Every finding on record at Fountain View Manor, Inc

Based on observation, record review, and interview, the facility failed to ensure call lights were operational and available for 14 of 14 rooms occupied by residents on the memory care unit.The DON identified 22 residents resided in the memory care unit. Findings:On 01/13/26 at 9:00 a.m., a tour of the memory care unit was conducted. On 01/13/26 at 9:01 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:02 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:03 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:04 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:05 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:06 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:07 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:08 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:09 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:10 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:11 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:12 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:13 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:14 a.m., room [ROOM NUMBER] was observed to have no call light.An undated Call Light Policy, read in part, A calling system must be available for each resident in the nursing home.On 01/13/26 at 9:50 a.m., CNA #5 stated they were told the rooms did not have call lights because they were a strangulation risk. CNA #5 stated if the resident needed staff they would have to holler out.On 01/20/26 at 10:15 a.m., the ADON stated the memory care unit did not have call lights because they were a safety hazard.

Based on observation and interview, the facility failed to prepare food in a manner to minimize the risk of infection/cross contamination for 1 (the noon meal) of 1 meal services observed. The DM identified 80 residents received meals from the kitchen. Findings: On 01/13/26 at 12:12 p.m., a tour of the kitchen was conducted. [NAME] #1was observed to prepare the puree dessert. DA #1 was observed to carry a bucket with sanitizing water to the sink in the cooking area, beside the prep table, used to prepare puree food. DA #1 was observed to dump the contents of the bucket in the sink, then they set the bucket on the prep table beside the food processor. On 01/13/26 at 12:39 p.m., DA #1 was observed to wipe down a prep table with a rag from the sanitizing bucket. DA #1 was then observed handling food trays without washing their hands. On 01/13/26 12:45 p.m., cook #1 was observed to take a large sheet pan of burritos out of the oven using a sanitizing rag as a potholder. They were observed to prepare trays without washing hands. On 01/20/26, at 1:40 p.m., the DM stated the staff should have washed their hands and not had the sanitizing bucket or rag by the area where the food was prepared.

Based on record review and interview, the facility failed to complete criminal history background checks for 2 (LPN #1 and LPN #2) of 5 sampled employees reviewed for criminal history background checks. The administrator identified 80 residents resided in the facility. Findings: An undated Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, read in part, Screening: The facility will screen employees for a history of abuse, neglect or mistreating residents by attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.1.An undated and untitled employee list showed LPN #1 was hired on 10/08/24.A review of the employee file for LPN #1 showed no criminal history/background check results. 2. An undated and untitled employee list showed LPN #2 was hired on 06/25/25. A review of the employee file for LPN #2 showed no criminal history/background check results. On 01/14/26 at 12:34 p.m., the administrator stated they were told they did not have to do background checks on nurses. They stated the Oklahoma nursing board managed the licenses. The administrator stated if they had a valid license nurses were free to work in Oklahoma.

Based on observation, record review, and interview, the facility failed to date and change oxygen equipment as ordered by the physician for 1 (#55) of 1 sampled resident reviewed for oxygen use. The ADON identified five residents with orders for oxygen use. Findings: On 01/12/26 at 2:17 p.m., Resident #55 was observed lying in bed with their eyes closed. The resident had humidified oxygen in place per nasal cannula. Resident #55's nasal cannula was not dated. The humidifier bottle and storage bag taped to the oxygen machine showed was dated 11/26/25. On 01/13/26 at 10:25 a.m., Resident #55 was observed resting with their eyes closed. Resident #55 had a nasal cannula with humidified oxygen in place. The nasal cannula was not dated, and the humidifier bottle was dated 11/26/25. A storage bag was taped to the side of the oxygen machine and was dated 11/26/25. On 01/13/26 at 4:10 p.m., Resident #55 was observed lying in bed with oxygen per nasal cannula in place. The oxygen tubing was not dated and the humidifier bottle and a storage bag hanging from the oxygen machine was dated 11/26/25. An undated facility policy titled FOUNTAIN VIEW MANOR OXYGEN POLICY, read in part, OXYGEN TUBING IS TO BE CHANGED OUT AT LEAST MONTHLY OR AS NEEDED FOR INFECTION CONTROL. A physician order for Resident #55, dated 10/16/23, showed to replace oxygen tubing/humidifier monthly related to a diagnosis of acute respiratory failure. An annual assessment, dated 10/15/25, showed Resident #55 had a BIMS of 9, which indicated they were moderately impaired for daily decision making. The assessment showed the resident was not receiving oxygen therapy. The assessment showed diagnoses which included dependence on supplemental oxygen, acute upper respiratory infection, major depressive disorder, anxiety disorder, and need for assistance with personal care. A care plan, dated 01/13/26, showed Resident #55 had an activity intolerance related to a disease process. The care plan showed Resident #55 was administered oxygen continuously at 2 to 3 liters per minute by nasal cannula and concentrator. On 01/13/26 at 4:15 p.m., LPN #2 stated Resident #55 received oxygen at 4 liters per nasal cannula. LPN #2 stated the oxygen tubing was not dated and should be dated. LPN #2 stated the humidifier bottle and storage bag taped to the side of the oxygen machine was dated 11/26/25. LPN #2 stated the medication/treatment administration record would indicate when the humidifier bottle, oxygen tubing, and storage bag should be changed. LPN #2 stated they thought the order was to change everything once a week. On 01/14/26 at 1:39 p.m., the DON stated the oxygen tubing for Resident #55 should have been dated. The DON stated the humidifier bottle and storage bag should have been changed monthly per the physician orders and was not.

Based on record review and interview, the facility failed to ensure residents and/or representatives were offered the opportunity to create an advance directive for 2 (#9 and #18) of 18 sampled residents reviewed for advance directives.The DON identified 80 residents resided in the facility. Findings:1.An undated admission record showed Resident #9 admitted to the facility on [DATE].A review of electronic health records for Resident #9 showed no advance directive acknowledgment form in the record.2. An undated admission record showed Resident #18 admitted to the facility on [DATE].A review of electronic health records for Resident #18 showed no advance directive acknowledgment form in the record.On 01/14/26 at 11:33 a.m., social services #1 stated there were no advance directive acknowledgement forms in the residents' charts. Social Services #1 stated the form must have been left out of the admission packet when they made more copies.

Based on observation, record review, and interview, the facility failed to implement enhanced barrier precautions during wound care for 2 (#49 and #75) of 3 sampled residents reviewed for wound care.The administrator identified three residents with open wounds and three residents with urinary catheters for the use of enhanced barrier precautions. Findings: 1. On 01/14/26 at 9:05 a.m., LPN #3 was observed to provide wound care for Resident #49. LPN #3 gathered the supplies and entered the room of Resident #49. LPN #3 was observed to don a pair of gloves, but was not observed to don a gown. An undated facility policy titled Enhanced Barrier Precautions, read in part, PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Wound Care: any skin opening requiring a dressing. An annual assessment, dated 12/17/25, showed Resident #49 was severely impaired for daily decision making and had memory problems. The assessment showed the resident did not have pressure ulcers. The assessment showed Resident #49 had diagnoses which included dementia, depressive disorder, anxiety disorder, chronic pain, and disorder of the skin and subcutaneous tissue. A physician order, dated 01/02/26, showed to apply Betadine (antiseptic used to prevent and treat wounds) to Resident #49's right and left heels until resolved. The order showed to cleanse the right buttock with wound wash, pat dry, apply Santyl (a topical debriding agent) or Anasept (an antimicrobial agent to clean/debride), calcium alginate (a wound dressing), and cover with bordered gauze until resolved. 2. On 01/14/26 at 9:30 a.m., LPN #3 was observed to provide wound care for Resident #75. LPN #3 gathered supplies and entered the room of Resident #75. LPN #3 was observed to don a pair of gloves, but was not observed to don a gown. An annual assessment, dated 11/22/25, showed Resident #75 was not cognitively impaired with a BIMS 14. The assessment did not show Resident #75 had pressure ulcers. The assessment showed Resident #75 had diagnoses which included congestive heart failure, anxiety disorder, pain, and an open wound of the left buttock. A physician order for Resident #75, dated 01/12/26, showed to cleanse area to the left buttock, pat dry, and apply Medihoney (a wound medication) and calcium alginate to area. The physician order showed to cover the area with a bordered gauze once a day and as needed. On 01/14/26 at 9:37 a.m., LPN #3 stated protective personal equipment such as gowns and face shields were needed if the resident had hepatitis C or an active infection. LPN #3 stated only gloves were needed for wound care. On 01/14/26 at 9:40 a.m., the DON stated enhanced barrier precautions were used when a resident had an active infection.

Based on record review and interview, the facility failed to ensure assessments were accurate for antipsychotic medications for 1 (#18) of 18 sampled residents reviewed for resident assessments.The DON identified 80 residents resided in the facility. Findings:A physician order, dated 11/12/25, showed Resident #18's Olanzapine (an antipsychotic) was discontinued.A quarterly assessment, dated 11/25/25, showed Resident #18 had a BIMS score of 10 which showed the resident's cognition was moderately impaired for daily decision making. The assessment showed diagnoses which included dementia and depression. The assessment showed Resident #18 had received an antipsychotic medication daily during the seven day look back period.On 01/20/26 at 10:39 a.m., the DON stated the assessment was inaccurate.

Based on observation and interview, the facility failed to ensure posting staffing information contained the required components and was accessible to all residents. This had the potential to affect 73 of 73 residents. The administrator identified 73 residents who resided in the facility. Findings: On 04/22/24 at 8:55 a.m., posted staffing information was observed on a white board at the nursing station. The facility name and staffing hours were not documented. On 04/23/24 at 9:00 a.m., posted staffing information was observed on a white board at the nursing station. The facility name and staffing hours were not documented. On 04/24/24 at 1:30 p.m., there was no posted staffing information in the Alzheimer's unit. On 04/25/23 at 9:30 a.m., the DON reported there was no posted staffing information in the Alzheimer's unit and reported anyone wanting to know staffing information would have to go to the central nursing station outside of the unit. The DON reported they were not aware of the requirements for posted staffing information.

Based on observation and interview, the facility failed to ensure multidose vials were dated upon opening. The Administator reported 73 residents resided in the facility. Findings: On 04/25/24 at 10:08 a.m., the north hall medication refridgerator was observed and the following medications were found. 1 vial house stock Tuberculin Purified Protein was opened and not dated, 2 vials of multi use Influenza vaccine were opened and not dated. On 04/25/24 at 10:30 a.m., the ADON reported the bottles should have been dated when opened.

Based on record review and interview, the facilty failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 9 (CNA #1, 2 and #3, Dietary Aides #1 and #2, SS Assistant #1, Activity Assistant #1 and #2 and Housekeeper #1) of 65 employees hired between 2016 and 2024. The administrator identified 73 residents who resided in the facility. Findings: The Abuse, Neglect, and Exploitation Policy, undated, read in part, .Screening: It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include .criminal background checks .A criminal background check will be conducted on all prospective employees . The Employees roster, undated, documented the following: a. CNA #1 was hired on 02/15/24 b. CNA #2 was hired on 03/27/19 c. CNA #3 was hired on 03/08/17 d. Dietary Aide #1 was hired on 01/23/24 e. Dietary Aide #2 was hired on 09/27/23 f. SS Assistant #1 was hired on 11/22/22 g. Activity Assistant #1 was hired on 02/02/23 h. Activity Assistant #2 was hired on 03/02/23 i. Housekeeper #1 was hired on 11/01/16 The [Facility name] Employee Roster, dated 04/24/24, provided by OK Screen did not document CNA #1, 2 and #3, Dietary Aide #1 and #2, SS Assistant #1, Activity Assistant #1 and #2 and Housekeeper #1 as current eligible employees. On 04/24/24 at 8:30 a.m., the facility provided an OK Screen clearance letter for Activity Assistant #2, dated 04/24/24. The [Facility name] Employee Roster, dated 04/24/24, provided by OK Screen documented Activity Assistant #2 as being in process. On 04/24/24 at 09:40 a.m., OK Screen employees [names withheld] reported the clearance letter for Activity Assistant #2 was not sent by their agency. They reported Activity Assistant #2 had not been fingerprinted keeping OK Screen from being able to complete a criminal background check and issue a clearance letter on them. On 04/24/24 at 12:10, the administrator reported the HR manager responsible for criminal background checks was home sick, but had reported via phone they could not provide the email from OK Screen in which they got the clearance letter for Activity Assistance #2. The administrator reported the HR manager reported once they print off the clearance letters from OK Screen they immediately delete the OK Screen email. The HR Manager could not explain why there were no criminal background checks/clearance letters for CNA #1, 2 and #3, Dietary Aide #1 and #2, SS Assistant #1, Activity Assistant #1 and #2 and Housekeeper #1. The HR Manager reported the employees were in the OK Screen system at one time and did not know why they were not on the current roster. The administrator and the HR Manager reported the employees should have been on the current OK Screen roster and have criminal background checks/clearance letters in their employee files. On 04/25/24 at 11:05 p.m., the administrator reported the HR Manager reported they did not received any emails from OK Screen with clearance letters. The HR Manager reported they had to go into the OK Screen system and print of clearance letters.

