Every finding on record at Golden Age Nursing Home of Guthrie, LLC

Based on observation, record review, and interview, the facility failed to ensure: a. a resident had a physician's order for oxygen administration for 1 (#98); and b. oxygen was administered as ordered for 1 (#11) of 2 sampled residents reviewed for respiratory services. The DON identified 28 residents received oxygen in the facility. Findings: 1. On 05/12/25 at 11:25 a.m., Resident #98 was observed to be on four liters of oxygen via nasal cannula. The oxygen tubing was dated 04/28. There was no documentation Resident #98 had an order for the use of oxygen. A policy titled Oxygen Administration, revised 10/10, read in part, Oxygen is administered under orders of physician, except in the case of resident with shortness of breath or respiratory distress, as needed. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable. Resident #98's physician order report, dated 05/2025, showed the resident had diagnoses which included unspecified combined systolic and diastolic congestive heart failure and dementia. Resident #98's quarterly resident assessment, dated 05/08/25, showed the resident had severe cognitive impairment with a BIMS score of 04. A progress note, dated 05/13/25 at 3:06 p.m., read in part, resident has been complaining of shortness of breath most of the day, lungs clear in all quads, 02 sats 98-96% room air. heart rate 90 -100 .02 2 liters given at 2 liters per n/c [nasal cannula], resident was able to calm down. A progress note, dated 05/09/25 at 3:28 p.m., read in part, Resident complained of shortness of breath, around 3:15, this nurse checked on them. 02 Sat-97%. Placed on 02 at 2 liters, encouraged to take deep breaths. On 05/12/25 at 11:25 a.m., Resident #98 stated they started using oxygen occasionally about a week or two ago. On 05/12/25 at 11:26 a.m., Resident #98 stated they did not know how much oxygen they were receiving. On 05/14/25 at 8:36 a.m., Resident #98 stated they did not need oxygen this morning. They stated the nasal cannula tubing was changed yesterday on 05/13/25. On 05/14/25 at 9:48 a.m., CNA #2 stated Resident #98 used oxygen every night. They stated they cared for the resident last week and this morning. On 05/14/25 at 9:49 a.m., CNA #2 stated the resident had on oxygen this morning on 05/14/25, but took it off when they got up. On 05/14/25 at 9:55 a.m., LPN #3 stated they were not aware the resident used oxygen. On 05/14/25 at 9:57 a.m., LPN #3 stated there was no order for the use of oxygen. On 05/14/25 at 9:59 a.m., LPN #3 stated if a resident had low oxygen saturation, they would call the doctor and get an order. On 05/14/25 at 10:07 a.m., the DON stated if a resident had shortness of breath, or in respiratory distress, they would administer oxygen and notified the provider for orders. 2. On 05/12/25 at 11:39 a.m., Resident #11 was observed to be on five liters oxygen via a nasal cannula. On 05/14/25 at 1:19 p.m., Resident #11 was observed to be on five liters of oxygen via a nasal cannula. A physician's order, dated 01/26/24, showed oxygen at three liters via nasal cannula continuously related to chronic obstructive pulmonary disease. Resident #98's physician order report, dated 04/14/25 to 05/14/25, showed the resident had diagnoses which included chronic obstructive pulmonary disease with acute exacerbation. Resident #11's discharge assessment-return anticipated, dated 05/01/25, showed the resident's memory was ok with some difficulties in cognitive skills for daily decision making. On 05/14/25 at 1:29 p.m., LPN #4 stated they last checked the resident's oxygen saturation at 9:11 a.m. on 05/14/25 and it was 98% on three liters. On 05/14/25 at 1:33 p.m., LPN #4 stated Resident #11's oxygen was set at five liters on the concentrator. On 05/14/25 at 1:34 p.m., LPN #4 stated the oxygen rate was incorrect. They stated it should be three liters as ordered.

Based on observation, record review, and interview, the facility failed to prevent accidents for 1 (#54) of 3 residents sampled for accident hazards. The DON identified three residents ambulated with wheelchairs independently. Findings: On 05/13/25 at 9:00 a.m., Resident #54 was observed ambulating in a wheelchair. Resident #54's hands were observed to have bruising on their right and left knuckles and the back of their hands. A facility policy titled Accident and Incidents -Investigating and Reporting, dated 07/2017, read in part, All accidents or incidents involving residence, employees, visitors, vendors, etc. [et cetera], Occurring on premises shall be investigated and reported to the administrator.Incident/accident reports will be reviewed for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Resident #54's admission record, dated 07/05/22, showed they were admitted with diagnoses which included edema, muscle weakness, and hyperlipidemia. Resident #54's care plan, dated 03/25/25, read in part, Approach: Xarelto [anticoagulant] Use - Many drugs interact with Xarelto to affect clotting time: most antibiotics, antifungals, anticonvulsants, anti-ulcer drugs, SSRI [selective serotonin reuptake inhibitors] antidepressants, various other drugs. Use caution when starting, changing, or discontinuing any medications on residents taking Xarelto. Monitor for S/S of bleeding. Notify Physician of any change in condition. Resident #54's quarterly MDS assessment, dated 04/05/25, showed their BIMS score was 15 indicating their cognition was intact for decision making. The assessment showed they ambulated with the assistance of a wheelchair independently and was prescribed and taking an anticoagulant. Resident #54's physician orders, dated 04/28/25, read in part, Xarelto (rivaroxaban) tablet; 20 mg; amt: 1 tab; oral at Bedtime. On 05/13/25 at 9:01 a.m., Resident #54 stated they bumped and hurt their hands while ambulating with a wheelchair and bruised easily due to taking an anticoagulant. On 05/14/25 at 9:42 a.m., LPN #1 was asked to discuss the bruising observed on Resident #54's hands. They stated the resident self propelled in their wheelchair and bumped into things and bruised because they were prescribed an anticoagulant. LPN #1 was asked what was done to prevent the injury. LPN #1 stated they had not done anything and did not document the bruising to the hands in the TAR for side effect monitoring of anticoagulants and did not complete an incident report. On 05/14/25 at 9:52 a.m., the ADON stated Resident #54's hands had several bruises on the backs of both hands due to Resident #54's hands on the doors while ambulating with a walker and a wheelchair. They stated the injuries had occurred since admission. They were asked what interventions were in place to prevent injury to the resident's hands. They stated the last intervention was educating the resident on 07/18/22. The ADON stated they needed to do an incident report and care plan and intervention to prevent further injury. On 05/14/25 at 10:19 a.m., the DON stated Resident #54 was not assessed after they reported the injuries to their hands and nursing should of assessed the resident and completed an incident report . The DON stated there were no interventions to prevent the bruising of the hands related to the resident ambulating with a wheelchair or walker.

Based on record review and interview, the facility failed to ensure a resident received pain medication in a timely manner for 1 (#315) of 2 sampled residents reviewed for pain management. The administrator identified 115 residents resided in the facility Findings: A policy titled Administering Pain Medications, revised 10/2022, read in part, Administer pain medications as ordered. Resident #315's medications administration history, dated 05/2025, showed the resident had diagnoses which included displaced intertrochanteric fracture of right femur, sequela and unspecified pain. Resident #315's physician's order, dated 05/05/25, showed tramadol (opioid pain medication) 50 mg oral, may take one tablet every four hours as needed by mouth for pain and diagnosis of displaced intertrochanteric fracture of right femur, sequela. A baseline care plan, dated 05/06/25, showed Resident #315's cognition was intact. Resident #315's medications administration history, dated 05/12/25, showed the resident received tramadol at 9:06 a.m. Resident #315's medications administration history, dated 05/12/25, showed the resident received tramadol at 2:09 p.m. On 05/12/25 at 1:03 p.m., Resident #315 asked CNA #1 for their pain medication. On 05/12/25 at 1:08 p.m., Resident #315 stated they had right hip surgery. They stated it took a long time to receive their pain medicine when they asked for it. On 05/12/25 at 1:10 p.m., Resident #315 stated their pain rating was a 10 out of 10 on the numerical pain scale because they wheeled themselves back to their room from the dining room. They stated their pain was all over. On 05/13/25 at 2:28 p.m., CNA #1 stated if a resident request pain medication, they would inform the nurse as soon as they were through and the nurse would inform the CMA. On 05/13/25 at 2:29 p.m., CNA #1 stated they informed LPN #2 and LPN #2 informed CMA #1 that Resident #315 needed pain medication. They stated CMA #1 stated it was not time for the resident to received their pain medication. CNA #1 stated they could not recall the time they told the nurse. On 05/13/25 at 2:36 p.m., CMA #1 stated if a resident request pain medication, they would inform the nurse and the nurse would assess the resident and tell the CMA what to give. On 05/13/25 at 2:37 p.m., CMA #1 stated they offered residents pain medication right away to keep their pain under control. On 05/13/25 at 2:38 p.m., CMA #1 stated Resident #315's tramadol order was for every four hours as needed. On 05/13/25 at 2:41 p.m., CMA #1 stated they administered the tramadol twice on 05/12/25. They stated at 9:06 a.m. and 2:09 p.m. CMA #1 stated Resident #315 did not receive any pain medication between 1:00 p.m. and 2:00 p.m. On 05/13/25 at 2:42 p.m., CMA #1 stated LPN #2 informed them of the resident's request for pain medication some time after 2:00 p.m. on 05/12/25. On 05/13/25 at 2:44 p.m., CMA #1 stated they did not remember discussing with CNA #1 about the resident's request of pain medication. They stated they did not remember telling CNA #1 and LPN #2 that it was not time for the resident to have their pain medication on 05/12/25. On 05/13/25 at 2:45 p.m., CMA #1 stated it was not acceptable for the resident to wait an hour for their pain medication. On 05/13/25 at 2:53 p.m., the DON stated it was not acceptable for the resident to wait an hour for the pain medication if the resident could have it.

