Every finding on record at Leisure Village Health Care Center

Based on observation, record review, and interview, the facility failed to maintain an indoor temperature of less than 81 degrees Fahrenheit for 1 (South hall) of 3 sampled halls reviewed for environment.The regional nurse manager identified 33 residents resided on South hall.Findings:On 07/30/26 at 3:00 p.m., the temperature on South hall in front of room [ROOM NUMBER] was observed to be 81.5 degrees F.On 07/30/26 at 3:05 p.m., the temperature inside of room [ROOM NUMBER] measured at ground level was observed to be 82.5 degrees F.On 07/31/26 at 2:35 p.m., the temperature in the south hallway outside of room [ROOM NUMBER] measured at ground level was observed to be 81.6 degrees F.On 07/31/26 at 2:40 p.m., the temperature measured at ground level in room [ROOM NUMBER] was observed to be 83.1 degrees F.On 07/31/26 at 2:45 p.m., the temperature measured at ground level in room [ROOM NUMBER] was observed to be 84.5 degrees F.On 07/31/26 at 3:45 p.m., the temperature measured at ground level in room [ROOM NUMBER] was observed to be 82.5 degrees F.On 07/31/26 at 3:47 p.m., the temperature measures at ground level in room [ROOM NUMBER] was observed to be 83.4 degrees F.A policy titled Resident Room Temperatures, approved 03/11/22, read in part, The facility will maintain resident rooms and resident occupied areas at a safe and comfortable temperatures. Target room temperature is 71 F to 75 F whenever practical. Temperatures should not routinely fall below 71 F or exceed 81 F except for resident preference, clinical need, or temporary equipment failure.On 07/30/26 at 2:40 p.m., Housekeeper #2 stated it had been uncomfortably warm on South hall for a couple of weeks. They stated fans and portable air conditioners had been brought in, but it was still warm.On 07/30/26 at 3:00 p.m., certified medication aide #2 stated it had been very hot on south hall for the last two or three weeks. They stated they had encouraged the residents to drink fluids and use fans.On 07/30/26 at 3:05 p.m., Resident #7 stated that when they woke up they were soaked in sweat. They stated the facility gave them a fan, but it had not worked.On 07/31/26 at 2:45 p.m., Resident #8 stated it was uncomfortably warm in their room. They stated the facility had passed ice and water frequently.On 07/31/26 at 3:30 p.m., the administrator stated they had issues with the breakers for the fans and the portable air conditioners. They stated those issues were resolved on 07/30/26.

Based on record review and interview, the facility failed to contact the physician regarding a request for medication for 1 (#4) of 4 sampled residents reviewed for medications.The regional nurse consultant identified 89 residents resided in the facility.Findings:A physician's order for Resident #4, dated 10/27/25, showed Resident #4 was to receive sulfasalazine (a medication for RA) 1000 milligrams by mouth, twice a day for 90 days. The order showed the end date for the medication was 11/06/25.A care conference note for Resident #4, dated 06/10/26, showed family member #1 attended a care plan meeting with facility staff and voiced concerns the resident was no longer receiving sulfasalazine for RA.A quarterly assessment for Resident #4, dated 06/17/26, showed the resident had a brief interview for mental status score of 4, which indicated severe cognitive impairment. The assessment showed Resident #4 had diagnoses which included RA and dementia.An email, dated 06/22/26, showed family member #1 contacted the SSD regarding the RA medication.An email, dated 07/12/26, showed family member #1 contacted the SSD regarding the RA medication.An email, dated 07/21/26, showed family member #1 contacted the SSD regarding the RA medication.On 07/31/26 at 2:15 p.m., the SSD stated the nurse in the care conference should have addressed the medication issue after the meeting. They stated they received multiple emails from family member #1 and forwarded them to nursing. They stated the nurse in the care conference and the nurse they were sending the emails too no longer worked at the facility.On 08/03/26 at 1:10 p.m., the director of nursing stated they had tried to contact Resident #4's rheumatologist on 07/24/26 but the office had already closed. They stated they forgot to follow up on it until 07/31/26 when they called the facility medical director and got an order for the sulfasalazine. They stated the concerns related to the RA medication were not handled in a timely manner.

Based on observation, interview, facility document and policy review, and U.S. [United States] Food and Drug Administration 2022 Food Code, guidelines, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, daily log documentation was lacking for the dish machine sanitation test strip levels and rinse temperature levels. Additionally, dietary staff did not perform hand hygiene during meal service. Additionally, food was not labeled and dated appropriately in facility refrigerators.These deficiencies had the potential to affect all residents in the facility.Findings included: 1. A facility policy titled, Warewashing, reviewed 08/25/2025, revealed, Nutritional services employees shall ensure food is prepared and served in clean food-safe supplies and maintain compliance with Federal, State, and Local regulations governing food safety. The policy also indicated, Procedure: 1. All tableware, utensils, preparation, and service supplies shall be washed and sanitized in the pot sink and/or through use of a commercially approved dish machine. 2. The dish machine, if low temp [temperature], shall use a detergent, a rinse drying agent, and a sanitizer. If the dish machine is a high temperature machine, a detergent and a rinse drying agent shall be used. The sanitizing temperature for a low temperature machine shall be above 120 degrees or at an appropriate temperature to activate the sanitizer per manufacturer's instructions. The policy continued, 4. Test strips shall be available for the pot sink and low temp [temperature] dish machine sanitizer. Results shall be checked and recorded daily. An undated document titled, [Name of Dish Machine] Operations Guide, revealed, Verify Sanitizer levels regularly. Use test strip to ensure sanitizer level is at least 50 ppm [parts per million] and no more than 200 ppm. A document titled, Low Temperature Dish Machine Log, for the month of May 2026, revealed no documented wash or rinse temperatures for breakfast, lunch, or dinner on 05/30/2026 and 05/31/2026. The column for the recording of the sanitizer had a heading that indicated, Sanitizer 50-100 ppm. The column revealed no recorded sanitizer levels for the entire month of May 2026. The facility's Low Temperature Dish Machine Log, for the month of June 2026, revealed the column for the recording of the sanitizer had a heading that indicated, Sanitizer 50-100 ppm. The column revealed no recorded sanitizer levels for the dates 06/01/2026 through the morning of 06/10/2026. During a tour of the kitchen on 06/08/2026 at 9:56 AM, Dietary Aide (DA) #22 stated they had a high temperature machine, and the temperature should be 180 degrees Fahrenheit (F) and then 120 degrees F for the rinse, and the test strips used for the machine should be at 200 PPMs. During an interview on 06/08/2026 at 10:00 AM, the Dietary Supervisor (DS) stated they had a low temperature machine and the washing temperature should be 180 degrees F. During an interview on 06/10/2026 at 8:50 AM, DA #20 reviewed the June 2026 Low Temperature Dish Machine Log and confirmed he documented the temperatures that morning but did not test the sanitizer. During an interview on 06/10/2026 at 9:00 AM, the DS reviewed the June 2026 Low Temperature Dishwashing Log and confirmed the sanitizer PPMs were not recorded. During a concurrent observation and interview on 06/10/2026 at 9:12 AM, the DS went to do a test strip for the dishwashing machine, and DA #22 stated they did not have the strips since Monday (06/08/2026). During an interview on 06/11/2026 at 2:39 PM, the Registered Dietician (RD) stated the dishwashing machine in the kitchen was a low temperature machine and utilized a sanitizer. The RD stated the dietary staff should have been doing the strips to test the sanitizer levels. The RD stated she audited the May Low Temperature Dish Machine Log on 05/18/2026, and she noted the dishwashing temperatures and sanitizer levels were missing for four days on the log. During an interview on 06/12/2026 at 10:05 AM, the Director of Nursing (DON) stated he expected staff to follow the regulations and at a minimum to determine what was needed related to the dishwasher maintenance. The DON stated they needed another system in place for doing audits and checking in with the DS. During an interview on 06/12/2026 at 10:59 AM, the Administrator (ADM) stated he expected dietary staff to follow the recommendations of the RD, who was the person in charge of training them. The ADM stated he expected dietary staff to follow their established processes. 2. A facility policy titled, Hand Hygiene, reviewed 04/28/2022, revealed, The Facility will provide guidelines to Employees on proper handwashing and Hand Hygiene techniques that will aid in the prevention of the transmission of Infections. An observation of the kitchen on 06/09/2026 at 12:03 PM revealed [NAME] #28 touched her face during the lunch meal tray line when placing plate covers on the plated food for residents, she did not perform hand hygiene, and she continued to assist with placing items on the residents' trays. A concurrent observation revealed Dietary Aide (DA) #20 touched his glasses, sorted diet tickets, and delivered food and beverages to residents without performing hand hygiene. An observation on 06/09/2026 at 12:05 PM revealed [NAME] #28 touched her hair, she did not perform hand hygiene, and she continued to put plates of food into carts. An observation of the kitchen on 06/10/2026 at 8:41 AM, revealed [NAME] #28 touched a tray of dirty dishes, then touched clean plates on the tray line, and then cooked eggs on the stove. The observation revealed [NAME] #28 did not perform hand hygiene during these tasks. During an interview on 06/10/2026 at 8:50 AM, DA #20 stated staff were to perform hand hygiene anytime they touched a dirty plate or anything that could result in cross contamination. DA #20 stated staff were to wash their hands before meal service and if they touched their hair, face, or clothes. During an interview on 06/10/2026 at 8:55 AM, [NAME] #28 stated they were to wash their hands prior to meal service and if they touched their hair. [NAME] #28 stated staff were to use the sanitizer every time they walked into the kitchen. During an interview on 06/10/2026 at 3:05 PM, [NAME] #27 stated hand hygiene should be performed when a staff member came back into the kitchen, and she stated staff had to sanitize when they entered the kitchen. [NAME] #27 stated staff had to wash their hands after they touched dirty dishes before they touched food. During an interview on 06/11/2026 at 2:39 PM, the Registered Dietician (RD) stated hand hygiene should be performed anytime staff went from dirty dishes to a clean area or preparation area and when staff touched their face or glasses. During an interview on 06/12/2026 at 10:59 AM, the Administrator (ADM) stated he expected dietary staff to follow the recommendations of the RD, who was the person in charge of training them. The ADM stated he expected dietary staff to follow their established processes. 3. A facility policy titled, Refrigeration, revised 08/21/2024, indicated, Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety. The policy continued, Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labelled and dated with an expiration date of no more than three (3) days unless otherwise indicated by the manufacturer. If food is not deemed potentially hazardous (PHF) then should be discarded after 7 days unless otherwise indicated by USDA [United States Department of Agriculture] recommended Food Storage Guideline. The policy continued, Dating of leftovers shall be as follows: Potentially hazardous foods (PHF) such as cooked eggs, fish and mayonnaise-based products and mixed dishes with multiple ingredients shall be used the same day of preparation then discarded. Other potentially hazardous leftovers shall be labelled with an expiration date of three (3) days. The U.S. [United States] Food and Drug Administration 2022 Food Code, dated 2022, in section 3-501 Temperature and Time Control revealed, Ready-to-Eat, Time/Temperature Control for Safety Food prepared and held in a Food Establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 [degrees] C [Celsius] (41 [degrees] F [Fahrenheit]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The Food Code continued, Refrigerated, Ready-to-Eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations. A. An observation during a tour of the kitchen on 06/08/2026 at 9:50 AM with the Dietary Supervisor (DS) revealed leftover food in the refrigerator including: - a container of chicken noodle soup about one eighth full, with a plastic wrap covering, dated 06/05/2026;- a full container of ketchup with a plastic wrap covering it, dated 06/11/2026; and- a full container of chocolate pudding with a plastic wrap covering it, dated 06/07/2026. The DS stated food items were to be discarded three days from the open date. The DS stated the chicken noodle soup should be labeled open date, which was 06/05/2026, and that day, 06/08/2026, was the last day for it to be in the refrigerator, and she was throwing it out. The DS stated the ketchup should have had the open date on it. The DS stated the ketchup had the use by/expiration date of 06/11/2026 on it. The DS stated the chocolate pudding had the open date of 06/07/2026 and not the use by date on the plastic wrap. During an observation and interview on 06/10/2026 at 8:50 AM, Dietary Aide (DA) #20 confirmed the leftover tomato soup in the refrigerator had one date, 06/09/2026, written on the plastic wrapping. DA #20 stated that was the date the tomato soup was put in the refrigerator, and the soup should be used within three days. DA #20 confirmed a container of chocolate pudding had one date, 06/07/2026, written on the plastic wrapping. DA #20 stated that was the date the chocolate was put in the refrigerator, and it should have been used by that day, 06/10/2026. DA #20 confirmed a container of ketchup had one date, 06/11/2026, written on the plastic wrapping and stated he did not know why it was dated that way. DA #20 stated, That is not what we do. During a concurrent observation and interview on 06/10/2026 at 2:57 PM, [NAME] #27 stated that when leftover food was placed in the refrigerator it should be labeled and dated with that day's date and the use by date. [NAME] #27 stated that for 06/10/2026, food should be labeled with 06/10/2026 and a use by date of 06/13/2026. [NAME] #27 stated the leftover tomato soup in the refrigerator was dated 06/09/2026 which indicated the date the soup was put in the refrigerator, and it should be used in three days. [NAME] #27 stated the container of grapes was dated 06/09/2026 which indicated the date the grapes were put in the refrigerator, and the grapes should be used in three days. [NAME] #27 stated the container of chocolate pudding was dated 06/07/2026 which indicated the date the chocolate pudding was put in the refrigerator, and it should be used in three days. [NAME] #27 stated the container of ketchup dated 06/11/2026 had the wrong date as the open date, as it was not 06/11/2026 yet. During an interview on 06/11/2026 at 2:39 PM, the Registered Dietician (RD) stated she audited the labeling and dating of food in the kitchen refrigerator and had no notes related to foods not being labeled and dated. The RD stated food should be labeled with an open date and not a use by date, because that date was different for different products. The RD stated that most food should be discarded within three days.B. A concurrent observation and interview was conducted with Licensed Practical Nurse (LPN) #6 of the north hall refrigerator on 06/10/2026 at 4:03 PM. The observation revealed the following opened items were in the refrigerator and were not labeled with an expiration date: an uncovered foam cup that contained brown sugar, a clear bag that contained of chunks of watermelon, and one wrapped pickle spear. LPN #6 stated that the food items should be dated. A concurrent observation and interview was conducted with LPN #9 of the refrigerator located at the main nurses' station on 06/11/2026 at 4:17 PM. The observation revealed a black coffee cup with a lid that was not labeled with an expiration date. The observation also revealed a bottle of sugar free ranch dressing with a best use-by date of 05/22/2026. LPN #9 stated she was not sure who was responsible for the food items in the refrigerator. During a follow-up interview on 06/11/2026 at 4:24 PM, LPN #19 stated that kitchen staff were in charge of the refrigerator at the main nurses' station. During an interview on 06/12/2026 at 10:05 AM, the Director of Nursing (DON) stated that he expected the facility staff to follow regulations. During an interview on 06/12/2026 at 10:59 AM, the Administrator stated he expected dietary staff to follow their established processes.

Based on facility policy review, record review, interview, a review of a Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety and Health (NIOSH) publication, observation, and a review of a glucometer's manufacturer instructions, the facility failed to develop/implement a comprehensive infection control program when they failed to do the following:- Complete annual fit testing for N95 respirators for staff, which had the potential to affect all residents in the building.- Properly utilize a barrier when placing a glucometer and insulin pens on surfaces, ensure staff wore gloves when handling a used glucometer, and failed to properly disinfect a glucometer, which affected 2 (Resident #66 and Resident #83) of 8 residents reviewed for the medication administration task.- Ensure staff did not touch medications with their bare hands during medication administration, which affected 1(Residents #9) of 8 residents reviewed for the medication administration task.Findings included: 1. During an interview on 06/12/2026 at 11:26 AM, Regional Nurse Consultant (RNC) #3 stated that the facility did not have a fit testing policy; the facility followed the guidelines set by the CDC. An undated publication by the CDC and the NIOSH titled, Filtering Out Confusion: Frequently Asked Questions about Respiratory Protection, included How Often Must Fit Testing Be Conducted?, which revealed, In addition to fit testing upon initially selecting a model of respirator, OSHA [Occupational Safety and Health Administration] 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.' During an interview on 06/12/2026 at 8:19 AM, Assistant Director of Nursing (ADON) #26/ Infection Preventionist (IP) stated that she started working at the facility on 04/06/202 and she was not sure what the facility's process was for fit testing for N95 respirators. She stated that she was not fit tested at the facility and had not been fit tested within the past year. During an interview on 06/12/2026 at 8:32 AM, Certified Medication Technician (CMT) #10 stated that she had been with the facility for 30 days and had not been fit tested for an N95 respirator. During an interview on 06/12/2026 at 8:38 AM, Certified Nurse Aide (CNA) #12 stated that she started with the facility two months prior. She stated that she had not been fit tested for an N95 respirator. During an interview on 06/12/2026 at 8:39 AM, CMT #13 stated that she started working at the facility a year prior, and she had not been fit tested for an N95 respirator. She stated that there had not been COVID-19 in the building during her time there. During an interview on 06/12/2026 at 8:44 AM, the Rehabilitation Director stated that he had been at the facility for a little over a month and had not been fit tested for an N95 respirator. During an interview on 06/12/2026 at 9:14 AM, RNC #3 stated that as of that moment, they were not fit testing staff for N95 respirators at the facility. RNC #3 stated that the facility had an upcoming skills fair on 06/26/2026, and he planned to implement fit testing. He stated that they did not fit test during the prior annual skills fair. He stated there had been no COVID outbreak since 2022 or 2023.2. A facility policy titled, Hand Hygiene, dated 04/28/2022 revealed, The Facility will provide guidelines to Employees on proper handwashing and Hand Hygiene techniques that will aid in the prevention of the transmission of infections. The policy revealed, Hand Hygiene should be performed following the Clinical indications, which included, Contact with blood, body fluids, or contaminated surfaces; and Before/After applying/removing Gloves/PPE [personal protective equipment]. Manufacturer instructions for the Assure Platinum Blood Glucose Monitoring System, revised 09/2024, included Cleaning and Disinfecting, which specified, Blood glucose meters be cleaned and disinfected after each use on each patient. The instructions revealed, ARKRAY recommends using these wipes to clean and disinfect the Assure Platinum meter, which included Super Sani-Cloth Germicidal Disposable Wipe. The instructions specified, Guidelines for cleaning and disinfecting the Assure Platinum meter included Always wear the appropriate protective gear, including disposable gloves. The instructions included Additional options for cleaning and disinfecting the Assure Platinum meter, which included Option 2, which specified, Clean the outside of the blood glucose meter with a lint-free cloth dampened with soapy water or isopropyl alcohol (70-80%); Disinfect the meter by diluting 1mL [milliliter] of household bleach (5-6% sodium hypochlorite solution) in 9mL water to achieve a 1:10 dilution; Use a lint-free cloth dampened with the solution to thoroughly wipe down the meter; and Use caution as to not allow moisture to enter the test strip port, data port or battery compartment, as it may damage the meter. An admission Record revealed the facility admitted Resident #66 on 03/10/2022. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 03/25/2026, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident had an active diagnosis of diabetes mellitus. Resident #66's Care Plan Report included a focus area initiated 04/07/2022, that indicated that the resident had type 2 diabetes mellitus. Interventions initiated 04/07/2022 directed staff to monitor the resident for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar), and to administer diabetes medication according to physician orders. Resident #66's Order Summary Report, with active orders as of 10/07/2024, contained an order, dated 10/07/2024, for insulin aspart injection solution 100 units per milliliter, with orders to inject per a sliding scale, four times a day for diabetes. During a concurrent observation of medication administration and interview on 06/09/2026 at 11:02 AM, Licensed Practical Nurse (LPN) #9 used a glucometer to check Resident #66's finger stick blood sugar (FSBS). After completion of the FSBS, LPN #9 removed her gloves, then using her bare hands, placed the glucometer under her left arm to sanitize her hands, then held the glucometer and cleaned it with an alcohol pad before she placed the glucometer in the plastic bag labeled for Resident #66. LPN #9 stated that she always used alcohol pads to clean the glucometer since each resident had their own glucometer. An admission Record revealed the facility originally admitted Resident #83 on 03/24/2021 and readmitted the resident on 05/22/2026. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A five-day MDS, with an ARD of 05/29/2026, revealed Resident #83 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident had an active diagnosis of diabetes mellitus. Resident #83's Care Plan Report included a focus area initiated 07/19/2024, that indicated the resident had a diagnosis of type 2 diabetes mellitus. Interventions initiated 05/18/2026 directed staff to administer fast-acting and long-acting insulin according to physician orders. Resident #83's Order Summary Report, with active orders as of 03/05/2026, contained an order, dated 03/05/2026, for insulin glargine injection solution 100 units per milliliter, with orders to inject 25 units one time a day for diabetes. The Order Summary Report also contained an order, dated 05/08/2026, for insulin apart solution 100 units per milliliter, with orders to inject per a sliding scale. During a concurrent observation of medication administration and interview 06/10/2026 at 7:55 AM, LPN #8 entered resident #83's room and placed insulin pens and a glucometer on a tray table without first using a barrier to set the items on. LPN #8 then used the glucometer to check Resident #83's FSBS. After completion of the FSBS and administering insulin to Resident #83, LPN #8 removed her gloves, then, using her bare hands, carried the glucometer and placed it directly on a medication cart without first placing a barrier on the cart. LPN #8 stated that she had not received education on barrier use after she used the glucometer. LPN #8 then performed hand hygiene, put on gloves, and disinfected the glucometer and the insulin pens. During an interview on 06/11/2026 at 1:37 PM, Assistant Director of Nursing (ADON) #26/Infection Preventionist (IP) stated that she expected nurses to use a barrier, perform hand hygiene, and put on gloves to clean and disinfect a glucometer. During an interview on 06/12/2026 at 11:58 AM, Director of Nursing stated that he expected nurses to perform hand hygiene, wear gloves, use a barrier on the tray table before setting the items on it to avoid cross-contamination, and disinfect the glucometer using a Super Sani wipe. 3. A facility policy titled, Medication Administration and General Guidelines, dated 01/2006, revealed, Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. The policy revealed, Checklist for completing proper steps in administration of medications included Does not handle pills with bare hands. An admission Record revealed the facility admitted Resident #9 on 10/10/2023. According to the admission Record, the resident had a medical history that included diagnoses of chronic pain and vertigo (a false sensation of motion or dizziness). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2026, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #9's Order Summary Report, with active orders as of 03/18/2026, contained an order, dated 03/18/2026, for acetaminophen 325 milligrams (mg), two tablets every four hours and as needed for fever. The Order Summary Report also contained an order, dated meclizine hydrochloride (HCl) (an antihistamine) 25 mg, one tablet three times a day for vertigo. During a concurrent observation of medication administration and interview on 06/10/2026 at 3:26 PM, Certified Medication Technician (CMT) #14, with bare hands, used her fingers to remove two acetaminophen 325 mg tablets and one meclizine 14 mg tablet from the medication bottles' lids and placed them in a medication cup and administered the medication to Resident #9. CMT #14 stated that she routinely touched the medication with her fingers. During a phone interview on 06/12/2026 at 11:01 AM, the Pharmacy Consultant stated that the staff should never touch the medication. During an interview on 06/11/2026 at 1:37 PM, Assistant Director of Nursing (ADON) #26/Infection Preventionist (IP) stated that the CMT should not touch medication with her fingers.

Based on interview, record review, and facility policy review, the facility failed to ensure that 3 (Residents #7, #14, and #44) of 5 sampled residents reviewed for immunizations were offered the Coronovirus-19 (COVID-19) vaccination.Findings included: A facility policy titled, COVID Vaccine, revised 09/04/2024, indicated, The Facility will offer the COVID Vaccine to Employees/Residents to assist in mitigating the spreads of COVID-19. The policy continued, The Facility shall maintain documentation for all Residents and Employees on COVID-19 Vaccination. 1. An admission Record revealed the facility admitted Resident #7 on 05/20/2026. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease without exacerbation, emphysema, and acute respiratory failure with hypoxia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2026, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident's COVID-19 vaccination was not up to date. Resident #7's Immunizations section in their Electric Medical Record (EMR) did not reflect that the resident was offered a COVID-19 vaccination or that the resident had refused the vaccine. The Immunizations section in the resident's EMR was blank. During an interview on 06/12/2026 at 12:57 PM, Resident #7 said they had not been offered a COVID-19 immunization at the facility, and they would not have been interested. 2. An admission Record revealed the facility admitted Resident #14 on 12/11/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic systolic congestive heart failure and chronic obstructive pulmonary disease. A quarterly MDS, with an ARD of 06/03/2026, revealed Resident #14 had a BIMS score of 14, which indicated the resident had intact cognition. The MDS indicated the resident's COVID-19 vaccination was not up to date. Resident #14's Immunizations section in their EMR did not reflect that the resident was offered a COVID-19 vaccination or that the resident had refused the vaccine. During an interview on 06/12/2026 at 1:03 PM, Resident #14 stated they could not remember if they had been offered vaccinations. They did not believe they had and would not have minded being offered. 3. An admission Record revealed the facility admitted Resident #44 on 02/15/2026. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and cerebral palsy. A quarterly MDS, with an ARD of 06/03/2026, revealed Resident #44 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated the resident's COVID-19 vaccination was not up to date. Resident #44's Immunizations section in their EMR did not reflect that the resident was offered a COVID-19 vaccination or that the resident had refused the vaccine. The Immunizations section in their EMR was blank. During an interview on 06/12/2026 at 12:16 PM, Resident #44 stated they had not been offered a COVID-19 immunization at the facility, and they would have liked to have been offered. During an interview on 06/12/2026 at 8:19 AM, the Assistant Director of Nursing (ADON) #26 /Infection Preventionist (IP) stated she started working as the infection preventionist two to three weeks prior. She said she had not reviewed the COVID-19 vaccinations. During an interview on 06/12/2026 at 9:14 AM, Regional Nurse Consultant (RNC) #3 stated that when a resident entered the facility, the Social Services Supervisor inquired if the resident wanted immunizations. Declinations were verbal and not documented, though the facility might put it in a progress note. RNC #3 said they were unable to find any documentation that indicated Residents #7, #14, and #44, had declined or received their COVID-19 vaccinations. During an interview on 06/12/2026 at 11:36 AM, the Administrator stated the facility followed the regulations regarding immunizations for residents. During an interview on 06/12/2026 at 1:05 PM, the Medical Director stated he expected the facility to offer COVID-19 vaccinations.

