Every finding on record at Heritage Hills Living & Rehabilitation Center

Based on record review and interview, the facility failed to convey funds to next of kin within 30 days of death for 3 (#8, 9, and #10) of 3 expired residents whose trust fund accounts were reviewed for conveyance of funds. The administrator identified 16 residents with funds in the facility. Findings: A facility policy titled Refunds, revised 04/2017, read in part, Within thirty (30) days of a resident's discharge or death, the facility will refund the resident's personal funds and provide a final accounting of those funds to the resident, the resident's representative or to the resident's estate, as applicable.Should a resident pay for services which then retroactively become Medicare/Medicaid eligible, the facility will promptly refund the amount charged to the resident for those services as soon as the facility receives the intermediary's payment. 1. A discharge assessment for Resident #8, dated [DATE], showed the resident expired in the facility on [DATE]. A handwritten ledger titled Ledger Sheet for Recipient's Account showed Resident #8 had a trust fund balance as follows:a. [DATE] - $300.04;b. [DATE] - $1831.14 (change denoted a deposit of $1531.00 and interest applied to the account);c. [DATE] - $1831.36 (change denoted interest applied to the account); d. [DATE] - $300.38 (change denoted refund to social security of $1531.00 and interest applied to the account); ande. [DATE] - $0.02 (change denoted a check made out to Heritage Hills for $300.36 on [DATE]). On [DATE] at 4:35 p.m., the administrator stated they were initially told by the owner of the facility that Resident #8 still owed the facility for services rendered but after careful review, they determined Resident #8 did not owe the facility and was due a refund of $300.38. The administrator stated they were not the administrator when the resident expired and did not know the disposition of funds from the trust account was part of their responsibilities. 2. A discharge assessment for Resident #9, dated [DATE], showed the resident expired in the facility on [DATE]. A handwritten ledger, titled Ledger Sheet for Recipient's Account showed Resident #9 had a trust fund balance as follows:a. [DATE] - $831.37;b. [DATE] - $2276.51 (change denoted receipt of social security funds and interest applied to account);c. [DATE] - $831.56 (change denoted refund to social security and interest applied to account);d. [DATE] - $831.66 (change denoted interest applied to account); ande. [DATE] - $831.81 (change denoted interest applied to account). On [DATE] at 4:35 p.m., the administrator stated they were not the administrator when the resident expired and did not know the disposition of funds from the trust account was part of their responsibilities. 3. A discharge assessment for Resident #10, dated [DATE], showed the resident expired in the facility on [DATE]. A handwritten ledger, titled Ledger Sheet for Recipient's Account showed Resident #10 had a trust fund balance as follows:a. [DATE] - $1559.24;b. [DATE] - $1613.31 (change denoted a $54.00 refund from the Heritage Hills);c. [DATE] - $1613.50 (change denoted interest applied to the account balance);d. [DATE] - $1613.87 (change denoted interest applied to the account balance); ande. [DATE] - $0.08 (change denoted a check made out to Heritage Hills for $1613.79 on [DATE]). On [DATE] at 4:35 p.m., the administrator stated they handled the monthly disposition of funds to each resident, but the facility owner kept the accounting books and determined what was owed by or due to the facility from each resident. The administrator stated they did not know why the owner wrote a check out to Heritage Hills for $1613.79 of Resident #10's funds six months after the resident expired.

Based on observation and interview, the facility failed to securely store protected health information. The DON identified 50 residents resided in the facility. Findings:On 10/22/25 at 11: 00 a.m., at the end of the East hall was an unsecured resident room with three 4-drawer tall file cabinets and one 5-drawer tall file cabinet. On top of one file cabinet were loose papers and files with residents' protected health information, including name, birthdate, social security numbers, insurance information, labs, and physician's progress notes. None of the file cabinet drawers were locked and two of the 4-drawer file cabinets held more resident clinical records. On 10/22/25 at 11:07 a.m., the DON observed the unsecured storage room and resident records. An undated and unnamed facility policy showed all resident records were to be behind locked doors at all times with keys kept in the administrator's office.On 10/22/25 at 11:07 a.m., the DON stated all resident records should be secured with a lock and with limited staff access.

Based on record review and interview, the facility failed to maintain an abuse free environment for 1 (Resident #1) of 4 sampled residents reviewed for allegations of abuse. The facility DON identified 50 residents resided in the facility. Findings:On 10/21/25 at 6:00 p.m., Resident #1 was observed in bed receiving oxygen via a nasal cannula. The resident was covered with blankets from their chin down. The resident appeared tired with dark circles under their eyes and congested with a hoarseness to their voice. On 10/22/25 at 11:20 a.m., Resident #1 was observed in bed receiving oxygen via a nasal cannula. The resident was covered with a blanket from their upper chest down. The resident spoke in a calm and animated voice without signs of fear or hesitation. Resident #1's incident statement, dated 10/02/25, read in part, [Resident #1] states was out smoking [and] did not realize [they] had BM on [their] way out to smoke. Nurse came out told [them] to come inside and clean up d/t [they] had soiled [themselves]. Resident states nurse grabbed chair, pushed forward, and [Resident #1] slid to [the] ground on [their] butt then nurse went inside, got a pitcher of water, and threw it on [Resident #1].Resident #5's incident statement, dated 10/02/25, read in part, [Resident #5] was outside smoking with [Resident #1]. Nurse came out telling [Resident #1] to come in and get cleaned up [and] resident said no. Nurse grabbed chair and the next thing [they] knew [Resident #1] was on ground. Nurse went in and came back out with a piture [sic] of water and threw it on [Resident #1]. A nurse's progress note, dated 10/02/25, read in part, Resident observed ambulating down hallway, incontinent of stool on floor, then proceeded outside during nonsmoking hours. Resident is a supervised smoker and refused to return indoors when directed by staff. While outside, resident became incontinent of urine, saturating clothing and ground. Resident stood, became incontinent of stool on concrete, stepped in the middle of stool, slipped on stool and wet surface, and fell onto edge of chair. This nurse grabbed chair to keep it from tipping over backwards, resident slid out of chair unto butt. No injuries observed upon assessment. Denies pain. Resident assisted to safe position, stool cleaned off concrete, resident assisted with mechanical lift to seated position. Resident able to stand with walker and ambulated with staff assistance to shower. Resident cleaned, fresh clothing provided, and comfort maintained. Safety precautions reinforced. PCP notified. EC notified. CNA #4's incident statement, dated 10/02/25, read in part, [LPN #1] came into facility telling me and [CNA #2] that [Resident #1] was on the ground outside and [they] had poop all over themselves. When we got outside [Resident #1] was laying on the ground [with a] puddle of fluid all around [them]. I asked [Resident #1] what it is. [Resident #1] said [LPN #1] threw water on [Resident #1] and [LPN #1] said no, I poured some water on your foot to get the shit off it. [Resident #1] was covered from head to toe in water. We got [Resident #1] off the ground. [LPN #1] then showed a picture of the poop in the floor to another resident and was making fun of [Resident #1] for the accident. CMA #2's incident statement, dated 10/02/25, read in part, I heard [LPN #1] tell [Resident #1] shit in the hallway on [their] way outside to smoke so I went outside to get [Resident #1] to come back in to change. I informed [Resident #1 they were] on supervised smoking and it wasn't time yet then I asked [them] to come in and change. [Resident #1] responded, 'I want to finish my cig.' So, I told [LPN #1] [they] wanted to finish smoking, [they] didn't want to come in right that second. [LPN #1] went outside with a med cup full of water from my med cart. I got [Resident #38] BP turned around and my pitcher was gone then [LPN #1] come from outside with it and refilled it and [unable to read] informed me [Resident #1] was on the ground. All the aides and [LPN #1] went and got [Resident #1] from outside. [Resident #1] was soaking wet and tracking BM through the whole building then [CNA #2] gave [Resident #1] a shower and got [Resident #1] cleaned up. When I move [sic] to west hall to finish my med pass, [LPN #1] was showing picture of [Resident #1's] BM on the floor to [Resident #7] and laughing and making fun of it.When I gave [Resident #7 their medication they were] talking about it with [Resident #39]. CNA #3's incident statement, dated 10/02/25, read in part, I was sitting at nurses' station on west and east hall when I witnessed [LPN #1] ask [Resident #1] if [they] just shit in the floor. [Resident #1] stated no. I witnessed [LPN #1] take a picture of the poop on [their] phone. A hour later, I witnessed [LPN #1] showing the pic to [Resident #40]. Resident #6 came out of [their] room about 8:45 p.m. and offered to take [Resident #1] to smoke since [Resident #1] is supervised. [LPN #1] told [Resident #6], only if [Resident #6] took a bio bag with [them] and clean [sic] up after [Resident #1,] if [Resident #6 was] going to be responsible for [Resident #1]. [LPN #1] said, 'Kinda like when you have to pick up after your pet.'CNA #1's incident statement, dated 10/02/25, read in part, I was sitting at nursing station while the nurse was showing pictures of [Resident #1's] poop. CNA #2's incident statement, dated 10/02/25, showed CNA #2 assisted Resident #1 from the ground to a seated position with the assistance of other staff and a mechanical lift. CNA #2 described Resident #1 as on the ground in a puddle of water. CNA #2's incident statement showed another CNA asked Resident #1 what the puddle was from and Resident #1 stated LPN #1 poured ice water on them. The statement showed LPN #1 responded that they only poured water on the resident's feet and Resident #1 replied no. CNA #2 incident statement showed CNA #2 escorted Resident #1 to the shower where Resident #1 started to cry and stated they had never been treated like that before. The incident statement showed Resident #1 stated LPN #1 shoved Resident #1 from behind, causing Resident #1 to fall from the chair and onto the ground. The statement showed Resident #1 stated LPN #1 then went inside and returned with a pitcher of ice water and poured the ice water all over Resident #1 before LPN #1 said that was what Resident #1 got for shitting themselves. The statement showed Resident #1 named two witnesses, including Resident #6. When CNA #2 asked Resident #6 what happened to Resident #1, Resident #6 stated LPN #1 pushed Resident #1 to the ground and poured water on them. LPN #1's incident statement, dated 10/02/25, showed at 6:15 p.m. Resident #1 left their room, walked to Center hall, and defecated in the middle of the hallway. The statement showed LPN #1 requested Resident #1 to return to their room to change clothes but the resident declined and continued to go outside. LPN #1's incident statement showed the LPN did not follow the resident outside but instead cleaned up the bowel movement from the hallway. The statement showed LPN #1 then went outside to retrieve Resident #1. The incident statement showed Resident #1 initially refused but then changed their mind. The incident statement showed Resident #1 stood from the chair, urinated on themselves and the ground, then defecated onto the ground, slipped in the feces, and fell back onto the chair. The statement showed LPN #1 attempted to stabilize the chair to keep Resident #1 from falling backwards and striking their head on the ground. The incident statement showed Resident #1 landed on the edge of the chair and fell to the ground. LPN #1's incident statement showed the LPN assessed the resident to ensure Resident #1 was ok and went inside the facility to request assistance. The incident statement showed LPN #1 retrieved a pitcher from a medication cart, emptied the pitcher of its content, and filled it with warm water before returning Resident #1. LPN #1 stated they used the warm water to wash feces from the surrounding concrete so when they rolled Resident #1 over to position and to attach the lift sling, Resident #1 would not get feces in their hair. The incident statement showed LPN #1 used warm water to wash the feces from the resident's feet. The incident statement showed the staff used the mechanical lift to help Resident #1 from the ground and into a chair. Once there, Resident #1 stood and ambulated with the assistance of their walker. The incident statement showed LPN #1 instructed CNA #2 to assist Resident #1 in the shower. The incident statement showed Resident #5 and Resident #6 were witnesses to the actions of LPN #1 while in the courtyard. The incident statement showed LPN #1 denied throwing water on Resident #1 in a vengeful manner. The incident statement showed LPN #1 accused another staff member of bullying LPN #1 and claimed the other LPN manipulated the two witnesses into falsifying their statements. On 10/22/25 at 2:30 p.m., the employee record for LPN #1 was reviewed. There was a termination of employment notice for LPN #1 dated 10/02/25. On 10/21/25 at 6:00 p.m., Resident #1 stated they felt safe in the facility and the staff treated them with kindness and respect. Resident #1 stated they felt under the weather, recently received cough syrup, and requested a return visit. On 10/22/25 at 11:20 a.m., Resident #1 stated earlier in the month, they walked to the inner courtyard and unknowingly defecated on the hall floor as they passed through the facility to the courtyard door. Resident #1 stated once outside, they sat in a chair, LPN #1 approached and demanded they return the facility. Resident #1 stated they told the nurse they had just sat and refused to return to their room right away. Resident #1 stated the next thing they knew, LPN #1 pushed the back of the chair and Resident #1 fell to the ground. Resident #1 stated LPN #1 poured a cup of water on them, left the courtyard and returned with a pitcher of ice water, and poured the water over Resident #1. Resident #1 stated after the LPN poured the water on them, the LPN stated that was what they got for shitting themselves. Resident #1 stated they did not think the incident was abusive but thought the LPN was trying to provoke a fight with the resident. Resident #1 stated the facility handled the situation to the resident's satisfaction. Resident #1 stated they had not seen LPN #1 since the incident, and they felt safe in their home. On 10/22/25 at 11:30 a.m., Resident #5 stated earlier in the month, they witnessed LPN #1 push Resident #1 from a chair and then pour water over the resident. Resident #5 stated they were shocked at the incident and felt how the LPN treated and spoke to the resident was uncalled for and abusive.On 10/22/25 at 4:40 p.m., Resident #6 stated earlier in the month, while outside smoking, they witnessed LPN #1 pour water from a pitcher onto Resident #1. Resident #6 was unable to provide further details. On 10/22/25 at 5:00 p.m., CNA #1 stated they were asked by LPN #1 to assist Resident #1 up from a fall. CNA #1 stated the resident was in the courtyard, laying on the ground with their head and shoulders slightly raised. The CNA stated there was a large volume of liquid both on Resident #1 and around them. The CNA stated when they asked the resident what all the liquid was, Resident #1 stated LPN #1 poured a pitcher of water over them. CNA #1 stated LPN #1 was present, denied the accusation, and stated Resident #1 had urinated on themselves. CNA #1 stated they remembered thinking there was more liquid present than urinating would likely produce and Resident #1 was wet above the waistline and in other areas you would not expect the urine to flow. On 10/22/25 at 5:10 p.m., CMA #2 stated they were starting a medication pass when LPN #1 grabbed the pitcher of ice water from their medication cart. CMA #2 stated they watched LPN #1 immediately exit the building to the inner courtyard with the water pitcher in their hands. CMA #2 stated LPN #1 returned the pitcher to the medication cart empty. On 10/22/25 at 5:30 p.m., the DON stated they had another nurse perform the investigation, but the findings were suspicious, and they could not risk the possibility that the abuse occurred. The DON stated they suspended LPN #1 as soon as the administration was notified and later terminated LPN #1. The DON stated LPN #1 did not work in the facility after they were informed of the allegation. On 10/22/25 at 6:00 p.m., the administrator stated right after the incident, they in-serviced all staff on abuse: what was abuse, what to do if you suspect abuse, what were the regulations regarding abuse, and what to do if you're too stressed with a resident to provide immediate care. The administrator stated they routinely in-serviced their staff on abuse but incidents like this still happened. On 10/22/25 at 6:20 p.m., CNA #2 stated they were in the hall with another CNA when LPN #1 approached and said Resident #1 was on the ground in the inner courtyard and needed help getting up. CNA #2 stated they retrieved the lift and sling to raise the resident from the ground. CNA #2 stated when they entered the courtyard, they saw Resident #1 laying in a large puddle of liquid and thought they may have urinated on themselves but quickly realized there was too much liquid and the resident was wet in places where urine would not have flowed. CNA #2 stated Resident #1 said LPN #1 had poured a pitcher of water over them. CNA #2 stated LPN #1 corrected the resident and said they poured water on the resident's feet to clean them of feces. CNA #2 stated the amount of liquid they saw and where Resident #1 was wet did not match with the statement LPN #1 said about washing the resident's feet. CNA #2 stated they assisted the resident to the shower and helped them shower. CNA #2 stated the resident had scrapes on their elbow, hip, and knee. CNA #2 stated Resident #1 was upset and told them that LPN #1 pushed them from the chair, poured a cup of water on their feet, left and returned to the courtyard with a pitcher of ice water, poured the ice water onto Resident #1, and then used profanity to tell them that was what they deserved for defecating on themselves. CNA #2 stated the allegation sounded like abuse, but they were not sure how to proceed since they were to report any allegation of abuse to their charge nurse which was LPN #1. They stated they asked other staff for help and was able to contact the facility administration and inform them of events. CNA #2 stated LPN #1 left the facility and everyone wrote statements as to what they saw and heard.

Based on observation, record review, and interview, the facility failed to secure chemicals which had the potential to harm residents if the chemicals were touched, inhaled, or ingested. The DON identified 50 residents resided in the facility. Findings: On 10/22/25 at 11: 00 a.m., there were no wandering residents observed on the East hall. At the end of the East hall was an unsecured resident room which was used for storage. There was no way to lock the storage room door and located behind the door was six 1-gallon sized bottles of unsecured chemicals. The chemicals included three 1-gallon bottles of ZEP Wet Look Floor Polish, two 1-gallon bottles of Floor Front Floor Finish, and a gallon bottle of Betco Advanced Alcohol Gel Sanitizer. Each of the 6 bottles of chemicals had a warning label which read to keep out of reach of children.On 10/22/25 at 11:07 a.m., the DON observed the unsecured chemicals in the storage room. An undated and unnamed facility policy showed all chemicals must be secured with locks and accessible to only housekeeping and maintenance.The MSDS for Floor Front Floor Finish, dated 05/15/19, showed the chemical may be harmful if swallowed, may cause skin irritation, may cause eye irritation, and inhalation of vapors or mist may cause respiratory irritation. The MSDS for Zep Wet Look Floor Polish, dated 05/24/19 showed the vapors may cause irritation to the eyes respiratory system and the skin. The MSDS showed to avoid contact with skin and eyes; smoking, eating and drinking should be prohibited in the application area; and to dispose of rinse water according to local and national regulations. The MSDS for Advanced Alcohol Gel Sanitizer, dated 06/08/22, showed the chemical was dangerous; was a highly flammable liquid and vapor; and caused serious eye irritation. On 10/22/25 at 11:07 a.m., the DON stated all chemicals were to be locked up and only accessible to housekeeping and maintenance. The DON stated the staff knew better than to store chemicals in an unsecured room.

Based on observation and interview, the facility failed to ensure protected health information was secure for 1 (East/West Hall) of 1 medication cart observed.The administrator identified 54 residents resided in the facility.Findings: On 07/29/25 at 1:17 p.m., a computer on top of an unattended medication cart at the corner of East/West Hall was observed to be open and showed protective health information.On 07/29/25 at 1:35 p.m., a computer on top of an unattended medication cart at the corner of East/West Hall was observed to be open and showed protective health information.On 07/30/25 at 1:32 p.m., a computer on top of an unattended medication cart on East Hall was observed to be open and showed protective health information.On 07/30/25 at 2:28 p.m., a computer on top of an unattended medication cart at the corner of East/West Hall was observed to be open and showed protective health information.On 07/30/25 at 2:55 p.m., the administrator and DON reported the computer should have been closed and not showing protected health information.

Based on observation, record review, and interview, the facility failed to ensure the environment was free from flies.The administrator identified 54 residents resided in the facility.Findings: On 07/29/25 at 11:42 a.m., flies too numerous to count were observed in the lobby. An unknown female resident was observed resting in a recliner. There were four cups of liquid on the table beside the recliner. Flies were observed in and around the cups of liquid, and a dead fly was observed floating in the liquid of one cup.On 07/29/25 at 1:30 p.m., in room [ROOM NUMBER], flies too numerous to count were observed all over the room, bed, and bedside table.An invoice for air curtains, dated 07/03/25 was reviewed.On 07/30/25 at 12:02 p.m., the administrator stated the facility had ordered blowers for the doors to help with the fly problem, but they were still waiting on them to come in.

Based on record review and interview, the facility failed to ensure care plans were developed to address the use of illegal substances for 2 (#3 and #4) of 2 sampled residents reviewed for care plans.The administrator identified 54 residents resided in the facility.Findings: 1.An undated face sheet showed Res #3 had diagnoses which included schizoaffective disorder, opioid dependence, and psychotic disorder. A nurse note, dated 06/12/25, showed the resident was found smoking an illegal substance using a soda can with holes punctured in the side. Education was provided to resident and to continue medication hold for 24 hours per physician.Res #3's care plan did not address the resident's use of an illegal substance.2. An undated face sheet showed Res #4 had diagnoses which included major depressive disorder, hypoxemia, and alcoholic hepatitis.Res #4's care plan did not address the resident's use of an illegal substance.A nurse note, dated 06/07/25, showed Res #4 was found smoking an illegal substance from a Pepsi can with holes punched in the side. Education was provided to resident and to continue medication hold for 24 hours per physician.On 07/30/25 at 1:18 p.m., LPN #2 reported both Res #3 and Res #4 had been caught multiple times smoking an illegal substance.On 07/30/25 at 1:26 p.m., MDS #1 stated they did not know how to care plan it.

Based on record and interview, the facility failed to ensure residents with substance abuse were provided services for 2 (#3 and #4) of 2 sampled residents reviewed for substance abuse.The administrator identified 54 residents resided in the facility.Findings: A facility policy titled Marijuana Policy for Residents, dated 07/03/20, read in part, We do not allow marijuana on the ground due to we accept federal monies. If you see residents smoking marijuana you must tell them to put it out then take it. Report on the State Health Department under suspected Criminal Act form 283 fill out form completely. Call police department give the Marijuana to them. Start your investigation .you must get at least 3 statements from other residents.1.An undated face sheet showed Res #3 had diagnoses which included schizoaffective disorder, psychotic disorder, and impulsiveness.A nurse note, dated 06/12/25, showed the resident was found smoking an illegal substance using a soda can with hole puncture in the side. Education was provided regarding the risks of recreational drug use and the facility policy that prohibited the use of recreational drugs. A nurse note, dated 07/05/25, showed the Res #3 was outside right after returning from visit with their sister, smoking illegal substance. Res #3 was re-educated on the potential interactions with medications. Res #3 stated they did not care.A nurse note, dated 07/09/25, showed the resident was found smoking an illegal substance. Education was provided and facility policy that prohibited the use of recreational drug use.2. An undated face sheet showed Res #4 had diagnoses which included major depressive disorder and alcohol hepatitis.A nurse note, dated 06/07/25, showed Res #4 was found smoking an illegal substance using a soda can with holes punctured in the side. Education was provided regarding the risks of recreational drug use and the facility policy that prohibited the use of recreational drugs.A nurse note, dated 06/10/25, showed Res #4 had a grape soda can with holes poked in the side with a burnt substance surrounding the holes. The can was thrown in the thrash, and administrator and PCP were notified.A nurse note, dated 07/01/25, showed Res #4 was rolling a blunt at the table and another rolled blunt just lying on the table. The resident did not have a medical prescription to have marijuana substance. The substance was taken, and the resident was re-educated. The administrator and PCP were notified.On 07/30/25 at 1:49 p.m., the administrator reported they had not offered a substance abuse program, they just take the substance every time the residents were caught with it. The administrator reported they did not know what the policy said.

Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for 1 (#1) of 9 sampled residents reviewed for abuse.The administrator identified 54 residents resided in the facility. Findings: On 07/29/25 at 12:43 p.m., Res #1 was observed up in the lobby in a wheelchair.An undated medical diagnosis list showed Res #1 admitted with diagnoses of left sided hemiparesis/hemiplegia and bilateral hard of hearing.An undated facility policy Investigation of Abuse, Neglect, and Exploitation, read in part, The facility prohibits mistreatment, neglect or abuse of residents. The resident has the right to be free from verbal, sexual, physical, or mental abuse.An Oklahoma State Department of Health incident form 283, dated 04/15/25, showed CNA #1 used unnecessary force when assisting Res #1 while in their wheelchair in the lobby. The report showed CNA #2 was asked why they did that, CNA #1 stated She was getting on my last nerve. The report showed CNA #1 was suspended immediately pending an investigation. The report showed an investigation was initiated and CNA #1 was ultimately terminated. An in-service form, dated 04/23/25, showed staff from all departments received training over abuse.On 07/29/25 at 12:43 p.m., Resident #1 stated they felt safe in the facility and the staff were good to her. On 07/30/25 at 10:24 a.m., the administrator and DON reported CNA #1 had been terminated and staff were re-educated over abuse in an in-service.

Based on observation and interview, the facility failed to maintain and clean, safe, and sanitary homelike environment during two of two observations. The administrator identified 59 residents resided in the facility. Findings: On 12/19/24 at 11:03 a.m., the following observations were made, a. a broken tile was observed with black tape over a loose and cracked tile in the main hallway, b. a tile in the main hall was cracked and pieces missing creating a trip hazard, c. there was a cracked and broken tile observed in room [ROOM NUMBER], d. room [ROOM NUMBER] had cracked tiles in the entry way, e. the double doors leading down the main hallway from the front commons had the lower panel separated from the door and had sharp edges, f. the walls in the main center hallway were scuffed with black marks and damaged in the commons area and the North main hallway, g. the tiled floors on the East hall were chipped, stained, and damaged where the center hall met. There was brown stained residue on the tile and the base boards and corners were damaged, h. the halls had missing paint and damaged sheetrock and resident doors were scuffed with marks, and i. there were cracked tiles and black mold around the toilet and shower area on the North hall. On 12/26/24 at 11:32 a.m., HK #1 was asked to discuss the broken tiles on the halls and resident rooms. They stated they noticed the tile with tape on the center hall on 12/25/24. They stated the East hall stains were because it needed waxed and it would not stay clean. They stated the cracked tile needed to be replaced. HK #1 stated the walls in the halls were scuffed with black marks throughout the facility from the residents' wheel chairs. On 12/27/24 at 9:39 a.m., a family representative was asked what they thought about the condition of the facility. They stated the place could use some help. They stated the floors and the walls were in disrepair. On 12/27/24 at 10:03 a.m., CNA #3 was asked to discuss the condition of the facility. They stated the tile floor on the East hall was not clean. They stated it was stained, cracked, and looked soiled. They stated the walls were usually soiled with spilled drinks and scuffed from carts and residents' wheelchairs. The CNA stated they report it to HK and maintenance. They were asked if they though it looked like a clean, sanitary, and safe home like environment. The CNA stated mainly the cleanliness and the condition of the environment and the walls. They stated it was definitely not how some of the residents would live. On 12/27/24 at 10:20 a.m., CNA #4 was asked to discuss the condition of the facility. They stated it was pretty bad. They stated the floors on East hall you could not tell if they were dirty or stained. They stated the tiles were cracked. The CNA stated the walls in the halls were scuffed up throughout the whole facility. They were asked if it looked like a clean, safe, and sanitary home like environment. They stated, No, I wouldn't want to live this. I would be fixing things. The CNA stated the doors in the hall were in disrepair and looked broken. On 12/27/24 at 10:45 a.m., HK #2 was asked to discuss the condition of the facility. They stated it was the nastiest facility they had ever worked in. They stated it was rough. HK #2 stated the walls were scuffed and was permanent. They stated they had scrubbed the walls and they were missing paint. They stated the walls needed to be repainted. HK #2 was asked to discuss the East hall floors. They stated they were old, the tiles were stained, and some were cracked. They stated they stained easily and they were stained and soiled and could not be cleaned. HK #2 stated the tiles in the center hall were cracked and some were missing. On 12/27/24 at 11:02 a.m., LPN #1 was asked to discuss the condition of the facility. They stated on the East hall the floors looked stained after they were mopped. They stated the tiles were cracked and looked horrible. The LPN stated the walls in the halls, resident doors and rooms were scuffed, missing paint, and base boards were damaged in places. They were asked if it looked like a clean ,sanitary, and safe home like environment. They stated, No, I know when house keeping cleans, it always looks dirty because of the stained and old floors. On 12/27/24 at 12:07 p.m., a tour of the facility was conducted with the DON. They were asked to discuss the observations made. They stated the fire doors in the main hall laminate was not attached for safety and it looked like it was in disrepair. They stated the halls needed to be painted. The DON stated the corners were very concerning due to disrepair and how it looked. They stated the back nurses station metal trim was damaged and could cause skin tears. They stated the base boards were trip hazards and looked like they were in disrepair. They stated the tile on East hall was cracked, stained, and did not not look clean when it was mopped due to stains. The DON was asked what was the facility's policy for maintaining a clean, safe, and sanitary home like environment. They stated it should be maintained and it was the residents rights to have a clean, safe, and sanitary home like environment. The DON was asked, based upon the above observations, what they thought about the condition of the facility in regard to their policy. They stated it needed to be painted, the floors needed to be redone, the base boards needed to be cleaned and tacked down, and the doors needed to be painted and repaired. They stated especially the fire doors. The DON was asked if the residents right to a clean, safe, and sanitary home like environment policy was followed. The DON stated, No. On 12/27/24 at 12:36 p.m., a tour of the facility was conducted with the administrator. They were asked to discuss the policy on maintaining a clean, sanitary, and home like environment. The administrator stated the house keepers were supposed to deep clean and maintenance quit on 12/26/24. They were asked to discuss what was observed on the walk through of the facility. The administrator stated the floor on the East hall needed to be redone. They stated it looked bad, had patches, the tile was cracked, and it was stained. They stated it did not look clean. They stated the corners needed to be replaced because they were in disrepair and looked bad. The administrator stated the walls needed to be touched up and they had black marks from wheelchairs and carts. They stated the North bathroom had mold on the floor and broken tiles which needed to be repaired. They stated the fire doors had rough edges and needed to be fixed on North and center. The administrator was asked how the doors looked on the halls. They stated the tops looked good, but the bottom did not. They were were asked, based upon the above observations, did they think it was a clean, safe, and sanitary home like environment. The administrator stated, I don't think it is that bad, we have hard people to take care of. They stated they did not have a policy regarding a clean, safe, and sanitary homelike environment and went by resident rights.

Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for two (#33 and #59) of three sampled residents reviewed for abuse. The administrator identified 58 residents who resided in the facility. Findings: An Investigation of Abuse, Neglect and Exploitation policy, undated, read in parts, .The facility prohibits mistreatment, neglect or abuse of residents. The resident has the right to be free from verbal, sexual, physical, or mental abuse .Physical abuse includes hitting, slapping, pinching, and kicking .In the event there is an allegation or incidents involving resident to resident abuse, the individuals involved in the abuse should be immediately separated by staff .Once safety is established, the Administrator and Director of Nursing should be notified immediately. Put the resident on 1:1 when needed and document .An investigation into what triggered the abuse shall be conducted by the DON with referrals made accordingly .The facility shall prevent the occurrence of abuse by reviewing past specific incidents for lessons learned and policy amendments .The facility shall ensure that any substantiated incidents of abuse are reported and analyzed, and that appropriate corrective remedial or disciplinary actions occurs in accordance with local, state or federal law . 1. Res #33 had diagnoses which included major depressive disorder, suicidal ideations, and persistent mood disorder. A nurse note, dated 04/13/2024 at 7:41 p.m., documented Res #33 ran into another resident in the hallway. The note documented Res #33 cursed the other resident. A nurse note, dated 04/17/24 at 10:09 a.m., documented Res #33 was yelling and cursing at staff. A nurse note, dated 05/17/24 at 9:20 a.m., documented Res #33 was yelling and verbally threatening staff. A nurse note, dated 06/03/24 at 4:39 p.m., documented Res #33 was yelling and verbally threatening staff. The note documented physical behaviors of knocking items off the nurses' station and hitting a CNA in the face with a metal drinking tumbler. A quarterly assessment, dated 06/07/24, documented Res #33 was cognitively intact, had minimal depression, and had exhibited physical and verbal behaviors towards others. A nurse note, dated 08/07/24 at 12:02 p.m., documented Res #33 was yelling and threatening another resident for not getting out of their way. A facility observation detail report, dated 08/07/24 at 12:02 p.m., documented Res #33 had aggressive behavior towards a peer and was yelling and cursing staff. The report documented continue plan of care as action taken to care plan. There was no documentation of verbal/physical behaviors on Res #33's care plan. 2. Res #59 had diagnoses which included Alzheimer's disease and insomnia. An admission assessment, dated 08/07/24, documented Res #59 was severely cognitively impaired, had no symptoms of depression, and had exhibited delusions. A nurse note, dated 08/07/24 at 4:22 p.m., documented Res #33 pushed Res #59 in the hallway resulting in a laceration to Res #59's head. The note documented Res #59 was transferred to the hospital for medical evaluation and treatment. A facility observation detail report, dated 08/07/24 at 4:35 p.m., documented Res #59 had been pushed by another resident resulting in a fall with head injury. An OSDH initial incident report form, dated 08/07/24, read in part, .At approx 3:45 pm was in office, heard a loud commotion then a crash in hallway. [Res #59] was noted laying on back with blood on floor. Laceration on upper back of head. Pressure applied and EMS notified. [Res #33] stated I told that [curse word] to stay away from my room. Unnamed resident was in hallway and stated [Res #59] wasn't even in [Res #33] room, [Res #59] was in the hallway when [Res #33] pushed them hard and was cussing at them. [Res #59] was sent to the hospital for evaluation and treatment. [Res #33] was placed on 1 on 1 . The report documented the physician, resident representative, law enforcement, and APS was notified of the incident. Hospital discharge instructions, dated 08/07/24 at 5:54 p.m., documented Res #59 had diagnoses which included skin tear and head injury/concussion. An OSDH final incident report form, dated 08/13/24, documented actual physical aggression by Res #33 against Res #59 witnessed by another unnamed resident. The report documented Res #33 had shoved Res #59 resulting in Res #59 falling to the floor and hitting their head. The unnamed resident witness stated the aggression was unprovoked. The report documented Res #33 had no further aggression noted and had no aggression against any resident witnessed or reported inside this facility prior to this incident. The report documented Res #59 did not return to the facility after discharge from the hospital. There was no documentation of an investigation related to the incident. On 10/31/24 at 8:35 a.m., Res #33 was observed sitting in their room. Res #33 stated Res #59 had attempted to come into their room and they had the right to defend their property. Res #33 stated they had pushed Res #59 out of their room. Res #33 stated they were not aware of any injuries Res #59 had received and did not care. On 10/31/24 at 8:30 a.m., CNA #1 stated they were present in the facility, but had not witnessed the incident between Res #33 and Res #59. They stated Res #33 was calm some of the time and angry at other times. CNA #1 stated they were not instructed to provide one-on-one supervision of Res #33 after the incident. They stated they had not been instructed on any interventions to prevent the occurrence of abuse regarding Res #33 prior to or after the incident. On 10/31/24 at 8:40 a.m., LPN #1 stated they were present in the facility, but had not witnessed the incident between Res #33 and Res #59. LPN #1 stated after the incident, Res #33 was instructed to stay in their room, but one-on-one staff supervision had not occurred. They stated Res #33 had a history of verbal/physical aggression, but no interventions had been implemented to prevent abuse. On 10/31/24 at 9:10 a.m., the DON stated the Res #33 had exhibited verbal aggression earlier in the day prior to the incident. They stated CNA #2 had been assigned to provide one-on-one supervision of Res #33. The DON stated CNA #2 had left Res #33 for a few minutes to answer a call light when the incident occurred with Res #59. They stated CNA #2 continued one-and-one supervision of Res #33 after the incident occurred. The DON stated one-on- one supervision of Res #33 continued for 72 hours and no additional verbal/physical behaviors were observed. They stated the one-on-one supervision would have been documented in the medical record. The DON stated they had not completed the incident report or investigation of the abuse. They stated the IP nurse or ADON usually completed those tasks. The DON stated there were not aware that Res #33's verbal/physical behaviors had not been documented in the care plan. On 10/31/24 9:50 a.m., CNA #2 stated they were present in the facility, but had not witnessed the incident between Res #33 and Res #59. CNA #2 stated they had not been instructed to provide one-on-one supervision of Res #33 prior to or after the incident of abuse. CNA #2 stated no interventions had been implemented for Res #33 before or after the incident to prevent verbal/physical abuse. On 10/31/24 at 9:40 a.m., the administrator was asked how the facility ensured residents were free from abuse. The administrator stated they were not sure other than rounding frequently. They stated Res #33's history of physical/aggressive behaviors should have been documented in their plan of care prior to the incident of abuse with Res #59. On 10/31/24 at 10:12 a.m., the IP stated they were not present in the facility when the incident occurred. The IP stated they completed the final incident report upon return to the facility. They stated they had interviewed staff and residents as part of the abuse investigation, but could not locate the documentation. The IP stated Res #33's history of verbal/physical behaviors should have been documented in the care plan. On 10/31/24 at 10:24 a.m., the ADON stated they were present in the facility, but had not witnessed the incident between Res #33 and Res #59. They stated they had completed the initial incident report of abuse. The ADON stated a nurse aide had been assigned to provide one-on-one supervision of Res #33 after the incident, but could not remember which one. The ADON stated they had not personally completed any interviews or documentation regarding the abuse investigation. The ADON stated documentation of the 72 hour supervision of Res #33 and staff/resident interviews should have been completed by the nursing staff, but none of the documentation could be located at this time. They stated Res #33's history of verbal/physical aggressive behaviors should have been documented in the plan of care.

Based on observation and interview, the facility failed to maintain the physical environment of the kitchen and ensure employees with facial hair wore a beard guard in the kitchen. The administrator identified 58 residents who resided in the facility. Findings: On 10/28/24 at 8:30 a.m., the kitchen was observed to have: a. a broken paper towel dispenser at the handwashing sink, b. missing trim on the exterior door, c. a broken cover on a fluorescent light fixture, d. build up of brown sticky substance on the walls around the grill area, and e. rusted air vents on the ceiling. On 10/28/24 at 12:15 p.m., a male employee with a partial beard was observed in the kitchen not wearing a beard guard. On 10/29/24 at 12:00 p.m., a male employee with a partial beard was observed in the kitchen not wearing a beard guard. On 10/30/24 at 8:41 a.m., the CDM stated they had made maintenance aware of the physical environment. They stated they would ensure staff wore beard guards when needed.

Based on record review and interview, the facility failed to implement a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. The administrator identified 58 residents who resided in the facility. Findings: CMS memo 17-30, revised date 06/09/17, documented CMS expects long term care facilities to have water management policies and procedures to reduce the risk of growth and the spread of Legionella and other opportunistic pathogens in the facility water system. No documentation of water management policies and procedures were found from record review. On 10/29/24 at 1:00 p.m., the maintenance supervisor was asked to provide documentation of water management policies and procedures. The maintenance supervisor stated they had never heard of a water management program to reduce the risk and growth of Legionella. They stated the facility did not need a water management program because they never had any standing water. On 10/29/24 at 1:22 p.m., the IP stated the facility did not have policies and procedures to reduce the risk of growth and spread of Legionella.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#30 and #41) of 15 sampled residents whose resident assessments were reviewed for accuracy. The administrator identified 58 residents who resided in the facility. 1. Res #30 had diagnoses which included depression, anxiety, mood disorder, and intermittent explosive disorder. An annual resident assessment, dated 08/31/24, documented a diagnosis of psychotic disorder. 2. Res #41 had diagnoses which included impulse disorder. A quarterly resident assessment, dated 11/24/21, documented a diagnosis of psychotic disorder. On 10/29/24 at 1:05 p.m., the IP reported no resident had a diagnosis of psychotic disorder in the facility. They were unsure as to why resident assessments would document the diagnosis of psychotic disorder. On 10/31/24 at 11:41 a.m., the MDS coordinator reported they started their position in December, and documented the diagnosis, psychotic disorder, on Res #30 and #41 because the diagnosis was documented on their previous resident assessments.

Based on observation, record review, and interview, the facility failed to change and label oxygen tubing according to physician orders for four (#17, 28, 31, and #50) of four sampled residents reviewed for respiratory treatments. The DON identified 13 residents who received oxygen therapy. Findings: A Respiratory Care/Oxygen Therapy policy, dated 09/07/22, read in part, .Change tubing weekly. Label tubing with date and initials . 1. Res #17 had diagnoses which included COPD and chronic respiratory failure with hypercapnia. An admission assessment, dated 01/17/22, documented the resident was cognitively intact and received oxygen therapy. A physician order, dated 09/27/22, documented to change oxygen tubing weekly on Thursdays. The order documented to date and initial the tubing. On 10/28/24 at 9:56 a.m., Res #17 was observed lying in bed. The resident was observed wearing oxygen delivered by nasal cannula at three liters per minute. The oxygen tubing was observed with a tape label dated 10/17/24. Res #17 stated the staff changed the tubing, but was not sure how often. 2. Res #28 had diagnoses which included COPD and chronic respiratory failure with hypercapnia. A physician order, dated 12/11/22, documented to change oxygen tubing weekly on Thursdays. The order documented to date and initial the tubing. An annual assessment, dated 12/12/23, documented the resident was cognitively intact and received oxygen therapy. On 10/28/24 at 10:11 a.m., Res #28 was observed sitting in a wheelchair. The resident was observed wearing oxygen delivered by nasal cannula at three liters per minute. The oxygen tubing was observed with a tape label dated 10/17/24. Res #28 stated they did not know when the tubing had been changed last. 3. Res #31 had diagnoses which included shortness of breath. A physician's order, dated 10/21/22, documented to change oxygen tubing weekly on Thursdays. On 10/28/24 at 2:05 p.m., Res #31 was laying in bed with oxygen infusing by nasal cannula at two liters per minute. The oxygen tubing was observed with tape labeled/dated 10/17/24. 4. Res #50 had diagnoses which included shortness of breath, chronic respiratory failure with hypercapnia and hypoxia, obstructive sleep apnea, congestive heart failure and COPD. A physician's order, dated 04/19/24, documented to change oxygen tubing weekly on Thursdays. On 10/28/24 at 2:06 p.m., Res #50 was laying in bed with oxygen infusing by nasal cannula at three liters per minute. The oxygen tubing was observed with tape labeled/dated 10/17/24. On 10/29/24 at 2:00 p.m., the DON was made aware of the oxygen tubing observations. The DON stated all oxygen tubing should have been changed weekly. They stated the tubing had not been changed on 10/24/24 per physician orders. 45913

Based on observation, record review, and interview, the facility failed to conduct a thorough investigation into an incident of abuse for two (#33 and #59) of three sampled residents reviewed for abuse. The administrator identified 58 residents who resided in the facility. Findings: An Investigation of Abuse, Neglect and Exploitation policy, undated, read in parts, .The facility prohibits mistreatment, neglect or abuse of residents. The resident has the right to be free from verbal, sexual, physical, or mental abuse .Physical abuse includes hitting, slapping, pinching, and kicking .In the event there is an allegation or incidents involving resident to resident abuse, the individuals involved in the abuse should be immediately separated by staff .Once safety is established, the Administrator and Director of Nursing should be notified immediately. Put the resident on 1:1 when needed and document .An investigation into what triggered the abuse shall be conducted by the DON with referrals made accordingly .The facility shall prevent the occurrence of abuse by reviewing past specific incidents for lessons learned and policy amendments .The facility shall ensure that any substantiated incidents of abuse are reported and analyzed, and that appropriate corrective remedial or disciplinary actions occurs in accordance with local, state or federal law . 1. Res #33 had diagnoses which included major depressive disorder, suicidal ideations, and persistent mood disorder. A quarterly assessment, dated 06/07/24, documented Res #33 was cognitively intact, had minimal depression, and had exhibited physical and verbal behaviors towards others. 2. Res #59 had diagnoses which included Alzheimer's disease and insomnia. An admission assessment, dated 08/07/24, documented Res #59 was severely cognitively impaired, had no symptoms of depression, and had exhibited delusions. An OSDH initial incident report form, dated 08/07/24, read in part, .At approx 3:45 pm was in office, heard a loud commotion then a crash in hallway. [Res #59] was noted laying on back with blood on floor. Laceration on upper back of head. Pressure applied and EMS notified. [Res #33] stated I told that [curse word] to stay away from my room. Unnamed resident was in hallway and stated [Res #59] wasn't even in [Res #33] room, [Res #59] was in the hallway when [Res #33] pushed them hard and was cussing at them. [Res #59] was sent to the hospital for evaluation and treatment. [Res #33] was placed on 1 on 1 . The report documented the physician, resident representative, law enforcement, and APS was notified of the incident. An OSDH final incident report form, dated 08/13/24, documented actual physical aggression by Res #33 against Res #59 witnessed by another unnamed resident. The report documented Res #33 had shoved Res #59 resulting in Res #59 falling to the floor and hitting their head. The unnamed resident witness stated the aggression was unprovoked. The report documented Res #33 had no further aggression noted and had no aggression against any resident witnessed or reported inside this facility prior to this incident. The report documented Res #59 did not return to the facility after discharge from the hospital. There was no documentation of an investigation related to the incident. On 10/31/24 at 8:35 a.m., Res #33 was observed sitting in their room. Res #33 stated Res #59 had attempted to come into their room and they had the right to defend their property. Res #33 stated they had pushed Res #59 out of their room. Res #33 stated they were not aware of any injuries Res #59 had received and did not care. On 10/31/24 at 8:30 a.m., CNA #1 stated they were present in the facility, but had not witnessed the incident between Res #33 and Res #59. They stated Res #33 was calm some of the time and angry at other times. CNA #1 stated they were not instructed to provide one-on-one supervision of Res #33 after the incident. They stated they had not been instructed on any interventions to prevent the occurrence of abuse regarding Res #33 after the incident. On 10/31/24 at 8:40 a.m., LPN #1 stated they were present in the facility, but had not witnessed the incident between Res #33 and Res #59. LPN #1 stated after the incident, Res #33 was instructed to stay in their room, but one-on-one staff supervision had not occurred. They stated Res #33 had a history of verbal/physical aggression, but no interventions had been implemented to prevent abuse. On 10/31/24 at 9:10 a.m., the DON stated the Res #33 had exhibited verbal aggression earlier in the day prior to the incident. They stated CNA #2 had been assigned to provide one-on-one supervision of Res #33. The DON stated CNA #2 had left Res #33 for a few minutes to answer a call light when the incident occurred with Res #59. They stated CNA #2 continued one-on-one supervision of Res #33 after the incident occurred. The DON stated one-on-one supervision of Res #33 continued for 72 hours and no additional verbal/physical behaviors were observed. They stated the one-on-one supervision would have been documented in the medical record. The DON stated they had not completed the incident report or investigation of the abuse. They stated the IP nurse or ADON usually completed those tasks. On 10/31/24 at 9:40 a.m., the administrator was made aware of the absence of abuse investigation documentation regarding Res #33 and Res #59. The administrator stated, That is not good. They stated an investigation should have been documented by the nursing staff. On 10/31/24 9:50 a.m., CNA #2 stated they were present in the facility, but had not witnessed the incident between Res #33 and Res #59. CNA #2 stated they had not been instructed to provide one-on-one supervision of Res #33 prior to or after the incident of abuse. CNA #2 stated no interventions had been implemented for Res #33 before or after the incident to prevent verbal/physical abuse. On 10/31/24 at 10:12 a.m., the IP stated they were not present in the facility when the incident occurred. The IP stated they completed the final incident report upon return to the facility. They stated they had interviewed staff and residents as part of the abuse investigation, but could not locate the documentation. On 10/31/24 at 10:24 a.m., the ADON stated they were present in the facility, but had not witnessed the incident between Res #33 and Res #59. They stated they had completed the initial incident report of abuse. The ADON stated a nurse aide had been assigned to provide one-on-one supervision of Res #33 after the incident, but could not remember which one. The ADON stated they had not personally completed any interviews or documentation regarding the abuse investigation. The ADON stated documentation of the 72-hour supervision of Res #33 and staff/resident interviews should have been completed by the nursing staff, but none of the documentation could be located at this time.

