decisions for myself. Sometimes when staff speaks to me I don't understand what they are saying... I enjoy being outside but have no concept as to temperature, or other weather conditions. I no longer recognize my family members. I have become totally dependent on staff to meet my daily needs... Evaluation: 12/20/13 (Resident #8) memory conts. to decline. He is no longer able to communicate wants and needs. Staff redirects him 95% of 8 hr shift. He conts. to become agitated when staff attempts to perform care. He hollers loudly... Problem: Psychosocial well-being: I have a mood deficit and behaviors r/t my Dementia. I pace the halls when I'm out of bed. I become agitated when staff wants to perform ADL care...I do not socialize with fell ow residents or staff as I cannot communicate socially... I am unable to voice my wants or needs r/t Dementia... Evaluation: 10/7/13...(Resident #8) is unable to obey simple commands..." A nurse's note, dated 03/31/14 at 11:00 a.m., documented, "...resident continues to wander, phallerig (sic) in others belongings, grappig (sic) on staff at fell ow residents - eats paper. Resident has not slept in 24 hrs..." A nurse's note, dated 04/15/14 at 2:00 p.m., documented, "...chewing pills and spitting them out as he chews..." A nurses's note, dated 04/17/14 at 12:00 p.m., documented, "...CMA notes resident choking on H2O at dining table...when eating pureed diet food is spewing out of his mouth also, and when tries to cough sounds as if he swallowed (illegible) wrap (and) it is crackling in throat when coughed..." A nurses's note, dated 04/17/14 at 4:00 p.m., documented, "...Awaiting for a call due to ER going to see if they can get resident scoped tonight to see if anything there. Did cough up part of a creamer package @ ER..." A nurse's note, dated 04/18/14 at 9:00 a.m., documented, "...continues with shallow cough similar to clearing throat but (with) more force and when does that odd sound heard at throat region..." A nurse's note, dated 04/18/14 at 5:00 p.m., documented, "...Amb about inside facility, picks up random items including food (and) drinks (and) often places things in his mouth whether food product or not cont to clear throat frequently (and) makes noise (with) resp..." A nurse's note, dated 04/18/14 at 10:00 p.m., documented, "...requires (illegible) continuous visual contact of staff R/T safety 'putting anything in mouth..." A nurse's note, dated 04/19/14 at 1:00 p.m., "...Resident roaming facility most of day. Will put anything in mouth example today - washrag, dietary placecard, cap off of marker. Cont to sound like clearing throat with slightly more force than you would normally..." A nurse's note, dated 04/19/14 at 5:00 p.m., documented, "...Pacing about bldg - puts any food or liquids he finds in his mouth and also any assorted variety of objects or 'things' he may see (and) pick up are placed in mouth Repeatedly redirected from nurses station (and) dining room areas clears throat continuously when awake..." On 04/29/14 at 11:30 a.m., the resident was observed in the north hallway pulling at his sweat pants which had wet spots at the seat. As he approached the nurses' desk he attempted to obtain paper laying on the desk and put the paper in his mouth. At 5:40 p.m., during observation of the evening meal, the resident was observed as he approached the medication cart. The resident was stopped by staff as he attempted to remove the lid from a plastic container of applesauce. On 04/30/14 at 2:08 p.m., the resident was observed on the north hallway near the nurse's desk with a wet washcloth in his mouth. Staff took the cloth from the resident. When asked what was on the washcloth that made it wet, CMA #1 stated, "Just water, I used it to clean the top of my med cart." 2. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 10/10/13, documented "...Problem:..I also cannot make safe decisions for myself...I cannot remember where my room is and enter other residents rooms...I do not recognize safety issues..." A quarterly assessment, dated 04/18/14, documented that she was moderately impaired with cognitive skills daily for decision making. She had short and long term memory loss. She had periods of disorganized thinking and inattention. She was independent with ambulation on and off the unit. On 04/29/14 at 11:45 a.m., RN#1 was asked if the resident wandered in the facility. She stated yes, but it varies from day to day. She goes all over, into other rooms. RN #1 then stated, "She thinks the whole place is her house. She doesn't know what she is doing is wrong." She was asked if the resident could open a screw cap bottle. She stated, "Yes." She could open a bottle top. At 12:00 p.m., LPN # 2 was asked if the resident wandered in the facility. She stated the resident wandered the halls and lobby up to three hours a day. She was asked if the resident stayed in the lobby area or if she wandered to the other halls. She stated the resident did wander to the other hall way. LPN #2 was asked if she thought the resident could open a screw top bottle. She stated, "Yes." 3. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 10/29/13, documented "...Problem...I wander up and down halls and into other resident rooms..." A significant change assessment, dated 03/30/14, documented the resident was severely impaired in cognitive skills for daily decision making. She wandered daily and ambulated independently on and off the unit. On 04/29/14 at 9:30 a.m., the resident was observed wandering throughout the facility from the north hall to the south hall. She was ambulatory and did not respond verbally when asked her name by the surveyor. At 2:20 p.m., she was observed wandering the hall going from room to room carrying a floor grate. Staff was observed attempting to redirect her and remove the floor grate from her hand.

On 11/19/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to implement their abuse policy to complete a thorough investigation for allegations of abuse and ensure residents were protected until a thorough investigation was completed. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy Situation. At 6:15 p.m. the Administrator and the Director of Nursing were notified of the IJ situation. On 11/20/13 at 9:30 a.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "Plan of removal of Immediate Jeopardy 11/19/2013 Inservice completed with all staff regarding investigative procedures and abuse policy, Reporting guidelines the need for immediate interviews with staff and other residents. Interview procedures with the accused. All alert residents interviewed regarding abuse of any kind. Employee named in accusation has been terminated. Investigation into second allegation and local law enforcement notified. Medical Director notified no new orders on resident. Head to toe assessment completed on resident. To be completed by 0800 11/20/13." The Immediate Jeopardy was removed on 11/20/13 at 12:35 p.m., after all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on clinical record review, review of policy and procedure and staff and resident interviews, it was determined the facility failed to implement their abuse policy to ensure an allegation of staff to resident abuse was investigated, and measures were put into place to ensure protection from further abuse for one (#1) of four sampled residents with allegations of abuse. This had the potential to affect all 33 residents who resided in the facility. Findings: The facility's Abuse Prohibition Policy documented: "...The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion...1st Shamrock Nursing Home does not allow its employees to use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion... Policy: Every resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents, physicians, consultants, volunteers, family members, legal guardians, friends or other individuals... Abusive Conditions can occur between employee and resident, resident and resident, family of a resident... Types of Abuse: 1. Physical: Any action that causes actual physical harm. For example, rough handling of a resident. 2. Verbal: Using profanity, name calling, cruel teasing 3. Negligence: Failing to properly care for a resident in the manner conducive to professional care standards 4. Sexual: Touching the resident in an intimate or suggestive manner, making sexual comments or allowing another resident to do so 5. Mental: Any act that makes a resident fearful, feel belittled or to make fun of a resident by mocking, imitating, or ridiculing... Prevention: Facility management staff is required to accept all allegations of abuse and conduct a complete investigation including reporting to the proper authorities. All reports whether from family, residents or staff will be reported immediately to the administrator and D.O.N. After the allegations of abuse are reported to the D.O.N. and the Administrator, an incident report is completed, and forwarded to the Safety Committee and Quality Improvement Committee. An analysis is conducted to immediately determine: Safety of resident... Investigation: 1. Any accused staff members will be immediately removed from contact with the resident suspected of being abused and the resident's safety will be protected. 2. The Administrator and the D.O.N. will conduct an investigation... 4. The investigating team will interview all parties concerned: witnesses, the victim, staff and the accused... 7. Appropriate steps will be taken to assure the abuse situations do not reoccur in the future..." Resident #1 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/01/13, documented the resident was cognitively intact with a Brief Interview for Mental Status score of thirteen. She required limited one person assistance with bed mobility and extensive one person assistance with personal hygiene. She was totally dependent with transfers, toilet use and bathing and she required two person assistance. She was independent with eating with setup help. She required extensive two person assistance with dressing and she was nonambulatory. The assessment documented she was independent with transfers, ambulation, dressing, eating, toilet use and personal hygiene. She required set-up assistance with bathing. She had limited range of motion in one upper extremity. She was always incontinent of bowel and bladder. A nurse's note, dated 11/09/13 for the 7:00 a.m. to 3:00 p.m. shift, documented, "... Resident made complaint about CNA that worked night shift, this was reported to DON and Administration, they are to check into incident..." A nurse's note, dated 11/09/13 at 3:45 p.m., documented, "Recd report from (initials deleted) LPN that resident reported 'sexual abuse' by male CNA 'last night' to CNA 'after lunch today' -To room c (initials deleted) LPN @ (name deleted) instruction (administrative assistant) to interview resident regarding her accusation. (Resident) stated that sometime after she was put to bed by female CNA that male CNA 'came to check if my bed was wet and tried to have sex with me in my a** and I told him it hurt and he stopped.' Also stated that 'He said he would deny it if I told anyone. States she is not injured or 'physically hurt'. No sign of 'injury' to buttocks or rectal area..." On 11/19/13 at 12:45 p.m., the resident was asked if anyone in the facility had ever abused her. She stated an aide (name deleted) sexually abused her. She stated he tried to stick his d**k in her butt hole. She stated she told him to stop because it hurt and he got up and got dressed and left the room. She stated she was lying on her back when the aide came in the room and he turned her over and tried to do it. She stated her roommate was in the room but her roommate cannot talk and the aid knew the roommate was in the room. She stated he told her not to say anything. She stated she reported what happened to another aide the next day because she was embarrassed. She stated the aide reported it to two other nurses. She stated the nurses came to physically assess her to make sure she was all right. She stated the aide that did this told her not to say anything but it got all around the facility. She stated the nurse called the doctor and told him what happened. Two police officers came in to talk to her. She stated (name deleted) denied the whole thing to the police. At 1:15 p.m., the Director of Nurses was asked if the resident had reported any kind of abuse to her. She stated the resident had reported a circumstance of abuse with (name deleted) and "for lack of a better word I guess rape that is how she put it." She stated the resident alleged this occurred on 11/08/13 but she did not report it until 11/09/13. She stated according to the resident, she was put in bed by a CNA (name deleted) around 8:00 p.m., and (name deleted) came in her room in his boxers, flipped her over and tried to put his p***s in her butt. The DON stated then the resident would tell you he didn't do anything, he just wanted to. She stated she was notified of the incident around 2:00 p.m., on 11/09/13, and she arrived at the facility around 4:45 p.m. on a Saturday. She stated she interviewed the resident, called the police and started the investigation. She has not talked to the resident since interviewing her on 11/09/13. She stated the resident was sent to a Hospital in Oklahoma City. She stated she refused any medications in case she contracted a STD and she was sent back to the facility. She stated a rape kit was done and the report was sent to the facility. The DON stated the results of the DNA test had not come back. She stated she spoke with (name deleted) a Social Services Inspector with the DHS and he