Based on record review and interview, the facility failed to ensure accurate coding of MDS assessments: a. for diuretic use for one (#23) of 19 sampled residents; b. for falls for two (#10 and #23) of 19 sampled residents; c. for insulin use for one (#9) of 19 sampled residents; and d. for antipsychotic medication use for one (#17) of 19 sampled residents whose MDS assessments were reviewed. The administrator identified 73 residents who resided in the facility. Findings: 1. Res #23 had diagnoses which included chronic obstructive pulmonary disease, chronic pain, and anxiety. An admission MDS assessment, dated 04/04/24, documented Res #23 was cognitively intact, received a diuretic, and had two falls with no injury during the review period. No documentation of an order for a diuretic was observed in Res #23's medical record. The medical record documented one fall without injury during the review period. On 04/25/24 at 10:09 a.m., MDS coordinator #1 stated Res #23 had not received a diuretic. They stated the MDS assessment was coded in error. On 04/25/24 at 12:17 p.m., MDS coordinator #1 stated Res #23 had one fall during the review period. They stated the second fall was coded in error. 2. Res #10 had diagnoses which included cerebral infarction, thrombocytopenia, and chronic pain. An annual assessment, dated 11/14/23, documented the resident was severely cognitively impaired, required partial assistance with transfers, and had one fall with major injury. A quarterly assessment, dated 02/14/24, documented the resident was severely cognitively impaired, required partial assistance with transfers, and had one fall with major injury. No documentation of a fall with major injury was observed in Res #10's medical record during the review periods. On 04/25/24 at 10:42 a.m., MDS coordinator #1 stated Res #10 did not have a fall with major injury during the review periods of the MDS assessments. They stated the MDS was coded in error. 43023 3. Res #9 admitted to the facility with diagnoses of major depression, insomnia, low back pain, and pain in right hip. A quarterly MDS assessment, dated 03/26/24, documented the resident received insulin injections 7 of 7 days of the look back period. The resident's medication list was reviewed and contained no documentation the resident was receiving insulin injections. On 04/25/24 at 10:09 a.m., The DON reported the resient was no longer receiving insulin and the assessment was coded wrong. 4. Res #17 was admitted to the facility with diagnoses of Alzheimer's, hypertension, and nutritional deficiency. A significant change assessment, dated 03/27/24, documented the resident had taken an antipsychotic 7 of 7 days of the look back period. On 04/25/24 at 9:30 a.m., the resident's current medication list contained no documentation the resident was currently receiving and antipsychotic medication. On 04/25/24 at 10:09 a.m., the DON reported the resident was no longer receiving antipsychotic and the assessment was coded wrong.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for two (#51 and #57) of two residents reviewed for accident hazards. The DON identified four residents whose beds were equipped with a bed rail of any type. Findings: A bedrail policy, dated 2023, read in part, .The facility will ensure that the resident's bed is appropriate and that bed rails are correctly installed and maintained, following manufacturers' recommendations and specifications . 1. Res #51 had diagnoses which included urinary incontinence, chronic pain, and morbid obesity. A care plan, dated 04/09/24, documented Res #51 was at risk for self-care deficit related to disease process. The care plan documented use of left half rail to assist with turning. A quarterly assessment, dated 04/13/24, documented the resident was moderately cognitively impaired, and dependent with ADLs and transfers. On 04/22/24 at 9:21 a.m., Res #51 was observed lying in bed. A half bed rail was observed in the up position to the upper left side of the bed. Res #51 stated the rail was used to assist with turning. 2. Res #57 was admitted with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and vascular dementia. A quarterly assessment, dated 03/17/24, documented the resident was severely cognitively impaired, dependent with most ADLs, and required substantial assistance with transfers. A care plan, dated 03/18/24, documented the resident was at risk for falls related to hemiplegia. The care plan documented to reposition the resident every two to three hours per shift. The care plan had no documentation of bed rail use. On 04/22/24 at 8:36 a.m., Res #57 was observed lying supine in bed. A half bed rail was observed in the up position to the upper right side of the bed. Res #57 stated the rail was used to assist with turning. On 04/23/24 at 1:37 p.m., the DON was asked to provide documentation of regular bed rail inspections for Res #51 and Res #57. On 04/24/24 at 9:00 a.m., the administrator stated the maintenance man routinely checked bed rails but doubted they kept documentation of the inspections. On 04/25/24 at 12:37 p.m., the DON stated there was no documentation of regular bed rail inspections for Res #51 and Res #57.

Based on observation, record review, and interview, the facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side rails for two (#51 and #57) of two residents reviewed for accident hazards. The DON identified four residents whose beds were equipped with a bed rail of any type. Findings: A bedrail policy, dated 2023, read in part, .The facility will ensure that before installing bed rails, the facility has attempted to use alternatives. If the attempted alternatives were not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails, which will include a review of risks, including entrapment . 1. Res #51 had diagnoses which included urinary incontinence, chronic pain, and morbid obesity. A care plan, dated 04/09/24, documented Res #51 was at risk for self-care deficit related to disease process. The care plan documented use of left half rail to assist with turning. A quarterly assessment, dated 04/13/24, documented the resident was moderately cognitively impaired, and dependent with ADLs and transfers. There was no documentation of alternatives prior to the use of side rails, or an entrapment risk assessment found in the clinical record. On 04/22/24 at 9:21 a.m., Res #51 was observed lying in bed. A half bed rail was observed in the up position to the upper left side of the bed. Res #51 stated the rail was used to assist with turning. 2. Res #57 was admitted with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and vascular dementia. A quarterly assessment, dated 03/17/24, documented the resident was severely cognitively impaired, dependent with most ADLs, and required substantial assistance with transfers. A care plan, dated 03/18/24, documented the resident was at risk for falls related to hemiplegia. The care plan documented to reposition the resident every two to three hours per shift. The care plan had no documentation of bed rail use. There was no documentation of alternatives prior to the use of side rails, or an entrapment risk assessment found in the clinical record. On 04/22/24 at 8:36 a.m., Res #57 was observed lying supine in bed. A half bed rail was observed in the up position to the upper right side of the bed. Res #57 stated the rail was used to assist with turning. On 04/24/24 at 9:00 a.m., the administrator stated only half bed rails are allowed for residents who are cognitively able to use them for mobility in the facility. The administrator stated because the rails are not used as a restraint, they did not think all the elements documented in the bed rail policy had to be completed. On 04/25/24 at 12:37 p.m., the DON stated there was no documentation of attempting alternatives prior to the use of side rails. They stated an entrapment risk assessment was not completed on Res #51 or Res #57.

Based on record review and interview, the facility failed to ensure residents did not receive a psychotropic medication, unless for a specific diagnosis condition for one (#33) of five residents reviewed for unnecessary medications. The Administrator reported 73 residents resided in the facility. Findings: Res #33 admitted to the facility with diagnoses of dementia, sleep disorder, and hypertension. A physician order, dated 03/27/24, documented Olanzapine 5mg every evening for dementia. On 04/25/24 at 10:53 a.m., the DON reported dementia is no an appropriate diagnosis for Olanzapine and should be changed.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for one (#51) of one resident reviewed for bathing. The administrator identified 73 residents who resided in the facility. Findings: Res #51 had diagnoses which included urinary incontinence and morbid obesity. A significant change assessment, dated 01/12/24, documented the resident was moderately cognitively impaired and required substantial assistance with bathing. A care plan, dated 04/09/24, documented Res #51 was at risk for self care deficit related to disease process. The care plan documented the resident's ADL needs will be completed by staff daily. A facility shower schedule documented Res #51 was to receive a bath/shower on Tuesday, Thursday, and Saturday weekly. The February 2024 electronic bathing record documented Res #51 was bathed one out of thirteen opportunities. The record had no documentation of refusals. The March 2024 electronic bathing record documented Res #51 was bathed six out of twelve opportunities. The record documented one refusal. The April 2024 electronic bathing record documented Res #51 was bathed five out of ten opportunities. The record had no documentation of refusals. On 04/22/24 at 9:18 a.m., Res #51 was observed lying in bed. They stated they had not received showers regularly. Res #51 stated they often had to demand a shower from the staff in order to ensure they received assistance with bathing. On 04/24/24 at 11:08 a.m., CNA #5 stated all showers are given according to the shower schedule. They stated completed showers are documented in the bathing record. CNA #5 stated if a resident refused a shower, the refusal should be documented in the bathing record. On 04/25/24 at 9:20 a.m., corporate nurse consultant #1 stated the CNAs should have documented completed and/or refused showers in the electronic bathing record. They stated due to the lack of documentation, there was no way to know if Res #51 received the appropriate number of baths/showers. On 04/25/24 at 12:45 p.m., the DON stated all baths should have been documented as completed or refused.

Based on observation and interview, the facility failed to ensure residents right to personal privacy for one (#40) of one resident sampled for personal privacy. The DON reported 27 residents resided on the Alzheimer's unit. Findings: Res #40 admitted to the facility with diagnoses of hypertension, dementia, and thyroid disorder. On 04/22/24 at 9:36 a.m., resident #40 complained of wandering residents coming into their room. On 04/24/24 at 10:10 a.m., an observation of the Alzheimer's unit was conducted. Residents were observed going in and out of several rooms. An unknown resident was observed sleeping on a bed in an unoccupied room. No staff was observed providing supervision at this time. On 04/24/24 at 10:12 a.m., CNA #4 was observed entering the unit with a resident. CNA #4 reported she was giving the resident a shower. This surveyor asked how many staff were assigned to the unit. They reported them and another CNA who was performing care for a resident. The CNA #4 was asked if residents always wander in and out of other resident rooms. They reported they try to redirect them the best they can, but it doesn't always work. On 04/24/24 at 10:16 a.m., resident #40's roommate complained about residents coming into their room trying to take their tv and other belongings. They reported staff doesn't do anything about it. On 04/25/24 at 2:00 p.m., the administrator reported, it is the Alzheimer's unit and they wander, your not going to stop them. They reported the families are aware of this when the residents are admitted that is why they advise them not bring personal items of value.

Based on record review and interview, the facility failed to ensure routine oral care was provided for one (#1) of six residents reviewed for ADL care. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: Res #1 had diagnoses which included myocardial ischemia, dementia, and congestive heart failure. A care plan, dated 03/20/22 documented the resident was total care related to cognition, on hospice services, required total assistance with ADL care, and the facility staff were to coordinate care with hospice staff to maintain continuity of care. A quarterly assessment, dated 04/05/23, documented the resident was severely impaired with cognition, required total assistance with all ADLs, and received hospice services. Hospice Visit Note Reports dated 05/19/23, 05/22/23, and 05/24/23 documented the resident received mouth care. There was no hospice documentation available for the days of 05/20/23 and 05/21/23. Hospice Visit Note Reports dated 05/25/23 and 05/26/23, did not document that mouth care was performed for the resident. The facility ADL care documentation did not document any oral care from facility staff since 05/19/23. A nurse note, dated 05/27/23 at 5:45 p.m., documented Hospice Nurse #1 summoned a core staff nurse to the resident's room and presented a cup to the charge nurse with maggots in it. The hospice nurse informed the nurse the maggots were removed from the resident's mouth. An in-service document, dated 05/27/23, documented all nursing staff and all hospice staff contracted with the facility were educated on proper oral care for all residents in the facility. They were also educated on fly reduction efforts to be implemented to prevent flies from being in the facility and fans would be ordered and placed by the entrance and exit doors to reduce the amount of flies entering the facility. Education on tooth brushes being replaced, lemon glycerin swabs to be utilized for residents, each resident would have mouthwash available, and dental cups with denture cleaner available. A pest control receipt, dated 06/05/23, documented the facility was sprayed for insects and placed fly bait throughout of the facility. In-service documents, dated 06/07/23, documented all departments were educated on how to reduce flies and other pest in all resident rooms. The in-service focused on keeping the rooms cleaned from food or spilled liquids, linen changes, proper disposal of wound care supplies after use, hydration, and oral care for residents. On 06/08/23 at 3:30 p.m., an interview was conducted with the administrator. She stated she had already addressed the matter in their quality assurance meetings and provided documentation on what had been completed to prevent this from happening again. The administrator stated interventions had been completed on 06/07/23. On 06/08/23, an observation was made of fans in place at each entrance and exit of the facility. There were observations of sticky fly traps hanging from the ceiling throughout the facility. On 06/12/23 at 2:05 p.m., an interview was conducted with the administrator and she stated she has placed fans at entrance and exit doors, hung sticky fly traps around the facility, continued to have pest control monthly, and in-services had been conducted to reduce the flies that enter the building. On 06/13/23 at 1:18 p.m., the hospice care coordinator was asked about the care the resident had received. They stated the resident was receiving end of life care which was 24 hours a day, seven days a week. They stated mouth care should have been performed every day by hospice staff. On 06/13/23 at 2:55 p.m., an interview was conducted with the hospice aide and she stated oral care was performed usually every visit she made but the nurse did the last two visits and she did not know if oral care had been performed on Res #1.