Based on record review and interview, the facility failed to notify the OHCA of a new possible serious mental disorder diagnosis for two (#37 and #20) of six sampled residents reviewed for PASARR assessments. The administrator identified 58 residents who resided in the facility. Findings: 1. A Level I PASARR, dated 07/19/21, documented Res #37 did not have a serious mental illness. On 10/06/21, Res #37 received a new diagnoses of specified persistent mood disorder. There was no documentation the OHCA had been contacted to see if a Level II PASARR was required. On 10/30/24 at 12:10 p.m., the administrator stated OHCA must not have been contacted because the notification information was not documented at the bottom of the Level I PASSAR that was reviewed. 42171 2. Resident #20 had diagnoses which included diabetes mellitus and adjustment disorder with depressed mood. A Level I PASARR screen, dated 11/29/22, documented no serious mental illness. On 01/06/23, the resident was diagnosed with delusional disorder. On 10/31/24 at 11:41 am, the administrator stated the OHCA should have been contacted regarding Resident #20's new diagnosis and it should have been documented in the nurse's notes. A review of Resident #20 medical record did not document the OHCA had been contacted regarding the diagnosis of delusional disorder.

Based on observation, record review, and interview, the facility failed to ensure: a. vaping of tobacco did not occur inside the facility, and smoking assessments were completed quarterly for one (#35) of two sampled residents reviewed for smoking; and b. oxygen tanks were stored properly for one (#12) of five sampled residents reviewed for oxygen. The DON identified 23 residents who smoked/vaped tobacco products and 13 residents who received oxygen therapy. Findings: A smoking policy, dated 01/09/22, documented smoking/vaping is only allowed in designated areas. The policy documented the courtyard is the only designated area for residents to smoke. 1. Res #35 had a diagnosis of nicotine dependence. A care plan, dated 09/10/20, documented the resident was an unsupervised smoker. The care plan documented the resident would follow facility policy related to smoking areas. An annual assessment, dated 08/12/23, documented the resident was cognitively intact. A quarterly smoking assessment, dated 11/07/23, documented the resident had a minimal problem of smoking in unauthorized areas and had no problem with the ability to understand the facility's safe smoking policy. There was no additional documentation of quarterly smoking assessments found in record review. On 10/28/24 at 8:51 a.m., Res #35 was observed lying in bed. Res #35 was observed utilizing a battery-powered tobacco vape device. Res #35 stated it was acceptable to vape in their room as long as their roommate did not object. On 10/29/24 at 9:30 a.m., the DON was made aware of the observation. The DON stated residents were not allowed to vape tobacco inside the facility per policy. On 10/29/24 at 9:57 a.m., the DON stated a smoking assessment should have been completed quarterly for Res #35. 42171 2. Res #12 had diagnoses which included COPD and respiratory failure. A physician's order, dated 06/15/23, documented Res #12 was to receive oxygen at three liters per minute via a nasal cannula. On 10/28/24 at 10:00 a.m., an oxygen tank was observed standing upright next to the wall in Res #12's room. The tank was not secured or in any type of holder. On 10/31/24 at 9:34 a.m., the DON stated oxygen tanks should be locked in the nurse's closet and not left in resident rooms unsecured.

Based on record review, observation, and interview the facility failed to ensure a safe and homelike environment for the residents. The Resident Census and Conditions of Residents report documented 59 residents resided in the facility. Findings: On 10/10/23 at 1:00 p.m., an environmental tour of the facility was completed. On the west hall there were two locations with tape placed across the tiles. The tiles were observed to have been loose. A document provided by the maintenance supervisor documented 18 of 26 broken tiles had been replaced. On 10/11/23 at 9:22 a.m., the maintenance supervisor stated they were available 24 hours a day seven days a week. The supervisor stated they had replaced some tiles on the resident halls but the residents had rolled over them with their wheelchairs before the tile cement had dried and broke them.

Based on record review, observation, and interview the facility failed to ensure: a. the ice machine was locked to prevent possible cross contamination. b. dietary staff washed hands after handling dirty items and before touching clean items. c. hand washing was completed during wound care treatment. The administrator identified 59 residents who resided in the facility and two residents who received wound care treatments. Findings: 1. On 10/11/23 at 8:50 a.m., a resident was observed in the dining room raising the unlocked lid on the ice machine and scooped a cup of ice with their bare hands and placed the ice in a disposable cup. The scoop for the ice machine was was observed lying uncovered on top of the ice machine. On 10/11/23 at 8:56 a.m., the assistant dietary manager stated the ice machine should have been locked and the ice scoop should have been covered. On 10/11/23 at 11:35 a.m., a meal service was observed. An unidentified resident was observed to approach the kitchen door with a glass of ice tea and requested the glass to be emptied. Dietary aide #1 who was wearing gloves was observed to take the glass, emptied it in the sink, and returned the glass to the resident. The dietary aide was then observed to continue preparing the meal without changing their gloves or washing their hands. On 10/11/23 at 11:38 a.m., dietary aide #1 stated they should not have brought items handled by the residents back into the kitchen. The dietary aide stated they should have washed their hands and changed their gloves after touching unclean surfaces. A document signed by the administrator, dated 10/12/23, documented the ice machine was to be locked after each use and the ice scoop was to be kept in a clear plastic bag on top of the machine. 2. A document titled Hand Hygiene for Healthcare Providers documented, .use an ABHR during direct care when shifting from a soiled body site to a clean body site, on the same patient .immediately after glove removal. On 10/11/23 at 12:41 p.m., a wound care observation was conducted. LPN #1 gathered supplies to perform a dressing change. The LPN donned a pair of gloves and removed the dressing which was in place, changed her gloves, and started to clean the wound when their gloves tore. The LPN was observed to remove the torn gloves and don a new pair of gloves and continue the treatment. The LPN was not observed to wash or sanitize their hands with ABHR between glove changes. On 10/11/23 at 1:03 p.m., the LPN stated they should have washed their hands between glove changes.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #1 received CPR, staff was CPR certified and a policy regarding CPR certification of staff was developed and implemented. On [DATE] at 5:20 p.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 5:38 p.m., the administrator was notified of the IJ situation. On [DATE] at 3:27 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal sent via email on [DATE] at 3:19 p.m. documented: CPR Certification: There are currently 15 out of 61 CPR certified staff members. Policy written and active to reflect at a minimum one CPR certified staff member is scheduled each shift. Staff to obtain current certification in BLS/CPR per regulatory compliance, encouraged but not mandated. Agreement with Kiamichi Vo-Tech to provide BLS/CPR Training. On [DATE] Time 8am to 12 noon staff members attending the class are [names withheld]. Auditing: DON &/or designee to track daily and ensure staff ratio compliance, effective 09.30.2022. Monitoring: QA Team will monitor weekly x6 months to ensure substantial compliance. BLS/CPR certification class will be offered to all new hires. The IJ was lifted, effective [DATE] at 3:27 p.m., when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm. Based on record review and interview, the facility failed to ensure Res #1 was provided with CPR, staff were CPR certified and had a policy regarding CPR certification of staff developed and implemented. The DON reported 48 residents were full codes. Findings: Res #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan last revised on [DATE], read in part, I am a Full code and want to have CPR initiated. CPR will be initiated in the event my heart or I stop breathing. A nursing note on [DATE] at 7:02 a.m., read in parts, .called to room during round by staff at 0530, resident found without respiration/pulse, CPR initiated, ems notified, 0545 ems arrived called [NAME] at that time . A TripTix EMS Patient Care Record dated [DATE], read in parts, .upon arrival .nursing staff stopped CPR as we were almost to the room and we checked for a carotid pulse that was absent . On [DATE] at 3:45 p.m., the DON stated, We do not have CPR certified staff. The nurses work off their license. No one is certified. The DON further reported the facility did not have a policy for CPR certification for staff. On [DATE] at 4:20 p.m., a message was left for LPN #1 to call. No return call was received on [DATE]. On [DATE] at 4:24 p.m., CNA #3 stated via phone interview they were not CPR certified nor had the facility inquired about their certification status. They reported on [DATE] they were asked to perform CPR on Res #1. When CNA #3 arrived to Res #1's room, they were laying on their side on a mattress on the floor with their head on a pillow. CPR was not being performed on Res #1. LPN #1 asked CNA #3 if they could do CPR. LPN #1 told CNA #3 they were unable to do compressions due to a back injury. CNA #3 reported Res #1 was purple and their skin was cold. CNA #3 reported they started chest compressions but was told to stop by LPN #1 because the patient was dead. CNA #3 reported only chest compressions were performed and stated LPN #1 stated they were not going to put their mouth on Res #1's mouth. CNA #3 reported the crash cart was not brought into the room to aide them in CPR.

On 04/13/17 at 4:54 p.m., the Oklahoma State Department of Health (OSDH) was notified an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from abuse and protected from abuse for resident #77. The facility failed to protect and investigate the allegation of sexual abuse. The facility failed to protect residents from further abuse. Resident #77 and resident #69 had been observed by staff engaging in sexual behavior. Resident #77 was unable to give consent. At that time, OSDH verified an immediate jeopardy situation existed related to the facility's failure to prevent abuse and protect the residents after allegations of abuse. An emergency department physician documentation form for resident #77, dated 04/09/17 at 2:20 p.m., was reviewed. The form documented the physician's primary impression was sexual assault. The form documented resident #77 was sent to the emergency department for a sexual assault nurse examiner (SANE) exam. The form documented the physician comments as SANE nurse on call notified and Police sent to nursing home to make report. discharged for SANE exam. A police incident report for resident #77, dated 04/09/16 at 2:24 p.m., was reviewed. The report indicated the incident status was active from 04/08/17 at 7:30 p.m. The report documented the offense as sexual battery. On 04/13/17 at 5:06 p.m., the administrator (adm) and the director of nursing (DON) were notified of an immediate jeopardy situation regarding an incident which occurred on 04/08/17 for an allegation of sexual abuse perpetrated by resident #69 against resident #77 which was not reported to the facility administration. The facility failed to protect resident #77 from further abuse as a second incident occurred on 04/09/17. The adm and DON were informed the IJ was related to the facility's failure to prevent and protect residents after an allegation of sexual abuse. On 04/13/17 at 8:05 p.m., the administrator provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: 04/13/17 Plan of Removal of Immediacy of IJ 1) The Administrator, DON, assistant DON, and the administrative consultant will inservice all employees on the abuse policy with the emphasis of reporting immediately to the charge nurse/and or the DON and Administrator, and to the Oklahoma State Department of Health within 2 hours, protecting the residents, and timely investigation. A copy of the abuse policy will be provided to each employee. An acknowledgement of the abuse policy will be signed by each employee. Any employee that was not inserviced in person or by telephone, will not be allowed to work until the inservice has been conducted and the acknowledgement has been signed. The staff will be instructed on the type of supervision provided to (name deleted, (resident #77)) and (name deleted, (resident #69)) and the specific things to document. 2) Both residents (resident names deleted, (#69 and #77)) will be placed on 1:1 supervision which will be full visualization at all times. The observations will be conducted by a nursing staff member in attendance at the nurse's station, in the resident room, in the lobby, or in the dining room. The staff have been instructed to document the resident's location and activity at the designated times every 15 minutes. One on one observations will continue until psych evaluations are conducted on (names deleted, (residents #77 and #69)). 3) The RN will identify all other residents that could be at risk for sexual abuse. The completion time for the inservices will be no later than 11:59 p.m. 04/13/17. On 04/14/17, between 9:40 a.m. and 10:40 a.m., facility nursing staff was interviewed regarding the facility's policy on abuse and monitoring of resident #69 and resident #77. The nursing staff verbalized understanding. The facility documented 14 residents who were assessed as having an increased risk for abuse. The administrator was informed the immediacy had been lifted effective 04/13/17 at 11:00 p.m. when all components of the plan of removal had been completed. The administrator was informed the deficiency remained at a harm level at a pattern and the facility remained in substandard quality of care. Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from sexual abuse for one (#77) of 35 residents sampled for abuse and neglect. The facility failed to prevent sexual abuse perpetrated by resident #69 against resident #77. The facility failed to: a) Prevent abuse for resident #77. b) Protect resident #77 from further abuse after an allegation of abuse had been made. c) Investigate the allegation of abuse for resident #77. d) Report to the facility administration, the physician, family, and OSDH following an allegation of sexual abuse. An emergency department physician documentation form for resident #77, dated 04/09/17 at 2:20 p.m., was reviewed. The form documented the physician's primary impression was sexual assault. The form documented resident #77 was sent to the emergency department for a sexual assault nurse examiner (SANE) exam. The form documented the physician comments as SANE nurse on call notified and Police sent to nursing home to make report. discharged for SANE exam. A police incident report for resident #77, dated 04/09/16 at 2:24 p.m., was reviewed. The report indicated the incident status was active from 04/08/17 at 7:30 p.m. The report documented the offense as sexual battery. The administrator identified a census of 67 residents. Findings: The facility policy titled Management of Suspected Abuse/Neglect documented the facility prohibited mistreatment, neglect, or abuse of residents. The policy documented residents had the right to be free from verbal, sexual, physical, or mental abuse. The policy documented all reported incidents of sexual abuse were to be reported promptly and investigated thoroughly. The policy documented the following protocol was to be used: 1. Immediately contact the Director of Nursing, Administrator and the resident's physician. 2. Director of Nursing or Administrator will contact the police department. 3. Assess the resident for possible injury. 4. Provide the resident with emotional support. 5. Do Not shower, bathe, or change resident's clothing. (NOTE: if clothes have been changed, bag the clothes in accordance with instructions from law enforcement officials.) 6. Do not disturb the location where the alleged rape took place, prepare the resident for transfer to the hospital examination, and 7. In consultation with police, continue the facility's investigation of the incident in accordance with established policy. 1. Resident #77 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/15/16, documented resident #77 was severely impaired with cognitive skills. The assessment documented the resident had a behavior of inattention continuously and was able to walk without assistance. The assessment documented the resident was continent of bowel and bladder and received an antidepressant medication for seven days during the seven day assessment period. An annual assessment, dated 03/15/17, documented resident #77 was severely impaired with cognitive skills. The assessment documented the resident had no behaviors. The assessment documented the resident was able to walk without assistance. The assessment documented the resident was continent of bowel and bladder and had received an antidepressant medication for seven days during the seven day assessment period. The care plan, dated 03/24/17, documented resident #77 would ambulate throughout the facility and into other residents' rooms at times but was easily redirected. The care plan documented the resident was at risk for behaviors, falls, and confusion. The care plan, dated 03/25/17, documented resident #77 had a [DIAGNOSES REDACTED]. A nursing note, dated 04/08/17 at 8:00 p.m. as a late entry (documented on 04/09/17 at 1:59 p.m.), documented resident #77 was found by an unidentified certified nursing aide (CNA) in bed with a male resident (resident #69) and the male resident was kissing resident #77. The nurse note documented the CNA told the nurse she redirected resident #77 out of the male resident's room. The note documented the nurse spoke with the male resident and told him the female resident was unable to make decisions and the male resident verbalized he understood. The note documented both residents would be on continuous supervision. The 24 hour report sheet for 04/08/17 was reviewed. The report for resident #77 documented see nurse note for the 6-2 shift, and continuous supervision for the 2-10 shift, and a check mark for the 10-6 shift. The report for resident #69 documented, OK for the 6-2 and 2-10 shift, and a check mark for the 10-6 shift. The 24 hour shift report, dated 04/09/17, for resident #77 documented, OK for the 6-2 and 2-10 shift, and a check mark for the 10-6 shift. The report for resident #69 documented see nurse note for the 6-2 shift, moved to room . for the 2-10 shift and a check mark for the 10-6 shift. A nurse note, dated 04/09/17 at 12:00 p.m., documented the nurse was notified by an unidentified CNA the male resident was in resident #77's room standing over her and resident #77's shirt was pulled up. The note documented the male resident was not touching resident #77. The note documented the CNA asked the male resident what he was doing and the male resident replied he gave resident #77 a kiss. The note documented the nurse redirected the male resident and told him he was not allowed in resident #77's room. The note documented the nurse told the male resident (resident #69) resident #77 was unable to make decisions for herself. The note documented during this incident, a second unidentified CNA reported to the nurse resident #69 had been in bed kissing resident #77 and had his hands were in resident #77's pants on 04/08/17. The note documented the nurse did not recall being told the male resident had his hands in resident #77's pants. The note documented resident #77 was unable to recall the incident. The note documented the male resident was spoken with regarding the prior incident but denied placing his hands inside resident #77's pants. The note documented the male resident stated he gave resident #77 a kiss. The note documented the nurse notified the administrator, DON, and resident #77's primary care provider. The note documented the nurse and another nurse examined resident #77 and found no bleeding, bruising, or tearing. The note documented resident #77's primary care provider was notified and the resident was sent to the emergency room of the local hospital for evaluation. The note documented resident #77's daughter was notified. A nurse note, dated 04/09/17 at 12:01 p.m., documented resident #77 had received her scheduled shower on the previous night. A care plan for resident #77, dated 04/09/17, documented the events described in the nurse note, dated 04/09/17 at 12:00 p.m. The documented goal for the care plan was for the resident not to be involved in inappropriate sexual behaviors for the next 90 days. The care plan documented one approach was continuous monitoring. An emergency department physician documentation form for resident #77, dated 04/09/17 at 2:20 p.m., was reviewed. The form documented the physician's primary impression was sexual assault. The form documented resident #77 was sent to the emergency department for a sexual assault nurse examiner (SANE) exam. The form documented the physician comments as SANE nurse on call notified and Police sent to nursing home to make report. discharged for SANE exam. A police incident report for resident #77, dated 04/09/16 at 2:24 p.m., was reviewed. The report indicated the incident status was active from 04/08/17 at 7:30 p.m. The report documented the offense as sexual battery. A nursing progress note for resident #77, dated 04/09/17 at 4:44 p.m., documented at 3:00 p.m. an officer from the local police department arrived at the facility. The note documented the officer reported he was unable to interview resident #77 due to her mental status. A nursing progress note, dated 04/09/17 at 4:56 p.m., documented resident #77 was returned to the facility accompanied by her son. The note documented the son stated all the tests came back negative and there was no sign of sexual abuse. A fax transmission report, dated 04/09/17 at 5:58 p.m., documented OSDH had been notified of the incident. The initial report documented the date of the incident as 04/09/17. A nursing progress note, dated 04/10/17 at 4:39 a.m., documented resident #77 was checked every 30 minutes. A nursing progress note, dated 04/11/17 at 4:00 a.m., documented resident #77 was checked every 30 minutes. A nursing progress note, dated 04/12/17 at 12:22 p.m., documented resident #77 was up and about the facility and was redirected when she attempted to enter other residents' rooms. On 04/13/17 at 11:02 a.m., the facility ombudsman notified the survey team the son of resident #77 had reported to another state agency his mother had been sexually assaulted by another resident. On 04/13/17 at 12:02 p.m., resident #77 was observed in her room on her bed. On 04/13/17 at 12:50 p.m., LPN #5 was interviewed regarding the incidents. The LPN stated she reported to work at 2:00 p.m. on 04/09/17 and had been given a report informing her resident #69 (the male resident) had been moved to another hall due to inappropriately touching resident #77. The LPN reported she was told by LPN #2 to monitor resident #69. The LPN was asked how often she was to monitor resident #69. The LPN reported she was not told how often she was to monitor the resident. The LPN reported she saw resident #69 up and down the halls but she did not follow him. The LPN stated anytime she looked for resident #69, she found him either in his room or in the smoking room. On 04/13/17 at 1:44 p.m., LPN #2 was contacted by phone and interviewed regarding the incidents on 04/08/17 and 04/09/17. The LPN reported an incident involving resident #69 and resident #77. The LPN reported she was told about the two incidents by CNA #2 and CNA #3. The LPN reported the incidents were reported to her around lunch time or after. The phone disconnected at that time. On 04/13/17 at 1:49 p.m., LPN #2 was recalled. The LPN was asked what was reported to her by CNA #2. The LPN reported she was trying to remember and thought it was about resident #69 had resident #77 in her room and touched her inappropriately. The LPN reported there was another incident on Sunday (04/09/17). The LPN was asked what was reported to her about Saturday (04/08/17). The LPN stated she was told resident #77 was in the room of resident #69 who was standing over her with his hands in her pants or on her pants and he leaned over and gave her a kiss. The LPN was asked if she was told about this on Saturday the 8th or Sunday the 9th. The LPN stated CNA #2 reported she told her on the 8th, but she didn't remember anything except being told resident #77 was in the room of resident #69. The LPN was asked about the incident reported to her by CNA #3. The LPN reported the CNA told her on Sunday (04/09/17) she walked into the room of resident #77 and found resident #69 standing at the bedside of resident #77. The LPN reported the CNA had said the shirt of resident #77 was lifted up exposing her stomach area. The LPN reported the CNA told her she asked resident #69 what he was doing and he said he gave resident #77 a kiss. The LPN reported when she was informed of this, she spoke with resident #69 and told him he could not be in resident #77's room. The LPN reported resident #69 resided in a room across the hall from resident #77 and was subsequently moved to another hall on the other side of the facility. The LPN stated she called the DON and was instructed to notify the primary care provider for resident #77, conduct a physical assessment of resident #77, and then re-call the primary care provider with her findings. The LPN was asked how she examined the resident. The LPN reported she and another nurse conducted a full head to toe assessment on the resident and looked for any vaginal tearing, bruising, or any drainage. The LPN reported she contacted resident #77's daughter. The LPN stated the DON and the administrator told her to notify the physician, send resident #77 to the hospital if the resident's primary care provider ordered it, and to monitor both of the residents involved in the incidents at all times. The LPN was asked what monitor meant. The LPN reported it meant the residents were not to have contact with each other. The LPN was asked how she ensured the residents did not have contact. The LPN reported the room of resident #77 was near the nursing station and the CNAs were instructed to observe both residents to make sure they did not have contact with each other. The LPN reported the residents were never out of visual sight. The LPN reported resident #77 was either in her room, near the nursing station, or in the lobby in front of the nursing station. The LPN was asked what kind of supervision resident #69 received. The LPN reported his room was observed at all times and if he went to the smoke room, he was followed. On 04/13/17 at 2:19 p.m., CNA #2 was interviewed by phone. The CNA stated she worked on 04/08/17 and 04/09/17. The CNA was asked about the incident on 04/08/17. The CNA stated at approximately 7:00 p.m., while she was picking up dinner trays, she entered the room of resident #69 and found him leaning over resident #77 who was lying on the first bed near the door. The CNA reported resident #69 was kissing resident #77 and had his hand down the front of resident #77's pants and was making a rubbing motion. The CNA reported when she entered the room, resident #69 removed his hand from resident #77's pants. The CNA stated she reported the incident to LPN #2. The CNA stated the LPN spoke with resident #69, told him resident #77 was not in her right mind, and he could not do that. The CNA was asked what she was instructed to do after the incident. The CNA reported she was told to keep an eye on them and keep them separated. The CNA reported the residents lived across the hall from each other at that time. The CNA reported resident #69 was moved to another hall the next day after lunch. The CNA stated he was moved because another CNA had found resident #69 in the room of resident #77 and resident #69 was standing over resident #77 and her shirt was pulled up. The CNA reported the other CNA told LPN #2 of the second incident and resident #69 was moved. On 04/13/17 at 2:40 p.m., CNA #3 was interviewed by phone. The CNA reported she worked on the weekend of 04/08/17 and 04/09/17 on the 6:00 a.m. to 10:00 p.m. shift. The CNA stated she witnessed resident to resident abuse on Sunday 04/09/17 at approximately noon. The CNA reported she entered the room of resident #77 and found the curtain covering the resident's side of the room to be pulled covering the resident's bed from view. The CNA reported she saw resident #69 standing at the bedside of resident #77 who was lying on her bed. The CNA stated resident #77 was holding the bottom of her shirt which was pulled up exposing her abdomen. The CNA stated resident #69 said all he did was kiss her. The CNA stated resident #69 left the room and went to the smoke room. The CNA was asked if she reported the incident. The CNA stated she reported it to LPN #2. The CNA stated resident #69 was moved to another hall at that time. The CNA was asked if she was instructed to monitor the residents. The CNA stated they were to try to keep resident #69 away from resident #77 and to watch them to make sure they were not together. The CNA stated resident #69 tried to come back to the hall where resident #77 resided stating he needed towels. The CNA reported an unidentified male CNA got towels for the resident. The CNA was asked if he tried to come back again. The CNA reported later on the same day resident #69 and #77 were walking in the hall of resident #69 and resident #77 grabbed the shirt of resident #69 and he shrugged her off. The CNA was asked if there had been any other incidents regarding residents #69 and #77. The CNA reported she was told about an incident the day before and there had been rumors by the aides where there was suspicion of resident #69 and #77 messing together. On 04/13/17 at 5:18 p.m., LPN #6 was asked how resident #69 and resident #77 were to be monitored. She said she was supposed to know their whereabouts at all times. She stated she was told in the stand up meeting on 04/10/17 to know where resident #69 was every 30 minutes but was told by LPN #5 it did not have to be every 30 minutes. On 04/13/17 at 5:23 p.m., resident #77 was observed walking in the hall. An unidentified staff member was observed to approach her, took her hand, and directed the resident into an office. The facility provided documentation the resident received a psychiatric evaluation by an advanced practice registered nurse-certified nurse practitioner on 04/14/17 at 7:30 a.m. On 04/14/17 at 8:40 a.m., the resident was observed in her room eating breakfast. An unidentified staff member was present at her bedside. On 04/14/17 at 10:57 a.m., the DON was interviewed regarding the sexual abuse allegation. The DON stated she was unaware of the incident on 04/08/17 until Sunday 04/09/17 during the evening around 7:00 p.m. She stated she was not aware of the two hour reporting regulation. On 04/14/17 at 11:06 a.m., the adm was interviewed regarding the sexual abuse allegation. The adm stated she was not aware of the incident on 04/08/17 until around 5:00 to 6:00 p.m. on 04/09/17. She said she was aware of the two hour reporting regulation. 2. Resident #69 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A significant change assessment, dated 11/17/16, documented the resident was cognitively intact and had no signs or symptoms of [MEDICAL CONDITION]. The assessment documented the resident exhibited no behaviors during the assessment period. The assessment documented the resident was independent with most activities of daily living (ADLs) and required set-up and supervision with toilet use, bathing, and personal hygiene. A care plan, dated 01/25/17, documented a problem of behaviors. The care plan documented the resident pushed another resident (name deleted), who was wheelchair bound, up behind a nurse in order for the resident to grab the nurse's buttocks. The care plan documented the residents went down the hall laughing. The goal for the care plan was for the resident not to engage in or encourage another resident to engage in inappropriate behavior towards caregivers. A quarterly assessment, dated 02/16/17, documented the resident was cognitively intact. The assessment documented the resident was independent with most ADLs and required supervision with eating, and set-up and supervision with bathing. A nurse progress note, dated 04/09/17, documented the resident was interviewed by an officer of the local police department. The note documented the police officer informed the nurse the resident stated the female resident was in his roommate's bed on 04/08/17. The note documented the resident told the officer he did not put his hand down resident #77's pants. The note documented the officer said the resident told him he leaned down to kiss the female resident and his hand was on her stomach when the unidentified CNA walked in. The note documented the resident remained on continuous monitoring. A nurse progress note, dated 04/09/17 at 11:54 p.m., documented a late entry for 04/08/17 for the 10 p.m., to 6 a.m. shift by LPN #3. The note documented the resident would get up occasionally and walk to the lobby or nurses' station for a snack. The note documented the resident was on two hour room checks. A nurse progress note, dated 04/10/17 at 12:05 p.m., documented the resident was on 30 minute checks and as needed. A nurse progress note, dated 04/10/17 at 6:51 p.m., documented the staff were continuing to monitor the resident's whereabouts every 30 minutes. On 04/11/17 at 3:56 p.m., the resident was observed smoking in the smoke room. A nurse progress note, dated 04/12/17 at 4:03 a.m., documented the resident was checked every 30 minutes and had no complaints of pain or discomfort. A nurse progress note, dated 04/13/17 at 5:01 a.m., documented the resident's location was monitored at all times and was noted to remain in authorized areas. The facility provided documentation the resident received a psychiatric evaluation by an advanced practice registered nurse-certified nurse practitioner on 04/14/17 at 8:30 a.m. On 04/14/17 at 9:45 a.m., the resident was observed sitting in the lobby in front of the nursing station watching television and an unidentified staff member was present beside him. On 04/14/17 at 10:15 a.m., the resident was observed in the dining room participating in an exercise class which was conducted by the activity director.

