Every finding on record at Forrest Manor Nursing Center

Based on record review and interview, the facilty failed to transmit MDS assessment data to CMS in the required timeframe for six (#13, 17, 26, 29, 37, and #51) of 20 sampled residents reviewed for MDS assessments. The administrator identified 61 residents resided at the facility. Findings: A facility policy titled MDS Completion and Submission Timeframes, dated 2001, read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. A facility MDS 3.0 Assessment Summary Report, was provided to the survey team on 09/10/24. The report documented quarterly assessments for six residents had been submitted to CMS beyond the required timeframe. The late assessments were: 1. Resident #13's quarterly assessment, completion date 07/17/24, had a transmit by date of 07/31/24. The transmitted date was documented as 08/29/24; 2. Resident #17's quarterly assessment, completion date 07/15/24, had a transmit by date of 07/29/29. The transmitted date was documented as 08/22/24; 3. Resident #26's quarterly assessment, completion date 08/04/24, had a transmit by date of 08/18/24. The transmitted date was documented as 09/10/24; 4. Resident #29's quarterly assessment, completion date 08/01/24, had a transmit by date of 08/15/24. The transmitted date was documented as 08/22/24; 5. Resident #37's quarterly assessment, completion date 06/20/24, had a transmit by date of 07/04/24. The transmitted date was documented as 07/23/24; and 6. Resident #51's quarterly assessment, completion date 07/30/24, had a transmit by date of 08/13/24. The transmitted date was documented as 09/10/24. On 09/10/24 at 10:49 a.m., the ADON stated they had just taken over the MDS coordinator duties. They stated they were aware of multiple overdue assessments. They stated they were aware the assessments were not transmitted. At 12:34 p.m., the administrator stated they had been unaware the MDS assessments had not been completed and transmitted. They stated it was their expectation all MDS assessment would be opened, completed, and submitted in a timely manner.

Based on record review and interview, the facility failed to provide direct care staff information to CMS in the required time frame. The administrator identified 61 residents resided at the facility. Findings: A PBJ report for the third quarter of 2024 documented direct care staffing data had not been received by CMS. On 09/10/24 at 7:40 a.m., the BOM stated the facility administrator was responsible for sending the staffing data to employee #1 who worked at corporate headquarters. They stated employee #1 was the person who sent the data to CMS. On 09/10/24 at 10:55 a.m., the administrator stated employee #1 was responsible for sending the staffing data to CMS. On 09/10/24 at 11:05 a.m., Employee #1 stated they had sent the data to CMS, but did not have the documentation to prove it. On 09/10/24 at 11:17 a.m., the administrator stated they were aware of the time frame for turning in the staffing data to CMS and they believed they had done so timely. They stated the problem may be that their company used standard calendar based quarters while the government did not.

Based on record review and interview, the facility failed to employee a full time DON. The administrator identified 61 residents resided in the facility. Findings: An undated facility policy, titled Nursing Services - Staffing , documented the facility would maintain a full time licensed RN or LPN as the director of nursing. On 09/08/24 at 8:51 a.m., the BOM stated the facility did not have a full time DON. They stated the DON had quit their position about three weeks prior to the survey. They stated the organization was actively advertising for a new DON. On 09/08/24 at 9:40 a.m., the administrator provide a letter that stated the former DON had resigned suddenly via text message on 08/26/24. They stated they were advertising for a new DON. They stated they had not assigned the DON's duties to another RN since the former DON had resigned.

Based on record review and interview, the facility failed to ensure GDR requests were attemped and/or addressed by the physician for two (#37, and #49) of five sampled residents reviewed for unnecessary medications. A Consultant Pharmacist Activity Report dated 09/11/24 documented 48 residents were receiving psychotropic medications. Findings: 1. Resident #37 had diagnoses which included PTSD and major depressive disorder. A physician's order, dated 03/16/23, documented Resident #37 was to receive 150 mg of venlafaxine xr (antidepressant medication) by mouth every day. A physician's order, dated 03/16/23, documented Resident #37 was to receive 30 mg of mirtazapine (antidepressant medication) by mouth at bedtime. A physician's order, dated 04/05/23, documented the resident was to receive 10 mg of buspirone (antianxiety medication) by mouth three times a day. A quarterly assessment, dated 6/14/24, documented Resident #37 had routinely received antidepressant medications and an antianxiety medication. A review of Resident #37's medical records did not document any GRD's had been attempted for resident #37. On 09/11/24 at 12:34 pm, the ADON stated no GDR's had been located for Resident #37. 2. Resident #49 had diagnoses which included unspecified dementia and anxiety disorder. A physician's order, dated 01/12/24, documented Resident #49 was to receive 0.75 mg of risperidone (antipsychotic medication) by mouth twice a day. A physician's order, dated 01/12/24, documented the resident was to receive 75 mg of sertraline (antidepressant medication) by mouth every day. A quarterly assessment, dated 05/03/24, documented Resident #49 routinely received an antipsychotic medication and an antidepressant medication. A GDR, dated 08/30/24, recommended a dose reduction be attempted for risperidone 0.75mg twice a day. There was no documentation that the physician had addressed the GDR. A review of Resident #49's medical records did not document any other GDR's for the resident. On 09/11/24 at 12:34 pm, the ADON stated no other GDR's had been located for Resident #49.

Based observation, interview, and record review, the facility failed to provide dietary interventions as ordered by the physician and/or documented in the plan of care for two (#19 and #50) of two sampled residents whose clinical records were reviewed for nutrition. A facility census list, dated 09/08/24, documented 61 residents resided in the facility. Findings: 1. Resident #19 had diagnoses which included end stage renal disease. The care plan, updated 05/09/24, documented the resident had the potential for alteration in nutrition status related to end stage renal disease. The facility interventions were to encourage the resident to follow the diet as planned and ordered by the physician, monitor weight, educate on diet, monitor appetite, diet consultant to monitor diet monthly, monitor labs and report results to physician, administer medications as ordered, and provide low sodium diet. It was documented the resident was on a regular renal diet with low sodium. The facility interventions were to serve the diet as ordered and offer substitutions if less than 75% was eaten, monitor/discuss food preferences, offer snacks within the resident's dietary limitations, obtain weights as ordered, remind and encourage the resident to follow the prescribed diet, and provide supplement of Nova Source renal [meal supplement] as ordered. A dialysis communication form, dated 06/28/24, documented the resident was to receive a diet with less phosphorus and no calcium. A dietary communication form, dated 06/28/24, documented the resident was to receive less phosphorus foods and no calcium. The monthly physician's orders, dated 08/01/24, documented no diet ordered for Resident #19. On 09/10/24 at 1:25 p.m., the DM stated all residents received the same meal or an alternate of their choosing from a list of soup, salad, grilled cheese, or a peanut butter and jelly sandwich. The DM stated it was the residents responsibility to make appropriate meal choices for their diet. The DM observed the dietary communication form dated 06/28/24. They stated the facility was not meeting the resident's nutritional needs. On 09/11/24 at 12:35 p.m., the ADON stated there were orders to limit the resident's phosphorus and calcium intake back in June and there was a communication form sent to dietary. The ADON stated they were not sure how dietary orders were followed. The ADON stated with the liberal diet and the alternate choices available, Resident #19 did not have the options for meal choices to limit the calcium and phosphorus intake. The ADON stated they were not accommodating the resident's dietary needs. 2. Resident #50 had diagnoses which included spina bifida and pressure ulcers. The August 2024 monthly physician's orders documented the resident was to receive double portions of protein. On 09/08/24 at 11:45 a.m., Resident #50 stated they did not receive double portions of protein on their meal trays or the protein drink with each meal. They stated they now purchase their own protein drinks to supplement their intake. They stated they did not think it was right to have to buy supplements when they were to receive supplements with each meal. On 09/08/24 at 1:20 p.m., the midday meal was observed on the resident's overbed table. There were four small beef tips in brown gravy on the resident's plate. Each were roughly the size of a half dollar. The resident's diet card located on their meal tray documented the resident was to receive double portions of protein. On 09/10/24 at 12:55 p.m., the noon meal was observed on the resident's overbed table. There was one bratwurst link on their plate. The resident's diet card located on their meal tray documented the resident was to receive double portions of protein. On 09/11/24 at 8:50 a.m., the DM stated the serving size for the prior days lunch was one link. The DM was asked about the above observations. The DM stated the resident did not receive double portions of protein as ordered and they thought staff overlooked the order on the diet card. On 09/11/24 at 12:35 p.m., the ADON was asked about the above observations. The ADON stated they did not follow the physician's order for double portions of protein for wound healing.

