Every finding on record at Marlow Nursing & Rehab

Based on record review and interview, the facility failed to ensure residents were free from for 2 (#1 and #2) of 2 sampled residents reviewed for abuse.The administrator identified two allegations of abuse in the past 60 days. Findings: An undated policy titled Abuse Policy and Procedure, read in part, We will endeavor to protect our occupants from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of resident property.Sexual abuse. Includes sexual harassment, sexual coercion, or sexual assault. 1.A care plan for Resident #1, dated 10/08/25, showed the resident had diagnoses which included COPD, diabetes, congestive heart failure, hypertension, and rheumatoid arthritis. A quarterly MDS assessment for Resident #1, dated 11/04/25, showed the resident has a BIMS of 15, which indicated the resident was cognitively intact. An OSDH [Oklahoma State Department of Health] Incident Report Form, dated 11/07/25, showed Resident #1 reported to the administrator CNA #1 had touched the resident's private part. The report showed notification to authorities and suspension of CNA #1 with an investigation initiated. On 11/12/25 at 9:30 a.m., Resident #1 was interviewed in their room and asked if anyone had touched them inappropriately. The resident did not give any details and asked the surveyor to talk to the administrator about the incident. On 11/12/25 at 10:40 a.m., the administrator reported Resident #1 initially went to a nurse and told them they needed to speak with the administrator, but did not tell the nurse what it was about. The administrator reported as soon as Resident #1 told them CNA #1 had touched them inappropriately, CNA #1 was suspended, and the investigation was initiated. The administrator reported in the process of interviewing other residents on 11/07/25, Resident #2 reported CNA #1 had groped them in the shower. The administrator reported Resident #2 stated the incident happened a while ago and the resident had not reported it to anyone. On 11/13/25 at 9:15 a.m., Resident #1 was interviewed in their room with the administrator present. Resident #1 reported the incident with CNA #1 happened in their room. Resident #1 reported CNA #1 had put lotion on their legs after they had their shower, which they did independently without the CNAs assistance. Resident #1 reported CNA #1 came at them and touched them. Resident #1 was asked if CNA #1 touched their private area. Resident #1 stated, Yes. Resident #1 was asked if they had clothes on and the resident reported they were wearing shorts. Resident #1 was asked if they thought CNA #1 could have touched them accidentally when applying lotion. Resident #1 reported no, the lotion had already been applied prior to CNA #1 touching their private area. Resident #1 stated CNA #1, came at me and rubbed me. Resident #1 reported CNA #1 did not reach inside their shorts, but rubbed them on the outside of their shorts. Resident #1 was asked if CNA #1 exposed themself. Resident #1 reported CNA #1 showed them their breasts. Resident #1 reported they were not afraid of CNA #1, but the incident made them feel uncomfortable and they wanted CNA #1 out of their room. Resident #1 reported CNA #1, went too far and crossed the line. Resident #1 reported CNA #1 left their room when they told them to leave. 2. A care plan for Resident #2, dated 02/16/25, showed the resident had COPD, chronic pain, kidney cancer, and osteoarthritis. A quarterly MDS assessment for Resident #2, dated 08/12/25, showed the resident had a BIMS of 15, which indicated the resident was cognitively intact. On 11/12/25 at 11:18 a.m., Resident #2 was asked if anyone had ever touched them inappropriately. Resident #2 reported they had just talked with the administrator a couple of days previous about an incident with CNA #1 in the shower. Resident #2 reported CNA #1 groped them while assisting them with a shower. Resident #2 reported they did not think of the incident as abuse, but knew it was inappropriate behavior. Resident #2 reported they could not remember exactly when the incident happened, but they did not tell anyone about the incident until the administrator questioned them recently. On 11/12/25 at 2:05 p.m., CNA #1 was interviewed by telephone. CNA #1 reported they had never touched a resident inappropriately or exposed themself to a resident. CNA #1 reported they did not know why the residents had made the accusations of being touched inappropriately.On 11/13/25 at 9:30 a.m., the ADON reported Resident #1 had not reported abuse of any kind prior to the incident with CNA #1. The ADON reported CNA #1 had worked at the facility a couple of months and there had been no previous allegations of abuse against the CNA.

Based on record review and interview, the facility failed to provide and document education related to COVID-19 immunizations for 5 (#2, 4, 22, 32, and #48) of 5 sampled residents reviewed for immunizations. The DON identified 17 residents declined the COVID-19 immunization.Findings: 1. Review of Resident #2's COVID 19 Vaccine Series form showed the resident declined the COVID-19 vaccination on 03/29/24. There was no documentation education regarding the COVID-19 vaccine was provided. 2. Resident #4's COVID 19 Vaccine Series form showed the resident declined the COVID-19 vaccine. The record did not contain documentation of a date of having declined the vaccine or education for the COVID-19 vaccine. 3. Resident #22's COVID 19 Vaccine Series form showed the resident declined the COVID-19 vaccine on 06/21/24. The record did not contain documentation of education for the COVID-19 vaccine. 4. Resident #32's COVID 19 Vaccine Series form showed the resident declined the COVID-19 vaccine on 09/18/24. The record did not contain documentation of education for the COVID-19 vaccine. 5. Resident #48's COVID-19 Vaccine Series form showed the resident declined the COVID-19 vaccine on 09/20/24. The record did not contain documentation of education for the COVID-19 vaccine. The facility's policy titled Infection Prevention & Control Manual, dated 10/10/24, read in part, Prior to offering COVID-19 vaccine, residents or residents' representative are provided with education (Fact Sheets) regarding benefits and risks and potential side effects associated with the vaccine, most common side effects at injection site is pain, swelling and redness. On 09/29/25, at 1:50 p.m., the IP stated the facility policy required staff to provide education regarding the COVID-19 vaccinations. The IP confirmed education was not provided to the residents regarding COVID-19 vaccinations.