On 04/13/17 at 4:54 p.m., the Oklahoma State Department of Health (OSDH) was notified an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to thoroughly investigate and report to the facility administration, the physician, family, and OSDH allegations of sexual abuse and failure to prevent further abuse for resident #77. Resident #77 and resident #69 had been observed by staff engaging in sexual behavior. Resident #77 was unable to give consent. An emergency department physician documentation form, dated 04/09/17 at 2:20 p.m., was reviewed. The form documented the physician's primary impression was sexual assault. The form documented the resident was sent to the emergency department for a sexual assault nurse examiner (SANE) exam. The form documented the physician comments as SANE nurse on call notified and Police sent to nursing home to make report. discharged for SANE exam. A police incident report, dated 04/09/16 at 2:24 p.m., was reviewed. The report indicated the incident status was active from 04/08/17 at 7:30 p.m. The report documented the offense as sexual battery. At that time, OSDH verified an immediate jeopardy situation existed related to the facility's failure to thoroughly investigate and report allegations of abuse and to protect resident #77 from further abuse. On 04/13/17 at 5:06 p.m., the administrator (adm) and the director of nursing (DON) were notified of an immediate jeopardy situation regarding an incident which occurred on 04/08/17 for an allegation of sexual abuse perpetrated by resident #69 against resident #77 which was not reported to the facility administration and not thoroughly investigated. The facility failed to protect resident #77 from further abuse as a second incident occurred on 04/09/17. On 04/13/17 at 8:05 p.m., the administrator provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: 04/13/17 Plan of Removal of Immediacy of IJ 1) The Administrator, DON, assistant DON, and the administrative consultant will inservice all employees on the abuse policy with the emphasis of reporting immediately to the charge nurse/and or the DON and Administrator, and to the Oklahoma State Department of Health within 2 hours, protecting the residents, and timely investigation. A copy of the abuse policy will be provided to each employee. An acknowledgement of the abuse policy will be signed by each employee. Any employee that was not inserviced in person or by telephone, will not be allowed to work until the inservice has been conducted and the acknowledgement has been signed. The staff will be instructed on the type of supervision provided to (name deleted, (resident # 77)) and (name deleted, (resident #69)) and the specific things to document. 2) Both residents (resident names deleted, (#69 and #77)) will be placed on 1:1 supervision which will be full visualization at all times. The observations will be conducted by a nursing staff member in attendance at the nurse's station, in the resident room, in the lobby, or in the dining room. The staff have been instructed to document the resident's location and activity at the designated times every 15 minutes. One on one observations will continue until psych evaluations are conducted on (names deleted, (residents #77 and #69)). 3) The RN will identify all other residents that could be at risk for sexual abuse. The completion time for the inservices will be no later than 11:59 p.m. 04/13/17. On 04/14/17 between 9:40 a.m. and 10:40 a.m., facility nursing staff was interviewed regarding the facility's policy on abuse and monitoring of resident #69 and resident #77. The nursing staff verbalized understanding. The facility documented 14 residents who were assessed as having an increased risk for abuse. The administrator was informed the immediacy had been lifted effective 04/13/17 at 11:00 p.m. when all components of the plan of removal had been completed. The administrator was informed the deficiency remained at a harm level at a pattern and the facility remained in substandard quality of care. Based on observation, interview, and record review, it was determined the facility failed to thoroughly investigate and report allegations of abuse to the administration, physician, family, and OSDH and failed to protect residents from further abuse for one (#77) of 35 residents sampled for abuse and neglect. The facility failed to thoroughly investigate and report allegations of sexual abuse perpetrated by resident #69 against resident #77 to the administration, physician, family, and OSDH and failed to protect resident #77 from further abuse by resident #69. An emergency department physician documentation form, dated 04/09/17 at 2:20 p.m., was reviewed. The form documented the physician's primary impression was sexual assault. The form documented the resident was sent to the emergency department for a sexual assault nurse examiner (SANE) exam. The form documented the physician comments as SANE nurse on call notified and Police sent to nursing home to make report. discharged for SANE exam. A police incident report, dated 04/09/16 at 2:24 p.m., was reviewed. The report indicated the incident status was active from 04/08/17 at 7:30 p.m. The report documented the offense as sexual battery. The administrator identified a census of 67 residents. Findings: The facility policy titled Management of Suspected Abuse/Neglect documented the facility prohibited mistreatment, neglect, or abuse of residents. The policy documented residents had the right to be free from verbal, sexual, physical, or mental abuse. The policy documented all reported incidents of sexual abuse were to be reported promptly and investigated thoroughly. The policy documented the following protocol was to be used: 1. Immediately contact the Director of Nursing, Administrator and the resident's physician. 2. Director of Nursing or Administrator will contact the police department. 3. Assess the resident for possible injury. 4. Provide the resident with emotional support. 5. Do Not shower, bathe, or change resident's clothing. (NOTE: if clothes have been changed, bag the clothes in accordance with instructions from law enforcement officials.) 6. Do not disturb the location where the alleged rape took place, prepare the resident for transfer to the hospital examination, and 7. In consultation with police, continue the facility's investigation of the incident in accordance with established policy. 1. Resident #77 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/15/16, documented resident #77 was severely impaired with cognitive skills. The assessment documented the resident had a behavior of inattention continuously and was able to walk without assistance. The assessment documented the resident was continent of bowel and bladder and received an antidepressant medication for seven days during the seven day assessment period. An annual assessment, dated 03/15/17, documented resident #77 was severely impaired with cognitive skills. The assessment documented the resident had no behaviors. The assessment documented the resident was able to walk without assistance. The assessment documented the resident was continent of bowel and bladder and had received an antidepressant medication for seven days during the seven day assessment period. The care plan, dated 03/24/17, documented resident #77 would ambulate throughout the facility and into other residents' rooms at times but was easily redirected. The care plan documented the resident was at risk for behaviors, falls, and confusion. The care plan, dated 03/25/17, documented resident #77 had a [DIAGNOSES REDACTED]. A nursing note, dated 04/08/17 at 8:00 p.m. as a late entry (documented on 04/09/17 at 1:59 p.m.), documented resident #77 was found by an unidentified certified nursing aide (CNA) in bed with a male resident (resident #69) and the male resident was kissing resident #77. The nurse note documented the CNA told the nurse she redirected resident #77 out of the male resident's room. The note documented the nurse spoke with the male resident and told him the female resident was unable to make decisions and the male resident verbalized he understood. The note documented both residents would be on continuous supervision. The 24 hour report sheet for 04/08/17 was reviewed. The report for resident #77 documented see nurse note for the 6-2 shift, and continuous supervision for the 2-10 shift, and a check mark for the 10-6 shift. The report for resident #69 documented, OK for the 6-2 and 2-10 shift, and a check mark for the 10-6 shift. The 24 hour shift report, dated 04/09/17, for resident #77 documented, OK for the 6-2 and 2-10 shift, and a check mark for the 10-6 shift. The report for resident #69 documented see nurse note for the 6-2 shift, moved to room . for the 2-10 shift and a check mark for the 10-6 shift. A nurse note, dated 04/09/17 at 12:00 p.m., documented the nurse was notified by an unidentified CNA the male resident was in resident #77's room standing over her and resident #77's shirt was pulled up. The note documented the male resident was not touching resident #77. The note documented the CNA asked the male resident what he was doing and the male resident replied he gave resident #77 a kiss. The note documented the nurse redirected the male resident and told him he was not allowed in resident #77's room. The note documented the nurse told the male resident (resident #69) resident #77 was unable to make decisions for herself. The note documented during this incident, a second unidentified CNA reported to the nurse resident #69 had been in bed kissing resident #77 and had his hands were in resident #77's pants on 04/08/17. The note documented the nurse did not recall being told the male resident had his hands in resident #77's pants. The note documented resident #77 was unable to recall the incident. The note documented the male resident was spoken with regarding the prior incident but denied placing his hands inside resident #77's pants. The note documented the male resident stated he gave resident #77 a kiss. The note documented the nurse notified the administrator, DON, and resident #77's primary care provider. The note documented the nurse and another nurse examined resident #77 and found no bleeding, bruising, or tearing. The note documented resident #77's primary care provider was notified and the resident was sent to the emergency room of the local hospital for evaluation. The note documented resident #77's daughter was notified. A nurse note, dated 04/09/17 at 12:01 p.m., documented resident #77 had received her scheduled shower on the previous night. A care plan for resident #77, dated 04/09/17, documented the events described in the nurse note, dated 04/09/17 at 12:00 p.m. The documented goal for the care plan was for the resident not to be involved in inappropriate sexual behaviors for the next 90 days. The care plan documented one approach was continuous monitoring. An emergency department physician documentation form for resident #77, dated 04/09/17 at 2:20 p.m., was reviewed. The form documented the physician's primary impression was sexual assault. The form documented resident #77 was sent to the emergency department for a sexual assault nurse examiner (SANE) exam. The form documented the physician comments as SANE nurse on call notified and Police sent to nursing home to make report. discharged for SANE exam. A police incident report for resident #77, dated 04/09/16 at 2:24 p.m., was reviewed. The report indicated the incident status was active from 04/08/17 at 7:30 p.m. The report documented the offense as sexual battery. A nursing progress note for resident #77, dated 04/09/17 at 4:44 p.m., documented at 3:00 p.m. an officer from the local police department arrived at the facility. The note documented the officer reported he was unable to interview resident #77 due to her mental status. A nursing progress note, dated 04/09/17 at 4:56 p.m., documented resident #77 was returned to the facility accompanied by her son. The note documented the son stated all the tests came back negative and there was no sign of sexual abuse. A fax transmission report, dated 04/09/17 at 5:58 p.m., documented OSDH had been notified of the incident. The initial report documented the date of the incident as 04/09/17. A nursing progress note, dated 04/10/17 at 4:39 a.m., documented resident #77 was checked every 30 minutes. A nursing progress note, dated 04/11/17 at 4:00 a.m., documented resident #77 was checked every 30 minutes. A nursing progress note, dated 04/12/17 at 12:22 p.m., documented resident #77 was up and about the facility and was redirected when she attempted to enter other residents' rooms. On 04/13/17 at 11:02 a.m., the facility ombudsman notified the survey team the son of resident #77 had reported to another state agency his mother had been sexually assaulted by another resident. On 04/13/17 at 12:02 p.m., resident #77 was observed in her room on her bed. On 04/13/17 at 12:50 p.m., LPN #5 was interviewed regarding the incidents. The LPN stated she reported to work at 2:00 p.m. on 04/09/17 and had been given a report informing her resident #69 (the male resident) had been moved to another hall due to inappropriately touching resident #77. The LPN reported she was told by LPN #2 to monitor resident #69. The LPN was asked how often she was to monitor resident #69. The LPN reported she was not told how often she was to monitor the resident. The LPN reported she saw resident #69 up and down the halls but she did not follow him. The LPN stated anytime she looked for resident #69, she found him either in his room or in the smoking room. On 04/13/17 at 1:44 p.m., LPN #2 was contacted by phone and interviewed regarding the incidents on 04/08/17 and 04/09/17. The LPN reported an incident involving resident #69 and resident #77. The LPN reported she was told about the two incidents by CNA #2 and CNA #3. The LPN reported the incidents were reported to her around lunch time or after. The phone disconnected at that time. On 04/13/17 at 1:49 p.m., LPN #2 was recalled. The LPN was asked what was reported to her by CNA #2. The LPN reported she was trying to remember and thought it was about resident #69 had resident #77 in her room and touched her inappropriately. The LPN reported there was another incident on Sunday (04/09/17). The LPN was asked what was reported to her about Saturday (04/08/17). The LPN stated she was told resident #77 was in the room of resident #69 who was standing over her with his hands in her pants or on her pants and he leaned over and gave her a kiss. The LPN was asked if she was told about this on Saturday the 8th or Sunday the 9th. The LPN stated CNA #2 reported she told her on the 8th, but she didn't remember anything except being told resident #77 was in the room of resident #69. The LPN was asked about the incident reported to her by CNA #3. The LPN reported the CNA told her on Sunday (04/09/17) she walked into the room of resident #77 and found resident #69 standing at the bedside of resident #77. The LPN reported the CNA had said the shirt of resident #77 was lifted up exposing her stomach area. The LPN reported the CNA told her she asked resident #69 what he was doing and he said he gave resident #77 a kiss. The LPN reported when she was informed of this, she spoke with resident #69 and told him he could not be in resident #77's room. The LPN reported resident #69 resided in a room across the hall from resident #77 and was subsequently moved to another hall on the other side of the facility. The LPN stated she called the DON and was instructed to notify the primary care provider for resident #77, conduct a physical assessment of resident #77, and then re-call the primary care provider with her findings. The LPN was asked how she examined the resident. The LPN reported she and another nurse conducted a full head to toe assessment on the resident and looked for any vaginal tearing, bruising, or any drainage. The LPN reported she contacted resident #77's daughter. The LPN stated the DON and the administrator told her to notify the physician, send resident #77 to the hospital if the resident's primary care provider ordered it, and to monitor both of the residents involved in the incidents at all times. The LPN was asked what monitor meant. The LPN reported it meant the residents were not to have contact with each other. The LPN was asked how she ensured the residents did not have contact. The LPN reported the room of resident #77 was near the nursing station and the CNAs were instructed to observe both residents to make sure they did not have contact with each other. The LPN reported the residents were never out of visual sight. The LPN reported resident #77 was either in her room, near the nursing station, or in the lobby in front of the nursing station. The LPN was asked what kind of supervision resident #69 received. The LPN reported his room was observed at all times and if he went to the smoke room, he was followed. On 04/13/17 at 2:19 p.m., CNA #2 was interviewed by phone. The CNA stated she worked on 04/08/17 and 04/09/17. The CNA was asked about the incident on 04/08/17. The CNA stated at approximately 7:00 p.m., while she was picking up dinner trays, she entered the room of resident #69 and found him leaning over resident #77 who was lying on the first bed near the door. The CNA reported resident #69 was kissing resident #77 and had his hand down the front of resident #77's pants and was making a rubbing motion. The CNA reported when she entered the room, resident #69 removed his hand from resident #77's pants. The CNA stated she reported the incident to LPN #2. The CNA stated the LPN spoke with resident #69, told him resident #77 was not in her right mind, and he could not do that. The CNA was asked what she was instructed to do after the incident. The CNA reported she was told to keep an eye on them and keep them separated. The CNA reported the residents lived across the hall from each other at that time. The CNA reported resident #69 was moved to another hall the next day after lunch. The CNA stated he was moved because another CNA had found resident #69 in the room of resident #77 and resident #69 was standing over resident #77 and her shirt was pulled up. The CNA reported the other CNA told LPN #2 of the second incident and resident #69 was moved. On 04/13/17 at 2:40 p.m., CNA #3 was interviewed by phone. The CNA reported she worked on the weekend of 04/08/17 and 04/09/17 on the 6:00 a.m. to 10:00 p.m. shift. The CNA stated she witnessed resident to resident abuse on Sunday 04/09/17 at approximately noon. The CNA reported she entered the room of resident #77 and found the curtain covering the resident's side of the room to be pulled covering the resident's bed from view. The CNA reported she saw resident #69 standing at the bedside of resident #77 who was lying on her bed. The CNA stated resident #77 was holding the bottom of her shirt which was pulled up exposing her abdomen. The CNA stated resident #69 said all he did was kiss her. The CNA stated resident #69 left the room and went to the smoke room. The CNA was asked if she reported the incident. The CNA stated she reported it to LPN #2. The CNA stated resident #69 was moved to another hall at that time. The CNA was asked if she was instructed to monitor the residents. The CNA stated they were to try to keep resident #69 away from resident #77 and to watch them to make sure they were not together. The CNA stated resident #69 tried to come back to the hall where resident #77 resided stating he needed towels. The CNA reported an unidentified male CNA got towels for the resident. The CNA was asked if he tried to come back again. The CNA reported later on the same day resident #69 and #77 were walking in the hall of resident #69 and resident #77 grabbed the shirt of resident #69 and he shrugged her off. The CNA was asked if there had been any other incidents regarding residents #69 and #77. The CNA reported she was told about an incident the day before and there had been rumors by the aides where there was suspicion of resident #69 and #77 messing together. On 04/13/17 at 5:18 p.m., LPN #6 was asked how resident #69 and resident #77 were to be monitored. She said she was supposed to know their whereabouts at all times. She stated she was told in the stand up meeting on 04/10/17 to know where resident #69 was every 30 minutes but was told by LPN #5 it did not have to be every 30 minutes. On 04/13/17 at 5:23 p.m., resident #77 was observed walking in the hall. An unidentified staff member was observed to approach her, took her hand, and directed the resident into an office. The facility provided documentation the resident received a psychiatric evaluation by an advanced practice registered nurse-certified nurse practitioner on 04/14/17 at 7:30 a.m. On 04/14/17 at 8:40 a.m., the resident was observed in her room eating breakfast. An unidentified staff member was present at her bedside. On 04/14/17 at 10:57 a.m., the DON was interviewed regarding the sexual abuse allegation. The DON stated she was unaware of the incident on 04/08/17 until Sunday 04/09/17 during the evening around 7:00 p.m. She stated she was not aware of the two hour reporting regulation. On 04/14/17 at 11:06 a.m., the adm was interviewed regarding the sexual abuse allegation. The adm stated she was not aware of the incident on 04/08/17 until around 5:00 to 6:00 p.m. on 04/09/17. She said she was aware of the two hour reporting regulation. 2. Resident #69 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A significant change assessment, dated 11/17/16, documented the resident was cognitively intact and had no signs or symptoms of [MEDICAL CONDITION]. The assessment documented the resident exhibited no behaviors during the assessment period. The assessment documented the resident was independent with most activities of daily living (ADLs) and required set-up and supervision with toilet use, bathing, and personal hygiene. A care plan, dated 01/25/17, documented a problem of behaviors. The care plan documented the resident pushed another resident (name deleted), who was wheelchair bound, up behind a nurse in order for the resident to grab the nurse's buttocks. The care plan documented the residents went down the hall laughing. The goal for the care plan was for the resident not to engage in or encourage another resident to engage in inappropriate behavior towards caregivers. A quarterly assessment, dated 02/16/17, documented the resident was cognitively intact. The assessment documented the resident was independent with most ADLs and required supervision with eating, and set-up and supervision with bathing. A nurse progress note, dated 04/09/17, documented the resident was interviewed by an officer of the local police department. The note documented the police officer informed the nurse the resident stated the female resident was in his roommate's bed on 04/08/17. The note documented the resident told the officer he did not put his hand down resident #77's pants. The note documented the officer said the resident told him he leaned down to kiss the female resident and his hand was on her stomach when the unidentified CNA walked in. The note documented the resident remained on continuous monitoring. A nurse progress note, dated 04/09/17 at 11:54 p.m., documented a late entry for 04/08/17 for the 10 p.m., to 6 a.m. shift by LPN #3. The note documented the resident would get up occasionally and walk to the lobby or nurses' station for a snack. The note documented the resident was on two hour room checks. A nurse progress note, dated 04/10/17 at 12:05 p.m., documented the resident was on 30 minute checks and as needed. A nurse progress note, dated 04/10/17 at 6:51 p.m., documented the staff were continuing to monitor the resident's whereabouts every 30 minutes. On 04/11/17 at 3:56 p.m., the resident was observed smoking in the smoke room. A nurse progress note, dated 04/12/17 at 4:03 a.m., documented the resident was checked every 30 minutes and had no complaints of pain or discomfort. A nurse progress note, dated 04/13/17 at 5:01 a.m., documented the resident's location was monitored at all times and was noted to remain in authorized areas. The facility provided documentation the resident received a psychiatric evaluation by an advanced practice registered nurse-certified nurse practitioner on 04/14/17 at 8:30 a.m. On 04/14/17 at 9:45 a.m., the resident was observed sitting in the lobby in front of the nursing station watching television and an unidentified staff member was present beside him. On 04/14/17 at 10:15 a.m., the resident was observed in the dining room participating in an exercise class which was conducted by the activity director.