Based on record review and interview, the facility failed to notify the resident's legal representative of a hospitalization for one (#2) of three sampled residents reviewed for notification of transfer/discharge. The Resident Census and Conditions of Residents documented 73 residents resided in the facility. Findings: Res #2 had diagnoses which included diabetes mellitus, pain, and history of UTI. A quarterly assessment, dated 02/14/23, documented the resident was moderately impaired with cognition and required total assistance with most ADLs. A durable POA form, dated 09/27/21, documented the resident's daughter was the POA. A hand written paper note was attached in the front of the resident's chart and documented to notify the POA at anytime, no matter what, and the POA's phone number was listed. A nurse note, dated 05/21/23 at 10:20 a.m., documented the resident was not feeling well and was in pain with a severe headache. The note documented Res #2 demanded to be sent out to the hospital. The note documented an order was obtained and proper paperwork filled out. The note documented EMS was called and administration, DON, and ADON were all notified. On 06/12/23 at 1:39 p.m., RN #1 reviewed the nurse note for 05/21/23 at 10:20 a.m., RN #1 stated the note did not documented the POA was notified of the resident being sent to the hospital. RN #1 stated the resident's daughter was the resident's POA. On 06/12/23 at 2:07 p.m., Res #2 was interviewed by telephone, Res #2 stated normally the facility notified her POA or family of changes, but on 05/21/23 no one was notified. Res #2 stated the POA called the facility on 05/22/23 and the administrator told the POA the resident was in the hospital.

Based on observation and interview, the facility failed to store, prepare, and serve food in a sanitary manner. The Resident Census and Conditions of Residents form documented 79 residents residing in the facility received their meals from the kitchen. Findings: On 03/06/23 from 9:20 a.m. through 10:15 a.m., the kitchen initial tour was conducted. The refrigerator in the back room contained a gallon and a quart sized bag of spinach which appeared discolored, brown, and soggy. The bags were not dated. An additional gallon sized bag of celery, dated 02/16/23 was appeared to be discolored, dark brown, and soggy. The refrigerator in the kitchen area was observed to have an undated large bag of shredded lettuce mix which appeared discolored and soggy. The refrigerator also held a large undated bag of bow tie noodles which appeared slimy. The kitchen area was observed to be dirty with trash, foil pieces, food, and wet with puddles of water noted on the floor in front of the stove and prep area. At that time, the DA and cook #1 disposed of the discolored, soggy, lettuce, spinach, and noodles. The cook stated the food was rotten. On 03/06/23 at 10:15 a.m., the kitchen floor was observed to have continued to be dirty with grease, trash, foil pieces, smashed food, and wet with puddles of water in front of the stove and prep area. On 03/06/23 at 2:01 p.m., the kitchen floor was observed to have the same food, trash, grease, and water puddles as before. On 03/07/23 at 11:48 a.m., the kitchen floor was observed to be dirty with trash, smashed food, and puddles of water. On 03/09/23 at 1:08 p.m., the kitchen floor was observed to be dirty with trash, smashed food, and puddles of water. On 03/09/23 between 11:18 a.m., and 12:44 p.m., meal preparation was observed. The following observations were made: Between 11:18 a.m. and 11:33 a.m., the water at the hand washing sink was left to run and remained cold. The kitchen floor was observed to be wet and dirty with puddles of water in front of the stoves and prep area. The floor was observed to have been littered with trash, sucker sticks, and food. At that time, cook #1 stated the garbage disposal was leaking and she had not had time to clean it up. The dishwasher dish basket was observed to have a dark brown substance covering the sides of the baskets. At that time the DM was asked how often the dishwashing baskets were cleaned, she stated she did not know. A cooking oil container with no lid on it was observed sitting on the floor. The cook was observed to pick up the oil container off the floor and place it on the prep station surface area. The cook was observed to wipe the prep area with a cloth she had used to wash dishes with rather than obtain a clean cloth with sanitizer solution. At that time, the cook stated she never used sanitizer when cleaning the prep station. The cook was then observed begin preparing pureed meals and did not wash her hands prior to starting the prep. The maintenance supervisor was observed to enter the kitchen for a straw or utensil without washing his hands. Cabbage was observed in the storage area and was observed to have been turning black. The refrigerator was observed to have raw hamburger meat stored on a shelf above vegetables. The ice machine was checked with a clean white cloth and a few specks of black substance was observed on the cloth. At that time the DM stated she did not know what the black substance was. She stated the ice machine was cleaned every six months. The DM was asked about the lack of hot water in the hand washing sink. The DM stated the tank did not provide hot water to the hand washing sink when the dishwasher was running. The cook was observed lighting the burners on the stove with a straw she had set on fire. At that time, the cook stated the igniter was broke and they were waiting for maintenance for repairs. The cook was observed to obtain temperatures of the meal and did not clean the thermometer prior to use. At that time, the cook stated she had never cleaned the thermometer prior to obtaining a temperature of the cooked food. The stove was observed to have a large, hard, black substance covering the side of the stove between the fryer and the stove. At that time, the cook stated the night shift was supposed to clean this area before they left for the day. She stated she also cleaned the area once a week. The cook was observed to start plating food without first washing her hands. DA #2 was observed using a small scoop to plate pureed cornbread into dishes. At that time, the DM stated he should have used a number two scoop which was larger.

Based on record review and interview, the facility failed to ensure completed resident assessments were transmitted to CMS within 14 days of completion for three (#29, 40, and #51) of three residents reviewed for resident assessments. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. An annual assessment for Res #29 had an ARD date of 02/18/23. On 03/09/23 at 9:30 a.m., the DON/MDS coordinator stated the MDS had been completed but not locked. She stated the MDS could not be transmitted if it was not locked. On 03/09/23 at 11:24 a.m., the EHR representative stated the survey team was unable to view the MDS dated [DATE] as it had just been submitted to CMS by the administrator. 2. A quarterly assessment for Res #51, dated 01/07/23, was unable to be viewed and had a question mark in the acceptance box of the EHR. A transmittal report, printed on 03/09/23, showed this assessment had been submitted more than 14 days from completion. 3. A quarterly assessment for Res #40, dated 01/07/23, was unable to be viewed. The transmittal reports, printed on 03/09/23, documented the last assessment submitted to CMS for Res #40 was the quarterly assessment dated [DATE]. On 03/09/23 at 1:00 p.m., the administrator stated she could not see the MDS assessments to submit them until the DON/MDS coordinator locked them. She confirmed she had submitted quite a few MDS assessments which had been late during that morning. On 03/10/23 at 4:33 p.m., the DON/MDS coordinator stated she went back through all of the MDS assessments the previous evening and found multiple MDS assessments which had not been locked and therefore had not been transmitted. She was asked at that time about Res #40's quarterly assessment, dated 01/07/23, and she confirmed it had not been transmitted to CMS yet.

