Every finding on record at Mcmahon-Tomlinson Nursing Center

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed to include skin integrity for 1 (#7) of 12 sampled residents whose care plans were reviewed. The administrator identified 122 residents resided in the facility. Findings: A Care Planning - Interdisciplinary Team policy, revised 2016, read in part, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. An undated care plan for Resident #7 did not show the resident being at risk for potential/actual skin impairment. An admission assessment for Resident #7, dated 05/10/26, showed the resident had a brief interview for mental status score of 4 indicating severe cognitive impairment, dependent with toileting and hygiene, always incontinent, and was at risk for developing pressure ulcers. A nursing note for Resident #7, dated 05/27/26, read in part, Received report that [Resident #7] has skin issue upon observation noted skin abrasion to rt inner ischium measures 9.5 x .5 cm with s/s [signs and symptoms] of irritation from Brief. and chaff spot to rt buttocks measures 1.5 x .5 cm no noted drainage no c/o [complaints of] pain nor discomfort. will clean area pat dry apply thin layer of [name withheld] ointment 1:1 mix with [name withheld] wound Paste. Pt [patient] aware and agreed SN [skilled nursing] notified. On 06/19/26 at 2:44 p.m., the wound care nurse stated Resident #7 had no skin issues upon admission. They stated they were notified of the skin issues on 05/27/26 and obtained orders for an ointment and a paste. On 06/19/26 at 3:09 p.m., the minimum data set coordinator stated skin impairment was not on Resident #7's care plan. They stated Resident #7 was at risk of skin impairment, and it should have been care planned.

Based on observation, record review, and interview, the facility failed to ensure staff implemented proper infection control practices while performing incontinent care for 2 (#10 and #11) of 2 sampled residents observed for incontinent care.The director of nursing identified 68 residents required assistance with incontinent care.Findings:1.On 06/25/26 at 1:06 p.m., CNA #1 and CNA #2 were observed to knock on Resident #10's door and ask permission to enter. CNA #1 and CNA #2 donned a gown and gloves prior to entering. CNA #1 explained they were there to provide incontinent care. CNA #1 assisted with removing the blanket and sheet from the resident. CNA #2 lowered the head of the bed and raised the bed. Each CNA assisted with pulling the resident's pajama pants below their knees. Resident #10's brief was dry. CNA #1 was observed to wipe each side of the genitalia with one wipe each and disposing of the wipe. CNA #1 used one wipe to clean the resident's indwelling catheter then disposed of the wipe. CNA #1 assisted Resident #10 to their right side. CNA #2 wiped the resident's perineal area and coccyx with one wipe each and disposed of the wipes. CNA #2 wiped each buttock with one wipe and disposed of the wipes. On 06/25/26 at 1:10 p.m., CNA #1 and CNA #2 did not change their gloves after cleaning Resident #10. CNA #2 obtained a clean brief from the resident's bedside dresser. CNA #2 then placed the clean brief under Resident #10's left hip and buttock. CNA #1 and CNA #2 assisted the resident to their back. CNA #1 pulled the brief through to the right side. Each CNA assisted with fastening the brief. CNA #1 and #2 assisted the resident with pulling their pajama pants up. CNA #1 assisted the resident with pulling their shirt down and pulling the sheet and blanket up to Resident #10's chest. CNA #1 and #2 used a folded sheet under the resident to pull them up in their bed. CNA #2 gave the resident their call light and raised the bed and placed the bed remote on the bed within reach of Resident #10. CNA #2 then grabbed the bedside table and placed it next to the resident's bed. CNA #1 and CNA #2 then each removed their gloves. CNA #1 and CNA #2 sanitized their hands as exiting Resident #10's room. A Perineal Care policy, revised 02/2018, read in part, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections. On 06/25/26 at 1:28 p.m., CNA #1 stated the facility policy for infection control was to change gloves between dirty and clean. They stated they should have changed their gloves more. CNA #1 stated they should have changed their gloves before touching all of those items after perineal care. 2. On 06/25/26 at 2:30 p.m., CNA #3 and CNA #4 were observed to wash and dry their hands. CNA #3 knocked on Resident #11's door and requested permission to enter the room. CNA #3 and CNA #4 donned a gown and gloves. On 06/25/26 at 2:38 p.m., CNA #4 informed Resident #11 they were going to provide incontinent care and indwelling urinary catheter care. CNA #3 set the bedside table as a workspace by placing a barrier then clean incontinent wipes and a clean brief. On 06/25/26 at 2:45 p.m., CNA #3 adjusted the height of the bed and lowered head of bed. CNA #3 and CNA #4 folded the bed linens down and opened the soiled brief. Resident #11 was assisted to lay on their left lateral side. CNA #4 helped Resident #11 to maintain their position while CNA #3 used incontinent wipes to clean Resident #11's buttocks area. Wipes were used for one swipe then folded to clean area and wiped another area of the buttocks until the buttocks area was clean. On 06/25/26 at 3:00 p.m., CNA #4 assisted CNA #3 with repositioning Resident #11 to laying on their back with their legs elevated and separated. CNA #4 assisted with holding Resident #11's legs apart while CNA #3 used incontinent wipes to clean the genitalia area. CNA #3 wiped down and away from the genitalia opening and continued this process with new wipes until the area was cleansed. CNA #3 stabilized the indwelling urinary catheter from the genitalia insertion while cleaning the catheter. On 06/25/26 at 3:08 p.m., CNA #3 grabbed a clean brief without changing their gloves and without sanitizing their hands. The brief was positioned under Resident #11 and then the brief was pulled through Resident #11's legs. CNA #4 then rolled the resident onto their left lateral side, adjusted the brief, then Resident #11 was returned to their back with their legs elevated and separated, and secured the brief. CNA #3 and CNA #4 each positioned the resident up higher into the bed and pulled the covers up on the resident. CNA #3 used the bed controls to raise the head of the bed and lowered the bed to a safe height and placed the call within reach. CNA #4 removed their gown and gloves and disposed of them into the trash can. CNA #3 removed their gown, kept their gloves on, placed their gown in the trash bag, removed the trash from the room to the trash bin. CNA #4 went to the sink to wash their hands and CNA #3 washed their hands after discarding the trash in the trash bin. On 06/25/26 at 3:15 p.m., CNA #3 and CNA #4 were asked if they should have changed their gloves while providing incontinent care for Resident #11. CNA #3 stated, Yes we should have changed our gloves after we cleaned the resident and before touching the blankets and bed remote. CNA #3 and CNA#4 were asked if they changed their gloves adequately. CNA #3 and CNA #4 stated, No.

Based on record review and interview, the facility failed to ensure an allegation of abuse was investigated to make certain residents were free from abuse for 1 (#1) of 3 sampled residents reviewed for abuse.The DON reported the facility census was 133.Listed below are abbreviations that will be used throughout this document.ADON - Assistant Director of NursingAPS - Adult Protective ServiceBIMS score - Brief Interview for Mental StatusDON - Director of NursingA Abuse and Neglect policy, dated 09/12/25, read in part, The facility shall immediately report allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. The admission assessment, dated 12 /05/25, showed Resident #1 was admitted to the facility on [DATE] with diagnosis of congestive heart failure. The assessment showed the residence's cognition was intact with a BIMS score of 15.A skilled assessment, dated 12/05/25, showed Resident #1 had a skin assessment and was found to have bruises on the right lateral thigh, left inner thigh, and one near the rib cage. On 03/06/26 at 8:22 a.m., an interview with the APS investigator took place. The APS investigator stated, They went to the facility on 12/05 and informed them they were there to investigate an allegation of abuse for Resident #1. On 03/05/26, at 10:50 a.m., the DON reported a meeting was held regarding Resident #1 for an allegation of abuse. The DON reported the meeting included the Administrator, DON, ADON and Skilled Nurse Manager. They discussed and investigated the bruising on Resident #1 and concluded the bruising was from the lift sling and did not find it to be abuse. They decided an investigation into the allegation of abuse would not be reported.On 03/05/26, at 2:20 p.m., the Administrator reported APS came to the facility on [DATE] and informed them they were there to do an investigation concerning an allegation of abuse for Resident #1. The Administrator reported they thought they would not have to report the allegation since APS is part of a state agency. The Administrator reported the abuse allegation should have been reported to OSDH and investigated.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the state agency within the 2-hour required timeframe for 1 (#1) of 3 sampled residents reviewed for abuse.The DON reported the facility census was 133.Listed below are abbreviations that will be used throughout this document.ADON - Assistant Director of Nursing APS - Adult Protective ServiceBIMs score - Brief Interview for Mental StatusDON - Director of Nursing A Abuse and Neglect policy, dated 09/12/25, read in part, The facility shall immediately report allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. The admission assessment, dated 12 /05/25, showed Resident #1 was admitted to the facility on [DATE] with diagnosis of congestive heart failure. The assessment showed the residence's cognition was intact with a BIMS score of 15.A skilled assessment, dated 12/05/25, showed Resident #1 had a skin assessment and was found to have bruises on the right lateral thigh, left inner thigh, and one near the rib cage. On 03/06/26 at 8:22 a.m., an interview with the APS investigator took place. The APS investigator stated, They went to the facility on 12/05 and informed them they were there to investigate an allegation of abuse for Resident #1. On 03/05/26, at 10:50 a.m., the DON reported a meeting was held regarding Resident #1 for an allegation of abuse. The DON reported the meeting included the Administrator, DON, ADON and Skilled Nurse Manager. They discussed and investigated the bruising on Resident #1 and concluded the bruising was from the lift sling and did not find it to be abuse. They decided an investigation into the allegation of abuse would not be reported.On 03/05/26, at 2:20 p.m., the Administrator reported APS came to the facility on [DATE] and informed them they were there to do an investigation concerning an allegation of abuse for Resident #1. The Administrator reported they thought they would not have to report the allegation since APS is part of a state agency. The Administrator reported the abuse allegation should have been reported to OSDH and investigated.

Based on observation, record review, and interview, the facility failed to follow physician's orders and care plans to prevent the worsening of wounds for 1 (#31) of 2 sampled residents reviewed for wound care.The DON identified 123 residents resided in the facility.Findings: On 12/10/25 at 10:50 a.m., Resident #31 was observed in bed. The resident had staples to a right above knee amputation siteA Skin Assessment and Ongoing Skin Integrity Monitoring policy, dated 03/16/24, showed comprehensive skin assessment and ongoing monitoring were performed to identify risks, prevent skin breakdown, and ensure timely interventions in accordance with professional standards. The policy showed that documentation of skin assessments should reflect the location, size, appearance, intervention implemented and resident response. A care plan for Resident #31, dated 02/23/25, showed a pressure ulcer development related to immobility and a low Braden score to the right foot, right inner foot, right ankle, and back of right leg. The care plan showed a goal for the resident's pressure ulcer would show signs of healing and remain free from infection. The care plan showed to follow facility policies/protocols for the prevention/treatment of skin breakdown. The care plan showed to provide weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate.A health status note, dated 09/29/25, showed Resident #31 had chronic bruises to the right foot had been followed for weeks, the area opened, and resulted in a sore to the area. The note showed the area first appeared as bruising when the resident was noted pressing the heel of their foot against the other foot. The note showed pillows were placed to separate the feet, but the resident managed to remove the pillows and continued to place their feet in that position. The note showed discoloration and a fluid filled blister also noted to lateral side of right foot, pulse noted within normal limits, and no signs or symptoms of pain.A physician's order, dated 09/29/25, showed Hydrogel (wound dressing) to right foot, right ankle, and back of right leg every day shift for wound care. The order showed to clean areas, pat dry, apply thin layer of hydrogel, place Meplix (wound dressing) transfer abdominal pad, cover with Kerlix, and observe for skin condition changes.A Skin & Wound evaluation, dated 10/01/25, showed a new in-house acquired intact blister to right lateral foot. A Skin & Wound evaluation, dated 10/01/25, showed an in-house acquired stage 2 pressure wound to the right medial foot, present for one week. The evaluation showed measurements to be 9.7 cm x 7.1 cm x 2.4 cm from a ruptured blister. The evaluation showed treatment to be generic wound cleanser, a polymem (wound dressing) dressing, and Tegaderm (wound dressing).A Skin Observation Tool, note, dated 10/05/25, showed Resident #31's dorsal right lower extremity wound bed appeared necrotic with clear, moderate drainage. The note showed the wound required further evaluation. The note showed the physician had not been contacted for a further evaluation of the wound.A health status note, dated 10/08/25, showed Resident #31 tolerated treatment to the right back of leg and right foot. The note showed the skin to the back of the leg was hardening and drying, with no noted drainage. The note documented no weekly measurements of the wounds.A health status note, dated 10/12/25, showed Resident #31's top layer of the skin of the blisters to the right foot had peeled over. The note showed the skin to the arch of the foot was also peeled over and very little skin left to approximate. The note showed no measurements of the wounds.Resident #31's treatment administration record, dated October 2025, showed physician ordered wound care, dated 10/13/25, for the right foot, right ankle, and back of the right leg. The record showed to clean the area, pat dry, apply a thin layer of hydrogel, place Meplix transfer abdominal pad, cover with Kerlix, and observe for skin condition changes to be done daily. A health status note, dated 10/13/25, showed Resident #31 had ruptured blisters to the right foot, ankle, and back of leg. The note showed hydrogel was applied, covered with Meplix and an abdominal pad, and secured with Kerlix. The note showed light serous drainage on discarded steri strips and dressings. The note showed no measurements of the wounds.A health status note, dated 10/15/25, showed Resident #31 tolerated treatment to right foot and ankle. The note showed no noted drainage and no signs or symptoms of infection. The note showed no measurements of the wound.A health status note, dated 10/21/25, showed Resident #31's dressing around the right foot was soiled. The note showed the wound had strong odor and had grown significantly in size. The note showed the wound dressing was last changed on 10/17/25. The note showed the wound care had not been performed as ordered daily on 12/18/25, 12/19/25, and 12/20/25 as documented on the resident's treatment administration record.A health status note, dated 10/21/25, showed treatment was completed to Resident #31's right lower leg extending to the ankle, and inner side of the foot. The note showed the wound bed had areas of necrotic (dead or dying) tissue, slight yellow slough (nonviable, dead tissue), and a small amount of red granulation (new, moist connective tissue) along wound edges. The note showed large fluid filled blisters noted to top of right foot, black discoloration noted to the outer side of right foot, and the lateral side of the toe. The note showed a strong foul odor noted at this time. The note showed the wound classified as a stage 3 with measurements to areas noted as the following: top of right foot 8 cm x 4 cm, inner side of foot 7.5 cm x 4 cm, posterior leg to ankle 14 cm x 7.5 cm.A physician's note, dated 10/21/25, showed Resident #31 had multiple wounds to the right lower extremity noted with some foul-smelling drainage noted. The note showed a culture to be obtained, Cipro (antibiotic), and obtain bilateral lower extremity arterial ultrasound A physician's note. dated 10/21/25, showed Resident #31's had an open wound visible on the dorsal aspect of the right foot with significant odor, and the flesh was broken down and macerated with a depth at least 4 mm. The note showed the wound appeared infected with bloody discharge. The note showed the extremity pulses were unable to be palpated on the right lower extremity. The note showed an assessment finding to be an infected ulcerating wound of the right lower extremity, possibly due to lack of arterial blood flow and reduced pulses bilaterally.An incident report (ODH Form 283) for an allegation of neglect, dated 10/21/25, showed as of 10/01/25, Resident #31 had a stage 2 wound to the right medial foot. The report showed the wound care nurse entered the resident's room to provide wound care and the wound was then a stage 3. The report showed the wound care was ordered to be performed daily and as needed. The report showed the wound care was not performed on 10/18/25, 10/19/25, and 10/20/25 and the nurse admitted to not performing the wound care. The report showed the resident's wound progressed from a stage 2 to a stage 3, indicating the wound worsened from the omission. The note showed the neglect allegation was substantiated.A doppler of the right arterial lower leg report, dated 10/22/25, showed findings were likely representing severe peripheral arterial disease with possibility of hemodynamic (pressure and resistance of the blood flow) significant stenosis (constriction).A health status note, dated 10/29/25, showed Resident #31 had been admitted to the hospital and was in surgery for a right below the knee amputation. The note showed the resident was admitted for wounds to the right foot.A quarterly assessment, dated 11/13/25, showed Resident #31's cognition was severely impaired, and the BIMS was not able to be scored. The assessment showed the resident was dependent on staff for all activities of daily living. The assessment showed a surgical wound and no pressure ulcers. The assessment showed a diagnosis of diabetes mellitus and coronary artery disease, and absence of right leg below the knee.On 12/15/25 at 12:19 p.m., the DON stated the finding from the investigation of the wound care not being performed for Resident #31's right foot on 10/18/25, 10/19/25, and 10/20/25 had caused worsening of the wound, and was found to be neglect by the nurse. The DON stated they could not be certain this resulted in the below-the-knee amputation the resident had on 10/29/25, since it was found the resident had severe peripheral arterial disease with significant stenosis.On 12/15/25 at 12:42 p.m., a family member stated they were told the resident had not received wound care as ordered by the physician.On 12/15/25 at 4:30 p.m., Physician #1 stated Resident #31's wound did not appear to be pressure related. The physician stated the wound appeared to be vascular and developed quickly. The physician stated they were unaware of the poor blood flow until the vascular study was performed. The physician stated they believed the missed wound care would not have mattered due to the restricted blood, and the amputation of the leg was inevitable.On 12/16/25 at 10:28 a.m., LPN #2 stated they had been covering for the wound care nurse on 10/21/25. The LPN stated they had found the wound to have worsened and appeared infected. LPN #2 stated wound care had not been completed daily as ordered. LPN #2 stated they were taking measurements of the wound at that time. LPN #2 stated the physician was in the building and evaluated the wound at that time and ordered a culture and doppler.On 12/16/25 at 10:57 a.m., the ADON stated skin assessments were not done weekly. The ADON stated the wound care nurse performed skin assessments, documented changes and a description of the wound. The ADON stated the physician should have been contacted the same day the nurse documented a skin observation needed to be assessed further. The ADON stated the wound should have been evaluated before it was seen again by the wound care nurse on 10/08/25. The ADON stated if the resident's care plan reads measurements and descriptions of skin breakdown were to be documented weekly, then the skin assessment should be completed weekly.On 12/16/25 at 11:45 a.m., the wound care nurse stated they measured wounds every 1-2 weeks and took pictures of the wound and documented in the medical record. The wound care nurse stated this had not been done on Resident #31 because they had not worked a lot during the month of October. The wound care nurse stated they had documented measurements and took pictures of the wound on 10/01/25.

