Every finding on record at Heartway at Heritage Village Health and Rehab

Based on record review and interview, the facility failed to ensure RN coverage eight consecutive hours seven days per week.The administrator identified 84 residents resided in the facility. Findings:Time card reports for RN coverage were reviewed July 2025 through January 2026. There was no RN coverage for eight consecutive hours for the following days:a. 08/03/25,b. 08/17/25,c. 10/04/25, d. 10/18/25, e. 11/29/25,f. 12/27/25, andg. 01/04/26.On 01/07/26 at 4:05 p.m., the administrator stated they had an agency RN scheduled for the dates above, but nobody showed up, nor did anybody notify the administrator.

Based on record review and interview, the facility failed to complete an informed consent for the use of antipsychotic medication for 1 (#17) of 2 sampled residents reviewed for the use of antipsychotic medication. The administrator identified 29 residents received antipsychotic medication. Findings: An undated facility policy titled Psychotropic & Opioid Medication Therapy Informed Consent Policy, read in part, This form must be completed and signed before administering the first dose of any psychotropic or Opioid medication, except in emergency situations as defined by regulatory guidelines. An undated admission record showed Resident #17 had diagnoses which included atrial fibrillation, anxiety disorder, and recurrent depressive disorder. A care plan, dated 12/04/25, showed Resident #17 received psychotropic medication. The care plan showed the resident was to be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. A physician order, dated 12/07/25, showed Resident #17 received Seroquel (an antipsychotic medication) 100mg by mouth at bedtime related to an anxiety disorder. An admission assessment, dated 12/10/25, showed Resident #17 was not impaired cognitively and had a BIMS of 14. The assessment showed the resident received antipsychotic medication, antidepressant medication, and anticoagulant medication. On 01/07/26 at 11:20 a.m., the DON reviewed the resident's clinical record and stated a consent for antipsychotic medication use was not completed. The DON stated a consent for the use of an antipsychotic medication should have been completed.

Based on record review and interview, the facility failed to ensure residents receiving antipsychotic medications had an appropriate diagnosis for 2 (#17 and #61) of 5 sampled residents reviewed for unnecessary medications.The administrator identified 29 residents received antipsychotic medication. Findings: 1. An undated facility policy titled Psychotropic & Opioid Medication Therapy Informed Consent Policy, read in part, This form must be completed and signed before administering the first dose of any psychotropic or Opioid medication, except in emergency situations as defined by regulatory guidelines. An undated admission record showed Resident #17 had diagnoses which included atrial fibrillation, anxiety disorder, and recurrent depressive disorder. A care plan, dated 12/04/25, showed Resident #17 received psychotropic medication. The care plan showed the resident was to be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. A physician order, dated 12/07/25, showed Resident #17 received Seroquel (an antipsychotic medication) 100mg by mouth at bedtime related to an anxiety disorder. An admission assessment, dated 12/10/25, showed Resident #17 was not impaired cognitively and had a BIMS of 14. The assessment showed the resident received antipsychotic medication, antidepressant medication, and anticoagulant medication. On 01/07/26 at 10:15 a.m., the DON reviewed the resident's physician orders and stated the resident was receiving Seroquel for an anxiety disorder. The DON stated this was not an appropriate diagnosis for the use of an antipsychotic medication. On 01/07/26 at 10:41 a.m., the pharmacy consultant reviewed the resident's physician orders and stated the resident was receiving Seroquel for anxiety. They stated an anxiety diagnosis was not an acceptable diagnosis for the use of an antipsychotic medication. 2. A diagnosis report, dated 02/12/23, showed Resident #61 had a diagnosis of dementia without behavioral, psychotic, or mood disturbances. A physician order, dated 12/06/24, showed to administer Seroquel 400 mg daily at bedtime for dementia without behavioral, psychotic, or mood disturbances. An annual assessment, dated 02/19/25, showed Resident #61 was severely cognitively impaired with a BIMS score of 04. The assessment showed Resident #61 received antipsychotic medication. On 01/07/26 at 1:48 p.m., the DON stated dementia was not an appropriate diagnosis for the use of an antipsychotic medication.

Based on observation, record review, and interview, the facility failed to ensure quarterly smoking assessments were completed for 1 (#5) of 1 sample resident reviewed for smoking.The DON identified eight residents smoked tobacco products.Findings:On 01/06/26 at 3:40 p.m., Resident #5 was observed outside smoking in designated area with monitoring by staff.An undated facility Smoking, Care of the resident policy, read in part, Complete a Supervised Smoking Assessment on all residents who smoke upon admission and quarterly thereafter.An initial smoking assessment dated [DATE], showed the evaluation would be utilized for the resident's smoking care plan on admission and as indicated.A care plan, dated 03/24/25, showed Resident #5 would always smoke in the designated smoking area. The care plan showed staff would assist resident to smoking areas and monitor as needed.An electronic admission Record, dated 01/06/26, showed Resident #5 was admitted to facility on 03/11/25 with a diagnosis of tobacco use.There was no additional documentation of quarterly smoking assessments completed for Resident #5.On 01/07/26 at 11:32 a.m., the DON was made aware of Resident #5 not having a quarterly smoking assessment during record review. The DON stated they thought smoking assessments were done annually. The DON was made aware of the facility's policy for quarterly smoking assessments. The DON stated they did not know why the smoking assessment was not completed quarterly for Resident #5.

