Every finding on record at Hensley Nursing & Rehab

Based on record review and interview, the facility failed to ensure a thorough investigation was completed for an allegation of sexual abuse for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 26 residents resided in the facility. A facility policy titled Abuse Policy and Procedure, dated 07/23/21, read in part, We will protect our occupants from abuse, neglect, physical abuse, sexual abuse, and misappropriation of resident property. It recognizes resident rights to be free from sexual abuse by staff.All allegations of resident sexual abuse shall be promptly reported to administrator and investigated by facility management. The administrator will report the allegation to the OSDH, APS, and local police. The accused employee will be suspended immediately from employment until an investigation has determined the employee is no longer a suspect.Even if there are no signs of physical harm, or the facility does not believe the allegation, the person shall be transported to the Hospital for a medical examination and treatment. The Hospital shall be requested to perform a rape kit examination.Any employee who fails to report actual or suspected abuse shall be subject to disciplinary actions up to or including termination. An undated facility time sheet showed CNA #1 worked on the night shift 07/31/26 from 10:53 p.m. to 7:03 a.m., 08/01/26 from 10:56 p.m. to 7:03 a.m., 08/02/26 from 10:55 p.m. to 7:08 a.m., and on 08/03/26 from 10:53 p.m. to 7:00 a.m. The time sheet showed CNA #1 had worked four shifts after CNA #4 reported Resident #1 had alleged abuse against CNA #1 to the charge nurse. An OSDH incident report, dated 08/04/26, showed Resident #1 had reported CNA #1 used chloroform and had raped them several times. The report showed the employee was suspended and a head-to-toe assessment was completed on the resident with no signs of abuse. The report showed the resident was then sent to the hospital for a rape kit and all parties were notified of the allegation. On 08/12/26 at 9:50 a.m., the DON and administrator stated they began an abuse investigation on 08/04/26 when the night shift charge nurse, who had been scheduled on 08/03/26, notified them of allegations of sexual abuse reported from Resident #1 against CNA #1. They stated abuse in-service were held to educate the staff on abuse and reporting. On 08/12/26 at 10:41 a.m., LPN #1 stated they worked the evening shift of 07/30/26 when CNA #4 had informed them of bruising on the bilateral forearms of Resident #1. LPN #1 stated CNA #4 had not mentioned Resident #1 had accused CNA #1 of raping them. On 08/12/26 at 10:54 a.m., the DON and administrator stated they had spoken with Resident #1 on 08/04/26. They stated the resident reported CNA #1 had used chloroform to drug them on 07/30/26. They stated Resident #1 verbalized they knew they had been raped because their underwear was wet, their hip hurts, and their bottom was sore. On 08/12/26 at 11:20 a.m., CMA #1 stated they had interviewed Resident #1 with the administrator. They stated the administrator had asked Resident #1 why they hadn't reported incident to them instead of CNA #4. CMA #1 stated Resident #1 had stated CNA #4 was the only person to ask about the bruises on their arms and that it had just happened last night. CMA #1 stated CNA #1 was assigned to work on the opposite hall from Resident #1 but had passed ice to all the residents. CMA #1 stated CNA #1 had been in and out of rooms within a few seconds. On 08/12/26 at 12:20 p.m., LPN #2 stated on 07/30/26, CNA #4 reported to them Resident #1 had accused CNA #1 of molesting them. LPN #2 stated they had not reported the allegation to anyone because CNA #1 was off of work on 07/30/26. They stated CNA #1 had never gone into Resident #1's room except to provide ice which only takes a few seconds. LPN #2 reported after the DON questioned and educated them on reporting and investigating allegations of abuse, they acknowledged they should have immediately suspended CNA #1 and reported to administration. On 08/12/26 at 4:05 p.m., RN #1, stated on 08/03/26, CNA #4 asked what was being done about the allegations of abuse they had reported. RN #1 stated not having been aware of any pending investigations for CNA #1. RN #1 stated they assigned CNA #1 to the other hall and watched them just in case. RN #1 stated CNA #1 was professional, respectful, and focused. RN#1 stated Resident #1 was independent with ADLs and continent. RN #1 stated they had called the DON and administrator at the end of the shift to ask questions about a possible investigation involving CNA #1 and Resident #1.

Based on record review and interview, the facility failed to ensure an allegation of sexual abuse was reported to the OSDH within two hours for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 26 residents resided in the facility. Findings: A facility policy titled Abuse Policy and Procedure, dated 07/23/21, read in part, We will protect our occupants from abuse, neglect, physical abuse, sexual abuse, and misappropriation of resident property. It recognizes resident rights to be free from sexual abuse by staff.All allegations of resident sexual abuse shall be promptly reported to administrator and investigated by facility management. The administrator will report the allegation to the OSDH, APS, and local police. The accused employee will be suspended immediately from employment until an investigation has determined the employee is no longer a suspect. An OSDH incident report, dated 08/04/26, showed Resident #1 had reported CNA #1 used chloroform and had raped them several times. The report showed the employee was suspended and a head-to-toe assessment was completed on the resident with no signs of abuse. The report showed the resident was then sent to the hospital for a rape kit and all parties were notified of the allegation. On 08/12/26 at 9:50 a.m., the DON and administrator stated they began an abuse investigation on 08/04/26 when the night shift charge nurse, who had been scheduled on 08/03/26, notified them of allegations of sexual abuse reported from Resident #1 against CNA #1. They stated abuse in-service were held to educate the staff on abuse and reporting. On 08/12/26 at 10:41 a.m., LPN #1 stated they worked the evening shift of 07/30/26 when CNA #4 had informed them of bruising on the bilateral forearms of Resident #1. LPN #1 stated CNA #4 had not mentioned Resident #1 had accused CNA #1 of raping them. On 08/12/26 at 10:54 a.m., the DON and administrator stated they had spoken with Resident #1 on 08/04/26. They stated the resident reported CNA #1 had used chloroform to drug them on 07/30/26. They stated Resident #1 verbalized they knew they had been raped because their underwear was wet, their hip hurts, and their bottom was sore. On 08/12/26 at 11:20 a.m., CMA #1 stated they had interviewed Resident #1 with the administrator. They stated the administrator had asked Resident #1 why they hadn't reported incident to them instead of CNA #4. CMA #1 stated Resident #1 had stated CNA #4 was the only person to ask about the bruises on their arms and that it had just happened last night. CMA #1 stated CNA #1 was assigned to work on the opposite hall from Resident #1 but had passed ice to all the residents. CMA #1 stated CNA #1 had been in and out of rooms within a few seconds. On 08/12/26 at 12:20 p.m., LPN #2 stated on 07/30/26, CNA #4 reported to them Resident #1 had accused CNA #1 of molesting them. LPN #2 stated they had not reported the allegation to anyone because CNA #1 was off of work on 07/30/26. They stated CNA #1 had never gone into Resident #1's room except to provide ice which only takes a few seconds. LPN #2 reported after the DON questioned and educated them on reporting and investigating allegations of abuse, they acknowledged they should have immediately suspended CNA #1 and reported to administration. On 08/12/26 at 4:05 p.m., RN #1, stated on 08/03/26, CNA #4 asked what was being done about the allegations of abuse they had reported. RN #1 stated not having been aware of any pending investigations for CNA #1. RN #1 stated they assigned CNA #1 to the other hall and watched them just in case. RN #1 stated CNA #1 was professional, respectful, and focused. RN#1 stated Resident #1 was independent with ADLs and continent. RN #1 stated they had called the DON and administrator at the end of the shift to ask questions about a possible investigation involving CNA #1 and Resident #1.

Based on observation, record review, and interview, the facility failed to ensure standard infection control precautions were used during urinary catheter care for 1 (#9) of 1 sampled resident for urinary catheters. The DON reported 34 residents resided in the facility and two residents had urinary catheters. Findings: On 05/13/25 at 2:07 p.m., CNA #1 was observed to empty Resident #9's urinary catheter bag. CNA #1 removed the catheter bag from the dignity cover to empty the catheter bag into the urinal. CNA #1 layed the catheter bag on the floor while attempting to drain all the urine from the catheter tubing and bag into the urinal. CNA #1 set the urinal on the floor and placed the catheter bag back into the dignity cover. CNA #1 picked up the urinal and placed it on Resident #9's small dresser, near some open chocolate candy. A policy titled Emptying a Urinary Drainage Bag, dated 10/01/10, showed to keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. A physician's order, dated 09/30/24, showed to flush suprapubic catheter with 60 milliliters of normal saline and provide catheter care two times a day. An annual assessment, dated 02/05/25, showed Resident #9's cognition was intact with a brief interview of mental status score of 15. The assessment showed diagnoses which included muscular dystrophy and neurogenic bladder, and the use of a urinary catheter. On 05/13/25 at 2:07 p.m., CNA #1 was asked if they should have done anything differently while emptying the urinary catheter bag. CNA #1 reported they should not have lifted the face shield to see better while emptying the catheter bag. On 05/14/25 at 11:10 a.m., the DON reported the catheter bag should not have been layed on the floor and staff needed to be in-serviced again on infection control techniques.