Based on observation, record review, and interview, the facility failed to ensure wound care was provided per physician orders for 1 (#31) of 2 sampled residents reviewed for wound care.The DON identified 123 residents resided in the facility.Findings: On 12/10/25 at 10:50 a.m., Resident #31 was observed in bed. The resident had staples to a right above knee amputation site.An Abuse & Neglect policy, dated 01/02/22, read in part, Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.A care plan for Resident #31, dated 10/02/25, showed a pressure ulcer development related to immobility and a low Braden score to the right foot, right inner foot, right ankle, and back of right leg. The care plan showed the resident's pressure ulcer would show signs of healing and remain free from infection. The care plan showed to follow facility policies/protocols for the prevention/treatment of skin breakdown.Resident #31's treatment administration record for October 2025 showed a physician ordered wound care, dated 10/13/25, for the right foot, right ankle, and back of the right leg. The record showed to clean the area, pat dry, apply a thin layer of hydrogel (wound dressing, place Meplix (wound dressing) transfer abdominal pad, cover with Kerlix, and observe for skin condition changes to be done daily. A health status note, dated 10/13/25, showed Resident #31 had ruptured blisters to the right foot, ankle, and back of leg. The note showed hydrogel was applied, covered with Meplix and an abdominal pad, and secured with Kerlix. The note showed light drainage on discarded steri strips and dressings.A health status note, dated 10/15/25, showed Resident #31 tolerated treatment to right foot and ankle. The note showed no noted drainage and no signs or symptoms of infection.A health status note, dated 10/21/25, showed Resident #31's dressing around the right foot was soiled. The note showed the wound had a strong odor and had grown significantly in size. The note showed the wound dressing was last changed on 10/17/25. The note showed the wound care had not been performed as ordered daily on 12/18/25, 12/19/25, and 12/20/25 as documented on the resident's treatment administration record.A health status note, dated 10/21/25, showed treatment was completed to Resident #31's right lower leg extending to the ankle, and inner side of the foot. The note showed the wound bed had areas of necrotic (dead or dying) tissue, slight yellow slough (nonviable, dead tissue), and a small amount of red granulation (new, moist connective tissue) along wound edges. The note showed large fluid filled blisters noted to top of right foot, black discoloration noted to the outer side of right foot, and the lateral side of the toe. The note showed a strong foul odor noted at this time. The note showed the wound classified as stage 3 with measurements to areas noted as the following: top of right foot 8 cm x 4 cm, inner side of foot 7.5 cm x 4 cm, posterior leg to ankle 14 cm x 7.5 cm. A physician's note, dated 10/21/25, showed Resident #31 had multiple wounds to right lower extremity noted with some foul-smelling drainage noted. The note showed a culture was to be obtained, Cipro (antibiotic), and obtain bilateral lower extremity arterial ultrasound. A physician's note, dated 10/21/25, showed Resident #31 had an open wound visible on the dorsal aspect of the right foot with significant odor, and the flesh was broken down and macerated with a depth of at least 4 mm. The note showed the wound appeared to be infected with a serosanguinous bloody discharge. The note showed the extremity pulses were unable to be palpated on the right lower extremity. The note showed an assessment finding to be an infected ulcerating wound of the right lower extremity, possibly due to lack of arterial blood flow and reduced pulses bilaterally. An incident report (ODH Form 283) for an allegation of neglect, dated 10/21/25, showed as of 10/01/25, Resident #31 had a stage 2 wound to the right medial foot. The report showed the wound care nurse entered the resident's room to provide wound care and the wound was then a stage 3. The report showed the wound care was ordered to be performed daily and as needed. The report showed the wound care was not performed on 10/18/25, 10/19/25, and 10/20/25 and the nurse admitted to not performing the wound care. The report showed the resident's wound progressed from stage 2 to a stage 3, indicating the wound worsened from the omission. The note showed the neglect allegation was substantiated. A doppler of the right arterial lower leg report, dated 10/22/25, showed findings were likely representing severe peripheral arterial disease with the possibility of hemodynamic significant stenosis. A health status note, dated 10/29/25, showed Resident #31 had been admitted to the hospital and was in surgery for a right below knee amputation. The note showed the resident was admitted for wounds to the right foot.A quarterly assessment, dated 11/13/25, showed Resident #31's cognition was severely impaired, and the BIMS was not able to be scored. The assessment showed the resident was dependent on staff for all activities of daily living. The assessment showed surgical wound and no pressure ulcers. The assessment showed the resident had diagnoses which included, diabetes mellitus, coronary artery disease, and absence of the right leg below the knee.On 12/15/25 at 12:19 p.m., the DON stated the finding from the investigation of the wound care not being performed for Resident #31's right foot on 10/18/25, 10/19/25, and 10/20/25 had caused worsening of the wound, and was found to be neglect by the nurse. The DON stated they could not be certain this resulted in the below-the-knee amputation the resident had on 10/29/25, since it was found the resident had severe peripheral arterial disease with significant stenosis. On 12/15/25 at 12:42 p.m., a family member stated they were told the resident had not received wound care as ordered by the physician.On 12/15/25 at 4:30 p.m., Physician #1 stated Resident #31's wound did not appear to be pressure related. The physician reported the wound appeared to be vascular and developed quickly. The physician stated they were unaware of the poor blood flow until the vascular study was performed. The physician stated they believed the missed wound care would not have mattered due to the restricted blood, and the amputation of the leg was inevitable.

Based on record review and interview, the facility failed infection prevention and control practices to ensure identification of high risk areas to include flushing of unused outlets to prevent the spread of a waterborne illness. The DON/IP reported 118 residents resided in the facility. Findings: A Water Management Program to Reduce Legionella and other Waterborne Path[ogens], dated 03/05/25, policy, read in part, The program will identify risk factors, establish control measures, and ensure monitoring and corrective actions to reduce the risk of Legionella and other waterborne pathogens. System Assessment: Conduct a comprehensive assessment of the facility's water systems, including . *Identify high-risk areas (e.g [for example]., showers, sinks, water tanks) .Regularly check water temperature. Documentation *Maintain detailed records of: *Testing and monitoring results *Maintenance and cleaning schedules .Water management program .We will flush hot water heaters once per year, even though the hot water systems are equivalent continuously circulating pumps. The fire sprinkler system is required every quarter and is completed by [Name withheld] controls. As a part of the control measures the house keeping department will implement into their daily cleaning the following as staff enters the room to clean: they will turn on the sinks and showers to let them run for one to two minutes while they are cleaning this will help keep the water moving and disinfecting going throughout the water system [sic] systems many of the residents rarely use their sinks or showers in their rooms and this will keep the water moving if the Legionella bacteria has [sic] found in the water system in a facility proceeded with DEQ [Department of Environmental Quality] in [sic] CDC [Centers for Disease Control and Prevention] recommendation as well as Oklahoma State Department of health. A hospital discharge report for Resident #1, dated 02/17/25, showed hospital course: patient admitted for altered mental status due to pneumonia from Legionella. On 03/07/25 at 10:30 a.m., the maintenance director stated they reviewed all the documentation related to the policy and procedure for Legionnaire's. They stated the only documentation they had was the water temperatures and air temperatures. They did not have any preventative documentation and cleaning schedules. They did not identify any high risk areas. They stated the house keeping staff would run water when they cleaned the rooms. They stated the water testing was conducted for Legionnaire's in Resident #1's room because it was the farthest from the city inlet on 03/06/25. On 03/07/25 at 11:49 a.m., the DON/IP stated the policy for Legionnaire's was part of the water management policy. On 03/10/25 at 2:20 p.m., housekeeper #1 stated they were instructed today to flush the toilets six times and had signed off on that today. They were asked if they had been running the water while cleaning before they had a case of Legionella. They stated not unless they had something to pour down the drain. They stated maintenance would do that. On 03/10/25 at 2:35 p.m., housekeeper #2 was asked if they would run the water in the sinks/showers while cleaning the room prior to the case of Legionella. They stated they did not leave it running. They were asked if they were instructed to do something specifically after the case of Legionella and they stated they were instructed to flush the toilet six times and they had signed off on that procedure. They were asked if they knew of any areas in the facility where the water was not routinely used. They stated no, everybody uses the water. On 03/11/25 at 10:15 a.m., the housekeeping supervisor was asked about an in-service related to flushing of the toilets six times. They stated they did that inservice yesterday. They stated they wanted us to run the sinks/showers for two minutes after everything was turned back on. They were asked if that was performed prior to the case of Legionella. They stated no it was not a set thing. They were asked about staff in-services related to running the water while cleaning the room prior to the case of Legionella. They stated they did not have any in-services related to that.

Based on record review and interview, the facility failed to update a care plan for 1 (#1) of 1 sampled resident with a new diagnosis of Legionella. The DON/IP reported one case of Legionella. Findings: A Care Plans, Comprehensive Person-Centered policy, dated March 2022, read in part, The interdisciplinary teams reviews and updates the care plan .c. when the resident has been readmitted to the facility from a hospital stay. On 03/10/25 at 4:48 p.m., the DON/IP was asked about Resident #1's care plan related to Legionella. They stated they thought it had been resolved. They stated it was not care planned because it was already resolved.

Based on record review and interview, the facility failed to ensure the minimum data set was coded accurately for Legionella for 1 (#1) of 1 sampled discharged resident from the hospital for skilled services. The DON/IP reported one case of Legionella. Findings: Resident #1 had diagnoses which included pneumonia (unspecified), high blood pressure, and non-Alzheimer's dementia. A hospital discharge report, dated 02/17/25, showed hospital course: patient admitted for altered mental status due to pneumonia from Legionella. A Medicare-5 day MDS assessment, dated 02/21/25, did not show the diagnosis of Legionella. On 03/11/25 at 12:45 p.m., the MDS coordinator stated the resident discharged to the hospital on 02/14/25 and returned from the hospital on 02/17/25 and the Medicare-5 day care MDS assessment was completed on 02/21/25 for skilled services. They stated the skilled services completed on 03/02/25. They stated the Legionella was not incorporated into the MDS and they did not see it on the discharge report from the hospital. They stated it would be the facility policy to list it under other.

Based on observation, record review and interview the facility failed to ensure staff maintained infection control measures, and a. changed gloves during provision of perineal care and personal hygiene for one (#55) of one sampled resident reviewed for perineal care, b. sanitized the blood pressure cuff and pulse oximeter during medication observation for three (#6, #64, and #23), and c. sanitized their hands between residents during medication observation for four (#17, #31, #144, #80) of eight sampled residents reviewed during medication pass observation. The Administrator identified 97 residents resided in the facility. Findings: A Cleaning and Disinfection or Resident-Care Items and Equipment policy revised October 2018, read in part, .Non-critical items are those that come in contact with intact skin but not mucous membranes .blood pressure cuffs .Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment . A Handwashing/Hand Hygiene policy, dated August 2019, read in parts, .Hand hygiene products and supplies .shall be readily accessible and convenient for staff use .Use an alcohol-based hand rub .or, alternatively, soap .and water .Before and after direct contact with resident .Before preparing or handling medications .After removing gloves .Before and after entering isolation precaution settings . 1. Resident #55 had diagnoses which included GERD and high cholesterol. A significant change assessment, dated 03/14/24, documented Resident #55 was always incontinent of bowel and bladder, was dependent on staff for assistance with toileting, transfers, dressing, and personal hygiene. On 04/08/24 12:10 p.m., CNA #2 was observed to remove Resident #55's shirt and dress them in a gown then transferred the resident to their bed. On 04/08/24 at 12:19 p.m., CNA #2 removed Resident #55's pants and cleansed the vaginal area with periwash and wipes. CNA #3 entered the room and assisted with positioning Resident #55. CNA #2 was observed to clean Resident #55's buttocks then applied barrier cream. CNA #2 and #3 then positioned Resident #55 to secure the brief. CNA #2 then straightened the residents gown, brushed the resident's hair, used a wipe to clean the residents eyes and mouth, positioned the resident to float their heels, then covered the resident with a blanket. CNA #2 was not observed to change their gloves at anytime during provision of care or during positioning or hygiene. On 04/08/24 12:26 p.m., CNA #2 was asked when they had changed their gloves during pericare. They stated they had not changed their gloves. CNA #2 was asked when they had cleaned Residents #55's eyes and mouth did they still have on the same gloves. They stated yes. 04/10/24 1:09 p.m., the DON was asked when should staff change their gloves when providing incontinent care. They stated when they get finished with dirty and go to clean. They were asked if staff should use the same gloves to clean the residents eyes and mouth that was used to clean their peri area and buttocks. They stated No. 2. On 04/10/24 at 7:43 a.m., CMA #1 was observed to obtain a blood pressure, pulse ox, and pulse using a dynamap machine on Resident #6. CMA #1 was not observed to sanitize the equipment after use. On 04/10/24 at 7:53 a.m., CMA #1 was observed to obtain a pulse ox on Resident # 64, return the dynamap near the medication cart and was not observed to sanitize the pulse oximeter. On 04/10/24 at 7:58 CMA #1 was observed to obtain a pulse ox, pulse and blood pressure on Resident #23 then returned the dynamap to the medication cart. CMA #1 was not observed to sanitize the blood pressure cuff or pulse oximeter after use. On 04/10/24 at 8:09 a.m., CMA #1 was asked when they had sanitized their equipment. They stated they did not sanitize their equipment. They were asked when they should sanitize their equipment. They stated after every resident. On 04/10/24 at 1:05 p.m., the DON was asked what was the policy for sanitizing resident equipment to include pulse oximeter and blood pressure cuff. The DON stated, staff should use wipes (sanitizer) in between residents. 21731 3. On 04/10/24 at 7:38 a.m., CMA #2 was observed to approach a medication cart and replace an insulin pen into a zip bag then into the medication cart. There was no hand sanitizer on the medication cart. Without washing or sanitizing their hands, CMA #2 obtained equipment from the medication cart to obtain a FSBS. CMA #2 walked down the hall, entered the room of Resident #17. Without washing or sanitizing their hands, CMA #2 donned gloves and obtained a FSBS for Resident #17. CMA #2, removed one glove, while holding the used sharps in the gloved hand, returned to the medication cart, disposed of the sharp, and removed the second glove. Without washing or sanitizing their hands, CMA #2 obtained a blood pressure on Resident #31, returned to the medication cart and prepared nine oral medications and administered to Resident #31. On 04/10/24 at 8:00 a.m., CMA #2 was asked what the facility policy for hand sanitation during medications administration was. CMA #2 stated they should have sanitized after each resident then washed their hands with soap and water after every third resident. CMA #2 was asked if they had sanitized their hands between Resident #17 and #31. They stated, No, there is none on the medication cart. On 04/10/24 at 8:05 a.m., CMA #3 was observed to approach a medication cart. There was no hand sanitizer on the medication cart. CMA #3 obtained a blood pressure cuff, and enter Resident #144's room to obtain a blood pressure. CMA #3 did not wash or sanitize their hands before obtaining the blood pressure. CMA #3 returned to the medication cart, without sanitizing their hands, prepared five oral medications for Resident #144, returned to the resident room and administered the oral medications. Without washing or sanitizing their hands, CMA #3 returned to the medication cart, and reviewed orders for Resident #80. Without washing or sanitizing their hands, CMA #3 entered into an isolation room, donned gloves and gown, removed gloves, donned clean gloves and obtained a blood pressure for Resident #80. CMA #3 then removed the gown and one glove, while taking the blood pressure cuff to the medication cart, placed the blood pressure cuff on top of the cart, removed their gloves, obtained a sanitizing wipe to clean the blood pressure cuff and the top of the medication cart prior to sanitizing their hands. On 04/10/24 at 8:13 a.m., CMA #3 was asked what the facility policy to wash or sanitize hands was. CMA #3 stated hands should be cleaned or sanitized going into and coming out of every resident room. CMA #3 stated, that was not what they did.