Based on record review and interview, the facility failed to protect a resident from abuse for 1 (#8) of 3 sampled residents reviewed for abuse. The administrator identified four allegations of abuse in the past six months. Findings:An undated facility policy titled ABUSE, NEGLECT, EXPLOITATION, MISTREATMENT AND MISAPPROPRIATION OF RESIDENT PROPERTY, read in part, Abuse and neglect exist in many forms and to varying degrees. The following are the approved CMS [Centers for Medicare and Medicaid Services] definitions of abuse and neglect from the Draft State Operations Manual Appendix PP effective November 28, 2016.Neglect,' as defined at 483.5, means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.An undated discharge/transfer report showed Resident #8 had diagnoses which included history of falls, muscle wasting and atrophy, and the need for assistance with personal care. An admission assessment, dated 08/03/25, showed Resident #8 had a brief interview for mental status of nine which indicated the resident was moderately impaired for daily decision making. The assessment showed the resident was continent of bowel/bladder and required partial/moderate assistance with toileting. An Oklahoma State Department of Health incident form, dated 10/28/25, showed the administrator was made aware by a charge nurse the family had noticed a bruise on Resident #8's right arm. The form showed Resident #8 was unaware of the bruise. The form showed Resident #8 stated a CNA last night was persistent the resident use a bedpan and not the bedside commode. The form showed Resident #8 stated they did not want the CNA to provide care for them again. The form showed an investigation was initiated. The form showed two CNAs were working the resident's hall at the time of the incident and both were suspended pending further investigation.On 10/28/25 the facility interviewed residents and statement reports were completed regarding abuse.A quality assurance document, dated 10/28/25, showed an investigation was initiated immediately for an allegation of abuse. The document showed an unidentified CNA forced Resident #8 to use the bedpan when they requested to use the bedside commode. The document showed the allegation of abuse was addressed, an investigation was initiated, and staff education regarding abuse was provided. The document showed after the investigation the CNA was identified, terminated, and staff was to receive ongoing education regarding abuse. An IN-SERVICE MEETING form, dated 10/29/25, showed 25 staff members received training related to abuse/mistreatment reporting.An Oklahoma State Department of Health incident form, date received 10/31/25, showed a final report regarding an allegation of physical abuse for Resident #8. The form showed CNA #4's employment was terminated due to evidence CNA #4 neglected to provide resident care per request and Resident #8 stated they were afraid of CNA #4.On 11/06/25 at 11:55 a.m., Resident #8 stated an unnamed staff member placed them on a bedpan and would not assist them to use the bedside commode. Resident #8 stated it made them mad and did not want the staff member to take care of them again.On 11/06/25 staff were interviewed regarding abuse. The staff stated they had received training regarding abuse. A typed statement, dated 11/06/25, showed CNA #4 and CNA #5 were suspended for regarding the allegation of abuse. The statement showed both CNAs worked to night shift and had worked the shift prior to the allegation of abuse. On 11/06/25 at 4:25 p.m., the administrator stated after the investigation had been completed it was determined CNA #4 placed Resident #8 on the bedpan. The administrator stated CNA #4 was terminated for failure to provide Resident #8's request for care.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess a resident with new onset respiratory changes for Res #72. Res #72 expired on [DATE]. A progress note, dated [DATE] at 6:44 a.m., documented Res #72 was having shortness of breath and wheezing. The note documented the physician was contacted and a breathing treatment was ordered. The note documented the Res #72 coughed up green sputum. The note did not document an assessment of the resident's lung sounds. A MAR, dated [DATE], documented the breathing treatment was administered as ordered at 6:46 a.m. The vital signs were documented as oxygen saturation 87%, heart rate 117, and irregular. There was no respiration rate documented. No oxygen saturation was documented after the administration. A progress note, dated [DATE] at 7:53 a.m., documented the breathing treatment was documented as effective. There were no vital signs or assessment of lungs documented. A progress note, dated [DATE] at 12:00 p.m., documented the breathing treatment was again documented as administered. The vital signs documented for the treatment were 89% oxygen saturation, and heart rate 104 and irregular. There was no respiration rate documented, and no post-treatment oxygen saturation documented. A progress note, dated [DATE] at 12:02 p.m., documented Res #72 vomited in the dining room and was taken to their room to clean up. The note documented the physician was notified and ordered a urinalysis and an anti-emetic (nausea medication). The note did not document vital signs or a respiratory assessment of the resident. A progress note, dated [DATE] at 1:00 p.m., documented the breathing treatment was documented as effective. There were no vital signs or respiratory assessment documented. A vital sign record, dated [DATE] at 8:50 p.m., documented Res 72's blood pressure was ,d+[DATE]. The CMA did not document any other vital signs. A progress note, dated [DATE] at 10:55 p.m., documented Res #72 was deceased . On [DATE] at 10:16 a.m., RN #1 (day shift RN) stated they had been informed Res #72 was ill upon arrival to their shift. They stated the resident had been sick all weekend prior. They stated Res #72 was kind of congested and had some wheezing. They stated Res #72's lungs sounded some better after the breathing treatment. They stated they did not document a respiratory assessment of the resident. They stated they passed the information along to the oncoming RN at the end of their shit. They stated there should be a focused assessment by a nurse on each shift if a resident has had a change. On [DATE] at 11:19 a.m., RN #2 (evening shift RN) stated they were informed right before the end of their shift Res #72 was having difficulty breathing, had congestion, and was asked by the aide if the resident had an order for breathing treatments. They stated they went to the computer to check for orders and notified the oncoming nurse (night shift RN) of the report from the aide. RN #2 denied assessing Res #72 on their shift or prior to clocking out. They stated as they were walking out the door the night shift RN came to them and stated they thought Res #72 had passed away. They stated they went with the night shift RN to Res #72's room and determined the resident had passed away. On [DATE] at 12:35 p.m., the DON stated they expected the nurses on shift to pass along changes in resident conditions at shift change. They stated shift report was given orally and there was no policy. They stated they would expect the staff to keep a close watch on residents experiencing new onset respiratory symptoms and for a respiratory assessment to be completed each shift. They stated there should have been a documented assessment of respiratory status for Res #72. A policy regarding respiratory assessment was requested. On [DATE] at 1:31 p.m., the DON stated the facility did not have a policy regarding respiratory assessment. They stated staff were expected to follow nursing 101 regarding nursing care. They stated a focused assessment should be done when a resident has changes. On [DATE] at 1:55 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 2:05 p.m., the administrator was notified of the IJ situation. On [DATE] at 10:04 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Plan for Removal of Immediate Jeopardy [name withheld] Date: [DATE] Time Started: 2:20 p.m. Time Completed: [DATE] 9:40 a.m. This plan is to show our compliance for the removal of the immediate jeopardy cited on [DATE]: 1. [DATE] at 2:30 pm the facility began in-service with the C.N.A. and C.M.A. regarding the importance of reporting any changes in condition in resident status including respiratory distress. (all c.n.a.'s and c.m.a.'s have been in-serviced. One unavailable staff will not be allowed to work until she has been in-serviced.) 2. [DATE] at 4:30 pm the facility began in-service with the licensed nursing staff addressing the importance of conducting a respiratory assessment on any resident who is exhibiting respiratory issues (see attached Change in Condition Monitoring Assessment). 