Based on observation, record review, and interview, the facility failed to:a. administer medications per physician's orders for 1 (#2) of 5 sampled residents reviewed for unnecessary medications, and b. provide supervision for 1 (#58) of 1 sampled resident reviewed for illicit substance use.The DON identified 52 residents resided in the facility. 1. A behavior note, dated 01/16/25 at 4:56 p.m., showed at 11:30 a.m., Resident #58 was observed in the hallway, walking quickly, and hollering out loud to staff. The note showed the resident proceeded to a housekeeper and inquired about where the tissue box in their room was. The note showed prior to the resident's encounter with the housekeeper, the housekeeping staff had alerted nursing staff about a tissue box that contained what appeared to be a broken glass pipe with a white substance in it. The note showed the tissue box also contained a piece of foil, scissors, and a standard light bulb with a burned area on top of it. The note showed Administration was made aware and was given paraphernalia with what appeared to be an illicit drug substance. A Resident Sign Out sheet, dated before 03/05/25, was not provided by the facility for review. A Resident Sign Out sheet, dated 03/05/25 through 03/21/25, showed Resident #58 signed out on 03/13/25 at 12:31 p.m.; no reason for sign out or sign in time was documented. Resident #58's progress notes showed no documentation that the resident was assessed upon return to the facility for 03/13/25. A Substance Use Disorder policy, dated 03/27/25, showed that residents who leave the facility are assessed upon return for signs/symptoms of substance use and potential overdose. A progress note, dated 04/07/25 at 3:48 p.m., showed the Resident #58 liked to go out of the facility with a friend. A progress note, dated 04/07/25 at 4:08 p.m., showed a drug and alcohol policy signed by Resident #58. A Resident Sign Out sheet, dated 05/01/25 through 05/11/25, showed Resident #58 signed in on 05/04/25 at 6:33 p.m.; no sign-out time was documented. The sheet showed the resident signed in with a visitor and no reason was documented. Resident #58's progress notes showed no documentation that the resident was assessed upon return to the facility on [DATE]. A quarterly assessment, dated 06/17/25, showed Resident #58's cognition was moderately impaired with a BIMS score of 09. The assessment showed the resident was independent with activities of daily living. The assessment showed the resident had a diagnosis of cirrhosis of the liver. A care plan, dated 06/18/25, showed no goals or interventions related to illicit substance use. A Discharge summary, dated [DATE], showed Resident #58 discharged on 07/15/25 due to death in the facility with hospice services. On 09/24/25 at 9:42 a.m., an APS worker reported they had received a complaint related to Resident #58 being able to leave the facility and go to a convenience store where the resident would meet an unknown person and smoke marijuana. The APS worker reported that the complainant voiced a concern that the resident was not supervised for their safety. On 09/29/25 at 9:29 a.m., the DON reported that residents are allowed to sign out of the facility if they sign out and they let them know where they are going, for the residents' safety. The DON reported the resident should be assessed upon return to the facility. On 09/29/2025 at 9:48 a.m., the ADON reported that no incident report was completed for staff finding drug paraphernalia in Resident #58's room. The ADON reported that the staff did not contact the police, and the paraphernalia was taken from the resident. just took the drug paraphernalia away from the resident; they did not contact the police or do an incident report. On 09/29/2025 at 2:36 p.m., the MDS Coordinator reported they were not doing the care plans at the time of this incident, but they would have added illicit substance use to Resident #58's care plan. On 09/29/2025 at 3:44 p.m., the Administrator reported not being aware of the incident with the drug paraphernalia until the surveyor requested information about the incident. The Administrator reported that a new substance abuse disorder policy was put in place in March of 2025. The Administrator reported that Resident #58 should have been checked out and monitored after the drug paraphernalia was found in the resident's room. The Administrator reported the resident should have had blood work done. The Administrator reported that they should have been notified, and they are not aware of how the drug paraphernalia items were discarded. 2. The monthly physicians orders dated 09/01/25 documented that Resident #2 was admitted [DATE] with diagnoses which included: Type 2 Diabetes Mellitus, paraplegia, Urinary Tract Infection, recurrent clostridium difficile, obesity, chronic pain, major depressive disorder, osteoarthritis, necrotizing vasculopathy, hypertension, end stage renal disease, anemia, gout, mood disorder, dementia and gastroesophageal reflux disease. Resident #2 medications include: Volteran gel topically to legs twice daily. Sertraline 50mg orally daily, Lorazepam 1mg orally three times daily, Phos binder 667mg (2) caps orally three times daily, Fentanyl patch 12mcg replace patch every 72 hours, Midodrine 5mg orally three times daily. Hold if SBP greater than 120 Famotidine 10mg orally daily, Oxycodone 20mg orally three times daily, Pregabalin 100mg orally three times daily, Apixaban 2.5mg orally twice daily, Donepezil 10mg orally daily and, Allopurinol 50mg, orally once daily on M, W, and F Trazodone 50mg orally daily at bedtime PRN MOM, Maalox, nitroglycerin, benadryl, narcan, zofran, and loperamide, fingerstick blood sugar as needed, and Narcan The significant change MDS dated [DATE] showed residents BIMS score was 12 The facility policy titled, Specific Medication Administration Procedures dated July 2015, read in part, obtain and record any vital signs or other monitoring parameters ordered prior to medication administration. Resident #2's medication administration record dated, 08/01/25, showed Midodrine tab 5mg give 1 tablet orally three times a day for hypotension hold for systolic blood pressure greater than 120 MM/HG. take BP. The August medication administration record showed errors as follows: a.) 08/01/25, 8:00 a.m., B/P 124/66, midodrine given b.) 08/07/25, 8:00 a.m., B/P 124/70, midodrine given c.) 08/07/25, 2:00 p.m., B/P 124/70, midodrine given d.) 08/07/25, 8:00 p.m., B/P 126/84, midodrine given e.) 08/16/25, 8:00 p.m., B/P 121/61, midodrine given f.) 08/24/25, 8:00 p.m., B/P 123/69, midodrine given g.) 08/25/25, 8:00 a.m., B/P 122/64, midodrine given h.) 08/26/25, 8:00 a.m., B/P 122/59, midodrine given i .) 08/26/25, 2:00 p.m., B/P 122/59, midodrine given j .) 08/30/25, 8:00 p.m., B/P 121/75, midodrine given The September physician's orders dated 09/01/25, showed Midodrine tab 5mg give 1 tablet orally three times a day for hypotension hold for systolic blood pressure greater than 120 MM/HG. take BP. The September medication administration record showed errors as follows: k.) 09/01/25, 8:00 a.m., B/P 127/65, midodrine given l .) 09/03/25, 8:00 a.m., B/P 130/62, midodrine given m.) 09/04/25, 2:00p.m., B/P 121/68, midodrine given n.) 09/04/25, 8:00 p.m., B/P 121/68, midodrine given o.) 09/06/25, 2:00 p.m., B/P 124/51, midodrine given p.) 09/07/25, 8:00 p.m., B/P 122/64, midodrine given q.) 09/10/25, 8:00 a.m., B/P 129/63, midodrine given r.) 09/12/25, 8:00 a.m., B/P 125/69, midodrine given s.) 09/21/25, 8:00 p.m., B/P 122/70, midodrine given t. ) 09/22/25, 8:00 a.m., B/P 125/49, midodrine given On 09/24/25, at 01:17 p.m., the DON was asked what the policy for monitoring improvement with medication aides was, after being educated on medication errors. The DON stated they will find out and report back. No policy or practice was presented. The DON verified that the medication should have been held per physician's orders.

Based on record review and interview, the facility failed to ensure the Oklahoma Health Care Authority was notified after a resident received a significant mental health diagnosis for 2 (#9 and #36) of 3 sampled residents reviewed for PASRR assessments.The DON identified 52 residents resided in the facility. Findings: The facility policy titled Member certification for long term care PASRR policy and procedure, revised date 09/01/17, read in part, A significant change in a resident's mental condition could trigger a Level ll Resident Review. If such a change should occur in a resident's condition, it is the responsibility of the NF to notify the LOCEU of the need to conduct a resident review. 1. Resident #9's monthly physicians orders, dated 09/01/25, documented resident was admitted on [DATE] with diagnoses which included heart failure, other specified viral diseases, post-polio syndrome, chronic pain, chronic pancreatitis, anemia, renal failure, hypertension, diabetes mellitus, and hallucinations. Additional diagnosis of unspecified psychosis, with effective date of 03/03/25. On 09/24/25 at 10:22 a.m., the MDS coordinator was asked if a Level ll PASRR was requested. They stated no. The MDS coordinator was asked if one should have been done. They stated, yes. 2. Resident #36's monthly physicians orders, dated 09/01/25, documented the resident was admitted on [DATE] with diagnoses which included Parkinson's disease, chronic obstructed pulmonary disease, anxiety, depression, hypertension, vascular dementia, hypothyroidism, diabetes mellitus, and hyperlipidemia. The monthly physician's orders, dated 09/01/25, showed Resident #36 with additional diagnoses of Puerperal psychosis and psychotic disorder with an effective start date of 01/03/23. On 09/29/25 at 9:35 a.m., the MDS coordinator was asked if a Level ll PASRR was requested. They stated no, but there should have been one.

Based on record review and interview, the facility failed to develop and implement a care plan for illicit substance use for 1 (#58) of 1 sampled resident reviewed for illicit substance use.The DON identified 52 residents resided in the facility.Findings:A Comprehensive Person-Centered Care Plan policy, dated 12/01/16, showed the care plan should incorporate identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident. A behavior note, dated 01/16/25 at 4:56 p.m., showed at 11:30 a.m., Resident #58 was observed in the hallway, walking quickly, and hollering out loud to staff. The note showed the resident proceeded to a housekeeper inquiring about where the tissue box in their room was at. The note showed just prior to the resident's encounter with the housekeeper, the housekeeping staff alerted nursing staff about a tissue box that contained what appeared to be a broken glass pipe with a white substance in it. The note showed the tissue box also contained a piece of foil, scissors, and a standard light bulb with a burned area on top of it. The note showed administration was made aware and was given paraphernalia with what appeared to be an illicit drug substance. A quarterly assessment, dated 06/17/25, showed Resident #58's cognition was moderately impaired with a BIMS score of 09. The assessment showed the resident was independent with activities of daily living. The assessment showed the resident had a diagnosis of cirrhosis of the liver. A care plan, dated 06/18/25, showed no goals or interventions related to illicit substance use.A Discharge summary, dated [DATE], showed resident discharged from the facility due to death while on hospice services.On 09/29/25 at 9:48 a.m., the ADON reported no incident report was done related to drug paraphernalia. The ADON reported the drug paraphernalia was taken from the resident, and police were not contacted.On 09/29/25 at 3:44 p.m., the MDS Coordinator reported Resident #58's care plan should have included substance abuse after drug paraphernalia was found in the resident's room.