On 04/13/17 at 4:54 p.m., the Oklahoma State Department of Health (OSDH) was notified an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to develop and/or implement abuse prevention policies and procedures to ensure residents were free from abuse. The the facility failed to prevent, investigate, and report to the facility administration, the physician, family, and OSDH following an allegation of sexual abuse for resident #77. The facility failed to protect resident #77 from further abuse. Resident #77 and resident #69 had been observed by staff engaging in sexual behavior. Resident #77 was unable to give consent. At that time, OSDH verified an immediate jeopardy situation existed related to the facility's failure to prevent abuse and protect the residents after allegations of abuse. On 04/13/17 at 5:06 p.m., the administrator (adm) and the director of nursing (DON) were notified of an immediate jeopardy situation regarding the facility's failure to develop and/or implement abuse prevention policies and procedures to ensure residents were free from abuse. The adm and DON were informed the IJ was related to the facility's failure to protect, investigate, and report, allegations of sexual abuse and failure to prevent sexual abuse for resident #77. On 04/13/17 at 8:05 p.m., the administrator provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: 04/13/17 Plan of Removal of Immediacy of IJ 1) The Administrator, DON, assistant DON, and the administrative consultant will inservice all employees on the abuse policy with the emphasis of reporting immediately to the charge nurse/and or the DON and Administrator, and to the Oklahoma State Department of Health within 2 hours, protecting the residents, and timely investigation. A copy of the abuse policy will be provided to each employee. An acknowledgement of the abuse policy will be signed by each employee. Any employee that was not inserviced in person or by telephone, will not be allowed to work until the inservice has been conducted and the acknowledgement has been signed. The staff will be instructed on the type of supervision provided to (name deleted, (resident # 77)) and (name deleted, (resident #69)) and the specific things to document. 2) Both residents (resident names deleted, (#69 and #77)) will be placed on 1:1 supervision which will be full visualization at all times. The observations will be conducted by a nursing staff member in attendance at the nurse's station, in the resident room, in the lobby, or in the dining room. The staff have been instructed to document the resident's location and activity at the designated times every 15 minutes. One on one observations will continue until psych evaluations are conducted on (names deleted, (residents #77 and #69)). 3) The RN will identify all other residents that could be at risk for sexual abuse. The completion time for the inservices will be no later than 11:59 p.m. 04/13/17. On 04/14/17 between 9:40 a.m. and 10:40 a.m., facility nursing staff was interviewed regarding the facility's policy on abuse and monitoring of resident #69 and resident #77. The nursing staff verbalized understanding. The facility documented 14 residents who were assessed as having an increased risk for abuse. The administrator was informed the immediacy had been lifted effective 04/13/17 at 11:00 p.m. after all components of the plan of removal had been completed. The administrator was informed the deficiency remained at a harm level at a pattern and the facility remained in substandard quality of care. Based on observation, interview, and record review, it was determined the facility failed to develop and/or implement their abuse policy to prevent abuse, protect residents following allegations of sexual abuse, thoroughly investigate the allegation of abuse, and to notify the administration, physician, and the resident's family for one (#77) of 35 residents sampled for abuse and neglect. The facility failed to notify OSDH within two hours following sexual abuse allegations perpetrated by resident #69 against resident #77. The facility failed to: a) Prevent abuse for resident #77. b) Protect resident #77 from further abuse after an allegation of abuse had been made. c) Investigate the allegation of abuse for resident #77. d) Report to the facility administration, the physician, family, and OSDH following an allegation of sexual abuse. An emergency department physician documentation form for resident #77, dated 04/09/17 at 2:20 p.m., was reviewed. The form documented the physician's primary impression was sexual assault. The form documented resident #77 was sent to the emergency department for a sexual assault nurse examiner (SANE) exam. The form documented the physician comments as SANE nurse on call notified and Police sent to nursing home to make report. discharged for SANE exam. A police incident report for resident #77, dated 04/09/16 at 2:24 p.m., was reviewed. The report indicated the incident status was active from 04/08/17 at 7:30 p.m. The report documented the offense as sexual battery. The administrator identified a census of 67 residents. Findings: The facility policy titled Management of Suspected Abuse/Neglect documented the facility prohibited mistreatment, neglect, or abuse of residents. The policy documented residents had the right to be free from verbal, sexual, physical, or mental abuse. The policy documented all reported incidents of sexual abuse were to be reported promptly and investigated thoroughly. The policy documented the following protocol was to be used: 1. Immediately contact the Director of Nursing, Administrator and the resident's physician. 2. Director of Nursing or Administrator will contact the police department. 3. Assess the resident for possible injury. 4. Provide the resident with emotional support. 5. Do Not shower, bathe, or change resident's clothing. (NOTE: if clothes have been changed, bag the clothes in accordance with instructions from law enforcement officials.) 6. Do not disturb the location where the alleged rape took place, prepare the resident for transfer to the hospital examination, and 7. In consultation with police, continue the facility's investigation of the incident in accordance with established policy. 1. Resident #77 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/15/16, documented resident #77 was severely impaired with cognitive skills. The assessment documented the resident had a behavior of inattention continuously and was able to walk without assistance. The assessment documented the resident was continent of bowel and bladder and received an antidepressant medication for seven days during the seven day assessment period. An annual assessment, dated 03/15/17, documented resident #77 was severely impaired with cognitive skills. The assessment documented the resident had no behaviors. The assessment documented the resident was able to walk without assistance. The assessment documented the resident was continent of bowel and bladder and had received an antidepressant medication for seven days during the seven day assessment period. The care plan, dated 03/24/17, documented resident #77 would ambulate throughout the facility and into other residents' rooms at times but was easily redirected. The care plan documented the resident was at risk for behaviors, falls, and confusion. The care plan, dated 03/25/17, documented resident #77 had a [DIAGNOSES REDACTED]. A nursing note, dated 04/08/17 at 8:00 p.m. as a late entry (documented on 04/09/17 at 1:59 p.m.), documented resident #77 was found by an unidentified certified nursing aide (CNA) in bed with a male resident (resident #69) and the male resident was kissing resident #77. The nurse note documented the CNA told the nurse she redirected resident #77 out of the male resident's room. The note documented the nurse spoke with the male resident and told him the female resident was unable to make decisions and the male resident verbalized he understood. The note documented both residents would be on continuous supervision. The 24 hour report sheet for 04/08/17 was reviewed. The report for resident #77 documented see nurse note for the 6-2 shift, and continuous supervision for the 2-10 shift, and a check mark for the 10-6 shift. The report for resident #69 documented, OK for the 6-2 and 2-10 shift, and a check mark for the 10-6 shift. The 24 hour shift report, dated 04/09/17, for resident #77 documented, OK for the 6-2 and 2-10 shift, and a check mark for the 10-6 shift. The report for resident #69 documented see nurse note for the 6-2 shift, moved to room . for the 2-10 shift and a check mark for the 10-6 shift. A nurse note, dated 04/09/17 at 12:00 p.m., documented the nurse was notified by an unidentified CNA the male resident was in resident #77's room standing over her and resident #77's shirt was pulled up. The note documented the male resident was not touching resident #77. The note documented the CNA asked the male resident what he was doing and the male resident replied he gave resident #77 a kiss. The note documented the nurse redirected the male resident and told him he was not allowed in resident #77's room. The note documented the nurse told the male resident (resident #69) resident #77 was unable to make decisions for herself. The note documented during this incident, a second unidentified CNA reported to the nurse resident #69 had been in bed kissing resident #77 and had his hands were in resident #77's pants on 04/08/17. The note documented the nurse did not recall being told the male resident had his hands in resident #77's pants. The note documented resident #77 was unable to recall the incident. The note documented the male resident was spoken with regarding the prior incident but denied placing his hands inside resident #77's pants. The note documented the male resident stated he gave resident #77 a kiss. The note documented the nurse notified the administrator, DON, and resident #77's primary care provider. The note documented the nurse and another nurse examined resident #77 and found no bleeding, bruising, or tearing. The note documented resident #77's primary care provider was notified and the resident was sent to the emergency room of the local hospital for evaluation. The note documented resident #77's daughter was notified. A nurse note, dated 04/09/17 at 12:01 p.m., documented resident #77 had received her scheduled shower on the previous night. A care plan for resident #77, dated 04/09/17, documented the events described in the nurse note, dated 04/09/17 at 12:00 p.m. The documented goal for the care plan was for the resident not to be involved in inappropriate sexual behaviors for the next 90 days. The care plan documented one approach was continuous monitoring. An emergency department physician documentation form for resident #77, dated 04/09/17 at 2:20 p.m., was reviewed. The form documented the physician's primary impression was sexual assault. The form documented resident #77 was sent to the emergency department for a sexual assault nurse examiner (SANE) exam. The form documented the physician comments as SANE nurse on call notified and Police sent to nursing home to make report. discharged for SANE exam. A police incident report for resident #77, dated 04/09/16 at 2:24 p.m., was reviewed. The report indicated the incident status was active from 04/08/17 at 7:30 p.m. The report documented the offense as sexual battery. A nursing progress note for resident #77, dated 04/09/17 at 4:44 p.m., documented at 3:00 p.m. an officer from the local police department arrived at the facility. The note documented the officer reported he was unable to interview resident #77 due to her mental status. A nursing progress note, dated 04/09/17 at 4:56 p.m., documented resident #77 was returned to the facility accompanied by her son. The note documented the son stated all the tests came back negative and there was no sign of sexual abuse. A fax transmission report, dated 04/09/17 at 5:58 p.m., documented OSDH had been notified of the incident. The initial report documented the date of the incident as 04/09/17. A nursing progress note, dated 04/10/17 at 4:39 a.m., documented resident #77 was checked every 30 minutes. A nursing progress note, dated 04/11/17 at 4:00 a.m., documented resident #77 was checked every 30 minutes. A nursing progress note, dated 04/12/17 at 12:22 p.m., documented resident #77 was up and about the facility and was redirected when she attempted to enter other residents' rooms. On 04/13/17 at 11:02 a.m., the facility ombudsman notified the survey team the son of resident #77 had reported to another state agency his mother had been sexually assaulted by another resident. On 04/13/17 at 12:02 p.m., resident #77 was observed in her room on her bed. On 04/13/17 at 12:50 p.m., LPN #5 was interviewed regarding the incidents. The LPN stated she reported to work at 2:00 p.m. on 04/09/17 and had been given a report informing her resident #69 (the male resident) had been moved to another hall due to inappropriately touching resident #77. The LPN reported she was told by LPN #2 to monitor resident #69. The LPN was asked how often she was to monitor resident #69. The LPN reported she was not told how often she was to monitor the resident. The LPN reported she saw resident #69 up and down the halls but she did not follow him. The LPN stated anytime she looked for resident #69, she found him either in his room or in the smoking room. On 04/13/17 at 1:44 p.m., LPN #2 was contacted by phone and interviewed regarding the incidents on 04/08/17 and 04/09/17. The LPN reported an incident involving resident #69 and resident #77. The LPN reported she was told about the two incidents by CNA #2 and CNA #3. The LPN reported the incidents were reported to her around lunch time or after. The phone disconnected at that time. On 04/13/17 at 1:49 p.m., LPN #2 was recalled. The LPN was asked what was reported to her by CNA #2. The LPN reported she was trying to remember and thought it was about resident #69 had resident #77 in her room and touched her inappropriately. The LPN reported there was another incident on Sunday (04/09/17). The LPN was asked what was reported to her about Saturday (04/08/17). The LPN stated she was told resident #77 was in the room of resident #69 who was standing over her with his hands in her pants or on her pants and he leaned over and gave her a kiss. The LPN was asked if she was told about this on Saturday the 8th or Sunday the 9th. The LPN stated CNA #2 reported she told her on the 8th, but she didn't remember anything except being told resident #77 was in the room of resident #69. The LPN was asked about the incident reported to her by CNA #3. The LPN reported the CNA told her on Sunday (04/09/17) she walked into the room of resident #77 and found resident #69 standing at the bedside of resident #77. The LPN reported the CNA had said the shirt of resident #77 was lifted up exposing her stomach area. The LPN reported the CNA told her she asked resident #69 what he was doing and he said he gave resident #77 a kiss. The LPN reported when she was informed of this, she spoke with resident #69 and told him he could not be in resident #77's room. The LPN reported resident #69 resided in a room across the hall from resident #77 and was subsequently moved to another hall on the other side of the facility. The LPN stated she called the DON and was instructed to notify the primary care provider for resident #77, conduct a physical assessment of resident #77, and then re-call the primary care provider with her findings. The LPN was asked how she examined the resident. The LPN reported she and another nurse conducted a full head to toe assessment on the resident and looked for any vaginal tearing, bruising, or any drainage. The LPN reported she contacted resident #77's daughter. The LPN stated the DON and the administrator told her to notify the physician, send resident #77 to the hospital if the resident's primary care provider ordered it, and to monitor both of the residents involved in the incidents at all times. The LPN was asked what monitor meant. The LPN reported it meant the residents were not to have contact with each other. The LPN was asked how she ensured the residents did not have contact. The LPN reported the room of resident #77 was near the nursing station and the CNAs were instructed to observe both residents to make sure they did not have contact with each other. The LPN reported the residents were never out of visual sight. The LPN reported resident #77 was either in her room, near the nursing station, or in the lobby in front of the nursing station. The LPN was asked what kind of supervision resident #69 received. The LPN reported his room was observed at all times and if he went to the smoke room, he was followed. On 04/13/17 at 2:19 p.m., CNA #2 was interviewed by phone. The CNA stated she worked on 04/08/17 and 04/09/17. The CNA was asked about the incident on 04/08/17. The CNA stated at approximately 7:00 p.m., while she was picking up dinner trays, she entered the room of resident #69 and found him leaning over resident #77 who was lying on the first bed near the door. The CNA reported resident #69 was kissing resident #77 and had his hand down the front of resident #77's pants and was making a rubbing motion. The CNA reported when she entered the room, resident #69 removed his hand from resident #77's pants. The CNA stated she reported the incident to LPN #2. The CNA stated the LPN spoke with resident #69, told him resident #77 was not in her right mind, and he could not do that. The CNA was asked what she was instructed to do after the incident. The CNA reported she was told to keep an eye on them and keep them separated. The CNA reported the residents lived across the hall from each other at that time. The CNA reported resident #69 was moved to another hall the next day after lunch. The CNA stated he was moved because another CNA had found resident #69 in the room of resident #77 and resident #69 was standing over resident #77 and her shirt was pulled up. The CNA reported the other CNA told LPN #2 of the second incident and resident #69 was moved. On 04/13/17 at 2:40 p.m., CNA #3 was interviewed by phone. The CNA reported she worked on the weekend of 04/08/17 and 04/09/17 on the 6:00 a.m. to 10:00 p.m. shift. The CNA stated she witnessed resident to resident abuse on Sunday 04/09/17 at approximately noon. The CNA reported she entered the room of resident #77 and found the curtain covering the resident's side of the room to be pulled covering the resident's bed from view. The CNA reported she saw resident #69 standing at the bedside of resident #77 who was lying on her bed. The CNA stated resident #77 was holding the bottom of her shirt which was pulled up exposing her abdomen. The CNA stated resident #69 said all he did was kiss her. The CNA stated resident #69 left the room and went to the smoke room. The CNA was asked if she reported the incident. The CNA stated she reported it to LPN #2. The CNA stated resident #69 was moved to another hall at that time. The CNA was asked if she was instructed to monitor the residents. The CNA stated they were to try to keep resident #69 away from resident #77 and to watch them to make sure they were not together. The CNA stated resident #69 tried to come back to the hall where resident #77 resided stating he needed towels. The CNA reported an unidentified male CNA got towels for the resident. The CNA was asked if he tried to come back again. The CNA reported later on the same day resident #69 and #77 were walking in the hall of resident #69 and resident #77 grabbed the shirt of resident #69 and he shrugged her off. The CNA was asked if there had been any other incidents regarding residents #69 and #77. The CNA reported she was told about an incident the day before and there had been rumors by the aides where there was suspicion of resident #69 and #77 messing together. On 04/13/17 at 5:18 p.m., LPN #6 was asked how resident #69 and resident #77 were to be monitored. She said she was supposed to know their whereabouts at all times. She stated she was told in the stand up meeting on 04/10/17 to know where resident #69 was every 30 minutes but was told by LPN #5 it did not have to be every 30 minutes. On 04/13/17 at 5:23 p.m., resident #77 was observed walking in the hall. An unidentified staff member was observed to approach her, took her hand, and directed the resident into an office. The facility provided documentation the resident received a psychiatric evaluation by an advanced practice registered nurse-certified nurse practitioner on 04/14/17 at 7:30 a.m. On 04/14/17 at 8:40 a.m., the resident was observed in her room eating breakfast. An unidentified staff member was present at her bedside. On 04/14/17 at 10:57 a.m., the DON was interviewed regarding the sexual abuse allegation. The DON stated she was unaware of the incident on 04/08/17 until Sunday 04/09/17 during the evening around 7:00 p.m. She stated she was not aware of the two hour reporting regulation. On 04/14/17 at 11:06 a.m., the adm was interviewed regarding the sexual abuse allegation. The adm stated she was not aware of the incident on 04/08/17 until around 5:00 to 6:00 p.m. on 04/09/17. She said she was aware of the two hour reporting regulation. 2. Resident #69 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A significant change assessment, dated 11/17/16, documented the resident was cognitively intact and had no signs or symptoms of [MEDICAL CONDITION]. The assessment documented the resident exhibited no behaviors during the assessment period. The assessment documented the resident was independent with most activities of daily living (ADLs) and required set-up and supervision with toilet use, bathing, and personal hygiene. A care plan, dated 01/25/17, documented a problem of behaviors. The care plan documented the resident pushed another resident (name deleted), who was wheelchair bound, up behind a nurse in order for the resident to grab the nurse's buttocks. The care plan documented the residents went down the hall laughing. The goal for the care plan was for the resident not to engage in or encourage another resident to engage in inappropriate behavior towards caregivers. A quarterly assessment, dated 02/16/17, documented the resident was cognitively intact. The assessment documented the resident was independent with most ADLs and required supervision with eating, and set-up and supervision with bathing. A nurse progress note, dated 04/09/17, documented the resident was interviewed by an officer of the local police department. The note documented the police officer informed the nurse the resident stated the female resident was in his roommate's bed on 04/08/17. The note documented the resident told the officer he did not put his hand down resident #77's pants. The note documented the officer said the resident told him he leaned down to kiss the female resident and his hand was on her stomach when the unidentified CNA walked in. The note documented the resident remained on continuous monitoring. A nurse progress note, dated 04/09/17 at 11:54 p.m., documented a late entry for 04/08/17 for the 10 p.m., to 6 a.m. shift by LPN #3. The note documented the resident would get up occasionally and walk to the lobby or nurses' station for a snack. The note documented the resident was on two hour room checks. A nurse progress note, dated 04/10/17 at 12:05 p.m., documented the resident was on 30 minute checks and as needed. A nurse progress note, dated 04/10/17 at 6:51 p.m., documented the staff were continuing to monitor the resident's whereabouts every 30 minutes. On 04/11/17 at 3:56 p.m., the resident was observed smoking in the smoke room. A nurse progress note, dated 04/12/17 at 4:03 a.m., documented the resident was checked every 30 minutes and had no complaints of pain or discomfort. A nurse progress note, dated 04/13/17 at 5:01 a.m., documented the resident's location was monitored at all times and was noted to remain in authorized areas. The facility provided documentation the resident received a psychiatric evaluation by an advanced practice registered nurse-certified nurse practitioner on 04/14/17 at 8:30 a.m. On 04/14/17 at 9:45 a.m., the resident was observed sitting in the lobby in front of the nursing station watching television and an unidentified staff member was present beside him. On 04/14/17 at 10:15 a.m., the resident was observed in the dining room participating in an exercise class which was conducted by the activity director.