3. The facility has conducted respiratory screening of all residents who have any type of respiratory diagnosis or exhibiting respiratory symptoms (see attached Respiratory Screener). 4. The facility has adopted a Change in Condition Policy addressing the importance of conducting a thorough and complete respiratory assessment on any resident exhibiting signs of respiratory distress (see attached policy). 5. All c.n.a.'s and c.m.a.'s have been in-serviced with the exception of one staff. [They] shall be in-serviced before [They] is allowed to return to work. The IJ was lifted effective [DATE] at 9:40 a.m. when all components of the plan of removal had been completed. The deficient practice remained at isolated with actual harm to the resident. Based on observation record review, and interview, the facility failed to: a. assess a resident with new onset respiratory changes for one (#72) of three sampled residents reviewed for closed records; b. change and date oxygen tubing for two (#36 and #46) of three sampled residents reviewed for respiratory care; and c. supervise the administration of a breathing treatment for one (#50) of three residents sampled for respiratory care. The DON identified 68 residents resided in the facility. Findings: A facility policy titled Specific Medication Administration Procedures, Oral Inhalation Administration for Nebulizer, dated [DATE], documented to remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. An oxygen administration policy, dated [DATE], docummented to change oxygen tubing and mask/cannula weekly and as needed. The policy had hand written changes documenting humidifier bottles were to be changed monthly on the first of the month on night shift. 1. Res #72 had diagnoses which included CHF and dementia. A progress note, dated [DATE] at 6:44 a.m., documented Res #72 was having shortness of breath and wheezing. The note documented the physician was contacted and a breathing treatment was ordered. The note documented the Res #72 coughed up green sputum. The note did not document an assessment of the resident's lung sounds. A physician order, dated [DATE], documented to administer albuterol sulfate nebulizer solution (a breathing treatment) 2.5 mg per 3 mL every six hours as needed for shortness of breath. The order documented to monitor pulse and oxygen saturation before and after treatment. A MAR, dated [DATE], documented the breathing treatment was administered as ordered at 6:46 a.m. The vital signs were documented as oxygen saturation 87%, heart rate 117, and irregular. There was no respiration rate documented. No oxygen saturation was documented after the administration. A progress note, dated [DATE] at 7:53 a.m., documented the breathing treatment was documented as effective. There were no vital signs or assessment of lungs documented. A progress note, dated [DATE] at 12:00 p.m., documented the breathing treatment was again documented as administered. The vital signs documented for the treatment were 89% oxygen saturation, and heart rate 104 and irregular. There was no respiration rate documented, and no post-treatment oxygen saturation documented. A progress note, dated [DATE] at 12:02 p.m., documented Res #72 vomited in the dining room and was taken to their room to clean up. The note documented the physician was notified and ordered a urinalysis and an anti-emetic (nausea medication). The note did not document vital signs or a respiratory assessment of the resident. A progress note, dated [DATE] at 1:00 p.m., documented the breathing treatment was documented as effective. There were no vital signs or respiratory assessment documented. A vital sign record, dated [DATE] at 8:50 p.m., documented Res 72's blood pressure was ,d+[DATE]. The CMA did not document any other vital signs. A progress note, dated [DATE] at 10:55 p.m., documented Res #72 was deceased . On [DATE] at 10:16 a.m., RN #1 (day shift RN) stated they had been informed Res #72 was ill upon arrival to their shift. They stated the resident had been sick all weekend prior. They stated Res #72 was kind of congested and had some wheezing. They stated Res #72's lungs sounded some better after the breathing treatment. They stated they did not document a respiratory assessment of the resident. They stated they passed the information along to the oncoming RN at the end of their shit. They stated there should be a focused assessment by a nurse on each shift if a resident has had a change. On [DATE] at 11:19 a.m., RN #2 (evening shift RN) stated they were informed right before the end of their shift Res #72 was having difficulty breathing, had congestion, and was asked by the aide if the resident had an order for breathing treatments. They stated they went to the computer to check for orders and notified the oncoming nurse (night shift RN) of the report from the aide. RN #2 denied assessing Res #72 on their shift or prior to clocking out. They stated as they were walking out the door the night shift RN came to them and stated they thought Res #72 had passed away. They stated they went with the night shift RN to Res #72's room and determined the resident had passed away. On [DATE] at 12:35 p.m., the DON stated they expected the nurses on shift to pass along changes in resident conditions at shift change. They stated shift report was given orally and there was no policy. They stated they would expect the staff to keep a close watch on residents experiencing new onset respiratory symptoms and for a respiratory assessment to be completed each shift. They stated there should have been a documented assessment of respiratory status for Res #72. A policy regarding respiratory assessment was requested. On [DATE] at 1:31 p.m., the DON stated the facility did not have a policy regarding respiratory assessment. They stated staff were expected to follow nursing 101 regarding nursing care. They stated a focused assessment should be done when a resident has changes. 2. Res #36 had diagnoses which included shortness of breath. Physician orders, dated [DATE], documented to administer oxygen at two liters per minute via nasal cannula every shift; and change the oxygen bottle and nasal cannula tubing every month on the 1st. On [DATE] at 10:44 a.m., Res #36 was observed resting in their recliner with their eyes closed. The oxygen concentrator was observed between the bed and the recliner. The oxygen tubing was observed dated [DATE]. The bottle was observed dated [DATE]. On [DATE] at 2:15 p.m., RN #1 stated oxygen tubing was to be changed and dated monthly or PRN. 33097 3. Res #46 had diagnoses which included acute respiratory failure with hypoxia, acute pulmonary edema, congestive heart failure, asthma, chronic obstructive pulmonary disease, dependence on supplemental oxygen, and obstructive sleep apnea. The care plan, dated [DATE], did not document the resident's use of oxygen. A physician order, dated [DATE], documented the resident was to receive oxygen at two liters per nasal cannula to keep oxygen saturation greater than 90 percent. An admission 5 day assessment, dated [DATE], documented the resident used continuous oxygen. On [DATE] at 1:34 p.m., the resident was sitting in a recliner watching television. The resident was receiving oxygen at two liters per nasal cannula. The oxygen tubing and humidifier bottle were not dated. On [DATE] 9:44 a.m., the DON stated oxygen tubing should be changed monthly. The DON reviewed the facility policy for respiratory care and stated the policy documented oxygen tubing was to be changed weekly. The DON stated the policy needed the be corrected. 43023 4. Res #50 admitted to the facility with diagnoses which included COPD, acute and chronic respiratory failure with hypoxia, and malignant neoplasm of upper lobe. A physician order, dated [DATE], documented to administer ipratropium-albuterol inhalant solution 0XXX,d+[DATE].5 MG/ML, inhale 3 ml four times a day related to COPD with acute exacerbation. A quarertly assessment, dated [DATE], documented the resident's cognition was intact. On [DATE] at 2:31 p.m., Res #50 was observed holding their nebulizer. The nebulizer was approximately half full with clear liquid. The resident stated they could not remember the name of medication, and they administered their own breathing treatments. On [DATE] at 2:35 p.m., Res #50 started their nebulizer machine. The resident's record was reviewed and did not contain an assessment to self-administer breathing treatments. On [DATE] at 10:37 a.m., the DON was made aware of the above observation and stated the nurse should have stayed with the resident.

