Every finding on record at Haskell Care Center

Based on observation and interview, the facility failed to ensure posted staffing information contained projected and actual staffing hours worked. The administrator identified 35 residents who resided in the facility. Findings: On 09/22/24 at 11:05 a.m., a white board at the nursing station was observed to contain the facility name, date, census, staff and their position, but did not contain projected and actual staffing hours worked. On 09/25/24 at 3:54 p.m., a white board at the nursing station was observed to contain the facility name, date, census, staff and their position, but did not contain projected and actual staffing hours worked. On 09/27/24 at 3:52 p.m., the corporate nurse stated they were not aware of the requirements to post projected and actual hours worked.

Based on record review and interview, the facility failed to implement their abuse policy for one (#10) of twelve sampled residents reviewed for abuse and one (CNA#1) of five sampled employees whose background checks were reviewed. The administrator identified 35 residents who resided in the facility. Findings: A policy titled ABUSE POLICY read in part, .THIS FACILITY HAS PROCEDURES TO IDENTIFY EVENTS, SUCH AS SUSPICIOUS BRUISING OF RESIDENT, OCCURRENCES, PATTERNS AND TRENDS THAT MAY CONSTITUTE ABUSE .THIS FACILITY HAS PROCEDURES TO INVESTIGATE DIFFERENT TYPES OF INCIDENTS AND IDENTIFY THE STAFF MEMBER/MEMBERS RESPONSIBLE FOR THE INITIAL REPORTING .PROTECT RESIDENTS FROM HARM DURING AN INVESTIGATION .REPORT ALL ALLEGED VIOLATIONS AND ALL SUBSTANTIATED INCIDENTS TO THE STATE AGENCY AND TO ALL OTHER AGENCIES AS REQUIRED . An undated Abuse Policy, read in part, This facility has procedures to screen potential employees for a history of abuse, neglect or mistreating residents. The screening will include .checking with the the appropriate licensing boards and registries. A Background Screening Investigations policy, dated, November 2015, read in part, Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees .The personnel/human resources director .will conduct background checks .and criminal conviction checks on all potential employee .within two days of an offer of employment or contract agreement . 1. Res #10 had diagnoses which included quadriplegia, depressive episodes, mood disorder due to known physiological condition, anxiety disorder, and pain. A care plan, dated 05/24/24, documented the resident had an ADL self care deficit related to a diagnosis of quadriplegia. The care plan documented the resident was at risk of altered psychosocial well being related to no family support and history of ineffective coping mechanisms. The quarterly assessment, dated 08/18/24, documented the resident was not impaired cognitively and was dependent with activities of daily living. On 09/23/24 at 1:22 p.m., CNA #3 stated nursing staff was told by the DON about a week ago Res #10 and CNA #2 were a couple. On 09/23/24 at 1:34 p.m., LPN #2 stated last week a staff member stated Res #10 and CNA #2 Were trying to get together. The LPN stated they were told by staff the DON was aware of the situation, so they did not take any further action. On 09/25/24 at 8:57 a.m., Res #10 was interviewed regarding their relationship with CNA #2. The resident stated they were good friends and nothing more. The resident stated CNA #2 would sometimes come in early or stay later after their shift to visit them. On 09/25/24 at 9:34 a.m., the administrator stated they were unaware of the relationship between Res #10 and CNA #2 until yesterday when the DON reported it to them. The administrator stated they thought it was a concern if the resident was cognitive and consenting. The administrator stated the previous administrator, when made aware of the relationship, did not investigate or report the incident. The administrator stated an incident report would be completed and the staff member suspended pending the investigation. On 09/25/24 at 10:03 a.m., CNA #2 was interviewed by telephone regarding their relationship with Res #10. The CNA stated two or three weeks ago a meeting was requested with administration regarding their relationship. The CNA stated a meeting was held with the previous administrator, the DON, and the assistant administrator/office manager regarding their relationship. The CNA stated the previous administrator, the DON, and the assistant administrator gave them their blessing regarding their relationship if it had developed into something more than just friends. The CNA stated physical contact with Res #10 were hugs at the time. 2. CNA #1 was hired on 10/09/15. There was no background check/clearance letter on file for their most recent date of hire. On 09/26/24 at 9:54 a.m., a representative from OK Screen stated the employee had been separated in the system by another employer on 10/12/15. The representative reported the facility did not put in a new application for CNA #1 upon hire. The representative stated CNA #1 had not been monitored since 2015. On 09/26/24 at 1032 a.m., the administrator stated there should have been a background check completed for CNA #1. The administrator stated they completed annual checks for all employees to ensure they have background checks/clearance letters, and the background check for CNA #1 must have been overlooked. 45913

Based on record review and interview, the facility failed to report an allegation of abuse for one (#10) of two sampled residents reviewed for abuse. The administrator identified seven allegations of abuse within the last six months. Findings: A policy titled ABUSE POLICY read in part, .REPORT ALL ALLEGED VIOLATIONS AND ALL SUBSTANTIATED INCIDENTS TO THE STATE AGENCY AND TO ALL OTHER AGENCIES AS REQUIRED AND TAKE ALL NECESSARY CORRECTIVE ACTIONS DEPENDING ON THE RESULTS OF THE INVESTIGATION . Res #10 had diagnoses which included quadriplegia, depressive episodes, mood disorder due to known physiological condition, anxiety disorder, and pain. A care plan, dated 05/24/24, documented the resident had an ADL self care deficit related to a diagnosis of quadriplegia. The care plan documented the resident was at risk of altered psychosocial well being related to no family support and history of ineffective coping mechanisms. The quarterly assessment, dated 08/18/24, documented the resident was not impaired cognitively and was dependent with activities of daily living. On 09/23/24 at 1:22 p.m., CNA #3 stated nursing staff was told by the DON about a week ago Res #10 and CNA #2 were a couple. On 09/23/24 at 1:34 p.m., LPN #2 stated last week a staff member stated Res #10 and CNA #2 Were trying to get together. The LPN stated they were told by staff the DON was aware of the situation, so they did not take any further action. On 09/25/24 at 8:57 a.m., Res #10 was interviewed regarding their relationship with CNA #2. The resident stated they were good friends and nothing more. The resident stated CNA #2 would sometimes come in early or stay later after their shift to visit them. On 09/25/24 at 9:34 a.m., the administrator stated they were unaware of the relationship between Res #10 and CNA #2 until yesterday when the DON reported it to them. The administrator stated they thought it was a concern if the resident was cognitive and consenting. The administrator stated the previous administrator, when made aware of the relationship, did not investigate or report the incident. The administrator stated an incident report would be completed and the staff member suspended pending the investigation. On 09/25/24 at 10:03 a.m., CNA #2 was interviewed by telephone regarding their relationship with Res #10. The CNA stated two or three weeks ago a meeting was requested with administration regarding their relationship. The CNA stated a meeting was held with the previous administrator, the DON, and the assistant administrator/office manager regarding their relationship. The CNA stated the previous administrator, the DON, and the assistant administrator gave them their blessing regarding their relationship if it had developed into something more than just friends. The CNA stated physical contact with Res #10 were hugs at the time.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for one (#10) of two sampled residents reviewed for abuse. The administrator identified seven allegations of abuse within the last six months. Findings: A policy titled ABUSE POLICY read in part, .THIS FACILITY HAS PROCEDURES TO INVESTIGATE DIFFERENT TYPES OF INCIDENTS AND IDENTIFY THE STAFF MEMBER/MEMBERS RESPONSIBLE FOR THE INITIAL REPORTING, LEADING TO THE INVESTIGATION OF ALLEGED VIOLATIONS AND REPORTING OF RESULTS TO THE PROPER AUTHORITIES . Res #10 had diagnoses which included quadriplegia, depressive episodes, mood disorder due to known physiological condition, anxiety disorder, and pain. A care plan, dated 05/24/24, documented the resident had an ADL self care deficit related to a diagnosis of quadriplegia. The care plan documented the resident was at risk of altered psychosocial well being related to no family support and history of ineffective coping mechanisms. A quarterly assessment, dated 08/18/24, documented the resident was not impaired cognitively and was dependent with activities of daily living. On 09/23/24 at 1:22 p.m., CNA #3 stated nursing staff was told by the DON about a week ago Res #10 and CNA #2 were a couple. On 09/23/24 at 1:34 p.m., LPN #2 stated last week a staff member stated Res #10 and CNA #2 Were trying to get together. The LPN stated they were told by staff the DON was aware of the situation, so they did not take any further action. On 09/25/24 at 8:57 a.m., Res #10 was interviewed regarding their relationship with CNA #2. The resident stated they were good friends and nothing more. The resident stated CNA #2 would sometimes come in early or stay later after their shift to visit them. On 09/25/24 at 9:34 a.m., the administrator stated they were unaware of the relationship between Res #10 and CNA #2 until yesterday when the DON reported it to them. The administrator stated they thought it was a concern if the resident was cognitive and consenting. The administrator stated the previous administrator, when made aware of the relationship, did not investigate or report the incident. The administrator stated an incident report would be completed and the staff member suspended pending the investigation. On 09/25/24 at 10:03 a.m., CNA #2 was interviewed by telephone regarding their relationship with Res #10. The CNA stated two or three weeks ago a meeting was requested with administration regarding their relationship. The CNA stated a meeting was held with the previous administrator, the DON, and the assistant administrator/office manager regarding their relationship. The CNA stated the previous administrator, the DON, and the assistant administrator gave them their blessing regarding their relationship if it had developed into something more than just friends. The CNA stated physical contact with Res #10 were hugs at the time.

Based on record review and interview, the facility failed to ensure discharge and entry resident assessments were completed for one (#7) of six sampled residents whose resident assessments were reviewed. The administrator identified 35 residents who resided in the facility. Findings: Res #7 had diagnoses which included cerebral infarction. A progress note, dated 06/24/24 at 2:56 p.m., documented Res #7 left the facility via the facility van to visit their family member at the hospital and stay with another family member. A progress note, dated 06/25/24 at 4:02 p.m., documented Res #7 returned to the facility via the facility van. A progress note, dated 07/09/24 at 9:59 a.m., documented Res #7 left the facility to stay with a family member who was hospitalized . A progress note, dated 07/12/24 at 1:56 p.m., documented Res #7 returned to the facility. There was no discharge return anticipated or re-entry resident assessments completed. On 09/27/24 at 3:27 p.m., the MDS coordinator stated they were not aware discharge and entry tracking resident assessments had to be done when someone was on therapeutic leave. They stated they thought it was only for hospitalization s.