Based on observation, record review and interview, the facility failed to ensure interventions were added to the care plan after a fall for two residents (#38 and #41) of 20 sampled residents reviewed for care plan revisions. The DON identified 97 Residents resided in the facility. Findings: An Assessing Falls and Their Causes policy, revised 03/2018, read in part, .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls . 1. Resident #38 had diagnoses which included type 2 diabetes mellitus, urinary incontinence, and hypertensive heart disease. Resident #38's quarterly assessment dated [DATE] documented Resident 38's cognition was mildly impaired and required partial to moderate assist with transferring. On 04/08/24 at 12:39 p.m., Resident #38 was observed to have a bruised left eye. Resident #38 stated they fell from the recliner while trying to go to the toilet. A incident report dated 04/15/23, documented the resident had an unwitnessed fall. A incident report dated 12/04/23, documented the resident had an unwitnessed fall. A incident report, dated 03/30/24, documented the resident had an unwitnessed fall. A incident report, dated 03/31/24, documented the resident had an unwitnessed fall. Resident #38's care plan for falls, last revised on 06/20/23, did not document any new interventions after the falls on the following dates: a. 03/30/24, b. 03/31/24, c. 12/04/23, and d. 04/15/23. On 04/10/24 at 02:35 p.m., the DON was asked about policy and procedure for fall interventions. The DON stated they are supposed to put in interventions in the care plan. The DON reviewed the care plan and stated no interventions for falls had been added to the care plan since 01/12/22. 41872 2. Resident #41 had diagnoses which included altered mental status, dementia and anxiety. Resident #41's care plan, initiated on 12/27/23, documented the resident was at high risk for falls and was unaware of safety needs. The care plan had been revised on 03/13/24 but no specific interventions had been updated for the following falls. An incident report, dated 01/16/24 at 3:07 a.m., documented the resident had an unwitnessed fall in their room. An incident report, dated 01/24/24 at 9:05 a.m., documented the resident had an unwitnessed fall in their room. An incident report, dated 01/24/24 at 12:29 a.m., documented the resident had an unwitnessed fall in their room. An incident report dated 02/02/24 at 8:18 a.m., documented the resident had an unwitnessed fall in their room. An incident report, dated 02/02/24at 3:42 a.m., documented the resident had an unwitnessed fall in their room. An incident report, dated 02/02/24 at 8:25 p.m., documented the resident had an unwitnessed fall in their room. An incident report, dated 02/22/24 at 6:00 p.m., documented the resident had an unwitnessed fall in their room. An incident report, dated 02/27/24 at 9:01 p.m., documented the resident was sitting on the floor. A family member had attempted to transfer the resident. An incident report, dated 03/01/24 at 6:30 p.m., documented the resident slipped to the floor during transfer with a family members assistance. An incident report dated 03/07/24 at 2:35 a.m., documented the resident had an unwitnessed fall in their room. An incident report, dated 03/15/24 at 10:00 a.m., documented the resident had a witnessed fall from a wheelchair. On 04/11/24 at 9:23 a.m., the DON was asked if the care plan had been updated on 04/10/24. They stated the care plan had been updated yesterday.

Based on observation, record review and interview, the facility failed to ensure; a. oxygen tubing was labeled and dated, per the facility policy and professional standards of care, for three (#14,64, and #143) and, b. respiratory medications were administered per the standard of practice for one (#64) of three residents sampled for respiratory care. The DON identified 11 residents received oxygen services. Findings: A Departmental (Respiratory therapy) - Prevention of Infection policy, revised 11/11, read in part, .Change the oxygen cannula, and tubing every seven days, or as needed . A Physicians Order, dated 11/15/23, read in part, .Please change oxygen tubing weekly .tag tubing with date a residents name . 1. Resident #14 had diagnoses which included macular degeneration, lesion of the plantar nerve, and osteoporosis. Resident #14's comprehensive assessment, dated 03/25/24, documented Resident #14 was dependent for transferring from bed to chair and cognition was moderately impaired and used oxygen. On 04/08/24 at 9:22 a.m., Resident #14 was observed in a geriatric chair wearing oxygen. The oxygen tubing was dated 02/26. On 04/08/24 at 9:52 a.m., LPN #1 was shown the oxygen tubing on Resident #14 was wearing. LPN #1 stated the tubing was dated 02/26. They stated there was an order to change the tubing every two weeks and it did not follow the physician orders. 2. Resident #64 was admitted with diagnoses which included dependence on supplemental oxygen and cranial cerebrospinal leak. Resident #64's comprehensive assessment, dated 10/18/23, documented Resident #64's cognition was intact and required oxygen therapy. A physicians order dated 05/16/23 read in part, .oxygen @ 2 LPMvia PER NASAL CANNULA two times a day .please change oxygen tubing weekly . Ipratropium-Albuterol Solution 05-2.5 (3) MG/ML 3 milliliter inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer . On 04/08/24 at 8:55 a.m., Resident #64 was observed resident getting a breathing treatment with no nurse present in the room. There was no assesment to self administer medication. 04/08/24 9:03 AM LPN #1 came into the Residents room. LPN #1 was asked if they should of been present during the breathing treatment. LPN #1 stated they were outside the door and not present in the room. They stated they were unsure if resident # 64 had an order to self administer medication. On 04/08/24 at 9:08 a.m., no date label on Resident #64's oxygen tubing connected to the oxygen saturator was observed. On 04/08/24 at 9:52 a.m., LPN #1 was shown the oxygen tubing on Resident #64's Oxygen saturator. LPN #1 stated the oxygen tubing was not labeled with a date and it should be. On 04/10/24 at 10:10 a.m., the DON was asked what was the policy for changing O2 tubing. The DON stated the policy says every 7 days and tracked in the TAR. The DON was asked what was their policy for residents receiving breathing treatments. The DON stated the Nurse should administer it. The DON stated Resident #64 does not have an assessment or order to self administer medication. 21731 3. Resident #143 was admitted on [DATE], with diagnoses to include chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Physician Orders:, dated 04/08/24 documented Resident #143 was to wear oxygen, and the tubing was to be changed, labeled, and dated every week on Sundays, and the respiratory bag was to be changed and labeled every two weeks on Sundays. On 04/09/24 at 9:42 a.m., Resident #143 was out of the room. An oxygen concentrator was running at 2-Liter with humidity, the nasal cannula was on bed. There was no date or label on the cannula or tubing. On 04/11/24 at 8:37 a.m., Resident #143 was out of the room. An oxygen concentrator was not turned on. The nasal cannula and tubing were on the bed. There was no date or label on the tubing. On 04/11/24 at 8:41 a.m., LPN #3 was asked what the facility protocol for oxygen tubing and equipment was. They stated the tubing was to be changed every Sunday and the tubing is to be dated. They stated, when the oxygen is not in use, the tubing is to be placed inside a plastic bag to keep it clean.

Based on record review and interview the facility failed to ensure neurological checks were completed after unwitnessed falls for one (#41) of three sampled residents reviewed for falls. The Administrator identified 97 residents resided in the facility. The Resident Matrix documented 21 residents had falls. Findings: A Neurological Assessment policy, revised October 2010, read in part, .The purpose of this procedure is to provide guidance for neurological assessment .when following and unwitnessed fall .When assessing neurological status, always include frequent vital signs .perform neurological checks with the frequency as ordered or per falls protocol . An Assessing Falls and Their Causes policy, revised March 2018, read in part, .Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record . Resident #41 had diagnoses which included altered mental status, dementia and anxiety. Resident #41's care plan, initiated on 12/27/23, documented the resident was at high risk for falls and was unaware of safety needs. An incident report, dated 01/16/24 at 3:07 a.m., documented the resident had an unwitnessed fall in their room. The clinical health record did not contain documentation neurological checks had been started completed. An incident report, dated 01/24/24 at 9:05 a.m., documented the resident had an unwitnessed fall in their room. Neurological checks were started but were incomplete. An incident report, dated 01/24/24 at 12:29 a.m., documented the resident had an unwitnessed fall in their room. There was no documentation neurological checks had been restarted after the second fall. An incident report dated 02/02/24 at 8:18 a.m., documented the resident had an unwitnessed fall in their room. A Neurological Assessment Flowsheet dated 02/02/24 documented neuro checks were only completed from 8:25 a.m., through 10:25 a.m. An incident report, dated 02/02/24 at 3:42 p.m., documented the resident had an unwitnessed fall in their room. A Neurological Assessment Flowsheet, dated 02/02/24 documented neurological checks were started but were incomplete. An incident report, dated 02/02/24 at 8:25 p.m., documented the resident had an unwitnessed fall in their room. Resident #41 was sent to the hospital for evaluation. An incident report, dated 02/22/24 at 6:00 p.m., documented the resident had an unwitnessed fall in their room. A Neurological Assessment Flowsheet dated 02/22/24 documented neuro checks were unable to obtain at 6:30 p.m., then were blank until 8:30 p.m., then documented the resident was resting at 9:00 p.m., through 5:00a.m. until 02/23/24. The checks were restarted at 9:00 a.m. An incident report, dated 03/15/24 at 10:00 a.m., documented the resident had a witnessed fall from a wheelchair. A Neurological Assessment Flowsheet dated 03/15/24 documented neuro checks were started at 10:00 a.m., then at 1:00 p.m., then 8:30 p.m. The flowsheet documentation was incomplete. On 04/11/24 at 8:37 a.m., the DON was asked for a policy for neurological checks. They stated if there was an unwitnessed fall neurological checks should be started. Resident #41's falls from 01/16/24 through 03/15/24 were reviewed with the DON. The DON stated a. there was no documenation neuro checks had been started on 01/16/24, b. the neuro checks should have been restarted after the second fall on 01/24/24, c. the neuro checks were not accurately completed on 02/02/24 at 8:18 am and 3:42 p.m., d. the neuro checks were not accurately completed on 02/22/24 and 03/15/24.

Based on record review and interview, the facility failed to ensure a. the resident assessment at the dialysis center was communicated between the dialysis center and nursing staff was in place, and b. pre- and post- dialysis assessments were completed by the facility for one #63) of one resident reviewed for dialysis. The DON stated four residents received dialysis. Findings: A Long Term Care Facility Dialysis Services Agreement dated 05/10/21, read in parts, . Dialysis Center Obligations .provide to Care Facility from time to time all appropriate information and guidance regarding the renal condition of Residents who are patients of Dialysis Center, including administration of medications, directions for handling medical and nonmedical emergencies . and the care of shunts and fistulas . An undated End-Stage Renal Disease, Care of a Resident with policy, read in parts, .Residents .will be cared for according to currently recognized standards of care .Staff .shall be trained in the care and special needs of these residents .Agreements between this facility and the contracted [Dialysis] facility include all aspects of how the resident's care will be managed .care plan will be developed and implemented .information will be exchanged between the facilities . Resident #63 had diagnoses to include orthopedic aftercare following surgical amputation, end stage renal disease, hypertensive chronic kidney disease, and dependence on renal dialysis. Physician Orders, dated 03/05/24 documented Resident #63 was to be provided the following: a. the dialysis access site was to be assessed, and a full set of vital signs obtained on each evening twice each day the resident received dialysis, b. ensure the Dialysis Form is completed and sent with the resident at each dialysis encounter, and c. a pre-dialysis assessment was to include vital signs, current weight prior to leaving the facility. An Admission Assessment, dated 03/08/24, documented Resident #63 was cognitively intact, and received dialysis prior to admission and while a resident of the facility. The facility Hemodialysis Communication Record was divided into three portions to include: a. pre-dialysis assessment of medications administered, vital signs, access site location and assessments, signature and title, and time of departure. b. dialysis center assessment with vital signs, pre- and post- weights, new orders assessment of the access site, lab values, pertinent or relevant observations, dialysis center information, signature and title, date and time. c. return to facility assessment of vital signs, assessment of access site, signature and title, date and time of return from dialysis center. Resident #63 received dialysis 14 events from 03/07/24 through 04/09/24. The Hemodialysis Communication Record, were as follows: a. pre-dialysis assessments had no information for two of 14 events, and the assessment only contained vital signs with not physical assessment of the resident on six of 14 events. b. dialysis center assessments had no information for three of 14 events, and the assessment only contained vital signs and weights with no physical assessment for 11 of 14 events. c. return to facility assessments had no information for eight of 14 events, and the assessment only contained vital signs and weights with no physical assessment for four of 14 events. On 04/08/24 at 8:48 a.m., Resident #63 stated they go to dialysis three times per week and did not know if they do any monitoring. Resident #63 stated, I think they just transport me. On 4/11/24 at 1:37 p.m., the DON stated the communications forms are utilized to communicate with the dialysis center and ensure proper after care upon return to the facility. The DON stated the forms are to be fully completed and remain in the resident's hard chart, staff only put in a progress note if the resident does not return from dialysis. The DON stated the forms are not being filled out completely and should be.

Based on record review and interview, the facility failed to ensure Registered Nurse coverage was provided 8 hours per day for 7 days a week for nine (10/01/23,10/07/23,10/15/23,10/22/23,11/11/23,11/19/23,12/03/23,12/09/23, and 12/17/23 of 92 days sampled for RN coverage. The DON identified 97 Residents resided in the facility. Findings: A Departmental Supervison, Nursing policy, revised 08/2022, read in part, .A registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week . A Detail of Time documents for the following dates did not document RN coverage for 8 consecutive hours; a.10/01/23, b.10/07/23, c.10/15/23, d.10/22/23, e.11/11/23, f.11/19/23, g.12/03/23, h.12/09/23, and i. 12/17/23. On 04/11/24 at 8:58 a.m., the Administrator was asked to show RN coverage on the above dates. The Administrator stated there was no RN on those dates for 8 consecutive hours which made the facility a one star rating.

Based on observation, record review, and interview the facility failed to ensure three extended release medications were not crushed for two (#6 and #23) of eight sampled residents reviewed during medication pass. A total of 39 opportunites were observed with three errors. The medication error rate was 6.94%. The Administrator identified 97 residents resided in the facility. Findings: A Crushing Medications policy, last revised April 2018, read in part, The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush that the manufacturer stated should not be crushed (for example, long-acting or enteric coated medications) . 1. Resident #6 had diagnoses which included high blood pressure, edema, and atrial fibrillation. A 'Physician Order, dated 05/16/23, documented to administer Metoprolol Succinate extended release 12.5 mg by mouth every morning, Potassium Chloride extended release 20 milliequivalents by mouth every morning, and may crush meds and open capsules as appropriate. On 04/10/24 at 7:43 CMA #1 was observed to prepare Resident #6's medications. CMA#1 was observed to crush and administer Resident #6's medications to include Metoprolol extended release 12.5 mg and Potassium extended release 20 meq. 2. Resident #23 had diagnoses which included high blood pressure. A Physician Order, dated 08/03/23, documented staff may open and crush medications as appropriate, but if medication is extended release to notify pharmacy for alternatives. A Physician Order, dated 12/11/23, documented to administer Metoprolol Succinate extended release 25 milligrams in the morning. On 04/10/24 at 7:58 a.m., CMA #1 was observed to prepare Resident #23's medications. CMA #1 was observed to crush and administer Metoprolol extended release 25 mg to Resident #23. On 04/10/24 at 12:29 p.m., CMA #1 was asked if an extended release medication be crushed. They stated, no. They were asked if they had crushed metoprolol and potassium for Resident #6. They stated yes. They were asked if they had crushed Resident #23's metoprolol extended release. They stated. Yes. On 04/10/24 at 12:59 p.m., the DON was asked if extended release medications can be crushed. They stated they can if the physician is aware, but no we are not supposed to. They were asked if potassium extended release or metoprolol extended release should be crushed. They stated if it is extended release it should not be crushed.

Based on record review and interview, the facility failed to ensure assessments were accurate for two (#83 and #87) of 22 sampled residents reviewed for assessments. The Administrator identified 97 residents resided in the facility. Findings: 1. Resident #83 had diagnosis which included weakness. An Alert Note, dated 03/22/24, documented Resident #83 was on the floor with a laceration to their left upper eyebrow and was sent to the hospital. An Admission assessment, dated 03/22/24, documented the resident had one non injury fall since admission. On 04/10/24 at 10:40 a.m., the DON stated they put falls under the health condition on the assessment. She stated a laceration was considered an injury. The DON was asked to review Resident #83's assessment and was asked what was coded for falls. She stated the resident had one no injury fall. The DON stated the resident had an injury from a fall on 03/22/24. She stated the assessment was not coded accurately. 2. Resident #87 had diagnosis which included sepsis. A Discharge Report, dated 01/15/24, documented Resident #87 discharged to a private home. A Discharge assessment, dated 01/15/24, documented Resident #87 discharged to the hospital. On 04/11/24 at 11:25 a.m., the MDS coordinator #1 stated when a resident discharges, they interview the staff then code the assessment. She was asked to review Resident #87's discharge assessment. The MDS Coordinator #1 stated it was documented the resident discharged to the hospital. She stated the notes documented the resident discharged to their home. She stated it was coded wrong.

Based on record review and interview, the facility failed to ensure side effect monitoring was in place for a resident who was prescribed anticoagulant therapy for one (#3) of five residents sampled for unnecessary medication. The DON identified 29 residents were prescribed anticoagulants. Findings: A Anticoagulation-Clinical Protocol policy, revised 11/2018, read in part, .Assess for any signs or symptoms related to adverse drug reactions to to the medication alone or in combination with other medication .The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems . Resident #3 had diagnoses which included pulmonary embolism, hypertensive heart disease, and peripheral vascular disease. A Physician Order, dated 02/02/24, read in part, .Apixaban Oral Tablet 5 mg .Give 1 tablet by mouth two times a day . A Quarterly Assessment, dated 02/03/24 documented resident 3's cognition was intact and was prescribed anticoagulant therapy. Resident #3's care plan for anticoagulant therapy, dated 05/15/23, read in part, .Monitor/document/report PRN adverse reaction of anticoagulant therapy . The Treatment Administration Record dated 02/01/24 through 04/09/24 did not document side effect monitoring for anticoagulants. The Active Order Summary dated 04/09/24, did not document side effect monitoring for anti coagulant therapy. On 04/10/24 at 9:43 a.m.,the DON was asked about the policy for anticoagulant therapy. The DON stated there should be an order and the monitoring is in the TAR. The DON reviewed Resident #3 EHR and stated there was no side effect monitoring in the orders and there was no side effect monitoring in the TAR. The DON stated the policy was not followed.