Based on observation, record review and interview, the facility failed to ensure comprehensive care plans were developed for two (#50 and #46) of 17 residents reviewed for care plans. The DON identified 68 residents resided in the facility. Findings: 1. Res #50 was admitted to facility with diagnoses which included COPD, acute and chronic respiratory failure with hypoxia, and malignant neoplasm of upper lobe. A review of the resident's care plan contained no documentation related to COPD On 10/31/24 at 11:49 a.m., MDS Coordinator #1 stated COPD should have been care planned. 33097 2. Res #46 had diagnoses which included acute respiratory failure with hypoxia, acute pulmonary edema, congestive heart failure, asthma, chronic obstructive pulmonary disease, dependence on supplemental oxygen, and obstructive sleep apnea. The care plan, dated 10/07/24, did not document the resident's use of oxygen. A physician order, dated 10/11/24, documented the resident was to receive oxygen at two liters per nasal cannula to keep oxygen saturation greater than 90 percent. An admission 5 day assessment, dated 10/13/24, documented the resident used continuous oxygen. On 10/28/24 at 1:34 p.m., the resident was sitting in a recliner watching television. The resident was receiving oxygen at two liters per nasal cannula. On 10/30/24 at 11:05 a.m., MDS Coordinator #1 reviewed the resident's care plan and stated the care plan should have document the use of oxygen for the resident.

Based on observation and interview, the facility failed to ensure food was stored in accordance with the professional standards for food service safety. The DON identified 68 residents resided in the facility. Findings: On 10/28/24 at 8:22 a.m., during a tour of the kitchen there were 10 plastic cups covered with clear wrap. Three cups had yellow liquid, four had red liquid, one had pink liquid, one with white liquid, and one with dark brown liquid. There was no label or date. On 10/28/24 at 8:35 a.m, [NAME] #1 was asked what was the policy for labeling and dating food. They stated everything was supposed to be labeled and dated for the date you made it.

Based on observation and interview, the facility failed to ensure chemicals were locked away from residents and shower rooms were clean and safe. The administrator identified 38 residents who resided in the facility. Findings: On 10/28/24 at 8:36 a.m., the shower room on hall six was observed with plastic draping taped to two of three walls from approximately three feet down to floor and secured with duct tape. A grey, black, and white fuzzy substance was observed on the ceiling where the walls met and on inside of the door jamb and frame. On 10/28/24 at 2:29 p.m., an observation of the janitor closet on the Southwest resident hall was conducted. The door was without a lock on the knob to secure the closet. The closet contained multiple gallons of paint, a five gallon bucket of paint, a spray bottle of Windex cleaner, and a bottle labeled bleach without lid. There were multiple additional bottles of unlabeled liquids on the shelf. On 11/01/24 at 9:23 a.m, the administrator stated they were made aware the janitor closet door on the Southwest hall was unlocked. The administrator stated, It would not happen again. The administrator stated the housekeeping staff were responsible for cleaning the showers. The administrator stated the shower was to be cleaned every other day and as needed. The administrator stated there was no documented schedule for cleaning the shower rooms. The administrator stated there were only verbal instructions for cleaning the shower rooms.

