Every finding on record at Lindsay Nursing & Rehab

Based on observation, record review, and interview, the facility failed to ensure portable oxygen cylinders were not stored unsecured in a resident's closet for 1 (#1) of 4 sampled residents reviewed for oxygen storage which had the potential to cause a severe fire hazard. The administrator identified 11 residents in the facility used oxygen. Findings:An undated Oxygen Storage and Safety policy, provided by the administrator on 04/14/26, showed full cylinders must be stored in a designated, well-ventilated area. The policy showed empty cylinders must be stored separately and labeled Empty. The policy showed oxygen in resident rooms must be secured to prevent tipping. The policy showed routine checks will be conducted to ensure proper storage and safety.An annual assessment for Resident #1, dated 01/13/26, showed the resident's cognition was intact with a BIMS score of 15. The assessment showed Resident #1 was independent with activities of daily living. The assessment showed Resident #1 received oxygen therapy and had diagnoses of chronic obstructive pulmonary disease and respiratory failure.A care plan for Resident #1, dated 02/03/26, showed the resident had oxygen therapy. The care plan intervention for Resident #1 showed a portable oxygen apparatus was to be provided. The care plan did not show interventions related to Resident #1's unsafe storage of portable oxygen cylinders brought into the facility.A physician's order for Resident #1, dated 02/25/26, showed administer oxygen at two liters per minute via nasal cannula as needed for a history of respiratory failure.Resident #1's medical record had no documentation the facility checked the resident's room for safe oxygen storage.On 04/14/26 at 9:20 a.m., Resident #1's room was observed to have 25 small cylinders of oxygen for an over-the-shoulder carrier bag stored in their closet. The oxygen cylinders were observed unsecured, standing up, and tipped over on the floor of Resident #1's closet.On 04/14/26 at 1:30 p.m., the DON was observed to check the oxygen cylinders in Resident #1's closet to ensure they were empty. The DON was observed to check three of the portable oxygen cylinders in Resident #1's closet, and two were found to be full.On 04/14/26 at 9:20 a.m., Resident #1 stated the facility would not supply the small portable oxygen cylinders they used in an over-the-shoulder carrier bag. Resident #1 stated they brought the oxygen cylinders to the facility from a family member's home. Resident #1 stated there were only empty cylinders in their closet and they had not stored full bottles in the closet.On 04/14/26 at 10:36 a.m., CNA #1 stated oxygen cylinders were to be stored in a locked room on the back hall designated for oxygen. CNA #1 stated no oxygen cylinders should be stored in residents' rooms.On 04/14/26 at 10:57 a.m., housekeeper #1 stated they had seen oxygen cylinders stored in Resident #1's closet when hanging up the resident's clothes. Housekeeper #1 stated they were not aware the oxygen cylinders were not allowed to be there.On 04/14/26 at 1:20 p.m., the DON stated oxygen cylinders were to be stored secured in a rack in a locked closet on the back hall of the facility. The DON stated they were not aware Resident #1 currently had any oxygen cylinders stored in their closet. The DON stated they had removed oxygen cylinders stored in Resident #1's room several times for safety. The DON stated they were not aware of what interventions had been put in place to prevent Resident #1 from storing oxygen cylinders in their closet.On 04/14/26 at 1:47 p.m., the administrator stated they were unaware Resident #1 had oxygen cylinders stored in their closet. The administrator stated the oxygen cylinders would be removed and Resident #1 and their family would be educated about the safety concern and policy for oxygen storage.

Based on observation, record review, and interview, the facility failed to ensure a resident's care plan was updated with interventions for safe storage of portable oxygen cylinders for 1 (#1) of 4 sampled residents reviewed for oxygen therapy. The administrator identified 11 residents used oxygen in the facility. Findings: On 04/14/26 at 9:20 a.m., Resident #1's room was observed to have 25 small cylinders of oxygen stored in their closet. The oxygen cylinders were observed standing up and tipped over on the floor of Resident #1's closet.On 04/14/26 at 1:30 p.m., the DON was asked to check the oxygen cylinders in Resident #1's closet to ensure they were empty. The DON was observed to check some of the oxygen cylinders. Two oxygen cylinders were observed to be full.A policy titled Care Plans, Comprehensive Person-Centered, dated 12/01/16, read in part, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.An annual assessment for Resident #1, dated 01/13/26, showed the resident's cognition was intact with a BIMS score of 15. The assessment showed Resident #1 was independent with activities of daily living, received oxygen therapy, and had chronic obstructive pulmonary disease.A care plan for Resident #1, dated 02/03/26, showed the resident had oxygen therapy. The care plan showed to provide Resident #1 with a portable oxygen apparatus. The care plan did not show interventions related to Resident #1's unsafe storage of portable oxygen cylinders brought into the facility.A physician's order for Resident #1, dated 02/25/26, showed administer oxygen at two liters per minute via nasal cannula as needed for a history of respiratory failure.On 04/14/26 at 9:20 a.m., Resident #1 stated the facility would not supply the small portable oxygen cylinders they used in an over-the-shoulder carrier bag. Resident #1 stated they brought the oxygen cylinders to the facility from a family member's home.On 04/14/26 at 10:36 a.m., CNA #1 stated no residents stored portable oxygen cylinders unsecured in their rooms or closets. On 04/14/26 at 1:20 p.m., the DON stated portable oxygen cylinders had been removed from Resident #1's room several times for safety. The DON stated they were not aware of what interventions had been put in place to prevent Resident #1 from storing oxygen cylinders in their closet. The DON stated interventions to ensure the resident was not storing oxygen cylinders unsecured should have been included on the care plan.On 04/14/26 at 1:47 p.m., the administrator stated they were unaware Resident #1 had oxygen cylinders stored in their closet. The administrator stated the oxygen cylinders had been removed and the care plan would be updated.

Based on observation, record review, and interview, the facility failed to ensure an allegation of abuse was reported to OSDH within the required 2-hour timeframe for 1 (#1) of 5 sampled residents reviewed for abuse. The administrator identified 76 residents resided in the facility. Findings:On 03/30/26 at 11:45 a.m., Resident #1 was observed up in a wheelchair and self-propelled into the dining room.The Abuse Prevention Program policy, not dated, read in part, Investigate and report any allegations of abuse within timeframes as required by federal requirements.A quarterly assessment, dated 02/03/26, showed Resident #1's cognition was intact with a BIMS score of 15. The assessment showed Resident #1 was independent with most ADL and had an indwelling catheter. The assessment showed the resident had a diagnosis of paraplegia.An incident report form, dated 02/25/26, showed an allegation of abuse for Resident #1 was faxed to OSDH on 02/26/26 at 11:16 a.m.A grievance form, dated 02/26/26, showed Resident #1 approached RN#1 on 02/25/26 to discuss their catheter bag. The form showed RN #1 looked mad and told Resident #1, I don't want any part of that. I don't give a damn. Go talk to [name removed] about it. The form showed the grievance was investigated, and verbal abuse was substantiated.On 03/31/26 at 12:40 p.m., the administrator stated being notified on 02/26/26 of an allegation of verbal abuse that occurred on 02/25/26 sometime around 2:00 p.m. The administrator stated that the activities director was asked to have the resident fill out a grievance form. The administrator stated that after they received the grievance form, they notified OSDH within two hours. The administrator was asked if the CMA #1 should have reported the incident immediately, and they replied: Staff were educated to report immediately, even if they are not sure it is abuse. The administrator stated the incident should have been reported within 2 hours of Res #1 notifying CMA #1 of the incident.On 03/31/26 at 2:22 p.m., CMA #1 stated on 02/25/26 around 8:45 p.m., Resident #1 told them about RN #1 hollering and cursing at them earlier in the day. The CMA stated Resident #1 was told it needed to be reported to the Administrator. The CMA stated that the resident verbalized that they would self-report to the administrator the next morning. The CMA stated the incident was not immediately reported to the administrator at the resident's request.On 03/31/26 at 2:51 p.m., Resident #1 stated being happy with everything in the facility and did not want to answer any questions.

Based on observation, record review, and interview, the facility failed to ensure a resident was free from verbal abuse by a staff member for 1 (#1) of 5 sampled residents reviewed for abuse.The administrator identified 76 residents resided in the facility. Findings:On 03/30/26 at 11:45 a.m., Resident #1 was up in a wheelchair and self-propelled into the dining room.An undated Abuse Prevention Program policy, read in part, As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals.A quarterly assessment, dated 02/03/26, showed Resident #1's cognition was intact with a BIMS score of 15. The assessment showed Resident #1 was independent with most ADLs and they had an indwelling urinary catheter. The assessment showed the resident had a diagnosis of paraplegia.A grievance form, dated 02/26/26, showed Resident #1 approached RN #1 on 02/25/26 to discuss their catheter bag. The form showed RN #1 looked mad and told Resident #1, I don't want any part of that. I don't give a damn. Go talk to [name removed] about it. It made me feel embarrassed, and I rolled back to my room. The form showed that the grievance was investigated, and verbal abuse was substantiated.An incident report, dated 02/26/26, showed the administrator received a grievance for a RN #1 being verbally aggressive towards Resident #1 on 02/25/26. The report showed an investigation was conducted, and abuse was substantiated based on resident and staff interviews. The report showed the resident showed no further signs of emotional distress, and the staff member was terminated.A facility QAPI plan, dated 02/27/26, showed a quality issue/problem of staff to resident abuse. The plan showed actions of: Staff member placed on suspension then terminated per facility policy,Victim assessed,Primary physician notified,Mental health notified,In-service to all staff,Reported to all applicable agencies. On 03/31/26 at 12:40 p.m., the administrator stated being notified on 02/26/26 of an allegation of verbal abuse that occurred on 02/25/26 between RN #1 and Resident #1. The administrator stated that an investigation was completed, and the allegation of verbal abuse was substantiated by resident and staff interviews.On 03/31/26 at 2:22 p.m., CMA #1 stated on 02/25/26 around 8:45 p.m., Resident #1 told them of RN #1 hollering and cursing at them earlier in the day.On 03/31/26 at 2:51 p.m., Resident #1 stated being happy with everything in the facility and did not want to answer any questions.

Based on observation, record review, and interview, the facility failed to ensure supervision to prevent an elopement for 1 (#6) of 3 sampled residents reviewed for elopement. The DON identified two residents at risk for wandering/elopement. Findings: On 06/30/25 at 2:05 p.m., Res #6 was observed ambulating independently in the hallway outside of their room. No exit-seeking behavior was observed. An undated policy titled Wandering and Elopement Prevention, read in part, It is the policy of facility to identify residents at risk for wandering and/or elopement and to implement appropriate interventions to ensure their safety. The facility will take reasonable steps to prevent unauthorized exits and promote a safe and secure environment for all residents. A medical diagnosis list, dated 05/29/25, showed Res #6 admitted to the facility with diagnoses which included hypertension and hyperlipidemia. A nursing note, dated 05/30/25, showed Res #6 had decreased awareness and required frequent redirection. The note showed Res #6 was wandering around the facility and looking for their truck in the parking lot. An elopement assessment, dated 05/31/25, showed Res #6 was not at risk for elopement. A nursing note, dated 05/31/25, showed Res #6 was allowed outside by another resident and was observed on the east side of the building looking for their truck. An admission assessment, dated 06/05/25, showed Res #6 had a brief interview for mental status score of 6 and was severely cognitively impaired with disorganized thinking. The assessment showed Res #6 was independent with mobility and had wandered one to three days. An incident report, dated 06/05/25, showed Res #6 was disoriented, agitated, and confused while wandering/pacing facility. The note showed Res #6 was observed leaving through the front door and walking through the parking lot towards the highway. The note showed staff assisted Res #6 back into the facility and they continued to wander and pace the inside of the facility. A nursing note, dated 06/25/25, showed an off-duty staff member had observed Res #6 walking down the highway in front of the facility. The note showed the staff member brought Res #6 back to the facility. The note showed Res #6 was assessed upon return to the facility and had not sustained injury. An elopement risk assessment, dated 06/26/25, showed Res #6 was at risk for elopement. A care plan, dated 06/26/25, showed Res #6 was an elopement risk with interventions to identify pattern of wandering and provide distractions when wandering is observed. On 06/30/25 at 2:23 p.m., Res #6 stated they did not remember leaving the facility and walking down the highway on 06/25/25. Res #6 stated they were not in prison and had the right to leave the facility grounds whenever they felt like it. On 07/01/25 at 1:36 p.m., the DON stated the facility determined which residents were at risk for elopement based on the results of an elopement risk assessment. The DON stated Res #6 should have been considered an elopement risk upon admission. They stated Res #6 should not have been outside unsupervised due to cognitive impairment. The DON stated interventions to prevent elopement should have been implemented prior to the incident on 06/25/25. On 07/03/25 at 8:03 a.m., LPN #1 stated Res #6 had been confused and required frequent redirection since admission. LPN #1 stated they had observed Res #6 push on the front door until it opened and exited the facility on 06/05/25. They stated Res #6 should have been considered an elopement risk since admission and interventions to prevent future elopements should have been implemented after the incident on 06/05/25. On 07/03/25 at 8:15 a.m., the administrator stated video surveillance had been reviewed and showed Res #6 had followed a staff member and another resident out of the front door of the facility on 06/25/25 around 9:00 p.m. They stated the staff member should have provided supervision that would have prevented Res #6 from being able to make it onto the highway without anyone's knowledge.