Based on record review and interview, the facility failed to ensure a resident who received an antipsychotic medication had an appropriate diagnosis/indication for the use of the medication for one (#49) and failed to ensure a PRN psychotropic medication was limited to 14 days for one (#42) of five sampled residents reviewed for unnecessary medications. A Consultant Pharmacist Activity Report dated 09/11/24 documented 48 residents received psychotropic medications. Findings: 1. Resident #42 had diagnoses which included anxiety. A Consultant Pharmacist Communication to Physician, dated 08/29/24, read in part, PRN Psychotropics: 14 day limitation on all PRN orders. The orders may be extended beyond 14 days if the attending physician or prescribing practitioner: 1.) Believes it is appropriate to extend the order 2.) Documents clinical rationale for the extension 3.) Provides a specific duration. The document provided a section for a practitioner to provide a rationale and signature. The form did not have a rationale or physician's signature. A September 2024 MAR documented an order for Ativan (antianxiety medication) 2 mg tablets to have been administered to Resident #42 every 4 hours as needed. The order had a start date of 02/19/24. The order did not have an end date. The record documented the resident had received three doses of the medication in during the month. 2. Resident #49 had diagnoses which included unspecified dementia and anxiety disorder. A quarterly assessment, dated 05/03/24, documented Resident #49 routinely received an antipsychotic medication. A physician's order, dated 01/12/24, documented Resident #49 was to receive risperidone (antipsychotic medication) 0.75 mg by mouth twice a day for unspecified dementia. On 09/11/24 at 12:34 p.m., the ADON stated dementia was not an appropriate diagnosis for an antipsychotic medication. On 09/11/24 at 1:17 p.m., the ADON stated they understood the regulation regarding the use of PRN Ativan and the requirement for a rationale for extended use beyond 14 days.

Based observation, record review, and interview, the facility failed to provide a therapeutic diet as ordered by the physician and/or documented in the plan of care for two (#19 and #50) of two sampled residents whose diets were reviewed. A facility census list, dated 09/08/24, documented 61 residents resided in the facility. Findings: 1. Resident #19 had diagnoses which included end stage renal disease. The care plan, updated 05/09/24, documented the resident had the potential for alteration in nutrition status related to end stage renal disease. The facility interventions were to encourage the resident to follow the diet as planned and ordered by the physician, monitor weight, educate on diet, monitor appetite, diet consultant to monitor diet monthly, monitor labs and report results to physician, administer medications as ordered, and provide low sodium diet. It was documented the resident was on a regular renal diet with low sodium. The facility interventions were to serve the diet as ordered and offer substitutions if less than 75% was eaten, monitor/discuss food preferences, offer snacks within the resident's dietary limitations, obtain weights as ordered, remind and encourage the resident to follow the prescribed diet, and provide supplement of Nova Source renal [meal supplement] as ordered. A dialysis communication form, dated 06/28/24, documented the resident was to receive a diet with less phosphorus and no calcium. A dietary communication form, dated 06/28/24, documented the resident was to receive less phosphorus foods and no calcium. The monthly physician's orders, dated 08/01/24, documented no diet ordered for Resident #19. On 09/10/24 at 1:25 p.m., the DM stated all residents received the same meal or an alternate of their choosing from a list of soup, salad, grilled cheese, or a peanut butter and jelly sandwich. The DM stated it was the residents responsibility to make appropriate meal choices for their diet. The DM observed the dietary communication form, dated 06/28/24, and stated the facility was not meeting the resident's nutritional needs. On 09/11/24 at 12:35 p.m., the ADON stated there were orders to limit the resident's phosphorus and calcium intake back in June. They stated there was a communication form sent to dietary. They stated they were not sure how dietary orders were followed. They stated with the liberal diet and the alternate choices available, Resident #19 did not have the options for meal choices to limit the calcium and phosphorus intake. The ADON stated they were not accommodating the resident's dietary needs. 2. Resident #50 had diagnoses which included spina bifida and pressure ulcers. The August 2024 monthly physician's orders documented the resident was to receive double portions of protein. On 09/08/24 at 11:45 a.m., Resident #50 stated they did not receive double portions of protein on their meal trays nor the protein drink with each meal. They stated they now purchase their own protein drinks to supplement their intake. They stated they did not think it was right to have to buy supplements when they were to receive supplements with each meal. On 09/08/24 at 1:20 p.m., the midday meal was observed on the resident's overbed table. There were four small beef tips in brown gravy on the resident's plate. Each roughly the size of a half dollar. The resident's diet card documented the resident was to receive double portions of protein. On 09/10/24 at 12:55 p.m., the noon meal was observed on the resident's overbed table. There was one bratwurst link on the resident's plate. The resident's diet card located on their meal tray documented the resident was to receive double portions of protein. On 09/11/24 at 8:50 a.m., the DM stated the serving size for the prior days lunch was one link. The DM was asked about the above observations. The DM stated the resident did not receive double portions of protein as ordered. They stated they thought staff overlooked the order on the diet card. On 09/11/24 at 12:35 p.m., the ADON was asked about the above observations. The ADON stated they did not follow the physician's order for double portions of protein for wound healing.

Based on record review and interview, the facility failed to: a. update the dietary menu, b. offer nutritionally equivalent alternatives to planned meals, and c. have a RD review the menus for nutritional adequacy. The DM identified 61 residents who ate meals from the kitchen. Findings: On 09/10/24 at 11:05 a.m., the extended menus were requested from the DM. The DM stated they were new to the position and did not know where to find the extended menu. They stated they received the week's menu from the BOM. On 09/10/24 at 12:35 p.m., the BOM and DM located the extended menu on a small flat bar above the steam table. The extended menu cover was dated November 2022. On 09/10/24 at 12:35 p.m., the BOM stated the residents complained they were continually receiving the same meals. The BOM stated they requested current menus from the company representatives, but never received the new menus. The BOM stated they started creating the weekly menus and/or substitutions the facility used based on the November 2022 menu and meals the residents requested. The BOM stated the old menus were reviewed and approved by the RD, but the facility created menus/substitutions were not reviewed or approved by the RD. On 09/11/24 at 8:50 a.m., the DM stated if a resident did not want what was served for the meal, they could request soup, salad, grilled cheese, or a peanut butter sandwich from the alternate menu. The DM stated the alternate menu was not nutritionally equivalent to the served meals.

Based on observation and interview, the facility failed to: a. follow standards of practice in meal service; b. serve meals in a sanitary manner; and c. utilize professional grade equipment in the kitchen. The BOM identified 61 residents who ate meals prepared and served in the kitchen. Findings: 1. On 09/08/24 at 8:20 a.m., observations were made in the kitchen. The hand washing sink was located in the corner of the kitchen and was blocked by a mop, bucket, and a covered trash can. Above the hand washing sink was a rack with cooking utensils hanging downward from the edge of a rack, blocking access to the hand washing sink. On 09/08/24 at 8:25 a.m., [NAME] #1 was observed to plate food for multiple residents with their gloved hands including grabbing and splitting biscuits before placing the biscuit on the plate, reaching into the steam table pans and grabbing bacon, fried eggs, toast, and pancakes with their gloved hands. The cook did not change gloves between food items or residents. The cook was observed to touch the pre-printed resident diet cards, the plates, trays, counter tops, steam table, and their clothing while plating meals. The cook was not observed to change gloves or sanitize their hands until after the morning meal was served. The cook did not wear a beard guard. On 09/08/24 at 9:10 a.m., the dish machine was observed. [NAME] #1 repeatedly ran the dish machine without reaching the minimum required wash/rinse water temperature of 120 degrees Fahrenheit. [NAME] #1 checked the disinfectant level multiple times without the litmus paper changing color, signifying no disinfectant was applied to the dishes. [NAME] #1 stated they were unsure of the required water temperatures and concentration of sanitizing agent in a three compartment sink. On 09/08/24 at 9:50 a.m., DA #1 was observed washing dishes through the dish machine. They stated the maintenance supervisor told them they could add sanitizing agent to the dish machine manually by pouring sanitizing agent into the bottom of the dish machine. The DA was observed to take an open cup they identified as the sanitizing agent and poured it into the bottom of the dish machine as the machine continued to run. Once the dish machine completed the cycle, litmus paper was used to check the level of disinfectant. There was no change in color to the litmus paper. On 09/08/24 at 10:00 a.m., the maintenance supervisor stated kitchen staff would need to use the three compartment sink to clean the dishes until the dish machine could be serviced. On 09/10/24 at 11:30 a.m., the DM stated the dish machine was serviced and the pump for the sanitizing agent was replaced. On 09/10/24 at 11:50 a.m., DA #3 was observed with gloves on to cut a sheet pan of brownies with a knife. They plated each serving of brownies using the side of the knife as a spatula and holding the brownie with their gloved hand as they plated it. The DA was observed to touch the other items with their gloved hand, including the countertop, baking sheet, knife/utensils, small plates, and kitchen towel while plating food. On 09/10/24 at 12:15 p.m., DA #2 was observed to plate food. The DA used their gloved hands to open the lid and grab packaged items from cool storage, and held/touched the individual resident meal tickets, utensils, plates, trays, and steam table. With the same gloved hands the DA was observed to grab bread from the package to serve. On 09/10/24 at 12:45 p.m., DA #2 stated they had helped to serve food from a steam table a few times, but had not been trained how to do so. They stated they felt nervous being watched as they served. On 09/10/24 at 12:50 p.m., the DM stated DA #2 had served from the steam table only a few times and should not have touched the bread with their gloved hands. The DM stated despite baking all morning the brownies were still gooey and difficult to cut and serve. The DM stated DA #3 should have used utensils to serve the brownies. 2. On 09/10/24 at 12:00 p.m., the following kitchen appliances were observed to be labeled for household/residential use only: a. a small waffle maker, b. a 6-8 quart slow cooker, c. a four slice toaster, and d. a food processor. On 09/10/24 at 12:35 p.m., the BOM stated they would contact administration regarding replacing the appliances.