Based on observation, record review, and interview, the facility failed to document side effect monitoring for the use of anticoagulants for 1 (#54) of 5 residents sampled for side effect monitoring of anticoagulants. The DON identified 22 residents were prescribed anticoagulants. Findings: On 05/13/25 at 9:00 a.m., Resident #54 was observed ambulating in a wheelchair. Resident #54's hands were observed to have bruising on their right and left knuckles and back of their hands. A facility policy titled High Risk Medications-Anticoagulants, read in part, The facility recognizes that some medication's, including anticoagulant, are associated with greater risk of adverse consequences than other medications.The residents plan of care shall alert staff to monitor for adverse consequences. Resident 54's admission record, dated 07/05/22, showed they were admitted with diagnoses which included edema, muscle weakness, and hyperlipidemia. Resident #54's TAR, dated 02/01/25 through 05/13/25, did not document bruising on the resident's hands related to side effect monitoring of anticoagulants and/or in the skin inspections. Resident #54's care plan, dated 03/25/25, read in part, Approach: Xarelto [anticoagulant] Use - Many drugs interact with Xarelto to affect clotting time: most antibiotics, antifungals, anticonvulsants, anti-ulcer drugs, antidepressants, various other drugs. Use caution when starting, changing, or discontinuing any medications on residents taking Xarelto. Monitor for S/S, of bleeding. Notify Physician of any change in condition. Resident #54's quarterly MDS assessment, dated 04/05/25, showed their BIMS score was 15 indicating their cognition was intact for decision making. The assessment showed they ambulated with the assistance of a wheelchair independently and was prescribed and taking an anticoagulant. Resident #54's physician orders, dated 04/28/25 read in part, Xarelto (rivaroxaban) tablet; 20 mg; amt: 1 tab; oral at Bedtime. On 05/13/25 at 9:01 a.m., Resident #54 stated they bumped and hurt their hands while ambulating with a wheelchair and bruised easily due to taking an anticoagulant. On 05/14/25 at 9:42 a.m., LPN #1 was asked to discuss the bruising observed on Resident #54's hands. They stated the resident self propelled in their wheelchair and bumped into things and bruised easily because they were prescribed an anticoagulant. LPN #1 stated they did not document the bruising to the hands in the TAR for side effect monitoring of anticoagulants or in the the skin inspections in the TAR. On 05/14/25 at 10:19 a.m., the DON stated Resident #54's TAR from 02/01/25 through 05/13/25 did not document the reported bruising observed on Resident #54's hands in the anticoagulant side effect monitoring or the skin inspections.

Based on observation and interview, the facility failed to ensure incontinent care was provided to dependent residents at least every two hours for two (#4 and #5) of five dependent residents observed for receiving incontinent care. The DON identified 112 residents resided in the facility. Findings: 1. A Comprehensive Assessment for Resident #4, dated 06/10/24, documented they had impaired ROM to both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. 2. A Comprehensive Assessment for Resident #5, dated 06/18/24, documented they had impaired ROM to both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. On 08/13/24 at 11:30 a.m., Resident #4 and Resident #5 were observed in the facility dining room on the lower level. On 08/13/24 at 12:30 p.m., Residents #4 was escorted in their reclining geri-chair from the dining room to their room and placed beside their bed by CNA #1. On 08/13/24 at 1:12 p.m., Residents #5 was escorted in their reclining geri-chair from the dining room to their room and placed beside their bed by CNA #2. On 08/13/24 at 2:00 p.m., after uninterrupted observation on the hall from 12:30 p.m., Resident #4 and Resident #5 were observed in their rooms sitting in their reclining geri-chairs, at the side of their beds. No staff had been observed entering or exiting Resident #4's room since 12:30 p.m. No staff had been observed entering or exiting Resident #5's room since 1:12 p.m. On 08/13/24 at 2:50 p.m., after uninterrupted observation from 2:00 p.m. to this time, CNA #1 and CNA #2 were observed while they put Resident #5 in bed and performed peri-care. Resident #5's brief was observed to be grossly saturated and contained a medium bowel movement. On 08/13/24 at 3:14 p.m., after further observation of Resident #4 sitting in their reclining geri-chair at the side of their bed, this surveyor asked CNA #3 who from the day shift was responsible for Resident #4's care. CNA #3 stated, I am, but I'm working 16 hours. CNA #3 was informed of my observations and immediately following our conversation, CNA #3 and CNA #4 were observed while they put Resident #4 in bed and performed peri-care. Resident #4's brief was observed to be moderately saturated and blanchable redness was noted to entire buttocks and sacral area. On 08/14/24 at 2:16 p.m., the DON was asked the facility policy regarding incontinent care for dependent residents. They reported dependent residents should be checked and/or provided incontinent care at least every two hours. The DON was informed of my observation for Residents #4 and #5. They acknowledged facility policy had not been followed for the above residents.

On 07/15/24, a past noncompliance was determined for facilities failure to ensure residents are free from abuse and neglect when staff is providing personal care to residents. The residents had pictures and/or videos taken during personal care. The Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents were free from abuse and neglect. At 3:58 p.m., the administrator and DON were informed of the past noncompliance IJ related to the facility's failure to ensure the residents were free from abuse and neglect that existed on 04/05/24, when the initial report to OSDH was reported regarding photos and/or videos of a resident being taken by CNA while giving personal care. On 04/05/24 the staff was inserviced on abuse, reporting abuse, the use of cell phones while caring for residents, and taking pictures and videos of residents and posting on social media. The in-service conducted on 04/05/24, documented, topic was Prohibition of abuse prevention, reporting abuse, video taping and photographs policy, and cell phone use. Based on record review, and interview, the facility failed to ensure residents were free from abuse and neglect for five (#1, 7, 8, 9, and #10) of five residents investigated for abuse. This resulted in a past noncompliance for abuse when the CNA's took compromising photos of the residents. Findings: The facilities Abuse Prohibition policy, revised March 2023, read in part, each individual resident has the right to be free from any form of abuse. This facility strictly prohibits any verbal, sexual, physical, mental abuse. The facilities Electronic Devices and Social Media policy, undated, read in part, personal use of electronic devices (such as cell phone, tablets, cameras, laptops, smart phones) is strictly prohibited in the facility and must be kept elsewhere during working hours. Reads in part, Violation of this policy can result in disciplinary action up to and including termination. 1. Res. #1 had diagnoses which included dementia with other behavioral disturbance, depression 2. Res. #7 had diagnosis which included dementia A Brief Interview for Mental Status dated 05/07/24, Resident #7 BIMS score was ten 3. Res. #8 had diagnosis which included dementia A Brief Interview for Mental Status dated 05/28/24, Resident #8 BIMS score was eight 4. Res. #9 had diagnosis which included vascular dementia, anxiety. A Brief Interview for Mental Status dated 04/25/24, Resident #9 BIMS score was ninety nine, and 5. Res. #10 had diagnosis which included dementia A Brief Interview for Mental Status dated 06/17/24, Resident #10 BIMS score was ninety nine A facility incident report, dated 04/05/24 at 8:41 a.m., an initial Incident Report documented CNA #1, 2, and #3 took compromising photos/video of resident #1 and posted on social media. All those involved were suspended until the investigation was complete. CNA #1 was separated from employment on 04/08/24, CNA #2 was separated from employment on 04/08/24, and CNA #3 was separated from employment on 04/08/24. All named staff members were reported to Oklahoma Nurse Aide Registry. On 04/05/24 an in-service and training was initiated by management to all staff members at the facility on abuse, neglect, reporting abuse, cell phone use while caring for residents, and posting pictures and/or videos on social media. On 04/05/24 management completed the in-service and training for all staff members at the facility. The facility was in past non compliance after completing a QAPI meeting, dated 04/22/24, which discussed the outcome of the State Reportable Incident(s) interventions. A. facility incident report, dated 06/06/24 at 3:56 p.m., a second follow up Incident Report was faxed to OSDH documenting the local law enforcement contacted the facility with additional information regarding an additional four residents (#7, 8, 9, and #10) pictures/videos found on alleged staff named in initial Incident Report. An In-servicesign in sheet, dated 04/05/24, included documentation of an in-service for staff on prohibition of Abuse, abuse prevention, reporting abuse, and video and picture taking. Cell phone random audit forms, dated 04/08/24 through 06/10/24, to ensure no cell phones being used while on shift or being used in resident care areas. A form titled Golden Age Nursing Home, LLC Quarterly QA Meeting, dated 04/22/24, documented, reviewed abuse policy and procedures, reviewed neglect, reviewed cell phone policy and reviewed video policy. On 07/15/24 at 11:26 a.m., Res #8 was observed resting in their bed. Res #8 was unable to be interviewed. On 07/15/24 at 11:37 a.m., Res. #1 was observed resting in their bed. Res. #1 was unable to be interviewed. On 07/15/24 at 11:43 a.m., Res. #7 was not in their room and in a facility activity. Res. #7 was unable to be interviewed. On 07/15/24 at 1:08 p.m., Res. #10 was resting in chair in their room. Res. #10 was unable to be interviewed. On 07/15/24 at 1:19 p.m., Res. #9 was unable to answer questions due to severe dementia. Attempted to place call to Res. #9 POA, un-successful attempt. On 07/15/24 at 1:21 p.m., placed call to Res. #8 family member on record, family member stated they could not answer any questions regarding staff mistreating resident. On 07/15/24 at 11:45 a.m., LPN #1 was asked what the facility policy on abuse. They stated report to the DON. They were then asked what the facility policy is for using cell phones. They stated only to use them on break. They were then asked if they had seen any staff taking pictures or using cell phones while caring for residents. They stated not while caring for residents. They were then asked if they had been in-inserviced on abuse and neglect. They stated yes. On 07/15/24 at 11:48 a.m., CNA #4 was asked what the facility policy on abuse. If we suspect abuse to report it immediately. They were then asked what the facility policy is for using cell phones. They stated they are not suppose to use cell phones while on duty. They were then asked if they had seen any staff taking pictures or using cell phones while caring for residents. They stated not while caring for residents. They were then asked if they had been in-inserviced on abuse and neglect. They stated yes On 07/15/24 at 11:55 a.m., CMA #1 was asked what the facility policy on abuse. They stated go straight to administrator and DON. They were then asked what the facility policy is for using cell phones. They stated that cell phones are not aloud in the building. They were then asked if they had seen any staff taking pictures or using cell phones while caring for residents. They stated not for a while. They were then asked if they had been in-inserviced on abuse and neglect. They stated yes On 07/15/24 at 12:00 p.m., CNA #5 was asked what the facility policy on abuse. They stated if you suspect it tell the nurse. They were then asked what the facility policy is for using cell phones. They stated that cell phones are not aloud, only on break. They were then asked if they had seen any staff taking pictures or using cell phones while caring for residents. They stated not while caring for residents. They were then asked if they had been in-inserviced on abuse and neglect. They stated yes On 07/15/24 at 12:10 p.m., the DON stated the facility did audits after the incident to ensure all cell phones were not being used while giving personal care, and in-serviced immediately on 04/05/24 regarding abuse/exploitation for all staff. The DON stated they also included this incident and the results of the monitoring at the next QA committee meeting. After review ofthe facility documneation of in-service education, staff interviews, and documentation of on going minitoring it was determined the facility had corrected this as of 04/05/24.

