Every finding on record at Gracewood Health & Rehab

Based on record review and interview, the facility failed to ensure a resident was not physically abused by another resident for 1 (#79) of 4 sampled residents reviewed for abuse.The administrator identified 69 residents resided in the facility.A Resident to Resident Incidents policy, dated 01/2024, read in part, Upon admission to the facility, each person will be assessed through the MDS process to determine if they are at risk for abusing others.Care plans will address interventions designed to prevent occurrences.An Oklahoma State Department of Health final report, dated 05/11/25, showed a staff member witnessed Resident #79 pour water on Resident #61. Resident #61 then pushed Resident #79 causing them to fall. Resident #79 was sent to the hospital.An undated nurse note showed that around 5:30 p.m., Resident #79 was found yelling and was on the ground in the smoking area. Resident #79 stated Resident #61 pushed them down. The note showed, We tried to get [Resident #79] up but [Resident #79] said [they] could not get up as [they] were in great pain. The note showed Resident #61 stated to nurses that Resident #79 poured water on them, so they pushed Resident #79 away and Resident #79 fell. A hospital x-ray record, dated 05/11/25, showed Resident #79 sustained a fracture to their leg.An annual assessment, dated 02/23/26, showed Resident #61 had diagnoses that included bipolar, PTSD, depression, and anxiety. The assessment showed Resident #61 had a BIMS score of 12 which indicated moderate cognitive impairment. On 04/02/26, Resident #61's care plan was reviewed and did not show any behaviors. On 04/01/26 at 9:29 a.m., Resident #61 denied any altercations with staff or other residents and stated they felt safe in the facility.On 04/02/26 at 1:01 p.m., LPN #2 stated there was not a behavior care plan initiated for Resident #61 and there should have been. On 04/02/26 at 1:29 p.m., the administrator stated the investigation showed Resident #79 was the aggressor in the situation. The administrator stated Resident #61 was not a problem unless they did not get to smoke.

Based on observation, record review, and interview, the facility failed to ensure: a. food items were properly sealed, dated, and labeled; b. bulging containers were removed from circulation in the dry storage; c. ensure food preparation utensils were stored in a clean environment; and d. ensure areas near food preparation were clean and free from pests, including a microwave for resident use.The administrator identified 69 residents ate meals from the kitchen.Findings: On 03/31/26 at 10:15 a.m., kitchen utensils were observed to hang over the sink where dirty dishes were to be washed.On 03/31/26 at 10:18 a.m., the following items were observed in the refrigerator:A bag of square brown patties was observed with no label or date,a pitcher of orange liquid was observed with no label or date, a bag of chunks of meat with no label or date, a bag of tan circular patties was observed in an unsealed plastic bag with no label or date, anda cookie sheet of seven sandwiches was observed in the refrigerator with a date of 03/30/26 on the saran wrap, but the saran wrap was not sealed around the edge of the pan. On 03/31/26 at 10:21 a.m., three cans of green beans were observed without dates written on them. A plastic bottle of salad dressing was observed on the shelf with other foods. The plastic bottle was observed to bulge on the top and bottom. The bottle was observed to be so rounded that it was not sitting up straight on the shelf. On 03/31/26 at 10:28 a.m., the dietary manager removed the green beans from circulation when asked about the dates they were received. The dietary manager then threw away the bottle of salad dressing.On 03/31/26 at 11:41 a.m., four cockroach carcasses were observed in two of the drawers beneath the counter top where the blender was stored and used to puree foods to be provided to residents. The microwave was stationed next to the blender and was observed with food debris on all inside surfaces. A Food Receiving and Storage policy, revised 10/2025, read in part, All foods stored in the refrigerator or freezer will be covered, labeled and dated.Beverages must be dated when opened and discarded after twenty four hours.On 03/31/26 at 10:27 a.m., the dietary manager stated they thought the brown patties were fish. The dietary manager stated the pitcher was orange juice from breakfast, the round patties were cookies, and the other bag was fajita meat. The dietary manager stated I know I am supposed to put a label and date on this. The dietary manager stated they had just arrived at work and had not had a chance to do their rounds to pull things like leftovers out of circulation. On 03/31/26 at 10:28 a.m., the dietary manager stated hmm when asked about the bulging bottle of salad dressing. On 03/31/26 at 11:10 a.m., Dietary Aide #2 stated they used the utensils hanging above the sink often, so they were washed often.On 03/31/26 at 11:41 a.m., [NAME] #1 stated they cleaned the microwave every day, but the residents used it often. On 03/31/26 at 12:00 p.m., when shown the cockroaches in the drawer, cook #1 stated they did not use the drawers underneath the serving counter for anything because they had not served in that dining room in over a year. The cook stated they did not know whose job it was to keep the drawers clean. On 04/03/26 at 1:00 p.m., the ADON stated food should be labeled and dated, and anything that showed signs of a problem should be thrown out.

Based on observation and interview the facility failed to:a. ensure a safe and sanitary kitchen floor, b. residents were not served meals on paper products, andc. ensure hot water was available in their restroom for 1 (#21) of 17 sampled residents reviewed for access to hot water in their restroom. The administrator identified 69 residents ate from the kitchen. Findings: On 03/31/26 at 10:18 a.m., the tile floor between the two sinks on opposite sides of the kitchen was observed to have been ripped up and was filled in with gravel. On 03/31/26 at 11:01 a.m., [NAME] #2 stated All I can do is wipe down and sanitize as much as I can. A pipe busted that is what caused the flood and why the floor is busted and filled in with gravel.On 03/31/26 at 11:41 a.m., [NAME] #1 stated the floor had been filled in with gravel for a year since the flood happened. They stated they did the best they could to keep the floor clean.On 03/31/26 at 12:15 p.m., the food was observed to be plated onto paper plates. Plastic silverware was also observed.On 03/31/26 at 12:36 p.m., Resident # 21's restroom hot water was observed to not work. The sink was observed to be pulled away from wall with paint chips on the back of the sink and some on wall behind the sink where it had previously been touching. The paint on the wall was observed torn away around the sink, and the toilet lid was observed sitting below the sink and not on the back of the toilet.On 04/02/26 at 1:29 p.m., the administrator stated the dishwasher was not currently being used due to ongoing construction in the kitchen. The administrator stated the residents had been using paper products since last Friday, but were hoping to have the dishwasher running again soon.On 04/03/26 at 10:33 a.m., Resident #21 stated they did not want to change rooms, they just wanted hot water available to wash their face.On 04/03/26 at 10:46 a.m., the ADON stated they knew the hot water in Resident #21's room was an issue that needed to be addressed, but it was a financial issue, and the maintenance person could only do what they were approved to do. The ADON stated they would have to ask maintenance about the toilet and sink in Resident #21's restroom.

Based on record review and interview, the facility failed to provide a SNF ABN to 2 (#10 and #37) of 3 sampled residents reviewed for beneficiary notices. The administrator identified four residents discharged from the facility with Medicare benefit days remaining. Findings:1.A SNF Beneficiary Protection Notification Review form, showed Resident #10 was admitted to the facility on skilled services on 01/28/26, discharged from skilled services on 03/27/26, and remained in the facility.A SNF Beneficiary Protection Notification Review form, showed an ABN was not provided to the resident/representative.2.A SNF Beneficiary Protection Notification Review form, showed Resident #37 was admitted to the facility on skilled services on 12/29/25, discharged from skilled services on 03/27/26, and remained in the facility.A SNF Beneficiary Protection Notification Review showed an ABN was not provided to the resident/representative.On 04/06/26 at 2:12 p.m., LPN #2 stated they were not aware they had to have an ABN form if they remained in the facility after they were discharged from skilled services.

Based on record review and interview, the facility failed to ensure behaviors were addressed in the care plan for 1 (#61) of 17 sampled residents reviewed for care plans.The administrator identified 69 residents resided in the facility. An Oklahoma State Department of Health final report, dated 05/11/25, showed a staff member witnessed Resident #79 pour water on Resident #61. Resident #61 then pushed Resident #79 causing them to fall. An annual assessment, dated 02/23/26, showed Resident #61 had diagnoses which included bipolar, PTSD, depression, and anxiety. The assessment showed Resident #61 had a BIMS score of 12 which indicated moderate cognitive impairment. A nurse's note, dated 03/06/26, showed Resident #61 became upset when they were unable to go smoke during a tornado warning. Resident #61 threw water in the hall and onto another resident. A nurse's note, dated 03/07/26, showed Resident #61 tried to steal cigarettes from the bucket at the nurses station with the LPN at the desk. When Resident #61 was told to stop, they kicked the bucket, and grabbed the nurses forearm.A nurse's note, dated 03/08/26, showed Resident #61 screamed at another resident for sitting in their spot in the dining room. Resident #61 was then sent to the emergency room to be evaluated. A nurse's note, dated 03/09/26, showed that Resident #61 returned from the emergency room after 17 hours with a pleasant attitude after they were given a Benadryl and Ativan injection for aggressive behavior.On 04/02/26, Resident #61's care plan was reviewed and did not show any behaviors. On 04/01/26 at 9:29 a.m., Resident #61 denied any altercations with staff or other residents, and stated they felt safe in the facility.On 04/02/26 at 1:01 p.m., LPN #2 stated there was not a behavior care plan initiated and there should have been.

Based on observation, record review, and interview, the facility failed to ensure adequate supervision to prevent an elopement for 1 (#20) of 2 sampled residents reviewed for elopement.The administrator identified 21 residents resided in the memory care unit.Findings:On 03/31/26 at 11:29 a.m., Resident #20 was observed resting in bed with their eyes closed. No elopement behaviors were observed. On 04/01/26 at 9:37 a.m., Resident #20 was observed resting in bed with their cover pulled up over their head. No elopement behaviors were observed. On 04/01/26 at 1:55 p.m., Resident #20 was observed walking out of their room in their pajamas. Res #20 was pleasant and easily redirected to their room by staff to get dressed. No elopement behaviors were observed. An undated face sheet showed Resident #20 admitted to the facility with diagnoses which included Alzheimer's, dementia, protein-calorie malnutrition, and hypertension. An Elopement Risk Assessment, dated 01/09/26, showed Resident #20 was not an elopement risk. An admission assessment, dated 01/19/26, showed Resident #20 did not exhibit any wandering behaviors. The assessment showed Resident #20's cognition was severely impaired. On 03/23/26, a new elopement risk assessment was completed on Resident #20. Resident Safety Checks, dated 03/23/26, 03/24/26, 03/25/26, 03/26/26, and 03/27/26 showed one on one observation with every 15-minute documentation. On 03/23/26, the QA committee met and implemented safety monitoring for all residents. An in-service, dated 03/24/26, showed the facility staff were educated on the elopement policy/procedure. Staff were educated to not let residents follow them out the doors, to pay attention to residents following closely or standing at doors, ensure checks every two hours, report concerns immediately, and nurses to perform head check every two hours while residents were in bed. Resident #20's care plan, dated 04/01/26, showed interventions were implemented for elopement. On 03/31/26 at 11:29 a.m., CNA #1 stated the staff kept close tabs on where Resident #20 was at all times. On 04/06/26 at 3:00 p.m., the administrator stated the staff should have made sure no resident followed them out of the exit door.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for 1 (#11) of 1 sampled resident with a PEG tube observed during medication administration.The DON identified two residents had PEG tubes.Findings:On 04/01/26 at 2:00 p.m., LPN #1 was observed during administration of medications to Resident #11 through their PEG tube. LPN #1 was not observed to have utilized PPE, except for gloves. Signage indicating EBPs and required PPE was not observed near the resident's room. The Enhanced Barrier Precautions policy, dated August 2022, read in part, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents.EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tube .) .Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required.PPE is available outside of the resident rooms.A face sheet, dated 08/12/25, showed Resident #11 had diagnoses which included unspecified severe protein calorie malnutrition and dysphagia.A quarterly assessment, dated 02/11/26, showed Resident #11 had a PEG tube. On 04/01/26 at 2:11 p.m., LPN #1 stated they should have donned a gown prior to the administration of medications through Resident #11's PEG tube. LPN #1 stated the facility had not practiced the use of EBPs. LPN #1 stated PPE was not readily available for staff use for residents requiring EBPs. On 04/01/26 at 2:22 p.m., the infection preventionist stated EBPs were not being utilized in the facility. The infection preventionist stated staff education and implementation of EBPs were in progress.

Based on observation, record review, and interview, the facility failed to ensure residents were provided with privacy curtains. The administrator identified 78 residents resided at the facility. Findings: A Bedrooms policy, reviewed May 2024, read in part, Each room is designed to provide full visual privacy for each resident (in the form of ceiling suspended curtains that extend around the bed) and equipped for adequate nursing care On 01/06/25 at 4:26 p.m., room [ROOM NUMBER] was observed to have no privacy curtain. Resident #24 stated there was no privacy and all activities other than using the restroom were completed in full view of their roommate. On 01/07/25 at 11:52 a.m., room [ROOM NUMBER] was observed to have no privacy curtain. The room had two residents residing in the room. On 01/09/25 at 10:44 a.m., LPN #3 stated a curtain should be in room [ROOM NUMBER] to provide privacy and they did not know why one was not installed. On 01/09/25 at 11:09 a.m., the DON stated one of the resident's in room [ROOM NUMBER] required extensive assist. They stated privacy was provided by closing the door and pulling the curtain. The DON looked in room [ROOM NUMBER] and stated the room had work completed a month ago and maintenance had removed the curtain. They stated privacy was not provided effectively in room [ROOM NUMBER]. On 01/13/25 at 10:17 a.m., maintenance #1 stated they were responsible for the privacy curtains. They stated room [ROOM NUMBER] had no curtain track and they had brought the issue up previously. Maintenance #1 stated they did not know why room [ROOM NUMBER] had no tracks for privacy curtains. They stated neither resident had privacy. On 01/14/25 at 10:35 a.m. the DON stated they were working on the privacy issue. They stated tracking for the privacy curtains needed to be installed.