Based on record review and interview the facility failed to complete a thorough abuse investigation for one (#1) of three residents reviewed for abuse. The Administrator reported 40 residents resided in the facility. Findings: The facility's Abuse policy and procedure, dated 07/23/21, read in part, Time for completing investigation: The Administrator or Administrative Designee will complete the investigation report within five working days .The ODH 283 form, shall be faxed to the Oklahoma State Department of Health within five working days of the submission of the Incident and Accident Report . The Administrator or Administrative Designee will conduct an investigation of alleged or actual incidents of abuse, neglect, or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the resident was mistreated to whom, and the measures needed to product occupants from further incidents. If the person is able to communicate, the Administrator or Administrative designee shall document, in sufficient detail, the resident's account of the incident, including a description of the perpetrator . Interviews: Identification and investigation of abuse, neglect, or misappropriation of property should include interviews with those persons the investigator determines are related to allegation or incident Resident #1 had diagnoses which included aphasia, hemiplegia, anxiety, and chronic pain. A nurse's note, dated 06/29/24, documented At approximately 6:30 p.m., after the evening meal, resident #1 was noted by CMA [name removed] acting weird and had a strange look to face and eyes .The dietary aide on duty at the time voiced to CMA that they had given the resident a 100 mg marijuana chewy .Incident reported to on coming nurse and nurse to observe resident .Reported to doctor [name removed] . There was no documentation the facility completed a through investigation. A ODH-283 incident report form, dated 06/30/24, documented, Initial report. Incident date: 06/30/24. Incident type: Allegation of abuse/mistreatment. Description of incident: Employee [name removed] stated she had given resident #1 a 100 mg edible marijuana gummy .Resident was glassy eyed, stoic looking, and looked odd .The resident was assessed and monitored throughout the night and the next day. Part C: 5 day and final report investigation had not been completed. A comprehensive assessment, dated 07/15/24, documented resident #1 had severe cognitive impairment. On 07/18/24 at 11:35 a.m., LPN #1 reported resident #1's incident was not reported to the Administrator or DON until the next morning 06/30/24. On 07/18/24 at 12:00 p.m., the Administrator reported she was notified of resident #1's incident on 06/30/24 at 8:18 a.m. The Administrator reported a written statement from LPN#1 of the reported incident was the only statement available. The Administrator reported no other residents or staff had been interviewed related to this incident. The Administrator reported the incident had been reported to the local police and other required entities. The Administrator reported a 5 day follow up or final investigation report had not been completed since the employee had admitted to giving the resident an edible marijuana gummy and the employee had been terminated.

Based on record review and interview, the facility failed to report a physical abuse incident to the Oklahoma State Department of Health in the required timeframe for one (#1) of three residents reviewed for abuse. The Administrator reported 40 residents resided in the facility. Findings: The facility's Abuse policy and procedure, dated 07/23/21, read in part, Immediate reporting: All allegations of residents maltreatment, including neglect, physical abuse, mental abuse, sexual abuse, involuntary isolation, verbal abuse, injuries of unknown origin, and/or misappropriation of property, must be reported immediately to Administrator by a facility employee or immediate supervisor, who will report incidents to the allegation to the Oklahoma State Department of Health as required by State law or regulation . Time reporting or completing incident and accident reports: An Incident and Accident report form will be completed by the Administrator or Administrator Designee within 24 hours of the incident's discovery .If the incident is required to be reported to the State Department of Health Care, the ODH-283 shall be faxed within 24 hours . Time for completing investigation: The Administrator or Administrative Designee will complete the investigation report within five working days .The ODH 283 form, shall be faxed within five working days of the submission of the Incident and Accident Report . Resident #1 had diagnoses which included aphasia, hemiplegia, anxiety, and chronic pain. A nurse's note, dated 06/29/24, documented At approximately 6:30 p.m., after the evening meal, resident #1 was noted by CMA [name removed] acting weird and had a strange look to face and eyes .The dietary aide on duty at the time voiced to CMA that they had given the resident a 100 mg marijuana chewy .Incident reported to on coming nurse and nurse to observe resident .Reported to doctor [name removed] . A nurse's note, dated 06/30/24 at [no time documented], documented Administrator, DON, dietary supervisor, and weekend RN [name removed] aware of resident #1's incident. A Employee Disciplinary Action form, dated 06/30/24, read in part: Employee Name: [name removed]. Department: Dietary. Date of Occurrence: 06/29/24. Date of Counseling: 06/30/24. Type of Action: Termination. Description of Occurrence: Administering a 100 mg edible to resident #1. Then told the CMA what you had done .CMA [name removed] stated he had already administered the resident's evening meds . An ODH-283 incident report form, dated 06/30/24, documented: Initial report. Incident date: 06/30/24. Incident type: Allegation of abuse/mistreatment. Description of incident: Employee [name removed] stated she had given resident #1 a 100 mg edible marijuana gummy .Resident was glassy eyed, stoic looking, and looked odd .The resident was assessed and monitored throughout the night and the next day. Part C: 5 day and final report had not been completed. The fax cover sheet attached to the incident report documented, the fax transmission was completed at 07/01/24 at 3:14 p.m. A comprehensive assessment, dated 07/15/24, documented resident #1's had severe cognitive impairment. On 07/18/24 at 11:35 a.m., LPN #1 reported resident #1's incident was not reported to the Administrator or DON until the next morning, 06/30/24. On 07/18/24 at 12:00 p.m., the Administrator reported she was notified of resident #1's incident on 06/30/24 at 8:18 a.m. The Administrator reported the incident date on the ODH 283 incident report should have been dated 06/29/24. The administrator reported she had received guidance from the cooperate office and sent the incident report to the Oklahoma State Department of Health on 07/01/24. The Administrator reported she did not do a 5 day follow up or final report since the employee had admitted to giving resident #1 the edible marijuana gummy and the employee had been terminated. The Administrator reported the abuse allegation should have been immediately reported to her, and the initial incident report should have been faxed to the Oklahoma State Department of Health within 24 hours of when the incident occurred.

Based on record review and interview, the facility failed to follow their policy to maintain an effective pest control program for one (#3) of three residents reviewed for pest control management. The DON identified the resident census was 38. A Bed Bugs, Preventing and Managing Infestations of policy, revised August 2011, read in parts, .Staff will employ infection control strategies to prevent and manage infestation of bed bugs .Remove and/or treat all infested materials .washing and drying bedding, linens, and clothing at high temperature .vacuuming or steam-cleaning floors, mattresses and any porous surfaces that cannot be machine washed .The following should be documented at the facility level .Identified instances of infestation .Response to the report of infestation .Actions taken including all interventions and strategies to eliminate the infestation .The following should be documented at the resident-level for those directly affected by the infestation .Resident response to the infestation .Interventions and treatment .If complications ensue (bites .) accident/incident reports must be completed . Resident #3 had diagnoses which included, chronic obstructive pulmonary disease, profound intellectual disability and chronic kidney disease. An outside pest control invoice, dated 10/16/23, read in parts, .Bedlam Plus 1.45% .2 found in 138 16 . A Weekly Skin Audit Record, dated 11/01/23, documented by a body diagram with circles the resident had a rash on the back of all four extremities. On 11/16/23 at 10:01 a.m., Maintenance #1 stated they had some bed bugs but not anything recently. They were asked if they did checks after pest control services treated the rooms to ensure there were no more concerns. They stated they were in an out of the residents rooms but did not do specific monitoring. On 11/16/23 at 10:41 a.m., the Administrator was asked what did two found in 138 and 16 mean they stated they did not know. They were asked what had the facility done to follow up to ensure the issue was resolved. They stated pest control had come on 11/03/23. They were asked for the invoice of services. They stated they did not have one. On 11/16/23 at 11:55 a.m., the ADON was asked if there had been any issues with bedbugs in Resident #3's room. They stated there had been. They were asked if they had assessed the resident for any bites. The ADON stated the resident had a rash, but they had not documented what interventions had been implemented. Resident #3's clinical health record did not contain documentation of the room cleaning, assessment, and interventions completed by the facility when staff had notified administration of a suspicion of bed bugs in the resident's room. On 11/16/23 at 1:06 p.m., an invoice for pest control services on 11/03/23 was requested from the Administrator. On 11/16/23 at 1:09 p.m., Resident #3 was observed in their room. They were asked is there had been any issues with bed bugs recently. Resident #3 stated, the first of the month they had some bug bites on their right arm. They were asked how long that had been going on. They stated it started Way back. On 11/16/23 at 1:20 p.m., the Administrator was shown the facility pest management policy and asked if the policy had been followed. They stated No. The Administrator stated they were unaware there was a bed bug policy until today. On 11/16/23 at 2:30 p.m., the DON was asked if they had followed the policy and procedure for pest management. They stated they had not followed the policy. The DON was asked if there had been any other bed bugs found in Resident #3's room after the pest control management had come out on 11/03/23. They stated they were not sure. The Administrator did not provide an invoice from the pest control services on 11/03/23 prior to the end of the investigation.

