Every finding on record at Heritage Park

Based on interview and document review, the facility failed to ensure all staff were fit-tested for an N-95 respirator mask (protects residents and staff from the transfer of microorganisms that can cause infectious disease) per the Centers for Disease Control (CDC). This deficient practice had the potential to affect all 43 residents who resided in the facility.Findings included: A CDC document titled, National Institute for Occupational Safety and Health (NIOSH) Personal Protective Equipment, dated 02/03/2025, indicated, Before using a tight-fitting respirator in the workplace, The Occupational Safety and Health Administration (OSHA) requires users to pass a fit test to confirm proper fit and a tight seal against the user's face. A CDC document titled, Filtering our Confusion: Frequently Asked Questions about Respiratory Protection, Fit Testing, dated April 2018, indicated, The Occupational Safety and health Administration (OSHA) (29 CFR [Code of Federal Regulations] 1910.134) requires an annual respirator fit test to confirm the fit of any respirator that forms a tight seal on the wearer's face before it is used in the workplace. The document further indicated, In addition to fit testing upon initially selecting a model of respirator, OSHA requires that fit testing be conducted annually, and repeated 'whenever an employee reports, or the employer or the physician or other licensed health care professional makes visual observations of changes in the employee's physical condition that could affect respirator fit (e.g. [exempli gratia, for example], facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight).' During an interview on 07/01/2026 at 12:01 PM, the Regional Nurse Consultant (RNC) stated the facility did not have a policy regarding N-95 fit testing. During an interview on 07/07/2026 at 2:15 PM, Certified Nurse Aide (CNA) #1, hired 06/16/2026, stated they had not been fit-tested for an N-95 mask. During an interview on 07/07/2026 at 4:23 PM, Certified Medication Aide (CMA) #2, hired 09/05/2024, stated they had not been fit-tested for an N-95 mask since they had been working at the facility. During an interview on 07/01/2026 at 11:32 AM, the Regional Nurse Consultant (RNC) stated that no recent N-95 fit testing had been completed at the facility. The RNC stated she did not know when the last fit testing was done. The RNC stated N-95 fit testing should be done annually and upon hire. The RNC stated that the Infection Preventionist (IP) was new to the IP role. During a follow-up interview on 07/01/2026 at 12:01 PM, the RNC stated the facility had no documented evidence that N-95 had been completed. During an interview on 07/08/2026 at 11:53 AM, the Director of Nursing (DON) stated she had been employed at the facility since 04/20/2026. The DON stated there had been no N-95 fit testing since she had been there, and she did not receive an N-95 fit test when she started. The DON stated she would expect to be fit-tested for an N-95 mask. During an interview on 07/06/2026 at 3:38 PM, the Previous Administrator stated they worked at the facility from March 2025 to May 2026 and was not involved in N-95 fit testing. The Previous Administrator stated they had been in the IP role for a time but was not trained to use the N-95 fit test kit. The Previous Administrator stated they were not tested while they worked at the facility and was not sure about the requirements for N-95 fit testing.

Based on interview and document review the facility's governing body failed to appoint a licensed administrator to be accountable and manage the facility since 05/07/2026. The deficient practice had the potential to affect all residents residing in the facility.Findings included: A letter from the Oklahoma State Department of Health (OSDH) to another facility, dated 06/18/2026, revealed this facility's Previous Administrator became the administrator of record of another facility beginning 05/07/2026. During an interview on 07/04/2026 at 11:00 AM, the Chief Financial Officer stated the last day the facility had a licensed administrator was on 05/07/2026, and the facility did not currently have a licensed administrator. He stated that he was not a licensed administrator and did not go into the building. On 07/08/2026 at 11:29 AM, the Director of Nursing (DON) stated that she expected that the facility would have a licensed nursing home administrator.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure allegations of abuse were reported to the state survey agency within two hours after the allegation was made, which affected 4 (Residents #35, #39, #51, and #56) of 7 residents reviewed for abuseFindings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 04/2021, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy revealed, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy revealed, 3. 'Immediately' is defined as, which included a. within two hours of an allegation involving abuse or result in serious bodily injury; and or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. An admission Record revealed the facility admitted Resident #33 on 11/30/2022. According to the admission Record, the resident had a medical history that included diagnoses of severe major depressive disorder with psychotic symptoms and anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #33's Care Plan Report included a focus area initiated 08/18/2023, that indicated the resident had poor impulse control in addition to controlling their anger in social settings and indicated that the resident was also known to slap other residents when angry. Interventions directed staff to immediately intervene for any aggressive behavior and report to charge nurse for additional interventions as needed (initiated 09/08/2023); monitor, document, and report any signs or symptoms of Resident #33 posing a danger to self and others (initiated 08/18/2023); and intervene before agitation escalates, guide the resident away from source of distress, engage the resident calmly in conversation, and if the resident's response was aggressive, walk calmly away and approach later (initiated 08/18/2023 and revised 09/19/2023). The Care Plan Report indicated that on 01/20/2026, Resident #33 slapped another resident on their face; on 01/23/2026, the resident slapped another resident and grabbed a playing card from the resident while cursing at them, and on 06/04/2026, the resident hit another resident on the shoulder after the other resident accidentally hit Resident #33's lower extremity when they were moving a chair. 1. An admission Record revealed the facility admitted Resident #56 on 01/08/2025 and discharged the resident on 01/05/2026. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's, dementia, anxiety disorder and depression. A quarterly MDS, with an ARD of 10/26/2025, revealed Resident #56 had a BIMS score of 1, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes revealed a note, dated 07/29/2025 at 1:56 PM and electronically signed by Licensed Practical Nurse (LPN) #3, that indicated that Resident #33 was observed pulling on another resident in an attempt to get the other resident off a couch so that Resident #33 could sit down. During an interview on 07/08/2026 at 9:42 AM, LPN #3 stated that regarding the 07/29/2025 incident, she witnessed Resident #33 telling another resident to move from their seat in the facility's TV room. LPN#3 stated that when the other resident did not move, Resident #33 pulled the resident by the arm out of the seat, against their will. LPN#3 stated that she immediately separated the residents, made a progress note regarding the incident, and informed the Director of Nursing (DON) at the time (DON #4). Attempts to contact DON #4 were unsuccessful. Review of facility documents revealed no evidence the incident between Resident #33 and another resident on 07/29/2025 was reported to the state survey agency prior to the survey. An Oklahoma State Department of Health Incident Report Form that was submitted to the state survey agency on 07/05/2026, during the survey, indicated that on 07/29/2025, Resident #33 was observed pulling on another resident's arm to move them off of a couch. The report identified the other resident as Resident #56. The previous Administrator (ADM), who was the ADM at the time of the incident was interviewed on 07/05/2026 at 11:53 AM. The ADM stated that the incident between Resident #33 and Resident #56 was not reported to the state survey agency and stated that she was unaware of the incident until that day (07/05/2026). 2. An admission Record revealed the facility admitted Resident #51 on 12/10/2025 and discharged the resident on 02/03/2026. According to the admission Record, the resident had a medical history that included diagnoses of violent behavior, mood disorder, and bipolar disorder. An admission MDS, with an ARD of 12/17/2025, revealed Resident #51 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes included a note, dated 01/20/2026 at 8:44 AM and electronically signed by the previous Administrator (ADM), who was the ADM at the time, that indicated that when Resident #33 approached another resident in the dining room pointing at the other resident's coffee, the other resident told Resident #33 to leave them alone. Per the note, Resident #33 then slapped at the other resident's face with an open hand and made contact slightly. Resident #51's Progress Notes included a note, dated 01/20/20256 and electronically signed by the previous ADM, that indicated that Resident #33 approached Resident #51 in the dining room and when Resident #51 told Resident #33 to leave them alone, Resident #33 slapped at Resident #51 with an open hand and made slight contact. An Oklahoma State Department of Health Incident Report Form for the incident that occurred on 01/20/2026, indicated that the facility reported an allegation of abuse/mistreatment to the state survey agency. The document indicated that after breakfast on 01/20/2026, Resident #33 open-handed slapped Resident #51 on 01/20/2026. The document indicated that Resident #33 was sent to the emergency room and returned with no new orders. Per the document, a psychiatric provider was notified and made medication changes and Resident #33 was educated to leave their hands to their self. The report indicated that it was submitted to the state survey agency as a Combined Initial and Final report. A facsimile receipt indicated that the facility submitted the report on 01/21/2026 at 12:24, which was over the two hour required timeframe. During an interview on 07/01/2026 at 11:23 AM, Licensed Practical Nurse (LPN) #5 stated that Resident #33 asked Resident #51 if they wanted a cup of coffee. She stated that Resident #51 told Resident #33 to go away, and Resident #33 responded by slapping Resident #51 across the face. LPN #5 stated that she immediately separated the residents and while walking Resident #51 back to their room, she notified the ADM of the incident. The previous ADM, who was the ADM at the time of the incident, was interviewed on 07/05/2026 at 11:53 AM. In regard to the incident on 01/20/2026, the previous ADM stated that she was not sure why she submitted the report as a combined initial and final report. She stated that it should have been reported to the state survey agency within two hours, and she did not have an excuse for why it was not. 3. Resident #39's annual MDS, with an ARD of 04/08/2026, revealed the facility admitted Resident #39 on 03/31/2025. The MDS indicated that Resident #39 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes included a note, dated 01/23/2026 at 3:30 PM and electronically signed by the Assistant Director of Nursing (ADON), that indicated that during a facility activity, Resident #33 snatched a card from another resident, called them a vulgar slur, and slapped their hand. During an interview on 07/07/2026 at 5:04 PM, the Activity Director revealed that she witnessed the incident between Resident #33 and Resident #39. The Activity Director stated that during a facility activity, Resident #33 took a bingo card from Resident #39, which caused Resident #39 to cry. She stated that Resident #33 then called Resident #39 a crybaby then a vulgar slur and slapped their hand. She stated that she reported the incident to the Administrator when she and another staff member assisted Resident #33 to their room. An Oklahoma State Department of Health Incident Report Form for the incident that occurred on 01/23/2026 indicated that the facility completed a report an allegation of abuse/mistreatment to the state survey agency, but there was no indication that the report was submitted to the state survey agency. The document indicated that Resident #33 allegedly snatched a bingo card from Resident #39 and called Resident #39 name. The document indicated that it was thought that Resident #33 slapped Resident #39's hand, but Resident #39 said no contact was made. The previous Administrator (ADM), who was the ADM at the time of the incident, was interviewed on 07/05/2026 at 11:53 AM. In regard to the incident that occurred on 01/23/2026, the previous ADM stated that she completed a report and thought she submitted it but was not sure when. She stated that she could not say that it was submitted timely. 4. An admission Record revealed the facility admitted Resident #35 on 05/21/2026. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, bipolar disorder, and anxiety. Resident #35's admission MDS assessment, with an ARD of 05/28/2026, revealed Resident #35 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #33's Progress Notes included a note, dated 06/04/2026 at 6:01 PM, that indicated that Resident #35 moved a chair in the dining room and bumped into Resident #33's lower extremity. The note indicated that Resident #33 retaliated and hit Resident #35 on the shoulder. The note indicated that Resident #33 was sent to the hospital for evaluation and treatment. During an interview on 07/07/2026 at 4:28 PM, Resident #11, who had a BIMS score of 15 indicating the resident had intact cognition, stated that they witnessed the incident between Resident #33 and Resident #35. Resident #11 stated that Resident #33 and Resident #35 were in the dining room around dinner time when Resident #33 told Resident #35 they were sitting in their chair. Resident #11 stated that Resident #35 got up and pushed the chair in Resident #33's direction but did not hit Resident #33 with it. Per Resident #11, Resident #33 retaliated by hitting Resident #35 on their shoulder. An Oklahoma State Department of Health Incident Report Form indicated that the facility reported an allegation of abuse/mistreatment to the state survey agency that occurred on 06/04/2026. The report indicated that Resident #35 bumped Resident #33 with a chair accidentally, then Resident #33 made contact smacking Resident #35's shoulder. A facsimile receipt indicated that the initial report was submitted to the state survey agency on 06/08/2026, four days later. During an interview on 07/08/2026 at 11:39 AM, the Assistant Director of Nursing (ADON) stated that all abuse allegations were to be reported immediately, and a report was to be submitted to the state survey agency within two hours. She stated that this did not happen for the incident on 06/04/2026. During an interview on 07/08/2026 at 12:16 PM, Director of Nursing (DON) stated that she was not aware of the incident between Resident #33 and Resident #35 when it occurred. She stated that she heard staff talking about the incident on 06/08/2026 and then she submitted the report. She stated that it was not reported within two hours During an interview on 7/04/2026 at 12:10 PM, the DON stated that she assumed the role of the facility's Abuse Coordinator the first week of May 2026. The DON stated that it was her responsibility to report allegations of abuse to the state survey agency within two hours and submit a final investigation within five days.

Based on interview, record review, facility document review, and facility policy review, the facility failed to protect the residents' right to be free from physical and verbal abuse perpetrated by a resident (Resident #33), which affected 4 (Residents #35, #39, #51, and #56) of 7 residents reviewed for abuse. Specifically, on 07/29/2025, Resident #33 pulled Resident #56 from a chair against their will, open-hand slapped Resident #51 on the face on 01/20/2026, caused Resident #39 to cry on 01/23/2026 when they snatched a bingo card from Resident #39 and called Resident #39 a vulgar slur, and hit Resident #35 on 06/04/2026. Findings included: A facility policy titled, Abuse Prevention Program, revised 12/2016, indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy revealed, As part of the resident abuse prevention, the administration will, which included 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals; 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents; 4. Require staff training/ orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; and 9. Establish and implement a QAPI [Quality Assurance and Performance Improvement] review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. An admission Record revealed the facility admitted Resident #33 on 11/30/2022. According to the admission Record, the resident had a medical history that included diagnoses of severe major depressive disorder with psychotic symptoms and anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #33's Care Plan Report included a focus area initiated 08/18/2023, that indicated the resident had poor impulse control in addition to controlling their anger in social settings and indicated that the resident was also known to slap other residents when angry. Interventions directed staff to immediately intervene for any aggressive behavior and report to charge nurse for additional interventions as needed (initiated 09/08/2023); monitor, document, and report any signs or symptoms of Resident #33 posing a danger to self and others (initiated 08/18/2023); and intervene before agitation escalates, guide the resident away from source of distress, engage the resident calmly in conversation, and if the resident's response was aggressive, walk calmly away and approach later (initiated 08/18/2023 and revised 09/19/2023). The Care Plan Report indicated that on 01/20/2026, Resident #33 slapped another resident on their face; on 01/23/2026, the resident slapped another resident and grabbed a playing card from the resident while cursing at them, and on 06/04/2026, the resident hit another resident on the shoulder after the other resident accidentally hit Resident #33's lower extremity when they were moving a chair. 1. An admission Record revealed the facility admitted Resident #56 on 01/08/2025 and discharged the resident on 01/05/2026. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's, dementia, anxiety disorder and depression. A quarterly MDS, with an ARD of 10/26/2025, revealed Resident #56 had a BIMS score of 1, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes revealed a note, dated 07/29/2025 at 1:56 PM and electronically signed by Licensed Practical Nurse (LPN) #3, that indicated that Resident #33 was observed pulling on another resident in an attempt to get the other resident off a couch so that Resident #33 could sit down. During an interview on 07/08/2026 at 9:42 AM, LPN #3 stated that regarding the 07/29/2025 incident, she witnessed Resident #33 telling another resident to move from their seat in the facility's TV room. LPN#3 stated that when the other resident did not move, Resident #33 pulled the resident by the arm out of the seat, against their will. LPN#3 stated that she immediately separated the residents, made a progress note regarding the incident, and informed the Director of Nursing (DON) at the time (DON #4). Attempts to contact DON #4 were unsuccessful. Review of facility documents revealed no evidence the incident between Resident #33 and another resident on 07/29/2025 was investigated or reported to the state survey agency prior to the survey. An Oklahoma State Department of Health Incident Report Form that was submitted to the state survey agency on 07/05/2026, during the survey, indicated that on 07/29/2025, Resident #33 was observed pulling on another resident's arm to move them off a couch. The report identified the other resident as Resident #56. The previous Administrator (ADM), who was the ADM at the time of the incident was interviewed on 07/05/2026 at 11:53 AM. The ADM stated that the incident between Resident #33 and Resident #56 was not investigated or reported to the state survey agency and stated that she was unaware of the incident until that day (07/05/2026). The previous ADM further stated that the facility should have implemented interventions for Resident #33 related to the resident touching other residents and sent Resident #33 for a psychiatric review to ensure they were deemed safe to themselves and other residents. 2. An admission Record revealed the facility admitted Resident #51 on 12/10/2025 and discharged the resident on 02/03/2026. According to the admission Record, the resident had a medical history that included diagnoses of violent behavior, mood disorder, and bipolar disorder. An admission MDS, with an ARD of 12/17/2025, revealed Resident #51 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes included a note, dated 01/20/2026 at 8:44 AM and electronically signed by the previous Administrator (ADM), who was the ADM at the time, that indicated that when Resident #33 approached another resident in the dining room pointing at the other resident's coffee, the other resident told Resident #33 to leave them alone. Per the note, Resident #33 then slapped at the other resident's face with an open hand and made contact slightly. Resident #51's Progress Notes included a note, dated 01/20/20256 and electronically signed by the previous ADM, that indicated that Resident #33 approached Resident #51 in the dining room and when Resident #51 told Resident #33 to leave them alone, Resident #33 slapped at Resident #51 with an open hand and made slight contact. An Oklahoma State Department of Health Incident Report Form for the incident that occurred on 01/20/2026, indicated that the facility reported an allegation of abuse/mistreatment to the state survey agency. The document indicated that Resident #33 open-handed slapped Resident #51 on 01/20/2026. The document indicated that Resident #33 was sent to the emergency room and returned with no new orders. Per the document, a psychiatric provider was notified and made medication changes and Resident #33 was educated to leave their hands to their self. During an interview on 07/01/2026 at 11:23 AM, Licensed Practical Nurse (LPN) #5 stated that Resident #33 asked Resident #51 if they wanted a cup of coffee. She stated that Resident #51 told Resident #33 to go away, and Resident #33 responded by slapping Resident #51 across the face. LPN #5 stated that she immediately separated the residents and while walking Resident #51 back to their room, she notified the ADM of the incident. The previous ADM, who was the ADM at the time of the incident, was interviewed on 07/05/2026 at 11:53 AM. In regard to the incident on 01/20/2026, the previous ADM stated that the facility did not implement any interventions following the incident to potentially prevent other incidents. 3. Resident #39's annual MDS, with an ARD of 04/08/2026, revealed the facility admitted Resident #39 on 03/31/2025. The MDS indicated that Resident #39 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes included a note, dated 01/23/2026 at 3:30 PM and electronically signed by the Assistant Director of Nursing (ADON), that indicated that during a facility activity, Resident #33 snatched a card from another resident, called them a vulgar slur, and slapped their hand. An Oklahoma State Department of Health Incident Report Form for the incident that occurred on 01/23/2026 indicated that the facility completed a report an allegation of abuse/mistreatment to the state survey agency, but there was no indication that the report was submitted to the state survey agency. The document indicated that Resident #33 allegedly snatched a bingo card from Resident #39 and called Resident #39 name. The document indicated that it was thought that Resident #33 slapped Resident #39's hand, but Resident #39 said no contact was made. During an interview on 07/07/2026 at 5:04 PM, the Activity Director revealed that she witnessed the incident between Resident #33 and Resident #39. The Activity Director stated that during a facility activity, Resident #33 took a bingo card from Resident #39, which caused Resident #39 to cry. She stated that Resident #33 then called Resident #39 a crybaby then a vulgar slur and slapped their hand. She stated that she reported the incident to the Administrator when she and another staff member assisted Resident #33 to their room. 4. An admission Record revealed the facility admitted Resident #35 on 05/21/2026. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, bipolar disorder, and anxiety. Resident #35's admission MDS assessment, with an ARD of 05/28/2026, revealed Resident #35 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #33's Progress Notes included a note, dated 06/04/2026 at 6:01 PM, that indicated that Resident #35 moved a chair in the dining room and bumped into Resident #33's lower extremity. The note indicated that Resident #33 retaliated and hit Resident #35 on the shoulder. The note indicated that Resident #33 was sent to the hospital for evaluation and treatment. An Oklahoma State Department of Health Incident Report Form indicated that the facility reported an allegation of abuse/mistreatment to the state survey agency that occurred on 06/04/2026. The report indicated that Resident #35 bumped Resident #33 with a chair accidentally, then Resident #33 made contact smacking Resident #35's shoulder. During an interview on 07/07/2026 at 4:28 PM, Resident #11, who had a BIMS score of 15 indicating the resident had intact cognition, stated that they witnessed the incident between Resident #33 and Resident #35. Resident #11 stated that Resident #33 and Resident #35 were in the dining room around dinner time when Resident #33 told Resident #35 they were sitting in their chair. Resident #11 stated that Resident #35 got up and pushed the chair in Resident #33's direction but did not hit Resident #33 with it. Per Resident #11, Resident #33 retaliated by hitting Resident #35 on their shoulder. During an interview on 07/08/2026 at 12:16 PM, Director of Nursing (DON) stated the facility failed to conduct thorough investigations for the incidents on 07/29/2025, 01/20/2026, 01/23/2026, or 06/04/2026. She stated that if they had investigated thoroughly, they could have identified interventions that could have potentially prevented additional incidents of abuse from Resident #33.