Based record review and interview, the facility failed to ensure code status was clearly identified in residents' medical records for two (#9 and #18) of twenty four sampled residents whose medical records were reviewed. A facility census list, dated [DATE], documented 61 residents resided in the facility. Findings: 1. Resident #9 had diagnoses which included chronic kidney disease and chest pain. Resident #9's medical record was reviewed. A sticker attached to the outside of the hard chart read, DNR [do not resuscitate]. A second sticker attached to the outside of the hard chart read, Full Code [which means to provide life saving measures]. An Oklahoma Do-Not -Rescucitate (DNR) Consent Form, dated [DATE], was found inside the resident's medical record and documented they wanted to a DNR code status. On [DATE] at 8:10 a.m., the ADON stated the sticker which identified the resident as a full code should have been removed once the DNR form had been signed. They stated they did have a policy and procedure that stated in such cases the staff was to look in the chart for the paperwork that stated the code status. They stated the presence of both stickers on the outside of the chart was a problem that should have been caught by staff. The code status policy was not provided. On [DATE] at 8:17 a.m., RN #1 stated the most convenient way they determined code status was to look at the stickers on the outside of each chart. They stated if the sticker was not there they were to look in the chart or in a binder at the nurses station that had each resident's code status. 42171 2. Resident #18 had diagnoses which included muscular dystrophy and vascular dementia. A face sheet, with an admitted [DATE], documented the resident was a full code. Physician orders, dated ,d+[DATE], documented Resident #18's code status was full code. Stickers on the front cover and the spine of Resident #18's medical record indicated the resident was a full code. A Certification of Physician section of Resident #18's DNR form indicated the physician certified Resident #18 would not have consented to the administration of CPR. This form was signed by the physician on [DATE]. On [DATE] at 8:18 a.m., the ADON stated Resident #18's chart and paperwork should document the resident had a DNR in place.

Based on record review and interview, the facility failed to consistently monitor for trends related to infectious disease. The ADON identified the census was 61. Findings: A policy titled [NAME] Manor Nursing Facility Infection Control Policy and Procedure, updated 05/23/22, read in part, .Facility has established an infection control program under which it .Investigates, controls and prevents infections in the facility . A review of the facilities infection surveillance documentation for 2024 did not document the facility had been tracking infectious disease or looking for trends related to infectious diseases for 01/24, 02/24 or 03/24. On 09/11/24 at 12:34 p.m., the ADON stated there were was no documentation infection surveillance could be located for 01/24, 02/24, or 03/24.

Based on record review and interview, the facility failed to provide an opportunity for a resident to create an advance directive for two (#9 and #50) of three sampled residents reviewed for advance directives. A facility census list, dated 09/08/24, documented 61 residents resided in the facility. Findings: A facility face sheet, dated 06/13/19, documented Resident #9 had been admitted to the facility on [DATE]. There was no documentation the resident was given an opportunity to create an advance directive. On 09/10/24 at 1:51 p.m., the ADON stated they had reviewed Resident #9's records and had not found documentation they had been provided the opportunity to create an advance directive. On 09/10/14 at 1:55 p.m. Resident #9 stated they did not recall talking to anyone about an advance directive. On 09/10/24 at 2:17 p.m., the BOM stated they had searched the resident's records that had been thinned from the chart and did not find documentation regarding an advance directive. On 09/11/24 at 10:15 a.m. the ADON stated a resident has a right to create an advance directive. 2. Resident #50 had diagnoses which included chronic pain and pressure ulcers. A review of the clinical record revealed there was no documentation the resident had an opportunity to create an advance directive. There was no documentation of the resident's code status in the physician's orders or chart cover. On 09/11/24 at 2:02 p.m., the resident's clinical record was reviewed with the ADON and BOM. The ADON stated the resident's code status should have been documented on the physician's order and a sticker placed on the front of the chart. The BOM located a blank copy of the facility form to address advance directives in the resident's clinical record. The BOM stated the form was blank and the facility had not addressed advance directives with Resident #50.

Based on interview and record review, the facility failed to perform a post dialysis assessment for one (#19) of one sampled resident who was reviewed for dialysis. The ADON identified one resident who required dialysis. Findings: Resident #19 had diagnoses which included end stage renal disease. The August 2024 monthly physician's orders documented the resident was to attend dialysis three times a week. The pre/post dialysis communication reports, dated 08/02/24, 08/05/24, 08/07/24, 08/09/24, 08/19/24, 08/21/24, 08/23/24, 08/26/24, 08/28/24, 08/30/24, 09/02/24, 09/04/24, 09/06/24, and 09/09/24, documented the pre-dialysis assessment and the section for communication from the dialysis unit were completed, but there was no documentation of a post dialysis assessment on the form. On 09/11/24 at 11:19 a.m., RN #1 stated the post dialysis assessment included checking the resident's weight, vital signs, dialysis site, and bruit. They stated the dialysis pre/post assessments were kept in a dialysis log book which traveled with the resident to dialysis and back to aide with communication between the dialysis center and the facility. RN #1 reviewed the documentation in the resident's dialysis log book and stated the nurses' had not performed the post dialysis assessment.

Based on observation, interview, and record review, the facility failed to provide showers as scheduled for one (#50) of two sampled residents whose clinical records were reviewed for ADL care for dependent residents. A facility census list, dated 09/08/24, documented 61 residents resided in the facility. Findings: On 09/08/24 at 11:45 a.m., Resident #50 was observed in bed. The resident's hair was long and appeared tangled and greasy. On 09/08/24 at 11:45 a.m., Resident #50 stated they were scheduled for two showers per week, but only received one a week. The resident stated they usually did not receive their shower scheduled for the weekend. The resident's clinical record was reviewed and documented they were scheduled to receive showers on Wednesdays and Saturdays. There was no documentation the resident was offered/received showers on 08/10/24, 08/17/24, 08/24/24, or 08/31/24 (all Saturdays). On 09/11/24 at 9:00 a.m., the ADON stated there should be a shower sheet filled out even if the resident refused. The ADON stated they needed to educate the weekend staff on ADL care and charting.

Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#203) of five sampled residents reviewed for care plans. The ADON identified 61 residents resided in the facility. Findings: Resident #203 had diagnoses which included diabetes mellitus and hypertension. There was no documentation a comprehensive care plan was completed for the resident. On 09/11/24 at 12:34 p.m., the ADON stated a care plan for resident #203 was not completed.

Based on record review and interview, the facility failed to ensure a resident was safe to self-administer medication for one (#204) of one sampled resident reviewed for self-administering medications. The ADON identified one resident that self-administered medications. Findings: An undated policy titled Right to Self-Administer Medications read in part, .Each resident has the right to self-administration of drugs unless the interdisciplinary team has determined that the practice would be a danger to the resident or others .The attached form will be completed and kept in the resident's medical record .the interdisciplinary team must assess the resident's cognitive, physical, and visual ability to carry out the responsibility . Physician orders, dated 08/09/24, documented Resident #204 was to receive albuterol 3 mg/ipratropium 0.5 mg (bronchodilator medication) via nebulizer four times a day and it could be kept at bedside; and tiotropium bromide (anticholinergic medication) 2.5 mcg two inhalations once a day and it could be kept at bedside. On 09/11/24 at 12:34 p.m., the ADON stated an self-administration of medication assessment should have been completed for Resident #204.