Based on record review and interview, the facility failed to electronically transmit resident assessments, within 14 days after completion, for six (#1, 5, 18, 19, 22, and #31) of six residents sampled for resident assessments. The Resident Census and Conditions of Residents, dated 01/10/23, documented 36 residents resided in the facility. Findings: A facility policy, Electronic Transmission of the MDS, revised March 2006, documented in part .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. On 01/10/23 at 4:02 p.m., the Minimum Data Set (MDS) regional coordinator provided a Final Validation Report, which documented the status of the electronic transmission of resident assessments. The Final Validation Report documented the assessment for Resident (Res) #1 was accepted, with a target date of 09/01/22. The report showed a submission date of 09/26/22, and documented, record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #5 was accepted, with a target date of 09/01/22. The report showed a submission date of 09/26/22, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #18 was accepted, with a target date of 09/01/22. The report showed a submission date of 09/26/22, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #19 was accepted, with a target date of 09/02/22. The report showed a submission date of 09/26/22, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #22 was accepted, with a target date of 11/21/22. The report showed a submission date of 01/10/23, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #31 was accepted, with a target date of 08/29/22. The report showed a submission date of 09/26/22, and documented record submitted late: the submission date is more than 14 days. On 01/10/23 at 4:02 p.m., the Minimum Data Set (MDS) regional coordinator reported the records were submitted late. She reported the facility MDS coordinator was having health issues and was not able to keep up with the required schedule.

Based on record review and interview, it was determined the facility failed to ensure: a. medication hold parameters for blood pressure medications were included on a resident's physician orders/medication administration record for one (#6) of five residents reviewed, and; b. insomnia medication was not given for an extended duration after being discontinued for one (#6) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents, dated 01/10/23, documented 36 residents resided in the facility. Findings: The facility's Consultant Pharmacist Reports policy, dated 01/01/18, read in parts, .The consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards .Recommendations are acted upon and documented by the facility staff and/or the prescriber .Prescriber accepts and acts upon suggestions or rejects and provides an explanation for disagreeing .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician interventions, e.g., monitor blood pressure . The facility's Medication Orders policy, dated 01/01/18, read in part, .The discontinue order is also entered on the physician orders sheet and noted on the medication administration record . Resident # 6 had diagnoses which included coronary artery disease, hypertension, anxiety, depression, and insomnia. A Physician Telephone Order, dated 11/01/22, documented Diltiazem HCL 1 tablet daily, hold if systolic blood pressure is less than 100 or diastolic blood pressure less than 50. A hospice Physician Order, dated 11/08/22, documented to discontinue Melatonin 10 mg at bedtime and start Trazadone 50 mg at bedtime. The resident's Physician Orders for the month of December 2022, documented .Pacerone (Amiodarone HCL) 200 mg tablet everyday .Diltiazem 24 HR ER (Diltiazem HCL) 300 mg cap everyday .Melatonin 10 mg tablet at bedtime for insomnia. The pharmacist's Note to Attending Physician/Prescriber, dated 11/23/22, read in parts, .Do you wish to add a HOLD parameter for Amiodarone based on heart rate? .The doctor agreed on 11/28/22 to hold for heart rate less than 60 beats per minute .Notify physician/clinician if held for 3 sequential doses. The resident's Care Plan, updated 12/29/22, documented in parts .Give me my medication as per orders .see MAR for my frequency and dosage . The resident's January 2023 Medication Administration Record documented, Diltiazem 24HR ER (Diltiazem HCL) 300 mg cap daily .Melatonin 10 mg tablet at bedtime for insomnia .Pacerone (Amiodarone HCL) 200 mg tablet daily, Trazadone 50 mg at bedtime . On 01/11/23 at 3:59 p.m., the DON reported the resident's medical record had been reviewed. The DON reported the heart rate hold parameter for Pacerone (Amiodarone HCL) and the blood pressure hold parameters for Diltiazem HCL should have been added to the resident's physician orders and MAR. The DON reported the order to discontinue Melatonin should have been removed from the resident's physician orders and MAR. The DON reported the resident's MAR and physician's orders had been corrected and a new policy put in place to prevent errors in the future.

On 01/24/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement infection control measures to prevent the spread of COVID, to use appropriate personal protective equipment (PPE), and to keep COVID-positive residents isolated from the non-positive residents in the facility. On 01/24/22 at 12:00 p.m., during the initial tour of the facility, isolation precaution signs were observed to be posted on the doors for eight residents. Containers with PPE supplies were observed at each door. The doors to the isolation rooms were noted to be open to the halls and common areas. Staff was observed entering the isolation rooms and exiting the rooms without donning and doffing PPE. Staff members were observed to enter isolation rooms wearing only regular surgical masks. Staff was observed to exit isolation rooms and enter non-isolation rooms without performing hand hygiene. At 12:20 p.m., a resident was observed by the nurse station without a mask. The resident was observed to be assisted back to his room by staff, where his door was open and an isolation sign was in place. The nurse was observed to wear only a regular surgical mask. The nurse reported the resident was COVID-positive. At 12:25 p.m., the same resident was observed at a different nurse station on the other side of the building. The resident was observed with a cloth mask covering only his mouth. Four staff members, known to be COVID-positive, were working and wearing only regular surgical masks. The director of nursing (DON) was also wearing only a regular surgical mask. The DON reported a shipment of N95 masks had arrived at the facility on 01/21/22 but none of the staff had been fit-tested and the masks had not been distributed to staff for use. The DON reported the facility had KN95 masks available but no staff members were observed to be wearing the KN95 masks. On 01/24/22, the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 5:03 p.m., the DON was notified of the IJ situation. On 01/26/22 at 8:25 a.m., a corrected, acceptable plan of removal was provided. The plan of removal documented: Infection Control Plan of Removal F880 Corrective Action: * On, 01/24/22 at 1:30 p.m., N95 mask were given to all staff members working in facility at that time. Inservice provided to DON on P&P to prevent the spread of Covid. * Resident doors were closed per P&P to prevent further spread of disease. * On 1/24/22 immediate Inservice provided to staff currently working on proper PPE, face mask usage and the TBP to prevent spread of Covid. To be completed to all staff by 1/25/22 6:00 p.m. * At 7:30 p.m. KN95 mask arrived at facility. DON/designee distributed to Covid positive resident's isolation station, visitor/employee screening station, posted proper PPE identification, ensured all resident's on isolation rooms doors are remaining shut. Completed 1/25/22 at 4:00 p.m. * Fit testing for Direct care staff started at 11:00 a.m. on 1/25/22 to be completed by: 1/25/22 5:30 p.m. * On 1/25/22 Covid Positive residents relocated to Covid positive hall. Moves completed at 4:00 p.m. * 01/25/22 Crisis staffing strategy was removed and current positive employees were sent home with guidance to return based on the CDC recommendations for Health Care workers. Completed at 4:00 p.m. * DON/designee to conduct satisfaction rounds to ensure P&P is being followed to prevent further spread of Covid 19. Rounds to be conduced at the following intervals: * Randomly throughout the day and/or random shift checks daily X's 7 days and weekly X3 weeks. Compliance 2/21/22 * Weekly monitoring of proper PPE and availability to staff. Compliance 2/21/22 * Weekly checks of covid testing logs to ensure compliance with P&P for return to work for healthcare workers per CDC guidance is maintained. Compliance 2/21/22 On 01/26/22, interviews were conducted with facility staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. Staff reported in-services were provided and completed by 01/25/22 at 6:00 p.m. Staff members were able to verbalize understanding of the information provided in the in-service training pertaining to the plan of removal. On 01/26/22, the IJ immediacy was removed, effective 01/25/22 at 6:00 p.m., when all components of the plan of removal had been completed. The deficiency remained at a level of widespread with the potential for more than minimal harm. Based on observation, interview, and record review, the facility failed to ensure COVID-positive residents were appropriately isolated, residents and staff were safe from infectious disease, failed to provide appropriate PPE, and failed to follow CDC guidelines for work restrictions for infection prevention and control measures to mitigate the spread of COVID. The Administrator reported 33 residents resided in the facility. Findings: A facility policy, Emergency Procedure - Pandemic Covid-19 ([CONDITION(S)]-CoV-2) read in parts .The following procedure should be utilized in the event of a Pandemic Covid-19 outbreak .Employees shall follow the guidelines implemented by the CDC .Employees will be provided with the essential PPE necessary for protection purposes .Adherence to infection prevention and control policies and procedure is critical .Adherence to droplet precautions during the care of a resident with symptoms or a confirmed case of pandemic Covid-19 is a must .Donning and doffing procedures will be adhered to .Cohort residents who have been exposed and put into place the necessary precaution signs, isolation equipment and quarantine the resident with the door closed .Residents under no circumstance can leave their room .For those residents who have been exposed, there will only be certain dedicated employees assisting such residents therefore, minimizing any exposures facility wide .Closing units where symptomatic and asymptomatic residents reside, i.e., restricting all residents to an affected unit, regardless of symptoms. A facility policy, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (Covid-19) read in part .PPE Utilization and Optimization .Staff to wear full PPE when working with individuals with known or suspected COVID-19. Incident reports provided to the State Agency, reporting COVID positive staff and residents, were reviewed for 01/11/22 through 01/21/22. The reports documented isolation and/or quarantine of staff and residents per the corporate protocol/policy. On 01/24/22 at 12:00 p.m., upon entrance to the facility, a sign was observed to be posted on the front door, Covid Outbreak. A staff member was observed to screen staff, vendors, and visitors as they entered the building. The screening included a questionnaire, temperature check, and provision of a regular surgical mask. During the initial tour, staff members were observed on all halls and departments to wear regular surgical masks. During the initial tour, isolation signs were observed on the doors of eight resident rooms. PPE containers and PPE signage was observed by each door. The doors to the isolation rooms were open to the halls and common areas. The door to one isolation room was observed to not close properly when staff tried to close it. At 12:20 p.m., Resident (Res) #19 was observed sitting by the nurse's station without any mask on and was reported by CMA #1 to be COVID-positive. CMA #1 was observed assisting the resident to his isolation room, the door was open, she entered without donning proper PPE, and not following appropriate hand washing protocols. Other staff members were observed going in and out of isolation rooms without donning PPE. Staff was observed to enter and exit isolation rooms without performing hand hygiene and then observed to enter non-isolation rooms. At 12:30 p.m., CMA #1 stated, We haven't worn N95 masks for a long time and haven't had any N95 masks since our first outbreak. At 12:35 p.m. Res #19 (known to be COVID positive) was observed in the hall on the other side of the facility wearing a cloth mask which covered only his mouth. At 1:35 p.m., the DON reported no designated staff had been assigned to COVID positive residents. Through interviews by surveyors during the initial tour, it was discovered four COVID-positive staff were on duty. The staff members were co-mingling with positive residents, non-positive residents, and other staff wearing only surgical masks. At 1:45 p.m., the DON provided result logs for COVID testing which documented the facility's COVID outbreak began on 01/11/22, with a total of 28 residents testing positive between 01/11/22 and 01/21/22. The DON reported 11 residents were currently still in isolation, three on the COVID hall and eight isolating in their individual rooms. The logs documented a total of 26 staff tested positive between 01/11/22 and 01/24/22. At 2:30 p.m., the ADON reported one resident, who tested positive for Covid, was sent to the hospital (per the families request) to receive more fluids. She reported he was still in the hospital. The ADON reported a resident who was on Hospice, passed away after testing positive for Covid. The DON reported the facility had received a shipment of N95 masks on 01/21/22, however, they were not given to staff because they had not been fit-tested . The DON reported they did have some KN95 masks in the facility but none of the staff were observed to be wearing the KN95 masks. On 01/25/22 the first plan of removal was rejected. A COVID-positive resident was observed walking in the hallway. The DON was informed of this and stated, I thought this was only about the staff, not the residents. On 01/26/22, a corporate consultant resubmitted the plan of removal and reported the DON had been sent home, along with all of the COVID-positive staff. The DON was reportedly COVID-positive and had not informed surveyors of her positive status.