Based on observation, record review, and interview, the facility failed to ensure activities were provided for four (#18, 22, 26, and #42) of four sampled residents who were reviewed for activities. The administrator identified 78 residents who resided at the facility. Findings: An Activity Programs policy, revised August 2024, read in parts, Activity programs designed to meet the needs of each resident are available on a daily basis .designed to encourage maximum individual participation and are geared to the individual resident's needs .are scheduled 7 (seven) days a week. 1. Resident #18 had diagnoses which included chronic pain, obesity, and limited mobility. On 01/06/25 at 11:18 a.m., Resident #18 stated they could not go to activities because they did not have a wheelchair that worked. They stated the bottom of the wheelchair had a hole in it and was not comfortable, so they did not get up much. On 01/07/25 at 3:46 p.m., CNA #1 stated they did not know if activities were offered or not. On 01/07/25 at 3:47 p.m., RN #1 stated there was an activities person, but they did not know what they did in patient rooms for residents that did not leave their rooms. On 01/07/25 at 3:59 p.m., CMA #4 stated they did not know of or see any activities in resident rooms for those who did not leave their room. On 01/07/25 at 4:00 p.m., CNA #3 stated the activities person passed out coloring books to patients and read cards to them if they got them in the mail. On 01/08/25 3:18 p.m., the activities director stated they had personal relationships with staff and residents. They stated they ensured all residents were offered activities because they knew who did what. The activities director stated Resident #18 got out of their room and went to most of the activities. The activities director stated they checked on bed bound residents at least once or twice a week, visited with them, offered them coloring opportunities, games, nail painting and anything they may be interested in. They stated it would be documented on the activity flow sheet and when completed the flow sheet would be put in the resident record. On 01/09/25 at 9:44 a.m., CNA #4 stated Resident #18 only got up for showers and had no cushion for their wheelchair. The CNA stated the resident stated their wheelchair was very uncomfortable and if they had a comfortable wheelchair they might get up. On 01/09/25 at 10:40 a.m. LPN #1 stated Resident #18 did not like to get out of their room. They stated they had not had anyone tell them anything about the wheelchair for Resident #18 and had not looked at it themselves. On 01/09/25 at 10:45 a.m., RN #1 stated Resident #18 refused to get up for activities. They stated Resident #18 did say something to them about getting a better wheelchair. RN #1 stated the physical therapist or social services director would look at it if they needed more items. They stated they did ask Resident #18 why they did not want to get up and encouraged Resident #18 to try. RN # stated they would go up the chain of command to the DON for possibly getting something different for a resident and it would be charted in the shift report if issues were identified. On 01/09/25 at 10:57 a.m., the DON stated if there were an issue with a wheelchair they would have physical therapy look at it to evaluate it. The DON stated it was the facility's responsibility. On 01/09/25 at 11:14 a.m., the DON accompanied the surveyor to the room of Resident #18 and observed the condition of the wheelchair. They removed the wheelchair and stated they would replace it that day. 2. Resident #22 had diagnoses which included dementia and anxiety. The Care Plan, dated 07/10/24, documented Resident #22 was at risk for alteration in activities due to having little interest or pleasure in doing things related to diagnosis of dementia. The plan documented Resident #22 would maintain activity level and continue to be encouraged to participate in activities at least weekly through review date. The plan documented an intervention was that Resident #22 would maintain alternate methods to engage in sensory stimulation and to provide structured activity program for intellectual stimulation. The September 2024 activity calendar for Resident #22 documented exercise, music therapy, and social visit. The activity note, dated 09/30/24, documented Resident #22 passively attended activities. The note documented Resident #22 wandered the hall and visited with other residents. Resident #22 did not have the attention span to actively participate, but did occasionally watch television a few minutes at a time. The October 2024 activity calendar for Resident #22 documented exercise. An undated note documented Resident #22 loved to keep busy and walk the hall regularly for exercise. The November 2024 activity calendar for Resident #22 documented exercise and social visit. An undated note documented Resident #22 walked a lot for exercise and was unable to do many activities due to health. On 01/06/25 at 11:22 a.m., Resident #22 was observed in bed with their eyes closed and facing the wall and covered with a blanket. On 01/07/25 at 1:54 p.m., Resident #22 was observed in bed. No activity was occurring on the memory unit. On 01/08/25 at 9:15 a.m., Resident #22 was observed in bed, legs over the side of the bed with their feet on the floor, but laying over on their side facing the door. No activities were occurring on the memory unit. On 01/08/25 at 9:18 a.m., a CMA #1 reported Resident #22 was being sent out due to a change in condition. They stated the resident was sleeping more, not eating, or getting up. On 01/13/25 at 11:19 a.m., the activities director was asked what the program activities and goals were for Resident #22. The activities director stated they walked around and visited with Resident #22. They stated Resident #22 would watch, but not get involved. The activity director stated they did not know that anybody monitored the activity documentation, but they reported to the administrator and social services director. 3. Resident #26 had diagnoses which included Alzheimer's disease, dementia, and anxiety. A Care Plan, dated 01/03/23, documented Resident #26 participated in some activities at times such as social events, bingo, birthday parties, but required supervision going to and from activities. The care plan documented Resident #26 would continue with self-directed activities daily through the review date. The interventions/approaches were to introduce Resident #26 to other residents with similar interests, disabilities, or limitations. The September 2024 activity calendar for Resident #26 documented activities for the month to be music, movies, television, and social visit were checked for the month. The activity note, dated 09/30/24, documented Resident #26 was up and out of their room daily. The note documented Resident #26 enjoyed music, TV, and social visits. The October 2024 activity calendar for Resident #26 documented activities for the month to be television and social visits. The note documented Resident #26 loved to hang out with friends and sometimes enjoyed watching television. The November 2024 activity calendar for Resident #26 documented activities for the month to be beauty shop once, movie time, television, and social visit. An undated activity note documented Resident #26 enjoyed watching television and hanging out with friends. On 01/06/25 at 11:54 a.m., no activities were observed on the unit. Residents were observed to be sitting in the dining room waiting for the noon meal and watching television. On 01/13/25 at 11:20 a.m., the activities director was asked what the program activities and goals were for Resident #26. They stated they just sat and visited, and played with their hands. The activities director stated they documented monthly on each resident. They stated the notes probably did need to be dated and they messed up. The activities director stated weekend activities were initiated by residents. 4. Resident #42 had diagnoses which included vascular dementia. A Care Plan, dated 07/23/24, documented Resident #42 had little to no involvement in activities related to cognitive impairment and would participate in at least one activity weekly. It documented to provide one-to-one visits in a quiet location when the resident was unable to tolerate group activities. It documented to provide a structured activity program for intellectual stimulation, when appropriate place Resident #42 in appropriate psychological group activities, give resident verbal reminders of activity before commencement of activity, and establish a daily routine with the same activity personnel/volunteers. A quarterly assessment, dated 09/30/24, documented the daily activity preferences answered by a resident representative for Resident #42 was going outside for fresh air as very important and to keep up with the news and listening to music as somewhat important. The October 2024 activity calendar for Resident #42 documented activities for the month to include television and social visit. An undated and unsigned note documented Resident #42 enjoyed meal time with friends and watching television and Resident #42 really enjoyed puppy time. The November 2024 activity calendar for Resident #42 documented activities for the month to include television. An undated and unsigned activity note documented Resident #42 enjoyed a good visit and looked forward to meal time. The note documented the resident watched television. The December 2024 activity calendar for Resident #42 documented activities for the month to include television. An undated note documented Resident #42 did not leave their room much and listened to the television and enjoyed a good conversation. On 01/06/25 at 11:17 a.m., no activities were observed to be provided. Resident #42 was observed in the dining area watching television. On 01/13/25 at 11:14 a.m., the activities director stated they were responsible to provide and document activities for the residents. They stated they do a survey for the MDS coordinator when a resident was admitted and that lead them to what the resident wanted to do for activities. When asked how that differed from the dementia unit, they stated they spent a lot of time with every resident. The activity director was asked what the program of activities and goals were for Resident #42. They stated they had taken coloring sheets and puzzles to the unit, but Resident #42 could not do any of that. The activities director stated their documentation did not reflect the interventions in the care plan for activities because they did not know that was something they needed to do. They stated their documentation did not reflect their attempts to encourage group activities or refusals by the resident. The activity director stated they had not had any formal training in dementia care, but they would love some. On 01/13/25 at 11:37 a.m., the administrator stated the activity director was responsible to document and complete activities for the facility. They stated the activity director had been hired three months ago. The administrator stated the activity director had been shown and told what to do and when to do it. They stated the documentation should be daily or monitored and tracked daily by the social services director, but they had been out of the facility.

Based on record review and interview, the facility failed to ensure pharmacist medication regimen reviews were conducted monthly for five (#24, 57, 62, 22, and #59) of five sampled residents who were reviewed for unnecessary medications. The DON identified 78 residents who received medications in the facility. Findings: The Medication Regimen Reviews policy, dated May 2024, read in parts, The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports .Copies of medication regimen review reports .are maintained as part of the permanent medical record. 1. Resident #24 had diagnoses which included schizoaffective disorder, bipolar type. The Care Plan, dated 12/09/24, read in part, Monitor pharmacist's drug regimen review for identification of potential drug interactions. Review of the clinical record and the monthly medication regimen reviews provided by the DON did not reveal the pharmacist had conducted a medication regimen review in January 2024, February 2024, March 2024, or July 2024 for Resident #24. 2. Resident #57 had diagnoses which included unspecified dementia. The Care Plan, dated 11/04/24, read in part, Monitor pharmacist's drug regime review for identification of potential drug interactions. Review of the clinical record and the monthly medication regimen reviews provided by the DON did not reveal the pharmacist had conducted a medication regimen review in December 2023 or March 2024 for Resident #57. 3. Resident #62 had diagnoses which included vascular dementia. The Care Plan, dated 11/08/24, read in part, Monitor pharmacist's drug regimen review for identification of potential drug interactions. Review of the clinical record and the monthly medication regimen reviews provided by the DON did not reveal the pharmacist had conducted a medication regimen review in January 2024 for Resident #62. 41809 4. Resident #22 had diagnoses which included Alzheimer's disease/dementia, anxiety, and depression. The facility provided medication regimen reviews, but were unable to provide January 2024, February 2024, March 2024, and August 2024. One gradual dose reduction was provided for 09/30/24 to reduce trazodone (an antidepressant) to 75 mg every hour of sleep from 100 mg. The physician refused and documented Resident #22 was stable on the current medication. Review of the clinical record revealed the last physician's orders were dated 07/24/24. A Care Plan, dated 07/10/24, documented a concern for psychotropic drug use and was updated/reviewed 10/08/24. The care plan revealed Resident #22 was taking Nuedexta (an antipsychotic), trazodone and Ativan (an anti-anxiety). The care plan was not updated to include Depakote (an antiepileptic) and Risperdal (an antipsychotic). The care plan documented approaches as evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. The care plan documented to monitor pharmacist's drug regimen review for identification of potential drug interactions. The care plan documented to administer Ativan and trazadone as per ordered and monitor for side effects. The care plan documented to monitor Resident #22 for signs of tremor documented and to report onset or increase to physician. The care plan documented to observe the resident's gait for steadiness, balance, muscle coordination, and ability to position and turn. The care plan documented to monitor the resident's mental status function and report any changes. 5. Resident #59 had diagnoses which included dementia and anxiety. Review of the clinical record for Resident #59 revealed missing MRR/GDRs for January, February, March, July, August, September and December 2024. The clinical record did not reveal lab results. An annual assessment, dated 05/21/24, documented Resident #59 had inattention and disorganized thinking with delusions. The assessment documented Resident #59 had rejected care four to six days during the seven day look back period. The assessment documented antipsychotic use and antidepressant use. The assessment documented no gradual dose reduction due to the physician documented a reduction would be clinically contraindicated on 12/15/23. Physician's Orders, dated November 2024, documented Resident #59 was ordered the following medications: duloxetine (an antidepressant) 90 mg every day, olanzapine ODT (an antipsychotic) 10 mg every hour of sleep and trazodone 100 mg every hour of sleep. The physician's orders documented an order for CBC and CMP every six months, HGA1C every three months and a lipid panel yearly. An updated care plan, dated 12/09/24, documented a concern for psychotropic drug use of antipsychotic medications olanzapine/duloxetine. On 01/09/25 at 9:58 a.m., the administrator stated they had not located more gradual dose reductions or medication regimen reviews. On 01/09/25 at 11:48 a.m., the DON was asked what the facility policy was regarding gradual dose reductions. The DON did not answer. The DON stated the facility was having an issue with medical records and that was why medication regimen reviews and gradual dose reductions were not in the clinical records. On 01/13/25 at 1:01 p.m., the DON was asked for the original start date for Ativan, Risperidone, and Depakote DR for Resident #22. The DON stated Resident #22 had started Ativan on 07/18/24, Depakote on 04/13/23 and Risperdal on 06/14/22. No gradual dose reductions or medication regimen reviews were provided by the end of the survey. On 01/13/25 at 5:15 p.m., the pharmacist stated they had not seen an order for Risperidone since they started in April 2023. They stated they had been following Depakote, Ativan, and trazodone for Resident #22 and had no notes about them being on Risperidone recently. The pharmacist stated they did not know how accurate the orders were in the clinical record. They stated they went by the medication administration record to see what the resident had been given and when they found an error, they never go to the actual clinical record because they do not find the record to be helpful at all. The pharmacist stated they had a hard time with labs as well and would ask staff to pull the labs up on the computer and tell them. They stated they had asked for lab access as well because they had not been able to find it in the clinical record. The pharmacist stated the best they could do was see that labs were ordered. They stated they came to the facility on ce a month toward the end of the month and the turn around was a physical delivery the next day or two. The pharmacist stated they would obtain a signature from administrative staff or a nurse.