On 08/16/16 at 6:20 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to prevent a burn injury to a resident. The facility failed to protect resident #4 from sustaining a coffee burn when hot coffee was spilled on the resident's lap. A facility incident report documented burns to the resident's thigh and scrotum were discovered by staff while bathing the resident. The report documented the resident's skin was very red and had blisters to the burned areas. The report documented the resident stated he was drinking coffee and spilled the coffee on his lap and scrotum. The report documented the accident occurred in the dining room. On 08/16/16 at 6:32 p.m., the director of nursing (DON) was informed of the IJ situation related to hot coffee which resulted in burns to the resident and the lack of preventative measures to prevent further coffee burns to this resident and/or other residents. The DON was informed the immediate jeopardy situation constituted substandard quality of care. The DON verbalized understanding. On 08/16/16 at 8:46 p.m., the DON provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: Fountain View Manor 08/16/16 All residents will have a hot liquid evaluation done by LPN by 9am 08/17/2016 All coffee pots will be put in the kitchen for staff to serve at this time until all evaluations are done to ensure safety for all residents! Inservice for resident safety with hot liquids has been done with understanding of risk for harm evaluation must be done yearly & new admissions. DON, ADON, RN will monitor this on all new admits from today & any significant change New hires will have policy and evaluation in their new hire packets for review Staff will supply all coffee given to the residents per individual evaluations as specified. On 08/17/16 at 9:45 a.m., the facility was informed the IJ was removed, effective 08/17/16 at 6:30 a.m., when all components of the plan of removal had been implemented including when the last staff member had been in-serviced and the staff had verbalized understanding of the in-service. The deficiency remained at the level of actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to prevent accident hazards for three (#4, #46, and #59) of three residents sampled for accidents. The facility failed to: a. monitor coffee temperatures and implement interventions to prevent coffee burns for resident #4. b. conduct smoking assessments for residents #46 and #59 to ensure resident safety while smoking. Findings: The facility did not provide a policy related to accident hazards. 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/11/16, documented the resident was moderately impaired with cognition. The assessment documented the resident required supervision and set-up assistance with eating and drinking. An incident report, dated 08/02/16 at 10:15 a.m., documented licensed practical nurse (LPN) #2 was called to the whirlpool room to look at the resident's right inner thigh and scrotum. The report documented the resident's skin was very red and had blisters to the area. The report documented the resident stated he had spilled hot coffee on his lap. The report documented the assistant director of nursing (ADON) was asked to look at the burns. The report documented the physician was notified and a new order was received to apply Silvadene twice a day until healed. The report documented the resident was instructed to fill his cup half full to decrease the risk of spills. A nursing note, dated 08/02/16 at 10:31 a.m., was documented by LPN #2. The note documented, was called to whirlpool room resident has a large red area on right inner thigh, and scrotum area with some blistering to right thigh, had ADON look at it, called (physician name deleted) and received order for Silvadene to the affected area BID til healed. A wound care specialist evaluation form, dated 08/08/16, documented an initial evaluation of resident #4. The form documented the physician examined the resident at the request of the primary care physician. The form documented the resident had a coffee burn wound of the right medial thigh of at least 3 days duration. The form documented the wound size to be 9.5 x 2 x 0.2 centimeters (cm). The form documented a plan for Silver Sulfadiazine, once daily, and a wound care specialist follow-up within seven days. A quarterly assessment, dated 08/10/16, documented the resident was moderately impaired with cognition. The assessment documented the resident required supervision and set-up assistance with eating and drinking. The assessment documented the resident had sustained a burn. The assessment documented the burn was a second or third degree. A care plan, updated 08/10/16, documented the resident had a potential for nutritional deficit related to a history of electrolyte imbalance. The care plan documented the resident had a fluid restriction but drank fluids freely. The care plan documented the resident was at risk for falls but could transfer independently using his wheelchair for mobility. The care plan documented the resident was to be supervised at all times related to dementia. The care plan documented safety concerns related to spilled coffee, resulting in burns with blistered areas to the resident's upper thigh. The care plan documented to assist and supervise the resident while up in public areas. The care plan documented the resident would be monitored and would be offered coffee as needed. A nursing note, dated 08/15/16 at 8:45 a.m., documented the resident was seen by the wound care physician. The note documented, burn to rt inner thigh 8x2, continue with Silvadene. On 08/16/16 at 11:37 a.m., licensed practical nurse (LPN) #1 reported the resident was being treated for [REDACTED]. The LPN reported someone had given the resident a cup of coffee and he spilled the coffee on his lap. The LPN reported the resident was known to exhibit some trembling or shaking at times. The LPN reported she normally gave residents a cup with a lid if she didn't think they could manage a regular cup. The LPN reported she also added cool water to their coffee if needed. On 08/16/16 at 4:03 p.m., the resident was observed to be lying on his bed in his room. The resident stated his burn was getting better. The resident reported he could get coffee when he wanted it. On 08/16/16 at 4:50 p.m., LPN #2 was observed to provide wound care to the burn on the resident's right inner thigh. The wound was cleansed and Silvadene was applied to the wound and surrounding area. The LPN reported there was no order to cover the wound with a dressing. The LPN reported the burn had initially covered much more of the resident's thigh and up to his scrotum. The LPN reported the wound had greatly improved and the area currently being treated was where the coffee had pooled when it spilled on the resident's lap. On 08/16/16 at 5:04 p.m., a cup of coffee was obtained from the coffee dispenser in the dining room. The coffee was carried from the dining room to the surveyor room. The coffee temperature was checked with a calibrated thermometer and found to be 150.0 degrees Fahrenheit (F) degrees F. On 08/16/16 at 5:13 p.m., the director of nursing (DON) was interviewed and reported the resident was capable of obtaining coffee from the self-serve dispenser. The DON reported the resident was not observed to drink coffee very often and typically preferred iced tea. The DON reported the resident had not sustained any other burns. On 08/16/16 at 5:33 p.m., the dietary manager (DM) reported the coffee maker and coffee dispensers did not contain visible thermostats. The DM reported the coffee dispenser was supposed to hold the temperature of the coffee at 155 degrees F. On 08/16/16 at 6:09 p.m., the resident was interviewed in his room. The resident reported he remembered spilling coffee on himself. The resident demonstrated how his hand jerked and caused the coffee to spill on his lap. The resident stated he told staff about the burn but could not remember who he spoke to. The resident stated, it hurt like the dickens. The resident reported he was in the dining room when the incident occurred. On 08/16/16 at 7:31 p.m., the DON was interviewed. The DON was asked what interventions had been put into place to protect all residents from coffee burns. The DON reported he had not researched what coffee temperatures should be. The DON reported no monitoring of coffee temperatures had been performed following the incident which resulted in a coffee burn. On 08/17/16 at 11:47 a.m., the resident was observed sitting in his wheelchair in the dining room. The resident was observed to be drinking from a container with a lid and straw. On 08/17/16 at 2:56 p.m., the resident was observed propelling himself per wheelchair in the hallway. The resident was observed to have a drink in a large open cup/mug sitting between his legs. A nursing note, dated 08/22/16 at 9:47 a.m., documented the resident was seen in the facility by the wound care physician. The note documented the burn to the right inner thigh 7x1.5 cm area dry with scab, continue with Silvadene. 2. Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 02/18/16, documented the resident's cognition was intact. The assessment documented the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident was not a current tobacco user. The care plan, dated 02/18/16, documented the resident smoked cigarettes and was now at a smoke free facility. The care plan documented to monitor the resident for safety needs. The care plan documented to encourage smoking cessation frequently. The care plan documented to maintain a safe environment. A quarterly review to the care plan, dated 05/19/16, documented the resident continued to smoke cigarettes and was able to self propel his wheelchair to and from the facility. The care plan documented the resident was aware of safety needs. The care plan documented to continue counseling per preferred staff. A care plan update, dated 08/01/16, documented the resident signed a contract related to being in a non smoking facility. The care plan documented to continue psych visits routinely, offer substitutes for smoking behavior, and consult for mental health counseling. A document to all residents, dated 08/01/16, documented it had been brought to the facility's attention that many residents were smoking across the street. The form documented the facility was nonsmoking. The form documented if a resident must smoke the facility would gladly find another facility to accommodate their needs. On 08/22/16 at 3:03 p.m., an unidentified staff member (for confidentiality) reported the facility had a lot of residents who were smokers. The staff member identified the resident as a smoker. The staff member reported the facility was supposed to be smoke free and smoking assessments were not completed on residents. The staff member reported the nonsmoking rule started three months ago but the facility just started enforcing it on 08/01/16. The staff member reported residents were smoking on the other side of the building the previous week. On 08/22/16 at 4:09 p.m., a second unidentified staff member (for confidentiality) reported having seen residents go outside to smoke. The staff member reported a resident had asked the staff member to accompany the resident outside to smoke and the staff member reported the resident had a cigarette on hand. On 08/23/16 at 1:22 p.m., a third unidentified staff member (for confidentiality) reported knowledge of three residents residing in the facility who were smokers. On 08/23/16 at 1:30 p.m., a fourth unidentified staff member (for confidentiality) reported knowledge of two residents who were smokers before 08/01/16. On 08/23/16 at 3:40 p.m., the resident was interviewed in his room. The resident was lying in bed. The resident stated when he came in he was not told it was a nonsmoking facility. The resident stated he kept his own cigarettes and lighter. The resident stated he had to smoke across the street. The resident stated staff knew he smoked. The resident stated when he was first admitted nobody asked if he smoked. The resident reported he got the information from the other residents. The resident reported he did not hide that he smoked from the facility. On 08/24/16 at 2:04 p.m., the director of nursing (DON) was interviewed. The DON stated residents signed a smoking contract when they were admitted to the facility. The DON reported the facility was a nonsmoking facility. The DON reported he was not aware there were any residents who smoked at any time. The DON reported the facility did not complete smoking assessments. 3. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 04/27/16, documented the resident was a fall risk. The care plan documented the resident smoked cigarettes and was now in a smoke free facility. The care plan documented to counsel family regarding not to leave the resident with cigarettes, lighters, etc. The care plan documented to encourage smoking cessation frequently. The care plan documented to remind the resident about the smoke free policy at this facility. A quarterly assessment, dated 07/20/16, documented the resident was moderately impaired with cognition. The assessment documented the resident was independent with bed mobility, transfers, and ambulation. The assessment documented the resident had impairment to both sides of the lower extremities. The care plan documented the resident signed a contract, dated 08/01/16, stating the resident was in a non smoking facility. On 08/22/16 at 10:29 a.m., an interview was conducted with the resident. The resident reported she walked down the street to smoke. The resident denied problems with smoking. The resident reported she kept her smoking materials in her room. On 08/22/16 at 10:52 a.m., an interview was conducted with the administrator regarding the facility's smoking assessments. The administrator reported smoking assessments were not conducted due to the fact the facility was a non smoking facility. On 08/22/16 at 3:25 p.m., an interview was conducted with an unidentified staff member (for confidentiality). The staff member reported the staff was aware the resident was a smoker. The staff member reported the resident had been seen several times walking up the block coming back from smoking. On 08/22/16 at 4:09 p.m., an interview was conducted with a second unidentified staff member. The staff member was asked if any residents living in the facility smoked. The staff member reported resident #46 smoked. The staff member reported the resident had asked the staff member to take her outside to smoke. The staff member reported it was the impression the resident needed someone to go out to smoke with her. The staff member reported the resident was taken outside to smoke on the bench. The staff member reported the resident kept her own cigarettes. On 08/23/16 at 9:31 a.m., an interview was conducted with the assistant director of nursing (ADON) regarding a smoking assessment on the resident. The ADON was asked if the resident had been assessed for safe smoking. The ADON reported the facility did not conduct smoking assessments due to the fact the facility is smoke free. The ADON reported the facility had been smoke-free for the last three years. On 08/24/16 at 2:00 p.m., the surveyors were presented with a signed document regarding the facility was smoke-free. The document was signed by the resident on 08/01/16.