stated the accused aide could return to work as long as he was kept out of close proximity with the resident and if everything was clear from the hospital and their was no evidence of rape. She stated the police have turned the case over to the District Attorney and are waiting for the DNA testing. She stated the aide had returned to work but he was not allowed to take care of any of the women resident's without someone else assisting him. The DON further stated the accused aide (name deleted) was not in the facility when she arrived to start her investigation. She stated he was late that day and she called him to find out his whereabouts. She stated she told him at that time there had been an allegation of sexual abuse against him that was reported by resident #1. She stated she asked him at that time if he raped resident #1 and (name deleted) said "No, who would say such a thing as that." She stated she told him to come in and he arrived at the facility around 4:50 p.m. She stated (name deleted) did work that evening until around 7:00 p.m. She stated the aide was suspended from 11/09/13 until 11/15/13. The DON provided a copy of an e-mail she received from (name deleted) Social Services Inspector III. The e-mail dated, 11/13/13 at 11:48 a.m., documented, "...If the police have completed their investigation and have found no evidence to support the allegations, and all the evidence suggests that no sexual activity has occurred, I think it would be appropriate to reinstate the employee though I would not assign him to work in proximity to or provide care to this resident. However, if there is evidence of sexual activity, and they are awaiting for DNA testing to determine if this individual has had sex with the resident, I think it would be prudent to wait for the results of the DNA testing, which unfortunately, can be for a long time..." At 1:25 p.m. the Assistant Administrator was asked about the sexual abuse allegation related to resident #1. She stated she received a phone call from the nurse (name deleted) who was working the day shift and the nurse (name deleted) who was working the evening shift on 11/09/13. She stated the nurses informed her of an alleged sexual abuse incident had taken place that they wanted her to be aware of. She stated she texted the DON and the DON stated she was going to come up to the facility. She was asked what time she texted the DON. She looked at her phone and was unable to find the text. The Assistant Administrator then stated she did not notify the DON that the nurses notified the DON before they contacted her. She stated she called the facility around 4:15 p.m., and the nurse told her the DON was coming to the facility. She stated the DON texted around 7:09 p.m., to tell her the resident was sent to the hospital and the police had been there to get a report. She stated she started her investigation the following Monday and she and the Administrator talked with the resident to find out what happened. She stated the resident stated the accused CNA came in her room in his boxer shorts and was standing there in his shorts and said he wanted to screw her in the butt. She stated she asked the resident how she knew he wanted to do that to her and the resident said she just knew. She was asked why she didn't call out or say anything. She stated the resident said she was just curious. She stated the resident also said at some point during the conversation the aide flipped her over. The Assistant Administrator stated to the resident that was against your will, why didn't you call out. She stated the resident said, "I didn't think about it." At 2:05 p.m., Nurse #1 was asked about the alleged sexual abuse related to resident #1. She stated she works Friday and Saturday evening and night shift doubles. She stated on 11/09/13 at 3:00 p.m., the 7:00 a.m. to 3:00 p.m., nurse (name deleted) reported to her resident #1 made an accusation the male aide that worked the night before made a sexual advance toward her. She stated the reported accusation was vague and no details were given to her except it occurred "on last night." She stated (name deleted) asked her if she should call the Assistant Administrator and tell her about the accusation. She stated yes, and the assistant administrator was called at that time. She stated the Assistant Administrator told both nurses to interview the resident. They both went to the resident's room and nurse #1 asked the resident what happened related to the sexual abuse. She stated resident #1 told her (name deleted) tried to f**k me in the a**. She asked when this happened. She stated she did not know what time it happened but it was right after she went to bed on Friday evening. The nurse stated she did not know what time she went to bed but she was in bed around 8:30 p.m. because she looked in on her at that time. She stated she asked the CNA who put the resident what time she put her to bed. She stated the CNA said it was around 8:00 p.m. She stated she asked the resident why she didn't report the incident the night before. The resident told her no one would have believed her. The nurse stated the resident had made accusations in the past toward other residents that have been true sometimes and sometimes untrue and that is probably why she didn't tell anyone. The nurse stated she asked the resident did she think the incident happened around 10:00 p.m. The resident stated yes the CNA came in to check her bed to see if it was wet and f****d her in the a**. The nurse asked her how he did it. The resident stated he made her turn toward the wall. The nurse asked the resident why she didn't tell her. The resident stated she didn't know. The nurse stated she asked if the resident was hurt from the incident and she stated no. The nurse stated she was in the residents room between 1:00 a.m. and 1:30 a.m., and the resident didn't say anything about the incident. At 2:30 p.m., nurse #2 was asked about the alleged sexual abuse related to resident #1. Nurse #2 stated the resident reported to the CNA (name deleted) that she had been sexually abused and that is when the nurse along with two other aides went to the resident's room to physically check on her. She stated there were no signs of physical abuse on the resident's skin. She stated after assessing the resident she called the DON and reported the incident. She stated the DON started yelling at her saying "You know how (name deleted) is and this is care planned." She stated the DON basically said she would take care of it later. She stated when nurse #2 came on duty it was reported to her and they went to talk to the resident and her story started changing. Nurse #1 asked Nurse #2 if she had charted the incident. Nurse #2 stated no because she didn't know how to chart it. She stated she called the Administrator and nurse #1 called the DON to report the incident. She stated the Administrator called the DON and the DON called the facility and asked to speak with nurse #2. Nurse #2 stated when she got on the phone the DON started yelling at her again and told her she would be there Monday to take care of the incident of alleged sexual abuse. Nurse #2 stated she informed the DON that the incident occurred on Friday and was reported on Saturday and it needed to be taken care of "Now." She then stated the DON said, "Well if (name deleted) can't work you are going to have to cover his shift," and they hung up the phone. She further stated, she left around 5:20 p.m. and saw the DON in the parking lot. During the investigation the accused employee's personnel file documented the following: On 04/10/11 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Failure to follow supervisor's directions...Remarks: ...Staff member asked to cont. to get up residents. Upset when told he could not go out to smoke. Then cont. to walk around et text instead of getting people up. When told again he had to cont. to get people up, he yelled @ nurses et stormed out of building..." On 04/30/12 CNA #1's employee file documented, "Employee Counseling Record Type of Warning: Verbal (circled)...Statement of Offense: Resident stated that this aid, 'rushes him, so he can hurry up and go out to smoke.'... Corrective Action: DON, (name deleted), counseled CNA regarding resident rights and proper procedure to be used when assisting residents to dress." On 05/02/12 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Insubordination... Arbitrary and belligerent...General conduct... Offenses...First warning...Disposition: Report to Supervisor's Office for conference...Remarks: On 5/1/12 CNA (name deleted) became angry when he was asked to stay + work the overnight shift as a coworker had called in due to death in the family. He let his temper get him in trouble. He was insubordinate to his charge nurse and told her he was not going to do what he was asked to do...It has also been reported (CNA #1 name deleted) has been doing things which are close to being abusive to a resident..." On 10/22/12 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Insubordination... General conduct... Offenses...Final warning...Disposition: Report to Supervisor's Office for conference...Remarks: Went off on Charge Nurse cursing and being verbally abusive to her, Assistant Adm, Social Service/Activity Director. Had to be removed from the area..." On 01/27/13 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Insubordination... General conduct...Remarks: Staff member has been moody most of the shift, et going around cussing using Fxxx word. Has been asked several x's to please clean up language. Disrespectful to other staff members et cursing @ them. Another staff member heard him tell a resident 'I would hit you if I could, but I can't..." On 02/01/13 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Insubordination... Arbitrary and belligerent... General conduct...Remarks: (CNA #1 name deleted) called this nurse, DON and cursed at her using the "F" word..." On 09/09/13 CNA #1's employee file documented, "Tonight @ 7:15 p.m. Sep 9, 2013 (CNA #1 name deleted) CNA was very violent with (name deleted) CMA He started yelling at her she came crying into the kitchen i (name deleted) Dietary Aid told her what was wrong she said (CNA #1) ...i told him before hand to not come in trying to avoid conflict between them two i nicely told him to get out of the kitchen he wouldn't (name deleted) Charge Nurse came in told him to step outside He started cussing at her He got violent really quickly (the charge nurse) got in the middle of (the CMA) and (CNA #1) he tried coming inside (name deleted) office He hit (the charge nurse) got a hold of her scrub top got mad walked out and he hit the kitchen door he punched Me (name deleted) witness all of this he is violent he should not be working in this facility He came to work and instead (sic) he harassed (CMA) and hit a fell ow coworker this is unacceptable behavior..." There was no disciplinary warning notice documented in CNA #1's employee file for this incident. On 11/19/13 at 3:00 p.m., the DON was asked if she had documentation of an investigation related to the allegation of verbal abuse by CNA #1 toward a resident on 01/27/13. She stated she did have any documentation of an investigation for that date. At 3:10 p.m., the DON was asked if she had documentation of an investigation related to the allegation of abuse she documented on the above disciplinary warning notices dated 05/02/12 and 10/22/12. She stated she did not have any documentation of an investigation for those dates. At 3:15 p.m., the DON was asked if there was any documentation of a disciplinary warning notice for the above incident on 09/09/13. She stated, "No." At 3:50 p.m. an interview was conducted with Police Officer (name deleted). He was asked if a rape kit was done on resident #1 when she went to the hospital on [DATE] and if so, did he pick it up and where did he take it. He stated a rape kit was done to check for DNA. He stated swabs of the resident's anal area were taken on 11/09/13 at the Hospital emergency room . He stated the hospital notified the Police station to come and pick up the rape kit that same night. He stated another Police Officer picked up the rape kit and brought it back to the Police station. The officer stated he took the rape kit to OSBI in Edmond Oklahoma 11/13/13. He stated OSBI did not say when the results would be ready. At 4:45 p.m. the DON was asked if she had a documented interview with the accused CNA (name deleted) related to the alleged sexual abuse. She stated she didn't write anything down, she just asked him if he did it and he said no. At 5:15 p.m., an interview was conducted with resident #4. She was asked if she had been abused by anyone in the facility. She stated, "Yes, (CNA #1 name deleted) tried to attack me sexually." She stated it happened within this year and that the CNA tried to get on top of her. She stated she didn't remember how she got him off of her. She stated she told her fiance who is another resident in the facility and she also told the DON and another nurse (name deleted). She stated they told her she was lying. At 5:25 p.m., resident #5 stated resident #4 had informed him of the incident with CNA #1. He stated he told the CNA that (resident #4) was his girl and he better not do that to her. At 5:45 p.m., LPN #3 was asked if resident #4 ever reported to her that CNA (name deleted) tried to sexually assault her. She stated, "No." At 5:50 p.m., the DON was asked if resident #4 ever reported to her that CNA #1 tried to sexually assault her. She stated, "No." The DON was informed that the resident reported this to the surveyor. She stated, "Ok."