Based on observation, record review and interview, the facility failed to ensure interventions were implemented for one (#14) of three residents sampled for falls. The DON identified 97 Residents resided in the facility. Findings: a. An Assessing Falls and Their Causes policy, revised 03/18, read in part, .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls . 1. Resident #14 had diagnoses which included macular degeneration, lesion of the plantar nerve, and osteoporosis. A Care plan document, dated 11/22/23, read in part, .Fall mats beside each side of her bed . Resident #14's comprehensive assessment, dated 03/25/24, documented Resident #14 was dependent for transferring from bed to chair and cognition was moderately impaired. On 04/09/24 at 9:36 a.m., Resident #14 was observed in bed unattended with bed in the lowered position. There were no fall mats observed on each side of the bed. On 04/09/24 at 9:41 a.m., CNA #1 was asked what interventions should have been in place to prevent falls for Resident #14. They stated there should be two fall mats on each side of the bed. CNA #1 was asked to observe the resident. CNA #1 stated Resident #14 was in bed sitting up in the lowered position and fall mats were not in place. On 04/09/24 at 9:51 a.m., LPN #2 was asked what interventions should be in place to prevent falls for Resident #14. LPN #2 observed the resident in bed and then reviewed the care plan. LPN #2 stated the resident should of had a low bed and fall mats in place by the bedside. LPN #2 stated the fall mats were not in place. On 04/10/24 at 10:04 a.m., the DON was asked what the facility policy was for implementing interventions after a fall. The DON stated the interventions would be care planned. The DON was asked what happened with Resident #14's fall mats. The DON stated staff felt like Resident #14 was no longer a fall risk. Therefore, staff was not utilizing the fall mats.

Based on record review and interview, the facility failed to identify the time frames for the steps regarding the medication regimen review, and a medication regimen review was responded to timely for one (#45) of five sampled residents reviewed for unnecessary medications. The Administrator identified 97 residents resided in the facility. Findings: A Drug Regimen Review policy, revised March 2023, did not identify time frame for the steps regarding the medication regimen review. Resident #45 had diagnosis which included depression. An Order Summary report, dated 09/12/23, documented Resident #45 was to receive venlafaxine every morning for depression. A medication regimen review, dated 02/13/24, documented a request to the physician regarding a reduction of venlafaxine or provide a rationale why a dose reduction was clinically contraindicated. The response from the physician was dated 04/05/24. On 04/10/24 at 8:21 a.m., the DON stated staff reviewed the MRR with the physician then scanned in the requests in the residents' EHR. On 04/10/24 at 9:38 a.m., the DON stated there was not a specific time frame in the policy regarding non urgent MRR. The Feburary 2024 MRR was reviewed with the DON with the response from the physician was dated 04/05/24. She was asked if it was addressed timely. She stated she would have to review the policy. The DON was observed to review the policy and stated, It doesn't say in there.

On 07/21/21 at 2:48 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to immediately intervene to protect a resident from alleged sexual abuse. A licensed practical nurse/charge nurse observed the resident in bed and a facility maintenance staff member was observed to have his hand under the resident's covers, with his hand moving back and forth over the resident's genital area. The nurse did not intervene, did not separate the resident from the staff member, and left the room without protecting the resident from further potential abuse. On 07/21/21, the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 3:20 p.m., the administrator was notified of the IJ situation. At 5:18 p.m., an acceptable plan of removal was provided. The plan of removal documented: 07/21/2021 - Plan of Removal (Immediate Jeopardy) Completion Date - 7/22/2021 - 10:00am #1 - The facility will in-service all employees either in person or over the phone on the facility abuse policy to include the following. a. Make sure employees know that if they witness potential abuse or neglect of ANY TYPE they must immediately intervene to stop the abuse or neglect of the resident (as long as doing so does not put their own life in danger). b. Reporting requirements and timelines when reporting abuse and neglect. Must be reported immediately to your Supervisor, DON, or Administrator. Completion Date - 7/21/2021 #2 - Reviewed facility policy to ensure policy is adequate for the reporting of abuse and neglect as well as adequate to prevent abuse and neglect. No changes have been made to current abuse prevention policy. Completion Date - 7/14/2021 (See attached) #3 - Immediately after reporting the alleged abuse to Administration, [name deleted], LPN was given a verbal reprimand on not intervening to stop the alleged abuse. She was in-service during the same conversation on her requirement to immediately intervene to stop any witnessed abuse or neglect. Completion Date - 7/14/2021 #4 - Maintenance employee was sent home on administrative leave with-in minutes of the allegations being made against him. His employment was terminated on 7/16/2021. Completion Date - 7/15/2021 #5 - Several alert and oriented residents were interviewed by [name deleted], Social Services Director on 7/15/2021 and asked about any inappropriate behavior or interactions with our maintenance team. All of the interviews spoke positively of the maintenance team, with no negative interactions noted. On 07/22/21, interviews were conducted with staff from all departments regarding education and in-service information pertaining to the immediate jeopardy plan of removal. Staff stated in-services were conducted the evening of 07/21/21 and the morning of 07/22/21. Staff members were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 07/22/21 at 11:15 a.m., the immediacy was removed when all components of the plan of removal had been completed. The deficient practice remained at a pattern with no actual harm with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to immediately put effective measures in place, and in-service staff, to intervene and protect a resident from sexual abuse for one (#2) of three residents reviewed for abuse. The licensed practical nurse/charge nurse walked out of the resident's room, without intervening and separating the resident from the staff member, while the staff member was allegedly sexually assaulting the resident. The facility reported three allegations of abuse in the previous six months. The facility reported 87 residents resided at the facility. Findings: The facility Abuse Investigation and Reporting policy documented the administrator would ensure that any further potential abuse, neglect, exploitation, or mistreatment was prevented. The policy documented the investigator would interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident. The policy documented other residents to whom the accused employee provided care or services would be interviewed. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 06/25/21, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with most activities of daily living and could ambulate with minimal assistance. A care plan, updated 06/29/21, documented the resident was out of her room daily for activities. The care plan documented the resident required a DepartAlert bracelet due to dementia and wandering. A progress note by the DON, dated 07/14/21 at 1:55 p.m., documented LPN #2 notified the DON and ADM of potential abuse to resident #2. The note documented the LPN walked into the resident's room and observed a maintenance employee leaning over the resident with his hand under the covers. The LPN reported she walked out of the room toward the nurse's station, turned around, and observed the maintenance man walking out of the room. The LPN then reported to the DON. A progress note, dated 07/14/21 at 2:43 p.m., documented RN #1 and LPN #2 assessed the resident in her room for any signs of sexual assault or injury. The note documented no distress noted. The note documented a full assessment of the resident's skin, including pubic area, inner thighs, and vaginal area without signs of redness or injury noted. A progress note, dated 07/14/21 at 4:03 p.m., documented the physician was notified of a report of alleged abuse to the resident. The physician was informed that at 1:50 p.m., LPN #2 observed a maintenance employee leaning over the resident in bed with his hand under the covers. The physician was informed of assessment findings and no new orders were received. A facility grievance management form, dated 07/14/21 and completed by the DON, documented LPN #2 reported a grievance against maintenance staff #1. The form documented it was a patient rights and safety concern. The description of the grievance documented, LPN witnessed maintenance employee leaned over bed of resident with his hand under cover. The form documented steps taken to investigate: police department contacted, statements obtained, APS contacted, and form 283 (an OSDH form) completed. A type-written statement by the facility administrator, dated 07/14/21, documented a verbal counseling with LPN #2. The statement documented the DON was present for the counseling. The statement documented counseling provided, .about making sure she intervenes immediately if she witnesses any type of activity that is potentially negatively affecting a resident in the facility. This includes any type of potential abuse or neglect of a patient. It is the responsibility of every MTNRC employee to ensure the safety and wellbeing of those residents under our care. A written statement by LPN #2, dated 07/14/21, documented she was entering resident #2's room and noted the door was part-way closed. The statement documented she stepped around the door and saw maintenance staff #1 leaning over the resident with his hand under the covers moving his hand in a back and forth manner over the resident's vaginal area. The statement documented, I then left the room and went back to the nurses desk a few moments later [name deleted] left the room and closed the door behind him. The statement documented the LPN then went to the DON's office to report what she had witnessed. An initial police report, dated 07/14/21 at 4:30 p.m. documented, On 07-14-2021 .Sgt. [name deleted] responded to [NAME]-[NAME] Nursing Home on a report of a possible Sexual Battery of a resident. Sgt. [name deleted] made contact with [name deleted], the Director of Nursing, and [name deleted], the Administrator of [NAME]-[NAME]. [name deleted] and [name deleted] gave Sgt. [name deleted] a brief overview of the incident and advised that [name deleted], the employee, had been sent home pending the completion of the investigation. Sgt. [name deleted] was advised that APS had been notified about the incident as well. [name deleted] escorted Sgt. [name deleted] to the room of [name deleted], an [AGE] year-old female, who suffers from Alzheimer's Dementia. [name deleted] (DON) told Sgt. [name deleted] that [name deleted], a [AGE] year-old male is employed as a maintenance worker. Sgt. [name deleted] met with Nurse [name deleted], the witness. Sgt. [name deleted] was not able to interview [name deleted] (maintenance worker). A statement by the maintenance supervisor, dated 07/15/21, documented he reviewed work orders and found two rooms for which maintenance staff #1 had work orders for on 07/14/21. Both work orders were for rooms other then that of Resdient #2. The statement documented to the best of his knowledge, the maintenance supervisor knew of no work to be done in resident #2's room. A written statement signed by maintenance staff #1, not dated, documented the maintenance staff was in resident #2's room checking the blinds. The statement documented he, pulled the covers up on [name deleted] to cover her up to keep her warm. Interview forms, dated 07/15/21 and signed by the social services director, documented eight residents were asked the question, Has anyone from the maintenance dept. ever been inappropriate in any way towards you? The interviews were conducted the following day after the sexual abuse had been observed by LPN #2. On 07/19/21 at 11:30 a.m., LPN #2 reported she was working the day of the incident involving resident #2. The LPN reported the resident had been given a shower, taken to her bed, and she wanted to check on the resident. The LPN reported she noticed the door to the resident's room was partly closed, which was very unusual because staff normally kept the door open to easily observe the resident and her roommate who were both at high risk for falls. The LPN stated she walked around the door and observed maintenance staff #1 bent over the resident, with one hand under the covers, and his hand moving back and forth over the resident's genitals. The LPN stated she stood there a second to see what he was doing, she was shocked, and immediately left the room. The LPN reported she went back to the nurse's desk without confronting the maintenance staff or intervening in any way. She stated maintenance came out of the resident's room shortly after. The LPN stated she then went to the DON and reported the incident, who in turn involved the ADM. LPN #2 and another nurse were instructed to assess the resident. The LPN stated the DON called the resident's family but she wasn't sure if anyone called the resident's physician. The LPN was asked what she would have done differently in this situation. She stated, I would have said something and made sure he left the room. On 07/19/21 at 2:45 p.m., the social services director reported she was not working the day of the incident involving resident #2. She stated she returned to work the following day on 07/15/21 and the DON and ADM briefed her on the incident. She reported she was assigned to interview residents and chose residents from the red and yellow units (long-term care halls) who were cognitively intact. She stated there were no cognitively intact residents who could be interviewed on the memory care unit. She reported she interviewed only residents, no staff, and to her knowledge a staff in-service was not done. She stated the facility had started their annual skills fair, which included abuse training, and some staff had done this on 07/15/21. She reported other staff would have the training on 07/22/21 but it was routine and not related to the incident with the resident. On 07/19/21 at 2:55 p.m., the resident was observed ambulating with CNA #1 who was observed to assist the resident with the use of a gait belt. The CNA reported she often worked on the same unit with the resident in the memory care unit. She stated she was working the day of the incident and observed police in the building. The CNA reported she wasn't told anything, was not interviewed, did not receive an in-service, and was made to feel it wasn't her business as to what was going on. On 07/19/21 at 3:20 p.m., the DON reported maintenance staff #1 had never had any issues or allegations against him. The DON stated the facility had not received anything back from the police but reported he was not arrested. The DON reported maintenance stated the resident was squirming in bed and he thought the resident was cold so he covered her up. The DON reported maintenance had already been sent home and suspended by the time the police arrived to the facility on [DATE]. The DON stated maintenance staff #1 was terminated two days later on 07/16/21. When asked why the employee was terminated, the DON reported it was not his place to be pulling covers up over the resident. The DON acknowledged the facility did not protect the resident #2 and resident interviews were not conducted in a timely manner. She then acknowledged all residents were not protected the way they should be. A copy of the facility termination form for maintenance staff #1, dated 07/16/21, was provided and reviewed. The employee file for maintenance staff #1 was reviewed and contained no other disciplinary measures or allegations of abuse. The employee had signed the facility abuse policy on 05/03/19. Background checks and sex offender checks were documented as clear upon hire. On 07/19/21 at 3:52 p.m., the maintenance supervisor (MS) was interviewed regarding the incident. He reported maintenance staff #1 had been given work orders to check on blinds in some of the resident rooms. The MS pulled the work orders and did not find one for resident #2's room. He stated maintenance staff #1 reported he was doing spot-checks in various rooms. He reported he went into the resident's room, noticed she looked cold, and covered her up. The MS reported he had worked at the facility for approximately six months and had not had an abuse in-service.