On 07/06/16 at 5:30 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to assess, monitor, and intervene following resident to resident abuse. The facility failed to perform neurological checks, adequately assess the resident, and obtain treatment for [REDACTED]. A facility incident report documented resident #1 was punched in the face by resident #2. The report documented resident #1 was blowing a [MEDICATION NAME] and resident #2 had asked resident #1 to stop for greater than four hours. The report documented resident #2 got up, walked over to resident #1, and punched him in the face. The report documented resident #1 had a left black eye and denied pain. An emergency room (ER) report for resident #1 documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to another hospital. A discharge summary from the second hospital documented resident #1's discharge [DIAGNOSES REDACTED]. On 07/06/16 at 5:45 p.m., the Administrator (ADM) was informed of the IJ situation related to lack of assessment, monitoring, and intervention for a resident who sustained a head injury following resident to resident abuse. The ADM was informed the immediate jeopardy situation constituted substandard quality of care. The ADM verbalized understanding. On 07/06/16 at 8:15 p.m., the ADM provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: Fountain View Manor 07/6/2016 Plan of removal 1. In-service all staff ABUSE a. Investigating incident/accident each person is to make their own written report of the incident reports by each nurse and staff of shift it occurred on with complete documentation in the resident nurses notes of the assessment with all safety interventions in place. b. SUSPECTED OR ACTUAL abuse & neglect reporting to the LPN immediately then LPN IS REQUIRED TO NOTIFY DON, ADM, & PHYSICIAN. c. MDS coordinator, DON, and Adm. Will review any potential admit for aggression &/or histories for aggression or abuse with specified interventions in the care plan or admission denial due to inability to maintain safety. ASSESSMENT: 1. Complete & accurate documentation in the nurses notes of complete assessment and resident monitoring in the nurses notes. ADON & ADM will review each and every resident in the facility for hx of abuse or potential for abuse and document in resident records with care plans specific for interventions. 2. Neuro checks to be done on any head injury requiring 24hr monitoring and complete documentation in the resident record q 15 minutes x 1 hr q 30 minutes x1 hour then hourly there after x 24hr. 3. Any fall with any noted injury or any known trauma will require an ER visit for evaluation. Resident specific interventions: (Resident name deleted) had a history of [REDACTED]. not have any aggressive behavior towards anybody or immediate discharge will occur and legal actions taken counseling started effective today. 2. Resident able to voice that he would not touch another resident that he would report anything that he felt was annoying or would trigger anger to staff immediately. 3. Redirect resident when others are having behaviors of any type to try to prevent any type of trigger response. 4. Report any signs of abuse or potential for abuse to the LPN immediately they will be required to notify Adm & DON immediately after removing the immediate threat will a full assessment done on any person with injuries. On 07/07/16 at 1:30 p.m., the facility was informed the IJ was removed, effective 07/07/16 at 1:30 p.m., when all components of the plan of removal had been implemented including when the last staff member had been in-serviced and the staff had verbalized understanding of the in-service. The deficiency remained at the level of actual harm at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene for two (#1 and #5) of four residents sampled for assessment, monitoring, and intervention following an injury. The facility failed to send resident #1 out for treatment in a timely manner following the head injury. The facility failed to perform more than one neurological exam and monitor residents #1 and #5 following an accident with head injury. An emergency room (ER) report for resident #1 documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to another hospital. A discharge summary from the second hospital documented resident #1's discharge [DIAGNOSES REDACTED]. The facility reported there were 11 accidents with injuries in the past 90 days. Findings: The facility's policy on neurological examination documented the facility would perform a neurological examination or neuro check on any resident who received a head injury. The policy documented the charge nurse or certified medication aide (CMA) would assess the extent of the head injury, administer all necessary first aid, and then notify the director of nursing (DON). The policy documented the DON would be responsible for contacting or give authorization to contact the resident's physician if necessary. The policy documented the charge nurse or CMA would be responsible for initiating neuro checks. The policy documented the charge nurse or the CMA would assess the resident's temperature, pulse, respiration, and blood pressure once every 15 minutes for the first hour. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission evaluation, dated 06/21/16, documented the resident had left-sided weakness from a previous stroke. The evaluation documented the resident required one person assistance with transfers and ambulated per a wheelchair. The evaluation documented the resident required assistance with all activities of daily living. A nursing note, dated 06/21/16 at 4:15 p.m., documented the resident arrived to the facility at 2:00 p.m. The note documented a head to toe assessment was done and the resident was oriented to his room. A nursing note, dated 06/21/16 at 4:19 p.m., documented the resident had exhibited behaviors which included yelling, screaming at staff, and throwing things. A nursing note, dated 06/21/16 at 8:41 p.m., documented the resident had been on the call light most of the shift. The note documented the resident was observed to talk to someone that was not there. A nursing note, dated 06/22/16 at 6:08 p.m., documented the resident was found sitting on the floor in his room. The resident was observed to be sitting with his back against his wheelchair. The resident reported he was trying to walk on his own. The note documented the resident had an abrasion to his back. The note documented family, administration, and the physician were notified. There were no further nursing notes documented between 06/22/16 at 6:08 p.m. and 06/23/16 at 11:40 a.m. An incident report with a hand-written date of 06/22/16 at 6:09 a.m. documented certified nurse aide (CNA) #1 walked in to give resident #1 and and his roommate their breakfast trays. The CNA reported resident #1 told him he had been hit. The report documented the resident was punched in the face by his roommate. The report documented resident #1 was blowing a [MEDICATION NAME] and his roommate had asked him to stop for greater than four hours, so he got up walked over & punched him in the face. The report documented neuro's were within normal limits and the resident had mild bruising to the left eye with no pain or tenderness to palpation. A care plan, dated 06/23/16, documented the resident required frequent visual checks for needs at night, especially during HS, related to the resident having dementia and the possibility of not using the call light. A nurse note with an electronic date of 06/23/16 at 11:40 a.m. documented licensed practical nurse (LPN) #1 was passing morning medications when CNA #1 summoned the nurse to the resident's room. The note documented the resident was visualized to have redness to the left eye and what appeared to be blood around the nose. The note documented the resident reported he had been hit. There were no other nursing notes documented related to resident care between the hours of 11:40 a.m. and 9:06 p.m. on 06/23/16. A nurse note, dated 06/23/16 at 9:06 p.m., documented the resident was found on the floor in his room when an unidentified CNA was passing snacks. The resident reported he had slipped out of his wheelchair when he tried to get something. The note documented there was bruising and swelling to the resident's left side of face from the previous incident. The note documented the nurse showed the resident his call light and showed him how to use it properly. The note documented the CNAs were to be checking on the resident more frequently. A nurse note, dated 06/23/16 at 10:01 p.m., documented the resident was in his wheelchair and reported he was not ready to get into bed. The note documented the resident was seeing things that were not there and talking to people who were not present. A nurse note, dated 06/24/16 at 3:45 a.m., documented the resident was checked at 11:00 p.m., 12:00 a.m., 1:00 a.m., 2:00 a.m., and 3:00 a.m. There were no further nursing notes documented between the hours of 3:45 a.m. and 5:21 p.m. on 06/24/16. A nurse note, dated 06/24/16 at 5:21 p.m., documented the resident's family reported the resident needed medical attention. The note documented the resident's vital signs were normal and the resident denied pain. The note documented the resident's family called the emergency medical service (EMS). The note documented the resident was transported via EMS to the local hospital per the family's request. An emergency room (ER) report from Hillcrest Hospital Henryetta, dated 06/24/16, documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to St. John's ER. A discharge summary from St. John's Medical Center, dated 06/28/16, documented discharge [DIAGNOSES REDACTED]. The summary documented the resident had been seen and evaluated by ENT (otolaryngology or ear, nose and throat) and surgical intervention was required. The summary documented the resident would follow up with (physician name deleted) in 10-14 days following a course of antibiotics. The summary documented the resident had also been evaluated by Ophtho and NSG specialists during the hospital stay. The resident did not return to the facility following discharge from the hospital. On 07/05/16 at 3:40 p.m., the assistant director of nursing (ADON) was interviewed regarding the altercation between resident #1 and his roommate. The ADON reported she did not think neuro checks were started for resident #1 following the head injury but normally a neuro check would be done. The ADON reported she dealt with discharging the resident's roommate following the incident so she was not certain of what assessments or monitoring had been done. On 07/06/16 at 12:25 p.m., licensed practical nurse (LPN) #3 was interviewed. The LPN reported she did not know if neuro checks had been started on resident #1 following the head injury. The LPN reported any neuro checks, assessments, or frequent monitoring would be documented in the nurse notes. The LPN reported if frequent checking of a resident was being done by nurse aides, that information would also be documented in the nurse notes. On 07/06/16 at 1:25 p.m., the ADM was interviewed. The ADM reported LPN #1 had obtained one set of neuro checks, and only one, after speaking with the resident's physician. The ADM reported LPN #1 was the first nurse to see the resident following the altercation. The ADM reported the nightshift staff did not know anything about the incident. On 07/06/16 at 3:16 p.m., LPN #4 was interviewed. The LPN reported it was routine for her to monitor with neuro checks and vital signs following a head injury. The LPN reported neuro checks were normally obtained every 30 minutes for two hours. The LPN stated, If anything is going to happen, it will happen then. The LPN reported a physician's orders [REDACTED]. The LPN reported physician #1 normally ordered neuro checks every one hour for 24 hours. The LPN reported she wasn't sure if there was a written facility policy related to neuro checks. On 07/06/16 at 3:26 p.m., LPN #5 was interviewed. The LPN reported she normally obtained a neuro check with the initial assessment following an incident. The LPN reported she would then call the physician and get an order for [REDACTED]. On 07/06/16 at 4:13 p.m., physician #1 was interviewed regarding resident #1. The physician was asked if he was notified of the incident when resident #1 was punched in the face. The physician stated, no. The physician reported he did not recall seeing the resident during the resident's stay at the facility. The physician reported he remembered someone notified him when the resident was sent out to be checked. The physician was asked if the ADM had sent him a picture of the resident's face. The physician stated, no. On 07/06/16 at 4:47 p.m., the ADM was interviewed. The ADM was asked how often staff checked on residents during the night. The ADM reported staff went into resident rooms every two hours. The ADM stated the day shift was the first to report the altercation between residents #1 and his roommate. The ADM was questioned about notification of the physician regarding the injuries resident #1 sustained. The ADM reported she had texted the physician and sent a picture of the resident to the physician. The ADM stated the physician called her back and stated the resident looked fine. The ADM reported the resident's niece later requested the resident be reassessed. The resident was reassessed and the resident reported he was having increased pain. The ADM reported the family stated they would feel more comfortable if the resident was sent out to be checked in the ER. The ADM reported the physician was called and an order received to send the resident out. The ADM reported EMS came to the facility, assessed the resident, reported it was not an emergency situation, and left the facility. The ADM reported EMS was called back to the facility because the family wanted the resident sent out. The ADM reported the resident had said his pain level was a 2, the resident had not been complaining of pain, and there was no reason to be seen by a doctor. A nurse note, dated 07/06/16 at 5:26 p.m., documented a late entry from 06/24/16 at 1721. The note documented EMS came to the facility to assess the resident. The note documented EMS reported there was no medical emergency and left the facility. The note documented the resident's family insisted the resident be sent to the emergency room (ER). The note documented physician #1 was notified and a new order received to send the resident to the ER. The note documented EMS was notified and the resident was transported to the local ER. 2. Resident #5 was admitted with [DIAGNOSES REDACTED]. An annual assessment, dated 05/12/16, documented the resident was severely impaired with cognition. The assessment documented the resident had short-term and long-term memory problems. The assessment documented the resident required assistance with all activities of daily living. A care plan, updated 05/12/16, documented the resident was at risk for falls. The care plan documented staff would use a calm quiet approach with the resident. The care plan documented staff would listen to the resident and not argue with the resident. An incident reported, dated 06/12/16 at 6:45 p.m., documented the resident was found on the floor of the dining room. The report documented the resident was lying on his side with his arm under his head. The report documented the resident denied pain. The report documented the resident was assessed for a lump on his posterior scalp. The report documented, neuro checks normal. A nurse note, dated 06/12/16 at 8:47 p.m., documented the resident was found on the floor in the dining room at 6:45 p.m. The note documented the resident was assessed and neuro check done. The note documented the resident's family, physician, administrator, and director of nursing were notified. The note documented the resident would continue to be monitored. There were no further nurse notes until the following morning, 6/13/16 at 9:17 a.m., when the resident had a routine skin evaluation. On 07/07/16 at 12:57 p.m., the resident was observed in the dining room of the facility Alzheimer's unit. The resident had just finished eating lunch and was sitting in his wheelchair. On 07/07/16 at 1:05 p.m., licensed practical nurse (LPN) #2 was interviewed regarding assessment and monitoring of residents following an accident. The LPN reported a head-to-toe assessment was done following a fall or incident. The LPN reported a neuro check would always be done either with an unwitnessed accident or head injury. The LPN reported any follow-up monitoring after an incident would be documented in the nursing notes. The LPN reported this documentation would only be found in the nursing notes.