Based on record review and interview, it was determined the facility failed to ensure resident assessments accurately reflected the current status for 1 (#10) of 5 sampled residents reviewed for assessments. The DON identified 52 residents resided in facility. Findings: A facility policy titled MDS Completion and Submission Timeframes, revised date July 2017, read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. A significant change assessment, dated 08/05/25, showed Resident #10 was originally admitted to facility on 10/31/24. The monthly physician's orders, dated 09/01/25, showed current diagnoses included atherosclerotic heart disease, hypokalemia, hypertension, chronic pain, emphysema, type 2 diabetes mellitus, anxiety, sciatica, nicotine dependence, heart failure, hyperlipidemia, stage 3 pressure ulcer of other site, and local infection of the skin and subcutaneous tissue. A progress note from a wound care company, dated 07/24/25, included wound assessments and diagnoses which included:a.) Wound #1, left heel, Chronic stage 3 pressure ulcer acquired on 12/26/24, and b.) Wound #2, right ankle, non-pressure chronic ulcer. A significant change assessment, dated 08/05/25, documented the resident was at risk for pressure ulcers. The assessment did not show a pressure ulcer or a venous ulcer. A care plan was updated with venous ulcer care on 08/19/25. On 09/24/25 at 12:05 p.m., the MDS coordinator was asked to verify Resident #10's assessment did not include a pressure ulcer or venous ulcer. The MDS coordinator stated it was checked as a diabetic foot ulcer.

Based on observation, record review, and interview, the facility failed to provide a warm and comfortable environment for one (#2) of three residents reviewed for a comfortable and homelike environment. The administrator reported 40 residents resided in the facility. Findings: A Safe and Homelike Environment policy, dated 2023, documented in part, .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .Comfortable and safe temperature levels .comfortable for the residents .If and when a resident prefers his or her room temperature be kept below 71 degrees .or above 81 degrees .the facility will assess the safety of this practice on the resident . Resident #2 had diagnoses which included cellulitis bilateral lower limbs, diabetes, chronic pain, osteoarthritis, polyneuropathy, and coronary artery disease. On 10/22/24 at 10:56 a.m., Resident #2 reported their room was too cold and had been for a long time. The resident stated they understood their medical conditions caused poor circulation, resulting in them being colder than normal, but would like their room to be warmer. The resident was observed to have a digital thermostat in their room that read 74 degrees at that time. The resident stated they currently had a blanket covering the air vent on the floor because the vent wouldn't close. The resident stated staff encouraged them to use more blankets to stay warm but stated this was uncomfortable on their legs. On 10/22/24 at 11:32 a.m., the administrator stated they had not been at the facility long but would check to see what had been done to make the resident's room warmer. On 10/22/24 at 11:55 a.m., the Ombudsman reported they had talked with Resident #2 and the previous administrator many times regarding their room being too cold. The Ombudsman stated he was aware staff encouraged the resident to use more blankets but this was uncomfortable for the resident. On 10/22/24 at 12:50 p.m., maintenance staff was observed to have a replacement air vent for Resident #2's room. Maintenance reported the old vent was completely covered with a blanket and boxes stacked on top, so they didn't think much air had been coming from the vent. On 10/23/24 at 12:15 p.m., the administrator reported Resident #2 had been offered a different room on several occasions but they had refused to change rooms. The administrator reported they would follow up with Resident #2 to see if there was improvement in the room temperature after the air vent was replaced, and would look into other options to make the room warmer for the resident.

Based on record review and interview, the facility failed to review and revise care plans, and to include the resident or their representative in care plan meetings, for one (#2) of three residents reviewed for care plans. The administrator reported 40 residents resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, dated December 2016, documented in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The IDT includes .The resident and the resident's legal representative (to the extent practicable) .Participate in the planning process .Request meetings .Request revisions to the plan of care . Resident #2 had diagnoses which included cellulitis bilateral lower limbs, diabetes, chronic pain, osteoarthritis, polyneuropathy, and coronary artery disease. A care plan for Resident #2, dated 03/31/23, documented in part, .therapy will evaluate and treat as per orders from MD .Please see therapy individualized care plan for specific therapy goal and interventions .Role(s) - Restorative Nursing Assistant, Therapy . The care plan was not updated to indicate restorative therapy was not available. An occupational therapy progress note, dated 09/13/24, documented, Resident approached to discuss participating in Part B service for Physical therapy, due to his 6 month check since last therapy discharge. Resident adamantly declined stating, I have other stuff in the works with the VA for exercise. Acting DON notified of refusal of evaluation. EDU provided and he verbalizes understanding. On 10/22/24 at 10:56 a.m., Resident #2 reported they didn't have a care plan, or at least not an official care plan. The resident reported they didn't remember the last time they were included in a care plan meeting. The resident reported they had restorative therapy in the past and would like to have this service again. The resident stated they had told facility staff they wanted restorative therapy. An updated care plan for Resident #2, dated 10/22/24, did not address the resident's request to have restorative therapy. On 10/22/24 at 11:32 a.m., the administrator reported the facility did not have a restorative program and this service was not available to the residents. The administrator reported they had not been at the facility long, and reported they had not been having care plan meetings. The administrator stated they didn't know when care plan meetings had last been conducted and was not aware of any currently being scheduled.

Based on observation, interview, and record review, the facility failed to provide showers as scheduled and/or requested for two (#1 and #3) of three residents reviewed for assistance with bathing and hygiene. The administrator reported 40 residents resided in the facility. Findings: An Activities of Daily Living (ADLs), Supporting policy, dated March 2018, documented in part, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with .hygiene (bathing, dressing, grooming, and oral care) . 1. On 10/22/24 at 2:05 p.m., Resident #1 was observed in their room lying in bed. The resident was observed to have facial hair and needed a shave. The resident was not sure when they had last had a shower or bath. Resident #1's Shower Sheets were reviewed for 09/11/24 through 10/17/24. The forms documented the resident refused a shower on 09/11, 09/13, 09/20, 09/23, and 09/25/24. The forms documented the resident received a shower on 09/16, 09/18, 09/27, 09/30, 10/08, 10/10, and 10/17/24. There were no shower sheets provided for 10/18/24 through 10/22/24. 2. On 10/22/24 at 12:35 p.m., Resident #3 reported they were not getting showers as scheduled. The resident reported they were supposed to get a shower on Monday, Wednesday, and Friday. The resident reported they were given a shower the previous day but not as scheduled the previous week. The resident stated sometimes the facility had an extra shower aide but often they would get pulled from giving showers to work the floor. Resident #3's Shower Sheets were reviewed for 09/11/24 through 10/16/24. The forms documented the resident received a shower on 09/11, 09/13, 09/16, 09/18, 09/20, 09/23, 09/25, 09/27, 09/30, 10/02, 10/09, 10/11, 10/14, and 10/16. The forms documented the resident refused a shower on 10/04. There were no shower sheets provided for 10/17 through 10/22/24. On 10/22/24 at 11:28 a.m., CNA #1 reported the CNAs filled out a Shower Sheet every time they gave a bath or shower. The CNA stated they gave the forms to the charge nurse for review, and the charge nurse then gave them to the DON for review. On 10/22/24 at 2:49 p.m., CNA #2 reported staffing was usually adequate for the resident census. The CNA stated the aides assisted each other as needed to provide appropriate care for the residents. On 10/23/24 at 12:10 p.m., the administrator reported the CNAs should also be documenting showers and/or baths on the EMR, but showers should be given per the resident's care plan or as requested.

Based on record review and interview, the facility failed to ensure blood work was obtained per physician orders for two (#7 and #11) of five residents reviewed for unnecessary meds. The corporate RN consultant reported 41 residents resided in the facility. Findings: The facility's Lab and Diagnostic Test Results-Clinical Protocol policy, read in part The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests . 1. Res #7 had diagnoses which included diabetes mellitus, anemia, and non-traumatic brain dysfunction. Res #7's physician orders, dated 06/01/24, read in part Order date 08/17/23: HGBA1C every 3 months in August, November, February, May. CBC, CMP every 6 months in August and February . A comprehensive assessment, dated 06/03/24 documented Res #7's cognition was not scored due to inability to verbalize. The assessment documented the resident was dependent on staff for activities of daily living. Res #7's clinical record documented no labwork results for February 2024. On 06/27/24 at 9:25 a.m., Corporate RN consultant reported resident #7's lab work (CBC, CMP, and HGBA1C) ordered for February 2024 had not been obtained. The Corporate RN consultant reported the facility had failed to order the lab work. 2. Res # 11 had diagnoses which included end stage renal failure, diabetes mellitus, anemia and hypothyroidism. Res #11's physician orders, dated 06/01/24, read in part Order date 02/03/23: TSH lab work yearly in April. CMP and CBC lab work every 6 months in April and October . A comprehensive assessment, dated 04/23/24, documented resident #11's cognition was intact and received dialysis services. The assessment documented dependent on staff for most activities of daily living. Res #11's clinical record documented no labwork results for April 2024. On 06/26/24 at 2:16 p.m., Corporate RN consultant reported resident #11's lab work (CBC, CMP, and TSH) ordered for April 2024 had not been obtained. The Corporate RN consultant reported the facility had failed to order the lab work.