Based on observation and interview, the facility failed to ensure residents were given the option to choose when to rise for the day for one (#19) of one sampled resident reviewed for choices. The DON identified 68 residents resided in the facility. Findings: Res #19 was admitted to the facility on [DATE] with diagnoses which included depression. On 10/28/24 at 10:24 a.m., Res #19 was observed seated in their recliner in their room. They stated they were not asked what time they liked to get up in the morning. They stated staff go them up at 4:00 a.m. and they can not go back to sleep. They stated they did not understand the reason they were being woken up at 4:00 a.m. just to sit there until breakfast. They stated they naturally wake up around 7:00 a.m. and would prefer to not be awoken by staff. On 10/31/24 at 11:05 a.m., the social services director stated the residents were not asked about what time they liked to get up in the morning.

Based on record review and interview, the facility failed to ensure residents receiving psychotropic medications were monitored for side effects for one (#19) of five sampled residents reviewed for unnecessary medications. The DON identified 68 residents resided in the facility. Findings: Res #19 had diagnoses which included depression. Physician orders, dated 08/17/24, documented to administer Sertraline (antidepressant medication) 150 mg daily for depression; and administer risperidone (antipsychotic medication) 2 mg at bedtime for depression. A chart review did not document side effect monitoring for the psychotropic medications. On 10/31/24 at 9:36 a.m., the DON stated there should have been side effect monitoring completed for the psychotropic medications.

Based on observation and interview, the facility failed to ensure gait belts were used during transfers for one (#50) of four sampled residents reviewed for accident hazards. The DON identified 68 residents resided in the facility. Findings: An undated facility policy titled Moving a Resident, Bed to Chair/Chair to Bed, documented if moving a resident from the bed to a chair, if a resident can not stand alone, two persons should use a gait belt. Res #50 was admitted to the facility with diagnosis which included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. On 10/28/24 at 1:10 p.m., CNA #1 was observed entering the resident's room to answer their call light. CNA #1 moved the resident's wheelchair close to the resident, then pulled a gait belt out of their pocket and placed it on the bed. The CNA then lifted the resident by holding them under under their arms from their recliner to their wheelchair. The resident remained in a bent knee position during the transfer. On 10/28/24 at 1:13 p.m., CNA #1 was asked what was the policy for using a gait belt. They stated they were supposed to use them getting residents up. On 10/31/24 at 10:41 a.m., the DON was made aware of the above observation and stated the gait belt should have been used.

Based on observation, record review, and interview, the facility failed to ensure care plans were updated to meet the residents' needs for three (#9, #21, and #56) of 24 residents whose care plans were reviewed. The facility failed to update the care plan: a. related to falls for Res #21. b. to reflected changes to antidepressant medications for Res #56. c. update the care plan to include end of life/hospice care for residents #9 and #56. The Resident Census and Conditions of Residents form documented 63 residents resided in the facility. Findings: 1. Res #56 had diagnoses which included depression and heart disease. A physician order, dated 11/03/22, documented mirtazapine (antidepressant medication) 7.5 mg. Give one tablet by mouth at bedtime. A care plan, dated 11/29/22, documented the resident used an antidepressant medication related to depression. It documented to give the medication as ordered and to monitor for side effects. A physician order, dated 03/22/23, documented to admit to hospice. There was no documentation the care plan was revised to reflect the resident was receiving hospice services. A physician order, dated 04/21/23, documented to discontinue mirtazapine 7.5 mg one tablet by mouth at bedtime. There was no documentation the care plan was revised to reflect the resident was no longer receiving an antidepressant. On 08/16/23 at 2:07 p.m., MDS Coordinator #1 was shown the resident's physician orders and care plan. They were asked if the care plan was revised to reflect the resident was receiving hospice services. They stated they did not see where it was. They stated the care plan should have been revised. MDS coordinator #1 was shown where the resident's care plan included an antidepressant was being used. They were asked to review the resident's physician orders for the use of an antidepressant. On 08/16/23 at 2:37 p.m., MDS coordinator #1 stated they saw where the resident had been on mirtazapine and it was discontinued on 04/21/23. They stated they missed it. They stated the care plan should have been revised. 46387 2. Res #21 had diagnoses which included muscle weakness and history of falls. An incident report, dated 06/30/23 at 8:20 a.m., documented Res #21 had a fall in the hallway while ambulating with family. The intervention documented to have staff assist the resident during ambulation. An admission MDS, dated [DATE], documented Res #21 was cognitively intact, required extensive assistance of two staff for ADLs, and had a fall in the month prior to the admission. An incident report, dated 07/25/23 at 9:00 p.m., documented the resident had a fall in their room while attempting to self transfer. The incident report documented an intervention to place a fall mat at bedside. A care plan, reviewed 07/25/23, documented the resident had an actual fall due to unsteady gait. The goal documented the resident would resume usual activities without further incident through the review date. The interventions documented the charge nurse would assess ROM upon incident; pharmacy consult to evaluate medications; PT consult for strength and mobility; and vital signs as ordered. On 08/15/23 at 9:40 a.m., Res #21 was observed in their room. A fall mat was observed at bedside and the bed was in the low position. On 08/16/23 at 1:58 p.m., the MDS coordinator was asked how interventions were added to the care plan. They stated during morning meeting any changes with residents were reviewed and they would add them at that time. They stated fall interventions were discussed in the meeting. They were shown Res #21's care plan for falls. They stated the interventions from the falls on 06/30/23 and 07/25/23 were not on the fall care plan. 47751 3. Res # 9 had diagnoses which included atrial fibrillation, congestive heart failure, chronic kidney disease, and dementia. A physician order dated 05/26/23, documented admit to hospice services. A significant change in assessment, dated 06/08/23, documented the resident was severely impaired in cognition, required limited to moderate assistance with most ADLs. On 08/16/23 at 3:00 p.m., the MDS coordinator was asked how interventions were added to the care plan. They stated during morning meeting any changes with residents were reviewed and they would add them at that time. They were shown Res #21's care plan. They were asked if a hospice care plan should have been initiated. They stated it should have been.