On 07/21/21 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy to prevent abuse and protect a resident from alleged sexual abuse. A licensed practical nurse/charge nurse observed the resident in bed and a facility maintenance staff member was observed to have his hand under the resident's covers, with his hand moving back and forth over the resident's genital area. The nurse did not intervene, did not separate the resident from the staff member, and left the room without protecting the resident from further potential abuse. The facility did not immediately interview other residents or staff members to identify potential concerns and further protect all residents. On 07/21/21, at 2:48 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 3:20 p.m., the administrator was notified of the IJ situation and informed the facility needed to submit a plan of removal. At 5:18 p.m., an acceptable plan of removal was provided. The plan of removal documented: 07/21/2021 - Plan of Removal (Immediate Jeopardy) Completion Date - 7/22/2021 - 10:00am #1 - The facility will in-service all employees either in person or over the phone on the facility abuse policy to include the following. a. Make sure employees know that if they witness potential abuse or neglect of ANY TYPE they must immediately intervene to stop the abuse or neglect of the resident (as long as doing so does not put their own life in danger). b. Reporting requirements and timelines when reporting abuse and neglect. Must be reported immediately to your Supervisor, DON, or Administrator. Completion Date - 7/21/2021 #2 - Reviewed facility policy to ensure policy is adequate for the reporting of abuse and neglect as well as adequate to prevent abuse and neglect. No changes have been made to current abuse prevention policy. Completion Date - 7/14/2021 (See attached) #3 - Immediately after reporting the alleged abuse to Administration, [name deleted], LPN was given a verbal reprimand on not intervening to stop the alleged abuse. She was in-service during the same conversation on her requirement to immediately intervene to stop any witnessed abuse or neglect. Completion Date - 7/14/2021 #4 - Maintenance employee was sent home on administrative leave with-in minutes of the allegations being made against him. His employment was terminated on 7/16/2021. Completion Date - 7/15/2021 #5 - Several alert and oriented residents were interviewed by [name deleted], Social Services Director on 7/15/2021 and asked about any inappropriate behavior or interactions with our maintenance team. All of the interviews spoke positively of the maintenance team, with no negative interactions noted. On 07/22/21, interviews were conducted with staff from all departments regarding education and in-service information pertaining to the immediate jeopardy plan of removal. Staff stated in-services were conducted the evening of 07/21/21 and the morning of 07/22/21. Staff members were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 07/22/21 at 11:15 a.m., the immediacy was removed when all components of the plan of removal had been completed. The deficient practice remained isolated with no actual harm with the potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to implement their abuse policy to protect a resident from sexual abuse for one (#2) of three residents reviewed for abuse. Licensed practical nurse (LPN) #2, the charge nurse, walked out of the resident's room, without intervening and separating the resident from the staff member who had sexually assaulted the resident. The facility did not immediately interview other residents or staff members to identify concerns and further protect all residents. The facility reported three allegations of abuse in the previous six months. Findings: The facility Abuse Investigation and Reporting policy documented the administrator would ensure that any further potential abuse, neglect, exploitation, or mistreatment was prevented. The policy documented the investigator would interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident. The policy documented other residents to whom the accused employee provided care or services would be interviewed. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 06/25/21, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with most activities of daily living and could ambulate with minimal assistance. A care plan, updated 06/29/21, documented the resident was out of her room daily for activities. The care plan documented the resident required a DepartAlert bracelet due to dementia and wandering. A progress note by the DON, dated 07/14/21 at 1:55 p.m., documented LPN #2 notified the DON and ADM of potential abuse to resident #2. The note documented the LPN walked into the resident's room and observed a maintenance employee leaning over the resident with his hand under the covers. The LPN reported she walked out of the room toward the nurse's station, turned around, and observed the maintenance man walking out of the room. The LPN then reported to the DON. A progress note, dated 07/14/21 at 2:43 p.m., documented RN #1 and LPN #2 assessed the resident in her room for any signs of sexual assault or injury. The note documented no distress noted. The note documented a full assessment of the resident's skin, including pubic area, inner thighs, and vaginal area without signs of redness or injury noted. A progress note, dated 07/14/21 at 4:03 p.m., documented the physician was notified of a report of alleged abuse to the resident. The physician was informed that at 1:50 p.m., LPN #2 observed a maintenance employee leaning over the resident in bed with his hand under the covers. The physician was informed of assessment findings and no new orders were received. A facility grievance management form, dated 07/14/21 and completed by the DON, documented LPN #2 reported a grievance against maintenance staff #1. The form documented it was a patient rights and safety concern. The description of the grievance documented, LPN witnessed maintenance employee leaned over bed of resident with his hand under cover. The form documented steps taken to investigate: police department contacted, statements obtained, APS contacted, and form 283 (an OSDH form) completed. A type-written statement by the facility administrator, dated 07/14/21, documented a verbal counseling with LPN #2. The statement documented the DON was present for the counseling. The statement documented counseling provided, .about making sure she intervenes immediately if she witnesses any type of activity that is potentially negatively affecting a resident in the facility. This includes any type of potential abuse or neglect of a patient. It is the responsibility of every MTNRC employee to ensure the safety and wellbeing of those residents under our care. A written statement by LPN #2, dated 07/14/21, documented she was entering resident #2's room and noted the door was part-way closed. The statement documented she stepped around the door and saw maintenance staff #1 leaning over the resident with his hand under the covers moving his hand in a back and forth manner over the resident's vaginal area. The statement documented, I then left the room and went back to the nurses desk a few moments later [name deleted] left the room and closed the door behind him. The statement documented the LPN then went to the DON's office to report what she had witnessed. An initial police report, dated 07/14/21 at 4:30 p.m. documented, On 07-14-2021 .Sgt. [name deleted] responded to [NAME]-[NAME] Nursing Home on a report of a possible Sexual Battery of a resident. Sgt. [name deleted] made contact with [name deleted], the Director of Nursing, and [name deleted], the Administrator of [NAME]-[NAME]. [name deleted] and [name deleted] gave Sgt. [name deleted] a brief overview of the incident and advised that [name deleted], the employee, had been sent home pending the completion of the investigation. Sgt. [name deleted] was advised that APS had been notified about the incident as well. [name deleted] escorted Sgt. [name deleted] to the room of [name deleted], an [AGE] year-old female, who suffers from Alzheimer's Dementia. [name deleted] (DON) told Sgt. [name deleted] that [name deleted], a [AGE] year-old male is employed as a maintenance worker. Sgt. [name deleted] met with Nurse [name deleted], the witness. Sgt. [name deleted] was not able to interview [name deleted] (maintenance worker). A statement by the maintenance supervisor, dated 07/15/21, documented he reviewed work orders and found two rooms for which maintenance staff #1 had work orders for on 07/14/21. The statement documented to the best of his knowledge, the maintenance supervisor knew of no work to be done in resident #2's room. A written statement signed by maintenance staff #1, not dated, documented the maintenance staff was in resident #2's room checking the blinds. The statement documented he, pulled the covers up on [name deleted] to cover her up to keep her warm. Resident interview forms, dated 07/15/21 and signed by the social services director the day after the incident, documented eight residents were asked the question, Has anyone from the maintenance dept. ever been inappropriate in any way towards you? The forms documented residents reported no issues and no negative outcomes reported. A copy of the facility termination form for maintenance staff #1, dated 07/16/21, was provided and reviewed. The employee file for maintenance staff #1 was reviewed and contained no other disciplinary measures or allegations of abuse. The employee had signed the facility abuse policy on 05/03/19. Background checks and sex offender checks were documented as clear upon hire. On 07/19/21 at 11:30 a.m., LPN #2 reported she was working the day of the incident involving resident #2. The LPN reported the resident had been given a shower, taken to her bed, and she wanted to check on the resident. The LPN reported she noticed the door to the resident's room was partly closed, which was very unusual because staff normally kept the door open to easily observe the resident and her roommate who were both at high risk for falls. The LPN stated she walked around the door and observed maintenance staff #1 bent over the resident, with one hand under the covers, and his hand moving back and forth over the resident's genitals. The LPN stated she stood there a second to see what he was doing, she was shocked, and immediately left the room. The LPN reported she went back to the nurse's desk without confronting the maintenance staff or intervening in any way. She stated maintenance came out of the resident's room shortly after. The LPN stated she then went to the DON and reported the incident, who in turn involved the ADM. LPN #2 and another nurse were instructed to assess the resident. The LPN stated the DON called the resident's family but she wasn't sure if anyone called the resident's physician. The LPN was asked what she would have done differently in this situation. She stated, I would have said something and made sure he left the room. On 07/19/21 at 2:45 p.m., the social services director reported she was not working the day of the incident involving resident #2. She stated she returned to work the following day on 07/15/21 and the DON and ADM briefed her on the incident. She reported she was assigned to interview residents and chose residents from the red and yellow units (long-term care halls) who were cognitively intact. She stated there were no cognitively intact residents who could be interviewed on the memory care unit. She reported she interviewed only residents, no staff, and to her knowledge a staff in-service was not done. She stated the facility had started their annual skills fair, which included abuse training, and some staff had done this on 07/15/21. She reported other staff would have the training on 07/22/21 but it was routine and not related to the incident with the resident. On 07/19/21 at 2:55 p.m., the resident was observed ambulating with CNA #1 who was observed to assist the resident with the use of a gait belt. The CNA reported she often worked on the same unit with the resident in the memory care unit. She stated she was working the day of the incident and observed police in the building. The CNA reported she wasn't told anything, was not interviewed, did not receive an in-service, and was made to feel it wasn't her business as to what was going on. On 07/19/21 at 3:20 p.m., the DON reported maintenance staff #1 had never had any issues or allegations against him. The DON stated the facility had not received anything back from the police but reported he was not arrested. The DON reported maintenance stated the resident was squirming in bed and he thought the resident was cold so he covered her up. The DON reported maintenance had already been sent home and suspended by the time the police arrived to the facility on [DATE]. The DON stated maintenance staff #1 was terminated two days later on 07/16/21. When asked why the employee was terminated, the DON reported it was not his place to be pulling covers up over the resident. The DON acknowledged the facility did not protect the resident #2 and resident interviews were not conducted in a timely manner. She then acknowledged all residents were not protected the way they should be. On 07/19/21 at 3:52 p.m., the maintenance supervisor (MS) was interviewed regarding the incident. He reported maintenance staff #1 had been given work orders to check on blinds in some of the resident rooms. The MS pulled the work orders and did not find one for resident #2's room. He stated maintenance staff #1 reported he was doing spot-checks in various rooms. He reported he went into the resident's room, noticed she looked cold, and covered her up. The MS reported he had worked at the facility for approximately six months and had not had an abuse in-service.

On 07/21/21 at 2:48 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect a resident from sexual abuse. A licensed practical nurse/charge nurse observed the resident in bed and a facility maintenance staff member was observed to have his hand under the resident's covers, with his hand moving back and forth over the resident's genital area. The nurse did not intervene, did not separate the resident from the staff member, and left the room without protecting the resident from further abuse. On 07/21/21, the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 3:20 p.m., the administrator was notified of the IJ situation. At 5:18 p.m., an acceptable plan of removal was provided. The plan of removal documented: 07/21/2021 - Plan of Removal (Immediate Jeopardy) Completion Date - 7/22/2021 - 10:00am #1 - The facility will in-service all employees either in person or over the phone on the facility abuse policy to include the following. a. Make sure employees know that if they witness potential abuse or neglect of ANY TYPE they must immediately intervene to stop the abuse or neglect of the resident (as long as doing so does not put their own life in danger). b. Reporting requirements and timelines when reporting abuse and neglect. Must be reported immediately to your Supervisor, DON, or Administrator. Completion Date - 7/21/2021 #2 - Reviewed facility policy to ensure policy is adequate for the reporting of abuse and neglect as well as adequate to prevent abuse and neglect. No changes have been made to current abuse prevention policy. Completion Date - 7/14/2021 (See attached) #3 - Immediately after reporting the alleged abuse to Administration, [name deleted], LPN was given a verbal reprimand on not intervening to stop the alleged abuse. She was in-service during the same conversation on her requirement to immediately intervene to stop any witnessed abuse or neglect. Completion Date - 7/14/2021 #4 - Maintenance employee was sent home on administrative leave with-in minutes of the allegations being made against him. His employment was terminated on 7/16/2021. Completion Date - 7/15/2021 #5 - Several alert and oriented residents were interviewed by [name deleted], Social Services Director on 7/15/2021 and asked about any inappropriate behavior or interactions with our maintenance team. All of the interviews spoke positively of the maintenance team, with no negative interactions noted. On 07/22/21, interviews were conducted with staff from all departments regarding education and in-service information pertaining to the immediate jeopardy plan of removal. Staff stated in-services were conducted the evening of 07/21/21 and the morning of 07/22/21. Staff members were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 07/22/21 at 11:15 a.m., the immediacy was removed when all components of the plan of removal had been completed. The deficient practice remained at a pattern with no actual harm with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to ensure a resident remained free from sexual abuse, and failed to immediately put effective measures in place, to intervene and protect the resident from sexual abuse for one (#2) of three residents reviewed for abuse. The licensed practical nurse/charge nurse walked out of the resident's room, without intervening and separating the resident from the staff member, while the staff member was sexually assaulting the resident. The facility reported three allegations of abuse in the previous six months. The facility reported 87 residents resided at the facility. Findings: The facility Abuse Investigation and Reporting policy documented the administrator would ensure that any further potential abuse, neglect, exploitation, or mistreatment was prevented. The policy documented the investigator would interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident. The policy documented other residents to whom the accused employee provided care or services would be interviewed. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 06/25/21, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with most activities of daily living and could ambulate with minimal assistance. A care plan, updated 06/29/21, documented the resident was out of her room daily for activities. The care plan also documented the resident required a DepartAlert bracelet due to dementia and wandering. A progress note by the DON, dated 07/14/21 at 1:55 p.m., documented LPN #2 notified the DON and ADM of potential abuse to resident #2. The note documented the LPN walked into the resident's room and observed a maintenance employee leaning over the resident with his hand under the covers. The LPN reported she walked out of the room toward the nurse's station, turned around, and observed the maintenance man walking out of the room. The LPN then reported to the DON. A progress note, dated 07/14/21 at 2:43 p.m., documented RN #1 and LPN #2 assessed the resident in her room for any signs of sexual assault or injury. The note documented no distress noted. The note documented a full assessment of the resident's skin, including pubic area, inner thighs, and vaginal area without signs of redness or injury noted. A progress note, dated 07/14/21 at 4:03 p.m., documented the physician was notified of a report of alleged abuse to the resident. The physician was informed that at 1:50 p.m., LPN #2 observed a maintenance employee leaning over the resident in bed with his hand under the covers. The physician was informed of assessment findings and no new orders were received. A facility grievance management form, dated 07/14/21 and completed by the DON, documented LPN #2 reported a grievance against maintenance staff #1. The form documented it was a patient rights and safety concern. The description of the grievance documented, LPN witnessed maintenance employee leaned over bed of resident with his hand under cover. The form documented steps taken to investigate: police department contacted, statements obtained, APS contacted, and form 283 (an OSDH form) completed. A type-written statement by the facility administrator, dated 07/14/21, documented a verbal counseling with LPN #2 was completed. The statement documented the DON was present for the counseling. The statement documented counseling provided, .about making sure she intervenes immediately if she witnesses any type of activity that is potentially negatively affecting a resident in the facility. This includes any type of potential abuse or neglect of a patient. It is the responsibility of every MTNRC employee to ensure the safety and wellbeing of those residents under our care. A written statement by LPN #2, dated 07/14/21, documented she was entering resident #2's room and noted the door was part-way closed. The statement documented she stepped around the door and saw maintenance staff #1 leaning over the resident with his hand under the covers moving his hand in a back and forth manner over the resident's vaginal area. The statement documented, I then left the room and went back to the nurses desk a few moments later [name deleted] left the room and closed the door behind him. The statement documented the LPN then went to the DON's office to report what she had witnessed. An initial police report, dated 07/14/21 at 4:30 p.m. documented, On 07-14-2021 .Sgt. [name deleted] responded to [NAME]-[NAME] Nursing Home on a report of a possible Sexual Battery of a resident. Sgt. [name deleted] made contact with [name deleted], the Director of Nursing, and [name deleted], the Administrator of [NAME]-[NAME]. [name deleted] and [name deleted] gave Sgt. [name deleted] a brief overview of the incident and advised that [name deleted], the employee, had been sent home pending the completion of the investigation. Sgt. [name deleted] was advised that APS had been notified about the incident as well. [name deleted] escorted Sgt. [name deleted] to the room of [name deleted], an [AGE] year-old female, who suffers from Alzheimer's Dementia. [name deleted] (DON) told Sgt. [name deleted] that [name deleted], a [AGE] year-old male is employed as a maintenance worker. Sgt. [name deleted] met with Nurse [name deleted], the witness. Sgt. [name deleted] was not able to interview [name deleted] (maintenance worker). A statement by the maintenance supervisor, dated 07/15/21, documented he reviewed work orders and found two rooms for which maintenance staff #1 had work orders for on 07/14/21. Both work orders were for rooms other then that of Resident #2. The statement documented to the best of his knowledge, the maintenance supervisor knew of no work to be done in resident #2's room. A written statement signed by maintenance staff #1, not dated, documented the maintenance staff was in resident #2's room checking the blinds. The statement documented he, pulled the covers up on [name deleted] to cover her up to keep her warm. Interview forms, dated 07/15/21 and signed by the social services director, documented eight residents were asked the question, Has anyone from the maintenance dept. ever been inappropriate in any way towards you? The interviews were conducted the following day after the sexual abuse had been observed by LPN #2. On 07/19/21 at 11:30 a.m., LPN #2 reported she was working the day of the incident involving resident #2. The LPN reported the resident had been given a shower, taken to her bed, and she wanted to check on the resident. The LPN reported she noticed the door to the resident's room was partly closed, which was very unusual because staff normally kept the door open to easily observe the resident and her roommate who were both at high risk for falls. The LPN stated she walked around the door and observed maintenance staff #1 bent over the resident, with one hand under the covers, and his hand moving back and forth over the resident's genitals. The LPN stated she stood there a second to see what he was doing, she was shocked, and immediately left the room. The LPN reported she went back to the nurse's desk without confronting the maintenance staff or intervening in any way. She then stated maintenance came out of the resident's room shortly after, and she then went to the DON and reported the incident, who in turn involved the ADM. She verified herself and another nurse were instructed to assess the resident. The LPN stated the DON called the resident's family but she wasn't sure if anyone called the resident's physician. The LPN was asked what she would have done differently in this situation. She stated, I would have said something and made sure he left the room. On 07/19/21 at 2:45 p.m., the social services director reported she was not working the day of the incident involving resident #2. She stated she returned to work the following day on 07/15/21 and the DON and ADM briefed her on the incident. She reported she was assigned to interview residents and chose residents from the red and yellow units (long-term care halls) who were cognitively intact. She stated there were no cognitively intact residents who could be interviewed on the memory care unit. She reported she interviewed only residents, no staff, and to her knowledge a staff in-service was not done. She stated the facility had started their annual skills fair, which included abuse training, and some staff had done this on 07/15/21. She reported other staff would have the training on 07/22/21 but it was routine and not related to the incident with the resident. On 07/19/21 at 2:55 p.m., the resident was observed ambulating with CNA #1 who was observed to assist the resident with the use of a gait belt. The CNA reported she often worked on the same unit with the resident in the memory care unit. She stated she was working the day of the incident and observed police in the building. The CNA reported she wasn't told anything, was not interviewed, did not receive an in-service, and was made to feel it wasn't her business as to what was going on. On 07/19/21 at 3:20 p.m., the DON reported maintenance staff #1 had never had any issues or allegations against him. The DON stated the facility had not received anything back from the police but reported he was not arrested. The DON reported maintenance stated the resident was squirming in bed and he thought the resident was cold so he covered her up. The DON reported maintenance had already been sent home and suspended by the time the police arrived to the facility on [DATE]. The DON stated maintenance staff #1 was terminated two days later on 07/16/21. When asked why the employee was terminated, the DON reported it was not his place to be pulling covers up over the resident. The DON acknowledged the facility did not protect resident #2 and resident interviews were not conducted in a timely manner. She then acknowledged all residents were not protected the way they should be. A copy of the facility termination form for maintenance staff #1, dated 07/16/21, was provided and reviewed. The employee file for maintenance staff #1 was reviewed and contained no other disciplinary measures or allegations of abuse. The employee had signed the facility abuse policy on 05/03/19. On 07/19/21 at 3:52 p.m., the maintenance supervisor (MS) was interviewed regarding the incident. He reported maintenance staff #1 had been given work orders to check on blinds in some of the resident rooms. The MS pulled the work orders and did not find one for resident #2's room. He stated maintenance staff #1 reported he was doing spot-checks in various rooms. He reported he went into the resident's room, noticed she looked cold, and covered her up. The MS reported he had worked at the facility for approximately six months and had not had an abuse in-service.