Based on observation, record review, and interview, the facility failed to: a. ensure medications were secured for one (300 hall treatment cart) of six medication carts observed; b. ensure medications were dated when opened and/or insulin was discarded after 28 days for two (200 hall treatment cart and 300 hall treatment cart) of three medication carts observed; and c. ensure expired medications were not in use for one (100 hall medication cart) of three medication carts observed. LPN #2 identified six medication carts in the facility. Findings: The Medication Storage policy, dated 07/21/24, read in parts, The facility shall not use .outdated .drugs or biologicals .Compartments (including .carts .) shall be locked when not in use. 1. On 01/07/25 at 4:34 p.m., RN #2 was observed during medication administration to prepare insulin and enter room [ROOM NUMBER]. The 300 hall treatment cart was observed to be left unattended and unlocked. On 01/07/25 at 4:35 p.m., RN #2 was observed to walk to the nurses station to obtain a cup of water. The 300 hall treatment cart was observed to be left unattended and unlocked for approximately 15 to 20 seconds. On 01/07/25 at 4:39 p.m., RN #2 was observed to walk into room [ROOM NUMBER] to administer medication. The 300 hall treatment cart was observed to be left unattended and unlocked. On 01/07/25 at 4:40 p.m., RN #2 returned to the treatment cart, wheeled it to the nurses station, and locked the cart. On 01/08/25 at 9:17 a.m., RN #1 was observed to prepare medications for administration. RN #1 was observed to enter room [ROOM NUMBER]. Four medication cups were observed to be left unattended on top of the 300 hall treatment cart. One cup was observed to contain three capsules, one cup was observed to contain crushed medications, one cup was observed to have a red liquid medication, and one cup was observed to contain a clear liquid medication. On 01/08/25 at 9:19 a.m., RN #1 was observed to return to the treatment cart and obtain the four cups with medications and re-enter room [ROOM NUMBER]. On 01/08/25 at 9:32 a.m., RN #1 was observed to obtain something from the 300 hall medication cart and re-enter room [ROOM NUMBER]. The 300 hall treatment cart was observed to be unattended and unlocked. On 01/08/25 at 9:39 a.m., RN #1 was observed to exit room [ROOM NUMBER]. RN #1 stated they usually locked the 300 hall treatment cart and the carts were to be kept locked when unattended. On 01/13/25 at 3:35 p.m., the DON stated medication carts were to be kept locked when unattended. 2. On 01/13/25 at 2:59 p.m., the 200 hall treatment cart was observed with LPN #2. The following was observed, a. the Trelegy inhaler and albuterol inhaler for Resident #178 were opened, but not dated, b. the Symbicort inhaler and Spiriva inhaler for Resident #49 were opened but not dated, c. the albuterol inhaler for Resident #78 was opened but not dated, d. the Ventolin inhaler for Resident #24 was opened but not dated, e. the Novolog insulin for Resident #66 was opened and dated 12/03/24, f. the Novolog insulin for Resident #16 was dated as opened on 12/03/24, and g. the glucometer test strips were opened and not dated. On 01/13/25 at 3:05 p.m., LPN #2 stated they did not know glucometer test strips were to be dated when opened. LPN #2 stated they kept open insulin for one month and the Novolog insulin for Resident #66 and Resident #16 should have been discarded. On 01/13/25 at 3:09 p.m., the 300 hall treatment cart was observed with RN #2. The glucometer test strips were observed to be open and not dated. On 01/13/25 at 3:35 p.m., the DON stated they did not date opened glucometer test strips and they monitored medication carts to ensure medications were dated when opened. They stated they did not know why medications were not dated when opened or discarded as indicated. 3. On 01/13/25 at 3:13 p.m., the 100 hall medication cart was observed with CMA #4. The following was observed, a. the house stock Tussin DM was observed to have a manufacturer expiration date of 12/2024, and b. the geri-lanta for Resident #179 had an expiration date of 12/20/24 on the label. On 01/13/25 at 3:22 p.m., CMA #4 stated they thought the DON monitored for expired medications on the medication carts. On 01/13/25 at 3:35 p.m., the DON stated they were responsible to monitor medications on the medication carts for expiration dates. They stated it was an oversight for the geri-lanta and the Tussin DM. On 01/13/25 at 3:44 p.m., the DON observed the house stock Tussin DM and stated it expired 12/2024. The DON observed the geri-lanta for Resident #179 and stated a manufacturer expiration date was not available on the bottle so they would reference the expiration date of 12/20/24 on the medication label.

Based on record review and interview, the facility failed to ensure resident records were complete and accessible for four (#57, 24, 22, and #59) of 18 sampled residents whose records were reviewed. The DON identified 78 residents who resided in the facility. Findings: The Medication Orders policy, dated 06/15/24, read in part, A current list of orders must be maintained in the clinical record of each resident. The Charting and Documentation policy, dated July 2024, read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1. Resident #57 had diagnoses which included unspecified dementia. Review of the clinical record revealed the last gradual dose reduction from the consultant pharmacist was dated 2023, the latest lab report was dated 11/28/23, and the physician's orders were from October 2024. 2. Resident #24 had diagnoses which included schizoaffective disorder, bipolar type. Review of the clinical record revealed the latest physician's orders in the clinical record were dated October 2024. On 01/09/25 at 11:58 a.m., the DON stated they and the MDS coordinator were responsible to ensure clinical records were complete and accessible. They stated current physician's orders, labs, and consultant pharmacist's reports had not been filed by the medical records staff member. The DON stated they did not know how clinical records were monitored to ensure they were complete and accessible. 3. Resident #22 had diagnoses which included Alzheimer's disease/dementia, anxiety, and depression. Review of the clinical record revealed the last physician's orders were dated 07/24/24. The facility provided medication regimen reviews, but were unable to provide January 2024, February 2024, March 2024 and August 2024. None were located in the clinical record for Resident #22. On 01/09/25 at 9:58 a.m., the administrator stated they had not located more gradual dose reductions or medication regimen reviews from medical records. On 01/09/25 at 11:48 a.m., the DON stated the facility was having an issue with medical records and that was why medication regimen reviews and gradual dose reductions were not in the clinical records. On 01/13/25 at 5:15 p.m., the pharmacist stated they had not seen an order for risperidone (an antipsychotic) since they started in April 2023. They stated they had been following Depakote (an antiepileptic), Ativan (an anti-anxiety), and trazadone (an antidepressant) for Resident #22, and had no notes about them being on risperidone recently. The pharmacist stated they did not know how accurate the orders were in the clinical record. They stated they go by the medication administration record to see what the resident had been given and when they found an error, they never go to the actual clinical record because they do not find the record to be helpful at all. The pharmacist stated they had a hard time with labs as well and would ask staff to pull the labs up on the computer and tell them. They stated they had asked for lab access as well because they had not been able to find it in the clinical record. The pharmacist stated the best they could do was see labs were ordered. They stated they came to the facility on ce a month toward the end of the month and the turn around was a physical delivery the next day or two. The pharmacist stated they would obtain a signature from administrative staff or a nurse. 4. Resident #59 had diagnoses which included dementia and anxiety. Review of the clinical record for Resident #59 revealed missing MRR/GDRs for January, February, March, July, August, September and December 2024. The clinical record did not reveal lab results.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for one (#279) of one sampled resident with a peg tube observed during medication administration. The nurse manager identified two residents who had peg tubes. Findings: The Enhanced Barrier Precautions policy, dated August 2022, read in parts, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tube .) .Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required .PPE is available outside of the resident rooms. Resident #279 had diagnoses which included unspecified severe protein calorie malnutrition. The significant change assessment, dated 05/27/24, documented the resident had a feeding tube. On 01/08/25 at 8:49 a.m., RN #1 was observed to administer medications to Resident #279 through their peg tube. RN #1 was not observed to utilize PPE, except for gloves. Signage to indicate enhanced barrier precautions and PPE was not observed near the resident's room. On 01/08/25 at 9:30 a.m., RN #1 was observed to perform peg tube site care. RN #1 was not observed to utilize PPE, except for gloves. On 01/09/25 at 11:29 a.m., RN #1 stated they would need to find out what the facility's policy was for enhanced barrier precautions. On 01/13/25 at 9:51 a.m., the DON stated they did not understand what enhanced barrier precautions were and needed to review the facility's policy.

Based on observation, record review, and interview, the facility failed to ensure call lights were operational and available for residents. The administrator identified 78 residents who resided at the facility. Findings: A Bedrooms policy, reviewed May 2024, read in part, All resident rooms are equipped with a resident call system that allows residents to call for staff assistance. Review of the maintenance log book revealed on 12/28/24 room [ROOM NUMBER] had a call light ripped from the wall and wires were exposed. The log book documented the date of repair was 12/30/24. The repair was initialed. On 01/08/25 at 11:36 a.m., room [ROOM NUMBER] was observed to have wires coming from the wall where the call light would be. On 01/06/25 at 10:15 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:16 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:18 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:19 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:21 a.m., room [ROOM NUMBER]B was observed to have no call light cord. On 01/06/25 at 10:22 a.m., room [ROOM NUMBER]B was observed to have no call light cord. On 01/06/25 at 10:23 a.m., room [ROOM NUMBER]A was observed to have exposed wires at the wall connection of the call light cord. On 01/08/25 at 11:36 a.m., room [ROOM NUMBER] was observed to have exposed wires at the wall connection of the call light cord. On 01/13/25 at 10:17 a.m., maintenance #1 stated residents removed the call lights and did not put them back. They stated it had been about a month since the call lights were ordered by the administrator. On 01/13/25 at 11:42 a.m., the administrator was asked how residents notify staff when they need assistance if they had no call light. The administrator did not answer.

Based on observation, record review, and interview, the facility failed to ensure nail care was provided for one (#57) of one sampled resident who was reviewed for ADL care. The nurse manager identified 56 residents who were dependent on staff for nail care. Findings: The Fingernails/Toenails, Care of policy, dated February 2024, read in parts, The purposes of this procedure are to clean the nail bed, to keep nails trimmed .Nail care includes daily cleaning and regular trimming .Documentation .If the resident refused the treatment, the reason(s) why and the intervention taken .Notify the supervisor if the resident refuses the care. Resident #57 had diagnoses which included unspecified dementia. The Care Plan, updated 11/04/24, documented the resident required varied levels of assistance with ADLs due to weakness. The Activity of Daily Living Record, dated December 2024, documented the resident had been offered and/or received nail care five times, including refusals of nail care, out of 93 opportunities. The Activity of Daily Living Record, dated 01/01/25 through 01/07/25, documented the resident had not been offered, refused, or received nail care out of 21 opportunities. On 01/06/25 at 9:38 a.m., Resident #57 was observed in their room. Their fingernails were observed to be approximately a quarter inch long with dark colored debris under the nails. Resident #57 stated they preferred their fingernails to be shorter. On 01/09/25 at 10:37 a.m., Resident #57 was observed in their room. Their fingernails were observed to be approximately a quarter inch long with dark colored debris under the nails. On 01/09/25 at 10:42 a.m., CNA #7 stated the CNAs were responsible to provide nail care for Resident #57. They stated at times the resident refused care and nail care was documented on the ADL record. On 01/09/25 10:44 a.m., LPN #3 stated the CNAs were to provide nail care for Resident #57 because they were dependent on staff for nail care. They observed Resident #57's fingernails and stated they needed to be trimmed and cleaned. They stated the resident refused care at times, but when a resident refused they asked them to sign a refusal form and documented the refusal. On 01/09/25 at 11:03 a.m., the DON stated fingernail care was to be provided on scheduled shower days and as needed and documented on the Activity of Daily Living Record. The DON reviewed the ADL record for December 2024 and January 2025 and stated they would need to check with the staff because fingernail care had not been documented. The DON stated there were some refusals documented, but there should have been more documentation regarding nail care. On 01/09/25 at 11:06 a.m., the DON observed Resident #57's fingernails and stated they did not look good. The DON stated they thought they had dropped the ball and should check resident fingernails more often for care.

Based on observation, record review, and interview, the facility failed to monitor and evaluate a resident's response to an intervention for one (#26) of one sampled resident who was reviewed for quality of care. The administrator identified 78 residents who resided at the facility. Findings: An Abuse Policy and Procedure policy, dated January 2024, read in parts, nursing staff shall document the incident and interventions in the Medical Record .Nursing Assessment. The Director of Nursing or designee is responsible for assessing the victim and shall document findings .in the medical record. Resident #26 had diagnoses which included vascular dementia, Alzheimer's disease, and delusions. Review of the care plan for Resident #26, dated 01/03/23 and updated 04/01/24, 07/01/24, and 07/25/24, documented a concern for alteration in skin due to incontinence and documented to monitor and notify physician and representative of changes such as bruising. The care plan revealed no concern regarding bruising through the review dates. On 01/06/25 at 11:52 a.m., Resident #26 was observed to have a bruise on the left side of their neck approximately the size of a nickel. Review of priority charting for Resident #26 revealed no documentation regarding a bruise to the left side of their neck. Review of physician progress notes for Resident #26 in 2024 and 2025 revealed no progress notes regarding bruising to the neck. On 01/08/25 at 11:01 a.m., LPN #1 stated they were not aware of a bruise on the neck of Resident #26. They stated the bruise would be an injury of unknown origin and they would need to do a report on it. On 01/08/25 at 11:03 a.m., the DON stated they would have to check on the bruising. On 01/08/25 at 11:11 a.m., CMA #2, CMA #3, CNA #5 and CNA #6 working on the memory unit stated Resident #26 would have random bruising on their neck and then the next day the bruising would be gone. They stated they had reported it to the nurse approximately a year ago. On 01/08/25 at 11:16 a.m. the DON and nurse manager came to the memory unit and questioned the staff. The staff stated to the DON they had addressed it before. The DON stated to this surveyor, [They] was on aspirin so [medical director] took [them] off the aspirin. The DON then walked away. On 01/08/25 at 11:53 a.m., the DON stated it was more than a year ago the bruising was addressed and had not been re-addressed because the bruising would resolve without intervention. The physician's progress note which documented the bruising was addressed was requested. On 01/08/25 at 3:52 p.m., the DON stated they had found the progress notes from the medical director and none had documented anything about bruising. The DON requested if they could call the medical director. The DON was informed to follow their protocol. They stated bruising should be reported to the nurse who then assessed and notified the doctor of the issue. The DON did not return with documentation of the bruising being addressed or re-addressed by the physician.