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to three (#13, #53, and #56) of three residents reviewed for beneficiary notification. The Administrator reported 63 residents resided in the facility. Findings: 1. Resident #56 was admitted to Part A skilled services on 05/07/24 and discharged from skilled services on 07/26/24. 2. Resident #53 was admitted to Part A skilled services on 09/19/24 and discharged from skilled services on 09/11/24. 3. Resident #13 was admitted to Part A skilled services on 11/18/24 and discharged from skilled services on 12/11/24. On 12/17/24 at 12:58 p.m., the MDS coordinator and DON provided documentation to be reviewed for beneficiary notification. The DON reported no SNF ABN form was provided to residents #13, #53, #56, and/or their representative. The DON reported the facility had not been completing a SNF ABN form for residents or providing this information in any form. On 12/17/24 at 1:03 p.m., RN #1 reported the SNF ABN form was previously included in the resident admission packet but was no longer a part of the packet. The RN stated she didn't know when it was removed from the packet, but it would be added immediately to ensure it was not missed.

Based on observation, record review, and interview, the facility failed to prevent elopement for one (#1) of two sampled residents reviewed for adequate supervision to prevent elopement. The administrator stated one resident elopement in the previous 60 days. Findings: An Elopements policy, dated December 2007, read in part, .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .If an employee discovers that a resident is missing from the facility .Determine if the resident is out on an authorized leave or pass .initiate a search of the building(s) and premises .initiate an extensive search of the surrounding area .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Examine the resident for injuries .Complete and file an incident report .Document relevant information in the resident's medical record . Resident #1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, depression, anxiety, chronic pain, dysphagia, and insomnia. A care plan for Resident #1, dated 01/16/24, documented the resident was at risk for wandering. Interventions included to implement facility protocol for locating an eloped resident if resident should exit the building. The care plan documented the resident left the faciity on [DATE] without staff and was returned to the facility and placed on 1:1 observation. There were no additional interventions added to prevent elopement following the 1:1 observation. A MDS assessment, dated 10/01/24, documented Resident #1 was severly cognitively impaired. The assessment documented the resident ambulated independently without assist. An Elopement Risk Evaluation, dated 10/03/24, documented the resident was at risk for elopement. The evaluation documented the resident had a history of attempting to leave the facility without informing staff. The evaluation documented the resident's wandering behavior was likely to affect the safety or well-being of self/others. An Incident Report Form, dated 10/04/24, documented the facility was notified by the local fire department Resident #1 had been found by the church neighboring the facility property. The report documented staff had seen the resident in bed 20 minutes prior to the phone call from the fire department. The report documented staff retrieved the resident and upon return to the facility the resident was assessed for injuries, neuro checks were initiated, and the resident was placed on 1:1 supervision. A follow-up to the report documented an alert and oriented resident had left the building after Resident #1 was seen in bed, but prior to the call from the fire department. The facility suspected Resident #1 followed the other resident out of the building. The report documented upon investigation there was not a witness to corroborate this. One-on-one safety check forms, dated 10/04/24 and 10/05/24, documented the resident would remain on 1:1 observation for eight hours, then every 15 minute checks for eight hours, every 30 minutes for eight hours, every hour for eight hours, then would return to normal care if no incident occurred. The forms documented if another incident occurred the resident would return to 1:1 supervision. An updated Elopement Risk Evaluation, dated 10/04/24, documented the resident was at risk for elopement. The evaluation documented the resident had a history of elopement. The evaluation did not include interventions to prevent elopement. On 10/10/24 at 11:30 a.m., Resident #1 was observed wandering the halls of the facility. The resident was observed to walk independently without assist. Resident #1 was observed to walk to the exit doors at the end of halls, but did not push on the doors or open them. On 10/10/24 at 12:30 p.m., LPN #1 stated they were working the night Resident #1 left the building. The LPN stated the resident was known to go to the exit doors and occasionally push on them, but the LPN was not aware of the resident ever leaving the premises. The LPN stated they had seen the resident in bed at approximately 9:25 p.m., about 20 minutes prior to the fire department calling the facility. The LPN stated they went to retrieve the resident, EMS was on the scene assessing the resident, and the LPN returned the resident to the facility where the resident was assessed and placed on 1:1 supervision. The LPN stated the resident had no injuries, but was placed on neuro checks and 1:1 supervision per facility protocol. On 10/10/24 at 12:40 p.m., the ADON stated there was a previous incident when Resident #1 got outside the doors, but did not leave the property and staff assisted the resident back inside. The ADON stated although Resident #1 wandered the halls and would go to the exit doors, the resident had never gone past the sidewalk in front of the building. The ADON was asked if additional interventions had been implemented to prevent a future elopement. The ADON stated they did not know of other interventions, other than to keep a closer eye on the resident and ensure doors were locked. On 10/10/24 at 12:57 p.m., the administrator stated there had been recent abuse staff in-services, but not one specifically related to resident elopements. They stated the facility had several alert and oriented residents who were free to check out and leave the facility as they wished. They stated staff were very familiar with Resident #1 and knew to supervise them closely due to wandering behaviors, but no additional interventions had been added after the elopement.

Based on record review and interview, the facility failed to ensure the DON did not work as a charge nurse when the facility census was more than 60 residents. Findings: The Administrator reported 68 residents resided in the facility. A facility policy titled Staffing not dated, documented, RN must be on duty 8 hours a day 7 days a week. DON will not work as a charge nurse when census rises above 60 per regulations. A document titled, Quality of Care Monthly Report date period, June 2024, documented, a census greater than 60 residents on June 24th, 26th, 27th, 28th, 29th, 30th. The census ranged from 61 to 62 residents on these days. A document titled, Daily Census dated, July, 2024, documented a census over 60 on July 17, 2024 through July 31, 2024. The census ranged from 61 residents to 68 residents on these days. On 08/07/24 at 11:55 p.m., the DON reported they worked as the charge nurse on July 25th and July 31st. The DON reported they worked as the charge nurse on June 24th. On 08/07/24 at 12:15 p.m., the corporate consultant was asked if the facility had the DON working as charge nurse with a resident's census over 60. They stated, Yes, but I do not know which days. On 08/07/24 at 1:24 p.m., LPN #2 reviewed staffing sheets. They reported the DON worked as the charge nurse on July 25, 2024 and July 31, 2024. They reported the DON was documented as the charge nurse on August 1st, 5th, and 6th, 2024, with a census range from 69-72 residents. The DON was available only upon request during the survey, because they were covering night shifts.

Based on observation, record review, and interview, the facility failed to ensure a resident at risk for elopement did not elope from the facility for one (#1) of one sampled resident reviewed for elopement. The Administrator reported 68 residents resided in the facility. Findings: An Elopements policy, dated 12/01/2007, read in part Staff shall investigate and report all cases of missing residents .The facility will encourage each resident to sign themselves out of the facility so that the facility will remain informed .When the resident returns to the facility, the DON or Charge Nurse should complete and file an incident report . A form, dated 10/03/19, presented by the Administrator for the illicit drug policy and procedure, read in part It is the policy of the [facility name removed] to prohibit the use of alcoholic beverages or illicit drugs on facility property unless prescribed by a physician .There is a concern with interaction of prescribed medications and the use of alcoholic beverages and/or illicit drugs .Residents who have been found to be in violation of facility policy will be reviewed by the administrative staff, care plan team, and physician or facility medical director to determine if the facility is able to meet the continued needs of the resident .If the resident is a danger to himself/herself or other residents as documented by the medical record and the facility is not capable of managing the resident then the facility will proceed with an involuntary transfer or discharge . 1. Res #3 had diagnoses which included traumatic brain injury, depression, schizoaffective disorder, and dementia disorder. The clinical record documented a court appointed co-guardianship, dated 09/25/18, for the person and estate of resident #3, an adult incompetent. A nurse note, dated 12/15/23 at 4:45 a.m., documented resident #3 was found in a peer's room smoking marijuana. A nurse note, dated 01/30/24 at 10:00 p.m., documented a staff member found resident #3 vape outside passed out on the ground by the dumpster. The nurse note documented the resident's room was searched for marijuana and five gummies and two vapes were found and confiscated. A nurse note dated 03/04/24 at 6:10 p.m., resident #3 was found rolling down the main highway in wheelchair heading towards the facility. The nurse's note documented that the resident left the facility without signing out or informing staff. A nurse note, dated 04/05/24 at 3:45 p.m., documented resident #3 left the facility without signing out via wheelchair. At 4:25 p.m. resident returned to the facility. At 8:00 p.m. the resident left the facility without notifying staff via wheelchair and refused to return. The note documented after two attempts the resident returned to the facility with staff. A nurse note, dated 04/07/24 at 9:00 a.m., resident #3 refused medication. A nurse's note, dated 04/09/24 at 8:00 p.m., documented a call was received reporting resident #3 was seen in wheelchair going down the main highway toward store. The note documented the resident sign out book was checked, and the resident had not signed out, and the staff could not see the resident. A nurse note, dated 04/09/24 at 8:30 p.m., documented the facility received a call from officer [name removed] who found resident #3 in someone's yard passed out. The note documented the officer had to repeatedly shake resident to wake resident up and the resident arrived back to the facility 8:40 p.m. The note documented resident's guardian was upset and wants him placed in a locked down facility. A nurse note, dated 04/10/24, documented resident #3 continued with one-on-one supervision, resident not concerned about doing things right because they will be leaving in 3 days. A nurse note, dated 04/12/24, documented resident #3 stated I don't want to be here I want to be closer to my daughter. A nurse note, dated 04/14/24 at 3:50 p.m., documented resident's guardian wants the resident in a locked facility so resident would not be allowed to leave because he is incompetent and makes terrible decisions. A nurse note, dated 04/19/24 at 3:45 p.m., resident #3 no signs of elopement noted. A comprehensive assessment, dated 05/16/24, documented resident cognition was intact and exhibited no behaviors. The assessment documented independent with wheelchair use. An elopement risk assessment, dated 05/25/24, documented the resident remained not a risk for elopement. The assessment instructions read in part One YES answer places the resident as a risk .Proceed to interventions. The assessment documented a YES answer for 4 of the resident evaluation factors. The assessment documented an intervention was: secured unit - all exit doors are key padded, date initiated was documented as continuous. A nurse note, dated 05/29/24 at 2:35 a.m., a staff member seen resident #3 propelling self in wheelchair down the street, charge nurse sent another staff member to pick up the resident, the resident refused to get in with staff member, and returned self to the facility. The note documented resident was placed on one-on-one supervision at this time. The note documented the resident stated who cares I will be on supervision for a little bit and when I come off, I will just do it again, unable to redirect. A nurse note, dated 06/08/24 at 12:10 a.m., documented a resident approached this nurse reporting that resident #3 had rolled off again. The note documented the facility and perimeter was searched and resident was not found, staff member sent to find the resident. The note documented the staff member found the resident on [name removed] street and refused to return to facility. The note documented the police department was contacted. A nurse note, dated 06/08/24 at 1:25 a.m., documented resident #3 arrived back to facility via police department escort. A nurse note, dated 06/19/24 at 12:00 a.m., documented a call was received that resident #3 had gone from the facility and in the road. The note documented a staff member was sent to pick up resident, the resident refused to get in with staff member and was ramming the staff member with the wheelchair and trying to through self out of wheelchair into the road. The note documented it took over an hour to get the resident back to the facility and resident was ramming into furniture with the wheelchair. The note documented the resident trying to get out of every exit door. The note documented the resident's guardian requested resident's wheelchair be taken away and for resident to use the walker only to ambulate. A nurse note, dated 07/01/24 at 8:30 p.m., documented resident #3 asked the nurse to take him to town when the nurse declined, the resident asked if another resident's wheelchair could be used to go to the store. The note documented the nurse informed resident another resident's wheelchair could not be taken. A comprehensive care plan related to elopement and illicit drug use was not developed. State reportables provided by the facility for the past 6 months documented no incidents of elopement or drug use for resident #3. On 08/05/24, the Administrator reported the facility had no incidents reports for elopement in the past 3 months. The Administrator reported resident #3 was not an elopement risk and residents were allowed to sign themselves out of the facility at any time. The Administrator reported a resident leaving the facility is considered an elopement if the resident has dementia, leaves the facility unattended, and leaves the facility premises. On 08/06/24 at 1:48 p.m., LPN #5 reported resident #3 is considered an elopement risk because he has a guardian that does not want him to leave the facility unsupervised. The LPN reported not being aware until they were informed on 08/05/24 by the RN consultant that an incident report needed to be filled out when any resident eloped from the facility. The LPN not being sure what interventions are in place for resident #3 to prevent elopement but they watch the resident closely because of his multiple elopements. The LPN reported no residents are safe being off facility premises at night unsupervised. On 08/06/24 at 3:46 p.m., resident #3 was in their room, wheelchair beside the bed, and reported residents are supposed to sign out in a book up front before leaving the facility but I never go anywhere. The resident reported he would like to go to a better facility. The resident refused to answer any other questions. On 08/06/24 at 4:01 p.m., the DON reported the incident on 04/09/24 when resident #3 was found by police passing out in someone's yard was considered an elopement. The DON reported anytime a resident is off facility premises out of staff sight, without signing out is an elopement event. The DON reported interventions have not been put into place officially on a care plan. The DON was not aware until 08/05/24 that incident reports were not being done for elopements or drug use.