Based on record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for three (#20, 29, and #37) of twelve sampled residents reviewed for advanced directives. The corporate RN consultant reported 41 residents resided in the facility. Findings: The facility policy Advance Directives and Do Not Resuscitate Orders not dated, read in part, The Patient Self-Determination Act of 1990 is a federal law that went into effect on December 1, 1991. The legislation was created to ensure the legal right of each competent adult to make his/her own medical decisions. The act mandates Medicare and Medicaid certified nursing facilities to give residents information about their right to make decisions concerning medical care including the right to accept or refuse treatment and the right to formulate advance directives. 1. Res #20 was admitted to the facility on [DATE]. The resident had diagnoses which included unspecified dementia. Res#20's advanced directive acknowledgement form was not completed. Res #20's electronic medical record documented the resident's code status was full code. 2. Res #29 was admitted to the facility on [DATE]. The resident had diagnoses which included generalized anxiety disorder. Res #29's advanced directive acknowledgement form was not completed. 3. Res #37 admitted to the facility on [DATE]. The resident had diagnoses which included chronic kidney disease. Res #37's advanced directive acknowledgement for was not completed. On 06/24/24 at 3:23 p.m., Corporate RN consultant reported Res #37 did not have an advance directive acknowledgement for this resident. On 06/24/24 at 3:25 p.m., Corporate RN consultant reported Res #29 did not have an advance directive acknowledgement on file. On 06/24/24 at 3:27 p.m., Corporate RN consultant reported Res#20 did not have an an advance directive acknowledgement on file.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for three (#11, 23 and #37) of twelve sampled residents reviewed for comprehensive care plans. Findings: The corporate RN consultant reported 41 residents reside in the facility. A Care Plans, Comprehensive Person-Centered policy, read in part, A comprehensive, person centered care plan that includes measurable objective's and timetables to meet the resident's physical, psychological, and functional needs is developed and implemented for each resident. 1. Res #11 had diagnoses which included end stage renal failure. A physician's order, dated 02/03/24, documented to obtain Res #11's weight on Monday, Wednesday, and Friday before going to dialysis. A comprehensive assessment, dated 04/23/24, documented Res #11's cognition to be intact and was dependent on staff for activities of daily living. The assessment documented the resident received dialysis services while a resident. A care plan, dated 05/03/24, documented no care area related to dialysis. On 06/27/24 at 3:02 p.m., MDS coordinator reported dialysis services should be included on Res #11's care plan. 2. Res #23 had diagnoses which included dementia, diabetes mellitus, and hypertension. A physician order, dated 01/17/23, documented Admit to Choice Hospice. A comprehensive assessment, dated 03/19/24, documented the Res #23's cognition was moderately impaired. The assessment documented the resident received hospice services. A care plan, dated 11/27/23, documented no care area related to hospice services. On 06/27/24 at 3:02 p.m., MDS coordinator reported hospice services should be included on Res #23's care plan. 30875 4. Res #37 had diagnosis which included anemia, renal insufficiency, and diabetes mellitus. A physician's orders, dated 05/19/24, documented, suprapubic catheter may use leg band 16 FR/30 CC bulb to urinary drainage bag change as needed for dislodgement sedimentation, catheter care every shift. The comprehensive care plan did not contain any information related to a suprapubic catheter. A physician orders, dated 05/19/24, for Res #37, documented, dialysis every Monday, Wednesday, and Friday. Please send copy of pre dialysis assessment to dialysis appointments. On 06/25/24 at 2:02 p.m., Res #37 sitting in recliner in his room and CNA #1 was asked about Res #37's dialysis. They reported they obtained vital signs and weight, when they leave and when they return back from dialysis. Reported they had a port on the upper chest area. On 06/26/24 at 2:27 p.m., Res #37 returned from dialysis and was eating a sandwich in the dining area. On 06/27/24 at 11:05 a.m., Corporate RN consultant was asked if Res #37 was care planned for a supra pubic catheter and/or dialysis. They reported they had already discussed this with the care plan coordinator to include a plan of care for dialysis and a supra pubic catheter. On 06/26/24 at 2:34 p.m., Corporate RN consultant reported Res #37 did not have a plan of care for dialysis and reported they would expect them to have one. On 06/27/24 at 11:05 a.m., Corporate RN consultant #1 was asked if Res #37 was care planned for a supra pubic catheter and/or dialysis. They reported they had already discussed this with the care plan coordinator to include a plan of care for dialysis and a supra pubic catheter. On 06/27/24 at 3:02 p.m., MDS coordinator reported suprapubic catheter and dialysis would be included on the plan of care. They stated they were completing one for Res #37 right now.

Based on record review and interview, the facility failed to ensure medication regimen reviews conducted by the pharmacist were acted on for two (#15 and #21) of five residents reviewed for unnecessary meds. The corporate RN consultant reported 41 residents resided in the facility. Findings: The facility's Medication Regimen Reviews policy, dated 05/01/23, read in part The Consultant Pharmacist performs a medication regimen review for every resident in the facility receiving medication .The medication regimen review involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities .The attending physician documents in the medical record that the irregularity has been reviewed and what action was taken to address it. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent record . 1. Res #15 had diagnoses which included depression, seizure disorder, and psychotic disorder. Res #15's physician orders, dated 03/01/24, documented the following medications: hydroxyzine hcl 50 mg 1 daily, Zoloft 100 mg 1 daily, trazodone 100 mg 1 at bedtime, haloperidol 5 mg 1 twice a day, and Haldol Deconoate 100 mg/ml 1 ml intramuscular every month. A pharmacist medication regimen review, dated 03/05/24, documented the pharmacist recommended the following psychotropic medications has/have been ordered and in place routinely for greater than or approaching 12 months without a gradual dose reduction. Please consider, if appropriate, such a reduction of one of these agents: hydroxyzine 50 mg daily, Haldol 5 mg twice daily, Haldol 100 mg intramuscular monthly. The medication regimen review documented no physician or facility response. A comprehensive assessment, dated 05/09/24, documented cognition was intact and no mood behaviors exhibited. The assessment documented antipsychotic, antidepressant, and hypnotic medication use. 2. Res #21 had diagnoses which included anxiety and depression,. A pharmacist medication regimen review, dated 03/05/24, documented a pharmacist recommendation, consider a dose reduction of one of the following: venlafaxine ER 75 mg daily, buspirone 5 mg twice daily. The medication regimen review documented no physician response or facility acknowledgement. Res #21's medical record documented an inpatient psych hospital stay 04/03/24 through 05/02/24. A comprehensive assessment, dated 05/07/24, documented cognition was intact and no mood behaviors exhibited. The assessment documented antianxiety, antidepressant, and hypnotic medication use. Res #21's physician orders, dated 06/01/24, documented the following medications: venlafaxine ER 75 mg 1 daily, buspirone 5 mg 1 twice a day, and trazodone 50 mg 1 at bedtime. On 06/27/24 at 2:10 p.m., Corporate RN consultant reported the medication regimen review, dated 03/05/24, for resident #15 had not been acted on by the physician or facility. The Corporate RN consultant reported the medication regimen review, dated 05/07/24, for Res #21 had not been acted on by the facility. The Corporate RN consultant reported the above medication regimen reviews were not found in the residents' medical records.