Based on observations, interviews, and record reviews, it was determined the facility failed to: ~ implement infection prevention and control practices to prevent the potential development and transmission of COVID-19; ~ ensure appropriate transmission based precautions were implemented and all required PPE (personal protective equipment) was donned for close contact of a resident with unknown COVID-19 status for one (#1) of one sampled resident who had admitted to the facility in the last 14 days; The DON (director of nurses) identified one resident who had admitted to the facility in the last 14 days. ~ ensure residents were provided and encouraged to use face masks when out of their rooms; and ~ ensure staff wore face masks in an appropriate manner, covering their mouth and nose, for three (administrator, DON and LPN #1 (licensed practical nurse)) of ten staff members observed for appropriate mask use; The administrator identified 31 residents who resided in the facility. Findings: A CDC (Centers for Disease Control and Prevention) website article, updated 05/19/20, documented: .HCP (health care personnel) should wear a facemask at all times while they are in the facility . Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility . A CDC website article, updated 06/22/20, titled, Preparing for COVID-19 in Nursing Homes, documented: .Reinforce adherence to standard infection prevention and control measures including hand hygiene .Make necessary PPE available in areas where resident care is provided .Consider designating staff responsible for stewarding those supplies and monitoring and providing just-in-time feedback promoting appropriate use by staff .Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles) . Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown .HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . On 07/15/20, the following observations and interviews were obtained. At 9:28 a.m., the DON and LPN #1 were observed at the nurse's station on the west hall. Both staff members had their surgical masks covering only their chins. The DON promptly escorted the surveyor to the administrator's office which was located next to the lobby area. The administrator was observed in her office without a mask on. There were five residents observed in the lobby area without masks on. At 9:42 a.m., resident #1 and another unidentified resident were observed ambulating the halls without masks on. There were no staff observed to provide the resident's with masks or redirect resident #1 to her room. The DON was observed in the administrator's office with her mask covering only her chin. At 9:55 a.m., three staff members were observed to place a mask on resident #1. CNA #1 (certified nurse aide) and LPN #1 and another unidentified staff member were observed to assist the resident back to her room. They used ungloved hands to touch the resident's arms, hands, and clothing. They walked with the resident up close to their sides. The staff members were only observed wearing surgical face masks. At 10:05 a.m., a resident was observed seated in his wheelchair outside of the whirlpool room. He was not wearing a mask. At 10:08 a.m., CNA #1 was observed exiting resident #1's room. She stated she had been in the resident's room holding her hand and arm and helping her ambulate around in her room. She stated the resident was not on any transmission based precautions that she knew of. She said, We don't need a gown or gloves to care for her. At 10:11 a.m., LPN #1 stated resident #1 admitted to the facility on [DATE]. She was asked if the resident was on any type of transmission based precautions. She stated the resident had a negative COVID test when she left the hospital. She was asked what PPE was required to care for the resident. She stated they always wore a mask and gloves if they were providing personal care. She stated they never had to wear a gown to care for the resident. She was then asked how should masks be worn by staff to ensure they prevent the potential for transmission of COVID. She stated masks should cover the mouth and nose. She stated it was not acceptable to wear a mask covering only your chin. At 10:20 a.m., one resident was observed asleep on a couch in the lobby area without a mask. Another resident was observed working on a puzzle in the lobby area without a mask. A third resident was observed in a geri-chair asleep without a face mask. At 10:42 a.m., a meeting was held with the administrator, DON, and the MDS (minimum data set) staff member. The administrative staff members reported they believed residents were not required to wear masks and they believed this was optional. They stated some residents were provided masks if they wanted one. They stated staff members should wear their masks covering their nose and mouths. They were notified of the observations. They were asked if residents who were newly admitted to the facility within the last 14 days required quarantine and droplet precautions. They stated they did require both. They acknowledged resident #1 was a newly admitted resident. They stated she liked to wander out of her room often and staff had to redirect her. They were notified she was observed outside of her room for several minutes and without a face mask. They were notified staff were observed to walk by the resident and not redirect her promptly. They acknowledged the concerns. They were asked what PPE was required for close contact with these residents. They stated staff should wear a mask and gloves if they were treating a wound or emptying a urinary catheter. They stated gowns should also be worn if there was bowel movement every where to clean up. They were asked if eye protection should be worn for close personal care. They stated yes. They were notified staff were required to wear gowns, gloves, masks, and eye protection if they were providing close personal care including transferring a resident from bed to chair, assisting a resident to dress, and during the provision of incontinent care. They were notified several staff members were observed touching the resident with out required PPE, including gloves, while assisting her to ambulate to her room and in her room. They were notified the staff assigned to care for the resident did not know the resident was on any type of transmission based precautions. They acknowledged the concerns.