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for the use of bed rails for one (#57) of one sampled resident who was reviewed for bed rails. The DON identified one resident who had bed rails. Findings: The Proper Use of Side Rails policy, dated December 2022, read in parts, Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents .When used for mobility or transfer, an assessment will include a review of the resident's .bed mobility .risk of entrapment from the use of side rails .that the bed's dimensions are appropriate for the resident's size and weight .Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails .The risks and benefits of side rails will be considered for each resident .Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. Resident #57 had diagnoses which included unspecified dementia and hemiparesis of the left side. The Admission Data Collection Form, dated 04/05/24, documented a side rail assessment. The assessment was not fully completed and was blank under the recommendations regarding bed rails and intervention areas of the side rail section of the form. The Care Plan, updated 11/04/24, documented the resident required extensive assistance with bed mobility. The care plan did not document the use of bed rails. Review of the clinical record did not reveal documentation the side rails treated a medical condition, a completed assessment had been conducted, alternative interventions had been attempted, that the resident/resident representative had been informed of the benefits and risks of bed rail use, or that consent for the use of bed rails for Resident #57 had been obtained. On 01/06/25 at 9:49 a.m., Resident #57 was observed in bed with half bed rails in the up position bilaterally. Resident #57 stated they did not use the bed rails and they assumed they were applied for safety to keep them in bed. On 01/09/25 at 10:51 a.m., LPN #3 stated Resident #57 utilized the bed rails to assist in repositioning during care. They stated they did not know why the resident had bilateral side rails since they were unable to utilize their left side. On 01/09/25 at 10:59 a.m., the DON stated residents were assessed for the use of bed rails prior to installation. The DON stated they did not obtain consents or discuss risks and benefits of side rail use with the resident and/or the resident representative. The DON stated Resident #57 could move their right hand a little. The DON stated they did not know why Resident #57 had bilateral half bed rails. On 01/09/25 at 11:42 a.m., the DON stated the resident preferred half bed rails bilaterally, but did not require them. The DON stated they did not know why the bed rail assessment had not been completed. On 01/13/25 at 10:01 a.m., the DON stated Resident #57 could not properly utilize the half bed rails bilaterally as a positioning device. On 01/13/25 at 11:29 a.m., the care plan coordinator stated they did not know Resident #57 had half bed rails bilaterally.

Based on observation, record review, and interview, the facility failed to ensure nurse staffing was posted for public view. The administrator identified 78 residents resided at the facility. Findings: A review of the QOC reports for October, November and December 2024 revealed staffing numbers were good with the exception of one day shift in December. On 01/14/25 at 9:20 a.m., the administrator stated they had the staff names and position for each shift on each hall. They stated they did not have the total number of nursing hours posted. On 01/14/25 at 10:32 a.m., the DON stated they had a book for the daily schedule at the nurses desk, but for the time during the survey the book was in their office. They stated total nursing hours were not in the book.

Based on record review and interview, the facility failed to ensure residents did not receive unnecessary medications for one (#22) of five sampled residents who were reviewed for psychotropic medications. The nurse manager identified 78 residents who received medications. Findings: Resident #22 had diagnoses which included Alzheimer's/dementia, anxiety and depression. A review of the clinical record for Resident #22 did not document side effect monitoring or that the physician was provided an MRR or GDR of Risperdal (risperidone) (an antipsychotic) for review and reduction. A Care Plan, dated 07/10/24, for Resident #22 documented a concern for psychotropic drug use and was updated/reviewed 10/08/24. The care plan revealed Resident #22 was taking an antipsychotic Nuedexta, an antidepressant trazodone, and an anti-anxiety medication of Ativan. The care plan was not updated to include Risperdal. The care plan documented approaches to evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. On 01/09/25 at 11:48 a.m., the DON was asked what the facility policy was regarding gradual dose reductions. The DON did not answer. The DON stated the facility was having an issue with medical records and that was why medication regimen reviews and gradual dose reductions were not in the clinical records. On 01/13/25 at 1:01 p.m., the DON was asked for the original start date for Ativan (lorazepam), Risperdal, and Depakote DR (an antiepileptic). The DON stated Resident #22 had started Ativan on 07/18/24, Depakote on 04/13/23 and Risperdal on 06/14/22. No evidence was provided. On 01/13/25 at 5:15 p.m., the pharmacist stated they had not seen an order for Risperdal since they started in April 2023. They stated they had been following Depakote, Ativan, and trazadone for Resident #22 and had no notes about them being on Risperdal recently.

Based on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for two (#24 and #62) of five sampled residents whose labs were reviewed. The DON identified 78 residents who had orders for labs. Findings: The Lab and Diagnostic Test Results - Clinical Protocol policy, dated July 2024, read in part, The staff will process test requisitions and arrange for tests. 1. Resident #24 had diagnoses which included schizoaffective disorder, bipolar type. A Physician's order, dated 02/05/21, documented to obtain a valproic acid level every 3 months in July, October, January, and April. A Physician's order, dated 11/01/23, documented the resident was ordered valproic acid 500 mg at bedtime. Review of the clinical record and labs provided by the DON did not reveal a valproic acid level had been obtained in July 2024 or October 2024. 2. Resident #62 had diagnoses which included vascular dementia. A Physician's Order, dated 02/12/24, documented to obtain a CMP every six months. Review of the clinical record and lab results provided by the DON revealed the last CMP was obtained on 05/31/24. A CMP for November 2024 was not seen in the clinical record or provided by the DON. On 01/09/25 at 11:48 a.m., the DON stated they were responsible to ensure labs were obtained as ordered by the physician. They stated there was a lab report binder in the MDS coordinator's office they would provide. On 01/13/25 at 9:32 a.m., the DON stated they felt there was something wrong with medical records obtaining and filing the lab reports, but they did not think they had any additional lab reports to provide. By the end of the survey the lab report binder or additional lab reports had not been provided for Resident #24 or Resident #62.

On 12/17/19 at 4:50 PM, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failures to provide supervision to prevent sexual abuse for resident #1. A facility incident report documented staff noticed resident #2 was bent over resident #1. The report documented the shirt of resident #1 was down and her breast was exposed. On 12/17/19 the IJ situation was verified with the Oklahoma State Department of Health. On 12/17/19 at 5:30 PM, the administrator was notified of the IJ situation related to failures in supervision to prevent sexual abuse. On 12/18/19 at 11:30 AM, the plan of removal for the Immediate Jeopardy pertaining to sexual abuse was accepted. The plan of Removal for the Immediate Jeopardy documented: On 12/17/19 Administrator/designee began an instant in-service with all staff on Policy and Procedures for sexual abuse and protecting resident from sexual abuse. All staff that are currently working will be in-serviced immediately. All other staff will be in-serviced by 11:00pm on 12/17/19. This is to insure staff have the proper knowledge and understanding of resident abuse, P&P and protecting residents from sexual abuse. For staff who are on a PRN status and were unable to be reached via phone, PRN staff will not be able to resume their duties until they have been in-served on abuse, sexual abuse and residents identified. On, 12/17/2019 DON/MDS Coordinator went through the chart review and identify residents that have the potential to be affected by this deficient practice. Care Plans will be reviewed and updated by 12/18/2019 by 5:00 pm On 12/14/2019 DON and nursing staff assessed resident on the memory unit for signs of abuse/sexual abuse. All new hires will be in-serviced before working on abuse. Documentation will be placed in employee file showing that they were given a copy of Policy and Procedures for resident abuse specific to sexual abuse. The new employees shall be oriented on residents who have behaviors more so on sexual behaviors, Beginning 12/17/2019, hospitality aide or staff member will be designated to be in the dining area at all times on the Memory Unit to monitor residents for appropriate behavior. Beginning 12/18/2019 DON/ designees will review documents related to sexual behaviors and monitoring daily xs 14 days and weekly during at risk meetings. On 12/17/2019, DON/MDS Coordinator identified residents with sexual behaviors or potential sexual behaviors and put into place Behavior Monitoring Sheet focused on Sexual Behaviors. On 12/17/2019 Administrator updated PP on Preventing Resident Abuse to include section K identifying sexual behaviors to be Monitored with Monitoring Sheets identified as Sexual Behaviors. 12/18/2019 updated and revised job description Hospitality Aide will be able to follow PP of Abuse to include separating and intervening with residents. (Resident #2 - name deleted) was removed from the facility on 12/13/2019 for evaluation and treatment. Currently seeking placement elsewhere in a more appropriate setting. On 12/18/19 interviews were conducted with the nursing staff regarding educational in-services pertaining to policies and procedures for abuse/sexual abuse and preventing abuse/sexual abuse. The staff stated an in-service was provided on 12/13/19, 12/14/19, and on 12/17/19. The staff was able to verbalize understanding of the abuse policy, prevention of abuse, sexual abuse, and residents whose sexual behaviors were to be monitored as provided in the in-services pertaining to the plan of removal. On 12/18/19 at 11:30 AM, the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at actual harm. Based on observation, interview, and record review, it was determined the facility failed to prevent sexual abuse for one (#1) of five sampled residents reviewed for abuse. A facility incident report documented staff noticed resident #2 was bent over resident #1. The report documented the shirt of resident #1 was down and her breast was exposed. The facility identified 16 residents lived in the memory unit at the time sexual abuse occurred. Findings: The facility policy for abuse prevention documented the facility would endeavor to protect residents from sexual abuse. The policy documented the staff would be screened and trained in regard to abuse prevention. The policy documented care plans would address residents who were at risk for abusive behaviors and interventions would be designed to prevent the occurrence of abuse. The policy documented the residents at risk would be visually monitored by nursing staff for triggers to abusive behaviors. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 09/04/19, documented the resident was severely impaired for daily decision making, had inattention, disorganized thinking, delusions, and received an antidepressant medication. The assessment documented the resident required minimal to extensive assistance with ADLs. The care plan, dated 09/10/19, documented the identification of cognition and communication needs. The care plan documented the staff were to ask simple yes/no questions, watch for attempts at verbal communication, encourage non-verbal communication, observe for moaning, crying, facial expressions, and explain procedures to resident. The physician orders [REDACTED]. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 03/07/19, documented the resident was severely impaired for daily decision making and required minimal assistance with activities of daily living (ADLs). The assessment documented the resident had mild depression, inattention, disorganized thinking, delusions, and behaviors. The assessment documented the resident received an antipsychotic medication. The care plan, dated 03/08/19, documented the resident had a history of [REDACTED]. The care plan documented the resident was to be in an area for constant observation, staff were to remove the resident from a public area for disruptive or inappropriate behavior, staff were to monitor and document resident behaviors and report any changes, social service was to evaluate and visit with the resident monthly, review his drug regimen monthly, and engage resident in activities for diversion. The care plan was reviewed on 09/06/19 and documented the resident's cognition had declined, no behaviors had been observed, and no changes were made to his care plan in regard to behaviors. An assessment, dated 11/09/19, documented the resident was severely impaired for daily decision making and had declined since the assessment completed on 03/07/19. The assessment documented the resident required minimal assistance with activities of daily living (ADLs). The assessment documented the resident had mild depression, inattention, disorganized thinking, delusions, and behaviors. The assessment documented the resident received an antipsychotic medication. The care plan did not document it had been reviewed in conjunction with the assessment completed on 11/09/19. The physician orders [REDACTED]. The behavior monitoring for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 documented the resident was monitored for pacing behaviors. An incident report, dated 12/13/19, documented at 6:00 PM staff noticed resident #2 was close and bent over resident #1. The report documented the shirt of resident #1 was down and her nipple was exposed. The report documented resident #2 was removed from the area and was placed on one to one monitoring. A staff witness statement, dated 12/13/19, documented certified nurse aide #1 was walking down the hall at 6:30 PM to assist a resident and he witnessed resident #2 standing over resident #1. Nurse notes for resident #1, dated 12/13/19 at 8:00 PM, documented the summary of events on the initial incident report and required notifications were completed. The note documented a physical assessment was completed and the resident's nipple was red. Nurse notes for resident #2, dated 12/13/19 at 9:15 PM, documented the summary of events on the initial incident report, required notifications were completed, and resident #2 was sent to the hospital for evaluation and treatment. An investigative resident witness statement, dated 12/14/19, documented resident #2 was seen going over to resident #1. The statement documented resident #2 pulled her shirt up, started sucking on her nipple, slipped her shirt back down, and walked away. The weekly skin integrity check for resident #1, dated 12/14/19, documented redness to the resident's right breast. On 12/17/19 at 9:30 AM, a tour of the locked memory care unit was conducted. Minimal interaction between residents was observed. Four staff persons were present on the unit. A certified medication aide (CMA) was making beds down the hall, one CNA was providing personal care, the activities coordinator was leading a coloring activity in the dining room, and a hospitality aide was assisting two residents with the activity. Six residents were in the dining room for the activity. One male resident was in a resident room with his pants down, handling his brief and catheter, and was moaning. One female resident holding a baby doll was in the doorway trying to talk to the male resident. A few residents were lying on their beds resting. Resident #1 was sitting at a table with another female resident and was coloring. The resident used incomprehensible words to communicate. Resident #1 did not exhibit behaviors or show signs of fear toward staff or residents. On 12/17/19 at 9:40 AM, a nurse from another hall came to assist the male resident with the catheter then left the unit. On 12/17/19 at 9:45 AM, CMA #1 was interviewed regarding staffing in the memory care unit. The CMA stated she was usually assigned as CMA on two halls and one of them being the memory unit. The CMA stated she was not on the memory unit for the entire shift but just to pass medications. She stated that day she was assigned as a CNA and a CMA to the unit and was on the unit for the entire shift. The CMA stated the staffing for the unit was two CNAs, a CMA for medication pass only, and a nurse made rounds. The CMA stated the staff prevented sexual abuse by keeping the the male residents on one end of the hall and the female residents on the other end of the hall. She stated the staff tried to keep the men and women separated as much as possible. On 12/17/19 at 10:00 AM, CNA #2 stated she normally worked the weekdays on the memory care unit with another CN[NAME] The CNA stated to prevent resident to resident sexual abuse the staff would keep the male and female residents separated. The CNA stated one CNA would go out and get assistance and one CNA would stay on the unit to supervise when a nurse was required in the unit. The CNA stated one CNA would stay on the unit during breaktime. On 12/17/19 at 10:25 AM, CNA #2 stated she had been working the 2:00 PM to 10:00 PM shift and at approximately 6:00 PM both the shift CNAs were in the hall next to the dining room behind the pillar. The CNA stated CNA #1 started to walk down the hall and observed resident #2 bent over resident #1. The CNA stated the residents were separated and CNA #1 went to get the nurse. CNA #2 stated she checked resident #1. She stated the resident had a wet nipple and her shirt was partially down. The CNA stated the licensed practical nurse #1 came and assessed resident #1. The CNA stated resident #1 did not have a change in expression and did not express signs of agitation or anxiety. The CNA stated resident #2 had been removed from the unit and was placed on one to one monitoring. CNA #2 continued and stated resident #2 had not had sexual behaviors since she had worked on the unit. She stated the resident usually stayed off by himself and did not talk to anyone. The CNA stated the resident would go out to supervised smoking and would be assisted back to the unit. The CNA stated she was aware of the resident's history of sexual behaviors. On 12/17/19 at 12:00 PM, multiple residents were in the dining area. Two CNA staff were providing personal care. A nurse and the hospitality aide were in the dining room. The nurse was kept busy intervening between residents. One female resident changed emotional states quickly, becoming verbally aggressive toward a male resident, and required assistance. As the nurse was redirecting the female resident, resident #1 verbalized incomprehensible sounds, stood up partially stable, and started walking across the room, and the nurse came over to assist. As the nurse was assisting resident #1 to sit, another resident complained of his catheter and started getting up to go to his room. The hospitality aide had difficulty getting the resident to take his walker and the nurse had to come and provide assistance. On 12/17/19 at 12:10 PM, licensed practical nurse #1 stated she was working the evening resident #2 was sent to the hospital. The nurse stated two CNAs were on the unit and she and the CMA shared two halls and were on the memory care unit off and on throughout the shift. The nurse stated resident #2 was seen next to and leaning over resident #1 at approximately 6:00 PM on 12/13/19. The LPN stated she went immediately to the unit and spoke with CNA #2. The nurse stated the residents were separated and she completed a head to toe assessment for resident #1. The nurse stated the resident had no signs of distress or agitation. The nurse stated resident #2 had not had sexual behaviors since his admission in (MONTH) 2019. The nurse stated interventions to prevent sexual abuse were in place and included keeping the male and female residents separate, administering medications as ordered by the physician, completing monthly assessments and assess for behaviors, and assessing resident behaviors daily. On 12/17/19 at 2:15 PM, the social service director (SSD) stated she reassessed resident #2's behaviors by reviewing them with the staff. She stated she would meet with the resident and would talk with him. The SSD stated she did not document social service progress notes for (MONTH) 2019 or (MONTH) 2019. On 12/17/19 at 2:55 PM, CNA #1 stated he had worked at the facility for four months and had worked on all the halls. He stated he now worked in the memory care unit on the 2:00 PM to 10:00 PM shift Mondays through Fridays. The CNA stated he had abuse prevention training when he was hired. He stated he had not been instructed regarding resident #2's sexual behaviors or which behaviors to monitor. The CNA stated he did not know resident #2 had sexual behaviors. On 12/17/19 at 3:05 PM, the director of nurses (DON) stated staff was increased from one CNA to two CNAs on the memory unit in order to prevent abuse/sexual abuse. The DON stated additional training on abuse and dementia had been provided to staff and were ongoing. The DON stated staff were to know where and what resident #2 was doing at all times. The DON was not able to state how sexual abuse was able to occur in the memory care unit when two CNAs were working in the unit and were next to the dining area. On 12/17/19 at 3:13 PM, the administrator stated an investigation related to sexual abuse was initiated and it was determined the accounts of the incident were the same and the situation had occurred. The administrator stated the staff were busy completing their CNA responsibilities when the sexual abuse occurred and was not able to state who was supervising the resident at that time.