Based on observation, interview, and record review, the facility failed to provide the necessary ADL assistance to residents who were unable to carry out their own for two (#23 and #55) of two residents sampled for ADL assistance. The facility failed to provide assistance with eating for resident #55 and oral care for resident #23. The DON identified 50 residents who required assistance with ADLs. Finding: 1. Res #55 had diagnoses which included cachexia, senile degeneration of brain, dementia, and anxiety. A quarterly MDS assessment, dated 07/29/23, documented Res #55 was severely impaired with cognition and required one person physical assistance with meals. On 08/15/23 at 11:53 a.m. Res #55 was observed seated at a half-round table in the lunch room in a wheelchair. On 08/15/23 at 11:59 p.m., Res #55 received their lunch tray. The plate was placed on the table in front of the resident and a cup of tea was placed on the far side of the plate. On 08/15/23 at 12:17 p.m., Res #55 was observed attempting to feed themselves. The resident was observed reaching out with their hands and placing them onto the edge of the plate grasping some of the entree with their hands. The resident was observed attempting to pull the plate closer to themselves tipping the plate and dumping some of the food off the plate and onto the table. The resident was then observed looking around the room. On 08/15/23 at 12:21 p.m., Res #55 was observed reaching for their glass of tea, the resident was unable to reach the glass. The resident continued to look around the dining room at passing staff, tracking their movements with their eyes. The resident's eyes would open wider and eyebrows raise as a staff came close to the table and then their eyebrows would fall. The resident would look down at their lap as the staff passed the table. On 08/15/23 at 12:25 p.m., Res #55 was observed reaching for and grasping some of the entree with their bare hands. The food fell from their fingers before reaching their mouth. The resident continued to attempt to feed self with hands for three minutes. On 08/15/23 at 12:31 p.m., CNA #5 sat down to assist Res #55 with their meal. The resident was observed to consume 10% of their meal with assistance. On 08/15/23 at 1:15 p.m., CNA #5 stated Res #55 had recently been declining and only recently started to need assistance during meals. On 08/16/23 at 12:05 p.m., CNA #4 was observed assisting Res #55 during lunch. The CNA stated it was not acceptable to wait 30 minutes for feeding assistance. 47751 2. Res #23 had diagnoses which included vascular dementia, muscle wasting, stroke, cognitive communication deficit, and for assist with personal care. A care plan, dated 09/20/16, documented the resident required assist of one to two persons with all ADLs. An annual assessment, dated 06/19/23, documented the resident was severely impaired in cognition and required extensive to total assist with most ADLs. On 08/15/23 at 10:14 a.m., CNA #3 documented Res #23 had received oral care. On 08/15/23 at 10:49 a.m., Res # 23 was observed to have a thick white film on their teeth. On 08/16/23 at 8:49 a.m., Res # 23 was observed to have a thick white film on their teeth. On 08/16/23 at 8:59 a.m. CNA #3 was observed in the resident's dressing them after a shower. On 08/16/23 at 9:15 a.m. Res # 23 continued to have a thick white film on their teeth. On 08/16/23 at 9:24 a.m., LPN #1 was shown Res #23's teeth. They stated they are a little grotty. LPN #1 was asked how often Res #23 should be receiving oral care. They stated after each meal. On 08/16/23 at 9:29 a.m., the DON was asked how often the Res #23 should be receiving oral care. The DON stated daily and as needed.

Based on observation and interview, the facility failed to ensure the kitchen and dining area were kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 08/15/23, documented 63 residents resided in the facility. Findings: On 08/15/23 at 9:10 a.m., a tour of the kitchen and dining area was conducted. The following observations were made: a. There was a hole in the wall below the three compartment sink. b. Water was leaking from the piping below the three compartment sink onto the floor and in a bus tub. There was standing water in the bus tub. c. There was an accumulation of brown residue around the base of the table mounted can opener. d. There was an accumulation of lint on the conduit on the wall behind the stove and on the back side of the stove. e. There was grease and lint on the oven hood filters. f. The plastic ice scoop utilized for the ice machine was cracked. g. There was black and white residue inside of the ice scoop holder. On 08/15/23 at 9:44 a.m., the DM was asked how staff ensured the kitchen and dining area was kept clean and maintained in good repair. They stated staff cleaned daily and maintenance concerns were reported to the maintenance department. The DM was made aware of and shown the above findings.

Based on observation, record review, and interview, the facility failed to answer a call light in a timely manner for one (#166) of five sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents form, dated 08/15/23, documented 63 residents resided in the facility. Findings: Res #166 admitted to the facility on [DATE] with diagnoses including displaced fracture of base of neck of right femur, depression, and mild intellectual disability. A nurse note, dated 08/16/23 at 6:42 a.m., documented the resident was non-weight bearing and required two staff for assistance with toileting and peri-care. The note documented the resident yells out for help and the call light was explained. On 08/16/23 at 8:09 a.m., upon surveyor's entry onto the resident's hall, Res #166's call light was observed on above their door and could be heard sounding in the hall. On 08/16/23 at 8:42 a.m., Res #166 was heard yelling out hey three times. On 08/16/23 at 8:58 a.m., RN #1 was observed entering the resident's room. During the time from 8:09 a.m. through 8:58 a.m. no other staff member entered the hall. On 08/16/23 at 9:01 a.m., RN #1 was observed leaving the resident's room. They were asked what the resident had needed from staff. The RN stated the resident was asking to have their urinal emptied and removed from their over-bed table. The RN was asked how quickly a call light should be answered, they stated as soon as possible. The RN was unsure what the facility policy was and stated they would check. On 08/16/23 at 9:02 a.m., Res #166 was observed in their bed. The resident was asked what they needed from staff and they waived towards the urinal now resting on the bedside table on a paper towel. When asked if they were able to reach their call light for assistance the resident uncovered the call light clipped to their blanket at their waist. The resident was unable to verbalize if they felt any negative emotions from the wait or what their expectations were. On 08/16/23 at 9:39 a.m., RN #1 stated there was no policy on wait times for call lights, but 49 minutes was not acceptable and the aids had been spoken to. On 08/16/23 at 10:36 a.m., the DON stated staff should answer call lights as soon as they can and 49 minutes was not up to the standard of the facility.

Based on observation, record review, and interview, the facility failed to ensure code status orders were accurately documented for one (#47) of three sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 08/15/23, documented 63 residents resided in the facility. Findings: Res #47 had diagnoses which included muscle weakness, HTN, anxiety, muscle wasting and atrophy, abnormalities of gait and mobility, dysphagia, and metabolic encephalopathy. A care plan, date initiated 05/31/23, documented the resident had chosen DNR status. It was documented staff would note chart with code choice and obtain and follow resident's code status choice. There was no physician order related to the resident's code status. On 08/16/23 at 10:49 a.m., LPN #1 was asked how staff determined what a residents' code status was. They stated they looked at their physician orders. They were asked what was Res #47's code status. They stated they were a full code. They were asked if there was a physician order for the resident's code status. They reviewed the resident's EHR and stated there was an order for a living will. They stated there should be a physician order for a full code. On 08/16/23 at 11:20 a.m., the DON was asked what was Res #47's code status. They stated the resident had no DNR on file. They stated the resident should be a full code. The DON was made aware there was no physician order related to code status and the care plan documented the resident had a DNR in place. On 08/16/23 at 12:12 p.m., MDS coordinator #1 stated they contacted the resident's family regarding a signed DNR. The stated the family signed a DNR at the hospital during their last visit. They stated they had the family fax them a copy of the DNR. They stated the resident should be a DNR.

Based on observation, record review, and interview, the facility failed to notify the physician and resident's legal representative of a change in condition for one (#47) of one sampled resident reviewed for physician ordered diets. The Resident Census and Conditions of Residents report, dated 08/15/23, documented 63 residents resided in the facility. Findings: Res #47 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia. A physician order, dated 01/03/23, documented regular diet with ground meat texture, nectar consistency, and no straws. An admission assessment, dated 06/01/23 documented the resident's cognition was severely impaired and had no signs or symptoms of a swallowing disorder. On 08/15/23 at 12:17 p.m., the resident was observed with pureed foods and nectar thick liquids. On 08/16/23 at 11:48 a.m., the resident was observed with pureed foods and nectar thick liquids. CNA #2 was asked the reason the resident received pureed foods. They stated the resident was having issues swallowing and they thought either hospice or speech therapy wanted to see how they did on a pureed diet. On 08/16/23 at 11:54 a.m., the DON was asked to provide documentation related to the resident having swallowing issues and being placed on the pureed diet they were receiving. On 08/16/23 at 12:02 p.m., the DM was asked about the resident receiving a pureed diet instead of a regular with ground meats as ordered by the physician. They stated the resident's diet order did not change. They stated staff came to dietary and wanted to try the resident on a pureed diet due to swallowing problems. They stated it had not been long since the pureed diet was requested. On 08/16/23 at 3:06 p.m., the DON stated nursing staff made the previous DM aware the resident was having swallowing issues and the DM stated to give the resident a trial run of a pureed diet. They stated there was no documentation related to the resident having swallowing issues or placing the resident on pureed foods on a trial basis. The DON stated there was no documentation the physician or resident's legal representative were notified of the resident having swallowing problems and implementing a pureed diet on a trial basis. They stated they should have been notified.