On 07/15/24, a past noncompliance was determined for facilities failure to ensure residents are free from abuse and neglect when staff is providing personal care to residents. The residents had pictures and/or videos taken during personal care. The Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents were free from abuse and neglect. At 3:58 p.m., the administrator and DON were informed of the past noncompliance IJ related to the facility's failure to ensure the residents were free from abuse and neglect that existed on 04/05/24, when the initial report to OSDH was reported regarding photos and/or videos of a resident being taken by CNA while giving personal care. On 04/05/24 the staff was inserviced on abuse, reporting abuse, the use of cell phones while caring for residents, and taking pictures and videos of residents and posting on social media. The in-service conducted on 04/05/24, documented, topic was Prohibition of abuse prevention, reporting abuse, video taping and photographs policy, and cell phone use. Based on record review, and interview, the facility failed to ensure residents were free from abuse and neglect for five (#1, 7, 8, 9, and #10) of five residents investigated for abuse. This resulted in a past noncompliance for abuse when the CNA's took compromising photos of the residents. Findings: The facilities Abuse Prohibition policy, revised March 2023, read in part, each individual resident has the right to be free from any form of abuse. This facility strictly prohibits any verbal, sexual, physical, mental abuse. The facilities Electronic Devices and Social Media policy, undated, read in part, personal use of electronic devices (such as cell phone, tablets, cameras, laptops, smart phones) is strictly prohibited in the facility and must be kept elsewhere during working hours. Reads in part, Violation of this policy can result in disciplinary action up to and including termination. 1. Res. #1 had diagnoses which included dementia with other behavioral disturbance, depression 2. Res. #7 had diagnosis which included dementia A Brief Interview for Mental Status dated 05/07/24, Resident #7 BIMS score was ten 3. Res. #8 had diagnosis which included dementia A Brief Interview for Mental Status dated 05/28/24, Resident #8 BIMS score was eight 4. Res. #9 had diagnosis which included vascular dementia, anxiety. A Brief Interview for Mental Status dated 04/25/24, Resident #9 BIMS score was ninety nine, and 5. Res. #10 had diagnosis which included dementia A Brief Interview for Mental Status dated 06/17/24, Resident #10 BIMS score was ninety nine A facility incident report, dated 04/05/24 at 8:41 a.m., an initial Incident Report documented CNA #1, 2, and #3 took compromising photos/video of resident #1 and posted on social media. All those involved were suspended until the investigation was complete. CNA #1 was separated from employment on 04/08/24, CNA #2 was separated from employment on 04/08/24, and CNA #3 was separated from employment on 04/08/24. All named staff members were reported to Oklahoma Nurse Aide Registry. On 04/05/24 an in-service and training was initiated by management to all staff members at the facility on abuse, neglect, reporting abuse, cell phone use while caring for residents, and posting pictures and/or videos on social media. On 04/05/24 management completed the in-service and training for all staff members at the facility. The facility was in past non compliance after completing a QAPI meeting, dated 04/22/24, which discussed the outcome of the State Reportable Incident(s) interventions. A. facility incident report, dated 06/06/24 at 3:56 p.m., a second follow up Incident Report was faxed to OSDH documenting the local law enforcement contacted the facility with additional information regarding an additional four residents (#7, 8, 9, and #10) pictures/videos found on alleged staff named in initial Incident Report. An In-servicesign in sheet, dated 04/05/24, included documentation of an in-service for staff on prohibition of Abuse, abuse prevention, reporting abuse, and video and picture taking. Cell phone random audit forms, dated 04/08/24 through 06/10/24, to ensure no cell phones being used while on shift or being used in resident care areas. A form titled Golden Age Nursing Home, LLC Quarterly QA Meeting, dated 04/22/24, documented, reviewed abuse policy and procedures, reviewed neglect, reviewed cell phone policy and reviewed video policy. On 07/15/24 at 11:26 a.m., Res #8 was observed resting in their bed. Res #8 was unable to be interviewed. On 07/15/24 at 11:37 a.m., Res. #1 was observed resting in their bed. Res. #1 was unable to be interviewed. On 07/15/24 at 11:43 a.m., Res. #7 was not in their room and in a facility activity. Res. #7 was unable to be interviewed. On 07/15/24 at 1:08 p.m., Res. #10 was resting in chair in their room. Res. #10 was unable to be interviewed. On 07/15/24 at 1:19 p.m., Res. #9 was unable to answer questions due to severe dementia. Attempted to place call to Res. #9 POA, un-successful attempt. On 07/15/24 at 1:21 p.m., placed call to Res. #8 family member on record, family member stated they could not answer any questions regarding staff mistreating resident. On 07/15/24 at 11:45 a.m., LPN #1 was asked what the facility policy on abuse. They stated report to the DON. They were then asked what the facility policy is for using cell phones. They stated only to use them on break. They were then asked if they had seen any staff taking pictures or using cell phones while caring for residents. They stated not while caring for residents. They were then asked if they had been in-inserviced on abuse and neglect. They stated yes. On 07/15/24 at 11:48 a.m., CNA #4 was asked what the facility policy on abuse. If we suspect abuse to report it immediately. They were then asked what the facility policy is for using cell phones. They stated they are not suppose to use cell phones while on duty. They were then asked if they had seen any staff taking pictures or using cell phones while caring for residents. They stated not while caring for residents. They were then asked if they had been in-inserviced on abuse and neglect. They stated yes On 07/15/24 at 11:55 a.m., CMA #1 was asked what the facility policy on abuse. They stated go straight to administrator and DON. They were then asked what the facility policy is for using cell phones. They stated that cell phones are not aloud in the building. They were then asked if they had seen any staff taking pictures or using cell phones while caring for residents. They stated not for a while. They were then asked if they had been in-inserviced on abuse and neglect. They stated yes On 07/15/24 at 12:00 p.m., CNA #5 was asked what the facility policy on abuse. They stated if you suspect it tell the nurse. They were then asked what the facility policy is for using cell phones. They stated that cell phones are not aloud, only on break. They were then asked if they had seen any staff taking pictures or using cell phones while caring for residents. They stated not while caring for residents. They were then asked if they had been in-inserviced on abuse and neglect. They stated yes On 07/15/24 at 12:10 p.m., the DON stated the facility did audits after the incident to ensure all cell phones were not being used while giving personal care, and in-serviced immediately on 04/05/24 regarding abuse/exploitation for all staff. The DON stated they also included this incident and the results of the monitoring at the next QA committee meeting.

Based on record review and interview, the facility failed to ensure an MDS was coded accurately for one (#23) of 24 sampled residents whose MDS assessments were reviewed. The Administrator identified 116 residents resided in the facility. The DON stated nine residents were receiving Plavix. Findings: Resident #23 had diagnoses which included atherosclerotic heart disease. An Order Summary report, dated 11/21/23, documented Resident #23 received Plavix once a day. An Annual assessment, dated 01/18/24, documented Resident #23 received an anticoagulant. A MAR, dated January for 2024, did not document Resident #23 received an anticoagulant. On 02/07/24 at 11:10 a.m., MDS Coordinator #1 stated medications were coded on the MDS if the resident took the medication in the seven day look back period. They stated Plavix was coded as an antiplatelet. MDS Coordinator #1 reviewed Resident #23's annual assessment dated [DATE]. They stated an anticoagulant was coded. They weren't able to locate an anticoagulant physician's order. They stated the MDS was not coded accurately.

Based on record review, observation, and interview, the facility failed to ensure staff wore gloves while administering insulin to one (#252) of two sampled residents reviewed for insulin administration. The ADON identified 13 residents received insulin. Findings: The facility's Subcutaneous Injections policy, reviewed March 2011, read in part, .Put on gloves .inject needle quickly .remove gloves . Resident #252 had diagnoses which included type two diabetes mellitus. A Physician Order, dated 01/21/23, documented to administer Humulin insulin per sliding scale. On 02/01/23 at 7:54 a.m., RN #1 stated to Resident #252, You get two units. RN #1 was observed to administer an injection subcutaneously to Resident #252's left upper arm without wearing gloves. RN #1 was asked what was the protocol for administering insulin. They stated staff checked the blood sugar, checked the physician order, then administered insulin. RN #1 was asked if they wore gloves when administering insulin. They stated they hadn't been taught to wear gloves when administering insulin. On 02/03/23 at 8:48 a.m., LPN #1 was asked if staff wore gloves when administering insulin. They stated, Yes.

Based on record review, observation, and interview, the facility failed to ensure staff locked medication/treatment carts prior to leaving carts unattended for two of two carts observed unlocked. The DON identified five medication carts and five treatment carts were in the facility. Findings: The facility's Storage of Medications policy, revised March 2019, read in part, .Compartments .containing drugs and biologicals shall be locked when not in use, and .carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . On 02/01/23 at 10:16 a.m., an unlocked and unattended treatment cart was observed in the hallway, outside rooms [ROOM NUMBERS]. On 02/01/23 at 10:17 a.m., RN #1 was observed to come out of room [ROOM NUMBER], walked to the treatment cart, and locked it. On 02/03/23 at 7:52 a.m., CMA #1 was observed to leave the medication cart outside room [ROOM NUMBER]. CMA #1 was observed to walk down the hall to room [ROOM NUMBER] leaving the medication cart unlocked and unattended. On 02/03/23 at 7:55 a.m., CMA #1 was observed to come back to the unlocked medication cart. They were asked how staff ensured medication carts were locked. CMA #1 stated they pushed the lock in the cart and took the keys when they left the cart. They were asked if the cart had been left unlocked. CMA #1 stated, Yes, I thought I pushed it in but didn't. On 02/03/23 at 8:50 a.m., LPN #1 was asked how staff ensured medication and treatment carts were locked. They stated the staff were to double check prior to walking away from the cart.