Based on record review and interview, the facility failed to conduct a thorough abuse investigation for one (#4) of three sampled residents reviewed for abuse. The Administrator reported 68 residents resided in the facility. Findings: The facility Abuse Policy and Procedure not dated, read in part, It recognizes resident rights to be free from physical, or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal regulations. The policy also read, Immediate reporting. Facility employee or immediate supervisor, who will report incidents immediately to local police and report to the Oklahoma State Department of Health as required by State law or regulation. The policy also read, Identification and Investigation. The investigation should determine whether an incident has occurred, to what extent the resident was mistreated, by whom, and the measures needed to protect occupants from further incidents. The policy also read, Interviews. The investigator should consider interviewing persons listed below: facility employees, contractors, volunteers; victim; . other occupants; .other persons who may have knowledge of the incident. The policy also read, Nursing Assessment. The Director of Nursing or designee is responsible for assessing the victim and shall document findings, including the lack of abnormal findings, if helpful, in the medical record. If a person alleges abuse, they should be assessed for mood and behavior changes that may indicate abuse, such as fear, isolation, depression, withdrawal, or other new signs. Findings will be documented in the medical record. The Medical Record and Care Plan will be reviewed. The policy also read, if physical abuse is alleged or suspected, vital signs may be taken and a skin audit completed by a licensed nurse following the incident and documented in the Medical Record. Resident #4 had diagnosis which included Schizophrenia, COPD, essential hypertension, and recurrent depressive disorders. An Incident Report Form Combined Initial and Final, Incident Date: 07/29/24, documented, Incident Type: Allegations of Abuse/Mistreatment. Description of Incident: While delivering a letter for [sic] OKDHS to [Res #4], [staff member #1] asked [Res #4] if they could read the letter with him so that the facility would be apprised of anything that needed to be done to keep Res #4 in DHS compliance and his title 19 Medicaid intact. Reportedly [Res #4] yanked the letter away and then struck [staff member #1] in the chest. [Res #4] came into the building claiming that [staff member #1] had pushed [Res #4] first that is when [Res #4] hit [staff member #1]. To protect this and all residents [staff member #1] was suspended pending the outcome of the investigation. While interviewing staff at the nurse's station who were in direct sight of the front porch, a resident, [Name removed-Res #9] approached the Administrator [Name removed]. [Res #9] had been on the porch during the incident and stated that [staff member #1] did not push him [Res #4]. The administrator asked [Res #9] if they had seen the incident. [Res #9] stated they had and then reiterated that [staff member #1] did not push [Res #4]. [Res #9] is AAO x4. [Staff member #1] will be allowed to return to work on 07-30-24. On 08/01/24 at 1:57 p.m., the DON reported they had left notes with the Administrator before related to staff member #1's approach and their tone. They reported they heard about the incident on 07/29/24 from Res #4 at 4:00 a.m., this morning. The resident asked the DON to fax a report to the police department, because the resident said they was turning staff member #1 in, because they put their hands on them. They reported staff member #1 and Res #4 had an ongoing personality conflict. The DON reported they made no assessment or updates to Res #4's clinical record or the plan of care related to the incident. On 08/01/24 at 2:30 p.m., the administrator was asked to submit statements from the nursing staff. The administrator stated, I didn't get statements, because I had a witness. The administrator was asked if they obtained a list of staff present. The administrator stated, As far as I know there was only one other person besides Res #4 and staff member #1. The administrator was asked how long staff member #1 was suspended. The administrator reported, The day it happened. They were asked if they notified the DON of the abuse allegation. They reported, No, I didn't they had been working nights. They were asked about reporting the incident to the local police department. They reported they did not, because they had a witness, and it was an allegation of abuse. They were asked if all witnesses were interviewed. They reported there was only one, it happened on the front porch. On 08/01/24 at 3:12 p.m., the ADON reported they were not aware of the allegation of abuse until July 31, 2024 and they were one of the charge nurses on duty on the day the allegation was made on 07/29/24.

Based on record review and interview, the facility failed to issue a written grievance decision upon request and to address the grievance in its entirety for one (#4) of one sampled grievance reviewed. Findings: A Grievance Policy and Procedure, not dated, documented, the facility has adopted an internal grievance procedure providing a prompt and equitable resolution or complaints/grievances. A copy of the written summary of the report will also be provided to the resident, if requested, and the original copy will be filed in the Business Office. The investigation and report may include the following: Patient's account of the alleged incident; employees account of the alleged incident; recommendations for corrective action. A Grievance Form, dated 06/12/24, documented, [Staff member #1] was being rude about smokers past the line. He also stated [staff member #1] would push them past the line. Res #4 said if something wasn't done, they will move out though they prefer not too [sic]. Name/Title of person accepting this form: Activity Manager. Nature of resolution: [Staff member #1] was keeping the facility within State regulations regarding smoking to close to an entrance. All smokers are required to be on the correct side of the red line while smoking. Discussed with person filing grievance on: (date) [blank] . The grievance did not address being rude and the grievance did not include the date the grievance was discussed. On 08/05/24 at 11:34 a.m., the administrator was asked about the grievance dated 06/12/24 from Res #4 about staff member #1 being rude. They reported everybody says the same thing that staff member #1 was rude or just blunt. The statements/interviews were requested related to the grievance. They reported they did not have any. They were asked if they completed the portion of the grievance with the date the grievance had been discussed with Res #4. They reported they did not, they reported the activity manager or staff member #1 would have completed that section. They were asked if they provided a written summary of the report to Res #4. They reported they would have just discussed it with them. They were asked if Res #4 requested a copy of the grievance. They reported they did request a copy. They were asked if Res #4 received a copy. They reported they did not give them one, it was their understanding it was an internal document. On 08/06/24 at 10:15 a.m., the activity manager was asked to review the grievance dated 06/12/24 and was asked if they discussed the grievance with Res #4. They reported they told Res #4 that staff member #1 was following the rules. They were asked if they provided the copy of the grievance to Res #4. They reported Res #4 requested a copy and the administrator informed them they did not have to give Res #4 a copy. They were asked if the portion of the grievance about being rude was addressed in the grievance. They reported it did not address being rude. On 08/07/24 at 12:05 p.m., the corporate consultant was asked if a resident would be allowed to have a copy of a grievance that they filed. They reported they could have a copy.

Based on record review and interview, the facility failed to ensure notification of the bed hold policy was provided upon transfer/discharge for one (#1) of one resident reviewed for discharge. The Administrator reported 68 residents resided in the facility. Findings: A Readmission to the Facility policy, dated 03/01/2022, read in part A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident meets the admission criteria .Bed hold terminates after a resident is discharged for 30 days and would be considered a new admission .Any resident who is admitted to another long term care facility from an acute care hospital stay will be discharged from this facility . Resident #1 had diagnoses which included hypertension and diabetes mellitus. A nurse's note, dated 06/21/24, documented resident #1 requested to go to [name removed] hospital for complaints of a swollen penis and difficulty breathing. A discharge summary, signed 06/29/24, documented a discharge date of [DATE]. The discharge summary documented, on 06/21/24, Resident #1 was transferred to [name removed] hospital for further evaluation of urinary retention and complaints of trouble breathing. The discharge summary documented Resident #1 was admitted to hospital for further work up. Resident #1's face sheet, read in part discharged - 06/21/24 .Discharge status - return anticipated . The clinical record did not contain documentation that the resident or representative had been provided written documentation of the bed hold policy at the time of discharge. On 08/07/24 at 10:50 a.m., the BOM reported not being aware of a bed hold policy for the facility. The BOM reported bed hold information is discussed in the admission packet. On 08/07/24 at 2:38 p.m., the ADON reported no information about bed hold was given to residents when they were transferred/discharged to a hospital. The ADON reported Resident #1 was not allowed to return as a resident since Resident #1 had been admitted to another long- term care facility after being discharged from the hospital on 06/27/24. On 08/07/24 at 4:37 p.m., the Administrator reported resident #1 was not allowed to readmit to the facility because the resident had been admitted to another long-term care facility after discharge from the hospital on 06/27/24. The Administrator reported bed hold had not been an issue when residents were transferred/discharged to the hospital since they were anticipated to return. The Administrator reported to meet the regulation requirements for bed hold they should have given resident #1 written notification related to the facility's bed hold policy upon transfer/discharge to the hospital.

Based on record review and interview, the facility failed to ensure the employee designated to be the dietary manager completed the required certification training within 1 year of hire. The Resident Census and Conditions of Residents, form, dated 09/11/23, documented 49 residents resided in the facility. Findings: The facility policy Food and Nutrition Services Staff, dated 10/01/22, documented The Food Services Department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department. The facility records documented the dietary manager was hired for the position on 06/21/21. On 09/11/23 at 9:38 a.m., the dietary manager reported they had been the dietary manager for two years. The dietary manager reported not being certified at this time. The dietary manager reported the facility contract to pay for the required training course needed for certification had been approved. The dietary manager reported the contract had not been signed and enrollment into the course had not been done. On 09/18/23 at 11:36 a.m., the administrator reported the dietary manager was approved approximately two months ago to be certified and should already be in enrolled in the training course. The administrator was not aware the dietary manager had not started the certification training course.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were developed and implemented to address the residents' needs related to: a. a pressure ulcer for one (#17), b. a history of falls for two (#28 and #34), and c. the use of antidepressant and antipsychotic medication and the related medical diagnoses for one (#43) of 14 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents dated 09/11/23, documented 49 residents resided in the facility. Findings: A facility Care Plans, Comprehensive Person-Centered policy, revised date December 2016, read in part, .The comprehensive, person-centered care plan will: reflect currently recognized standards of practice for problem areas and conditions . 1. A Baseline Care Plan, dated 04/26/23, for Res #17 documented a heel protector, currently has wound located on rt. heel with blister & discoloration. An admission assessment, dated 05/03/23, documented the resident was cognitively intact, required limited assistance with ADL's, and had diagnoses including anemia, DM, depression, and asthma. A physician order, dated 08/10/23, documented to cleanse wound to right heel with NS, pat dry, apply collagen gel with silver, with non-adherent dressing hold in place with Kerlix and tape, change dressing daily, and PRN dislodgement/soilage. The care plan, dated 08/31/23, for Res #17 did not document a wound with nursing interventions. On 09/18/23 09:59 a.m., Res #17 was sitting in recliner in their room with feet up in recliner. The dressing to the right heel was intact and dated 09/18/23. At that a nurse reported a dressing change was done this morning. They reported the wound doctor visited weekly. The nurse reported the dressing was changed according to the physician's orders and done daily. On 09/18/23 at 10:41 a.m., the DON was asked about a care plan for skin for Resident #17. They stated the resident did not have a plan of care for skin and they just created one today and she would discuss the plan of care with the family today. 2. Res #28 was readmitted to the facility on [DATE] with diagnoses which included fracture of left femur that resulted from a previous fall. The care plan, dated 07/15/23, documented the resident required assistance with mobility. The care plan did not document a history of falls or the high fall risk for falls. A Fall Risk Assessment, dated 07/16/23, documented the resident was a high risk for falls. The MDS assessment, dated 07/18/23, documented Res #28's cognition was intact. The assessment documented a fall with fracture in the past 6 months. On 09/12/23 at 12:04 p.m., Res #28 was observed ambulating with rolling walker in the dining room. The Res #28 reported he had fallen a few month ago coming out of the bathroom. The resident reported he did not have shoes on and his leg gave out and he fell . The resident reported he broke his hip from the fall. On 09/13/23 at 11:00 p.m., the MDS coordinator was asked for Res #28's care plan related to fall risks. The MDS coordinator reported, No care plan had been developed for fall risk. The MDS coordinator reported, A care plan for falls would be developed. 3. Res #34 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury. The MDS assessment, dated 06/08/23, documented Res #34's cognition was severely impaired. The assessment documented one non-injury fall, two injury falls and no major injury falls since the last assessment. Res #34's Fall Risk Evaluation assessments, dated 06/19/23 and 07/29/23, documented high risk for falls. The care plan, dated 09/07/23, documented Res #34's antipsychotic use and impaired vision. The care plan did not reflect past falls or the risk for falls. On 09/11/23 at 2:26 p.m., Res #34 reported he had fallen because, he would get in a hurry. Res #34 reported no major injuries had resulted from the falls. On 09/15/23 at 2:45 p.m., the DON reported the MDS coordinator was new to the position and was working on getting care plans updated. The DON reported no fall risk had been care planned and would be developed today. 4. Res #43 was admitted to the facility on [DATE] with diagnoses which included dementia, anxiety disorder, depression, and psychotic disorder. The MDS assessment, dated 06/18/23, documented Res #43's cognition was severely impaired. The assessment documented wandering behavior and rejection of care behavior had occurred one to three of the days reviewed. The care plan, dated 08/19/23, documented Res #43's wandering behaviors. The care plan did not document the resident's anxiety, depression, or use of antipsychotic drug use. On 09/13/23 at 3:00 p.m., Res #43 was observed wandering throughout the facility with a staff member following behind him. The resident was observed trying to exit the locked front door and going into other rooms. The resident was observed being redirected by staff. On 09/15/23 at 2:45 p.m., the DON reported the MDS coordinator was new to the position and was working on getting care plans updated. The DON reported Res #43's care plan did not document the diagnoses of anxiety, depression or the use of antipsychotic drugs. The DON reported the resident's care plan would be updated. 41873