Based on interview, record review, facility policy review, the facility failed to notify the physician when ordered medication was not administered for 1 (Resident #41) of 2 residents reviewed for dialysis. Specifically, the facility failed to notify the physician that Resident #41's hydroxyzine (a medication used to treat anxiety) medication was scheduled to be given at a time when the resident was gone for dialysis and was not routinely administered per physician's order for approximately five months.Findings included: A facility policy titled, Medication Administration and General Guidelines, dated 01/2026, revealed, 2. Medications are administered in accordance with written orders of the attending physician. The policy also revealed, 10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the med [medication] must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise). The policy revealed, 12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. Per the policy, The physician must be notified when a dose has not been given. If an electronic medical record is being utilized than [sic] the caregiver administering the medication will enter the correct documentation that will then be electronically date/time stamped with their initials. An admission Record revealed the facility admitted Resident #41 on 09/09/2025. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease (ESRD) and dependence on renal dialysis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2026, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received antianxiety medication during the seven-day assessment look-back period. Resident #41's Care Plan Report, included a focus area initiated 02/21/2024, that indicated the resident needed hemodialysis on Tuesdays, Thursdays, and Saturdays from 6:50 AM to 10:55 AM. Interventions directed staff to give an anti-anxiety medication before dialysis (initiated 08/30/2024). Resident #41's Care Plan Report, also included a focus area initiated 07/19/2024, that indicated the resident used anti-anxiety medication due to anxiety/ESRD, with instructions to give the medication before dialysis. Interventions also directed staff to administer hydroxyzine per orders before dialysis (initiated 09/17/2025). Resident #41's Order Summary Report contained a physician's order dated 09/11/2025 for hydroxyzine 10 milligrams (mg), 1 tablet by mouth one time a day every Tuesday, Thursday, and Saturday for end stage renal disease, with instructions to give the medication before dialysis. Resident #41's January, February, March, April, May, and June 2025 Medication Administration Record [MAR] revealed that the facility scheduled hydroxyzine administration for the resident for 6:15 AM on Tuesdays, Thursdays, and Saturdays. The resident's MARs revealed the following: - January 2026 MAR revealed staff documented that hydroxyzine was not administered prior to dialysis five times during the month because the resident was out of the facility and one dose of the medication was held. - February 2026 MAR revealed staff documented that hydroxyzine was not administered on eight days because Resident #41 was out of the facility and on one day, the medication was documented as held. - March 2026 MAR revealed staff documented that hydroxyzine was not administered on seven days because Resident #41 was out of the facility and on one day the medication was documented as being held. - April 2026 MAR revealed staff documented that eight doses of hydroxyzine for Resident #41 was not administered because the resident was out of the facility. - May 2026 MAR revealed staff documented that hydroxyzine was not administered to Resident #41 on six days because the resident was out of the facility. - 06/01/2026 to 06/11/2026 MAR revealed staff documented that one dose of hydroxyzine for Resident #41 was held and two instances when staff documented that Resident #41 was out of the facility and hydroxyzine was not administered (06/06/2026 and 06/11/2026). During an interview on 06/08/2026 at 11:40 AM, Resident #41 stated that they had anxiety and stress and did not believe their medication had been given as ordered. During a follow-up interview on 06/10/2026 at 4:00 PM, Resident #41 stated that they did not think that they received any medication prior to going to dialysis because they left the facility at 4:00 AM. Resident #41 stated that they were not aware of a current physician order for hydroxyzine to be administered prior to going to dialysis. During an interview on 06/11/2026 at 10:00 AM, Resident #41 stated that they had just returned from dialysis. Per Resident #41, they did not receive any medication prior to leaving for dialysis that morning. During an interview on 06/11/2026 at 11:22 AM, Transportation Specialist (TS) #23 stated that he routinely transported residents to appointments and on that date he had transported Resident #41 to dialysis. He stated he usually picked up Resident #41 to go to dialysis at 5:20 AM, as the resident was scheduled to arrive for their dialysis appointments at 5:45 AM. During an interview on 06/11/2026 at 9:08 AM, Certified Medication Technician (CMT) #10 stated that Resident #41 was typically gone to dialysis by the time her shift started (6:00 AM). CMT #10 stated that the hydroxyzine should have been given on Tuesdays, Thursdays, and Saturdays before Resident #41 left for dialysis, which was a task for the night shift nurse. During an interview on 06/11/2026 at 11:37 AM, CMT #13 stated that she has typically worked the 6:00 AM to 2:00 PM shift and had not worked the overnight shift. She stated that she had never administered medication to Resident #41 prior to dialysis. She stated that usually Resident #41 was already gone to dialysis when she arrived at work. CMT #13 stated that typically she documented in Resident #41's MAR that the resident was out of the facility. During an interview on 06/11/2026 at 11:46 AM, Licensed Practical Nurse (LPN) #8 stated that if medication was scheduled to be given at 6:15 AM then the 6:00 AM to 2:00 PM shift staff should have administered the medication. Per LPN #8, if the physician's order was for the medication to be given before dialysis and the resident's dialysis chair time was 6:00 AM or before, staff should administer the medication prior to the resident leaving for dialysis. According to LPN #8, Resident #41's chair time was 6:00 AM, and the night shift staff was responsible for ensuring the medication was given. LPN #8 stated if there was a pattern of a resident not receiving their medications, staff should have let the nurse know so that changes could have been made to the order. She stated that she expected the resident to receive their medication before dialysis. During an interview on 06/11/2026 at 4:02 PM, LPN #16 stated that she was a charge nurse and worked the night shift. LPN #16 stated that she had not administered any morning medications to residents before they left for dialysis. She stated if there were residents who required medication prior to going to dialysis in the morning, it would have been up to her to administer the medications. LPN #16 stated that Resident #41 typically was out of the facility to dialysis by 5:30 AM. She stated that she had never administered anti-anxiety medication to Resident #41. She stated that if a physician order directed staff to give medication before dialysis, the medication should be administered when Resident #41 was awakened before the resident left for dialysis. During an interview on 06/12/2026 at 10:35 AM with Director of Nursing (DON) and Regional Nurse Consultant (RNC) #3, RNC #3 stated that documentation would be completed in the residents' electronic charts each day to make sure medication had been documented as given. The DON stated his expectation was that an adjustment should be made to ensure that medications were given as ordered. The DON stated that in general, if there was a reoccurring situation that a resident was not getting their medication, management should have been alerted so that the problem could be fixed. During an interview on 06/12/2026 at 10:16 AM, the Administrator stated that the process for administering medication was that once the physician order was put into the electronic record, the CMTs were responsible for administrating the medication. Depending on medication, the nurse may have been responsible for administering the medication. The Administrator stated that his expectation was that the residents receive their medication exactly as the doctor had ordered. He stated that if staff noticed a trend where a resident was not receiving their medication, it should have been communicated to the supervisor. During an interview on 06/12/2026 at 1:10 PM, the Medical Director stated that if there was a physician order for medication, then the resident should be getting the medication. He stated that the concern with Resident #41 not getting their medication should have been addressed and reported.

Based on interview and facility document and policy review, the facility failed to ensure nutritional nighttime snacks were provided to the residents on 1 (South Hall) of 3 facility halls.Findings included: A facility policy titled, Meals & Snacks, reviewed 09/12/2025, revealed, Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. Nutritional Services shall be responsible for all food preparation including snacks and shall deliver meals [with assigned assistance] to the residents or to the nursing units. Snacks shall be delivered to the nursing units by nutritional services personnel. Nursing shall be responsible for distributing snacks to the residents. The policy also indicated, Procedure: 3. An evening snack shall be provided by Nutritional Services and offered to the residents by Nursing. Additional snacks shall be provided between meals as ordered by the Physician, Registered Dietician, per facility's determination of resident preferences and/or per resident request. The policy also indicated, Procedure: 5. Nutritional Services shall deliver nourishment to the nursing units. Nursing shall be responsible for offering and/or distributing snacks. An untitled and undated facility document with information about meal times revealed, Hydration Station and snacks are available throughout the day. An untitled facility snack delivery log, beginning 05/18/2026 through 05/29/2026 and 06/01/2026 through 06/09/2026, revealed, Snacks are to go out every night between 6:30 PM and 7PM for nightly snacks. This includes ([nutritionally dense frozen snack] cups, health shakes, and PBJS [peanut butter and jelly sandwiches]) [Dietary Supervisor (DS)]. The facility snack delivery log revealed snacks were delivered to the North Station and Main Station, including signatures indicating dietary staff had prepared and delivered resident snack trays. An admission Record revealed the facility admitted Resident #80 on 10/31/2024. According to the admission Record, the resident had a medical history that included diagnoses of iron deficiency anemia and a history of peptic ulcer disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2026, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident required supervision or touching assistance with eating. The MDS revealed the resident did not require a mechanically altered or therapeutic diet. The MDS revealed the resident was able to walk with supervision and required no mobility devices. During an interview on 06/08/2026 at 12:21 PM, Resident #80, who resided on the South Hall, stated the facility did not make or provide enough snacks for everyone. Resident #80 stated the snacks were placed at the main nurses' station and the residents had to snatch and grab them in order to get one. Resident #80 stated there were not enough snacks if you did not get to the nurses' station early. Resident #80 stated the snacks were just placed at the nurses' station and not passed out to residents. An admission Record revealed the facility admitted Resident #77 on 04/07/2026. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and mild protein-calorie malnutrition. An admission MDS, with an ARD of 04/14/2026, revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognition. The MDS revealed the resident required partial to moderate assistance with eating. The MDS revealed the resident required a mechanically altered diet. The MDS revealed the resident required the use of a walker or wheelchair. During an interview on 06/12/2026 at 9:31 AM, Resident #77, who resided on the South Hall, stated they did not get nighttime snacks. Resident #77 stated the snacks were at the main nurses' station, and the snacks were picked over by the time Resident #77 got there, and usually there were no snacks left. Resident #77 stated the residents got the snacks themselves. During an interview on 06/10/2026 at 3:27 PM, Certified Nurse Aide (CNA) #17 stated snacks were delivered by the kitchen and put at the main nurses' station between the East Hall and South Hall. CNA #17 stated an aide or nurse signed off that the snacks were received from the kitchen. CNA #17 stated the East Hall residents got snacks before the South Hall residents and before the staff on the South Hall even knew the snacks were delivered. CNA #17 stated staff on the South Hall were not notified when the snacks were delivered. During an interview on 06/10/2026 at 3:32 PM, CNA #18 stated she worked the South Hall and the residents did not receive nighttime snacks. CNA #18 stated the kitchen took snack trays to the main nurses' station. CNA #18 stated the kitchen staff used to deliver two bowls of snacks, one for the East Hall and one for the South Hall, and the nursing care staff would then deliver snacks to the residents, or the residents would come to staff and ask for one. CNA #18 stated that now kitchen staff just brought trays to the main nurses' station, and that started about three months prior. CNA #18 stated residents had complained, and she told the Dietary Supervisor, nurses, and management. CNA #18 stated it would change for one or two nights and then it would happen again. During an interview on 06/10/2026 at 3:41 PM, Licensed Practical Nurse (LPN) #19 stated the kitchen brought the residents' snacks to the main nurses' station and residents would get their snacks. LPN #19 stated sometimes the residents would ask the CNAs to get the snacks for them. LPN #19 stated any staff could sign off that the kitchen delivered the snacks.During a phone interview on 06/11/2026 at 6:24 AM, LPN #16 stated for months the residents on the South Hall had no snacks provided by the facility. LPN #16 stated the provision of snacks for the residents on the South Hall did not always happen. During a follow-up interview on 06/11/2026 at 8:26 AM, Resident #80 stated that the previous night was the first night in months that the residents had snacks (on the South Hall). Resident #80 stated the snacks were delivered to the main nurses' station by the North Hall. Resident #80 stated residents on the South Hall usually did not get snacks at night, but they used to get them. During an interview on 06/11/2026 at 8:36 AM, the Dietary Supervisor (DS) stated snacks were delivered at 7:00 PM every night and there were three trays, one for each hall (North, East, and South). The DS stated the kitchen delivered snack trays to the main nurses' station and nursing staff signed off that the trays were received. The DS stated it was the responsibility of nursing staff to deliver the snacks to each hall. The DS stated her job was to get the snack trays to the nurses. The DS stated that when nursing signed off on receiving the snacks, she did not know when the snacks were delivered to the halls because nursing did that part. During an interview on 06/11/2026 at 2:39 PM, the Registered Dietician (RD) stated that recently the facility started the process where dietary staff would put the snacks on trays and there was a log where the nurses and dietary signed off on the delivery to show the hand-off. The RD stated the number of snacks provided should be based off the census and allow, at minimum, one snack per person. The RD stated that once dietary staff handed off the snacks, it was nursing's responsibility to distribute them to the residents. During an interview on 06/11/2026 at 4:28 PM, LPN #19 stated she would sign off on the snacks for the South Hall and leave the snacks at the main nurses' station, and sometimes the CNAs would come to the nurses' station for the residents from the South Hall to get them a snack. During an interview on 06/12/2026 at 9:47 AM, the Assistant Director of Nursing (ADON) #26 stated the DS brought out the resident nighttime snacks on a tray. ADON #26 stated a nurse signed off on snacks for the North Hall and Main Nurses' station that they received the snacks. ADON #26 stated she was not sure how the nurse for the South Hall would know when the snacks were delivered; she just knew nurses were to sign off when the snacks were delivered. ADON #26 stated residents who could ambulate came to the Main Nurses' station, and CNAs would distribute the snacks for the residents who could not ambulate. During an interview on 06/12/2026 at 10:42 AM, the Administrator (ADM) stated his expectation was that staff were following the established process.

Based on interview, record review, and facility policy review, the facility failed to ensure that 3 (Residents #7, #44, and #77) of 5 sampled residents reviewed for immunizations were offered the pneumococcal vaccination.Findings included: A facility policy titled, Pneumococcal Vaccine, reviewed 12/05/2024, indicated, The opportunity to receive the Pneumococcal Vaccine will be extended to all Residents. The Facility will provide pertinent information regarding the Risks/ Benefits of receiving the vaccine. The policy continued, Residents; Document Immunizations in the Medical Record: Vaccine Name, Date, Education, Time, Route, Amount, Location, Manufacturer Name, Expiration Date, Lot Number, Person Administering. 1. An admission Record revealed the facility admitted Resident #7 on 05/20/2026. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease without exacerbation, emphysema, and acute respiratory failure with hypoxia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2026, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident's pneumococcal vaccine was not up to date and that the resident had not received the pneumococcal vaccine because it was not offered. Resident #7's Immunizations section in their Electric Medical Record (EMR) did not reflect that the resident was offered a pneumococcal vaccination or that the resident had refused the vaccine. The Immunizations section in the resident's EMR was blank. During an interview on 06/12/2026 at 12:57 PM, Resident #7 said they had not been offered a pneumococcal immunization at the facility, and they would not have been interested. 2. An admission Record revealed the facility admitted Resident #44 on 02/15/2026. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and cerebral palsy. A quarterly MDS, with an ARD of 06/03/2026, revealed Resident #44 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated the resident's pneumococcal vaccine was not up to date and that the resident had not received the pneumococcal vaccine because it was not offered. Resident #44's Immunizations section in their EMR did not reflect that the resident was offered a pneumococcal vaccination or that the resident had refused the vaccine. The Immunizations section in the resident's EMR was blank. During an interview on 06/12/2026 at 12:16 PM, Resident #44 stated they had not been offered a pneumococcal immunization at the facility, and they would have liked to have been offered. 3. An admission Record revealed the facility admitted Resident #77 on 04/07/2026. According to the admission Record, the resident had a medical history that included diagnoses of heart failure and type two diabetes mellitus. An admission MDS, with an ARD of 04/14/2026, revealed Resident #77 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident's pneumococcal vaccine was not up to date and that the resident had not received the pneumococcal vaccine because it was not offered. Resident #77's Immunizations section in their EMR did not reflect that the resident was offered a pneumococcal vaccination or that the resident had refused the vaccine. The Immunizations section in the resident's EMR was blank. During an interview on 06/12/2026 at 12:19 PM, Resident #77 stated they had not been offered a pneumococcal immunization at the facility, and they would have liked to have been offered. During an interview on 06/12/2026 at 8:19 AM, the Assistant Director of Nursing (ADON) #26 /Infection Preventionist (IP) stated she started working as the infection preventionist two to three weeks prior. She said she had not looked at the pneumococcal vaccinations. During an interview on 06/12/2026 at 9:14 AM, Regional Nurse Consultant (RNC) #3 stated that when a resident entered the facility, the Social Services Supervisor inquired if the resident wanted immunizations. Declinations were verbal and not documented, though the facility might put it in a progress note. RNC #3 said they were unable to find any documentation that indicated Residents #7, #44, and #77 had declined or received their pneumococcal vaccinations. During an interview on 06/12/2026 at 11:01 AM, with the Director of Nursing (DON) and RNC #3, the DON did not comment on immunizations. RNC #3 said that pneumococcal immunizations should be offered annually, and that the facility would begin doing that going forward. During an interview on 06/12/2026 at 11:36 AM, the Administrator stated the facility followed the regulations regarding immunizations for residents. During an interview on 06/12/2026 at 1:05 PM, the Medical Director stated he expected the facility to offer pneumonia vaccinations.

Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (Resident #14) of 3 residents reviewed for respiratory care. Specifically, Resident #14 received oxygen therapy without a physician's order, the resident's nebulizer mask was observed stored improperly, and a physician ordered oxygen humidifier bottle was not provided for the resident.Findings included: A facility policy titled, Oxygen Administration and Storage, dated 01/01/2014, revealed, Purpose: To ensure staff follow safety guidelines and regulation for storage and use of oxygen. The policy also revealed, Concentrator: Residents are to be provided with an oxygen concentrator whenever possible for the purpose of maximizing mobility and overall consistency in regulation of oxygen administration. A facility policy titled, Medication Administration and General Guidelines, dated 01/2026, revealed, Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. An admission Record revealed the facility readmitted Resident #14 on 12/11/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), encephalopathy, and chronic systolic heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2026, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) of 14, which indicated the resident had intact cognition. The MDS revealed the resident had active diagnoses of COPD and shortness of breath (SOB). The MDS did not indicate that Resident #14 received oxygen therapy. Resident #14's Care Plan Report included a focus area, initiated 12/23/2025, that indicated the resident had altered respiratory status/difficulty breathing related to COPD, wheezing, and SOB. Interventions directed staff to: administer medication for SOB and wheezing as ordered and monitor for side effects and effectiveness; change and date the humidifier bottle and oxygen tubing weekly every Wednesday night; change the nebulizer mask and tubing every Wednesday night if in use and document Y if changed and N if not in use ; change nebulizer tubing and mask per orders; monitor for signs and symptoms of respiratory distress and report to the physician as needed; and to provide oxygen per orders as/if needed. Resident #14's Order Summary Report, with active orders as of 06/08/2026, did not include orders for supplemental oxygen administration. The Order Summary Report included orders:- to change the nebulizer tubing and mask weekly on the night shift every seven days, dated 05/14/2026;- to change the humidifier bottle on the oxygen concentrator, the tubing, the mouthpiece, the mask, and the water in the oxygen humidifier every night shift every seven days, dated 05/14/2026; and- for albuterol sulfate (a bronchodilator) inhalation nebulization solution 1.25 milligrams (MG)/3 milliliters (ML), one application to be inhaled orally four times a day for SOB, 12/19/2025. Resident #14's Medication Administration Records (MARs), dated 05/2026 and 06/2026, did not indicate the resident received supplemental oxygen treatment. An observation on 06/08/2026 at 10:43 AM revealed Resident #14 in bed receiving supplemental oxygen via a nasal cannula (a thin flexible tube to deliver oxygen through the nose). The observation revealed Resident #14's oxygen concentrator was set at a rate of 3.5 liters per minute (LPM). The observation revealed a nebulizer mouthpiece and tubing were observed on Resident #14's nightstand uncovered and not stored in a bag. An observation on 06/08/2026 at 2:18 PM revealed Resident #14 in bed receiving supplemental oxygen via a nasal cannula, the oxygen concentrator was set at 3.5 LPM, and a nebulizer mouthpiece and tubing were observed on the resident's nightstand uncovered and not stored in a bag. An observation on 06/09/2026 at 10:56 AM revealed Resident #14 in bed receiving supplemental oxygen via a nasal cannula, the oxygen concentrator was set at 3.5 liters per LPM, and there was no humidifier bottle. The observation revealed a nebulizer mouthpiece and tubing on Resident #14's nightstand uncovered and not stored in a bag. An observation on 06/10/2026 at 9:55 AM revealed Resident #14 in bed receiving supplemental oxygen via a nasal cannula, the oxygen concentrator was set at 3.5 LPM, and there was no humidifier bottle. The observation revealed a nebulizer mouthpiece and tubing on Resident #14's nightstand uncovered and not stored in a bag. During a concurrent interview, Resident #14 stated they took the nebulizer treatment four times a day every day. During an interview on 06/10/2026 at 10:10 AM, Certified Medication Technician (CMT) #10 stated nurses managed residents' oxygen and inhalers, and the nebulizer mouthpiece and tubing should be stored in a plastic bag, labeled and dated. Immediately following the interview, on 06/10/2026 at 10:14 AM, CMT #10 observed the nebulizer mouthpiece and tubing on Resident #14's nightstand and confirmed it was not stored correctly. During an interview on 06/10/2026 at 1:24 PM, Licensed Practical Nurse (LPN) #8 confirmed Resident #14 utilized oxygen, and she stated the resident was on continuous oxygen. LPN #8 reviewed Resident #14's electronic medical record and stated she did not see a physician's order for use of supplemental oxygen. During concurrent interviews in Resident #14's room on 06/10/2026 at 2:01 PM, LPN #8 acknowledged Resident #14's oxygen concentrator was at 3.5 LPM, and there was no oxygen humidifier. Concurrently, Resident #14 stated staff never put the water bottle on the oxygen concentrator. Resident #14 stated the resident had received oxygen at 3.5 LPM for a long time. Resident #14 stated staff did not put the nebulizer mouthpiece or tubing in a bag until that day. During a phone interview on 06/11/2026 at 6:24 AM, LPN #16 stated Resident #14 had been on oxygen since the resident arrived at the facility. During an interview on 06/11/2026 at 10:27 AM, LPN #15 stated Resident #14 received oxygen and breathing treatments. LPN #15 stated she did not notice that there was no physician's order for Resident #14's oxygen, and if she had she would have contacted the doctor for an order. During an interview on 06/12/2026 at 3:08 PM, LPN #19 stated Resident #14 received supplemental oxygen, and she was unaware Resident #14 had no physician's order for supplemental oxygen. During an interview on 06/12/2026 at 10:14 AM, the Director of Nursing (DON) stated if a resident had no oxygen order and was receiving oxygen, he expected staff to make sure the physician's orders for supplemental oxygen were in the electronic medical record and the nurses were following the orders. The DON stated he expected the nursing team to ensure the nebulizer mask, mouthpiece, and tubing were stored correctly.

Based on observation, interview, and record review, the facility failed to maintain a sanitary, orderly, and comfortable environment for 1 (Resident #88) of 2 residents who utilized a wheelchair. Specifically, observation revealed Resident #88 had damaged wheelchair armrests, and there was no documented evidence that efforts to repair the damage had been made, despite the Maintenance Director being aware of the issue.Findings included: During an interview on 06/11/2026 at 8:41 AM, the Administrator stated there was no policy regarding maintenance or maintaining resident care equipment. An admission Record revealed the facility admitted Resident #88 on 06/24/2025. According to the admission Record, the resident had a medical history that included diagnoses of dementia, muscle weakness, unsteadiness on feet, and a history of falling. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2026, revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. According to the MDS, Resident #88 used a wheelchair for mobility. During an observation on 06/08/2026 at 12:30 PM, Resident #88's wheelchair had a cracked armrest on the left side with an area of exposed foam that was approximately 3 inches wide by 1 inch long, and the foam was projecting outwards onto the armrest. The armrest on the right side of the resident's wheelchair revealed the lining was torn from an area that was approximately five square inches. During an interview on 06/10/2026 at 2:15 PM, Certified Medication Technician (CMT) #7 stated they reported damaged or torn equipment to the charge nurse. When she observed the torn armrests to Resident #88's wheelchair, she stated she should have noticed it and brought it to someone's attention. During an interview on 06/10/2026 at 2:15 PM, the Maintenance Supervisor stated staff reported damaged equipment via the building's maintenance management system. He stated he was familiar with the issue with Resident #88's chair and had not fixed it yet. He stated that he believed the issue had already been documented. During an interview on 06/12/2026 at 11:01 AM, the Director of Nursing (DON) stated that if nursing staff noticed damaged equipment, they notified maintenance staff to repair the equipment. Per the DON, if the equipment was no longer safe to use, they immediately removed it. During an interview on 06/10/2026 at 4:04 PM, the Administrator stated that he was first notified about Resident #88's armrests that day (06/10/2026) and reviewed the building's maintenance management system on 06/10/2026 at 2:22 PM. Per the Administrator, there were no prior system entries regarding Resident #88's wheelchair. The Administrator stated that if staff noticed damaged resident care equipment, they should enter the concern into the building's maintenance management system, which would produce a ticket indicating the facility was addressing the issue.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a dignified dining experience for 3 (Residents #80, #13, and #77) sampled residents during 2 of 2 meal observations. Specifically, on 06/08/2026, 23 minutes after being served, Resident #13 had finished their meal and Resident #77 and Resident #80, who were seated at the same table, had not been served their meal. On 06/11/2026, the residents were seated at the same table again and staff had not served Resident #13 and Resident #77's meals when Resident #80 had consumed 75% of their meal.Findings included: A facility policy titled, Resident Rights, revised 01/28/2026, revealed, The facility shall treat Residents with kindness, respect, and dignity and ensure Resident Rights are being followed. An admission Record revealed the facility admitted Resident #80 on 10/31/2024. According to the admission Record, the resident had a medical history that included diagnoses of iron deficiency anemia and a history of peptic ulcer disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2026, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed that the resident required supervision or touching assistance with eating. The MDS also revealed the resident did not require a mechanically altered or therapeutic diet. An admission Record revealed the facility admitted Resident #77 on 04/07/2026. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and mild protein-calorie malnutrition. An admission MDS, with an ARD of 04/14/2026, revealed Resident #77 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required partial to moderate assistance with eating. The MDS also revealed the resident required a mechanically altered diet. An admission Record revealed the facility admitted Resident #13 on 05/20/2025. According to the admission Record, the resident had a medical history that included diagnoses of protein calorie malnutrition, anxiety, and depression. A quarterly MDS, with an ARD of 05/27/2026, revealed Resident #13 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required partial to moderate assistance with eating and required a mechanically altered diet. During an observation of the lunch meal service on 06/08/2026 at 12:30 PM in the main dining room, Resident #13 was seated at a table with Resident #80 and Resident #77. Resident #13 was eating their meal, and staff had not served Resident #80 and Resident #77 their lunch meal. At 12:47 PM on 06/08/2026, staff served Resident #80's lunch. At 12:53 PM, Resident #13 finished their lunch and left the table, and Resident #77 still had not received their lunch. At that time, Resident #77 stated the resident was eating lunch today, but had not received their food yet. During a concurrent observation and interview on 06/11/2026 at 8:22 AM, Residents #77, #13, and #80 were sitting at the same table for breakfast meal service in the main dining room. Resident #77 had their meal at that time, and Resident #13 and Resident #80 did not. Resident #80 stated they received their meal when their meal ticket came up, and it was random. Resident #80 stated that the delivery of meals was sporadic, and they did not get their meals at the same time when sitting together at a table. At that time, Resident #77, who was eating the meal that was delivered, stated it bothered them when the others were eating, and the resident did not have their meal. During the interview, Resident #13 stated it bothered them a little when the others had their meal, and Resident #13 did not, especially when the others were finished eating, and they still had not received a meal. An observation at 8:34 AM on 06/11/2026, revealed Resident #77 had eaten 75 percent (%) of their meal, and Resident #80 and Resident #13 did not have their meals. During a concurrent observation and interview on 06/11/2026 at 8:36 AM, the Dietary Supervisor (DS) observed Resident #80 and Resident #13 without a meal and Resident #77 eating their meal. The DM stated the staff were to serve the whole table at the same time. She stated they should organize the meal tickets by table when doing the beverage service then give the tickets to the cook. During an interview on 06/09/2026 at 11:39 AM, Dietary Aide (DA) #20 stated they were to serve everyone at the table at the same time, but he followed the cook's flow when delivering meals. During an interview on 06/12/2026 at 9:47 AM, the Assistant Director of Nursing (ADON) #26 stated that residents should be served at the same time. ADON #26 stated it would not be fair for a person to watch another person eat a meal in front of them. During an interview on 06/12/2026 at 9:55 AM, the Director of Nursing stated his expectation would be to produce a better system for choosing how meal tickets were planned. He stated they had a monitoring system in place for dining service, but they were not monitoring to ensure residents were served at the same time when sitting at the same table. During an interview on 06/12/2026 at 10:42 AM, the Administrator stated the expectation was to serve table by table and follow the orders on meal tickets; however, he stated that meal service at the facility was not the same as a restaurant. He stated that the expectation was for dietary staff to serve meals based on diet orders. He stated he could not say what may have been going on in the main dining room at the time of the observations.