On 07/06/16 at 5:30 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to follow their abuse policy to prevent resident to resident abuse. The facility failed to protect resident #1 from abuse and failed to assess and identify the potential for abusive behavior for resident #2 with a known history of abuse. A facility incident report documented resident #1 was punched in the face by resident #2. The report documented resident #1 was blowing a [MEDICATION NAME] and resident #2 had asked resident #1 to stop for greater than four hours. The report documented resident #2 got up, walked over to resident #1, and punched him in the face. The report documented resident #1 had a left black eye and denied pain. The report documented resident #2 stated, I lost my temper after 4 hrs so I will face my punishment. An emergency room (ER) report for resident #1 documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to another hospital. A discharge summary from the second hospital documented resident #1's discharge [DIAGNOSES REDACTED]. On 07/06/16 at 5:45 p.m., the administrator (ADM) was informed of the IJ situation related to resident to resident abuse which involved a resident with a known history of abusive behavior. The ADM was informed the immediate jeopardy situation constituted substandard quality of care. The ADM verbalized understanding. On 07/06/16 at 8:15 p.m., the ADM provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: Fountain View Manor 07/6/2016 Plan of removal 1. In-service all staff ABUSE a. Investigating incident/accident each person is to make their own written report of the incident reports by each nurse and staff of shift it occurred on with complete documentation in the resident nurses notes of the assessment with all safety interventions in place. b. SUSPECTED OR ACTUAL abuse & neglect reporting to the LPN immediately then LPN IS REQUIRED TO NOTIFY DON, ADM, & PHYSICIAN. c. MDS coordinator, DON, and Adm. Will review any potential admit for aggression &/or histories for aggression or abuse with specified interventions in the care plan or admission denial due to inability to maintain safety. ASSESSMENT: 1. Complete & accurate documentation in the nurses notes of complete assessment and resident monitoring in the nurses notes. ADON & ADM will review each and every resident in the facility for hx of abuse or potential for abuse and document in resident records with care plans specific for interventions. 2. Neuro checks to be done on any head injury requiring 24hr monitoring and complete documentation in the resident record q 15 minutes x 1 hr q 30 minutes x1 hour then hourly there after x 24hr. 3. Any fall with any noted injury or any known trauma will require an ER visit for evaluation. Resident specific interventions: (Resident name deleted) had a history of [REDACTED]. not have any aggressive behavior towards anybody or immediate discharge will occur and legal actions taken counseling started effective today. 2. Resident able to voice that he would not touch another resident that he would report anything that he felt was annoying or would trigger anger to staff immediately. 3. Redirect resident when others are having behaviors of any type to try to prevent any type of trigger response. 4. Report any signs of abuse or potential for abuse to the LPN immediately they will be required to notify Adm & DON immediately after removing the immediate threat will a full assessment done on any person with injuries. On 07/07/16 at 1:30 p.m., the facility was informed the IJ was removed, effective 07/07/16 at 1:30 p.m., when all components of the plan of removal had been implemented including when the last staff member had been in-serviced and the staff had verbalized understanding of the in-service. The deficiency remained at the level of actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to implement policies and procedures to prevent resident to resident abuse for two (#1 and #2) of three residents sampled for abuse. An emergency room (ER) report for resident #1 documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to another hospital. A discharge summary from the second hospital documented resident #1's discharge [DIAGNOSES REDACTED]. The facility reported two abuse investigations had been conducted since the previous survey. Findings: The facility's policy on abuse documented the facility would maintain an environment free of abuse and neglect. The policy documented residents would not be subjected to abuse by anyone including, but not limited to, facility staff and other residents. The policy documented the facility would identify, correct, and intervene in situations in which abuse was more likely to occur. The policy documented a general analysis of the facility's risk for incidents would include: residents exhibiting needs and behaviors which would predispose them to have conflict with others (such as: residents with history of aggressive behaviors). 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission evaluation, dated 06/21/16, documented the resident had left-sided weakness from a previous stroke. The evaluation documented the resident required one person assistance with transfers and ambulated per a wheelchair. The evaluation documented the resident required assistance with all activities of daily living. A nursing note, dated 06/21/16 at 4:15 p.m., documented the resident arrived to the facility at 2:00 p.m The note documented a head to toe assessment was done and the resident was oriented to his room. A nursing note, dated 06/21/16 at 4:19 p.m., documented the resident had exhibited behaviors which included yelling, screaming at staff, and throwing things. A nursing note, dated 06/21/16 at 8:41 p.m., documented the resident had been on the call light most of the shift. The note documented the resident was observed to talk to someone that was not there. A nursing note, dated 06/22/16 at 6:08 p.m., documented the resident was found sitting on the floor in his room. The resident was observed to be sitting with his back against his wheelchair. The resident reported he was trying to walk on his own. The note documented the resident had an abrasion to his back. The note documented family, administration, and the physician were notified. There were no further nursing notes documented between 06/22/16 at 6:08 p.m. and 06/23/16 at 11:40 a.m. An incident report with a hand-written date of 06/22/16 at 6:09 a.m. documented certified nurse aide (CNA) #1 walked in to give resident #1 and resident #2 their breakfast trays. The CNA reported resident #1 told him he had been hit. The report documented the resident was punched in the face by resident #2. The report documented resident #1 was blowing a [MEDICATION NAME] and resident #2 had asked resident #1 to stop for greater than four hours, so he got up walked over & punched him in the face. The report documented resident #1 had a left black eye and denied pain. The report documented resident #2 stated, I lost my temper after 4 hrs so I will face my punishment. A care plan, dated 06/23/16, documented the resident required frequent visual checks for needs at night, especially during HS, related to the resident having dementia and the possibility of not using the call light. A nurse note with an electronic date of 06/23/16 at 11:40 a.m. documented licensed practical nurse (LPN) #1 was passing morning medications when CNA #1 summoned the nurse to the resident's room. The note documented the resident was visualized to have redness to the left eye and what appeared to be blood around the nose. The note documented the resident reported he had been hit. The note documented a police report had been filed against resident #2. There were no other nursing notes documented related to resident care between the hours of 11:40 a.m. and 9:06 p.m. on 06/23/16. A nurse note, dated 06/23/16 at 9:06 p.m., documented the resident was found on the floor in his room when an unidentified CNA was passing snacks. The resident reported he had slipped out of his wheelchair when he tried to get something. The note documented there was bruising and swelling to the resident's left side of face from the previous incident. The note documented the nurse showed the resident his call light and showed him how to use it properly. The note documented the CNAs were to be checking on the resident more frequently. A nurse note, dated 06/23/16 at 10:01 p.m., documented the resident was in his wheelchair and reported he was not ready to get into bed. The note documented the resident was seeing things that were not there and talking to people who were not present. A nurse note, dated 06/24/16 at 3:45 a.m., documented the resident was checked at 11:00 p.m., 12:00 a.m., 1:00 a.m., 2:00 a.m., and 3:00 a.m. There were no other nursing notes documented between the hours of 3:45 a.m. and 5:21 p.m. on 06/24/16. A nurse note, dated 06/24/16 at 5:21 p.m., documented the resident's family reported the resident needed medical attention. The note documented the resident's vital signs were normal and the resident denied pain. The note documented the resident's family called the emergency medical service (EMS). The note documented the resident was transported via EMS to the local hospital per the family's request. An emergency room (ER) report from Hillcrest Hospital Henryetta, dated 06/24/16, documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to St. John's ER. A discharge summary from St. John's Medical Center, dated 06/28/16, documented discharge [DIAGNOSES REDACTED]. The summary documented the resident had been seen and evaluated by ENT (otolaryngology or ear, nose and throat) and surgical intervention was required. The summary documented the resident would follow up with (physician name deleted) in 10-14 days following a course of antibiotics. The summary documented the resident had also been evaluated by Ophtho and NSG specialists during the hospital stay. The resident did not return to the facility following discharge from the hospital. On 07/06/16 at 4:13 p.m., physician #1 was interviewed regarding resident #1. The physician was asked if he was notified of the incident when resident #1 was punched in the face. The physician stated, no. The physician reported he did not recall seeing the resident during the resident's stay at the facility. The physician reported he remembered someone notified him when the resident was sent out to be checked. The physician was asked if the ADM had sent him a picture of the resident's face. The physician stated, no. A nurse note, dated 07/06/16 at 5:26 p.m., documented a late entry from 06/24/16 at 5:21 p.m The note documented EMS came to the facility to assess the resident. The note documented EMS reported there was no medical emergency and left the facility. The note documented the resident's family insisted the resident be sent to the emergency room (ER). The note documented physician #1 was notified and a new order received to send the resident to the ER. The note documented EMS was notified and the resident was transported to the local ER. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A discharge summary from Hillcrest Hospital Henryetta Senior Focus, dated 03/09/16, documented the resident was admitted from another nursing home due to increased agitation and violence toward a female resident. The summary documented the resident stated the female resident hit him first so he hit her back. The summary documented police were called and it was a very disruptive and disturbing situation. The summary documented the other nursing home reported the resident had increased irritability and agitation that had increased over the last several weeks. A care plan, dated 03/10/16, documented the resident had a history of [REDACTED]. The care plan documented to always use a quiet, calm approach. An admission assessment, dated 03/22/16, documented the resident was cognitively intact. The assessment documented the resident exhibited no behaviors. The assessment documented the resident required minimal assistance with some activities of daily living. A quarterly assessment, dated 06/21/16, documented the resident was cognitively intact. The assessment documented the resident had exhibited no behaviors. The assessment documented the resident required minimal assistance with some activities of daily living. A nurse note, dated 06/23/16 at 10:01 a.m., documented the resident had become upset with his roommate, resident #1. The note documented the resident became upset when his roommate continued to make noise during the night. The note documented the resident became angry and punched his roommate in the face, giving him a black eye and bloody nose. The note documented the physician was notified. The note documented Senior Focus was notified and accepted the resident. The note documented the resident was sent to Henryetta Medical Center (HMC) Sr. Focus, transported via staff. A nurse note, dated 06/23/16 at 11:26 a.m., documented a late entry from 06/23/16 at 8:15 a.m. by licensed practical nurse (LPN) #1. The note documented the LPN was summoned to the administrator's (ADM) office and found resident #2 with the director of nursing (DON) and the ADM. The note documented the resident stated, Yes I am the one who hit my room mate and I just couldn't take it anymore. He was blowing that [MEDICATION NAME] thing and he wouldn't stop so I popped him right in the face. The note documented the resident was made aware he would have to go to Senior Focus for evaluation. A discharge instruction sheet from Hillcrest Senior Focus, dated 06/29/16, documented a discharge [DIAGNOSES REDACTED]. The instruction sheet did not document new orders for resident #2. On 07/05/16 at 11:31 a.m., resident #2 was interviewed in the facility's sun room. The resident reported he had an altercation with his roommate. The resident stated his roommate would not stop blowing on his horn so he hit him. On 07/05/16 at 11:42 a.m., the ombudsman was interviewed in the facility. The ombudsman reported he had come to the facility following the incident between residents #1 and #2. The ombudsman reported he had planned to speak with resident #1 but he had already been discharged . The ombudsman reported he did not know of any other incidents involving resident #2. On 07/05/16 at 3:40 p.m., the assistant director of nursing (ADON) was interviewed regarding the altercation between residents #1 and #2. The ADON reported resident #2 told her resident #1 would not stop tooting his horn. The ADON reported resident #2 told her he knew he shouldn't have hit resident #1 but he couldn't stand it any longer. The ADON reported this was resident #2's first outburst since coming to the facility from Senior Focus. The ADON reported she did not know of any other residents who might agitate resident #2. The ADON reported resident #2 did not currently have a roommate and staff would be very cautious in placing another resident with him. The ADON reported Senior Focus had informed the facility resident #2 had exhibited verbal outbursts but never anything physical while he was there. On 07/06/16 at 1:02 p.m., CNA #1 was interviewed regarding the altercation between residents #1 and #2. The CNA reported he went into the resident's room and observed resident #1 with blood on his face and a puffy eye. The CNA reported he immediately went to get LPN #1. The CNA reported resident #1 told him he got hit at 3:00 or 4:00 in the morning. The CNA reported he understood resident #1 woke up resident #2 by blowing on a straw. The CNA reported resident #2 hit resident #1. The CNA reported resident #1 had a history of [REDACTED]. The CNA reported he and other aides were told to keep a closer eye on resident #1 and resident #2 was sent out to Senior Focus. On 07/06/16 at 1:25 p.m., RN #1 was interviewed regarding the care plan for resident #2. The RN reported the resident had never been aggressive until the incident with resident #1. The RN reported she had not updated resident #2's care plan since he had returned to the facility from Senior Focus. The RN was informed the care plan documented a history of aggressive behavior and was asked where she had obtained that information. The RN stated she assumed it was in the resident's admission paperwork but she would need to look. On 07/06/16 at 2:00 p.m., a psychiatric evaluation, dated 02/24/16, was provided by RN #1. The evaluation documented the resident had been sent to the Hillcrest Henryetta Senior Focus program from another nursing home. The evaluation documented the resident had experienced increased agitation. The evaluation documented the resident had hit a resident who was sitting in a Geri chair. The evaluation documented the resident reported he was trying to help a resident who hit him and then he hit the resident back. On 07/06/16 at 2:20 p.m., RN #1 was interviewed regarding the psychiatric evaluation for resident #2 which documented the aggressive behavior exhibited by the resident at a previous nursing home. The RN reported the ADM normally sees all of the intake documentation for new admissions. The RN reported she did not know if the form came in with the resident or if it was received at a later date. The RN stated the facility normally received a verbal report by telephone for admissions coming from Senior Focus or the hospital. The RN stated she either saw the psychiatric evaluation when the resident was admitted or she was told by someone of the resident's previous aggressive behavior. On 07/06/16 at 4:20 p.m., the ADM was interviewed regarding the altercation between residents #1 and #2. The ADM reported she had no knowledge resident #2 had ever been aggressive prior to coming to the facility. The ADM reported the history and physical paperwork came later after resident #2 was admitted . The ADM reported resident #2 had exhibited no behaviors since admission. The ADM stated Senior Focus had reported the resident had shown no signs of aggression. On 07/06/16 at 4:47 p.m., the interview with the ADM was resumed. The ADM was asked how often staff checked on residents during the night. The ADM reported staff went into resident rooms every two hours. The ADM stated the day shift was the first to report the altercation between residents #1 and #2. The ADM was questioned about notification of the physician regarding the injuries resident #1 sustained. The ADM reported she had texted the physician and sent a picture of the resident to the physician. The ADM stated the physician called her back and stated the resident looked fine. The ADM reported the resident's niece later requested the resident be reassessed. The resident was reassessed and the resident reported he was having increased pain. The ADM reported the family stated they would feel more comfortable if the resident was sent out to be checked in the ER. The ADM reported the physician was called and an order received to send the resident out. The ADM reported EMS came to the facility, assessed the resident, reported it was not an emergency situation, and left the facility. The ADM reported EMS was called back to the facility because the family wanted the resident sent out. The ADM reported the resident had said his pain level was a 2, the resident had not been complaining of pain, and there was no reason to be seen by a doctor.