Based on observation and interview, the facility to ensure residents' privacy was maintained for three (#16, 24, and #47) of 14 residents reviewed for privacy. The Resident Census and Conditions of Residents form, dated 09/11/23, documented 49 residents resided in the facility. Findings: The facility policy Quality of Life - Dignity, dated 08/01/23, read in part, .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures including privacy curtains, blinds and etc . The facility policy Quality of Life - Homelike Environment, dated 08/01/23, read in part, .Rooms will be set so that privacy is maintained while providing care to resident including but not limited to privacy curtains, blinds and etc . 1. Res #24 was admitted to the facility on [DATE]. Res #24's cognition is severly impaired and requires total extensive care. On 09/12/23 at 9:47 a.m., the ADON and CNA #1 were observed providing peri care to Res #24. The window blinds next to the Res #24's bed was observed to be broken off on south corner of the blind, which caused a clear view of the outside. On 09/13/23 at 1:58 p.m., Res #24's hospice aide was observed providing a bed bath. The window blinds were down but had broken and missing blinds causing a clear view of the outside. The broken window blinds could result in privacy being compromised with blinds down and open missing or broken blinds. 2. Res # 47 was admitted to the facility on [DATE]. The Res's cognition was moderately impaired. On 09/13/23 at 2:36 p.m., Res #47's room was observed to have broken window blinds. The resident reported they dressed themselves and it did bother them that the blinds were broken and allowed a sight line from the outside in, if any one were to walk by. The resident reported she would like new blinds and doesn't know who to ask about them. 3. Res #16 was admitted to the facility on [DATE]. The medical record documented resident's cognition was intact. On 09/13/23 at 2:39 p.m., Res #16's room was observed to have broken and missing pieces of window blinds. Res #16 reported the window blinds have been that way for a while and it does bother her that it allows light in at night. On 09/15/23 at 11:30 a.m., the maintenance supervisor reported he was aware there were resident rooms that had broken window blinds. The maintenance supervisor reported he had ordered window blinds about 6 weeks ago but the order had not been delivered yet. On 09/18/23 at 2:00 p.m., the administrator provided an invoice for window blinds that had been ordered 08/15/23. The administrator reported he had turned the order into the cooperate office and was not aware when they would be delivered. The administrator reported broken blinds could cause and issue with privacy and curtains may be put up for privacy until the window blinds arrived and were installed.

Surveyor: [NAME], [NAME] Based on record review and interview, the facility failed to electronically transmit resident assessments, within 14 days after completion for one (#3) of three residents reviewed for discharge assessments. The Resident Census and Conditions of Residents, dated 09/11/23, documented 49 residents resided in the facility. Findings: A facility policy MDS Completion and Submission Timeframes, dated 07/01/23, read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines .Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual.'' Resident #3 was admitted to the facility on [DATE] and discharged from the facility on 05/14/23 due to death. On 09/18/23 at 12:58 p.m., the MDS Coordinator reported the discharge assessment was completed on 05/17/23. The MDS Coordinator reported the assessment was sent in a batch with other assessments to be approved by a corporate nurse. The MDS Coordinator reported the assessment should have been approved and transmitted to CMS within 14 days of completion, but it must have been missed and was not transmitted.

Based on record review, observation, and interview, the facility failed to ensure: a. a refrigerator containing PHF was maintained at or below 41 degrees and b. kitchen staff did not handle food with their bare hands. The DON identified 37 residents resided in the facility and 37 residents received services from the kitchen. Findings: A Refrigerators policy, revised December 2014, read in part, .This facility will ensure safe refrigerator and freezer maintenance, temperatures .Acceptable temperature ranges are 35 [degrees] F to 40 [degrees] F for refrigerators . A Refrigerator Temperatures log, dated 09/12/22, read in part, .Temp .37 . On 9/12/22 at 9:14 a.m., a tour of the kitchen was conducted. A refrigerator, located in the back corner of the kitchen, had two thermometers inside of it. One thermometer read 50 degrees F and the other read 52 degrees F. Ambient air temperatures were taken inside the refrigerator and were 65 degrees F on one side of the refrigerator and 70 degrees F on the other. On 9/12/22 at 9:39 a.m., the CDM was asked if the current temperature reading of 55 degrees F was an appropriate temperature for the refrigerator. They stated the refrigerator had been open a lot while checking dates and that the air conditioning in the kitchen had not been working and had pulled the temperature down. The CDM was asked what was the process was if the refrigerator temperature was out of range. They stated they would alert the administration. On 9/12/22 at 9:43 a.m., the internal temperature of a block of butter from the refrigerator was taken and registered at 52 degrees F. The temperature of a block of cheese read at 51 degrees F. On 9/12/22 at 11:07 a.m., the internal temperature of one egg from the refrigerator registered at 59 degrees F and sausage patties 52 degrees F. On 9/12/22 at 11:10 a.m., the CDM was asked what the procedure was for ensuring potentially hazardous foods were maintained at appropriate refrigerator temperatures. They stated they checked the temperatures and if they were not right then they would go to the store and buy what was needed. The CDM stated, Now it is crucial to go to the store, I'm out of time. They were asked what the risk was in serving potentially hazardous foods out of the appropriate temperature ranges. They stated it could make people sick. On 9/12/22 at 12:30 p.m., the CDM was asked how frequently refrigerator temperatures were checked. They stated daily. They were asked what the temperatures should be. They stated below 41 degrees. The CDM was asked what was considered the danger zone. They stated 35 - 41 degrees. The CDM was asked if the refrigerator was at the appropriate temperature. They stated, No. On 9/12/22 at 12:47 p.m., Cook #1 was asked how do they ensure the coolers/refrigerators kept temperature. They stated they check them several times a day to ensure it does not get over what is suppose to be. They were asked what they did if the refrigerators were not holding at the correct temperature. They stated they would call maintenance to get it figured out and if they were not able to get it working they would call their refrigerator guy. On 09/14/22 at 11:45 a.m., the CDM was observed scooping ground meat from a silver pan with her bare hands and placing the food onto meal trays. Staff were observed serving the meal trays to residents. On 09/14/22 at 12:07 p.m., the CDM was asked what the policy was for handling food. They stated they were to wear gloves when handling food. The CDM was asked if staff ever handled foods with their bare hands. They stated, No, they don't. The CDM was asked if they used used their bare hands to scoop the ground meat onto resident's meal trays. They stated they did.

Based on observation, record review, and interview, the facility failed to update and/or revise the Care Plan, related to resident behaviors, for one (#1) of three residents reviewed for care plans. The Administrator reported 37 residents resided in the facility. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, dated 01/09/22, contained no documentation of the resident checking himself out of the facility frequently and not returning until nighttime. The Care Plan contained no documentation related to the resident not having safe transportation while out in the community, use of alcohol while out of the facility, and being returned to the facility by the local police. The Care Plan did not address behaviors of not allowing staff to throw out old and/or spoiled food from the resident's room. A psychiatric visit note, dated 04/14/22, documented, .resident refuses all meds and brought alcohol into the facility. The annual Resident Assessment, dated 07/10/22, documented the resident's cognition was intact, required no assistance with most ADLs, use of a wheelchair to ambulate, and behaviors of daily rejection of care. A nurse note, dated 07/29/22 at 7:30 p.m., documented, .resident returned to facility via police department, resident had slurred speech, glossy eyes, and had beer in his possession .no distress noted, resident able to make needs known, voiced no concerns at this time .At 11:00 p.m., refused all treatments, medication, and flushes this shift. A nurse note, dated 08/08/22 at 5:00 p.m., documented, .arrived to facility via delta bus, bus driver reports resident was found behind the gas station drinking a beer, resident refused all treatment, pcp aware. A nurse note, dated 08/30/22 at 12:15 a.m., documented, .returned back to facility, escorted by local police. The log book, which residents used to sign in and out of the facility, documented the resident had signed out of the facility 12 times in the last 14 days. On 09/07/22 at 10:00 a.m., the resident was observed in his room in his wheelchair. The resident's room had multiple meal trays, containers of food, papers, and empty plastic bags stacked around the room and on his bed. The resident reported this was his stuff and he didn't want staff throwing it away, and that it was important to him. The resident reported this was a free country and he was able to leave the facility when he wanted. On 09/07/22 at 12:10 p.m., the Administrator reported the facility was not legally able to restrict the resident from checking himself out of the facility and he was his own responsible person. The Administrator reported the facility did not have transportation for residents and the local bus would no longer transport this resident due to him drinking alcohol while out of the facility and his unacceptable behaviors on the bus. He reported the resident also had behaviors of not allowing staff to throw away food in his room. On 09/07/22 at12:30 p.m. the MDS nurse reported the resident's care plan had not been recently reviewed and updated. On 09/07/22 at 2:00 p.m., the resident was observed signing himself out and leaving the facility in his wheelchair. On 09/07/22 at 3:00 p.m., the DON reported she was concerned for the resident's safety when he was out of the facility due to him crossing a busy highway in his wheelchair and his use of alcohol while out of the facility. The DON reported she had not updated the resident's care plan related to these behaviors.

Based on observation, record review and interview, it was determined the facility failed to identify accident hazards and failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for one (#44) of three residents whose records were reviewed for accidents. Resident #44 had 15 falls 01/03/19 through 07/02/19 which involved her WC. One of these falls resulted in a nondisplaced radial styloid fracture. This had the potential to affect 14 residents who were identified as high risk for falls. Findings: A facility fall protocol, documented the staff and physician will identify pertinent interventions to try to prevent subsequent falls Resident #44 had [DIAGNOSES REDACTED]. An incident report, dated 03/21/19, documented, the resident fell to floor while transferring from WC to couch. No injuries were present. Steps taken to prevent recurrence was for staff to lock WC brakes when transferring. A careplan entry, dated 03/21/19, documented to assist with transfers and for staff to lock the WC brakes when transferring. An incident report, dated 03/30/19, documented, staff member was pushing resident in WC and stopped near the nurse's station. The resident jumped up out of the WC and fell to the floor and landing on her right side. No injury noted. Steps taken to prevent recurrence were no signs and symptoms of injury. Sent to hospital for nausea and vomiting on 04/01/19. No injuries were noted. An incident report, dated 04/06/19, at 1:30 p.m., documented, the resident attempted to stand unassisted by grabbing onto the WC. The WC slid causing the resident to fall backwards. Steps taken to prevent recurrence included the WC to be added to the maintenance log to check brakes. An incident report, dated 04/06/19, at 4:50 p.m., documented, the resident attempted to stand from the couch, by holding on to WC. The WC slipped away and the resident fell backwards. Steps taken to prevent recurrence were to have frequent visual checks and the WC to be added to the maintenance log to check brakes. A careplan entry, dated 04/06/19, documented, frequent visual checks, WC added to maintenance log to check brakes, and assure brakes are locked at all times. An incident report, dated 04/13/19, documented, the resident was sitting on sofa removing clothes. She stood up and her shoes came off and knocked over the WC. A reddened area above the navel was observed. There were no steps to prevent recurrence documented. An incident report, dated 04/17/19, documented the resident was walking with WC and fell back into the Med Cart and then sliding down the side of the Med Care. Steps taken to prevent reoccurrence were to assist the resident when she is ambulating with her WC. An incident report, dated 04/22/19, documented, the resident was standing up with WC, she started to walk and fell hitting her head on the wall. Steps taken to prevent recurrence were neuro checks and position her in view of the staff. No signs and symptoms of distress were observed. An incident report, dated 04/29/19, documented fell on floor landing on right side, WC folded on top of legs, hit head on right side. There were no steps documented to prevent recurrence. An incident report, dated 05/10/19, documented the resident was standing up out of her WC and fell . There were no steps documented to prevent recurrence. A quarterly assessment, dated 05/21/19, documented the resident's cognition was severely impaired. She required limited, one person assist with transfers, walking and dressing. The resident's mobility device was a WC and walker. The resident had two or more falls with no injuries since the last MDS. An incident report, dated 07/02/19, documented, the resident stood up from her WC to transfer to a chair when she stepped forward tripping on her WC . On 07/03/19, due to the resident not acting her normal self, an X-ray was obtained of her right shoulder, arm and hip. The X-ray impression findings were: a nondisplaced radial styloid [MEDICAL CONDITION] wrist. A final radiology report, dated 07/03/19, documented, .IMPRESSION: Nondisplaced radial styloid fracture .There is nondisplaced radial styloid fracture(a [MEDICAL CONDITION]) . A Nurse's Note, dated 07/03/19 at 5:45 p.m., documented the X-Ray results showed a nondisplaced left radial styloid fracture, a possible nondisplaced right femoral neck fracture with a Subcontract cyst noted to the femoral neck. Physician notified and new orders received to send the resident to the emergency room . The resident was awake and alert with swelling to her wrist and shoulder. A quarterly assessment, dated 08/20/19, documented the resident's cognition was severely impaired. She required limited, one person assist with transfers, walking and dressing. The resident's mobility device was a WC. The resident had one fall with a major injury since the last MDS. On 09/04/19, at 2:30 p.m., CNA #1 was asked about this resident's numerous falls. She stated, Her WC still moves even when it is locked down. We had maintenance tighten the brakes but it still moves around. At 2:45 p.m., the maintenance manager was asked about the brakes on this resident's wheel chair. He stated, I have not ever messed with this resident's WC cause it is a personal WC. He was asked if he had been asked to fix the brakes. He stated, No one has ever asked me to do anything to it. He was asked if there was any previous documentation of the WC having been fixed or worked on or adjusted. He stated, No. At 3:25 p.m., the ADON was asked about this resident's care for falls and how her WC locks. She locked the two back wheels and said it was locked. The wheel chair was still able to be moved around with the back wheels locked. She agreed it was dangerous. She was asked, with this WC still moving after it was locked had it been the cause of a lot of her falls. She stated, Yes. At 3:28 p.m., The DON was asked if a root cause analysis had been done since 12/01/19. She stated, No, nothing has been done on paper. She stated we did figure out that she has had the majority of her falls in the lobby between 2:30 and 5:00 p.m. We obviously have not done enough to keep her protected and keep her safe. The DON was shown the resident's WC and how the two back wheels lock, but the front wheels don't lock and how it can still be moved around like it is not locked. She stated, I'm in 100% agreement the WC is not safe and this was probably the cause of most of this resident's falls involving her WC.