On 11/19/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to complete a thorough investigation for allegations of abuse and failure to ensure residents were protected until a thorough investigation was completed. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy Situation. At 6:15 p.m. the Administrator and the Director of Nursing were notified of the IJ situation. On 11/20/13 at 9:30 a.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "Plan of removal of Immediate Jeopardy 11/19/2013 Inservice completed with all staff regarding investigative procedures and abuse policy, Reporting guidelines the need for immediate interviews with staff and other residents. Interview procedures with the accused. All alert residents interviewed regarding abuse of any kind. Employee named in accusation has been terminated. Investigation into second allegation and local law enforcement notified. Medical Director notified no new orders on resident. Head to toe assessment completed on resident. To be completed by 0800 11/20/13." The immediate Jeopardy was removed on 11/20/13 at 12:35 p.m., after all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on clinical record review, review of policy and procedure and staff and resident interviews, it was determined the facility failed to ensure an allegation of staff to resident abuse was investigated, and measures were put into place to ensure protection from further abuse for one (#1) of four sampled residents with allegations of abuse. This had the potential to affect all 33 residents who resided in the facility. Findings: The facility's Abuse Prohibition Policy documented: "...The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion...1st Shamrock Nursing Home does not allow its employees to use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion... Policy: Every resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents, physicians, consultants, volunteers, family members, legal guardians, friends or other individuals... Abusive Conditions can occur between employee and resident, resident and resident, family of a resident... Types of Abuse: 1. Physical: Any action that causes actual physical harm. For example, rough handling of a resident. 2. Verbal: Using profanity, name calling, cruel teasing 3. Negligence: Failing to properly care for a resident in the manner conducive to professional care standards 4. Sexual: Touching the resident in an intimate or suggestive manner, making sexual comments or allowing another resident to do so 5. Mental: Any act that makes a resident fearful, feel belittled or to make fun of a resident by mocking, imitating, or ridiculing... Prevention: Facility management staff is required to accept all allegations of abuse and conduct a complete investigation including reporting to the proper authorities. All reports whether from family, residents or staff will be reported immediately to the administrator and D.O.N. After the allegations of abuse are reported to the D.O.N. and the Administrator, an incident report is completed, and forwarded to the Safety Committee and Quality Improvement Committee. An analysis is conducted to immediately determine: Safety of resident... Investigation: 1. Any accused staff members will be immediately removed from contact with the resident suspected of being abused and the resident's safety will be protected. 2. The Administrator and the D.O.N. will conduct an investigation... 4. The investigating team will interview all parties concerned: witnesses, the victim, staff and the accused... 7. Appropriate steps will be taken to assure the abuse situations do not reoccur in the future..." Resident #1 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/01/13, documented the resident was cognitively intact with a Brief Interview for Mental Status score of thirteen. She required limited one person assistance with bed mobility and extensive one person assistance with personal hygiene. She was totally dependent with transfers, toilet use and bathing and she required two person assistance. She was independent with eating with setup help. She required extensive two person assistance with dressing and she was nonambulatory. The assessment documented she was independent with transfers, ambulation, dressing, eating, toilet use and personal hygiene. She required set-up assistance with bathing. She had limited range of motion in one upper extremity. She was always incontinent of bowel and bladder. A nurse's note, dated 11/09/13 for the 7:00 a.m. to 3:00 p.m. shift, documented, "... Resident made complaint about CNA that worked night shift, this was reported to DON and Administration, they are to check into incident..." A nurse's note, dated 11/09/13 at 3:45 p.m., documented, "Recd report from (initials deleted) LPN that resident reported 'sexual abuse' by male CNA 'last night' to CNA 'after lunch today' -To room c (initials deleted) LPN @ (name deleted) instruction (administrative assistant) to interview resident regarding her accusation. (Resident) stated that sometime after she was put to bed by female CNA that male CNA 'came to check if my bed was wet and tried to have sex with me in my a** and I told him it hurt and he stopped.' Also stated that 'He said he would deny it if I told anyone. States she is not injured or 'physically hurt'. No sign of 'injury' to buttocks or rectal area..." On 11/19/13 at 12:45 p.m., the resident was asked if anyone in the facility had ever abused her. She stated an aide (name deleted) sexually abused her. She stated he tried to stick his d**k in her butt hole. She stated she told him to stop because it hurt and he got up and got dressed and left the room. She stated she was lying on her back when the aide came in the room and he turned her over and tried to do it. She stated her roommate was in the room but her roommate cannot talk and the aid knew the roommate was in the room. She stated he told her not to say anything. She stated she reported what happened to another aide the next day because she was embarrassed. She stated the aide reported it to two other nurses. She stated the nurses came to physically assess her to make sure she was all right. She stated the aide that did this told her not to say anything but it got all around the facility. She stated the nurse called the doctor and told him what happened. Two police officers came in to talk to her. She stated (name deleted) denied the whole thing to the police. At 1:15 p.m., the Director of Nurses was asked if the resident had reported any kind of abuse to her. She stated the resident had reported a circumstance of abuse with (name deleted) and "for lack of a better word I guess rape that is how she put it." She stated the resident alleged this occurred on 11/08/13 but she did not report it until 11/09/13. She stated according to the resident, she was put in bed by a CNA (name deleted) around 8:00 p.m., and (name deleted) came in her room in his boxers, flipped her over and tried to put his p***s in her butt. The DON stated then the resident would tell you he didn't do anything, he just wanted to. She stated she was notified of the incident around 2:00 p.m., on 11/09/13, and she arrived at the facility around 4:45 p.m. on a Saturday. She stated she interviewed the resident, called the police and started the investigation. She has not talked to the resident since interviewing her on 11/09/13. She stated the resident was sent to a Hospital in Oklahoma City. She stated she refused any medications in case she contracted a STD and she was sent back to the facility. She stated a rape kit was done and the report was sent to the facility. The DON stated the results of the DNA test had not come back. She stated she spoke with (name deleted) a Social Services Inspector with the DHS and he stated the accused aide could return to work as long as he was kept out of close proximity with the resident and if everything was clear from the hospital and their was no evidence of rape. She stated the police have turned the case over to the District Attorney and are waiting for the DNA testing. She stated the aide had returned to work but he was not allowed to take care of any of the women resident's without someone else assisting him. The DON further stated the accused aide (name deleted) was not in the facility when she arrived to start her investigation. She stated he was late that day and she called him to find out his whereabouts. She stated she told him at that time there had been an allegation of sexual abuse against him that was reported by resident #1. She stated she asked him at that time if he raped resident #1 and (name deleted) said "No, who would say such a thing as that." She stated she told him to come in and he arrived at the facility around 4:50 p.m. She stated (name deleted) did work that evening until around 7:00 p.m. She stated the aide was suspended from 11/09/13 until 11/15/13. The DON provided a copy of an e-mail she received from (name deleted) Social Services Inspector III. The e-mail dated, 11/13/13 at 11:48 a.m., documented, "...If the police have completed their investigation and have found no evidence to support the allegations, and all the evidence suggests that no sexual activity has occurred, I think it would be appropriate to reinstate the employee though I would not assign him to work in proximity to or provide care to this resident. However, if there is evidence of sexual activity, and they are awaiting for DNA testing to determine if this individual has had sex with the resident, I think it would be prudent to wait for the results of the DNA testing, which unfortunately, can be for a long time..." At 1:25 p.m. the Assistant Administrator was asked about the sexual abuse allegation related to resident #1. She stated she received a phone call from the nurse (name deleted) who was working the day shift and the nurse (name deleted) who was working the evening shift on 11/09/13. She stated the nurses informed her of an alleged sexual abuse incident had taken place that they wanted her to be aware of. She stated she texted the DON and the DON stated she was going to come up to the facility. She was asked what time she texted the DON. She looked at her phone and was unable to find the text. The Assistant Administrator then stated she did not notify the DON that the nurses notified the DON before they contacted her. She stated she called the facility around 4:15 p.m., and the nurse told her the DON was coming to the facility. She stated the DON texted around 7:09 p.m., to tell her the resident was sent to the hospital and the police had been there to get a report. She stated she started her investigation the following Monday and she and the Administrator talked with the resident to