Based on record review, interview, and facility policy review, the facility failed to ensure that dialysis services were consistent with professional standards of practice for 1 (Resident #58) of 2 residents reviewed for dialysis. Specifically, the facility failed to ensure Resident #58 had a physician order and care plan for dialysis treatment and for care/monitoring of the resident's hemodialysis (a process in which blood is pulled from a dialysis access, such as a catheter, circulated outside the body through a dialysis machine, then pumped back into the blood stream) catheter/catheter site. The facility also failed to ensure staff completed an ongoing assessment of the resident's condition and monitored for complications after hemodialysis treatments.Findings included: A facility policy titled, Care of Hemodialysis Resident, issued 01/01/2014, revealed the purpose was, To ensure the needs of the resident receiving hemodialysis are met by both the facility and the dialysis center. Residents receiving hemodialysis are transported routinely out of the facility. Communication is essential for the continuity of care. The policy revealed Post Dialysis care included, Review communication documents for any pertinent information. Take vital signs per physician order. The policy revealed care of External Catheters [a hemodialysis catheter is a flexible tube inserted into a large vein to provide immediate access to the bloodstream for dialysis] included, Care should be taken so the external catheter is not pinched poked, bent or pulled. A smooth clamp should be kept at the bedside for emergency situations. Avoid getting catheter wet during bathing. You may cover the plastic wrap during bathing. Replace the dressing if it comes off or becomes wet. Cleanse the area with cleanser such as Betadine swab or Hibiclens and apply new sterile dressing. An admission Record revealed the facility readmitted Resident #58 on 02/28/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute kidney failure and type 2 diabetes mellitus with diabetic chronic kidney disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2026, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had an active diagnosis of renal insufficiency and renal failure. The MDS did not indicate that the resident received dialysis. A hospital After Visit Summary revealed Resident #58's was hospitalized from [DATE] through 05/11/2026. The After Visit Summary indicated that Resident #58 was started on dialysis and was to continue as a dialysis outpatient beginning 05/12/2026. The summary revealed that the location of the dialysis center was listed and indicated that dialysis was scheduled every Tuesday, Thursday, and Saturday at 11:00 AM. A hospital Discharge Summary revealed Resident #58's was hospitalized again from 05/19/2026 through 05/22/2026. The Discharge Summary indicated discharge diagnoses included end stage renal disease on hemodialysis (HD). The Discharge Summary revealed Resident #58 was admitted on [DATE] for altered mental status and somnolence noted at the dialysis center, which precluded the resident's scheduled dialysis session. Per the Discharge Summary, follow up instructions included ensuring the resident followed up with regularly scheduled HD. Resident #58's Progress Note, created by Licensed Practical Nurse (LPN) #15 on 05/22/2026, revealed the resident returned to the facility from the hospital and had a new HD catheter located on the right side of the resident's chest and the dressing to the area was clean, dry, and intact. Resident #58's Care Plan Report included a focus area, initiated on 10/13/2023, that indicated the resident had acute renal failure related to Stage 2 chronic kidney disease. There was no documented evidence that the facility developed a care plan for dialysis with interventions that directed staff how to care for the resident who was receiving dialysis or assessment/monitoring/treatment of the resident's HD catheter. Resident #58's Order Summary Report, with active orders as of 06/08/2026, revealed no documented evidence that the resident had orders for dialysis services, or for care of the resident's HD catheter. Resident #58's Medication Administration Records [MARs] and Treatment Administration Records [TARs] for May 2026 and for 06/01/2026 through 06/08/2026 (printed 06/08/2026 at 4:53 PM Central Daylight Time) revealed no documented evidence that the resident received dialysis services, that staff were monitoring the HD catheter site for signs and symptoms of bleeding or infection, or that staff were providing treatment to the HD catheter site. Resident #58's Dialysis Communication Transfer Form revealed the resident had dialysis at an offsite hemodialysis center on 05/12/2026, 05/14/2026, 05/16/2026, 05/23/2026, 05/30/2026, 06/06/2026 and 06/09/2026. The Dialysis Communication Transfer Form revealed that upon return to the facility, staff were required to assess the resident's vital signs and cognition status, monitor the access site dressing, document whether or not the physician was notified of any concerns, and sign and date the bottom of the form. Per the Dialysis Communication Transfer Forms, with the exception of 05/14/2026 when staff documented the resident's vital signs, cognition status, and that the access site dressing was changed, there was no documented evidence that staff assessed Resident #58 upon return from dialysis on the aforementioned dates. Resident #58's Progress Notes for the timeframe from 05/12/2026 through 06/10/2026 also revealed no documented evidence that staff monitored/assessed the resident after dialysis or assessed/monitored/treated the resident's HD catheter site/dressing. During an interview on 06/10/2026 at 3:52 PM, Resident #58 stated the hospital put a shunt (HD catheter) in the right side of the resident's chest for dialysis. The resident confirmed they went to dialysis on Tuesdays, Thursdays, and Saturdays. Resident #58 stated the nurses checked the HD catheter a couple of times a week but did not usually check the resident's vital signs or the HD catheter access site when the resident returned from dialysis. During an interview on 06/09/2026 at 5:02 PM, Certified Medication Technician (CMT) #5 stated that when Resident #58 came back from dialysis, she checked the resident's vital signs and administered the resident's medications. Per CMT #5, she had not seen the resident yet that day and did not know whether the resident had returned from dialysis. During an interview on 06/09/2026 at 5:02 PM, LPN #6 also stated that she did not know whether Resident #58 had returned from the dialysis center. She stated that when the resident returned, CMT #5 would take the resident's vital signs, and she (LPN #6) would check the resident's blood sugar. Per LPN #6, she did not do anything else when the resident returned from dialysis unless the resident had a complaint. According to LPN #6, she never saw Resident #58's paperwork from dialysis. She stated she worked on Tuesdays, and per LPN #6, the paperwork was processed at the main nurses' station. During a concurrent observation and interview on 06/09/2026 at 5:18 PM, Resident #58 was in the main dining room waiting for dinner. The resident stated that they returned to the facility from the dialysis center a little after 4:00 PM on 06/09/2026. There was no documented evidence at that time (over an hour after returning from dialysis) that staff had assessed the resident. During an interview on 06/09/2026 at 10:48 AM, LPN #15 stated that staff obtained vital signs before leaving for dialysis and when the resident returned. Per LPN #15, a resident's electronic TAR prompted the nurse to obtain and document a resident's vital signs. However, LPN #15 reviewed Resident #58's MAR and TAR for June 2026 and stated the resident did not have a physician's order for pre and post dialysis vital signs. She also stated she did not see a physician's order for dialysis treatment for Resident #58. During a follow-up interview on 06/10/2026 at 9:31 AM, LPN #15 stated that she reviewed Resident #58's electronic medical record and stated she did not see a physician's order for monitoring or assessing the resident HD catheter access site. During an interview on 06/10/2026 at 1:39 PM, LPN #8 stated that when a resident returned from dialysis, the nurse was supposed to obtain the resident's vital signs if there was a physician's order and the nurse should also check and make sure the HD access site was not bleeding. She stated that if a resident was receiving dialysis, there should be a physician's order and there should also be an order to monitor the access site and make sure it was clean and dry. She reviewed Resident #58's electronic medical record and stated there was no physician order for dialysis or monitoring and assessing the access site. During an interview on 06/12/2026 at 11:41 AM, the Nurse Practitioner (NP) stated that the facility providers typically did not provide orders for dialysis. She stated that dialysis orders were determined prior to the resident being discharged from the hospital. However, the NP stated that she expected there to be an order for dialysis, and the facility dropped the ball. During an interview on 06/12/2026 at 9:43 AM, Assistant Director of Nursing (ADON) #26 stated nurses should obtain a resident's vital signs after dialysis and, depending on each resident, they needed to monitor the HD catheter dressing to make sure it was clean and dry and follow up if necessary. ADON #26 stated that staff should monitor residents when they came back from HD, and they should document the assessment on the Dialysis Transfer Communication forms. Per ADON #26, if staff did not see a physician's order for HD, they should get an order from the physician. During an interview on 06/12/2026 at 10:19 AM, with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) #4, the DON stated his expectation was for nurses to make sure post dialysis care was completed and documented on the Dialysis Transfer Communication form. RNC #4 stated that the monitoring should be completed and documented on the resident's TAR, and the Dialysis Transfer Communication Form should be uploaded into the electronic medical record. During an interview on 06/12/2026 at 10:58 AM, the Administrator stated his expectation was that doctor's orders were to be followed.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure their medication rate was below 5% for 1 (Resident #83) of 8 residents observed for medication administration. Specifically, staff did not perform an insulin pen safety check before insulin administration which resulted in 2 medication errors of 27 opportunities. The facility's overall medication error rate was 7.41%.Findings included: A facility policy titled, Medication Administration and General Guidelines, revised 01/2026, indicated, Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. An undated facility document titled, Standardized Priming (Safety Test) Instructions, indicated, Priming is essential before every injection to remove air bubbles from the needle and cartridge, and to ensure the device is functioning correctly. The policy also indicated, 2. The Priming Step (Safety Test) 1. Dial the dose: Turn the dose selector to 2 units. 2. Position the pen: Hold the pen with the needle pointing straight upward. 3. Tap the cartridge: Gently tap the insulin reservoir (cartridge) with your finger to help any air bubbles rise toward the needle. 4. Inject the prime: Press the injection button all the way in. Check the dose window to ensure it returns to 0. 5. Verify: Look for a drop or stream of insulin at the tip of the needle. If you see a drop: The pen is primed and ready to dial the required dose. Findings included: An admission Record revealed the facility admitted Resident #83 on 03/24/2021. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2026, revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident received insulin injections. Resident #83's Care Plan included a problem statement, initiated 07/19/2024, that indicated the resident had Type II diabetes mellitus. Interventions directed the staff to administer insulin as ordered. Resident #83's Order Summary Report, with active orders as of 03/05/2026, revealed an order dated 03/06/2026 for 25 units of glargine (Lantus, a long-acting insulin) injected subcutaneously via pen-injector one time a day for diabetes and 5 units of NovoLog (a fast-acting insulin) injected subcutaneously via pen-injector with meals for diabetes. During a concurrent observation of medication administration and an interview on 06/10/2026 at 7:55 AM, Licensed Practical Nurse (LPN) #8 removed one NovoLog insulin pen and one Lantus insulin pen. The observation revealed LPN #8 dialed up 5 units of insulin on the NovoLog pen and 25 units of insulin on the Lantus insulin pen and then started toward Resident #83's room. LPN #8 stated she was ready to give the doses unless she needed to add more based on the blood glucose reading. LPN #8 stated she had not primed the insulin pens with two units of insulin and stated that she was not shown how to prime the insulin pens. LPN #8 left with the insulin pens and came back after she stated she went to the Director of Nursing (DON) for education on priming the insulin pens. During an interview on 06/11/2026 at 1:37 PM, Assistant Director of Nursing/Infection Preventionist (ADON/IP #26) stated her expectation would be to prime the insulin pen with 2 units of insulin before dialing up the ordered dose.During a phone interview on 06/12/2026 at 11:01 AM, the Pharmacy Consultant stated the nurses should prime the insulin pens prior to use.During an interview on 06/12/2026 at 11:58 AM, the DON stated he expected staff to prime the insulin pens per manufacturer's instructions.During a phone interview on 06/12/2026 at 1:02 PM, the Medical Director stated he expected insulin dosage to be accurate each time.

Based on observation, record review, and interview, the facility failed to ensure comfortable water temperatures were maintained for 5 of 5 shower rooms. The DON identified 79 residents received showers. Finding:On 01/27/26 at 3:23 p.m., an observation of the large South shower showed an initial temperature of the water flow out of the shower head to be 100.4 degrees F. Within 11 minutes the water temperature was observed to be 77.4 degrees F.On 01/28/26 at 8:42 a.m., an observation of the small East shower showed an initial temperature of the water flow out of the shower head to be 107.4 degrees F. Within eight minutes the water temperature was observed to be 85.2 degrees F.On 01/28/26 at 9:01 a.m., an observation of the large East shower showed an initial temperature of the water flow out of the shower head to be 97.6. degrees F. Within one minute the water temperature was observed to be 98.4 degrees F.On 01/28/26 at 9:15 a.m., an observation of the North shower showed an initial temperature of the water flow out of the shower head to be 81.3 degrees F. Within two minutes the water temperature was observed to be 70.5 degrees F. On 01/28/26 at 1:18 p.m., an observation of the small South shower showed an initial temperature of the water flow out of the shower head to be 104.6 degrees F. Within five minutes the water temperature was observed to be 85.8 degrees F.A facility policy titled ADL [activity of daily living] CARE BATHING, dated 07/21/22, read in part, ENSURE BATHING AREA is at a comfortable temperature.A facility maintenance document titled Direct Supply Tels, dated 11/17/25, read in part, Hot water not working on north hall.On 01/22/26 at 8:58 a.m., Res #2 stated they had a problem with the water being cold. They stated last week they took a shower and it was warm for about two minutes and then the water became ice cold. They stated they did not take many showers now because the water in the shower got ice cold.On 01/27/26 at 3:41p.m., CNA #3 stated when they started the showers for the residents the water turns very cold within three minutes. They stated they had to hurry and get the soap washed off the residents. CNA #3 stated residents felt their showers were cut short. They stated residents would refuse showers because they knew the water got cold fast.On 01/27/26 at 3:45 p.m., CNA #5 stated residents told them the water got cold too fast. They stated they noticed the water got cold fast. CNA #5 stated they reported the cold water in the shower rooms to the maintenance supervisor several times.On 01/27/26 at 4:00 p.m., Res #8 stated within five minutes the water was freezing in the shower. They stated it was very difficult to take a shower when it was ice cold, and they hated that it was just frigid.On 01/27/26 at 4:20 p.m., Res #9 stated the water was freezing within a minute on the North hall shower.On 01/28/26 at 10:47 a.m., the maintenance supervisor stated they did not perform routine checks on water temperatures, and they had no logs of temperature checks. On 01/28/26 at 2:01 p.m., the administrator stated after feeling the water coming out of the shower head on the North hall, they would not take a shower in that water because it was too cold.

Based on observation and interview, the facility failed to ensure there were qualified dietary staff to meet the needs of the residents for 2 of 3 dietary staff reviewed for qualifications. The DON identified 81 residents received nutrition from the kitchen. The DM identified 11 staff members who worked in the dietary department. Findings:On 01/27/26 at 1:35 p.m., dietary aide #1 and dietary aide #2 were observed washing dishes in the low temperature dish machine and dietary aide #2 stopped the dish machine during the wash cycle and walked away.On 01/27/26 at 1:38 a.m., dietary aide #2 stated there were suds in the side tank and that was how they knew the water was not hot enough. They stated they waited awhile and tried running the dishwasher again. Dietary Aide #2 stated they had not been shown how to check the temperature with the gauge or use test strips on the machine. Dietary Aide #2 stated they had worked at the facility for about a month and were trained by another staff member but had not learned anything about testing the dish machine, even though they used it several times a day.On 01/27/26 at 1:40 p.m., dietary aide #1 stated they looked at the temperature gauge and mad sure it was between the two green lines. They stated they knew there were strips to check the machine with, but they did not know where they were. Dietary Aide #1 stated they did not usually worry about testing or documentation. They stated they just watched for suds to know if the water was too cold.On 01/28/26 at 9:56 a.m., the DM stated they were unable to locate the quarterly training documents, 90-day nutrition services, training or annual competencies for the dietary staff. The DM stated they reviewed the process for checking temperatures and sanitation strips in orientation and were not sure why the staff were not following the process or did not have an understanding for the need or frequency for the dish machine testing.

Based on observation, record review, and interview, the facility failed to ensure staff performed their duties in a manner that would ensure clean and proper sanitation of dishes during 2 of 2 kitchen observations.The DON identified 81 residents received nutrition from the kitchen. Findings:On 01/27/26 at 1:30 p.m., the low temperature dishwasher was observed being stopped mid-cycle by dietary aide #2. The dishwasher reservoir water was observed to have suds. The temperature gauge was observed and showed the dial between the green arrows marked on the gauge and water temperature was measured to be 140 degrees F.A facility policy titled Warewashing, dated 08/25/25, read in part, dishware shall be washed in (3) sink unit with sanitizer or disposable dishware shall be used if dish machine is not working or reaching regulatory requirements.test strips shall be available for the pot sink and low temp dish machine sanitizer. Results shall be checked and recorded daily.A facility log sheet titled Warewashing Log - Dishmachine, dated January 2026, showed lines marked through 01/21/26 with a note hot water being installed. The log sheet did not show documentation was recorded for 01/21/26 through 01/28/26. On 01/22/26 at 8:30 a.m., cook #2 stated hot water had been an issue and the facility was getting a new hot water tank installed. [NAME] #2 stated they were washing dishes in the tubs since the dishwasher was out of service due to the availability of hot water. They stated they were heating water on the stove to wash pots and pans and other cooking utensils and used paper plates and paper containers for serving food to the residents.On 01/22/26 at 9:00 a.m., the DM stated they were using paper products for residents and washing cooking utensils in three plastic tubs. The DM stated they did not know they needed to check the temperature of the water or the sanitizer solution in the tubs, but they were using the sanitizer. The DM stated they were heating the water on the stove.On 01/27/26 at 1:30 p.m., dietary aide #1 stated they looked at the temperature gauge and made sure it was between the two green lines. Dietary Aide #1 stated they knew there were strips to check the machine, but they did not know where they were. Dietary Aide #1 stated they did not usually worry about testing or documentation. They stated they just watched for suds in the side reservoir to know if the water was too cold.On 01/27/26 at 1:35 p.m., dietary aide #2 stated they had not been shown how to check the water temperature with the gauge or use test strips. Dietary aide #2 stated they had worked at the facility for about a month and they were trained by another staff member. Dietary Aide #2 stated they washed dishes when they worked but had not learned anything about testing the machine.On 01/27/26 at 2:16 p.m., the administrator stated they were unsure of training of staff or that they were completing the process for dish machine testing since there was no documentation to show it had been completed. The administrator stated the testing of the dishwasher should be done daily per facility policy. On 01/28/26 at 10:30 a.m., the DM stated they were at the facility and worked over the weekend but had not realized the dish machine had not been tested for temperature or sanitation, or that documentation was not completed from 01/21/26 through 01/28/26. They stated they felt like there was some miscommunication between the staff. The DM stated the temperature, and sanitizer should be checked daily and that it was not documented.

Based on record review and interview, the facility failed to ensure resident representatives were notified of a change in condition for 2 (#4 and #9) of 4 sampled residents reviewed for change in condition.The DON reported the census in the facility was 80. Findings: A facility policy titled Notification of Change in Condition, revised 02/06/25, read in part, The attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative will be notified of a change in resident's condition, per standards of practice and federal and/or state regulations.1. An admission record, dated 10/23/20, showed Res #4 had diagnoses which included congestive heart failure and obstructive sleep apnea.A nurse note, dated 12/05/24, showed Res #4 had complained of nausea and the physician had been notified and ordered Zofran 4mg (a medication used to prevent nausea) every four hours as needed. The note did not show the resident's representative had been notified of the new medication.A nurse note, dated 01/21/25, showed Res #4 had an elevated A1C level (a test that measures average blood sugar levels). The note showed the physician was notified and the physician ordered metformin 500mg (an antihyperglycemic medication) twice a day by mouth for a new diagnosis of type II diabetes mellitus. The note did not show the resident's representative had been notified of the abnormal laboratory value, the new medication, or the new diagnosis.An annual assessment, dated 06/18/25, showed Res #4 had a brief interview for mental status score of 15 which was indicative of intact cognition.On 09/09/25 at 11:30 a.m., Res #4's representative stated they had been contacted by the facility once since admission on [DATE].2. An admission record dated 02/28/25, showed Res #9 had diagnoses which included diabetes mellitus and muscle weakness.A nurse note, dated 05/02/25, showed Res #9 fell from the bed onto a fall mat. The note showed the physician, the DON and Res #9's family member were notified.On 09/09/25 at 10:55 a.m., Res #9's family member stated the facility did not notify them of the fall that occurred on 05/02/25.On 09/09/25 at 11:40 a.m., LPN #1 stated that resident representatives should be notified of any significant change to a resident's condition. LPN #1 stated if the resident was cognitively intact, they did not always have to notify family. On 09/09/25 at 11:45 a.m., LPN #2 stated representatives should be notified whenever a resident was sent to the hospital, had a medication change, or any other significant event.On 09/09/25 at 11:55 a.m., the DON stated representatives should be notified of significant changes, but it was not always necessary to notify the representatives of cognitively intact residents unless the representative requested to be notified.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for 1 (#1) of 3 sampled residents whose care plans were reviewed. The DON identified 75 residents resided in the facility. Findings: A policy titled Signing out LOA [leave of absence], dated January 2016, showed each resident leaving the premises was to be signed out on the sign out register at the nurses' station. A policy titled Comprehensive Person Centered Care Plan, dated 01/23/19, read in part, Each resident will have a person centered plan of care to identify proems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. A care plan, dated 02/22/25, did not show the resident was able to sign themselves out for outings, enjoyed being outside on their motorized wheel chair, or that staff had to sign the resident out at times. An admission assessment, dated 02/24/25, showed Resident #1 had a diagnosis of hypertension and a brief interview for mental status score of 13, which indicated the resident was cognitively intact for daily decision making. A sign out sheet, dated 02/28/25 through 04/16/25, showed the resident had signed themselves out of the facility five times and the facility staff had signed them out six times. A nurse note, dated 04/16/25 at 10:14 a.m., showed Resident #1 was observed to leave the facility in their motorized wheel chair and had not signed themselves out on the sign out log. On 04/23/25 at 11:42 a.m., LPN #1 stated Resident #1 enjoyed going outside, riding around the neighborhood on their motorized wheel chair, and was safe to do so. They stated Resident #1 was aware of the protocol to sign out but, at times they did not. LPN #1 stated staff had to sign the resident at times because the resident would not sign the book or alert staff they were leaving. On 04/23/25 at 12:03 p.m., the DON stated Resident #1 had been assessed and deemed safe to leave the facility in their motorized wheel chair and the resident enjoyed being outside. They stated at times the resident would not sign themselves out and staff would sign the book for them. The DON stated they had provided education on the protocol for signing out of the facility and they thought it had been care planned. On 04/23/25 at 1:15 p.m., Resident #1 stated they had been informed of the protocol to sign out of the facility and thought they did each time, but could not remember. On 04/23/25 at 4:15 p.m., care plan coordinator #1 reviewed the care plan for Resident #1 and stated they had not developed a care plan which indicated the resident was able to sign themselves out of the facility, at times would not sign out and staff had to sign the resident out, enjoyed being outside/leaving the facility, or that the protocol for signing out had been care planned. Care Plan Coordinator #1 stated, I guess I just failed to do that.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#3) of three sampled residents for abuse. The DON identified 81 residents who resided at the facility. Findings: Review of an incident investigation, dated 09/04/24, revealed an allegation of verbal abuse by staff to Resident #3. The investigation completed by the administrator revealed the roommate of Resident #3 overhead the verbal abuse of the staff to Resident #3. The investigation revealed the administrator had reported the incident to OSDH in a timely manner and investigated the incident. The employee was terminated and all notifications were made. A QAPI dated 09/05/24, revealed the plan of action by the facility regarding a substantiated allegation of abuse. An in-service dated 09/05/24, documented education was provided to all staff regarding a substantiated allegation of abuse. On 09/23/24 at 12:30 p.m., CNA #1 stated they had been in-serviced recently on all abuse types, who to report incidents to and when to report. On 09/23/24 at 12:34 p.m., CNA #2 stated they had been in-serviced the previous week on all abuse types, who to report incidents to and when to report. On 09/23/24 at 12:50 p.m., the administrator stated the allegation of verbal abuse by Resident #3 was substantiated due to a witness who heard the staff member cursing in the room while speaking to Resident #3. They stated the staff member was reported and terminated, an in-service was conducted and a QAPI adhoc meeting took place the next day.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less during medication administration. A total of 25 opportunities were observed with three medication errors. The medication error rate was 12%. The DON identified 78 residents who resided in the facility who received medications. Findings: 1. Resident #24 had diagnoses which included GERD and constipation. A Physician's Order, dated 01/31/24, documented an order for docusate sodium 100 mg twice daily for constipation. A Physician's Order, dated 06/03/24, documented an order for famotidine 20 mg once daily for GERD. On 08/21/24 at 8:49 a.m., CMA #1 was observed to administer medications to Resident #24. Docusate sodium and famotidine were not medications CMA #1 administered during the medication pass. On 08/23/24 at 9:25 a.m., CMA #1 stated they did not know how they forgot to administer the docusate sodium or the famotidine. CMA #1 stated they remembered they had verified they had 15 pills in their medication cup and one patch to administer. CMA #1 stated they had forgotten to review the MAR to obtain the two medications from the house stock supply after retrieving the patch. 2. Resident #9 had diagnoses which included glaucoma. A Physician's Order, dated 04/17/24, documented the resident was ordered bimataprost ophthalmic solution 0.01% one drop in both eyes at bedtime. On 08/22/24 at 2:42 p.m., CMA #2 was observed to administer medications to Resident #9. CMA #2 administered one drop of latanoprost ophthalmic solution 0.005% to both eyes. On 08/22/24 at 3:34 p.m., CMA #2 stated Resident #9 was ordered bimataprost eye drops twice daily at 8:00 a.m. and 8:00 p.m. CMA #2 stated the resident had requested an eye drop so they had administered the medication early. On 08/22/24 at 4:02 p.m., the DON stated bimataprost and latanoprost were interchangeable medications. The DON reviewed the electronic clinical record and stated the bimataprost was ordered to be administered at 8:00 p.m. and CMA #2 should not have administered at 2:42 p.m. On 08/23/24 at 9:42 a.m., ADON #1 stated they monitored medication administration three times a week for medication errors. They stated they had not observed missed medications like the docusate sodium and famotidine or medications administered at the wrong time.