Based on interview and record review, it was determined the facility failed to ensure the medication regimen review for gradual dose reductions, were implemented in a timely manner for two (#33 and #46) of five residents whose records were reviewed for unnecessary medication. This had the potential to affect 50 residents that reside in the facility. Findings: 1. Resident #33 had [DIAGNOSES REDACTED]. A pharmaceutical MRR, dated 01/15/19, documented a recommendation for a GDR for five of the resident's psychoactive medications. The (MONTH) and (MONTH) 2019 MAR indicated [REDACTED]. The GDR had not been signed by the physician, or the facility nurse. A pharmaceutical MRR, dated 02/12/19, documented a recommendation for a GDR for the resident's nasal spray. It was agreed upon by the doctor, signed but not dated. The MRR was noted by the nurse on 04/08/19. A medication change was made almost two months after the recommendation. A MRR, dated 07/31/19, documented The (MONTH) GDR letter is not on the chart for review. Please address The MRR had not been signed by the doctor or the nurse. On 09/05/19 at 09:17 a.m., the DON was shown the above MRR's and asked if the physician had responded to the recommendations. She stated, I have no idea I did not work here then. The DON agreed that the MRR's were not acted upon in a timely manner and stated that she had talked to the doctor about responding to the MRR's in a timely manner. She stated we are working on this. 2. Resident #46 had [DIAGNOSES REDACTED]. An MRR, dated 03/14/19, documented a recommendation for a GDR to discontinue an as needed antianxiety medication. The physician agreed and signed the MRR but did not date it. The MRR had documented noted not signed or dated. The (MONTH) and (MONTH) 2019 MAR indicated [REDACTED] An MRR, dated 04/24/19, documented a recommendation for a GDR to discontinue the same as needed antianxiety medication as the 03/14/19 MRR. The physician agreed and signed the MRR but did not date it. It was noted on 05/16/19 by a facility nurse. A physician order [REDACTED]. Two months and two days after the 03/14/19 GDR recommendation. The MRR, dated 06/13/19, had a GDR recommendation, it was agreed upon and signed by the doctor but not dated, it was noted by the facility on 07/17/19. At 03:00 p.m., the DON reported that nothing was done with GDR's in the months of[NAME] Feb, and (MONTH) of 2019 for any residents, before she took over as DON.

On [DATE] at 11:07 a.m., an Immediate Jeopardy (IJ) situation was identified related to the facility's failure to assess, monitor and provide treatment to a resident with [MEDICAL CONDITIONS] and having respiratory distress. The resident was eventually (4 days later) sent out via ambulance to a hospital were he expired 26 minutes after arrival. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the I[NAME] At 11:10 a.m., the facility administrator, director of nursing (DON) and the regional manager were notified of the I[NAME] At 2:00 p.m., the plan of removal (POR) was received and accepted. It documented: On, [DATE] RN began an instant in-service with all nurses on Policy and Procedures for Oxygen Administration, Pulse Oximetry, Physician Notifications, and [MEDICAL CONDITION]. All nurses that are currently working will be in-service (sic) immediately. All other nurses will be inserviced by 5 pm on [DATE]. This is to insure (sic) nurses have the proper knowledge and understanding of all listed Policy and Procedures. On, [DATE] Admin/Designees through chart review identified 8 residents that have the potential to be affected by this deficient practice. All new nurse hires will be in-service (sic) before working as a charge nurse. Documentation will be placed in employee file showing that they were given a copy of Policy and Procedures for Oxygen Pulsox (sic), Physician Notification and [MEDICAL CONDITION]. DON/designee reviewed records of 8 residents with Physician orders for Oxygen will be administered per order and saturation range between doctor permeator (sic) or dc'd (discontinued). Beginning on [DATE], DON/designees will review full assessment on new admissions/re-admissions/change of condition. Beginning on [DATE] DON/Designee will review new Oxygen orders, new admission/re-admission/change of condition daily for 14 days then weekly x 1 month until substantial compliance is achieved. Beginning on [DATE], Policy and Procedure for Pulse Oximetry, Physician Notification, and [MEDICAL CONDITION] will be re iterated weekly for 1 month then quarterly until substantial compliance is maintained. DON/designee to perform random chart audits weekly x 1 month starting on [DATE] until substantial compliance is achieved. On [DATE] at 8:45 a.m., the administrator stated they had since identified 23 residents receiving oxygen (O2)therapy that could be affected by the deficient practice since the initial identification of 8 residents. On [DATE] at 9:00 a.m., the administrator produced inservice sheets with nurses' signatures, documenting all nurses had been inserviced on policies and procedures as documented in the POR by 3:30 p.m. on [DATE]. Nurses were interviewed to verify the inservices had taken place. At 10:32 a.m., an amended POR was accepted with the only change being 23 residents were identified, as opposed to the initial 8 that could be affected by the deficient practice, with physician orders for oxygen. On [DATE] at 1:30 p.m., the administrator and DON were informed the IJ was removed as of [DATE] at 2:30 p.m., when the DON and physician stated the last resident's O2 order had been reviewed and updated. The deficient practice remained at a level of actual harm, at a pattern. Based on record review and interview, it was determined the facility failed to assess, monitor and provide treatment in a timely manner to a resident (#1) with [MEDICAL CONDITIONS] and having respiratory distress. The resident was eventually (4 days later) sent out via ambulance to a hospital were he expired 26 minutes after arrival. The facility failed to ensure current accepted professional standards were followed for the use of a non- rebreather mask for resident #1. Four records were reviewed of residents who received oxygen therapy. This had the potential to affect 23 residents with physician's orders for O2 according to the administrator, and The facility also failed to conduct a full assessment according to their policy for one (#1) of two residents reviewed for admission assessment. This had the potential to affect all 49 residents. Findings: A facility policy for O2 administration, revised (MONTH) 2010, documented, Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for the procedure. 2. Review the resident's care plan to assess for any special needs of the resident . Assessment 1. Signs or symptoms of cyanosis (i.e., blue tone to skin and mucous membranes); 2. Signs or symptoms of [MEDICAL CONDITION] (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); 3. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); 4. Vital signs; 5. Lung sounds; 6. Arterial blood gases and oxygen saturation, if applicable; and . A facility policy for pulse oximetry (assessing O2 saturation), revised (MONTH) 2010, documented, .Preparation 1. Review the physician's orders . 2. Review the resident's care plan to assess for any special needs of the resident . General Guidelines . 2. Normally SpO2 is between 90 and 100 percent . Assessment 1. Assess the resident for the following signs and symptoms of impaired oxygen saturation: a. Altered respirations, difficulty breathing, abnormal breath sounds; b. Cyanotic appearance of nail beds, lips, skin, mucous membranes c. Restlessness, irritability, and/or d. Confusion, loss of consciousness .If SpO2 is less than 90 percent: .notify the physician . A facility policy for admission assessment documented, .Conduct a physical assessment, including the following systems: a. Eyes, Ears, Nose, Throat; b. Head and Neck; c. Teeth and Gums; d. Cardiovascular; e. Respiratory f. Neurological; g. Musculoskeletal; h. Gastrointestinal; i. Genito-Urinary; and j. Skin .Reconcile the list of medications from the medication history, admitting orders, the previous MAR (medication administration records) .Contact the Attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [REDACTED]. A fact sheet from redcross.org documented a non-rebreather mask should only be utilized on a resident using ,[DATE] liters of oxygen per minute to deliver the oxygen. It also documented that moderate [MEDICAL CONDITION] (low oxygen) is present when SpO2 is ,[DATE] % and severe [MEDICAL CONDITION] is present with less than or equal to 85 % SpO2. Resident #1 had a [DIAGNOSES REDACTED]. He required extensive assistance with dressing and was totally dependent on staff for transfers and bathing. He was always incontinent of bowel and bladder and had a [DIAGNOSES REDACTED]. The resident's record did not contain a care plan. The consultant nurse stated his last updated care plan was from (MONTH) (YEAR). A nurse's note, dated [DATE], documented the resident was admitted to a hospital from the facility related to a colon obstruction. This resulted in surgery. A nurse's note, dated [DATE] at 6:10 p.m., documented the resident was readmitted to the facility. His SpO2 was 59%. The vital signs (VS) were: temperature 99.1 degrees Fahrenheit, pulse was 123 beats per minute, respirations were 30 and the blood pressure was ,[DATE]. The note had not contained any further documentation in regard to his respiratory status or any further assessment. There was no documentation of physician notification concerning the resident's low SpO2 or the vital signs being out of normal range, indicating potential problems. The re-admission physician's orders had not included an order for [REDACTED]. A nurse's note, dated [DATE] at 10:00 a.m., documented the resident had pulled his oxygen off three times in 20 minutes. .Re-applied each time d/t (due to) O2 sats (saturations) in upper 70's without . This was the first mention of the SpO2 being checked since his re-admission on the evening of [DATE], when it was 59%. There was no further documented assessment or that the physician had been notified. A nurse's note, dated [DATE] at 8:00 p.m., documented the resident continued to be confused at times. A nurse's note, dated [DATE] at 4:00 a.m., documented .Resp (respirations) 34 shallow/rapid . A nurse's note, dated [DATE] at 10:00 a.m., documented the resident's SpO2 was 84%. He had on O2 at 3 liters per minute. No further assessment was documented. A nurse's note, dated [DATE] at 3:00 p.m., documented the resident's SpO2 at 88 % with O2 on at 3 liters per minute via nasal cannula. No further assessment was documented. A nurse's note, dated [DATE] at 7:14 p.m., documented a new order was received for [MEDICATION NAME] (breathing treatment medication) four times daily as needed for [MEDICAL CONDITION]/shortness of breath. The clinical record contained a telephone order for the [MEDICATION NAME], but it did not document the [MEDICATION NAME] treatment had ever been administered to the resident. A nurse's note, dated [DATE] at 7:30 p.m., documented the resident's heart rate was 121 beats per minute, respirations were 26 breaths per minute and his SpO2 was 89 % with O2 on at 2 liters a minute via nasal cannula. No further assessment was documented. A nurse's note, dated [DATE] at 9:30 p.m. documented the resident was on O2 at 3 liters a minute and his SpO2 was 89 %. No further assessment was documented. The clinical record had not contained any documentation of lung sounds, respiratory status or physician notification of SpO2 at ,[DATE] %. There was no documentation of monitoring of the resident overnight from [DATE] to [DATE]. A nurse's note, dated [DATE] at 7:30 a.m., documented the resident was on O2 at 3 liters a minute and his SpO2 was 82 %. There was no documentation of any further assessment or that the physician was notified of the SpO2%. A nurse's note at 9:00 a.m., documented, res (resident) required assist c (with) [NAME]M meal, appetite poor . res[DIAGNOSES REDACTED]iculty swallowing meds (medications) this [NAME]M, speech quite (sic) et (and) slurred. No further assessment was documented. A nurse's note at 10:00 a.m., documented the resident was on O2 at 3 liters a minute and his SpO2 was 57 %. The DON was called to his room and a non-rebreather mask was applied with the oxygen rate increased to 3 ,[DATE] liters per minute (the current standard is for ,[DATE]) and, .O2 sats (saturations) (arrow pointing up) to ,[DATE]% c (heart symbol) rate of ,[DATE] (?) . The ambulance was called. A nurse's note at 10:50 a.m., documented the ambulance had arrived. On [DATE], the ambulance record documented the emergency unit had received a call from the nursing home at 10:40 a.m. and arrived at the facility at 10:45 a.m. The record documented, .Hx (history) reporting staff state that (resident's name deleted) has been Hypoxic (decrease of oxygen supply to tissues) in the seventies for most of the day and has been having breathing difficulty since the following (previous?) Friday .in obvious respiratory distress . conscious but non responsive to verbal stimuli .airway/breathing shallow and labored, circulation is delayed .LS (lung sounds) active in all fields with ronchi globally .SpO2 74 % with respirations @ (at) 30 and shallow . The hospital emergency record on [DATE], documented the resident was brought in by ambulance at 12:40 p.m When he arrived he was [MEDICAL CONDITION] (slow heart rate of less than 60). Medication was administered, but his pulse was lost and he had no cardiac activity at 1:06 p.m. The body was released to the medical examiner. The state of Oklahoma, certificate of death, documented the resident's immediate cause of death was [MEDICAL CONDITION] with the underlying cause of death being [MEDICAL CONDITION]. On [DATE] at 11:21 a.m. the assistant director of nurses (ADON) was interviewed and asked what SpO2 percent should be reported to the physician. She stated below 90 %. She stated the percentage for resident #1 would be reported if less than 88 % and that a non-rebreather should be used with 5 liters of O2. She stated she made a deal with the resident that if his SpO2 got above 90 %, he could go and smoke a cigarette. It never did. She stated she thought the resident had orders for O2 at ,[DATE] liters/minute and had parameters to notify the physician if SpO2 was less than 88 %. She stated he did not have O2 on when he arrived via the ambulance (on [DATE]) and she had put O2 on him on his arrival to the facility. At 12:16 p.m., licensed practical nurse (LPN) #1 was interviewed and asked if the physician should have been notified at 7:30 a.m. on [DATE], when the resident's SpO2 was 82 %. She stated the facility policy documented to notify the physician if the SpO2 was less than 90 %. She stated she had not called, that the DON or ADON was supposed to have called. She stated that morning, according to his state, she would have let him get up in his chair. He did what he wanted to. She stated she had listened to his lungs and they were diminished all over, but she had forgot to document that. She stated there was nothing normal for him that morning (he was sent out to the hospital). At 12:48 p.m., the ADON was asked who had been responsible for calling the physician for the resident the morning of [DATE]. She stated it would have been the DON. At 12:49, the DON was asked who would have been responsible for calling the physician for the resident on the morning of [DATE]. She stated LPN #1, the charge nurse that morning. At 2:20 p.m., LPN #2 was interviewed and asked when the physician should have been contacted in regard to resident #1. He stated he thought they had orders for the resident for oxygen. He was always dropping back and forth (SpO2). I believe his SpO2 to report to the doctor was 88%. He stated the physician would usually tell them to monitor the resident. He stated he should have notified the physician of the resident's 88 % SpO2 at 3:00 p.m. on [DATE]. He stated he had called the physician and received a new order for [MEDICATION NAME] breathing treatments and believed he gave a treatment the evening of [DATE]. He was told the [MEDICATION NAME] had never been documented as having been given. He then stated he was unsure if he had administered the breathing treatment. On [DATE] at 10:25 a.m., the DON was interviewed and asked why a non-rebreather mask was used on the resident with O2 at a flow rate of 3 ,[DATE] liters per minute. She stated the resident was in trouble. I made the call. He was up and down (SpO2) and mouth breathing. I got the rebreather. She was not able to state why she had used the non-rebreather mask with a an O2 rate of 3 ,[DATE] liters. The consultant nurse stated the facility did not order or keep non-rebreather masks in the building because they did not utilize oxygen at ,[DATE] liters per minute. She was unsure how the mask was in the building. The DON and consultant nurse were asked if the resident was assessed and monitored as he should have been. They stated, No. They were asked if the physician was contacted when he should have been. They stated, No. They were asked if a non-rebreather mask should have been utilized with such a low flow of oxygen at 3 ,[DATE] liters per minute, instead of the recommended ,[DATE] liters per minute. They stated, No.