On [DATE] at 12:30 PM, a past noncompliance Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failures to prevent resident to resident sexual abuse for residents #56 and #278. Resident #56 was sexually fondled by resident #63 and resident #56 attempted to push resident #63's hand away. Resident #278 was in her room and resident #277 came out of the room with his pants down and his private parts exposed. On [DATE] the past noncompliance IJ situation was verified with the Oklahoma State Department of Health regarding the failure to prevent resident to resident sexual abuse. The deficient practice was determined to be past non compliance since the facility identified the IJ situation and implemented interventions to prevent the recurrence of the situation. The administrator upon notification of the IJ situation provided protection for resident #56 and #278 and placed resident #63 and #277 on one to one monitoring. Resident #56 was sent to the hospital for examination and resident #278 was examined by staff nurses. Residents #63 and #277 were sent to the hospital for psychological evaluation. Two investigations were completed and staff was inserviced regarding identification of sexual abuse and monitoring. The staff was interviewed regarding inservice education. The facility completed a quality assurance (QA) report and plan of action dated [DATE]. The plan of action identified the problem as a lack of understanding of sexual behavior verses sexual abuse. The plan was to: a) Inservice staff regarding sexual abuse and add sexual abuse education quarterly. b) Resident #63 would be monitored for sexual behaviors every two hours and negative findings would be reported immediately. c) The staff would monitor resident #277 every two hours for sexual behaviors and report negative findings immediately. d) The administrator would review documentation for continued behaviors for 14 days, then randomly. e) The administrator would review state [MEDICATION NAME] involving sexual abuse every month for six months and report findings to QA. On [DATE] at 12:45 PM, the administrator and the director of nurses were notified of the past noncompliance IJ situation related to failures in preventing resident to resident sexual abuse. Based on observation, interview, and record review, it was determined the facility failed to prevent abuse for two (#56 and #278) of five residents reviewed for abuse. Resident #56 was sexually fondled by resident #63 and resident #56 attempted to push resident #63's hand away. Resident #278 was in her room and resident #277 came out of the room with his pants down and his private parts exposed. The facility census and condition report documented 77 residents lived at the facility. Findings: The facility policy and procedures for abuse documented the facility would prevent residents from abuse by anyone, including other residents. The policy documented the facility would develop and implement policies and procedures to aid in preventing abuse including verbally or physically aggressive resident behavior. 1. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated [DATE], documented the resident was severely impaired for daily decision making and did not have behaviors. The assessment documented the resident required limited to extensive assistance with activities of daily living (ADLs). The assessment documented the resident received antipsychotic and antidepressant medications and hospice care. The care plan, dated [DATE], documented the resident required varied levels of assistance with ADLs. The care plan documented the resident wandered about the unit, had difficulty in making decisions, and had episodes of [MEDICAL CONDITION]. 2. Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission data collection form, dated [DATE], documented resident #63 was alert and socially inappropriate. The first page of the form was completed and the remaining pages were not completed. The care plan records did not document a completed temporary care plan for the resident. A nurse's note, dated [DATE] at 10:55 AM, documented certified nurse aide (CNA) #1 found resident #63 with his hand inside the front of resident #56's pants and was moving his hand back and forth quickly. The note documented the CNA notified the nurse immediately. The note documented the administrator was notified. A nurse's note, dated [DATE] at 11:30 AM, documented resident #63 was provided one to one supervision by administrative staff. The note documented the physician was notified. The note documented an order was received to send resident #63 to the hospital for psychiatric evaluation and send resident #56 to the hospital for an examination. A nurse's note, dated [DATE] at 12:10 PM, documented resident #63's family, resident #56's legal representative, and the Tulsa Police Department were notified. The monitoring sheet, dated [DATE] at 12:30 PM, documented resident #63 was on one to one supervision with administrative staff. A nurse's note, dated [DATE] at 2:00 PM, documented resident #56 was transported by ambulance to the hospital, and adult protective service (APS) and family were notified. A nurse's note, dated [DATE] at 5:45 PM, documented two staff transported resident #63 to the hospital for a psychiatric evaluation and treatment. A nurse's note, dated [DATE] at 7:30 PM, documented resident #56 returned to the facility by ambulance and the physician was notified. An incident report, dated [DATE], documented the details of the resident to resident incident, the persons and agencies notified, and each resident was sent to specific hospitals for evaluations. 3. Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. The significant change assessment, dated [DATE], documented the resident was significantly impaired for daily decision making, required minimal assistance with ADLs, and did not have [MEDICAL CONDITIONS], or behaviors. The physician orders, dated [DATE], documented the resident was to receive [MEDICATION NAME]. The care plan, dated [DATE], documented the resident's inappropriate behaviors. The care plan documented two of the interventions put into place were to monitor the resident when he was in the hallway and document the resident's behaviors daily. A nurse note, dated [DATE], documented certified nurse aide (CNA) #4 reported to the nurse she had seen resident #277 come out of resident #278's room with his pants down and his private area exposed. The incident report, dated [DATE] at 4:30 PM, documented resident #277 was to be placed on one on one monitoring. A nurse note, dated [DATE], documented resident #277 was recently moved off the memory care unit to another hall. A nurse note, dated [DATE], documented resident #277 was transported to the hospital for psychiatric evaluation and treatment. The monitoring sheet for (MONTH) 2019 did not document behaviors for resident #277. 4. Resident #278 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated [DATE], documented the resident was severely impaired for daily decision making. The assessment documented the resident was rarely understood. A nurse note, dated [DATE] at 4:30 PM, documented a certified nurse aide (CNA) reported to the nurse she had seen resident #277 coming out of the room of resident #278 with his pants down and his private area exposed. The nurse did a head to toe assessment of resident #278 and notified the physician and the director of nurses (DON). A quality assurance (QA) report, dated [DATE], documented the facility identified the staff did not have the understanding of the difference between sexual behaviors and sexual abuse toward others. The report documented the plan of action was: a) to inservice staff on sexual abuse; b) staff was to monitor resident #63 for sexual behaviors every two hours and report negative findings immediately; c) staff was to monitor resident #277 every two hours for sexual behaviors and report negative findings immediately; d) the administrator would review documentation for continued behaviors for 14 days, then randomly; and e) the administrator would review state [MEDICATION NAME] involving sexual abuse every month for six months and report findings to QA. The sexual abuse monitoring sheets for [DATE] through [DATE] were reviewed and documented monitoring was completed. The care plan, dated [DATE], documented the resident had alterations in cognition and was unresponsive to environmental stimuli. The care plan documented the resident was rarely understood and had difficulty communicating. A nurse's note, dated [DATE], documented resident #277 had expired. A nurse's note, dated [DATE], documented resident #278 had expired. On [DATE] at 5:10 PM, resident #56 was observed in bed. The resident was confused, rambled, and unable to engage in conversation. On [DATE] at 10:00 AM, resident #56 was in common area of the memory care unit with peers during activities. [DATE] at 2:00 PM, resident #63 was outside the memory care unit, sitting by himself in the main living area watching television. The resident was not directly monitored, the nurses at the 200 hall desk were exchanging report, and were not aware the resident was in the living area. The CNA on the memory care unit came and identified the resident. The resident was quiet and did not interact with other residents. He did not exhibit signs of sexual behaviors. On [DATE] at 12:30 PM, CNA #1 stated on [DATE] she was in a resident's room assisting with ADLs. She stated she was the only staff on the memory care unit at the time of the incident. The CNA stated when she walked out of the resident's room, she saw resident #63 with his hand inside resident # 56's pants moving them up and down. The CNA stated she took resident #56 and went to the unit door which led to the main facility area to call for help. The CNA stated the nurse took resident #63 to administrator #2's office. The CNA stated Tulsa Police Department investigators came a few days later for her report. She stated resident #56 was sent to the hospital for examination. The CNA stated she had been told resident #63 was sexually inappropriate with employees and the plan was to watch him more. The CNA stated when in a resident's room, it was impossible to watch resident #63. She stated the nurse was only on the unit to give treatments and medications. The CNA stated she had a co-worker on the unit but she had gone to get something off the unit, leaving her by herself. On [DATE] at 2:50 PM, LPN #2 stated CNA #1 came out of the unit to get help. LPN #2 stated she went to the unit to assist and took resident #63 to administrator's office immediately where he was monitored one to one with the administrator. LPN #2 stated she was not aware resident #63 had a history of [REDACTED]. She did not know the facility was expecting a new resident. The LPN stated she did not get a report from the hospital or from the admission's coordinator at the facility. The LPN stated the DON talked with resident #63 and made the decision to admit him into the memory care unit. The LPN stated she'd been on the unit multiple times the day of the incident and was not aware the certified medication aide (CMA) had left the unit. The LPN stated had she been aware of resident #63's history of sexually inappropriate behaviors, she would have made sure there were two staff at all times to supervise him. On [DATE] at 1:08 PM, RN #1 stated she worked on the memory care unit at times. The RN stated she did not know the resident required one on one supervision. The RN stated most of the time there were two CNAs on the memory care unit. The RN stated at times the unit required more supervision. The RN stated if an emergency happened, she would use her cell phone to call for assistance or one of the CNAs would leave the unit to get help which left only one staff member on the unit. The RN stated she did not feel it was safe in those situations. On [DATE] at 3:10 PM, CNA #2 stated resident #277 had become aggressive and started taking off his clothes. The CNA stated when the resident was redirected to put his clothes back on he would become aggressive. The CNA stated one time resident #277 had tried to remove a blanket off of a female resident lying in bed. The CNA stated the female resident yelled and resident #277 became angry. The CNA stated she had worked on the memory care unit alone occasionally and did not think it was safe. The CNA stated she was not able to monitor all the residents when she was the only one on the unit. The CNA was not sure of what she would do in the event of an emergency and was the only one on the unit. On [DATE] at 4:35 PM, CNA #4 stated resident #277 would pull his pants down. The CNA stated resident #277 would look for staff in order to avoid being seen by staff when he pulled his pants down. On [DATE] at 3:15 PM, resident #56 was ambulating in hallway with staff assisting.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from abuse and/or neglect for seven (#4, #5, #10, #11, #12, #13, and #17) of 14 sampled residents. The facility failed to: a) Ensure residents were treated professionally and with respect for residents #10, #5, #13, #12, #17, #4, and #11. b) Ensure residents were free from neglect related to the timely provision of incontinent care, request for assistance, and using correct care procedures for residents #10, #5, #13, #12 and #11. c) Ensure residents were free from verbal abuse related to verbal degradation and humiliation for residents #5, #13, #17, #4. d) Ensure residents were free from mental abuse including freedom from humiliation and fear for residents #10, #5, #13, #12, #17, #4, and #11. e) Ensure residents were free from physical abuse related to rough and hurtful care for residents #10, #5, #12, #17, and #11. Resident #10 had increase pain with rough care, had delayed incontinent care, was subject to cursing and sexual comments. The resident experienced humiliation and was made to cry. Resident #5 was subjected to degrading sexual comments, delayed incontinent care, painful rough care and disrespect. Resident #13 did not receive timely continent care, soiled herself and felt embarrassed. The resident was subject to cursing and sexually degrading comments. Resident #12 was subjected to rough care and increased pain. The resident received delayed care from staff. Resident #17 was subjected to rough care causing pain. The resident was called a liar and was made to cry. Resident #4 was subjected to degrading comments from the staff and felt staff were talking about her. The resident was fearful of staff. Resident #11 was subjected to rough and incorrect care causing physical pain. The resident experienced retaliation in the form of rough physical care. The resident experience physical abuse when staff threw a wet brief hitting her. The facility identified 77 residents lived in the facility. Findings: The facility policy for abuse documented the facility would attempt to protect their residents from any form of abuse. The policy documented recognition of resident rights to be free from any form of abuse. 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change assessment, dated 01/08/18, documented the resident was moderately impaired for daily decision making. The assessment documented the resident had a score of zero for behaviors. The assessment documented the resident required extensive assistance with most activities of daily living (ADLs). The care plan, dated 01/19/18, documented the resident required extensive assistance with ADLs. The care plan documented the resident was incontinent of bowel and bladder and required assistance with toileting. The incident report, dated 02/05/18 at 3:00 p.m., documented the resident reported to the social service director an incident which took place on 1/13/18. The report documented the incident type was an allegation of abuse/mistreatment. The report documented certified nurse aide (CNA) #5 was very disrespectful, told the resident to stop pushing his call light, and refused to provide assistance. The report documented the resident stated the CNA would not provide incontinent care or reposition him. The report documented the CNA was suspended and an investigation was initiated. The investigative report, dated 02/07/18, documented several residents were interviewed regarding abuse. The report documented several residents stated CNA #4 and #5 were hateful, lazy, rough, and made rude comments to the residents or about other residents. On 02/07/18 at 5:05 p.m., the director of nurses (DON) was interviewed regarding abuse. The DON stated if he overheard staff making sexual comments he would send them home and report them. The DON stated cussing could be a form of abuse whether it was directed at an individual or just used in conversation. The DON stated it was not appropriate to joke about your body or someone else's body. The DON stated he had not had reports of abuse since 02/05/18. On 02/08/18 at 9:30 a.m., the resident was observed sitting up in his wheelchair. The resident was interviewed regarding his care in the facility. The resident stated some of the workers were good and some were not. The resident stated he did not care if CNA #4 came back or not. The resident stated the CNA came into his room the day before and ask him questions. The resident stated the CNA asked him what he had told the supervisor regarding CNA #4 and #5. On 02/08/18 at 2:45 p.m., the resident stated he needed assistance with toileting and repositioning. The resident stated the staff told him he would have to wait. The resident stated CNA #4 had never refused to assist with personal care but told him he would be the last person they assisted. The resident stated CNA #4 told him to not say anything to CNA#5. The resident stated CNA #4 told him CNA #5 would come back at him. The resident stated CNA #5 would tell him to mind his own business and to stay out of the conversation between her and his roommate. The resident stated the CNA told him she could only assist him every two or two and a half hours and if he used the bathroom more than every two hours she would not help him. The resident stated the CNA's comments hurt his feelings and made him cry a little. The resident stated CNA #5 talked and laughed with his roommate about having babies together and how CNA #5 was his (the roommate's) baby. The resident stated he had heard the staff comment they did not know why they had to clean him up all the time. The resident stated CNA #5 told him to shut his mouth and she didn't work for anyone but herself. The resident stated he was afraid of the CN[NAME] The resident stated the CNA told him to quit [***] ing when he complained they were being to rough. The resident stated when the CNAs were rough it intensified his pain. 2. Resident #5 was admitted to the facility 03/11/13 with [DIAGNOSES REDACTED]. The annual assessment, dated 11/16/17, documented the resident was independent for daily decision making. The assessment documented the resident had no behaviors. The assessment documented the resident did not ambulate. The assessment documented the resident required extensive assist with most ADLs. The care plan, dated 11/17/17, documented the resident required assistance with ADLs. The care plan documented the resident was incontinent of bowel and bladder. The care plan identified the resident had anxiety and pain. On 02/07/18 at 1:53 p.m., the resident was observed lying in bed watching television. The resident was interviewed regarding respect and dignity. The resident stated he heard CNA #5 on the other side of the privacy curtain make a comment about someone's private part. The resident stated the CNA said the person's penis was like a Vienna sausage. The resident stated the CNA did not say a name but the resident felt the CNA was referring to him. The resident stated he spoke with the director of nurses (DON). The resident stated the DON said he would speak to the staff. The resident stated the staff had continued to assist him with personal care. The resident stated the staff displayed and an attitude. The resident stated the evening shift continually postponed providing incontinent care. The resident stated he requested incontinent care prior to the dinner meal and would not receive incontinent care until 9 o'clock in the evening. The resident stated he felt he was not treated with respect. The grievance log, dated 02/07/18, documented a grievance reported by resident #5. The log did not document the nature of the grievance. On 02/07/18, multiple residents were interviewed regarding abuse by the staff. Several residents stated CNA #4 and CNA #5 were hateful, lazy, rough, and made rude comments to the residents. The residents stated they had overheard the CNAs make comments about other residents. On 02/07/18 at 5:05 p.m., the director of nurses (DON) was interviewed regarding abuse. The DON stated sexual abuse could be an act or comment which made another person uncomfortable. The DON stated if he overheard staff making sexual comments he would send them home and report them. The DON stated cussing could be a form of abuse whether it was directed at an individual or just used in conversation. The DON stated it was not appropriate to joke about your body or someone else's body. The DON stated he had not had anyone report abuse since 02/05/18. On 02/08/18 at 4:06 p.m., the DON was interviewed regarding the allegation of abuse. The DON stated he was notified on 02/07/18 before 6:00 p.m., regarding the allegation of abuse by resident #5. The DON stated he thought the social worker reported the incident to the administrator. The DON stated CNA #5 was already suspended for a previous incident. The DON stated CNA #4 was informed of her suspension that day. The DON stated CNA #4 did work her entire shift on 02/07/18 after the allegation of abuse was reported. The DON stated he should have suspended the CNA the day before but was involved with another issue and forgot. On 02/08/18 at 4:55 p.m., the social worker stated resident #5 made an allegation of abuse between 2:00 p.m. and 3:00 p.m. on 02/07/18. The social worker stated the resident stated he overheard the staff talking about his penis and laughing. The social worker stated she reported the allegation to the DON that afternoon. On 02/08/18 at 5:50 p.m., resident #5 stated he was afraid of CNA #5. The resident stated CNA #4 was rough and would just drop his legs when she repositioned him. The resident stated he had foot drop and repositioning it caused pain. The resident stated he felt degraded and upset when he overheard the staff making fun of him. 3. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly assessment, dated 11/16/17, documented the resident was independent for daily decision making. The assessment documented the resident required extensive assistance with ADLs. The assessment documented the resident did not ambulate. The care plan, dated 11/27/17, documented the resident had a self care deficit related to weakness, falls, and a recent hospitalization . On 02/07/18 at 3:52 p.m., resident #13 was observed sitting in wheelchair. The resident was interviewed regarding abuse. The resident stated the facility did not have enough staff. The resident stated she had soiled herself waiting for assistance. The resident stated she was embarrassed. The resident stated she had spoken with the DON regarding the problem. The resident stated the evening staff was not professional and attentive. The resident stated the staff would tell her she was not the only one there. The resident stated she had overheard the staff talk about resident body parts. The resident stated the staff made degrading comments about the residents. The resident stated she felt her life and body parts were private. The resident stated she had heard the staff cuss and stated the staff had no respect for the residents. The resident stated it made her feel like the staff did not want to provide care for her. The resident stated she had overheard the staff make a comment about resident #7. The resident stated she heard the staff say resident #7 was a big old stinky you know what. The resident stated the staff said all the resident did was lay in bed and eat. The resident stated she had overheard the staff talk about resident #5. The resident stated the staff was talking about his private body parts. The resident stated she overheard CNA #4 and #5 being asked to assist resident #10. The resident stated CNA #5 said she did not have time to help the resident because she was going to make a baby with a different resident. On 02/08/17 at 5:40 p.m., the resident stated she was afraid of CNA #5. She stated the CNA made her feel terrible about herself. The resident stated she knew if CNA #5 talked about other residents she would talk about her too. 4. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 01/16/18, documented the resident was moderately impaired for daily decision making. The assessment documented the resident require extensive to total assistance with most ADLs. The assessment documented the resident did not ambulate. The care plan, dated 01/23/18, documented the resident required help with ADLs due to an old stroke with left sided [MEDICAL CONDITION]. The care plan documented the resident had an impaired cognitive status. On 02/07/18 at 1:51 p.m., resident #12 was observed lying in bed with his eyes closed. On 02/07/18 at 5:34 p.m., the resident was heard yelling and arguing with CNA #4. The resident was interviewed regarding the situation. The resident stated the CNA was rough when providing care. The resident stated when the CNA turned him he hit his hand on the wall. The resident stated if staff did not answer his call light after 30 minutes he would start yelling or hitting the wall to get staff to respond. On 02/08/18 at 6:00 p.m., the resident stated he was afraid of CNA #4. The resident stated he was afraid she would let him fall on the floor because she turned him so quickly. 5. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change assessment, dated 12/07/17, documented the resident was moderately impaired for daily decision making. The assessment documented the resident had no behaviors. The assessment documented the resident required limited assistance with most ADLs. The assessment documented the resident needed extensive assistance with dressing, hygiene, and bathing. The assessment documented the resident did not ambulate. The care plan, dated 12/16/17, documented the resident needed limited to extensive assist with ADLs. The care plan documented the resident had a cognitive deficit related to poor memory. On 02/12/18 at 4:15 p.m., the resident was lying in bed, was clean, was groomed, and was free of odor. The resident had a call light within reach and her bedside table was next to the bed. The resident had a wheelchair located at the end of her bed. Several personal items were seen in her room. The resident was interviewed regarding abuse. The resident stated she had a problem with some of the staff. The resident stated CNA #4 was very hateful, rough, and she hated when it was time for the second shift to start. The resident stated the CNA would pull and yank her clothes and felt like she would pull off. The resident stated one night the CNA was so rough LPN #1 had to come into the room. The resident stated the LPN tried to get the CNA to do the right thing but the CNA pointed at the resident and called her a liar. The resident stated she did not cry easily but the CNA had made her cry. The resident stated CNA #5 was not very nice at times either. 6. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change assessment, dated 11/07/17, documented the resident was independent for daily decision making. The assessment documented the resident needed limited to extensive assistance with ADLs. The assessment documented the resident had limited range of motion (ROM) of the lower extremities. The assessment documented the resident did not ambulate. The care plan, dated 11/14/17, documented the resident needed assistance with ADLs. The care plan documented the resident had impairments on both sides of the lower extremities. On 02/07/18 the resident was observed sitting in her wheelchair in her room while eating. The resident was well groomed, clean, and had no odors. On 02/08/18 at 9:45 a.m., the resident stated some of the staff had an attitude. The resident stated the staff had told her she would have to wait for assistance. The resident stated she had overheard the staff make a comment about being tired of lifting her fat ass. The resident stated it upset her because she felt the staff were talking about her. The resident stated she had heard the staff cussing in general but not necessarily to a person. The resident stated she did not tell the DON because the DON and staff were friends. During the interview the resident kept looking at the door and stated, don't talk so loud. 7. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The incident report, dated 12/08/17, documented the resident reported CNA #4 was rough with her when providing personal care. The report documented the CNA was immediately suspended pending further investigation. The report documented the CNA would be required to complete training on abuse and neglect, proper peri-care, and a check off on peri-care. The report documented the CNA had received one hour of training with a skills check off list. The report did not document training for personal care or abuse and neglect had been completed. The quality assessment and assurance statement, dated 12/08/17, documented a resident interview was obtained regarding the allegation. The statement documented the resident stated CNA #4 hurt her when providing her care. The statement documented the CNA continued to provide rough care after the resident complained. The statement documented the resident stated the rough care was ongoing. The statement documented the CNA would wipe from back to front during the provision of personal care. The statement documented the incorrect technique was pointed out to the CN[NAME] The statement documented the CNA stated that was how she did it. The statement documented the CNA was so rough and gouged the resident's peri area. The statement documented the resident almost came out of the bed. The statement documented the CNA was ask to change her bed and the CNA refused. The statement documented the the CNA threw a wet brief toward the trash hitting the resident in her stomach. The quarterly assessment, dated 12/21/17, documented the resident was independent for daily decision making. The assessment documented the resident needed extensive assist with most ADLs. The assessment documented the resident did not ambulate. The care plan, dated 12/27/17, documented the resident had a ADL self care deficit related to [MEDICAL CONDITION]. The care plan documented the resident had impaired cognitive skills related to a history of [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 02/07/18 at 2:05 p.m., the resident was lying in bed finishing lunch. The resident was clean, groomed, and free of odor. The resident's call light was within reach. The resident had personal items throughout her room. On 02/08/18 the resident was interviewed regarding staff treating her roughly. The resident stated one staff person was rough. The resident stated the staff person was required to complete training regarding the provision of personal care. The resident stated the CNA did not provide personal care for her per the resident's choice.