Based on record review and interview, the facility failed to ensure a resident assessment was accurate for one (#7) of six sampled residents whose resident assessments were reviewed. The administrator identified 35 residents who resided in the facility. Findings: Res #7 had diagnoses which included major depressive disorder, anxiety, bipolar disorder, and suicidal ideations. Res #7 had a level II PASARR which was completed on 09/22/21. An annual resident assessment, dated 08/29/24, documented Res #7 did not have a level II PASARR. On 09/27/24 at 3:22 p.m., the MDS coordinator stated they miscoded the resident assessment for Res #7. They stated knew the resident had a level II PASARR, but just failed to code it on the resident assessment.

Based on observation, record review, and interview, the facility failed to: a. ensure a level II PASARR was care planned for one (#7); and b. make a referral to the OHCA after a new serious mental illness diagnosis for one (#9) of two sampled residents whose PASARRs were reviewed. The administrator identified 35 residents who resided in the facility. Findings: 1. Res #7 had diagnoses which included major depressive disorder, anxiety, bipolar disorder, and suicidal ideations. Res #7 had a level II PASARR completed on 09/22/21 and it documented the resident needed a psychiatric consult and counseling services. The care plan for Res #7 did not contain documentation regarding a psychiatric consult or counseling services. On 09/27/24 at 3:22 p.m., the MDS coordinator stated they failed to add interventions as recommended on the PASARR for psych visits/counseling. They stated they usually care planned things like that ,but just failed to do it. 2. Res #9 was admitted to the facility on [DATE]. On 06/29/20 the resident received a diagnosis of schizoaffective disorder. A PASARR level I, dated 04/07/20, documented a level II referral to the OHCA was not required. A form titled PASRR COMMUNICATION FORM, dated 05/24/22, documented notification regarding a diagnosis of schizoaffective disorder was given to the resident. The form did not document who was contacted or if the referral was completed for a level II PASARR. On 09/26/24 at 10:40 a.m., the administrator reviewed the resident's clinical record and stated there was no documentation the OHCA had been contacted regarding the new diagnosis of schizoaffective disorder. 45913

Based on record review and interview, the facility failed to ensure a resident was competent to self administer medication and report medication errors to the physician for one (#7) of six sampled residents whose medications were reviewed. The administrator identified 35 residents who resided in the facility. Findings: Res #7 had diagnoses which included major depressive disorder, anxiety, bipolar disorder, and suicidal ideations. Res #7's Level II PASARR, dated 09/22/21, documented Res #7 required professional nursing supervision with medication and required medication management. A physician's order, dated 07/05/23, documented an order for folic acid (a supplement) 1 mg daily. A physician's order, dated 07/05/23, documented an order for tamsulosin (a medication for enlarged prostate) 0.4 mg at bedtime. A physician's order, dated 07/05/23, documented an order for Sodium Bicarbonate (a medication for heartburn) 650 mg three times a day. A physician's order, dated 07/05/23, documented an order for calcitriol (a medication for low calcium) 0.25 mcg every other day. A physician's order, dated 07/14/23, documented an order for magnesium (a supplement) 400 mg twice a day. A physician's order, dated 08/31/23, documented an order for atorvastatin (a medication to decrease cholesterol) 40 mg at bedtime. A physician's order, dated 09/01/23, documented an order for fish oil (a supplement) 1000 mg daily. A physician's order, dated 04/19/24, documented an order for buspirone (a medication for anxiety) 5 mg twice a day. A progress note, dated 07/09/24 at 9:59 a.m., documented Res #7 left the facility with their medication to stay with a family member in the hospital. A Release of Responsibility & Medication for Leave of Absence or Discharge and Return form, dated 07/09/24, documented Res #7 left the facility with the following amount of medication: a. folic acid 1 mg - 8 pills, b. Tamsulosin 0.4 mg - 27 pills, c. Sodium Bicarbonate 650 mg - 53 pills, d. calcitriol 0.25 mcg - 12 pills, e. magnesium 400 mg - 43 pills, f. atorvastatin 40 mg - 34 pills, g. fish oil 1000 mg - 27 pills, and h. buspirone 5 mg - 20 pills. A progress note, dated 07/12/24 at 1:56 p.m., documented Res #7 returned to the facility with their medication. A Release of Responsibility & Medication for Leave of Absence or Discharge and Return form, with a return date of 07/12/24, documented Res #7 returned to the facility with the following amount of medication: a. folic acid 1 mg - 6 pills, b. Tamsulosin 0.4 mg - 25 pills, c. Sodium Bicarbonate 650 mg - 47 pills, d. calcitriol 0.25 mcg - 10 pills, e. magnesium 400 mg - 38 pills, f. atorvastatin 40 mg - 28 pills, and g. fish oil 1000 mg - 25 pills h. Buspirone 5mg - 12 pills. The amount of medication returned was reconciled against Res #7's July 2024 MAR with the following discrepancies/errors noted: a. folic acid 1 mg - two doses were missing when there should have been three doses missing, b. Tamsulonsin 0.4 mg - two doses were missing when there should have been three doses missing, c. Sodium Bicarbonate 650 mg - six doses were missing when there should have been nine doses missing, d. calcitriol 0.25 mcg - two doses were missing when there should have only been one dose missing, e. magnesium 400 mg - five doses were missing when there should have been six doses missing, f. atorvastatin 40 mg - six doses were missing when there should have only been three doses, g. fish oil 1000 mg - two doses were missing when there should have been three doses missing, and h. buspirone 5 mg - eight doses were missing when there should have only been six doses missing. There was no self administration of medication assessment for Res #7. There was no documentation the medication discrepancies/errors were reported to Res #7's physician. On 09/26/24 at 4:15 p.m., the resident stated when they were at hospital with their family member, they took their medication without assistance and stated, I think I did it correctly. I hope I took them right. On 09/26/24 at 4:30 p.m., an interview was conducted with the DON, the corporate nurse and the administrator. The DON stated there was no self administration of medication assessment for Res #7. The corporate nurse stated they thought completing a self administration of medication assessment was only for residents who kept medication at bedside. The corporate nurse stated Res #7 was cognitively intact so they assumed the resident could give themselves their own medication. The DON stated they did not reconcile the returned medication count sheet against the MAR to ensure the resident took their medication properly. The DON stated the medication discrepancy/errors should have been reported to the physician and were not. On 09/27/24 at 9:30 a.m., CNA #4 stated Res #7 took their medication while at the hospital, but they were not sure if the resident took the medication as ordered.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing and humidifier bottles were changed and labeled monthly for one (#5) of two sampled residents whose oxygen tubing/humidifier bottles were observed. The administrator identified 35 residents who resided in the facility Findings: Res #5 had diagnoses which included COPD, chronic respiratory failure, dyspnea, abnormalities of breathing, and congestive heart failure. A physician's order, dated 07/20/23, documented Res #5's oxygen tubing and humidifier bottle were to be changed and labeled monthly on the 20th of each month. A care plan focus, dated 08/30/23, documented the resident's oxygen tubing and humidifier bottle were to be changed and labeled monthly. A TAR for September 2024, documented Res #5's oxygen tubing and humidifier bottle was changed on 09/20/24. On 09/22/24 at 11:10 a.m., the oxygen tubing and humidifier bottle labels were dated 08/21/24. On 09/23/24 at 2:38 p.m., the oxygen tubing and humidifier bottle labels were dated 08/21/24. On 09/25/24 at 9:41 a.m., the oxygen tubing and humidifier bottle labels were dated 08/21/24. On 09/27/25 at 3:30 p.m., the corporate nurse stated the oxygen tubing and humidifier bottle should have been labeled with a date of 09/20/24.