find out what happened. She stated the resident stated the accused CNA came in her room in his boxer shorts and was standing there in his shorts and said he wanted to screw her in the butt. She stated she asked the resident how she knew he wanted to do that to her and the resident said she just knew. She was asked why she didn't call out or say anything. She stated the resident said she was just curious. She stated the resident also said at some point during the conversation the aide flipped her over. The Assistant Administrator stated to the resident that was against your will, why didn't you call out. She stated the resident said, "I didn't think about it." At 2:05 p.m., Nurse #1 was asked about the alleged sexual abuse related to resident #1. She stated she works Friday and Saturday evening and night shift doubles. She stated on 11/09/13 at 3:00 p.m., the 7:00 a.m. to 3:00 p.m., nurse (name deleted) reported to her resident #1 made an accusation the male aide that worked the night before made a sexual advance toward her. She stated the reported accusation was vague and no details were given to her except it occurred "on last night." She stated (name deleted) asked her if she should call the Assistant Administrator and tell her about the accusation. She stated yes, and the assistant administrator was called at that time. She stated the Assistant Administrator told both nurses to interview the resident. They both went to the resident's room and nurse #1 asked the resident what happened related to the sexual abuse. She stated resident #1 told her (name deleted) tried to f**k me in the a**. She asked when this happened. She stated she did not know what time it happened but it was right after she went to bed on Friday evening. The nurse stated she did not know what time she went to bed but she was in bed around 8:30 p.m. because she looked in on her at that time. She stated she asked the CNA who put the resident what time she put her to bed. She stated the CNA said it was around 8:00 p.m. She stated she asked the resident why she didn't report the incident the night before. The resident told her no one would have believed her. The nurse stated the resident had made accusations in the past toward other residents that have been true sometimes and sometimes untrue and that is probably why she didn't tell anyone. The nurse stated she asked the resident did she think the incident happened around 10:00 p.m. The resident stated yes the CNA came in to check her bed to see if it was wet and f****d her in the a**. The nurse asked her how he did it. The resident stated he made her turn toward the wall. The nurse asked the resident why she didn't tell her. The resident stated she didn't know. The nurse stated she asked if the resident was hurt from the incident and she stated no. The nurse stated she was in the residents room between 1:00 a.m. and 1:30 a.m., and the resident didn't say anything about the incident. At 2:30 p.m., nurse #2 was asked about the alleged sexual abuse related to resident #1. Nurse #2 stated the resident reported to the CNA (name deleted) that she had been sexually abused and that is when the nurse along with two other aides went to the resident's room to physically check on her. She stated there were no signs of physical abuse on the resident's skin. She stated after assessing the resident she called the DON and reported the incident. She stated the DON started yelling at her saying "You know how (name deleted) is and this is care planned." She stated the DON basically said she would take care of it later. She stated when nurse #2 came on duty it was reported to her and they went to talk to the resident and her story started changing. Nurse #1 asked Nurse #2 if she had charted the incident. Nurse #2 stated no because she didn't know how to chart it. She stated she called the Administrator and nurse #1 called the DON to report the incident. She stated the Administrator called the DON and the DON called the facility and asked to speak with nurse #2. Nurse #2 stated when she got on the phone the DON started yelling at her again and told her she would be there Monday to take care of the incident of alleged sexual abuse. Nurse #2 stated she informed the DON that the incident occurred on Friday and was reported on Saturday and it needed to be taken care of "Now." She then stated the DON said, "Well if (name deleted) can't work you are going to have to cover his shift," and they hung up the phone. She further stated, she left around 5:20 p.m. and saw the DON in the parking lot. During the investigation the accused employee's personnel file documented the following: On 04/10/11 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Failure to follow supervisor's directions...Remarks: ...Staff member asked to cont. to get up residents. Upset when told he could not go out to smoke. Then cont. to walk around et text instead of getting people up. When told again he had to cont. to get people up, he yelled @ nurses et stormed out of building..." On 04/30/12 CNA #1's employee file documented, "Employee Counseling Record Type of Warning: Verbal (circled)...Statement of Offense: Resident stated that this aid, 'rushes him, so he can hurry up and go out to smoke.'... Corrective Action: DON, (name deleted), counseled CNA regarding resident rights and proper procedure to be used when assisting residents to dress." On 05/02/12 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Insubordination... Arbitrary and belligerent...General conduct... Offenses...First warning...Disposition: Report to Supervisor's Office for conference...Remarks: On 5/1/12 CNA (name deleted) became angry when he was asked to stay + work the overnight shift as a coworker had called in due to death in the family. He let his temper get him in trouble. He was insubordinate to his charge nurse and told her he was not going to do what he was asked to do...It has also been reported (CNA #1 name deleted) has been doing things which are close to being abusive to a resident..." On 10/22/12 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Insubordination... General conduct... Offenses...Final warning...Disposition: Report to Supervisor's Office for conference...Remarks: Went off on Charge Nurse cursing and being verbally abusive to her, Assistant Adm, Social Service/Activity Director. Had to be removed from the area..." On 01/27/13 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Insubordination... General conduct...Remarks: Staff member has been moody most of the shift, et going around cussing using Fxxx word. Has been asked several x's to please clean up language. Disrespectful to other staff members et cursing @ them. Another staff member heard him tell a resident 'I would hit you if I could, but I can't..." On 02/01/13 CNA #1's employee file documented, "Disciplinary Warning Notice... Warning for: Insubordination... Arbitrary and belligerent... General conduct...Remarks: (CNA #1 name deleted) called this nurse, DON and cursed at her using the "F" word..." On 09/09/13 CNA #1's employee file documented, "Tonight @ 7:15 p.m. Sep 9, 2013 (CNA #1 name deleted) CNA was very violent with (name deleted) CMA He started yelling at her she came crying into the kitchen i (name deleted) Dietary Aid told her what was wrong she said (CNA #1) ...i told him before hand to not come in trying to avoid conflict between them two i nicely told him to get out of the kitchen he wouldn't (name deleted) Charge Nurse came in told him to step outside He started cussing at her He got violent really quickly (the charge nurse) got in the middle of (the CMA) and (CNA #1) he tried coming inside (name deleted) office He hit (the charge nurse) got a hold of her scrub top got mad walked out and he hit the kitchen door he punched Me (name deleted) witness all of this he is violent he should not be working in this facility He came to work and instead (sic) he harassed (CMA) and hit a fell ow coworker this is unacceptable behavior..." There was no disciplinary warning notice documented in CNA #1's employee file for this incident. On 11/19/13 at 3:00 p.m., the DON was asked if she had documentation of an investigation related to the allegation of verbal abuse by CNA #1 toward a resident on 01/27/13. She stated she did have any documentation of an investigation for that date. At 3:10 p.m., the DON was asked if she had documentation of an investigation related to the allegation of abuse she documented on the above disciplinary warning notices dated 05/02/12 and 10/22/12. She stated she did not have any documentation of an investigation for those dates. At 3:15 p.m., the DON was asked if there was any documentation of a disciplinary warning notice for the above incident on 09/09/13. She stated, "No." At 3:50 p.m. an interview was conducted with Police Officer (name deleted). He was asked if a rape kit was done on resident #1 when she went to the hospital on [DATE] and if so, did he pick it up and where did he take it. He stated a rape kit was done to check for DNA. He stated swabs of the resident's anal area were taken on 11/09/13 at the Hospital emergency room . He stated the hospital notified the Police station to come and pick up the rape kit that same night. He stated another Police Officer picked up the rape kit and brought it back to the Police station. The officer stated he took the rape kit to OSBI in Edmond Oklahoma 11/13/13. He stated OSBI did not say when the results would be ready. At 4:45 p.m. the DON was asked if she had a documented interview with the accused CNA (name deleted) related to the alleged sexual abuse. She stated she didn't write anything down, she just asked him if he did it and he said no. At 5:15 p.m., an interview was conducted with resident #4. She was asked if she had been abused by anyone in the facility. She stated, "Yes, (CNA #1 name deleted) tried to attack me sexually." She stated it happened within this year and that the CNA tried to get on top of her. She stated she didn't remember how she got him off of her. She stated she told her fiance who is another resident in the facility and she also told the DON and another nurse (name deleted). She stated they told her she was lying. At 5:25 p.m., resident #5 stated resident #4 had informed him of the incident with CNA #1. He stated he told the CNA that (resident #4) was his girl and he better not do that to her. At 5:45 p.m., LPN #3 was asked if resident #4 ever reported to her that CNA (name deleted) tried to sexually assault her. She stated, "No." At 5:50 p.m., the DON was asked if resident #4 ever reported to her that CNA #1 tried to sexually assault her. She stated, "No." The DON was informed that the resident reported this to the surveyor. She stated, "Ok."