Based on facility policy review, interview, and record review, the facility failed to ensure medical records were complete and accurate related to documentation of the provision of activity of daily living (ADL) care for 3 (Residents #12, #13, and #29) of 4 residents reviewed for ADLs.Findings included: A facility policy titled, Charting and Documentation, revised 07/2017, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. 1. An admission Record indicated the facility admitted Resident #13 on 01/23/2026. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus, severe protein-calorie malnutrition, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2026, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident required substantial/maximal assistance with bathing. Resident #13's Care Plan Report included a focus area initiated 06/05/2026, that indicated the resident had an ADL self-care deficit. Interventions indicated that the resident required one-person assistance with bathing (initiated 06/05/2026). Resident #13's June 2026 ADL task record indicated the resident was to get a bath on 06/21/2026, 06/22/2026, 06/24/2026, 06/26/2026, 06/28/2026, and 06/29/2026. The record revealed staff did not document on those days to indicate if the bath had been offered or provided. During an interview on 07/08/2026 at 11:12 AM, Certified Nurse Aide (CNA) #1 stated that CNAs documented showers and stated that it was required for CNAs to document each shift. During an interview on 07/02/2026 at 2:18 PM, Licensed Practical Nurse (LPN) #8 stated that the provision of care should be documented. LPN #8 stated the certified nurse aides (CNAs) documented their charting electronically and should document whether the care was provided or refused. During an interview on 07/07/2026 at 5:06 PM, LPN #5 stated that the CNAs documented the provision of baths electronically. LPN #5 stated that the Assistant Director of Nursing (ADON) was responsible for monitoring the CNA documentation. During an interview on 07/08/2026 at 11:30 AM, the ADON stated she monitored the ADL documentation but did not monitor specific ADLs like bathing. The ADON stated if documentation of an ADL was missed, it would be flagged, and a list was generated from the flags, not from specific ADLs, and the report was turned in to the Director of Nursing (DON), then the DON sent the report to the corporate office. The ADON stated she expected the staff to document for bathing. During an interview on 07/02/2026 at 2:03 PM, Certified Medication Aide (CMA) #9 stated that some type of bath was provided every day. CMA #9 stated that if a resident refused, she reported it to the nurse and documented it. CMA #9 stated the bath should be documented in the electronic record whether provided or refused. She stated that she had not been able to document, and she had told someone the previous week and was able to currently. She stated that she did provide baths to Resident #13, but she had not been able to document it. During an interview on 07/08/2026 at 11:53 AM, the Director of Nursing (DON), upon review of Resident #13's bathing task form, stated there should be documentation for Resident #13 and there was not any documentation at the end of June for bathing. The DON stated she expected staff to document. She stated that if it was not documented, then they could not prove it was done. 2. An admission Record indicated the facility admitted Resident #12 on 06/24/2025. According to the admission Record, the resident had a medical history that included diagnoses of multiple sclerosis, adult failure to thrive, and schizoaffective disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2026, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident was dependent on staff for the provision of bathing. Resident #12's Care Plan Report included a focus area initiated on 09/11/2025 that indicated the resident had an ADL self-care deficit. Interventions indicated that the resident required one-person assistance with bathing (initiated 09/11/2025). Resident #12's June 2026 Documentation Survey Report indicated that the resident was to get a bath on 06/01/2026, 06/03/2026, 06/05/2026, 06/08/2026, 06/10/2026, 06/12/2026, 06/15/2026, and 06/17/2026. The record revealed staff did not document on those days to indicate if the bath had been offered or provided. During an interview on 07/02/2026 at 2:03 PM, Certified Medication Aide (CMA) #9 stated that some type of bath was provided every day. CMA #9 stated that if the resident refused, she reported it to the nurse and documented it. CMA #9 stated the bath should be documented in the electronic record whether provided or refused. She stated that she had not been able to document it, and she had told someone the previous week and was able to currently. During an interview on 07/08/2026 at 11:12 AM, Certified Nurse Aide (CNA) #1 stated that CNAs documented showers and stated that it was required for CNAs to document each shift. During an interview on 07/02/2026 at 2:18 PM, Licensed Practical Nurse (LPN) #8 stated that the provision of care should be documented. LPN #8 stated the certified nurse aides (CNAs) documented their charting electronically and should document whether the care was provided or refused. During an interview on 07/07/2026 at 5:06 PM, LPN #5 stated that the CNAs documented the provision of baths electronically. LPN #5 stated that the Assistant Director of Nursing (ADON) was responsible for monitoring the CNA documentation. During an interview on 07/08/2026 at 11:30 AM, the ADON stated she monitored the ADL documentation but did not monitor specific ADLs like bathing. The ADON stated if documentation of an ADL was missed, it would be flagged, and a list was generated from the flags, not from specific ADLs, and the report was turned in to the Director of Nursing (DON), then the DON sent the report to the corporate office. The ADON stated she expected the staff to document for the provision of bathing. During an interview on 07/08/2026 at 11:53 AM, the Director of Nursing (DON), upon review of Resident #12's bathing task for June 2026, stated there was no documentation and there should have been. The DON stated she expected baths to be provided three days a week and expected baths to be documented, whether it was provided or refused.3. An admission Record revealed the facility admitted Resident #29 on 03/20/2026. According to the admission Record, the resident had a medical history that included diagnoses of incomplete paraplegia, chronic respiratory failure, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2026, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated that the resident was dependent on staff for toileting hygiene and personal hygiene and was always incontinent of bowel and bladder. Resident #29's Care Plan Report included a focus area revised 02/08/2026, that indicated the resident was incontinent of bowel and bladder. Interventions directed staff to provide incontinence care as needed (revised 02/08/2026). Resident #29's June 2026 ADL documentation for Bowel and Bladder Elimination revealed staff did not document any care being provided on 06/06/2026, 06/14/2026, 06/20/2026, 06/21/2026, 06/23/2026, 06/24/2026, 06/25/2026, 06/26/2026, 06/27/2026, or 06/28/2026. During an interview on 07/08/2026 at 9:30 AM, Certified Nurse Aide (CNA) #11 stated that incontinence care was documented in the electronic health record (EHR) for residents. She stated incontinence care was documented each shift under bowel and bladder elimination. She stated that refusals were also documented. She stated that she did work on the days in question but worked in a different hall. During an interview on 07/08/2026 at 9:58 AM, CNA #12 stated that all ADL care, including incontinence care, was required to be documented. She stated that if a resident refused incontinence care, the aide told the nurse and then documented in the EHR that the resident refused. She stated that there should not be any blanks on the CNA documentation. Per CNA #12, if there was no documentation, that was incomplete charting. She stated that she did work from 06/23/2026 to 06/26/2026, but stated that the resident often refused her, so it may have been an agency staff who worked with the resident. She stated that she would not have documented anything for Resident #29. During an interview on 07/08/2026 at 9:54 AM, CNA #13 stated she was agency staff and worked with Resident #29 and was familiar with them. She stated that Resident #29 needed incontinence care, which was charted in the EHR under bowel and bladder elimination. She stated aides charted once per shift, and one person for the hall documented. She stated she would not document again if someone else was already documenting. She stated aides were required to document, but sometimes there was missed communication and staff would say they would document but would get busy, or their partner thought they were doing it, but the partner was supposed to. She stated that she did work and provide incontinence care for Resident #29 on 06/20/2026, 06/21/2026, 06/27/2026, and 06/28/2026. She stated she did not recall if she documented on those days. She stated she did not know why there was no documentation but reiterated she did provide incontinence care. The Assistant Director of Nursing (ADON) was interviewed on 07/08/2026 at 11:08 AM. She stated that ADL documentation by the CNAs in the EHR was mandatory. She stated that documentation was reviewed Monday through Friday during a clinical meeting. She stated that they tracked all missed documentation on a form, submitted it to corporate staff, and then turned it in to the Director of Nursing (DON). The ADON stated that it was then posted at the nurses' station for aides to get it done within 24 hours, and the DON followed up from there. The DON was interviewed on 07/08/2026 at 11:29 AM. She stated that she expected documentation of ADL care, including incontinence care, to be completed in the EHR every shift by CNAs. She stated that she and the ADON were responsible for reviewing documentation for the previous shift each day, Tuesday through Friday, and on Monday, they review the previous three days. She stated the process was to have a clinical correction sheet filled out daily for any missing documentation. She stated that the sheet was sent to corporate daily, then she and the ADON followed up with the CNA the next day to let them know what they needed to make up. She stated she hung the clinical correction sheet at the nurses' station, which she then realized was not the best process.

Based on interview, record review, document review, and facility policy review, the facility failed to thoroughly investigate alleged incidents of verbal and physical abuse, which affected 5 (Residents #35, #36, #39, #51, and #56) of 7 residents reviewed for abuse. Specifically, alleged incidents of abuse perpetrated by Resident #33 occurred on 07/29/2025, 01/20/2026, 01/23/2026, 03/22/2026, and 06/04/2026 and were not thoroughly investigated.Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 04/2021, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy revealed, Investigating Allegations included 1. All allegations are thoroughly investigated. The administrator initiates investigations; 2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations; and 7. The individual conducting the investigation as a minimum, which included a. reviews the documentation and evidence; b. reviews the residents medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witness to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members and visitors; k. reviews all events leading up to the allege incident; and l. documents the investigation completely and thoroughly. An admission Record revealed the facility admitted Resident #33 on 11/30/2022. According to the admission Record, the resident had a medical history that included diagnoses of severe major depressive disorder with psychotic symptoms and anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #33's Care Plan Report included a focus area initiated 08/18/2023, that indicated the resident had poor impulse control in addition to controlling their anger in social settings and indicated that the resident was also known to slap other residents when angry. Interventions directed staff to immediately intervene for any aggressive behavior and report to charge nurse for additional interventions as needed (initiated 09/08/2023); monitor, document, and report any signs or symptoms of Resident #33 posing a danger to self and others (initiated 08/18/2023); and intervene before agitation escalates, guide the resident away from source of distress, engage the resident calmly in conversation, and if the resident's response was aggressive, walk calmly away and approach later (initiated 08/18/2023 and revised 09/19/2023). The Care Plan Report indicated that on 01/20/2026, Resident #33 slapped another resident on their face; on 01/23/2026, the resident slapped another resident and grabbed a playing card from the resident while cursing at them, and on 06/04/2026, the resident hit another resident on the shoulder after the other resident accidentally hit Resident #33's lower extremity when they were moving a chair. 1. An admission Record revealed the facility admitted Resident #56 on 01/08/2025 and discharged the resident on 01/05/2026. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's, dementia, anxiety disorder and depression. A quarterly MDS, with an ARD of 10/26/2025, revealed Resident #56 had a BIMS score of 1, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes revealed a note, dated 07/29/2025 at 1:56 PM and electronically signed by Licensed Practical Nurse (LPN) #3, that indicated that Resident #33 was observed pulling on another resident in an attempt to get the other resident off a couch so that Resident #33 could sit down. During an interview on 07/08/2026 at 9:42 AM, LPN #3 stated that regarding the 07/29/2025 incident, she witnessed Resident #33 telling another resident to move from their seat in the facility's TV room. LPN#3 stated that when the other resident did not move, Resident #33 pulled the resident by the arm out of the seat, against their will. LPN#3 stated that she immediately separated the residents, made a progress note regarding the incident, and informed the Director of Nursing (DON) at the time (DON #4). Attempts to contact DON #4 were unsuccessful. Review of facility documents revealed no evidence the incident between Resident #33 and another resident on 07/29/2025 was investigated prior to the survey. An Oklahoma State Department of Health Incident Report Form that was submitted to the state survey agency on 07/05/2026, during the survey, indicated that on 07/29/2025, Resident #33 was observed pulling on another resident's arm to move them off of a couch. The report identified the other resident as Resident #56. The previous Administrator (ADM), who was the ADM at the time of the incident was interviewed on 07/05/2026 at 11:53 AM. The ADM stated that she was not aware of the incident between Resident #33 and Resident #56 until that day (07/05/2026). She stated that the incident should have been reviewed, but she did not know about it. 2. An admission Record revealed the facility admitted Resident #51 on 12/10/2025 and discharged the resident on 02/03/2026. According to the admission Record, the resident had a medical history that included diagnoses of violent behavior, mood disorder, and bipolar disorder. An admission MDS, with an ARD of 12/17/2025, revealed Resident #51 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes included a note, dated 01/20/2026 at 8:44 AM and electronically signed by the previous Administrator (ADM), who was the ADM at the time, that indicated that when Resident #33 approached another resident in the dining room pointing at the other resident's coffee, the other resident told Resident #33 to leave them alone. Per the note, Resident #33 then slapped at the other resident's face with an open hand and made contact slightly. An Oklahoma State Department of Health Incident Report Form for the incident that occurred on 01/20/2026, indicated that the facility reported an allegation of abuse/mistreatment to the state survey agency. The document indicated that after breakfast on 01/20/2026, Resident #33 open-handed slapped Resident #51 on 01/20/2026. The document indicated that Resident #33 was sent to the emergency room and returned with no new orders. Per the document, a psychiatric provider was notified and made medication changes and Resident #33 was educated to leave their hands to their self. During an interview on 07/01/2026 at 11:23 AM, Licensed Practical Nurse (LPN) #5 stated that Resident #33 asked Resident #51 if they wanted a cup of coffee. She stated that Resident #51 told Resident #33 to go away, and Resident #33 responded by slapping Resident #51 across the face. LPN #5 stated that she immediately separated the residents and while walking Resident #51 back to their room, she notified the ADM of the incident. The facility's investigative documents revealed that it did not include witness statements to the incident or documentation of what the facility did to investigate the incident. The previous ADM, who was the ADM at the time of the incident, was interviewed on 07/05/2026 at 11:53 AM. In regard to the incident on 01/20/2026, the previous ADM stated that she thought reviewing camera footage of the incident was enough for an investigation. She stated that she now knew that she needed to obtain interviews with staff, victims, and witnesses, and make notifications. She stated that it was not a thorough investigation. 3. Resident #39's annual MDS, with an ARD of 04/08/2026, revealed the facility admitted Resident #39 on 03/31/2025. The MDS indicated that Resident #39 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #33's Progress Notes included a note, dated 01/23/2026 at 3:30 PM and electronically signed by the Assistant Director of Nursing (ADON), that indicated that during a facility activity, Resident #33 snatched a card from another resident, called them a vulgar slur, and slapped their hand. During an interview on 07/07/2026 at 5:04 PM, the Activity Director revealed that she witnessed the incident between Resident #33 and Resident #39. The Activity Director stated that during a facility activity, Resident #33 took a bingo card from Resident #39, which caused Resident #39 to cry. She stated that Resident #33 then called Resident #39 a crybaby then a vulgar slur and slapped their hand. She stated that she reported the incident to the Administrator (ADM) when she and another staff member assisted Resident #33 to their room. An Oklahoma State Department of Health Incident Report Form for the incident that occurred on 01/23/2026 indicated that the facility completed a report an allegation of abuse/mistreatment to the state survey agency, but there was no indication that the report was submitted to the state survey agency. The document indicated that Resident #33 allegedly snatched a bingo card from Resident #39 and called Resident #39 name. The document indicated that it was thought that Resident #33 slapped Resident #39's hand, but Resident #39 said no contact was made. The facility's investigative documents revealed that it did not include witness statements or documentation of what the facility did to investigate the incident. The previous ADM, who was the ADM at the time of the incident, was interviewed on 07/05/2026 at 11:53 AM. In regard to the incident on 01/23/2026, stated that she was not fully trained on the facility's abuse policy. The previous ADM stated she should have gotten statements from staff from all shifts related to the allegation, victims, and families. The previous ADM stated that the investigation was not thorough. 4. A quarterly MDS, with an ARD of 04/29/2026, revealed Resident #36 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. An Oklahoma State Department of Health Incident Report Form indicated that the facility reported an allegation of abuse/mistreatment to the state survey agency that occurred on 03/22/2026. The document indicated that another resident, Resident #11, witnessed Resident #33 slapping Resident #36's hand. The report did not include the time of the alleged incident. A review of Resident #36's records and facility documents revealed no evidence of a progress note, incident report, witness statements, or any other documents that provided the time the incident occurred or other information regarding the incident or investigation. The previous Administrator (ADM), who was the ADM at the time of the incident, was interviewed on 07/05/2026 at 11:53 AM. In regard to the incident on 03/22/2026, the previous ADM stated that she had reviewed the video footage of the incident and did not see any physical contact between Resident #33 and Resident #36 and did not investigate the issue further. ADM further stated that she should have gotten statements from staff, the victim, and family and reviewed Resident #33's previous behavior to ensure a thorough investigation was completed. She stated that the investigation was incomplete and not thorough. 5. An admission Record revealed the facility admitted Resident #35 on 05/21/2026. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, bipolar disorder, and anxiety. Resident #35's admission MDS assessment, with an ARD of 05/28/2026, revealed Resident #35 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #33's Progress Notes included a note, dated 06/04/2026 at 6:01 PM, that indicated that Resident #35 moved a chair in the dining room and bumped into Resident #33's lower extremity. The note indicated that Resident #33 retaliated and hit Resident #35 on the shoulder. The note indicated that Resident #33 was sent to the hospital for evaluation and treatment. An Oklahoma State Department of Health Incident Report Form indicated that the facility reported an allegation of abuse/mistreatment to the state survey agency that occurred on 06/04/2026. The report indicated that Resident #35 bumped Resident #33 with a chair accidentally, then Resident #33 made contact smacking Resident #35's shoulder. During an interview on 07/07/2026 at 4:28 PM, Resident #11, who had a BIMS score of 15 indicating the resident had intact cognition, stated that they witnessed the incident between Resident #33 and Resident #35. Resident #11 stated that Resident #33 and Resident #35 were in the dining room around dinner time when Resident #33 told Resident #35 they were sitting in their chair. Resident #11 stated that Resident #35 got up and pushed the chair in Resident #33's direction but did not hit Resident #33 with it. Per Resident #11, Resident #33 retaliated by hitting Resident #35 on their shoulder. The facility's investigative documents revealed that it did not include witness statements or documentation of what the facility did to investigate the incident. During an interview on 07/08/2026 at 11:39 AM, Assistant Director of Nursing (ADON) stated that she expected investigations to include statements from any witnesses. She stated that the incident on 06/04/2026 was not investigated thoroughly. The Director of Nursing (DON) was interviewed on 07/08/2026 at 12:16 PM. In regard to the incident on 06/04/2026, the DON stated that she was not aware on how in depth the investigation should have been. She stated that she did talk to nurses about what they knew about the incident and did interview the residents but did not believe she documented them. She stated that the incident was not thoroughly investigated. The DON stated the facility also failed to conduct thorough investigations for the incidents on 07/29/2025, 01/20/2026, 01/23/2026, or 03/22/2026. During an interview on 7/04/2026 at 12:10 PM, the DON stated that she assumed the role of the facility's Abuse Coordinator the first week of May 2026. The DON stated that she was responsible for conducting thorough investigation, which entailed interviewing residents, staff, notifying local law enforcement, and contacting families and the facilities' physician. The DON stated that she could also reach out to their corporate office to request access to video footage to assist with investigating an incident.

Based on interview, record review, and facility document and policy review, the facility failed to follow physician orders for 1 (Resident #12) of 13 sampled residents. Specifically, on 10/29/2025, staff failed to administer Resident #12's medication per physician orders and in accordance with standards of practice.Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. The policy indicated, Medication errors are documented, reported, and reviewed by the QAPI [quality assurance and performance improvement] committee to inform process changes and or the need for additional staff training. An admission Record revealed the facility admitted Resident #12 on 06/24/2025. According to the admission Record, the resident had a medical history that included a diagnosis of multiple sclerosis. Resident #12's Order Summary Report included an order dated 04/22/2026 for oxycodone-acetaminophen 7.5 milligrams (mg)/325 mg, one tablet by mouth every four hours as needed for pain. Resident #12's Care Plan Report, revealed a focus area for miscellaneous information, which contained an intervention dated 10/29/2026, that indicated there was a medication error with no adverse reactions. A Medication Error incident report, dated 10/29/2025 at 5:30 PM, for Resident #12 indicated a Certified Medication Aide (CMA) notified the nurse that the resident had received the wrong medication (medication name not documented). The incident report indicated that the resident's physician, Director of Nursing (DON), and Administrator were notified of the medication error. Resident #12's nursing Progress Notes revealed an Incident Note, dated 10/29/2025 at 6:25 PM, that indicated a CMA notified the nurse that the resident received the wrong medication. Per the notes, the resident denied shortness of breath, nausea, or vomiting and was alert and oriented, with no signs or symptoms of distress. The note revealed that the Physician, DON, Administrator, and family were notified of the medication error. During an interview on 07/08/2026 at 11:53 AM, the DON stated that she had worked at the facility since 04/20/2026. The DON stated she expected residents to receive the right medication and the right dose of the medication. During an interview on 07/06/2026 at 3:38 PM, the Previous Administrator revealed a CMA made a medication error with Resident #12. The Previous Administrator stated that the CMA was not allowed to return to the facility to work.

Based on interview, record review, and facility policy review, the facility failed to ensure they had record of a resident/responsible party being informed of risks and benefits and receiving informed consent prior to administering psychotropic medications for 1 (Resident #3) of 5 residents whose medication regimen were reviewed.Findings included: An undated facility policy titled, Psychotropic Informed Consent, indicated, Responsible Party-Actions Required: Primary care physician, PA [Physician Assistant] or APN [Advanced Practice Nurse], which included 1. Orders for psychotropic medication only for the treatment of specific medical and/or psychiatric conditions or when the medication meets the needs of the resident to alleviate significant distress for the resident not met by the use of non-pharmacologic approaches; 2. Documents rational and diagnosis for use and identifies target symptoms; and 3. Documents or ensures documentation of discussion completed with the resident and/or responsible party regarding the risk versus benefit of the used of these medications included in the discussion and documentation must be the presence of any black box warning or off label use of the medication affecting the prescribing of the medication to the resident. The policy revealed, Nursing included 1. Informed consent will be obtained prior to first dose and every dosage change. An admission Record revealed the facility admitted Resident #3 on 01/19/2024. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, and other psychotic disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Resident #3's Care Plan Report included a focus area initiated 01/31/2024, that indicated the resident had behaviors and was resistive to care, including medications. Interventions initiated 01/31/2024 directed staff to allow Resident #3 to make decisions about treatment regime in order to provide a sense of control and to educate Resident #3/family/caregivers of the possible outcome(s) of not complying with treatment or care. Resident #3's Order Summary Report, dated 07/08/2026, contained the following active orders:- Aripiprazole (an antipsychotic) 2 milligrams (mg), one tablet by mouth one time a day for bipolar disorder, with a start date of 08/21/2024.- Citalopram hydrobromide (a selective serotonin reuptake inhibitor [SSRI]) 10 mg, one tablet by mouth one time a day for depression, with a start date of 09/13/2024.- Mirtazapine (an antidepressant) 7.5 mg, one tablet by mouth in the evening related to major depressive disorder, with a start date of 01/30/2025. During an interview on 07/02/2026 at 10:40 PM, the Regional Nurse Consultant (RNC) stated the facility did not have any informed consents for the psychotropic medications for Resident #3. During a follow-up interview on 07/03/2026 at 9:26 AM, the RNC stated that she had completed an audit in January 2026 for all informed consents and talked to the residents who did not have them. She stated that for those residents with lower BIMS scores, she reached out to family. She stated that she thought Resident #3 was one had left to do, and she did not have any documentation of reaching out to family. During an interview on 07/08/2026 at 10:39 AM, Licensed Practical Nurse (LPN) #8 stated that the facility was required to get informed consent for psychotropic medications. She stated that the consent was acquired by the Admissions Coordinator. She stated that if it was a new medication, the nurse talked to the resident or responsible party to inform them of the medication and get consent. She stated that staff needed to document the conversation with the responsible party obtaining informed consent for the medication and ensure it was scanned into the electronic health record. In regard to who would have gotten the informed consents for Resident #3, LPN #8 stated that she did not get the informed consents. The Assistant Director of Nursing (ADON) was interviewed on 07/08/2026 at 11:08 AM. The ADON stated that there was a form in the electronic health record that was completed at admission for informed consent for psychotropic medications. She stated that typically, she got consent from the responsible party as the ADON. She stated that if it was a new order, she or the charge nurse who received the order would get the informed consent. She stated that Resident #3 was at the facility prior to her employment at the facility, and she was not sure who was responsible for getting the informed consent prior to her employment. She stated that she did not know of an audit process to ensure informed consents were being completed. During an interview on 07/08/2026 at 11:29 AM, the Director of Nursing (DON) stated that she expected informed consent for all psychotropic medications being administered in the facility. She stated that the admitting nurse was responsible for getting consent prior to the administration of any doses. She stated that if a doctor prescribed a new psychotropic medication, it was the responsibility of the charge nurse to get consent and scan it into the electronic health record. She stated informed consent was to make sure the patient understood what they were being prescribed and that they were agreeable to it. The DON stated it did not meet her expectations for Resident #3 to have received those medications without any informed consent.