Based on record review and interview, it was determined the facility failed to maintain an effective quality assurance (QA) program to identify, assess, monitor, develop, and implement corrective interventions to address problems and prevent further occurrences. The QA committee failed to identify systems failures pertaining to weight loss, notification of change of condition and the development of comprehensive care plans. Sixty-one residents resided in the facility. Findings: 1. The facility failed to ensure: a. an organized system was in place to document residents' weights so significant/severe weight loss could be recognized. b. identify residents with severe weight loss and intervene to prevent further weight loss. c. the physician was notified when when weight loss was identified or should have been identified. This affected two (#1 and #4) of two sampled residents who had experienced severe weight loss. The facility also failed to care plan severe weight loss and implement interventions to prevent further weight loss for (#1) of two sampled residents with severe weight loss. The facility had identified no residents with significant/severe weight loss. (Refer to F692, F580 and F656.) On 03/06/18 at 3:45 p.m., the administrator was asked who was on the QA committee. He stated the administrator, the director of nurses, the assistant director of nurses, the minimum data set coordinator, the business office manager and department heads were on the committee. He was asked if the certified dietary manager was on the committee. The administrator stated, No, but we tell her about concerns. He was asked if the medical director served on the QA committee. He stated the medical director had not attended any meetings. The administrator was asked how often the committee met. He stated it met quarterly and as needed. He was asked what documents the committee reviewed to determine if systems for resident care/services were effective. He stated the committee looked at grievances, complaints from family members, minimum data sets and admission/quarterly assessments. He did not state the facility reviewed residents' weight documentation. The administrator was asked if the QA committee had functioned effectively to identify systems failures related to organized documentation of residents' weights to be able to identify significant/severe weight loss and intervening when weight loss was identified. He stated, No.

Based on record review and interview, it was determined the facility failed to ensure: a. an organized system was in place to document residents' weights so significant/severe weight loss could be recognized. b. identify residents with severe weight loss and intervene to prevent further weight loss. c. the physician was notified when weight loss was identified or should have been identified. This affected two (#1 and #4) of two sampled residents who had experienced severe weight loss. The facility also failed to care plan severe weight loss and implement interventions to prevent further weight loss for one (#1) of two sampled residents with severe weight loss. The facility had identified no residents with significant/severe weight loss. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. The care plan, dated 11/30/17, did not address the resident's risk for nutritional problems related to her swallowing disorder or that the resident had a feeding tube removed just prior to her admission to the facility in 11/2017 (Admission medication orders had been written for medications to be administered via feeding tube in error.) A physician's orders [REDACTED]. The admission assessment, dated 12/06/17, documented the resident had severe cognitive impairment, required extensive assistance with eating; had a swallowing disorder related to coughing or choking during meals or when swallowing medications; was 56 inches tall and weighed 76 pounds; had experienced no significant weight loss/gain in 30 or 180 days; and received a mechanically altered diet. A nutritional risk assessment, dated 12/05/17, completed by the dietary consultant, documented the resident was at moderate nutritional risk. The resident's weights were as follows: 11/30/17 (admission) - 76 pounds 12/06/17 - 73.3 pounds 01/2018 - 68 pounds 01/31/18 - 67 pounds 02/27/18 - 66 pounds The documented weights constituted the following severe weight losses: * a 10.5% weight loss in 30 days from 11/30/17 to 01/2018 * a 13.16% weight loss in 90 days from 11/30/17 to 02/27/18. There was no documentation the resident's physician had been notified of the severe weight losses. A comprehensive care plan had not been developed to address the severe weight loss and interventions to be initiated to prevent further weight loss. A dietary progress note, dated 01/18/18, written by the dietary consultant, documented the resident weighed 68 pounds, a loss of 8 pounds during the past month. Documentation of an 11% weight loss in the past month had been circled. The note documented the dietary consultant recommended MedPass 2.0 60 milliliters (ml) four times daily. The note documented the residents meal intake had been 45-65%. There was no documentation the resident's physician had been notified of the severe weight loss. The dietary consultant's charting log, dated 01/18/18, documented she recommended MedPass 2.0 60 ml four times daily and the resident had an 11% weight loss in the past month. A telephone order, dated 01/18/18, had been written for MedPass 2.0 60 milliliters to be administered four times daily. The reason/[DIAGNOSES REDACTED]. (The physician-signed telephone order was not posted in the clinical record.) A nutritional evaluation, dated 01/22/18, written by the certified dietary manager, documented the resident had a good appetite. Will offer supplement if she eats (less than) 50% of her meal. There was no documentation of and/or interventions for the severe weight loss the resident had already experienced as of the end of 12/2017 when the 01/2018 weights were obtained. A dietary progress note, dated 02/01/18, written by the dietary consultant, documented the resident's weight was 67 pounds, down 1 pound in the past month. The note documented the resident's appetite was good and to continue the MedPass 2.0 60 ml four times daily. No additional interventions for the severe weight loss were recommended by the dietary consultant. The dietary consultant's charting log, dated 02/01/18, documented she recommended to continue MedPass 2.0 60 ml four times daily. No additional interventions to prevent further weight loss. (The resident had lost another pound since the consultant's last visit.) Nurses's notes, physician's orders [REDACTED]. weight loss. No documentation was found. On 03/04/18, in the early afternoon, the surveyor asked the director of nurses (DON) for documentation of the residents' weights. After approximately 2 hours, she provided several pages of residents' weights. The pages were disorganized, the date the weights were taken was not written on some of the pages, all residents' names/weights were not written on pages for some of the months. The DON was asked if any organized weight recording system was accessible to her so weight loss/gain could be identified without having to look through all the pages. She stated the pages for the various months was all she had. She was asked if she had access to the weight recording system the dietary consultant used. She stated she had not seen that documentation. On 03/04/18 at 3:13 p.m., the minimum data set (MDS) coordinator provided the Resident Census and Conditions of Residents which the surveyor had asked for that morning. The Census and Conditions documented one resident had experienced unplanned significant weight loss/gain. The MDS coordinator was asked who the resident who had experienced unplanned significant weight loss/gain was. She stated it was a male resident who had experienced significant weight gain. She was asked if any resident had experienced unplanned significant/severe weight loss. She stated no resident in the facility had experienced unplanned significant weight loss. On 03/05/18 at 8:58 a.m., the director of nurses (DON) was asked for the dietary consultant's reports. She stated she did not know where they were. She was asked if she received report from the dietary consultant before the consultant left the facility. The DON stated she had started to work at the facility as DON on 02/01/18. The surveyor informed the DON the dietary consultant report documented the consultant had been at the facility on 02/01/18. The DON was asked if she had received report from the consultant on 02/01/18. She stated she did not think she had received report from the consultant. The DON then obtained the dietary consultant's reports from the CDM and provided them to the surveyor. (The reports are referenced above.) On 03/05/18 at 9:16 a.m., the DON and the assistant director of nurses (ADON) were interviewed. They were asked if any residents had been identified with significant/severe weight loss. The DON stated, (Resident #3). The ADON stated, (Resident #1) lost a little bit, I think. They were asked who reviewed the residents' weights to determine if weight loss had occurred. The DON stated, As far as I know, dietary has been doing that. That's who had the (dietary consultant) reports. The DON and ADON were asked what the facility's policy and procedure was when a resident was identified as having experienced significant/severe weight loss. The ADON stated, Call the doctor and get an order for [REDACTED]. They were asked if significant weight loss was a significant change of status of which the physician should be notified. They both stated, Yes. They were asked who was responsible to notify the physician. The ADON stated, The nurses. The surveyor asked how soon after the weight loss was identified the physician should be notified. The ADON stated, Within that day or as soon as possible. They were asked how nurses could be responsible to notify the physician if they do not know if a resident had lost weight. The ADON stated, Exactly. The DON stated, The (dietary consultant) reports will have to start coming to us. The surveyor reviewed the resident's weight and % of weight loss (documented above) with the DON and ADON and asked if they were aware the resident had experienced the severe weight loss. The ADON stated, No. The DON stated, I was not aware it was that severe. The DON and ADON were asked if the resident's physician had been notified of her severe weight loss. The ADON stated, No. They were asked what interventions had been initiated to prevent further weight loss. The ADON stated, Just the MedPass. The surveyor asked if an intervention should have been initiated prior to 01/18/18. The ADON stated, Probably. The DON and ADON were shown the resident's care plan and were asked if the resident's severe weight loss had been care planned. The DON reviewed the care plan and stated, No. She was asked if the severe weight loss should have been care planned. She stated, Yes.