On 05/21/19 an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide adequate supervision and implement new interventions for a resident with a history of falls. The facility failed to reassess the resident's fall risk, investigate to determine the root cause and implement interventions to aide in the prevention of further falls. As a result, the resident sustained [REDACTED]. At 10:12 a.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation. At 10:20 a.m., the administrator, director of nursing (DON), and assistant director of nursing (ADON) were informed an IJ situation existed due to the facility's failure to provide supervision and interventions to prevent falls which lead to injuries. At 1:24 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Immediate Jeopardy was cited on Hensley Nursing Home at 11:00 am on 5-21-2019. The following is the corrective action the facility took. Identified eight residents out of 38 residents who are at an extremely high risk for falls. 1. A fall risk assessment will be conducted on eight residents who are at high risk for falls. 2. Rooms will be free from clutter, call light will be in reach. Ensure proper footwear, monitor every hour. 3. Interventions will be care planned and documented in the residents' chart. 4. Interventions will be established on an individual basis, and will include but not limited to redirection, offer snacks, and drinks, give them small task to perform, encourage them to attend activities, and group functions, spend one on one time with them, offer toileting, check on them frequently, review medications. Physical therapy will evaluate residents to see if they could benefit from therapy. 5. A root cause analysis will be conducted. An intervention will be established. 6. All nursing staff will be in serviced and educated on all new interventions established today and the facility will be in compliance by 5 pm on 05-21-2019. 7. No nursing staff will be allowed to work until they are properly in serviced and educated on the new interventions established to help decrease falls in this facility. Interviews were conducted with facility staff on 05/22/19. After the last staff member was interviewed and was able to verbalize knowledge of the plan of removal and review of all falls risk assessments, the IJ was removed as of 05/21/19 at 3:20 p.m. The deficient practice remained at a level of harm at a pattern. Based on observation, record review and staff interviews, it was determined the facility failed to reassess the resident's fall risk, investigate to determine the root cause and implement interventions to aide in the prevention of further falls for one (#34) three sampled residents who had experienced falls in the facility. The facility identified 8 residents who were at high risk for falls. Findings: Resident #34 had [DIAGNOSES REDACTED]. An initial admission activities of daily living skills (ADL's) plan of care, dated 03/15/18, documented the resident was a risk for falls. Interventions documented for the call light to be in reach, remind the resident to use the call light when assistance was needed and to check on her frequently. The care plan also documented the resident had impaired decision making was confused at times. The residnet was able to ambulate using a walker with supervision. A significant change assessment, dated 05/30/18, documented the resident's cognition was severely impaired, required supervision for ambulation, limited assistance with toilet use and was occasionally incontinent of her bladder and always continent of her bowels. The assessment documented the resident received an antipsychotic and an antidepressant for seven of seven days in the look back period. The resident had two or more falls with minor injury since last assessment. An incident report, dated 08/22/18 at 5:15 p.m., documented the resident had a fall and referred to the nurses note of the same date. A mobile x-ray was ordered and results documented no fractures were sustained. The nurse also noted the resident had dementia with behavioral disturbances, depression and gout. The nurse's note documented the resident was lying in supine position on the floor in the lobby. The resident reported she was ambulating with her walker and just fell down onto her knees and hit her chin on the floor and then onto her elbow. The resident had a bruise to her left posterior hand near the carpal area which measured approximately 3 x 3.5 oblong area, a reddened area to the chin with notable swelling and a 1 centimeter (cm) skin tear to the right elbow. The resident also had an approximate 2.5 x 3 cm irregular shaped bruise to the right elbow near the skin tear, 2 x 3 reddened area to her left elbow, 3 cm bruise to both knees and a 2 x 4 cm reddened area to the left side of the head near her left ear and eye. The resident reported pain to her knees. The care plan, updated on 08/22/18, documented the resident was encouraged to allow staff to assist her with ambulation. (This is the same intervention implemented at the time of admission.) A incident report, dated 10/26/18 at 10:30 p.m., documented the resident had a fell on her way to the bathroom and complained of her right elbow hurting. The right elbow was tender to touch and the resident rated the pain at a level of four on a scale of 1-10. The incident report further documented an x-ray had been ordered by the physician and the resident had a suspected distal femoral fracture junction of shaft. The resident was sent to the hospital for treatment of [REDACTED]. The fall care plan, updated on 10/26/18, documented the bathroom light to be kept on by resident request, floor free of clutter and the resident was to be assisted by staff. A nurse's note, dated 10/26/18 at 11:00 p.m., documented the resident received 500 milligrams (mg) of Tylenol for the elbow pain. A nurse's note, dated 10/27/18 at 3:30 a.m., documented the resident was up to the restroom and complained of right elbow and right leg pain. The resident was administered 500 mg of Tylenol. The resident ambulated slowly and continued to complain of pain at a level of four. A nurse's note, dated 10/27/18 at 6:00 a.m., documented the physician had been notified of the resident's complaints of pain and an x-ray was ordered. A nurse's note, dated 10/27/18 at 9:15 a.m., documented the mobile x-ray company was in the facility and obtained the x-rays. A nurse's note, dated 10/27/18 at 9:30 a.m., documented after moving around for X-rays, the resident screamed out in pain from at a level of 9 on a scale of 1-10. The pain site was identified as the right elbow. The physician was notified of the severe pain and a new order for [MEDICATION NAME] 5/325 mg by mouth once every four hours as needed. The first documented dose was provided at 1:00 p.m. on 10/27/18. The x-ray results, dated 10/27/18, documented the resident had a suspected distal femoral fracture of shaft and condylar/supracondylar junction. All other studies were negative for any fractures. The final impression was a mildly displaced acute fractures at the left superior and inferior pubic rami. A discharge return anticipated assessment, dated 10/27/18, documented the resident's cognition was moderately impaired, supervision was required for ambulation, extensive assistance with toileting and had one fall with minor injury since the last assessment. The assessment further documented no mobility devices that were used, received an antipsychotic and an antidepressant for seven of seven days in the look back period. A hospital report, dated 10/28/18, documented the resident had been admitted to the hospital due to a pelvic fracture and right elbow pain on 10/27/18. The report documented the resident had been admitted to the nursing home in (MONTH) and since that time had approximately three falls with a history of bilateral wrist fracture and surgery on the right wrist, left elbow and right ankle. The resident had sustained a fall yesterday on her right side with her right hip being painful. The x-ray image showed a pubic ramus fracture and she had uncontrolled pain, therefore she was admitted for pain management and physical therapy. A consultation report, dated 10/28/18, documented the resident had an x-ray that showed a radial neck [MEDICAL CONDITION] elbow. A significant change assessment, dated 11/07/18, documented the resident's cognition was severely impaired and had no falls since the prior assessment. A nurse's note, dated 11/17/18 at 2:45 a.m., documented the nurse heard a noise related to resident yelling out for help. The resident complained of right knee pain and had a 0.5 cm skin tear to the knee. The resident was assisted up onto the bedside commode to void and then peri care was provided. Steri strips were applied to the right knee. An attempt was made to place an ice pack on the knee, however the resident refused to keep in place. The pain was rated at a 10 out of 10 and pain medication was administered. The note further documented the physician would be notified in the morning per the physician's request of the incident. A nurse's note documented at 2:00 p.m., the x-ray results were received and faxed to the physician. A nurse's note documented at 2:40 p.m., the resident's pain was now a 6/10 and she was administered pain medication. A nurse's note documented at 4:00 p.m., an order was received to send the resident to the hospital for evaluation and treatment. The x-ray results, dated 11/17/18, documented an impression the resident had an acute comminuted [MEDICAL CONDITION]. An incident report, dated 11/17/18, documented the resident had a fall and was reminded to wait for assistance and not get up by herself. The resident voiced understanding. The resident was transferred to the hospital. The falls care plan, updated on 11/17/18, documented the resident was encouraged to call for help and to wait for staff to arrive and help resident with her needs. An incident report, dated 12/05/18 at 8:20 p.m., documented the resident had a fall in her room and complained of right arm pain. The resident's right arm had a previous fracture and was in a brace with an elastic bandage. The x-ray results documented they were unable to make an accurate [DIAGNOSES REDACTED]. The report documented the resident stated she was okay but has dementia. The care plan was updated with the intervention of an x-ray was to be completed on the right arm. An incident report, dated 01/12/19 at 9:30 p.m., documented the resident had a fall in her room while she was ambulating and lost her balance. The report documented she had scraped her left upper arm on the bed and sustained a skin tear 1 cm x 1 cm. The resident was encouraged to use her walker and allow staff to assist her with her activities of daily living skills. The resident stated Okay but has dementia and short term memory problems. The care plan documented the same intervention of Encouraged to wait for staff to assist. A quarterly assessment, dated 02/07/19, documented the resident's cognition was severely impaired, required extensive assist with transfers and toileting. The assessment documented she was occasionally incontinent of bladder and bowel, she used a used a walker or wheel chair for locomotion and had two falls with minor injuries since the last assessment. The assessment documented she received an antipsychotic, antidepressant, hypnotic and an antianxiety medication for seven of seven days in the look back period. An incident report, dated 02/26/19 at 4:45 a.m., documented the resident had a fall in her room and was found with her pants down and a large puddle of diarrhea under her bottom. The resident was encouraged to use the call light or tell someone she needed assistance. The resident stated okay, however she had short tem memory so staff will continue to remind her use her call light. A care plan, dated 02/26/19, documented the goals was to have the resident use her call light for assistance. The documented interventions was the resident was educated, and will continue to be educated on the placement of the call light to use and to call for assistance with transfers and other tasks. An incident report on 03/10/19 at 3:45 a.m., documented the resident had a fall and was sitting on the floor with her back against the bed. The resident was assisted up and found to have a 2 cm irregular shaped hematoma to the back of her head and a 3 cm irregular shaped hematoma below the 2 cm one. The resident did not know what happened and was assisted to the bathroom and back to bed. The resident was encouraged to allow staff to assist with her activities of daily living and ambulation. The resident had voiced understanding, but had short term memory problems. The care plan was updated on the same day with the intervention in which the resident will be encouraged to ask for help and use her call light for transfers and all tasks. An incident report, dated 03/22/19, documented the resident was found on her bottom in front of her bed. The resident was reaching for water on the bedside table and slipped off the bed. The resident was encouraged to use her call light and allow staff to assist her. The care plan, updated 03/22/19, documented, .Goal . (arrow down) falls, res (resident) will wait for staff to assist .intervention .res encouraged to call for help and wait for staff to assist /c (with) needs . An incident report, dated 04/19/19 at 9:00 p.m., documented staff witnessed the resident slide out of her recliner onto the floor. The resident was again encouraged to use the call light and allow staff to assist with transfers. The resident voiced understanding but was very confused at times and had short term memory problems. The care plan, updated 04/19/19, documented, .Goal (arrow down) falls, encouraged to wait for staff to assist .intervention .educate resident to ask for assistance will cont (continue) to encourage resident to ask for assistance /c task and transfers encouraged to use call light for assistance . A significant change assessment, dated 05/09/19, documented the resident's cognition was severely impaired, required extensive assistance with transfers, toilet use, personal hygiene and was frequently incontinent of her bladder and occasionally incontinent of her bowels, The assessment documented the resident used a wheel chair for locomotion, had two or more falls with injury and one fall with a minor injury. The assessment further documented the resident received an antipsychotic, antianxiety, antidepressant, hypnotic and an opiod for seven of seven days in the look back period. On 05/1919 at 5:14 p.m., the resident was observed attempting to stand by her self at the dining room table. The staff had to continually redirect her to sit down. At 6:45 p.m., licensed practical nurse (LPN) #4 stated the resident falls and reminding her to sit down was an all day, every day thing. She stated if she stood up she would fall. The resident then stood up and approached the LPN. The LPN had to redirect the resident to sit down several times. At 7:00 p.m., the resident's room was observed with a star on the outside of the door. LPN #1 stated the star indicated the resident was a fall risk. On 05/20/19 at 11:53 a.m., the director of nursing (DON) and assistant director of nursing (ADON) confirmed the resident had falls which resulted in a fracture to the pelvis. At 11:59 a.m., LPN #5 stated the resident had falls and she did not know all of the interventions that had been put in place. She stated she was not sure where to find the interventions and the ADON would have to be asked. The nurse confirmed the resident had sustained fractures during the falls. At 12:03 p.m., certified nurse aide (CNA) #3, an agency aide, stated she would have to check the book for the care plan or ask the nurse to know the interventions. She stated she had been to the facility about 10 times working and was not aware of the interventions for falls for the resident. At 12:05 p.m., LPN #6 stated the resident's intervention for falls was to orient the resident to use the call light several times. She then stated she does not remember to use the call light and ask staff for assistance.