Based on record review and interview, it was determined the facility failed to ensure pain medication was obtained and administered as ordered by the physician for one (#1) of three sampled residents reviewed for pain. Resident #1 had to wait over 8 hours to receive pain medication after admission. The pain medication had to be brought from home. The resident complained of severe pain that she rated as a 6 and then as a 10 on a scale of 1-10 with 10 being the most severe. Findings: The resident was admitted on [DATE] between 10:30 a.m. and 11:00 a.m., with a [DIAGNOSES REDACTED]. The nursing admit/admission assessment, dated 10/05/17 at 11:03 a.m., documented the resident's pain was at a 6. The facimile transmission log, dated 10/05/17 at 5:13 p.m, documented the resident's prescription for the Percocet 7.5/325 mg PO 1 or 2 every 6 hours for pain had been faxed to the facility pharmacy. The Medication Administration Record, [REDACTED]. The documentation did not show this was the resident's home medication. The medication sign in log, dated 10/05/17, was reviewed with the floor staff for the resident's pain medication. The staff stated it had been signed by the night shift nurse and was received about 10:00 p.m. on the evening of 10/05/17. The resident's admission assessment, dated 10/12/17, documented the resident's cognition was intact. She required extensive assistance with bed mobility, transfers, dressing and toilet use. She required supervision for eating. On 10/17/17 at 12:00 p.m., the resident was asked about the day she was admitted to the facility and what could she tell me about her pain and pain medication. She stated, she had not received any pain medication right before leaving the local hospital. She stated, when she was admitted to the skilled nursing unit the nurse was notified of her pain and she requested a pain pill according to her pain pill schedule. She was told they had not received them yet, the order had to be sent to the pharmacy in Oklahoma City (OKC) and then brought down from there. Her husband was in the room at the time of the interview and he stated, I told the staff this was unacceptable. He stated, I called our family physician and told him about it. He said to use her home pain medication and have them give that to her. I went to the nurses station and told the registered nurse (RN) #1, LPN #2 and certified medication aide (CMA) they all sat there dumbfounded, they told me there was no other pharmacy they could use. None of them called a physician. Her pain level ranged between an 8 to 10. The CMA gave her, her home pain pills that I had gotten for her. The resident's husband stated he would not have become involved or called their primary care physician (PCP) if her pain hadn't risen to a critical level. I got involved because her pain was so severe. The RN and LPN knew about it because I personally asked them why her medication had not gotten here. The resident was asked if the facility physician came to see her the day she was admitted . She stated, Yes, I told him I needed some pain medication, he said he would let some one know and have them bring me something. At 1:43 p.m., CMA #1 was asked about this resident's pain and pain medication. She stated, The pain medication was not here when I arrived, it was still not here when I got off work at 7 p.m. She stated (RN #1) and (LPN #2) and the admitting nurse (LPN #1) were made aware that she didn't have her medication. She stated the script had been sent to the pharmacy in Oklahoma City that's why we didn't go to a local pharmacy. She stated she called the facility pharmacy to check on her medication. They said they hadn't received the fax. LPN #1 sent her fax to a wrong fax number so I refaxed it. She stated she talked to LPN #1 about it and showed her she sent it to a wrong number. The resident's husband was quite upset about it. He called their own PCP and used her home supply of medication. She stated she documented that she gave it to her. She was asked if she documented this was her home pain medication. She stated, I didn't document it was her home supply of pain medication. At 1:59 p.m., LPN #1 was asked about the resident's pain medication. She stated, when the order came from the hospital I faxed it to the pharmacy and then placed the order in Point Click Care (PCC) it was put in PCC at 10:09 a.m. She was asked if she followed up to ensure the medication had arrived within a timely manner. She stated, She was not aware the medication hadn't come in. She was asked what is the process if medication doesn't arrive in a timely manner. She stated, There is no process for us to ensure that we have their medication. She was shown the admit/assessment she had done that stated her pain was a 6. She was asked when was her pain at a 6. She stated when she arrived at the facility. She was asked if any nursing measures were taken to help relieve her pain. She stated, No, nothing was given for pain and no nursing measures were done. She stated, Her husband asked about her pain medication right after they arrived. I told them the order had been sent to the pharmacy. This initial fax was not found in the transmission log record. At 2:09 p.m., RN #1 was asked about the resident's pain medication on the day she was admitted to the facility. He stated, He was not aware she didn't have her pain medication. He was asked what was their process for ordering medication. He stated, we get the order, we put it in the computer and send it to the pharmacy in Oklahoma City. They have 4 hours to deliver it. What happens if you don't get it in 4 hours. He stated the assistant director of nursing (ADON) or director of nursing (DON) can go to the local pharmacy to pick up medication if the pharmacy in OKC is out. On 10/18/17 at 9:00 a.m., LPN #2 was asked about the residet's pain and pain medication. She stated, I went in her room around 4:00 p.m., to check on her, her pain was at a 10. I then told the CMA she needed pain medication. I was told her pain medication hadn't been delivered. Her husband called her PCP and her home medication was given to her. She was asked were any non-pharmacuetical pain relieveing nursing measures taken. She stated, No, I didn't do any other pain relieving measures. She was asked if any of this was documented. She stated, I didn't document anything on it. She was asked if the physician was notified. She stated, No, the script had already been faxed to the pharmacy. She was asked if someone could have gone to a local pharmacy to get it filled. She stated, We don't have permission to go to the local pharmacy and get medication that I'm aware of. At 1:30 p.m., the resident's PCP was asked about the resident's pain on 10/05/17 the day she was admitted to the facility. He stated, the resident's husband called me 4 or 5 times because she was in severe pain. The facility was having a problem getting her pain medication. Her husband was very upset. I called the floor and authorized them to give her, her home pain medication. At 2:27 p.m., the director of nursing (DON) was informed of the above findings regarding the resident's pain medication. She stated, She didn't know anything about all of this. She was asked if they should have contacted the local pharmacy to get the resident's pain medication. She stated, Yes. She was asked if they should have done other nursing measures to relieve the resident's pain. She stated, Yes. She stated, they should have contacted me or the administrator. She was in agreement the New Admission Check Sheet had not been followed to ensure resident's pain was controlled. She stated, All of the resident's medications were faxed to the pharmacy in Oklahoma City. I talked with them to see why they had not contacted us when they hadn't received the fax for her pain medication. They stated they can not see a narcotic order in the computer, they only know they have a narcotic order when they receive the faxed hardscript and since it was sent to a wrong number they didn't even know they had one to be filled. She stated, We didn't know this. At 2:28 p.m., the administrator was informed of the above findings regarding the resident's pain medication. He stated they were not aware this had happened. He stated, A large amount of turnover in staff had caused problems for us, a lot of the issues are due to new staff on the floor and the hospital had doubled our intake of skilled residents. He was informed that LPN #1 and LPN #2 stated they had not been trained on the medication policy, calling the physician, or permission to call another pharmacy if medications hadn't arrived in a timely manner. He stated, I don't believe it's a lack of education.

Based on interview and record review, it was determined the facility failed to administer pain medication in a timely manner to maintain a resident's highest well being and comfort for one (#1) of three sampled residents whose pain medication was reviewed. Resident #1 had to wait over 8 hours to receive pain medication after admission. The pain medication had to be brought from home. The resident complained of severe pain that she rated as a 6 and then as a 10 on a scale of 1-10 with 10 being the most severe. This had the potential to effect all 134 residents who resided in the facility. Findings: The resident was admitted on [DATE] between 10:30 a.m. and 11:00 a.m., with a [DIAGNOSES REDACTED]. On 10/05/17 at 11:03 a.m., the nursing admit/admission assessment, documented the residents' pain was at a 6 (On a pain scale of 0 to 10, 0 being none and 10 being severe). No initial care plan for pain was found. A physician's progress note, dated 10/05/17 at 3:07 p.m., documented the resident's pain is controlled for now . The facimile transmission log documented the resident's prescription had been faxed to the pharmacy on 10/05/17 at 5:13 p.m. The Medication Administration Record, [REDACTED]. The documentation did not show this was the resident's home medication. A skilled nurse's daily assessment record, dated 10/05/17 at 6:38 p.m., had no documentation for pain under the pain section. The medication sign in log, dated 10/05/17, was reviewed with the floor staff for the resident's pain medication. The staff stated it had been signed by the night shift nurse and was received about 10:00 p.m. on the evening of 10/05/17. The resident's admission assessment, dated 10/12/17, documented the resident's cognition was intact. She required extensive assistance with bed mobility, transfers, dressing and toilet use. She required supervision for eating. On 10/17/17 at 12:00 p.m., the resident was asked about the day she was admitted to the facility and what could she tell me about her pain and pain medication. She stated, she had not received any pain medication right before leaving the local hospital. She stated when she was admitted to the skilled nursing unit the nurse was notified of her pain and she requested a pain pill according to her pain pill schedule. She was told they had not received them yet, the order had to be sent to the pharmacy in Oklahoma City (OKC) and then brought down from there. Her husband was in the room at the time of the interview and he stated, I told the staff this was unacceptable. I called our family physician and told him about it. He said to use her home pain medication and have them give that to her. I went to the nurse's station and told the registered nurse (RN), LPN and certified medication aide (CMA) they all sat there dumbfounded, they told me there was no other pharmacy they could use. None of them called a physician. Her pain level ranged between an 8 and 10. The CMA gave her, her home pain pills that I had obtained for her. The resident's husband stated I would not have become involved or called their primary care physician (PCP) if her pain hadn't risen to a critical level. I got involved because her pain was so severe. The RN and LPN knew about it because I personally asked them why her medication had not gotten here. The resident was asked if the facility physician came to see her the day she was admitted . She stated, Yes, I told him I needed some pain medication, he said he would let someone know and have them bring me something. At 1:43 p.m., CMA #1 was asked about the resident's pain and pain medication. She stated the resident's pain medication was not here when she arrived, it was still not here when I got off at 7 p.m. She stated (RN #1), (LPN #2) and the admitting nurse (LPN #1) were made aware that she didn't have her medication. The script had been sent to the facility pharmacy in OKC that's why we didn't go to a local pharmacy. She stated she called the facility pharmacy to check on her medication. They said they hadn't received the fax. She stated (LPN #1) sent the fax to a wrong fax number so I refaxed it. She stated she talked to LPN #1 about it and showed her she sent it to a wrong number. The resident's husband was quite upset about it. He called their own PCP and used her home supply of medication. She stated I documented that I gave it to her, I didn't document it was her home supply of pain medication. At 1:59 p.m., LPN #1 was asked about the resident's pain medication. She stated, when the order came from the hospital I faxed it to the pharmacy and then placed the order in Point Click Care (PCC) it was put in PCC at 10:09 a.m. She was asked if she followed up to ensure the medication had arrived within a timely manner. She stated, I was not aware the medication hadn't come in. She was asked what is the process if a medication doesn't arrive in a timely manner. She stated, There is no process for us to ensure that we have their medication. She was shown the admit/assessment in PCC she had done that stated her pain was a 6. She was asked when was the resident's pain at a 6. She stated when she arrived at the facility. She was asked if any nursing measures were taken to help relieve her pain. She stated, No, nothing was given for pain and no nursing measures were done. She stated, Her husband asked about her pain medication right after they arrived. I told them the order had been sent to the pharmacy. This initial fax was not found in the transmission log record. At 2:09 p.m., RN #1 was asked about the resident's pain medication on the day she was admitted to the facility. He stated, He was not aware she didn't have her pain medication. He was asked what was their process for ordering medication. He stated, when we get the order, we put it in the computer and send it to the pharmacy in OKC. They have 4 hours to deliver it. He was asked what happens if it is not received in 4 hours. He stated the assistant director of nursing (ADON) or director of nursing (DON) can go to the local pharmacy to pick up medication if the pharmacy in OKC is out. On 10/18/17 at 9:00 a.m., LPN #2 was asked about this resident's pain and pain medication. She stated, I went in her room around 4:00 p.m. to check on her, her pain was at a 10. I then told the CMA she needed pain medication. I was told her pain medication hadn't been delivered. Her husband called her PCP and her home medication was given to her. She was asked were any non-pharmacuetical pain relieving measures taken. She stated, No, I didn't do any other pain relieving measures. She was asked if any of this was documented. She stated, I didn't document anything on it. She was asked if the physician was notified. She stated, No, the script had already been faxed to the pharmacy. She was asked if someone could have gone to a local pharmacy to get it filled. She stated, We don't have permission to go to the local pharmacy and get medication that I'm aware of. At 1:30 p.m., the resident's PCP was asked about the resident's pain on 10/05/17 the day she was admitted to the facility. He stated, her husband called me 4 or 5 times because she was in severe pain. The facility was having a problem getting her pain medication. Her husband was very upset. I called the floor and authorized them to give her, her home pain medication. He stated, The staff acted relieved that someone was doing something about it. At 2:27 p.m., the DON was informed of the above findings regarding the resident's pain medication. She stated, She didn't know anything about all of this. She was asked if they should have contacted the local pharmacy to get the resident's pain medication. She stated, Yes She was asked if they should have done other nursing measures to relieve the resident's pain. She stated, Yes. She stated, they should have contacted me or the administrator. She was in agreement the New Admission Check Sheet had not been followed to ensure resident's pain was controlled.

Based on interview and record review, it was determined the facility failed to ensure a resident was not transferred to bed after falling in the bathroom. The resident was assessed to have a significant injury and severe pain prior to and after the transfer for one (#1) of three residents whose records were reviewed for falls. This had the potential to effect 96 residents in the facility who were at risk for falls according to the director of nursing. Findings: Resident #1 had [DIAGNOSES REDACTED]. An annual assessment, dated 08/09/17, documented the resident's cognition was intact. She required supervision with transfers, dressing, and eating. She was independent with walking. A Morse Fall Scale (a scale to determine a resident's risk for falls), dated 08/10/17, documented the resident was a high risk for falling. The facility policy and procedure for, After a Fall documented, . 3. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position . A health status note, dated 08/22/17, documented, Writer heard resident yelling for help and roommate yelling this lady fell , she's on the floor. Writer and LPN (name deleted) run into room. Resident was laying on right side head out of the bathroom door entrance, body laying in bathroom. Resident yelling that she is in pain. Head to toe (assessment) done and noted excruciating pain to left lower back, left hip, and left leg. Unable to move left leg. Staff x (times) 5 used sheet under her to lift her to the bed . Once in bed on back she was yelling in pain. Used sheet to turn her on right side and small size pillow between knees . but was yelling for somebody to just give her a shot in her hip for pain Notified MD (name deleted) . if in a lot of pain send to ER for x-rays . transported by (name deleted) ambulance . The local area hospital (name deleted) Operative report, dated 08/23/17, documented the resident had a left hip femur fracture. On 09/06/17 at 10:30 a.m., licensed practical nurse #1 was interviewed and asked about the resident's fall. She stated the resident was yelling and yelling and yelling and screaming in pain. We moved her to the bed cause we were trying to make her comfortable. She was then screaming for a shot, shot, shot. We probably shouldn't have moved her. I told the Dr. she was in excruciating pain and needed to be sent out for an X-ray. I would have left her there if I knew her hip was broken. She was asked if her assessment was considered to be a significant injury. She stated, Oh Yes. At 11:00 a.m., the director of nursing was interviewed and asked if someone falls and is screaming out in pain, would you move them. She stated, We would not move them if they are in pain, we would call an ambulance. She was asked if the resident should have been moved. She stated, No, she shouldn't have been.

Based on record review and interview it was determined the facility failed to ~administer pain medication in a timely manner to maintain a residents well-being and comfort for one (#2) of three sampled residents whose pain medication administration was reviewed and ~ follow physician's orders [REDACTED].#2) of three residents reviewed for physician's orders [REDACTED]. This had the potential to affect all 128 residents who resided in the facility. The resident had to wait greater than 10 hours to receive pain medication after being admitted to the facility. This resulted in harm to the resident. Findings: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, dated 02/20/17, documented the resident's cognition was intact and she required extensive assistance for transfers, dressing, and bathing. The admission nursing assessment, dated 02/17/17 at 12:40 p.m., documented the resident had a pain level of a 9 (0-10 pain scale with 0 being none and 10 being severe) on admission to the facility. The physician's orders [REDACTED]. A weights and vitals summary, dated 02/17/17 at 5:26 p.m., documented the resident's pain level was a 6 and at 10:02 p.m., the pain level was documented at a 10. A pharmacy record documented the pain medication orders were received by the pharmacy on 02/17/17 and were not delivered to the facility until 02/18/17 at 1:58 a.m. The resident was discharged to another facility on 03/02/17. On 03/08/17 at 4:26 p.m., a family member of the resident was contacted by phone. She stated the ordered medications had not been delivered to the facility and she had given the resident her pain medication she had from home sometime around midnight on 02/18/17, with the facility's permission. On 03/08/17 at 3:20 p.m., the assistant director of nursing (ADON) stated the physician had not correctly dated the hard scripts for the pain medications and that caused the delay. On 03/09/17 at 11:00 a.m., the DON stated she provided an in-service on 03/03/17 for all nurses and certified medication aides (CMA's). The nurses and CMA's were given a new policy to read for ordering narcotic medications. The policy documented, Mark orders as STAT (immediately), .if there is a problem with hard scrips (not received, no date, etc.) call the physician and ask them to call in an emergency order to one of the local pharmacies .a staff member will then need to go pick up the medication. The in-service signature sheets were reviewed. The following staff members had signed the document. On 03/09/17 at 2:40 p.m., registered nurse #1 was interviewed and asked how the new medication policy was working. She stated, We are still having problems. When we need a STAT order for 4 hours, it still takes 6 hours or more. If we have to get the doctor involved it usually takes until the next day. This is our biggest complaint from our new admits. At 2:42 p.m., licensed practical nurse #1 was interviewed and asked about the new medication policy. She was asked what the time frame was for a STAT order. She stated I don't know a time frame for it. She was asked what do you do if the pharmacy takes more than 4 hours. She stated I would call the pharmacy again or call the family. She was not aware that a staff member could go to a local pharmacy and pick up the medication. At 2:45 p.m., licensed practical nurse #2 was interviewed and asked about the new medication policy. She was asked what the time frame for STAT was. She stated, I don't know a time frame but I think it would be within the same day. She was asked, what would you do if you don't get the medication in the same day. She stated, I would have the doctor call a local pharmacy and have the pharmacy deliver it. She was asked if she had ever been told a staff member could go to the local pharmacy and pick it up. She stated, I've never been told anything like that before.