Based on record review and interview, it was determined the facility failed to ensure the physician was notified of a severe weight loss for two (#1 and #4) of two sampled residents who had experienced severe weight loss. The facility had identified no residents with significant/severe weight loss. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. The care plan, dated 11/30/17, did not address the resident's risk for nutritional problems related to her swallowing disorder or that the resident had a feeding tube removed just prior to her admission to the facility in 11/2017 (Admission medication orders had been written for medications to be administered via feeding tube in error.) The admission assessment, dated 12/06/17, documented the resident had severe cognitive impairment, required extensive assistance with eating; had a swallowing disorder related to coughing or choking during meals or when swallowing medications; was 56 inches tall and weighed 76 pounds; had experienced no significant weight loss/gain in 30 or 180 days; and received a mechanically altered diet. The resident's weights were as follows: 11/30/17 (admission) - 76 pounds 12/06/17 - 73.3 pounds 01/2018 - 68 pounds 01/31/18 - 67 pounds 02/27/18 - 66 pounds The documented weights constituted the following severe weight losses: * a 10.5% severe weight loss in 30 days from 11/30/17 to 01/2018 * a 13.16% severe weight loss in 90 days from 11/30/17 to 02/27/18. There was no documentation the resident's physician had been notified of the severe weight losses. A dietary progress note, dated 01/18/18, written by the dietary consultant, documented the resident weighed 68 pounds, a loss of 8 pounds during the past month. Documentation of an 11% weight loss in the past month had been circled. There was no documentation the resident's physician had been notified of the severe weight loss. Nurses's notes, physician's orders [REDACTED]. weight loss. No documentation was found. On 03/05/18 at 9:16 a.m., the director of nurses (DON) and the assistant director of nurses (ADON) were interviewed. They were asked what the facility's policy and procedure was when a resident was identified as having experienced significant/severe weight loss. The ADON stated, Call the doctor and get an order for [REDACTED]. They both stated, Yes. They were asked who was responsible to notify the physician. The ADON stated, The nurses. The surveyor asked how soon after the weight loss was identified should the physician be notified. The ADON stated, Within that day or as soon as possible. They were asked how nurses could be responsible to notify the physician if they do not know if a resident had lost weight. The ADON stated, Exactly. The DON stated, The (dietary consultant) reports will have to start coming to us. The surveyor reviewed the resident's weight and % of weight loss (documented above) with the DON and ADON and asked if they were aware the resident had experienced the severe weight loss. The ADON stated, No. The DON stated, I was not aware it was that severe. The DON and ADON were asked if the resident's physician had been notified of her severe weight loss. The ADON stated, No. 2. Resident #4 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 10/20/17, documented the resident had moderate cognitive impairment; was dependent upon staff for activities of daily living except for eating for which she required extensive assistance; was always incontinent of bladder and bowel; was 65 inches tall and weighed 145 pounds; was at risk for the development of pressure ulcers; had no unhealed pressure ulcers; and received hospice services. The quarterly assessment, dated 01/19/18, documented the same as the 10/20/17 assessment with the exception that the resident's weight was 135 pounds. The current care plan documented the resident had exhibited anorexia and weight loss. Appropriate goals and interventions were addressed in the care plan. The facility's weight records consisted of multiple pages with different formatting which documented the resident's weights. Documentation of the residents' weights were incomplete during some of the months reviewed. The weight records documented resident #4's weights as follows: 09/2017 - 145 pounds 10/2017 - 145 pounds 11/2017 - 139 pounds 12/2017 - 135 pounds 01/2018 - 118 pounds 02/2018 - 114 pounds 03/2018 - 114 pounds The documented weights constituted the following severe weight losses: * a 12.59% severe weight loss in 30 days from 12/2017 to 01/2018 * an 18.6% severe weight loss in 90 days from 10/2017 to 01/2018 * a 17.98% severe weight loss in 90 days from 11/2017 to 02/2018 * a 15.55% severe weight loss in 90 days from 12/2017 to 03/2018 * a 21.37% severe weight loss in 180 days from 09/2017 to 03/2018 There was no documentation in the clinical record which indicated the resident's physician had been notified of the resident's severe weight loss until 01/18/18, approximately three weeks after the severe weight loss should have been identified by the facility. On 03/06/18 at 1:22 p.m., in a telephone interview with the resident's physician, he stated he had been informed about the resident's weight loss on 01/18/18 when the facility had asked for an intervention for the weight loss. He stated he believed the weight loss was unavoidable due to the resident's disease processes. On 03/06/18 at 2:15 p.m., the surveyor asked the DON if the resident's physician had been notified in a timely manner, approximately three weeks after the severe weight loss should have been identified by the facility. She stated, No.

On [DATE] at 2:45 p.m., a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide immediate cardiopulmonary resuscitation (CPR) for one resident (#1) who was found unresponsive and without a pulse and who had a full code status. The Oklahoma Sate Department of Health was notified. The past non-compliance IJ was verified. At 2:50 p.m., the director of nurses (DON) and administrator were informed of the past non-compliance IJ situation, which constituted substandard quality of care. Based on record review and interview, it was determined the facility failed to initiate cardiopulmonary resuscitation (CPR) to one (#1) of three sampled residents who were reviewed for their documented CPR status. Resident #1 was a Full Code according to her clinical record and should have received CPR. This had the potential to affect 29 residents who could potentially require CPR, according to their clinical record. Findings: A(NAME)Manor Nursing Home policy documented .identify upon admission the expressed code status of the resident . .meet the resident request of either a FULL CODE or a DNR . Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An assessment, dated [DATE], documented the resident was moderately cognitively impaired. It documented the resident needed limited assistance with dressing, hygiene, and transfers. It documented the resident was independent in eating, required extensive assistance with bathing, had a range of motion limitation on one side in the lower extremities, had a catheter for bladder elimination, and was always incontinent of bowel. A physician's monthly summary, dated ,[DATE], documented the resident was a Full Code. A nurse's note dated [DATE] and timed 3:45 a.m. documented, Resident was checked and was not c/o (complaining of) any pain - She was cleaned et (and) dry linen put on her bed - so she could be gotten up later. A nurse's note, dated [DATE] and timed 4:45 a.m., documented, Resident's spouse came in and went to her room and came running out hollering she was dead . The note documented the resident had no vital signs. An investigative statement, dated [DATE], documented by licensed practical nurse (LPN) #1 documented, .I (LPN #1's name deleted) was at the nurses station doing my charting at 0445 (4:45 a.m.) - The CNAs (certified nurse aides) had bed checked the front halls between 0330 (3:30 a.m.) to 0430 (4:30 a.m.) before getting residents up for breakfast. (Resident #1) was changed and cleaned per protocol at this time. (Resident #1's husband) came in at 0445 and went to his wife's room finding her unresponsive he came out of the room talking loudly saying, My wife is dead don't you people ever check them. I immediately went in to check (resident #1) and her husband kept saying she was cold and stiff. When checking she had vomited again and she was gone but still warm .(Resident #1) was a Full code but she had been gone long enough I didn't think about doing CPR and I was told later I should have stated (sic) CPR on her when she was found, but I didn't . An investigative statement, dated [DATE], written by CNA #1, documented she was informed of the patient's condition. She entered the room to clean the resident and the resident was warm to the touch. An investigative statement, dated [DATE], written by CNA #2, documented she was informed the resident had passed away and entered the room to clean the resident and the resident was still warm. An Oklahoma Board of Nursing report of nursing practice incident, dated [DATE], documented LPN #1 was reported to have not started CPR for a resident who was found unresponsive with no vital signs and was a full code. An In-Service form, dated [DATE], documented staff received education related to when a resident is a full code, CPR must be initiated when there is an absence of vital signs. On [DATE] at 1:09 p.m., CNA #3 was asked how staff was informed a resident was a full code. She stated it is in the activities of daily living (ADL) book, in the resident's chart, and on a list behind the cabinet door located behind the nurses' station. She was asked what she would do if a resident was unresponsive. She stated she would notify the charge nurse immediately. At 1:11 p.m., CNA #4 was asked how staff was informed a resident was a full code. She stated it is in the ADL book, in the resident's chart, and on a list behind the cabinet door located behind the nurses' station. She was asked what she would do if a resident was unresponsive. She stated she would notify the charge nurse immediately. At 1:12 p.m., certified medication aide (CMA) #1 was asked how staff was informed a resident was a full code. She stated it is in the ADL book, in the resident's chart, and on a list behind the cabinet door located behind the nurses' station. She was asked what she would do if a resident was unresponsive. She stated she would notify the charge nurse immediately. At 1:12 p.m., CMA #2 was asked how staff was informed a resident was a full code. She stated it is in the ADL book, in the resident's chart and on a list behind the cabinet door located behind the nurses' station. She was asked what she would do if a resident was unresponsive. She stated she would notify the charge nurse immediately. At 1:13 p.m. CNA #5 was asked how staff was informed a resident was a full code. She stated it is in the ADL book, in the resident's chart and on a list behind the cabinet door located behind the nurses' station. She was asked what she would do if a resident was unresponsive. She stated she would notify the charge nurse immediately. At 1:14 p.m., CNA #6 was asked how staff was informed a resident was a full code. She stated it is in the ADL book, in the resident's chart and on a list behind the cabinet door located behind the nurses' station. She was asked what she would do if a resident was unresponsive. She stated notify the charge nurse immediately. At 1:18 p.m., LPN #2 was asked how staff was informed a resident was a full code. She stated it is in the ADL book, in the resident's chart and on a list behind the cabinet door located behind the nurses' station. She was asked what she would do if a resident was unresponsive. She stated she would assess the resident and start CPR if they were a full code. She was asked what in-services she had recently received. She stated one on documentation and also when to administer CPR. At 1:18 p.m., LPN #3 was asked how staff was informed a resident was a full code. She stated it is in the ADL book, in the resident's chart and on a list behind the cabinet door located behind the nurses' station. She was asked what she would do if a resident was unresponsive. She stated she would assess the resident and start CPR if they were a full code. She was asked what in-services she had recently received. She stated documentation and when to administer CPR. At 2:04 p.m., the DON was asked if CPR should have been started on resident #1. She stated it should have been. She stated an investigation had occurred for the resident. She stated LPN #1 was terminated and was reported to the Oklahoma Board of Nursing.