Based on record review, observation, and interview, the facility failed to provide adequate supervision and assistance to help prevent falls for two (#1 and #5) of three residents reviewed for falls. Res #1 had four falls in two months, they suffered a hematoma to back of head and abrasion to elbow with one fall and had a fracture to their orbital facial bones on the last fall. The facility failed to: a) Implement interventions and/or appropriate interventions to prevent falls for the residents after each fall occurrence. b) Monitor and/or update the residents' plan of care for appropriate fall interventions. c) Ensure staff were aware of additional care needs for the residents. The administrator identified 16 residents had fallen in the last six months. Findings: A Falls and Fall Risk, Managing policy documented .staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls .If falling recurs despite initial interventions staff will implement additional or different interventions, or indicate why the current approach remains relevant .If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . 1. Res #1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, depressive disorder, chronic pain, and diabetes. The resident was not in the facility at the time of the survey. The care plan, dated 08/14/23, documented the resident was at risk for falls related to altered mobility status and used a walker for ambulation. The care plan goal was to maintain resident safety and prevent further falls and was ongoing. Interventions to prevent falls were for staff to ensure: a) The resident's walker was within reach and in good condition. b) A fall risk assessment was completed on admit, quarterly, and with a significant change. c) The resident's pathway was free of clutter and well lit. d) Monitoring was completed for changes in gait and mobility status. e) Monitoring of medication changes and their affects on resident risk for falls. f) Falls were reported to the physician, family/POA, and administration. The care plan documented the resident had a self care deficit. Interventions documented the resident was mostly incontinent of bladder, able to toilet self and change brief when incontinent episodes occurred. The care plan documented the resident had limited physical mobility related to decreased activity tolerance and used a wheelchair for ambulation. The care plan documented the resident required supervision for safety and monitoring for possible changes in gait. The admission assessment, dated 08/27/23, documented the resident was severely impaired cognitively and required supervision to limited assistance with ADLs. The assessment documented the resident required supervision and physical assistance of one person for transfers, toileting, and walking in resident room. An incident report, dated 09/14/23, documented the resident was found laying on the floor near the bathroom door in their room. The report documented the resident had a hematoma to the back of their head and an abrasion to the left elbow. The report documented the immediate action was the resident was set to the ER. The care plan, updated 09/14/23, documented a repeated intervention that the staff were to report all falls to the physician, family/POA, and administration. There was no added intervention to the care plan to help prevent falls. A progress note, dated 09/15/23, documented the resident had returned from the hospital. The note documented the resident was extremely sore and was provided a wheelchair to aid with mobility. The note documented the resident was alert and oriented to self only and was continent of bowel and bladder. The wheelchair was not added to the care plan. An incident report, dated 09/16/23, documented the resident was noticed on her knees in front of the bathroom door leaning down on both hands, with their walker in front of them. The report documented predisposing factors were gait imbalance and ambulating without assist. The report documented the immediate action was to take the resident every two hours to the bathroom. The care plan, updated on 09/16/23, documented the resident had a non-injury fall on 09/16/23. The interventions added were a repeat intervention for staff to report all falls to the physician, family/POA, and administrations; and for staff to assist the resident to the bathroom every two hours for 48 hours following the fall for safety. A progress note, dated 09/17/23, documented the resident was assisted to the restroom every two hours and the call light was within reach. A progress note, dated 09/18/23, documented the resident was resting with a C-Pap in place and every two hour checks for toileting was completed. An incident report, dated 10/08/23, documented the resident was in the lobby on the floor in front of their wheelchair. The report documented the resident did not know what happened or how they had fallen. The report documented the immediate action taken was to re-educate the resident to ask for assistance when transferring from the wheelchair. The care plan did not document new interventions to prevent falls after the fall occurring 10/08/23. A state reportable, dated 10/24/23, documented the resident had fallen when getting out of bed. The report documented the maintenance staff heard a crash and the resident cry out. The resident was found lying face down next to the restroom door, call light was in place, and was bleeding at their nose onto the floor. The report documented the resident did not use their call light prior to the fall. The report documented an investigation was completed and a root cause was conducted with no clear cause determined. The report documented the resident could not provide any information due to their injury and being sent out by ambulance. The report documented it was discovered later at the hospital the resident had fractured their orbital bones. The care plan, updated 10/24/23, documented the resident had a fall on 10/24/23. The interventions added was for: a) Staff to evaluate resident for injuries, stabilize position, and alert emergency response. b) Staff to move the resident to a room closer to the nurses station when they return from the hospital, for better visual of resident. c) Staff to notify the physician, family/POA, and administration. d) Staff to sent the resident to the emergency room for evaluation and treatment. A hospital form titled, Emergency Documentation, documented on 10/24/23 an emergency room triage was performed. The form read in part, .Chief Complaint Description: trauma transfer orbital fx after fall and hit head today . A hospital form titled, Discharge Summaries, documented the resident was admitted on [DATE]. The form documented the resident said they had needed to use the restroom, but a nurse was not around to help them. The form documented the resident was moaning in pain, was confused, and unable to tell their name. The form documented the resident appeared cyanotic in the face and supplemental oxygen was started. The form documented the resident received two units of packed red blood cells overnight. On 11/21/23 at 11:10 a.m., CNA #1 was interviewed regarding fall prevention for the resident. The CNA stated interventions were to keep the resident in areas of visual sight and ensure the resident had their walker. No other interventions were identified. On 11/21/23 at 11:24 a.m., CNA #2 was interviewed regarding fall prevention for the resident. The CNA stated the resident usually ate meals in the dining room and was observed. The CNA stated they tired to check on resident between meals when in their room. The CNA stated the resident was educated to use the call light for assistance, but due to the resident's disease process the resident did not remember to use the call light. On 11/21/23 at 11:36 a.m., the DON was interviewed regarding falls for the resident. The DON reviewed the resident's clinical records and incident reports. The DON stated new interventions to prevent falls were not updated after each fall occurrence and some interventions were not appropriate for the resident. 2. Res #5 was admitted to the facility on [DATE] with diagnoses which included dyspnea, pain, and anemia. A significant change assessment, dated 06/22/23, documented the resident was severely impaired cognitively and required supervision to limited assistance with activities of daily. The assessment documented the resident had fallen once with no injury. An incident report,dated 07/16/23, documented the resident had a witnessed non-injury fall. The report did not document action taken to prevent falls. An incident report, dated 07/25/23, doucmented the resident had a witnessed non-injury fall. The report documented the resident fell to their knees next to the front patio door. The report documented an intervention to place the resident on outdoor supervision. An incident report, dated 07/28/23, documented the resident had an un-witnessed fall in the dining room. The report documented the resident had a skin tear to the right elbow. The report did not document an intervention to help prevent further falls. An incident report, dated 08/29/23, documented had a witnessed non-injury fall in the dining room. The report documented an intervention to ensure the resident wore shoes when ambulating. The care plan, dated 09/28/23, documented the resident was at risk for falls related to decline (unexpected weight loss) and related to disease progression of chronic obstructive pulmonary disease. The goal was to maintain safety and prevent falls. Documented interventions were for staff: a) to complete fall risk asessments quarterly and with a significant change, b) to encourage frequent rest periods and monitor for weakness or decreased activity tolerance, c) to ensure adequate lighting in resident's room, d) to monitor for safety daily with resident ambulation in hallways, e) to monitor for abnormalities in resident's gait, f) to monitor daily for signs and symptoms of pain, and g) to report all falls to the physician, family/POA, and administration. On 11/21/23 at 11:10 a.m., CNA #1 stated the resident was not a fall risk and was not aware of falls for the resident. On 11/21/23 at 11:20 a.m., the resident was observed lying in bed, oxygen in place, and the resident's wheelchair was beside the bed. The resident stated they had not fallen recently and was able to toilet themselves. On 11/21/23 at 11:24 a.m., CNA #2 stated the resident was a fall risk, tried to check on the resident every two hours, and the resident sometimes used the call light for assistance. On 11/21/23 at 11:36 a.m., the DON reviewed the resident's clinical records and stated interventions were not put in place after each resident fall to prevent reoccurrence.

Based on observation, record review, and interview, the facility failed to develop a wound care plan for one (#24) resident of three residents reviewed for pressure ulcers. Findings: The Resident Census and Conditions of Residents, dated 08/07/23, documented three residents had pressure ulcers. Res #24 was admitted with diagnoses which included diabetes and hemiplegia (paralysis of one side of the body) affecting the left side. Skin assessments dated 07/07/23, 07/14/23, and 07/21/23 documented Res #24 had a pressure ulcer on the right heel. On 08/07/23 at 9:50 a.m., Res #24 was observed lying on their left side. On 08/09/23 at 10:46 a.m., LPN #1 was observed applying Betadine (a topical antiseptic) to a pressure ulcer on Res #24's right heel. On 08/09/23 at 10:47 a.m.,LPN #1 reported Res #24 was noncompliant with wearing a heel protector on their right foot and keeping their right foot off of the surface of the bed. On 08/09/23 at 11:06 a.m., the MDS coordinator reported the wound care for Res #24 should have been on the care plan. On 08/09/23 11:07 at 11:07 a.m., LPN #1 reported the wound care for Res #24 was not on the care plan and they would have expected to find the wound care for Res #24 on the care plan. On 08/09/23 at 11:08 a.m.,the DON reported the current wound and wound care for Res #24 should have been on the care plan. A significant change resident assessment, dated 05/26/23, documented Res #24 had impaired range of motion of both extremities on the left side. The assessment documented the resident was nonambulatory and required extensive assistance with turning and repositioning. A Care Plans, Comprehensive Person-Centered policy, revised 12/16, read in part, .care plans are revised as information about the residents and and residents' conditions change . A physician's order, dated 06/28/23 read in part, wound care: right medial heel- apply Betadine every day and evening shift

Based on observation, record review, and interview, the facility failed to ensure residents' care plans were reviewed and revised for two (#18 and #25) of 12 residents whose care plans were reviewed. The facility failed to update the residents' care plans: a. with new interventions in response to psychotropic drugs for resident #18, and b. with new interventions in response to weight loss for resident #25. The Resident Census and Conditions of Residents documented 34 residents resided in the facility. Findings: a. Resident #18 was admitted with diagnoses of disorder with delusions, psychosis, Alzheimer's, and alcohol-induced persisting dementia. A quarterly resident assessment dated [DATE] documented the resident's cognition was severely impaired. The assessment also documented the resident required supervision with all ADLs. A care plan dated 07/22/22 for mood and behavioral status documented to administer antidepressants and antipsychotic medications as prescribed by physician with a target date of 07/21/23. There was no documented revision to the care plan for Res #18 as of 08/09/23. On 08/09/23 at 2:06 p.m., the MDS coordinator stated the facility changed computer systems on 07/05/23 and they did not get a chance to update the old care plans, but the care plans would be updated since they had a new computer system. b. Resident #25 was admitted with diagnoses of cerebral infarction, anemia due to antineoplastic chemotherapy, history of transient ischemic attacks, depression, pain, and nausea. A significant change resident assessment dated [DATE], documented the resident's memory was ok and they had mild depression. The assessment also documented the resident required limited assistance with all ADLs. A care plan dated 06/09/22, for altered nutritional status, documented to notify the physician if weight loss or gain was five % in one month or 10% in six months. On 04/12/23 at 3:30 p.m., a weight was documented at 212.0 pounds for Res #25. On 05/03/23 at 2:11 p.m., a weight was documented at 195.5 pounds, a 7.78% weight loss for Res #25. On 08/09/23 at 12:49 p.m., the MDS coordinator stated the facility changed computer systems on 07/05/23 and they did not get a chance to update the old care plans, but the care plans would be updated since they had a new computer system.

Based on observation and interview, the facility failed to ensure daily staffing information containing all of the required components was posted and retained for the required amount of time. Findings: The Resident Census and Conditions of Residents, dated 08/07/23, documented a census of 36 residents. On 08/07/23 at 10:00 a.m., a dry erase board on the west wall adjacent to the nurse's station documented the staff currently on duty and the census. The board did not contain documentation of the actual hours worked for the staff. On 08/08/23 at 10:20 a.m., a dry erase board on the west wall adjacent to the nurse's station documented the staff currently on duty and the census. The board did not contain documentation of the actual hours worked by the staff. On 08/08/23 at 10:23 a.m. the GM and corporate nurse #1 reported the white board did not contain the actual hours worked by the staff. The GM and corporate nurse #1 also reported they did not have documentation of the daily staffing information for the past 18 months. The GM also reported they did not currently have a system to keep the daily staffing information for 18 months.

Based on observation and interview, the facility failed to provide a hand washing sink in the kitchen with soap and water separate from the sink used for food preparation. The Resident Census and Conditions of Residents, dated 08/07/23, documented 34 residents resided in the facility. On 08/07/23 at 9:28 a.m., an initial tour of the kitchen was conducted. The following observations were made: a. a sink utilized for hand hygiene was in a separate room with pots and pans laying in and around the sink, b. an OUT OF ORDER sign was hanging above the sink, c. no soap was available to wash hands before food preparations, and d. no paper towels were available to dry hands before food preparations. On 08/07/23 at 9:28 a.m., Cook #1 stated they used the same sink to wash their hands as they used to prepare food for the residents. They also stated there was a separate sink in the other room but it did not work. Cook #2 stated the hand washing sink had not worked since they had started working at the facility. On 08/07/23 at 9:43 a.m., Maintenance #1 stated the hand washing sink was not out of order and they didn't know why the sign was there. They also reported the water worked and if they needed to make it work better they would. On 08/07/23 at 1:27 p.m., the general manager stated they did have a separate sink in the kitchen for hand washing, but the staff did not know the sink was working because the hot water did not come out quickly. They also stated the pots and pans had been removed and they were getting it ready to use for hand washing.