Based on record review and interview, the facility failed to provide a CMS-10123 form to a resident who discharged from part Medicare Part A services for one (#50) of three sampled residents reviewed for required paperwork related to discharging from Medicare Part A services. The BOM stated six resident had discharged from Medicare Part A services in the previous six months to the survey. Findings: An undated CMS-10123 form, documented Resident #50's coverage for Medicare Part A services would end on 06/14/24. The form was not signed. On 09/09/24 at 1:31 p.m., the BOM stated they had forgot to provide Resident #50 a CMS-10123 form for Medicare Part A services which Resident #50 discharged from on 06/14/24.

Based on observation, record review, and interview, the facility failed to care plan the use of bedrails for one (#42) of three sampled resident reviewed for accidents. The ADON identified 10 residents had some form of bed rail attached to their beds. Findings: A care plan, dated 05/23/24, did not include a problem, goal, or intervention regarding the safe use of bedrails. On 09/11/24 at 12:38 p.m., Resident #42's assigned bed was observed to have a full side rail attached to each side. On 09/11/24 at 12:46 p.m., CNA #2 stated Resident #42 had used a bed with bedrails for about six months. On 09/11/24 at 1:39 p.m., the ADON stated they had reviewed Resident #42's current care plan. They stated the resident's use of bedrails was not care planned. They stated the bedrails should have been care planned.

Based on observation, record review, and interview, the facility failed to provide a care plan intervention for contracted hands of one (#6) of 24 sampled residents reviewed for the presence of contractures. The ADON identified five residents had contractures. Findings: A care plan problem for bilateral contracted hands, updated 06/04/24, documented the resident was to have contracture cushions or rolled rags in their hand if possible. On 09/08/24 at 12:32 p.m., Resident #6 was observed sitting in the dining room. Both of their hands appeared to be contracted. Neither hand had a device or material to protect and support their contracted hands. On 09/10/24 at 7:33 a.m., Resident #6 was observed in their room watching television. Both hands of the resident appeared contracted. There was nothing in either hand to protect or support the hands. On 09/10/24 at 1:56 p.m., RN #1 stated Resident #6 did have two contracted hands. On 09/11/24 at 11:12 a.m., CNA #1 stated the staff sometimes put rags in Resident #6's hands. They stated the resident did not have anything in their hand at that time. They stated they did not know if the rags were care planned. On 09/11/24 at 11:16 a.m. RN #1 stated the resident did not currently have rags in their hand. They stated there was no order for the rags and they were unaware if the rags were care planned. On 09/11/24 at 12:14 p.m., RN #1 stated they had got an order for the rolled rags to be place in the resident's hands. On 09/11/24 at 2:12 p.m., the ADON stated the rolled rags should have been placed in the resident's hands as they were care planned. They stated the staff had not been following the resident's care plan.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed for one (#203) of five sampled residents reviewed for care plans. The ADON identifed 61 residents resided in the facility. Findings: Resident #203 had diagnoses which included diabetes mellitus and hypertension. There was no documentation a baseline care plan had been completed. On 09/12/24 at 10:21 a.m., RN #1 stated they did not complete Resident #203's admission. They stated they did not know if a baseline care plan was completed. On 09/11/24 at 12:34 pm, the ADON stated a baseline care plan for resident #203 was not located.