Based on record review and interview, the facility failed to assess, monitor and intervene in a timely manner when a resident experienced a change in mentation and required increased assistance. The resident continued to decline and it was over 26 hours before emergency services was called. At another time the resident experienced an extremely low blood oxygen level that was an emergency situation. Facility staff waited 20 minutes to call emergency services. These examples were for one (#1) of nine residents reviewed for assessment, monitoring and timely intervention. This resulted in harm to the resident. The resident was hospitalized for [REDACTED]. This had the potential to affect all 44 residents residing in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. She had a history of [REDACTED]. She had [MEDICAL CONDITION] and was dependent on oxygen therapy at all times. The named resident had physician's orders [REDACTED]. A normal SPO2 reading is 90-100 %. The care plan, dated 11/03/16, documented, .Problem/need: (name withheld) has the potential for complications, s/sx (signs and symptoms) related to [MEDICAL CONDITION]. Goals/objectives: Will have respiratory rate within normal limits, be free of s/s/x of respiratory distress and maintain optimal functioning within limitations imposed by the disease process through the review date in 90 days. Approaches: Evaluate/record/report to MD (medical doctor) prn (as needed). anxiety, restlessness, SOB (shortness of breath), wheezing, dyspnea, rapid or shallow respirations, cough, cyanosis, confusion, altered mental status, fatigue, headache, administer meds as ordered and monitor for side effects, administer 02 (oxygen) as ordered, monitor vital signs, listen for breath sounds, take and record pulse oximetry as ordered .Problem: Resident is on 02 as part of their treatment for [REDACTED]. Approaches: 02 as ordered, .notify physician as needed . A nurse's note, dated 01/30/17 at 5:15 a.m., documented the resident was slow to respond, not acting like herself. The note documented vital signs as: blood pressure-108/50, pulse-82, respirations-16, temperature-98.8 degrees Fahrenheit and the SPO2 was 92 %. .Resident oriented to name, unable to determine further orientation .Dr. (name withheld) paged, awaiting return call. Will cont (continue) to monitor . There was no documented return call from the physician or any new orders received. A nurse's note, dated 01/30/17 at 8:00 a.m., documented the resident seemed to be sedated and unable to get up for breakfast. Vital signs were documented as: blood pressure-161/68, pulse-86, and respirations-16-18. No temperature was documented. The SPO2 was 91-97 %. A nurse's note, dated 01/30/17 at 1:00 p.m., documented the resident had to be assisted with feeding. The facility staff stated she normally fed herself. A nurse's note, dated 01/30/17 at 8:30 p.m., documented the resident was crying out that somebody stabbed her and to help her. A nurse's note, dated 01/31/17 at 8:00 a.m., documented the resident was weak and had a decreased level of consciousness. Her respirations were 28 and she could not hold her head up. The ambulance was called and the resident was transported to a hospital where she was admitted with the [DIAGNOSES REDACTED]. A facility patient transfer form, dated 01/31/17, documented the resident's vital signs were: temperature-97.8 Fahrenheit, pulse-86, respirations-28 and blood pressure-131/70. No SPO2 was documented. There was no follow-up for the call made to the physician on 01/30/17, at 5:15 a.m., when the change of condition started. There was no continued assessment and monitoring of her condition. The resident continued to decline and no action was taken until 01/31/17 at 8:00 a.m., when her condition became emergent. This was 26 hours and 45 minutes after her condition change was first observed. The resident was re-admitted to the facility on [DATE]. A 14-day assessment, dated 02/19/17, documented the resident's cognition was intact. She required limited assistance with activities of daily living with the exception of eating, in which she only required supervision and she required extensive assistance with bathing. She was occasionally incontinent of bowel and bladder. A nurse's note from the night shift nurse, dated 02/22/17 at 11:10 p.m., documented an aide had called the nurse to the resident's room .large amt (amount) of mucous coughed out-resident attempting to catch breath-SPO2 52 % -decreased level of consciousness-administered straight O2 (oxygen) @ (at) 3 L(liters)/min (minute) nc (nasal cannula)-resident continued (accessory) respirations-skin pale-(arrow pointing up indicating increased) anxiety-cool-clammy skin noted - at 2330 (11:30 p.m.) (this was 20 minutes after she was found to have an SPO2 of 52%) -911 called-request EMS (emergency medical services) transport . The ambulance arrived and transferred the resident at 11:45 p.m. The resident was admitted to the hospital with [REDACTED]. The named resident never returned to the facility. A physician's orders [REDACTED]. On 04/12/17 at 4:00 p.m., the night shift nurse that had worked the night of 02/22/17 and had the resident transferred out by ambulance was interviewed in regard to waiting 20 minutes to call the ambulance when the resident's SPO2 was 52 %. He stated the resident had similar episodes in the past and when he switched her oxygen from a concentrator to a tank, her SPO2 had always gone back to normal. On 04/12/17 at 4:15 p.m., the director of nurses was interviewed and was in agreement the resident had not been fully assessed, monitored or had timely interventions for her changes in condition and low SPO2.

On 06/06/16 at 11:12 a.m., an Immediate Jeopardy (IJ) situation was identified related to the failure of the facility to store refrigerated items at the proper temperature to prevent the potential for food borne illnesses due to a refrigerator in need of repair. At 11:18 a.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ. At 11:27 a.m., the administrator was notified of the IJ situation. At 12:30 a.m., A Plan of Removal (POR) was presented and accepted by the team. The POR documented: All food in the refrigerator has been disposed of and all containers have been bleached, washed, and sanitized by 12:15 p.m. on 6/6/16. All kitchen staff has been in serviced on proper temperatures for the refrigerator and other equipment in the kitchen. Staff has also been in serviced on when they should temp the kitchen equipment. In order to prevent this deficiency from reoccurring, staff will complete the temperature logs three times a day indefinitely. The dietary supervisor and administrator will be notified immediately when any temperature rises above 41 degrees in the refrigerator and 32 degrees in the freezer. After being notified, all will be moved to an approved refrigerator and temperatures will continue to be monitored. Results of temperature logs will be brought to QA weekly times 4 weeks then monthly to verify continued compliance with temperatures. At 12:40 p.m., the final dietary staff had been in-serviced by telephone per the facility's documentation. At 3:00 p.m., the refrigerator had been repaired and the temperature was holding at 41 degrees Fahrenheit or less. The administrator was informed the IJ had been removed. The deficient practice remained at a level of no actual harm with the potential for more than minimal harm, at a pattern. Based on observation, interview, and record review, the facility failed to store refrigerated foods at the proper temperature to prevent the potential for food borne illnesses. This had the potential to affect 41 residents who received food from the kitchen as identified by the dietary manager. Two residents were fed via tube feedings and one resident was out of the facility. Findings: A facility policy documented .Hold food - Cold =40 F or below. .maintain milk at 40 degrees F or lower On 06/06/16 09:13 a.m., the refrigerator labeled dairy was observed to have a thermometer located inside the machine that read 54 degrees Fahrenheit. On 06/06/16 at 09:15 a.m., an unopened container of milk was taken from the left section, top left shelf. It was opened by this surveyor and a small glass of milk was poured. The temperature of the milk was 47.2 degrees Fahrenheit. An unopened container of sour cream was taken from the middle section, middle shelf of the machine. It was opened by this surveyor and a portion was placed in a small cup. The temperature of the sour cream was 43.3 degrees Fahrenheit. A tomato was taken from the left section, bottom left shelf of the machine. The temperature of the tomato was 43.3 degrees Fahrenheit. A single serve container of butter was taken from the middle section, middle shelf of the machine. The temperature of the butter was 47.0 degrees Fahrenheit. An individual American cheese slice was taken from the right section, middle shelf. The temperature of the cheese slice was 47.3 degrees Fahrenheit. A pasteurized egg was taken from the left section bottom shelf from the back. The temperature of the egg was 47 degrees Fahrenheit. At 09:17 a.m., dietary aide #1 was asked what the temperature of the dairy refrigerator was. She checked the thermometer and stated it was 54 degrees Fahrenheit. She stated she would have usually told the dietary manager what the temperature was, but the dietary manager was off. She stated they have had trouble with the refrigerator since last week around Wednesday or Thursday. No food was observed being taken out the refrigerator for use prior to taking the temperatures. At 09:20 a.m., the dairy refrigerator's temperature log was reviewed. The log had documented a temperature of 40 degrees Fahrenheit on 06/01/16 at 6:00 a.m., 41 degrees Fahrenheit on 06/02/16 at 9:30 a.m., no temperature was documented on 06/03/16, 06/04/16, or 06/05/16. A temperature of 54 degrees Fahrenheit was documented on 06/06/16 at 9:00 a.m. On 06/06/16 at 10:43 a.m., the dietary manager was asked if they had any problems with the kitchen equipment. She stated there had been some problems with the kitchen refrigerators. She stated the maintenance supervisor had looked at the refrigerators on 06/01/16. She stated he had put a temporary fix in place but, she did not know what it was. She stated a company was supposed to have been at the facility on 06/03/06, but had not made it out because of the weather. She stated they were scheduled to arrive at the facility on 06/06/16. On 06/06/16 at 11:06 a.m., dietary aide #2 was observed to remove a jar of mayonnaise, ready to eat ham slices, ready to eat turkey slices and a container of individual sliced pieces of American cheese from the dairy refrigerator. She was observed to have prepared a sandwich with the mayonnaise, three slices of turkey, three slices of ham, and one slice of cheese. The temperatures of these items was taken as soon as the aide had removed them from the refrigerator and was beginning to use them. The temperature of the mayonnaise was 48 degrees Fahrenheit. The temperature of the ham was 52 degrees Fahrenheit. The temperature of the turkey was 51 degrees Fahrenheit. The temperature of the cheese slice was 47.3 degrees Fahrenheit. The dietary aide had prepared the sandwich and was getting ready to hand it to a resident when the surveyor stopped her. On 06/06/16 at 2:00 p.m., a refrigerator repairmen was observed working on the machines. At 3:00 p.m., the refrigerators were observed to have been repaired. The dairy refrigerator's temperature was 36 degrees Fahrenheit. On 06/07/16 and 06/08/16, after the repair of the dairy refrigerator, the log documented temperatures below 41 degrees Fahrenheit.

Based on record review and interview, it was determined the facility failed to assist a resident to safely transfer from the bed to the bedside commode for one (#1) of four sampled residents, resulting in actual harm to the resident. This had the potential to affect 30 residents identified by the director of nurses (DON) as needing assistance from the staff with transfers. Findings: The Oklahoma State Department of Health Course Standards To Teach The Oklahoma Long Term Care Nurse Aide Training and Competency Evaluation Program documented: "...Topic 23: Transferring... ...6. CNA's role: ... e. Be very aware of the position and location of the resident's arms and legs when transferring and transporting and keep safety first..." Resident #1 had [DIAGNOSES REDACTED]. The care plan, dated 10/12/13, documented the resident had impaired physical mobility, limited range of motion and weakness in her lower extremities. She required the assistance of two persons for a safe transfer and the mechanical lift could be used as needed. The quarterly assessment, dated 02/27/14, documented the resident had moderate cognitive impairment and she was dependent on the staff for transfers. An incident report form, dated 03/19/14, documented two facility staff members had transferred resident #1 from her bed to a bedside commode in her room. The resident's left leg was caught in the space where the bed frame had been raised. Staff reported they did not notice the resident's foot being caught inside the bed frame. The foot of the bed was remotely lowered with the resident's foot still stuck in the bed frame. "When staff tried to get her foot out it caused a three inch laceration to the leg." The resident was taken to the emergency room for treatment. On 03/21/14 at 12:34 p.m., certified nurse aide (CNA) #1 was interviewed in regard to transferring resident #1 on the morning of 03/19/14. She stated the resident was sitting up on the side of the bed with her right leg crossed over her left leg. "She was almost on the floor." CNA #1 stated she should have ensured both of the resident's feet were on the floor before she was transferred from the bed to the bedside commode. At 1:10 p.m., the licensed practical nurse (LPN) who was the charge nurse on duty the morning of 03/19/14, was interviewed. She was in agreement that for a proper transfer of a resident, the staff should ensure both of the resident's feet are on the floor and secure prior to the transfer. At 3:55 p.m. the DON was interviewed and was in agreement the staff had not assessed for where the resident's legs were before transferring resident #1, which resulted in an injury.

Based on observation, record review and interview, it was determined the facility failed to provide supervision to prevent falls that resulted in actual harm with head injuries that required sutures for one (#12) of seven residents who had sustained falls. This deficient practice had the potential to affect twelve residents who had sustained falls in the last three months, according to the facility's roster/sample matrix. Findings: The facility's policy for falls, documented, "Purposes: To evaluate extent of injury and prevent complications." 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's current care plan, dated 01/06/11, documented, "(Resident) has the potential for falls related to generalized weakness and decline in cognitive function." The fall interventions documented, "Keep the bed in a low position; keep call light within reach; respond promptly...; use appropriate mobility appliances: wheelchair, walker, etc...; keep environment free from clutter, spills, etc...; PT/OT to evaluate and treat as indicated." An incident report and nurse's note, dated 01/19/11, documented the resident had an unwitnessed fall in her room with an injury to her thumb. An incident report and nurse's note, dated 01/28/11, documented, "CNA responding to bed alarm, upon entering room, found pt on back. Resident denied pain. Small 1mm lac noted to back of head." The fall was unwitnessed. A nurse's note, dated 02/14/11, documented, "1445 (2:45 p.m.) Summoned to room. Found resident lying on back (with) legs straight out (and) head on floor (with) blood in floor. Applied cool rag (with) pressure to back of head (with) 1 cm open area...Staff holding pressure to back of head. Assessed back of head again (with) (no) more bleeding noted." "1500 (3:00 p.m.) - Resident in shower to wash hair. Area to back of head opened up. Doctor notified of need for sutures. New order to transport to (local hospital)." "1730 (5:30 p.m.) Returned to facility from (local hospital) via private vehicle of friend. 15 sutures noted to back of head (with) (no) drainage noted." The resident requested to go to the bathroom and for something to eat. The resident's care plan for falls was updated on 04/10/11. An added intervention was to attach a bed and chair alarm to the resident. The care plan update documented, "Continue POC." The resident's comprehensive assessment, dated 04/13/11, documented her cognition was severely impaired. It documented she required extensive assistance with transfers, ambulation and all activities of daily living. She was unsteady on her feet and not able to stabilize without assistance. Her main transportation was in a wheelchair. A nurse's note, date 05/01/11, documented, "830 pm - Called to resident room by CNA where resident was found on (left) side in floor. Laceration noted to (left) wrist. Wound cleansed (with) NS, steri-strips applied to well-approximated cut...Hematoma noted to (left) forehead. Ice pak placed on head for 15 minutes." This was an unwitnessed fall. The physician and family were notified. The resident's care plan for falls had not been updated to include the four unwitnessed falls. The interventions had not been evaluated or revised with new interventions to prevent further falls. On 05/10/11 at 2:20 p.m., LPN #5 was asked who did the careplans and why there was no careplan documenting the resident's falls. She stated, "(RN #4) does them and I help her. I didn't realize (RN #4) did not update the care plans." On 05/11/11 at 10:45 a.m., the DON and MDS coordinator were interviewed regarding the falls with no updates or revisions to the resident's care plan. The MDS coordinator stated she updates the care plans if (RN #4) is not working. She stated the RN is supposed to update the care plans.