Based on observations, record review, and interviews, it was determined the facility failed to: ~ store cooked food items covered and at an appropriate temperature. The Resident Census and Conditions of Residents form, dated 10/28/19, documented 119 residents who resided in the facility. The DM (dietary manager) identified 118 residents who received meals from the kitchen. One resident received nutrition and hydration solely via a gastric feeding tube. ~ clean a food processor container and blade using standardized cleaning practices between uses. The DM identified two residents who received pureed diets and had their meals prepared in the downstairs kitchen of the facility. Findings: On 10/29/19 at 11:40 a.m., two baking trays of baked chicken breast were observed open to air in the dry food storage area of the kitchen. The surface underneath the trays were cool to the touch. The ambient air temperature on the wall thermostat in the room was 74 degrees Fahrenheit. At 11:42 a.m., the DM was shown the two trays of baked chicken breasts in the dry food storage area. She stated they should not be there. She further stated the trays of chicken breasts should have been covered to cool and then placed in the refrigerator until the kitchen staff could package and freeze them as individual servings. At 11:45 a.m., cook #1 stated she took the chicken breasts out of the oven and placed them in the dry food storage area to cool until they could be packaged and frozen as individual servings. She was asked how the baked chicken should have been stored until it could be packaged and frozen as individual servings. She stated,Covered and in the refrigerator. At 12:10 p.m., cook #2 was observed in the downstairs kitchen. A food processor container was observed on the counter. It had visible food residue on the sides of the container from prior use. Cook #2 disassembled the food processor container and blade, washed and rinsed the container and blade under running water, shook the residual water into a two compartment sink and then reassembled the container and blade. She then placed a cooked chicken strip into the food processor container. She then pureed it and placed it on to a plate and served it to a resident. She then placed the food processor container and blade into the kitchen sink. On 10/30/19 at 11:00 a.m., dietary staff #1 was asked how often the food processor was used. He stated there were two residents who received pureed diets from the downstairs kitchen. He was asked how the food processor was cleaned after each use. He stated during the meals the container and blade were washed in the two compartment kitchen sink with soap and water, and then after the meal service the container and blade were sent to the main kitchen to be cleaned in the dish machine. He was asked if the food processor unit should have been hand washed using a three compartment sink process in between uses. He stated they washed it in the sink and then sent it to the main kitchen to be washed in the dish machine after the meal service. At 2:15 p.m., the DM was asked if the food processor unit should have been cleaned between uses using acceptable ware washing practices. She said, Yes. She was asked if the hot water temperature in the downstairs kitchen sink reached a temperature of at least 171 degrees Fahrenheit. She stated it did not.

Based on interviews and record reviews, it was determined the facility failed to implement an antibiotic stewardship program for three (#103, 111 and #164) of three sampled residents reviewed for antibiotic use. The DON (director of nurses) identified 37 residents who had received antibiotics in the last 90 days. Findings: A facility policy titled, Antibiotic Stewardship Program, documented: .Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program .Appropriate indications for use of antibiotics include .Criteria met for clinical definition of active infection or [MEDICAL CONDITION] (McGeer Criteria) .Nurses will receive initial orientation and ongoing treatment on .Specific information that should be reported to the physician or provider upon identifying signs and symptoms of possible infection . A facility assessment tool titled, Revised McGeer Criteria, documented criteria defining urinary tract infections for residents with and without a urinary catheter. For a resident without a urinary catheter, no symptom criteria listed on the McGeer assessment tool included a change in mental status or confusion as a criteria defining a urinary tract infection. For a resident without a urinary catheter, there were no criteria symptoms which included milky urine. For a resident without a urinary catheter, pain alone was not listed as a defining criteria for a UTI. The following pain symptoms could have been included along with other required symptoms to define a UTI; pain on urination, suprapubic pain (pain in the area of the urinary bladder) or acute costovertebral angle (abdominal area) pain. A facility policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, documented: .As a part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review .by .a designee .The .designee will review antibiotic utilization .and identify specific situations that are not consistent with the appropriate use of antibiotics .Therapy may require .changes if .Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics . 1. Resident #103 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/09/19, documented she was moderately impaired in cognitive skills for daily decision making. She required extensive assistance from one staff member with toileting and hygiene. She was frequently incontinent of bowel and bladder. She did not have a urinary catheter. A nurse's progress note, dated 10/20/19 at 2:02 p.m., documented she was transferred to a local emergency department after experiencing slurred speech. A nurse's progress note, dated 10/20/19 at 7:00 p.m., documented the resident returned to the facility with a new order, .to start [MEDICATION NAME] (an antibiotic) 300 mg (milligrams) PO (by mouth) every 12 hours x (for) 7 days for bladder infection . A physician's orders [REDACTED]. A vitals report log, dated 10/20/19 at 9:19 p.m., documented the resident's temperature was 97.6 'F (degrees Fahrenheit), indicating the resident did not have a fever. No other symptoms were documented in the resident's medical record indicating a urinary tract infection. A MAR (medication administration record), dated 10/21/19 through 10/24/19, documented the resident received seven doses of [MEDICATION NAME]. A final laboratory report, dated 10/24/19, documented a urine sample collected on 10/22/19 had not grown any bacteria. A handwritten note on the laboratory report documented the physician had been called with this information and had discontinued the antibiotic. A McGeer criteria infection assessment tool, dated 10/24/19, documented the resident had been started on [MEDICATION NAME] on 10/21/19; however, no criteria for infection had been selected on the assessment tool. The assessment tool documented UTI criteria had not been met, and the antibiotic had been discontinued on 10/24/19. A surveillance of infections/antibiotics form, dated 10/24/19, documented the resident had symptoms of a change in mental status prior to starting [MEDICATION NAME] on 10/22/19, and the antibiotic was discontinued on 10/24/19 because McGeer criteria were not met. An infection control note, dated 10/25/19 at 10:49 a.m., documented .[MEDICATION NAME] discontinued 10/24/19. McGeer criteria not met for UTI (urinary tract infection). 2. Resident #111 had a [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/08/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance from one staff member with toileting and hygiene. She was frequently incontinent of bowel and occasionally incontinent of urine. She did not have a urinary catheter. A nurse's progress note, dated 10/16/19 at 8:31 a.m., documented, .slightly elevated temp (temperature) @ (at) 99.3. (99.3 degrees Fahrenheit) (Named Physician#1) doctor faxed .a request for a UA (urinalysis laboratory test) for possible UTI (urinary tract infection) . A urinalysis laboratory report, dated 10/16/19 at 10:03 a.m., documented an abnormal slightly elevated leukocyte esterase count (indicating white blood cells). A normal urine leukocyte esterase count would have been negative. The resident's clinical record documented no other criteria of a urinary tract infection. There was no documentation a McGeer's assessment tool had been completed to determine if the resident met criteria to begin an antibiotic. A physician's orders [REDACTED].[MEDICATION NAME] (an antibiotic) .500 mg .1 tablet by mouth BID (two times a day) x 5 days for UTI A MAR, dated 10/16/19 through 10/20/19, documented she received eight doses of [MEDICATION NAME]. A surveillance of infections/antibiotics form, dated 10/21/19, documented the resident had symptoms of confusion prior to starting [MEDICATION NAME] on 10/16/19. The assessment documented the antibiotic was discontinued on 10/20/19 because McGeer criteria were not met. An infection control note, dated 10/21/19 at 8:40 a.m., documented, .Culture results received from 10/16/19 .McGeer criteria not met for UTI. ABT (antibiotic) discontinued on 10/20/19 . 3. Resident #164 had a [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/16/19, documented the resident was moderately impaired in cognitive skills for daily decision making. She was independent with toileting and hygiene. She was always continent of bowel and bladder. She did not have a urinary catheter. A vitals report log, dated 08/29/19 at 7:52 a.m., documented the resident's temperature was 97.8 'F indicating the resident did not have a fever. The resident's clinical record documented no other symptoms indicating a urinary tract infection prior to the start of the antibiotic. A preliminary urinalysis laboratory report, dated 08/29/19, documented the presence of bacteria in the urine. A normal urine would have had no bacteria. A handwritten note documented an order for [REDACTED]. A MAR indicated [REDACTED]. A final urinalysis laboratory report, dated 08/30/19, documented, .polymicrobial (many different kinds of bacteria) growth consistent with normal urethral floral or colonizing bacteria . A McGeer criteria infection assessment tool, dated 08/30/19, documented the resident had been started on [MEDICATION NAME] on 08/30/19. However, the assessment tool was incomplete as only pain with urination had been selected as a symptom and the additional required microbiology laboratory symptoms had been left blank. The assessment tool documented UTI criteria had not been met, and the antibiotic had been discontinued on 08/30/19. A surveillance of infections/antibiotics form, dated 09/02/19, documented she had symptoms of pain (site of pain undefined) prior to starting [MEDICATION NAME] on 08/29/19. The assessment documented the antibiotic was discontinued on 08/30/19 because McGeer criteria were not met. A nurse's note, dated 09/07/19 at 11:24 p.m., documented the resident stated her lower abdomen hurt. The note documented the pain scale was explained to her, and she rated her pain at a 3 on a scale of 0-10. The note documented her temperature was 98.8 'F indicating she did not have an elevated temperature. A MAR, dated 09/07/19 through 09/09/19, documented the resident received three doses of [MEDICATION NAME] 500 mg tablets. A final urinalysis laboratory report, dated 09/08/19, documented, .polymicrobial (many different kinds of bacteria) consistent with normal . A McGeer criteria infection assessment tool, dated 09/09/19, documented the resident had been started on [MEDICATION NAME] on 09/07/19. However, no criteria for infection had been selected on the assessment tool. The assessment documented UTI criteria had not been met, and the antibiotic had been discontinued on 09/09/19. A surveillance of infections/antibiotics form, dated 09/10/19, documented she had symptoms of milky urine prior to starting [MEDICATION NAME] on 09/07/19, and the antibiotic was discontinued because McGeer criteria were not met. On 10/30/19 at 12:23 p.m., the infection control RN (registered nurse) was asked if the facility was implementing their antibiotic stewardship program. She said, Yes, we are following the antibiotic protocol. She was informed of the findings with residents #103, 111 and #164 where antibiotics had been started without required criteria documented on the McGeer's assessment tool. She was shown the instances where antibiotics had been started prior to receiving culture results. She was shown when results came back negative antibiotics were then stopped. She acknowledged the concerns. She stated the facility physicians were not following the program. She stated if a resident went to the hospital and came back with an order for [REDACTED]. She acknowledged the residents were administered antibiotics without indications for use. At 2:25 p.m., the DON and the corporate nurse consultant reviewed the concerns relate to antibiotic use for the residents. They stated they had misunderstood. They stated they thought they should initiate the antibiotics before cultures were received and discontinue later if they needed to due to negative culture results. They acknowledged the concerns.