Based on observation, record review and interview, it was determined the facility failed to ensure CNA's were competent to: a. position residents properly in bed during incontinent care to prevent falls for two (#1 and #3) of two sampled residents with falls during the provision of care; b. supervise residents during the provision of incontinent care to prevent falls for one (#1) of two sampled residents with falls during the provision of care; c. provide proper incontinent care for two (#9 and #10) of six residents observed during routine bed checks for incontinence and; d. properly wash their hands during the provision of care for six (#5 - #10) of six residents observed during routine bed checks for incontinence. Resident #1 sustained a left [MEDICAL CONDITION] and resident #3 sustained a head injury when her head hit the night stand. This had the potential to affect 20 residents identified by the facility as being incontinent of bowel and/or bladder. Findings: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 06/15/12, documented: "06/15/12 Problem As a result of my dementia I have loss of my mobility and my cognitive skills are diminished. I require extensive help with activities of daily living. Goal I require staff to keep me clean, dry and odor free... Interventions ...(5) When I'm incontinent of bowel and bladder 1 CNA will provide me pericare... Evaluation (Resident) is totally dependent on staff for all activities of daily living... She is incontinent of bowel and bladder - Pericare is performed after each episode... Problem I have experienced the loss of physical ability as a result of my Dementia... Goal Staff will allow me to maintain my current level of physical function and meet my safety needs ie no falls... Interventions ...(4) while providing me care CNA will position me q 2 hrs... Evaluations 6-15-12 (Resident) is unable to reposition self or transfer self..." A fall risk assessment, dated 06/15/12, documented the resident was at high risk for falls. A nurse's note, dated 07/21/12 at 5:00 a.m., documented, "CNA (#4) providing incontinent care + stated that res. rolled off edge of bed onto spenco mattress on floor between (resident) + her roommate's bed." An incident/accident report, dated 07/21/12 at 5:00 a.m., documented, "...CNA providing incont. care + reports resident rolled off edge of bed onto floor..." A fax cover sheet, dated 07/21/12, documented, "(Resident) rolled off edge of bed when CNA providing cares (sic) this am - no noted injury no bruising, redness, or skin breaks noted - no s/s of pain c movement..." An update to the care plan, dated 07/21/12, documented, "(Resident) rolled off side of bed onto floor during CNA (#4) care..." A nurse's note, dated 07/22/12 at 1:00 a.m., documented, "No s/s injury from fall - CNA (#3) believes res is keeping left knee in unusual flexed position - ROM WNL - do note some apparent 'roughness' to flexion of (L) knee..." A nurse's note, dated 07/22/12 at 8:30 p.m., documented, "Resident in bed c (L) knee flexed + left leg rotated outward - grimaces c movement of (L) leg - noted 3" x 3" area of faint bluish bruising to inner left thigh + 1 1/2" x 1/2" area of brighter bluish bruising to lower position of inner left thigh... Do note facial color to be more 'pale' than usual this shift." A nurse's note, dated 07/23/12 at 4:00 a.m., documented, "Slight swelling & faint bruising to inner left thigh... continues c flexed L knee & outward rotation of L L extremity while in bed." A nurse's note, dated 07/23/12 at 9:30 a.m., documented, "Noted resident c outward rotation of (L) foot. (Illegible) hip tender to touch + jerking when attempts made to roll pt from side. Dr. called + notified + asked for (name deleted) - xray to (L) hip will return call... A nurse's note, dated 07/23/12 at 3:20 p.m., documented "...Report from x-Ray Tech that resident has Acute fracture of Lt. hip..." A Final Radiology Report, dated 07/23/12 at 3:34 p.m., documented, "...Impression: Comminuted intertrochanteric fracture proximal femur, with angulation and displacement by approximately 13 mm..." A nurse's note, dated 07/23/12 at 4:45 p.m., documented, "RTC from (physician). Explained results of x-ray New Orders: 1.) [MEDICATION NAME] 5/500mg i po q 4 (hrs) PRN for pain. 2.) Place Lt leg in long leg immobilizer." An update to the care plan, dated 07/23/12, documented, "Orders received to x-ray (Lt) hip. X-ray results show intertrochanteric fracture proximal femur with angulation and displacement by approximately 13mm..." An OSDH Incident Report Form, fax dated 07/24/12 at 11:08 a.m., documented, "...Part B Description of Incident... A hand written statement, with a fax date of 07/24/12 at 11:08 a.m., documented, "Part B - #1 On 07/21/12 at 5 AM, CNA (#4) was doing Pericare on resident (name deleted) when she turned and went to the door of room to put dirty linens in linen barrell (sic), (resident) rolled off her bed and fell to the floor onto mat then rolled to floor... (RN #2) charted CNA (#3) stated (resident) was holding her left leg in different position than usual on the 11 - 7 shift of 7-21-12 but still no pain with movement. On Sunday, 7-22-12, while assessing resident for (illegible) incident reporting, (RN #2) noticed grimacing with movement... On 07-23-2012, after assessing resident, both LPN (name deleted, #1) and myself (DON) felt it was appropriate due to rotation of left leg and grimacing of resident when moved to obtain x-ray..." A hand written statement, by CNA #4, dated 07/24/12, documented, "On Sat. July 21, 2012 at 5:00 AM, I went to check on (resident) and she was awake... She was doing her erratic movement that she does when you are moving around, more so than usual. I had put her undergarment on, and placed her on her left side facing the wall, I thought I had her in the middle of the bed. I do this every morning, then I took her wet pads to the laundry barrel by the door. I turned around just as (resident) hit the mat on the floor..." 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/02/12, documented the resident was severely impaired in her cognitive skills for daily decision making. She was independent with bed mobility and had limited ROM to both upper extremities and both lower extremities. A nurse's note, dated 02/02/13 at 1:20 a.m., documented, "CNA (#4) providing incontinent care and resident slid off the edge of her bed when CNA rolled her to her left side - Resident bruised left temporal area on bedside table resulting in a superficial 3/4" laceration to left outer canthal- temporal area Cleansed c NSS + 2 steristrips applied to approximate edges..." An incident/accident report, dated 02/02/13 at 1:20 a.m., documented, "...CNA providing incontinent care + resident slid off the edge of bed when CNA rolled her to her left side - Bumped left temporal area on bedside table... Type of injury: (1) Laceration (checked) 3/4" superficial..." A fax cover sheet, dated 02/02/13 at 1:20 a.m., documented, "...Re: (resident #3) - CNA providing incontinent care and resident slid off the edge of bed when CNA rolled her to her left side. Bumped left temporal area on bedside table resulting in superficial 3/4" laceration to left outer cauthal/temporal area. Cleansed c NSS + 2 steri strips applied to approximate edges..." A nurse's note, dated 02/02/13 at 6:00 a.m., documented, "...beginning to (illegible) some bruising to periorbital area..." A hand written statement by CNA #4, dated 02/02/13, documented, "At 1:20 AM, when I rolled (resident) over to change her pad, I had her up against my legs, and she started bouncing, and the top of her slid of (sic) the bed, and she went on the floor... She hit her head on the night stand..." A nurse's note, dated 02/02/13 at 2:30 p.m., documented, "Bruising still noted to to (sic) left eye extending down side of face..." A nurse's note, dated 02/02/13 at 4:30 p.m., documented, "...Purplish bruising around (L) eye area..." A nurse's note, dated 02/03/13 at 9:05 p.m., documented, "Cont c bruising to Lt side of forehead et down of Lt side of face Steri strips in place..." A nurse's note, dated 02/04/13 at 5:00 a.m., documented, "Bruising remains to Bil eyes..." On 03/14/13 at 2:57 p.m., CNA #3 was asked if he remembered the incident with resident #3. He stated, "Well maybe I reported the redness under her breasts." No further comment was made. At 4:50 p.m., the administrator was asked about CNA proficiency and how was it monitored. She stated, "I didn't start until the fourth of March. I am way early into this." At 4:55 p.m. the assistant administrator was asked what the facility did to help prevent accidents. She stated, "Lots of inservices and continued training." She was asked about the interventions put into place after the accident with resident #1. She stated, (DON) usually does the inservices." She was asked about the accident with resident #3. She stated she wasn't familiar with that one. On 03/14/12 at 5:15 p.m, the DON was asked about accidents and supervision during the provision of care. She stated, "We have inserviced her (CNA #4) and her charge nurse inserviced about getting residents dressed and giving pericare. She was asked about the identification of residents at risk for falls. She stated, "We do fall risk assessments and check for UTI's. She was asked about the CNAs skills assessment for maneuvering and/or positioning a resident in bed. She stated, "We spoke to (name deleted, CNA #4)." She further stated she may not have written it down. 3. On 03/14/13 at 3:25 a.m., CNA #1 and CNA #2 were observed as they performed routine bed checks for incontinence. At 3:25 a.m., resident #5 was checked for incontinence. Both CNAs did not wash their hands after the resident was checked and they moved on to the next resident. At 3:30 a.m., resident #6 was checked for incontinence. Both CNAs did not wash their hands before or after the resident was checked. They moved on to the next resident. At 3:40 a.m., resident #7 was checked for incontinence. Both CNAs did not wash their hands before the resident was checked. At 3:50 a.m., resident #8 was checked for incontinence. Both CNAs donned a pair of gloves without first washing their hands. The resident's pad was checked and the resident had not been incontinent. The resident was rolled onto her right side. CNA #1 applied some barrier cream to the resident's buttocks in a circular fashion. The resident was repositioned in bed. Both CNAs removed their gloves and discarded them. They did not wash their hands after the provision of care. They moved onto the next resident. At 3:55 a.m., resident #9 was checked for incontinence. Without washing their hands, they both donned a pair of gloves. The resident was rolled to her right side. The resident had been incontinent of urine. Both CNAs removed the wet pad from underneath the resident. With her soiled gloves still on, CNA #2 rolled up a clean pad and placed it next to the resident. The resident was rolled to her left side and CNA #1 applied barrier cream to her wet buttocks. Pericare was not performed. Both CNAs discarded their gloves and did not wash their hands. They moved on to the next resident. At 4:05 a.m., resident #10 was checked for incontinence. Both CNAs donned a new pair of gloves without first washing their hands. CNA #1 rolled resident to his left side. The resident had been incontinent of urine. She applied barrier cream to his wet buttocks in the same circular fashion. A clean dry pad was rolled under the resident. The resident was rolled to his right side as the clean pad was pulled under him. No pericare was provided for the resident. Both CNAs removed their gloves. They did not wash their hands after the provision of care. On 03/14/13 at 4:20 a.m., the CNAs were asked how frequently they wash their hands during resident care. CNA #1 stated, "Usually quite a bit." CNA #2 stated, "My hands are dry." They were asked what the facility policy and procedure was for handwashing. CNA #2 stated, "Every time we go into the room and leave the room." They were asked when would they wash their hands if two residents occupy a room. CNA #2 stated, "Then in between." They were asked how many times they washed their hands during bed checks. CNA #1 stated, "I didn't." CNA #2 stated, "We didn't." They were asked if they knew about pericare. CNA #2 stated, "You use a clean wipe each time and wipe to the left side then to right side and down the middle. Then the bottom." They were asked how often they performed pericare for the resident. CNA #2 stated, "Whenever you change the patient." They were asked if they performed pericare during the bed checks. Both stated no. On 03/15/13 at 10:10 a.m., the DON was asked how often aides provide pericare. She stated, "They provide pericare if needed." She was asked about the staff proficiency with pericare. She stated, "That is what we were written up for in October." She further stated we followed up c checking off the staff. She stated she had been told about the lack of pericare and handwashing. She stated, "I was dumb-founded." CNA #4's personnel file was reviewed. There was no documentation of an inservice provided to the CNA after either of the two incidents involving resident #1 and resident #3. There was no performance review to verify the CNA's competency.