Based on record review and interview, the facility failed to reevaluate for preadmission screening and resident review (PASRR) level 1 after a change in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Census and Conditions of Residents form documented 40 residents lived in the facility. Findings: 1. Res #32 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A PASRR I assessment, dated 10/03/18, documented no to all questions regarding the resident having a serious mental illness. On 10/09/18, it was documented Res #32 received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/11/18, Res #32 received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed no documentation the OHCA was notified of the new diagnosis. The resident currently takes [MEDICATION(S)] (an antipsychotic medication) daily. On 04/13/22 at 11:24 a.m., the DON stated when a resident gets a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Res #10 was admitted to the facility 04/11/13. An annual assessment, dated 01/26/22, documented the resident was cognitively intact and received antipsychotic and antidepressant medications. The resident's list of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility could not provide any documentation the OHCA was notified of the resident's new mental illness diagnosis. On 04/14/22 at 10:29 a.m., the corporate nurse stated the facility should have called the state concerning the addition of the [CONDITION(S)] diagnosis.

Based on record review, observation, and interviews, the facility failed to ensure an open wound and [CONDITION(S)] were assessed for one (#89) of three sampled residents reviewed for skin issues. The ''Resident Census and Conditions of Residents'' report documented 40 residents resided at he facility. Findings: Res #89 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission nurse note, dated 03/28/22, documented the resident had completed an antibiotic for [CONDITION(S)] and had a wound on the back of knee and on the heel. A physician order, dated 03/29/22, documented to cleanse posterior right knee with wound cleanser, pat dry, and cover with non-adherent dressing and wrap with Kerlix. A physician order, dated 04/09/22, documented to administer [MEDICATION(S)] (a diuretic medication) 20 mg daily for [CONDITION(S)]. An admission assessment, dated 04/10/22, documented the resident was cognitively intact, had a stage III pressure ulcer, and received a diuretic. The care plan, dated 04/11/22, documented the resident had an open wound on the posterior right knee and [CONDITION(S)]. The care plan documented the nurse would conduct weekly skin assessments. On 04/11/22 at 12:52 p.m., during an interview with Res #89, an observation was made of the resident's right lower leg which was dark and had scarring from a history of [CONDITION(S)]. The right heel was wrapped and both feet had [CONDITION(S)]. On 04/13/22 at 10:51 a.m., the DON was asked to provide any wound assessments for the leg wound. She stated there were no assessments for the leg wound in the record. She stated the wound physician was scheduled to see the resident today. On 04/13/22 at 11:27 a.m., the DON was asked to provide any documentation of the resident's [CONDITION(S)] being monitored. She stated if there was any it would be in the nurse notes. No documentation was provided. On 04/13/22 at 3:32 p.m., the wound physician was observed to measure the resident's wound to the back of the knee. The wound contained pink tissue with moderate drainage. The wound measured 3.0 x 6.0 cm. The physician stated she would change the order for the knee wound. [CONDITION(S)] was observed to both feet. On 04/13/22 at 3:35 p.m., LPN #2 stated she had not completed an assessment on the resident's skin. She stated she was waiting on the wound doctor to measure and assess the wounds. She stated today was the first day the wound doctor had seen the wound. On 04/14/22 at 9:43 a.m., LPN #1 stated she had not checked or documented about the resident's [CONDITION(S)]. She stated it would be in the nurse notes if anyone had monitored it. On 04/14/22 at 12:36 p.m., LPN #1 stated she checked the resident's [CONDITION(S)] on his feet and it was 2+. LPN #1 stated she called the physician and the physician increased the dosage of [MEDICATION(S)] and said to monitor the [CONDITION(S)] every shift.

Based on record review, observation, and interview, the facility failed to provide restorative services to help prevent further decline in range of motion for two (#22 and #25) of two residents sampled for limited range of motion. The ''Resident Census and Conditions of Residents'' report documented three residents with contractures. Findings: 1. Res #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 11/13/19, documented to provide passive range of motion (PROM) of right hand three to five times a week. A significant change MDS assessment, dated 11/16/21, documented the resident had severely impaired cognition, required limited to extensive assistance with ADLs, had range of motion impairment to one upper extremity, and did not receive restorative services. A quarterly MDS assessment, dated 02/14/22, documented the resident was moderately cognitively impaired, required limited to extensive assistance with ADLs, had range of motion impairment to one upper extremity, and did not receive restorative services. The care plan, dated 02/20/22, documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented the resident had a contractured right hand. The goal was to have no decline, a reduction of pain in the hand, loosen the [MEDICATION(S)] of muscles, and learn PROM exercises he can utilize himself. The interventions included to provide PROM to fixated area, gradually building up in time two to five times per week, attempt to gently release muscles associated with contractures, and educate resident on self exercises with a focus on PROM. On 04/11/22 at 10:52 a.m., Res #22 was observed resting in bed, his right hand contracted and resting against his chest, and no brace was observed on his hand or in view. Res #22 stated he did not receive any therapy or stretching to his hand. Res #22 stated he did not wear a brace or other device on his hand. On 04/12/22 at 1:39 p.m., CNA #2 stated the facility did not have someone assigned to restorative full time, and was unaware of where the facility documented restorative services. On 04/12/22 at 1:50 p.m., MDS Coordinator stated all therapy was provided by a contracted company, and there was no in-house therapy. On 04/12/22 at 2:55 p.m., during an interview with Res #22, he stated his hand had been contracted since before he came to the facility. On 04/12/22 at 3:48 p.m., the DON stated the facility did not have a restorative aid, and the CNAs were to do PROM when they turned and/or changed the residents. The DON stated that there was no documentation to show that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Res #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated 08/23/17, documented to provide PROM to all planes three to five times a week. An annual MDS assessment, dated 08/24/21, documented the resident was cognitively intact, required total assistance with ADL's, had limited range of motion in all four limbs, and did not receive restorative care. The care plan, dated 02/24/22, documented a restorative focus of resident at risk of developing further contractures due to quadraplegia, and had slight contractures of hands and feet. The goal for the resident was to not develop further contractures of joint areas. The care plan intervention documented PROM to all planes three times per week, restorative aide to notify nurse of any decline in resident's flexibility while performing the PROM. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, required total assistance with ADL's, had limited range of motion in all four limbs, and did not receive restorative care. On 04/11/22 at 9:58 a.m., Res #25 was observed in his bed, lying on left side facing door with a modified call light, which was modified for him to be able to blow in it, within reach above his head. He stated that he needed, and would like to receive range of motion exercises, but was not getting them at the time. On 04/12/22 at 1:39 p.m., CNA #2 stated the facility did not have someone assigned to restorative full time, and she was unaware of where the facility documented restorative services. On 04/12/22 at 1:50 p.m., MDS Coordinator stated all therapy was provided by a contracted company and there was no in-house therapy. On 04/12/22 at 2:55 p.m., Res #22 stated he had been contracted since before he came to the facility. On 04/12/22 at 3:48 p.m., the DON stated the facility did not have a restorative aid, and the CNAs were to do PROM when they turned and/or changed the residents. The DON stated that there was no documentation to show that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, observation, and interview, the facility failed to: a. Evaluate the resident for the risk of falls. b. Determine the root causes of falls. c. Ensure interventions were relevant and implemented consistently. d. Implement new interventions to reduce risks, and e. Evaluate the effectiveness of interventions for one (#28) of three sampled residents reviewed for accident hazards The ''Resident Census and Conditions of Residents report documented 40 residents resided in the facility. Findings: Res #28 was admitted to the facility on [DATE] and had diagnoses which included [CONDITION(S)] and closed displaced fracture of right radial styloid process. A nurse note, dated 02/02/22, at 10:24 p.m., documented the resident was walking in the front lobby with her walker when she lost her balance and fell . The note documented the resident hit her head on the floor and an a area on the back of her head started swelling and turning purple. The note documented the resident's slippers were coming off her feet and another resident said he thought she may have turned her walker around backwards. The note documented the resident was sent to the hospital. The note documented to prevent further falls the slippers would not be used for the resident anymore and different foot wear would be provided. A hospital record, dated 02/02/22, documented the resident sustained a closed head injury. An admission MDS assessment, dated 02/13/22, documented the resident was severely cognitively impaired, required only supervision with most ADLs, and had one fall with injury. The CAA (a tool included in the MDS to evaluate the care area risks) was not used to evaluate the risk of falls and was not checked to care plan. The care plan, dated 02/15/22, documented to help the resident find and put on a different pair of shoes that fit better. A nurse note, dated 02/17/22 at 3:27 a.m., documented the resident was walking in the hallway in her socked feet, without her walker, and slid, falling to the floor. The note documented no apparent injuries. Non-slip footwear was provided and resident was reoriented to her walker. A nurse note, dated 02/17/22 at 2:58 p.m., documented the resident was observed with swelling and bruising of the left wrist. The note documented a hospice nurse would be out to evaluate in an hour. The note documented the resident stated, It hurt a little bit. A nurse note, dated 02/17/22 at 4:37 p.m., documented an x-ray was ordered. A nurse note, dated 02/17/22 at 6:49 p.m., documented the resident had a mildly displaced fracture of the distal radius. The care plan, dated 02/18/22, documented non-slip foot wear provided. A significant change MDS assessment, dated 03/02/22, documented the resident was severely cognitively impaired, required supervision with most ADLs, had impairment of one upper extremity, and had one fall with major injury. A nurse note, dated 03/03/22 at 8:45 a.m., the resident was lying on the floor. The note documented another resident stated Res #28 got up from the couch and when she turned to go in the opposite direction, she lost her balance and fell . The note documented that witnesses reported the resident hit her head on the floor. The note documented the nurse palpated a large contusion to the right posterior head. The note documented the resident was sent to the hospital at 9:03 a.m. A nurse note, dated 03/03/22 at 11:20 a.m., documented an intervention to remove all regular socks from the resident's room and replace with non-slip socks as resident dresses herself at times. A nurse note, dated 03/03/22 at 4:23 p.m., documented the resident returned from the hospital with diagnosis of hematoma of scalp. The ''Falls Plan of Care'' document, initiated on 02/02/22, documented the following interventions: a. 02/02/22 - Give resident different footwear. b. 02/17/22 - Provide non-slip footwear. c. 03/03/22 - Remove all regular socks from room and replace with non-slip ones. The care plan, dated 03/10/22, was updated with the following interventions: a. Always put bed in the lowest position. b. Complete fall risk assessment. c. Ensure adequate lighting in resident's room. d. Ensure call light is accessible. e. May ambulate ad-lib in hallways daily with staff to monitor for safety. f. Monitor for abnormalities in gait. g. Monitor every two hours and PRN. On 04/11/22 at 10:43 a.m., Res #28 was observed ambulating in hall to nurse station without assistance or assistive device. The resident was observed not wearing shoes or socks. On 04/14/22 at 8:44 a.m., Res #28 was observed lying in bed with eyes closed. A fall mat was observed under the bed. The call light was observed hanging off the foot of the bed. Slide-on slippers were observed at the bedside and the resident was not wearing socks of any kind. On 04/14/22 at 8:46 a.m., LPN #1 stated interventions were added to the plan of care and all staff were responsible for checking the care alert book for changes in residents' needs. On 04/14/22 at 9:12 a.m., the DON stated care alert documentation was completed including interventions after each fall. She stated charting was completed to reflect interventions and incident reports were filled out after falls. She stated nurses were responsible for the fall interventions. She stated the interventions were reviewed to see what the prior ones were being used.