Based on record review and interview, the facility failed to ensure the medication was necessary to treat a specific condition indicated in the clinical record and failed to ensure an as needed psychotropic medication was limited to 14 days for one (#20) of five residents reviewed for unnecessary medications. The corporate RN consultant reported 41 residents resided in the facility. Findings: The facility's Medication Regimen Reviews policy, dated 05/01/23, read in part The Consultant Pharmacist performs a medication regimen review for every resident in the facility receiving medication .The medication regimen review involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities. A physician order, dated May 2024, for Res #20, documented, Lorazepam 1 mg tablet give 1 tablet per peg every 6 hours as needed for anxiety. Res #20's diagnosis included unspecified dementia, depression, unspecified, and essential hypertension. The Res # 20 did not have a diagnosis of anxiety. On 06/28/24 at 9:50 a.m., MDS coordinator was asked if the MDS dated [DATE] included a diagnosis of anxiety. They stated they did not see one on there. They were asked if they would expect the Res #20 to have a diagnosis of anxiety if they received anti-anxiety medication. They stated they would expect them to have that diagnosis. On 06/28/24 at 10:10 a.m., Corporate RN consultant stated Lorazepam was ordered on 03/26/24 and Res #20 had not received any in June 2024, but they knew you could not have a PRN order over 14 days.

Based on observation, record review, and interview, the facility failed to ensure the medication rate less than 5%. A total of 25 opportunities were observed with two errors. The total medication error rate was 8%. The corporate RN consultant reported 41 residents reside in the facility. Findings: A Medication and Treatment Orders, policy, dated 07/2023, read in part, Orders for medications and treatments will be consistent with principles of safe and effective order writing. A medication pass was conducted on 06/27/24 at 9:03 a.m., with ACMA #1. They administered one Clonidine 0.2 mg tablet to Res #35. They were asked if they already checked the blood pressure. They reported it was not required and their blood pressure ran pretty high and they had discontinued the blood pressure. A physician orders, dated June 2024, for Res #35 documented, Clonidine 0.2 mg tablet give one tablet by mouth twice daily hold if BP less than 100/60 and or pulse is less than 60 for Hypertension .Glipizide 5 mg two tabs to equal 10 mg by mouth daily. The pharmacy card read to administer the medication 30 minutes before breakfast and ACMA #1 reported they did not give them the Glipizide 30 minutes before breakfast. On 06/27/24 at 10:20 a.m., Corporate RN consultant was asked about Res #35's blood pressure. They reported they should have checked the blood pressure and the order should have been ordered separately, so there would be an order to record the blood pressure. They were asked about the discrepancy between the pharmacy card and physician's orders. They reported the original order documented to administer the Glipizide 30 minutes before breakfast and during the transcription of the order that part was left off.

Based on observation, record review, and interview, the facility failed to ensure staff was alerted to implement enhanced barrier precautions for three (#7, 20, and #37) of five sampled residents reviewed enhanced barrier precautions. The Corporate RN consultant reported 41 residents resided in the facility. Findings: 1. Res #7 had diagnoses which included non-traumatic brain dysfunction. Res #7's physician order, dated 10/19/23, read in part Bolus feed - Jevity 1.2 give 237 ml via peg tube .Feed 6 times a day to gravity for meal replacement . A comprehensive assessment, dated 06/03/24 documented Res #7's cognition was not scored due to inability to verbalize. The assessment documented the Res #7 was dependent on staff for activities of daily living and received tube feeding services. On 06/24/24 at 2:19 p.m., Res #7 was observed in bed, peg tube in place, no PPE supplies or enhanced barrier precautions signage in place. On 06/24/24 at 10:06 a.m., Corporate RN reported there was no EBP in the facility, but there probably should be enhanced barrier precautions in place. On 06/26/24 at 11:59 a.m., LPN# 3 was observed using full PPE to perform Res #7's tube feeding. The LPN #3 reported the nurses received training on 06/25/24 related to enhanced barrier precautions and had just started using full PPE during tube feedings and care. The LPN #3 reported no enhanced barrier precautions had been in place until 06/25/24. 30875 2. An admission assessment, for Res #20, dated 03/29/24, documented no upper or lower impairment with moderate cognitive impairment. A care plan, dated 03/29/24, for Res #20, documented, nutritional intake: peg tube for only source of nutrition and fluids, IS NPO. Maintain in an upright position for a specified time after each feedings. A physician order, dated June 2024, documented, Jevity 1.5 cal give 8 ounces via peg five times daily to check residual every five hours before feeding. Flush peg with 30 ml water prior to and after administration of meds. Give 120 ml free water every 4 hours. NPO (nothing by mouth). On 06/24/24 at 10:06 a.m., Corporate RN reported there was no EBP in the facility, but there probably should be enhanced barrier precautions in place. On 06/25/24 at 09:28 a.m., Res #20 has Jevity 1.5 at bedside with syringe dated 06/25/24. No enhanced barrier precautions sign was posted on the door. On 06/26/24 at 10:48 a.m., EBP sign was posted on Res #20's door today and a container with PPE was located outside of the resident's door on the second day of survey. 3. Resident #37 had diagnosis which included anemia, renal insufficiency, and diabetes mellitus. An admission assessment, dated 05/30/24, documented, Res #37 with a moderate cognitive impairment and an indwelling cath in place. A care plan, dated 06/05/24, documented an indwelling catheter. A physician's orders, dated 05/19/24, suprapubic catheter may use leg band 16 FR/30 CC bulb to urinary drainage bag change as needed for dislodgement sedimentation. Catheter care every shift. On 06/25/24 at 09:19 a.m., indwelling catheter to gravity. The door was not marked for enhanced barrier precautions. On 06/25/24 at 01:45 p.m., CMA #2 obtained BP from Resident #19 and then entered Resident #37's room to take his blood pressure with the same blood pressure cuff. They were asked if they sanitized the BP cuff they stated, No,they did not, but they reported they had purple wipes in the medication cart. They pulled the wipes out and sanitized the cuff. On 06/25/24 at 02:02 p.m., Resident #37 sitting in recliner in his room and CNA #1 washed hands and donned gloves and emptied Res 37's catheter. There was 180 milliliters of yellow colored urine measured in the urinal. They removed the gloves and sanitized hands. They were asked if they had training for EBP. They reported they were not familiar with that and had not received training to wear a gown when emptying the indwelling catheter. On 06/26/24 at 02:23 p.m., CNA #1 was asked when the PPE was placed outside of Res #37's door. They reported this morning. They were asked if they received in-service related to EBP. They reported they were in-serviced yesterday.

Based on record review and interview, the facility failed to refer a resident with a newly evident or possible serious mental illness to the OHCA for a level II PASRR evaluation for one (#23) of two sampled residents reviewed for PASARR. The corporate RN consultant reported 41 residents resided in the facility. Findings: Res #23 had diagnoses which included dementia, anxiety, depression, psychotic disorder, and schizoaffective disorder. A level I PASRR, dated 07/14/22, documented Res #23 had a primary diagnosis dementia with behavioral disturbances. The PASARR documented no evidence or diagnosis of a serious mental illness. A comprehensive assessment, dated 03/19/14, documented Res #23 had moderate cognitive impairment. The assessment documented the resident had active diagnoses to include dementia, anxiety, depression, psychotic disorder, and schizoaffective disorder. Res #23's physician's order, dated 06/01/24, documented the following medications and orders: 01/17/23 Millennium Mental Health Evaluate and treat. 04/22/24 Melatonin 3 for dementia with behavioral disturbance. 06/20/23 Buspirone HCL 10 mg for anxiety. 12/13/23 Lorazepam 0.5 mg for anxiety 0/28/23 Zoloft 50 mg for depression 01/17/23 Trazodone HCL 100 mg for depression. 07/31/23 Risperdal 2 mg for schizoaffective disorder. 12/31/23 Hydroxyzine HCL 25 mg prn for anxiety. There was no documentation the resident had been referred to the OHCA for a level II PASRR evaluation. On 06/26/24 at 10:25 am., Corporate RN consultant reported resident #23's PASARR had not been reevaluated with the diagnoses of anxiety, depression, or schizoaffective disorder. The corporate RN consultant reported these diagnoses were not included on the PASARR dated 07/14/22 and the resident should have been rescreened for need of a level II services.

Based on record review and interview, the facility failed to ensure accurate coding of a MDS assessment for one (#29) of one sampled resident related to a discharge to the hospital after a reportable fall. The corporate RN consultant reported 41 residents resided in the facility. Findings: A quarterly assessment, dated 04/30/24, documented no upper or lower impairment and independent with transfers. A nurse's note, dated 05/28/24, for Res #29, documented, resident fell in bathroom from toilet. Mobile x-ray confirmed left femur femoral neck fracture. Physician notified. Resident transferred to hospital. A State reportable, dated 05/28/24, documented, self transferring and fell x-ray of left hip acute femoral neck fracture. A nurse's note, dated 05/31/24, read Res #29 returned to facility from hospital per facility van. Alert and oriented x2, cheerful and cooperative, dressing to left hip. On 06/28/24 at 10:50 a.m., MDS coordinator confirmed the MDS assessment recorded Res #29 was discharged on [DATE] and returned to the facility on [DATE] from a fall and a fracture. On 06/28/24 at 11:07 a.m., MDS coordinator reviewed MDS assessment, they reported they made an error and entered the wrong date and the resident had discharged on [DATE] and returned to the facility on [DATE] to skilled services.