On 05/18/22 at 5:40 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident was free from abuse. Two facility staff observed the interaction between the administrator and a resident and determined the interaction was abuse. The administrator was observed holding Resident #1 to their bed by their arms in an attempt to remove personal items from the resident's possession. On 05/18/22 at 5:23 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/18/22 at 5:40 p.m., the administrator and DON were notified of the IJ situation. On 05/19/22 at 6:49 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removed documented in part: .1) One resident was affected by this deficient practice. There were no apparent injuries such as bruises, cuts, or abrasions on the affected resident noted the date of the incident and days following to present. Resident was deemed safe and all resident were continued on 2 hour checks as usual by staff, 4 hour checks for day 1 through 7, 8 hour checks day 8 through 15, Q shift checks day 16-23 by a supervisor to ensure safety of all residents continued. After day 23 which began 05/19/22 resume Q 2 hour checks by staff indefinitely. No resident voiced to staff they felt unsafe during the process. The owner of the facility was notified of the alleged incident and 3 IJ's cited May 18, 2022 at 6:50 p.m. The perpetrator was immediately escorted off facility property and suspending [sic] pending investigation by the owner, [facility owner's name and credentials omitted]. 2) All residents have the potential to be affected by this deficient practice. 3) Systemic changes: A) Updated Abuse, Neglect, and Misappropriations policies and procedures. B) 5/19/22 4:30 a.m. new signage throughout facility posted for staff, residents, families, and visitors, indicating an offsite manager name and phone number to contact if not comfortable reporting incidents of alleged abuse, neglect, and misappropriation to management on site or fear of retaliation. C) 5/19/22 8:29 a.m. [Owner's name omitted] reported the unreported incident to O.S.D.H. at 8:29 a.m. with fax confirmation indicating sent ok. 5 Day report to be submitted by [owner's name omitted] upon completing extending investigation into the alleged complaint. 6) Physician, Family, Resident's Legal Representative, APS, and Local Law Enforcement notified of alleged incident. 7) [NAME] Police [NAME] [sic] [officer's name omitted] investigated the incident report and interviewed affected resident 05/19/22 at 8:45 a.m. 8) Facility Owner [owner's name omitted] begain [sic] in-servicing Department Managers on Abuse, Neglect, Misappropriation of residents by reviewing the updated abuse, neglect, and misappropriation policies and procedures to also include but not limited to reporting allegations to facility and requirements of the facility to report the allegations to regulatory agencies. In addition to the inservice, the Department Managers attend a quality assurance meeting to correct the problem of not reporting abuse, neglect, and misappropriation. Following inservice and quality assurance, the department managers were given written assessment and competency tests to determine level of knowledge in following facility abuse, neglect, and misappropriation policies and procedures as well as requirement to report timely. 9) New forms implemented titles a) Abuse, Neglect, and Exploitation Competency Assessment; and b) All Staff Abuse, Neglect, and Misappropriation Competency Checklist. These new forms implemented 05/19/22 will be completed on all current and future staff upon hiring. 10) An all staff in person in-service was held 5/19/22 at 10:00 a.m. to educate, discuss, learn, and give written competency evaluations on each employee. 11)The Nursing Facility Owner, [owner's name omitted] led a QAPI Meeting 05/19/22 at 11:15 a.m. with all QAPI committee members attending. Name of QAPI Project: Abuse, Neglect, and Misappropriation Training. QAPI Goals: To ensure that all staff and residents are knowledgeable on how to report suspected/alleged abuse, neglect, and misappropriation. To ensure that all staff and residents are knowledgeable on different types of abuse, neglect, and misappropriation. SCOPE of QAPI Meeting: Understanding the resident's right to be free from abuse, neglect, and misappropriation as well as reporting policies. Project Phase Initiation: 05/19/22. Project Planning start date: 05/19/22. Project Implementation Date 05/19/22. Project Monitoring Date 05/19/22. Closing Date: To be determined. Performance Improvement Project: To ensure all staff and residents are educated on abuse, neglect, and misappropriation. The Committee shall monitor knowledge of staff and residents regarding abuse, neglect, and misappropriation through personal interview during shift time to refresh the memory of the policies trained and tested on . Residents shall be educated through Resident Council and personal interviews. 4) The Director of Nursing Shall be responsible for monitoring the effectiveness of this plan of removal/correction. 5) Negative Findings shall be referred to the facility quality assurance team for review and corrective action . On 05/20/22, all inservice attendance sheets, teaching material, and testing material used in the inservice was reviewed. Facility staff final test answers were reviewed. Interviews were conducted with facility staff, including nursing staff, kitchen staff, and housekeeping staff, regarding inservice and abuse training pertaining to the Immediate Jeopardy plan of removal. All interviewed staff verbalized attending the inservice and understanding of the abuse training. On 05/20/2 at 7:45 p.m., the facility was notified the immediacy of the IJ was lifted, effective 05/19/22 at 10:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at an isolated level of actual harm. Based on record review and interview, the facility failed to ensure the facility was free from abuse of one (Res #1) of six residents reviewed for abuse. Resident #1 was held by their arms to the bed in an attempt to remove personal items from Resident #1 possession. The director of nursing identified 61 residents residing in the facility. Findings: An undated policy, titled Abuse Prohibition Policy, read in parts, .abuse is defined as .unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .Forest Manor Nursing Center does not allow its employees to use verbal, mental .physical abuse . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 02/16/22, documented the resident was cognitively intact with daily decision making and required minimum assistance with activities of daily living. The nurse's progress note, dated 05/05/22 at 8:00 a.m., documented in part, .Resident upset cigarettes taken from [personal pronoun omitted] and room as resident tried to light cigarettes in hallway. Resident confused. Resident trying to hit and kick staff member . On 05/17/22 at 11:30 a.m., a complaint investigation was announced to the DON and administrator. No details of the complaint were shared with the facility but the administrator reported a state investigator for Adult Protective Services had completed an investigation the prior week. The administrator stated the investigation was related to resident #1. The administrator and DON were asked for all state reportable incident reports for the last six months. The administrator stated there were no state reportable incident reports for the last six months other than one for a power outage. She was asked if there were no injuries of unknown origin or incidents involving major injury. She stated no. The administrator was asked if the facility had investigated any allegations of abuse and she stated no. On 05/17/22 at 12:20 p.m., resident (Res) #1 stated staff held their arms down to the bed and grabbed their cigarettes from their pocket. When asked who held their arms down, the resident stated it was the woman. The resident stated the woman was standing very close and yelling for the resident to relinquish their cigarettes to her. The resident stated the woman grabbed their arms and held them down to the bed and instructed another staff member to grab the cigarettes from the resident's pocket. On 05/17/22 at 12:55 p.m., CMA #2 stated she observed the administrator hold the resident's arms down, pinning the resident to the bed. The CMA stated early in the shift on 05/05/22, the resident wanted to go outside to smoke. She stated it was raining and the resident had lit their cigarette just inside the building before staff saw and escorted the resident outside to smoke. The CMA stated staff requested the cigarettes from the resident and was refused. CMA #2 stated when the administrator arrived later in the morning, the administrator was informed the resident lit their cigarette inside the building. The administrator instructed staff to get the resident's cigarettes. She stated when the resident again refused, the administrator went to speak with the resident and pulled the CMA and the social service director into the room as witnesses. The administrator requested the cigarettes multiple times and the resident continually refused. The CMA stated the administrator grabbed the resident's arms and instructed the CMA to grab the resident's cigarettes and lighter. She stated when the administrator grabbed the resident, the CMA stepped to the side and reached out her arm to block a kick from the resident aimed at the administrator. She stated she informed the administrator there was a better way to handle the situation and refused to grab the resident's cigarettes and lighter. The CMA stated the administrator released the resident's arms and left the room. The CMA stated later in the morning, the resident came to the nurse's station and relinquished their cigarettes and lighter without further incident. She stated since the incident, the resident appeared confused at times. On 05/17/22 at 1:20 p.m., the administrator was asked what happened with resident #1 on 05/05/22. She stated before she had arrived at work, resident #1 had lit a cigarette inside the building. The administrator stated when she was informed of the resident's actions, she went to the resident's room and requested the resident give up possession of their cigarettes. The administrator stated the resident refused and attempted to kick her. The administrator stated it was obvious the resident was agitated and her presence was making it worse, so she left the room. On 05/17/22 at 1:30 p.m., the social service director stated she was asked by the administrator to get the cigarettes and lighter from Resident #1. She stated when she asked the resident for their cigarettes and lighter, the resident refused. The social service director stated she informed the administrator of the refusal and returned to the resident's room. The social service director stated the resident was sitting on the side of the bed when the administrator entered the room and asked the resident for their cigarettes and lighter and the resident repeatedly refused. The social service director stated the administrator quickly grabbed the resident's arms and held the resident down towards the bed, calling out for staff to grab the resident's cigarettes and lighter from the resident's hand. The social service director stated she informed the administrator there was a better way to handle the situation and refused to grab the resident's cigarettes and lighter. The social service director stated the administrator released the resident's arms, left the room. The Social Service Director stated they remained talked calmly with the resident and after several minutes Resident #1 became visibly relaxed. The Social Service Director further stated the resident and her laughed about breaking the rule of lighting a cigarette inside the building and the administrator was provided the cigarettes and lighter. The Social Service Director added Resident #1 appeared confused more often after the incident. On 05/18/22 at 9:30 a.m., Resident #1 stated their cigarettes were taken away after they lit a cigarette in the building. They stated it was raining outside and the resident could not light their cigarette in the rain. The resident stated they lit the cigarette and then attempted to go out the door but could not get the door open. The resident stated staff assisted them outside and once finished, asked for the cigarettes. The resident stated they refused to give up their cigarettes. The resident stated the administrator came to their room and demanded they give up their cigarettes and again they refused. The resident stated she was sitting on the side of the bed and the administrator pinned their arms to the bed and yelled for the other staff to take her cigarettes. The resident stated they could not break the hold the administrator had on their arms so they tried to kick the administrator away. Resident #1 stated the cigarettes were taken and the administrator left the room. On 05/18/22 at 1:40 p.m., the investigator for Adult Protective Services was contacted to confirm details of the resident's interview. The investigator stated the resident appeared cognitively intact during their conversation. The investigator stated the resident informed him the administrator held the resident's arms while staff grabbed the resident's cigarettes. On 05/18/22 at 5:40 p.m. the Immediate Jeopardy templates were reviewed with the administrator and DON. The administrator stated she felt sorry the resident misinterpreted her actions. The administrator stated when the resident started punching and kicking at her, she grabbed the resident's arms briefly to protect herself and the resident but then immediately released the resident and left the room.