Based on record review, observation, and interview, the facility failed to assess the need and risk of using bed rails for two (#17 and #90) of two sampled residents reviewed for bed rail usage. The Census and Conditions of Residents form documented 40 residents lived in the facility. Findings: 1. Res #17 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change assessment, dated 02/03/22, documented the resident was severely impaired with cognition and required extensive assistance with two person assist with bed mobility and total assistance with two person assist with transfers. A care plan, last review date of 03/14/21, did not address side rail usage for the resident. The clinical record revealed no assessments related to the use of bed rails. On 04/11/22 at 10:04 a.m., Res #17 was observed in bed with a quarter bed rail up and on an air mattress. On 04/12/22 at 1:21 p.m., Res # 17 was observed in bed with a quarter bed rail up on the bed. On 04/12/22 at 1:27 p.m., the DON was asked where the bed rail assessments could be found. She stated, if a resident had bed rails, it would be on the MDS and care plan. She directed me to the MDS coordinator. She said the facility did not have a separate assessment for bed rails. On 04/12/22 at 1:30 p.m., the MDS coordinator stated they did have a bed rail assessment. She stated she did the assessments. On 04/12/22 at 1:49 p.m., the MDS coordinator stated she did not have the bed rail assessment for the resident. 2. Res #90 was admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurses note, dated 04/04/22, documented resident was observed trying to climb out of bed. A physicians order, dated 04/07/22, documented one right quarter side rail. A care plan, updated 04/11/22, documented half side rails to resident's bed for repositioning to keep the resident comfortable and decrease the possibility of a fall. On 04/12/22 at 1:19 p.m., Res #90 was observed in bed with a quarter rail up on the bed. The resident was sleeping at this time. On 04/12/22 at 1:49 p.m., the MDS coordinator stated she did not have the bed rail assessment for the resident.