Based on clinical record review, review of incident reports, review of policy/procedures and staff interviews, it was determined the facility failed to ensure: a. residents were positioned properly in bed during incontinent care to prevent falls for two (#1 and #3) of two sampled residents with falls during the provision of care and; b. residents were supervised by staff during the provision of incontinent care to prevent falls for one (#1) of two sampled residents with falls during the provision of care. Resident #1 sustained a left hip fracture and resident #3 sustained a head injury when her head hit the night stand. This had the potential to affect 20 residents identified by the facility as being incontinent. Findings: A policy titled, Safety (General Guidelines For Resident Safety), documented: "Basic Responsibility: Licensed Nurse and Nursing Assistant... Purpose: 1. To create a safe environment for the resident. 2. To communicate concerns about resident safety issues. General Instructions: ...7. support the resident's body well during all positioning..." A policy titled, Perineal Care, documented: "...7. Provide resident safety & raise head of bed to best level for body mechanics... A. Female Resident: ...2. Remove pads & replace, if needed & provide for resident safety..." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 06/15/12, documented: "06/15/12 Problem As a result of my dementia I have loss of my mobility and my cognitive skills are diminished. I require extensive help with activities of daily living. Goal I require staff to keep me clean, dry and odor free... Interventions ...(5) When I'm incontinent of bowel and bladder 1 CNA will provide me pericare... Evaluation (Resident) is totally dependent on staff for all activities of daily living... She is incontinent of bowel and bladder - Pericare is performed after each episode... Problem I have experienced the loss of physical ability as a result of my Dementia... Goal Staff will allow me to maintain my current level of physical function and meet my safety needs ie no falls... Interventions ...(4) while providing me care CNA will position me q 2 hrs... Evaluations 6-15-12 (Resident) is unable to reposition self or transfer self..." A fall risk assessment, dated 06/15/12, documented the resident was at high risk for falls. A nurse's note, dated 07/21/12 at 5:00 a.m., documented, "CNA (#4) providing incontinent care + stated that res. rolled off edge of bed onto spenco mattress on floor between (resident) + her roommate's bed." An incident/accident report, dated 07/21/12 at 5:00 a.m., documented, "...CNA providing incont. care + reports resident rolled off edge of bed onto floor..." A fax cover sheet, dated 07/21/12, documented, "(Resident) rolled off edge of bed when CNA providing cares (sic) this am - no noted injury no bruising, redness, or skin breaks noted - no s/s of pain c movement..." An update to the care plan, dated 07/21/12, documented, "(Resident) rolled off side of bed onto floor during CNA (#4) care..." A nurse's note, dated 07/22/12 at 1:00 a.m., documented, "No s/s injury from fall - CNA (#3) believes res is keeping left knee in unusual flexed position - ROM WNL - do note some apparent 'roughness' to flexion of (L) knee..." A nurse's note, dated 07/22/12 at 8:30 p.m., documented, "Resident in bed c (L) knee flexed + left leg rotated outward - grimaces c movement of (L) leg - noted 3" x 3" area of faint bluish brusing to inner left thigh + 1 1/2" x 1/2" area of brighter bluish bruising to lower position of inner left thigh... Do note facial color to be more 'pale' than usual this shift." A nurse's note, dated 07/23/12 at 4:00 a.m., documented, "Slight swelling & faint bruising to inner left thigh... continues c flexed L knee & outward rotation of L L extremity while in bed." A nurse's note, dated 07/23/12 at 9:30 a.m., documented, "Noted resident c outward rotation of (L) foot. (Ilegible) hip tender to touch + jerking when attempts made to roll pt from side. Dr. called + notified + asked for (name deleted) - xray to (L) hip will return call... A nure's note, dated 07/23/12 at 3:20 p.m., documented "...Report from x-Ray Tech that resident has Acute fracture of Lt. hip..." A Final Radiology Report, dated 07/23/12 at 3:34 p.m., documented, "...Impression: Comminuted intertrochanteric fracture promixal femur, with angulation and displacement by approximately 13 mm..." A nurse's note, dated 07/23/12 at 4:45 p.m., documented, "RTC from (physician). Explained results of x-ray New Orders: 1.) Lortab 5/500mg i po q 4 (hrs) PRN for pain. 2.) Place Lt leg in long leg immobilizer." An update to the care plan, dated 07/23/12, documented, "Orders received to x-ray (Lt) hip. X-ray results show intertrochanteric fracture proximal femur with angulation and displacement by approximately 13mm..." An OSDH Incident Report Form, fax dated 07/24/12 at 11:08 a.m., documented, "...Part B Description of Incident... A hand written statement, with a fax date of 07/24/12 at 11:08 a.m., documented, "Part B - #1 On 07/21/12 at 5 AM, CNA (#4) was doing Pericare on resident (name deleted) when she turned and went to the door of room to put dirty linens in linen barrell (sic), (resident) rolled off her bed and fell to the floor onto mat then rolled to floor... (RN #2) charted CNA (#3) stated (resident) was holding her left leg in different position than usual on the 11 - 7 shift of 7-21-12 but still no pain with movement. On Sunday, 7-22-12, while assessing resident for (illegible) incident reporting, (RN #2) noticed grimacing with movement... On 07-23-2012, after assessing resident, both LPN (name deleted, #1) and myself (DON) felt it was appropriate due to rotation of left leg and grimacing of resident when moved to obtain x-ray..." A hand written statement, by CNA #4, dated 07/24/12, documented, "On Sat. July 21, 2012 at 5:00 AM, I went to check on (resident) and she was awake... She was doing her erratic movement that she does when you are moving around, more so than usual. I had put her undergarment on, and placed her on her left side facing the wall, I thought I had her in the middle of the bed. I do this every morning, then I took her wet pads to the laundry barrel by the door. I turned around just as (resident) hit the mat on the floor..." A nurse's note, dated 07/24/12 at 12:00 p.m., documented, "...Shows pain c movement..." A nurse's note, dated 07/24/12 (untimed), documented, "...Staff log rolling resident to (change) her @ bedchecks. Noted painful grimace when moved..." A nurse's note, dated 07/26/12 at 2:00 p.m., documented, "... New order written for Nurse to (check) positioning in bed et of left leg..." An update to the care plan, dated 07/26/12, documented, "New orders received (illegible) nurse to check positioning in bed." An update to the care plan, dated 09/14/12, documented, "(Resident) remains bedfast R/T Left fx hip..." On 03/14/13 at 2:57 p.m., CNA #3 was asked if he remembered the incident with resident #1. He stated, "It was my day off." He stated the charge nurse told him that CNA #4 rolled her and she fell . He was told the resident's nurse's note documented he saw her leg twisted out. He stated, "It was a day or two days after the incident." 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/02/12, documented the resident was severely impaired in her cognitive skills for daily decision making. She was independent with bed mobility and had limited ROM to both upper extremities and both lower extremities. A nurse's note, dated 02/02/13 at 1:20 a.m., documented, "CNA (#4) providing incontinent care and resident slid off the edge of her bed when CNA rolled her to her left side - Resident bruised left temporal area on bedside table resulting in a superficial 3/4" laceration to left outer canthal- temporal area Cleansed c NSS + 2 steristrips applied to approximate edges..." An incident/accident report, dated 02/02/13 at 1:20 a.m., documented, "...CNA providing incontinent care + resident slid off the edge of bed when CNA rolled her to her left side - Bumped left temporal area on bedside table... Type of injury: (1) Laceration (checked) 3/4" superficial..." A fax cover sheet, dated 02/02/13 at 1:20 a.m., documented, "...Re: (resident #3) - CNA providing incontinent care and resident slid off the edge of bed when CNA rolled her to her left side. Bumped left temporal area on bedside table resulting in superficial 3/4" laceration to left outer cauthal/temporal area. Cleansed c NSS + 2 steri strips applied to approximate edges..." A nurse's note, dated 02/02/13 at 6:00 a.m., documented, "...beginning to (illegible) some bruising to periorbital area..." A hand written statement by CNA #4, dated 02/02/13, documented, "At 1:20 AM, when I rolled (resident) over to change her pad, I had her up against my legs, and she started bouncing, and the top of her slid of (sic) the bed, and she went on the floor... She hit her head on the night stand..." A nurse's note, dated 02/02/13 at 2:30 p.m., documented, "Bruising still noted to to (sic) left eye extending down side of face..." A nurse's note, dated 02/02/13 at 4:30 p.m., documented, "...Purplish bruising around (L) eye area..." A nurse's note, dated 02/03/13 at 9:05 p.m., documented, "Cont c bruising to Lt side of forehead et down of Lt side of face Steri strips in place..." A nurse's note, dated 02/04/13 at 5:00 a.m., documented, "Bruising remains to Bil eyes..." On 03/14/13 at 2:57 p.m., CNA #3 was asked if he remembered the incident with resident #3. He stated, "Well maybe I reported the redness under her breasts." No further comment was made. At 4:50 p.m., the administrator was asked about CNA proficiency and how was it monitored. She stated, "I didn't start until the fourth of March. I am way early into this." At 4:55 p.m. the assistant administrator was asked what the facility did to help prevent accidents. She stated, "Lots of inservices and continued training." She was asked about the interventions put into place after the accident with resident #1. She stated, (DON) usually does the inservices." She was asked about the accident with resident #3. She stated she wasn't familiar with that one. On 03/14/12 at 5:15 p.m, the DON was asked about accidents and supervision during the provision of care. She stated, "We have inserviced her (CNA #4) and her charge nurse inserviced about getting residents dressed and giving pericare. She was asked about the identification of residents at risk for falls. She stated, "We do fall risk assessments and check for UTI's. She was asked about the CNAs skills assessment for maneuvering and/or positioning a resident in bed. She stated, "We spoke to (name deleted, CNA #4)." She further stated she may not have written it down.