Based on record review and interview, the facility failed to ensure residents had access to their trust account money on nights and weekends for three (#9, 10, and #26) of three sampled residents reviewed for access to their trust account money. The BOM identified 33 residents who had money in the trust account. Findings: The Policy and Procedure of Resident Trust Fund, last updated 03/01/24, read in part, .The management of the trust shall be managed by the business office or it's designees and ensure that proper accounting principals are followed .but not to exclude State and Federal regulations . A review of the trust account ledgers for Resident #9, Resident #10 and Resident #26 contained no entries of money being withdrawn at night or on the weekends. On 10/20/24 at 2:21 p.m., Resident #26 stated they could not get funds on the weekends. They stated if they wanted money they would need to request it and get it on Friday. On 10/22/24 at 8:25 a.m., the BOM stated they worked at the facility Monday through Friday and resident funds were kept in a safe in the administrators office. They stated the administrator and themselves were the only ones that had access to the funds. The BOM then stated if the residents wanted money at night they were not able to get it. When asked about access on the weekends they stated the residents needed to get the money requested on Friday. They stated the residents did not have access to funds on the nights and weekends. On 10/22/24 at 8:34 a.m., Resident #10 stated they could not get money on the weekends or when the BOM was gone. They stated they had to ask for money on Friday for the weekends.

Based on observation, record review, and interview the facility failed to: a. monitor fluid input and output for one (#93) of one sampled resident reviewed for fluid restrictions; and b. provide nutritional interventions for weight loss of providing nutritional supplements and double portions at meals for two (#3 and #5) of two sampled residents reviewed for nutritional. The DM identified four residents who were on a pureed diet. The ADON identified one resident on a fluid restriction, 13 residents who had physician orders for double portions, and 23 residents who had orders for health shakes with meals. Findings: An undated policy Encouraging and Restricting Fluids , read in part, .restricting fluids .record the amount of fluid .intake and output . 1. Resident #93 was admitted to the facility on [DATE] with diagnosis which included ESRD and acute kidney failure. Resident #93's October 2024 orders documented they had dialysis services every Tuesday, Thursday and Saturday. It documented they received a renal diet with a 2,000 milliliter fluid restriction. Resident #93's care plan, dated 10/18/24, documented they received hemodialysis related to stage four chronic kidney disease. Interventions included to monitor input and output. There was no documentation the facility was monitoring the input and output. On 10/20/24 at 4:06 p.m., Resident #93 was observed in their room with a small refrigerator with over thirty cans of various drinks. Resident #93 stated they were on a fluid restriction and they did not follow it all the time. They stated the facility did not monitor or ask them how much they have consumed in fluids. On 10/23/24 at 8:20 a.m., LPN #1 stated Resident #93 was on a fluid restriction, but they did not document input and output. They stated it should be documented on the TAR if they documented them. On 10/23/24 at 9:32 a.m., the ADON stated Resident #93 was on a fluid restriction and no monitoring was being completed on input and output. 2. Resident #3 had diagnosis which included dementia, dysphagia, and major depression. Resident #3's care plan dated 02/05/24, documented interventions of diet as ordered. A physician order, dated 06/10/24, documented the resident was to receive a pureed diet with double portions and a supplemental shake for weight loss. Resident #3's significant change assessment, dated 10/11/24, documented they were on a mechanically altered diet and had no weight loss. Resident #3's diet card documented they were to receive a pureed meal with double portions and a shake with each meal. On 10/20/24 at 2:37 p.m., Resident #3 was observed receiving a pureed meal. Dietary staff was observed serving a single portion of pureed meat loaf, potato salad, and cabbage. The resident was not served a shake or double portions. On 10/21/24 at 12:50 p.m., Resident #3 was observed receiving the noon meal with single portions and no shake. On 10/21/24 at 1:18 p.m., CNA #1 stated Resident #3 received a pureed diet and only received a shake if they wanted one. CNA #1 stated Resident #3 always received a single portion unless they asked for more and never received a double portion. 3. Resident #5 had diagnosis of abnormal weight loss and dementia. Resident #5's care plan, dated 10/19/23, documented nutrition interventions were to provide and serve diet as ordered and to receive health shakes with all meals. A physician order, dated 09/12/24, documented the resident was to receive a double portion pureed diet with a shake with meals for weight loss. On 10/20/24 at 2:37 p.m., Resident #5 was observed receiving a pureed meal. Dietary staff was observed serving a single portion of pureed meat loaf, potato salad, and cabbage. The resident was not served a shake or double portions. On 10/21/24 at 12:50 p.m., Resident #5 was observed receiving the noon meal with single portions and no shake. On 10/21/24 at 1:12 p.m., CNA #2 stated Resident #5 did not have any orders for a health shake, but was to receive double portions. CNA #2 stated Resident #5 did not have double portions served to them and dietary staff were to ensure the portion sizes were correct. CNA #2 stated the meal ticket did have double portions and health shake on it, but it was not provided. On 10/21/24 at 1:29 p.m., the DM stated Resident #3 and Resident #5 had orders for double portions and health shakes with each meal. They stated health shakes were not provided due to running out and not having any on hand. They stated Resident #3 and Resident #5 had not been provided double portions with their meals as care planned and ordered. On 10/21/24 at 2:37 p.m., the ADON stated Resident #3 and Resident #5 had orders and care plan interventions for double portions and health shakes with each meal. The ADON stated the care plan interventions and orders for weight loss were not being followed.

Based on record review and interview, the facility failed to ensure residents received notification when they were within $200 of the Medicaid resource limit of $2,000 for four (#5, 9, 10, and #26) of four sampled residents reviewed for notifications of trust balances. The BOM identified 33 residents who had money in the trust account. Findings: The Policy and Procedure of Resident Trust Fund, last updated 03/01/24, read in part, .The management of the trust shall be managed by the business office or it's designees and ensure that proper accounting principals are followed .but not to exclude State and Federal regulations . 1. Resident #5's face sheet documented they had a payer source of Medicaid. Resident #5's trust account ledger, dated 10/21/24, documented a current balance of $2,444.21. 2. Resident #10's face sheet documented they had a payer source of Medicaid. Resident #10's trust account ledger, dated 10/21/24, documented a current balance of $2,152.88. 3. Resident #9's face sheet documented they had a payer source of Medicaid. Resident #9's trust account ledger, dated 10/21/24, documented a current balance of $2,446.25. 4. Resident #26's face sheet documented they had a payer source of Medicaid. Resident #26's trust account ledger, dated 10/21/24, documented a current balance of $1,853.72. There was no documentation the facility had notified Resident #5, Resident #9, Resident #10, and Resident #26 when their trust account balance was within $200 of the Medicaid resource limit of $2,000. On 10/22/24 at 8:25 a.m., the BOM stated the resource limit for residents with Medicaid was $2,000. They were asked how they provided notices to Resident #5, Resident #9, Resident #10, and Resident #26 when their trust account was within $200 of the resource limit. They stated notices have not been provided to the residents when they were close to the resource limit. On 10/22/24 at 8:34 a.m., Resident #10 stated the facility had not provided any notices. They stated they needed to spend money. On 10/22/24 at 8:37 a.m., Resident #26 stated they were not aware their balance was close to $2,000 and they needed to spend money.

Based on record review and interview, the facility failed to complete pre and post dialysis assessments for one (#93) of one sampled resident reviewed for dialysis services. The administrator identified one resident who received dialysis. Findings: An undated policy Dialysis Care/ Arterial Fistula, read in parts, .All residents receiving dialysis will have monitoring before and after dialysis treatment to ensure condition is stable after treatment .The charge nurse prior to an upon return from dialysis shall evaluate the residents condition, including but not limited to vital signs and the graft/fistula site .check bruit and thrill . Resident #93 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease and acute kidney failure. Resident #93's October 2024 orders documented they had dialysis services every Tuesday, Thursday, and Saturday. A dialysis communication form, dated 10/03/24, did not document a post assessment had been completed. There was no documentation a dialysis communication form had been completed on 10/05/24. A dialysis communication form, dated 10/17/24, did not document all areas in the pre and/or post assessment were completed. Resident #93's care plan, dated 10/18/24, documented they received hemodialysis related to stage four chronic kidney disease. Interventions included to encourage resident to go to scheduled dialysis appointments on Tuesday, Thursday and Saturday. Dialysis communication forms, dated 10/19/24 and 10/22/24, did not document pre and/or post assessments had been fully completed. On 10/23/24 at 8:20 a.m., LPN #1 stated Resident #93 was the only resident who received dialysis. LPN #1 stated Resident #93 was to be checked before and after disables with vitals, bruit, thrill, and to make sure all information was filled out in the dialysis binder. On 10/23/24 at 9:32 a.m., the ADON was asked how the facility monitored dialysis residents. The ADON stated they had communication forms which were filled out before and after disables and all other monitoring was documented in the progress notes. The ADON reviewed the communication forms and stated the facility had not been completing pre and post dialysis assessments.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than five percent during the medication pass observation. LPN #2 identified 41 residents resided in the facility. The ADON identified 21 residents with ordered blood pressure parameters. Findings: An Administering Medications, policy, revised 04/19, read in part, .Medications are administered in a safe and timely manner, and as prescribed .The following information is checked/verified for each resident prior to administering medications .vital signs, if necessary . 1. Resident #33 had diagnoses which included polyneuropathy and neurogenic bowel. A Physician Order, start date 09/10/24, documented Colace (laxative) give 100 mg by mouth two times a day related to neurogenic bowel. A fax transmission, dated 10/18/24 at 11:17 a.m., documented Resident #33's Colace order was faxed with an order category of pharmacy. On 10/21/24 at 9:20 a.m., CMA #1 was observed preparing Resident #33's medications for administration. They stated they were waiting for the resident's Colace to be delivered by pharmacy because it was a new order. CMA #1 stated they had to go to their nurse on Friday because the Colace was discontinued on the pharmacy's end, but it was still an active order for the facility. They stated last week they said they would get it in. On 10/21/24 at 9:43 a.m., CMA #1 provided a copy of the fax transmission for Resident #33's Colace dated 10/18/24. They stated it usually took a few days to get medications in. They stated they believed the issue was pharmacy had it as a discontinued order. They stated the Colace could be received that night because medications were delivered on the evening shift. On 10/21/24 at 9:47 a.m., CMA #1 was observed administering Resident #33's morning medications. The scheduled Colace was not administered. On 10/22/24 at 11:30 a.m., CMA #1 stated Resident #33's Colace had come in. 2. Resident #38 had diagnoses which included hypertension. A Physician Order, start date 10/09/24, documented carvedilol (nonselective adrenergic blocker) 25 mg give one tablet by mouth two times a day, hold for systolic 110 or below or diastolic 60 or below. On 10/21/24 at 9:50 a.m., ACMA #2 was observed preparing Resident #38's medication. They placed the resident's carvedilol 25 mg one tablet into a separate medicine cup from the other medications. On 10/21/24 at 9:56 a.m., ACMA #2 entered Resident #38's room and took their blood pressure. The reading was blood pressure 146/50 with a pulse of 83. ACMA #2 administered all of the resident's medications by mouth including the carvedilol. On 10/21/24 at 10:25 a.m., ACMA #2 stated they would triple check medications and ensure it was the right medication, right dosage, and ensure the medications were available to administer. They stated they would also ensure the resident took all of the medications before leaving. On 10/21/24 at 10:27 a.m., ACMA #2 stated if a resident had blood pressure parameters with a medication, they would separate that medication and not give it if the blood pressure was below parameters. On 10/21/24 at 10:28 a.m., ACMA #2 reviewed Resident #38's order and stated the parameter was for a systolic lower than 110 and a diastolic for 60 or below. They stated Resident #38's diastolic blood pressure was below 60 and they did administer the resident's carvedilol. They stated they honestly thought the order said pulse rate. They stated, Yes, that is on me. On 10/21/24 at 10:32 a.m., ACMA #2 stated routine medications came in packets daily to the facility. They stated if medications were not routine, the facility would order them monthly. They stated if a medication was not available for administration, they would mark not here, notify the nurse, and call pharmacy to get it sent out. They stated pharmacy delivered medications everyday.

Based on record review and interview, the facility failed to ensure the medical director was part of the quality assurance program. LPN #2 identified 41 residents resided in the facility. Findings: The undated Quality Assurance and Performance Improvement policy, read in part, .The administrator is responsible for assuring that the facilities QAPI program complies with federal, state, local regulatory agency requirements . A review of the facility list of committee members as listed in their QAPI plan indicated all department heads, the administrator, and DON were part of the committee. The list did not include a physician and/or medical director. A review of the sign in sheets for the QA meetings for January 2024 to October 2024 contained no signature medical director being part of of the committee. A review of the medical director contract documented they were to participate as part of the QA program. On 10/23/24 at 12:04 p.m., the administrator stated the facility had not had a physician or medical director that participated as part of the committee for all of 2024. The administrator stated the last time the medical director was part of the committee was December 2023.

Based on observation and interview, the facility failed to ensure contact information for filing a complaint with the State agency was available to the residents. LPN #2 identified 41 residents resided in the facility. Findings: On 10/21/24 at 1:06 p.m., both resident halls and the main living area were observed. There was no information regarding filing a complaint with the State agency. On 10/21/24 at 2:15 p.m., a confidential interview was held with the resident council group. On 10/21/24 at 2:33 p.m., the resident council group was asked if they had been informed of their rights, and given information on how to formally complain to the State about the care they were receiving. They stated, No. On 10/21/24 at 2:51 p.m., the administrator stated the facility had information on how to formally file a complaint with the State agency posted. The administrator walked out of their office and observed the wall next to their office and stated it was right by the ombudsman sign. They stated it was not posted, but it used to be.

Based on observation, record review and interview, the facility failed to ensure the most recent survey results were readily accessible to the residents. LPN #2 identified 41 residents resided in the facility. Findings: On 10/21/24 at 1:01 p.m., binders with survey results for 2018, 2019, and 2022 were located on the wall between the medication storage room and the administrator's office. The survey results from the most recent survey were not located. On 10/21/24 at 2:15 p.m., a confidential interview was held with the resident council group. On 10/21/24 at 2:32 p.m., the resident council group stated the State survey results were not available to read without having to ask. They stated they did not even know that they post them. On 10/21/24 at 2:50 p.m., the administrator stated the latest survey results were supposed to be posted. They stated they never got posted back after the painting.

Based on observation, record review and interview the facility failed to provide a homelike environment for one (#10) of one sampled resident reviewed for homelike environment. LPN #2 identified 41 residents resided in the facility. Findings: A Homelike Environment policy, revised ,d+[DATE], read in part, .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .The facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect a personalized homelike setting. These characteristics include .clean, sanitary and orderly environment . Resident #10 had diagnoses which included cardiomyopathy and acute respiratory failure with hypoxia. A Quarterly Resident Assessment, dated [DATE], documented Resident #10's cognition was intact. On [DATE] at 2:37 p.m., Resident #10 stated they had concerns with the wall spackle and the top of their wall. They stated they paid a lot of money to live at the facility and they wanted it to look good. On [DATE] at 8:58 a.m, Resident #10's wall next to their television was observed to have two areas of white plaster like material covering the wall as well as five plastic screw anchors in the wall. Resident #10 stated the wall had been in that condition since they moved in. On [DATE] at 9:29 a.m., CNA #3 stated anything they took into a residents room they made sure they took it back out. They stated they would put items away so nothing was hanging out and tidied up when they could to provide a clean homelike environment. They stated if something needed repaired, they would notify maintenance and write it in the book. On [DATE] at 9:37 a.m., LPN #3 stated the facility provided a homelike environment by allowing residents to go out as they wished. They stated they would notify maintenance if a residents room needed repaired. On [DATE] at 9:44 a.m., Maintenance #1 stated they were the staff member responsible for repairs. On [DATE] at 9:47 a.m., Maintenance #1 walked into Resident #10's room and observed the wall. They stated the wall looked like someone had started the repairs and did not finish them. They stated this was prior to them taking on the maintenance role.

Based on record review and interview the facility failed complete a discharge summary with a recapitulation of their stay for one (#41) two closed records reviewed. LPN #2 identified 41 residents resided in the facility. Findings: The undated policy, Discharge Summary and Plan , read in part, .a discharge summary and post discharge pan will be developed .the discharge summary will include the recapitulation of the resident's stay at this facility and a final summary of the residents status at the time of discharge . An incident progress note, dated 08/12/24 at 8:19 p.m., documented the emergency services arrived. It documented Resident #41 coded and the emergency services took over care. Resident #41's discharge assessment, dated 08/12/24, documented the discharge was due to a death in the facility. Resident #41's census report documented they were discharged from the facilty on 08/12/24. There was no documentation the facilty had completed a discharge summary for Resident #41. On 10/21/24 at 9:27 a.m., the DON was asked for the discharge summary for Resident #41. The DON looked through the record and stated they did not see one and would try and locate it. On 10/21/24 at 9:41 a.m., the ADON with the DON present stated the facility did not have a discharge summary because they were in the hospital when they passed away.

Based on observation, record review, and interview, the facility failed to ensure pureed meals were served at the correct consistency for one of one pureed meal preparation. The DM identified four residents who had diet orders for pureed meals. Findings: An undated facility policy, Therapeutic Diets, read in part, .Therapeutic diets are reflected on the menu extension . The menu extension, dated 10/20/24, documented the noon pureed meal was to have baked meat loaf, scalloped potatoes, dinner roll, and pineapple cake. On 10/20/24 at 12:33 p.m., the DM was observed preparing the noon purred. The DM pureed meat loaf, potato salad, and cabbage. The DM added water to each of the items pureed. Once completed the pureed item was tasted by the DM and surveyor. Items were not smooth and had fine chunks of meat, cabbage, and potatoes. On 10/202/4 at 1:10 p.m., the dietary staff was observed serving four out of four pureed trays with the incorrect consistency. On 10/21/24 at 1:29 p.m., the DM stated pureed foods should be made to a smooth consistency. When asked about the consistency of the Sunday noon meal, the DM stated it was not smooth, the food was grainy, and had fine chunks in it.

Based on observation, record review, and interview, the facility failed to ensure menus were followed for pureed diets for one of one meal service observed. The DM identified four residents who had diet orders for pureed meals. Findings: An undated facility policy, Therapeutic Diets, read in part, .Therapeutic diets are reflected on the menu extension . The menu extension, 10/20/24, documented the noon pureed meal was to have baked meat loaf, scalloped potatoes, dinner roll, and pineapple cake. On 10/20/24 at 12:33 p.m., the DM was observed preparing the noon purred meal. The DM pureed single portions of meat loaf, potatoes salad, and cabbage. The dietary manager did not pureed any bread, or pineapple cake. On 10/20/24 at 1:10 p.m., the dietary staff was observed serving four out of four pureed trays without bread or pineapple cake. On 10/21/24 at 1:29 p.m., the DM stated the current diet orders were on each meal ticket for all diet types. They stated they prepared four pureed meals on Sunday afternoon and all residents were to receive their diet order and all menu items. They stated the pineapple cake was not made and nothing else was provided. The dietary manager stated there was no bread as the menu called for. They stated the potato salad was a substitute for scalloped potatoes because the residents had the scalloped potatoes the night before. The dietary manager stated they did not provide all menu items like they should have.