On 07/06/16 at 5:30 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to prevent resident to resident abuse. The facility failed to protect resident #1 from abuse and failed to assess and identify the potential for abusive behavior for resident #2 with a known history of abuse. A facility incident report documented resident #1 was punched in the face by resident #2. The report documented resident #1 was blowing a [MEDICATION NAME] and resident #2 had asked resident #1 to stop for greater than four hours. The report documented resident #2 got up, walked over to resident #1, and punched him in the face. The report documented resident #1 had a left black eye and denied pain. The report documented resident #2 stated, I lost my temper after 4 hrs so I will face my punishment. An emergency room (ER) report for resident #1 documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to another hospital. A discharge summary from the second hospital documented resident #1's discharge [DIAGNOSES REDACTED]. On 07/06/16 at 5:45 p.m., the administrator (ADM) was informed of the IJ situation related to resident to resident abuse which involved a resident with a known history of abusive behavior. The ADM was informed the immediate jeopardy situation constituted substandard quality of care. The ADM verbalized understanding. On 07/06/16 at 8:15 p.m., the ADM provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: Fountain View Manor 07/6/2016 Plan of removal 1. In-service all staff ABUSE a. Investigating incident/accident each person is to make their own written report of the incident reports by each nurse and staff of shift it occurred on with complete documentation in the resident nurses notes of the assessment with all safety interventions in place. b. SUSPECTED OR ACTUAL abuse & neglect reporting to the LPN immediately then LPN IS REQUIRED TO NOTIFY DON, ADM, & PHYSICIAN. c. MDS coordinator, DON, and Adm. Will review any potential admit for aggression &/or histories for aggression or abuse with specified interventions in the care plan or admission denial due to inability to maintain safety. ASSESSMENT: 1. Complete & accurate documentation in the nurses notes of complete assessment and resident monitoring in the nurses notes. ADON & ADM will review each and every resident in the facility for hx of abuse or potential for abuse and document in resident records with care plans specific for interventions. 2. Neuro checks to be done on any head injury requiring 24hr monitoring and complete documentation in the resident record q 15 minutes x 1 hr q 30 minutes x1 hour then hourly there after x 24hr. 3. Any fall with any noted injury or any known trauma will require an ER visit for evaluation. Resident specific interventions: (Resident name deleted) had a history of [REDACTED]. not have any aggressive behavior towards anybody or immediate discharge will occur and legal actions taken counseling started effective today. 2. Resident able to voice that he would not touch another resident that he would report anything that he felt was annoying or would trigger anger to staff immediately. 3. Redirect resident when others are having behaviors of any type to try to prevent any type of trigger response. 4. Report any signs of abuse or potential for abuse to the LPN immediately they will be required to notify Adm & DON immediately after removing the immediate threat will a full assessment done on any person with injuries. On 07/07/16 at 1:30 p.m., the facility was informed the IJ was removed, effective 07/07/16 at 1:30 p.m., when all components of the plan of removal had been implemented including when the last staff member had been in-serviced and the staff had verbalized understanding of the in-service. The deficiency remained at the level of actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to prevent resident to resident abuse for two (#1 and #2) of three residents sampled for abuse. An emergency room (ER) report for resident #1 documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to another hospital. A discharge summary from the second hospital documented resident #1's discharge [DIAGNOSES REDACTED]. The facility reported two abuse investigations had been conducted since the previous survey. Findings: The facility's policy on abuse documented the facility would maintain an environment free of abuse and neglect. The policy documented residents would not be subjected to abuse by anyone including, but not limited to, facility staff and other residents. The policy documented the facility would identify, correct, and intervene in situations in which abuse was more likely to occur. The policy documented a general analysis of the facility's risk for incidents would include: residents exhibiting needs and behaviors which would predispose them to have conflict with others (such as: residents with history of aggressive behaviors). 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission evaluation, dated 06/21/16, documented the resident had left-sided weakness from a previous stroke. The evaluation documented the resident required one person assistance with transfers and ambulated per a wheelchair. The evaluation documented the resident required assistance with all activities of daily living. A nursing note, dated 06/21/16 at 4:15 p.m., documented the resident arrived to the facility at 2:00 p.m. The note documented a head to toe assessment was done and the resident was oriented to his room. A nursing note, dated 06/21/16 at 4:19 p.m., documented the resident had exhibited behaviors which included yelling, screaming at staff, and throwing things. A nursing note, dated 06/21/16 at 8:41 p.m., documented the resident had been on the call light most of the shift. The note documented the resident was observed to talk to someone that was not there. A nursing note, dated 06/22/16 at 6:08 p.m., documented the resident was found sitting on the floor in his room. The resident was observed to be sitting with his back against his wheelchair. The resident reported he was trying to walk on his own. The note documented the resident had an abrasion to his back. The note documented family, administration, and the physician were notified. There were no further nursing notes documented between 06/22/16 at 6:08 p.m. and 06/23/16 at 11:40 a.m. An incident report with a hand-written date of 06/22/16 at 6:09 a.m. documented certified nurse aide (CNA) #1 walked in to give resident #1 and resident #2 their breakfast trays. The CNA reported resident #1 told him he had been hit. The report documented the resident was punched in the face by resident #2. The report documented resident #1 was blowing a [MEDICATION NAME] and resident #2 had asked resident #1 to stop for greater than four hours. The report documented resident #2 got up, walked over to resident #1, and punched him in the face. The report documented resident #1 had a left black eye and denied pain. The report documented resident #2 stated, I lost my temper after 4 hrs so I will face my punishment. A care plan, dated 06/23/16, documented the resident required frequent visual checks for needs at night, especially during HS, related to the resident having dementia and the possibility of not using the call light. A nurse note with an electronic date of 06/23/16 at 11:40 a.m. documented licensed practical nurse (LPN) #1 was passing morning medications when CNA #1 summoned the nurse to the resident's room. The note documented the resident was visualized to have redness to the left eye and what appeared to be blood around the nose. The note documented the resident reported he had been hit. The note documented a police report had been filed against resident #2. There were no other nursing notes documented related to resident care between the hours of 11:40 a.m. and 9:06 p.m. on 06/23/16. A nurse note, dated 06/23/16 at 9:06 p.m., documented the resident was found on the floor in his room when an unidentified CNA was passing snacks. The resident reported he had slipped out of his wheelchair when he tried to get something. The note documented there was bruising and swelling to the resident's left side of face from the previous incident. The note documented the nurse showed the resident his call light and showed him how to use it properly. The note documented the CNAs were to be checking on the resident more frequently. A nurse note, dated 06/23/16 at 10:01 p.m., documented the resident was in his wheelchair and reported he was not ready to get into bed. The note documented the resident was seeing things that were not there and talking to people who were not present. A nurse note, dated 06/24/16 at 3:45 a.m., documented the resident was checked at 11:00 p.m., 12:00 a.m., 1:00 a.m., 2:00 a.m., and 3:00 a.m. There were no other nursing notes documented between the hours of 3:45 a.m. and 5:21 p.m. on 06/24/16. A nurse note, dated 06/24/16 at 5:21 p.m., documented the resident's family reported the resident needed medical attention. The note documented the resident's vital signs were normal and the resident denied pain. The note documented the resident's family called the emergency medical service (EMS). The note documented the resident was transported via EMS to the local hospital per the family's request. An emergency room (ER) report from Hillcrest Hospital Henryetta, dated 06/24/16, documented a [DIAGNOSES REDACTED]. The report documented the resident's condition at discharge was serious. The report documented the resident was transferred to St. John's ER. A discharge summary from St. John's Medical Center, dated 06/28/16, documented discharge [DIAGNOSES REDACTED]. The summary documented the resident had been seen and evaluated by ENT (otolaryngology or ear, nose and throat) and surgical intervention was required. The summary documented the resident would follow up with (physician name deleted) in 10-14 days following a course of antibiotics. The summary documented the resident had also been evaluated by Ophtho and NSG specialists during the hospital stay. The resident did not return to the facility following discharge from the hospital. On 07/06/16 at 4:13 p.m., physician #1 was interviewed regarding resident #1. The physician was asked if he was notified of the incident when resident #1 was punched in the face. The physician stated, no. The physician reported he did not recall seeing the resident during the resident's stay at the facility. The physician reported he remembered someone notified him when the resident was sent out to be checked. The physician was asked if the ADM had sent him a picture of the resident's face. The physician stated, no. A nurse note, dated 07/06/16 at 5:26 p.m., documented a late entry from 06/24/16 at 1721. The note documented EMS came to the facility to assess the resident. The note documented EMS reported there was no medical emergency and left the facility. The note documented the resident's family insisted the resident be sent to the emergency room (ER). The note documented physician #1 was notified and a new order received to send the resident to the ER. The note documented EMS was notified and the resident was transported to the local ER. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A discharge summary from Hillcrest Hospital Henryetta Senior Focus, dated 03/09/16, documented the resident was admitted from another nursing home due to increased agitation and violence toward a female resident. The summary documented the resident stated the female resident hit him first so he hit her back. The summary documented police were called and it was a very disruptive and disturbing situation. The summary documented the other nursing home reported the resident had increased irritability and agitation that had increased over the last several weeks. A care plan, dated 03/10/16, documented the resident had a history of [REDACTED]. The care plan documented to always use a quiet, calm approach. An admission assessment, dated 03/22/16, documented the resident was cognitively intact. The assessment documented the resident exhibited no behaviors. The assessment documented the resident required minimal assistance with some activities of daily living. A quarterly assessment, dated 06/21/16, documented the resident was cognitively intact. The assessment documented the resident had exhibited no behaviors. The assessment documented the resident required minimal assistance with some activities of daily living. A nurse note, dated 06/23/16 at 10:01 a.m., documented the resident had become upset with his roommate, resident #1. The note documented the resident became upset when his roommate continued to make noise during the night. The note documented the resident became angry and punched his roommate in the face, giving him a black eye and bloody nose. The note documented the physician was notified. The note documented Senior Focus was notified and accepted the resident. The note documented the resident was sent to Henryetta Medical Center (HMC) Sr. Focus, transported via staff. A nurse note, dated 06/23/16 at 11:26 a.m., documented a late entry from 06/23/16 at 8:15 a.m. by licensed practical nurse (LPN) #1. The note documented the LPN was summoned to the administrator's (ADM) office and found resident #2 with the director of nursing (DON) and the ADM. The note documented the resident stated, Yes I am the one who hit my room mate and I just couldn't take it anymore. He was blowing that [MEDICATION NAME] thing and he wouldn't stop so I popped him right in the face. The note documented the resident was made aware he would have to go to Senior Focus for evaluation. A discharge instruction sheet from Hillcrest Senior Focus, dated 06/29/16, documented a discharge [DIAGNOSES REDACTED]. The instruction sheet did not document new orders for resident #2. On 07/05/16 at 11:31 a.m., resident #2 was interviewed in the facility's sun room. The resident reported he had an altercation with his roommate. The resident stated his roommate would not stop blowing on his horn so he hit him. On 07/05/16 at 11:42 a.m., the ombudsman was interviewed in the facility. The ombudsman reported he had come to the facility following the incident between residents #1 and #2. The ombudsman reported he had planned to speak with resident #1 but he had already been discharged . The ombudsman reported he did not know of any other incidents involving resident #2. On 07/05/16 at 3:40 p.m., the assistant director of nursing (ADON) was interviewed regarding the altercation between residents #1 and #2. The ADON reported resident #2 told her resident #1 would not stop tooting his horn. The ADON reported resident #2 told her he knew he shouldn't have hit resident #1 but he couldn't stand it any longer. The ADON reported this was resident #2's first outburst since coming to the facility from Senior Focus. The ADON reported she did not know of any other residents who might agitate resident #2. The ADON reported resident #2 did not currently have a roommate and staff would be very cautious in placing another resident with him. The ADON reported Senior Focus had informed the facility resident #2 had exhibited verbal outbursts but never anything physical while he was there. On 07/06/16 at 1:02 p.m., CNA #1 was interviewed regarding the altercation between residents #1 and #2. The CNA reported he went into the resident's room and observed resident #1 with blood on his face and a puffy eye. The CNA reported he immediately went to get LPN #1. The CNA reported resident #1 told him he got hit at 3:00 or 4:00 in the morning. The CNA reported he understood resident #1 woke up resident #2 by blowing on a straw. The CNA reported resident #2 hit resident #1. The CNA reported resident #1 had a history of [REDACTED]. The CNA reported he and other aides were told to keep a closer eye on resident #1 and resident #2 was sent out to Senior Focus. On 07/06/16 at 1:25 p.m., registered nurse (RN) #1 was interviewed regarding the care plan for resident #2. The RN reported the resident had never been aggressive until the incident with resident #1. The RN reported she had not updated resident #2's care plan since he had returned to the facility from Senior Focus. The RN was informed the care plan documented a history of aggressive behavior and was asked where she had obtained that information. The RN stated she assumed it was in the resident's admission paperwork but she would need to look. On 07/06/16 at 2:00 p.m., a psychiatric evaluation, dated 02/24/16, was provided by RN #1. The evaluation documented the resident had been sent to the Hillcrest Henryetta Senior Focus program from another nursing home. The evaluation documented the resident had experienced increased agitation. The evaluation documented the resident had hit a resident who was sitting in a Geri chair. The evaluation documented the resident reported he was trying to help a resident who hit him and then he hit the resident back. On 07/06/16 at 2:20 p.m., RN #1 was interviewed regarding the psychiatric evaluation for resident #2 which documented the aggressive behavior exhibited by the resident at a previous nursing home. The RN reported the ADM normally sees all of the intake documentation for new admissions. The RN reported she did not know if the form came in with the resident or if it was received at a later date. The RN stated the facility normally received a verbal report by telephone for admissions coming from Senior Focus or the hospital. The RN stated she either saw the psychiatric evaluation when the resident was admitted or she was told by someone of the resident's previous aggressive behavior. On 07/06/16 at 4:20 p.m., the ADM was interviewed regarding the altercation between residents #1 and #2. The ADM reported she had no knowledge resident #2 had ever been aggressive prior to coming to the facility. The ADM reported the history and physical paperwork came later after resident #2 was admitted . The ADM reported resident #2 had exhibited no behaviors since admission. The ADM stated Senior Focus had reported the resident had shown no signs of aggression. On 07/06/16 at 4:47 p.m., the interview with the ADM was resumed. The ADM was asked how often staff checked on residents during the night. The ADM reported staff went into resident rooms every two hours. The ADM stated the day shift was the first to report the altercation between residents #1 and #2. The ADM was questioned about notification of the physician regarding the injuries resident #1 sustained. The ADM reported she had texted the physician and sent a picture of the resident to the physician. The ADM stated the physician called her back and stated the resident looked fine. The ADM reported the resident's niece later requested the resident be reassessed. The resident was reassessed and the resident reported he was having increased pain. The ADM reported the family stated they would feel more comfortable if the resident was sent out to be checked in the ER. The ADM reported the physician was called and an order received to send the resident out. The ADM reported EMS came to the facility, assessed the resident, reported it was not an emergency situation, and left the facility. The ADM reported EMS was called back to the facility because the family wanted the resident sent out. The ADM reported the resident had said his pain level was a 2, the resident had not been complaining of pain, and there was no reason to be seen by a doctor.