On [DATE] at 4:40 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to identify a resident had a peripherally inserted central catheter (PICC) upon admission, failure to obtain PICC line care orders from the physician until 12 days after admission, and failure to provide PICC line flushes as ordered by the physician. The facility failed to ensure facility staff followed policy and procedure when the resident's [MEDICAL CONDITION] was dislodged. The staff failed to attempt to re-insert the [MEDICAL CONDITION], failed to monitor the resident's pulse oximetry readings, and failed to provide respiratory support/oxygenation by an Ambu bag as per the facility's policy. On [DATE] at 5:00 p.m., OSDH verified an immediate jeopardy situation existed related to the facility's failure to provide assessment, monitoring, and intervention for a PICC line and to follow policy and procedure when a resident's [MEDICAL CONDITION] was dislodged. On [DATE] at 5:20 p.m., the administrator (ADM) and the director of nursing (DON) were informed of the IJ situation. The ADM and the DON were informed of the immediate jeopardy situation which constituted substandard quality of care. The ADM and the DON verbalized understanding. On [DATE] at 5:50 p.m., the ADM provided a plan of removal for immediate jeopardy. The plan of removal was accepted and documented the following: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY [DATE] @ 5:26 PM ALL RESIDENTS THAT HAVE TRACHESTOMY (sic) CAN BE AFFECTED ALL LICENSED STAFF WILL BE INSERVICED ON THE POLICY AND PROCEDURE FOR WHEN A TRACHESTOMY (sic) HAS COME OUT AND IF A RESIDENT BECOMES ANXIOUS OR APPEARARS (sic) TO BE DISORENTED (sic) AND PULLING AT THE TRACHESTOMY (sic). ALL EMPLOYEES WILL BE INSERVICED BY [DATE]. NO EMPLOYEE WILL BE ABLE TO WORK UNTIL THEY HAVE BEEN INSERVICED BY THE DON OR DESIGNEE. ALL LICENSED NURSES WILL BE INSERVICED ON THE POLICY AND PROCEDURE ON HOW TO CARE FOR A RESIDENT WITH A PICC LINE. 1. ASSESSMENT OF THE PICC LINE 2. DOCUMENTATION OF SITE 3. DRESSING CHANGES 4. PICC LINE ORDERS WILL BE UPDATED TO THE CAREPLAN 5. HEAD TO TOE ASSESSMENTS WILL BE COMPLETED DAILY 6. UPON ADMISSION THE RESIDENT WILL HAVE A COMPLETE HEAT TO TOE ASSESSMENT DOCUMENTED IN THE CLINICAL RECORD REGARDING THE RESIDENT'S PICC LINE AND CONDITION. On [DATE], the survey team interviewed staff to verify their knowledge related to PICC line care procedures and [MEDICAL CONDITION] emergency procedures. The staff verbalized understanding of the facility's policies in relation to the [MEDICAL CONDITION] and PICC line policy and procedures. The survey team observed the rooms of the four residents, who currently had tracheostomies, for the presence of replacement [MEDICAL CONDITION] cannulas. On [DATE] at 11:00 a.m., the facility was informed the IJ was removed, effective [DATE] at 5:00 p.m., when all components of the plan of removal had been implemented. The deficiency remained at actual harm level at a pattern. Based on observation, record review, and interview, it was determined the facility failed to ensure residents maintained their highest levels of well-being for two (#3 and #1) of four residents reviewed for well-being. The facility failed to: a. Identify a PICC line was present until 12 days after admission, failed to assess or monitor the PICC line for signs of infection until 12 days after admission, failed to obtain physician orders for PICC line flushes and dressing changes, until 12 days after admission, and failed to administer the PICC line flushes as ordered by the physician for resident #3. b. Ensure staff followed the facility's policy and procedures when the [MEDICAL CONDITION] became dislodged for resident #3. Three residents reviewed for [MEDICAL CONDITION] care and services. The staff failed to monitor the resident's oxygen levels by pulse oximetry, failed to attempt to replace the [MEDICAL CONDITION], and failed to provide supplemental oxygenation via Ambu bag. c. Ensure neurological status was assessed and monitored after a fall for resident #1. d. Ensure the resident #1's condition was assessed and monitored when the resident returned from the hospital. The DON reported 78 residents lived in the facility. The DON reported four residents required tracheostomies and no resident had a PICC line. Findings: 1. The facility's policy on central lines documented for the staff to assess the insertion site daily for [MEDICAL CONDITION], [DIAGNOSES REDACTED], or pain and dressing changes should be performed every seven days. The facility's policy on procedures following a [MEDICAL CONDITION] dislodgement documented the nurse was to attempt to reinsert a new [MEDICAL CONDITION] using guide and reattach oxygen if needed. The policy documented if unable to maintain airway, the nurse was to call 911 immediately and have staff use an ambu bag for oxygenation and transfer the resident to the hospital immediately. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 3:09 a.m., documented an admission head to toe assessment. The note documented the resident was alert and oriented, had a [MEDICAL CONDITION], a boot on her left lower extremity, and pink areas to her coccyx and buttocks. The note documented the resident complained of pain and was repositioned. The note documented the resident was continent of bowel and bladder and required the assistance of staff for the use of the bedpan. The note was documented by licensed practical nurse (LPN) #1. A nurse's note, dated [DATE] at 3:30 a.m., documented the resident became unresponsive when being repositioned. The note documented the resident's Sp02 was 69% and the resident was sent to the hospital at 11:55 p.m. A nurse's note, dated [DATE] at 3:36 a.m., documented the resident arrived back at the facility. A nurse's note, dated [DATE] at 8:45 a.m., documented the physician ordered all intravenous medications for hypertension to be discontinued. A physician's order, dated [DATE], documented to cleanse the [MEDICAL CONDITION] site and change the inner cannula every other day and as needed. A physician's order, dated [DATE], documented to provide indwelling urinary catheter care with soap and water each shift. An admission assessment, dated [DATE], documented the resident was moderately impaired in cognition, exhibited mild depression symptoms, and exhibited no behavioral symptoms. The assessment documented the resident required total assistance with transfers and bathing, required set-up assistance with eating, required an indwelling urinary catheter, and was occasionally incontinent of bowel. A care plan, dated [DATE], documented the resident was unable to turn and position, transfer, ambulate, or perform self care needs. The approaches included for the staff to provide catheter care each shift and provide oxygen to the [MEDICAL CONDITION] continuously. A physician's order, dated [DATE], documented, FLUSH DOUBLE LUMEN PICC (peripherally inserted central catheter) TO RIGHT ARM WITH 5CC [MEDICATION NAME] FOLLOWED BY 10 CC NS (normal saline) Q SHIFT AND PRN TO MAINTAIN PATENCY. The clinical record contained no assessment or documentation of the resident having a PICC line. The [DATE] treatment administration report documented the PICC line was flushed on [DATE] on the three shifts and once on [DATE] on the night shift. The PICC line flushes were discontinued on the treatment sheet with no physician's order. A physician's order, dated [DATE], documented, CHANGE PICC LINE DRSG (dressing) WEEKLY ON TUES AND PRN. The [DATE] treatment administration report documented the dressing changes were performed on [DATE] and [DATE]. The nurses' notes documented the resident experienced low blood pressure readings on [DATE], [DATE], [DATE], and [DATE]. The nurses' notes documented the physician was notified and no new orders were received. A nurse's note, dated [DATE], documented the resident had small shearing area to her left buttock. A nurse's note, dated [DATE] at 4:20 a.m., documented the resident had a loose, dark green, mucous stool which had a foul odor. The note documented the resident was given an [MEDICATION NAME]. A nurse's note, dated [DATE] at 12:00 p.m., documented the resident was assessed and had no open areas. Two registered nurses and nine licensed practical nurses had documented in the resident's clinical record during the resident's stay in the facility. None of the entries documented the presence of a PICC. The clinical record contained only one entry in regard to the size of the [MEDICAL CONDITION] cannula. A nurse's note, dated [DATE] at 3:53 a.m., documented, [MEDICAL CONDITION] - NURSING (-) IT WAS BROUGHT TO THIS NURSE ATTENTION THAT THE RES HAD PULLED [MEDICAL CONDITION]. UPON ENTERING THE RES ROOM, I NOTICED THAT BOTH THE INNER AND OUTER CANNULA OF [MEDICAL CONDITION] OUT AND THE RES HAD A BROWN LIQUID DRAINING FROM THE CORNERS OF HER MOUTH. 911 CALLED, REPORT CALL TO (name deleted) .LEFT VIA AMBULANCE . An EMS (emergency medical service) patient care record, dated [DATE] at 03:41 a.m., documented, .Pulse is 74 .Respiratory rate is Labored at 20. Blood pressure is ,[DATE] 76 .SpO2: 76. Patient is Alert. Pain score of 0 .Narrative .WAS (dispatched) TO (nursing home name deleted) FOR A (patient) THAT HAD PULLED [MEDICAL CONDITION] .WE MADE CONTACT WITH THE NURSE AND SHE SAID SHE DOESN'T KNOW THE SIZE [MEDICAL CONDITION] DIDN'T KNOW FOR SURE HOW LONG IT HAD BEEN OUT . An emergency department nurse's notes, dated [DATE] at 4:15 a.m., documented, PT TO ROOM VIA EMS FROM NURSING HOME AFTER REMOVING TRACH. PT ARRIVED TO ROOM DIRTY OF EMESIS AND RUNNY WATERY STOOL. PT ALSO HAS FOLEY (indwelling urinary catheter) TO GRAVITY IN PLACE FROM NURSING HOME . A emergency department nurse's note, dated [DATE] at 4:20 a.m., documented, PT TO ED (emergency department) (with) DOUBLE LUMEN PICC IN PLACE TO RT UPPER ARM. An emergency department's physician's note, dated [DATE] at 5:47 a.m., documented, .Had pulled [MEDICAL CONDITION] and now sob (short of breath) and [MEDICAL CONDITION]. Sats in 70s .Reported nausea, vomiting, and bad diarrhea for last ,[DATE] weeks. Poor PO intake in last one week. BP (blood pressure) here in ,[DATE]s systolic. Sats coming up [MEDICAL CONDITION] .Primary impression:[MEDICAL CONDITION] .due to unspecified organism .Additional impressions: Pneumonia .Acute [MEDICAL CONDITION] Dehydration Gastroenteritis . An intensive care nurse's note, dated [DATE] at 7:56 a.m., documented, Recd (received) patient from ER .patient has 3 stage 2 bedsores approx dime size on coccyx and buttocks. incontinent of stool and patient cleaned. right upper arm duel lumen PICC noted. new foley catheter was placed in the ER. patient [MEDICAL CONDITION] flow by . An intensive care nurse's note, dated [DATE] at 8:30 a.m., documented, .iv started in left (antecubital). picc line pulled and tip sent to lab for culture . A physician's discharge summary, dated [DATE], documented, Discharge Problems/Diagnosis .(1)[MEDICAL CONDITION] .due to unspecified organism .potential source of infection: PICC line, [MEDICAL CONDITION] site, PNA,[DIAGNOSES REDACTED] infection (2) Acute [MEDICAL CONDITION] .(3) Diarrhea .(4) Dehydration .(5) Pneumonia .Hospital Course .Patient had a PICC in place from (nursing home) and it was replaced with a Central line .Patient is to be transferred to (name deleted) for higher level of care . A discharge summary, dated [DATE] at 1:48 p.m., from the receiving hospital documented, DISCHARGE Diagnosis: [REDACTED]. Acute hypoxic [MEDICAL CONDITION] . 2. [MEDICAL CONDITION] secondary to acute hypoxic [MEDICAL CONDITION]. 3. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] infection. 4. [MEDICAL CONDITIONS]. 5. Acute [MEDICAL CONDITION]. 6. Chronic [MEDICAL CONDITION] . BRIEF HOSPITAL COURSE: .The patient had a history of [REDACTED].resulting in multiple fracture, [MEDICAL CONDITION] with mechanical ventilation for approximately 4 weeks as well as approximately 4 weeks of [MEDICAL TREATMENT] secondary to [MEDICAL CONDITION]. The patient was discharged from the hospital in (name deleted) .on [DATE]. A PICC line had been placed during her hospitalization and she was discharged to the nursing home with PICC line and her Foley catheter . The discharge summary documented the resident became unresponsive on [DATE] and expired following two resuscitative episodes. On [DATE] at 2:00 p.m., the DON was asked if any residents had PICC lines. The DON reported none of the residents had PICC lines. The DON was asked how could she be sure since the resident had no documentation of a line and then had orders for flushes and dressing changes. The DON reported she performed the weekly skin assessments and knew no one had a PICC. At that time, the DON was asked why the flushes were only done for one day and discontinued. The DON reported she would find out. On [DATE] at 9:00 a.m., the DON was asked if she found out about the PICC line flushes. The DON reported she had removed the PICC line on [DATE] and made a late entry in the nurses' notes. The DON was informed the resident had a PICC line when she went to the emergency roiagnom on [DATE]. The DON stated, I could have sworn I took her PICC line out. At that time, the DON was asked if the staff should have documented the presence of the PICC when admitted and during the resident's stay. The DON stated, Yes. The DON was asked why none of the licensed staff questioned why no flushes or care was ordered for the resident. The DON reported she had a lot of education she needed to do with the staff. On [DATE] at 2:50 p.m., the surveyor attempted to contact the LPN who had worked the night the resident's [MEDICAL CONDITION] was dislodged. The LPN no longer worked for the facility and did not return the surveyor's telephone call. On [DATE] at 2:53 p.m., certified nurses aide (CNA) #1 was contacted by telephone and asked about the night the resident's [MEDICAL CONDITION] became dislodged. The CNA reported the resident stated she had pulled her [MEDICAL CONDITION] out. The CNA reported the resident was chewing on the [MEDICAL CONDITION] cannula and had black watery substance coming from her mouth. The CNA reported the resident had been hallucinating about seeing snakes for the past couple of nights. The CNA reported the resident's door was left open because she had a [MEDICAL CONDITION] and the resident would start screaming. On [DATE] at 3:57 p.m., CNA #2 was was contacted by telephone and asked about the night the resident's [MEDICAL CONDITION] became dislodged. The CNA reported the aides had made rounds on the resident at change of shift and at 1:00 a.m. The CNA reported she went into the resident's room at approximately 3:00 a.m. to empty the resident's indwelling catheter urinary drainage bag. The CNA reported the resident was making noises and saw the resident was vomiting brown liquid. The CNA reported she saw the [MEDICAL CONDITION] cannula was completely out and she ran and got the charge nurse. The CNA reported the resident's family had visited the day before and had told the resident the [MEDICAL CONDITION] need to be removed because she did not need it any more. The CNA reported the resident had not been sleeping much during the night. On [DATE] at 4:00 p.m., CNA #3 was contacted by telephone and asked about the night the resident's [MEDICAL CONDITION] was dislodged. The CNA reported the resident was vomiting, the aides elevated her head immediately, and got the charge nurse. The CNA reported the resident handed her the [MEDICAL CONDITION] and stated she had taken it out. The CNA reported the resident had asked her the night before and earlier that shift to help her remove the necklace. The CNA reported she reminded the resident it was not a necklace but her [MEDICAL CONDITION]. The CNA also reported the family had told the resident she needed the [MEDICAL CONDITION] removed. The CNA reported the resident did not seem short of breath to her. At that time, the CNA was asked if the resident's vital signs were taken. The CNA reported the vital signs were taken but did not know what the readings were. The CNA reported she knew the pulse oximeter reading was taken but did not know what the readings were. The CNA reported oxygen was placed on the resident. The CNA reported the aides had cleaned and placed a clean gown on the resident by the time the ambulance arrived. On [DATE] at 4:20 p.m., the DON was asked if the charge nurse should have replaced the [MEDICAL CONDITION] or used the Ambu bag. The DON reported yes. At that time, the DON was asked if the staff should have monitored the resident more closely when the resident was restless and experienced hallucinations. The DON stated, Yes. On [DATE] at 10:00 a.m., LPN #1 was asked if she knew the resident had a PICC in place. The LPN reported she noticed the PICC when the resident was moved to the her unit. The LPN reported she had flushed the PICC and had not worked with the resident very much. On [DATE] at 11:00 a.m., the ADM and the DON were asked if they expected the staff to follow policy and procedure in caring for residents with PICC lines or tracheostomies. Both reported yes. At that time, the ADM and the DON were asked if they understood the dangers the lack of identifying and intervening with the PICC line could cause. Both reported systems would be implemented to prevent recurrence. The ADM reported she did not know how the staff could have not addressed the resident's PICC line. 2. Resident #1 was admitted to the facility on [DATE]. The admission assessment, dated [DATE], documented the resident was cognitively intact and required assistance with activities of daily living (ADLs) including transfers, dressing, hygiene, and bathing. The assessment documented the resident was always incontinent of bowel and bladder. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated [DATE], documented the resident was cognitively intact, required extensive assistance of two or more staff members for transfers, and extensive assistance of one staff member to dress, hygiene, and bathing. The assessment documented the resident was always incontinent of bowel and bladder. A care plan, dated [DATE], documented the resident was at risk for falls. Approaches listed was for the staff to monitor the environment for wet spots or items placed below field of vision on the floor, adequate lighting, call light was to be kept close and the light answered promptly. The staff was to check on the resident every two hours when she was in bed and to encourage the resident to use her call light to ask for assist when she felt weak. A nurse's note, dated [DATE] at 7:30 a.m., documented, THIS NURSE WAS COMING UP THE CENTER HALLWAY WHEN I HEARD THIS RESIDENT HOLLAR (sic) OH NO WHEN I TURNED AROUND I NOTED THIS RESIDENT TO BE LAYING ON HER BACK NEXT TO THE CHAIR . A nurse's note, dated [DATE] at 10:21 p.m., documented the resident denied pain or discomfort from falling earlier in the day. There were no further assessments or monitoring documented in the nurses' notes. A nurse's note, dated [DATE] at 11:24 a.m., documented, RESIDENT NOTED TO HAVE MODERATE AMOUNT OF COFFEE GROUND EMESIS THIS MORNING. RECEIVED ORDER TO TRANSFER TO ER FOR EVALUATION AND TREATMENT . The clinical record did not contain the resident's vital signs or an abdominal assessment to indicate the resident was assessed and monitored following the emesis. A nurse's note, dated [DATE] at 4:46 p.m., documented the resident had returned from the hospital. The resident's vital signs and an abdominal assessment had not been completed. The nurse's notes did not document if the resident experienced any further episodes of vomiting. A nurse's note, dated [DATE] at 7:12 p.m., documented the resident was observed to have dried coffee ground emesis on herself and her blanket. The nurse's note documented the resident complained of abdominal pain and reported, She felt it was going to happen again. The nurse's note documented the ambulance was notified the resident was to be transported to the hospital for care. A nurse's note, dated [DATE] at 4:55 a.m., documented an assessment had been conducted for the resident. The nurses' notes did not contain documentation of when the resident returned to the facility or of an assessment had been conducted when the resident returned to the facility. No further assessments or monitoring the resident for abdominal pain or vomiting blood were located in the nurses' notes. A nurse's note, dated [DATE] at 3:45 p.m., documented, Nursing [DATE] (name deleted) heard resident hit the floor .Resident stated that she tried to put on underwear and fell head first onto floor. Resident stated that the only place she hurt was her head and that she had a headache. Resident had a lump above the forehead .Resident continued to complain about her head. Resident was transferred to ER. The clinical record did not contain documentation a neurological assessment was conducted. A nurse's note, dated [DATE] at 10:08 p.m., documented, Nursing [DATE] Resident fell in room at approximately 5:30 p.m. Resident complained of headache. An assessment was not documented at this time. A nurse's note, dated [DATE] at 10:15 p.m., documented, Nursing [DATE] Resident arrived via EMS transport . The clinical record did not contain documentation the resident was assessed and monitored on return to the facility. The clinical record contained no documentation the resident was assessed and monitored after experiencing a head injury. A nurse's noted, dated [DATE] at 12:00 p.m., documented, RESIDENT IS ALERT AND ORIENTED X'S 3 THIS AM SHE IS ABLE TO ANSWER ALL QUESTION APPROPRIATELY SHE STATED THAT SHE WAS GETTING UP TO GET DRESSED YESTERDAY EVE WHEN SHE fell SHE POINTED TO HER FORE HEAD AND STATED THAT IS WHERE I HIT MY HEAD THERE IS A VERY LIGHT DISCOLORATION TO THAT AREA. NO LUMPS OR BUMPS NOTED AT THIS TIME . A neurological assessment was conducted at that time. The clinical record contained no consistent or specific assessment and monitoring of the resident following the fall and return to the facility. On [DATE] at 11:30 a.m., the DON was interviewed. The DON was asked, when a resident experienced a fall did she expect the staff to monitor and assess the resident. The DON reported yes, the staff should monitor and assess a resident when the resident experienced a fall. The DON reported she was aware of the documentation issues and was in the process of conducting staff education. The DON was asked when a resident experienced a fall should the nursing staff the fall and an assessment at that time instead of waiting until the following day to document the resident experienced a fall. The DON reported documentation, assessing, and monitoring were to be completed upon the time of the incident and not the following day. The DON was asked, when a resident experienced an episode of vomiting coffee ground emesis did she expect the staff to monitor and assess the resident including obtaining a complete set of vital signs. The DON reported yes. The DON was asked when a resident returned from a hospitalization as a result of vomiting coffee ground emesis did she expect the staff to monitor and assess the resident upon return to the facility. The DON reported yes. The DON was asked when a resident experienced an episode of dried coffee ground emesis and abdominal pain did she expect the staff to conduct an assessment with vital signs and monitor the resident until the EMS arrived to transport the resident to the emergency department. The DON reported yes. The DON was asked did she expect staff to monitor and assess the resident after a resident returned from a second hospitalization due to vomiting blood. The DON reported yes. The DON reported there were several new staff members and was aware of the documentation issue. The DON reported education would be conducted in regard to the assessment and monitoring necessary following a change in a resident's condition.