On [DATE] at 1:05 p.m., an immediate jeopardy situation was determined to exist related to the facility's failure to ensure the physician was notified of critical lab values. The OSDH was notified and verified the existence of the immediate jeopardy situation. At 1:15 p.m., the administrator and the DON were notified of the immediate jeopardy situation related to the facility's failure to notify the physician of critical lab values for resident #1. At 4:30 p.m., the facility submitted an acceptable Plan of Removal, which documented: "Plan of Removal [DATE] 1. Review Comprehensive Assessment Policy pertaining to changes in condition and update accordingly. 2. Create a Facility Laboratory Policy 3. In-Service Nurses, CNAs, CMAs by [DATE] at 3 pm. 1. What Constitutes a change in condition, i.e. elevated temp, increase or decrease in B/P, changes in breathing, changes in behavior, skin changes, dietary changes, change in LOC, etc... 2. How often resident's are to be reassessed. 1. Every shift. 2. More frequently for those that have a significant change and PRN. 3. Reassessment shall include: Head to toe, v/s, O2 sat, 3. Approaches/Steps to take when a Significant Change occurs 1. Notify physician and family/resident 2. Complete Significant Change Form and place with Nurses Notes in 24 hr book 3. Documentation of the assessment in the Nurses Notes 4. Actions to take when the Physician does not respond 5. New Lab Policy 6. 24 Hour Report to be given to D.O.N. and/or Assistant Administrator on a daily basis 7. Documentation 4. Assessments will be completed on all current Resident's from head to toe, v/s and O2 sat for any Significant Changes by [DATE] at 3:00 p.m. 5. Complete Chart Reviews for any Abnormal Lab Values that have not been addressed for the month of January. Contact Physician via fax or telephone. Document method of contact. Will be completed by [DATE] at 3 p.m..." On [DATE] at 3:00 p.m., the immediate jeopardy situation was removed. The deficient practice remained at a pattern level of actual harm. Based on clinical record review and staff interview, it was determined the facility failed to notify the physician of abnormal lab results, including critical lab values, for one (#1) of six sampled residents with critical lab results in the last five months. This had the likelihood to affect all residents who resided in the facility. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. No initial assessment was provided by the facility. A care plan, dated [DATE], documented, "... Problem: I am risk for cardiovascular problems... Interventions:... My blood pressure will be monitored daily and documented on the MAR... Nurse will monitor for S/S of cardiovascular problems such as: weak pulse, chest pain, [MEDICAL CONDITION] and report any symptoms to Dr... Problem: Hypertension: I have the potential for complications such as [MEDICAL CONDITIONS] and stroke... CMA will monitor my blood pressure BID. Notify nurse of concerns... A physician's progress note, dated [DATE], documented, "... hypertension is running under good control. Her [MEDICAL CONDITION] is under good control as well... [MEDICAL CONDITION] is stable... Diabetes is also running good... When she came, she had some [MEDICAL CONDITION] of both legs that is getting better. She still has a few open sores that are scabbing over nicely and healing great. Peripheral artery disease is present with not very good circulation, but they are healing and looking much better..." A nurse's note, dated [DATE], documented, "... To cardiologist appt... return to facility c (physician's orders [REDACTED]. A laboratory report, dated [DATE], documented: "...Sodium 123 (low) reference range ,[DATE]... Potassium 5.7 (high) reference range 3XXX,[DATE].1... Chloride 87 (low) reference range ,[DATE]... BUN 86 (critical) reference range ,[DATE]... Creatinine 1.6 (high) reference range 0XXX,[DATE].3... Glucose 117 (high) reference range ,[DATE]... BUN/Creatinine 53 (high) reference range ,[DATE]..." The lab report also documented the laboratory technologist notified the DON by phone of the critical lab value on [DATE] at 10:18 a.m. The report documented the facility faxed the lab report to the physician on [DATE] at 2:20 p.m. There was no documentation that indicated the physician was called about the critical lab value. A nutritional progress note, dated [DATE] and written by the CDM, documented, "... PO intake good. (No) diet (changes), skin intact, (no) lab..." There was no documentation that indicated the consultant dietitian evaluated the resident and reviewed laboratory results during the month of [DATE]. A treatment sheet, dated [DATE], documented the resident had daily [MEDICAL CONDITION] checks to the lower extremities on the ,[DATE] shift. The documentation indicated the resident had no [MEDICAL CONDITION] to the lower legs during the month of [DATE]. A nurse's note, dated [DATE] at 7:30 a.m., documented, "... Cont to c/o not feeling well. Reported had emesis on (,[DATE] shift) last noc. Refusing up for breakfast... refused to eat..." A nurse's note, dated [DATE] at 8:50 a.m., documented, "... Dr. appt made for resident, 11 AM today..." There was no documentation as to why the doctor's appointment was made. A physician's telephone order, dated [DATE], documented, "admitted to (hospital name deleted)." There was no documentation as to why the resident was admitted to the hospital. A hospital triage assessment, dated [DATE] at 10:58 a.m., documented, "... T: 99.8 / P: 69 / R: 20 / BP: ,[DATE]... Weight:180# ... Chief Complaint/Physical Assessment: weakness, loss of appetite for about 1 week... Patient has multiple [MEDICAL CONDITION] on lower legs bilaterally, redness, swelling and draining serous fluid bilaterally... Triage Acuity: Emergent... Heart tones:(regular) weak... [MEDICAL CONDITION]: Present 2+..." A hospital laboratory report, dated [DATE] at 12:13 p.m., documented: "... Sodium 123 (low) reference range ,[DATE]... Potassium 6.8 (critical) reference range 3XXX,[DATE].1... Chloride 83 (low) reference range ,[DATE]... CO2 15 (low) reference range ,[DATE]... BUN 135 (critical) reference range ,[DATE]... Creatinine 4.1 (high) reference range 0XXX,[DATE].3... Myoglobin 397 (high) reference range ,[DATE]... Troponin 0.80 (high) reference range 0XXX,[DATE].1..." An ER physician's record, dated [DATE], documented, "... Pt is severely dehydrated (has not eaten or drank in 3 days d/t nausea), has multiple open sores on both LEs... Physical Exam: Ill appearing, dry mucous membranes... weak heart sounds... Diagnosis: [REDACTED].) (Elevated) Troponin 3.) [MEDICAL CONDITION] 4.) Dehydration 5.) Venous Stasis [MEDICAL CONDITION]/[MEDICAL CONDITION] (lower) legs..." An emergency room nurse's note at 11:10 a.m., documented, "...11:25 a.m.: Applied O2 @ 4 L NC due to sats dropping to 87% even with deep breathing... (3:30 p.m.) transferred to (hospital name deleted) OKC by EMS..." A history and physical report from the receiving hospital, dated [DATE], documented, "... The patient has intensely [DIAGNOSES REDACTED]tous lower extremities from about mid shin distally with several areas of excoriation which appear to be infected... Assessment: 1. [MEDICAL CONDITION] 2. Acute on chronic heart failure 3. Acute on [MEDICAL CONDITION] 4. Acute [MEDICAL CONDITION] infarction ... She has received several antibiotics in the emergency room ... She was also given [MEDICATION NAME] for elevated potassium..." A hospital discharge summary, dated [DATE], documented, "... The patient's condition continued to deteriorate and... on the afternoon of [DATE]... the patient expired..." On [DATE] at 3:15 p.m., the DON was asked to provide the facility's lab policy. She stated there was no facility policy pertaining to lab services, or how lab reports were to be handled by the facility. On [DATE] at 9:00 a.m., LPN #1 was asked what happened when the facility received notification of critical lab values. She stated the facility called the physician's office and left a message on the answering machine or with office staff. She was asked if the facility ever talked to the physician directly about a critical lab report. She stated, "Not usually." She was asked how the facility handled abnormal or critical lab hard-copy reports. She stated that after a report was received, the facility faxed the report to the physician's office. Then the reports were filed in the resident's record. She stated the facility documented on the lab report the date and time it was faxed to the physician. She was asked how the staff kept track of pending physician responses to a critical or abnormal lab values. She stated, "I just keep track of it in my head. There's no real system." She was asked if the MD had been notified of the critical lab values for the resident on [DATE]. She stated she wasn't sure. She was asked if there was documentation the physician had been called and his response. She stated she didn't think so. She was asked about the condition of the resident's leg wounds prior to her transfer. She stated she didn't know about the resident's condition. At 9:20 a.m., the DON was asked if the facility had a policy and procedure for handling abnormal and critical lab values. She stated there was no policy. She was asked if the physician was aware of the resident's critical lab values on [DATE]. She stated, "I think so." The physician was called twice by the surveyor to ask if he had been made aware of the resident's critical lab values. There was no return phone call. At 11:30 a.m., the director of the hospital laboratory was asked how critical lab values were handled in his facility. He stated the lab technologists had to call all critical lab results to the entity that ordered the test, and then had to document who they talked to in the computer program. This information was documented on the laboratory report. He stated if the critical lab result was called to the nursing home, the laboratory relied on the facility to contact the attending physician. He stated, "We trust that First Shamrock called the doctor."