Based on record review and interview, the facility failed to ensure residents' drug regimen was free from unnecessary medication for four (#2, 7, 26, and #32) of five sampled residents who were reviewed for unnecessary medication. The facility failed to monitor blood pressures as ordered for residents #2, 7, 26, and #32 and failed to administer the correct dose of insulin for resident #7. The Census and Conditions of Residents form documented 40 residents lived in the facility. Findings: 1. Res #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 05/22/20, documented to administer [MEDICATION(S)] (an antihypertensive drug) 0.1mg twice a day for [CONDITION(S)]. A physician order, dated 12/08/20, documented to monitor and document blood pressure twice daily, therapeutic range <160/90 and >90/60, and notify physician if out of range. A physician order, dated 04/30/21, documented to administer [MEDICATION(S)] (a diuretic medication) 40mg twice a day for hypertension. A physician order, dated 10/31/21, documented [MEDICATION(S)] (an insulin medication) was to be administered twice daily at 6:00 a.m. and 8:00 p.m., per sliding scale, for type two diabetes mellitus. The clinical record had FSBS documented and the sliding scale insulin administered to the resident. On 04/01/22 at 8:00 p.m., resident #7's FSBS was 128. Res #7 should have received two units of insulin per sliding scale and he received zero units. On 04/03/22 at 8:00 p.m., the resident's FSBS was 162 and should have received three units per sliding scale and received one unit. On 04/09/22 at 8:00 p.m., Res #7's FSBS was 194 and should have received three units of insulin and received one unit. On 04/12/22 at 6:00 a.m., Res #7's FSBS was 83 per sliding scale the resident should have not received any insulin, the resident received one unit of insulin. The clinical record was reviewed for April 2022. Blood pressure monitoring was missing for 04/01/22 through 04/13/22. On 04/13/22 at 2:18 p.m., the corporate nurse stated the computer was not prompting the staff to enter the BP in the system. She stated the staff said they were obtaining the BP and then throwing the paper away they wrote it down on. She stated there was not any documentation of the BP's being done. On 04/14/22 at 10:18 a.m., the corporate nurse stated according to the documentation the resident did not get the correct amount of insulin on the four days in April. 2. Res #32 was admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated 12/08/20, documented to monitor and document blood pressures twice daily, therapeutic range <160/90 and >90/60, and notify the physician if out of range. A physician order, dated 02/01/22, documented to administer [MEDICATION(S)] (a calcium channel blocker) 10 mg one daily for hypertension. A physician order, dated 02/01/22, documented to administer [MEDICATION(S)] extended release (a beta blocker) 25 mg daily for hypertension. The clinical record did not document BPs were obtained as ordered for April 2022. 3. Res #2 had a physician order, dated 04/01/20, which documented to administer [MEDICATION(S)] 12.5 mg twice a day for chronic systolic heart failure. A physician order, dated 12/08/20, documented to monitor and document blood pressure twice daily. The order documented the therapeutic range was more than 90/60 and less than 160/90. The order documented to notify the physician if out of range. As of 04/13/22, the April 2022 MAR, documented two blood pressures for the month. No other blood pressure documentation was provided. 4. Resident #26 had a physician order, dated 12/04/20, which documented to check and record BPs two times a day at 8:00 a.m. and 4:00 p.m. A physician order, dated 10/06/21, documented to administer [MEDICATION(S)] 50 mg three times a day for hypertension. A physician order, dated 11/12/21, documented to administer [MEDICATION(S)] 12.5 mg two times a day for hypertension. A physician order, dated 04/04/22, documented to administer [MEDICATION(S)] 10 mg every day for hypertension. The clinical record was reviewed for April 2022 and there were only two BPs recorded out of 20 opportunities. On 04/13/22 at 2:31 p.m., the corporate nurse stated she had reviewed the blanks in the BP monitoring, and that's how she knew that there were some residents that had documentation of this, but she didn't know why they were not consistently documenting.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls for two (#14 and #43) of three sampled residents who were reviewed for falls. The facility failed to develop and/or implement care plans to prevent falls for residents #14 and #43. Resident #4 fell on [DATE] and 05/10/17. The resident had a third fall on 05/20/17 and the resident sustained [REDACTED]. The facility identified 11 residents who experienced falls at the facility in the last three months. Findings: The facility policy for falls documented the facility would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. The policy documented if interventions had been successful in preventing falls staff would continue the interventions or reconsider whether the measures were still needed if a problem that required the intervention had resolved. If the resident continued to fall the staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions. The policy documented the staff and physician would monitor and document the individuals response to interventions intended to reduce falling or the consequences of falling. 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment, dated 05/08/17, documented the resident was alert; oiented to person, place, and time; and required assistance for bed mobility, transfers, locomotion, dressing, toileting, hygiene, and bathing. The assessment documented the resident used a walker with assist/supervision. The assessment documented the resident was incontinent of bowel and bladder at times. The facility could not provide an admission care plan. The Pharmcare admission note, dated 05/08/17, documented the resident was admitted with a [DIAGNOSES REDACTED]. The note documented the resident was taking medication for seizures. The nurse note, dated 05/09/17, documented the resident required extensive assistance for mobility, transfers, locomotion, and toileting. The note documented the resident was occasionally incontinent of bowel and bladder. The note documented the resident was unsteady of gait and had a problem with balance and weakness. The note documented the resident was heard by staff yelling for help. The note documented the resident was found sitting on the floor a few feet from her bed. The note documented the resident needed to use the bathroom but couldn't make it so she sat down on the floor. The note documented upon notification of the fall to the resident's daughter, a request was made for the resident to have a fall mat and a bed alarm. An incident report, dated 05/09/17, documented the resident was heard yelling from her room and was found sitting on the floor beside her bed. The fall investigation worksheet, dated 05/09/17, documented the resident was attempting to use the bedside commode and fell . The intervention was to re-educate the resident to use her call light and change positions slowly. The facility was not able to provide a care plan which correlated to the resident's fall on 05/09/17. The nurse note, dated 05/10/17, documented the resident required extensive assistance for mobility, transfers, locomotion, and toileting. The note documented the resident was occasionally incontinent of bowel and bladder. The note documented the resident was unsteady of gait, had a balance problem, and weakness. The note documented the resident was found sitting on the floor by the housekeeper. The note documented the resident sat down because she was tired and did not want to fall. The incident report, dated 05/10/17, documented the resident had a fall and was found sitting on the floor by the housekeeper. The fall investigation worksheet, dated 05/10/17, documented the resident was trying to get to the bedside commode and was scared she would fall so she sat down on the floor. The worksheet documented the resident was concerned she was bothering the staff when asking for help. The new interventions were to educate the resident to use the call light, the bedside commode was moved closer to the resident's bed, and the resident was educated she was not bothering staff when asking for help. The facility could not provide an admission/updated care plan for the resident. The fall risk assessment, dated 05/15/17 documented the resident was a high risk for falls. The admission assessment, dated 05/15/17, documented the resident was independent for daily decision making. The assessment documented the resident required limited assistance for activities of daily living (ADLs). The assessment documented the resident was always continent of bowel and bladder. The assessment documented the resident had one fall since admission with no injury. The nurse note, dated 05/20/17, documented the resident was disoriented at times. The note documented the resident required extensive assistance for transfers and locomotion. The note documented the resident had a problem with balance, weakness, and and was unsteady of gait. The note documented the resident was heard calling out for help. The note documented the resident was on the floor next to the bedside commode which was on the opposite side of the room from the resident's bed. The note documented the resident was a little sore but fine and the resident was assisted to bed. The note documented once the resident was in bed she began to complain of pain to her left hip area. The note documented bruising and swelling started to develop a short time later. The note documented the resident was given medication for pain. The note documented the resident's daughter was notified of the resident's fall and the daughter requested an x-ray be obtained at the facility. The note documented an x-ray was obtained and an obvious fracture was viewed. The state incident report, dated 05/20/17, documented the resident had a fall and an x-ray was ordered. The x-ray documented the resident had a hip fracture. The report documented the resident was transferred to the hospital for treatment. The fall investigation worksheet, dated 05/20/17, documented the resident was attempting to reach the potty chair and fell . The worksheet documented the resident refused to use her call light. The worksheet documented the resident had a fractured hip and was transferred to the hospital for treatment. The worksheet documented the resident was receiving physical therapy and was on a toileting program. The worksheet documented the resident's shoes would be assessed, the call light would be accessible, the resident would be assessed for pain, the resident's medications would be evaluated, a bed alarm would be provided, and the resident would be educated to change positions slowly. The initial care plan, dated 05/20/17, documented the resident had a fall in her room and obtained a fracture of her left hip requiring surgical repair. The care plan, updated 05/22/17, documented the resident was a fall risk. The care plan documented the facility would keep the resident's room free of clutter, assist the resident with transfers as needed, encourage/re-educate the resident to use the call light, physical therapy and occupational therapy would be ordered to increase strength and mobility, the staff would anticipate the resident's needs and help when required, the certified nurse aids (CNA)/nurses would answer the call light promptly, and the resident would have a fall mat per family request. The care plan did not document the interventions for a toileting program, a shoe assessment, or a bed alarm. The Pharmcare admission note, dated 05/23/17, documented the resident was readmitted to the facility with [DIAGNOSES REDACTED]. The note documented the resident was taking medication for seizures. A monthly assessment, dated 05/27/17, documented the resident had no behaviors, the resident's short-term and long-term memory was okay, the resident required limited assistance for bed mobility, transfers, dressing, was independent for eating, and required extensive assistance for toileting and bathing. The assessment documented the resident was occasionally incontinent of bowel and bladder. The assessment documented the resident verbalized frequent moderate pain. The fall risk assessment, dated 05/30/17, documented the resident was a high risk for falls. The care plan, updated 06/06/17, documented the resident was non weight bearing related to a left hip fracture. The care plan documented the resident was on fall precautions. The care plan documented the resident would have a bed alarm as requested by the family. The nurse note, dated 06/10/17, documented the resident was found sitting in the floor by the door. The note documented the resident was trying to walk to the bathroom. The note documented the resident was complaining of left hip and leg pain and was sent to the hospital for evaluation. The incident report, dated 06/10/17, documented the resident was found sitting on the floor. The report documented the resident was trying to walk to the bathroom. The report documented the resident was sent to the hospital for evaluation. The report documented the intervention was to encourage the resident to use the call light for assistance. The fall investigation worksheet, dated 06/10/17, documented the resident had a fall trying to transfer to the bedside commode. The worksheet documented the resident was transferred to the hospital for an evaluation. The worksheet documented the resident would be encouraged to use the call light for assistance, implement the bed alarm, check the resident's socks, and consult physical therapy. The worksheet documented the interventions would be a shoe assessment, non skid socks, lighting, accessible call light, weakness and why, a bed alarm, and a fall mat to the floor. The care plan did not document new interventions to prevent falls after the fall which occurred on 06/10/17. The fall risk assessment, dated 06/18/17 documented the resident was a high risk for falls. The significant change assessment, dated 06/18/17, documented the resident was severely impaired for daily decision making. The assessment documented the resident required limited to extensive assistance with activities of daily living. The assessment documented the resident used a wheelchair for mobility and had an upper and lower extremity functional limitation. The assessment documented the resident was occasionally incontinent of bowel and bladder. The assessment documented the resident had a fall with a fracture prior to admission to the facility. The care plan, updated 06/23/17, documented the resident was sent to the hospital on [DATE] for evaluation after a fall. The nurse note, dated 06/28/17, documented the resident was alert and disoriented to place and time. The note documented the resident had a short term and long term memory diagnosis. The note documented the resident was short-tempered and annoyed. The note documented the resident was a risk for physical injury. The note documented the resident required limited to extensive assistance with activities of daily living. The note documented the resident had a problem with balance and weakness. The note documented the resident was found sitting on the floor in front of her bed by kitchen staff. The note documented the resident was trying to save the children. The note documented the resident had a scrape to her back. An incident report, dated 06/28/17, documented the resident had a fall and was found sitting on the floor in front of her bed and had a scrape to her back. The facility could not provide a fall investigation worksheet for the fall which occurred on 06/28/17. The care plan was not updated with new interventions for the fall which occurred on 06/28/17. On 07/17/17 at 11:01 a.m., the resident was observed lying in her bed in her gown with an adult coloring book and colored pencils at her side. The resident stated her home was up the street and she was at her daughter-in-law's house on that day. The resident stated the nursing home was up the road. The resident was asked how she hurt her arm. The resident stated she was moving furniture and she leaned against the truck and fell . There was no fall mat in place and the resident's bedside commode was at the foot of the bed. On 07/18/17 at 3:16 p.m., the resident was observed in her bed in her room. The resident's room was located across the hall from the nurse station. The resident was observed to remove her shoe and the shoe fell to the floor. The resident was observed to pull at her socks and move around in the bed. The resident moved her legs to the side of the bed and bent over to retrieve her shoe. The resident did not have a fall mat beside the bed and the bedside commode was at the foot of the bed. The resident attempted to get out of bed and stated she needed to use the toilet. The resident did not attempt to use the call light. On 07/18/17 at 4:10 p.m. the minimum data set (MDS)/care plan coordinator stated there were no new interventions for the resident's falls on the care plan. The MDS coordinator stated the standard fall precautions were in place and a bed alarm had been ordered but the family did not want it in place because it was driving them crazy and therefore the alarm had been removed. The MDS/care plan coordinator stated she did not know a new intervention was needed for each fall and thought the standard fall precautions was all that was required for the care plan. On 07/19/17 at 11:10 a.m., certified nurse aid (CNA) #2 was asked how she kept the resident from falling. The CNA stated the resident used to have a bed alarm but it was keeping the resident up at night so the resident's daughter had asked the facility to have it taken away. The CNA stated to prevent the resident from falling she would put the bed rail up and the resident had a fall mat. The CNA stated she didn't think the resident was on a toileting program. The CNA stated she checked the resident every two hours when she was on the hall and when the resident used the call light. On 07/19/17 at 11:14 a.m., CNA #1 was asked how she kept the resident from falling. The CNA stated she checked on the resident more frequently because she would get up without assistance. The CNA stated the resident used to have a bed alarm but the resident's daughter wanted it removed. The CNA stated she would ask the resident if she needed to go to the bathroom and show her the call light. The CNA stated the resident puttered around in the bed a lot. The CNA stated the resident was on two hour checks. The CNA stated the resident had declined a lot since she broke her hip. On 07/19/17 at 11:20 a.m., the administrator (ADM) stated the resident was not on an actual toileting program but the girls would try to take her as needed. The ADM stated the resident was very confused. The ADM was asked if the resident could use the call light. The ADM stated physically the resident could push the call light but she did not realize it was there to use for toileting. The ADM stated she didn't know where the resident's fall mat was but she had one in her room previously. The ADM stated to prevent falls the facility staff would do frequent checks. The ADM stated I guess I don't really have an answer. On 07/19/17 at 2:45 p.m., the resident was observed in her bed in her room. No fall mat was observed and the bedside commode was at the foot of the bed. On 07/19/17 at 3:00 p.m., the ADM was asked how she knew who was at risk for falls. The ADM stated she knew the resident's history and background from admission. The ADM stated a fall risk assessment was also provided after admission and if the resident scored high on the fall risk assessment they would be care planned as a fall risk. The ADM was asked if the fall risk should be on the care plan. The ADM stated a resident at risk for falls should be on the care plan and interventions should be implemented at that time depending on the score. The ADM was asked how falls were investigated. The ADM stated the nurses did the initial assessment to determine if the resident was hurt. The ADM stated she just took in all the factors such as what the resident was doing, where they were when the fall occurred, did they have new medications, or had they had a change in condition. The ADM stated from the report she was able to determine why the resident had a fall. The ADM was asked if she had been able to determine the root cause for the resident's falls. The ADM stated it was getting out of bed to use the bedside commode. The ADM stated the intervention to prevent falls was to educate the resident to use the call light and re-educate the staff to make sure the call light was accessible. The ADM stated the resident could push the call button but she was pretty confused and may not know what she was pushing. The ADM was asked if she felt the call light was an effective intervention since the resident was confused. The ADM stated it was probably not an effective intervention. The ADM was asked if the resident was on a toileting program. The ADM stated she was not on an actual toileting program but the staff would take her as often as she needed to go. The ADM was asked if the facility had provided a toileting study for the resident. The ADM stated they had not done a toileting study for the resident. The ADM was asked if the facility had re-evaluated the resident's interventions for falls and how the staff knew what new interventions were in place. The ADM stated there was a care alert book at the nurse desk for staff to read before their shift. Staff did not mention the care alert book when interviewed regarding interventions for falls for the resident. On 07/20/17 at 8:25 a.m., the resident was not in her room. No fall mat was observed at the bedside and the resident's bedside commode was observed across the room by the empty bed. On 07/20/17 at 10:51 a.m., licensed practical nurse (LPN) #1 stated the resident required more assistance with ADLs since her hip fracture and her cognition had gone down also. The LPN stated the resident would get confused and thought she was at home. The LPN stated the night the resident fell and broke her hip she heard the resident yell help, help. The LPN stated the resident had gotten up to go to the bedside commode across the room and fell . The LPN was asked how the staff knew what interventions were in place to prevent falls. The LPN stated the CNAs just know because it's their normal routine. The LPN stated they asked her if she needed to toilet and they got her up on the commode. The LPN stated the resident had a bed alarm but per the daughter's request, it had been removed because it was keeping the resident awake at night. The LPN was asked if the resident was on a toileting program. The LPN stated the resident was not on a toileting program. The LPN stated the resident had a fall mat at one point but it was removed because we thought it might cause her to fall. 2. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders, dated 02/08/17, documented the resident received Keppra (an antiseizure medication), a Scopalamine patch, Oxycodone, Lisinopril, and Metoprolol. The orders did not document the resident was at risk for falls. The admission assessment, dated 02/11/17, documented the resident was comatose and required total assistance with the activities of daily living (ADLs). The assessment documented the resident had not fallen since admission. The fall assessment, dated 02/11/17, documented the resident was at high risk for falls. The care plan, dated 02/17/17, did not document the resident was at risk for falls and did not document interventions to prevent falls. The fall assessment, dated 05/08/17, documented the resident was at high risk for falls. The fall assessment, dated 06/30/17, documented the resident's score for falls had increased and was at high risk for falls. An incident report, dated 06/18/17 at 9:05 p.m., documented the resident was found on the floor. The report documented the resident was alert and oriented to person, was confused, and was non-verbal. The report documented the resident's respirations were regular and coughing was noted. The report documented the resident sustained [REDACTED]. The report documented the physician, family, and administrator were notified. The report documented new interventions to prevent falls were for the staff to place a fall mat next to the resident's bed, ensure the call light was next to resident, and check the resident every 30 minutes. A fall investigation was completed. The care plan was updated on 06/20/17 and did not document the resident was at risk for falls and did not document interventions to prevent falls. The care plan, dated 07/18/17, documented the staff were to monitor the resident closely for falls. The care plan did not document the resident sustained [REDACTED]. The monitoring log, dated 06/23/17 through 06/26/17, documented monitoring was completed every 30 minutes. On 07/18/17 at 11:51 a.m., the resident was observed. The resident was in bed with his eyes closed. The resident was quiet and still. The resident had a quarter rail on his bed and the rail was up. The resident had a fall mat on the floor next to his bed and the bed was in the low position. The call light was within reach. On 07/19/17 at 10:47 a.m., certified nurse aide (CNA) #3 was interviewed regarding falls and fall prevention for the resident. The CNA stated residents at risk for falls had fall mats and side rails. The CNA stated a resident risk for falls was on the care plan. The CNA stated the interventions to prevent falls for the resident were to place a pillow between the resident and the side rail, a fall mat next to his bed, and to keep the bed in the lowest position. The CNA stated the resident liked to place his legs over the side of the bed. On 07/19/17 at 12:32 p.m., licensed practical nurse (LPN) #1 was interviewed regarding the resident's fall and fall prevention. The LPN stated every 30 minute checks were completed when the resident returned from hospital and the checks were documented on specific records. On 07/19/17 at 3:00 p.m., the administrator and the corporate nurse were interviewed regarding falls and fall prevention. The administrator stated a resident's risk for falls would be determined through the admission paper work and the fall risk assessments. The administrator stated the staff would determine a resident was at high risk for falls, the risk would be care planned, and interventions would be initiated.