Based on record review and interview, the facility failed to ensure accurate diagnoses coding of an MDS for one (#27) of 17 sampled residents whose MDS was reviewed. The Resident Census and Conditions of Residents form, dated 08/15/23, documented 63 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, documented in part .Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses . Res #27 had active diagnoses which included depression, chronic pain, GERD, and candidiasis. An annual MDS, dated [DATE], documented active diagnoses of MDRO and pneumonia. The resident's medical record did not document treatments or monitoring for MDRO or pneumonia during the review period. On 08/16/23 at 3:07 p.m., the MDS coordinator was asked about their process for reviewing diagnosis codes on the MDS. They stated for long term care residents they did not review the diagnosis codes to ensure they were accurate on the MDS. They stated they were unaware the codes on the MDS must be active during the seven day review period. When asked if Res #27's diagnoses of MDRO and pneumonia were active during the review period, they stated, No. On 08/16/23 at 3:21 p.m., the DON was notified of the above findings. They stated the MDS coordinator needed additional training.

Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#56) of 17 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report, dated 08/15/23, documented 63 residents resided in the facility. Findings: Res #56 had diagnoses which included history of UTI and cognitive communication deficit. A significant change assessment, dated 09/27/22, documented on the CAA summary, communication and urinary incontinence were care areas triggered and care plan decisions. It was documented behavioral symptoms was a care plan decision. On 08/16/23 at 2:07 p.m., MDS coordinator #1 was shown the resident's CAA summary on their significant change assessment. They were asked if communication, urinary incontinence, and behavioral symptoms were care areas developed on the care plan. On 08/16/23 at 2:37 p.m., MDS coordinator #1 stated they did not develop the care plan to include communication, urinary incontinence, and behavioral symptoms.

On 05/07/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the failure to follow the facility's policy for reporting an allegation of abuse to the appropriate personnel for failing to investigate an allegation of abuse and for failing to have a policy that would ensure all residents were protected during the investigation of an allegation of abuse. At 12:00 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 12:10 p.m., the ADM and the DON came into the room where the surveyors were working. The ADM and the DON were notified of the IJ situation. At 1:15 p.m. an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "1. The Administrator and the Director of Nursing will begin an investiagtion of the allegation of abuse immediately. The Director of Nursing and Administrator will interview the resident in question in order to obtain information regarding the allegation of abuse and take appropriate action including reporting to the appropriate agencies. If an employee is identified through the course of this investigation that individual will be suspended pending a complete investigation in order to protect the residents until the allegation is found to be substantiated or unsubstantiated. 2. The director of Nursing and the Administrator will in-service all staff addressing the importance of reporting all suspected allegations of abuse immediately to their supervisor and the Administrator. 3. The abuse policy will be revised in order to prohibit any employee who is suspected of abuse to continue to be in direct care of residents until which time the allegation is found to be unsubstantiated." Based on record review, observation, and family, resident and staff interviews, it was determined the facility failed to: follow the facility's policy for reporting an allegation of abuse to the appropriate personnel; investigate an allegation of abuse and have a policy that would ensure all residents were protected during the investigation of an allegation of abuse for one (#1) of one sampled resident. This had the potential to affect all 79 residents who resided in the facility. Findings: A facility policy on resident abuse, under prevention, documented, "The protection of the resident is the primary concern of the facility during the course of the investigation of abuse....Staff to Resident Abuse...Relocation of the employee to another wing during the investigation of the allegation of abuse...." The resident abuse policy, under reporting, documented, "In the event of any evidence or cause to believe that a resident has suffered any of the above abuses the employee, visitor or family member are requested to report all allegations, suspicions or incidents to the administrator or his designee or to the State Officials as posted in the facility next to the administrator's office...." Resident # 1 had [DIAGNOSES REDACTED]. An admission assessment, dated 3/30/12, identified the resident was moderately impaired with cognition, required limited assistance of one person with transfers, walking, dressing, and personal hygiene, and was continent of bowel and bladder. A care plan, dated 3/19/12, documented the following: "Focus (Resident's name deleted) has limited physical mobility due to Debilitation and Decline in function. Goal (Resident's name deleted) will maintain current level of mobility by next review. Interventions Asst. of one for transfer on/off of commode and adjusting clothes." On 05/07/12 at 5:30 a.m., LPN #1 was interviewed regarding the steps taken by the facility to protect the residents if an allegation of abuse was reported to her. The LPN stated, "I'd talk to the resident and the CNA involved and if I thought it was a true complaint I would give the CNA a verbal warning. I would then have the CNA apologize for what ever it was that happened. Usually, that helps." At that time, the surveyor asked if the LPN would take any other steps for an allegation of abuse against a CNA which was working her shift. The LPN stated, "No, not really. I haven't heard of anything like that in a long time. You know you have those residents that say things like, they push me too fast. You have to take into account who that resident is. Some residents yell out even when nobody is touching them." The surveyor asked the LPN if she would fill out an incident report. The LPN stated, "Again, it would just depend on the resident and the situation." At 6:00 a.m., LPN #2 was interviewed regarding the steps taken by the facility to protect the residents if an allegation of abuse was reported to her. The LPN stated, "I'd report it to the DON and ADM but first I'd go and observe the CNA give care. I've not had a resident complain in long time though. I'd try to keep the resident and the CNA apart by having them not go in the resident's room or if they needed to care for the resident I'd go with the CNA to give care." At 8:50 a.m., the MDS coordinator was interviewed regarding an allegation of abuse that was voiced during a care plan meeting with resident #1 and the resident's family. The MDS coordinator stated, "The only thing I can recall is the resident had an accident and the resident was pushed over. We didn't know who it was. We talked to the staff. I think the resident said she had soiled herself and they roughly grabbed her and turned her to the wall. We assessed her and she didn't have any injury." The coordinator was then asked if the resident had described the person who had been rough with her. The coordinator reported the resident said the person had been an indian lady. The MDS coordinator reported the facility had several native american indians employed as CNAs. At that time, the MDS coordinator was asked if she had reported the allegation and to whom. The MDS coordinator stated, "Honestly, I was told after the fact. Someone had already been told. I asked (Name deleted) the ADON about it and she said she had addressed it." At 9:15 a.m., the DON was interviewed and asked if any allegation of abuse had been reported to her. The DON reported there had not been an allegation reported to her. At 9:25 a.m., the Activity Director (AD) was interviewed and asked if any allegation of abuse had been reported to her. The AD stated, the resident had told her several days before the care plan meeting that a CNA had been rough with her. The resident told her one (CNA) had come in and thought she had wet her bed and they used the sheet or pad and pushed her into the wall. The AD stated, "She (the resident) was pretty hurt they treated her that way." On 05/07/12 at 9:30 a.m., LPN #3 was interviewed regarding the steps taken by the facility to protect the residents if an allegation of abuse was reported to her. The LPN stated, "If I did, I'd go and talk to the resident and assess the resident. If it was against a staff member, I would get with (Name deleted) ADM and the DON." The surveyor then asked if the ADM and DON were not in the facility how would the allegation be handled. The LPN stated, "I would talk to the CNA and get their side of the story. I would make sure someone stayed with the CNA when they were going to give care to that resident." At 9:50 a.m., the ADON was interviewed and asked if an allegation of abuse was reported to her in regard to the resident. The ADON stated, "I don't work her hall. (MDS coordinator name deleted) told me just now that they had turned her rough. I talk to her husband all the time though and he didn't say anything. I didn't have any idea that it came up in a care plan meeting." The surveyor asked if the MDS coordinator had told her of the allegation after the care plan meeting. The ADON stated, "I don't remember her telling me." At that time, the ADON was asked what steps would be taken by the facility to protect the residents if an allegation of abuse was reported to her. The ADON stated, "I'd investigate it and if the residents were OK I'd send the employee to the house and turn it over to (Name deleted ADM)." The surveyor then asked what steps would be taken if the ADM was not present in the facility when the allegation took place. The ADON stated, "I'd pull the employee away from the patient till I could check." On 05/07/12 at 10:10 a.m., the ADM was asked if he was aware of any allegation of abuse. He reported he was not aware of any alleged abuse concerning resident #1 before today. He also reported he became aware of the alleged abuse today during this investigation. The ADM was asked what he would expect his staff to do if an alleged abuse was reported to them. The ADM reported they should go to their charge nurse and the charge nurse should report it to the DON and/or ADM. The ADM was asked what the charge nurse should do if he or the DON were not in the building. He reported the charge nurse should investigate the problem, talk to the resident and report it to him. He reported if it was a staff member, the facility would take steps to remove that person from the resident's care until the investigation was completed. The ADM reported the allegation should have been followed up on. He reported he would have placed the involved staff member on another hall until the investigation was completed. He reported he considered the staff member innocent until proven guilty. He reported it depended on the circumstances of the incident. The ADM reported if during the investigation, the facility would find there was evidence of abuse, the facility would terminate the staff member. He reported if there was an allegation of abuse and didn't think it was real, the facility would move them to another hall during the investigation. The ADM was asked if the facility handled the abuse allegation correctly. The ADM reported no, it was not handled correctly. He reported during the next in-service, he would make the point to say it's better to over report than under report. On 05/07/12 at 10:30 a.m., an interview was conducted via telephone with the resident's family member. The family member was asked at what time was he/she made aware that a staff handled the resident roughly. The family member reported he/she became aware of the allegation of abuse during a recent family meeting. The family member asked the resident if she had anything to say about her care. At that time, the resident told their family member something had happened one night. The resident reported a staff person, who came into her room, was angry and cranky. The staff member told the resident she had soiled her bed. The resident told the staff member she had not wet the bed. The resident reported the staff member then wrapped her up in a sheet and threw her against the wall. At that time, the family member stopped the conversation with the resident and went to the MDS coordinator. The family member reported to the surveyor she had told the MDS coordinator what the resident had reported. The MDS coordinator reported to the family member she was aware of the situation and was told the employee usually didn't work that shift. On 05/07/12 at 11:05 a.m., an interview was conducted with resident #1. The resident was asked if any staff had harmed her. The resident reported one night a staff person came into her room and told her she had wet the bed. The resident reported she told the staff, no, she had not. The resident reported the staff member was argumentative with her. The resident reported the staff member wrapped her in a sheet and pushed her into the wall. The resident reported she remembered thinking, if she would have been a child, the staff member would have killed her. The resident reported she could tell the staff member was strong by the way the staff had lifted her. The resident reported the incident was such a shock to her. The resident was asked if she reported the incident to anyone. She stated, "Yes." The resident reported she had told a nurse. The resident reported the nurse told her she thought she knew who the staff member was. The resident was asked if she had been assessed for injuries after the incident. The resident stated, "No." The resident was asked if she could identify the staff member. She reported it was dark in the room and she could not identify the person, but she thought the staff member was native american. At 12:35 p.m., the AD was re-interviewed regarding the allegation of abuse. The AD was asked what she did after she had learned of the incident. The AD stated, " I don't have any idea who works 11-7, but I think it happened the night before she told me. I told (Name deleted LPN #3) the CNAs had gotten rough with her but (Name Deleted LPN #3) has so much going on. She may not have understood." At 12:45 p.m., LPN #3 was re-interviewed regarding the allegation of abuse. The surveyor asked if anyone had reported an allegation of abuse to her. The LPN stated, " I don't remember anyone telling me any allegation of abuse or hearing of one." On 05/07/12, eleven CNAs on the night shift and day shift were interviewed regarding training and reporting allegations of abuse. All eleven of the CNAs reported if they had an allegation of abuse, witnessed abuse or heard of abuse they would report the incident to their charge nurse. All eleven CNAs reported they had been trained on abuse during in-services throughout the year. All eleven CNA's reported they had not heard of any allegations of abuse in the facility lately. The facility's staff failed to report the alleged abuse to the administrator or his designee as the policy documented. No investigation was conducted to investigate the alleged abuse. No steps were taken to protect the residents. No reports were filed with the appropriate state agencies. The facility's abuse policy did not address steps to remove an employee from direct resident care to protect the residents during the investigative process. On 05/09/12 at 9:00 a.m., the immediate jeopardy was removed after all staff had been in-serviced on the abuse policy and procedures and after staff were interviewed on all shifts and showed current knowledge of the abuse policy and procedures. The deficient practice remained at no actual harm with potential for more than minimal harm at a pattern.