Based on observation, record review, and interview, the facility failed to provide bathing as outlined in their care for one (#6) of one sampled resident reviewed for bathing assistance. The corporate RN reported 41 residents resided in the facility. Findings: Res #6 diagnosis included debility, cardiorespiratory conditions, heart failure and depression. An assessment, dated 06/04/24, for Res #6, documented impairment on both sides and required substantial max dependence for ADL's. On 06/24/24 at 1:53 p.m., Res #6 voiced no complaints, there was a smell of body odor in the room; however, resident reported they received their showers. On 06/27/24 at 3:37 p.m., Corporate RN consultant submitted the shower sheets for resident #6 and reported they had a designated person who did the showers and they may or may not have filled out the ADL book. After they submitted the sheets, they agreed there were still blanks because Res #6 was supposed to be showered on Monday, Wednesday, and Friday and they were not. A shower list, not dated, documented Res #6 showered on Monday, Wednesday, and Friday. An ADL list, dated June 2024, for Res #6, documented, bathing: S-Shower, BB-bed bath, N-not bath day. The sheet documented five days as a S and one day as a R, and 21 days were marked as N out of 27 opportunities for the month of June.

Based on record review and interview, the facility failed to ensure a resident's care plan was reviewed and revised for one (#15) of 12 residents reviewed for care plans. The RN consultant reported 41 residents resided in the facility. Findings: The facility's Care Plans, Comprehensive Person-Centered policy, read in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Res #15 had diagnoses which included depression, seizure disorder, and psychotic disorder. A care plan, dated 05/18/23, read in part Antidepressant medication use: At risk for side effects .Antipsychotic drug use: At risk for side effects .Seizure disorder: At risk for side effects . The care plan documented the last date revised was 06/13/23 and last reviewed on 08/18/23. Res #15's clinical record documented an inpatient psych hospital admission from 04/03/24 through 05/02/24. A comprehensive assessment, dated 05/09/24, documented cognition was intact and no mood behaviors. The assessment documented antipsychotic, antidepressant, and hypnotic medication use. Res #15's physician orders, dated 06/01/24, documented Seroquel XR 150 mg, Zoloft 100 mg, Trintellix 10 mg, Melatonin 3 mg, Keppra 500 mg, Namenda 10 mg, Rozerem 8 mg, and Vraylar 3 mg. On 06/27/24 at 11:20 a.m., the RN consultant reported care plans had been an issue and the new MDS nurse was working on getting them updated. The RN consultant reported the resident's care plan should have been revised with the last comprehensive assessment.