On 10/27/15 a past-noncompliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to immediately report an allegation of sexual abuse to the administrator. A certified nurse aide reported to the director of nurses she had seen a male nurse with his pants at his ankles in the room of resident #2 with the door closed. The director of nurses failed to immediately report the allegation of abuse to the administrator, failed to immediately begin an investigation into the allegations, and the nurse involved remained on duty and continued to work through the end of the shift. On 10/27/15 the Oklahoma State Department of Health (OSDH) was notified and verified the past-noncompliance IJ situation in regard to the failure of the facility to notify the administrator, provide for the protection of the residents, and failed to begin an investigation into the allegation. The deficient practice was determined to be past-noncompliance since the facility identified the IJ situation and implemented interventions to prevent the recurrence of the situation. The administrator immediately upon receiving the report of the allegation of sexual abuse; provided protection for the residents by suspending the male nurse involved and the director of nurses; ensured the safety and well-being of resident #2; had two female nurses examine the resident for physical harm; and initiated the investigation into the allegations including interviewing the residents and staff, conducting in-services for the staff regarding the reporting of abuse and/or neglect, and conducted an educational meeting regarding abuse for the residents. The facility staff and the residents were interviewed regarding the education provided and verified the information was provided by facility administration. On 10/28/15 at 12:15 p.m., the administrator and corporate managers were notified of the past-noncompliance IJ situation which constituted substandard quality of care (SQC). Based on observation, interview, and record review, it was determined the facility failed to ensure allegations of abuse were reported immediately to the administrator of the facility for one (#2) of four sampled residents reviewed for abuse. The facility staff failed to report an allegation of abuse by a nurse immediately to the administrator. The nurse continued to perform resident care activities for six hours until the end of the shift. The facility failed to provide protection for the resident. The facility identified 37 residents lived in the facility. Findings: The facility's policy and procedures for abuse documented any allegation of abuse or neglect should be reported immediately to the administrator. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/06/15, documented the resident was severely impaired for daily decision-making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident the resident was unable to communicate. The care plan for (MONTH) (YEAR) documented the resident required extensive assistance with bathing and toileting needs. An incident report, dated 10/16/15 at 9:05 a.m., documented on 10/15/15 at 5:15 p.m., a certified nurse aide (CNA) had reported an allegation of abuse involving the resident to the director of nursing (DON). The report documented the DON did not report the allegation to the administrator. The report documented the administrator was notified on 10/16/15 at 9:05 a.m. The report documented the following actions were initiated. The nurse involved in the allegation and the DON were placed on suspension and the corporate manager was notified. The report documented two nurses completed a physical assessment for the resident. The report documented in-services for the staff regarding the reporting of abuse were conducted that day. On 10/26/15 at 10:30 a.m., a tour of the facility was complete. The residents were clean, groomed, and without odors. The residents were relaxed and conversed freely with the staff. The residents were interactive with the staff and residents did not respond fearfully to the staff. The staff interactions with the residents were kind, caring, and with a professional manner. On 10/26/15 at 1:09 p.m., the resident was lying in her bed with the covers over her head. The resident responded by uncovering her face. The resident was calm, quiet, and had no signs of fear. The resident was residing in the same room with her daughter. On 10/26/15 at 2:20 p.m., CNA #1 was interviewed regarding the allegation of abuse. The CNA stated on 10/15/15 at 5:15 p.m., she returned to the facility to bring a co-worker some food. The CNA believed the co-worker was in the resident's room. The CNA stated she knocked on the room door and entered. The CNA stated a male nurse was standing next to the resident with his pants around his ankles. The CNA stated she immediately reported the incident to the DON. The CNA stated the DON reported the nurse had been loosing weight and had problems with his pants. The CNA stated she was uncomfortable all night and reported the incident to the administrator on 10/16/15 at approximately 9:05 a.m. On 10/26/15 at 3:36 p.m., the DON was interviewed regarding the allegation of abuse. The DON stated CNA #1 had reported an allegation of abuse to her on 10/15/15 at 5:15 p.m. The DON stated the CNA reported a male nurse in a resident room next to the female resident with his pants around his ankles. The DON stated she thought the nurse was readjusting his pants due to his weight loss. The DON stated allegations of abuse were to be reported to the administrator. The DON stated she did not think it was abuse so she did not report the incident. The DON was asked if it was her responsibility to determine if the situation was abuse. The DON stated no and it was the up to the administrative team to investigate abuse and determine the outcome. The DON stated she did not follow the policy and immediately report the allegation of abuse to the administrator. On 10/26/15 at 4:01 p.m., the administrator was interviewed regarding the allegation of abuse. The administrator stated the nurse and the director of nurses were placed on suspension immediately when the allegation of abuse was reported. The administrator stated an investigation was initiated, an examination was completed for the resident, in-services were conducted, notifications to the required agencies were completed, and monitoring was begun.

On 10/27/15 a past-noncompliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to implement a policy to report abuse to the administrator, provide protection in response to an allegation of sexual abuse. A certified nurse aide reported she had seen a male nurse with his pants at his ankles in the room of resident #2 with the door closed. The director of nurses failed to immediately report the allegation of abuse to the administrator, failed to immediately begin an investigation into the allegations, and the nurse involved remained on duty and continued to work through the end of the shift. On 10/27/15 the Oklahoma State Department of Health (OSDH) was notified and verified the past-noncompliance IJ situation in regard to the failure of the facility to notify the administrator, provide for the protection of the residents, and failed to begin an investigation into the allegation. The deficient practice was determined to be past-noncompliance since the facility identified the IJ situation and implemented interventions to prevent the recurrence of the situation. The administrator immediately upon receiving the report of the allegation of sexual abuse; provided protection for the residents by suspending the male nurse involved and the director of nurses; ensured the safety and well-being of resident #2; had two female nurses examine the resident for physical harm; and initiated the investigation into the allegations including interviewing the residents and staff, conducting in-services for the staff regarding the reporting of abuse and/or neglect, and conducted an educational meeting regarding abuse for the residents. The facility staff and the residents were interviewed regarding the education provided and verified the information was provided by facility administration. On 10/28/15 at 12:15 p.m., the administrator and corporate managers were notified of the past-noncompliance IJ situation which constituted substandard quality of care (SQC). Based on observation, interview, and record review, it was determined the facility failed to implement the facility's abuse policy and procedure for one (#2) of four sampled residents reviewed for abuse. The facility staff failed to report an allegation of abuse by a nurse immediately to the administrator. The nurse continued to perform resident care activities for six hours until the end of the shift. The facility failed to provide protection for the resident. The facility identified 37 residents lived in the facility. Findings: The facility's policy and procedures for abuse documented any allegation of abuse or neglect should be reported immediately to the administrator. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/06/15, documented the resident was severely impaired for daily decision-making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident the resident was unable to communicate. The care plan for (MONTH) (YEAR) documented the resident required extensive assistance with bathing and toileting needs. An incident report, dated 10/16/15 at 9:05 a.m., documented on 10/15/15 at 5:15 p.m., a certified nurse aide (CNA) had reported an allegation of abuse involving the resident to the director of nursing (DON). The report documented the DON did not report the allegation to the administrator. The report documented the administrator was notified on 10/16/15 at 9:05 a.m. The report documented the following actions were initiated. The nurse involved in the allegation and the DON were placed on suspension and the corporate manager was notified. The report documented two nurses completed a physical assessment for the resident. The report documented in-services for the staff regarding the reporting of abuse were conducted that day. On 10/26/15 at 10:30 a.m., a tour of the facility was complete. The residents were clean, groomed, and without odors. The residents were relaxed and conversed freely with the staff. The residents were interactive with the staff and residents did not respond fearfully to the staff. The staff interactions with the residents were kind, caring, and with a professional manner. On 10/26/15 at 1:09 p.m., the resident was lying in her bed with the covers over her head. The resident responded by uncovering her face. The resident was calm, quiet, and had no signs of fear. The resident was residing in the same room with her daughter. On 10/26/15 at 2:20 p.m., CNA #1 was interviewed regarding the allegation of abuse. The CNA stated on 10/15/15 at 5:15 p.m., she returned to the facility to bring a co-worker some food. The CNA believed the co-worker was in the resident's room. The CNA stated she knocked on the room door and entered. The CNA stated a male nurse was standing next to the resident with his pants around his ankles. The CNA stated she immediately reported the incident to the DON. The CNA stated the DON reported the nurse had been loosing weight and had problems with his pants. The CNA stated she was uncomfortable all night and reported the incident to the administrator on 10/16/15 at approximately 9:05 a.m. On 10/26/15 at 3:36 p.m., the DON was interviewed regarding the allegation of abuse. The DON stated CNA #1 had reported an allegation of abuse to her on 10/15/15 at 5:15 p.m. The DON stated the CNA reported a male nurse in a resident room next to the female resident with his pants around his ankles. The DON stated she thought the nurse was readjusting his pants due to his weight loss. The DON stated allegations of abuse were to be reported to the administrator. The DON stated she did not think it was abuse so she did not report the incident. The DON was asked if it was her responsibility to determine if the situation was abuse. The DON stated no and it was the up to the administrative team to investigate abuse and determine the outcome. The DON stated she did not follow the policy and immediately report the allegation of abuse to the administrator. On 10/26/15 at 4:01 p.m., the administrator was interviewed regarding the allegation of abuse. The administrator stated the nurse and the director of nurses were placed on suspension immediately when the allegation of abuse was reported. The administrator stated an investigation was initiated, an examination was completed for the resident, in-services were conducted, notifications to the required agencies were completed, and monitoring was begun.