On 05/18/22 at 5:40 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to develop and implement written polices and procedures that prohibited, prevented, investigated, and trained facility staff on the abuse policy. Two facility staff observed the interaction between the administrator and a resident and determined the interaction was abuse. Neither staff member knew the requirements for notification of allegations of abuse and did not notify an outside agency for 24 hours. On 05/18/22 at 5:23 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/18/22 at 5:40 p.m., the administrator and DON were notified of the IJ situation. On 05/19/22 at 6:49 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removed documented in part: .1) One resident was affected by this deficient practice. There were no apparent injuries such as bruises, cuts, or abrasions on the affected resident noted the date of the incident and days following to present. Resident was deemed safe and all resident were continued on 2 hour checks as usual by staff, 4 hour checks for day 1 through 7, 8 hour checks day 8 through 15, Q shift checks day 16-23 by a supervisor to ensure safety of all residents continued. After day 23 which began 05/19/22 resume Q 2 hour checks by staff indefinitely. No resident voiced to staff they felt unsafe during the process. The owner of the facility was notified of the alleged incident and 3 IJ's cited May 18, 2022 at 6:50 p.m. The perpetrator was immediately escorted off facility property and suspending [sic] pending investigation by the owner, [facility owner's name and credentials omitted]. 2) All residents have the potential to be affected by this deficient practice. 3) Systemic changes: A) Updated Abuse, Neglect, and Misappropriations policies and procedures. B) 5/19/22 4:30 a.m. new signage throughout facility posted for staff, residents, families, and visitors, indicating an off site manager name and phone number to contact if not comfortable reporting incidents of alleged abuse, neglect, and misappropriation to management on site or fear of retaliation. C) 5/19/22 8:29 a.m. [owner's name omitted] reported the unreported incident to O.S.D.H. at 8:29 a.m. with fax confirmation indicating sent ok. 5 Day report to be submitted by [owner's name omitted] upon completing extending investigation into the alleged complaint. 6) Physician, Family, Resident's Legal Representative, APS, and Local Law Enforcement notified of alleged incident. 7) [NAME] Police [NAME] [sic] [officer's name omitted] investigated the incident report and interviewed affected resident 05/19/22 at 8:45 a.m. 8) Facility Owner [owner's name omitted] begain [sic] in-servicing Department Managers on Abuse, Neglect, Misappropriation of residents by reviewing the updated abuse, neglect, and misappropriation policies and procedures to also include but not limited to reporting allegations to facility and requirements of the facility to report the allegations to regulatory agencies. In addition to the inservice, the Department Managers attend a quality assurance meeting to correct the problem of not reporting abuse, neglect, and misappropriation. Following inservice and quality assurance, the department managers were given written assessment and competency tests to determine level of knowledge in following facility abuse, neglect, and misappropriation policies and procedures as well as requirement to report timely. 9) New forms implemented titles a) Abuse, Neglect, and Exploitation Competency Assessment; and b) All Staff Abuse, Neglect, and Misappropriation Competency Checklist. These new forms implemented 05/19/22 will be completed on all current and future staff upon hiring. 10) An all staff in person in-service was held 5/19/22 at 10:00 a.m. to educate, discuss, learn, and give written competency evaluations on each employee. 11)The Nursing Facility Owner, [owner's name omitted] led a QAPI Meeting 05/19/22 at 11:15 a.m. with all QAPI committee members attending. Name of QAPI Project: Abuse, Neglect, and Misappropriation Training. QAPI Goals: To ensure that all staff and residents are knowledgeable on how to report suspected/alleged abuse, neglect, and misappropriation. To ensure that all staff and residents are knowledgeable on different types of abuse, neglect, and misappropriation. SCOPE of QAPI Meeting: Understanding the resident's right to be free from abuse, neglect, and misappropriation as well as reporting policies. Project Phase Initiation: 05/19/22. Project Planning start date: 05/19/22. Project Implementation Date 05/19/22. Project Monitoring Date 05/19/22. Closing Date: To be determined. Performance Improvement Project: To ensure all staff and residents are educated on abuse, neglect, and misappropriation. The Committee shall monitor knowledge of staff and residents regarding abuse, neglect, and misappropriation through personal interview during shift time to refresh the memory of the policies trained and tested on . Residents shall be educated through Resident Council and personal interviews. 4) The Director of Nursing Shall be responsible for monitoring the effectiveness of this plan of removal/correction. 5) Negative Findings shall be referred to the facility quality assurance team for review and corrective action . On 05/20/22, all inservice attendance sheets, teaching material, and testing material used in the inservice was reviewed. Facility staff final test answers were reviewed. Interviews were conducted with facility staff, including nursing staff, kitchen staff, and housekeeping staff, regarding inservice and abuse training pertaining to the Immediate Jeopardy plan of removal. All interviewed staff verbalized attending the inservice and understanding of the abuse training. On 05/20/2 at 7:45 p.m., the facility was notified the immediacy of the IJ was lifted, effective 05/19/22 at 10:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at an isolated level of actual harm. Based on record review and interview, the facility failed to develop and implement a policy for an abuse free environement, idenitfying who to report allegations of abuse to in the absence of the administror or when the adminsitrator was the alleged perpetrator.for one (#1) of six sampled residents reviewed for abuse. The Social Service Director and CMA #2 observed the administrator holding Resident #1 to the bed by the arms to take their cigrarttes away from them. The two employee did not report the abuse becuase the administrator was the perpertrator and they had no knowledge of who else to report the abuse to immediatly. The director of nursing identified 61 residents residing in the facility. Findings: An undated policy, titled Abuse Prohibition Policy, read in part, .abuse is defined as .unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .Forest Manor Nursing Center does not allow its employees to use verbal, mental .physical abuse In the event of any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor or family members are requested to report all allegations, suspension [sic] or incidents to the administrator .Upon report of any allegations or violations the administrator or his/her designated representative will thoroughly investigate the situation in accordance with the Oklahoma Law .The results of all investigations are reported to the Administrator or his/her designated representative. The Administrator will then make the decision as to notification of the Licensing Agency and/or local authorities within twelve (12) hours per telephone and in writing within five (5) working days . The policy did not indicate who staff would report allegations of abuse to if the alleged perpetrator was the administrator and/or the administrator was not available. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 02/16/22, documented the resident was cognitively intact with daily decision making and required minimum assistance with activities of daily living. The nurse's progress note, dated 05/05/22 at 8:00 a.m., documented in part, .Resident upset cigarettes taken from [personal pronoun omitted] and room as resident tried to light cigarettes in hallway. Resident confused. Resident trying to hit and kick staff member . On 05/17/22 at 11:30 a.m., a complaint investigation was announced to the DON and administrator. No details of the complaint were shared with the facility but the administrator reported a state investigator for Adult Protective Services had completed an investigation the prior week. The administrator stated the investigation was related to resident #1. The administrator and DON were asked for all state reportable incident reports for the last six months. The administrator stated there were no state reportable incident reports for the last six months other than one for a power outage. She was asked if there were no injuries of unknown origin or incidents involving major injury. She stated no. The administrator was asked if the facility had investigated any allegations of abuse and she stated no. On 05/17/22 at 12:20 p.m., resident (Res) #1 stated staff held their arms down to the bed and grabbed their cigarettes from their pocket. When asked who held their arms down, the resident stated it was the woman. The resident stated the woman was standing very close and yelling for the resident to relinquish their cigarettes to her. The resident stated the woman grabbed their arms and held them down to the bed and instructed another staff member to grab the cigarettes from the resident's pocket. On 05/17/22 at 12:55 p.m., CMA #2 stated she observed the administrator hold the resident's arms down, pinning the resident to the bed. The CMA stated early in the shift on 05/05/22, the resident wanted to go outside to smoke. She stated it was raining and the resident had lit their cigarette just inside the building before staff saw and escorted the resident outside to smoke. The CMA stated staff requested the cigarettes from the resident and was refused. The CMA stated when the administrator arrived later in the morning, the administrator was informed the resident lit their cigarette inside the building. The administrator instructed staff to get the resident's cigarettes. She stated when the resident again refused, the administrator went to speak with the resident and pulled the CMA and the social service director into the room as witnesses. The administrator requested the cigarettes multiple times and the resident continually refused. The CMA stated the administrator grabbed the resident's arms and instructed the CMA to grab the resident's cigarettes and lighter. She stated when the administrator grabbed the resident, the CMA stepped to the side and reached out her arm to block a kick from the resident aimed at the administrator. She stated she informed the administrator there was a better way to handle the situation and refused to grab the resident's cigarettes and lighter. The CMA stated the administrator released the resident's arms and left the room. The CMA was asked what she considered the actions of the administrator to be. She stated abuse. The CMA was asked who she contacted. She stated normally she would immediately contact the administrator if she suspected abuse but since it was the administrator she witnessed abuse the resident, she did not know who to contact. She stated it was the next morning when she notified Adult Protective Services. On 05/17/22 at 1:20 p.m., the administrator was asked what happened with Resident #1 on 05/05/22. She stated before she had arrived at work, resident #1 had lit a cigarette inside the building. The administrator stated when she was informed of the resident's actions, she went to the resident's room and requested the resident give up possession of their cigarettes. The administrator stated the resident refused and attempted to kick her. The administrator stated it was obvious the resident was agitated and her presence was making it worse, so she left the room. On 05/17/22 at 1:30 p.m., the social service director stated she was asked by the administrator to get the cigarettes and lighter from resident #1. She stated when she asked the resident for their cigarettes and lighter, the resident refused. The social service director stated she informed the administrator of the refusal and returned to the resident's room. The social service director stated the resident was sitting on the side of the bed when the administrator entered the room and asked the resident for their cigarettes and lighter. She stated the resident repeatedly refused. The social service director stated the administrator quickly grabbed the resident's arms and held the resident down toward's the bed, calling out for staff to grab the resident's cigarettes and lighter from the resident's hand. The social service director stated she informed the administrator there was a better way to handle the situation and refused to grab the resident's cigarettes and lighter. The social service director stated the administrator released the resident's arms and left the room. Social Service Director stated they remained talked calmly with the resident and after several minutes Resident #1 became visibly relaxed. The social service director was asked what she considered the actions of the administrator to be. She stated abuse. The social service director was asked who she contacted. She stated she did not know who to contact in the facility. She stated it was the next morning when she notified Adult Protective Services. On 05/18/22 at 9:30 a.m., Resident #1 stated their cigarettes were taken away after they lit a cigarette in the building. They stated it was raining outside and the resident could not light their cigarette in the rain. The resident stated they lit the cigarette and then attempted to go out the door but could not get the door open. The resident stated staff assisted them outside and once finished, asked for the cigarettes. The resident stated they refused to give up their cigarettes. The resident stated the administrator came to their room and demanded they give up their cigarettes and again they refused. The resident stated she was sitting on the side of the bed and the administrator pinned their arms to the bed and yelled for the other staff to take her cigarettes. The resident stated they could not break the hold the administrator had on their arms so they tried to kick the administrator away. Resident #1 stated the cigarettes were taken and the administrator left the room. On 05/18/22 at 1:40 p.m., the investigator for Adult Protective Services was contacted to confirm details of the resident's interview. The investigator stated the resident appeared cognitively intact during their conversation. The investigator stated the resident informed him the administrator held the resident's arms while staff grabbed the resident's cigarettes. On 05/18/22 at 5:40 p.m. the Immediate Jeopardy templates were reviewed with the administrator and DON. The administrator stated she felt sorry the resident misinterpreted her actions. The administrator stated when the resident started punching and kicking at her, she grabbed the resident's arms briefly to protect herself and the resident but then immediately released the resident and left the room.