Based on observation, interview, and record review, it was determined the facility failed to assess and monitor the use of an indwelling urinary catheter, and/or to provide catheter care and catheter changes as required for three (#1, #3, and #4) of three residents with indwelling urinary catheters. Resident #1 required hospitalization [MEDICAL CONDITION] and a complicated urinary tract infection. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission screening/history, dated 09/18/19, documented the resident had an indwelling urinary catheter last changed 09/17/19. Daily skilled summaries, dated 09/19/19 and 09/20/19, documented the resident had an indwelling urinary catheter. They did not document an assessment of the genital/urinary system nor of the urinary catheter. They did not document the color, clarity, or odor of the urine. The daily skilled summary, dated 09/21/19, documented the resident had an indwelling urinary catheter which was patent and draining clear yellow urine. The daily skilled summary, dated 09/22/19, documented the resident had an indwelling urinary catheter which was patent and intact. It did not document an assessment of the genital/urinary system nor of the urinary catheter. It did not document the color, clarity, or odor of the urine. The care plan, dated 09/23/19, documented, .Focus .Foley Catheter: I have a 16 french with a 10ml bulb Foley Catheter r/t [MEDICAL CONDITION] Bladder. Provide FC care every shift and as needed. Empty catheter each shift .Goal .I will show no s/sx of Urinary infection through review date .Interventions .CATHETER: last changed at hospital. Change catheter monthly as ordered . Daily skilled summaries, dated 09/23/19, and 09/24/19, documented the resident had an indwelling urinary catheter. They did not document an assessment of the genital/urinary system nor of the urinary catheter. They did not document the color, clarity, or odor of the urine. The admission assessment, dated 09/24/19, documented the resident was cognitively intact, required assistance with all activities of daily living, and had an indwelling urinary catheter. There were no daily skilled summaries documented for 09/25/19 or 09/26/19. The daily skilled summary, dated 09/27/19, documented the resident had an indwelling urinary catheter. It did not document an assessment of the genital/urinary system nor of the urinary catheter. It did not document the color, clarity, or odor of the urine. There were no daily skilled summaries documented for 09/28/19 or 09/29/19. The daily skilled summary, dated 09/30/19, documented the resident had an indwelling urinary catheter. It did not document an assessment of the genital/urinary system nor of the urinary catheter. It did not document the color, clarity, or odor of the urine. There was no daily skilled summary documented for 10/01/19. The daily skilled summary, dated 10/02/19, documented the resident had an indwelling urinary catheter for which bladder management was provided. It did not document an assessment of the genital/urinary system nor of the urinary catheter. It did not document the color, clarity, or odor of the urine. Daily skilled summaries, dated 10/03/19 and 10/04/19, documented the resident had an indwelling urinary catheter. They did not document an assessment of the genital/urinary system nor of the urinary catheter. They did not document the color, clarity, or odor of the urine. There was no daily skilled summary documented for 10/05/19. Daily skilled summaries, dated 10/06/19 and 10/07/19, documented the resident had an indwelling urinary catheter. They did not document an assessment of the genital/urinary system nor of the urinary catheter. They did not document the color, clarity, or odor of the urine. A nurse's note, dated 10/08/19 at 1:30 a.m., documented, Notified by aide that resident was not responding to assistance. Upon arrival to room, resident lying in bed with both arms raised above head in a fixed position and mouth open and twitching. Resident slow to respond to questions when trying to determine level of orientation. Displayed increased confusion and A&OX1 TO SELF. Resident just cont to repeat his name .Notified Dr. (name deleted) and adv (advised) to send resident to ER for further evaluation The emergency department triage nurse progress note, dated 10/08/19, documented, .Pt from Leisure Village. Tonights nurse reports decreased L[NAME] from pt norm approx 2200 tonight. At midnight pt was Aox1 and more lethargic than normal .Pt has new onset of tremors. Decreased UOP and decreased [MEDICAL CONDITION] output. Pt also had one episode of 'thick/clear vomitus. It came out of his mouth and made a splatter noise when it hit the ground.' According to EMS crew .[MEDICAL CONDITION], foley in place. Foley has '8/29 dated on foley collection bag.' Leaking noted around catheter . The emergency department nurse's progress note, dated 10/08/19, documented, .Pt foley removed. Pt had bloody, pus drainage from penis. Cleaned with green wipes. Foley replaced .Thick. tenacious, blood tinged/gray/red urine dranage noted in foley tubing >1100 ml noted and continuing to flow .Pt foley has total of 1500 ml of red colored urine. Pt foley flushed with 30 ml of flush, returned into catheter bag. Drainage light red in color. Clots noted . The emergency department physician's progress note, dated 10/08/19, documented, .He has an indwelling Foley catheter. Material is very exudative and appears to be pus. This catheter was removed and a significant amount of puslike material was found .Following the pus that withdraws drain was then hematuria that was manually irrigated with 30 cc and is now clearing .He is found to have acute [MEDICAL CONDITION] that I suspect is postobstructive secondary to urine was not draining . The hospital discharge summary, dated 10/16/19, documented the resident had a complicated urinary tract infection associated with his indwelling urinary catheter caused by Proteus mirabilis. The discharge summary also documented the resident [MEDICAL CONDITION] on admission likely secondary to the catheter associated urinary tract infection. The (MONTH) 2019 treatment record documented the resident's indwelling urinary catheter was to be changed on the 18th of every month. There was no documentation the indwelling urinary catheter was changed as scheduled. On 10/24/19 at 3:30 p.m., resident #1 was asked if he received timely urinary catheter care. The resident stated he did not receive urinary catheter care. On 11/12/19 at 4:20 p.m., LPN #2 was asked what his responsibilities were when a resident had an indwelling urinary catheter. He stated he was to monitor the indwelling urinary catheter, keep the catheter clean, make sure the catheter drained well, and monitor the quality of the urine. He was asked where he charted the care he provided a resident with an indwelling urinary catheter. He stated it was on the treatment sheets. He was asked when was an indwelling urinary catheter changed. He stated when it was pulled out or when it was clogged/not draining. He was asked when he had changed the catheter for resident #1. He stated he was not sure but the bulb had deflated and the indwelling urinary catheter had come out so he replaced it. He was asked if the indwelling urinary catheter was routinely scheduled to be changed. He stated he thought they were changed every two weeks. He was asked if there was any daily care he provided to residents with indwelling urinary catheters. He stated they did indwelling urinary catheter care every shift. He was asked who performed the care. He stated the nurses or the CNA was to do it when performing peri-care. On 11/13/19 at 12:10 p.m., the ADON was asked when the indwelling urinary catheter had been changed for resident #1. She stated the catheter was changed on 10/25/19 by LPN #2. She stated all other indwelling urinary catheter changes had been performed in the hospital. On 11/13/19 at 1:10 p.m., the DON and ADON was asked if the CNA documented anything related to the care of indwelling urinary catheters. The DON stated no. The ADON stated there was alot they thought were on the treatment sheets for the nurses and task screens for the CNAs to perform that were not. She stated they planned to add task screen for the CNA to chart care and urine output. On 11/13/19 at 3:40 p.m., the DON was asked what was the facility policy regarding when to change an indwelling urinary catheter. She stated they were to be changed every 30 days. She was asked how they were to know when an indwelling urinary catheter was to be changed if the resident was admitted with an indwelling urinary catheter. She stated they determined the date to change it by reviewing the documentation received with the resident or scheduling 30 days from their admitted . She stated due to the increased risk of introducing infections they did not want to change it early. She was asked what was the facility policy regarding the care of an indwelling urinary catheter. She stated nursing was to provide care every shift. She stated it was to be documented on the nurse's treatment sheet but it was not always the nurse who provided the care. She stated the CNA was also able to provide indwelling urinary catheter care and should have had a way to chart the care. She was asked if nursing staff was to assess the urine from the indwelling urinary catheter. She stated yes. She was asked where that would be charted. She stated in the clinical record. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The care plan, dated 09/17/19, documented, .Focus .Foley Catheter: I readmitted with a 16 French/30ml bulb Foley Catheter. I have (sic) one in the past and it was removed .Goal .I will show no s/sx of Urinary infection through review date .Interventions . - Catheter: last changed at hospital. Change catheter monthly . - Catheter: Position catheter bag and tubing below the level of the bladder and away from entrance room door . - Check tubing for kinks each shift . - Monitor and document intake and output as per facility policy . - Monitor for s/sx of discomfort on urination and frequency . - Monitor/document for pain/discomfort due to catheter . - Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns . The Medication Administration Record [REDACTED]. A hand written note blocked out the area of documentation noting, .On TAR . The treatment record for (MONTH) 2019 documented the indwelling urinary catheter was to be changed on the 23rd of every month. There was no documentation the indwelling urinary catheter was changed. The treatment record for (MONTH) 2019 did not document urinary catheter care. The (MONTH) 2019 monthly physician's orders [REDACTED]. The orders did not document an order for [REDACTED].>The Medication Administration Record [REDACTED]. Hand written diagonal lines blocked out the area of documentation. The treatment record for (MONTH) 2019 documented the indwelling urinary catheter was to be changed on the 23rd of every month. There was no documentation the indwelling urinary catheter was changed. The treatment record for (MONTH) 2019 did not document urinary catheter care. The quarterly assessment, dated 10/14/19, documented the resident was cognitively intact, required extensive assistance with all activities of daily living and had an indwelling urinary catheter. The (MONTH) 2019 monthly physician's orders [REDACTED]. The orders did not document an order for [REDACTED].>The Medication Administration Record [REDACTED]. A hand written note blocked out the area of documentation noting, .Nurses Book . The treatment record for (MONTH) 2019 did not document urinary catheter care. On 11/12/19 at 4:00 p.m., LPN #1 was asked what was the nurse's responsibilities for a resident with an indwelling urinary catheter. She stated the nurse was to change the indwelling urinary catheter usually every 30 days, flush the indwelling urinary catheter if ordered, obtain urine for lab work if ordered, and ensure catheter care was performed by either the CNA or licensed nurse. She was asked where the indwelling urinary catheter care was documented. She stated on the treatment sheets. She was asked to review the clinical records of residents #3 for documentation of indwelling urinary catheter care. She reviewed the clinical record and stated there was no documentation of indwelling urinary catheter care. She was asked how she knew when an indwelling urinary catheter was due to be changed. She stated it was usually scheduled to be changed 30 days from admission with an indwelling urinary catheter unless the indwelling urinary catheter was dated. On 11/13/19 at 10:35 a.m., the ADON was asked when was the indwelling urinary catheter for resident #3 last changed. She stated it was last changed on 11/08/19 but was not documented. She was asked how she knew the indwelling urinary catheter was changed on 11/08/19. She stated she received the information in report. She was asked to provide documentation of indwelling urinary catheter care for resident #3. She stated she would continue to look. On 11/13/19 at 12:10 p.m., the ADON was asked if she was able to provide the documentation of indwelling urinary catheter care for resident #3. She stated resident #3 had an order for [REDACTED]. She stated because it was not on the treatment sheets, there was no documentation of indwelling urinary catheter care. On 11/13/19 at 1:10 p.m., the DON and ADON was asked if the CNA documented anything related to the care of indwelling urinary catheters. The DON stated no. The ADON stated there was alot they thought were on the treatment sheets for the nurses and task screens for the CNAs to perform that were not. She stated they planned to add task screens for the CNA to chart care and urine output. On 11/13/19 at 3:40 p.m., the DON was asked what was the facility policy regarding when to change an indwelling urinary catheter. She stated they were to be changed every 30 days. She was asked how they were to know when an indwelling urinary catheter was to be changed if the resident was admitted with an indwelling urinary catheter. She stated they determined the date to change it by reviewing the documentation received with the resident or scheduling 30 days from their admitted . She stated due to the increased risk of introducing infections they did not want to change it early. She was asked what was the facility policy regarding the care of an indwelling urinary catheter. She stated nursing was to provide care every shift. She stated it was to be documented on the nurse's treatment sheet but it was not always the nurse who provided the care. She stated the CNA was also able to provide indwelling urinary catheter care and should have had a way to chart the care. She was asked if nursing staff was to assess the urine from the indwelling urinary catheter. She stated yes. She was asked where that would be charted. She stated in the clinical record. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission history, dated 10/30/19, documented the resident had an indwelling urinary catheter. It did not document an assessment of the genital/urinary system nor of the urinary catheter. It did not document the color, clarity, or odor of the urine. Daily skilled summaries, dated 10/31/19 and 11/01/19, documented the resident had an indwelling urinary catheter. They did not document an assessment of the genital/urinary system nor of the urinary catheter. They did not document the color, clarity, or odor of the urine. The daily skilled summary, dated 11/02/19, was not completed nor signed/locked. There was no documentation of an indwelling urinary catheter nor of an assessment of the genital/urinary system nor of the urinary catheter. It did not document the color, clarity, or odor of the urine. Daily skilled summaries, dated 11/03/19, 11/04/19, and 11/05/19, documented the resident had an indwelling urinary catheter. They did not document an assessment of the genital/urinary system nor of the urinary catheter. They did not document the color, clarity, or odor of the urine. The care plan, dated 11/05/19, documented, .Focus .Foley Catheter: I have a 18 french Foley Catheter with a 10ml bulb. I am at risk for UTI's (sic) and skin breakdown .Goal .I will remain free from catheter-related trauma through review date .Interventions . - Catheter: last changed at hospital. Change catheter as ordered . - Catheter: Position catheter bag and tubing below the level of the bladder and away from entrance room door . - Check tubing for kinks each shift . - Foley cath care with soap and water every shift and as needed . - Monitor and document output as per facility policy . - Monitor for s/sx of discomfort on urination and frequency . - Monitor/document for pain/discomfort due to catheter . - Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns . The admission assessment, dated 11/06/19, documented the resident was intact in cognition, required extensive assistance with activities of daily living, and had an indwelling urinary catheter. The daily skilled summary, dated 11/06/19, documented the resident had an indwelling urinary catheter. It did not document an assessment of the genital/urinary system nor of the urinary catheter. It did not document the color, clarity, or odor of the urine. The daily skilled summary, dated 11/07/19, documented the resident utilized adult briefs. It did not document an assessment of the genital/urinary system. It did not document the color, clarity, or odor of the urine. There was no documentation to indicate the indwelling urinary catheter had been discontinued/removed. The daily skilled summary, dated 11/08/19, documented the resident was always continent of urine. It did not document an assessment of the genital/urinary system. It did not document the color, clarity, or odor of the urine. There was no documentation to indicate the indwelling urinary catheter had been discontinued/removed. The (MONTH) 2019 monthly physician's orders [REDACTED]. The orders did not address catheter care. Daily skilled summaries, dated 11/11/19 and 11/12/19, documented the resident was always continent of urine. They did not document an assessment of the genital/urinary system. They did not document the color, clarity, or odor of the urine. There was no documentation to indicate the indwelling urinary catheter had been discontinued/removed. On 11/12/19 at 4:00 p.m., LPN #1 was asked what was the nurse's responsibilities for a resident with an indwelling urinary catheter. She stated the nurse was to change the indwelling urinary catheter usually every 30 days, flush the indwelling urinary catheter if ordered, obtain urine for lab work if ordered, and ensure catheter care was performed by either the CNA or licensed nurse. She was asked where the indwelling urinary catheter care was documented. She stated on the treatment sheets. She was asked to review the clinical records of residents #4 for documentation of indwelling urinary catheter care. She reviewed the clinical record and stated there was no documentation of indwelling urinary catheter care. She was asked how she knew when an indwelling urinary catheter was due to be changed. She stated it was usually scheduled to be changed 30 days from admission with an indwelling urinary catheter unless the indwelling urinary catheter was dated. The daily skilled summary, dated 11/13/19, documented the resident had an indwelling urinary catheter. It did not document an assessment of the genital/urinary system nor of the urinary catheter. It did not document the color, clarity, or odor of the urine. The treatment record for (MONTH) 2019 did not document urinary catheter care. A review of the nurses' progress note revealed no documentation of indwelling urinary catheter assessment, care, discontinuation, or insertion. On 11/13/19 at 10:35 a.m., the ADON was asked to review the clinical record for resident #4 and provide documentation of indwelling urinary catheter care. She stated the indwelling urinary catheter was placed on 10/30/19 but there was no documentation of indwelling urinary catheter care. On 11/13/19 at 1:10 p.m., the DON and ADON was asked if the CNA documented anything related to the care of indwelling urinary catheters. The DON stated no. The ADON stated there was alot they thought were on the treatment sheets for the nurses and task screens for the CNAs to perform that were not. She stated they planned to add task screens for the CNA to chart care and urine output. On 11/13/19 at 3:40 p.m., the DON was asked what was the facility policy regarding when to change an indwelling urinary catheter. She stated they were to be changed every 30 days. She was asked how they were to know when an indwelling urinary catheter was to be changed if the resident was admitted with an indwelling urinary catheter. She stated they determined the date to change it by reviewing the documentation received with the resident or scheduling 30 days from their admitted . She stated due to the increased risk of introducing infections they did not want to change it early. She was asked what was the facility policy regarding the care of an indwelling urinary catheter. She stated nursing was to provide care every shift. She stated it was to be documented on the nurse's treatment sheet but it was not always the nurse who provided the care. She stated the CNA was also able to provide indwelling urinary catheter care and should have had a way to chart the care. She was asked if nursing staff was to assess the urine from the indwelling urinary catheter. She stated yes. She was asked where that would be charted. She stated in the clinical record.

Based on record review, observation, and interview, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement inteventions to aid in the prevention of falls, and failed to ensure a resident with a history of falling from the bed was not left unsupervised with the bed in a high position for one (#4) of six residents who were reviewed for falls. Resident #4 fell from the bed and sustained a laceration to her forehead, a subdural hematoma, a cervical 1 fracture, and a type II dens fracture. The facility identified 72 residents who were at high risk for falls. Findings: A falls management guidelines overview policy, with a revision date of 07/14/17, documented, .If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall scale, completed on 08/12/17, documented the resident's .Score: 60 .Category: High Risk for Falling .Scoring: High Risk 45 or higher . A care plan, dated 08/14/17, documented, Focus .is at risk for falls r/t decreased safety awareness, L sided weakness, [MEDICAL CONDITION], hx of falling, pain, use of [MEDICAL CONDITION] medications, and need for assist with transfers and mobility .Goal: Fall related injuries will be minimized .Interventions: Anticipate and meet the Residents needs. Encourage the Resident to call for assistance .Check with res frequently to see if she needs assist with toileting .Keep frequently used items within easy reach of res .Monitor res need for pain relief .Ensure res room is free from clutter and spills .Concave mattress to define perimeter of bed .Encourage the Resident to wear appropriate footwear when transferring or ambulating: rubber sole shoes, nonskid socks .Follow therapy recommendations for transfers and mobility .Place call light within reach while in room .Sitter in the evenings on 10-7am shift to provide 1:1 care . An incident report, dated 08/21/17 at 03:01 a.m., documented, .Was sitting on floor. Moves ext. with out discomfort. No bruising or abrasions noted. Red area on left cheek under neath (sic) the eye. Stated She rolled out of bed hitting eye on chair arm that was padded. Denies pain except for the area underneath eye Stated That she went to turn over and roll (sic) out of bed .Immediate Action Taken .Was assisted back to bed. Ice pack to cheek. Resident provided with a concave mattress to define the Parameter of bed. The state reported incident, dated 08/21/17, documented, .CNA found resident sitting on the floor beside her bed .has a red area to left cheek under eye. Resident able to move all extremities without difficulty. Family and physician notified. Neuro checks initiated. Resident stated I went to turn over and rolled out of bed. Resident is confused and disoriented. Resident was dressed in her night clothes with no socks on. Bed was checked and found to be in lowest position for resident transfer, bed found to be in locked position. Area around incident was checked for any environmental hazards and none were found .Bolster overlay will be placed on bed to define the parameters of the bed, fall mat placed beside bed for added protection . The care plan did not address any new fall interventions to be implemented after the resident had fallen on 08/21/17. An incident report, dated 09/15/17 at 9:53 p.m., documented, .resident was laying in the floor on her back in night gown on and no brief she had small amount of loose stool in the floor on the ground under her .resident was pleasant, when asked if she could move her right leg she didn't need assistance even moving either leg she also said I can move both arms too .Immediate Action Taken .called and talked to husband .as well as notified Dr . The care plan did not address any new fall interventions to be implemented after the resident had fallen from the bed on 09/15/17. A fall scale, completed on 09/15/17, documented the resident's .Score: 75 .Category: High Risk for Falling .Scoring: High Risk 45 or higher . An incident report, dated 09/18/17 at 6:09 a.m., documented, .Resident sitting on floor in front of chair in her room. Legs straight out in front. med hematoma to right sideupper (sic) on head. Denies headache. Moves all ext to the best of her abilities. No bruising or abrasions noted. Had non skid socks on. Alert. Stated I was getting up and walking and my legs gave out and I sit (sic) down. Could not tell what she bumped head on .Immediate Action Taken .Assisted back to bed. Ice pack to head. She uses walker but apparently didn't have in use at this time . A state reported incident, dated 09/18/17, documented, .resident .got out of her bed attempted to self transfer, legs became weak and fell . Resident was sitting in front of her wheelchair, legs straight out in front of her .noted a hematoma to right side of head, bruising noted to area no open areas noted .Neuro checks initiated. Family and physician notified. Resident has full range of motion to all extremities without difficulty. Resident noted to be in non-skid socks and gown .Resident sent to hospital due to critical potassium level .Upon return from hospital care plan will be updated. Therapy eval to be done upon return from hospital . The care plan, updated 09/18/17, documented, .Interventions: Follow therapy recommendations for mobility, safety, and transfers. See Physical therapy notes. Handhold assistance for balance support .frequent checks on rounds for ADL care needs, mobility needs . An admission assessment, dated 09/19/17, documented the resident had a BIMS score of 10, this score indicated the resident was moderately impaired for daily decision making. The assessment documented the resident had exhibited physical and verbal behaviors in the past one to three days, required supervision with extensive assistance with bed mobility, transfers, mobility, dressing, toileting, personal hygiene, and bathing. The assessment documented the resident was frequently incontinent of bowel and bladder, and had one non-injury fall and one fall with injury fall since admission. The assessment documented the resident had received an antipsychotic medication three of the last seven days, an antianxiety medication one of the last seven days, an antidepressant medication three of the last seven days, and an anticoagulant five of the last seven days. A fall scale, completed on 09/21/17, documented the resident's .Score: 55 .Category: High Risk for Falling .Scoring: High Risk 45 or higher . An incident report, dated 09/26/17 at 1:22 a.m., documented, .Kept trying to climb out of bed. Several times she was lay (sic) back down. CNA had step (sic) out of the room and she was on the floor. Trying to put her back to bed. she was scratching and hitting at staff. Unable to obtain vital signs. Yelling and screaming .Immediate Action Taken: Refused [MEDICATION NAME] was able to give some of the [MEDICATION NAME] before she spit it out. Moved off of floor to geri chair. Hospice notified to obtain topical [MEDICATION NAME] but cannot receive till (sic) am (sic) . The care plan did not address any new fall interventions to be implemented after the resident had fallen from the bed on 09/26/17. An incident report, dated 09/26/17 at 7:53 a.m., documented, Resident started screaming and curessing (sic) .nurse went to room where she was kicking she throug (sic) her legs off the bed and then just sat her self to the floor .nurse assisted her to lay (sic) down .Immediate Action Taken .Dr .was notified as well as family DR .gave N/O for [MEDICATION NAME] 2.MG/ML .Hospice was notfied (sic) of N/O .Hospice (sic) said it be out A.S.A.P. She would go get it and bring it outherself (sic). The care plan did not address any new fall interventions to be implemented after the resident had fallen from the bed on 09/26/17. An incident report, dated 09/27/17 at 10:03 a.m., documented, .@ 1000 resident observed alert and lying on her back scooting herself on the floor in the middle of her room. Able to MAE. C/O pain to RLE where a 2cm superficial skin tear was observed. No bumps or swelling observed .Immediate Action Taken .Assisted dressing in cloths (sic) and into geri chair for 1:1 . The care plan, updated 09/28/17, documented, .Private sitter obtained due to increase in behaviors and recent fall on 9/27/17. During episodes of increased behaviors and if no sitter or family available assist (name deleted) into gerichair and out to commons area for increased visualization and 1:1 . An incident report, 10/30/17, documented, .Slid out of recliner. Had not been able to keep in bed or her geri chair. Tried recliner with foot up and she went to sleep. Few minutes later she was sitting on floor. Pull (sic) off of the chair and put under her head and laid down on floor. No bruising or abrasions noted .Immediate Action Taken .Assisted to geri chair taken to her room. Brief change and return to geri chair and returned to front where she could be monitored . The care plan, updated 10/30/17, documented, .had a non-injury fall. She slid out of her geri chair. She had c/o pain. Hospice will be contacted to review her pain medications. RN pain assessment will be completed by DON .review pain medication, no (sic) for Tylenol and keep [MEDICATION NAME] PRN. An incident report, dated 11/03/17 at 7:15 a.m., documented, .Resident was observed sitting on her knees on the floor with her hands on the bed as in a praying position. Resident alert and aware of surroundings. MAE without difficulty. No bruiseing redness or swelling observed. No s/sx of pain or discomfort. Staff observed that all ties were not tied down on air mattress so air mattress shifted allowing weight to slide off bed .Immediate Action Taken .nurse tied all straps to mattress . The care plan did not address any new fall interventions to be implemented after the resident had fallen from the bed on 11/03/17. An incident report, dated 11/26/17 at 3:52 p.m., documented, .Staff called .nurse to room where resident was laying (sic) in the floor on the left side she had a brife (sic) on with T-shirt Resident denied hitting head, but did note a blueish area on forehead .Immediate Action Taken .Nero (sic) checke (sic) were started and family was notified as well as dR (sic) .did remind staff to make sure the blue matt(sic) was next to bed . The care plan, updated on 11/26/17, documented, .had a fall. Neuro checks initiated .was moved to another room before this fall d/t safety concerns r/t the bed hospice delivered for her. It is possible this fall is r/t the move and change in environment .Intervention: A new bed was delivered by hospice .will be moved back to her room and her normal environment . An incident report, dated 12/12/17 at 3:13 p.m., documented, .resident was found laying on the fall mat on left side had brief on as well as shirt resident was able to move her lower extremities are able to move somewhat she is contracted bilateral resident stated she did not know how she rolled off the bed. did c/o shoulder pain and stated she thought she hit her forehead .Immediate Action Taken .Dr .notified .received n/o to x-ray left shoulder to r/o fx from fall . The care plan, updated on 12/12/17, documented, .had non-injury fall .rolled out of bed. She was found laying on her fall mat .Intervention: X-ray was ordered, results were neg for fx. Hospice to provide bolsters to provide parameters for the edge of the bed . A fall scale, completed on 12/21/17, documented the resident's .Score: 75 .Category: High Risk for Falling .Scoring: High Risk 45 or higher . A quarterly assessment, dated 12/26/17, documented the resident had a BIMS score of six, this score indicated the resident was severely impaired for daily decision making. The assessment documented the resident required supervision with extensive assistance with bed mobility, transfers, mobility, dressing, toileting, personal hygiene, and bathing and had impairment to one both the upper and lower extremity on one side. The assessment documented the resident was always incontinent of bowel and bladder, and had two or more non-injury fall and one fall with injury fall since prior assessment. The assessment documented the resident had received an antipsychotic medication seven of the last seven days and an antianxiety medication seven of the last seven days. An incident report, dated 01/24/18 at 7:50 a.m., documented, .Resident was yelling I fell , I fell !. CNAs found that resident had fallen out of her bed onto the floor and had blood on the front of her head and on the floor. The fall was not witnessed by any staff member. CNA stated she was getting Resident up for breakfast with the bed elevated, left the room for a moment, and Resident fell off the bed. CNA stated she had forgotten to lower the bed before leaving the room. Nursing notified and upon basic inspection of Resident's condition discovered the bleeding was coming from an open gash on the Resident's forehead and a cut on Resident's bridge of her nose .Immediate Action Taken .911 called immediately and they arrived at approximately 0800. ADON applied gauze bandage to the Resident's head to try and stop the bleeding . A state reportable incident, dated 01/24/18, documented, .Resident rolled off her bed. She has blood to her forehead. Sent to .Hospital for assessment and intervention .Employee .states she was changing resident and noticed something on her bottom. She went to the hallway to get the nurse. When she came back into the room the resident had fallen off the bed on to the floor. Employee was suspended during investigation. Employee had raised the bed to change the resident. There was nothing in the care plan that stated low bed or mats for the resident. Employee states she probably should have lowered the bed when she went to get the nurse. Employee was brought back to work the following day. Resident went to the hospital and was discharged home . The care plan did not address any new fall interventions to be implemented after the resident had fallen from the bed on 01/24/18. Hopital records for the resident were obtained on 01/31/18. The final report documented, .An 83 y/o female with a hx of HTN, HLD, [MEDICAL CONDITION], and [MEDICAL CONDITION] presents to the ED following a fall that occurred this AM. Pt fell from her bed this morning, approximately 3 ft off the ground. No L[NAME] .She currently presents with a laceration on her forehead and bleeding. She also states that she can't move her head from the pain .She was initially evaluated by ED physicians including indicated imaging showing a subdural hematoma, C1 fracture, and type II dens fracture. The husband was very clear in that the patient would not want to have aggressive measures She was made comfortable while in the hospital and was discharged on [DATE] home with hospice care. On 01/31/18 at 11:05 a.m., CNA #1 was was asked if she had cared for the resident on the morning of 01/24/18. She was asked if the resident was a fall risk. She stated, She was a fall risk. She was asked what interventions were to be used for the resident. She stated the bed was to be in lowest position and a fall mat. The CNA was asked if those interventions were in place at the time of the resident's fall. She stated, I had raised the bed to dress the resident for breakfast. Her roommate distracted me, I took the roommate out of the room to the nurse, and I didn't think to lower the bed down or to replace the fall mat. At 1:38 p.m., the DON, ADON, and regional nurse were interviewed. They were asked how interventions to prevent further falls were determined. The DON stated, We try to determine the cause of the fall and put interventions in place at that time. The falls are reviewed in morning meetings. They were asked how they made staff aware of the new interventions. The DON stated, Typically I go to the charge nurse and then the staff on the hall to let them know the intervention. They are updated verbally and the care plan is updated. The DON was asked when care plans were updated. She stated, At the morning meetings. The DON was asked what was the facility fall policy. She stated, I can not, we've been going over the policies. The DON was asked how the falls were documented. She stated, The nurse was to assess the resident, address the fall, notify the physician, family, and the DON, complete an incident report, document in the progress notes, and provide an intervention. The ADON was asked what was the circumstance regarding the fall for resident #4 on 01/24/18. She stated, I went into the resident's room after the fall. In my opinion she slid out of bed and received a laceration to the middle of her forehead. The ADON was asked if the resident's bed was raised up higher than it should have been. She stated, Yes. She was asked if the fall mat was beside the bed. She stated, No. The regional nurse was asked if the facility caused the resident's fall with injury. She stated, The CNA did leave the resident unattended with the bed in highest position and without the fall mat beside the bed. She was suspended and re-educated.