On 07/25/15 at 12:30 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to follow their abuse policy for allegations of staff to resident abuse. A resident had informed the surveyors of an incident he had witnessed occurring the previous week when a certified nurse aide (CNA) physically and verbally abused a resident. The charge nurse, a certified nurse aide, and a certified medication aide were aware of the allegation made by the resident witness and had ignored the allegation by failing to notify the Administrator and/or the Director of Nursing. The facility failed to prevent staff to resident verbal and physical abuse, identify verbal and physical abuse, protect residents from abuse, and investigate abuse allegations. On 07/25/15 OSDH verified an immediate jeopardy situation existed related to the facility's failure to prevent, investigate, protect, and report allegations of staff to resident verbal and physical abuse. On 07/25/15 at 1:30 p.m., the administrator (ADM) and the director of nursing (DON) were informed of the IJ situation related to the facility's failure to identify abuse, notify the proper entities, investigate, prevent abuse, and protect residents after allegations of verbal and physical abuse had occurred. The ADM and the DON were informed of the immediate jeopardy situation which constituted substandard quality of care. The ADM and the DON verbalized understanding. On 07/25/15 at 3:10 p.m., the ADM presented to the survey team a plan of removal. The plan of removal was accepted and documented the following: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY - RESIDENT ABUSE All residents have the potential to be affected. Alleged perpetrator was removed 07/25/2015 from employment at Heritage Hills at 12:20 p.m. Heritage Hills will immediately implement a comprehensive in service training program on 07/25/2015. The in service program will educate staff on the abuse policy and procedure regarding identifying, reporting, preventing, and investigating elder abuse. The first training will begin on 07/25/2015 at 12:30 p.m. and continue until all staff members have completed the training. All staff members will be in serviced on the abuse policy and procedure and demonstrate a clear understanding of how to identify, report, investigate, and prevent elder abuse. On 07/27/15, the survey team interviewed staff to verify their knowledge of the facility's policy related to preventing, investigating, protecting, and reporting following allegations of abuse. The staff verbalized an understanding of the facility's policy related to investigation, protection, and reporting following allegations of abuse. On 07/27/15 at 5:30 p.m., the facility was informed the IJ was removed, effective 07/25/15 at 8:00 p.m., when all components of the plan of removal had been implemented, inservices had been completed, and staff had verbalized an understanding of the inservices related to prevention, investigation, protection, and reporting following allegations of abuse. The deficiency remained at the level of no actual harm at a widespread level. Based on record review, observation, and interview, it was determined the facility failed to ensure residents were free from staff to resident verbal and physical abuse for one (#7) of three residents sampled for abuse. The facility failed to identify abuse, prevent abuse, investigate, and protect residents following allegations of verbal and physical abuse as witnessed by the roommate of resident #7. Resident #7's roommate stated resident #7 had been both verbally and physically abused by a certified nurse aide (CNA). The facility identified 68 residents resided in the facility. Findings: The facility's policy and procedure, Investigation of Abuse, Neglect and Exploitation, documented the following: .Federal and State Law require that a person, including an owner or employee of an institution, who has cause to believe abuse, neglect or misappropriation of resident's property has been or may be adversely affected by another person, shall report the incident to the Department and to the Department of Human Services. The person reporting must send a written report and a copy of the facility incident report no later than the fifth working day after the incident. In the case of a direct care giver being suspected of an allegedly abusing, neglecting or mistreating a resident, the Administrator or the Director of Nursing will relieve the individual of her/his duties regarding their allegation until the investigation is completed by the facility . Proper Notice to the Department: The initial report to the Department shall be made by telephone within (24) twenty four hours of the reportable incident; 2. Must state the facts of the alleged abuse, neglect or misappropriation of resident's property; 3. Must include all documents of the investigation; 4. Must notify the Department in writing within (5) five working days of the incident; 5. Must included a copy of the written notice given to the nurse aide or other person of their right to request a hearing by the Department . RESIDENT ABUSE, NEGLECT AND EXPLOITATION BY EMPLOYEES It is the policy of this facility to treat all residents and other persons, who come into contact with this facility, with dignity and respect. The following criteria will constitute resident abuse, neglect, or exploitation by employees or volunteers: Physical and/or verbal abuse, rude behavior, or discourtesy . Procedure Should a resident feel that he/she, a family member, or any other person may have been abused, neglected, or exploited, they may report this to any member if this facility according to the Resident Grievance Procedure. Additionally, if the resident, family or other party will be given any and all assistance necessary to complete the complaint procedure. This includes providing them with access to written addresses and point of contact for any regulatory or protective agency. The Director of Nursing and/or Administrator will be informed immediately and given the report as soon as possible. Any employee or volunteer who has knowledge of an alleged incident involving acts or omissions which may constitute abuse, neglect, or exploitation will make an immediate verbal report to the Director or Administrator. This includes situations in which an employee receives a resident complaint alleging acts or omissions which may constitute abuse, neglect, or exploitation, or has some other reason to believe that such an incident may have occurred . An employee or other person associated with the facility who reasonable believes or who knows of information that would reasonably cause a person to believe that the facility or an employee of or health care provider associated with the facility, has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the facility or medical services provided shall as soon as possible report the information supporting the belief to the Department of Health, or the appropriate state health care regulatory agency, by telephone or in writing or by personal visit. A complaint may included physical or verbal abuse or sexual exploitation. A health care provider who fails to report shall be referred by the Department of Health to the individual's licensing board for appropriate disciplinary action. This facility may not suspend or terminate the employment of or discipline or otherwise discriminate against an employee for reporting the employee's supervisor, the administrator of this facility, a state regulatory agency, or a law enforcement agency violation of the law. The facility may not retaliate against a person who is not an employee for reporting a violation of the law. This facility will prominently and conspicuously post for display in a public area of the facility that is readily available for residents, volunteers, employees and visitors a statement that employees and non-employees are protected from discrimination or retaliation for reporting a violation of the law. The statement will be in English or in a second language appropriate to the demographic makeup of the community served. Any type of abuse or sexual misconduct will be incorporated into the resident's plan of care . PROCEDURE FOR MANAGEMENT OF SUSPECTED ABUSE/NEGLECT In the event there is am allegation or incidents involving employee to resident, resident to resident abuse, visitor to resident abuse, or visitor to employee abuse, the following shall occur: 1. The individuals involved in the abuse should be immediately separated by the staff. 2. A complete assessment of the resident and other parties should be done by the charge nurse. 3. Once safety is established, the Administrator and Director of Nursing should be notified immediately. 4. The charge nurse should complete an incident report, being very precise about the incident and obtain statements from any witnesses to the incident. 5. The incident report and statements must be completed before the end of the shift. 6. Place the incident report on Q-Shift focused charting of any incidents or other behaviors. If there is an allegation of abuse against the employee: 1. Re-assign the employee to another area separate from the resident who was involved in the abuse. The Administrator and Director of Nursing must address the employee situation immediately by placing the employee on unpaid leave of absence pending completion of the facility's investigation. 2. If a visitor is involved in the abuse, they will be asked to leave the building. If they refuse to leave call the Police Department for assistance . Resident #7 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. An admission assessment, dated 05/01/15, documented resident #7 had moderately impaired cognition; had problems falling or staying asleep; was feeling tired or having little energy; had trouble concentrating; required extensive assistance with the help of one person with bed mobility; required total assistance with the help of two people with transfers and bathing; and required total assistance with the help of one person with dressing, eating, toileting, and hygiene. The assessment documented the resident had an indwelling catheter and was always continent of bowels. A care plan, dated 05/05/15, documented resident #7 was unable to reposition in bed, transfer, or perform self care activities of daily living (ADLs) without extensive assist from staff. A care plan, dated 05/08/15, documented the resident had a problem with cognition and memory, and staff was to explain all care with step by step direction before providing it. On 07/25/15 (time unknown) a typed letter was given to the survey team by administration. The letter was dated 07/25/15. The letter documented the following: A sampling of 14 residents was interviewed on this date. The interview investigated abuse, safety, and fear of staff. No residents in the sample reported any abuse or fear of staff. A sampling of 5 staff members were interviewed on this date. The interview investigated the potential for residents to be abused. None of the staff interviewed witnessed abuse. DON took a statement from (Resident #15's Name deleted). (Resident #15's Name deleted) reported that he witnessed nurse aide, (CNA #8's Name deleted) performing ADL care on (Resident #7's Name deleted) and at that time she handled him in a rough manner. (Resident #15's Name deleted) reported that (Resident #7's Name deleted) nearly hit his head on the window sill due to the rough handling. DON took a statement from (Resident #7's Name deleted) and he confirmed that he was handled rough during his interaction with nurse aide (CNA #8's Name deleted). The letter was signed by the administrator and the director of nursing. On 07/25/15 at 8:40 a.m., resident #15, whose cognition was intact, reported to the survey team about the abuse he had witnessed the previous week to resident #7 (his roommate) by certified nurse aide (CNA) #8. Resident #15 said CNA #8 had been yelling at resident #7 who was totally dependent on others for activities of daily living. Resident #15 said CNA #8 was calling resident #7 bad names. He said the CNA then picked resident #7 up and threw him into his bed almost hitting his head on the window sill. Resident #15 told CNA #8 she shouldn't do that to his roommate and the CNA stated, What are you gonna do about it? Resident #15 said he told the charge nurse licensed practical nurse (LPN) #3 about the incident. He said the incident had occurred the previous week and CNA #8 continued to provide care to his roommate, resident #7. On 07/25/15 at 11:15 a.m., resident #7 was interviewed regarding an allegation of abuse his roommate had informed the surveyor about. The resident was asked if any staff had ever verbally and/or physically abused him in the facility. The resident shook his head up and down indicating yes. The resident was asked if one or more staff had abused him. He help up one finger. He was asked if he wanted the CNA to assist him with care. He shook his head indicating no he did not want the CNA to help him. On 07/25/15 at 11:20 a.m., the ADM, DON, and assist director of nursing (ADON) were interviewed regarding the verbal and physical abuse resident #15 told the surveyors had occurred the past week to resident #7 by CNA #8. The ADM, DON, and ADON denied ever being told about the abuse allegations. On 07/25/15 at 12:05 p.m., certified medication aide (CMA) #1 was interviewed regarding the allegation of abuse towards resident #7. The CMA said he had been passing medications the day the alleged abuse had occurred but had not witnessed the incident. CMA #1 said he went into resident #7 and #15's room to see why resident #15 was upset and talking loudly. CMA #1 said resident #7, resident #15, CNA #8, CNA #9, and LPN #3 were in the room. The CMA said resident #15 was observed very upset and talking loudly saying CNA #8 had talked rudely to resident #7 and then had thrown the resident into his bed almost hitting his head on the wall. The LPN talked to resident #15 to get him to lower his voice and asked him what he had observed. He said as they were leaving the room the LPN told CMA #1 she was going to call the DON regarding the allegations. On 07/25/15 at 12:15 p.m., LPN #3 was called per telephone. The LPN was the charge nurse the day the alleged abuse occurred. The LPN was asked what had occurred the day of the alleged abuse. The LPN said around 11:00 a.m. she heard resident #15 hollering in his room. The LPN stated she went down to the residents' room and asked resident #15 what had happened to upset him. She stated resident #15 told her CNA #8 was talking bad to resident #7 and had hurt him. The charge LPN said she took CNA #8 off the hall and put her on another hall. The LPN was asked if she had filled out an incident report. She stated, No. The LPN was asked if she had told the ADM or the DON. She said she had not told them. The LPN said she had asked resident #7 if CNA #8 had verbally or physically abused him and he had shook his head back and forth indicating no. On 07/27/15 at 11:40 a.m., resident #15 was asked what exactly he saw and heard CNA #8 do to resident #7. Resident #15 said he was sitting on the side of his bed by the door when the incident had occurred. He stated resident #7 was sitting in his recliner. Resident #15 stated the privacy curtain was closed and resident #15 demonstrated how he was able to see the resident sitting in his recliner and the resident's bed through the mirror over their sink. Resident #15 said CNA #8 said in a loud gruff voice to resident #7, Put your legs and feet down right now! Resident #15 stated while she was saying that, resident #7 was trying to tell the CNA his legs were hurting but she was ignoring his pleas. Resident #15 stated CNA #8 said, I'm tired of messing with you! Resident #15 said CNA #8 picked the resident up by herself and threw him onto his bed like a sack of potatoes. Resident #15 said resident #7 almost hit his head on the wall.

Based on record review, observation and staff and resident interviews, it was determined the facility failed to prevent continual verbal abuse, cursing, threatening bodily harm and talking vulgar to female residents by one (#13) of three sampled residents with identified abusive behavior. This had the potential to affect all residents, except three which were identified on the 'Resident Census and Conditions of Residents' as being bedfast. The facility census at the time of the survey was 77. Findings: The medical record for resident #13 documented the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 12/07/11, documented the resident was cognitively intact, had no mood indicators or behaviors, was independent in transfers, ambulation via W/C and had limitation in ROM to the lower extremities on one side. The resident's care plan, dated 12/14/11, documented: "Problem...made inappropriate remarks to female staff members. Goal...Will recognize that female staff do not want him making inappropriate remarks to them and will refrain from doing so thru next review. Approach...Council (Name deleted) how staff feels when he makes remarks to them that makes them feel uncomfortable around him. If (Name deleted) continues to make inappropriate remarks to female staff notify physician and request psych eval. Place CNA on (Name deleted's) hall that is older or a male CNA to assist (Name deleted) with his care." A nurse's note, dated 01/28/12 at 8:15 p.m., documented the following: "Resident up ambulating T/O facility. Became verbally aggressive c residents, and threatened physical violence on residents & this nurse. This nurse intervened to attempt to calm resident down @ which time he stood up 1 foot in front of this nurse with his hands out stating "What are you gonna do?" "I'll knock you down." This nurse stated calmly "We need to calm down. We don't want to hurt anyone. Putting our hands on people wont help." Resident then sat down & stared @ this nurse for a little bit. Then this resident ambulated to another area of facility." An incident report, dated 01/28/12 at 8:15 p.m., documented, "Resident was agitated c residents then threatened bodily harm on this nurse." The report documented the physician had been notified. Steps to prevent recurrence documented, "Explained to res that he could go other places in corridor & have alone time he agree." A nurse's note, dated 03/15/12 at 7:20 p.m., documented: "Summoned to lobby by visitor (Name deleted), who reported, "Those two men are fixin to fight!" Accompanied by RN (Name deleted) - observed res in W/C, facing fell ow res. Res had hands in air, fists clenched et expressing threats toward fell ow male res. who had no obvious idea what was happening. Removed other res from immediate area while (Name deleted RN) attempted to calm res. He refuse to stop threatening et began verbally threatening (Name deleted RN). This LPN notified the police, et (Name deleted RN) awaited their arrival while monitoring res. whereabouts. Just prior to police arrival res stated he wanted to "stop all this - 'I'm ready to quit'." Police X3 arrived et spoke c res. who was calm @ that time et denied he intended to harm anyone. After police left, res cont to brag about "they only sent three - it would take more than that." After speaking again c res about his behavior res expressed thoughts that he would not hit any resident here." There was no documentation the physician had been notified of the resident's behaviors or the police having to be called. The incident book was reviewed for any documentation regarding the incident. There was no incident report found for this incident. A nurse's note, dated 03/29/12 at 7:30 p.m., documented: "CNA (Name deleted) reported she was giving res a shower et he had repeatedly tried to touch her inappropriately et had slapped his penis against her buttocks after she had attempted to re-direct him several X's. She stated further that he was blocking her from exiting the shower room. She stated she finally was able to move enough around him to get out. This LPN spoke c resident regarding the inappropriate behaviors et that he had made the CNA feel very uncomfortable et upset. He verbalized understanding et stated he wouldn't do it again. There was no incident report filled out or notification to the physician regarding the resident's inappropriate behavior during the above incident. A nurse's note, dated 04/05/12 at 6:30 p.m., documented: "Female resident reported to this LPN that res makes her "sick' by speaking "vulgar". Stated res told her that he and his girlfriend "go out back behind a tree and bang." She stated further that she will not go outside anymore and will go to her room if he tries to talk to her anymore. This LPN spoke with resident (Name deleted resident #13) et asked that he not discuss private intimate matters c fell ow residents as this makes them uncomfortable. No staff is aware of res (Name deleted) having a girlfriend or going "out back" c any female." There was no incident report regarding the incident of the resident speaking vulgar to the female resident and upsetting her to the point she would not go outside. There was no documentation the physician had been notified of the above incident. A nurse's note, dated 04/08/12 at 6:00 p.m., documented: " A female resident came to nurses station stating that this resident had upset her greatly . Supposively this resident was saying very sexually vulgar things to female resident & she stated he had to be stopped. Female resident very upset. This nurse went & spoke c this resident about these accusations. The resident denied all accusation. This nurse then suggested that this resident not go to east side of building at all where this female resident's room is..." A notation on the resident's care plan under comment, dated 04/10/12, documented, "...has been going down east hall where all Residents are female and one of the female residents stated she felt uncomfortable with him being on her hall. Also was reported by CNA while assisting him c shower that he took his penis & hit her on the leg. (Name deleted) has been told that because east hall is all female residents that he is not to go down that hall. Also (Name deleted) has been talked to about behavior towards CNA & that he can not be inappropriate c female staff." A nurse's note, dated 05/16/12 at 7:20 p.m., documented: "LPN (Name deleted) informed this LPN that resident was threatening to kick another resident. This LPN spoke c res to inquire about situation. Res stated, "He was kicking the door so I told him I was gonna kick him!" Informed res that he may not threaten another resident for any reason. He cont to state he would kick or hit other resident if he wanted to et then he hit the sofa several times c his fist et cont to state how he could knock out any body he wanted to. Attempted to explain to res that he is to inform staff of incidents that he thought needed to be taken care of but he cont to speak aggressively. This LPN contacted the police dept to have an officer come speak c res. Res stated, "Call the cops" "I'm not scared of no cop even if they got a gun." Once the police arrived res began denying threats made et appeared to calm down some even though he did tell the officer he could knock someone out. Residents were separated et monitored until police officer arrived @ the facility et p officer left resident removed himself from lobby. 0 threats were heard p officer left. Will cont to monitor." An incident report, dated 05/16/12 at 7:20 p.m., documented, "Resident made threats of bodily harm to another resident d/t he did not want other res kicking the door." The report documented a message had been left on the physician's answering machine. Steps to prevent recurrence documented, "Removed res from situation, redirected." The incident report did not document the police had been called and had came to the facility to talk to the resident. An entry on the resident's care plan, dated 05/16/12, documented, "Res made threats of bodily harm to another res d/t he didn't want other res kicking door. Res removed from situation. Explained to res if becomes agitated to get staff member, don't threaten other res. Res agreed." A nurse's note, dated 07/23/12 at 7:00 p.m., documented: "This LPN over-heard loud, angry conversation on N Hall. Observed res yelling about another res (confused female) going into his room et picking up his stuff. Res was very irate but did not touch other res. This LPN spoke c res et instructed him to put up a strap barrier or shut door to prevent again. Calmed et was cooperative. Dr notified." An incident report, dated 07/23/12 at 7:00 p.m., documented, "This LPN heard loud, angry conversation on N hall. Observed res yelling about another res (confused female) going into his room et P/U his stuff. Steps to prevent recurrence: Instructed Res to keep door closed or apply barrier strap to door to prevent occurrence. Res agreed." The report documented the physician had been notified. A notation on the resident's care plan, dated 07/23/12, documented, "(Name deleted) became upset when female resident who is confused went into his room & was picking up his personal items. (Name deleted resident #13) was making threats toward resident. Charge nurse calmed him down & instructed him to keep door shut or have barrier strap applied to door to prevent reoccurrence. (Name deleted) agreed & complied by shutting door." A nurse's note, dated 07/24/12 at 1:00 a.m., documented: "Came into lobby yelling, "If in morning I am missing anything I am gonna use these (fist) to fix the problems- Proceeded to hit his L hand c his R hand in a fist over and over. "I will go to (Name deleted the administrator) and hit L hand c R hand and he will know that I mean business. Told him to go back to his room and go to bed. 3am Sitting in door way hitting his L hand c his R hand over & over. " On 08/19/12 at 2:15 p.m., during the initial tour, LPN #1 reported the resident had no behaviors and was independent with most ADLs. At 3:10 p.m., the resident was observed in a W/C coming inside the facility from a side door at the end of North Hall. The resident was asked if the temperature of the hot water in his bathroom could be check. The resident gave his permission. On 08/20/12 at 5:00 p.m., observation was made of the delivery of supper trays to the residents in the dining room. Resident #13 entered the dining room in his W/C and attempted to get to his regular place at the dining room table. The resident was unable to get between the two rows of other residents. The resident began yelling at another male resident. The staff intervened and helped resident #13 get to his place at the table. The resident remained upset and started hitting his right fist against his left hand. He was yelling, "I will give them this and don't they know it will kill them. I will kill them." The resident continued hitting his hand and yelling the same phrase repeatedly. The staff was unable to calm the resident. The ADON was observed to leave the dining room and return with the ADM. The ADM walked over to resident #13 and bent down to be at resident's eye level. The resident then stood and repeatedly said, "I will give them some of this", while shaking his fist. He stated, "They have to know this will kill them." The Administrator maintained eye contact and stayed at eye level with the resident. After the incident, the delivery of the meal services continued. Resident #13 received his tray and began to eat his supper. The Administrator reported, to the surveyor who had observed the entire incident, that the resident gets worked up sometimes, but he has never caused any issues. The supper meal continued without further incident. A nurse's note, dated 08/20/12 at 6:30 p.m., documented: "During the Dinner meal service this nurse noticed Res verbally in threatening manner talking to confuse Res c table across from him. This resident stating he would take care/handle confused resident. This nurse tried to calm him telling him other resident was confused & didn't know what he was saying. Confused resident had not approached (resident #13) but was talking to himself. (Name deleted resident #13) stood up doubled up fist & told this nurse that he could handle her also that he was the handler and took care of things and would take care of the situation & nurse in threatening manner. Administer was notified of situation & went to DR to talk c (resident) who was still argumentive. (Resident) again stood up c fist doubled up & threatened administrator who cont to talk c (resident)...Finally (resident) calmed down & ate his evening meal. (Name deleted resident #13) is alert & oriented X 3 and is very aware of what he is doing. Will cont to observe for further behavior/outbursts for resident." There was no documentation the physician had been notified of the resident's behavior. There was no incident report completed regarding the above episode. The resident's care plan had not been revised to address the resident's threatening behaviors, cursing or vulgar language. The care plan had addressed the resident's inappropriate behaviors toward staff members, but had not addressed the threatening behaviors, cursing and vulgar conversations toward residents. On 08/23/12 at 9:00 a.m., the ADM was interviewed regarding the resident's behaviors. The ADM was asked what would have happened if he had not been at the facility to calm the resident down on 08/20/12. The ADM reported the resident would respond to a male and calm down. He reported they didn't always have a male working, so the nurses would then have had to calm him down. The ADM reported the resident's behavior had only happened once. The ADM was informed of the behaviors going back to January. The ADM reported the resident was just guarding the door. He reported he was not aware of the resident threatening other residents or any the other incidents documented in the nurses' notes. ADM reported he was not aware the police had been called due to the resident's aggressive behavior. At 10:00 a.m., the DON was interviewed regarding the resident's behaviors. The DON reported the nurses attempt to calm him down but if they couldn't they would call the police. The DON reported the resident gets mad and his anger escalates until the nurses have to call the police. The DON was informed the resident's care plan did not address all the resident's behaviors and there were no approaches added to the care plan to prevent or handle the resident's multiple aggressive behaviors. The DON was asked if the resident had been placed on a behavior management program since he had repeated incidents of aggressive behavior. She reported he had not been placed on a behavior management program. She reported he would spend a lot of time out doors. The DON was asked if the resident had been seen by a psychiatrist or any behavior management agency. She reported he had not. She reported he had not been seen because he always calms down. The DON was informed there were multiple incidents documented in the nurses' notes, but only three had an incident report. The DON reported the resident had not harmed anyone and that was why the incident reports had not been written. She was asked if she had sent any of the incidents to OSDH. The DON reported she had not. She reported she did not think she had to send them. The DON was informed the physician had only been notified of the resident's behavior documented on the three incident reports. She was asked how the physician could respond to the behaviors if they were not reported to him. She stated, "I see what you are saying." The DON was asked if she was aware of the resident talking vulgar to female residents. She reported she was only aware of one incident with a female. The DON was informed the nurse's note documented the female resident was very upset and would not go outside because of the resident and his vulgar language. The DON was asked what the facility had done to prevent the resident's aggressive behavior from escalating and harming another resident. She reported he would usually calm down after he verbalized his anger. The DON shook her head and stated, "I see what you mean." On 08/23/12 at 10:20 a.m., resident #28, who had been identified by the DON as one of the female residents upset by resident #13's vulgar language, was interviewed. The resident reported she had been very upset by the vulgar language the resident had used. She reported she no longer went outside where he was at. The resident reported she had not seen the resident during his aggressive behaviors, but had heard of them. She was asked if she would be frightened if he was waving his fist and cursing at her. She reported she would be. She stated, "Anyone would be afraid." At 2:00 p.m., resident #28 was again interviewed and was asked about the incident of resident #13 speaking vulgar in front of female residents. The resident stated resident #13 had spoken to her in a very vulgar manner and in great detail about what he had done sexually with his girlfriend. As the resident spoke of the incident, she began crying and used a Kleenex to dry her face. She stated the incident had upset her greatly and that she just tries to stay away from resident #13. At 2:15 p.m., the DON was asked if she knew who the other female resident was who complained of resident #13 using vulgar language. The DON reported did not know. She reported she had asked, but no one was aware of who the resident was who reported the resident upsetting her.