Based on observations, record reviews, and interviews, it was determined the facility failed to ensure: a. medications were labeled with current MEDICATION ORDERS FOR [REDACTED] b. medications were packaged or in containers labeled in the medication carts for two (medication cart for hall 100/200 and medication cart for hall 600/700) of five medication carts observed for medication storage. The DON (director of nurses) identified 119 who received medications from the facility. c. a physician's orders [REDACTED].#31) for one (medication cart for hall 300/400) of five medication carts observed for medication storage. The DON identified three residents who had physician's orders [REDACTED]. Findings: A facility policy titled, Labeling of Medication documented: .Labeling for legend medications must be typed or printed and clearly indicate the resident's full name, prescription number, name and strength of drug, route, quantity of drug, date dispensed, expiration date of all the time dated drugs, lot number, Physicians name, address and telephone number of the pharmacy supplying the medications, the directions for taking the medication and any other pertinent information as may be needed or required .When directions for use are no longer current, and a LABEL CHANGE STICKER is applied to the pharmacy label on the medication container. The medication may be used until gone . A facility policy titled, Storage of Medications documented: .Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals . 1. On 10/30/19 at 8:35 a.m., CMA (certified medication aid) #1 was observed while she prepared and administered resident #362 medications. The medication label documented, Paricalcitol (an [MEDICAL CONDITION] medication) 1 MCG (microgram), give two tablets (two micrograms) by mouth each day. A physician's orders [REDACTED]. She was then asked if the medication was labeled correctly. She stated it was not correct. At 2:25 p.m., the DON was asked if medication labels should reflect the current physician's orders [REDACTED]. She further stated if there was a change in physician's orders [REDACTED]. 2. On 10/30/19 at 10:39 a.m., the medication cart on hall 600/700 was observed with CMA #2. An unpackaged, loose pill was found stored in the cart. She was asked if she knew what type of pill was found and who it belonged to. She stated she did not. At 8:12 a.m., the medication cart on hall 100/200 was observed with CMA #3. Two unpackaged, loose pills were found stored in the cart. She was asked if she knew what type of pills were found and who they belonged to. She stated she did not. At 2:25 p.m., the DON was asked should loose pills be stored on the medication cart without packaging and labels. She stated no loose pills should be stored in containers or packages which have labels. 3. On 10/30/19 at 11:50 a.m., the medication cart on hall 300/400 was observed with LPN (licensed practical nurse) #2. One bottle of acetic acid solution for resident #31 was dated 10/14/19 to be discarded. She was asked should the out dated solution be used for resident care. She stated it should not and it should have been discarded. At 2:25 p.m., the DON was asked should you flush a catheter with a physician's orders [REDACTED]. She stated no they should discard the solution

Based on interviews and record reviews, it was determined the facility failed to ensure residents were not administered antibiotics without indications for use for three (#103, 111, and #164) of five sampled residents reviewed for unnecessary medications. The DON (director of nurses) identified 37 residents who were administered antibiotics in the last 90 days. Findings: A facility assessment tool titled, Revised McGeer Criteria, documented criteria defining urinary tract infections for residents with and without a urinary catheter. For a resident without a urinary catheter, no symptom criteria listed on the McGeer assessment tool included a change in mental status or confusion as a criteria defining a urinary tract infection. For a resident without a urinary catheter, there were no criteria symptoms which included milky urine. For a resident without a urinary catheter, pain alone was not listed as a defining criteria for a UTI. The following pain symptoms could have been included along with other required symptoms to define a UTI; pain on urination, suprapubic pain (pain in the area of the urinary bladder) or acute costovertebral angle (abdominal area) pain. 1. Resident #103 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/09/19, documented she was moderately impaired in cognitive skills for daily decision making. She required extensive assistance from one staff member with toileting and hygiene. She was frequently incontinent of bowel and bladder. She did not have a urinary catheter. A nurse's progress note, dated 10/20/19 at 2:02 p.m., documented she was transferred to a local emergency department after experiencing slurred speech. A nurse's progress note, dated 10/20/19 at 7:00 p.m., documented the resident returned to the facility with a new order, .to start [MEDICATION NAME] (an antibiotic) 300 mg (milligrams) PO (by mouth) every 12 hours x (for) 7 days for bladder infection . A physician's orders [REDACTED]. A vitals report log, dated 10/20/19 at 9:19 p.m., documented the resident's temperature was 97.6 'F (degrees Fahrenheit), indicating the resident did not have a fever. No other symptoms were documented in the resident's medical record indicating a urinary tract infection. A MAR (medication administration record), dated 10/21/19 through 10/24/19, documented the resident received seven doses of [MEDICATION NAME]. A final laboratory report, dated 10/24/19, documented a urine sample collected on 10/22/19 had not grown any bacteria. A handwritten note on the laboratory report documented the physician had been called with this information and had discontinued the antibiotic. A McGeer criteria infection assessment tool, dated 10/24/19, documented the resident had been started on [MEDICATION NAME] on 10/21/19; however, no criteria for infection had been selected on the assessment tool. The assessment tool documented UTI criteria had not been met, and the antibiotic had been discontinued on 10/24/19. A surveillance of infections/antibiotics form, dated 10/24/19, documented the resident had symptoms of a change in mental status prior to starting [MEDICATION NAME] on 10/22/19, and the antibiotic was discontinued on 10/24/19 because McGeer criteria were not met. An infection control note, dated 10/25/19 at 10:49 a.m., documented .[MEDICATION NAME] discontinued 10/24/19. McGeer criteria not met for UTI (urinary tract infection). 2. Resident #111 had a [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/08/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance from one staff member with toileting and hygiene. She was frequently incontinent of bowel and occasionally incontinent of urine. She did not have a urinary catheter. A nurse's progress note, dated 10/16/19 at 8:31 a.m., documented, .slightly elevated temp (temperature) @ (at) 99.3. (99.3 degrees Fahrenheit) (Named Physician#1) doctor faxed .a request for a UA (urinalysis laboratory test) for possible UTI (urinary tract infection) . A urinalysis laboratory report, dated 10/16/19 at 10:03 a.m., documented an abnormal slightly elevated leukocyte esterase count (indicating white blood cells). A normal urine leukocyte esterase count would have been negative. The resident's clinical record documented no other criteria of a urinary tract infection. There was no documentation a McGeer's assessment tool had been completed to determine if the resident met criteria to begin an antibiotic. A physician's orders [REDACTED].[MEDICATION NAME] (an antibiotic) .500 mg .1 tablet by mouth BID (two times a day) x 5 days for UTI A MAR, dated 10/16/19 through 10/20/19, documented she received eight doses of [MEDICATION NAME]. A surveillance of infections/antibiotics form, dated 10/21/19, documented the resident had symptoms of confusion prior to starting [MEDICATION NAME] on 10/16/19. The assessment documented the antibiotic was discontinued on 10/20/19 because McGeer criteria were not met. An infection control note, dated 10/21/19 at 8:40 a.m., documented, .Culture results received from 10/16/19 .McGeer criteria not met for UTI. ABT (antibiotic) discontinued on 10/20/19 . 3. Resident #164 had a [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/16/19, documented the resident was moderately impaired in cognitive skills for daily decision making. She was independent with toileting and hygiene. She was always continent of bowel and bladder. She did not have a urinary catheter. A vitals report log, dated 08/29/19 at 7:52 a.m., documented the resident's temperature was 97.8 'F indicating the resident did not have a fever. The resident's clinical record documented no other symptoms indicating a urinary tract infection prior to the start of the antibiotic. A preliminary urinalysis laboratory report, dated 08/29/19, documented the presence of bacteria in the urine. A normal urine would have had no bacteria. A handwritten note documented an order for [REDACTED]. A MAR indicated [REDACTED]. A final urinalysis laboratory report, dated 08/30/19, documented, .polymicrobial (many different kinds of bacteria) growth consistent with normal urethral floral or colonizing bacteria . A McGeer criteria infection assessment tool, dated 08/30/19, documented the resident had been started on [MEDICATION NAME] on 08/30/19. However, the assessment tool was incomplete as only pain with urination had been selected as a symptom and the additional required microbiology laboratory symptoms had been left blank. The assessment tool documented UTI criteria had not been met, and the antibiotic had been discontinued on 08/30/19. A surveillance of infections/antibiotics form, dated 09/02/19, documented she had symptoms of pain (site of pain undefined) prior to starting [MEDICATION NAME] on 08/29/19. The assessment documented the antibiotic was discontinued on 08/30/19 because McGeer criteria were not met. A nurse's note, dated 09/07/19 at 11:24 p.m., documented the resident stated her lower abdomen hurt. The note documented the pain scale was explained to her, and she rated her pain at a 3 on a scale of 0-10. The note documented her temperature was 98.8 'F indicating she did not have an elevated temperature. A MAR, dated 09/07/19 through 09/09/19, documented the resident received three doses of [MEDICATION NAME] 500 mg tablets. A final urinalysis laboratory report, dated 09/08/19, documented, .polymicrobial (many different kinds of bacteria) consistent with normal . A McGeer criteria infection assessment tool, dated 09/09/19, documented the resident had been started on [MEDICATION NAME] on 09/07/19. However, no criteria for infection had been selected on the assessment tool. The assessment documented UTI criteria had not been met, and the antibiotic had been discontinued on 09/09/19. A surveillance of infections/antibiotics form, dated 09/10/19, documented she had symptoms of milky urine prior to starting [MEDICATION NAME] on 09/07/19, and the antibiotic was discontinued because McGeer criteria were not met. On 10/30/19 at 12:23 p.m., the infection control RN (registered nurse) was asked to review the documentation of the antibiotic use for residents #103, 111, and #164. She was asked if the residents had signs/symptoms which warranted the use of the antibiotics according to the McGeer criteria. She stated they did not. She was shown the instances where antibiotics had been started prior to receiving culture results. She was shown when results came back negative antibiotics were then stopped. She acknowledged the concerns. She stated the facility physicians were not following the program. She stated if a resident went to the hospital and came back with an order for [REDACTED]. At 2:25 p.m., the DON and the corporate nurse consultant reviewed the concerns relate to antibiotic use for the residents. They stated they had misunderstood. They stated they thought they should initiate the antibiotics before cultures were received and discontinue later if they needed to due to negative culture results. They acknowledged the concerns.