Based on observation, record review and interview, it was determined the facility failed to ensure: ~ a mechanical lift was used for all transfers for one (#1) of four sampled residents who required the use of a mechanical lift for transfers. Resident #1 was transferred by one staff member two times on 01/20/15 without the use of a mechanical lift. Bruising was observed to the left knee on 01/20/15 and an xray revealed a fracture of the left tibia. ~ the appropriate size of sling was used with the mechanical lift for one (#2) of three sampled residents observed during transfers utilizing mechanical lifts. ~ Slings utilized with mechanical lifts were in good repair for one (#6) of three sampled residents observed during transfers utilizing mechanical lifts. The facility identified six residents who required the use of mechanical lifts. Findings: A policy, dated 01/01/14, and titled Using a Mechanical Lift, documented, "...Place the sling, fan-folded, along the back of the resident (Note: Be sure the top of the sling is at the head of the resident and the bottom at the resident's knees.)..." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 11/04/14, documented, "...Focus...I am High risk for falls r/t Unaware (sic) of safety needs and Confusion...Goal...I will be free of falls through the review date...Interventions...Anticipate and meet my needs. Follow facility fall protocol. Pt evaluate and treat as ordered or PRN. I am a hoyer lift d/t my pathological fx. Staff to use a lift for all transfers...Focus...I have Pathological Bone Fracture of unknown origin consider Osteoporosis...Goal...I will not develop complications or permanent loss of mobility related to fracture through review date...Interventions...Encourage use of affected limb as much as tolerated, to help maintain range of motion. Give pain, anti-inflammatory medications as ordered. Monitor/document side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. PT, OT evaluate and treat as indicated..." A physical therapy progress and discharge summary documented, "...**GOAL NOT MET - on 1/13/2015**The patient will be able to transfer from bed < > wheelchair with mod assistance and be able to sit in wheelchair for 60 mins and propel self in wheelchair for 50 ft x 2. Explanation: Limited mobility and patient is more than a 1 person assist transfer and requires the hoyer lift for all transfers..." A daily skilled nurse's note, dated 01/20/15 at 7:00 p.m., documented, "...1900 Res. in w/c in tv area. Alert (no) c/o. Edema to BLE, ate in D/R c assistance. (No) s/s of distress. (No) s/s of SOB. Smiles pleasant & cooperative with care. 2015 Aide called nurse to room to look @ a bruise as she described to nurse as on (upper) thigh. Came to room, light yellow bruising noted to top of (L) knee/leg. (No) c/o pain to site. ROM to LLE (without) difficulty or pain from side to side. Advised aide to elevate c pillow..." A statement by CNA #1, dated 01/21/15, documented, "...I am writing this statement about (resident #1). I transferred the resident with one assist. I was not aware she was a hoyer, the transfer was fine, with not problems. I don't have the front end of the hall. I was helping because the aide that was working left and didn't come back after her lunch break...When I took the resident cloths (sic) off, I found a bruise around the top of her knee and below, purple, black, and it didn't look right. So I informed the nurse. (Another aide) showered the resident Monday evening and we didn't notice the bruise. This had to have been around 8pm Tuesday..." A final state reportable incident report, faxed 01/28/15, documented, "...Resident had a retrograde femoral nail for a displaced supracondylar femur fracture on October 8th. Prior to previous fracture, resident able to transfer into wheelchair with minimal assistance, and would propel self in wheelchair. On 1-20, bruising noted to left lower knee area. Xray ordered. results were fx of left tibia. All staff who care for her was interviewed. No reports of inappropriate transfers or injuries. Returned from hospital on 1-27-15. Immobilizer in place to left lower extremity. Resident alert with no signs or symptoms of pain..." On 02/04/15 at 10:20 a.m., CNA #3 was asked how resident #1 transferred to and from the bed. The CNA stated the resident was on bedrest since returning from the hospital with a fractured leg. She stated that before the fracture, resident #1 transferred using a hoyer lift. CNA #3 stated the facility had a no lift policy which meant any resident who required two person assistance would be transferred by mechanical lift. On 02/04/15 at 2:50 p.m., CNA #1 was asked if she had worked with resident #1 on the 20th of January. The CNA stated she worked the 2 p.m. to 10 p.m. shift on the 20th of January. The CNA was asked if she transferred resident #1 the evening of the 20th of January. The CNA stated she transferred resident #1 between 7 p.m. and 8 p.m. that evening. She stated the resident stood up with her holding onto the back of the resident's pants and the resident placed her arms over her shoulder's in a hug like embrace. The CNA stated she helped the resident lay in bed by supporting her legs. She stated she got her undressed and saw the bruising around the knee but noticed there was no swelling yet. The CNA was asked how she knew how to transfer the resident. The CNA stated, "I didn't see any card saying how she transferred on her wall or bed. She had recently moved over from the east side. The CNA was asked where staff can look to find the transfer status of a resident. The CNA stated, "In the ADL book they have a list of resident's who require a hoyer or sit-to-stand." The CNA was asked if resident #1 was on that list. The CNA stated, "No, I did not see her name on there." The CNA was again asked how she knew how resident #1 transferred. The CNA stated, "If they are not on the list, they can transfer with the help of one person." On 02/05/15 at 09:55 a.m., the MDS coordinator was asked when had she updated the care plan for resident #1 to reflect the use of a hoyer lift. The MDS coordinator stated she had updated the care plan some time in November after therapy had determined the resident needed to be a mechanical lift. The MDS coordinator stated, "She is an extensive assist on everything and we are a no lift facility so our staff know to use the hoyer." On 02/05/15 at 11:15 a.m., the physical therapy assistant (PTA) was asked if she had worked with resident #1. The PTA stated, "Yes. You will see therapy notes showing our goals and current level of functioning." The PTA was asked if resident #1 could bear weight. The PTA stated, "No. She required max assist with therapy and my notes reflect facility staff to use a mechanical lift with her." The PTA was asked if resident #1 was able to transfer without a mechanical lift while a resident in the facility. The PTA stated, "No. My recommendation was for her to use a mechanical lift at all times. I never changed that recommendation nor gave them permission to transfer her any other way than with a mechanical lift." On 02/05/15 at 3:15 p.m., CNA #2 was asked if she had worked the evening shift on the 20th of January. The CNA stated she had started working at the facility on the 10th of January for weekend doubles and picked up an extra shift on the evening of the 20th of January. The CNA was asked if she received an orientation at the facility. The CNA stated she had been instructed to follow another CNA for a shift. She stated the CNA she followed was assigned to the back half of the hall and not the front half of the hall where she was hired to work and so she was not oriented to the residents she would be working with. The CNA was asked where staff can find the transfer status of a resident in the facility. The CNA stated, "In the ADL book." The CNA was asked how resident #1 transferred. The CNA stated, "I did not know she was a hoyer lift til after I got in trouble for it. I transferred (resident #1) with a gait belt to the wheelchair. I did not know about the ADL books until after the transfer of (resident #1)." The CNA was asked how she transferred resident #1. The CNA stated, "I did a stand/pivot transfer. I started rocking and stood up, twisted, and turned around to the wheelchair. I rested and put her in the wheelchair. The wheelchair only had one foot rest on the right side. I told her, '(Resident #1) we're gonna go and she lifted the (left) foot up and held it up all the way to the dining room.'" The CNA was asked if she had taken resident #1 into the dining room. The CNA stated, "I pushed her to the dining room table." The CNA was asked if resident #1 had hit her legs on anything during the transport to the dining room or while positioning the wheelchair near the dining room table. The CNA stated, "No, her legs did not hit anything." On 02/05/15 at 1:45 p.m., the physician for resident #1 was asked what may have caused the left tibial fracture for resident #1. The physician stated it was a weight bearing type of fracture. He stated with the resident's history of osteoporosis and such, any time she was twisting or putting tension on the area, it may cause a spontaneous fracture. The physician was asked if the fracture could have happened while the resident was in bed. The physician stated it was unlikely. He stated the fracture could have happened in bed but it would have had to have happened during a turn or some other way where physical stress would have been applied to the area. On 02/12/15 at 08:27 a.m., the DON and MDS coordinator were asked how the CNA's know who requires the use of a lift. The DON stated there was a list in the ADL book. If the resident was not on the lift list, there were able to transfer with assistance. The DON and MDS coordinator were asked how did the CNA know what type or hor much assistance was required. The MDS coordinator stated there was no place where it stated what each resident required to transfer as a one or two person assist. The DON and MDS coordinator were asked what type of training do the staff receive on using the lift. The MDS coordinator stated that before the rehabilitation aide would do inserves which included a demonstration. The DON and MDS coordinator were asked when did they last receive training on using a lift. The MDS coordinator stated she did not remember the last inservice on using a lift but there was a sign off sheet. The DON and MDS coordinator were asked what training new employees received in using a lift. The MDS coordinator stated that in the last month, the new employees had been checked off on the use of a lift but before then, it was performed on their CNA proficiency. The DON and MDS coordinator were asked how often the CNAs were assessed for proficiency. The DON stated the MDS coordinator had been performing the CNA proficiencies yearly and on hire date. The DON and MDS coordinator were asked who ensured CNA proficiency on a day to day basis. The DON stated if someone was to see a problem, they would correct it by doing an inservice and the nurses, therapists, and rehabilitation aide would monitor the progress. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 12/29/14, documented the resident was cognitively moderately impaired and required extensive two person assist with transfers. The care plan, initiated 01/16/15, documented, "...Focus...I need extensive assistance with my adls as I am weak and have dementia. Please use a hoyer lift to transfer me as I am unable to stand. I need assistance with eating my meals, bathing, dressing, toileting, hygiene, bed mobility and transfers...Goal...I will maintain a clean, well groomed appearance x 90 days...Interventions...Allow extra time to perform adls as it may be painful and tiring...Hoyer lift with assist of 2 for transfers..." On 02/04/15 at 1:30 p.m., CNA #3 was observed to transfer resident #2 from the chair to bed with a mechanical lift. The resident was previously positioned in a sling. The lift was placed above the resident and the sling was attached using colored coded loops. The resident was lifted into the air. The sling was observed to be very large. The area of the sling used to support the resident's head and shoulders was well above the resident's head. The sling curved over and above the resident's head, pushing her head downward and pinning her chin to her chest. The resident's shoulders were drawn inward and towards one another and her legs were drawn tight against each other. The resident was transferred to the bed without incident. On 02/04/15 at 1:50 p.m., CNA #3 and CNA #4 were observed to transfer another resident to bed. CNA #3 stated they needed to adjust the position of the sling downward to support the head and shoulders or the transfer would be like it was for resident #2. CNA #3 was asked what had been wrong with the transfer of resident #2. The CNA stated the sling was too big and did not support her head and shoulders. She stated the facility did not have the right size sling to transfer resident #2. The CNA was asked if she had informed anyone of the need for a sling for resident #2. She stated, "Oh yea, the nurses know." On 02/12/15 at 08:27 a.m., the DON and MDS coordinator were asked how the CNA's know who requires the use of a lift. The DON stated there was a list in the ADL book. If the resident was not on the lift list, there were able to transfer with assistance. The DON and MDS coordinator were asked how did the CNA know what type or hor much assistance was required. The MDS coordinator stated there was no place where it stated what each resident required to transfer as a one or two person assist. The DON and MDS coordinator were asked what type of training do the staff receive on using the lift. The MDS coordinator stated that before the rehabilitation aide would do inserves which included a demonstration. The DON and MDS coordinator were asked when did they last receive training on using a lift. The MDS coordinator stated she did not remember the last inservice on using a lift but there was a sign off sheet. The DON and MDS coordinator were asked what training new employees received in using a lift. The MDS coordinator stated that in the last month, the new employees had been checked off on the use of a lift but before then, it was performed on their CNA proficiency. The DON and MDS coordinator were asked how often the CNAs were assessed for proficiency. The DON stated the MDS coordinator had been performing the CNA proficiencies yearly and on hire date. The DON and MDS coordinator were asked who ensured CNA proficiency on a day to day basis. The DON stated if someone was to see a problem, they would correct it by doing an inservice and the nurses, therapists, and rehabilitation aide would monitor the progress. 3. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 01/20/15, documented the resident was cognitively moderately impaired and required extensive two person assistance with transfers. On 02/05/15 at 5:40 p.m., CNA #4 and CNA #5 were observed to transfer resident #6 from the chair to bed with a sit to stand mechanical lift. The resident sat forward in the chair and a sling was placed inside out and around the resident's back and secured with a three inch wide nylon belt and plastic buckle across the resident's abdomen. There was no padding present on the nylon belt or buckle. The resident's feet were positioned on the platform of the lift and the sling was attached to the lift. The lift was engaged and the resident was lifted from the chair but remained in a bent and seated position while the lift was pushed to the bed. The nylon belt and buckle was observed to be across the left ribcage and chest and under the resident's right breast. There were two strips of terrycloth padding approximately 3 inches wide and more than a foot long waving from each side of the sling. The resident was transferred to the bed without incident. CNA #4 was asked what the loose terrycloth padding was used for on the sling. The CNA stated, "It's extra pieces I guess." CNA #5 stated that the extra terrycloth looked like it once was secured to the nylon belt and pointed to a broken strap on the back of one of the terrycloth pads. CNA #5 stated that many of the slings were in need of repair and not all of their lift equipment was in working order. On 02/06/15 at 5:10 p.m., the DON was observed to be marking with a permanent marker on the sit to stand sling used to transfer resident #6. The DON stated he was marking which side of the sling was to be positioned against the resident. The DON held up one of the terrycloth pads and said he thought this could be fixed so it again attached to one side of the nylon belt. On 02/12/15 at 08:27 a.m., the DON and MDS coordinator were asked how the CNA's know who requires the use of a lift. The DON stated there was a list in the ADL book. If the resident was not on the lift list, there were able to transfer with assistance. The DON and MDS coordinator were asked how did the CNA know what type or hor much assistance was required. The MDS coordinator stated there was no place where it stated what each resident required to transfer as a one or two person assist. The DON and MDS coordinator were asked what type of training do the staff receive on using the lift. The MDS coordinator stated that before the rehabilitation aide would do inserves which included a demonstration. The DON and MDS coordinator were asked when did they last receive training on using a lift. The MDS coordinator stated she did not remember the last inservice on using a lift but there was a sign off sheet. The DON and MDS coordinator were asked what training new employees received in using a lift. The MDS coordinator stated that in the last month, the new employees had been checked off on the use of a lift but before then, it was performed on their CNA proficiency. The DON and MDS coordinator were asked how often the CNAs were assessed for proficiency. The DON stated the MDS coordinator had been performing the CNA proficiencies yearly and on hire date. The DON and MDS coordinator were asked who ensured CNA proficiency on a day to day basis. The DON stated if someone was to see a problem, they would correct it by doing an inservice and the nurses, therapists, and rehabilitation aide would monitor the progress.

On 12/04/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to thoroughly investigate an incident of potential sexual abuse and ensure protection of residents from the likelihood of further abuse. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to thoroughly investigate an incident of potential sexual abuse and protect residents. At 4:25 p.m., the administrator and DON were informed of the IJ related to the facility's failure to thoroughly investigate an incident of potential sexual abuse and protect residents. At 7:44 p.m., an acceptable plan of removal was provided. The plan of removal documented, "...Corrective Action: a. At 4:40 p.m. the administrative staff were informed of new information related to an allegation of resident to resident abuse. b. At 4:45 p.m. facility initiated abuse policy and procedure. c. At 5:00 p.m. on 12/4/14 a third interview, second in person interview, was completed with (CNA #2). New information was obtained during this interview. The new information coincides with what (CNA #2) stated to surveyor. This is the first time the Administrative staff were told this information. (CNA #2) was interviewed at length by the Administrative staff earlier in the day (approximately noon) and did NOT obtain the same information that was obtained at 5:00 p.m. interview. d. At 5:10 p.m. male resident was put on one-on-one supervision with 15 minute documentation. e. At 5:20 physician for both residents (they both have physician) was called. An urgent message was left. d. (sic) At 5:26 p.m. the Tulsa Police Department was notified. e. (sic) At 5:40 initial OSDH form 283 completed and faxed to OSDH and DHS. f. At 5:43 DON called responsible party of both involved residents. g. At 5:48 p.m. two officers from Tula (sic) Police Department arrived. Officer (names withheld). Monitoring: The male resident will have one-on-one monitoring until resident can be appropriately placed for a psychiatric evaluation. The facility will ensure protection of others when behaviors occur. This monitoring will be documented every 15 minutes. Facility is communicating with families of both residents. Staff will be in-serviced on abuse reporting, definitions of abuse, abuse policy and procedure, investigative protocol, appropriate notifications, protection of residents, appropriate interventions for residents with dementia and monitoring of residents that wander. In-servicing will begin immediately with each shift personnel prior to them being able to work on the hall. No employees will be allowed to work on the hall before being in-serviced. In-servicing begins immediately and will be completed by 12/5/14 by 5:00 p.m. If any employees have not completed in-service by 5:00 p.m. on 12/5/14, they will be removed from the schedule. Any employees currently on vacation time will be in-serviced before they can return to work. In-services will be completed by Administrator, DON, and QA Nurse. Facility staff will monitor all residents that wander or have behaviors on the dementia care neighborhood." On 12/08/14 at 8:45 a.m., the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 12/08/14 in regards to their knowledge of the inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 12/06/14 at 6:52 a.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to thoroughly investigate an incident of potential sexual abuse involving one (#1) of four sampled residents who were identified as having sexually inappropriate behaviors. The facility also failed to protect residents from the likelihood of further abuse. This had the likelihood to affect 87 residents who resided at the facility. Findings: A policy, titled Abuse and neglect prevention, dated, 01/01/14, documented, "...Purpose: To establish guidelines that prevents, identifies and report resident abuse and neglect... The resident has the right to be free from verbal, sexual...abuse...It is the policy of the facility, to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse... Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents... 'Sexual abuse' includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault... It is the responsibility of the Administrator and Director of Nursing Services to ensure the training of employees, through orientation and on-going in-services on issues related to abuse prohibition practices such as...Appropriate interventions to deal with aggressive and/or catastrophic reactions of Residents...What constitutes abuse... Provide residents, families and staff information on how and to whom they may report concerns, incidents.... Identify, correct, and intervene in situations in which abuse...is more likely to occur... The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, or behaviors such as entering other residents' rooms... The Administrator and/or the Director of Nursing Services are responsible for initiation of the investigation immediately upon notification of alleged event or findings. Facility will document investigation findings, including witness statements, corrective actions, and conclusions in administrative file... for taking immediate action and ensuring the resident is protected from harm during the investigation of the alleged incident..." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 06/05/14, documented, "...Cognition...I have a [DIAGNOSES REDACTED]. I have disorganized thinking and impaired decision making skills...Psych evaluation as warranted by my doctor... Behavior...I can become angry, agitated, and resist care at times...If I become inappropriately agitated wander in out (sic) of rooms. Please redirect me. Involve me c activities & 1 on 1... Elopement/wandering (sic)...I have a dx of Alzheimer's and [MEDICAL CONDITION]. I am independent with ambulation..." A nurse's note, dated 10/15/14 at 6:30 a.m., documented, "...Resident observed coming out of (resident #2's) room. (Resident #2) was asleep and undisturbed. Staff instructed resident to stay out of (resident #2's) room. Redirection sucessful (sic) momatarily (sic)..." A nurse's note, dated 10/15/14 at 9:00 a.m., documented, "...Resident observed kissing (resident #2) in the dining room. Resident was instructed by staff that (resident #2) is not his wife and is married. Resident stated 'well I am married too.' Redirection momertarily (sic) sucessful (sic)..." Another nurse's note, dated 10/15/14 at 9:00 a.m., documented, "...Resident was observed coming out of (resident #2's) room. (Resident #2) was asleep. (CNA #1) checked on (resident #2) and observed that she was undisturbed. CNA informed Resident that he was not allowed to go into (resident #2's) room when (resident #2) was asleep. 12:45 p.m. Resident was observed attempting to kiss (resident #2's) face. (CNA #8) stoped (sic) and redirected resident and informed resident that (resident #2) was a married woman. Redirection successful..." A nurse's note, dated 10/16/14 at 7:30 a.m., documented, "...Resident was coming out of (resident #2's) room. Resident was informed that was not his room and he was not to go into (resident #2's) room w/out her permission. This nurse checked on (resident #2) and she stated she was 'ok' but wanted to go back to sleep..." A nurse's note, dated 10/16/14 at 1:00 p.m., documented, "...Resident was observed trying to kiss (resident #2). Staff redirected resident. Resident was heard telling (resident #2) that he wasn't supposed to kiss her but that he still loved her. Redirection w/ resident is only momentarily successful..." A nurse's note, dated 10/16/14 at 6:30 p.m., documented, "...Physician in facility. Discussed residents inappropriate behavior toward other residents. N/O obtained..." A physician's orders [REDACTED]. (name withheld) to eval for sexually inappropriate behavior..." A nurse's note, dated 10/17/14 at 8:00 a.m., documented, "...Resident told (resident #2) her husband was dead. Redirection successful..." A nurse's note, dated 10/18/14 on the six to two shift, documented, "...Resident inappropriate behavior turn down bed asking (resident #2) if she though (sic) it was time for them to go to bed...staff intervened went to D/R for something to drink..." An untimed nurse's note, dated 10/21/14, documented, "...Continues to say (resident #2) is his wife. Resident became emotional, crying when this nurse tried to redirect resident from this belief. Resident continues to try to kiss (resident #2)..." A nurse's note, dated 10/21/14 at 10:00 a.m., documented, "...Resident (up) in dinning (sic) room. Resident continues to think (resident #2) is his wife. Resident kissed (resident #2) 2x, redirection successful momentarily..." A nurse's note, dated 10/22/14 at 10:25 a.m., documented, "...This nurse talked w/ Dr. (name withheld) and requested eval & tx for sexually inapropriate (sic) behaviors..." No documentation of the results of the assessment. A nurse's note, dated 10/23/14 at 8:00 a.m., documented, "...Resident (up) in dining room...Resident continues to be confused about (resident #2). Resident continue (sic) to believe she is his wife. Redirection successful momentarily. Resident attempted to kiss (resident #2) 2x. Staff intervention successful (sic)..." An untimed nurse's note, dated 10/24/14, documented, "...Resident (up) in dinning (sic) room. Resident continues to be confused about (resident #2) being his wife. Resident attempted to kiss her 2x. Staff intervention successful. Resident became emotional when staff tells him he cannot kiss (resident #2)..." A physician's progress note, dated 10/27/14, documented, "...Psych - focused on female peer, thinks she is his wife trys (sic) to get her to his room & trys (sic) to kiss her...Rec Consider D/C [MEDICATION NAME] Consider low dose Neurotin 100 TID..." A nurse's note, dated 10/27/14, documented, "...Resident (up) in dining room. Resident kissed (resident #2) before staff could intervene. Redirection - unimposed (sic) continues to be confused about (resident #2) being his wife..." A nurse's note, dated 10/28/14, documented, "...Resident (up) in dining room. Resident tried to kiss (resident #2) 1x. Staff intervention sucessful (sic)..." A quarterly assessment, dated 10/31/14, documented resident #1 was severely impaired in cognition; had signs and symptoms of [MEDICAL CONDITION] which included inattention and disorganized thinking which fluctuated; was depressed; and had no behaviors. An untimed nurse's note, dated 11/01/14, documented, "...Resident had numerous behaviors w/female residents this shift, attempting to kiss and hug them. Redirection momentarily sucsesful (sic)..." An untimed nurse's note, dated 11/07/14, documented, "...resident hit a female resident in the back w/his walker because she was in his room...." A nurse's note, dated 11/18/14 at 7:00 p.m., documented, "...A female resident was observed in this resident's bed while he was out by a CNA. Staff escorted her out of his room. This resident returned to room and stated 'he didn't mind her in his bed.' And cont c suggestive remarks. Staff counsilled (sic) resident on innappropriate (sic) behaviors and redirected both residents..." An untimed nurse's note, dated 11/21/14 on the six to two shift, documented, "...Resident kissed (resident #2). Redirection successful..." A nurse's note, dated 11/21/14 at 5:20 p.m., documented, "...Resident out to main living area to view movie & popcorn. Resident continues to kiss other female resident. When redirected, resident expresses complete understanding that the resident he is kissing is not his wife and that she also has a husband. Resident expresses intent to continue kissing her. Residents separated. Cont c redirection when behaviors occur..." An untimed nurse's note, dated 11/27/14, documented, "...kissed (resident #2) today..." A nurse's note, dated 11/28/14, documented, "...Resident had to be redirected (undetermined) from (resident #2) @ breakfast. Will continue to monitor for behaviors and redirect away from (resident #2)..." An incident report, dated 11/28/14 at 12:20 a.m., documented, "...Describe exactly what happened; why it happened; what the causes were....This nurse was informed by aide that a male res. was noted coming out (resident #2's) room. Aide stated res was lying on R side c eyes closed in distress (sic), but when covers were pulled back brief was not intact. This nurse entered room to ask res questions about what happen (sic). She was resting c eyes closed and woke easily & c voice command. Upon asking question she answered, 'huh' to every question...Time of physician notification...on site @ approx 1000...time of husband notification 0540...Additional comments and/or steps taken to prevent recurrence: (blank)..." Statements were attached to the incident report. The statements documented the following: ~ CNA #2 documented, "While walking the hall at approx. 12:20 I observed (resident #1) exiting (resident #2's) room. I redirected (resident #1) to his room and discouraged him from entering other resident's room's (sic). Resident #1 denies any interaction with (resident #2). He stated that 'I didn't touch her I just covered her up.' After redirecting (resident #1) I entered (resident #2's) room observed resident res on a right side lying position resident sleeping as evidence by snoring resident covered with blanket when I pulled back blanket resident's brief was not intact brief was not soiled notified nurse immediately." ~ The ADON documented, "11/28/14 This nurse and LPN #1 did head to toe assessment of (resident #2). Rsd was resting in bed c eyes closed @ that time. Arouse to verbal stimuli. Rsd was asked if I could perform the assessment rsd stated 'yes'. This nurse & LPN #1 began assessment. Skin C/D/I no bruising or redness noted. No s/s noted of inapproprate behavior noted." ~ LPN #1 documented, "11/28/14 at 1:45 p.m., Resident resting in bed, eyes open to verbal stimulation. Breathing even and unlabored. Skin warm, pink, dry to the touch. no s/s of injuries or pain. Assessment performed by this nurse and ADON" ~ CNA #3 documented, "...I was working last night 10 - 6 and as I started my shift. I walked down the hall I didn't see him take (resident #2's) brief off. But I could see the (sic) he was in her room as I was coming down the hall me and seen that he had taken her brief off. And this was on 11/27/14 and 12:30 a.m." ~ LPN #2 documented, "11/28/14 This nurse was informed by hall aide that (resident #1) was noted in doorway of room, of female res.. When aide asked him what he was doing in her room. Res stated, 'I didn't do anything, I just covered her up'. Aide assisted res. to room, went back to check on female res., and came to inform this nurse of occurrence (sic). This nurse went to res. room and asked him what was he doing in female res. room. Res told me same thing he stated to aide. That he did not touch her, just covered her up. Daughter was called and informed of occurrence (sic), and she stated, 'I don't believe he tried anything, all they've ever done is hug and kiss.' She also stated that she has been here visiting her father when female res. entered his room to visit and sit c him. ~ LPN #2 also documented, "11/28/14 Hall aide informed this nurse that a male res was noted in doorway of (resident #2's) room. She stated when she asked res (male) what he was doing? The male res. stated, 'I didn't do anything, I just covered her up.' The hall aide assisted male res. to his room then returned to (resident #2's) room where she was noted snoring and sleep. The aide then came and informed me of what she had witnessed. This nurse went to (resident #2's) room and noted her turned on left side sleep. This nurse proceeded to ask res had she been touched, or in any distress. Res just kept stating, 'Huh.' This nurse informed her that I needed to look her over. Res was cooperative, and there was no noted trauma or signs that any sexual activity had occurred. (Resident #2's) husband was called and informed of occurrence (sic) and he stated, 'What will be done about male res." This nurse informed him that I would speak c supervisor to see if we could get him moved to another hall. He stated, That would be fine, and could he receive a call letting him know.' I informed him that I would notify supervisor and they would let him know..." An untitled, unsigned typed paper which was dated 12/01/14, documented, "On 11-28-14, this administrator received a call from (facility) that a male resident on Appletree Lane had entered the room of a female resident early that morning. Nurse states that (resident #1) was witnessed coming out of (resident #2's) room when nurse aide was making rounds about 12.30 that morning. When the nurse aide walked in the room, (resident #1) was standing inside the door speaking to (resident #2). Nurse aide asked what he was doing in there, he stated just covering her up. Nurses state (resident #2) was not in any distress, and not complaining of any pain or discomfort. Nurse state she called families later that morning to let them know, as protocol. Nurse is relatively new to (facility). When aide went in to change (resident #2), she noticed her brief was not fastened all the way. Nurse did an assessment. No bruising, markings, or signs of inappropriate contact. Nothing to allege (sic) that she was touched in any way. When ADON came in to work, she did an interview and did a head to toe assessment to follow up with night nurse assessment. Physician happened to be in facility and looked at resident too. No signs or symptoms of inappropriate touching. Apple tree lane is an Alzheimers unit. All resident roam and wander in and out of each others rooms on a daily basis. I called (resident #2's) husband to apologize if the night nurse had upset him in any way and that if we had alarmed him about the situation, we did not mean to but that there was no indication that anything happened when the male resident wandered into her room..." On 12/04/14 at 9:00 a.m., CNA #1 was asked which residents on the memory unit wandered in and out of residents' rooms. He stated, "(residents #1 and #3) and we have two women, (residents #4 and #5). He was asked if any male residents on the memory unit had sexually inappropriate behaviours. He stated, "One crossed boundries by hugging and kissing but I would not call it sexual and one woman (resident #2) will lay her head on your shoulder and kiss a person's cheek. He stated resident #1 thought she was his wife when she has done this. He was asked if resident #1 and #2 had been in a room alone together. He stated, "Not on my watch." On 12/04/14 at 9:48 a.m., LPN #1 was asked if a male and female resident had been in a room unattended. She stated, "(Residents #1 and #2) last week on the ten to six shift. A CNA reported (resident #1) was observed coming out of (residents #2's) room. Resident #2 was still asleep and an incident report was completed." On 12/04/14 at 10:05 a.m., the ADON was asked if there was an incident in the memory unit when a male resident was in a female resident's room unattended. She stated, "Yes. (Residents #1 and #2)." She was asked when this had occurred. She stated, "On the night shift on Thanksgiving. I was called and the doctor was called." She was asked what was told to her. She stated, "I was called and they said when they went into (resident #2)'s room to assess her, the resident was sound asleep and had a problem waking up enough to be interviewed. Her brief was unhooked but no signs of abuse. The next day, I came in the morning and assessed her and the doctor was here." She was asked if the physician assessed the resident. She stated, "Yes. We completed an incident report." She was asked if the incident and assessments were documented. She stated, "It should be. We took statements." She was asked what was put into place after resident #1 was seen coming out of resident #2's room. She stated, "We placed a person outside the female resident's room all night." She was asked if that was documented. She stated she did not think so. No documentation was found. On 12/04/14 at 10:30 a.m., the administrator was informed the surveyor needed to speak with the staff who worked the night of the incident. The administrator stated one person no longer worked here. She was fired when we reviewed the video tape from that night and it revealed she was sleeping in the dining room and she was terminated. She was asked when she reviewed the video, how long was resident #1 in resident's 2 room. She stated we could not tell from the video how long it was. On 12/04/14 at 12:20 p.m., LPN #2 was asked what happened the night resident #1 was in resident #2's room unattended. She stated, "The hall aide (CNA #2) saw resident coming out of (resident #2's) room and redirected the male resident. She stated the CNA said the brief was unfastened. She was asked what unfastened meant. She stated, "It was not intact." She was asked if the brief was pulled down. She stated the CNA had not informed her of that. LPN #2 stated the CNA checked the brief and it was dry and then informed her of the incident. She stated she went to the female resident's room and interviewed her. She stated she asked the resident if she had been violated or touched but she just said 'Huh.' She stated she changed her and assessed her peri area. She stated there were no signs of trauma or sexual activity. She was asked what the signs of sexual activity would have been. She stated, "No redness, no tearing around the vagina." She stated she then went to the male resident's room, and he stated he did not and that he just covered her up. She was asked what time the incident happened. She stated, "12:20 a.m. I told the CNAs to keep a close eye on the resident and filled out an incident report." LPN #2 was asked when had she informed her supervisor. She stated, "Right before I filled out the incident report, I reported to the ADON." She was asked if the ADON had given her any instructions. She stated the ADON told her to complete an incident report and keep a close watch and document. She was asked if resident #1 had entered resident #2's room unattended in the past. She stated she did not know. She was asked when she informed the physician. She stated, "Due to the holiday we, told by the ADON, paged him in the morning around 6:30 a.m. She was asked when she informed the police. She stated, "They weren't called." She was asked if she had training regarding assessing a potential sexual assault. She stated, "No." She was asked what the facility's policy was regarding potential sexual assault. She stated, "Inform supervisors." On 12/04/14 at 12:40 p.m., CNA #2 was asked if she witnessed resident #1 when he came out of resident #2's room. She stated, "Yes. I told him to go back to his room. Then I checked on her. She was on her right side sleeping. She was facing me." She was asked if the resident was covered. She stated, "Yes. I pulled the covers back and the brief was undone." She was asked what undone meant. She stated, "Not taped, not between her legs, lying on the bed under and behind her." She stated resident #1 wandered and looked for (resident #2). She stated, "He thinks she is his wife." She was asked how long resident #1 was in resident #2's room. She stated she did not know. She was asked if she had spoken with resident #2's husband. She stated, "No." She was asked if she had changed resident #2's brief. She stated, "Yes. It was not dirty or wet." On 12/04/14 at 2:13 p.m., the ADON was asked when she was informed about the incident. She stated, "I received a text at 12:45 a.m." She was asked why the physician was not informed. She stated, "I didn't get the text till I woke up and the doctor's office was closed due to the holiday. When I got to the facility, I instructed her, she could call the doctor because he had a service. I was told the brief was unfastened and instructed the nurse to follow the abuse policy." She was asked if she was aware the brief was not between the resident's legs. She stated, "I was unaware of that." On 12/04/14 at 2:22 p.m., the DON was asked if she was in the facility during the incident. She stated, "No, I was off Thursday and Friday but they did text me." She was asked what time the staff texted her. She stated, "At 7:26 a.m. the ADON texted me and told me the (brief) was unfastened." She was asked if the brief had been on the resident. She stated, "They just said unfastened." On 12/04/14 at 3:14 p.m., CNA #2 was asked if the resident had unfastened or removed her brief in the past. She stated, "Yes, if she was wet she had taken her brief off and thrown it on the floor. She did not like to be wet." On 12/04/14 at 3:17 p.m., the resident's physician was asked when he was called regarding resident #1 being in resident #2's room unattended. He stated, "I was not called. I was told when I came to the facility." He was asked if he had known the resident's brief was unfastened and not between her legs. He stated, "No. I would have sent her to the hospital for an exam at that time. You would need to have a SANE exam to know what happened." He was asked if he would have sent her for a SANE (sexual assault nurse exam). He stated, "Yes." He was asked if he was aware of the psych physician's recommendation to discontinue the [MEDICATION NAME] and add Neurotin. He stated, "I never saw that." On 12/04/14 at 3:27 p.m., CNA #4 was asked if resident #2 would take her brief off. She stated, "Yes." She was asked if she only took off her brief when it was wet. She stated when it was wet and dry and I have observed her coming down the hall pulling it off. She was asked if the resident removed her brief while in bed. She stated, "I don't think so." On 12/08/14 at 10:10 a.m., LPN #3 was asked what happened the night resident #1 was in resident #2's room unattended. He stated a little after midnight CNA #2 said she did not want to tell me but she saw resident #1 come out of resident #2's room. He stated she checked on resident #2 and her brief was unfastened and the resident was covered. He stated LPN #2 went to assess the resident. LPN #3 was asked if there had been two LPNs on the memory unit on the night of the incident. He stated he was assigned to a different hall and happened to be at the nurses' desk on the memory unit at the time. He was asked if any interventions were instituted to ensure resident #1 did not go into resident #2's room. He stated, "The next day the (resident #2) was placed on one to one as soon as staff arrived at the facility." He was asked why resident #1 was not on one to one now. He stated he was not sure when the one on one for (resident #2) stopped. He did not reply. On 12/08/14 at 10:22 a.m., the DON was asked when the video tapes were reviewed from the night resident #1 was in resident #2's room unattended, how long resident #1 was in resident #2's room. She stated, "Approximately 20 minutes." On 12/08/14 at 11:31 a.m., the DON was asked how she thought this incident came about. She stated, "One CNA was at the nurses' desk and one was in the dining room. They could not see the hall. The one in the dining room was asleep and was fired."