Based on observation, record review and interview, it was determined the facility failed to ensure: ~ incontinent care was provided in a manner to prevent cross contamination for one (#24) of one sampled residents whose incontinent care was observed. The facility identified 25 residents who were occasionally or frequently incontinent of bladder and six who were occasionally or frequently incontinent of of bowel; ~ assistance with eating was provided in a sanitary manner for two (#24 and #27) of two residents observed for assistance with eating. The facility identified four residents who were totally dependent on staff for assistance with eating. Findings: 1. Resident #24 had [DIAGNOSES REDACTED]. An initial admission activities of daily living (ADL) care plan, dated 03/04/19 documented the resident was incontinent of bowel and bladder at times and wore briefs. The care plan also documented the resident required assistance of two staff for toileting. A significant change assessment, dated 04/23/19, documented the resident was frequently incontinent of bowl and bladder and required one person extensive assistance with toileting. On 05/19/19 at 6:48 p.m., certified medication aide (CMA) #1 and certified nurse aide (CNA) #2 was observed providing incontinent care to the resident. The CMA donned gloves and proceeded to remove the residents pants and briefs, CMA #1 stated the resident had a bowel movement. With the soiled gloved hands the CMA obtained the wipes and began to clean the buttocks. She wiped several times with the same wipe smearing feces down on the resident's leg. She repeated this process several times. While using the same gloved hands, the CMA placed a brief on the resident, repositioned the resident on her back and fastened the brief. The CMA then removed her soiled gloves and positioned a pillow under the resident's legs and covered her with a blanket. The CMA used the same soiled gloves throughout the care process. The CMA did not wash her hands until after the care had been completed. On 05/22/19 at 1:02 p.m., the director of nursing (DON) was informed of the above observation. She stated it was hard when you get new CNA's and you have to put them on the floor and their was no one to train them. 2. On 05/19/19 at 5:24 p.m., certified nursing assistant (CNA) #1 was observed as she assisted residents #24 and #27 with eating. The CNA was observed to pull the chair up to the table between the two residents with her gloved hands. With the same gloved hands she was observed to tear a piece of bread from the plate of resident #24 and gave it to the resident to eat. The CNA proceeded to give resident #27 two bites of food then assisted resident #24 with another bite. As she continued to assist the residents with the same gloved hands, CNA #1 was observed to touch the food of resident #24 as she scooped it onto the spoon She then touched the end of the straw as she removed it from the wrapper and assisted resident #27 with a drink. At 5:43 p.m., CNA #1 was asked if it was the facility's policy to wear gloves. She stated no. She was asked if she should touch the chair, table and then handle the resident's bread with the same gloved hands. She stated no and she was aware she had handled the bread. The CNA stated she had not been aware she had touched the food as she scooped it on the spoon or touched the straw as she opened and placed it in the cup. On 05/22/19 at 11:56 a.m., the assistant director of nursing was notified of the observations. She stated she would address infection control while assisting with eating with all the staff so they would be aware of proper technique to ensure assistance was provided in a sanitary manner.

Based on observation, record review and interview, it was determined the facility failed to ensure a resident received timely incontinent care for one (#24) of three sampled residents observed for incontinent care. Findings: Resident #24 had [DIAGNOSES REDACTED]. An initial admission activities of daily living (ADL) care plan, dated 03/04/19, documented the resident was incontinent of bowel and bladder at times and wore briefs. The care plan also documented the resident required assistance of two staff for toileting. A significant change assessment, dated 04/23/19, documented the resident was frequently incontinent of bowel and bladder and required one person extensive assistance with toileting. On 05/19/19 from 2:40 p.m. to 5:00 p.m., the resident was observed seated in a recliner in the living in front of the television. At 5:01 p.m. the resident was observed to be transferred to the dining room for the evening meal. No staff was observed at this time to provide any care or repositioning to the resident. At 5:53 p.m., the resident was brought back out to the living room. The resident began to yell momma over and over again. At 6:03 p.m., staff was observed asking the resident what was wrong and if she was cold. They did not check the resident and provide any care to the resident during this time. After staff left the resident, she began to continually moan and yell momma over and over until 6:31 p.m., when the director of nursing (DON) told certified nurse aide (CNA) #2 to take her to her room and lay her down. At 6:34 p.m., the resident was placed in her doorway while the CNA waited for a second CNA to assist with laying the resident down. There was an odor of urine permeating from the resident. At 6:48 p.m., certified medication aide (CMA) #1 came in the room and assisted the resident back to bed and then proceeded to provide incontinent care. The CMA stated the resident had a bowel movement as well. The resident was observed over four hours, from 2:40 p.m. through 6:48 p.m., without being provided any care. On 05/22/19 at 1:02 p.m., the director of nursing (DON) was informed of the observation. She stated it depended on how wet they were as to when they were provided care.