Based on observation, interview, and record review, it was determined the facility failed to identify pressure ulcers, implement care plan interventions related to pressure ulcers, and have an effective system for the prevention and treatment of [REDACTED].#1, #7, #8, and #9) of six sampled residents who were reviewed for pressure ulcers. The facility identified five residents as having pressure ulcers. Findings: The facility's undated skin program policy documented, "...Implement Plan of Care interventions for resident's identified at risk for Pressure Ulcers...C.N.A will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse...Identify residents who currently have skin breakdown...Resident(s) with wounds will have appropriate treatment..." 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/05/14, documented the resident was cognitively impaired; required extensive assistance with bed mobility, transfers, and bathing; was incontinent of bowel and bladder; and was at risk for pressure ulcers. It was documented the resident did not have a pressure ulcer. The resident's care plan, dated 05/19/14, documented a problem of being at risk for skin breakdown. The goal was the resident's skin would maintain integrity and exhibit no signs or symptoms of pressure ulcers over the next 90 days. Interventions included to check every two hours and as needed for positioning; monitor skin weekly and document any skin breakdown; and notify the nurse of any redness, discoloration or open areas. It was documented the nurse was to obtain treatment orders as needed. A nurse's note, dated 07/30/14 and untimed, documented, "...Nurse found a wound to (right) inner heal (sic) c black eschar, drainage, unstageable, notified (physician name withheld), N.O. wound culture, wet to dry drsg. Notified (laboratory), wound culture placed in fridge (lab)..." On 07/31/14 at 9:06 a.m., the DON reported a skin sweep had been completed throughout the facility on the evening of 07/30/14, in response to being notified by the surveyor of the pressure ulcers for resident #1. She reported an additional two residents had been identified to have pressure ulcers, and a third resident, who already had skin concerns, was identified to have another pressure ulcer. Resident #8 was one of the residents identified to have a pressure ulcer. The DON reported the resident had been identified to have an unstageable pressure ulcer to her medial right heel during the skin sweep. She stated the pressure ulcer was covered with a black scab that was cracked. She reported that when RN #1 pressed on the area, drainage appeared. She stated the pressure ulcer had been reported by a CNA to LPN #4 on 07/30/14. The DON stated LPN #4 had measured the pressure ulcer but had failed to do anything else. The DON stated LPN #3 had also been notified of the pressure ulcer by the same CNA and did not do anything either. The DON stated she had instructed LPN #4 to write a late entry into the resident's chart detailing that he was informed of the pressure ulcer but failed to do anything other than measure the wound. The DON stated the pressure ulcer measured 2.0 x 2.0 cms and showed signs of infection. She stated a wound culture had been obtained, and the facility was awaiting the results. Review of the clinical record revealed documentation a physician's orders [REDACTED]. A nurse's note, dated 08/04/14 on the 7-3 shift, documented, "...Aid (sic) reported that the rsd had a red area above the buttock. Red area noted to (left) side of the sacral area. Repositioned rsd c pillow under (right) side/hip. Will pass along to evening nurse to reposition..." On 08/07/14 at approximately 11:00 a.m., the resident was observed sitting in her geriatric chair in her room. She had a pressure relieving device on the right foot. There was no pressure relieving device in the chair, and there were no signs of any type of isolation precautions. On 08/07/14 at approximately 11:15 a.m., a review of the resident's clinical record was completed. There were no laboratory results of the resident's pressure ulcer wound culture test in the record. At 11:25 a.m., the DON was asked for the results of the wound culture. On 08/07/14 at 11:52 a.m., a copy of the culture results and a copy of a physician's orders [REDACTED]. The culture results documented the specimen was collected on 07/30/14, received by the laboratory on 07/31/14, and results reported to the facility on [DATE] at 5:01 p.m. The report documented the pressure ulcer was infected with moderate [MEDICAL CONDITION] (MRSA) and moderate Staphylococcus Hominis. The physician's orders [REDACTED]. A nurse's note, dated 08/07/14 at 12:00 p.m., documented, "...Recieved (sic) wound culture. DR aware new order for Bactrim (an antibiotic)...MRSA (right) inner heel, isolation..." On 08/07/14 at 12:05 p.m., RN #1 was asked what the facility's process was for obtaining laboratory tests. She stated once an order was received, the order was logged in, the lab was called, a copy of the order was provided to the ADON, and the order was placed on the 24 hour report. She stated a tracking paper was placed in the lab book once the lab had picked up the specimen. RN #1 was asked when the wound culture was obtained for resident #8. She stated it was obtained the day of the skin sweep. The skin sweep occurred on 07/30/14. She was asked what day the results came back to the facility. She stated, "I believe they said Sunday (08/03/14)." RN #1 was asked when the physician was notified of the lab results. She stated she had just been provided with the order, so she dated it for that day (08/07/14). She was asked why orders were not obtained until that day. She stated she had been provided the culture report and order that day (08/07/14) and was told the physician had been contacted, so she had assumed it was obtained that day. On 08/07/14 at 12:15 p.m., the lab book and 24 hour shift reports were reviewed. Review of the lab book revealed no documentation related to the wound culture. Review of the 24 hour shift reports, from 07/30/14 through 08/07/14, revealed only one entry related to the wound culture. This was on 07/30/14, and it was documented a wound culture had been obtained. On 08/07/14 at 12:30 p.m., RN #1 and the DON were interviewed. RN #1 was asked when the order for the wound culture was received. She stated it was on 07/30/14 or 07/31/14. She was asked where the lab was documented in the lab tracking book. She stated she did not put in a tracking sheet. She stated she had handed the lab off to the charge nurse. She was asked to review the lab book for documentation related to the wound culture specimen and when it was sent to the lab. She reviewed the book and stated there was not a tracking sheet for the specimen. She was asked how the staff would know to monitor for the return of the lab results. No comment was made. RN #1 was asked how the facility was notified of lab results. She stated the lab faxed the results to the facility. She was asked when the lab results came to the facility for resident #8. The DON stated, "I had to pull it off (the computer)." The DON was asked if the facility had the faxed copy of when the results were reported to the facility on [DATE]. She stated, "No." RN #1 was asked who followed up with the lab to ensure the facility obtained the results of the wound culture. She stated, "Should have been the nurse." She was asked how the nurse would know to follow-up on the results. She stated it should have been on the 24 hour shift report. On 08/07/14 at 1:00 p.m., the DON was asked who monitored during the week to see if the lab results for resident #8 had came back. She stated it had been missed in the monitoring process. She was asked when the physician had been notified of the culture report. She stated that day. She stated she had notified the physician. On 08/07/14 at 1:20 p.m., the resident was observed to be in a different room. An isolation sign had been placed on her door, and personal protective equipment was available outside the room. The resident was sitting in her geriatric chair. There was no pressure relieving device in the chair. RN #1 was observed performing a dressing change on the resident's right medial heel pressure ulcer, with the assistance of CNA #9. The pressure ulcer was open. RN #1 was asked if she had observed the pressure ulcer since 07/30/14, the day of the skin sweep. She stated she had observed the ulcer earlier on this day, and the ulcer was now open. RN #1 was asked to describe the resident's pressure ulcer. She stated it was a stage II pressure ulcer, measuring approximately 1.0 x 1.2 cms. She stated there was some yellow slough on the wound bed, and the edges were raised and somewhat macerated. RN #1 was asked if the pressure ulcer was open when she saw it earlier during the day. She stated yes. RN #1 applied a wet to dry dressing on the pressure ulcer. She was asked if she had notified the physician the pressure ulcer was now open. She stated he knew it was draining when he ordered the wet to dry dressing. She was asked again if he had been notified the pressure ulcer was now open and if he had been apprised of the ulcer's description. She stated no. She stated she would notify the physician. CNA #9 was asked if the resident had a pressure relieving device in her chair. She stated no. She was asked if the resident had any breakdown on her buttocks or sacral area. She stated, "No." On 08/07/14 at 2:00 p.m., RN #1 reported the pressure ulcer treatment had been changed. On 08/07/14 at 4:46 p.m., the DON and administrator were asked if any concerns related to the facility's system for pressure ulcers had been identified prior to the survey. The administrator stated they had identified a concern with the previous wound nurses' measurements so RN #1 had been assigned to be responsible for the pressure ulcer system. They were asked how they thought the concerns related to unidentified pressure ulcers and staff not implementing the care plans related to pressure ulcers occurred. The administrator stated, "It was a breakdown in communication." 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pressure ulcer risk assessment, dated 03/20/14, documented the resident was at risk for the development of pressure ulcers. The resident's care plan, dated 04/02/14, documented the resident was at risk for a wound infection related to the stage III pressure ulcer on her sacrum. The goal was for the resident to maintain proper skin integrity and exhibit no signs or symptoms of pressure ulcers for the next 90 days. Interventions included to monitor the resident's skin weekly and document any skin breakdown. Another intervention was to alert the charge nurse of any areas of redness, discoloration, or open areas noted during care or bathing. A pressure ulcer record, dated 04/02/14, documented the stage III pressure ulcer to the resident's sacrum was resolved. A quarterly assessment, dated 06/25/14, documented the resident was cognitively intact; required extensive assistance with transfers and bed mobility; and was incontinent of bowel. It was documented the resident received [MEDICAL TREATMENT] treatments outside the facility and was at risk for the development of pressure ulcers. A skin observation/bath sheet form, dated 07/28/14, documented the resident had an open area, bruise, red area, and rash. The form did not document where any of the skin conditions were located. On 07/30/14 at 12:16 p.m., CNA #1 was observed performing bowel incontinent care for the resident. There was no specialty mattress observed on the resident's bed, and there was no cushioning noted in the resident's wheelchair. When the resident was rolled to her left, three open areas were observed on her left buttock and coccyx areas. The areas measured approximately 0.5 x 0.5 cms to 2 x 2 cms. CNA #1 was observed applying a barrier cream to the resident's buttocks and coccyx area. Review of the resident's clinical record revealed no documentation of the three open areas. There were no assessments, nurses' notes, or physician orders. On 07/30/14 at 4:00 p.m., LPN #1 was asked if anyone had reported any open skin areas for any resident. She stated, "No." She was asked if resident #1 had any pressure ulcers. She reviewed the treatment book and stated no. She stated the resident could receive barrier cream to the buttocks and coccyx as needed for redness. LPN #1 was asked what a CNA was supposed to do if new open areas were identified. She stated they were to notify the nurse, who would notify the physician, and a treatment order would be obtained. LPN #1 was asked if resident #1 was at risk for skin breakdown. She stated, "Yes." She stated the resident was to be turned and repositioned every two hours and as needed. She stated she had only seen the resident out of bed one time. At 4:05 p.m., the DON and LPN #1 were notified of the open areas on the resident's left buttock and coccyx areas. At 4:15 p.m., RN #1, who was responsible for the facility's pressure ulcer program, and LPN #1 observed the resident's skin. RN #1 was asked how many open areas the resident had. She stated, "Two." RN #1 was asked if she had been aware of the open areas. She stated no. RN #1 was asked to describe the areas. She stated pressure ulcer #1 was a stage II; measured 2 x 1.5 cms; and the wound bed was red, beefy, and moist. She stated pressure ulcer #2 was a stage II; measured 1 x 0.3 cms; and the wound bed was red, beefy, and had a scant amount of serosanguinous drainage. RN #1 was asked to assess the third area. She stated that yes, it was a pressure ulcer. She stated it was a stage II, and the wound bed was red and beefy. She stated the measurements were 0.5 x 0.5 cms. RN #1 was asked what she would do next. She stated she would call the physician and obtain treatment orders. At approximately 5:00 p.m., staff was observed putting an air overlay mattress on the resident's bed. On 07/31/14 at 9:06 a.m., the DON stated an aide had identified the pressure ulcers on 07/28/14, according to the bath sheet, but had failed to report the areas to the charge nurse. On 07/31/14 at 1:10 p.m., resident #1 was observed sitting in her wheelchair in the hallway. No pressure relieving device was noted in her wheelchair. At 3:58 p.m., the DON was asked how often the resident was up in her wheelchair. She stated usually twice daily. She was asked if the resident was transported to [MEDICAL TREATMENT] in her wheelchair. She stated yes. The DON was asked how long the resident had to sit in her wheelchair once at the [MEDICAL TREATMENT] center. She stated usually 15 to 20 minutes before her treatment began. The DON was asked what type of pressure relieving device was in the resident's wheelchair. She stated, "None." 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/21/14, documented the resident was cognitively intact; required limited assistance with transfers, dressing, and bathing; and was occasionally incontinent of urine. It was also documented the resident was at risk for developing pressure ulcers but had none. The resident's care plan, updated 06/02/14, documented the resident was at risk for further breakdown due to [MEDICAL CONDITION], occasional incontinent episodes of bladder, and shearing. The goal was proper skin integrity would be maintained, and the resident would have no pressure ulcers over the next 90 days. Interventions were to observe the skin during care, monitor skin weekly, and notify the charge nurse of any open areas, redness, irritation, or bruising. On 07/31/14 at 9:06 a.m., the DON informed the surveyor the resident had been found with a pressure ulcer on the right leg, below the buttock. The DON stated the ulcer measured 0.2 x 0.2 cms. She stated it was in the area where the resident's leg rested against the edge of the wheelchair seat. The DON stated it had not been noted by anyone prior to a skin sweep completed the evening of 07/30/14. On 07/31/14 at 1:28 p.m., the resident was observed up in her wheelchair. She was asked if she had any type of pressure relieving device in her chair. She stated no. At 2:33 p.m., the resident was observed up in her wheelchair participating in activities. She continued with no type of pressure relieving device in her chair. On 07/31/14 at 4:10 p.m., the DON was asked why interventions listed on the care plan were not being implemented. She stated, "I can't answer that." On 08/07/14 at 11:15 a.m., the resident was observed lying in bed. A cushion was noted in her wheelchair. The resident stated a foam cushion had been ordered for her wheelchair, and is was supposed to be at the facility on the following day. 4. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/22/14, documented the resident was cognitively intact; required assistance with transfers; was incontinent of bowel and bladder; and was at risk for pressure ulcers. It was documented the resident had one stage II pressure ulcer, measuring 3.3 x 3.0 cms. The resident's care plan, updated 05/06/14, documented a problem of pressure ulcers. The goal was to maintain proper skin integrity and exhibit no signs or symptoms of pressure ulcers over the next 90 days. Interventions included to monitor the skin every week and document any skin breakdown. It was documented to alert the charge nurse if any redness, discoloration, or open areas were noted during care or bathing. On 07/31/14 at 9:06 a.m., the DON reported the resident was identified to have a pressure ulcer measuring 1.0 x 1.0 cms during a skin sweep on 07/30/14. She stated the aides had not reported the open area to the charge nurses.