On 12/04/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to implement the facility's abuse policy related to an incident of potential sexual abuse. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to implement the facility's abuse policy related to an incident of potential sexual abuse. At 4:25 p.m., the administrator and DON were informed of the IJ related to the facility's failure to implement the facility's abuse policy related to an incident of potential sexual abuse. At 7:44 p.m., an acceptable plan of removal was provided. The plan of removal documented, "...Corrective Action: a. At 4:40 p.m. the administrative staff were informed of new information related to an allegation of resident to resident abuse. b. At 4:45 p.m. facility initiated abuse policy and procedure. c. At 5:00 p.m. on 12/4/14 a third interview, second in person interview, was completed with CNA #2 (name withheld). New information was obtained during this interview. The new information coincides with what CNA #2 (name withheld) stated to surveyor. This is the first time the Administrative staff were told this information. CNA #2 (name withheld) was interviewed at length by the Administrative staff earlier in the day (approximately noon) and did NOT obtain the same information that was obtained at 5:00 p.m. interview. d. At 5:10 p.m. male resident was put on one-on-one supervision with 15 minute documentation. e. At 5:20 physician for both residents (they both have physician) was called. An urgent message was left. d. (sic) At 5:26 p.m. the Tulsa Police Department was notified. e. (sic) At 5:40 initial OSDH form 283 completed and faxed to OSDH and DHS. f. At 5:43 DON called responsible party of both involved residents. g. At 5:48 p.m. two officers from Tula (sic) Police Department arrived. Officer (names withheld). Monitoring: The male resident will have one-on-one monitoring until resident can be appropriately placed for a psychiatric evaluation. The facility will ensure protection of others when behaviors occur. This monitoring will be documented every 15 minutes. Facility is communicating with families of both residents. Staff will be in-serviced on abuse reporting, definitions of abuse, abuse policy and procedure, investigative protocol, appropriate notifications, protection of residents, appropriate interventions for residents with dementia and monitoring of residents that wander. In-servicing will begin immediately with each shift personnel prior to them being able to work on the hall. No employees will be allowed to work on the hall before being in-serviced. In-servicing begins immediately and will be completed by 12/5/14 by 5:00 p.m. If any employees have not completed in-service by 5:00 p.m. on 12/5/14, they will be removed from the schedule. Any employees currently on vacation time will be in-serviced before they can return to work. In-services will be completed by Administrator, DON, and QA Nurse. Facility staff will monitor all residents that wander or have behaviors on the dementia care neighborhood. On 12/08/14 at 8:45 a.m., the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 12/08/14 in regards to their knowledge of the inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 12/06/14 at 6:52 a.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to implement the facility's abuse policy related to an incident of potential sexual abuse involving one (#1) of four sampled residents who were identified as having sexually inappropriate behaviors. The facility failed to thoroughly investigate an incident of potential sexual abuse and failed to ensure protection of residents from the likelihood of further abuse. This had the likelihood to affect 87 residents who resided at the facility. Findings: A policy, titled Abuse and neglect prevention, dated, 01/01/14, documented, "...Purpose: To establish guidelines that prevents, identifies and report resident abuse and neglect... The resident has the right to be free from verbal, sexual...abuse...It is the policy of the facility, to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse... Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents... 'Sexual abuse' includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault... It is the responsibility of the Administrator and Director of Nursing Services to ensure the training of employees, through orientation and on-going in-services on issues related to abuse prohibition practices such as...Appropriate interventions to deal with aggressive and/or catastrophic reactions of Residents...What constitutes abuse... Provide residents, families and staff information on how and to whom they may report concerns, incidents.... Identify, correct, and intervene in situations in which abuse...is more likely to occur... The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, or behaviors such as entering other residents' rooms... The Administrator and/or the Director of Nursing Services are responsible for initiation of the investigation immediately upon notification of alleged event or findings. Facility will document investigation findings, including witness statements, corrective actions, and conclusions in administrative file... for taking immediate action and ensuring the resident is protected from harm during the investigation of the alleged incident..." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 06/05/14, documented, "...Cognition...I have a [DIAGNOSES REDACTED]. I have disorganized thinking and impaired decision making skills...Psych evaluation as warranted by my doctor... Behavior...I can become angry, agitated, and resist care at times...If I become inappropriately agitated wander in out (sic) of rooms. Please redirect me. Involve me c activities & 1 on 1... Elopment/wandering (sic)...I have a dx of Alzheimer's and [MEDICAL CONDITION]. I am independent with ambulation..." A nurse's note, dated 10/15/14 at 6:30 a.m., documented, "...Resident observed coming out of (resident #2's) room. (Resident #2) was asleep and undisturbed. Staff instructed resident to stay out of (resident #2's) room. Redirection sucessful (sic) momatarily (sic)..." A nurse's note, dated 10/15/14 at 9:00 a.m., documented, "...Resident observed kissing (resident #2) in the dining room. Resident was instructed by staff that (resident #2) is not his wife and is married. Resident stated 'well I am married too.' Redirection momertarily (sic) sucessful (sic)..." Another nurse's note, dated 10/15/14 at 9:00 a.m., documented, "...Resident was observed coming out of (resident #2's) room. (Resident #2) was asleep. (CNA #1) checked on (resident #2) and observed that she was undisturbed. CNA informed Resident that he was not allowed to go into (resident #2's) room when (resident #2) was asleep. 12:45 p.m. Resident was observed attempting to kiss (resident #2's) face. (CNA #8) stoped (sic) and redirected resident and informed resident that (resident #2) was a married woman. Redirection successful..." A nurse's note, dated 10/16/14 at 7:30 a.m., documented, "...Resident was coming out of (resident #2's) room. Resident was informed that was not his room and he was not to go into (resident #2's) room w/out her permission. This nurse checked on (resident #2) and she stated she was 'ok' but wanted to go back to sleep..." A nurse's note, dated 10/16/14 at 1:00 p.m., documented, "...Resident was observed trying to kiss (resident #2). Staff redirected resident. Resident was heard telling (resident #2) that he wasn't supposed to kiss her but that he still loved her. Redirection w/ resident is only momentarily successful..." A nurse's note, dated 10/16/14 at 6:30 p.m., documented, "...Physician in facility. Discussed residents inappropriate behavior toward other residents. N/O obtained..." A physician's orders [REDACTED]. (name withheld) to eval for sexually inappropriate behavior..." A nurse's note, dated 10/17/14 at 8:00 a.m., documented, "...Resident told (resident #2) her husband was dead. Redirection successful..." A nurse's note, dated 10/18/14 on the six to two shift, documented, "...Resident inappropriate behavior turn down bed asking (resident #2) if she though (sic) it was time for them to go to bed...staff intervened went to D/R for something to drink..." An untimed nurse's note, dated 10/21/14, documented, "...Continues to say (resident #2) is his wife. Resident became emotional, crying when this nurse tried to redirect resident from this belief. Resident continues to try to kiss (resident #2)..." A nurse's note, dated 10/21/14 at 10:00 a.m., documented, "...Resident (up) in dinning (sic) room. Resident continues to think (resident #2) is his wife. Resident kissed (resident #2) 2x, redirection successful momentarily..." A nurse's note, dated 10/22/14 at 10:25 a.m., documented, "...This nurse talked w/ Dr. (name withheld) and requested eval & tx for sexually inapropriate (sic) behaviors..." No documentation of the results of the assessment. A nurse's note, dated 10/23/14 at 8:00 a.m., documented, "...Resident (up) in dining room...Resident continues to be confused about (resident #2). Resident continue (sic) to believe she is his wife. Redirection successful momentarily. Resident attempted to kiss (resident #2) 2x. Staff intervention successful (sic)..." An untimed nurse's note, dated 10/24/14, documented, "...Resident (up) in dinning (sic) room. Resident continues to be confused about (resident #2) being his wife. Resident attempted to kiss her 2x. Staff intervention successful. Resident became emotional when staff tells him he cannot kiss (resident #2)..." A physician's progress note, dated 10/27/14, documented, "...Psych - focused on female peer, thinks she is his wife trys (sic) to get her to his room & trys (sic) to kiss her...Rec Consider D/C [MEDICATION NAME] Consider low dose Neurotin 100 TID..." A nurse's note, dated 10/27/14, documented, "...Resident (up) in dining room. Resident kissed (resident #2) before staff could intervene. Redirection - unimposed (sic) continues to be confused about (resident #2) being his wife..." A nurse's note, dated 10/28/14, documented, "...Resident (up) in dining room. Resident tried to kiss (resident #2) 1x. Staff intervention sucessful (sic)..." A quarterly assessment, dated 10/31/14, documented resident #1 was severely impaired in cognition; had signs and symptoms of [MEDICAL CONDITION] which included inattention and disorganized thinking which fluctuated; was depressed; and had no behaviors. An untimed nurse's note, dated 11/01/14, documented, "...Resident had numerous behaviors w/female residents this shift, attempting to kiss and hug them. Redirection momentarily sucsesful (sic)..." An untimed nurse's note, dated 11/07/14, documented, "...resident hit a female resident in the back w/his walker because she was in his room...." A nurse's note, dated 11/18/14 at 7:00 p.m., documented, "...A female resident was observed in this resident's bed while he was out by a CNA. Staff escorted her out of his room. This resident returned to room and stated 'he didn't mind her in his bed.' And cont c suggestive remarks. Staff counsilled (sic) resident on innappropriate (sic) behaviors and redirected both residents..." An untimed nurse's note, dated 11/21/14 on the six to two shift, documented, "...Resident kissed (resident #2). Redirection successful..." A nurse's note, dated 11/21/14 at 5:20 p.m., documented, "...Resident out to main living area to view movie & popcorn. Resident continues to kiss other female resident. When redirected, resident expresses complete understanding that the resident he is kissing is not his wife and that she also has a husband. Resident expresses intent to continue kissing her. Residents separated. Cont c redirection when behaviors occur..." An untimed nurse's note, dated 11/27/14, documented, "...kissed (resident #2) today..." A nurse's note, dated 11/28/14, documented, "...Resident had to be redirected (undetermined) from (resident #2) @ breakfast. Will continue to monitor for behaviors and redirect away from (resident #2)..." An incident report, dated 11/28/14 at 12:20 a.m., documented, "...Describe exactly what happened; why it happened; what the causes were....This nurse was informed by aide that a male res. was noted coming out (resident #2's) room. Aide stated res was lying on R side c eyes closed in distress (sic), but when covers were pulled back brief was not intact. This nurse entered room to ask res questions about what happen (sic). She was resting c eyes closed and woke easily & c voice command. Upon asking question she answered, 'huh' to every question...Time of physician notification...on site @ approx 1000...time of husband notification 0540...Additional comments and/or steps taken to prevent recurrence: (blank)..." Statements were attached to the incident report. The statements documented the following: ~ CNA #2 documented, "While walking the hall at approx. 12:20 I observed (resident #1) exiting (resident #2's) room. I redirected (resident #1) to his room and discouraged him from entering other resident's room's (sic). Resident #1 denies any interaction with (resident #2). He stated that 'I didn't touch her I just covered her up.' After redirecting (resident #1) I entered (resident #2's) room observed resident res on a right side lying position resident sleeping as evidence by snoring resident covered with blanket when I pulled back blanket resident's brief was not intact brief was not soiled notified nurse immediately." ~ The ADON documented, "11/28/14 This nurse and LPN #1 did head to toe assessment of (resident #2). Rsd was resting in bed c eyes closed @ that time. Arouse to verbal stimuli. Rsd was asked if I could perform the assessment rsd stated 'yes'. This nurse & LPN #1 began assessment. Skin C/D/I no bruising or redness noted. No s/s noted of inapproprate behavior noted." ~ LPN #1 documented, "11/28/14 at 1:45 p.m., Resident resting in bed, eyes open to verbal stimulation. Breathing even and unlabored. Skin warm, pink, dry to the touch. no s/s of injuries or pain. Assessment performed by this nurse and ADON" ~ CNA #3 documented, "...I was working last night 10 - 6 and as I started my shift. I walked down the hall I didn't see him take (resident #2's) brief off. But I could see the (sic) he was in her room as I was coming down the hall me and seen that he had taken her brief off. And this was on 11/27/14 and 12:30 a.m." ~ LPN #2 documented, "11/28/14 This nurse was informed by hall aide that (resident #1) was noted in doorway of room, of female res.. When aide asked him what he was doing in her room. Res stated, 'I didn't do anything, I just covered her up'. Aide assisted res. to room, went back to check on female res., and came to inform this nurse of occurrence (sic). This nurse went to res. room and asked him what was he doing in female res. room. Res told me same thing he stated to aide. That he did not touch her, just covered her up. Daughter was called and informed of occurrence (sic), and she stated, 'I don't believe he tried anything, all they've ever done is hug and kiss.' She also stated that she has been here visiting her father when female res. entered his room to visit and sit c him. ~ LPN #2 also documented, "11/28/14 Hall aide informed this nurse that a male res was noted in doorway of (resident #2's) room. She stated when she asked res (male) what he was doing? The male res. stated, 'I didn't do anything, I just covered her up.' The hall aide assisted male res. to his room then returned to (resident #2's) room where she was noted snoring and sleep. The aide then came and informed me of what she had witnessed. This nurse went to (resident #2's) room and noted her turned on left side sleep. This nurse proceeded to ask res had she been touched, or in any distress. Res just kept stating, 'Huh.' This nurse informed her that I needed to look her over. Res was cooperative, and there was no noted trauma or signs that any sexual activity had occurred. (Resident #2's) husband was called and informed of occurrence (sic) and he stated, 'What will be done about male res." This nurse informed him that I would speak c supervisor to see if we could get him moved to another hall. He stated, That would be fine, and could he receive a call letting him know.' I informed him that I would notify supervisor and they would let him know..." An untitled, unsigned typed paper which was dated 12/01/14, documented, "On 11-28-14, this administrator received a call from (facility) that a male resident on Appletree Lane had entered the room of a female resident early that morning. Nurse states that (resident #1) was witnessed coming out of (resident #2's) room when nurse aide was making rounds about 12.30 that morning. When the nurse aide walked in the room, (resident #1) was standing inside the door speaking to (resident #2). Nurse aide asked what he was doing in there, he stated just covering her up. Nurses state (resident #2) was not in any distress, and not complaining of any pain or discomfort. Nurse state she called families later that morning to let them know, as protocol. Nurse is relatively new to (facility). When aide went in to change (resident #2), she noticed her brief was not fastened all the way. Nurse did an assessment. No bruising, markings, or signs of inappropriate contact. Nothing to allege (sic) that she was touched in any way. When ADON came in to work, she did an interview and did a head to toe assessment to follow up with night nurse assessment. Physician happened to be in facility and looked at resident too. No signs or symptoms of inappropriate touching. Apple tree lane is an Alzheimers unit. All resident roam and wander in and out of each others rooms on a daily basis. I called (resident #2's) husband to apologize if the night nurse had upset him in any way and that if we had alarmed him about the situation, we did not mean to but that there was no indication that anything happened when the male resident wandered into her room..." On 12/04/14 at 9:00 a.m., CNA #1 was asked which residents on the memory unit wandered in and out of residents' rooms. He stated, "(residents #1 and #3) and we have two women, (residents #4 and #5). He was asked if any male residents on the memory unit had sexually inappropriate behaviours. He stated, "One crossed boundries by hugging and kissing but I would not call it sexual and one woman (resident #2) will lay her head on your shoulder and kiss a person's cheek. He stated resident #1 thought she was his wife when she has done this. He was asked if resident #1 and #2 had been in a room alone together. He stated, "Not on my watch." On 12/04/14 at 9:48 a.m., LPN #1 was asked if a male and female resident had been in a room unattended. She stated, "(Residents #1 and #2) last week on the ten to six shift. A CNA reported (resident #1) was observed coming out of (residents #2's) room. Resident #2 was still asleep and an incident report was completed." On 12/04/14 at 10:05 a.m., the ADON was asked if there was an incident in the memory unit when a male resident was in a female resident's room unattended. She stated, "Yes. (Residents #1 and #2)." She was asked when this had occurred. She stated, "On the night shift on Thanksgiving. I was called and the doctor was called." She was asked what was told to her. She stated, "I was called and they said when they went into (resident #2)'s room to assess her, the resident was sound asleep and had a problem waking up enough to be interviewed. Her brief was unhooked but no signs of abuse. The next day, I came in the morning and assessed her and the doctor was here." She was asked if the physician assessed the resident. She stated, "Yes. We completed an incident report." She was asked if the incident and assessments were documented. She stated, "It should be. We took statements." She was asked what was put into place after resident #1 was seen coming out of resident #2's room. She stated, "We placed a person outside the female resident's room all night." She was asked if that was documented. She stated she did not think so. No documentation was found. On 12/04/14 at 10:30 a.m., the administrator was informed the surveyor needed to speak with the staff who worked the night of the incident. The administrator stated one person no longer worked here. She was fired when we reviewed the video tape from that night and it revealed she was sleeping in the dining room and she was terminated. She was asked when she reviewed the video, how long was resident #1 in resident's 2 room. She stated we could not tell from the video how long it was. On 12/04/14 at 12:20 p.m, LPN #2 was asked what happened the night resident #1 was in resident #2's room unattended. She stated, "The hall aide (CNA #2) saw resident coming out of (resident #2's) room and redirected the male resident. She stated the CNA said the brief was unfastened. She was asked what unfastened meant. She stated, "It was not intact." She was asked if the brief was pulled down. She stated the CNA had not informed her of that. LPN #2 stated the CNA checked the brief and it was dry and then informed her of the incident. She stated she went to the female resident's room and interviewed her. She stated she asked the resident if she had been violated or touched but she just said 'Huh.' She stated she changed her and assessed her peri area. She stated there were no signs of trauma or sexual activity. She was asked what the signs of sexual activity would have been. She stated, "No redness, no tearing around the vagina." She stated she then went to the male resident's room, and he stated he did not and that he just covered her up. She was asked what time the incident happened. She stated, "12:20 a.m. I told the CNAs to keep a close eye on the resident and filled out an incident report." LPN #2 was asked when had she informed her supervisor. She stated, "Right before I filled out the incident report, I reported to the ADON." She was asked if the ADON had given her any instructions. She stated the ADON told her to complete an incident report and keep a close watch and document. She was asked if resident #1 had entered resident #2's room unattended in the past. She stated she did not know. She was asked when she informed the physician. She stated, "Due to the holiday we, told by the ADON, paged him in the morning around 6:30 a.m. She was asked when she informed the police. She stated, "They weren't called." She was asked if she had training regarding assessing a potential sexual assault. She stated, "No." She was asked what the facility's policy was regarding potential sexual assault. She stated, "Inform supervisors." On 12/04/14 at 12:40 p.m., CNA #2 was asked if she witnessed resident #1 when he came out of resident #2's room. She stated, "Yes. I told him to go back to his room. Then I checked on her. She was on her right side sleeping. She was facing me." She was asked if the resident was covered. She stated, "Yes. I pulled the covers back and the brief was undone." She was asked what undone meant. She stated, "Not taped, not between her legs, lying on the bed under and behind her." She stated resident #1 wandered and looked for (resident #2). She stated, "He thinks she is his wife." She was asked how long resident #1 was in resident #2's room. She stated she did not know. She was asked if she had spoken with resident #2's husband. She stated, "No." She was asked if she had changed resident #2's brief. She stated, "Yes. It was not dirty or wet." On 12/04/14 at 2:13 p.m., the ADON was asked when she was informed about the incident. She stated, "I received a text at 12:45 a.m." She was asked why the physician was not informed. She stated, "I didn't get the text till I woke up and the doctor's office was closed due to the holiday. When I got to the facility, I instructed her, she could call the doctor because he had a service. I was told the brief was unfastened and instructed the nurse to follow the abuse policy." She was asked if she was aware the brief was not between the resident's legs. She stated, "I was unaware of that." On 12/04/14 at 2:22 p.m., the DON was asked if she was in the facility during the incident. She stated, "No, I was off Thursday and Friday but they did text me." She was asked what time the staff texted her. She stated, "At 7:26 a.m. the ADON texted me and told me the (brief) was unfastened." She was asked if the brief had been on the resident. She stated, "They just said unfastened." On 12/04/14 at 3:14 p.m., CNA #2 was asked if the resident had unfastened or removed her brief in the past. She stated, "Yes, if she was wet she had taken her brief off and thrown it on the floor. She did not like to be wet." On 12/04/14 at 3:17 p.m., the resident's physician was asked when he was called regarding resident #1 being in resident #2's room unattended. He stated, "I was not called. I was told when I came to the facility." He was asked if he had known the resident's brief was unfastened and not between her legs. He stated, "No. I would have sent her to the hospital for an exam at that time. You would need to have a SANE exam to know what happened." He was asked if he would have sent her for a SANE (sexual assault nurse exam). He stated, "Yes." He was asked if he was aware of the psych physician's recommendation to discontinue the [MEDICATION NAME] and add Neurotin. He stated, "I never saw that." On 12/04/14 at 3:27 p.m., CNA #4 was asked if resident #2 would take her brief off. She stated, "Yes." She was asked if she only took off her brief when it was wet. She stated when it was wet and dry and I have observed her coming down the hall pulling it off. She was asked if the resident removed her brief while in bed. She stated, "I don't think so." On 12/08/14 at 10:10 a.m., LPN #3 was asked what happened the night resident #1 was in resident #2's room unattended. He stated a little after midnight CNA #2 said she did not want to tell me but she saw resident #1 come out of resident #2's room. He stated she checked on resident #2 and her brief was unfastened and the resident was covered. He stated LPN #2 went to assess the resident. LPN #3 was asked if there had been two LPNs on the memory unit on the night of the incident. He stated he was assigned to a different hall and happened to be at the nurses' desk on the memory unit at the time. He was asked if any interventions were instituted to ensure resident #1 did not go into resident #2's room. He stated, "The next day the (resident #2) was placed on one to one as soon as staff arrived at the facility." He was asked why resident #1 was not on one to one now. He stated he was not sure when the one on one for (resident #2) stopped. He did not reply. On 12/08/14 at 10:22 a.m., the DON was asked when the video tapes were reviewed from the night resident #1 was in resident #2's room unattended, how long resident #1 was in resident #2's room. She stated, "Approximately 20 minutes." On 12/08/14 at 11:31 a.m., the DON was asked how she thought this incident came about. She stated, "One CNA was at the nurses' desk and one was in the dining room. They could not see the hall. The one in the dining room was asleep and was fired."