Based on interview and record review, it was determined the facility failed to provide care and services to prevent a pressure ulcer for one (#5) of 3 residents whose records were reviewed for skin breakdown. The facility identified 32 residents who lived in the facility. Findings: The clinical record for resident #5 documented the resident was admitted on [DATE] from the hospital to the facility. The record documented the resident had [DIAGNOSES REDACTED]. Hospital discharge records documented the resident had zero skin breakdown. The facility admitting note, dated 05/01/20, documented the resident had zero skin breakdown. The resident record documented the resident was admitted for PT/OT/Speech Therapy. An initial assessment, dated 05/01/20, documented the resident's cognition was intact and the resident needed extensive help with transfer and repositioning. The assessment documented under Skin and Ulcer/Injury Treatments: a check mark by Turning/repositioning program. A Pressure Ulcer Risk Evaluation, dated 05/02/20, documented a total score of 15 (Total score of 8 or above represents HIGH RISK). The clinical record contained no careplan, activities of daily living records, treatment administration records, or medication administration records. SNN from 05/01/20 at 2130 to 05/04/20 at 2000, documented the resident had been repositioned two times out of a possible 35 times. The note documented Peri-care one time. There was no SNN for 05/02/20. There was no SNN for 05/05/20. A SNN, dated 05/07/20 at 1530, documented the resident had two small open areas to the inner R and L buttocks, lantaseptic applied, and resident repositioned. A SNN, dated 05/08/20 at 1400, documented the resident's coccyx had the top layer of skin sheered off. The note documented a new order for [MEDICATION NAME] to be applied every shift till healed. There was no documentation of repositioning. A physician's telephone order, dated 05/08/20, documented a new order for [MEDICATION NAME] to the coccyx. The order documented a diagnosis (DX) of Breakdown. A SNN, dated 05/09/20, contained no documentation. The note contained no repositioning or wound care documented. A SNN, dated 05/10/20, contained no documentation of wound care or repositioning. A SNN, dated 05/11/20 at 1800 to 2100, documented a physician order [REDACTED]. No documentation of wound care or repositioning was documented. A SNN, dated 05/12/20 at 2300, contained no documentation of wound care or repositioning. A SNN, dated 05/13/20 at 2315, contained no documentation of wound care or repositioning. A SNN, dated 05/14/20 at 2250, documented coccyx shearing and TX done with good results. The note documented incontinent care was done every two hours and as needed. A SNN, dated 05/15/20 at 1030 and 2145, contained no documentation of wound care or peri-care provision by staff per episode. The note contained no documentation of repositioning. A SNN, dated 05/16/20 at 1150 and 2310, contained no documentation of wound care. A SNN, dated 05/17/20 at 1545 and 2130, contained no documentation of wound care. A SNN, dated 05/18/20 at 1745 and 2010, contained no documentation of wound care. A SNN, dated 05/19/20 at 1800 and 2315, contained no documentation of wound care. A SNN, dated 05/20/20 at 1800 and 2115, contained no documentation of wound care. A SNN, dated 05/21/20 at 1500 and 2245, contained no documentation of wound care, no documentation of peri care, or no documentation of repositioning. A SNN, dated 05/22/20 at 1000, contained no documentation of wound care or repositioning. A physician's telephone order, dated 05/22/20, documented to clean the wound with wound cleanser and apply zeroform dressing to the coccyx daily. The order documented to refer to wound care. A SNN, dated 05/23/20 at 230 and 2145 documented, a 4.0 cm black area on the coccyx, dressed with Zeroform, and repositioned when incontinent care was given. A SNN, dated 05/24/20 at 100, documented the resident was repositioned every two hours; Coccyx dressing to area; repositioned when care is given; and Coccyx dressing changed and in place. A SNN, 05/25/20 at 1730, documented wound care to coccyx and cleansed with NS pad; dry; lantaseptic; foam dressing; wound 50 cent size; necrotic tissue to wound; foul odor; brownish yellow drainage mod. amount to dressing; and aides to turn and reposition every 2 hours while in bed. A SNN 05/26/20 at 1400, documented dressing to coccyx changed; cleansed with NS to sacral dressing applied; wound 1.3 cm depth, 5 cm L, and 2.5 cm NW; wound bed with necrotic tissue; foul odor; and brownish yellow drainage note to dressing. The note documented the Dr. was notified via phone; would be at the facility the following day to see resident; and would instruct on wound care. The note documented the resident was turned and repositioned. A weight record for the resident contained no documentation. The facility provided the surveyor with a typed report documenting the resident's admit weight was 122 and her discharge weight was 122. A physician's progress note, dated 05/27/20, documented the nurse reported the patient had a necrotic buttock wound at that time. The note documented the patient's family was moving her to another facility the next date. A Focused Wound Exam by the wound care Dr. documented unstageable necrosis; wound size 5.5 X 3 X 0.1 cm; and surface area 16.50 C; and necrotic tissue 90%. The form documented the wound was in an [MEDICAL CONDITION] stage and was unable to progress to a healing phase; the resident was sent to the ER for the wound to be debrided; and after the hospital stay the resident was sent to another facility. A discharge summary form documented a summary of resident's stay; shearing to the coccyx; treatment given; and no documentation of a necrotic wound. A hospital record, dated 06/03/20 and labeled late entry, documented admission Diagnosis: [REDACTED]. On 11/13/20 at 1:30 p.m., the administrator was asked about the turning/repositioning program. She reported residents were to be repositioned every 2 hours. She reported the facility had no policy for it, but she would look. On 11/13/20 at 1:52 p.m., Dr. (name deleted) via a phone call reported he had ordered the [MEDICATION NAME] and Xeroform dressing with a referral to wound care. He stated his NP was notified on 05/27/20 of a necrotic wound. On 11/13/20 at 2:45 p.m., the ADON via a telephone call, stated the resident could not turn herself and she had to have help from staff. She reported the [MEDICATION NAME] never helped, the ulcer continued to get worse, so she called the Dr. on 05/22/20 for another order. The ADON stated she did not know why someone waited four days to call the wound care Dr. On 11/14/20 at 12:57 p.m., the wound care Dr. stated she was called on 05/26/20 and notified of a black wound, opened with heavy drainage, and a foul odor. She stated she told the facility she would come the next morning to look at it. The wound care Dr. stated she saw the resident the morning of the 27th and knew the resident had to be sent to the hospital. She stated she called the resident's primary Dr. and the resident's daughter to get them involved to make sure where she (the resident) was being sent after the hospital was aware of the situation. On 11/16/20 at 3:30 p.m., the administrator was made aware of the above findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure all allegations of abuse were reported and thoroughly investigated, to prevent further abuse, for six residents (#1, #2, #3, #4, #5 and #6) of six sampled residents reviewed for abuse. Appropriate interventions were not implemented to prevent recurrence of resident to resident abuse and staff members failed to immediately report alleged verbal and physical abuse. Findings: The facility Abuse Policy and Procedure documented all allegations of maltreatment, including neglect, physical abuse, mental abuse, and verbal abuse would be reported immediately to the administrator by a facility employee or immediate supervisor. The policy documented the administrator or designee would conduct an immediate investigation of all alleged or actual incidents of abuse. The policy documented the director of nursing or designee would be responsible for assessing the victim and would document findings, including the lack of abnormal findings, if helpful, in the medical record. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 05/29/20, documented the resident was independent with activities of daily living. The care plan documented the resident was prescribed an anticoagulant (blood thinner) and was at risk for bleeding. An incident report, dated 07/10/20 at 10:00 p.m., documented the resident was sitting in the hallway in her wheelchair when resident #4 came up to the resident, grabbed her by the head, and began pulling her hair and jerking her head back and forth. The report documented, CNA told her to stop and she did. The report documented steps taken to prevent recurrence, Resident taken to room. Was told to stay in room. On 07/13/20 at 9:45 a.m., the resident reported there was an incident the night of 07/10/20 when resident #4 hit her on the back of her head and pulled her hair. The resident expressed concern that she is on blood thinners and could have been badly hurt. The resident stated the incident happened in the hallway near her room and she was now considering moving to a different facility where she would feel safer. The resident reported the DON was present when the incident happened and told her to stay in her room away from resident #4. On 07/17/20 at 12:30 p.m., the resident reported she was still considering a transfer to a different facility. The resident stated she usually wouldn't go past the nurse's station in order to avoid resident #4. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 02/22/20, documented the resident could get upset at times and become violent. Interventions included offering the resident something to eat or taking the resident on a walk one on one. The care plan documented the resident was independent with most activities of daily living. An incident report, dated 02/29/20, documented the resident slapped resident #6 on the back of the head twice. The report documented resident #4 would be placed on 1:1 monitoring for behaviors. One on one monitoring sheets were provided for the dates of 03/09, 03/10, and 03/11/20. There was no documentation of 1:1 monitoring started on 02/29/20. On 07/10/20 at 5:30 p.m., the resident was not observed in her room. Staff reported the resident might be in the dining room or walking around the facility. An incident report, dated 07/10/20 at 10:00 p.m., documented the resident grabbed resident #1 by her hair and was shaking her head back and forth. The report did not document any steps taken to prevent recurrence. An OSDH incident report form, dated 07/10/20, documented, Care plan in place. 1:1 monitoring for resident safety. The DON was questioned regarding 1:1 monitoring related to the incident on 07/10/20. The DON reported there was no documentation and could not verify the monitoring was implemented. On 07/13/20 at 10:10 a.m., the resident was observed alone in her room. The surveyor attempted to interview the resident. An unidentified staff member walked by and advised the surveyor to keep a good distance from the resident, stating she might get you. On 07/13/20 at 2:15 p.m., CNA #2 reported one of the new aides had been attacked by the resident and did not return to work. The CNA reported there had been no training provided related to caring for psychiatric residents. When asked about resident to resident abuse, the CNA stated, I don't think everything is being reported. On 07/13/20 at 2:30 p.m., the DON reported the resident had acted up a lot when she first came to the facility but her behaviors had improved. The DON was asked if she observed the incident with resident #1 on 07/10/20. She stated she was working the floor that evening and resident #4 tore up the nurse's station and was walking the hall. The DON reported she told resident #1 to go to her room to avoid resident #4 but she didn't. She then heard resident #1 screaming and saw that resident #4 had her by the hair. The DON stated CNA #2 told the resident to let go and she did. The DON stated, I told her she should have gone to her room. The DON did not report any interventions and could not provide documentation of interventions implemented to prevent recurrence. 3. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, updated 01/09/20, documented the resident was at risk for falls, walked without a walker, and often wandered from room to room and in the halls. An incident report, dated 02/29/20, documented the resident was slapped on the back of the head twice by resident #4. The report documented the residents were separated. A skin audit record, dated 02/29/20, documented no injury or bruising. A quarterly assessment, dated 04/09/20, documented the resident was severely impaired with cognition. On 07/17/20 at 1:25 p.m., the resident was observed sitting in her room after lunch. The resident was noted to be pleasantly confused and unable to interview regarding incidents involving resident to resident abuse. 4. Resident #2 was admitted to the facility on [DATE] with delusional disorders, [MEDICAL CONDITION], and [MEDICAL CONDITION]. An admission assessment, dated 04/29/20, documented the resident was moderately impaired with cognition. The assessment documented behaviors related to rejection of care and the resident required extensive assistance with most activities of daily living. A care plan, dated 05/10/20, documented the resident exhibited combative and verbally abuse behavior. An incident report, dated 07/02/20, documented an allegation of abuse/mistreatment. The report documented the ADM was informed by an APS worker that on 06/25/20, LPN #1 and CNA #4 were verbally abusive to the resident. An investigation was completed and the report documented four employees stated they had witnessed the LPN and CNA to be verbally abusive toward residents. The report documented resident interviews were conducted and residents reported hearing and witnessing verbal abuse by the two employees. A signed statement, dated 07/06/20, documented CMA #2 reported hearing LPN #1 make verbally abusive comments directed toward the resident. The statement documented the DON was in the facility at the time of the incident. A signed statement, dated 07/06/20, documented dietary staff #1 reported having witnessed LPN #1 to be physically and verbally abusive toward a resident. On 07/10/20 at 5:30 p.m., ADM #1 reported he was first notified of the 06/25/20 incident on 07/02/20 when informed by an APS worker. The ADM stated he started an investigation and reported the alleged abuse as soon as he was made aware, then inserviced employees on 07/06/20 (four days later). The ADM reported the incident occurred prior to him working at the facility and he did not know if the incident was reported to anyone at the time it happened. The DON reported she was not aware of the incident until an APS worker came to the facility to investigate. On 07/13/20 at 12:45 p.m., an anonymous aide reported other residents were on the hall when the incident happened on 06/25/20. The aide reported that although the resident might not comprehend what was being said, other residents did witness the verbal abuse. The aide stated she did not report the incident because the charge nurse was involved and she thought the DON was in the facility at the time. On 07/13/20 at 1:00 p.m., the resident was observed in his room with an aide assisting with lunch. The surveyor attempted to speak with the resident but he became agitated, yelling, threatening to throw his food and drink. The surveyor left the room to allow the resident to calm down. On 07/13/20 at 1:50 p.m., CNA #1 reported she witnessed the incident on 06/25/20. She stated LPN #1 told EMSA staff she didn't want the resident back and CNA #4 refused to assist with care for the resident. She stated she did not report the incident because the charge nurse was involved. 5. Resident #5 was admitted to the facility on [DATE]. The resident's care plan documented the resident was his own person and could make his own decisions. The care plan documented the resident had episodes of agitation at times. An OSDH incident report form, dated 05/19/20, documented an allegation of abuse/mistreatment involving LPN #1 and verbal abuse of the resident. An inservice education report, dated 05/29/20, documented ADM #2 counseled LPN #1 on tone of voice, talking to residents, resident rights, and yelling. There was no documentation to indicate other employees were inserviced regarding allegations of abuse. A facility investigative report for abuse and neglect (related to another resident), dated 07/06/20, documented the resident reported a staff member told him he couldn't make a phone call. The report documented the resident stated, .took the phone away from me and tap the top of my head with the phone and hung phone up. There was no documentation to indicate this particular allegation was investigated. On 07/13/20 at 1:50 p.m., CNA #1 reported she had witnessed LPN #1 take a telephone away from the resident. The CNA stated the LPN was mean and hateful to the resident. The CNA stated she reported the incident to the DON. On 07/13/20 at 2:20 p.m., the DON reported she was present when the phone incident occurred. The DON stated the resident had been at the nurse's station numerous times wanting to call his girlfriend. The DON stated the LPN told the resident loudly he would have to wait. The DON stated the resident is hard of hearing and she thought the LPN was misunderstood, but did not remember the allegation of the LPN hitting the resident with the phone. On 07/13/20 at 4:00 p.m., the resident was interviewed in his room. The resident reported he couldn't remember the exact date but LPN #1 took the phone out of his hand and hit me on the head with it. The resident stated the nurse told him he wasn't allowed to use the phone. On 07/13/20 at 4:10 p.m., CNA #1 was questioned again regarding the incident involving the resident. The CNA was asked if she witnessed the nurse hit the resident on the head with the phone. She stated the nurse did not hit the resident but she was mean and hateful to him. On 07/13/20 at 4:15 p.m., the ADM and DON were interviewed regarding incident reports and reporting of abuse allegations. The ADM reported the phone incident happened before he came to the facility but he remembered it being mentioned during a separate investigation involving LPN #1 and another staff member. Neither the DON or ADM knew of an incident report or investigation specifically related to this resident and the phone incident. The ADM stated the incident was mentioned during the course of another investigation related to resident #2, the staff involved were subsequently terminated, but he was not aware of a separate report or investigation related to this resident. 6. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 06/01/20, documented to admit the resident to isolation for 14 days due to possible exposure to COVID-19. An admission assessment, dated 06/08/20, documented the resident was independent with most activities of daily living. The assessment documented the resident exhibited verbal behaviors, rejection of care, and wandering which included intrusion on privacy of others. The assessment documented the resident was severely impaired with cognition. A care plan was not provided for this resident. A physician order, dated 07/09/20, documented to readmit the resident to isolation for 14 days due to potential exposure to COVID-19. The resident was observed on 07/10/20 and 07/13/20 to wander throughout the facility, into the main dining room, and other common areas among other residents and staff. On 07/13/20 at 12:45 p.m., an anonymous staff member reported staff had not had any training in dealing with psychiatric residents. The staff member reported the resident would not remain in his room and did what he wanted. On 07/13/20 at 1:00 p.m., CNA #3 reported staff had received no training in caring for psychiatric residents. The CNA stated she felt the resident needed to have 1:1 supervision but there wasn't enough staff. The CNA reported that over the weekend, she had witnessed the resident go into a female resident's room and pull the covers back. She stated she stopped the resident and redirected him. The CNA reported she later witnessed the resident go into a male resident's room, pull his own pants down to expose himself, and asked the resident to touch it. She again redirected the resident and the other resident did not appear affected by the incident. The CNA stated she reported the incidents to the charge nurse but didn't know if the nurse had completed an incident report. The CNA stated she also reported the incidents to the ADM but his response was, maybe you all are provoking him. On 07/13/20 at 1:25 p.m., CMA #1 reported it was common for the resident to be sexually inappropriate but she had not witnessed anything between him and another resident. On 07/13/20 at 2:30 p.m., the DON reported the resident was supposed to be quarantined related to a recent hospital stay but he would not stay in his room. The DON stated nothing had been reported to her regarding incidents over the weekend. On 07/13/20 at 5:00 p.m., ADM #1 reported the weekend charge nurse was not available but nothing had been reported to him and he had not seen an incident report. On 07/13/20 at 6:00 p.m., the DON reviewed nurse notes and could not locate any documentation related to the incidents. ADM #1 advised the DON to start an investigation immediately. The DON asked an unidentified staff member to go question the other male resident. The staff member returned and reported the resident stated the incident did not happen. ADM #1 advised the DON to complete an incident report and document the investigation. On 07/13/20 at 6:05 p.m., ADM #1 reported staff had been inserviced on 07/06/20 regarding identifying and reporting abuse and neglect. He reported any allegation should be reported immediately to the charge nurse, DON, or himself and a thorough investigation conducted. On 07/17/20 at 12:30 p.m., ADM #2 reported ADM #1 was no longer at the facility and resident #3 had been transferred out to another facility. ADM #2 was in the process of orienting to the facility and current circumstances. A final incident report with investigation could not be located.