Based on record review and interviews, it was determined the facility failed to have an effective system for ordering and obtaining sleep medication and pain medication in a timely manner for one (#2) of three sampled residents whose medications were reviewed. Resident #2 had to wait over 10 hours to receive pain medication after admission. This resulted in harm to the resident. Findings: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, dated 02/20/17, documented the resident's cognition was intact and she required extensive assistance for transfers, dressing, and bathing. The admission nursing assessment, dated 02/17/17 at 12:40 p.m., documented the resident had a pain level of a 9 (0-10 pain scale with 0 being none and 10 being severe) on admission. The physician's orders [REDACTED]. A weights and vitals summary, dated 02/17/17 at 5:26 p.m., documented the resident's pain level at a 6 and at 10:02 p.m., the pain level was documented at a 10. A pharmacy record documented the pain medication orders were received by the pharmacy on 02/17/17 and were not delivered to the facility until 02/18/17 at 1:58 a.m. A physician's orders [REDACTED]. An individual narcotic record for the Restoril documented the medication ran out on 02/24/17 and no more was received by the facility until 02/26/17. The resident had not received the medication on 02/25/17. The resident was discharged to another facility on 03/02/17. On 03/08/17 at 4:26 p.m., a family member of the resident was contacted by phone. She stated the ordered medications had not been delivered to the facility and she had given the resident her pain and sleep medications from home sometime around midnight on 02/18/17 with the facility's permission. On 03/08/17 at 3:20 p.m., the assistant director of nursing (ADON) stated the physician had not correctly dated the hard scripts for the pain medication which caused the delay. On 03/09/17 at 11:00 a.m., the DON (director of nurses) stated she provided an in-service on 03/03/17 for all nurses and certified medication aides (CMA's). The nurses and CMA's were given a new policy to read for ordering narcotic medications. The policy documented, .Mark orders as STAT (immediately) .if there is a problem with hard scrips (not received, no date, etc.) call the physician and ask them to call in an emergency order to one of the local pharmacies .a staff member will then need to go pick up the medication. The in-service signature sheets were reviewed. The following staff members had signed the document. At 2:40 p.m., registered nurse #1 was interviewed and asked how the new medication policy was working. She stated, We are still having problems. When we need a STAT for 4 hours it still takes 6 hours or more. If we have to get the doctor involved it usually takes until the next day. This is our biggest complaint from our new admits. At 2:42 p.m., licensed practical nurse #1 was interviewed and asked about the new medication policy. She was asked what the time frame was for a STAT order. She stated I don't know a time frame for it. She was asked what do you do if the pharmacy takes more than 4 hours. She stated I would call the pharmacy again or call the family. She was not aware that a staff member could go to a local pharmacy and pick up the medication. At 2:45 p.m., licensed practical nurse #2 was interviewed and asked about the new medication policy. She was asked what the time frame for STAT was. She stated, I don't know a time frame but I think it would be within the same day. She was asked what would she do if the facility didn't get the medication in the same day. She stated, I would have the doctor call a local pharmacy and have the pharmacy deliver it. She stated she had never bee been told a staff member could go to the local pharmacy and pick up the medication for a resident. At 3:00 p.m, the DON stated the resident's Restoril had changed from a scheduled dose to an as needed dosing on 02/22/17 and had required another hard script signed by the physician for the pharmacy to fill it. She was in agreement the medication was not available for the resident on 02/25/17.

Based on record review and interviews, it was determined the facility failed to have an effective system for ordering and obtaining pain medication in a timely manner for one (#1) of three sampled residents whose medications were reviewed. Resident #1 had to wait 6 hours to receive pain medication after complaining of pain. This resulted in harm to the resident. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's clinical record was reviewed. The resident had been admitted to the facility on [DATE] at 4:30 p.m. from an out-of-state hospital. He was discharged from the facility on 01/16/17. The admission nursing assessment, dated 01/05/17 at 4:30 p.m., documented the resident had a pain level of an 8 (0-10 pain scale with 0 being none and 10 being severe) on admission. The admission assessment dated [DATE], documented the resident's cognition was intact and he required minimal assistance of one staff for transfer, dressing and bathing. On 02/10/17 at 10:15 a.m., the director of nursing (DON) stated the physician's orders [REDACTED]. At 10:51 a.m. the resident was contacted by phone. He stated when he arrived at the facility he was in a lot of pain and he stated he had to wait a long time before he received any pain medication. He stated he only received 5 milligrams (mg) of his pain medication and he had previously been taking 15 mg. He stated he was in pain all night even after he received the medication. He stated he had not received the 15 mg dose of his pain medication until late the next day. He stated he had asked for his antianxiety medication the next morning along with his 5 mg of his pain medication. He stated the anxiety medication helped him to calm down. At 11:15 a.m.,the nurse who admitted the resident was interviewed via phone. She stated she had 3 admissions that same day and she stated the resident had not came with a handwritten prescription for his pain medication. She also stated the DON was assisting her with his admission. She stated sometimes it just took a while to get medication from the pharmacy. At 1:25 p.m., the DON stated she notified the facility's medical director on 01/05/17 at 7:06 p.m. The medical director gave a verbal order to the facility's pharmacy for Percocet (pain medication) 5 mg one tab every 4-6 hours as needed for pain. The facility's pharmacy was located approximately 86 miles from the facility. The pain medication was not received by the facility until 10:08 p.m. that night. The resident's January 2017 Medication Administration Record [REDACTED]. On 02/10/17 at 1:25 p.m., the DON agreed the resident should not have had to wait 6 hours for pain medication.

Based on record review and interview, it was determined the facility failed to ~administer pain medication in a timely manner to maintain a residents well-being for one (#1) of three sampled residents whose pain medication administration was reviewed and ~follow physician's orders [REDACTED].#1) of three residents reviewed for physician's orders [REDACTED]. This had the potential to affect all 118 residents who resided in the facility. The resident had to wait 6 hours to receive pain medication after complaining of pain. This resulted in harm to the resident. Findings: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, dated 01/12/17, documented the resident's cognition was intact and he required minimal assistance of one staff for transfer, dressing and bathing. The resident had been admitted to the facility on [DATE] at 4:30 p.m. from an out-of-state hospital. He was discharged from the facility on 01/16/17. The admission nursing assessment, dated 01/05/17 at 4:30 p.m., documented the resident had a pain level of an 8 (0-10 pain scale with 0 being none and 10 being severe) on admission. On 02/10/17 at 10:15 a.m., the director of nursing (DON) stated the physician's orders [REDACTED]. At 10:51 a.m. the resident was contacted by phone. He stated when he arrived at the facility he was in a lot of pain and he had to wait a long time before he received any pain medication. He stated he only received 5 milligrams (mg) of his pain medication and he had previously been taking 15 mg. He stated he was in pain all night even after he received the medication. He stated he had not received the 15 mg dose of his pain medication until late the next day. He stated he had asked for his antianxiety medication the next morning along with his 5 mg of his pain medication. He stated the anxiety medication helped him to calm down. At 11:15 a.m.,the nurse who admitted resident #1 was interviewed via phone. She stated she had 3 admissions that same day and stated the named resident had not came with a handwritten prescription for his pain medication. She also stated the DON was assisting her with his admission. She stated sometimes it just took a while to get medication from the pharmacy. At 12:30 p.m., the wound nurse was interviewed. She stated she was working the day of the resident's admission. She stated the resident voiced to her he was in moderate to severe pain upon admission and the resident would not allow her to assess his abdominal wound or change his dressing until he had pain medication. At 1:25 p.m., the DON stated she should have called the out-of-state hospital the resident was discharged from for clarification of the narcotic pain medication order. According to the DON, the resident's attending physician was notified and he was out of town and wasn't able to give the facility a handwritten prescription for the pain medication. The DON stated she notified the facility's medical director on 01/05/17 at 7:06 p.m. The medical director gave a verbal order to the facility's pharmacy for [MEDICATION NAME] (pain medication) 5 mg one tab every 4-6 hours as needed for pain. The facility's pharmacy was located in another city approximately 86 miles from the facility. The pain medication was not received by the facility until 10:08 p.m. that night. The resident's January 2017 medication administration record (MAR) documented the pain medication had not been given to the resident until 10:33 p.m. The record documented his pain level was an 8. On 02/10/17 at 1:25 p.m., the DON agreed the resident should not have had to wait 6 hours for his pain medication. The resident's January 2017 MAR and physician's orders [REDACTED]. The MAR documented on 01/06/17 at 5:55 a.m., he received 5 mg tab of [MEDICATION NAME] for a pain level of a 7. On 01/06/17 at 7:00 a.m. one hour and 5 minutes later, the MAR documented the resident was given another [MEDICATION NAME] for a pain level of 10. No documentation was found in the clinical record to indicate the nurse called the physician to inform him of the resident's increased pain or to obtain an order to give another [MEDICATION NAME]. The physician's orders [REDACTED]. At 1:27 p.m., the DON was asked if she knew why the physician's orders [REDACTED]. She stated she had not known, but she would investigate to find out why.

Based on observation, interview and record review, it was determined the facility failed to ensure adequate supervision and other interventions were put in place to prevent falls for one (#39) of 10 residents reviewed for falls. This resulted in actual harm of a nose fracture to resident #39. This had the potential to affect 104 residents that are at high risk for falls according to the director of nurses. Findings: 1. Resident #39 had [DIAGNOSES REDACTED]. The admission assessment, dated 03/22/16, documented the resident's cognition was moderately impaired. She required extensive assistance with transfers, locomotion, dressing, toileting, and hygiene. She required set up for eating. She was frequently incontinent of bladder and always incontinent of bowel. The resident's careplan documented, Revision on: 01/11/2016 *Bed pad alarm when in bed date initiated: 09/08/2015. * safety mat at bedside when res (resident) in bed date initiated: 09/14/2015 . A fall risk assessment, dated 03/15/16, documented the resident was at high risk for falls. A clinical record review documented the resident had 12 falls between 08/17/15 and 06/06/16. It documented with three of these falls she reported hitting her head. A nurse's notes, dated 04/10/16 at 8:35 a.m., documented, Resident found in room on the floor lying in supine position with right eye hematoma with bleeding noted as well as possible nose fracture (fx). Resident very lethargic. Pain 7/10 to right hip and right side of face .Resident states that she was trying to get up and get coffee. Resident floor mat not in place, bed alarm not on, and bed not in lowest position when resident fell out of bed as described by appearance of room at time of incident . Resident sent to (local hospital). A nurse's note, at 12:24 p.m., documented, Received resident back from ER (emergency) via stretcher with ems (emergency medical staff) at side . Report received from (name deleted) registered nurse (RN) at (local hospital) . Resident has nose fracture (fx), right orbital hematoma . On 06/20/16 at 9:00 a.m., licensed practical nurse #1 was interviewed and asked if the resident ever had increased supervision. She stated, She has not had any increased supervision since being on the blue hall. She came to the blue hall on 04/06/16. Extra supervision has never been careplanned for her. At 9:19 a.m., certified nurse aide #2 was interviewed and asked if she felt the resident needed extra supervision. She stated, Most the time I feel that she needs extra supervision. But no one has ever told me she needs extra supervision. At 1:16 p.m., the assistant director of nurses was interviewed and asked if the appropriate interventions were in place to prevent falls. She stated, No, they should have been.

Based on interview, observation, and record review it was determined the facility failed to ensure a resident's pain was controlled for one (#1) of three sampled residents whose records were reviewed for timely administration of medication. This had the potential to affect all 129 residents residing in the facility. Findings: A quarterly assessment for resident #1 dated 04/12/15, documented her cognition was intact. She was independent in all her activities of daily living. She was always continent of bowel and bladder. Her pain frequency was almost constantly and pain intensity was documented at a numeric rating of 10, (on a numeric rating pain scale 0 -10 where 10 is the worst pain) for the 5 day look back period. [DIAGNOSES REDACTED]. The facility's Administering Medications Policy Statement documented: #3) Medications must be administered in accordance with the orders . including any required time frame. #4) Medications must be administered within one (1) hour of their prescribed time . The facility Medication Administration Times Policy documented: for pain meds: Daily - QID - 8am, 2pm, 8pm, 2am. This was handwritten on the policy in a box. Q 6 hrs (every 6 hours) read: 8am-10am, 12pm-2pm, 6pm-8pm, 12am-2am. The April, May and June Medication Administration Record [REDACTED]. E. [MEDICATION NAME] 1 tab. by mouth Q 6 h (every 6 hours) at 8 a.m., at 2 p.m., at 8 p.m., and at 2 a.m. A care plan for chronic pain r/t (related to) [MEDICAL CONDITION] arthritis and migraine was initiated on 04/14/14 revised on 09/24/14 with a target date of 07/06/15. Goal: The resident will verbalize adequate relief of pain . Intervention: Anticipate the residents need for pain relief and respond immediately to any complaint of pain. A care plan for [MEDICAL CONDITION] was initiated 06/09/14 revised on 01/13/15 with a target date 07/06/15 documented: Resident states that pain is a big factor that sometimes does not let her sleep . Clinical record review for resident #1 revealed her last pain assessment was dated 03/29/15, and documented: What makes your pain better, medication/sleep. Effects of pain on ADLS (activities of daily living): Sleep and rest, yes. Social activities, yes. Physical activity and mobility, yes. Emotions, yes. There were no pain assessments documented for April or May. A nurse's note for resident #1, dated 05/04/15, documented . resident questioned pain medication administration. Provided information on medication information times. Signed by assistant director of nurses. On 06/01/15 at 9:05 p.m., resident #1 stated, My medications are not usually given on time. My night pills are due at 8 p.m. and I usually don't get them until 10 p.m. or later. My pain pills are given late too. I have it all written down in a book, do you want to see it? My Dr. wants me to get up at 8:00 a.m. but when they bring my medication in late, then I sleep in the next morning. It throws me off. When I'm in a lot of pain and I ask for my medication. The staff says, I'll get to you when I get to you. The administrator is aware of me getting my pills late. He just says, we'll work on it. The resident's notebook revealed: April 23rd, [MEDICATION NAME] due at 8 a.m., given at 12:20 p.m. April 30th, [MEDICATION NAME] due at 8 p.m., given at 10:30 p.m. May 3rd, [MEDICATION NAME] due at 8 p.m., given at 10:30 p.m. May 4th, [MEDICATION NAME] due at 8 p.m., given at 10:00 p.m. May 7th, [MEDICATION NAME] due at 8 p.m., given at 10:00 p.m. May 8th, [MEDICATION NAME] due at 8 p.m., given at 10:35 p.m. May 12th, [MEDICATION NAME] due at 8 p.m. given at 10:00 p.m. May 20th, [MEDICATION NAME] due at 8 a.m., given at 11:25 a.m. May 20th, [MEDICATION NAME] due at 2 p.m., given at 3:55 p.m. May 25th [MEDICATION NAME] due at 8 a.m., given at 10:30 a.m. May 28th [MEDICATION NAME] due at 8 a.m., given at 10:45 a.m. On 06/01/15 at 9:45 p.m., licensed practical nurse #1 was observed passing the 8:00 p.m. medications. She was asked what the medication policy was for the time window for passing medications. She stated, One hour before or one hour after they are due. She was asked if the medications being administered were late. She stated, Yes, they are late and I still have a lot to pass. At 10:30 a.m., the consulting pharmacist was asked if a medication was prescribed at 8:00 p.m. what is the time range for that medication to be given. He stated, The facility provides us with the range. We put that range on the medication administration record. The 1 hour before and 1 hour after should not be applied because the range is already there. At 11:45 a.m., the assistant director of nurses stated, If the order says 8 p.m. the window should be 7 p.m. to 9 p.m. At 12:25 p.m., Resident #1 was asked if she knows the policy for medication administration times. The resident stated, The assistant director of nurses told me I should have received my medication one hour before or one hour after it's due. The ombudsman told me the window should be one hour before or one hour after On 06/02/15 at 12:40 p.m., The resident was asked if she received her pain medication on time and was her pain controlled. She stated, When I receive it on time it's controlled, it's tolerable. When I'm in pain I can't function very well. I missed some of my activities a couple of weeks ago and I missed bingo cause I was in pain. Do you let them know when you're in pain? Yes, I tell the aides that come in my room I'm in pain when I don't get my medication on time. I've told staff. I can't deal with this anymore, I'm in too much pain. At 1:15 p.m., certified nurse aide (#1) was asked if resident #1 ever told you she was in pain. She stated, Yes, when she told me she was in pain, I would go straight to the nurse and tell her, I don't know if the nurse went right away or not. She has told me her pain meds were late. It has happened quite often, but not every day. At 1:19 p.m., certified nurse aide (#2) was asked if resident #1 ever told you she's in pain. She stated, She has called us into her room often to ask for her PRN (as needed) pain medication. Sometimes she has called us in again, and says they haven't brought them in so, we have told the nurse again. The nurses have given them late because there is only one nurse. She (resident #1) keeps a book and puts the times her meds are given and who is giving it to her. On 06/05/15 at 2:30 p.m., the administrator was asked if he was aware that resident #1 had received her medication late. He stated, She has commented to me a couple of times that her meds were late. What did you do with that information? I had reported it to the director of nurses. She (name deleted) has told me her medication she was getting was not enough. I think an adjustment from the physician needs to be done. I'm not sure if that's been done. At 2:40 p.m., the director of nurses was asked if she was aware that resident #1's pain had not been controlled. She stated, No one has told me (resident's name deleted) has complained of being in pain. She was asked what was their policy on pain assessments being completed? She stated, They should be done monthly and quarterly by the registered nurse.