On 03/28/23 at 3:20 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure residents were not missing from the facility and had procedures in place to account for all residents during the shift. Resident #1 had diagnoses which included depression, insomnia, alcohol dependency with alcohol induced dementia. The Residents cognition was intact and he was his own responsible party. The resident had wandering assessments dated 08/15/22, 11/01/22 and 01/18/23 with scores of 7.0 which was a moderate risk for wandering. The care plan did not address wandering or elopement risk for Resident #1. Resident #1 was interviewed and stated he had left the facility by climbing over the fence by a ladder that was in the court yard. Resident #1 stated they left after the 6:30 p.m., smoking when everyone was back in the facility including the staff supervising the smoking. Video surveillance was observed with the DON and Resident #1 was last seen on the camera in any part of the facility and/or property at 7:05 p.m. on 03/12/23. Interviews with the staff working on 03/12/23 when the resident eloped were conducted and they had no knowledge the resident was gone from the facility until they received a call at approximately 1:30 a.m. The 3-11 p.m. staff had no knowledge Resident #1 was out of the facility. On 03/28/23 two ladders remained in the court yard. On 03/29/223 at 8:05 a.m., an acceptable plan of care was received. The plan of removal documented, Heritage Park Plan of Removal Immediate Jeopardy 3/28/23 The facility's response to the IJ called for the facility to implement a plan of removal to ensure there is a system in place to account for all residents at all times. 1. Wander assessments to be completed on all residents to determine elopement risk by 8pm 3/28/23. 2. Any resident noted to be at risk for elopement will have care plan updated with strategies and interventions to maintain the resident's safety by 8pm on 3/28/23. 3. In-service all staff, including agency staff, over Wander and Elopement Policy by 8pm on 3/28/23. 4. In-service nursing staff, to include agency staff over the new policy and procedure for checking residents at least every 2 hours and/or according to their care plan to account for all residents at all times by 8pm on 3/28/23. 5. In-service nursing staff to include agency staff, over performing walking rounds at shift change to check that all residents are safe and present to be completed by 8pm on 3/28/23. On 02/29/23 after interviews with facility staff, review of wandering assessments for all residents, care plans for moderate to high risk residents, and in-services the immediacy was lifted effective 03/29/23 at 10:43 a.m., when the last in-service was provided. The deficient practice remained at a pattern with potential for more then minimal harm. Based on observation, record review, and interview, the facility failed to have a system in place to account for residents that were moderate to high risk wandering and elopement for one (#1) of three sampled residents who were a moderate of high risk for wandering and elopement. Resident #1 left the faciity on [DATE] at approximately 7:05 p.m., and was gone for over seven hours without staff knowing he was missing. Resident #1 was cold, hungry and weak when they had someone call from a convenience store and was returned to the facility. The corporate nurse identified seven residents that were a moderate to high risk for wandering and elopement. Findings: An undated facility policy, Wandering and Elopements, read in parts, .if identified as at risk for wandering, elopement .the resident's care plan will include strategies and interventions to maintain resident's safety . Resident #1 had diagnoses which included depression, insomnia, alcohol dependency with alcohol induced dementia. The Wandering assessments dated 08/15/22, 11/01/22 and 01/18/23, documented Resident #1 was a moderate risk for wandering and elopement. A review of Resident #1 care plan, reviewed on 02/28/23 did not address the resident moderate risk for wandering and elopement. A review of the sign in and out sheet for Resident #1 had no documented times they had signed out of the facility. A review of the staffing schedule documented LPN #1, LPN #2, CMA #1, CNA #2, CNA #3 and CNA #4 worked on 03/12/23 for the 3:00 p.m. through 11:00 p.m. shift; and LPN #3, CNA #3, CNA #6, and CNA #7 worked on the 11:00 p.m. through 7:00 a.m. shift. A review of the MAR documented Resident #1 received Melatonin 3 mg at 8:00 p.m., on 03/12/23. The medication were documented as being provided by CMA #1. A nursing progress note, dated 03/13/23 at 1:45 a.m., read in parts, .Received call from gas station, this resident had a customer of the store call facility. Resident had exited facility, and went to gas station. Facility staff on the way to pick up resident from gas station . A final report to the Oklahoma State Department of Health, dated 03/20/23, read in parts, .Staff was notified that Resident was at a gas station. Resident left the facility without staff knowledge ladder that was chained to courtyard fence was removed to prevent other residents from using . The report was signed by the administrator. A review of the care plan last up dated 03/13/23, read in parts, .A care plan dated 03/13/2023 read in parts, problem .[Resident #1] is at risk for elopement/wandering r/t dx [related to diagnosis] of alcohol induced persisting dementia and poor safety awareness .Interventions .monitor location every 30 min X 72 hours document wandering behavior and attempted diversonal interventions .Distract .from wandering by offering pleasant diversions, structured activities, food, conversation, television, books etc .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist .looking for something .Does it indicate the need for more exercise .Intervene as appropriate . This was the first care plan to address Resident #1 wandering and elopement risk. On 03/26/23 at 10:05 p.m., CNA #4 stated there had been no problems with residents getting out of the building and eloping and all residents were checked on every two hours. CNA #4 stated Resident #1 had never left the building and there had been no problems with him wandering or attempting to elope. CNA #4 was on the schedule the night Resident #1 eloped from the facility. On 03/26/23 at 10:10 p.m., CNA #2 stated Resident #1 had never eloped from the facility. CNA #2 stated there had been no one that had left during their shifts and all residents should be checked on at least every two hours. CNA #2 was on the schedule working the night Resident #1 had eloped from the facility. On 03/26/23 at 10:20 p.m., CNA #1 stated Resident #1 had never eloped from the facility. CNA #1 further stated he had never attempted to leave the building while working and they were required to check on all residents every two hours. On 03/26/23 at 10:20 p.m., CNA #3 stated Resident #1 had never left the building and all residents were to be checked on every two hours. CNA #3 was scheduled to work and assigned to Resident #1 on the 3:00 p.m. through 11:00 p.m. shift and 11:00 p.m. through 7:00 a.m. shift on the night they had eloped from the building. On 03/26/23 at 10:31 p.m., CMA #1 stated Resident #1 had never been missing from the facility. CMA #1 further stated all residents were to be checked on at least every two hours. CMA #1 was scheduled to work and assigned to Resident #1 on the 3:00 p.m. through 11:00 p.m. shift on 03/12/23, and documented the the Resident received melatonin at 8:00 p.m. On 03/26/23 at 10:39 p.m., CMA #2 stated Resident #1 had never been missing from the facility and all residents were to be checked on every two hours. CMA #2 was scheduled to work on the 3:00 p.m. through 11:00 p.m. shift on 03/12/23, the night the Resident had eloped from the building. On 03/26/23 at 11:05 p.m., Resident #1 was observed wandering the facility from his room to the common areas and back to his room. The resident stated he had left the facility two weeks ago and climbed over fence using a ladder. Resident #1 stated they left the facility after 6:30 p.m. The resident stated it was a cold night and he was very cold and hungry when arriving back at the facility. On 03/26/23 at 11:35 p.m., CNA #5 stated they were not aware of Resident #1 being at risk for wandering and elopement. They further stated no Resident had left the facility including Resident #1 and all residents needed checked on every two hours. On 03/26/23 at 11:55 p.m., CNA #6 stated Resident #1 had left the facility two weeks ago and no one knew he was gone until the received a call from a 7-11 between 1:30 a.m. and 2:00 a.m. on 03/13/23. CNA #6 stated they went to pick up Resident #1 approximately eight to ten miles away from the facility. CNA #6 stated the resident was cold and weak when they picked them up from the 7-11. CNA #6 was scheduled to work on the 11:00 p.m. through 7:00 a.m. shift on 03/12/23, the night the Resident had eloped from the building. On 03/27/23 at 12:04 a.m., CNA #7 stated Resident #1 had left the facility two weeks ago after they signed out. CNA #7 stated the facility went and picked Resident #1 up from a 7-11 between 1:30 a.m. and 2:00 a.m. on 03/13/23. CNA #7 stated the resident was cold and hungry once they arrived back to the facility. CNA #7 stated they did not check the sign in and out book to know if Resident #1 had signed out. CNA #7 was scheduled to work on the 11:00 p.m. through 7:00 a.m. shift on 03/12/23. On 03/27/23 at 12:04 a.m., LPN #3 stated the facility did not know Resident #1 was gone until a call was received and someone went and picked them up. LPN #3 stated CNA #3 never told them he was gone and the resident would not tell them how he got out, but LPN #3 never checked the sign out book located at the front door. LPN #3 then stated Resident #1 had left earlier in the evening. The LPN stated the resident was cold, weak and hungry when arriving back at the facility. LPN #3 stated they provided a sandwich and Resident #1 went to bed. LPN #3 was the charge nurse working on the 11:00 p.m. through 7:00 a.m. shift on 03/12/23. 03/28/23 at 9:05 a.m., a tour of the court yard was conducted. There were no unlocked fences, the south west gate had a secured coded gate and the North east gate had a padlock. There were two ladders observed in the court yard resting against the facility behind some bushes. On 03/28/23 at 10:10 a.m., the Corporate Maintenance Supervisor stated there were two ladders in the court yard between the bushes and the facility. They stated the ladders have always been out there and had never been moved. On 03/28/23 at 10:19 a.m., Resident #1 stated they went over the fence after the 6:30 p.m. smoke break when everyone came back in. Resident #1 stated the ladder was in the corner near a shed when they climbed over and the ladders were no longer in the courtyard. On 03/28/23 at 10:40 a.m., the administrator received a call from LPN #3 informing them Resident #1 was at a gas station and told someone to call the facility. I instructed the nurse to have someone go and pick up the resident. The administrator stated there was no code on the exit door to the smoke area and that was how the resident exited the building. The administrator stated Resident #1 used a ladder that was against the fence to climb over the fence and leave. The administrator stated they reviewed the MAR and he received his medication and they had no knowledge of in accurate documentation. The administrator stated staff should check on Resident's every two to three hours or more often depending on the resident. The administrator stated the ladders had been removed from the court yard. On 03/28/23 at 10:55 a.m., LPN #1 stated they worked a double shift on 03/12/23 and worked with Resident #1. The LPN stated she does not know when the Resident was last observed in the facility. LPN #1 stated Resident #1 had signed themselves out of the facility and went to the store and would be shocked if he did not sign out. LPN #1 further stated they did not confirm if Resident #1 had signed out of the facility on 03/12/23. LPN #1 stated the facility aides should monitor residents every two hours and they were not aware the resident had used a ladder to leave the facility. On 03/28/23 from 12:50 p.m., through 2:00 p.m., the facility surveillance camera footage for 03/12/23 was observed with the director of nursing. The footage was observed continuously for the time frame of 6:00 p.m. through 9:30 p.m. Resident #1 was observed setting a ladder up against the south fence line towards the east corner, attempting to get out a lock gate near the smoke area twice and attempting to climb a tree. The last observation of Resident #1 was at 7:05 p.m. as he took a wheel chair and rolled it towards a gate on the southwest side of the building. Resident #1 was not observed in the video footage inside the building or on the grounds after 7:05 p.m. On 03/28/23 at 2:00 p.m., The DON stated Resident #1 was last on camera at 7:05 p.m., and Resident #1 had been gone a long time without anyone knowing. The DON then stated Resident #1 had been gone over seven hours without staff knowing they were missing.

Based on record review and interview, it was determined the facility failed to manage a resident's pain at a tolerable level by assessing and intervening as needed for one (#40) of one resident whose records were reviewed for pain. The Resident Census and Conditions of Residents form, dated 03/14/18, documented forty-one residents received pain management. Findings: Resident # 40 had [DIAGNOSES REDACTED]. The resident had [DIAGNOSES REDACTED] as a young adult which required the removal of the tumor in his lower back. An admission pain assessment, dated 02/12/18, documented the resident rated his pain at an 8 to 9 over the past five days. At present, his pain was rated at a 9 on a scale of 0 -10. The assessment documented the worst the pain level ever got was a 10. The body language assessment description of the resident was tense, distressed, fidgeting, and/or pacing. The pain assessment conclusion was to re-assess quarterly or with onset of pain. The clinical record contained no additional pain assessments. The resident's comprehensive care plan, dated 02/20/18, documented: .Date 2/20/18 . Problem .(Named resident) takes different medication for different DX (diagnoses) . Interventions .7. [MEDICATION NAME] 600 mg (milligram) PO (by mouth) QID (four times a day) Dx:[MEDICAL CONDITION] .9. [MEDICATION NAME] 100mg PO QID @ (at) 0800,1200,and 2100 Dx:moderate pain .11. [MEDICATION NAME] 100mg 1 po x (times) 1 dose Q (every) nightly between 2200-600 PRN (as necessary). -Discontinued 2/22/18 .15. [MEDICATION NAME] 5/325mg 1 tab (tablet) q 6 hours prn-discontinued 03-18 .3/6/18 update [MEDICATION NAME] 5/325 1 po Q 4 hours prn Problem (Named resident) has chronic pain d/t (due to) [MEDICAL CONDITION] .2. Monitor for s/s (signs and symptoms) pain, assess for possible cause and intervene accordingly The (MONTH) (YEAR) Medication Administration Record [REDACTED]. This was a time frame of fifteen days. The (MONTH) treatment administration record (TARs), dated from 02/13/18 to 02/28/18, sign out sheet documented the resident received [MEDICATION NAME] 5/325 26 times. A nurse's note, dated 02/13/18 at 2:00 p.m., documented the resident complained of pain medication not being effective, especially at night. A physician's orders [REDACTED]. The order also documented the resident could be administered one dose between 10:00 p.m., and 6:00 a.m., for moderate pain. A new physician's orders [REDACTED]. The resident's admission assessment, dated 02/20/18, documented the resident was cognitively intact, understood others, and made himself understood. He required supervision for most of his activities of daily living and he had impairment on both sides of his lower extremities. The pain assessment section of the assessment documented the resident had frequent pain which he rated at a 10 on a scale of 0 - 10 and documented it interfered with his sleep. A nurse's note, dated 02/20/18 at 3:45 p.m., documented the pharmacy informed the facility medicaid would not pay for the refill of [MEDICATION NAME]. A nurse's note, dated 02/21/18 (no time given), documented the physician was notified (no subject noted). The note documented the physician stated if medicaid would pay for it, to change the [MEDICATION NAME] order to 7.5 mg., one tablet, two times a day and one tablet every 6 hours as necessary. The note also documented the pharmacy stated medicaid would not pay for [MEDICATION NAME] 7.5/325 mg due to the prescription for [MEDICATION NAME] 5/325 having been filled two days ago. A nurse's note, dated 02/22/18 at 12:45 a.m., documented the resident was complaining of pain. The note documented the resident was informed he could not have pain medication until 3:20 a.m. He was informed if he took [MEDICATION NAME] dose at this time he could not take his 8:00 a.m., dose. He agreed to take his [MEDICATION NAME] at this time. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The (MONTH) TAR documented the resident received pain medication thirteen times during the first six days of March, before the administration times were increased to every four hour as necessary instead of every 6 hours. The resident received pain medication nineteen times during the seven days after the [MEDICATION NAME] 5 mg order was changed. On 03/12/18 at 3:45 p.m., the resident was interviewed about his pain. He stated the [MEDICATION NAME] 5/325 did not provide total relief. He rated his pain a 5 or 6 on a scale of 0 - 10. He stated that was as much relief as he could ever get. He stated the physician had told the facility he could have [MEDICATION NAME] 7.5/325 mg tablets but the facility had not ordered them. He stated they had told him medicaid would not pay for them until he had taken all of the [MEDICATION NAME] 5 mg tablets. At 3:55 p.m., the director of nurses (DON) was interviewed about the resident's pain management. She was asked why the new order for [MEDICATION NAME] 7.5 mg had not been filled. She stated we are working with the resident regarding his pain. She then added she did not consider the physician's statement to inquire about payment, to be an order for [REDACTED]. She stated they were, but last week we got an order to change his [MEDICATION NAME] 5 mg from every 6 hours as necessary to every 4 hours as necessary. She was asked if she had evaluated his pain since the [MEDICATION NAME] 5 mg dose was changed last week. She just repeated we are working with him. She was asked why he wasn't receiving [MEDICATION NAME] 7.5 mg. She stated because the pharmacy said the insurance wouldn't pay for it. She was asked if she knew why. She stated because he had to use all of the [MEDICATION NAME] 5 mg tablets first. She was asked why he did not have a routine order for [MEDICATION NAME] pain medication. She stated the physician had not ordered one. The DON stated when she spoke with the pharmacy they had told her they could not fill the [MEDICATION NAME] 7.5 mg because the [MEDICATION NAME] 5 mg had just been filled two days ago. She was asked what other attempts she had made to try to get the [MEDICATION NAME] 7.5 mg. She said, Nothing because it wasn't a real physician's orders [REDACTED]. She added that when the pharmacy told her they wouldn't fill it, she dropped it. She was asked if she had notified the physician. She stated no because it was not a real order. She was asked why an order was not obtained for the [MEDICATION NAME] 7.5 mg tablets two days ago, instead of getting a new order for the [MEDICATION NAME] 5 mg tablets. Since the resident was still complaining of pain. She stated because she had an order for [REDACTED].>At 4:15 p. m., the consultant pharmacist was asked if she knew why the pharmacy had refused to pay for the [MEDICATION NAME] 7.5 mg tablets. She stated she did not know why, she had never heard of them not paying for a new pain order. The pharmacy was contacted. A pharmacist stated he had told the facility medicaid would only pay for four [MEDICATION NAME] tablets a day. He was asked what would need to be done in order for the resident to start receiving [MEDICATION NAME] 7.5 mg tablets. He stated they had never received a written script for the [MEDICATION NAME] 7.5 mg tablets. He added if the facility would send a written script along with a discontinue order for the [MEDICATION NAME] 5 mg tablets they would send him a new prescription for the [MEDICATION NAME] 7.5 mg tablets. On 03/13/18 at 10:37 a.m., certified medication aide (CMA) #2 was asked how often the resident was in pain. She stated a lot of the time. She was asked what he usually rated his pain level at. She stated usually a 9 or a 10. She was asked if he appeared to be in pain when he requested pain medication. She stated he did appear to be in pain. At 10:42 a.m., the resident was in bed on his right side. He was asked if he was in pain. He stated he was. He was asked to rate his level of pain on scale of 0 to 10. He stated a 9 or a 10. He was asked when his pain pill was due next. He stated he had taken a pill about an hour ago. It helped but didn't totally relieve the pain. At 11:00 a.m., the assistant director of nurses was asked if the resident had a pain assessment conducted since his admission pain assessment. She stated she couldn't find one.