On [DATE] at 1:05 p.m., an immediate jeopardy situation was determined to exist related to the facility's failure to respond to critical lab values and failure to assess a resident's change in condition, failure to monitor the resident's condition and failure to intervene for the change in condition. The OSDH was notified and verified the existence of the immediate jeopardy situation. At 1:15 p.m., the administrator and the DON were notified of the immediate jeopardy situation related to the facility's failure to respond to a critical lab value for resident #1 and for failure to assess, monitor and intervene in the resident's change in condition. They were notified the immediate jeopardy indicated a substandard quality of care. At 4:30 p.m., the facility submitted an acceptable Plan of Removal, which documented: "Plan of Removal [DATE] 1. Review Comprehensive Assessment Policy pertaining to changes in condition and update accordingly. 2. Create a Facility Laboratory Policy 3. In-Service Nurses, CNAs, CMAs by [DATE] at 3 pm. 1. What Constitutes a change in condition, i.e. elevated temp, increase or decrease in B/P, changes in breathing, changes in behavior, skin changes, dietary changes, change in LOC, etc... 2. How often resident's are to be reassessed. 1. Every shift. 2. More frequently for those that have a significant change and PRN. 3. Reassessment shall include: Head to toe, v/s, O2 sat, 3. Approaches/Steps to take when a Significant Change occurs 1. Notify physician and family/resident 2. Complete Significant Change Form and place with Nurses Notes in 24 hr book 3. Documentation of the assessment in the Nurses Notes 4. Actions to take when the Physician does not respond 5. New Lab Policy 6. 24 Hour Report to be given to D.O.N. and/or Assistant Administrator on a daily basis 7. Documentation 4. Assessments will be completed on all current Resident's from head to toe, v/s and O2 sat for any Significant Changes by [DATE] at 3:00 p.m. 5. Complete Chart Reviews for any Abnormal Lab Values that have not been addressed for the month of January. Contact Physician via fax or telephone. Document method of contact. Will be completed by [DATE] at 3 p.m..." On [DATE] at 3:00 p.m., the immediate jeopardy situation was removed. The deficient practice remained at a pattern level of actual harm. Based on clinical record review, policy and procedure review and staff interview, it was determined the facility failed to: a. respond to a critical laboratory value; and b. failed to assess, monitor and intervene in a resident's change in condition for one (#1) of two sampled residents who had critical lab values and who had a change in condition. These deficient practices were determined to result in an immediate jeopardy situation. This had the likelihood to affect all residents who resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, "... Problem: I am risk for cardiovascular problems... Interventions:... My blood pressure will be monitored daily and documented on the MAR... Nurse will monitor for S/S of cardiovascular problems such as: weak pulse, chest pain, [MEDICAL CONDITION] and report any symptoms to Dr... Problem: Hypertension: I have the potential for complications such as [MEDICAL CONDITIONS] and stroke... CMA will monitor my blood pressure BID. Notify nurse of concerns... Problem: Impaired skin integrity. I have multiple open wounds to my lower extremities and feet from poor circulation. I have a Dx of [MEDICAL CONDITION] of lower extremities and require daily drsg changes... Interventions: 1.) Nurses will observe effectiveness of my current treatment and notify Dr if ineffective. 2.) Nurse will clean my lower extremities with wound cleanser, apply [MEDICATION NAME] cream. Cover drsg with kerlix daily until healed..." A physician's progress note, dated [DATE], documented, "... hypertension is running under good control. Her [MEDICAL CONDITION] is under good control as well... [MEDICAL CONDITION] is stable... Diabetes is also running good... When she came, she had some [MEDICAL CONDITION] of both legs that is getting better. She still has a few open sores that are scabbing over nicely and healing great. Peripheral artery disease is present with not very good circulation, but they are healing and looking much better..." Monthly physician's orders [REDACTED]. A nurse's note, dated [DATE], documented, "... To cardiologist appt... return to facility c (physician's orders [REDACTED]. A laboratory report, dated [DATE], documented: "...Sodium 123 (low) reference range ,[DATE]... Potassium 5.7 (high) reference range 3XXX,[DATE].1... Chloride 87 (low) reference range ,[DATE]... BUN 86 (critical) reference range ,[DATE]... Creatinine 1.6 (high) reference range 0XXX,[DATE].3... Glucose 117 (high) reference range ,[DATE]... BUN/Creatinine 53 (high) reference range ,[DATE]..." The lab report also documented the laboratory technologist notified the DON by phone of the critical lab value on [DATE] at 10:18 a.m. The report documented the facility faxed the lab report to the physician on [DATE] at 2:20 p.m. There was no documentation that indicated the physician was called about the critical lab value or that new physician's orders [REDACTED]. A nutritional progress note, dated [DATE] and written by the CDM, documented, "... PO intake good. (No) diet (changes), skin intact, (no) lab..." There was no documentation that indicated the consultant dietitian evaluated the resident and reviewed laboratory results during the month of [DATE]. Monthly physician's orders [REDACTED]. A treatment sheet, dated [DATE], documented the resident had daily [MEDICAL CONDITION] checks to the lower extremities on the ,[DATE] shift. The documentation indicated the resident had no [MEDICAL CONDITION] to the lower legs during the month of [DATE]. A weekly skin assessment, dated [DATE], documented, "... Skin turgor fair. Cont c open areas to legs. Small fluid filled blisters to Lt (lower) leg... TX done to legs per orders..." A treatment sheet, dated [DATE] at 6:30 a.m., documented the resident weighed 167.4 lbs. A nurse's note, dated [DATE] at 7:30 a.m., documented, "... Cont to c/o not feeling well. Reported had emesis on (,[DATE] shift) last noc. Refusing up for breakfast... refused to eat..." There was no documentation of an assessment of the resident and no documentation of monitoring. There was no documentation prior to [DATE] that indicated the resident had been ill or had a change in condition. A nurse's note, dated [DATE] at 8:50 a.m., documented, "... Dr. appt made for resident, 11 AM today..." There was no documentation as to why the doctor's appointment was made. There was no documentation of an assessment of the resident prior to leaving the facility, or of what care and treatment had been provided. A discharge assessment, (the only assessment provided by the facility), dated [DATE], documented the resident was independent in cognitive skills for daily decision-making and needed extensive assistance with toileting and personal hygiene. The assessment documented the resident was totally dependent on staff for bathing. A physician's telephone order, dated [DATE], documented, "admitted to (hospital name deleted)." There was no documentation as to why the resident was admitted to the hospital. A hospital triage assessment, dated [DATE] at 10:58 a.m., documented, "... T: 99.8 / P: 69 / R: 20 / BP: ,[DATE]... Weight:180# ... Chief Complaint/Physical Assessment: weakness, loss of appetite for about 1 week... Patient has multiple [MEDICAL CONDITION] on lower legs bilaterally, redness, swelling and draining serous fluid bilaterally... Triage Acuity: Emergent... Heart tones:(regular) weak... [MEDICAL CONDITION]: Present 2+..." A hospital laboratory report, dated [DATE] at 12:13 p.m., documented: "... Sodium 123 (low) reference range ,[DATE]... Potassium 6.8 (critical) reference range 3XXX,[DATE].1... Chloride 83 (low) reference range ,[DATE]... CO2 15 (low) reference range ,[DATE]... BUN 135 (critical) reference range ,[DATE]... Creatinine 4.1 (high) reference range 0XXX,[DATE].3... Myoglobin 397 (high) reference range ,[DATE]... Troponin 0.80 (high) reference range 0XXX,[DATE].1..." An ER physician's record, dated [DATE], documented, "... Pt is severely dehydrated (has not eaten or drank in 3 days d/t nausea), has multiple open sores on both LEs... Physical Exam: Ill appearing, dry mucous membranes... weak heart sounds... Diagnosis: [REDACTED].) (Elevated) Troponin 3.) [MEDICAL CONDITION] 4.) Dehydration 5.) Venous Stasis [MEDICAL CONDITION]/[MEDICAL CONDITION] (lower) legs..." An emergency room nurse's note at 11:10 a.m., documented, "... [MEDICAL CONDITION] on legs appear to be leaking serous fluid continuously... 11:25 a.m.: Applied O2 @ 4 L NC due to sats dropping to 87% even with deep breathing... (3:30 p.m.) transferred to (hospital name deleted) OKC by EMS..." A history and physical report from the receiving hospital, dated [DATE], documented, "... The patient has intensely [DIAGNOSES REDACTED]tous lower extremities from about mid shin distally with several areas of excoriation which appear to be infected... Assessment: 1. [MEDICAL CONDITION] 2. Acute on chronic heart failure 3. Acute on [MEDICAL CONDITION] 4. Acute [MEDICAL CONDITION] infarction ... She has received several antibiotics in the emergency room ... She was also given [MEDICATION NAME] for elevated potassium..." A hospital discharge summary, dated [DATE], documented, "... The patient's condition continued to deteriorate and... on the afternoon of [DATE]... the patient expired..." On [DATE] at 2:30 p.m., the DON was asked to provide an initial assessment for the resident. None was provided. At 2:45 p.m., the DON was asked to provide the following policies that were listed in the Nursing Policies Table of Contents: Standards of Resident Care Change in Condition Transfer of a Resident Documentation Emergency Care At 3:15 p.m., the DON stated she could not locate these policies. She was asked to provide the facility's lab policy. She stated there was no policy pertaining to lab services or how lab reports were to be handled by the facility. On [DATE] at 9:00 a.m., LPN #1 was asked what happened when the facility received notification of critical lab values. She stated the facility called the physician's office and left a message on the answering machine or with office staff. She was asked if the facility ever talked to the physician directly about a critical lab report. She stated, "Not usually." She was asked how the facility handled abnormal or critical lab hard-copy reports. She stated that after a report was received, the facility faxed the report to the physician's office. Then the reports were filed in the resident's record. She stated the facility documented on the lab report the date and time it was faxed to the physician. She was asked how the staff kept track of pending physician responses to a critical or abnormal lab values. She stated, "I just keep track of it in my head. There's no real system." She was asked if the MD had been notified of the critical lab values for the resident on [DATE]. She stated she wasn't sure. She was asked if there was documentation the physician had been called and his response. She stated she didn't think so. At 9:20 a.m., the DON was asked if the facility had a policy and procedure for handling abnormal and critical lab values. She stated there was no policy. She was asked if the physician was aware of the resident's critical lab values on [DATE]. She stated, "I think so." The physician was called twice by the surveyor to ask if he had been made aware of the resident's critical lab values. There was no return phone call. At 11:30 a.m., the director of the hospital laboratory was asked how critical lab values were handled in his facility. He stated the lab technologists had to call all critical lab results to the entity that ordered the test, and then had to document who they talked to in the computer program. This information was documented on the laboratory report. He stated if the critical lab result was called to the nursing home, the laboratory relied on the facility to contact the attending physician. He stated, "We trust that First Shamrock called the doctor." At 12:30 p.m., the DON was asked about the condition of the resident prior to transfer to the hospital. She stated, "She just wasn't feeling well. We talked her into going to the doctor." She was asked if the resident had been assessed for a change in condition. She stated, "I assume so." She was asked about the condition of the resident's legs prior to transfer to the hospital. She stated, "Her legs were healed the last time I saw them. I don't know what happened after she left here." At 4:45 p.m., CNA #1 was asked about the resident's condition prior to transfer to the hospital. She stated the resident's legs had just recently opened up and started weeping. She stated the resident complained about not feeling well. She also stated the resident had severe gaulding around the groin and abdominal fold areas. At 5:10 p.m., CNA #2 stated the resident had been vomiting for a couple of days before her transfer to the hospital. She stated the resident had no energy and didn't feel well. She further stated, "I thought she needed to go to the hospital a few days before she went." At 5:30 p.m., RN #1 stated she noticed a gradual deterioration in the resident prior to her transfer. She stated the resident had started to refuse care. She stated on one occasion, the resident complained of chest pain. She stated the resident's vital signs were normal and she gave the resident Tylenol. She was asked if she had documented the resident's complaint of chest pain and the vital signs she obtained during the episode. She stated she didn't remember. She was informed there was no documentation of such an episode in the resident's clinical record. She stated, "I may have written the resident had [MEDICAL CONDITION] pain instead of chest pain." No documentation of [MEDICAL CONDITION] pain was found in the nurse's notes. On [DATE] at 4:45 p.m., the resident's family member stated she was present with the resident at the time of transfer out of the facility. She stated when she arrived at the facility, she was alarmed at the resident's condition. She stated the facility made an appointment for the resident to see her doctor in his office that day, but she believed the resident's condition was too critical for an office visit. She stated she requested the resident be sent to a local emergency room . She stated the DON told the family member to call the physician's office to cancel the appointment. The family member called and explained to the office staff her concerns about the resident's condition. They agreed the resident should be seen in the emergency room . The family member stated as the resident and family prepared to leave the facility, the DON said, "If you see her doctor at the emergency room , tell him I sent him a fax about a critical BUN level on her that he didn't respond to."