On 10/09/11, at 6:55 a.m., the Oklahoma State Department of Health was contacted regarding an Immediate Jeopardy situation related to under-cooked, non-pasteurized eggs with runny yolks being prepared to serve to residents at breakfast and frozen meat left out to thaw in the dry storage area. At 7:00 a.m., the IJ situation was verified by the Oklahoma State Department of Health. At 7:05 a.m., the RN charge nurse was informed of the IJ situation. At that time, the Administrator nor the Director of Nursing were present in the facility. The ADM and the owner lived two hours away. The RN immediately notified the ADM by cell phone regarding the IJ situation. At 12:30 p.m., an acceptable Plan of Removal for the IJ was submitted by the facility. The facility's Plan of Removal documented the following: "All non-pasteurized eggs will be immediately discarded. All meats that were improperly thawed will be discarded immediately. All dietary staff will be in-serviced, today, regarding proper thawing techniques and that pasteurized eggs must be used at all times. Meats will be thawed on the bottom rack of the refrigerator or under running cold water. The above issues will be monitored by the Dietary Manager and the Dietary Manager will in-service all new employees on these procedures." The dietary in-service documented all the dietary staff would be trained before their shifts. The in-service documented the following: "All eggs used in the facility must be pasteurized eggs. All meats must be thawed in the refrigerator on the bottom shelf or in running cold water. All non-pasturized eggs must be thrown away immediately. All improperly thawed meats will be thrown away immediately." On 10/10/11, at 2:15 p.m., the ADM reported all the dietary personnel had been in-serviced. At 2:30 p.m., the dietary staff were interviewed regarding their knowledge of the in-service. All the dietary staff were knowledgeable about the items covered in the in-service. The IJ was removed on 10/10/11 at 2:30 p.m., when the last dietary staff had been interviewed and had verbalized their knowledge of not ever serving non-pasteurized eggs to the residents. The deficient practice remained at a pattern level of no actual harm, with a potential for more than minimal harm. Based on record review, observation, and staff interviews, it was determined the facility failed to: a) Ensure non-pasteurized eggs were thoroughly cooked before serving to residents. b) Ensure multiple non-pasteurized eggs were never prepared in the same skillet at the same time. c) Ensure meat was properly thawed. d) Ensure the chlorine level in the dishwasher was monitored on a regular basis and recorded in a log. e) Ensure dietary staff had knowledge of using a three compartment sink and what steps to take if the dishwasher was not properly functioning. f) Ensure the floor and shelves used to store pots and pans, in the dietary department, was free of food crumbs. g) Ensure food items in the refrigerator were covered and dated the day they had been opened. h) Ensure a trash can located near the handwashing sink was in functioning order. i) Ensure the dietary department was free of flies, during the two observed meal services. j) Ensure the ice machine remained locked when the staff was not utilizing the machine. This had the potential to affect 61 of 61 residents per the DON. Findings: On 10/09/11 at 5:30 a.m., during the initial tour of the kitchen the following was found: Several flats of non-pasteurized eggs were observed in the bottom of the refrigerator. At 5:30 a.m., DA #1 was asked to check the dishwasher for sanitation. A log on a sheet of paper, on the wall, documented dishwasher chlorine readings. The last documentation of the machine being checked was on 10/05/11. The DA checked the dish machine, three different times, the water did not show any chlorine being utilized for dish sanitation. The DA was asked who had worked the day before. She reported she had. The DA was then asked if she had checked the machine the day before. She reported she had not because the log sheet had been full and she could not find another log sheet to record the amount of chlorine even if she took it. The DA was then asked how they had cleaned the dishes the day before. She reported in the dishwasher. She was then asked what steps would be taken if the dish machine was not working. The DA reported they would do them by hand. The DA was asked how and where they would clean the dishes. The DA pointed to a two compartment sink. She reported she would put soap and water in the first sink, then put sanitizer and water in the second sink. The DA was asked if she was aware of the three compartment sink method for cleaning and sanitizing the dishes. She reported, no, but they only had two sinks. The DA did not have knowledge of the three compartment sink cleaning/rinsing/sanitizing method. The DA was asked if the facility had a supply of paper goods. She reported they had some paper cups, but no plates or plastic utensils. The floor under the dishwasher and in the dry storage area was observed to have food crumbs scattered about. In the dry storage area, a large stainless steel pan was observed to contain: Three bags of precooked thawed chicken, the bags were dated "9/14." A thawed 10 lb roll of hamburger meat. Two packages of lunch meat, thawed. and, A box of chicken leg. At that time, the DA was asked how long the meat had been sitting there. She reported since 4:00 a.m.. The DA was asked where the meats had been previously. She reported the DM had come in the previous day before lunch and told them what to prepare today. She reported they had laid the meat out to thaw at that time. The DA was asked if the meat had been left out overnight. She reported they put it back in the refrigerator when they left yesterday at 4:30 p.m. The DA was asked how she had been trained to thaw meat. She reported she really wasn't. She then stated, "(Name deleted the DM) said according to the state it is okay to lay it out overnight." The temperature of the hamburger meat was checked and registered 52 degrees F. The temperature of the pre-cooked chicken registered 34 degrees F. The box of raw chicken legs registered 40 degrees F. A stainless steel refrigerator in the storage area contained: A bowl of fruit with a whipped topping, covered and dated "10/4" and a bowl of beans dated "9/17." A trash can located near the handwashing sink, was observed to be broken and the top had to be lifted manually to dispose of paper towels used for handwashing. A stainless steel refrigerator in the meal preparation area was observed to contain 2 cups of milk. The cups of milk were uncovered and undated. Two shelves containing pans were observed to contain a moderate amount of food particles. Flies were observed to land on cooking utensils, dishes and serving areas. At 6:10 a.m., it was observed there was no ice to serve with breakfast or to keep the drink items cold that were sent out on the halls. LPN #1 was asked why there was no ice available. She reported the ice machine had been shut down last night, because it had been left unlocked and a resident stuck his hand into the ice. At 6:30 a.m., a skillet on the stove was observed to contain six partially cooked non-pasteurized eggs. The eggs were observed cooked over-easy with undercooked yolks. The flame under the skillet was turned off. The cook was observed to prepare a breakfast plate for resident #25. The cook placed a non-pasteurized fried egg, dry cereal and sausage on the plate. The yolk of the egg served was observed to not be thoroughly cooked. The cook and DA were stopped from serving the egg to the resident. The egg was cut with a butter knife and the yolk of the egg was observed to run out onto the plate touching the cooked sausage patty. The cook and the DA were asked if they knew what the problem was with serving undercooked, non-pasteurized eggs to the residents. Neither of the staff members had knowledge of the difference between pasteurized and non-pasteurized eggs or what the proper temperature should be for cooked non-pasteurized eggs. At 7:00 a.m., the meats on the stainless steel pan in the dry storage area continued to set out in the same place. At 7:30 a.m., many flies were observed in the kitchen. They were observed to land on a pan of lemon bars the staff had reported were for the lunch meal. The flies were also observed to land on eating utensils, dishes and serving areas. The back door of the kitchen was observed open. The door was locked next to the serving area. There was a gap of a few inches between the door frame and the screen door, which was allowing flies to enter the facility. At 8:30 a.m., the DM arrived. The DM placed the thawing meats from the dry storage area back into the refrigerator. The meats had been out since 4:00 a.m. At 8:40 a.m., the temperature of the meats were checked. The box of raw chicken legs registered 33 degrees F. The hamburger meat was 61 degrees F. At 9:00 a.m., the maintenance man was observed with the ice machine unlocked and being cleaned. At 10:20 a.m., the ADM was interviewed regarding sanitation issues in the kitchen. The ADM stated, "I have already talked to the DM and the meat was to be disposed of." The ADM then reported the DM was planning on coming in today and check on the staff to ensure the dietary department was running properly. At 10:25 a.m., the DM was interviewed. She was asked what she had done with the meat that had been thawing. She reported she had placed it back in the refrigerator. The DM was then asked if she had discussed the issue of the way meats were being thawed with the ADM. She stated, "I haven't said anything to him about it yet, I haven't had time. The DM was then asked if she had planned on coming to the facility that day to help in the dietary department. She stated, "No, this was my first weekend off in a long time."

Based on record review, observations and staff interviews, it was determined the facility failed to: a) Ensure residents who complained of pain or showed signs and symptoms of pain received the necessary treatment to relieve the pain in a timely manner, for three (#1, 11, and #15) of nine sampled residents who had been identified with pain. This caused actual harm to residents #1 and #15. This had the potential to affect 49 residents receiving pain medication, per the DON. b) Ensure indwelling catheter care was performed in a manner to prevent possible UTIs for two (#1 and #4) of three sampled residents with indwelling urinary catheter. This had the potential to affect four residents with indwelling urinary catheters per the DON. Findings: The facility's policy and procedure documented: "Emergency pharmacy services: Policy: Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the by special order from (Name deleted pharmacy), supplies emergency medications including emergency drugs, antibiotics, (controlled substances...)" 1. Resident #1 had been admitted to the facility on [DATE]. A care plan, dated 06/09/11, documented, "Problem: Phantom limb pain D/T above knee amputation of right leg... Approach: Medicate as ordered with [MEDICATION NAME]/APAP monitor and record response. Alternate pain relief methods... responds well to pain meds and elevation of remaining extremity...notify physician of any changes." A pain evaluation, dated 06/30/11, documented the resident had a AKA. A pain evaluation, dated 09/16/11, documented the resident had acute internal pain. The cause of the pain had been identified as D/T arthritis, AKA and phantom pain. The evaluation also documented, "Check yes or no for each of the following nonverbal/non-cognitive sign which could indicate the presence of pain. The following signs were marked yes: grimacing/distorted face, clenched jaw/teeth, frowning/scowling, tightly shut lips, glazed eyes, wrinkled brow, turned down mouth, tearing, moaning, grunting, gasping, crying, screaming, cursing, thrashing, pounding, biting, rocking, threatening gestures, rubbing body parts, altered gait/posture, strenuous or altered breathing, knees pulled up into abdomen, fidgeting, pacing, irritability, clenched fists, wringing of hands, increased hand/finger movements, striking out at others... Does the resident receive scheduled medications? Yes, [MEDICATION NAME] Does the resident receive a PRN medication? Yes, [MEDICATION NAME]" A quarterly assessment, dated 09/19/11, documented the resident had inadequate short and long term memory, had severely impaired cognition, required extensive assistance with bed mobility, transferring between surfaces, eating, dressing, toilet use, bathing and hygiene, was not ambulatory, was always incontinent of bowel and bladder, was on a routine pain medication, hurt at all times in last 5 days, frequently, hard to sleep at night related to pain and limited day to day activities and reported the pain as being moderate on a scale of 1-10 with the pain a 7. A post operative report, dated 09/29/11, documented, "Gangrene (L) foot c associated [MEDICAL CONDITION] (L) above knee amputation..." The October 2011, physician's orders documented, "Diagnoses: [REDACTED]..DJD...Fx Neck of Femur...AKA, [MEDICATION NAME]... q 72 hr... Dx: psychogenic pain...Tylenol 325 mg... q 4 hrs prn pain/[MEDICATION NAME] 7.5 mg/500 mg q 4 hrs. Dx: pain..." The October 2011, MAR documented a [MEDICATION NAME] had been placed on the resident on 10/09/11. On 10/10/11, at 9:30 a.m., CNA #9 and CNA #10 were observed transferring the resident into her bed. The resident was observed to have bilateral AKA's. A dressing was observed on the (L) stump, with a moderate amount of red blood. The (R) stump had a smaller dressing. The dressing was soiled with a small amount of drainage. The resident had been sitting in her G/C, with a sheet under her. Each of the CNAs were observed to take corners of the sheet, one corner in each of their hands, lifting the resident and transferring her into the bed. During the transfer and after the resident was lying in the bed, she kept saying, "Oh, Oh, Oh, that hurts." At 10:35 a.m., LPN #2 was observed providing dressing changes for the resident. The dressing on the (R) stump had a date of 10/08/11, and was not due to be changed. The dressing on the (L) stump was observed being changed. During the dressing change, the resident was moaning, crying and saying, "Oh, it hurts!" The LPN asked the resident if she was hurting. The resident stated, "Yes!" On 10/10/11, at 12:30 p.m., the resident was observed sitting up in a G/C in the front lobby. CMA #1 was asked if the resident had her [MEDICATION NAME] on. The CMA examined the resident then reported the resident did not have on her [MEDICATION NAME]. She then reported the patch had come off twice in the past month. The CMA was then asked if the facility had a system in place for monitoring pain patches. She reported they did not have a system for monitoring on the MAR. The CMA was then asked how she had known that the resident had been without the patch on the other occasions. She stated, "Because she kept complaining of pain, so I looked. It wasn't on her." The CMA was then asked how the facility monitored the resident's pain. She stated, "We don't. There is nothing on the MAR." The CMA was then asked if she monitored the resident for pain. She reported they did not, because the resident was on a routine pain medication. At 12:40 p.m., LPN #2 was interviewed. The LPN was asked if the physician had been contacted about the resident's pain. She reported she had called the physician about the resident being gaulded and to find out what to do about the resident not having on her [MEDICATION NAME]. The LPN reported the physician had ordered some cream for the resident's gaulded perineal area and ordered the patch to be replaced. At 12:45 p.m., the DON was interviewed. She was asked for the pain assessments for the resident. The DON presented a monthly pain assessment completed by herself. She was then asked if the resident's pain had been assessed with [REDACTED]. She reported the monthly assessment was the only pain assessment being done. At 1:00 p.m., CMA #1 was asked if the resident was wearing a [MEDICATION NAME]. She reported she had just put a patch on the resident. A nurses' note, dated 10/11/11, at 10:35 a.m., documented, "Called (Name deleted physician) and requested something stronger for pain or possibly refer to pain specialist." On 10/12/11, at 9:30 a.m., the DON was interviewed. The DON was asked what the facility's policy and procedure was for monitoring pain patches, to ensure the patches remained intact and pain control was provided. She stated, "We don't monitor them, but we will start." The DON was informed of the resident not having a [MEDICATION NAME] on, complaining and crying in pain, lack of monitoring of the [MEDICATION NAME] and only one pain assessment being done. The DON reported she would follow up on these issues and get the resident's pain addressed. A nurses' note, dated 10/12/11, at 1:15 p.m., documented, "Spoke c (Name deleted physician's) nurse on resident's current pain meds. Nurse going to call back after she talks c (Name deleted physician)." On 10/12/11, at 1:55 p.m., LPN #2 was asked how long the resident had been in as much pain as she had experienced two days ago. The LPN reported the resident usually always had some pain, but the pain usually occurred whenever the tape was removed from one of her amputation sites or if she touched a certain area. The LPN reported the pain did not usually last throughout the entire treatment like it had two days ago. At 2:00 p.m., CNA #10 and #11 were interviewed. They were asked what they did when residents complained of pain. They both reported they would report it to the charge nurse. A nurses' note, dated 10/12/11, at 2:55 p.m., documented, "(Name deleted physician) notified of resident's increase c/o pain. (Name deleted physician) c no call back. (Name deleted physician) gave N/O to increase [MEDICATION NAME] to 75 mcg. MAR updated. Pharmacy notified." A nurses' note, dated 10/12/11, at 3:45 p.m., documented, "Resident cont c increased c/o pain. (Name deleted physician) notified. New one time order [MEDICATION NAME] 7.5/500 mg 1 po r/t c/o severe pain. MAR updated. CMA to administer @ this time." A nurses' note, dated 10/12/11, at 8:00 p.m., documented, "[MEDICATION NAME] 75 mcg received from pharmacy. Old patch taken off and 75 mcg applied. In bed resting @ this time. Will cont to monitor." A nurses' note, dated 10/12/11, at 9:00 p.m., documented, "Resting c OU closed. Resp equal and non labored. No s/s or c/o pain or distress noted @ this time. Awakened easily to verbal and tactile stimuli. Resident asked if hurting @ this time. Stated no." 2. Resident #15 had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The hospital discharge order sheet documented the resident was to receive [MEDICATION NAME] 30 mg. p.o. BID and [MEDICATION NAME] 10/325 mg. 1 - 2 tablets p.o. every 4 hours PRN for pain. The nurses' notes, dated 08/18/11, at 10:50 a.m., documented, "Resident admitted to facility SNF level of care...SPO2 93% on 2 L via N/C. Resident had an open reduction internal fixation (L) ankle. Non WB X 6 wks... (Name deleted physician) notified of new admit. Meds ordered from (Name deleted) pharmacy..." An admission nursing assessment, dated 08/18/11, documented, "Pain on admission: 4 aching..." At 12:00 p.m., a nurses' note, documented, "Resident c/o (L) ankle pain rated 4 on pain scale 1-10. Resident had pain med @ 10 am @ (Name deleted hospital). Pain meds to be given as ordered..." At 5:00 p.m., the nurses' note, documented, "Dr. (Name deleted) on rounds. N/O obtain, CBC, Chem 8, lab book updated." A pain evaluation, dated 08/18/11, documented, "...[DIAGNOSES REDACTED]. Does the resident verbalize pain? yes As the patient describes it, what does the pain feel like? throbbing, shooting. Pain is increased by... movement of ankle/leg. Pain type: internal, external, acute. At present: 4 (on scale 1/10) 1 hour after medication: 3 3 hours after medication: 3...What is the resident's acceptable pain level: 4 Does the resident receive a PRN medication? [MEDICATION NAME] 10/325 mg 1 or 2 po q 4 hrs prn pain..." A Social Progress Note, dated 08/19/11, documented, "Last night (Name deleted son), DON, via phone call in regards to meds. SSD called (facility's Name deleted). Nurse said (Name deleted pharmacy) had not delivered medications yet for the day. SSD called DON back and explained." A nurses' note, dated 08/19/11, at 8:00 a.m., documented, "Res taking Br (breathing) tx c/o SOB. O2 sat 98% on 2 lpm. This nurse attempted to assist res c relaxation/breathing exercises. Res crying & having some anxiety. Res c/o (L) ankle hurting. CMA notified, meds brought to res but then res started to shake. Res then stopped & became unresponsive to verbal or tactile stimuli. Pupils reactive... called Dr. (Name deleted) gave TO to send to ER for further eval & treat..." A medication consolidated delivery sheet, dated 08/18/11, at 5:46 p.m., documented the resident's medications were delivered to the facility and included [MEDICATION NAME] and [MEDICATION NAME]. The [MEDICATION NAME] was not delivered. [MEDICATION NAME] was scheduled to be administered at 5:00 p.m. The MAR did not contain documentation of the medication being administered. [MEDICATION NAME] 10/325 1 po q 4 hrs prn- The MAR documented the medication had been administered four times. The back of the MAR documented, "8-18 8pm- [MEDICATION NAME] 10/325 mg 1 po c/o pain x 6. helpful. 8/19/11 0100- [MEDICATION NAME] 1 po for c/o pain. 8/19/11 0530- [MEDICATION NAME] 1 po for c/o pain." The resident was admitted to the facility on [DATE] at 10:50 a.m. and was not administered any medication for pain until 8:00 p.m. A fax to the resident's physician and the facility's medical director, dated 08/18/11, documented, "Please fax hard script for [MEDICATION NAME]." The nurses' notes, documented the physician had been at the facility and had seen the resident at 5:00 p.m., on 08/18/11. A transfer and referral form, dated 08/19/11, documented, "...Res was admitted here (the facility's Name deleted) yesterday. Had some anxiety & c/o SOB this AM, gave her br (breathing) tx, res asked for PRN pain med c/o pain to (L) foot. Res then started shaking for approx 30 sec then stopped. Pupils reactive, res not responding to verbal or tactile stimuli." A discharge summary, dated 08/19/11, documented, "Resident was admitted c ORIF of (L) ankle pain & anxiety. Had stay of 1 day, then had [MEDICAL CONDITION] was sent to (Name Deleted health center)... Res was discharged to hospital then moved to another facility." On 10/12/11, at 9:25 a.m., the DON was interviewed. The DON was shown the resident's MAR and asked why the resident had not received the routine pain medication of [MEDICATION NAME] as ordered by the physician. The DON reported they had to have a paper script from the physician before the pharmacy would fill the prescription. On 10/12/11, at 10:00 a.m., LPN #2 was interviewed. The LPN had been the charge nurse when the resident had been admitted to the facility. The LPN was asked what steps she had taken when the resident was admitted to the facility. The LPN reported she had contacted the physician that the resident had been admitted , then faxed the list of medications ordered to the pharmacy. The LPN was asked what time the medications were usually delivered from the pharmacy. She reported they usually arrived on the evening shift, around 5:00 p.m. The LPN was then shown her nurse's note of the resident's pain at 12:00 p.m., and the resident needing something for pain relief. The note documented the resident had not been treated for [REDACTED]. The MAR for the hospital documented the resident had received the routine [MEDICATION NAME], but had not received the PRN [MEDICATION NAME]. The LPN reported they were unable to give the resident anything for pain, because the resident's medications had not arrived from the pharmacy. The LPN was asked what was the facility's policy for obtaining medications when needed sooner than the 5:00 p.m., delivery time from the pharmacy. She reported they could call a local pharmacy for pain medications if needed for severe pain, like 5 or above on the pain scale. The LPN was then asked if the [MEDICATION NAME] and [MEDICATION NAME] should had been obtained from the local pharmacy for pain management for the resident. She stated, "I could have." On 10/12/11, at 3:00 p.m., the DON was interviewed. The DON was shown the documentation of the resident experiencing pain, the pain medications not being available in the facility and resident's pain not being treated. She reported she would work on the problem. 3. The medical record for resident #11, documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's care plan, dated 12/28/09, documented a problem with ADL function. Approaches included monitoring for signs and symptoms of pain and to consult with physician and therapists for any changes in status. A quarterly assessment, dated 08/22/11, documented the resident was cognitively intact, required extensive assist with ADLs, and had moderate pain rated as a "7" on a scale of "1 - 10." The resident's October 2011, physician's orders, documented the resident was to receive [MEDICATION NAME] 10/500 mg every 6 hours for pain. The medication was scheduled for 3:00 a.m., 9:00 a.m., 3:00 p.m. and 9:00 p.m. A physician's order, dated 10/13/11, documented the resident was to receive [MEDICATION NAME] 100 mg TID at 9:00 a.m., 1:00 p.m. and 5:00 p.m. On 10/09/11, at 6:45 a.m., LPN #4 was observed obtaining a FSBS from the resident. The resident complained of having a headache and requested something to relieve the headache. The LPN reported the resident did not have an order for [REDACTED]. The LPN informed the resident she was sorry, but she did not have a physician's order for a prn Tylenol. On 10/10/11, the medical record was reviewed for documentation the physician had been notified of the resident's complaints of a headache. There was no documentation the physician had been notified and there was no physician's order of a treatment for [REDACTED]. At 3:30 p.m., the resident was interviewed regarding the headache. The resident was asked if she would like to have an order for [REDACTED]. The resident reported she would like to have something to take for her headaches. On 10/12/11, at 5:10 p.m., the DON was interviewed regarding the lack of notification and acquiring a physician's PRN pain medication to treat the resident's headache. The DON reported the physician should have been notified and an order obtained to treat the resident's headache. 4. Resident #4 had a [DIAGNOSES REDACTED]. The resident also had experienced a UTI on 06/27/11. The September 2011, physician's orders, documented, "F/C care with soap and water every shift..." On 10/10/11, at 11:10 a.m., LPN #2 and CNA #6, were observed providing catheter care for the resident. The LPN told the CNA to place a portion of the tubing between the resident's legs to hold it in place. The CNA was observed to place a part of the tubing in between the resident's legs. LPN #2 had two wash cloths soaked in soap and water. The LPN took one of the soapy wash cloths and wiped one side of the penis from the head of the penis down the shaft of the penis. The LPN then took the other soapy wash cloth and did the same down the other side of the penis. The back side of the penis was never cleaned. The LPN then rotated the soapy wash cloth and went down the tubing approximately three inches to the area where the tubing was being held by the resident's legs. The LPN then took the wash cloth which had been soaked in plain water and wiped off the areas she had cleaned with the soapy wash cloths. The LPN then took a dry wash cloth and dried around the areas she had cleaned and wiped off. On 10/12/11, at 9:25 a.m., the DON was informed of the F/C care observed. She stated, "She knows better." 5. A urine culture and sensitivity report for resident #1, dated 08/18/11, documented the specimen had a organism of Escherichia coli..." A quarterly assessment, dated 09/19/11, documented the resident required extensive assistance with toilet use, bathing and hygiene, was not ambulatory and was always incontinent of B & B. The October 2011, physician's orders documented, "Foley cath continuous- [MEDICAL CONDITION] bladder...Catheter care..." The October 2011, treatment sheet documented, "Foley cath care q shift..." On 10/10/11, at 10:35 a.m., LPN #2 was observed providing indwelling urinary catheter care for the resident. The resident was observed lying in her bed. The LPN obtained three wet washcloths and sprayed each of the washcloths with peri-wash. The LPN using one of the washcloths was observed to clean the resident's (L) & (R) groin areas with separate cloths. The LPN with a different washcloth cleaned the perineal area. The LPN then gathered her soiled supplies and removed her gloves and said she had completed the catheter care. The LPN had not cleaned the tubing of the indwelling urinary catheter. On 10/12/11, at 9:30 a.m., the DON was interviewed. The DON was informed of the observed indwelling urinary catheter care. She reported the nurse should have cleaned the catheter tubing.