On 02/22/13 at 1:20 p.m., the Oklahoma State Department of Health (OSDH) was notified of the immediate jeopardy situation related to unsecured hazardous chemicals located on the Alzheimer's unit. They were also notified of an immediate jeopardy situation related to liquids being in reach of a wandering and unsupervised resident who was NPO with a history of aspiration pneumonia. The IJ situation was verified. On 02/22/13 at 1:25 p.m., the surveyors attempted to discuss the immediate jeopardy situation with the DON. The DON stated he could not discuss the immediate jeopardy until the ADM was present. At 1:35 p.m., the DON was observed to enter the Alzheimer's unit, go into the shower room and remove a container of liquid soap and the sharps container, which contained used razors. At 1:45 p.m., the DON was observed at the back nurses' station, alone. At that time, the DON was informed of the IJ situation. At 3:25 p.m., a plan of removal was presented, but it was not acceptable. At 4:00 p.m., another plan of removal was presented, but it too, was unacceptable. The facility failed to present an acceptable plan of removal while the survey team remained in the building. On 02/25/13 at 4:45 p.m., the ADM faxed an acceptable plan of removal to the OSDH. The Plan of Removal documented the following: "On the Alzheimer's unit: 1350 (1:50 p.m.) - 02/22/13 All chemicals were removed and all cups picked up from rooms. 1400 (2:00 p.m.) - 02/22/13 All staff inserviced on properly securing all chemicals they must have them in their possession at all times when in use or must be placed in a secured area that does not have resident access. Supervisors are to monitor and ensure compliance every shift. 1500 (3:00 p.m.) - 02/22/13 All staff inserviced on offering fluids to all residents on the Alzheimer unit every 2 hours with prompt removal of the cups after drinking the fluids to decrease the NPO resident potential of obtaining the liquids until alternative placement can be found attempted x 2 places and refused him due to no behaviors, aggression, or threat to self or others. Continue to look for permanent placement in long term care. 1500 (3:00 p.m.) - 02/22/13 Entire building has been reviewed for chemicals and none found unsecured but all staff inserviced on proper use and security. 02/25/13 0900 (9:00 a.m.) - NPO resident is with one on one care to ensure no oral intake & will be placed in another long term care facility (name deleted facility) at 12:00 p.m. 02/25/12. 0915 (9:15 a.m.) - 02/25/13 All cups & pitchers have been put back in reach of all residents allow fluid intake as tolerated on the Alzheimer unit. 1500 (3:00 p.m.) - 02/25/13 All staff was inserviced on proper use & keeping all chemicals out of access to residents. They are to be used & in view of a staff member or secured in a locked area @ all times." The immediate jeopardy was removed as of 02/25/13 at 3:00 p.m., after all the staff had been inserviced. The deficient practice remained at a pattern of no actual harm with potential for more than minimal harm. Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure chemicals were maintained in a secure, safe manner on one of one Alzheimer's unit. This had the likelihood to harm eight residents who wandered and resided on the Alzheimer's unit, per ADM. b) Provide supervision on the Alzheimer's unit for one (#4) of one sampled resident who was NPO (nothing by mouth) due to history of aspiration pneumonia and wandered throughout . This had the likelihood to harm one resident who was NPO. c) Ensure the hallways were not blocked by equipment on three (SW, NW, and Alzheimer's) of six hallways. This had the potential to affect 35 ambulatory residents, per the ADM. d) Ensure sharps containers containing used razors were closed for safety in shower/W/P rooms for three (shower/W/P rooms on halls SW, SE, NE) of a total of six observed shower/W/P rooms. This had the potential to affect 70 residents residing on these halls, per the ADM. e) Ensure used razors were not left on a shower room floor in one (Alzheimer's shower room) of three observed shower rooms. This had the potential to affect eight residents on the Alzheimer's unit who wandered, per CNA #4 on the Alzheimer's unit. Findings: 1. On 02/22/13 at 12:20 p.m., a tour of the unlocked whirlpool room (W/P) on the Alzheimer's unit was conducted. The following was found in the W/P room: A linen cart was observed to contain two spray bottles. One of the spray bottles was observed to be approximately 1/8 full of liquid. The label on the side of the bottle documented: "Room Sense 200 Disinfectant Cleaner Keep Out of Reach of Children" The 'Material Safety Data Sheet', for this substance documented: "Hazardous Ingredients: Didecyl dimethyl ammonium chloride... Emergency First Aid Procedures- This product is listed with most poison control centers in the U.S. Ingestion: Give large quantities of water or milk. Do not induce vomiting. Never give anything by mouth to an unconscious person. Obtain medical attention. Inhalation: Remove to fresh air and insure... Skin Contact: Flush with water. Remove contaminated clothing; wash before reuse..." The second spray bottle was observed to contain 2/3 full of liquid. The label on the side of the bottle documented: "Room Sense 100 Air Freshener Keep Out of Reach of Children For Industrial Use Only..." The 'Material Safety Data Sheet', for this substance documented: "...Ingestion: Drink two glasses of milk or water. Do not induce vomiting. Never administer anything by mouth to an unconscious person. Seek medical attention immediately..." On 02/22/13 at 12:22 p.m., CNA #4 was observed passing two lunch trays to residents that ate in their rooms. The CNA was asked if there were any residents on the Alzheimer's unit that wandered about and went into other residents' rooms. The CNA gave a list of eight residents. The CNA was then asked if any of the wandering residents drank liquids while wandering about the unit. The CNA stated, "Yes, (Name deleted resident #4), will go into other residents' rooms looking for something to drink." The CNA reported resident #4 was NPO and had a 'feeding tube'. The CNA stated, "We have to make sure we pick up any cups that have an opened top, because he will drink out of them." The CNA reported the resident would not drink out of the water pitchers, just the open top cups. At 12:25 p.m., the staff was observed in the common area assisting residents with their lunch meal. Residents' rooms and the W/P room were not visible from the common area. There were no nursing staff observed on the hallway where residents' rooms and the W/P room were located. Resident #4 was observed to wander into other residents' rooms. While in a resident's room, resident #4, was observed to open the bathroom door, enter the bathroom and closed the door behind him. At 12:30 p.m., the resident came out of the bathroom and continued to wander from room to room aimlessly. On 02/22/13, during lunch, resident #4 was observed in another resident's room trying to take apart a dirty suction machine container that contained liquid. On 02/22/13 at 5:00 p.m., the ADM was interviewed. She said the locked unit was made for the residents to be able to wander around freely. She was informed of the chemicals found in the unlocked W/P room and that the DON had been informed of the situation also. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 09/25/12, documented the resident entered the facility from a psychiatric hospital, had severe cognition problems, wandered, walked in corridor without assistance, supervision of eating was required, did not have ROM limitations, had an anxiety disorder, had received an antipsychotic and an antidepressant medication in the last 7 days and had received 120 minutes of speech-language pathology services. No family or significant other participated in the assessment. The CAA (care area assessment) dated 09/25/12, documented the care plan should address the resident's dementia, psychosocial well-being, behavioral symptoms, nutritional status, and psychotropic drug use. On 01/21/13, an X-ray was obtained D/T dyspnea, syncope, and a low level of consciousness. The final report documented, Impression: Ill-defined opacities in the bilateral upper lungs, cannot exclude pneumonia..." On 01/28/13, diet orders documented, "Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)... A 'Dysphagia Medical Workup-Clinical Evaluation', dated 02/05/13, documented the resident had a swallowing disorder involving the resident's pharyngeal, oral, and esophageal phase. Dysphagia rehabilitation potential is expected to be 'poor.' The resident had a history of [REDACTED]. The resident was a definite risk for aspiration, reverse aspiration, chronic aspiration, nocturnal aspiration, aspiration pneumonia, and choking. The resident had a delayed or slow swallow reflex, experienced a wet or gurgly voice after swallowing liquids and had oral food retention. The resident also experienced postural difficulties with incoordination and sensation loss. Other conditions existed such as reduced or inadequate laryngeal closure and reduced or inadequate laryngeal elevation. The "A-P Study Results" dated 02/05/13, documented the resident had reduced oral control, premature spilling, delayed/absent swallow reflex, and had been unable to clear valleulae. Recommendations, "NPO c alt feeding method for nutrition & hydration secondary high risk of aspiration c all PO intake." A care plan, dated 02/05/13, documented the resident had altered nutrition related to dementia. Goals included diet as ordered by the physician. On 02/10/13, a handwritten note added to the care plan, documented, "NPO GT see CP ST Services as ordered." There were no new interventions/approaches documented on the care plan. At 12:22 p.m., CNA #4 was observed passing two lunch trays to residents that ate in their rooms. The CNA was asked if there were any of the residents on the Alzheimer's unit that wandered about and went into other residents' rooms. The CNA gave a list of eight residents. The CNA was then asked if any of the wandering residents drank liquids while wandering about the unit. The CNA stated, "Yes, (Name deleted resident #4), will go into other residents' rooms looking for something to drink." The CNA reported resident #4 was NPO and had a 'feeding tube'. The CNA stated, "We have to make sure we pick up any cups that have an opened top, because he will drink out of them." The CNA reported the resident would not drink out of the water pitchers, just the open top cups. At 12:25 p.m., the staff was observed in the common area assisting residents with their lunch meal. Residents' rooms were not visible from the common area. There were no nursing staff observed on the hallway where residents' rooms were located during the observation. Resident #4 was observed to wander into other residents' rooms. While in a resident's room, resident #4, was observed to open the bathroom door, enter the bathroom and closed the door behind him. At 12:30 p.m., the resident came out of the bathroom and continued to wander from room to room aimlessly. On 02/22/13, during lunch, resident #4 was observed in another resident's room trying to take apart a dirty suction machine container that contained liquid. A staff person was observed sweeping the floor in the same room at that time. The staff person never attempted to redirect the resident or immediately report the observation to the nursing staff. In the room, a Styrofoam cup of water was observed setting beside the resident's bed. No lid was on the cup. The resident was observed ambulating out of the room when he was unable to take apart the suction machine. No nursing staff were observed on the hall where the residents' rooms were located. Two other residents' rooms were observed at that time to have Styrofoam cups containing water accessible to the resident. On 02/22/13 at 1:15 p.m., resident #4 was observed on the Alzheimer's unit wandering into other residents' rooms. Staff were in the common area assisting residents after lunch. A CNA was observed on the unit, coming out of a resident's room and entering another room. The resident was observed to enter a room at the east end of the hall. The resident went into the room and sat in a rocking chair. The CNA, on the unit, was observed to come down the hall and remove the resident from the room. The resident was then observed to wander down the hall. The resident was observed to enter another resident's room. The resident was observed standing in the room, looking around. At 1:45 p.m., the DON was informed a Styrofoam cup, 1/2 full of a clear liquid and a water pitcher with a straw, were observed setting in the same room as the suction machine, in reach of resident #4. On 02/22/13 at 5:00 p.m., the ADM was interviewed. She said the locked unit was made for the residents to be able to wander around freely. She was informed of the liquids in reach of resident #4 and that the DON had been informed of the situation also. 3. On 02/21/13 at 1:00 p.m., an initial tour of the Alzheimer's unit was conducted. The corridor connecting the residents' rooms to the common area was observed to have two fire doors. One of the doors was observed opened. The corridor was observed with two Hoyer lifts, two over-bed tables and two chairs stored on the south side. The residents would not have been able to use the handrail on the south side of the corridor due to the equipment stored there. On 02/26/13 at 3:30 p.m., the DON was interviewed. The DON was informed of the equipment being stored in the corridor on the Alzheimer's unit. He stated, "Those should not be left there. They are usually stored in an empty room." 4. On 02/21/13 at 12:25 p.m., a Hoyer lift was observed setting in the hallway at the end of the SW Hall. There were other Hoyer lifts and a sit-to-stand lift observed stored in front of the nurses' station. On 02/26/13 at 12:45 p.m., a Hoyer lift was observed at the end of the hall in the same location a Hoyer lift had been observed on 02/21/13. At 1:45 p.m., CNA #2 was interviewed regarding the lift at the end of the SW Hall. The CNA was asked if the lift was supposed to be in the hall. She reported the lift should not be left in the hall. She said it should be placed in front of the nurses' station. At 3:15 p.m., the Hoyer lift continued to be in the hallway in the same location as observed at 12:45 p.m. At 3:30 p.m., the DON was interviewed regarding the Hoyer lift at the end of the SW Hall being observed last week and again today. The DON reported he did not know why the lift was in the hallway. He reported the lifts were not to be stored in the hallway, but were to be kept in front of the nurses' station. 5. On 02/21/13 at 12:25 p.m., the SW and SE Halls were toured. The W/P room located on the SW hall was checked. The door to the W/P was not locked. In the W/P room, a sharps container was observed on the floor, under the sink. A used razor was observed on top of the container. There were several used razors inside the container. There was no lid closing the container to keep the razors from falling out if turned over or to prevent residents from reaching into the container. The opening on top of the sharps container was wide enough to allow someone to reach inside the container. A clear plastic shield, which belonged on the sharps container, was observed on the floor next to it. The shield, when attached to the sharps container, would keep the contents inside the container and prevent residents from reaching into the container. LPN #1, who was present at the time of the observation, was asked why there was not a lid on the sharps container. The LPN was observed to bend down and place the used razor into the sharps container. She reported the aides had removed the lid. The LPN then assisted with making observations in the shower room on the SE Hall. The shower room was not locked. A sharps container was observed on the floor, under the sink. The sharps container had used razors inside. There was no lid closing the container to keep the razors from falling out if turned over, or to prevent residents from reaching into the container. The LPN was asked why the sharps container did not have a lid. She bent to check the container and reported the aides had not closed it. The LPN was asked if the W/P room or shower room was ever locked. The LPN reported they did not keep either of the rooms locked. On 02/22/13 at 11:15 a.m., LPN #2 was interviewed regarding the residents who might wander into the shower room. The LPN reported they had three residents who were independent in taking showers. She reported there were several residents who wandered, but she was not aware of any of them wandering into the shower room. On 02/22/13 at 1:15 p.m., the Alzheimer's unit was observed. While monitoring the activity on the Alzheimer's unit, the DON was observed to enter the unit, go into the shower room and remove the sharps container, which contained used razors. 6. On 02/21/13, at 12:25 p.m., the NE shower room was observed. A sharps container, which was half full of used shaving razors, was sitting on the floor. The lid on the container was open. The opening was large enough to allow a resident's hand to enter into the container. On 02/21/13, at 12:27 p.m., a mechanical lift was observed in the hallway against the wall between room #18 and #19. On 02/21/13, at 12:28 p.m., CNA #5 was asked if the lift was supposed to be stored in the hall. She said it was usually kept in the resident's room.