On 12/04/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide supervision for a resident with known sexually inappropriate behavior. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to provide supervision for a resident with known sexually inappropriate behavior. At 4:25 p.m., the administrator and DON were informed of the IJ related to the facility's failure to provide supervision for a resident with known sexually inappropriate behavior. At 7:44 p.m., an acceptable plan of removal was provided. The plan of removal documented, "...Corrective Action: a. At 4:40 p.m. the administrative staff were informed of new information related to an allegation of resident to resident abuse. b. At 4:45 p.m. facility initiated abuse policy and procedure. c. At 5:00 p.m. on 12/4/14 a third interview, second in person interview, was completed with CNA #2 (name withheld). New information was obtained during this interview. The new information coincides with what CNA #2 (name withheld) stated to surveyor. This is the first time the Administrative staff were told this information. CNA #2 (name withheld) was interviewed at length by the Administrative staff earlier in the day (approximately noon) and did NOT obtain the same information that was obtained at 5:00 p.m. interview. d. At 5:10 p.m. male resident was put on one-on-one supervision with 15 minute documentation. e. At 5:20 physician for both residents (they both have physician) was called. An urgent message was left. d. (sic) At 5:26 p.m. the Tulsa Police Department was notified. e. (sic) At 5:40 initial OSDH form 283 completed and faxed to OSDH and DHS. f. At 5:43 DON called responsible party of both involved residents. g. At 5:48 p.m. two officers from Tula (sic) Police Department arrived. Officer (names withheld). Monitoring: The male resident will have one-on-one monitoring until resident can be appropriately placed for a psychiatric evaluation. The facility will ensure protection of others when behaviors occur. This monitoring will be documented every 15 minutes. Facility is communicating with families of both residents. Staff will be in-serviced on abuse reporting, definitions of abuse, abuse policy and procedure, investigative protocol, appropriate notifications, protection of residents, appropriate interventions for residents with dementia and monitoring of residents that wander. In-servicing will begin immediately with each shift personnel prior to them being able to work on the hall. No employees will be allowed to work on the hall before being in-serviced. In-servicing begins immediately and will be completed by 12/5/14 by 5:00 p.m. If any employees have not completed in-service by 5:00 p.m. on 12/5/14, they will be removed from the schedule. Any employees currently on vacation time will be in-serviced before they can return to work. In-services will be completed by Administrator, DON, and QA Nurse. Facility staff will monitor all residents that wander or have behaviors on the dementia care neighborhood. On 12/08/14 at 8:45 a.m., the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 12/08/14 in regards to their knowledge of the inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 12/06/14 at 6:52 a.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to provide supervision for one (#1) of four sampled residents who were identified as having sexually inappropriate behaviors. This had the likelihood to affect 18 residents who resided at the facility in the memory unit. Findings: A policy, titled Abuse and neglect prevention, dated, 01/01/14, documented, "...Purpose: To establish guidelines that prevents, identifies and report resident abuse and neglect... The resident has the right to be free from verbal, sexual...abuse...It is the policy of the facility, to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse... Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents... 'Sexual abuse' includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault... It is the responsibility of the Administrator and Director of Nursing Services to ensure the training of employees, through orientation and on-going in-services on issues related to abuse prohibition practices such as...Appropriate interventions to deal with aggressive and/or catastrophic reactions of Residents...What constitutes abuse... Provide residents, families and staff information on how and to whom they may report concerns, incidents.... Identify, correct, and intervene in situations in which abuse...is more likely to occur... The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, or behaviors such as entering other residents' rooms... The Administrator and/or the Director of Nursing Services are responsible for initiation of the investigation immediately upon notification of alleged event or findings. Facility will document investigation findings, including witness statements, corrective actions, and conclusions in administrative file... for taking immediate action and ensuring the resident is protected from harm during the investigation of the alleged incident..." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 06/05/14, documented, "...Cognition...I have a [DIAGNOSES REDACTED]. I have disorganized thinking and impaired decision making skills...Psych evaluation as warranted by my doctor... Behavior...I can become angry, agitated, and resist care at times...If I become inappropriately agitated wander in out (sic) of rooms. Please redirect me. Involve me c activities & 1 on 1... Elopment/wandering (sic)...I have a dx of Alzheimer's and Psychosis. I am independent with ambulation..." A nurse's note, dated 10/15/14 at 6:30 a.m., documented, "...Resident observed coming out of (resident #2's) room. (Resident #2) was asleep and undisturbed. Staff instructed resident to stay out of (resident #2's) room. Redirection sucessful (sic) momatarily (sic)..." A nurse's note, dated 10/15/14 at 9:00 a.m., documented, "...Resident observed kissing (resident #2) in the dining room. Resident was instructed by staff that (resident #2) is not his wife and is married. Resident stated 'well I am married too.' Redirection momertarily (sic) sucessful (sic)..." Another nurse's note, dated 10/15/14 at 9:00 a.m., documented, "...Resident was observed coming out of (resident #2's) room. (Resident #2) was asleep. (CNA #1) checked on (resident #2) and observed that she was undisturbed. CNA informed Resident that he was not allowed to go into (resident #2's) room when (resident #2) was asleep. 12:45 p.m. Resident was observed attempting to kiss (resident #2's) face. (CNA #8) stoped (sic) and redirected resident and informed resident that (resident #2) was a married woman. Redirection successful..." A nurse's note, dated 10/16/14 at 7:30 a.m., documented, "...Resident was coming out of (resident #2's) room. Resident was informed that was not his room and he was not to go into (resident #2's) room w/out her permission. This nurse checked on (resident #2) and she stated she was 'ok' but wanted to go back to sleep..." A nurse's note, dated 10/16/14 at 1:00 p.m., documented, "...Resident was observed trying to kiss (resident #2). Staff redirected resident. Resident was heard telling (resident #2) that he wasn't supposed to kiss her but that he still loved her. Redirection w/ resident is only momentarily successful..." A nurse's note, dated 10/16/14 at 6:30 p.m., documented, "...Physician in facility. Discussed residents inappropriate behavior toward other residents. N/O obtained..." A physician's orders [REDACTED]. (name withheld) to eval for sexually inappropriate behavior..." A nurse's note, dated 10/17/14 at 8:00 a.m., documented, "...Resident told (resident #2) her husband was dead. Redirection successful..." A nurse's note, dated 10/18/14 on the six to two shift, documented, "...Resident inappropriate behavior turn down bed asking (resident #2) if she though (sic) it was time for them to go to bed...staff intervened went to D/R for something to drink..." An untimed nurse's note, dated 10/21/14, documented, "...Continues to say (resident #2) is his wife. Resident became emotional, crying when this nurse tried to redirect resident from this belief. Resident continues to try to kiss (resident #2)..." A nurse's note, dated 10/21/14 at 10:00 a.m., documented, "...Resident (up) in dinning (sic) room. Resident continues to think (resident #2) is his wife. Resident kissed (resident #2) 2x, redirection successful momentarily..." A nurse's note, dated 10/22/14 at 10:25 a.m., documented, "...This nurse talked w/ Dr. (name withheld) and requested eval & tx for sexually inapropriate (sic) behaviors..." No documentation of the results of the assessment. A nurse's note, dated 10/23/14 at 8:00 a.m., documented, "...Resident (up) in dining room...Resident continues to be confused about (resident #2). Resident continue (sic) to believe she is his wife. Redirection successful momentarily. Resident attempted to kiss (resident #2) 2x. Staff intervention successful (sic)..." An untimed nurse's note, dated 10/24/14, documented, "...Resident (up) in dinning (sic) room. Resident continues to be confused about (resident #2) being his wife. Resident attempted to kiss her 2x. Staff intervention successful. Resident became emotional when staff tells him he cannot kiss (resident #2)..." A physician's progress note, dated 10/27/14, documented, "...Psych - focused on female peer, thinks she is his wife trys (sic) to get her to his room & trys (sic) to kiss her...Rec Consider D/C Namenda Consider low dose Neurotin 100 TID..." A nurse's note, dated 10/27/14, documented, "...Resident (up) in dining room. Resident kissed (resident #2) before staff could intervene. Redirection - unimposed (sic) continues to be confused about (resident #2) being his wife..." A nurse's note, dated 10/28/14, documented, "...Resident (up) in dining room. Resident tried to kiss (resident #2) 1x. Staff intervention sucessful (sic)..." A quarterly assessment, dated 10/31/14, documented resident #1 was severely impaired in cognition; had signs and symptoms of delirium which included inattention and disorganized thinking which fluctuated; was depressed; and had no behaviors. An untimed nurse's note, dated 11/01/14, documented, "...Resident had numerous behaviors w/female residents this shift, attempting to kiss and hug them. Redirection momentarily sucsesful (sic)..." An untimed nurse's note, dated 11/07/14, documented, "...resident hit a female resident in the back w/his walker because she was in his room...." A nurse's note, dated 11/18/14 at 7:00 p.m., documented, "...A female resident was observed in this resident's bed while he was out by a CNA. Staff escorted her out of his room. This resident returned to room and stated 'he didn't mind her in his bed.' And cont c suggestive remarks. Staff counsilled (sic) resident on innappropriate (sic) behaviors and redirected both residents..." An untimed nurse's note, dated 11/21/14 on the six to two shift, documented, "...Resident kissed (resident #2). Redirection successful..." A nurse's note, dated 11/21/14 at 5:20 p.m., documented, "...Resident out to main living area to view movie & popcorn. Resident continues to kiss other female resident. When redirected, resident expresses complete understanding that the resident he is kissing is not his wife and that she also has a husband. Resident expresses intent to continue kissing her. Residents separated. Cont c redirection when behaviors occur..." An untimed nurse's note, dated 11/27/14, documented, "...kissed (resident #2) today..." A nurse's note, dated 11/28/14, documented, "...Resident had to be redirected (undetermined) from (resident #2) @ breakfast. Will continue to monitor for behaviors and redirect away from (resident #2)..." An incident report, dated 11/28/14 at 12:20 a.m., documented, "...Describe exactly what happened; why it happened; what the causes were....This nurse was informed by aide that a male res. was noted coming out (resident #2's) room. Aide stated res was lying on R side c eyes closed in distress (sic), but when covers were pulled back brief was not intact. This nurse entered room to ask res questions about what happen (sic). She was resting c eyes closed and woke easily & c voice command. Upon asking question she answered, 'huh' to every question...Time of physician notification...on site @ approx 1000...time of husband notification 0540...Additional comments and/or steps taken to prevent recurrence: (blank)..." Statements were attached to the incident report. The statements documented the following: ~ CNA #2 documented, "While walking the hall at approx. 12:20 I observed (resident #1) exiting (resident #2's) room. I redirected (resident #1) to his room and discouraged him from entering other resident's room's (sic). Resident #1 denies any interaction with (resident #2). He stated that 'I didn't touch her I just covered her up.' After redirecting (resident #1) I entered (resident #2's) room observed resident res on a right side lying position resident sleeping as evidence by snoring resident covered with blanket when I pulled back blanket resident's brief was not intact brief was not soiled notified nurse immediately." ~ The ADON documented, "11/28/14 This nurse and LPN #1 did head to toe assessment of (resident #2). Rsd was resting in bed c eyes closed @ that time. Arouse to verbal stimuli. Rsd was asked if I could perform the assessment rsd stated 'yes'. This nurse & LPN #1 began assessment. Skin C/D/I no bruising or redness noted. No s/s noted of inapproprate behavior noted." ~ LPN #1 documented, "11/28/14 at 1:45 p.m., Resident resting in bed, eyes open to verbal stimulation. Breathing even and unlabored. Skin warm, pink, dry to the touch. no s/s of injuries or pain. Assessment performed by this nurse and ADON" ~ CNA #3 documented, "...I was working last night 10 - 6 and as I started my shift. I walked down the hall I didn't see him take (resident #2's) brief off. But I could see the (sic) he was in her room as I was coming down the hall me and seen that he had taken her brief off. And this was on 11/27/14 and 12:30 a.m." ~ LPN #2 documented, "11/28/14 This nurse was informed by hall aide that (resident #1) was noted in doorway of room, of female res.. When aide asked him what he was doing in her room. Res stated, 'I didn't do anything, I just covered her up'. Aide assisted res. to room, went back to check on female res., and came to inform this nurse of occurrence (sic). This nurse went to res. room and asked him what was he doing in female res. room. Res told me same thing he stated to aide. That he did not touch her, just covered her up. Daughter was called and informed of occurrence (sic), and she stated, 'I don't believe he tried anything, all they've ever done is hug and kiss.' She also stated that she has been here visiting her father when female res. entered his room to visit and sit c him. ~ LPN #2 also documented, "11/28/14 Hall aide informed this nurse that a male res was noted in doorway of (resident #2's) room. She stated when she asked res (male) what he was doing? The male res. stated, 'I didn't do anything, I just covered her up.' The hall aide assisted male res. to his room then returned to (resident #2's) room where she was noted snoring and sleep. The aide then came and informed me of what she had witnessed. This nurse went to (resident #2's) room and noted her turned on left side sleep. This nurse proceeded to ask res had she been touched, or in any distress. Res just kept stating, 'Huh.' This nurse informed her that I needed to look her over. Res was cooperative, and there was no noted trauma or signs that any sexual activity had occurred. (Resident #2's) husband was called and informed of occurrence (sic) and he stated, 'What will be done about male res." This nurse informed him that I would speak c supervisor to see if we could get him moved to another hall. He stated, That would be fine, and could he receive a call letting him know.' I informed him that I would notify supervisor and they would let him know..." An untitled, unsigned typed paper which was dated 12/01/14, documented, "On 11-28-14, this administrator received a call from (facility) that a male resident on Appletree Lane had entered the room of a female resident early that morning. Nurse states that (resident #1) was witnessed coming out of (resident #2's) room when nurse aide was making rounds about 12.30 that morning. When the nurse aide walked in the room, (resident #1) was standing inside the door speaking to (resident #2). Nurse aide asked what he was doing in there, he stated just covering her up. Nurses state (resident #2) was not in any distress, and not complaining of any pain or discomfort. Nurse state she called families later that morning to let them know, as protocol. Nurse is relatively new to (facility). When aide went in to change (resident #2), she noticed her brief was not fastened all the way. Nurse did an assessment. No bruising, markings, or signs of inappropriate contact. Nothing to allege (sic) that she was touched in any way. When ADON came in to work, she did an interview and did a head to toe assessment to follow up with night nurse assessment. Physician happened to be in facility and looked at resident too. No signs or symptoms of inappropriate touching. Apple tree lane is an Alzheimers unit. All resident roam and wander in and out of each others rooms on a daily basis. I called (resident #2's) husband to apologize if the night nurse had upset him in any way and that if we had alarmed him about the situation, we did not mean to but that there was no indication that anything happened when the male resident wandered into her room..." On 12/04/14 at 9:00 a.m., CNA #1 was asked which residents on the memory unit wandered in and out of residents' rooms. He stated, "(residents #1 and #3) and we have two women, (residents #4 and #5). He was asked if any male residents on the memory unit had sexually inappropriate behaviours. He stated, "One crossed boundries by hugging and kissing but I would not call it sexual and one woman (resident #2) will lay her head on your shoulder and kiss a person's cheek. He stated resident #1 thought she was his wife when she has done this. He was asked if resident #1 and #2 had been in a room alone together. He stated, "Not on my watch." On 12/04/14 at 9:48 a.m., LPN #1 was asked if a male and female resident had been in a room unattended. She stated, "(Residents #1 and #2) last week on the ten to six shift. A CNA reported (resident #1) was observed coming out of (residents #2's) room. Resident #2 was still asleep and an incident report was completed." On 12/04/14 at 10:05 a.m., the ADON was asked if there was an incident in the memory unit when a male resident was in a female resident's room unattended. She stated, "Yes. (Residents #1 and #2)." She was asked when this had occurred. She stated, "On the night shift on Thanksgiving. I was called and the doctor was called." She was asked what was told to her. She stated, "I was called and they said when they went into (resident #2)'s room to assess her, the resident was sound asleep and had a problem waking up enough to be interviewed. Her brief was unhooked but no signs of abuse. The next day, I came in the morning and assessed her and the doctor was here." She was asked if the physician assessed the resident. She stated, "Yes. We completed an incident report." She was asked if the incident and assessments were documented. She stated, "It should be. We took statements." She was asked what was put into place after resident #1 was seen coming out of resident #2's room. She stated, "We placed a person outside the female resident's room all night." She was asked if that was documented. She stated she did not think so. No documentation was found. On 12/04/14 at 10:30 a.m., the administrator was informed the surveyor needed to speak with the staff who worked the night of the incident. The administrator stated one person no longer worked here. She was fired when we reviewed the video tape from that night and it revealed she was sleeping in the dining room and she was terminated. She was asked when she reviewed the video, how long was resident #1 in resident's 2 room. She stated we could not tell from the video how long it was. On 12/04/14 at 12:20 p.m., LPN #2 was asked what happened the night resident #1 was in resident #2's room unattended. She stated, "The hall aide (CNA #2) saw resident coming out of (resident #2's) room and redirected the male resident. She stated the CNA said the brief was unfastened. She was asked what unfastened meant. She stated, "It was not intact." She was asked if the brief was pulled down. She stated the CNA had not informed her of that. LPN #2 stated the CNA checked the brief and it was dry and then informed her of the incident. She stated she went to the female resident's room and interviewed her. She stated she asked the resident if she had been violated or touched but she just said 'Huh.' She stated she changed her and assessed her peri area. She stated there were no signs of trauma or sexual activity. She was asked what the signs of sexual activity would have been. She stated, "No redness, no tearing around the vagina." She stated she then went to the male resident's room, and he stated he did not and that he just covered her up. She was asked what time the incident happened. She stated, "12:20 a.m. I told the CNAs to keep a close eye on the resident and filled out an incident report." LPN #2 was asked when had she informed her supervisor. She stated, "Right before I filled out the incident report, I reported to the ADON." She was asked if the ADON had given her any instructions. She stated the ADON told her to complete an incident report and keep a close watch and document. She was asked if resident #1 had entered resident #2's room unattended in the past. She stated she did not know. She was asked when she informed the physician. She stated, "Due to the holiday we, told by the ADON, paged him in the morning around 6:30 a.m. She was asked when she informed the police. She stated, "They weren't called." She was asked if she had training regarding assessing a potential sexual assault. She stated, "No." She was asked what the facility's policy was regarding potential sexual assault. She stated, "Inform supervisors." On 12/04/14 at 12:40 p.m., CNA #2 was asked if she witnessed resident #1 when he came out of resident #2's room. She stated, "Yes. I told him to go back to his room. Then I checked on her. She was on her right side sleeping. She was facing me." She was asked if the resident was covered. She stated, "Yes. I pulled the covers back and the brief was undone." She was asked what undone meant. She stated, "Not taped, not between her legs, lying on the bed under and behind her." She stated resident #1 wandered and looked for (resident #2). She stated, "He thinks she is his wife." She was asked how long resident #1 was in resident #2's room. She stated she did not know. She was asked if she had spoken with resident #2's husband. She stated, "No." She was asked if she had changed resident #2's brief. She stated, "Yes. It was not dirty or wet." On 12/04/14 at 2:13 p.m., the ADON was asked when she was informed about the incident. She stated, "I received a text at 12:45 a.m." She was asked why the physician was not informed. She stated, "I didn't get the text till I woke up and the doctor's office was closed due to the holiday. When I got to the facility, I instructed her, she could call the doctor because he had a service. I was told the brief was unfastened and instructed the nurse to follow the abuse policy." She was asked if she was aware the brief was not between the resident's legs. She stated, "I was unaware of that." On 12/04/14 at 2:22 p.m., the DON was asked if she was in the facility during the incident. She stated, "No, I was off Thursday and Friday but they did text me." She was asked what time the staff texted her. She stated, "At 7:26 a.m. the ADON texted me and told me the (brief) was unfastened." She was asked if the brief had been on the resident. She stated, "They just said unfastened." On 12/04/14 at 3:14 p.m., CNA #2 was asked if the resident had unfastened or removed her brief in the past. She stated, "Yes, if she was wet she had taken her brief off and thrown it on the floor. She did not like to be wet." On 12/04/14 at 3:17 p.m., the resident's physician was asked when he was called regarding resident #1 being in resident #2's room unattended. He stated, "I was not called. I was told when I came to the facility." He was asked if he had known the resident's brief was unfastened and not between her legs. He stated, "No. I would have sent her to the hospital for an exam at that time. You would need to have a SANE exam to know what happened." He was asked if he would have sent her for a SANE (sexual assault nurse exam). He stated, "Yes." He was asked if he was aware of the psych physician's recommendation to discontinue the Namenda and add Neurotin. He stated, "I never saw that." On 12/04/14 at 3:27 p.m., CNA #4 was asked if resident #2 would take her brief off. She stated, "Yes." She was asked if she only took off her brief when it was wet. She stated when it was wet and dry and I have observed her coming down the hall pulling it off. She was asked if the resident removed her brief while in bed. She stated, "I don't think so." On 12/08/14 at 10:10 a.m., LPN #3 was asked what happened the night resident #1 was in resident #2's room unattended. He stated a little after midnight CNA #2 said she did not want to tell me but she saw resident #1 come out of resident #2's room. He stated she checked on resident #2 and her brief was unfastened and the resident was covered. He stated LPN #2 went to assess the resident. LPN #3 was asked if there had been two LPNs on the memory unit on the night of the incident. He stated he was assigned to a different hall and happened to be at the nurses' desk on the memory unit at the time. He was asked if any interventions were instituted to ensure resident #1 did not go into resident #2's room. He stated, "The next day the (resident #2) was placed on one to one as soon as staff arrived at the facility." He was asked why resident #1 was not on one to one now. He stated he was not sure when the one on one for (resident #2) stopped. He did not reply. On 12/08/14 at 10:22 a.m., the DON was asked when the video tapes were reviewed from the night resident #1 was in resident #2's room unattended, how long resident #1 was in resident #2's room. She stated, "Approximately 20 minutes." On 12/08/14 at 11:31 a.m., the DON was asked how she thought this incident came about. She stated, "One CNA was at the nurses' desk and one was in the dining room. They could not see the hall. The one in the dining room was asleep and was fired."

Based on observation, interview, and record review, it was determined the facility failed to obtain medications for one (#1) of three sampled resident whose medications were reviewed. This resulted in actual harm for resident #1 when he was without pain medication for 17 hours and experienced severe pain. The facility identified 40 residents as receiving pain medications. Findings: The facility's policy on emergency pharmacy service and emergency kits, dated 09/2010, documented, "...Emergency pharmaceutical service is available on a 24-hour basis. Emergency needs for medication are met by using the nursing care center's approved emergency medication supply or by special order from the provider pharmacy..." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital discharge orders, dated 10/02/14, documented the resident was to receive the following medications for pain: ~ Fentanyl patch, 50 mcg, every 72 hours; ~ Morphine extended release, 15 mg by mouth, every 12 hours; ~ Morphine, 15 mg by mouth, every six hours as needed; and ~ gabapentin, 300 mg by mouth three times a day. A pain evaluation, dated 10/02/14, documented the resident had chronic pain, rheumatoid arthritis, and neuropathy. It was documented the resident described his pain as heaving, tender, shooting at times, and stabbing at times. It was documented the resident rated his pain at that time as a 6 out of 10. It was documented the best his pain ever got was a 4 and the worst was a 9 to 10 out of 10. A temporary care plan, dated 10/02/14, did not address pain as a problem for the resident. A nurse's note, dated 10/02/14 at 10:10 p.m., documented, "...arrived to facility...(alert and oriented x 3)...Resident c/o lower back pain c repositioning scale of 7/10. Resident has a dx of chronic pain and neuropathy..." A nurse's note, dated 10/02/14 at 10:15 p.m., documented, "...This nurse went back to review pain meds r/t c/o pain for pain regimen. Resident @ this time resting c OU closed roused easily cont to c/o lower back pain offered PRN Tylenol @ this time but resident refused. Grimacing and moaning noted c repositioning...Resident wanting to just sleep for now r/t fatigue..." A five day pay per service assessment, dated 10/03/14, documented the resident was on a scheduled pain medication regimen and received prn pain medications. It was documented a pain assessment interview should not be completed as the resident rarely understood or was never understood. A nurse's note, dated 10/03/14 at 6:30 a.m., documented, "...Resident states pain. This nurse informed resident that pain meds were not in the building. This nurse informed resident that she would call pharmacy about pain meds. Resident refused care by this nurse..." A nurse's note, dated 10/03/14 at 7:00 a.m., documented, "...Resident awake in bed. Resident states pain level is too high for this nurse to do assessment on wounds...." A nurse's note, dated 10/03/14 at 7:35 a.m., documented a physician's orders [REDACTED]. A nurse's note, dated 10/03/14 at 8:00 a.m., documented, "...This nurse call(ed) (pharmacy name withheld) inquiring about why pain meds were not in the building yet. No answer @ pharmacy, this nurse left a message for pharmacist to call back. Pharmacy called @ (9:00 a.m.) and informed this nurse that a secondary pharmacy was being used and pharmacy was coming to (pick up) hard scripts from (nursing home) to take to secondary pharm. This nurse asked why pain meds were taking so long to get to (nursing home). Pharmacy stated 'because of secondary pharmacy.' This nurse informed resident and family that pain meds were still not in (nursing home.) This nurse informed resident and family that this nurse would instruct med aid to administer pain meds as soon as they were delivered to (nursing home)..." A nurse's note, dated 10/03/14 at 8:30 a.m., documented, "...Resident's(family member) upset about pain meds not being administered. Resident's (family member) stated that she had pain meds from home and would administer them herself. This nurse stated that pain meds from home could not be administered by this facility. Resident's wife asked to talk to DON..." A nurse's note, dated 10/03/14 at 11:00 a.m., documented, "...Resident observed in bed grimacing and moaning. Resident refused any care from this nurse..." A nurse's note, dated 10/03/14 at 11:30 a.m., documented, "...Resident and wife visibly upset about pain medicine not being available. This nurse did not observe resident's (family member) administering pain meds from home. This nurse thinks that resident's (family member) administered pain meds from home..." An occupational therapy plan of care, dated 10/03/14 and untimed, documented, "...Unable to test patient, secondary to increased pain on eval. Pain medication had not arrived at the time of the eval..." A physical therapy plan of care, dated 10/03/14 and untimed, documented, "...patient did not have pain meds and patient was in a lot of pain and (family member) says patient needs his pain meds before can try out of bed activities; patient unable to test the above functions secondary to patient in severe pain and pain meds have not arrived from pharmacy..." A nurse's note, dated 10/03/14 at 1:00 p.m., documented, "...Resident asleep in bed..." A nurse's note, dated 10/03/14 at 3:30 p.m., documented, "...Resident requested pain meds. This LPN adm morphine 15 mg (one) tab po prn for pain 'all over 5/10' on pain scale..." A nurse's note, dated 10/03/14 at 4:00 p.m., documented, "...Voiced pain better 3/10 on pain scale..." A nurse's note, dated 10/03/14 at 6:00 p.m., documented, "...(Family member) approached (nursing) station c request to give (8:00 p.m.) meds. MD notified, ok to give @ this time..." A nurse's note, dated 10/03/14 at 10:30 p.m., documented, "...(Family member approached nursing station stated resident in pain. This LPN checked MAR. Noted resident just had morphine 15 mg extended release given routinely @ (8:00 p.m.)..." A nurse's note, dated 10/03/14 at 11:30 p.m., documented, "...This 10-6 nurse was on duty waiting to get report...@ around (11:00 p.m.), this nurse observed resident's (family member) complaining about (resident) being in pain which was severe, stated 'I want to send (resident #1) to the hospital.' This nurse observed resident being sweaty and slightly moaning. Resident stated 'I want to go to the hospital'...orders given to send resident to the hospital..." Review of medication administration records, dated 10/02/14 and 10/03/14, revealed the resident received the following medications for pain while at the facility: ~ One dose of morphine 15 mg, immediate release, at 3:25 p.m. on 10/03/14; ~ One dose of gabapentin 300 mg at 4:00 p.m. on 10/03/14; and ~ One dose of Morphine 15 mg, extended release. This dose was documented as being given at 8:00 p.m. on 10/03/14, even though the nurses' notes documented the medication was given at approximately 6:00 p.m. The resident was without pain medication from 10:10 p.m. on 10/02/14 until 3:25 p.m. on 10/03/14. This was a total of over 17 hours without pain medication. An emergency room physician's note, dated 10/07/14, documented, "...Pain is better with Fentanyl..." A hospital discharge summary, dated 10/09/14, documented, "...at the end of this previous hospitalization , he was discharged to a skilled nursing facility. Unfortunately, they were not able to get him any of his medications for approximately 24 hours and he went into an acute withdrawal..." A discharge summary, dated 10/18/14, documented, "...(family member) reported to charge nurse that resident was in pain (and) requested that he be transferred to E.R...Event(s) leading to discharge: c/o pain..." On 10/24/14 at 9:39 a.m., LPN #1 was asked if she had cared for resident #1. She stated yes, she had taken care of him on the day shift. LPN #1 was asked what happened with the resident. She stated when she came on duty, she was told the resident's medications were not in the facility. She stated she went to assess the resident but he told her he was in too much pain to do anything with him. LPN #1 stated she informed the resident she would call about his medications. LPN #1 was asked what she did. She stated she called the pharmacy and had to leave a message. She stated the pharmacy called back at approximately 9:00 a.m., and informed her they would have to come to the facility and obtain the written prescriptions, have them filled, and then bring the medications back. LPN #1 stated she continued to check on the resident but he did not want her to do anything with him. She was asked why the resident did not want her to do anything. She stated, "Because of pain is what he said." LPN #1 was asked what she did about the resident's pain. She stated the resident would not allow her to touch him. She was asked if she rated the resident's pain. She stated she did not write it down but she could see the resident grimacing. LPN #1 was asked if the resident's Fentanyl patch was in place. She stated she did not know. LPN #1 was asked what the process was for ordering medications. She stated if a resident was admitted after hours, the orders were supposed to be faxed to the pharmacy and then staff needed to call the pharmacy as well. She stated if the medications had not arrived at the facility within two hours, staff was supposed to call the pharmacy again and let the on-call nurse know there were difficulties in obtaining medications. LPN #1 stated if a resident was in too much pain, they should be sent to the hospital. She was asked if she sent resident #1 out to the hospital. She stated, "No." When asked why, LPN #1 stated, "I don't really know." She was asked if his pain was severe enough that he should have been sent out. LPN #1 stated, "I think so." LPN #1 was asked if she had problems with the pharmacy. She stated yes, but that nothing like this had happened before. She stated sometimes she had to call again to find out why refills were not at the facility. She was asked if she had difficulties in getting pain medications for other residents. She stated no. LPN #1 was asked if she had received any education or instruction after the incident with resident #1. She stated, "Yes." She stated administration had provided education on that day about what to do when sending medication orders to the pharmacy after hours. LPN #1 was asked who provided the education. She stated the administrator and ADON. On 10/24/14 at 9:58 a.m., LPN #2 was asked if she had admitted resident #1 to the facility. She stated, "Yes." She was asked what she did to obtain the resident's medications. She stated she wrote the medication list, faxed it to the pharmacy, and placed a call to the on-call pharmacist. LPN #2 was asked if the resident was in pain at admission. She stated yes. She stated the resident had complained of pain but when she looked at his medications, all he had available was Tylenol. LPN #2 stated the resident refused the Tylenol and stated he just wanted to be left alone. LPN #2 was asked at what the resident rated his pain. She stated a 7 out of 10. She was asked how the resident rested over the night. She stated he slept all night. LPN #2 was asked when the resident's pain medications arrived at the facility. She stated, "They didn't on my shift." She was asked why the medications did not arrive. She stated she was unsure. She was asked if she called the pharmacy back after the medications did not arrive. She stated, "No, that was my mistake." LPN #2 was asked if the resident had his Fentanyl patch on. She stated she did not see one when she looked at the resident. LPN #2 was asked if she was provided any education after the incident. She stated yes. She stated she was educated on ordering medications and what to do if medications were not at the facility within four hours. LPN #2 was asked if the facility had an emergency pharmacy. She stated yes and named the pharmacy. She was asked when the emergency pharmacy would be used. She stated when an emergency antibiotic or one time orders were needed. She stated it might be used for medications that needed to be in the facility "right now." LPN #2 was asked if a resident was having pain, would the pain medications need to be in the facility right away. She stated it would depend on the resident. On 10/24/14 at 10:11 a.m., the administrator, DON, and ADON were asked to explain what occurred with the resident. They told the surveyor the resident had been admitted at 10:00 p.m., and it was discovered by the day nurse that his medications were not in the building. They stated the day nurse called the pharmacy and discovered the prescriptions had not been filled at that time. The administrator stated the incident had been reported to the Oklahoma State Department of Health and nursing staff had been inserviced on ordering medications from the pharmacy after hours. She was asked if it was the same system that had been in place before the incident with resident #1. She stated a process was in place but it had been "tweaked." She stated the pharmacy had always instructed to fax and call with after hours prescriptions. The administrator, DON, and ADON were asked how long the resident was in pain. The administrator stated, "We don't know." She stated the resident was supposed to leave the hospital with the Fentanyl patch. They were asked why staff did not call and utilize the emergency pharmacy. The administrator stated, "I can't answer that." The administrator was asked to provide documentation of the education provided to the staff after the incident with resident #1. Review of the documentation revealed neither the use of the emergency pharmacy nor caring for a resident in pain were addressed. On 10/24/14 at 1:11 p.m., a facsimile from the facility's pharmacy was obtained. The facsimile documented MEDICATION ORDERS FOR [REDACTED]. The pharmacy had no record of any phone call after the fax. The facsimile documented the pharmacy's driver obtained the prescriptions and arrived at a secondary pharmacy on 10/03/14 at 9:16 a.m. The prescriptions were filled and the medications delivered to the facility on [DATE] at 11:40 a.m. LPN #1 signed for the medications. On 10/24/14 at 2:03 p.m., the administrator, DON, and ADON were asked what the purpose was of an emergency pharmacy. The administrator stated it was back up in case the facility did not get medications from the regular pharmacy.