Based on observation, record review and interviews, it was determined the facility failed to ensure a resident's code status of Do Not Resuscitate (DNR) was accurately identified for one (#186) of nine sampled residents who were reviewed for advanced directives. The facility identified 19 residents with a DNR code status who resided in the facility. Findings: On 05/19/19 at 4:00 p.m., the DNR form was observed in the clinical record of resident #186. There was no sticker observed on the outside of the resident's chart to indicate the resident was a DNR. At 7:00 p.m. licensed practical nurse (LPN) #1 stated a yellow sticker on the chart indicated a resident was a DNR status. She did not indicate any other way to identify the code status. At 7:08 p.m., certified nurse aide (CNA) #1 stated resident #186 was a full code and not a DNR. At 7:09 p.m. LPN #2 stated resident #186 was a DNR because she was on hospice. She then stated they would look in the chart to find the resident's code status. At 7:10 p.m., CNA #2 stated they could find the code status located in the chart and/or on the resident's bed. At 7:12 p.m., LPN #2 returned and stated there was a sticker on the outside of the chart as well as a binder which listed every resident who had a DNR code status. At 7:13 p.m., the director of nursing (DON) stated the only way to know the code status was a sticker on the chart. She then turned to LPN #3, the assistant director of nursing (ADON) who stated stickers were to be placed outside the door also. At 7:27 p.m. LPN #3 confirmed the chart for resident #186 did not have a sticker on the outside of the binder. She then provided a list of 19 residents who currently had their code status as DNR.

Based on observation and interview it was determined the facility failed to ensure the kitchen was maintained in a sanitary manner as evidenced by dust/debris on surfaces and broken equipment. This had the potential to affect 32 of 32 residents who received food from the kitchen. Findings: On 04/05/18 at 08:30 AM a tour of the kitchen was conducted. 1. In the main kitchen: --There was a greasy substance on the outside of the light cover, inside the hood over the stove. A brown substance was on the bottom of the light cover. --A white dry substance was on the outside edge of the floor mixer. --Serving tongs were stored on a wire rack. A step ladder was leaned against the serving ends of the tongs. --Dry food debris was inside 1 ounce and 3/4 ounce serving scoops stored inside a drawer of the baker's rack. The handles of the scoops were sticky to touch. --There was a white dry powder substance on the lids of the flour and sugar containers. --A brown rusty colored substance was on the 5 ceiling air vents. --A greasy debris was on the 3 ceiling light fixtures. Grey duct tape was on the end of one of the fixtures. --Dust/debris was on 2 of the 4 sprinkler heads. 2. In the dry storage room: --Dry food debris was on the inside of the microwave and the inside surfaces were sticky to touch. --Dust/debris was on the compressor equipment over the microwave. --Regarding the chest freezer: the lid seal was worn/broken. The upper ledge had chipped/broken/missing pieces. There was an ice build-up along the sides and top edges. Numerous zip bags were unlabeled regarding their contents. 3. The metal ledge of the walk in cooler was broken and had missing pieces, There was dust/debris on the motor cage of the fan cooling system inside the cooler. 4. In the dishwasher room: --Dust/debris was on the return air vent, --Debris was on the inner ledge of the ice maker lid. There was dust/debris on the fan cover of the ice maker. --There was an ice build-up on the sides and upper ledge of the chest freezer. The front ledge was broken with a missing piece. At 9:30 A.M. the above findings were shown to the dietary manager (DM). She was asked who was responsible for cleaning the light fixture inside the vent hood. She stated dietary staff were to clean the light fixture. She was shown the items soiled with dust/debris and was asked who was to clean the items. She stated the dietary staff did the cleaning. She was asked how the staff would know what needed to be cleaned and when to clean the items. She stated, I tell them. The DM was asked if the facility had a cleaning schedule or check off list. She stated they were working on it. The DM was asked to identify the foods in the zip bags in the freezer. She stated she was not aware the foods were to be labeled when placed into a zip bag for storage in the freezer. The DM was asked to view the freezers and cooler with broken/missing fragments. She stated they were broken and needed to be fixed.

Based on observation, record review, and interview, it was determined the facility failed to ensure the plan of care was implemented for 1 (#29) of 14 sampled residents whose clinical records were reviewed for plan of care. The facility census was 32. Findings: Resident #29 had [DIAGNOSES REDACTED]. The admission assessment dated [DATE] documented the resident was cognitively intact in daily decision making. The assessment documented the resident was administered an anticoagulant medication 7 of 7 days prior to the assessment. The current physician's orders [REDACTED]. The medication administration record/treatment administration records (MAR/TAR) dated 03/2018 and 04/2018 contained no documentation to indicate bleeding or bruising had been monitored. The resident was observed throughout the survey. She was pleasant in conversation and able to make her needs known. There was no bruising or bleeding noted. On 04/09/18 at 1:45 PM, licensed practical nurse #1 was asked to review the physician's orders [REDACTED]. She stated, Yes. She was asked where the documentation would be for monitoring bleeding/bruising. She stated on the TAR. She was asked to review the TAR. After review, she was asked if bleeding/bruising was monitored as ordered by the physician. She stated, No.

Based on observation, record review, and interview, it was determined the facility failed to ensure signs/symptoms (s/s) of anxiety were monitored for 1 (#29) of 5 sampled residents whose clinical records were reviewed for unnecessary medications. This had the potential to affect 3 residents who received antianxiety medications as identified by the resident census and conditions of residents. Findings: Resident #29 had [DIAGNOSES REDACTED]. The admission assessment dated [DATE] documented the resident was cognitively intact in daily decision making. The assessment documented she had an active [DIAGNOSES REDACTED]. The care plan dated 03/27/18 documented the resident had anxiety. The care plan documented the following interventions: ~ administer [MEDICATION NAME] (an antianxiety medication) and document/report any adverse effects, ~ report s/s of anxiety - restlessness, difficulty concentrating, muscle tension, sleep difficulties, sudden periods of intense fear, pounding heart, sweating, trembling, shortness of breath, choking, feeling of impending doom, and panic attacks, ~ and, non-medical interventions were to include one-on-one, music, television, snacks, and group activities. The physician's orders [REDACTED]. Nurses' notes were reviewed. There was no documentation to indicate the resident had exhibited s/s of anxiety. The behavior monthly flow sheets dated 03/2018 and 04/2018 did not indicate specific behaviors to be monitored for anxiety. The resident was observed throughout the survey. She was pleasant in conversation and able to make her needs known. On 04/09/18 at 1:45 PM, licensed practical nurse #1 was asked what s/s of anxiety the resident exhibited. She stated the resident would get confused and want to go home. She was asked where the documentation would be found. She stated she documented it on the behavior sheet and made a note in the nurse's notes. She was asked to review the behavior sheets. After review, she was asked if specific behaviors to be monitored for anxiety had been identified/monitored. She stated, No.

Based on observations, record review and interview, it was determined the facility failed to maintain an effective Quality Assessment and Assurance (QA&A) program to identify, assess, implement and monitor corrective interventions to address problems and/or prevent further occurrences. The QA&A committee failed to identify system failures in the areas of accident hazards related to falls and the use of unnecessary medication. This deficient practice had the potential to affect all 37 residents who resided in the facility. Findings: 1. The facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls. Refer to F323 2. The facility failed to ensure residents were free of unnecessary medications. Refer to F329 On 02/02/17 at 12:19 p.m., the administrator and director of nursing (DON) were asked if the QA&A committee had identified any concerns related to accident hazards regarding falls. The DON stated, she monitored and tracked the falls every month. The administrator and DON were asked if the QA&A committee had identified any concerns related to the use of unnecessary medication. The DON stated no, medication issues were dealt with directly by the nursing department. The administrator stated, many issues were handled within the individual departments and not brought to the committee to have been reviewed and monitored.

Based on record review and interview, it was determined the facility failed to allow residents choices regarding bathing for two (#26 and #42) of three residents whose records were reviewed for choices. The facility identified 37 residents who resided in the facility: Findings: 1. Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/24/16, documented the resident was cognitively intact and required extensive assistance with transfers, dressing, toileting and hygiene. The resident required total assistance with bathing. On 01/30/17 at 2:07 p.m., the resident was asked if he chose how many times a week he took a shower or a bath. He stated he received a shower every Monday, Wednesday and Friday. He was not given the choice to receive a shower or a bath on the weekend. The clinical record was reviewed and contained no documentation of the resident's preferences regarding his bathing schedule. 2. Resident #42 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/26/16, documented the resident was cognitively intact and required supervision with dressing and hygiene. The resident required extensive assistance with bathing. On 01/30/17 at 1:22 p.m., the resident was asked if she chose how many times a week she took a shower or a bath. She stated she would like to have one every day. The clinical record was reviewed and contained no documentation of the resident's preferences regarding her bathing schedule. On 02/01/17 at 8:23 a.m., certified nursing assistant (CNA) #1 was asked how she knew the bathing schedule for each resident. She stated the schedule was documented in the shower book. She continued to explain the resident would be scheduled for showers on Monday, Wednesday and Friday or Tuesday, Thursday and Saturday. She was asked if a resident would receive an extra shower or bath if it were requested on an unscheduled day. She stated, yes. On 02/01/17 at 11:37 a.m., the social services director was asked if the clinical records for resident #26 and resident #42 contained their preferences regarding their bathing schedule. She stated, no. On 02/01/17 at 2:20 p.m., the director of nursing (DON) was asked if the residents preferences were considered when scheduling their shower days. She stated no, we have no documentation of the residents bathing preferences.