Based on observations, record reviews, and interviews, it was determined the facility failed to: ~ change out oxygen supplies for two (#6 and #86) of three sampled residents reviewed for oxygen use; and ~ administer oxygen at the correct physician's orders [REDACTED].#6) of three sampled residents reviewed for oxygen use. The Resident Census and Conditions of Residents form, dated 10/28/19, documented 22 residents who had physician's orders [REDACTED]. Findings: A facility policy titled,Departmental (Respiratory Therapy) - Prevention of Infection, documented: .purpose .is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents .Check water levels of refillable humidifier units daily .Change the reservoir every month .Change the oxygen cannula and tubing every month . 1. Resident #6 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. physician's orders [REDACTED]. An annual assessment, dated 10/20/19, documented the resident was cognitively alert in skills for daily decision making. She required extensive assistance by one staff member for activities of daily living. The resident used oxygen therapy. A care plan, last revised on 10/22/19, documented, .PROBLEM: Resident has potential for ineffective airway clearance R/T (related to) Hx (history) of pneumonia impaired mobility related to [MEDICAL CONDITION] .APPROACH: Change and label humidifier bottle and tubing monthly as ordered .APPROACH: Change O2 (oxygen) tubing as ordered . APPROACH: Administer oxygen at 2-3L (two to three liters per minute) via N/C (nasal cannula) to keep SATS (saturation) above 90 % as needed. Observe oxygen precautions . On 10/28/19 at 10:00 a.m., the resident's oxygen concentrator was set at 2L (two liters) per nasal cannula. The oxygen humidification bottle was dated 09/05/19 and the oxygen tubing was undated. On 10/29/19 at 3:00 p.m., the resident's O2 concentrator had oxygen tubing dated 10/29/19 and the humidification bottle was dated 09/05/19. On 10/30/19 at 8:25 a.m., the resident's oxygen humidification bottle was dated 09/05/19. The resident entered the room from the dining room. She was seated up in a power chair with a portable O2 tank in use. She stated she used oxygen continuously. At 10:50 a.m., LPN #1 was asked how often was oxygen tubing changed out. She stated they were changed every week. She was asked how often were oxygen humidification bottles changed. She stated every month. She was asked who was responsible to change and label the oxygen tubing and humidification bottles. She stated the nurses were responsible. She was asked to observe the resident's oxygen tubing and humidification bottle. She stated the bottle was dated 09/05/19 and the tubing was dated 10/29/19. She was asked if the the humidification bottle should have been changed out. She stated yes. 2. Resident #86 had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A quarterly assessment, dated 10/03/19, documented the resident was moderately impaired in cognitive skills for daily decision making. She required set up to limited assistance with one staff member for activities of daily living. The resident used oxygen therapy. A physician's orders [REDACTED]. A care plan, last revised on 10/17/19, documented, .PROBLEM: Resident is at risk for complications related to [DIAGNOSES REDACTED]. Observe oxygen precautions .APPROACH: Change Humidifier bottle and check water level as ordered .APPROACH: Change O2 tubing as ordered . On 10/28/19 at 10:15 a.m., the resident's oxygen concentrator was observed at 3.5L/NC (three and a half liter per minute flow via nasal cannula). The humidification bottle was dated 07/09/19 and the oxygen tubing was undated. On 10/29/19 at 2:00 p.m., the resident was observed seated up in a w/c (wheelchair) in her room. The oxygen concentrator was at 3.5L/NC flow. The oxygen tubing was undated and the oxygen humidification bottle was dated 07/09/19. The resident stated she used oxygen continuously. On 10/30/19 at 8:30 a.m., the oxygen concentrator was at 3.5L/NC flow. The tubing was unlabeled and the humidification bottle was dated 07/09/19. At 10:50 a.m., LPN #1 was asked how often should oxygen tubing be changed. She stated they were changed every week. She was asked how often were oxygen humidification bottles changed. She stated every month. She was asked who was responsible to change and label the oxygen tubing and humidification bottles. She stated the nurses were responsible. She was asked to observe the resident's oxygen tubing and humidification bottle. She stated the bottle was dated 07/09/19 and the tubing was undated. She was asked if the humidification bottle should have been changed out. She said, Yes. She was asked if the tubing was labeled the date it was opened. She stated it was not and should have been. She was asked if the resident's flow rate of 3.5L was the correct physician's orders [REDACTED]. At 11:05 a.m., the DON (director of nurses) was asked how often the residents oxygen tubing and humidification bottles should be changed and labeled. She stated oxygen tubings were changed out weekly and the humidification bottles were changed monthly or as needed. She was asked if the oxygen tubing and humidification bottles should be labeled with the date when they were changed out. She stated yes. The DON was notified of the resident's oxygen supplies and acknowledge the concerns.

Based on interviews and record reviews, it was determined the facility failed to investigate or thoroughly investigate and maintain documentation of investigations for allegations of abuse for two (#40 and #111) of two sampled residents reviewed for abuse. The Resident Census and Conditions of Residents form, dated 10/28/19, identified 119 residents who resided in the facility. Findings: A facility policy titled, Abuse Prohibition Policy, documented: .Identification of Abuse .Identification of events (such as suspicious bruising of residents), occurrences, suspicions, patterns and trends that may constitute abuse shall be reported to the facility administrator, the nursing director, local law enforcement, and the OSDH . Investigation of Abuse .All reports of potential abuse will be investigated by the administrator and/or nursing director according to policy . Follow-up action/documentation .The investigation must be documented from the initial report to completion of the investigation. Any action taken with any party involved must be recorded. The content and results of the investigation should be kept confidential in an administrative file. Any follow-up with the resident/family or resident's representative, including feedback, must be recorded . 1. Resident #40 had [DIAGNOSES REDACTED]. A significant change assessment, dated 08/20/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required total to extensive assistance from staff with all her activities of daily living. physician's orders [REDACTED]. A nurse's progress note, dated 09/19/19, documented the resident had a small bruised hematoma to her left eye. Mild tenderness was observed upon palpation. The note documented a CNA (certified nurse aide) observed the bruised hematoma at breakfast time and the cause was unknown. The resident's physician was in the building and was notified of the hematoma. A facility incident report, dated 09/19/19, documented the description of the incident as hematoma to left eye. The report documented the cause of the injury was unknown. A physician notification facsimile report, dated 09/20/19, documented, Per IDT (interdisciplinary team) meeting this morning we discussed resident's recent hematoma to L (left) eye. During meeting, (Named QA (quality assurance) LPN (licensed practical nurse)) and IC (Infection Control RN (registered nurse)) assessed it further and noticed a new fluid filled bump on resident's forehead which has a bluish tint around it. We were wanting to see if you (Physician #1) .can take a look at it next time you're up because it doesn't look like it's from trauma. Also, we are unable to find any areas of concern upon environmental eval (evaluation) .(signed IC (infection control) RN) . (handwritten physician response) I already looked at it yesterday. Doesn't look like from trauma. Will eval again next week if still there .(09/20/19) . A nurse's progress note, dated 09/20/19, documented the staff continued observations for a hematoma to the resident's left upper eye. The note documented the area was slightly tender to touch and no other injuries noted. On 10/28/19, the resident's clinical record was reviewed from 08/19/19 to 09/19/19. There was no documentation of a fall during the time period reviewed. At 10:00 a.m., the DON (director of nurses) was asked to provide OSDH incident reports for the previous three months including documentation of investigations for the incidents. At 10:20 a.m., the facility reported OSDH incident reports were reviewed. There was no further documentation the facility had investigated the injury of unknown origin to rule out abuse. On 10/30/19 at 9:50 a.m., the administrator was asked what types of injuries of unknown origin were considered suspicious in nature and investigated to rule out possible abuse. She said, Any injury that we don't know what happened. We report it and investigate it to find out what happened. She was asked if a hematoma to the upper eye with an unknown origin should have been investigated. She said, Yes. The administrator was asked to review the nurse's progress notes and facility incident report for the hematoma which developed on the resident's left upper eye. She stated the injury was investigated because the physician assessed the resident and felt the hematoma was not due to trauma. She then said, We thought maybe she bumped her head. She was asked to provide the documentation of a thorough investigation related to the resident's injury of unknown origin. She stated she would look and find the documentation. At 10:57 a.m., the administrator returned to the surveyor room with three other staff members including; the IC RN, the QA LPN, and the corporate consultant. The IC RN stated she had typed a scenario of the occurrences during the IDT meeting on 09/20/19. The IC RN statement, incident date 09/20/19, documented the following: .during IDT, reviewed notes of what appeared to be a fluid filled bump with discoloration to (Named resident #40) left eye. During IDT, (Named IC RN and QA LPN) assessed resident's left eye and assessed resident's physical environment. After IDT meeting, (Named CNA #5 and LPN #3) interviewed. (Named Physician #1) was then faxed after IDT Meeting regarding assessment of resident and environmental survey. (Named Physician #1) responds to fax, stating 'I already looked at it yesterday. Doesn't look like from trauma. Will eval again next week if still there.' Maintenance removed repositioning bar by bed as a precautionary measure .(signed IC RN). The administrator was asked if during the investigation interviews were conducted with staff who were working and assigned to the resident. She was asked if residents were interviewed, who were cared for by the same staff, to determine if there were related concerns and if the residents felt safe. The QA LPN stated she had conducted interviews with staff and residents. She was asked if she documented the questions asked and the responses. She said, No, we did not. The administrator was notified the facility must maintain documentation of a complete and thorough investigation when investigating allegations of abuse. She was notified allegations of suspected abuse must be thoroughly investigated to determine if allegations were substantiated or unsubstantiated. 2. Resident #111 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/08/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance from staff with her activities of daily living. A nurse's progress note, dated 10/16/19 at 11:44 a.m., documented, Resident was seen w/ (with) hands around another residents neck x (times) 2, resident states that the other resident has her babies/cats & (and) rabbits. Resident redirected both times & completely separated from other resident . On 10/30/19 at 12:00 p.m., the DON was asked to provide an OSDH incident report and completed investigation for the resident to resident altercation documented in the nurse's progress note on 10/16/19. At 12:20 p.m., the DON stated there was no investigation completed for the documented resident to resident altercation. She stated she had just spoken to the nurse who documented the altercation. She stated the nurse reported the resident was not forceful when she placed her hands around another resident's neck two times. She repeated the incident was not investigated. She reported the nurse who wrote the note did not notify administration staff of the altercation. At 2:20 p.m., the administrator was asked if an incident of another resident placing their hands around another resident's neck should have been reported investigated. She said, Yes, we would have investigated. She was notified a thorough investigation must be conducted and documented for all allegations of abuse, regardless of injury. She acknowledged the concerns. She reported the resident to resident altercation was not investigated for the resident.