On 04/27/17 at 7:20 p.m., the existence of an IJ (immediate jeopardy) situation was verified with the Oklahoma State Department of Health (OSDH) related to the facility's failure to implement their abuse policy and procedure to ensure a resident was free from abuse and from potential further abuse, thoroughly investigate an allegation of abuse, and report an allegation of abuse to the OSDH. On 04/27/17, facility security video footage was reviewed for events which occurred on 04/25/17. The following is a recapitulation of the video footage: On 04/25/17 at 2:33 p.m., resident #1, who was observed to refuse care/treatment, was physically transferred in a rough manner, placed on the floor in the hall, and then taken to the shower against her will. The resident exhibited behaviors of pulling away and hitting at staff. The resident voiced she did not want to go with the staff to be showered and voiced she wanted to be left alone. Witnesses reported seeing staff grab the resident by her arms and ankles and heard the DON (director of nurse's) state, Do whatever it takes. Statements reported the resident was provided a shower by three staff members when she refused care. At 3:47 p.m., a (CNA) certified nurse aid was observed to forcefully pull a resident away from a wall and push her across the hall into another wall while the resident refused to go to her room. The administrator was notified on 04/25/17 at 3:55 p.m., of an allegation of abuse by two staff members. A thorough investigation of the alleged perpetrators was not conducted, staff members were not suspended during the investigation, and residents were not interviewed which left the potential for further abuse to the resident or other residents. On 04/27/17 at 8:00 p.m., the administrator and DON were notified of the existence of the IJ situation. At 9:37 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: (Named facility) PLAN OF REMOVAL 04-27-17 8:45 pm This Plan of Removal will be addressed by: * Residents will be free from abuse while living at (named facility). * Allegations will be thoroughly investigated to determine if actual abuse happened. Investigation will be completed by 5:00 pm, 4-28-17. Process of investigation will be: *Seeking Investigative Statements for Employees *Interviewing Employees and Residents *Viewing the security camera for all common areas. *When an allegation is alleged, staff members that are accused will be suspended from duty until the investigation is completed. Employees that were accused of abuse have been suspended pending the completion of the investigation and the determination of the investigation. Employees suspended are: *(named licensed practical nurse #1) Suspended (at) 8:45 pm 4-27-17 *(named certified medication aid #1) Suspended (at) 9:15 pm 04-27-17 *(named certified nurse aid #1) Suspended (at) 9:13 pm on 04-27-17 *(named certified nurse aid #2) Suspended (at) 8:35 pm 04-27-17 *(named certified nurse aid #3) Suspended (at) 5:10 pm 4-27-17. The Administrator (named administrator) and the Director of Nurses will be In-Serviced by 5:00 pm, 04-28-17. (named administrator #2) will be performing the In-Service. Employees In-serviced on 04-28-17 are: RN's (registered nurses), LPN's (licensed practical nurses), CMA's (certified medication aides), CNA's (certified nurse assistants), Activity Staff, Housekeeping Staff, Dietary Staff and Social Service Departments. Employees that Administrator and or DON (director of nurses) cannot reach by telephone, by 5:00 pm on 04-28-17 will be removed from the staffing schedule until they have completed the In-service for Abuse and Reporting Abuse. All above listed Staff will be In-serviced for: Protecting Residents from abuse, Investigating Allegations of Abuse, Protecting Residents from further abuse during and after investigation, implementation of Policy and Procedures for reporting abuse, reporting, responding and investigating per State and Federal Regulations and as needed. *By suspending the accused and not being allowed to visit facility during investigation, the resident will be free of risk. (Named facility) will continue to In-Service per State and Federal Regulations on a consistent base's (sic) and staff will also be In-serviced randomly as needed. On 05/01/17 at 1:30 p.m., the administrator was asked to review provided documentation related to the facility's plan of removal. She stated she had not completed a thorough investigation for the allegation of abuse. The administrator provided documentation of resident and staff interviews for the investigation of the allegation of abuse. The questions were reviewed and it was determined the questions were not inclusive enough to determine if an abusive environment existed within the facility. The administrator was asked how she determined what questions to ask the residents and staff members. She said, I determined these questions based on your allegations. She was then asked if she asked residents specifically if they felt safe in the nursing home and around staff members. She stated she did not know because she did not ask the questions. She further stated she did ask residents if they became physically and mentally impaired and had soiled themselves with urine and feces would they prefer to be carried to their room by two staff members for proper care or would they rather be left on the floor or allowed to wander the facility in soiled clothing. She said, I don't think we had a resident who was ok with being left on the floor in feces. She further stated, I was trying to figure out what residents would determine was acceptable. She was then asked if the staff interview questions were all related to a specific incident. She said, Yes, towards (named resident #1). She further stated each question was related to the alleged incidents with the resident. She did not report any questions which were asked to determine how staff responded if a resident refused care and determine other potential incidents of abuse. On 05/01/17 at 6:57 p.m., an addendum was received to the facilities plan of removal and accepted. The addendum documented the following: *Allegations will be investigated to determine if actual abuse happened. Additional investigative statements will be addressed with the residents that are cognitively able to discuss the issue of mistreatment. Investigative statements will include: *if residents are afraid of staff *are residents made to do anything they don't want to do *have they ever refused a shower and what happened if they did *if the resident feels that they have been mistreated by staff. These identified investigative statements will be completed by 5:00 pm, 5-2-2017. *Additional investigative statements will be addressed with the staff member, as stated below: *ask staff what happens if resident's (sic) refuse care *have you ever observed if a resident has been mistreated or abused *have you ever observed residents refuse care, shower in general and what happens, how do you address it. These identified investigative statements will be completed by 5:00 pm, 5-2-2017. (Named DON) was suspended pending an investigation for verbal inappropriateness and actions. Her suspension date and time is 5-1-2017 @ (at) 5:20 p.m. The investigation of all identified staff in this plan of removal will be completed by 5:00 pm on 5-2-2017. The IJ was removed on 05/02/17 at 1:51 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm that was isolated. Based on record review, resident and staff interviews, review of facility policy and procedures, and observations of facility surveillance video footage, it was determined the facility failed to implement their abuse policy and procedures to: a. ensure a resident was free from abuse and residents were free from potential further abuse for one (#1) of six sampled residents reviewed for abuse; and b. ensure an allegation of abuse was reported to the Oklahoma State Department of Health for one (#1) of six sampled residents reviewed for abuse. c. ensure an allegation of abuse was thoroughly investigated for one (#1) of six sampled residents reviewed for abuse. The administrator identified 50 residents resided in the facility. Findings: A facility policy titled, Investigating Allegations of Physical Abuse documented, .All reported incidents of physical abuse are promptly and thoroughly investigated . A facility policy titled, Reporting Abuse to State Agencies and other Entities/Individuals documented; .All alleged/suspected violations .will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law .notices .shall be made within 12 hours after the occurrence of the incident when the facility learns of the abuse . A facility policy titled, Protection of Individuals During Abuse Investigations documented; .Our facility will protect residents from harm during investigations of abuse allegations .employees accused of participating in the alleged abuse .will be suspended until the findings of the investigation have been reviewed . A facility policy titled, Abuse Investigation Protocol documented; .The individual conducting the investigation will, as a minimum .conduct interviews in the presence of a witness .interview the person (s) reporting the incident .interview any witnesses to the incident .interview the resident (as medically appropriate) .interview staff members (on all shifts) who have had contact with the resdient during the 48 hour period prior to the time of the incident .interview the residents roommate .interview other residents to whom the accused employee provides care or services to determine if they have complaints about the employee .interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee .employees of the home who have been accused of resident abuse will be .suspended from duty . Resident #1 was admitted to the facility on [DATE] with the following diagnoses; aggressive behavior, major [MEDICAL CONDITIONS], anxiety, diabetes type 2, and amnesia. A hospital visit summary, dated 04/24/17, documented the resident was discharged from the hospital on [DATE] and the nursing home accepted the resident's transfer to the facility. A skilled nurse's note, dated 04/24/17 for evening shift, documented, .States she refuses to stay here and wants to go home. Refused assessments. Sits in day room refused to go to assigned room .Wants to be 'left alone' . An initial care plan, dated 04/24/17, documented the resident had a behavior/mental status problem. The care plan identified the resident was alert, uncooperative, antisocial, and irritable. The following interventions for the identified problems were: reality orientation, reassurance, and redirection. A skilled nurse's note, dated 04/24/17 untimed, documented the resident exhibited memory problems and disorganized thinking. She exhibited behavior problems: social inappropriateness, rejection of care, and wandering. She was continent of bowel and bladder. A skilled nurse's note, dated 04/24/17 for night shift, documented, .Resident noncompliant c (with) care combative. Biting, pinching, hitting (at) staff .Refused to dress. Re-directed c (with) conversation .Oriented x 1, paces hallway and back . A behavior monitoring record, dated 04/24/17 for the night shift, documented the resident exhibited five behaviors of biting, four behaviors of hitting, and two behaviors of pinching. The resident was redirected and reassured and her behaviors improved. A skilled nurse's note, dated 04/25/17 untimed, documented the resident exhibited memory problems which included inattention and disorganized thinking. She exhibited the following behavior problems: physical behaviors of hitting and kicking, verbal behaviors of screaming and cursing, rejection of care, and wandering. She required limited assistance with transfers and locomotion. She was continent of bladder. She was incontinent of bowel. A skilled nurse's note, dated 04/25/17 for the day shift, documented, .Res (resident) became combative towards administrator for asking this res to shower .Res noncompliant c (with) all tx's (treatments). res to be sent out to (named hospital emergency room ) .Res placed on gurney (and) transported to (named hospital emergency room ). Res also has head lice (and) cont (continues) to refuse to shower . A skilled nurse's note, dated 04/25/17 for the evening shift, documented, .Received res back to facility. N.O. (new order) for [MEDICATION NAME] gel .res arrived (at) approximately 1350 (1:50 p.m.), immediately upon her return res was trying to get out of the front door, res then sat down in a chair (and) was saying 'stay away from me. I'll call the police.' [MEDICATION NAME] gel 1 mg was applied to area between shoulder blades, res trying to hit (and) bite (at) this nurse, res then moved over to sofa in common area . An addendum to the skilled nurse's note, dated 04/25/17 untimed, documented, .Cont (continued) .another res was also on the sofa (and) this res was trying to lie on top of this res. Asked res to sit up that she was lying on top of another res. 'Leave me alone. I don't care.' Asst (assisted) res x 2 up off the sofa, res refused to stand (and) res was lowered to the floor, then she layed down on her back laughing the whole time, asst res again to standing position x 3 staff members asst res to shower while in the shower res was kicking, hitting, (and) trying to bite staff, explained to res that she had an odor (and) needed to be washed. 'I already had a shower today' Res did not . Shower was completed, clean clothes were put on res .Res then escorted out of shower (and) to her room where she layed down .Briefly before getting back up, enc (encouraged) res just to stay in her room away from other res. 'I don't have to do anything you say' . An OSDH incident report, dated 04/25/17 and signed by the administrator documented, .(checked box) Combined Initial and Final . Incident Date 04/25/17 . Resident(s)/Client(s) Involved (Named licensed practical nurse #3) (Named resident #1) . Incident Type .(checked box) Allegations of Neglect . Description of Incident .This nurse alleged that 2 employees forcefully made a resident walk down the hall. She did not report this to me until I became upset with her for not helping take care of her resident. She set in the nursing station and looked down the hall at the employees and resident but never quit eating and drinking or setting in the nursing station. She did not make an attempt to go check on the resident or tell employees not to be forceful, which in fact, if that is what she believed . This nurse refused to assist other staff while trying to take care of a resident .I turned to the LPN (licensed practical nurse) for help and support for this resident and self and the Nurse said, 'I saw them forcing her down the hallway to her room and I am not going to do that' I said, 'who was forcing her down hall.' She said, '(named certified nurse aide #3) and somebody'. I said, 'I did not see anything like that. If you are not going to help and do your job go to the nursing station'. She started saying 'I am doing my job'. I (administrator) went to get the DON (director of nurses) and let her know what happened and when I came out of the DON's office, this LPN was still standing against the wall and I told her to come to (named DON) office. I terminated her for failure to attempt to assess a resident, for not reporting forceful actions that she alleged, failing to attempt interventions to help Admin (administrator) and staff with the resident that was in severe need of care . The incident report was not sent to the Oklahoma State Department of Health until 04/27/17 at 2:00 p.m. This was verified by a facsimile Transmission Verification Report. There was no documentation the facility initiated an investigation of an allegation of abuse alleged by LPN #3. This failure to investigate the allegation of abuse subsequently placed residents at risk for potential further abuse. There were no staff members suspended pending an investigation, which included CNA #3. A nurse's note, dated 04/26/17, documented the resident continued to have noncomplaint behaviors. Facility staff obtained an order for [REDACTED]. On 04/27/17 at 2:48 p.m., CNA #4 was asked if she had ever observed a resident refuse care at the facility and if so what was the reaction of the staff. She stated she observed (named resident #1) refuse care on 04/25/17 at 2:30 p.m. She stated she observed (named CNA #1)(named CNA #2), and (named LPN #1) pick up the resident by her arms and legs and they carried her to the shower room because she refused to go and she had been incontinent of bowel. She then stated after they completed the resident's shower staff attempted to keep the resident in her room and she kept coming out. She stated (CNAs #2 and #3) forcefully took the resident by locking their arms with hers and dragged her down the hall back to her room. She was asked if she had reported this to the administrator or charge nurse. She stated she heard (named LPN #3) report the incident to the administrator. She then stated the administrator was in the facility and aware of the incident in the shower. On 4/27/17 at 2:50 p.m., resident #2 was interviewed about her interactions with the staff. The resident stated the staff was kind unless you did not want to take a bath and then they would, drag you out of bed. The resident added, That happened to me. The resident clarified it happened a while ago and 4 or 5 staff members were involved. The resident reported they said, If you don't get out of bed, we will pull you out. At that time, she told them they did not remember their classes and she did not have to take a bath if she did not want to. She said they made her take a bath. The resident did not report the incident or tell anyone. The resident reported she thought, Why tell them? Why bother? Now she would just take a bath. The resident said, I just stay in bed and don't give anyone any trouble. The resident stated she does not like it here. On 04/27/17 at 3:12 p.m., resident #7 was asked if she had ever observed a resident refuse care at the facility and if so what was the reaction of the staff. She stated she had observed a resident refuse a shower a couple of nights ago. She reported she was in the common day area and witnessed the incident. She stated the resident was combative. She said, She wouldn't stand up. They just picked her up and carried her. She then said, Staff had her under her arms and another under her legs. She was fighting. She then stated she heard staff state the resident was contaminating the nursing home. She further said, They said something about lice I think. She said, She was fighting and yelling and saying she wasn't going to go with them. She was then asked if she could remember which staff members carried the resident to the shower room. She stated the staff members involved were the DON, a female staff member and she was not sure but she may have also observed CNA #3. At 3:20 p.m. resident #2 was interviewed again. The resident stated they (staff) had also drug another resident out of bed for a bath. She stated she told the staff members the resident did not want a bath, but they got men to help and They drug her out like they did me with an arm around her neck. On 04/27/17 at 3:50 p.m., the administrator was asked to provide investigative documentation to accompany the OSDH incident report regarding the allegation of abuse on 04/25/17 for resident #1. She stated the allegation was not reported to her until (named LPN #3) said something to her in the north hall on 04/25/17. She further stated the staff member had received a disciplinary action the day before for sexual solicitation of two staff members during working hours. She said, So I think this was all retaliation. She then provided the following documented handwritten timeline for 04/25/17 of her investigation: 1:52 p.m., (named LPN #3) came into dining room for in-service. 2:50 p.m., everybody was released from the in-service except nursing which included (LPN #3) and (CNA #4). 3:29 p.m., (named LPN #3) came in nurse's station and was eating. She then walked back to the common day area and was eating with her face turned away from the nurse's station. She then was in the nurse's station eating while staff were giving shift report. 3:39 p.m., she was observed standing in the doorway of the nurse's station. 3:41 p.m., she moved to the west side of the nurse's station, rested her bottom on the counter with her back to the common area. She was then observed to glance down the north hall two times for 4 seconds. 3:43 p.m., she was observed to glance to the left for 2 seconds. 3:44 p.m., her back was observed to the common area. She then walked into the back of the nurse's station (chart room). Her back remained to the common area. 3:45 p.m., she exited the back of the nurse's station and was observed drinking. (named CNA #2 and #3) got her (resident #1) off the sofa. There was no documentation in the administrator's investigative timeline of the manner in which the resident was transferred and if she had observed whether staff had been forceful in handling the resident. She was asked why she had not observed the identified segments of the video when she was given an allegation of potential abuse by LPN #3. She stated when she reviewed the video she was observing where and what LPN #3 was doing. She stated she was in the nurse's station and chart room and not in the common area. She then said, I was focused on her cause she alleged abuse. She further stated she attempted to observe what the staff member observed and then noted the staff member did not intervene when she reported the alleged abuse was occurring and she then became focused on what the nurse was doing. She stated she reported the staff member to state agencies for neglect. On 04/27/17 at 4:03 p.m., the video capturing events in the common area and north hallway which occurred on 04/25/17 between 2:20 p.m. and 4:00 p.m., with the resident was reviewed. The administrator was present during the viewing and made statements during the playback. The following is a recapitulation of the observed video surveillance: The section of the video between 2:33 p.m. and 2:45 p.m., was viewed without audio. The administrator stated some cameras did not have working audio. Staff members were observed to attempt to lift the resident to a standing position three times by lifting the resident under her armpits. Three staff members were observed to lift the resident by grabbing her by her ankles and two other staff members lifted her under her armpits. The resident was observed suspended in the air while staff walked the resident at a fast pace out of the common area and down to the end of the north hall. The resident was placed on the floor, on her back, outside of her room. Three staff members were then observed to lift the resident in the same manner and carry her at a fast pace to the shower room. The administrator then paused the video. While the video was paused and prior to staff lifting the resident up by her arms and ankles she said, See I haven't watched this either. They also told me someone had to carry her or something. The surveillance camera video footage was viewed with audio for the time frame of 3:29 p.m. through 4:00 p.m. The following observations were made: At 3:29 p.m., the resident was in a rolling office chair next to the public restroom in the common area of the facility. She got up and walked to the north hallway, returned to the lobby and sat on the couch in front of the nurse's station. At 3:45 the administrator motioned for CNA #2 and CNA #3, to come over to the resident. The staff took the resident by the arms and guided her back to the room being followed by LPN #2. The resident was left in the room and staff was observed leaving the room. At 3:47 p.m., the resident was observed leaving her room and walking down the hallway, she stopped outside of a closed resident's room door. She was observed touching a yellow plastic chain. She was not observed to touch the closed resident's room door handle or try to enter the closed resident's room door. The chain was not across the door frame and was hanging on the right side of the door. In the background, a stern voice was heard which stated, You need to go back to your room. You need to turn around and go to your room. Go, go back to your room. CNA #3 entered the camera's view while making those statements. He then placed his hands on the resident's right shoulder and began to forcefully push her away from the closed door and yellow plastic chain. The resident had the yellow plastic chain in her grasp and would not let go. CNA #3 was observed to forcefully push the resident away from the chain, and the chain flew out of her grasp and was heard slamming against the door frame. CNA #3 was then observed to forcefully push the resident from one side of the hall to the other side, by her shoulders, approximately fifteen feet away. The resident was observed with an unsteady gait as he pushed her by the shoulders. CNA #3 said, No, No. You're not going anywhere. He then forced her against the wall and held her in place to prevent her from moving. The video playback was paused. The administrator said, I haven't seen that. That was a little rough. The administrator then resumed the video footage and audio. At 3:48 p.m., audio documented the resident stated, Leave me alone. Leave me alone. CNA #3 continued to hold the resident against the wall and prevent her from moving for approximately two minutes. At 3:51 p.m., the administrator was observed entering the hallway and talking with the resident. At 3:54 p.m., CNA #2 approached the resident and held onto the resident's arm. The resident pulled her arm away two times and CNA #2 released the resident's arm. CNA #2 said in a stern voice, We are gonna change your pants and you're gonna come with me and cooperate. The administrator said, You have dirtied your pants. The resident said, So. At 3:55 LPN #3 approached the resident and other staff in the hallway. The administrator stated to the resident she needed her to go with CNA #2 and LPN #3. At this time LPN #3 said to the administrator, I am not going to restrain her. The administrator said, I am not asking you to restrain her. Then if you're not gonna do your job go to the nurse's station. LPN #3 said again, I am not going to restrain her. The administrator said, What do you mean. LPN #3 said, I watched them walk her down the hall forcefully. The administrator asked who. LPN #3 said, (Named CNA #3) and whoever else was down there. The resident was heard telling staff to leave her alone and she did not want to go back to her room. The video play back was paused. The administrator was asked to confirm what the LPN had said to her in the hallway. She stated the nurse had told her CNA #3 and another employee had forced the resident down the hallway. She was asked if that was an allegation of abuse. She stated it was. She confirmed she was notified of an allegation of abuse for CNA #3 and other unidentified staff members at 3:55 p.m. A written statement, dated 04/27/17 and untimed, for certified nurse aide #3 was obtained by the administrator after she observed the video surveillance segment from 04/25/17 between 3:29 p.m. and 3:55 p.m. The statement documented the following: As I approached her she was atemping (sic) to enter another person (sic) room and had the privacy chain unhooked in her hand. I put one open hand on her back. Because I didn't know how she was going to react when I approached. Reach c (with) R (right) hand to put chain back on door. She jerked away and started losing her balance. I was trying to steady her. She cont'd (continued) to Jerk (and) pull away from me loosing her balance. I thought she was to (sic) fall. I put my arm underneath pits because she was leaning .I thought was (sic) going to fall. At no point was I trying hurt (sic) or Restrain her. I was only trying to help her. I thought she was going to Fall. (certified nurse aide #3's signature). An undated written statement that was signed by LPN #1 documented, .we picked res (resident) up off the floor, 2 CNA's & (and) myself 2 under the arms .and one person holding the legs .took res to her room, but res refused to go into her room, we then took res into the shower . On 04/27/17 at 6:42 p.m., LPN #1 was asked if the resident had been provided a shower at anytime while she was at the facility. She stated we took her to the shower and put her in the second day she was at the facility (04/25/17). She was asked how the resident was transported to the shower. She stated, We carried her in there. She was asked to describe how they carried the resident to the shower. She stated, (CNA #1) had her under one arm, (CNA #2) had her under the other arm and I was holding her legs. She was asked if the resident wanted to have a shower. She stated the resident said she already had a shower and was not going to take one. She was asked how the resident reacted to them carrying her and giving her a shower. She stated, She was angry and mad. She was asked if the resident had the right to refuse bathing and hygiene. She stated the resident always had the right to refuse showers. She was asked if forcing a resident into the shower was abusive. She stated the resident's body odor was offensive and they had to do something about it. She then stated, We forced her because of the offensive odor. On 04/27/17 at 8:10 p.m., CNA #2 was asked if a resident had the right to refuse care. She stated residents always had the right to refuse care. She was asked what lead to the resident being carried by the arms and ankles to the shower. She stated, 'We thought it was the right thing to do. She stated the resident kept saying she already had showered and she was covered with feces and it was going all over the place. She was asked if the resident had a choice of taking the shower or not. She stated, We just told her she was taking a shower. She was asked to describe how the resident was transferred to the shower room. She stated we carried her down the hallway. She stated one person had the resident by the feet and ankles and the other two on each arm. On 05/01/17 at 10:00 a.m., the DON was asked if she could play video surveillance with audio from 04/25/17. She stated she would attempt to. The video capturing events in the common area and north hallway which occurred on 04/25/17 between 2:20 p.m. and 2:40 p.m., with the resident was reviewed with audio. The administrator was present in the room during the viewing and listening. The following is a recapitulation of the observed video surveillance with audio: At 2:20 p.m., the resident was observed seated on the sofa in the common area. At 2:33 p.m., the resident was observed to ambulate by the entrance door in the common area. The DON and LPN #1 approached the resident and were observed to speak to the resident. (TRUNCATED)