On 11/04/10 at 1:35 p.m., an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to implement their abuse policy and procedure to protect residents, by re-hiring a former employee who was alleged and verified by the facility to have physically and verbally abused 1 of 1 (#1) sampled residents. The Oklahoma State Department of health was notified. The IJ was verified. At 1:40 p.m., the administrator, director of nurses, corporate nurse, facility owner and general manager were notified of the IJ situation, which constituted substandard quality of care. At 3:55 p.m., an acceptable plan of removal was presented to the survey team. The plan of removal documented the following: "1. Immediate termination of (licensed practical nurse #1). 2. Immediate documentation in the data base of the facility employee program, that (licensed practical nurse #1) is no longer eligible for re-hire in this facility. 3. The owner, corporate nurse, general manager, administrator, and director of nursing will sign an acknowledgement/in-service covering never re-hiring past employees that an abuse investigation was completed and the finding were substantiated. 4. Effective 11/04/2010 an "Employee substantiated past abuse history roster" has been implemented to keep a running log of past employees who are not eligible for re-hire due to substantiated abuse investigations. This will be kept in the administration office and updated as needed. 5. The following policy: If an employee's, in the opinion of Haskell Care Center, investigation of abuse or neglect is substantiated, then that employee is no longer eligible for re-hire and the information is then added to the data base of the facility employee program and the employee substantiated abuse roster for future reference. 6. A policy and practice is implemented on 11/04/2010 concerning the re-hiring and hiring of employees. Rehires: Any prospective re-hire employee is to complete the Oklahoma State Department of Health's uniform employment application for nurses aide staff (Haskell Care Center uses the above listed application for all hires) prior to consideration of rehiring, there is no timeline for exceptions of this application completion. All new prospective new hires, will complete an application (as listed above). In both considerations of re-hire and new hire particular attention will be paid on the application to the page 3 of 5 section 8 background information letter C and evidence will be shown on the application in the form of initials of the administrative staff that reviews the application prior to consideration of hiring. If the above listed section is marked with a yes or any information given pertaining to pending or substantiated abuse/neglect, no consideration will be given to hiring the applicant." On 11/04/10 at 4:05 p.m., the IJ was removed when all components of the plan of removal had been completed and the facility administration staff had all been in-serviced and had knowledge of the plan of removal for the immediate jeopardy situation. The deficiency remained at a pattern level of actual harm, until the facility could demonstrate a system was in place to prevent the deficient practice from reoccurring. Based on observation, record review and interview, it was determined the facility failed to follow their abuse policy and procedure to screen employees for prior allegations of abuse prior to hiring them and failed to protect 1 of 1 (#1) sampled residents from the likelihood of verbal and physical abuse from a facility employee. This had the potential to affect all 31 residents residing in the facility. The facility's policy for "Abuse" documented, "It is the policy of this facility for each resident to have the right to be free from abuse, mistreatment, neglect and misappropriation of property.... Screening: This facility has procedures to screen potential employees for a history of abuse, neglect or mistreating residents. The screening will include attempting to obtain information from previous employers and or current employers and checking with the appropriate licensing boards and registries.... Protection: Protect residents from harm during an investigation.... Analyze the occurrences to determine what changes are needed, if any to policies and procedures to prevent further occurrences. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Monthly physician's orders [REDACTED]. A quarterly assessment dated [DATE], documented the resident had short-term memory problems, no behavior problems, was independent with transfers and ambulation and required little assistance with activity of daily living needs except with bathing. A statement written by a certification medication aide (CMA), dated 9/24/10, documented, "Friday 24th of Sept. I done my noon med (medication) pass at that time and gave (resident #1) a pain pill at 12 noon. At about 12:38 (p.m.) or 12:45 (p.m.). I had to leave for a short time, when I returned about 3 p.m.(3:00 p.m.), I started getting ready for med pass at 4 p.m. (4:00 p.m.). I saw where the nurse had gave another pain pill at 1400 time (2:00 p.m.). I then asked her why she had gave her another pill so early. Because I had told her before I left I had gave her a pain pill at 12 noon (12:00 p.m.). She said I don't know, she asked for one. Then when I went in to give the resident (#1) her meds she told me that the licensed practical nurse (LPN #1) had came in and jumped all over her about pain pill. She told me she tried to tell (LPN #1), she couldn't remember she had one at 12 noon. She told me (LPN #1) was talking very hateful to her. I told her I was going to call someone and tell them, and she said no I want to take care of this myself. And I told her okay but I was going to talk to the (administrator) Monday about. Because she can't talk to you like that and she said okay." Review of the resident's 09/24/10, "Individual Patients Narcotic Record" documented the resident received (1) [MEDICATION NAME] 10/325 milligrams (mg) from the CMA at 12:00 noon. The record indicated the resident received another [MEDICATION NAME] 10/325 mg on 09/24/10 at 2:00 p.m., 2 hours later, by LPN #1. A nurse's note dated 9/25/10 at 3:45 p.m., "Resident came to this nurse and told that yesterday evening 9/24/10, before offices closed, that she had walked to front desk to ask for pain pill. Charge nurse (LPN #1) was there and said she would ask (CMA #1) if it was time for her to have one (pain pill), per (resident #1). Resident said she went back to her room and shortly after nurse (LPN #1) had came in her room and in loud firm tone and stated, "You got me in trouble." Resident (#1) said she told nurse that she had not done nothing to get her in trouble. Resident said she then had raised up out of chair and nurse had touched shoulder, and pushed her back down in chair and kept her from going up front to tell someone. She also said nurse (LPN #1) was saying that (resident #1) was over medicated and staggering when she walked and that she had already been up to med cart 20 - 30 min (minutes) before and got pain medication. Corporate management notified on call for administrator and DON (director of nursing) notified. Resident's family present when statement made. Assessed resident, no injury noted. Skin color good. Dr. (resident #1's doctor) notified by faxing office." On 9/25/10, an "Alleged Abuse Procedure Investigation Tool" documented an investigation was started by the administrator. On 9/26/10, an "Investigation Tool form #6" documented a complaint made by the resident's daughter. The complaint stated, "My mother told me that she went up to the desk for pain medication. The LPN (#1) gave her something. Later the LPN (#1) came into mom's room and stated loudly mother had got her in trouble - she kept on verbally scolding and going on at her. Mom started to get out of her chair and (LPN #1) pushed her back into the chair and told her she was over medicated telling her she couldn't walk down the hall straight. This person should not (be) working with the public if she can't control herself. This is what mom told me." The complaint was signed by the daughter of (resident #1). On 9/27/10, an "Investigation Tool form #1" documented the administrator interviewed the resident. The resident stated, "She came to desk and asked for a pain pill. LPN (#1) was at desk and she got up to give her one. Resident states that she didn't look in book to see when she had one last. Resident returned to her room. She states that Ms. (LPN #1) entered her room later and angrily stated "you got me in trouble." Resident #1 asked what she was talking about. LPN #1 stated that the CMA had given her a pain pill 2 hours earlier. Resident stated that she would go talk to someone and LPN (#1) pushed her back in her chair when she tried to get up. She grabbed her (resident #1) arm and pushed her into chair. Resident #1 states that when LPN (#1) left she was not angry and she had had no problems with her in the past. Resident #1 states that she has always liked LPN #1 but doesn't want her to treat her that way." An interview conducted with the resident by the facility owner on 9/28/10 at 6:30 p.m., documented the resident stated, "Friday late LPN (#1) came saying you got me in trouble very sarcastic. I was sitting in my recliner watching TV on the 24th. What did I do (LPN #1)? What happened? I will go find out and began to rise from recliner, pushed me back down." On 9/30/10 (no documented time), a resignation was accepted by the facility from LPN #1. The facility excepted the resignation after substantiating an abuse allegation made by resident #1. On 10/01/10, the facility reported the abuse allegation to the State Department of Health. The facility documented, "Due to the repeated history of both losing her temper and the nursing skills it was determined that she could no longer be an employee of Haskell Care Center. Prior to notification to (LPN #1), she brought a resignation letter to the administrator effective immediately. In the opinion of Haskell Care Center the allegations of physical abuse are verified due to a past history of losing her temper and admitted and written proof of medication error. The nursing board will be notified of this investigation as well as the APS (adult Protective Services), DHS (Department of Human Services), attn (attention): (name withheld) investigator." Review of the staff schedule documented LPN #1 worked the 7:00 a.m. to 3:00 p.m. shift on 10/31/10. The schedule documented she was scheduled to work on the weekends of 11/6/10 and 11/7/10, 11/13/10 and 11/14/10, and 11/20/10 and 11/21/10. On 11/4/10 at 11:25 a.m., an interview was conducted with resident #1 regarding the incident with LPN #1. The surveyor asked the resident to tell her what happened with LPN #1. She stated she went to the desk and asked for pain medication. She stated the nurse who gave her the pain medication was LPN #1, not the medication aide. She stated the nurse jumped up and got the medication for her, then later burst into her room and yelled, "You got me in trouble." The resident stated when she went to get up the nurse pushed her back down. On 11/4/10 at 12:45 p.m., an interview was conducted with the facility's owner, general manager, corporate nurse, administrator and DON regarding the rehiring of LPN #1, after she had resigned due to allegations of abuse. The surveyor asked if someone could tell her about the incident with LPN #1 and resident #1. The general manager stated they had a complaint from the resident and her daughter regarding LPN coming into the resident's room and speaking in a loud voice telling the resident she got her (LPN #1) in trouble over the medication. The general manager stated resident (#1) told her LPN #1 pushed her back down into her chair when she tried to get up and find out what was going on at the nurses' desk. The surveyor asked if the LPN was terminated. The general manager stated the LPN was put on suspension while the investigation was ongoing, but turned in a letter of resignation on 9/30/10. The general manager stated the facility did not have to terminate the LPN because of this. She stated, "This started with the survey you guys did when she had the incident with the peg tube. Her attitude started changing. She was overheard cursing in front of the residents at that time. Then this happened." The surveyor asked when the LPN was re-hired. The general manager stated, "Last weekend. We were desperate. We probably should not have re-hired her, but we are desperate for help here. We cannot get help. This is a rural area. We did hire 2 new LPNs last week and LPN #1 is not here permanently, just until we can train these two new LPNs." The DON stated she had been working her 40 hours every week plus 36 additional hours to cover the shifts. She stated, "All my employees are getting the burn-out including me. The owner stated this is probably my fault. When they called me telling me they were burned out, I suggested they call LPN #1." The surveyor asked why they re-hired LPN #1 back after the investigation of abuse was filed with the state and with the state board of nursing. The owner, general manager and administrator stated they were just desperate. They stated they were afraid of loosing the help they had because of over working them and LPN #1 was all they had to pull from. The owner stated the resident had been persistent with her story from the beginning. She stated the resident hadn't changed her story with anyone. The surveyor asked the owner if she doubted the resident's story in any way. The owner stated, "No, I do not doubt the resident."