Based on interviews and record reviews, it was determined the facility failed to: ~ ensure a suspicious injury of unknown origin was reported to the OSDH (Oklahoma State Department of Health) for one (#40) of one sampled resident reviewed with an injury of unknown origin; and ~ report a resident to resident altercation to the OSDH for one (#111) of two sampled residents reviewed for abuse. The Resident Census and Conditions of Residents form, dated 10/28/19, identified 119 residents who resided in the facility. Findings: A facility policy titled, Abuse Prohibition Policy, documented: .Identification of Abuse .Identification of events (such as suspicious bruising of residents), occurrences, suspicions, patterns and trends that may constitute abuse shall be reported to the facility administrator, the nursing director, local law enforcement, and the OSDH . Reporting/Response to alleged violations .All alleged violations and all substantiated incidents will be reported to the appropriate authorities and state agencies as required according to the Investigation of Abuse Policy . Reports shall include the following .Summary of exactly what happened: Name all persons involved and attach witness(es) statements . OSDH Reporting Information .All reports to the Department shall be made by telephone or facsimile within twenty-four (24) hours of the reportable incident unless otherwise noted . 1. Resident #40 had [DIAGNOSES REDACTED]. A significant change assessment, dated 08/20/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required total to extensive assistance from staff with all her activities of daily living. physician's orders [REDACTED]. A nurse's progress note, dated 09/19/19, documented the resident had a small bruised hematoma to her left eye. Mild tenderness was observed upon palpation. The note documented a CNA (certified nurse aide) observed the bruised hematoma at breakfast time and the cause was unknown. The resident's physician was in the building and was notified of the hematoma. A facility incident report, dated 09/19/19, documented the description of the incident as hematoma to left eye. The report documented the cause of the injury was unknown. A physician notification facsimile report, dated 09/20/19, documented, Per IDT (interdisciplinary team) meeting this morning we discussed resident's recent hematoma to L (left) eye. During meeting, (Named QA (quality assurance) LPN (licensed practical nurse)) and IC (Infection Control RN (registered nurse)) assessed it further and noticed a new fluid filled bump on resident's forehead which has a bluish tint around it. We were wanting to see if you (Physician #1) .can take a look at it next time you're up because it doesn't look like it's from trauma. Also, we are unable to find any areas of concern upon environmental eval (evaluation) .(signed IC (infection control) RN) . (handwritten physician response) I already looked at it yesterday. Doesn't look like from trauma. Will eval again next week if still there .(09/20/19) . A nurse's progress note, dated 09/20/19, documented the staff continued observations for a hematoma to the resident's left upper eye. The note documented the area was slightly tender to touch and no other injuries noted. On 10/28/19, the resident's clinical record was reviewed from 08/19/19 to 09/19/19. There was no documentation of a fall during the time period reviewed. At 10:00 a.m., the DON (director of nurses) was asked to provide OSDH incident reports for the previous three months. At 10:20 a.m., the facility reported OSDH incident reports were reviewed. There was no documentation the facility had reported the injury of unknown origin for the resident to the OSDH. On 10/30/19 at 9:50 a.m., the administrator was asked what types of injuries of unknown origin were considered suspicious in nature and reported to the OSDH. She said, Any injury that we don't know what happened. We report it. She was asked if a hematoma to the upper eye with an unknown origin should have been reported. She said, Yes. The administrator was asked to review the nurse's progress notes and facility incident report for the hematoma which developed on the resident's left upper eye. She stated the injury of unknown origin should have been reported to the OSDH and it was not. At 10:57 a.m., the administrator returned to the surveyor room with three other staff members including; the IC RN, the QA LPN, and the corporate consultant. The IC RN stated she had typed a scenario of the occurrences during the IDT meeting on 09/20/19. The IC RN statement, incident date 09/20/19, documented the following: .during IDT, reviewed notes of what appeared to be a fluid filled bump with discoloration to (Named resident #40) left eye. During IDT, (Named IC RN and QA LPN) assessed resident's left eye and assessed resident's physical environment. After IDT meeting, (Named CNA #5 and LPN #3) interviewed. (Named Physician #1) was then faxed after IDT Meeting regarding assessment of resident and environmental survey. (Named Physician #1) responds to fax, stating 'I already looked at it yesterday. Doesn't look like from trauma. Will eval again next week if still there.' Maintenance removed repositioning bar by bed as a precautionary measure .(signed IC RN). The administrator stated the administration staff did not feel they needed to report the bruise/hematoma to the resident's left eye because the physician stated it was probably not trauma related. She was notified the injury was suspicious in nature due to location and it was of an unknown origin and should have been reported to the OSDH. She was notified the physician assessment was part of the investigation the facility had conducted related to the injury. She was notified allegations of suspected abuse must be reported to the OSDH. 2. Resident #111 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/08/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance from staff with her activities of daily living. A nurse's progress note, dated 10/16/19 at 11:44 a.m., documented, Resident was seen w/ (with) hands around another residents neck x (times) 2, resident states that the other resident has her babies/cats & (and) rabbits. Resident redirected both times & completely separated from other resident . On 10/30/19 at 12:00 p.m., the DON was asked to provide an OSDH incident report for the resident to resident altercation documented in the nurse's progress note on 10/16/19. At 12:20 p.m., the DON stated there was no OSDH incident report completed for the documented resident to resident altercation. She stated she had just spoken to the nurse who documented the altercation. She stated the nurse reported the resident was not forceful when she placed her hands around another resident's neck two times. She repeated the incident was not reported. She reported the nurse who wrote the note did not notify administration staff of the altercation. At 2:20 p.m., the administrator was asked if an incident of another resident placing their hands around another resident's neck should have been reported to the OSDH. She said, Yes, we would have investigated. She further stated the facility had not been reporting allegations of abuse including resident to resident altercations unless there was an injury or the allegation was substantiated and determined it was abuse. She was notified all allegations of abuse, regardless of injury, must be reported to the OSDH. She was notified the process of the investigation would determine whether the allegation was substantiated or not, but regardless all allegations must be reported to the OSDH. She acknowledged the concerns.

Based on interviews and record reviews, it was determined the facility failed to implement their abuse policy for: ~ a suspicious injury of unknown origin for one (#40) of one sampled resident reviewed with an injury of unknown origin; and ~ a resident to resident altercation for one (#111) of two sampled residents reviewed for abuse. This included the facility's failure to; report allegations of abuse to the OSDH (Oklahoma State Department of Health) and investigate or thoroughly investigate allegations of abuse. The Resident Census and Conditions of Residents form, dated 10/28/19, identified 119 residents who resided in the facility. Findings: A facility policy titled, Abuse Prohibition Policy, documented: .Identification of Abuse .Identification of events (such as suspicious bruising of residents), occurrences, suspicions, patterns and trends that may constitute abuse shall be reported to the facility administrator, the nursing director, local law enforcement, and the OSDH . Investigation of Abuse .All reports of potential abuse will be investigated by the administrator and/or nursing director according to policy. Action will be taken to protect any potential victim(s) identified during the investigation . Reporting/Response to alleged violations .All alleged violations and all substantiated incidents will be reported to the appropriate authorities and state agencies as required according to the Investigation of Abuse Policy . Reports shall include the following .Summary of exactly what happened: Name all persons involved and attach witness(es) statements . OSDH Reporting Information .All reports to the Department shall be made by telephone or facsimile within twenty-four (24) hours of the reportable incident unless otherwise noted . Follow-up action/documentation .The investigation must be documented from the initial report to completion of the investigation. Any action taken with any party involved must be recorded. The content and results of the investigation should be kept confidential in an administrative file. Any follow-up with the resident/family or resident's representative, including feedback, must be recorded . 1. Resident #40 had [DIAGNOSES REDACTED]. A significant change assessment, dated 08/20/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required total to extensive assistance from staff with all her activities of daily living. physician's orders [REDACTED]. A nurse's progress note, dated 09/19/19, documented the resident had a small bruised hematoma to her left eye. Mild tenderness was observed upon palpation. The note documented a CNA (certified nurse aide) observed the bruised hematoma at breakfast time and the cause was unknown. The resident's physician was in the building and was notified of the hematoma. A facility incident report, dated 09/19/19, documented the description of the incident as hematoma to left eye. The report documented the cause of the injury was unknown. A physician notification facsimile report, dated 09/20/19, documented, Per IDT (interdisciplinary team) meeting this morning we discussed resident's recent hematoma to L (left) eye. During meeting, (Named QA (quality assurance) LPN (licensed practical nurse)) and IC (Infection Control RN (registered nurse)) assessed it further and noticed a new fluid filled bump on resident's forehead which has a bluish tint around it. We were wanting to see if you (Physician #1) .can take a look at it next time you're up because it doesn't look like it's from trauma. Also, we are unable to find any areas of concern upon environmental eval (evaluation) .(signed IC (infection control) RN) . (handwritten physician response) I already looked at it yesterday. Doesn't look like from trauma. Will eval again next week if still there .(09/20/19) . A nurse's progress note, dated 09/20/19, documented the staff continued observations for a hematoma to the resident's left upper eye. The note documented the area was slightly tender to touch and no other injuries noted. On 10/28/19, the resident's clinical record was reviewed from 08/19/19 to 09/19/19. There was no documentation of a fall during the time period reviewed. At 10:00 a.m., the DON (director of nurses) was asked to provide OSDH incident reports for the previous three months. At 10:20 a.m., the facility reported OSDH incident reports were reviewed. There was no documentation the facility had reported the injury of unknown origin for the resident to the OSDH. There was no further documentation the facility had investigated the injury of unknown origin to rule out possible abuse. On 10/30/19 at 9:50 a.m., the administrator was asked what types of injuries of unknown origin were considered suspicious in nature and reported to the OSDH and investigated to rule out possible abuse. She said, Any injury that we don't know what happened. We report it and investigate it to find out what happened. She was asked if a hematoma to the upper eye with unknown origin should have been reported and investigated. She said, Yes. The administrator was asked to review the nurse's progress notes and facility incident report for the hematoma which developed on the resident's left upper eye. She stated the incident was not reported to the OSDH. She stated the injury was investigated because the physician assessed the resident and felt the hematoma was not due to trauma. She then said, We thought maybe she bumped her head. She was asked to provide the documentation of a thorough investigation related to the resident's injury of unknown origin. She stated she would look and find the documentation. She then stated the injury of unknown origin should have been reported to the OSDH and it was not. At 10:57 a.m., the administrator returned to the surveyor room with three other staff members including; the IC RN, the QA LPN, and the corporate consultant. The IC RN stated she had typed a scenario of the occurrences during the IDT meeting on 09/20/19. The IC RN statement, incident date 09/20/19, documented the following: .during IDT, reviewed notes of what appeared to be a fluid filled bump with discoloration to (Named resident #40) left eye. During IDT, (Named IC RN and QA LPN) assessed resident's left eye and assessed resident's physical environment. After IDT meeting, (Named CNA #5 and LPN #3) interviewed. (Named Physician #1) was then faxed after IDT Meeting regarding assessment of resident and environmental survey. (Named Physician #1) responds to fax, stating 'I already looked at it yesterday. Doesn't look like from trauma. Will eval again next week if still there.' Maintenance removed repositioning bar by bed as a precautionary measure .(signed IC RN). The administrator was asked if during the investigation interviews were conducted with staff who were working and assigned to the resident. She was asked if residents were interviewed, who were cared for by the same staff, to determine if there were related concerns and if the residents felt safe. The QA LPN stated she had conducted interviews with staff and residents. She was asked if she documented the questions asked and the responses. She said, No, we did not. The administrator was notified the facility must maintain documentation of a complete and thorough investigation when investigating allegations of abuse. The administrator then stated the administration staff did not feel they needed to report the bruise/hematoma to the resident's left eye because the physician stated it was probably not trauma related. She was notified the injury was suspicious in nature due to location and it was of an unknown origin and should have been reported to the OSDH. She was notified the physician assessment was part of the investigation the facility had conducted related to the injury. She was notified allegations of suspected abuse must be reported to the OSDH and a thorough investigation must be completed to determine if allegations were substantiated or unsubstantiated. 2. Resident #111 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/08/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance from staff with her activities of daily living. A nurse's progress note, dated 10/16/19 at 11:44 a.m., documented, Resident was seen w/ (with) hands around another residents neck x (times) 2, resident states that the other resident has her babies/cats & (and) rabbits. Resident redirected both times & completely separated from other resident . On 10/30/19 at 12:00 p.m., the DON was asked to provide an OSDH incident report for the resident to resident altercation documented in the nurse's progress note on 10/16/19. At 12:20 p.m., the DON stated there was no OSDH incident report completed for the documented resident to resident altercation. She stated she had just spoken to the nurse who documented the altercation. She stated the nurse reported the resident was not forceful when she placed her hands around another resident's neck two times. She repeated the incident was not reported and no investigation was conducted. She reported the nurse who wrote the note did not notify administration staff of the altercation. At 2:20 p.m., the administrator was asked if an incident of another resident placing their hands around another resident's neck should have been reported to the OSDH and investigated. She said, Yes, we would have investigated. She further stated the facility had not been reporting allegations of abuse including resident to resident altercations unless there was an injury or the allegation was substantiated and determined it was abuse. She was notified all allegations of abuse, regardless of injury, must be reported to the OSDH and a thorough investigation must be conducted and documented. She was notified the process of the investigation would determine whether the allegation was substantiated or not, but regardless all allegations must be reported to the OSDH. She acknowledged the concerns. She reported the resident to resident altercation was neither reported or investigated for the resident.