On 04/27/17, the existence of an IJ (immediate jeopardy) situation was verified with the Oklahoma State Department of Health (OSDH) related to the facility's failure to ensure an allegation of abuse was thoroughly investigated, failed to ensure residents were free from potential further abuse and failed to report the allegation of abuse to the OSDH. On 04/27/17, facility security video footage was reviewed for events which occurred on 04/25/17. The following is a recapitulation of the video footage: On 04/25/17 at 2:33 p.m., resident #1, who was observed to refuse care/treatment, was physically transferred in a rough manner, placed on the floor in the hall, and then taken to the shower against her will. The resident exhibited behaviors of pulling away and hitting at staff. The resident voiced she did not want to go with the staff to be showered and voiced she wanted to be left alone. Witnesses reported seeing staff grab the resident by her arms and ankles and heard the DON (director of nurse's) state, Do whatever it takes. Statements reported the resident was provided a shower by three staff members when she refused care. At 3:47 p.m., a (CNA) certified nurse aid was observed to forcefully pull a resident away from a wall and push her across the hall into another wall while the resident refused to go to her room. The administrator was notified on 04/25/17 at 3:55 p.m., of an allegation of abuse by two staff members. A thorough investigation of the alleged perpetrators was not conducted, staff members were not suspended during the investigation, and residents were not interviewed which left the potential for further abuse to the resident or other residents. On 04/27/17 at 8:00 p.m., the administrator and DON were notified of the existence of the IJ situation. At 9:37 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: (Named facility) PLAN OF REMOVAL 04-27-17 8:45 pm This Plan of Removal will be addressed by: * Residents will be free from abuse while living at (named facility). * Allegations will be thoroughly investigated to determine if actual abuse happened. Investigation will be completed by 5:00 pm, 4-28-17. Process of investigation will be: *Seeking Investigative Statements for Employees *Interviewing Employees and Residents *Viewing the security camera for all common areas. *When an allegation is alleged, staff members that are accused will be suspended from duty until the investigation is completed. Employees that were accused of abuse have been suspended pending the completion of the investigation and the determination of the investigation. Employees suspended are: *(named licensed practical nurse #1) Suspended (at) 8:45 pm 4-27-17 *(named certified medication aid #1) Suspended (at) 9:15 pm 04-27-17 *(named certified nurse aid #1) Suspended (at) 9:13 pm on 04-27-17 *(named certified nurse aid #2) Suspended (at) 8:35 pm 04-27-17 *(named certified nurse aid #3) Suspended (at) 5:10 pm 4-27-17. The Administrator (named administrator) and the Director of Nurses will be In-Serviced by 5:00 pm, 04-28-17. (named administrator #2) will be performing the In-Service. Employees In-serviced on 04-28-17 are: RN's (registered nurses), LPN's (licensed practical nurses), CMA's (certified medication aides), CNA's (certified nurse assistants), Activity Staff, Housekeeping Staff, Dietary Staff and Social Service Departments. Employees that Administrator and or DON (director of nurses) cannot reach by telephone, by 5:00 pm on 04-28-17 will be removed from the staffing schedule until they have completed the In-service for Abuse and Reporting Abuse. All above listed Staff will be In-serviced for: Protecting Residents from abuse, Investigating Allegations of Abuse, Protecting Residents from further abuse during and after investigation, implementation of Policy and Procedures for reporting abuse, reporting, responding and investigating per State and Federal Regulations and as needed. *By suspending the accused and not being allowed to visit facility during investigation, the resident will be free of risk. (Named facility) will continue to In-Service per State and Federal Regulations on a consistent base's (sic) and staff will also be In-serviced randomly as needed. On 05/01/17 at 1:30 p.m., the administrator was asked to review provided documentation related to the facility's plan of removal. She stated she had not completed a thorough investigation for the allegation of abuse. The administrator provided documentation of resident and staff interviews for the investigation of the allegation of abuse. The questions were reviewed and it was determined the questions were not inclusive enough to determine if an abusive environment existed within the facility. The administrator was asked how she determined what questions to ask the residents and staff members. She said, I determined these questions based on your allegations. She was then asked if she asked residents specifically if they felt safe in the nursing home and around staff members. She stated she did not know because she did not ask the questions. She further stated she did ask residents if they became physically and mentally impaired and had soiled themselves with urine and feces would they prefer to be carried to their room by two staff members for proper care or would they rather be left on the floor or allowed to wander the facility in soiled clothing. She said, I don't think we had a resident who was ok with being left on the floor in feces. She further stated, I was trying to figure out what residents would determine was acceptable. She was then asked if the staff interview questions were all related to a specific incident. She said, Yes, towards (named resident #1). She further stated each question was related to the alleged incidents with the resident. She did not report any questions which were asked to determine how staff responded if a resident refused care and determine other potential incidents of abuse. On 05/01/17 at 6:57 p.m., an addendum was received to the facilities plan of removal and accepted. The addendum documented the following: *Allegations will be investigated to determine if actual abuse happened. Additional investigative statements will be addressed with the residents that are cognitively able to discuss the issue of mistreatment. Investigative statements will include: *if residents are afraid of staff *are residents made to do anything they don't want to do *have they ever refused a shower and what happened if they did *if the resident feels that they have been mistreated by staff. These identified investigative statements will be completed by 5:00 pm, 5-2-2017. *Additional investigative statements will be addressed with the staff member, as stated below: *ask staff what happens if resident's (sic) refuse care *have you ever observed if a resident has been mistreated or abused *have you ever observed residents refuse care, shower in general and what happens, how do you address it. These identified investigative statements will be completed by 5:00 pm, 5-2-2017. (Named DON) was suspended pending an investigation for verbal inappropriateness and actions. Her suspension date and time is 5-1-2017 @ (at) 5:20 p.m. The investigation of all identified staff in this plan of removal will be completed by 5:00 pm on 5-2-2017. The IJ was removed on 05/02/17 at 1:51 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm that was isolated. Based on record review, resident and staff interviews, review of facility policy and procedures, and observations of facility surveillance video footage, it was determined the facility failed to: a. report an allegation of abuse to the Oklahoma State Department of Health for one (#1) of six sampled residents reviewed for abuse; b. thoroughly investigate an allegation of abuse for one (#1) of six sampled residents reviewed for abuse; and c. ensure residents were protected from further potential abuse for one (#1) of six sampled residents reviewed for abuse. The administrator identified 50 residents resided in the facility. Findings: A facility policy titled, Investigating Allegations of Physical Abuse documented, .All reported incidents of physical abuse are promptly and thoroughly investigated . A facility policy titled, Reporting Abuse to State Agencies and other Entities/Individuals documented; .All alleged/suspected violations .will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law .notices .shall be made within 12 hours after the occurrence of the incident when the facility learns of the abuse . A facility policy titled, Protection of Individuals During Abuse Investigations documented; .Our facility will protect residents from harm during investigations of abuse allegations .employees accused of participating in the alleged abuse .will be suspended until the findings of the investigation have been reviewed . A facility policy titled, Abuse Investigation Protocol documented; .The individual conducting the investigation will, as a minimum .conduct interviews in the presence of a witness .interview the person (s) reporting the incident .interview any witnesses to the incident .interview the resident (as medically appropriate) .interview staff members (on all shifts) who have had contact with the resdient during the 48 hour period prior to the time of the incident .interview the residents roommate .interview other residents to whom the accused employee provides care or services to determine if they have complaints about the employee .interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee .employees of the home who have been accused of resident abuse will be .suspended from duty . Resident #1 was admitted to the facility on [DATE] with the following diagnoses; aggressive behavior, major [MEDICAL CONDITIONS], anxiety, diabetes type 2, and amnesia. A hospital visit summary, dated 04/24/17, documented the resident was discharged from the hospital on [DATE] and the nursing home accepted the resident's transfer to the facility. A skilled nurse's note, dated 04/24/17 for evening shift, documented, .States she refuses to stay here and wants to go home. Refused assessments. Sits in day room refused to go to assigned room .Wants to be 'left alone' . An initial care plan, dated 04/24/17, documented the resident had a behavior/mental status problem. The care plan identified the resident was alert, uncooperative, antisocial, and irritable. The following interventions for the identified problems were: reality orientation, reassurance, and redirection. A skilled nurse's note, dated 04/24/17 untimed, documented the resident exhibited memory problems and disorganized thinking. She exhibited behavior problems: social inappropriateness, rejection of care, and wandering. She was continent of bowel and bladder. A skilled nurse's note, dated 04/24/17 for night shift, documented, .Resident noncompliant c (with) care combative. Biting, pinching, hitting (at) staff .Refused to dress. Re-directed c (with) conversation .Oriented x 1, paces hallway and back . A behavior monitoring record, dated 04/24/17 for the night shift, documented the resident exhibited five behaviors of biting, four behaviors of hitting, and two behaviors of pinching. The resident was redirected and reassured and her behaviors improved. A skilled nurse's note, dated 04/25/17 untimed, documented the resident exhibited memory problems which included inattention and disorganized thinking. She exhibited the following behavior problems: physical behaviors of hitting and kicking, verbal behaviors of screaming and cursing, rejection of care, and wandering. She required limited assistance with transfers and locomotion. She was continent of bladder. She was incontinent of bowel. A skilled nurse's note, dated 04/25/17 for the day shift, documented, .Res (resident) became combative towards administrator for asking this res to shower .Res noncompliant c (with) all tx's (treatments). res to be sent out to (named hospital emergency room ) .Res placed on gurney (and) transported to (named hospital emergency room ). Res also has head lice (and) cont (continues) to refuse to shower . A skilled nurse's note, dated 04/25/17 for the evening shift, documented, .Received res back to facility. N.O. (new order) for [MEDICATION NAME] gel .res arrived (at) approximately 1350 (1:50 p.m.), immediately upon her return res was trying to get out of the front door, res then sat down in a chair (and) was saying 'stay away from me. I'll call the police.' [MEDICATION NAME] gel 1 mg was applied to area between shoulder blades, res trying to hit (and) bite (at) this nurse, res then moved over to sofa in common area . An addendum to the skilled nurse's note, dated 04/25/17 untimed, documented, .Cont (continued) .another res was also on the sofa (and) this res was trying to lie on top of this res. Asked res to sit up that she was lying on top of another res. 'Leave me alone. I don't care.' Asst (assisted) res x 2 up off the sofa, res refused to stand (and) res was lowered to the floor, then she layed down on her back laughing the whole time, asst res again to standing position x 3 staff members asst res to shower while in the shower res was kicking, hitting, (and) trying to bite staff, explained to res that she had an odor (and) needed to be washed. 'I already had a shower today' Res did not . Shower was completed, clean clothes were put on res .Res then escorted out of shower (and) to her room where she layed down .Briefly before getting back up, enc (encouraged) res just to stay in her room away from other res. 'I don't have to do anything you say' . An OSDH incident report, dated 04/25/17 and signed by the administrator documented, .(checked box) Combined Initial and Final . Incident Date 04/25/17 . Resident(s)/Client(s) Involved (Named licensed practical nurse #3) (Named resident #1) . Incident Type .(checked box) Allegations of Neglect . Description of Incident .This nurse alleged that 2 employees forcefully made a resident walk down the hall. She did not report this to me until I became upset with her for not helping take care of her resident. She set in the nursing station and looked down the hall at the employees and resident but never quit eating and drinking or setting in the nursing station. She did not make an attempt to go check on the resident or tell employees not to be forceful, which in fact, if that is what she believed . This nurse refused to assist other staff while trying to take care of a resident .I turned to the LPN (licensed practical nurse) for help and support for this resident and self and the Nurse said, 'I saw them forcing her down the hallway to her room and I am not going to do that' I said, 'who was forcing her down hall.' She said, '(named certified nurse aide #3) and somebody'. I said, 'I did not see anything like that. If you are not going to help and do your job go to the nursing station'. She started saying 'I am doing my job'. I (administrator) went to get the DON (director of nurses) and let her know what happened and when I came out of the DON's office, this LPN was still standing against the wall and I told her to come to (named DON) office. I terminated her for failure to attempt to assess a resident, for not reporting forceful actions that she alleged, failing to attempt interventions to help Admin (administrator) and staff with the resident that was in severe need of care . The incident report was not sent to the Oklahoma State Department of Health until 04/27/17 at 2:00 p.m. This was verified by a facsimile Transmission Verification Report. There was no documentation the facility initiated an investigation of an allegation of abuse alleged by LPN #3. This failure to investigate the allegation of abuse subsequently placed residents at risk for potential further abuse. There were no staff members suspended pending an investigation, which included CNA #3. A nurse's note, dated 04/26/17, documented the resident continued to have noncomplaint behaviors. Facility staff obtained an order for [REDACTED]. On 04/27/17 at 2:48 p.m., CNA #4 was asked if she had ever observed a resident refuse care at the facility and if so what was the reaction of the staff. She stated she observed (named resident #1) refuse care on 04/25/17 at 2:30 p.m. She stated she observed (named CNA #1)(named CNA #2), and (named LPN #1) pick up the resident by her arms and legs and they carried her to the shower room because she refused to go and she had been incontinent of bowel. She then stated after they completed the resident's shower staff attempted to keep the resident in her room and she kept coming out. She stated (CNAs #2 and #3) forcefully took the resident by locking their arms with hers and dragged her down the hall back to her room. She was asked if she had reported this to the administrator or charge nurse. She stated she heard (named LPN #3) report the incident to the administrator. She then stated the administrator was in the facility and aware of the incident in the shower. On 4/27/17 at 2:50 p.m., resident #2 was interviewed about her interactions with the staff. The resident stated the staff was kind unless you did not want to take a bath and then they would, drag you out of bed. The resident added, That happened to me. The resident clarified it happened a while ago and 4 or 5 staff members were involved. The resident reported they said, If you don't get out of bed, we will pull you out. At that time, she told them they did not remember their classes and she did not have to take a bath if she did not want to. She said they made her take a bath. The resident did not report the incident or tell anyone. The resident reported she thought, Why tell them? Why bother? Now she would just take a bath. The resident said, I just stay in bed and don't give anyone any trouble. The resident stated she does not like it here. On 04/27/17 at 3:12 p.m., resident #7 was asked if she had ever observed a resident refuse care at the facility and if so what was the reaction of the staff. She stated she had observed a resident refuse a shower a couple of nights ago. She reported she was in the common day area and witnessed the incident. She stated the resident was combative. She said, She wouldn't stand up. They just picked her up and carried her. She then said, Staff had her under her arms and another under her legs. She was fighting. She then stated she heard staff state the resident was contaminating the nursing home. She further said, They said something about lice I think. She said, She was fighting and yelling and saying she wasn't going to go with them. She was then asked if she could remember which staff members carried the resident to the shower room. She stated the staff members involved were the DON, a female staff member and she was not sure but she may have also observed CNA #3. At 3:20 p.m. resident #2 was interviewed again. The resident stated they (staff) had also drug another resident out of bed for a bath. She stated she told the staff members the resident did not want a bath, but they got men to help and They drug her out like they did me with an arm around her neck. On 04/27/17 at 3:50 p.m., the administrator was asked to provide investigative documentation to accompany the OSDH incident report regarding the allegation of abuse on 04/25/17 for resident #1. She stated the allegation was not reported to her until (named LPN #3) said something to her in the north hall on 04/25/17. She further stated the staff member had received a disciplinary action the day before for sexual solicitation of two staff members during working hours. She said, So I think this was all retaliation. She then provided the following documented handwritten timeline for 04/25/17 of her investigation: 1:52 p.m., (named LPN #3) came into dining room for in-service. 2:50 p.m., everybody was released from the in-service except nursing which included (LPN #3) and (CNA #4). 3:29 p.m., (named LPN #3) came in nurse's station and was eating. She then walked back to the common day area and was eating with her face turned away from the nurse's station. She then was in the nurse's station eating while staff were giving shift report. 3:39 p.m., she was observed standing in the doorway of the nurse's station. 3:41 p.m., she moved to the west side of the nurse's station, rested her bottom on the counter with her back to the common area. She was then observed to glance down the north hall two times for 4 seconds. 3:43 p.m., she was observed to glance to the left for 2 seconds. 3:44 p.m., her back was observed to the common area. She then walked into the back of the nurse's station (chart room). Her back remained to the common area. 3:45 p.m., she exited the back of the nurse's station and was observed drinking. (named CNA #2 and #3) got her (resident #1) off the sofa. There was no documentation in the administrator's investigative timeline of the manner in which the resident was transferred and if she had observed whether staff had been forceful in handling the resident. She was asked why she had not observed the identified segments of the video when she was given an allegation of potential abuse by LPN #3. She stated when she reviewed the video she was observing where and what LPN #3 was doing. She stated she was in the nurse's station and chart room and not in the common area. She then said, I was focused on her cause she alleged abuse. She further stated she attempted to observe what the staff member observed and then noted the staff member did not intervene when she reported the alleged abuse was occurring and she then became focused on what the nurse was doing. She stated she reported the staff member to state agencies for neglect. On 04/27/17 at 4:03 p.m., the video capturing events in the common area and north hallway which occurred on 04/25/17 between 2:20 p.m. and 4:00 p.m., with the resident was reviewed. The administrator was present during the viewing and made statements during the playback. The following is a recapitulation of the observed video surveillance: The section of the video between 2:33 p.m. and 2:45 p.m., was viewed without audio. The administrator stated some cameras did not have working audio. Staff members were observed to attempt to lift the resident to a standing position three times by lifting the resident under her armpits. Three staff members were observed to lift the resident by grabbing her by her ankles and two other staff members lifted her under her armpits. The resident was observed suspended in the air while staff walked the resident at a fast pace out of the common area and down to the end of the north hall. The resident was placed on the floor, on her back, outside of her room. Three staff members were then observed to lift the resident in the same manner and carry her at a fast pace to the shower room. The administrator then paused the video. While the video was paused and prior to staff lifting the resident up by her arms and ankles she said, See I haven't watched this either. They also told me someone had to carry her or something. The surveillance camera video footage was viewed with audio for the time frame of 3:29 p.m. through 4:00 p.m. The following observations were made: At 3:29 p.m., the resident was in a rolling office chair next to the public restroom in the common area of the facility. She got up and walked to the north hallway, returned to the lobby and sat on the couch in front of the nurse's station. At 3:45 the administrator motioned for CNA #2 and CNA #3, to come over to the resident. The staff took the resident by the arms and guided her back to the room being followed by LPN #2. The resident was left in the room and staff was observed leaving the room. At 3:47 p.m., the resident was observed leaving her room and walking down the hallway, she stopped outside of a closed resident's room door. She was observed touching a yellow plastic chain. She was not observed to touch the closed resident's room door handle or try to enter the closed resident's room door. The chain was not across the door frame and was hanging on the right side of the door. In the background, a stern voice was heard which stated, You need to go back to your room. You need to turn around and go to your room. Go, go back to your room. CNA #3 entered the camera's view while making those statements. He then placed his hands on the resident's right shoulder and began to forcefully push her away from the closed door and yellow plastic chain. The resident had the yellow plastic chain in her grasp and would not let go. CNA #3 was observed to forcefully push the resident away from the chain, and the chain flew out of her grasp and was heard slamming against the door frame. CNA #3 was then observed to forcefully push the resident from one side of the hall to the other side, by her shoulders, approximately fifteen feet away. The resident was observed with an unsteady gait as he pushed her by the shoulders. CNA #3 said, No, No. You're not going anywhere. He then forced her against the wall and held her in place to prevent her from moving. The video playback was paused. The administrator said, I haven't seen that. That was a little rough. The administrator then resumed the video footage and audio. At 3:48 p.m., audio documented the resident stated, Leave me alone. Leave me alone. CNA #3 continued to hold the resident against the wall and prevent her from moving for approximately two minutes. At 3:51 p.m., the administrator was observed entering the hallway and talking with the resident. At 3:54 p.m., CNA #2 approached the resident and held onto the resident's arm. The resident pulled her arm away two times and CNA #2 released the resident's arm. CNA #2 said in a stern voice, We are gonna change your pants and you're gonna come with me and cooperate. The administrator said, You have dirtied your pants. The resident said, So. At 3:55 LPN #3 approached the resident and other staff in the hallway. The administrator stated to the resident she needed her to go with CNA #2 and LPN #3. At this time LPN #3 said to the administrator, I am not going to restrain her. The administrator said, I am not asking you to restrain her. Then if you're not gonna do your job go to the nurse's station. LPN #3 said again, I am not going to restrain her. The administrator said, What do you mean. LPN #3 said, I watched them walk her down the hall forcefully. The administrator asked who. LPN #3 said, (Named CNA #3) and whoever else was down there. The resident was heard telling staff to leave her alone and she did not want to go back to her room. The video play back was paused. The administrator was asked to confirm what the LPN had said to her in the hallway. She stated the nurse had told her CNA #3 and another employee had forced the resident down the hallway. She was asked if that was an allegation of abuse. She stated it was. She confirmed she was notified of an allegation of abuse for CNA #3 and other unidentified staff members at 3:55 p.m. A written statement, dated 04/27/17 and untimed, for certified nurse aide #3 was obtained by the administrator after she observed the video surveillance segment from 04/25/17 between 3:29 p.m. and 3:55 p.m. The statement documented the following: As I approached her she was atemping (sic) to enter another person (sic) room and had the privacy chain unhooked in her hand. I put one open hand on her back. Because I didn't know how she was going to react when I approached. Reach c (with) R (right) hand to put chain back on door. She jerked away and started losing her balance. I was trying to steady her. She cont'd (continued) to Jerk (and) pull away from me loosing her balance. I thought she was to (sic) fall. I put my arm underneath pits because she was leaning .I thought was (sic) going to fall. At no point was I trying hurt (sic) or Restrain her. I was only trying to help her. I thought she was going to Fall. (certified nurse aide #3's signature). An undated written statement that was signed by LPN #1 documented, .we picked res (resident) up off the floor, 2 CNA's & (and) myself 2 under the arms .and one person holding the legs .took res to her room, but res refused to go into her room, we then took res into the shower . On 04/27/17 at 6:42 p.m., LPN #1 was asked if the resident had been provided a shower at anytime while she was at the facility. She stated we took her to the shower and put her in the second day she was at the facility (04/25/17). She was asked how the resident was transported to the shower. She stated, We carried her in there. She was asked to describe how they carried the resident to the shower. She stated, (CNA #1) had her under one arm, (CNA #2) had her under the other arm and I was holding her legs. She was asked if the resident wanted to have a shower. She stated the resident said she already had a shower and was not going to take one. She was asked how the resident reacted to them carrying her and giving her a shower. She stated, She was angry and mad. She was asked if the resident had the right to refuse bathing and hygiene. She stated the resident always had the right to refuse showers. She was asked if forcing a resident into the shower was abusive. She stated the resident's body odor was offensive and they had to do something about it. She then stated, We forced her because of the offensive odor. On 04/27/17 at 8:10 p.m., CNA #2 was asked if a resident had the right to refuse care. She stated residents always had the right to refuse care. She was asked what lead to the resident being carried by the arms and ankles to the shower. She stated, 'We thought it was the right thing to do. She stated the resident kept saying she already had showered and she was covered with feces and it was going all over the place. She was asked if the resident had a choice of taking the shower or not. She stated, We just told her she was taking a shower. She was asked to describe how the resident was transferred to the shower room. She stated we carried her down the hallway. She stated one person had the resident by the feet and ankles and the other two on each arm. On 05/01/17 at 10:00 a.m., the DON was asked if she could play video surveillance with audio from 04/25/17. She stated she would attempt to. The video capturing events in the common area and north hallway which occurred on 04/25/17 between 2:20 p.m. and 2:40 p.m., with the resident was reviewed with audio. The administrator was present in the room during the viewing and listening. The following is a recapitulation of the observed video surveillance with audio: At 2:20 p.m., the resident was observed seated on the sofa in the common area. At 2:33 p.m., the resident was observed to ambulate by the entrance door in the common area. The DON and LPN #1 approached the resident and were observed to speak to the resident. The DON said, Here's the thing. You are going to take your pills and we are going to put you in the shower. CMA #1 (certified medication aide) was observed to(TRUNCATED)