Based on observation, interview, and record review, it was determined the facility failed to ensure there were sufficient staff to meet the needs of the residents on one (300 hall) of four halls. This had the potential to affect 32 residents who resided on Hall 300. Findings: Review of facility wound records, dated 07/24/14, documented seven residents out of 32 on the 300 hall had wounds; including a friction/abrasion and venous, pressure, and surgical wounds. The total number of treatments was 16. On 07/30/14 at 12:07 p.m., resident #10 was asked if there was enough staff to meet the resident's needs and if she received her baths as scheduled. She stated she did not always get her baths on the scheduled day because staff would tell her they were short. She stated she would get her baths on the next day. On 07/30/14 at 4:05 p.m., the DON and LPN #1 were notified that resident #1 had been identified by the surveyor to have three stage II pressure ulcers that had not been addressed by the facility. On 07/31/14 at 9:06 a.m., the DON reported a skin sweep had been completed throughout the facility on the evening of 07/30/14, in response to being notified by the surveyor of the pressure ulcers for resident #1. She reported an additional two residents had been identified to have pressure ulcers, and a third resident, who already had skin concerns, was identified to have another pressure ulcer. This made a total of 20 treatments for 10 residents on the 300 hall. On 07/31/14 at 10:07 a.m., LPN #3 was asked how he monitored to ensure CNAs delivered quality care. He stated when he walked the hall and walked into rooms, he could tell. He was asked how he monitored to ensure incontinent care was provided properly. He stated he had "never actually" watched incontinent care being performed. He was asked how long he had worked at the facility. He stated five or six months. He was asked what hall he normally worked. He stated the 300 Hall. He stated, "It's too much." LPN #3 was asked if he was the only nurse assigned to the 300 hall. He stated, "Yes." LPN #3 was asked what his duties were. He stated he had "close to" ten treatments; two residents with tracheostomies, with one that sometimes required frequent suctioning; one resident with a [MEDICAL CONDITION], feeding tube, urinary catheter, and wounds; five feeding tubes, and three total care residents. He stated he had to perform finger stick blood sugars and give insulin; perform any breathing treatments; and chart. On 08/07/14 at 11:45 a.m., resident #11 was asked if there was enough staff in the facility to meet the needs of the residents. She stated no. She stated, "Sometimes they only have one staff. I think they have enough to get legally by." On 08/07/14 at 3:40 p.m., CNA #6 was asked if she felt there was enough staff in the facility to meet the residents' needs. She stated, "No. Even when my side is short, I have to work on the other floors." She was asked if she could provide an example of a time when a resident's needs were not met. She stated, "Not really. They just need more people." On 08/07/14 at 5:00 p.m., the ADON, who was in charge of staffing, was asked how she determined the number of direct care staff that were required. She stated she went off the census and the "PPD." She was asked what "PPD" was. She stated that was the budget. She stated normally she and the DON would look at the census, and if if was a heavy, difficult hall, they would add an extra CNA. The ADON was asked how she adjusted the staffing for resident acuity, especially on the 300 hall. She stated they had recently added another CNA to the hall. She was asked if she had adjusted the nurses based on the acuity. She stated the nurses on the other halls would help the 300 hall nurse if needed. The ADON was asked how many nurses were scheduled for the day shift on the 300 hall. She stated, "One." The ADON was asked how many residents on the 300 hall received their medications through their feeding tubes. She stated four. She was asked how many residents had tracheostomies. She stated two. She was asked how often the residents had to be suctioned. She stated she was unsure but at times, one had to be suctioned continuously. The ADON was asked what duties the day shift charge nurse had to perform on the 300 hall, in addition to the treatments, tracheostomies, and feeding tube medication deliveries. She stated the charge nurses had to pass narcotics, complete assessments, monitor the aides, and complete blood sugars, including giving insulin. The ADON stated the facility's policy said that one nurse was enough for the 300 hall. She stated, "Some nurses can handle it and some others can't."