Based on observation, record review and interview, it was determined the facility failed to intervene to provide pain relief for one (#4) of twelve sampled residents with documented complaints of pain. This had the potential to affect twenty-eight other residents who triggered for pain on the facility's Roster/Sample Matrix form provided by the DON. Resident #4 was admitted with multiple diagnoses which included dementia, hallucinations, chronic pai[DIAGNOSES REDACTED], [MEDICAL CONDITION] ulcer disease and depression. The resident was admitted with a [MEDICAL CONDITION] that had not been repaired three years ago. Monthly pain screening forms, dated 10/25/11 through 06/22/12, documented the resident scored a "10" for pain. A score of 10 or greater indicated a comprehensive assessment was needed by an RN. The pain screening forms documented the resident experienced either "No Pain" or "intermittent/occasionally (less than daily)" pain. The pain screening forms dated 10/25/11 - 01/13/12, documented the resident had PRN pain medication ordered and received it more than 3 times per week. The pain screening forms dated 02/29/12 - 06/22/12, documented the resident had PRN pain medication ordered and received it less than 3 times per week. The nurses' notes, dated 06/08/12, documented the resident hit another resident because she wouldn't move when she asked her to. The facility sent the resident to a psychiatric hospital for a medication adjustment and evaluation. The hospital MAR indicated [REDACTED]. The resident returned to the facility on [DATE], without a physician's orders [REDACTED]. The resident's care plan, dated 06/21/12, documented, "I have a [DIAGNOSES REDACTED]. Approaches: Please monitor me for signs/symptoms of pain (verbal/nonverbal)." There was no other care plan for her [DIAGNOSES REDACTED]. The RN (DON) conducted a quarterly pain evaluation after each pain screening score of a "10." The quarterly pain evaluations dated 09/30/11, 12/01/11, and 03/02/12, completed by the DON documented, "Does the resident have any [DIAGNOSES REDACTED].? Yes...If yes, describe cause and origin of pain: [MEDICAL CONDITION]. Does the resident verbalize pain? No...Intensity (No hurt - Hurts little bit, was circled)...Does the resident receive scheduled (pain) medications? No...Does the resident receive a PRN (pain) medication? No...Conclusion ...No pain, intervention is not necessary. Re-assess quarterly or with onset of pain (this was left blank on the 12/01/11 assessment)...(Signed by the DON)." The last quarterly pain evaluation, dated 06/30/12, documented the resident had no [DIAGNOSES REDACTED]. The resident's comprehensive assessment, dated 07/02/12, documented her cognition was severely impaired. It documented she was independent in ambulation and transfers. She required limited assistance in personal hygiene and toileting. Her assessment documented she displayed physical behavior symptoms toward others and resisted care. Her assessment documented she displayed facial expressions and protective movements/postures of pain. The assessment documented the resident had indicators of pain one to two days during the observation period. The resident's MAR for July 2012 was reviewed. There were no pain medications ordered for the resident. On 07/18/12 at 9:20 a.m., the MDS coordinator was asked if her pain assessments on the resident indicated the resident was having pain. She stated, "Yes." She was asked if the resident had told her where her pain was located. She stated the resident didn't say. She stated the resident was previously on routine [MEDICATION NAME] (a pain [MEDICATION NAME]) before going to a psychiatric hospital in June 2012. But when she came back, it was not reordered. At 10:20 a.m., the resident was asked if she ever had pain. She stated, "Yes." She was asked where her pain was located. She stated in her stomach. At 4:00 p.m., LPN #5 was asked if the resident's primary care physician had been called to see if the resident's pain medications were to be continued in the facility. She stated, "No." On 07/19/12 at 12:10 p.m., the resident refused to eat lunch. LPN #4 and #5 were observed in the resident's room talking to the resident. The LPN's were asked why the resident had refused her lunch. LPN #4 stated the resident had told her she was in pain.