On 04/27/17, the existence of an IJ (immediate jeopardy) situation was verified with the Oklahoma State Department of Health (OSDH) related to the facility's failure to ensure a resident was not abused, and to ensure residents were free from potential further abuse. On 04/27/17, facility security video footage was reviewed for events which occurred on 04/25/17. The following is a recapitulation of the video footage: On 04/25/17 at 2:33 p.m., resident #1, who was observed to refuse care/treatment, was physically transferred in a rough manner, placed on the floor in the hall, and then taken to the shower against her will. The resident exhibited behaviors of pulling away and hitting at staff. The resident voiced she did not want to go with the staff to be showered and voiced she wanted to be left alone. Witnesses reported seeing staff grab the resident by her arms and ankles and heard the DON (director of nurse's) state, Do whatever it takes. Statements reported the resident was provided a shower by three staff members when she refused care. At 3:47 p.m., a (CNA) certified nurse aide was observed to forcefully pull a resident away from a wall and push her across the hall into another wall while the resident refused to go to her room. The administrator was notified on 04/25/17 at 3:55 p.m., of an allegation of abuse by two staff members. A thorough investigation of the alleged perpetrators was not conducted, staff members were not suspended during the investigation, and residents were not interviewed, which left the potential for further abuse to the resident or other residents. On 04/27/17 at 8:00 p.m., the administrator and DON were notified of the existence of the IJ situation. At 9:37 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: (Named facility) PLAN OF REMOVAL 04-27-17 8:45 pm This Plan of Removal will be addressed by: * Residents will be free from abuse while living at (named facility). * Allegations will be thoroughly investigated to determine if actual abuse happened. Investigation will be completed by 5:00 pm, 4-28-17. Process of investigation will be: *Seeking Investigative Statements for Employees *Interviewing Employees and Residents *Viewing the security camera for all common areas. *When an allegation is alleged, staff members that are accused will be suspended from duty until the investigation is completed. Employees that were accused of abuse have been suspended pending the completion of the investigation and the determination of the investigation. Employees suspended are: *(named licensed practical nurse #1) Suspended (at) 8:45 pm 4-27-17 *(named certified medication aid #1) Suspended (at) 9:15 pm 04-27-17 *(named certified nurse aid #1) Suspended (at) 9:13 pm on 04-27-17 *(named certified nurse aid #2) Suspended (at) 8:35 pm 04-27-17 *(named certified nurse aid #3) Suspended (at) 5:10 pm 4-27-17. The Administrator (named administrator) and the Director of Nurses will be In-Serviced by 5:00 pm, 04-28-17. (named administrator #2) will be performing the In-Service. Employees In-serviced on 04-28-17 are: RN's (registered nurses), LPN's (licensed practical nurses), CMA's (certified medication aides), CNA's (certified nurse assistants), Activity Staff, Housekeeping Staff, Dietary Staff and Social Service Departments. Employees that Administrator and or DON (director of nurses) cannot reach by telephone, by 5:00 pm on 04-28-17 will be removed from the staffing schedule until they have completed the In-service for Abuse and Reporting Abuse. All above listed Staff will be In-serviced for: Protecting Residents from abuse, Investigating Allegations of Abuse, Protecting Residents from further abuse during and after investigation, implementation of Policy and Procedures for reporting abuse, reporting, responding and investigating per State and Federal Regulations and as needed. *By suspending the accused and not being allowed to visit facility during investigation, the resident will be free of risk. (Named facility) will continue to In-Service per State and Federal Regulations on a consistent base's (sic) and staff will also be In-serviced randomly as needed. On 05/01/17 at 1:30 p.m., the administrator was asked to review provided documentation related to the facility's plan of removal. She stated she had completed a thorough investigation. She was asked if she asked residents specifically if they felt safe in the nursing home and around staff members. She stated she did not know because she did not ask the questions. She further stated she did ask residents if they became physically and mentally impaired and had soiled themselves with urine and feces would they prefer to be carried to their room by two staff members for proper care or would they rather be left on the floor or allowed to wander the facility in soiled clothing. She said, I don't think we had a resident who was ok with being left on the floor in feces. She further stated, I was trying to figure out what residents would determine was acceptable. She was then asked if the staff interview questions were all related to a specific incident. She said, Yes, towards (named resident #1). She further stated each question was related to the alleged incidents with the resident. She did not report any questions which were asked to determine how staff responded if a resident refused care and determined other potential incidents of abuse. On 05/01/17 at 6:57 p.m., an addendum was received to the facilities plan of removal and accepted. The addendum documented the following: *Allegations will be investigated to determine if actual abuse happened. Additional investigative statements will be addressed with the residents that are cognitively able to discuss the issue of mistreatment. Investigative statements will include: *if residents are afraid of staff *are residents made to do anything they don't want to do *have they ever refused a shower and what happened if they did *if the resident feels that they have been mistreated by staff. These identified investigative statements will be completed by 5:00 pm, 5-2-2017. *Additional investigative statements will be addressed with the staff member, as stated below: *ask staff what happens if resident's (sic) refuse care *have you ever observed if a resident has been mistreated or abused *have you ever observed residents refuse care, shower in general and what happens, how do you address it. These identified investigative statements will be completed by 5:00 pm, 5-2-2017. (Named DON) was suspended pending an investigation for verbal inappropriateness and actions. Her suspension date and time is 5-1-2017 @ (at) 5:20 p.m. The investigation of all identified staff in this plan of removal will be completed by 5:00 pm on 5-2-2017. The IJ was removed on 05/02/17 at 1:51 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm that was isolated. Based on record review, resident and staff interviews, review of facility policy and procedures, and observations of facility surveillance video footage, it was determined the facility failed to ensure a resident was free from abuse and residents were protected from potential further abuse for one (#1) of six sampled residents reviewed for abuse. The administrator identified 50 residents resided in the facility. Findings: A facility policy titled, Preventing Individual Abuse, documented; .Our abuse prevention/intervention program includes, but is not limited to the following .monitoring staff all shifts to identify inappropriate behaviors toward individuals (eg .rough handling of residents .) .encouraging all personnel .to report any signs of suspected incidents of abuse to facility management immediately . Resident #1 was admitted to the facility on [DATE] with the following diagnoses; aggressive behavior, major [MEDICAL CONDITIONS], anxiety, diabetes type 2, and amnesia. A hospital visit summary, dated 04/24/17, documented the resident was discharged from the hospital on [DATE] with a primary [DIAGNOSES REDACTED]. The summary further identified the nursing home accepted the resident's transfer to the facility. A skilled nurse's note, dated 04/24/17, for the evening shift documented, .Received at facility at 1800 (6:00 p.m.) from (named emergency transport services) with personal belongings. States she refuses to stay here and wants to go home. Refused assessments. Sits in day room refused to go to assigned room .Wants to be 'left alone' . An initial care plan, dated 04/24/17, documented the resident had a behavior/mental status problem. The care plan identified the resident was alert, uncooperative, antisocial, and irritable. The following interventions for the identified problems were: reality orientation, reassurance, and redirection. A skilled nurse's note, dated 04/24/17 and untimed, documented the resident exhibited memory problems and disorganized thinking. She exhibited the following behavior problems: social inappropriateness, rejection of care, and wandering. She was continent of bowel and bladder. A skilled nurse's note, dated 04/24/17 for the night shift, documented, .Resident noncompliant c (with) care combative. Biting, pinching, hitting (at) staff .Refused to dress. Re-directed c (with) conversation .Oriented x 1, paces hallway and back . A behavior monitoring record, dated 04/24/17 for the night shift, documented the resident exhibited five behaviors of biting, four behaviors of hitting, and two behaviors of pinching. The resident was redirected and reassured and her behaviors improved. A skilled nurse's note, dated 04/25/17 and untimed, documented the resident exhibited memory problems which included inattention and disorganized thinking. She exhibited the following behavior problems: physical behaviors of hitting and kicking, verbal behaviors of screaming and cursing, rejection of care, and wandering. She required limited assistance with transfers and locomotion. She was continent of bladder. She was incontinent of bowel. A skilled nurse's note, dated 04/25/17 for the day shift, documented, .Res (resident) became combative towards administrator for asking this res to shower .Res noncompliant c (with) all tx's (treatments) . res to be sent out to (named hospital emergency room ) .Res also has head lice (and) cont (continues) to refuse to shower . Hospital discharge instructions, dated 04/25/17 at 12:20 p.m., documented the [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Stromectal 3 mg (milligrams) Give 5 tabs (tablets) .today, then same dose Q (every) weeks (sic) on Tuesday .Dx: (diagnosis) Head Lice . A physician's orders [REDACTED].topically .x 1 as soon as medication is received from pharmacy, then Q 6 hours PRN (as needed) .Dx: Severe Anxiety . A Medication Administration Record, [REDACTED]. A skilled nurse's note, dated 04/25/17 for the evening shift, documented, .Received res back to facility. N.O. (new order) for [MEDICATION NAME] gel .res arrived (at) approximately 1350 (1:50 p.m.), immediately upon her return res was trying to get out of the front door, res then sat down in a chair (and) was saying 'stay away from me. I'll call the police.' [MEDICATION NAME] gel 1 mg was applied to area between shoulder blades, res trying to hit (and) bite (at) this nurse, res then moved over to sofa in common area . An addendum to the skilled nurse's note, dated 04/25/17 and untimed, documented, .Cont (continued) .another res was also on the sofa (and) this res was trying to lie on top of res. Asked res to sit up that she was lying on top of another res. 'Leave me alone. I don't care.' Asst (assisted) res x 2 up off the sofa, res refused to stand (and) res was lowered to the floor, then she layed down on her back laughing the whole time, asst res again to standing position x 3 staff members asst res to shower while in the shower res was kicking, hitting, (and) trying to bite staff, explained to res that she had an odor (and) needed to be washed. 'I already had a shower today' Res did not . Shower was completed, clean clothes were put on res .Res then escorted out of shower (and) to her room where she layed down .Briefly before getting back up, enc (encouraged) res just to stay in her room away from other res. 'I don't have to do anything you say' . An OSDH incident report, dated 04/25/17, and signed by the administrator documented, .(checked box) Combined Initial and Final . Incident Date 04/25/17 . Resident(s)/Client(s) Involved (Named licensed practical nurse #3) (Named resident #1) . Incident Type .(checked box) Allegations of Neglect . Description of Incident .This nurse alleged that 2 employees forcefully made a resident walk down the hall .She set in the nursing station and looked down the hall at the employees and resident but never quit eating and drinking or setting in the nursing station. She did not make an attempt to go check on the resident or tell employees not to be forceful, which in fact, if that is what she believed . This nurse refused to assist other staff while trying to take care of a resident .I turned to the LPN (licensed practical nurse) for help and support for this resident and self and the Nurse said, 'I saw them forcing her down the hallway to her room and I am not going to do that' I said, 'who was forcing her down hall.' She said, '(named certified nurse aid #3) and somebody'. I said, 'I did not see anything like that . There was no documentation the facility initiated an investigation of an allegation of abuse alleged by LPN #3 and suspended the employees, including CNA #3 to protect from potential further abuse. On 04/27/17 at 2:48 p.m., CNA #4 (certified nurse aide) was asked if she had ever observed a resident refuse care at the facility and if so, what was the reaction of the staff. She stated she observed Resident #1 refuse care on 04/25/17 at 2:30 p.m. She stated she observed the DON, CNA #2, and LPN #1 pick up the resident by her arms and legs and they carried her to the shower room because she refused to go and she had been incontinent of bowel. She then stated after they completed the resident's shower, staff attempted to keep the resident in her room and she kept coming out. She stated CNA #2 and #3 forcefully took the resident by locking their arms with theirs and dragged her down the hall back to her room. She was asked if she had reported this to the administrator or charge nurse. She stated she heard LPN #3 reported the abuse to the administrator. She then stated the administrator was in the facility and aware of the incident in the shower. On 4/27/17 at 2:50 p.m., resident #2 was interviewed about her interactions with the staff. The resident stated the staff was kind unless you did not want to take a bath and then they would, drag you out of bed. The resident added, That happened to me. The resident clarified it happened a while ago and 4 or 5 staff members were involved. The resident reported they said, If you don't get out of bed, we will pull you out. At that time, she told them they did not remember their classes and she did not have to take a bath if she did not want to. She said they made her take a bath. The resident did not report the incident or tell anyone. The resident reported she thought, Why tell them? Why bother? Now she would just take a bath. The resident said, I just stay in bed and don't give anyone any trouble. The resident stated she does not like it here. On 04/27/17 at 3:12 p.m., resident #7 was asked if she had ever observed a resident refuse care at the facility and if so what was the reaction of the staff. She stated she had observed a resident refuse a shower a couple of nights ago. She reported she was in the common day area and witnessed the incident. She stated the resident was combative. She said, She wouldn't stand up. They just picked her up and carried her. She then said, Staff had her under her arms and another under her legs. She was fighting. She then stated she heard staff state the resident was contaminating the nursing home. She further said, They said something about lice I think. She said, She was fighting and yelling and saying she wasn't going to go with them. She was then asked if she could remember which staff members carried the resident to the shower room. She stated the staff members involved were the DON, a female staff member and she was not sure but she may have also observed CNA #3. At 3:20 p.m. resident #2 was interviewed again. The resident stated they (staff) had also drug another resident out of bed for a bath. Resident #2 told them the other resident did not want a bath, but they got men to help and They drug her out like they did me with an arm around her neck. On 04/27/17 at 3:50 p.m., the administrator was asked to provide investigative documentation to accompany the OSDH incident report regarding the allegation of abuse on 04/25/17 for resident #1. She stated the allegation was not reported to her until (named LPN #3) said something to her in the north hall on 04/25/17. She further stated the staff member had received a disciplinary action the day before for sexual solicitation of two staff members during working hours. She said, So I think this was all retaliation. She then provided the following documented handwritten timeline for 04/25/17 of her investigation: 1:52 p.m., (named LPN #3) came into dining room for in-service. 2:50 p.m., everybody was released from the in-service except nursing which included (LPN #3) and (CNA #4). 3:29 p.m., (named LPN #3) came in nurse's station and was eating. She then walked back to the common day area and was eating with her face turned away from the nurse's station. She then was in the nurse's station eating while staff were giving shift report. 3:39 p.m., she was observed standing in the doorway of the nurse's station. 3:41 p.m., she moved to the west side of the nurse's station, rested her bottom on the counter with her back to the common area. She was then observed to glance down the north hall two times for 4 seconds. 3:43 p.m., she was observed to glance to the left for 2 seconds. 3:44 p.m., her back was observed to the common area. She then walked into the back of the nurse's station (chart room). Her back remained to the common area. 3:45 p.m., she exited the back of the nurse's station and was observed drinking. (named CNA #2 and #3) got her (resident #1) off the sofa. There was no documentation in the administrator's investigative timeline of the manner in which the resident was transferred and if she had observed whether staff had been forceful in handling the resident. On 04/27/17 at 4:03 p.m., the video capturing events in the common area and north hallway which occurred on 04/25/17 between 2:20 p.m. and 4:00 p.m., with the resident was reviewed. The administrator was present during the viewing and made statements during the playback. The following is a recapitulation of the observed video surveillance: The section of the video between 2:33 p.m. and 2:45 p.m., was viewed without audio. The administrator stated some cameras did not have working audio. Staff members were observed to attempt to lift the resident to a standing position three times by lifting the resident under her armpits. Three staff members were observed to lift the resident by grabbing her by her ankles and two other staff members lifted her under her armpits. The resident was observed suspended in the air while staff walked the resident at a fast pace out of the common area and down to the end of the north hall. The resident was placed on the floor, on her back, outside of her room. Three staff members were then observed to lift the resident in the same manner and carry her at a fast pace to the shower room. The administrator then paused the video. While the video was paused and prior to staff lifting the resident up by her arms and ankles she said, See I haven't watched this either. They also told me someone had to carry her or something. She was asked again if she could play the audio with the video. She stated, There is no audio. The video playback was continued by the administrator. The surveillance camera video footage was viewed with audio for the time frame of 3:29 p.m. through 4:00 p.m. The following observations were made: At 3:29 p.m., the resident was in a rolling office chair next to the public restroom in the common area of the facility. She got up and walked to the north hallway, returned to the lobby and sat on the couch in front of the nurse's station. At 3:45 the administrator motioned for CNA #2 and CNA #3, to come over to the resident. The staff took the resident by the arms and guided her back to the room being followed by LPN #2. The resident was left in the room and staff was observed leaving the room. At 3:47 p.m., the resident was observed leaving her room and walking down the hallway, she stopped outside of a closed resident's room door. She was observed touching a yellow plastic chain. She was not observed to touch the closed resident's room door handle or try to enter the closed resident's room door. The chain was not across the door frame and was hanging on the right side of the door. In the background, a stern voice was heard which stated, You need to go back to your room. You need to turn around and go to your room. Go, go back to your room. CNA #3 entered the camera's view while making those statements. He then placed his hands on the resident's right shoulder and began to forcefully push her away from the closed door and yellow plastic chain. The resident had the yellow plastic chain in her grasp and would not let go. CNA #3 was observed to forcefully push the resident away from the chain, and the chain flew out of her grasp and was heard slamming against the door frame. CNA #3 was then observed to forcefully push the resident from one side of the hall to the other side, by her shoulders, approximately fifteen feet away. The resident was observed with an unsteady gait as he pushed her by the shoulders. CNA #3 said, No, No. You're not going anywhere. He then forced her against the wall and held her in place to prevent her from moving. The video playback was paused. The administrator said, I haven't seen that. That was a little rough. The administrator then resumed the video footage and audio. At 3:48 p.m., audio documented the resident stated, Leave me alone. Leave me alone. CNA #3 continued to hold the resident against the wall and prevent her from moving for approximately two minutes. At 3:51 p.m., the administrator was observed entering the hallway and talking with the resident. At 3:54 p.m., CNA #2 approached the resident and held onto the resident's arm. The resident pulled her arm away two times and CNA #2 released the resident's arm. CNA #2 said in a stern voice, We are gonna change your pants and you're gonna come with me and cooperate. The administrator said, You have dirtied your pants. The resident said, So. At 3:55 p.m., LPN #3 approached the resident and other staff in the hallway. The administrator stated to the resident she needed her to go with CNA #2 and LPN #3. At this time LPN #3 said to the administrator, I am not going to restrain her. The administrator said, I am not asking you to restrain her. Then if you're not gonna do your job go to the nurse's station. LPN #3 said again, I am not going to restrain her. The administrator said, What do you mean. LPN #3 said, I watched them walk her down the hall forcefully. The administrator asked who. LPN #3 said, ( CNA #3) and whoever else was down there. The resident was heard telling staff to leave her alone and she did not want to go back to her room. The video play back was paused. The administrator was asked to confirm what the LPN had said to her in the hallway. She stated the nurse had told her CNA #3 and another employee had forced the resident down the hallway. She was asked if that was an allegation of abuse. She stated it was. A written statement, dated 04/27/17 and untimed, for certified nurse aide #3 was obtained by the administrator after she observed the video surveillance segment from 04/25/17 between 3:29 p.m. and 3:55 p.m. The statement documented the following: As I approached her she was atemping (sic) to enter another person (sic) room and had the privacy chain unhooked in her hand. I put one open hand on her back. Because I didn't know how she was going to react when I approached. Reach c (with) R (right) hand to put chain back on door. She jerked away and started losing her balance. I was trying to steady her. She cont'd (continued) to Jerk (and) pull away from me loosing her balance. I thought she was to (sic) fall. I put my arm underneath pits because she was leaning .I thought was (sic) going to fall. At no point was I trying hurt (sic) or Restrain her. I was only trying to help her. I thought she was going to Fall. (certified nurse aide #3's signature). An undated written statement that was signed by LPN #1 documented, .we picked res (resident) up off the floor, 2 CNA's & (and) myself 2 under the arms .and one person holding the legs .took res to her room, but res refused to go into her room, we then took res into the shower . An interview was conducted on 04/27/17 at 6:42 p.m., with LPN #1. She was asked to describe the resident. She stated the resident was mean, noncompliant, refused bathing and hygiene. She was asked if the resident had been provided a shower at anytime while she was at the facility. She stated we took her to the shower and put her in the second day she was at the facility (04/25/17). She was asked how the resident was transported to the shower. She stated, We carried her in there. She was asked to describe how they carried the resident to the shower. She stated, (CNA #1) had her under one arm, (CNA #2) had her under the other arm and I was holding her legs. She was asked if the resident wanted to have a shower. She stated the resident said she already had a shower and was not going to take one. She was asked how the resident reacted to them carrying her and giving her a shower. She stated, She was angry and mad. She was asked if the resident had the right to refuse bathing and hygiene. She stated the resident always had the right to refuse showers. She was asked if forcing a resident into the shower was abusive. She stated the resident's body odor was offensive and they had to do something about it. She then stated, We forced her because of the offensive odor. She was asked if there had been any other issues or concerns that happened that day with the resident. She stated about 8:00 p.m., the resident had went up to CNA #3 and pushed him twice on the chest and then turned to me and stated she did not have to do anything we told her to do because she (LPN #1) wasn't her mother. An interview was conducted on 04/27/17 at 8:10 p.m., with CNA #2. She was asked if a resident had the right to refuse care. She stated residents always had the right to refuse care. She was asked what lead to the resident being carried by the arms and ankles to the shower. She stated, 'We thought it was the right thing to do. She stated the resident kept saying she already had showered and she was covered with feces and it was going all over the place. She was asked if the resident had a choice of taking the shower or not. She stated, We just told her she was taking a shower. She was asked to describe how the resident was transferred to the shower room. She stated we carried her down the hallway. She stated one person had the resident by the feet and ankles and the other two on each arm. On 05/01/17 at 10:00 a.m., the DON (director of nurses) was asked if she could play video surveillance with audio from 04/25/17. She stated she would attempt to. The video capturing events in the common area and north hallway which occurred on 04/25/17 between 2:20 p.m. and 2:40 p.m., with the resident was reviewed with audio. The administrator was present in the room during the viewing and listening. The following is a recapitulation of the observed video surveillance with audio: At 2:20 p.m., the resident was observed seated on the sofa in the common area. At 2:32 p.m., CMA #1 (certified medication aide) was observed to approach the resident with a small medicine cup. He offered the medication to the resident and the resident refused. He then walked away from the resident with the medication. The resident got up from the sofa and walked over to the entrance door. At 2:33 p.m., the resident was observed to ambulate by the entrance door in the common area. The DON and LPN #1 approached the resident and were observed to speak to the resident. The DON said, Here's the thing. You are going to take your pills and we are going to put you in the shower. CMA #1 (certified medication) was observed to stand behind the DON and LPN #1 with a medication cup. The resident said, No. No. I don't have to. The resident returned herself to the sofa and sat down. There was a resident observed seated on the opposite end of the sofa. Resident #1 was seated in the middle of the sofa. The DON then said, (Resident) you can't sit on the furniture. You're going to have to go to your room. The DON and LPN #1 then placed one of their arms under the resident's armpits and lifted her to a standing position. The resident's legs then slid and the resident was lowered to a seated position on the floor. The DON then said with a stern voice, Stand up. You're gonna take a pill. You're gonna take a shower and we are gonna put cream on you. She then stated with a stern voice, You're contaminating the whole building. At 2:34 p.m., the resident was observed to roll to her knees and stand herself up from the floor. She then seated herself on the sofa. The resident grabbed a pillow which was next to her on the sofa. She swung the pillow at LPN #1 and hit her in the leg. The DON then grabbed a hold of the other end of the pillow and begun to pull it away from the resident. The DON stated, (Resident) let go. You're contaminating our whole building. Let go! Let go of our property! She then forcefully pulled the pillow out of the resident's hands and tossed it aside. At 2:35 p.m., LPN #1 was observed with the cup of medication. She offered it to the resident and the resident swatted the cup away. The DON then stated in a stern voice, Get off the couch now. The DON then looked at the staff members in close proximity to the resident. She then stated, Pick her up. Do whatever you have to do. Get her off the couch!. Then CMA #1 and CNA #1 placed one of their arms under the resident's armpits and lifted her to a standing position. The resident's legs then slid and the resident was lowered to a seated position on the floor. At 2:35 p.m., the DON, LPN #1 and CMA #1 were observed as they stood over the resident and spoke to the resident. Then LPN #1 and CNA #1 placed one of their arms under the resident's armpits and attempted to lift the resident. They were unable to lift the resident and she slid approximately 2 feet across the floor while (TRUNCATED)