Based on observations, record reviews, and interviews, it was determined the facility failed to provide sufficient supervision to ensure residents were transferred in a safe manner for two (#4 and #25) of three sampled residents who were observed during transfers. The DON (director of nurses) identified 11 residents who required assistance of two staff members during a mechanical lift transfer. Findings: A facility policy titled, Safe Lifting and Movement of Residents, documented: .to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents . The mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary . 1. Resident #4 had [DIAGNOSES REDACTED]. A care plan, last updated 08/01/19, documented, Problem .Total dependent with .transfers . Goal .allow resident to perform ADLs (activities of daily living) to his/her capability safely .while providing appropriate assistance . A quarterly assessment, dated 10/18/19, documented the resident was cognitively alert in skills for daily decision making. He required total dependence of two staff members with transfers. On 10/30/19 at 9:16 a.m., the resident was observed lying in his bed. CNA (certified nursing assistant) #2 was observed entering the resident's room by herself with a mechanical lift. At 9:21 a.m., CNA #2 was observed exiting the resident's room. The resident was observed lying in bed with the lift sling under the resident and the mechanical lift parallel to bed. At 9:27 a.m., CNA #2 returned to the resident's room accompanied by CNA #4. At 9:29 a.m., CNA #4 was observed exiting the resident's room and stated she would return. The resident was observed lying in bed with the lift sling under him. At 9:40 a.m., CNA #2 was observed exiting the resident's room and pushing the resident in a wheelchair. No additional staff had been observed entering the resident's room to assist with the lift transfer. At 9:43 a.m., CNA #4 returned to the resident's room. When asked what assistance she provided to resident, CNA #4 stated she had not assisted with the transfer of the resident and had informed the other staff she would return. CNA #4 stated the resident was still in the bed when she left the room. At 10:02 a.m., RN #1 was asked how staff were able to identify how residents should be transferred. She stated a care plan quick reference card was available inside the closet door in the residents' rooms. She stated the resident utilized a Hoyer lift and required assistance of two staff members for transfers. A care plan quick reference card was observed hanging on the inside of the resident's closet door. The reference card documented the resident utilized a Hoyer lift for transfers which required two staff members. At 10:07 a.m., CNA #2 was asked how she had assisted the resident from his bed to his wheelchair. She stated the resident required two person assistance with the mechanical lift and she had help in the room. She was asked if she had assisted the resident from his bed to his wheelchair without assistance. She said Yes. At 10:46 a.m., the DON was asked if it was acceptable for staff to utilize the mechanical lift without the assistance of another staff member during a resident transfer. She stated mechanical lifts can be utilized by one or two staff depending on the care plan of the individual resident. She was then asked if the resident required the assistance of two staff members for a lift transfer. She said, Yes. 2. Resident #25 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/12/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required total dependence of two staff members with transfers. On 10/28/19 at 9:45 a.m., CNA #2 was observed entering the resident's room with a mechanical lift. At 10:03 a.m., the resident's door was opened by CNA #2. The resident was observed in the sling of the mechanical lift elevated above bed. There were no additional staff members observed in the room. At 10:06 a.m., CNA #2 was observed again opening the resident's door. She then looked down hallway and said, I don't see no help. At 10:11 a.m., CNA #2 was observed exiting the resident's room. There were no additional staff members observed exiting the resident's room. The resident was observed sitting in wheelchair with her legs elevated. CNA #2 was asked if she had assisted the resident from her bed to her high-back wheel chair. She said, Yes. She was asked how she had assisted the resident from her bed to her high-back wheelchair. She stated she utilized the Hoyer lift. She further said, I know that she is two person for all of her care including transfer, but I know how to transfer her on my own. At 10:46 a.m., the DON was asked if it was acceptable for staff to utilize the mechanical lift without the assistance of another staff member. She stated mechanical lifts can be utilized by one or two staff depending on the care plan of the individual resident. She was then asked if the resident required the assistance of two staff members for a lift transfer. She said, Yes.

Based on observations, record reviews, and interviews, it was determined the facility failed to notify a resident's family member of a change in condition for one (#1) of five sampled residents reviewed for family member notification when a resident had a change in condition. The facility administrator identified 121 residents resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A comprehensive assessment, dated 01/31/19, documented the resident was mildly cognitively impaired for daily decision making skills and could make her needs known. The resident required limited to extensive assistance by one person for activities of daily living, used a wheelchair for mobility due to non weight bearing to the right lower extremity and was continent of bowel and bladder. A nursing progress note, dated 03/11/19, documented the resident was seen by the nurse practitioner at the bedside. An order to transport the resident to the hospital for further medical evaluation and treatment related to low blood pressure, increased heart rate, and weight gain was received. A facility form titled, Resident Transfer Form, dated 03/11/19, documented the resident was transferred via ambulance to the hospital (name with held). The form did not contain resident time of transport. The form documented the resident's relative had been notified of the transfer. On 03/26/19 at 12:30 p.m., a family member of the resident was interviewed by telephone. She was asked if the facility had informed her of the resident's transfer to the hospital on [DATE]. She stated she had not been notified by the facility and did not know the resident was in the hospital until she called the facility on 03/13/19 to check on the resident and was told the resident had been hospitalized . At 1:00 p.m., the resident's POA (power of attorney) was interviewed by telephone. She was asked if the facility had informed her of the resident's transfer to the hospital on [DATE]. She stated she did not know the resident had been transferred to the hospital, and later hospitalized until a family member called to inform her of the resident's status on 03/13/19. At 1:15 p.m., RN (registered nurse) #1 was asked if she had transferred the resident to the hospital on [DATE]. She stated she did. She was asked if she had informed the resident's family member or POA of the resident's change in condition or transfer to the hospital. She stated she had not. She further stated she had told the oncoming nurse at the change of shift and he stated he would do it right then. She was asked if she knew if the resident's family members had been notified. She stated she did not know. At 2:15 p.m., RN #2 was asked if he recalled the resident's transfer to the hospital on [DATE]. He stated the resident had been transferred to the hospital because of low blood pressure and increased weakness but he was not on duty or present when the resident was transported by the ambulance. He was asked if the nurse who was on duty at the time of the resident's transport had asked him to contact the resident's family members during the shift report. He stated he did not recall being asked to contact the family. He was asked if he had contacted the resident's family members to inform them of the resident's transfer to the hospital. He stated he had not. On 03/27/19 at 8:20 a.m., the director of nurses was asked when were resident family members notified of a resident change in condition or when a resident was transferred out of the facility. She stated family members were notified by the nurse on duty when a change in a resident's condition occurred or when the transfer summary was being completed prior to the transfer of a resident out of the facility. She was asked if the resident's family had been notified of the transfer out of the facility on 03/11/19. She stated the nurse who was on duty at that time documented on the transfer summary the family had been notified. She further stated the nurses should not document a family was contacted until after it occurred.