Based on interview and record review, it was determined the facility failed to identify and implement interventions to aid in the reduction of pain for one (#1) of three sampled residents who were reviewed for pain. This resulted in actual harm for resident #1 when he was without pain medication for 17 hours and no interventions were identified or implemented to aid in the reduction of his severe pain. The facility identified 40 residents as being on a pain management program. Findings: The facility's policy on emergency pharmacy service and emergency kits, dated 09/2010, documented, "...Emergency pharmaceutical service is available on a 24-hour basis. Emergency needs for medication are met by using the nursing care center's approved emergency medication supply or by special order from the provider pharmacy..." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital discharge orders, dated 10/02/14, documented the resident was to receive the following medications for pain: ~ [MEDICATION NAME], 50 mcg, every 72 hours; ~ [MEDICATION NAME] extended release, 15 mg by mouth, every 12 hours; ~ [MEDICATION NAME], 15 mg by mouth, every six hours as needed; and ~ [MEDICATION NAME], 300 mg by mouth three times a day. A pain evaluation, dated 10/02/14, documented the resident had chronic pain, [MEDICAL CONDITION] arthritis, and [MEDICAL CONDITION]. It was documented the resident described his pain as heaving, tender, shooting at times, and stabbing at times. It was documented the resident rated his pain at that time as a 6 out of 10. It was documented the best his pain ever got was a 4 and the worst was a 9 to 10 out of 10. A temporary care plan, dated 10/02/14, did not address pain as a problem for the resident. A nurse's note, dated 10/02/14 at 10:10 p.m., documented, "...arrived to facility...(alert and oriented x 3)...Resident c/o lower back pain c repositioning scale of 7/10. Resident has a dx of chronic pain and [MEDICAL CONDITION]" A nurse's note, dated 10/02/14 at 10:15 p.m., documented, "...This nurse went back to review pain meds r/t c/o pain for pain regimen. Resident @ this time resting c OU closed roused easily cont to c/o lower back pain offered PRN Tylenol @ this time but resident refused. Grimacing and moaning noted c repositioning...Resident wanting to just sleep for now r/t fatigue..." A five day pay per service assessment, dated 10/03/14, documented the resident was on a scheduled pain medication regimen and received prn pain medications. It was documented a pain assessment interview should not be completed as the resident rarely understood or was never understood. A nurse's note, dated 10/03/14 at 6:30 a.m., documented, "...Resident states pain. This nurse informed resident that pain meds were not in the building. This nurse informed resident that she would call pharmacy about pain meds. Resident refused care by this nurse..." A nurse's note, dated 10/03/14 at 7:00 a.m., documented, "...Resident awake in bed. Resident states pain level is too high for this nurse to do assessment on wounds...." A nurse's note, dated 10/03/14 at 7:35 a.m., documented a physician's orders [REDACTED]. A nurse's note, dated 10/03/14 at 8:00 a.m., documented, "...This nurse call(ed) (pharmacy name withheld) inquiring about why pain meds were not in the building yet. No answer @ pharmacy, this nurse left a message for pharmacist to call back. Pharmacy called @ (9:00 a.m.) and informed this nurse that a secondary pharmacy was being used and pharmacy was coming to (pick up) hard scripts from (nursing home) to take to secondary pharm. This nurse asked why pain meds were taking so long to get to (nursing home). Pharmacy stated 'because of secondary pharmacy.' This nurse informed resident and family that pain meds were still not in (nursing home.) This nurse informed resident and family that this nurse would instruct med aid to administer pain meds as soon as they were delivered to (nursing home)..." A nurse's note, dated 10/03/14 at 8:30 a.m., documented, "...Resident's(family member) upset about pain meds not being administered. Resident's (family member) stated that she had pain meds from home and would administer them herself. This nurse stated that pain meds from home could not be administered by this facility. Resident's wife asked to talk to DON..." A nurse's note, dated 10/03/14 at 11:00 a.m., documented, "...Resident observed in bed grimacing and moaning. Resident refused any care from this nurse..." A nurse's note, dated 10/03/14 at 11:30 a.m., documented, "...Resident and wife visibly upset about pain medicine not being available. This nurse did not observe resident's (family member) administering pain meds from home. This nurse thinks that resident's (family member) administered pain meds from home..." An occupational therapy plan of care, dated 10/03/14 and untimed, documented, "...Unable to test patient, secondary to increased pain on eval. Pain medication had not arrived at the time of the eval..." A physical therapy plan of care, dated 10/03/14 and untimed, documented, "...patient did not have pain meds and patient was in a lot of pain and (family member) says patient needs his pain meds before can try out of bed activities; patient unable to test the above functions secondary to patient in severe pain and pain meds have not arrived from pharmacy..." A nurse's note, dated 10/03/14 at 1:00 p.m., documented, "...Resident asleep in bed..." A nurse's note, dated 10/03/14 at 3:30 p.m., documented, "...Resident requested pain meds. This LPN adm [MEDICATION NAME] 15 mg (one) tab po prn for pain 'all over 5/10' on pain scale..." A nurse's note, dated 10/03/14 at 4:00 p.m., documented, "...Voiced pain better 3/10 on pain scale..." A nurse's note, dated 10/03/14 at 6:00 p.m., documented, "...(Family member) approached (nursing) station c request to give (8:00 p.m.) meds. MD notified, ok to give @ this time..." A nurse's note, dated 10/03/14 at 10:30 p.m., documented, "...(Family member approached nursing station stated resident in pain. This LPN checked MAR. Noted resident just had [MEDICATION NAME] 15 mg extended release given routinely @ (8:00 p.m.)..." A nurse's note, dated 10/03/14 at 11:30 p.m., documented, "...This 10-6 nurse was on duty waiting to get report...@ around (11:00 p.m.), this nurse observed resident's (family member) complaining about (resident) being in pain which was severe, stated 'I want to send (resident #1) to the hospital.' This nurse observed resident being sweaty and slightly moaning. Resident stated 'I want to go to the hospital'...orders given to send resident to the hospital..." Review of medication administration records, dated 10/02/14 and 10/03/14, revealed the resident received the following medications for pain while at the facility: ~ One dose of [MEDICATION NAME] 15 mg, immediate release, at 3:25 p.m. on 10/03/14; ~ One dose of [MEDICATION NAME] 300 mg at 4:00 p.m. on 10/03/14; and ~ One dose of [MEDICATION NAME] 15 mg, extended release. This dose was documented as being given at 8:00 p.m. on 10/03/14, even though the nurses' notes documented the medication was given at approximately 6:00 p.m. The resident was without pain medication from 10:10 p.m. on 10/02/14 until 3:25 p.m. on 10/03/14. This was a total of over 17 hours without pain medication. An emergency room physician's note, dated 10/07/14, documented, "...Pain is better with [MEDICATION NAME]" A hospital discharge summary, dated 10/09/14, documented, "...at the end of this previous hospitalization , he was discharged to a skilled nursing facility. Unfortunately, they were not able to get him any of his medications for approximately 24 hours and he went into an acute withdrawal..." A discharge summary, dated 10/18/14, documented, "...(family member) reported to charge nurse that resident was in pain (and) requested that he be transferred to E.R...Event(s) leading to discharge: c/o pain..." On 10/24/14 at 9:39 a.m., LPN #1 was asked if she had cared for resident #1. She stated yes, she had taken care of him on the day shift. LPN #1 was asked what happened with the resident. She stated when she came on duty, she was told the resident's medications were not in the facility. She stated she went to assess the resident but he told her he was in too much pain to do anything with him. LPN #1 stated she informed the resident she would call about his medications. LPN #1 was asked what she did. She stated she called the pharmacy and had to leave a message. She stated the pharmacy called back at approximately 9:00 a.m., and informed her they would have to come to the facility and obtain the written prescriptions, have them filled, and then bring the medications back. LPN #1 stated she continued to check on the resident but he did not want her to do anything with him. She was asked why the resident did not want her to do anything. She stated, "Because of pain is what he said." LPN #1 was asked what she did about the resident's pain. She stated the resident would not allow her to touch him. She was asked if she rated the resident's pain. She stated she did not write it down but she could see the resident grimacing. LPN #1 was asked if the resident's [MEDICATION NAME] was in place. She stated she did not know. LPN #1 was asked what the process was for ordering medications. She stated if a resident was admitted after hours, the orders were supposed to be faxed to the pharmacy and then staff needed to call the pharmacy as well. She stated if the medications had not arrived at the facility within two hours, staff was supposed to call the pharmacy again and let the on-call nurse know there were difficulties in obtaining medications. LPN #1 stated if a resident was in too much pain, they should be sent to the hospital. She was asked if she sent resident #1 out to the hospital. She stated, "No." When asked why, LPN #1 stated, "I don't really know." She was asked if his pain was severe enough that he should have been sent out. LPN #1 stated, "I think so." LPN #1 was asked if she had problems with the pharmacy. She stated yes, but that nothing like this had happened before. She stated sometimes she had to call again to find out why refills were not at the facility. She was asked if she had difficulties in getting pain medications for other residents. She stated no. LPN #1 was asked if she had received any education or instruction after the incident with resident #1. She stated, "Yes." She stated administration had provided education on that day about what to do when sending medication orders to the pharmacy after hours. LPN #1 was asked who provided the education. She stated the administrator and ADON. On 10/24/14 at 9:58 a.m., LPN #2 was asked if she had admitted resident #1 to the facility. She stated, "Yes." She was asked what she did to obtain the resident's medications. She stated she wrote the medication list, faxed it to the pharmacy, and placed a call to the on-call pharmacist. LPN #2 was asked if the resident was in pain at admission. She stated yes. She stated the resident had complained of pain but when she looked at his medications, all he had available was Tylenol. LPN #2 stated the resident refused the Tylenol and stated he just wanted to be left alone. LPN #2 was asked at what the resident rated his pain. She stated a 7 out of 10. She was asked how the resident rested over the night. She stated he slept all night. LPN #2 was asked when the resident's pain medications arrived at the facility. She stated, "They didn't on my shift." She was asked why the medications did not arrive. She stated she was unsure. She was asked if she called the pharmacy back after the medications did not arrive. She stated, "No, that was my mistake." LPN #2 was asked if the resident had his [MEDICATION NAME] on. She stated she did not see one when she looked at the resident. LPN #2 was asked if she was provided any education after the incident. She stated yes. She stated she was educated on ordering medications and what to do if medications were not at the facility within four hours. LPN #2 was asked if the facility had an emergency pharmacy. She stated yes and named the pharmacy. She was asked when the emergency pharmacy would be used. She stated when an emergency antibiotic or one time orders were needed. She stated it might be used for medications that needed to be in the facility "right now." LPN #2 was asked if a resident was having pain, would the pain medications need to be in the facility right away. She stated it would depend on the resident. On 10/24/14 at 10:11 a.m., the administrator, DON, and ADON were asked to explain what occurred with the resident. They told the surveyor the resident had been admitted at 10:00 p.m., and it was discovered by the day nurse that his medications were not in the building. They stated the day nurse called the pharmacy and discovered the prescriptions had not been filled at that time. The administrator stated the incident had been reported to the Oklahoma State Department of Health and nursing staff had been inserviced on ordering medications from the pharmacy after hours. She was asked if it was the same system that had been in place before the incident with resident #1. She stated a process was in place but it had been "tweaked." She stated the pharmacy had always instructed to fax and call with after hours prescriptions. The administrator, DON, and ADON were asked how long the resident was in pain. The administrator stated, "We don't know." She stated the resident was supposed to leave the hospital with the [MEDICATION NAME]. They were asked why staff did not call and utilize the emergency pharmacy. The administrator stated, "I can't answer that." The administrator was asked to provide documentation of the education provided to the staff after the incident with resident #1. Review of the documentation revealed neither the use of the emergency pharmacy nor caring for a resident in pain were addressed. On 10/24/14 at 1:11 p.m., a facsimile from the facility's pharmacy was obtained. The facsimile documented MEDICATION ORDERS FOR [REDACTED]. The pharmacy had no record of any phone call after the fax. The facsimile documented the pharmacy's driver obtained the prescriptions and arrived at a secondary pharmacy on 10/03/14 at 9:16 a.m. The prescriptions were filled and the medications delivered to the facility on [DATE] at 11:40 a.m. LPN #1 signed for the medications. On 10/24/14 at 2:03 p.m., the administrator, DON, and ADON were asked what the purpose was of an emergency pharmacy. The administrator stated it was back up in case the facility did not get medications from the regular pharmacy.

Based on observation, interview, and record review, it was determined the facility failed to provide sufficient fluid intake to maintain hydration for one (#34) of five sampled residents who were reviewed for hydration. The resident required hospitalization with critical laboratory values and [DIAGNOSES REDACTED]. The resident did not regain her previous mental status and was discharged on hospice and comfort care. The resident expired on [DATE]. The facility identified 20 residents who were at risk for dehydration. Findings: A policy, titled Dehydration, dated 2013, documented, "Policy: Individuals at risk for dehydration will be identified, assessed, and provided with sufficient fluid intake to maintain proper hydration and health. Procedure: Assure that each individual receives sufficient amounts of fluids based on individual need to prevent dehydration and maintain health... Risk factors for dehydration will be identified through continual nursing assessment. Risk factors for dehydration include: ...Functional impairments that make it difficult to drink, reach fluids, or communicate fluid needs... Dementia in which the individual forgets to drink... Clinical signs of possible insufficient fluid intake are assessed through continual nursing assessment: ...Concentrated urine... Confusion or change in mental status Lethargy Newly present constipation... Laboratory values (hemoglobin and hematocrit, potassium, chloride, sodium, [MEDICATION NAME], transferrin, BUN or urine specific gravity)... Functional decline... For individuals identified at risk of dehydration, assure that adequate fluids are provided... Fluid needs calculations are generally based on the following estimates: Without renal or cardiac distress: 30mL/kg body weight...diagnosed with [REDACTED]. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A temporary care plan, dated [DATE], did not address the resident's hydration needs or that the resident was at risk for dehydration. The care plan documented a problem of, "Pot (potential) for ADL impairment d/t new surroundings, dec mobility, physical limitations." Approaches included, "...Diet as ordered, assist with feeding prn." A nursing evaluation, dated [DATE], documented, "weight 137.8 lb...eating/nutrition: chokes easily hx of aspiration..." A nurse's note, dated [DATE] at 3:30 a.m., documented, "...denies discomfort...voices needs and cooperative c (with) care..." A nurse's note, dated [DATE] at 10:30 a.m., documented, "Resident (up) in w/c in common area. Alert...(No) c/o pain...pleasant & cooperative c care..." A nurse's note, dated [DATE] at 11:00 a.m., documented, "...Alert pleasant & cooperative c care...appetite fair..." A nurse's note, dated [DATE] at 12:00 a.m., documented, "...Alert c understandable speech..." A nurse's note, dated [DATE] at 2:00 p.m., documented the resident complained of burning on urination. The nurses' notes documented a urine specimen was collected via straight cath on [DATE] at 2:00 a.m. A nurse's note, dated [DATE] at 9:00 a.m. documented, "Res c/o pain to rectum. Eval of res notice small amt of hard bowel protruding out of rectum. PCP notified N/O for fleet enema. Prune juice & prn MOM administered..." A nurse's note, dated [DATE] (sic) at 1:00 a.m., documented, "Resident in bed resting c eyes open, resident squirming in bed and moaning. Resident has visible stool in rectal area...Tylenol admin. for pain and MOM adm. for constipation...0200 (2:00 a.m.) Resident has visible stool in rectum...appearing to be in pain. Softly answered yes when asked if painful rectal area. Fleets enema rectally..." A nurse's note, dated [DATE] at 2:30 a.m., documented, "...Blood c urine in brief..." A nurse's note, dated [DATE] at 9:12 a.m., documented, "...Poor appetite this am..." A nurse's note, dated [DATE], documented, "poor appetite this evening..." An admission assessment, dated [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making and was totally dependent on staff for eating and drinking A nurse's note, dated [DATE] at 12:00 a.m., documented, "Resident in bed c eyes open, moaning some, unable to determine where resident is hurting. Resident does not respond to questions @ times..." An untimed nurse's note, dated [DATE], documented, "Resident moaning and restless. Resident unable to verbalize where she is hurting..." A nurse's note, dated [DATE] at 5:45 a.m., documented, "...In bed c eyes closed, no eye contact. Residents extremities flaccid, (decrease) response to stimuli compared to earlier on shift. Resident breathing using abdominal muscles. Resident rolled to side c very little response. v/s ,[DATE] (blood pressure) 80 (heart rate) 20 (respirations) 98 (temperature) ax. O2 sat 92 @ R/A...went back to residents room, breaths became very shallow to the point where appeared to be a period of apnea. b/p retaken and got ,[DATE] c pulse 79..." At 6:10 a.m., a nurse's note, documented, "Transferred to hospital (name withheld)..." A form, titled Dietary, dated [DATE], documented: Breakfast: drink on ,[DATE] through ,[DATE]: "100%"; health shake on ,[DATE], ,[DATE], and ,[DATE]: "50%"; ,[DATE]: "25%." Lunch: drink on ,[DATE] through ,[DATE]: "100%; health shake on ,[DATE] and ,[DATE]: "25%"; ,[DATE] and ,[DATE]: "50%." Dinner: drink on ,[DATE] through ,[DATE]: "100%"; health shake on ,[DATE], ,[DATE], and ,[DATE]: "50%"; ,[DATE]: "25%"; ,[DATE]: "75%". A comprehensive intake-output record, dated [DATE] through [DATE] documented: "..XXX[DATE]...eve...200cc; [DATE]...night:..100cc, day:..200cc, eve:..250cc; [DATE]...night:..250cc, day:..300cc, eve:..250cc; [DATE]...night:..0, day:..360cc, eve:..200cc; [DATE]...night:..0, day:..240cc, eve:..200cc..." A form, titled Dietary, dated [DATE], documented: Breakfast: drink on ,[DATE] through ,[DATE]: "100%"; ,[DATE]: "75%"; health shake on ,[DATE] through ,[DATE]: "75%"; ,[DATE]: "50%." Lunch: drink on ,[DATE] through ,[DATE]: "100%; health shake on ,[DATE] through ,[DATE]: "100%." Dinner: drink on ,[DATE] through ,[DATE]: "100%"; ,[DATE] through ,[DATE]: 75%; health shake on ,[DATE] through ,[DATE]: "100%." A comprehensive intake-output record, dated [DATE] through [DATE] documented: "..XXX[DATE]...night:..60cc, day:..60cc, eve:..60cc; [DATE]...night:..90cc, day:..20cc, eve:..40cc; [DATE]...night:..90cc, day:..10cc, eve:..0; [DATE]...night:..50cc, day:..100cc, eve:..100cc; [DATE]...night:..60cc, day:..100cc, eve:..60cc; [DATE]...night:..60cc, day:..0, eve:..60cc; [DATE]...night:..60cc, day:..30cc, eve:..60cc; [DATE]...night:...30cc, day:...20cc, eve:...30cc; [DATE]...night:...30cc, day: 10cc, eve:...30cc..." The resident's weight of 137.8 pounds indicated she required 1879 cc of fluids at a minimum daily. The dietary records and the intake and output records documented the resident did not have sufficient fluids on the following dates: On [DATE], the resident had 1830cc. On [DATE], the resident had 1830cc. On [DATE], the resident had 1800cc. On [DATE], the resident had 1770cc. On [DATE], the resident had 1680cc. On [DATE], the resident had 1610cc. On [DATE], the resident had 1480cc. Resident #34 had not received the 30mL/kg per day per the facility's policy. Nurses' notes were reviewed from [DATE] through [DATE]. There was no documentation to indicate staff offered or encouraged fluids. Emergency Department physician notes, dated [DATE] at 6:52 a.m., documented, "...BUN 162...HI...Creatinine 5.50...HI...Sodium 176...CRIT (critical)...Chloride [MEDICATION NAME] 31...HI...Calcium 12.6 CRIT(critical)...Impression...Acute [MEDICAL CONDITIONS] urinary tract infection... Notes: Is (sic) was told by nursing home staff that the patient's baseline mental status is nonverbal and bed bound. Reviewed medical record indicates that she was actually able to talk at the end of December. It is unclear when she actually became nonverbal. Her vital signs were normal best (sic) she was relatively unresponsive. Laboratory evaluation showed significant [MEDICAL CONDITION] and acute [MEDICAL CONDITION]" A hospital discharge summary, dated [DATE], documented, "...Admission diagnoses...pressure ulcer, left heel...change in mental status... The patient was admitted to the hospital with [REDACTED]. The patient had clinical signs and objective signs of dehydration, admitted with a white count of 34,000. The patient progressively improved and on [DATE], white count was down to 11.5. her initial creatinine was 5.5 and by [DATE], was down to 2.3. Initial sodium was 176. By [DATE], it was down to 148 with potassium of 3.9. Initial calcium was 12. With hydration it went down to 10...the patient's mental status had not significantly changed back to baseline...Although her electrolytes had improved and she was better hydrated family elected to proceed with supportive care at this point. Arrangements were made for the patient to return to the nursing home with hospice and comfort care... Final diagnoses...severe dehydration...electrolyte disorder secondary to dehydration...chronic dementia..." On [DATE] at 8:40 a.m., a nursing tour was conducted. Resident #33 was observed in bed. Three cups of thickened water were observed on her bedside table. At 9:10 a.m., resident #33 was observed in her bed with three cups of thickened water at the same level as at 8:40 a.m. The cups were located on her bedside table. At 10:02 a.m., resident #33 was not in her room and the three cups of thickened water were at the same level as at 8:40 a.m. At 1:17 p.m., resident #33 was observed asleep in her room. No water was observed on her bedside table. On [DATE] at 9:15 a.m., resident #33 was observed in the hallway. She asked a CNA to put her to bed. No fluids were on the bedside table or night stand. At 9:22 a.m., a family member of resident #36, was asked why he did not have any fluids by his bed. She stated, "Well, he couldn't get it on his own anyways." At 11:22 a.m., the DON was asked if the dietary and nursing staff communicate residents' fluid intake. She stated, "Yes." She was asked who is responsible to monitor intake records. She stated, "No one." She was asked how she was aware a resident had received sufficient fluids. She stated, "I look for signs and symptoms." She was asked if she was aware of resident #34's decreased intake. She stated, "Yes. Put resident on [MEDICATION NAME]." She was asked if she was aware resident #34's decrease in fluid intake. She stated, "Fluid intake went from 100% to 75%." She was asked what interventions were implemented to increase the resident's fluid intake. She stated, "Encourage to drink fluids." She was asked where was it documented. She stated, "It should be in the nurses' notes." At 12:05 p.m., the dietary manager was asked what amount of fluids are residents served at each meal. He stated, "Eight ounces of water and eight ounces of tea or fruit drink, except at breakfast and they get eight ounces of water and 120cc of juice." He stated the health shakes were 120 cc. At 12:45 p.m., CNA #8 was asked if he documented or told the charge nurse how much fluid residents had drank on his shift. He stated, "Yes, or tell nurse." He was asked how much fluid does a resident need each shift. He stated he did not know. He was asked what would he report to the charge nurse regarding fluid intake. He stated, "If they had a glass of 120cc and only took a sip or two." At 12:50 p.m., CMA #3 was asked if she documented fluids given to the resident during the med pass. She stated, "No, I don't." At 12:53 p.m., CNA #9 was asked if he documented fluids given to the resident throughout the day. He stated, "Yes." He was asked how much fluid per shift does a resident need. He stated, "One cup." He was asked how many cc. He stated, "120cc." At 12:58 p.m., CMA #2 was asked if she documented fluids given to the resident during the med pass. She stated, "No, I do not." At 1:12 p.m., LPN #3 was asked if he documented fluid intake on residents. He stated only on skilled residents and residents with a fluid restriction. He was asked if CNAs reported the amount of fluid intake each shift. He stated, "Yes." He was asked where it was documented. He stated, "No, only if skilled and residents who had a fluid restriction."