Based on record review and interviews, it was determined the facility failed to ensure ~ comprehensive care plans were fully developed for the use of psychoactive medications for two (#13 and #49) of five sampled residents whose care plans were reviewed for unnecessary medications, and ~ comprehensive care plans were fully developed for the use of an antiplatelet medication for one (#13) of five sampled residents whose care plans were reviewed for unnecessary medications. The facility's 'Resident Census and Conditions of Residents' report, dated 01/30/17, identified 27 residents who received an antipsychotic medication. The facility identified 6 residents who resided in the facility and received an antiplatelet medication. Findings: 1. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 01/16/17, documented the resident's cognition was moderately impaired and had no episodes of behaviors. The resident received an antidepressant medication seven of the seven days in the look back period. A care plan, dated 01/16/17, documented the resident was administered [MEDICATION NAME] for depression and the staff was to monitor for effectiveness and any adverse reactions. The care plan did not document the targeted behaviors or side effects to be monitored for the continued use of the antipsychotic medication. On 02/01/17 at 3:55 p.m., the assistant director of nursing (ADON) was asked if the monitored behaviors and side effects should be care planned for psychoactive medications. She stated, yes. She was asked if the care plan for resident #13 was fully developed to indicate the targeted behaviors and side effects for the use of the [MEDICATION NAME]. She stated, no. 2. Resident #49 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/06/17, documented the resident's cognition was severely impaired and had no episodes of [MEDICAL CONDITION] or behaviors. The resident received an antipsychotic medication and an antidepressant medication seven of the seven days in the look back period. A care plan, dated 01/06/17, documented the resident was administered [MEDICATION NAME] and the staff were to monitor, document and report behaviors. The care plan did not document the targeted behaviors or side effects to be monitored for the continued use of the antipsychotic medication. On 02/01/17 at 3:55 p.m., the ADON was asked if the monitored behaviors and side effects should be care planned for psychoactive medications. She stated, yes. She was asked if the care plan for resident #49 was fully developed to indicate the targeted behaviors and side effects for the use of the [MEDICATION NAME]. She stated, no. 3. Resident #13 was admitted to facility with [DIAGNOSES REDACTED]. An admission assessment, dated 01/16/17, documented the resident's cognition was moderately impaired and had no episodes of behaviors. The resident received an antidepressant medication seven of the seven days in the look back period. Physician orders, dated 01/2017, documented the resident was to be administered [MEDICATION NAME] every day related to long term use of [MEDICAL CONDITION]/antiplatelets. A care plan, dated 01/16/17, was reviewed from the resident's clinical record. The care plan did not address the use of an antiplatelet. On 02/01/17 at 3:55 p.m., the ADON was asked if the use of antiplatelets should be care planned. She stated, yes. She was asked if the care plan for resident #13 was fully developed to include the use and monitoring of side effects for the [MEDICATION NAME]. She stated, no.

On 11/16/15 at 11:55 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure hot water temperatures were maintained at a safe level in the shared men's bathroom. The facility identified one resident who was cognitively impaired and wandered the facility. The identified resident was ambulatory, able to independently open doors and turn on water faucets. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 12:04 p.m., the administrator and DON were informed of the IJ regarding the hot water temperature. At 2:10 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: Immediate Jeopardy was cited on (named facility) at 12:10 pm. On 11-16-15. The following is the corrective action the facility took. East restroom water temperature reported above compliance in east ends men's bathroom. 1. East ends (sic) men's restroom closed immediately and secured so no resident could enter restroom, and water temps/thermostat was adjusted to decrease temperature to under 120 degrees by 11/16/15 by 12:40 p.m. 2. All personnel currently on duty were informed of this corrective action by 11/16/15 at 12:11 p.m (sic) 3. Water temperatures will be monitored in east end men's bathroom every thirty minutes until temperature is in compliance of 120 degrees or below by 11/16/15 at 12:15 p.m. 4. All facility personnel on or off duty will be inserviced by five pm, including Dietary, CNAs, CMAs, RNs, LPNs, Activities. In addition, Maintenance and Housekeeping will be given additional in-service to ensure daily monitoring. The facility will be in compliance by 5 p.m. on 11/16/15. 5. An inservice will be performed, including safe water temperatures of 120 degrees or less. Water temperatures will be monitored on a daily basis by Housekeeping and Maintenance by 11/16/15. If water temperature is above 120 degrees, the Administrator will be notified. Bathrooms will be closed and secured. Thermostat will be adjusted to reach temperature under 120 degrees. Temperatures will be monitored every 30 minutes until desired temperature is reached. 6. All sinks (resident accessible) will be monitored for temperatures 120 degrees or above. If discovered above 120, Maintenance, Housekeeping and Administrator will be informed. If water temperature is above 120 degrees. Bathrooms will be closed and secured. Thermostat will be adjusted to reach temperature under 120 degrees. Temperatures will be monitored every 30 minutes until desired temperature is reached by 11/16/15 at 3:00 p.m. 7. No staff members will be allowed to work until they are properly inserviced about excessive water temperatures. The IJ was removed on 11/17/15 at 2:55 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with no actual harm with the potential for more than minimal harm. Based on observation, clinical record review and staff interview, it was determined the facility failed to maintain a safe hot water temperature in the east shared resident men's bathroom. The hot water temperature in the sink in the resident shared men's bathroom was measured between 130.5 to 134.6 degrees Fahrenheit. The facility identified one cognitively impaired resident (#7) who wandered the facility. Findings: Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 01/23/15, documented, .Focus .The resident has a behavior problem (verbally and physically aggressive) r/t dementia. Wanders into other residents' rooms and pilfers in their belongings at times . Interventions .Approach/Speak in a calm manner. Divert attention with activities she enjoys .when being re-directed from wandering/pilfering in other residents' rooms/belongings . Focus .The resident is an elopement risk/wanderer r/t dementia/confusion . Goal .The resident will not leave facility unattended through the review date . Interventions .Distract resident from wandering by offering pleasant diversions, simple activities, food, conversation, tv, music, doll . Focus .The resident has occasional bladder incontinence/dribbling. Unable to remember where her bathroom is and unable to ask for assistance due to severe dementia/Alzheimer's . Interventions .Staff to toilet resident q 1 hour while awake. Give peri-care when needed and change soiled clothes. Re-orient to her bathroom often . A quarterly assessment, dated 10/22/15, documented the resident was severely impaired in cognitive skills for daily decision making. She required supervision with ambulation. She required extensive assistance with dressing, hygiene and bathing. She wandered daily during the seven day look back period. On 11/16/15 at 10:11 a.m., water temperatures were taken from the resident shared men's bathroom on the east hall. There were three sinks in the men's bathroom. The water temperature in the middle sink measured 131.4 degrees Fahrenheit. At 10:49 a.m., the water temperature was rechecked in the resident shared men's bathroom on the east hall. The water temperature in the middle sink measured 130.5 degrees Fahrenheit. At 11:15 a.m., the surveyor's thermometer was recalibrated. At 11:34 a.m., the water temperature was rechecked in the resident shared men's bathroom on the east hall. The water temperature in the middle sink measured 134.6 degrees Fahrenheit. On 11/16/15 at 11:48 a.m., the ADON was asked if the facility had any resident's who wander. She stated, Yes we do. (named resident #7) wanders throughout the facility. She was then asked if the resident is able to open closed doors. She stated, I think she is able to, yes. At 11:51 a.m., the activities director was asked if the facility had any resident's who wander. She stated, Yes (named resident #7). Yes she wanders down the east end and west end. She was asked if the resident is able to open closed doors. She stated, She can open closed doors. She was then asked if she was able to turn on water faucets without assistance. She stated yes. At 11:51 a.m., LPN #3 stated, Yes, she can turn faucets on all by herself. She does all the time. At 11:53 a.m., CNA #1 was asked if any resident's in the facility wander. She stated, (named resident #7) is the only one that wanders. She likes to go everywhere. She was then asked if the resident is able to open closed doors without assistance. She stated, Oh yes, everyday. She opens resident rooms and peeks in. She will open the women's bathroom door. She was asked if the resident requires assistance with toileting. She stated, She likes to do most of it herself. She was then asked if the resident can turn the water faucets off and on in the shared bathrooms. She stated, Oh yeah. She can turn the water faucets off and on by herself. On 11/16/15 at 12:04 p.m., the DON was asked what could occur if a resident used a water faucet and the water temperature was too high. She stated resident's skin is very thin and they could get a burn easily.