Based on observation, record review, and interview, it was determined the facility failed to: ~ prevent the development of three facility acquired pressure ulcers for one (#45) of four sampled residents who were reviewed for pressure ulcers. This deficient practice resulted in an actual harm for resident #45. ~ assess, monitor, and intervene for pressure ulcers that were present upon admission for one (#51) of four sampled residents who were reviewed for pressure ulcers. There was one other resident (#57) with pressure ulcers. Findings: 1. Resident #45 had a [DIAGNOSES REDACTED]. An admission Resident-Data Collection form, dated 09/09/16, documented the resident was ambulatory, but had an unsteady gait and was a fall risk. The note documented the resident had reddened areas to his coccyx and buttocks. An admission nurse's note, dated 09/09/16 at 6:30 p.m., documented the resident had a reddened area to his coccyx and buttocks. The facility's pressure ulcer risk assessment, dated 09/09/16, documented the resident had a score of 11. The assessment tool documented a score of 12 or less indicated the resident was at high risk for the development of pressure ulcers. An admission care plan, dated 09/13/16, contained no documentation a care plan had been developed for the resident's high risk of developing pressure ulcers. The resident's admission assessment, dated 09/22/16, documented the resident was not a high risk for developing pressure ulcers. The assessment also documented the resident was severely impaired in cognition and was independent and/or required supervision with his activities of daily living (ADLs). A nurse's note, dated 10/02/16, documented the resident continued to refuse to eat in the dining room, but ate candy bars in his room. A social service note, dated 10/03/16, documented the resident had been slowing down and had been placed in a w/c (wheelchair) for safety. A psychiatric evaluation, dated 10/07/16, documented the resident had a dramatic decline in the past month, due to progression of disease process. A social service progress note, dated 10/24/16, documented the resident was having a hard time while standing to transfer. A weekly skin assessment, dated 11/12/16, documented the resident had a stage I pressure ulcer to his right hip and a treatment was in place. No additional information was documented. A physician's orders [REDACTED]. A nurse's note, dated 11/13/16 (no time provided), documented reddened area over right hip approximately 6 centimeters (cm) by 5.5 cm in length and width. [MEDICATION NAME] applied and covered with a foam dressing. The resident was positioned onto the left side to lesson pressure to his right side. The clinical record contained no documentation of the resident having been on a repositioning program prior to this nurse's note. The resident's care plan, dated 11/13/16, documented; Problem (Named resident) has potential impairment to skin integrity r/t (related to) fragile skin . Interventions 1. Weekly skin audits. 2. Encourage PO (per mouth) intake within dietary limits 4. CNA's (certified nurse aides) to report any redness or s/sx (signs and/or symptoms) of breakdown immediately to charge nurse 5. REPOSITIONING Q (every) 2 HRS (hours) 6. EDUCATE FAMILY, RES (resident) AND STAFF OF CAUSATIVE FACTORS AND MEASURES TO PREVENT SKIN INJURY 7. Encourage good nutrition and hydration in order to promote healthier skin. 8. [MEDICATION NAME] TO RIGHT HIP Q SHIFT COVERED WITH DRESSING A weekly skin assessment sheet, dated 11/19/17, documented the resident had a stage II pressure ulcer to his right hip with treatment in place. No additional information was documented. The resident's care plan, updated 11/21/16, documented; 11/21/16 UPDATE Goal (Named resident) stage 2 to R (right) HIP will be healed by review date Interventions 1. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue and exudate and any other notable . 3. Identify/document potential causative factors and eliminate/resolve where possible The facility's pressure ulcer risk assessment, dated 11/22/16, documented the resident had a score of 13. The assessment tool documented a score of 12 or less indicated the resident was a high risk for development of pressure ulcers. According to this assessment tool the resident was at a lower risk of developing pressure ulcers than upon admission; even though he had developed a new pressure ulcer on 11/12/16. A physician's orders [REDACTED]. A nurse's note, dated 11/24/16 (no time provided), documented wounds to the resident's bilateral heels. The right heel measured 4 cm x 2 cm x 0.5 cm. The left heel measured 5 cm x 3 cm x 0.5 cm. The resident was repositioned every hour for comfort. The clinical record contained no additional documentation the resident had been placed on a repositioning program. A physician's orders [REDACTED]. Apply [MEDICATION NAME], and secure with tape daily until healed. The updated care plan, dated 11/25/16, documented; Change dressing to bilateral heel wounds daily A weekly skin assessment, dated 11/26/16, documented the resident had a stage II to his right hip with a treatment in place. The skin assessment also documented there were wounds to his bilateral heels with treatments in place. No additional information was documented. The updated care plan, dated 11/28/16, documented; .1. L-Emental (1) pkt (packet) mixed c (with) 4 oz (ounces) of juice at 8 am and 1600 (4 p.m.). Dx: (diagnosis) pressure wnd (wound) The resident's treatment administration record (TAR) for December 2016, documented to float feet on wedge at hour of sleep, with a start date of 11/28/16. The TAR documented no additional interventions, such as repositioning, to be provided in regards to the pressure ulcers. A nurse's note, dated 12/08/16, documented the left heel wound measured 2 cm x 1.5 cm, and the right heel wound measured 2.2 cm x 1.5 cm. A weekly skin assessment, dated 12/09/16, documented the resident had a stage II to his right hip and stage IIs to his bilateral heels. No additional information was documented. A weekly skin assessment, dated 12/16/16, documented the resident had a stage II to his right hip, stage IIs to his bilateral heels, and a reddened area to his coccyx. A weekly skin assessment, dated 12/24/16, documented the resident had a stage II to his right hip and his bilateral heels had stage IIs. The right calf had a busted blister. No additional information was documented. A nurse's note, dated 12/25/16 (no time provided), documented the resident's right hip wound had a yellowish eschar in the center of the wound. The note documented the left heel wound had healed. The resident's quarterly assessment, dated 12/30/16, documented the resident sometimes made himself understood, usually understood others, was severely impaired in cognition, and he required extensive assistance with all of his activities of daily living except eating. The assessment also documented the resident was at risk for developing pressure ulcers and had two stage II pressure ulcers. The assessment contained no documentation the resident had an unstageable pressure ulcer to his right hip. A weekly skin assessment, dated 01/02/16 (sic-01/02/17), documented an ulcer to the resident's bilateral heels and skin tears to bilateral calves. No additional information was documented. A weekly skin assessment, dated 01/08/16, documented a stage II to the right hip and the right heel. Skin tears to the bilateral calves. No additional information was documented. A nurse's note, dated 01/09/16 (no time provided), documented the new wound measurements were as follows; right heel 1.3 cm in width, 1.0 cm in length, and the left heel had healed. The nurse's note provided no documentation regarding the right hip wound. On 01/11/17 at 3:02 p.m., the resident was observed asleep in bed, he was laying on his back. On 01/12/17 at 8:00 a.m., The resident was observed eating breakfast at the assisted table, he was feeding himself. At 8:45 a.m., the resident was transferred from the w/c into bed. He required the assistance of one staff for the transfer. He was not able to stand and pivot. At 9:29 a.m., wound care was observed. The resident was observed with a pressure ulcer on his right greater trochanter area with dark eschar in the center. The wound appeared to be approximately 1.5 cm by 1 cm. There was a ridge of white tissue encircling the wound. The wound was free of drainage and odors. A scant area of pink tissue was visualized in the wound bed. The skin surrounding the wound was bright pink. The resident had a second pressure ulcer located on the lateral aspect of his right foot approximately 2 cms below his ankle. It appeared to be approximately 2 cms long by 0.5 cms wide. The wound bed was pink, free from drainage, and free of odor. The surrounding tissue was pink. After the wound care the resident was repositioned in bed on his back, with the head of the bed elevated, and pillows under his knees. The licensed practical nurse (LPN) #2 was asked how the resident acquired the pressure ulcers. She stated the heel wounds were acquired during a hospital stay and the resident was admitted with a reddened area to the right hip. The LPN was asked what were the stages of the pressure ulcers. She stated they were stage IIs. She was asked why they were stage IIs. She stated because they were open. She was asked if the right hip ulcer had eschar. She stated it did. The LPN was asked what the white ridge around the right hip wound was. She stated she didn't know. She was asked if it could be moisture. She stated it could be so she was going to call the physician. At 10:33 a.m., the director of nurses (DON) was asked if the resident had been admitted to the hospital since his admission. She reviewed the clinical record and stated he had not. She was asked if the resident's pressure ulcers had been acquired while he resided in the facility. The DON stated they had been. At 10:41 a.m., the resident was observed asleep on his back in bed with the head of his bed elevated and his heels floated. At 11:45 a.m., the resident was observed up in his wheelchair in the lobby. At 1:30 p.m., the resident was observed in bed asleep on his back with his heels floated. At 1:35 p.m., the DON was asked how the resident acquired his pressure ulcers. She stated he began to have a decline, quit ambulating, and refused to eat. The DON was asked if preventative measures had been initiated to prevent the development of pressure ulcers after the resident quit ambulating and wasn't eating anything but candy. She stated they had not. The DON stated he started spending more time in bed and he preferred to stay on his right side. She stated they turned his bed around to face a different direction so he would stay off his right side and they started floating his heels. She stated the left heel pressure ulcer had healed. The DON stated the resident was on an every 2 hour repositioning program. She was asked if these interventions had been initiated prior to the resident developing the pressure ulcers. She stated they were not, except for the repositioning every two hours. The DON was asked if the repositioning was documented. No documentation was provided prior to the exit from the facility. At 2:30 p.m., LPN # 2 was re-interviewed and she was asked if the resident's pressure ulcers were stageable. She stated they were. She was asked if she knew how the resident acquired the wounds. She stated the resident started going down hill, quit eating, and he quit ambulating. She added he would lay on his right side. The LPN was asked if it was possible to stage the right hip pressure ulcer since it had eschar. She stated it was. The LPN was asked what interventions had been initiated to prevent pressure ulcers when the resident started declining and quit ambulating. She stated they had turned his bed around to face another direction and his heels were being floated. She was asked it the interventions were put in place prior to the development of the pressure ulcers or after. She stated after. At 3:25 p.m., the DON was asked to review the pressure ulcer risk assessments for 09/09/16 and 11/22/16. The DON was asked if it was possible for the resident to become a lower risk for developing pressure ulcers after he had a decline in condition and had actually developed a pressure ulcer. She stated the score of 13 obtained on 11/22/16, was incorrect. She stated he was a higher risk after his decline. She was asked if the resident's pressure ulcer risk should have been reassessed after the pressure ulcer was discovered on his right hip. She stated he should have been reassessed. . The DON was asked if weekly descriptions and staging of the pressure ulcers had been documented, as indicated in the care plan. She stated it should be in the nurses' notes or weekly skin assessments. No documentation was provided prior to the exit from the facility. 2. Resident #51 was admitted to the facility with a [DIAGNOSES REDACTED]. A hospital history and physical (H & P), dated 08/24/16, documented, .He has chronic wounds to his foot and buttocks, which are being managed locally by the local wound care . An admission nursing assessment, dated 09/01/16, documented the resident had a stage one to the right buttock, a stage two to the left buttock, and a venous stasis ulcer to the left shin. A Braden scale, dated 09/01/16, documented the resident was not at risk for pressure ulcers with a score of 21. The following scores placed the resident at risk: nine or less - severe, 10-12 high, 13-14 moderate, and 15-18 mild. Over 18 was no risk. The admission physician orders, dated 09/01/16, documented, [MEDICATION NAME] oint (ointment) 1 app (application) topical bid (twice a day) apply to buttock bid until rash resolves .dry skin. A nurse's note, dated 09/01/16 at 2:20 p.m., documented, [AGE] year old male admitted .for services .Dressings on bilateral buttocks & (and) (L) (left) shin . A Skilled Daily Nurse's Note, dated 09/01/16, documented the resident had pressure ulcers and received wound care and/or dressings. The initial plan of care, dated 09/01/16, did not document the resident had a pressure ulcer. Under skin integrity on the plan of care it documented there were no wound care orders. The Daily Skilled Nurse's Note, dated 09/02/16 through 09/18/16, contained no documentation the resident had any pressure ulcers. The only documented skin problems were other open [MEDICAL CONDITION], and other open [MEDICAL CONDITION] on the foot. One note documented the resident had open [MEDICAL CONDITION] on the right shin. The Patient History and Physical, dated 09/02/16, documented, .source patient, staff, records (all three circled) .past medical history .[MEDICAL CONDITIONS], stasis ulcer .wound inf (infection) L/E (lower extremity) .exam .skin see wound sheet (circled) . The initial nutrition note, dated 09/02/16, did not document the resident had any pressure ulcers. There was no documentation on the patient history and physical to indicate the resident had a pressure ulcer. The form was signed by the nurse practitioner. There were no documented assessments of the pressure ulcers to indicate the condition of the wounds. A care plan, dated 09/06/16, documented, Problem (Resident) is @ (at) risk for altered skin integrity r/t (related to) incontinence and impaired physical mobility. Goal will have clean, dry and intact skin, without breakdown through the next 90 days. Interventions .weekly skin audit .encourage PO intake within dietary limits .medications, lab, x-ray and treatments as ordered .relieve pressure @ least q 2 Hrs .assist to toilet @ least q 2 hrs and prn .CNA's to report any redness or s/sx of breakdown immediately to charge nurse .[MEDICATION NAME] apply to buttocks BID until healed .shin and foot wound care apply triple antibiotic oint (ointment), [MEDICATION NAME], Kerlix, wrap with coban if needed, until healed . A Patient Progress Note, dated 09/09/16 and 09/16/16, did not document the resident had any pressure ulcers. The 09/16/16, progress note documented to refer to the wound sheet. There were no wound sheets for the resident. A History and Physical, dated 09/13/16, documented, .Skin: has resolving [MEDICAL CONDITION] on the R (right) foot, on antibiotics for this . There was no documentation in the history and physical of a pressure ulcer. An admission Minimum Data Set (MDS) assessment, dated 09/14/16, documented the resident was at risk for pressure ulcers, had one stage one and one stage two unhealed pressure ulcers with [MEDICATION NAME] tissue. The assessment further documented the stage two pressure ulcer was present on a prior assessment and there were other ulcers, wounds or skin problems. The September 2016, monthly summary, dated 09/15/16, documented the resident had no pressure ulcers. A Patient Transfer Form, dated 09/18/16, documented the resident had been transferred to the hospital. There was no documentation on the transfer form to indicate the resident had any pressure ulcers. There was no documentation in the clinical record the facility had assessed the resident's skin condition prior to him being transferred to the hospital. A Resident-Data Collection form, dated 09/23/16, the day the resident was readmitted from the hospital, documented the resident had the following pressure ulcers: stage one to the right buttocks, and a stage two to the coccyx. A nurse's note, dated 09/23/16 at 8:10 p.m., documented, .stage I to (R) (right) buttock, Stage II to (L) (left) buttocks . A care plan, dated 09/24/16, documented: Problem (Resident) has been admitted to (Named) hospice for terminal care r/t end stage [MEDICAL CONDITIONS]. Goal (Resident) will be comfortable and pain free within one hour of intervention. The treatment administration record (TAR) upon readmission to the facility on [DATE], documented the following treatments: [MEDICATION NAME] ointment 1 app topically bid to buttocks until rash healed. The treatment was first applied on 09/02/16 at 10:00 a.m., during the resident's previous admission. Wound care (R) shin & foot TABO (triple antibiotic ointment), [MEDICATION NAME] & tape. The wound care was first provided on 09/10/16, during the resident's admission. The treatment record for September 2016, documented the following treatments: [MEDICATION NAME] ointment 1 app topically bid to buttocks until rash healed. The treatment was first applied on 09/02/16 at 10:00 a.m. Wound care (R) (right) shin & foot TABO (triple antibiotic ointment), [MEDICATION NAME] & tape. The wound care was first provided on 09/10/16. There were no documented treatments for the stage I and the two pressure ulcers the resident had. The admission physician orders, dated 09/23/16, the date the resident was readmitted from the hospital, documented, [MEDICATION NAME] top (topical)ointment 1 app topical bid apply to buttocks until rash resolves A resident discharge summary, dated 09/26/16, did not document the resident had any pressure ulcers. An interview was conducted on 01/17/17 at 9:38 a.m., with the director of nursing (DON), present during the interview was the administrator. The DON was asked how many pressure ulcers the resident had on admission to the facility on [DATE]. She stated he had been admitted to the facility with a stage one to the right buttock, a stage two to the left buttock, and a stasis ulcer to the right lower shin. She was asked what treatment had been ordered for the pressure ulcers. She stated, [MEDICATION NAME] until the rash is healed. She then pointed the order out on the facility admission orders [REDACTED] She was asked where the order was obtained from. She pulled out the discharge orders from the hospital and said it was carried forward from the hospital. The administrator then stated they never get a doctor's order for [MEDICATION NAME] because it was used for preventative measures to prevent residents from getting skin breakdown. The DON was asked if the resident had any pressure ulcers, on 09/23/16, when he was readmitted from the hospital. She stated the resident had a stage one to the buttocks and a stage two to the coccyx area. She was asked if the facility had assessed the resident's pressure ulcers on admission or any time after admission. She looked through the chart then stated, There were no measurements or further information on the wounds. She was asked if the assessments would be documented anywhere else. She stated the facility completed weekly skin sheets, but this resident had no skin sheets or any further assessments. She was asked if the pressure ulcers were properly assessed according to facility protocol. She stated, I don't have an answer to that. She was asked what the doctor had said about the pressure ulcers. She looked through the clinical record and said he only addressed the stasis ulcer. She was asked if the facility had notified the doctor of the presence of a stage one and two pressure ulcers on the buttocks. She stated she had called the doctor and reviewed the startup orders, but never let him know about the pressure ulcers. She was asked if the facility had notified the physician of the pressure ulcers when he was readmitted from the hospital on [DATE]. She stated, I don't know, I was not here when he came back from the hospital. She then looked through the clinical record and stated she did not see any documentation the physician had been notified on 09/23/16. She was asked if the care plan was developed for the pressure ulcers. She stated, Yes, under skin integrity. She was asked if the care plan addressed the presence of the pressure ulcers. She stated it's not differentiating between the two. She then stated the orders had been followed, but the care plan did not fully address the pressure ulcers. An interview was conducted on 01/17/17 at 1:45 p.m., with registered nurse (RN) #1, the nurse who did the admission assessment for the resident on 09/01/16. She was asked to describe the condition of the resident's skin on admission. She stated the resident had pressure ulcers on the buttocks and one was open. She was asked if she completed a full assessment of the pressure ulcers. She stated, No. I did not assess the areas any further. She was asked if she notified the physician of the stage one and stage two pressure ulcers. She stated, I did not call the doctor. She was asked what treatment had been ordered for the resident. She stated the facility used [MEDICATION NAME] and it seemed to work on the pressure ulcers. Z

Based on observation, record review, and interview, it was determined the facility failed to provide as needed (PRN) pain medication prior to the provision of pressure ulcer treatments for one (#57) of 18 sampled residents who had physician orders [REDACTED]. This resulted in an actual harm for resident #57. The facility identified 44 residents in the facility who had physician orders [REDACTED]. Findings: Resident #57 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Start up physician's orders [REDACTED]. [MEDICATION NAME] 5/325 mg (milligram) - give one tab (tablet) by mouth every 6 hours NTE (not to exceed) 4 gm (grams)/24 hours dx (diagnosis): chronic pain . [MEDICATION NAME] 5/325/mg - give one tab by mouth every 4 hours as needed for pain . A Resident - Data Collection form, dated 12/30/16, documented the resident denied pain on admission and he had 2 stage II pressure ulcers to his left foot and 2 blisters to his right foot. A nurse's note dated 12/30/16 at 6:30 p.m., documented, .Resident denied pain upon admission but showed s/s (signs/symptoms) of pain during dressing change to BLLE'S (bilateral lower leg extremities). PRN [MEDICATION NAME] 5/325 mg Q 4 hrs for pain available . The medication administration records (MARS) dated 12/30/16, did not document an order for [REDACTED]. There was no [MEDICATION NAME] pain medication available for use nor was any pain medication given when the resident exhibited pain during the dressing change. A Pain Evaluation completed by registered nurse (RN) #1, on 01/01/17, documented the resident had a [DIAGNOSES REDACTED]. The evaluation documented the resident was asked if he had pain in the last 5 days and he responded, Yes. The resident described the pain as throbbing/shooting. He further stated the pain was worse at night. The evaluation documented the resident had a cognitive deficit and the pain type was documented as being external/chronic. The nurse who performed the evaluation, asked the resident to rate the intensity of his pain. Using the Wong-Baker rating scale using different faces, the resident indicated his pain was between a 6 (hurts even more) and an 8 (hurts whole lot). The evaluation further documented the resident's pain improved 1 hour after medication was administered, but would begin hurting again 3 hours after the pain medication was administered. The evaluation documented the resident had negative vocalizations of cursing, facial grimacing/distorted face, frowning/scowling, and his pain was relieved by medication. A nurse's note dated, 01/01/17 at 11:00 a.m., documented, .Wound care done per orders. Yelled out @ (at) times. Cussed towards staff . The clinical record contained no documentation the resident was administered pain medication prior to the wound treatments and after the resident exhibited symptoms of pain. A nurse's note dated 01/03/17 at 2:00 p.m., documented, .wound care performed to bil (bilateral) feet, Gent./Santyl ([MEDICATION NAME]/Santyl) 1:1 (equal parts) to necrotic areas, covered c/ (with) gauze, secured c/ tape, L (left) heel all non necrotic wounds TAO (triple antibiotic ointment), [MEDICATION NAME], secured c/ tape, all wounds cleansed c/ ns (normal saline) + pat dried. Very verbal, cursing c/ any stimulation . The clinical record contained no documentation the resident was administered pain medication prior to the wound treatments and after the resident exhibited symptoms of pain. The resident's care plan, dated 01/08/16, documented, Problem (Resident) is at risk for altered skin integrity. Goal (Resident) will have clean, dry and intact skin, without breakdown or injury through next 90 days. Interventions 1. Weekly skin audit on Monday 3-11 Shift .4. Gent./Santyl 1:1 to wounds (unstageable) to (L) (left) bilateral heels, and Right plantar foot, cleanse with NS (normal saline), pat dry, apply Gent./santyl, cover with dry gauze, secure with tape, change daily 1/9/2017 Update 5. D/C (discontinue) previous wound care to Right foot, begin Gent./Santyl 1:1 to Right ankle and right outer foot, Cleanse with NS, pat dry, apply gent/santyl, cover with damp NS gauze, dry gauze, secure with tape daily. Problem (Resident) has a DX (diagnosis) of Chronic Pain D/T (due to) [MEDICAL CONDITION]. Goal (Resident) will have minimal pain with minimal pain medication through the next 90-day review period. Interventions 1. Give medications .treatments .as ordered. 2. Monitor for S/S (signs/symptoms) pain, assess for possible cause and intervene accordingly .4. Monitor for relief of pain and document on back of MAR within one hour of administering pain medications. 5. [MEDICATION NAME] 5/325Mg PO (by mouth) Q (every) 4 Hrs. (hours) PRN Do not exceed 4 G in 24 Hours DX: Chronic Pain. 6. [MEDICATION NAME] 5/325Mg Give 1 Tab PO Q 6 Hrs. Do not exceed 4 G in 24 Hours. 7. Tylenol Extra Strength 500Mg Give 1 Tab PO Q 12 Hrs. PRN DX. Pain. 1/11/17 Update 1) [MEDICATION NAME] 5/325mg 1 PO @ (at) 1200 (noon) + (and) 1800 (6:00 p.m.) A nurse's note, dated 01/08/17 at 2:00 p.m., documented, Refused Tx/dsg (treatment/dressing) change to wounds. leave me alone . The clinical record contained no documentation the resident was administered pain medication prior to the wound treatments. A nurse's note, dated 01/11/17, (no time), documented, Prior to wound care asked res. (resident) if he was in pain. no I don't speaks very slow, while doing wound care, res. was yelling & cussing, I stopped wound care & asked again if he was in pain no proceeded c/ wound care. believe res. is ticklish on his feet. only seems to yell as tape is being removed . The clinical record contained no documentation the resident was administered pain medication prior to the wound treatments and after the resident exhibited symptoms of pain. An admission Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive deficits, had moderate hearing deficits and wore no hearing aides, had symptoms of [MEDICAL CONDITION] of inattention and disorganized thinking which fluctuated, was physically and verbally abusive 1-3 days out of 7 days and rejected care 1-3 days out of 7 days. The assessment documented the resident was at risk for pressure ulcers, had two unstageable and two stage II pressure ulcers on admission, and had experienced no pain in the past 5 days. A nurse's note dated 01/15/17 at 9:00 p.m., documented, .yelling when there is pain to lower extremities . A nurse's note dated 01/16/17 at (time illegible), documented, Some yelling, cursing during transfer r/t pain in lower ext's (extremities) . A nurse's note dated 01/17/17 at 3:00 p.m., documented, .Will on occasion refuse wound care, res will kick & hit when attempting to provide wound care, also uses profanity . On 01/19/17 at 3:55 p.m., licensed practical nurse (LPN) #2 was shown the resident's admission MAR and was asked if there was any orders for routine and/or PRN [MEDICATION NAME] 5/325 mg. After reviewing the MAR, she stated she didn't see an order for [REDACTED]. She stated the [MEDICATION NAME] pain medication could not be administered if it was not on the MAR. LPN #2 was shown a nurse's note dated 01/03/17 at 2:00 p.m., which she had documented. The note documented the resident began cursing and yelling when his pressure ulcer treatment was being provided. The LPN was asked if the resident had been provided his PRN pain medication prior to starting the treatments. She stated she did ask the resident if he needed pain medication and he responded, No. She was asked where this would be documented. She stated she didn't document what he said, so she couldn't prove she asked him if he needed pain medication. On 01/19/17 at 4:10 p.m., an interview was conducted with LPN #3. She was asked if resident #57 was administered PRN pain medication when he exhibited signs and symptoms of pain during the pressure ulcer treatment she provided on 12/30/16, when he was admitted to the facility. She stated if you were waiting for the medication to come from the pharmacy,or if the physician did not provide a hard script, then the medication would not be available to give to the resident. She was shown the admission nurse's note which documented the medication was available. She was asked what that statement would indicate to her regarding the pain medication. She stated she would think it meant the medication was in the facility. She was shown the resident's MAR dated 12/30/16, and asked if the routine and PRN pain medication orders should have been transcribed onto the MAR. She stated, Yes. On 01/19/17 at 4:15 p.m., the assistant director of nursing was shown the MAR dated 12/30/16, when the resident was admitted to the facility. She was asked if she knew who completed the MARS. After looking at the signature, she stated it was LPN #1. She was asked if she saw an order for [REDACTED]. She stated, No. She was asked what it meant when documented, Med available. She stated that would mean the medication was in the facility. She was asked what should be done if a resident exhibited signs/symptoms of pain during a wound treatment. She stated the wound treatment should be stopped and pain medication administered, if there was an order for [REDACTED]. On 01/19/17 at 4:55 p.m., an interview was conducted with the resident. He was asked if it hurt when the nurses did the dressing changes on his feet. He stated, Well, sometimes. He was asked if he was given pain medication before the dressing changes on his feet were started. He stated, Well, sometimes they do. He was asked if he would like to be given pain medication before the dressing changes on his feet were started. He stated, I sure would. On 01/20/17 at 9:00 a.m., an observation of the resident's pressure ulcer treatment was observed being provided by LPN #1. The LPN was asked if a resident was unable to verbalize or comprehend pain, what signs/symptoms would she look for that might indicate the resident was experiencing pain. She stated, Facial grimacing, guarding, yelling. The resident was observed to have a small open area to the right ankle and another area to the right outer foot. Both areas were slightly smaller than dime sized, were reddened around the circumference of the open area, and contained yellow slough inside the opening. The left, underside of the heel, was approximately 5 by 3.5 centimeters, with black eschar inside. The medial aspect of the left metatarsal, had a dime sized area with yellow slough inside the opening. The LPN asked the resident if he was in any pain. He stated, No. She stated the resident had been medicated with [MEDICATION NAME] 5/325 mg. at 8:30 a.m. At 9:25 a.m., while the LPN was cleansing the pressure ulcers, the resident began yelling loudly, cursing at the nurse and certified nurse aide, while yanking his legs back toward his body. The resident's face was reddened. She asked the resident if it hurt. The resident stated, Hell yes it hurts all the time. The resident was observed slapping and hitting at the nurse and certified nurse aide. The nurse was unable to apply the treatment or dressings due to the resident's increased pain. At 11:10 a.m., the nurse reported she had called the physician and he gave an order for [REDACTED]. She was asked why the physician ordered the [MEDICATION NAME]. She stated it was because of the resident's combativeness, kicking, and hitting. She was asked if she thought those behaviors might be indicative of the resident experiencing pain. She stated it was hard to tell with the resident because he was easily agitated. She was asked to describe times the resident became agitated. She stated, Like if you try to put his bib on in the dining room, he gets agitated. She was asked if the resident tried to kick staff when they were trying to put his clothing protector on. She stated, No. She was asked if she asked the physician about a stronger pain medication. She stated, No. She further stated she wanted to see how the extra dose of the PRN [MEDICATION NAME] worked before a stronger pain medication was requested. On 01/20/17 at 10:15 a.m., an interview was conducted with registered nurse (RN) #1. She was asked if she completed the pain evaluation for the resident when he was admitted to the facility. She stated she did complete the evaluation. She was asked what the evaluation indicated regarding pain for the resident. She stated the resident had [DIAGNOSES REDACTED]. She stated she could tell right away he had pain when his feet were touched. She was asked if this happened all the time. She stated, Yes, every time his feet are touched. She was asked if his pain medications were affective. She stated she wasn't sure how he responded to his pain medication, because she didn't take care of him or do his treatments. She stated another nurse took care of the hall the resident was on, but she sometimes would assist the other nurse when she did the resident's wound treatments. She stated the resident always yelled when she assisted the nurse and she could hear the resident yelling at other times when the nurse would be doing the wound treatments. The RN was asked when she worked at the facility. She stated she usually only worked as the weekend RN. A nurse's note dated 01/20/17 at 10:30 a.m., documented, attempted wound care to res bilat LE (lower extremities), res became combative, cursing @ staff, res denied pain multiple times when questioned by this nurse and CNA, res then confirmed pain to L heel, tx. (treatment) stopped at that time . On 01/20/17 at 11:20 a.m., an interview was conducted with the director of nursing (DON). She was asked if she was aware of the resident experiencing pain during the attempted provision of pressure ulcer treatments. She stated she heard him yelling and saying No he didn't hurt when the nurse asked him if he was in pain. She was asked who did wound treatments. She stated, all the nurses do wound treatments. She was asked what type of things the nurses were to report to her when doing wound treatments. She stated they were to report any changes in the wounds, declines, and/or whether they were having difficulty providing wound care for a resident. She was asked if any of the nurses had reported to her about having a difficult time providing the wound treatments for resident #57. She stated, No. She stated she could hear the resident all over the building yelling and cursing when wound treatments were being completed. She was asked if she did an in depth investigation to determine what was causing the resident's pain, particular times when the resident experienced pain, and/or what was happening at the time of the resident's indicators of pain. She stated an investigation was not completed to determine the cause of the resident's pain. She was asked if an investigation should have been conducted to determine the cause of the resident's pain. She stated, Yes. She stated she didn't know what the resident was yelling about because he yells/cusses frequently about other things.