On 05/07/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to investigate an allegation of abuse and ensure residents were protected. At 12:00 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 12:10 p.m., the ADM and the DON were notified of the IJ situation. At 1:15 p.m. an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "1. The Administrator and the Director of Nursing will begin an investigation of the allegation of abuse immediately. The Director of Nursing and Administrator will interview the resident in question in order to obtain information regarding the allegation of abuse and take appropriate action including reporting to the appropriate agencies. If an employee is identified through the course of this investigation that individual will be suspended pending a complete investigation in order to protect the residents until the allegation is found to be substantiated or unsubstantiated. 2. The director of Nursing and the Administrator will in-service all staff addressing the importance of reporting all suspected allegations of abuse immediately to their supervisor and the Administrator. 3. The abuse policy will be revised in order to prohibit any employee who is suspected of abuse to continue to be in direct care of residents until which time the allegation is found to be unsubstantiated." Based on record review, observation, and family, resident and staff interviews, it was determined the facility failed to ensure an allegation of abuse made by one (#1) of one sampled resident was reported to the appropriate staff and investigated. This had the potential to affect all 79 residents who resided in the facility. Findings: A facility policy on resident abuse, under prevention, documented, "The protection of the resident is the primary concern of the facility during the course of the investigation of abuse....Staff to Resident Abuse...Relocation of the employee to another wing during the investigation of the allegation of abuse...." The resident abuse policy, under reporting, documented, "In the event of any evidence or cause to believe that a resident has suffered any of the above abuses the employee, visitor or family member are requested to report all allegations, suspicions or incidents to the administrator or his designee or to the State Officials as posted in the facility next to the administrator's office...." Resident # 1 had [DIAGNOSES REDACTED]. An admission assessment, dated 3/30/12, identified the resident was moderately impaired with cognition, required limited assistance of one person with transfers, walking, dressing, and personal hygiene, and was continent of bowel and bladder. A care plan, dated 3/19/12, documented the following: "Focus (Resident's name deleted) has limited physical mobility due to Debilitation and Decline in function. Goal (Resident's name deleted) will maintain current level of mobility by next review. Interventions Asst. of one for transfer on/off of commode and adjusting clothes." On 05/07/12 at 5:30 a.m., LPN #1 was interviewed regarding the steps taken by the facility to protect the residents if an allegation of abuse was reported to her. The LPN stated, "I'd talk to the resident and the CNA involved and if I thought it was a true complaint I would give the CNA a verbal warning. I would then have the CNA apologize for what ever it was that happened. Usually, that helps." At that time, the surveyor asked if the LPN would take any other steps for an allegation of abuse against a CNA which was working her shift. The LPN stated, "No, not really. I haven't heard of anything like that in a long time. You know you have those residents that say things like, they push me too fast. You have to take into account who that resident is. Some residents yell out even when nobody is touching them." The surveyor asked the LPN if she would fill out an incident report. The LPN stated, "Again, it would just depend on the resident and the situation." At 6:00 a.m., LPN #2 was interviewed regarding the steps taken by the facility to protect the residents if an allegation of abuse was reported to her. The LPN stated, "I'd report it to the DON and ADM but first I'd go and observe the CNA give care. I've not had a resident complain in long time though. I'd try to keep the resident and the CNA apart by having them not go in the resident's room or if they needed to care for the resident I'd go with the CNA to give care." At 8:50 a.m., the MDS coordinator was interviewed regarding an allegation of abuse that was voiced during a care plan meeting with resident #1 and the resident's family. The MDS coordinator stated, "The only thing I can recall is the resident had an accident and the resident was pushed over. We didn't know who it was. We talked to the staff. I think the resident said she had soiled herself and they roughly grabbed her and turned her to the wall. We assessed her and she didn't have any injury." The coordinator was then asked if the resident had described the person who had been rough with her. The coordinator reported the resident said the person had been an indian lady. The MDS coordinator reported the facility had several native american indians employed as CNAs. At that time, the MDS coordinator was asked if she had reported the allegation and to whom. The MDS coordinator stated, "Honestly, I was told after the fact. Someone had already been told. I asked (Name deleted) the ADON about it and she said she had addressed it." At 9:15 a.m., the DON was interviewed and asked if any allegation of abuse had been reported to her. The DON reported there had not been an allegation reported to her. At 9:25 a.m., the Activity Director (AD) was interviewed and asked if any allegation of abuse had been reported to her. The AD stated, the resident had told her several days before the care plan meeting that a CNA had been rough with her. The resident told her one (CNA) had come in and thought she had wet her bed and they used the sheet or pad and pushed her into the wall. The AD stated, "She (the resident) was pretty hurt they treated her that way." On 05/07/12 at 9:30 a.m., LPN #3 was interviewed regarding the steps taken by the facility to protect the residents if an allegation of abuse was reported to her. The LPN stated, "If I did, I'd go and talk to the resident and assess the resident. If it was against a staff member, I would get with (Name deleted) ADM and the DON." The surveyor then asked if the ADM and DON were not in the facility how would the allegation be handled. The LPN stated, "I would talk to the CNA and get their side of the story. I would make sure someone stayed with the CNA when they were going to give care to that resident." At 9:50 a.m., the ADON was interviewed and asked if an allegation of abuse was reported to her in regard to the resident. The ADON stated, "I don't work her hall. (MDS coordinator name deleted) told me just now that they had turned her rough. I talk to her husband all the time though and he didn't say anything. I didn't have any idea that it came up in a care plan meeting." The surveyor asked if the MDS coordinator had told her of the allegation after the care plan meeting. The ADON stated, "I don't remember her telling me." At that time, the ADON was asked what steps would be taken by the facility to protect the residents if an allegation of abuse was reported to her. The ADON stated, "I'd investigate it and if the residents were OK I'd send the employee to the house and turn it over to (Name deleted ADM)." The surveyor then asked what steps would be taken if the ADM was not present in the facility when the allegation took place. The ADON stated, "I'd pull the employee away from the patient till I could check." On 05/07/12 at 10:10 a.m., the ADM was asked if he was aware of any allegation of abuse. He reported he was not aware of any alleged abuse concerning resident #1 before today. He also reported he became aware of the alleged abuse today during this investigation. The ADM was asked what he would expect his staff to do if an alleged abuse was reported to them. The ADM reported they should go to their charge nurse and the charge nurse should report it to the DON and/or ADM. The ADM was asked what the charge nurse should do if he or the DON were not in the building. He reported the charge nurse should investigate the problem, talk to the resident and report it to him. He reported if it was a staff member, the facility would take steps to remove that person from the resident's care until the investigation was completed. The ADM reported the allegation should have been followed up on. He reported he would have placed the involved staff member on another hall until the investigation was completed. He reported he considered the staff member innocent until proven guilty. He reported it depended on the circumstances of the incident. The ADM reported if during the investigation, the facility would find there was evidence of abuse, the facility would terminate the staff member. He reported if there was an allegation of abuse and didn't think it was real, the facility would move them to another hall during the investigation. The ADM was asked if the facility handled the abuse allegation correctly. The ADM reported no, it was not handled correctly. He reported during the next in-service, he would make the point to say it's better to over report than under report. On 05/07/12 at 10:30 a.m., an interview was conducted via telephone with the resident's family member. The family member was asked at what time was he/she made aware that a staff handled the resident roughly. The family member reported he/she became aware of the allegation of abuse during a recent family meeting. The family member asked the resident if she had anything to say about her care. At that time, the resident told their family member something had happened one night. The resident reported a staff person, who came into her room, was angry and cranky. The staff member told the resident she had soiled her bed. The resident told the staff member she had not wet the bed. The resident reported the staff member then wrapped her up in a sheet and threw her against the wall. At that time, the family member stopped the conversation with the resident and went to the MDS coordinator. The family member reported to the surveyor she had told the MDS coordinator what the resident had reported. The MDS coordinator reported to the family member she was aware of the situation and was told the employee usually didn't work that shift. On 05/07/12 at 11:05 a.m., an interview was conducted with resident #1. The resident was asked if any staff had harmed her. The resident reported one night a staff person came into her room and told her she had wet the bed. The resident reported she told the staff, no, she had not. The resident reported the staff member was argumentative with her. The resident reported the staff member wrapped her in a sheet and pushed her into the wall. The resident reported she remembered thinking, if she would have been a child, the staff member would have killed her. The resident reported she could tell the staff member was strong by the way the staff had lifted her. The resident reported the incident was such a shock to her. The resident was asked if she reported the incident to anyone. She stated, "Yes." The resident reported she had told a nurse. The resident reported the nurse told her she thought she knew who the staff member was. The resident was asked if she had been assessed for injuries after the incident. The resident stated, "No." The resident was asked if she could identify the staff member. She reported it was dark in the room and she could not identify the person, but she thought the staff member was native american. At 12:35 p.m., the AD was re-interviewed regarding the allegation of abuse. The AD was asked what she did after she had learned of the incident. The AD stated, " I don't have any idea who works 11-7, but I think it happened the night before she told me. I told (Name deleted LPN #3) the CNAs had gotten rough with her but (Name Deleted LPN #3) has so much going on. She may not have understood." At 12:45 p.m., LPN #3 was re-interviewed regarding the allegation of abuse. The surveyor asked if anyone had reported an allegation of abuse to her. The LPN stated, " I don't remember anyone telling me any allegation of abuse or hearing of one." On 05/07/12, eleven CNAs on the night shift and day shift were interviewed regarding training and reporting allegations of abuse. All eleven of the CNAs reported if they had an allegation of abuse, witnessed abuse or heard of abuse they would report the incident to their charge nurse. All eleven CNAs reported they had been trained on abuse during in-services throughout the year. All eleven CNA's reported they had not heard of any allegations of abuse in the facility lately. The facility's staff failed to report the alleged abuse to the administrator or his designee as the policy documented. No investigation was conducted to investigate the alleged abuse. No steps were taken to protect the residents. No reports were filed with the appropriate state agencies. The facility's abuse policy did not address steps to remove an employee from direct resident care to protect the residents during the investigative process. The abuse policy was updated to reflect this. On 05/09/12 at 9:00 a.m., the immediate jeopardy was removed after all staff had been in-serviced on the abuse policy and procedures and after staff were interviewed on all shifts and showed current knowledge of the abuse policy and procedures. The deficient practice remained at no actual harm with potential for more than minimal harm at a pattern.