On 05/18/22 at 5:40 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to report an allegation of abuse to the Oklahoma State Department of Health within two hours. Two facility staff observed the interaction between the administrator and a resident and determined the interaction was abuse. Neither staff member knew the requirements for notification of allegations of abuse and did not notify an outside agency for 24 hours. On 05/18/22 at 5:23 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/18/22 at 5:40 p.m., the administrator and DON were notified of the IJ situation. On 05/19/22 at 6:49 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removed documented in part: .1) One resident was affected by this deficient practice. There were no apparent injuries such as bruises, cuts, or abrasions on the affected resident noted the date of the incident and days following to present. Resident was deemed safe and all resident were continued on 2 hour checks as usual by staff, 4 hour checks for day 1 through 7, 8 hour checks day 8 through 15, Q shift checks day 16-23 by a supervisor to ensure safety of all residents continued. After day 23 which began 05/19/22 resume Q 2 hour checks by staff indefinitely. No resident voiced to staff they felt unsafe during the process. The owner of the facility was notified of the alleged incident and 3 IJ's cited May 18, 2022 at 6:50 p.m. The perpetrator was immediately escorted off facility property and suspending [sic] pending investigation by the owner, [facility owner's name and credentials omitted]. 2) All residents have the potential to be affected by this deficient practice. 3) Systemic changes: A) Updated Abuse, Neglect, and Misappropriations policies and procedures. B) 5/19/22 4:30 a.m. new signage throughout facility posted for staff, residents, families, and visitors, indicating an off site manager name and phone number to contact if not comfortable reporting incidents of alleged abuse, neglect, and misappropriation to management on site or fear of retaliation. C) 5/19/22 8:29 a.m. [owner's name omitted] reported the unreported incident to O.S.D.H. at 8:29 a.m. with fax confirmation indicating sent ok. 5 Day report to be submitted by [owner's name omitted] upon completing extending investigation into the alleged complaint. 6) Physician, Family, Resident's Legal Representative, APS, and Local Law Enforcement notified of alleged incident. 7) [NAME] Police [NAME] [sic] [officer's name omitted] investigated the incident report and interviewed affected resident 05/19/22 at 8:45 a.m. 8) Facility Owner [owner's name omitted] begain [sic] in-servicing Department Managers on Abuse, Neglect, Misappropriation of residents by reviewing the updated abuse, neglect, and misappropriation policies and procedures to also include but not limited to reporting allegations to facility and requirements of the facility to report the allegations to regulatory agencies. In addition to the inservice, the Department Managers attend a quality assurance meeting to correct the problem of not reporting abuse, neglect, and misappropriation. Following inservice and quality assurance, the department managers were given written assessment and competency tests to determine level of knowledge in following facility abuse, neglect, and misappropriation policies and procedures as well as requirement to report timely. 9) New forms implemented titles a) Abuse, Neglect, and Exploitation Competency Assessment; and b) All Staff Abuse, Neglect, and Misappropriation Competency Checklist. These new forms implemented 05/19/22 will be completed on all current and future staff upon hiring. 10) An all staff in person in-service was held 5/19/22 at 10:00 a.m. to educate, discuss, learn, and give written competency evaluations on each employee. 11)The Nursing Facility Owner, [owner's name omitted] led a QAPI Meeting 05/19/22 at 11:15 a.m. with all QAPI committee members attending. Name of QAPI Project: Abuse, Neglect, and Misappropriation Training. QAPI Goals: To ensure that all staff and residents are knowledgeable on how to report suspected/alleged abuse, neglect, and misappropriation. To ensure that all staff and residents are knowledgeable on different types of abuse, neglect, and misappropriation. SCOPE of QAPI Meeting: Understanding the resident's right to be free from abuse, neglect, and misappropriation as well as reporting policies. Project Phase Initiation: 05/19/22. Project Planning start date: 05/19/22. Project Implementation Date 05/19/22. Project Monitoring Date 05/19/22. Closing Date: To be determined. Performance Improvement Project: To ensure all staff and residents are educated on abuse, neglect, and misappropriation. The Committee shall monitor knowledge of staff and residents regarding abuse, neglect, and misappropriation through personal interview during shift time to refresh the memory of the policies trained and tested on . Residents shall be educated through Resident Council and personal interviews. 4) The Director of Nursing Shall be responsible for monitoring the effectiveness of this plan of removal/correction. 5) Negative Findings shall be referred to the facility quality assurance team for review and corrective action . On 05/20/22, all inservice attendance sheets, teaching material, and testing material used in the inservice was reviewed. Facility staff final test answers were reviewed. Interviews were conducted with facility staff, including nursing staff, kitchen staff, and housekeeping staff, regarding inservice and abuse training pertaining to the Immediate Jeopardy plan of removal. All interviewed staff verbalized attending the inservice and understanding of the abuse training. On 05/20/2 at 7:45 p.m., the facility was notified the immediacy of the IJ was lifted, effective 05/19/22 at 10:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at an isolated level of actual harm. Based on record review and interview, the facility failed to have staff report allegations of abuse to a designeed employee or reppresentive of the facility when an abusive incident occured between the administrator and Resident one (#1) of six residents reviewed for abuse.1.The Social Service Director and CMA #2 observed the administrator holding Resident #1 to the bed by the arms to take their cigrarttes away from them. The two employee did not report the abuse becuase the administrator was the perpertrator and they had no knowledge of who else to report the abuse to immediatly. The director of nursing identified 61 residents residing in the facility. Findings: An undated policy, titled Abuse Prohibition Policy, documented in part, .In the event of any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor or family members are requested to report all allegations, suspension [sic] or incidents to the administrator . Upon report of any allegations or violations the administrator or his/her designated representative will thoroughly investigate the situation in accordance with the Oklahoma Law .The results of all investigations are reported to the Administrator or his/her designated representative. The Administrator will then make the decision as to notification of the Licensing Agency and/or local authorities within twelve (12) hours per telephone and in writing within five (5) working days . The policy did not indicate who staff would report allegations of abuse to if the alleged perpetrator was the administrator and/or the administrator was not available. A facility policy, dated November 2001 and titled Policy and Procedure for Reporting Unusual Occurrences, documented the charge nurse was to notify the administrator and DON immediately. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 02/16/22, documented the resident was cognitively intact with daily decision making and required minimum assistance with activities of daily living. The nurse's progress note, dated 05/05/22 at 8:00 a.m., documented in part, .Resident upset cigarettes taken from [personal pronoun omitted] and room as resident tried to light cigarettes in hallway. Resident confused. Resident trying to hit and kick staff member . On 05/17/22 at 11:30 a.m., a complaint investigation was announced to the DON and administrator. No details of the complaint were shared with the facility but the administrator reported a state investigator for Adult Protective Services had completed an investigation the prior week. The administrator stated the investigation was related to Resident #1. The Administrator and DON were asked for all state reportable incident reports for the last six months. The administrator stated there were no state reportable incident reports for the last six months other than one for a power outage. She was asked if there were no injuries of unknown origin or incidents involving major injury. She stated no. The administrator was asked if the facility had investigated any allegations of abuse and she stated no. On 05/17/22 at 12:20 p.m., Resident #1 stated staff held their arms down to the bed and grabbed their cigarettes from their pocket. When asked who held their arms down, the resident stated it was the woman. The resident stated the woman was standing very close and yelling for the resident to relinquish their cigarettes to her. The resident stated the woman grabbed their arms and held them down to the bed and instructed another staff member to grab the cigarettes from the resident's pocket. On 05/17/22 at 12:55 p.m., CMA #2 stated she observed the administrator hold the resident's arms down, pinning the resident to the bed. The CMA stated early in the shift on 05/05/22, the resident wanted to go outside to smoke. She stated it was raining and the resident had lit their cigarette just inside the building before staff saw and escorted the resident outside to smoke. The CMA stated staff requested the cigarettes from the resident and was refused. The CMA stated when the administrator arrived later in the morning, the administrator was informed the resident lit their cigarette inside the building. The administrator instructed staff to get the resident's cigarettes. She stated when the resident again refused, the administrator went to speak with the resident and pulled the CMA and the social service director into the room as witnesses. The administrator requested the cigarettes multiple times and the resident continually refused. The CMA stated the administrator grabbed the resident's arms and instructed the CMA to grab the resident's cigarettes and lighter. She stated when the administrator grabbed the resident, the CMA stepped to the side and reached out her arm to block