Based on observation, interview, and record review, it was determined the facility failed to ensure administrative systems were in place which enabled the facility to run in an efficient and effective manner. This had the potential to affect 72 of 72 residents who resided at the facility. Findings: 1. The facility failed to identify pressure ulcers, implement care plan interventions related to pressure ulcers, and have an effective system for the prevention and treatment of [REDACTED].#1, #7, #8, and #9) of six sampled residents who were reviewed for pressure ulcers. The facility identified five residents as having pressure ulcers. See F-314. 2. The facility failed to ensure there were sufficient staff to meet the needs of the residents on one (300 hall) of four halls. This had the potential to affect 32 residents who resided on Hall 300. See F-353. 3. The facility failed to ensure CNAs were trained to: A. Provide bowel incontinent care in a manner to prevent infection and report new pressure ulcers for one (#1) of two sampled residents who were observed receiving bowel incontinence care and had new pressure ulcers. The facility identified 27 residents as being incontinent of bowel and five residents with pressure ulcers; and B. Provide baths for one (#2) of three sampled residents who were reviewed for assistance with activities of daily living. The facility identified 72 residents as requiring assistance or being completely dependent on staff for bathing. See F-498. 1. On 07/31/14 at 10:07 a.m., LPN #3 was asked how he monitored to ensure CNAs delivered quality care. He stated when he walked the hall and walked into rooms, he could tell. He was asked how he monitored to ensure incontinent care was provided properly. He stated he had "never actually" watched incontinent care being performed. On 07/31/14 at 10:15 a.m., the DON was asked if nurse aide competency checks were completed. She stated, "Yes." She was asked when the checks were completed. She stated they were supposed to be completed upon hire. Review of competency checks for CNAs #2, #10, and 12 revealed the competency checks were performed from two to six months after hire. The DON stated the facility was "trying to get the competencies done." She was asked how the facility monitored to ensure the aides were providing quality care. She stated inservices were completed, and a senior aide was responsible for completing the competency checks. She stated the nurses were responsible for ensuring the aides were monitored performing their tasks. 2. Review of facility wound records, dated 07/24/14, documented seven residents out of 32 on the 300 hall had wounds; including a friction/abrasion and venous, pressure, and surgical wounds. The total number of treatments was 16. On 08/07/14 at 5:00 p.m., the ADON, who was in charge of staffing, was asked how she determined the number of direct care staff that were required. She stated she went off the census and the "PPD." She was asked what "PPD" was. She stated that was the budget. She stated normally she and the DON would look at the census, and if if was a heavy, difficult hall, they would add an extra CNA. The ADON was asked how she adjusted the staffing for resident acuity, especially on the 300 hall. She stated they had recently added another CNA to the hall. She was asked if she had adjusted the nurses based on the acuity. She stated the nurses on the other halls would help the 300 hall nurse if needed. The ADON was asked how many nurses were scheduled for the day shift on the 300 hall. She stated, "One." The ADON was asked how many residents on the 300 hall received their medications through their feeding tubes. She stated four. She was asked how many residents had tracheostomies. She stated two. She was asked how often the residents had to be suctioned. She stated she was unsure but at times, one had to be suctioned continuously. The ADON was asked what duties the day shift charge nurse had to perform on the 300 hall, in addition to the treatments, tracheostomies, and feeding tube medication deliveries. She stated the charge nurses had to pass narcotics, complete assessments, monitor the aides, and complete blood sugars, including giving insulin. The ADON stated the facility's policy said that one nurse was enough for the 300 hall. She stated, "Some nurses can handle it and some others can't." 3. On 08/07/14 at 4:45 p.m., the DON and administrator were asked if, prior to the survey, any concerns had been identified with pressure ulcers. The administrator stated during 06/2014, an outside wound nurse had been coming to the facility. She stated they had identified some discrepancies with wound measurements, so RN #1 had been placed in charge of the pressure ulcer program. She was asked if there had been any concerns identified with staff not reporting new pressure ulcers. She stated no. The DON and administrator were asked how they ensured staff was knowledgeable of the facility's processes. The DON stated inservices were completed. The administrator and DON were asked how the nursing staff was monitored to ensure the processes were put into place. The DON stated, "We weren't following up." The administrator stated, "That is a problem." She stated, "Right now, we have a process in place. They aren't new nurses." The DON and administrator were asked how they thought the harm level deficiency in pressure ulcers had occurred. The administrator stated, "Breakdown in communication." They were asked what resources they had available to them. The administrator stated they had a regional nurse and could always call sister facilities. She stated they would continue to retrain and inservice the nursing staff until they realized follow-through was required.

Based on observation, interview, and record review, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies. The facility failed to identify and implement a plan of action to correct system failures related to: A. Pressure ulcers; B. Nurse aide proficiency; and C. Documentation. This had the potential to affect 72 of 72 residents who resided at the facility. Findings: 1. The facility failed to identify pressure ulcers, implement care plan interventions related to pressure ulcers, and have an effective system for the prevention and treatment of [REDACTED].#1, #7, #8, and #9) of six sampled residents who were reviewed for pressure ulcers. The facility identified five residents as having pressure ulcers. See F-314. 2. The facility failed to ensure CNAs were trained to: A. Provide bowel incontinent care in a manner to prevent infection and report new pressure ulcers for one (#1) of two sampled residents who were observed receiving bowel incontinence care and had new pressure ulcers. The facility identified 27 residents as being incontinent of bowel and five residents with pressure ulcers; and B. Provide baths for one (#2) of three sampled residents who were reviewed for assistance with activities of daily living. The facility identified 72 residents as requiring assistance or being completely dependent on staff for bathing. See F-498. 3. The facility failed to have accurate and complete clinical records related to bathing for two (#1 and #3) of six sampled residents whose records were reviewed. The facility identified 72 residents as requiring the assistance of one or more staff for bathing. See F-514. On 07/31/14 at 10:07 a.m., LPN #3 was asked how he monitored to ensure CNAs delivered quality care. He stated when he walked the hall and walked into rooms, he could tell. He was asked how he monitored to ensure incontinent care was provided properly. He stated he had "never actually" watched incontinent care being performed. On 07/31/14 at 10:15 a.m., the DON was asked if nurse aide competency checks were completed. She stated, "Yes." She was asked when the checks were completed. She stated they were supposed to be completed upon hire. She stated the facility was "trying to get the competencies done." Review of competency checks for CNAs #2, #10, and 12 revealed the competency checks were performed from two to six months after hire. The DON stated the facility was "trying to get the competencies done." She was asked how the facility monitored to ensure the aides were providing quality care. She stated inservices were completed, and a senior aide was responsible for completing the competency checks. She stated the nurses were responsible for ensuring the aides were monitored performing their tasks. On 08/07/14 at 4:45 p.m., the DON and administrator were asked if, prior to the survey, any concerns had been identified with pressure ulcers. The administrator stated during 06/2014, an outside wound nurse had been coming to the facility. She stated they had identified some discrepancies with wound measurements, so RN #1 had been placed in charge of the pressure ulcer program. She was asked if there had been any concerns identified with staff not reporting new pressure ulcers. She stated no. The DON and administrator were asked if, prior to the survey, any concerns had been identified with bathing documentation. The administrator stated there had been one example of a CNA not being forthright with a nurse, but the problem had been addressed. The DON and administrator were asked if, prior to the survey, any concerns had been identified regarding residents not receiving their baths as scheduled. The administrator stated one family had verbalized concern but the resident had a bath and refused a bath twice. They were asked how staff was educated regarding bathing schedules and documentation. The DON stated staff had been inserviced. The administrator stated the nurses were supposed to follow up, but they had a turn over in nursing staff. The DON and administrator were asked how they ensured staff was knowledgeable of the facility's processes. The DON stated inservices were completed. The administrator and DON were asked how the nursing staff was monitored to ensure the processes were put into place. The DON stated, "We weren't following up." The administrator stated, "That is a problem." She stated, "Right now, we have a process in place. They aren't new nurses."