a kick from the resident aimed at the administrator. She stated she informed the administrator there was a better way to handle the situation and refused to grab the resident's cigarettes and lighter. The CMA stated the administrator released the resident's arms and left the room. The CMA was asked what she considered the actions of the administrator to be. She stated abuse. The CMA was asked who she contacted. She stated normally she would immediately contact the administrator if she suspected abuse but since it was the administrator she witnessed, and did not know who to contact. They stated the next morning they notified Adult Protective Services. On 05/17/22 at 1:20 p.m., the Administrator was asked what happened with Resident #1 on 05/05/22. She stated before she had arrived at work, Resident #1 had lit a cigarette inside the building. The administrator stated when she was informed of the resident's actions, she went to the resident's room and requested the resident give up possession of their cigarettes. The administrator stated the resident refused and attempted to kick her. The administrator stated it was obvious the resident was agitated and her presence was making it worse, and left the room. On 05/17/22 at 1:30 p.m., the social service director stated she was asked by the Administrator to get the cigarettes and lighter from resident #1. She stated when she asked the resident for their cigarettes and lighter, the resident refused. The social service director stated she informed the administrator of the refusal and returned to the resident's room. The social service director stated the resident was sitting on the side of the bed when the administrator entered the room and asked the resident for their cigarettes and lighter. She stated the resident repeatedly refused. The social service director stated the administrator quickly grabbed the resident's arms and held the resident down toward's the bed, calling out for staff to grab the resident's cigarettes and lighter from the resident's hand. The social service director stated she informed the administrator there was a better way to handle the situation and refused to grab the resident's cigarettes and lighter. The social service director stated the administrator released the resident's arms and left the room. The Social Service Director stated they remained talking calmly with the resident and after several minutes Resident #1 became visibly relaxed. The social service director was asked what she considered the actions of the administrator to be. She stated abuse. The social service director was asked who she contacted. She stated she did not know who to contact in the facility and the next morning notified Adult Protective Services. On 05/18/22 at 9:30 a.m., Resident #1 was asked if about their cigarettes. The resident stated their cigarettes were taken away after they lit a cigarette in the building. They stated it was raining outside and the resident could not light their cigarette in the rain. The resident stated they lit the cigarette and then attempted to go out the door but could not get the door open. The resident stated staff assisted them outside and once finished, asked for the cigarettes. The resident stated they refused to give up their cigarettes. The resident stated the administrator came to their room and demanded they give up their cigarettes and again they refused. The resident stated she was sitting on the side of the bed and the administrator pinned their arms to the bed and yelled for the other staff to take her cigarettes. The resident stated they could not break the hold the administrator had on their arms so they tried to kick the administrator away. Resident #1 stated the cigarettes were taken and the administrator left the room. On 05/18/22 at 1:40 p.m., the investigator for Adult Protective Services was contacted to confirm details of the resident's interview. The investigator stated the resident appeared cognitively intact during their conversation. The investigator stated the resident informed him the administrator held the resident's arms while staff grabbed the resident's cigarettes. On 05/18/22 at 5:40 p.m. the Immediate Jeopardy templates were reviewed with the administrator and DON. The administrator stated she felt sorry the resident misinterpreted her actions. The administrator stated when the resident started punching and kicking at her, she grabbed the resident's arms briefly to protect herself and the resident but then immediately released the resident and left the room. The administrator was asked if CMA #2 and the Social Service Director reported the allegation of abuse to anyone. She stated she was the alleged perpetrator and was not aware of the incident and if they had reported it to anyone.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident was transfered in a manner to prevent accidents for one (#11) of one sampled resident who was reviewed for transfers. The resident sustained [REDACTED]. The resident census and condition report documented 26 residents in the facility who required the assist of one or two staff members for transfers. Findings: Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A care plan, dated 08/30/17, documented: Problem The resident is at risk for falls with injury related to impaired cognition, decreased mobility, and physical impairment. The resident has a [DIAGNOSES REDACTED]. Goal No occurrence of falls with injury will occur over the next 90 days. Approach Monitor for proper body alignment and balance. Assist with repositioning as needed. Assist with ADLs and transfers using position devices as needed. A quarterly assessment, dated 05/17/18, documented the resident was moderately impaired cognitively, and required limited to extensive assistance with activities of daily living. An annual assessment, dated 08/16/18, documented the resident was cognitively intact, and required extensive assistance from staff for activities of daily living, including transferring. On 09/16/18 at 12:45 p.m., the resident was observed dressed and sitting in his wheelchair having lunch. The resident showed the surveyor his knee where something was pushing out under his skin. The resident stated he had knee surgery in the past and felt like that was a pin trying to come out of his knee. At 2:00 p.m., the resident stated he had told the nurse about the pin trying to come out of his knee in the dining room at lunch. On 09/17/18 at 8:42 a.m., the resident was observed in bed with the head of the bed up. His breakfast was on the over bed table across his bed. He had eggs and biscuits and gravy. He stated he was not hungry. Nothing tasted good. The resident showed the surveyor a bandage on his right knee. He stated he had surgery on his knee in the past and he felt like there was a pin trying to poke out. He stated staff put a bandage on it and were going to check it later. A nurse's note, dated 09/18/18 at 5:00 p.m., documented a raised area was observed to the medial aspect of the lower tibia. The note documented the x-ray tech who had come to x-ray the resident's knee had x-rayed the resident's leg and confirmed a [MEDICAL CONDITION] tibia. The note documented the resident's leg was elevated and ice was applied while waiting for the ambulance to arrive. An incident report, dated 09/18/18, documented while transferring the resident from his wheelchair to his bed the resident's right leg became hung up and then gave way with a muffled snap or crack sound. The report documented the resident yelled his leg was broken. An untimed nurse's note, dated 09/20/18, written by LPN #4, documented, .I placed the resident facing me, my back to the bed .I counted and lifted the resident and began turning to my left. As we started to turn when there was resistance I thought his bottom wasn't clearing the wheel chair, so I lifted up and around which is when the resident yelled out. When he yelled out, was when I realized the Right leg with the fused knee was caught on the bed above the ankle . On 09/24/18 at 9:20 a.m., the resident was observed in bed. The resident had a splint on his right leg. The resident was asked what happened. He stated his leg had broken when he was being transferred to bed for an x-ray. The resident was unable to provide any details of the event. At 2:11 p.m., LPN #4 was asked how long she had worked at the facility. She stated three and a half years. The LPN was asked what had happened during the resident's transfer which had caused his leg fracture. She stated the resident had told staff that something was sticking out a little bit on his knee and he thought it was a pin from a previous surgery. The LPN stated the physician had ordered an x-ray to be taken because the pin looked like it was coming out. She stated the x-ray tech had arrived to the facility and the CNA was busy so she had taken the resident to his room to transfer him to bed in order for the x-ray to be taken. She stated she pushed his chair near the bed but not next to the bed. She stated she put her arms around his waist and lifted him up. She stated it felt like she needed to lift him higher to clear the arm of the wheelchair and she tried to turn around to set him on the bed. She stated his foot got caught under the bed and she heard a loud pop and the resident cried out that his leg was broken. She stated she should have changed the position of the wheelchair to next to the resident's bed so there was less opportunity for his foot to get caught. The LPN was asked if she had used a gait belt. She stated she had not. At 2:50 p.m., the LPN was asked if she had transferred the resident safely. She stated she had obviously done something wrong or the resident would not have broken his leg. She stated next time she would have the CNA transfer the residents. At 3:25 p.m., CNA #3 was asked how she transferred the resident. She stated she put his wheelchair next to the bed and had him put his arms around her neck and then she lifted him at the waist and pivoted one step and onto the bed. She stated he was very easy to transfer. At 4:11 p.m., the DON was asked about the resident's leg fracture. The DON was asked if the LPN had used a gait belt. She stated she did not think so. She stated they had called to have an x-ray of the resident's knee and the LPN was transferring him so the resident could have the x-ray done. She stated after the transfer the resident's leg was x-rayed and was found to be broken. She stated they transferred the resident to the emergency room and he had returned to the facility with a splint in place and an order to contact the orthopedist.