On [DATE] at 7:15 p.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to fully investigate allegations of abuse. At 7:22 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 7:35 p.m., the facility administrator and director of nurses (DON) were notified of the existence of an IJ pertaining to the failure to fully investigate and protect all residents from abuse. At 11:35 p.m., the facility submitted an acceptable plan of removal which documented: "...Plan of Removal of Immediate Jeopardy Steps: 1. Employee (name withheld) was immediately suspended on [DATE] at 8:00 p.m. by Administrator, Kip Cummins and Senior Director of Human Resources until further investigation is finalized. 2. Employee (name withheld) was immediately suspended on [DATE] at 8:20 p.m. by Administrator, Kip Cummins and Senior Director of Human Resources until further investigation is finalized. 3. Resident Abuse Prevention Policy #910 dated [DATE] by Kip Cummins, Administrator and Tammy Roberts, Director of Nursing was reviewed immediately and approved. 4. Re-educate all McMahon-Tomlinson Nursing Center's employees to include Administrator and Director of nursing on Resident Abuse Prevention Policy #910 via mandatory in-service to be started by 9:00 p.m. on [DATE] and be completed by 5:00 p.m. on [DATE]. No employee will be allowed to work in the facility after this date and time without completion of education. 5. Each employee will sign an "Acknowledgement of Abuse Policy and Reporting Requirements" after following re-education on the Resident Abuse Prevention Policy #910 by 5:00 p.m. on [DATE]. No employee will be allowed to work in the facility after this date and time until "Acknowledgement of Abuse Policy and Reporting Requirement" is signed. 6. Each employee will also satisfactorily complete "Abuse Prohibition Management Program Post Test". No employee will be allowed to work in the facility after this date and time until "Abuse Prohibition Management Program Post Test" is completed. 7. The Administrator, the Director of Nursing, or person designated on their behalf will receive and investigate all complaints of abuse immediately. This person will be identified on the staffing schedule to begin at 9:00 p.m. at [DATE]. 8. Immediate Investigation of any alleged abuse will be conducted by the above identified staff member. The report will contain the following: a. Immediate removal of the alleged perpetrator. b. Head to toe evaluation will be completed on the resident involved. c. The date and time the incident took place. d. The circumstances surrounding the incident. e. Where the incident took place. f. The names of any witnesses and their account of the incident; including written statements. g. The residents' account of the incident. h. The employee's account of the incident; written statement. i. Accounts of any other individuals involved (i.e., employee's supervisor, etc.); and 9. All abuse complaints to be immediately communicated to the Administrator, Director of Nursing or person designated on their behalf. 10. Initial reports will be submitted within 24 hours to the OK State Department of Health. 11. An investigation of the facility for abuse and neglect to include interviews with 100% of residents and/or family members will be conducted by 5 p.m. on [DATE]." On [DATE] at 5:00 p.m., the IJ was removed after inservices and post tests were completed and staff were interviewed and determined to be knowledgeable concerning abuse prohibition. The deficiency remained at no actual harm with a potential for more than minimal harm, at a pattern. Based on interview and record review, it was determined the facility failed to follow their Abuse Prevention Policy & Procedure and fully investigate allegations of abuse for four (#1,#2, #24 and #25) of four sampled residents reviewed for allegations of abuse. This had the potential to affect all 109 residents residing in the facility. Findings: The facility's Resident Abuse Prevention Policy and Procedure, last reviewed on [DATE], documented "... McMahon-Tomlinson Nursing Center will do everything possible to prevent any type of resident abuse. However, should any resident abuses ever occur, the administrator of the facility or in his absence the persons designated to act on behalf of the facility will be notified immediately, usually by the department director. This notification shall apply at any time, day or night. In addition to this notification, the incident reporting system will be completed by all persons having any knowledge of the incident. The Administrator, Director of Nursing or persons designated to and on their behalf is responsible for investigating any alleged violations of abuse. The investigator is responsible for obtaining any evidence of abuse and must prevent further potential abuse while the investigation is in progress, including immediate suspension of the alleged perpetrator. The investigation and report will include: a. Immediate removal of the alleged perpetrator b. The date and time the incident took place; c. The circumstances surrounding the incident; d. Where the incident took place; e. The names of any witnesses and their account of the incident; including written statements. f. The residents' account of the incident; g. The employees' account of the incident; written statements. h. Accounts of any individuals involved (i.e., employees' supervisor, etc.); and i. Corrective action taken to prevent future occurrences. The Administrator, the Director of Nursing, or person designated on their behalf is responsible for reporting any alleged abuse to officials in accordance with state law immediately with an initial report of the incident and a final report within 5 days. If the alleged violation is verified, the alleged perpetrator will be terminated and the appropriate licensing agencies will be notified. The following agencies are to be notified: a. Oklahoma State Department of Health (Form 283). B. Nurse Aide Registry (Form 718). c. Licensing Boards (if applicable). d. DHS/Local Law Enforcement." 1. Resident #1 had [DIAGNOSES REDACTED]. The resident's significant change assessment, dated [DATE], documented the resident had moderately impaired cognition, required total assistance with all activities of daily living and was always incontinent of bowel and bladder. On [DATE] at 4:00 p.m., the DON was asked for any allegations of abuse since [DATE]. At 5:50 p.m., no documentation of any allegations had been presented to the surveyor. At 5:52 p.m., the social services director (SSD) was asked for any allegations of abuse since [DATE]. She presented an allegation of abuse for resident #1. The untitled form, dated [DATE] and signed by the SSD, documented resident #1's son was told by the resident that a black nurse on the night shift had been rough during care. The resident stated the nurse was not heavy set. The resident had not named the staff member. The SSD stated she had notified the charge nurse, the administrator and the director of nursing. No documentation was found in the clinical record of the incident. A review of reportable incidents required by the State were reviewed. The incident was not reported by the facility. At 6:30 p.m., the DON was shown the above findings and asked if any investigation had been conducted for the allegation of abuse. She stated, "There isn't any." The DON stated she was not aware of the allegation. At 8:20 p.m., the administrator was observed on resident #1's unit and escorted a female staff member of African American descent out of the facility. The administrator later stated the staff member had been suspended. The facility had not investigated the allegation of abuse by the staff member resident #1 had described. No staff members had been interviewed about the allegation until the survey on [DATE]. 2. Resident #2 had [DIAGNOSES REDACTED]. The quarterly assessment, dated [DATE], documented the resident's cognition was severely impaired. He required limited assistance with transfers, he did not ambulate and he required extensive assistance with eating, hygiene and bathing. A Personnel Action Request, dated [DATE], documented a certified nurses aide (CNA) was terminated because she, "was seen rolling resident (#2) very fast and scaring resident, witnesses in dining room." This form was signed by the administrator and the DON. On [DATE] at 9:45 a.m., the DON was asked if she had found any documentation of the investigation on this incident. She stated, "No." She was asked if a State reportable incident was done or if the CNA was reported to the nurse aide registry. She stated, "No we terminated her. We should have reported her so she couldn't be hired somewhere else." At 12:05 p.m., employee #1 stated she had witnessed the above incident and had reported it to the charge nurse. She was asked if anyone had followed up with her. She stated, "No." An untitled form written by the SSD, dated [DATE], documented resident #25 reported a staff member was mean to resident #2. It documented, "He (staff member) does not know how to talk to people. He was saying Turn over! and was talking real mean to him..." On [DATE] at 8:00 p.m., the administrator suspended the employee reported as being mean to resident #2 and the employee left the building. 3. Resident #24 had [DIAGNOSES REDACTED]. The quarterly assessment, dated [DATE], documented the resident's cognition was severely impaired. Transfers, ambulation, dressing and eating were a one person physical assist. She was always incontinent of bladder and occasionally incontinent of bowel. On [DATE], a grievance report was filled out by the SSD. The report documented resident #24's son stated his mother had complained to him 3 to 4 times about rough physical treatment by (name deleted) night nurse. "She was quite afraid of her." On [DATE], a typed written note by the SSD documented she had went to the room of resident #24 after the charge nurse stated the resident had a complaint. The resident was asked if she had a concern about one of the staff members and the resident stated, yes. The resident reported she did not know the name or description of the staff member but had stated the staff member was mean, "She jerks me around and rushes me." The note documented an RN and an LPN had talked to the resident and the resident's roommate was interviewed. The note documented, "The son's claims of rough treatment were unfounded, but to avoid more conflict between (resident's name deleted) and (name deleted staff member), (name deleted staff member) was removed from caring for (resident's name deleted)." This was the only documentation found in relation to an investigation. On [DATE], the resolution section of the grievance report was filled out and signed by the SSD. It documented, "I talked to resident (#24) and told her the (name deleted) night nurse would no longer be caring for her..." A thorough investigation was not conducted. No measures were put in place to protect the residents. The incident had not been reported to the State. The resident expired on [DATE]. On [DATE] at 1:08 p.m., the SSD stated, "I write up a grievance and if it's abuse I give it to the director of nurses. I leave it up to nursing to determine if it is a State reportable. I will not do that in the future." 4. Resident #25 was admitted with [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented his cognition was intact, he did not ambulate, and required assistance from staff for transfers, bathing, and toileting. A review of the grievance/complaint log kept by the SSD, dated [DATE], documented the resident had made a complaint to the SSD concerning staff were rough in handling him. The complaint log, dated [DATE], documented disposition of the complaint as "resolved." The facility incident reports were requested for review. No documentation of an investigation of this allegation of abuse was presented. The resident's clinical record was reviewed. The nurses' notes from admit to present date did not document any complaints from the resident or any abuse investigation. On [DATE] at 9:45 a.m., an interview was conducted with the abuse coordinator (Administrator) concerning the investigation of an alleged abuse complaint. He stated, "I depend on the DON to handle it if it's a State reportable." At 10:00 a.m., the DON was interviewed and asked for documentation of an investigation of alleged abuse for this resident. She stated she couldn't find one. At 1:55 p.m., an interview with the resident was conducted and he was asked if any staff member had talked with him concerning the "rough handling." He stated, "No." The resident would not name the staff member who he had reported to the SSD. He stated the staff member was rough and went too fast when providing care. He stated he wanted her to take care of him, but wanted her to slow down.

On [DATE] at 7:15 p.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to fully investigate allegations of abuse. At 7:22 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 7:35 p.m., the facility administrator and director of nurses (DON) were notified of the existence of an IJ pertaining to the failure to fully investigate and protect all residents from abuse. At 11:35 p.m., the facility submitted an acceptable plan of removal which documented: "...Plan of Removal of Immediate Jeopardy Steps: 1. Employee (name withheld) was immediately suspended on [DATE] at 8:00 p.m. by Administrator, Kip Cummins and Senior Director of Human Resources until further investigation is finalized. 2. Employee (name withheld) was immediately suspended on [DATE] at 8:20 p.m. by Administrator, Kip Cummins and Senior Director of Human Resources until further investigation is finalized. 3. Resident Abuse Prevention Policy #910 dated [DATE] by Kip Cummins, Administrator and Tammy Roberts, Director of Nursing was reviewed immediately and approved. 4. Re-educate all McMahon-Tomlinson Nursing Center's employees to include Administrator and Director of nursing on Resident Abuse Prevention Policy #910 via mandatory in-service to be started by 9:00 p.m. on [DATE] and be completed by 5:00 p.m. on [DATE]. No employee will be allowed to work in the facility after this date and time without completion of education. 5. Each employee will sign an "Acknowledgement of Abuse Policy and Reporting Requirements" after following re-education on the Resident Abuse Prevention Policy #910 by 5:00 p.m. on [DATE]. No employee will be allowed to work in the facility after this date and time until "Acknowledgement of Abuse Policy and Reporting Requirement" is signed. 6. Each employee will also satisfactorily complete "Abuse Prohibition Management Program Post Test". No employee will be allowed to work in the facility after this date and time until "Abuse Prohibition Management Program Post Test" is completed. 7. The Administrator, the Director of Nursing, or person designated on their behalf will receive and investigate all complaints of abuse immediately. This person will be identified on the staffing schedule to begin at 9:00 p.m. at [DATE]. 8. Immediate Investigation of any alleged abuse will be conducted by the above identified staff member. The report will contain the following: a. Immediate removal of the alleged perpetrator. b. Head to toe evaluation will be completed on the resident involved. c. The date and time the incident took place. d. The circumstances surrounding the incident. e. Where the incident took place. f. The names of any witnesses and their account of the incident; including written statements. g. The residents' account of the incident. h. The employee's account of the incident; written statement. i. Accounts of any other individuals involved (i.e., employee's supervisor, etc.); and 9. All abuse complaints to be immediately communicated to the Administrator, Director of Nursing or person designated on their behalf. 10. Initial reports will be submitted within 24 hours to the OK State Department of Health. 11. An investigation of the facility for abuse and neglect to include interviews with 100% of residents and/or family members will be conducted by 5 p.m. on [DATE]." On [DATE] at 5:00 p.m., the IJ was removed after inservices and post tests were completed and staff were interviewed and determined to be knowledgeable concerning abuse prohibition. The deficiency remained at no actual harm with a potential for more than minimal harm, at a pattern. Based on interview and record review, it was determined the facility failed to protect all residents after four (#1, #2, #24 and #25) of four sampled residents made an allegation of a facility staff member being abusive. This had the potential to affect all 109 residents residing in the facility. Findings: The facility's Resident Abuse Prevention Policy and Procedure, last reviewed on [DATE], documented "... McMahon-Tomlinson Nursing Center will do everything possible to prevent any type of resident abuse. However, should any resident abuses ever occur, the administrator of the facility or in his absence the persons designated to act on behalf of the facility will be notified immediately, usually by the department director. This notification shall apply at any time, day or night. In addition to this notification, the incident reporting system will be completed by all persons having any knowledge of the incident. The Administrator, Director of Nursing or persons designated to and on their behalf is responsible for investigating any alleged violations of abuse. The investigator is responsible for obtaining any evidence of abuse and must prevent further potential abuse while the investigation is in progress, including immediate suspension of the alleged perpetrator. The investigation and report will include: a. Immediate removal of the alleged perpetrator b. The date and time the incident took place; c. The circumstances surrounding the incident; d. Where the incident took place; e. The names of any witnesses and their account of the incident; including written statements. f. The residents' account of the incident; g. The employees' account of the incident; written statements. h. Accounts of any individuals involved (i.e., employees' supervisor, etc.); and i. Corrective action taken to prevent future occurrences. The Administrator, the Director of Nursing, or person designated on their behalf is responsible for reporting any alleged abuse to officials in accordance with state law immediately with an initial report of the incident and a final report within 5 days. If the alleged violation is verified, the alleged perpetrator will be terminated and the appropriate licensing agencies will be notified. The following agencies are to be notified: a. Oklahoma State Department of Health (Form 283). B. Nurse Aide Registry (Form 718). c. Licensing Boards (if applicable). d. DHS/Local Law Enforcement." 1. Resident #1 had [DIAGNOSES REDACTED]. The resident's significant change assessment, dated [DATE], documented the resident had moderately impaired cognition, required total assistance with all activities of daily living and was always incontinent of bowel and bladder. On [DATE] at 4:00 p.m., the DON was asked for any allegations of abuse since [DATE]. At 5:50 p.m., no documentation of any allegations had been presented to the surveyor. At 5:52 p.m., the social services director (SSD) was asked for any allegations of abuse since [DATE]. She presented an allegation of abuse for resident #1. The untitled form, dated [DATE] and signed by the SSD, documented resident #1's son was told by the resident that a black nurse on the night shift had been rough during care. The resident stated the nurse was not heavy set. The resident had not named the staff member. The SSD stated she had notified the charge nurse, the administrator and the director of nursing. No documentation was found in the clinical record of the incident. A review of reportable incidents required by the State were reviewed. The incident was not reported by the facility. At 6:30 p.m., the DON was shown the above findings and asked if any investigation had been conducted for the allegation of abuse. She stated, "There isn't any." The DON stated she was not aware of the allegation. At 8:20 p.m., the administrator was observed on resident #1's unit and escorted a female staff member of African American descent out of the facility. The administrator later stated the staff member had been suspended. The facility had not investigated the allegation of abuse. No staff members had been interviewed about the allegation until [DATE], during the survey. The alleged perpetrator had been allowed to work from [DATE] to [DATE], without an initiation of an investigation and without measures put in place to protect the residents. 2. Resident #24 had [DIAGNOSES REDACTED]. The quarterly assessment, dated [DATE], documented the resident's cognition was severely impaired. Transfers, ambulation, dressing and eating were a one person physical assist. She was always incontinent of bladder and occasionally incontinent of bowel. On [DATE], a grievance report was filled out by the SSD. The report documented resident #24's son stated his mother had complained to him 3 to 4 times about rough physical treatment by (name deleted) night nurse. "She was quite afraid of her." On [DATE], a typed written note by the SSD documented she had went to the room of resident #24 after the charge nurse stated the resident had a complaint. The resident was asked if she had a concern about one of the staff members and the resident stated, yes. The resident reported she did not know the name or description of the staff member but had stated the staff member was mean, "She jerks me around and rushes me." The note documented an RN and an LPN had talked to the resident and the resident's roommate was interviewed. The note documented, "The son's claims of rough treatment were unfounded, but to avoid more conflict between (resident's name deleted) and (name deleted staff member), (name deleted staff member) was removed from caring for (resident's name deleted)." This was the only documentation found in relation to an investigation. On [DATE], the resolution section of the grievance report was filled out and signed by the SSD. It documented, "I talked to resident (#24) and told her the (name deleted) night nurse would no longer be caring for her..." A thorough investigation was not conducted. No measures were put in place to protect the residents. The resident expired on [DATE]. On [DATE] at 1:08 p.m., the SSD stated, "I write up a grievance and if it's abuse I give it to the director of nurses. I leave it up to nursing to determine if it is a State reportable. I will not do that in the future." 3. Resident #25 was admitted with [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented his cognition was intact, he did not ambulate, and required assistance from staff for transfers, bathing, and toileting. A review of the grievance/complaint log kept by the SSD, dated [DATE], documented the resident had made a complaint to the SSD concerning staff were rough in handling him. The complaint log, dated [DATE], documented disposition of the complaint as "resolved." The facility incident reports were requested for review. No documentation of an investigation of this allegation of abuse was presented. The resident's clinical record was reviewed. The nurses' notes from admit to present date did not document any complaints from the resident or any abuse investigation. On [DATE] at 9:45 a.m., an interview was conducted with the abuse coordinator (Administrator) concerning investigation of an alleged abuse complaint. He stated, "I depend on the DON to handle it if it's a State reportable." At 10:00 a.m., the DON was interviewed and asked for documentation of an investigation of alleged abuse for this resident. She stated she couldn't find one. At 1:55 p.m., an interview with the resident was conducted and he was asked if any staff member had talked with him concerning the "rough handling." He stated, "No." The resident would not name the staff member who he had reported to the SSD. He stated the staff member was rough and went too fast when providing care. He stated he wanted her to take care of him, but wanted her to slow down.

On [DATE] at 7:15 p.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to fully investigate allegations of abuse. At 7:22 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 7:35 p.m., the facility administrator and director of nurses (DON) were notified of the existence of an IJ pertaining to the failure to fully investigate and protect all residents from abuse. At 11:35 p.m., the facility submitted an acceptable plan of removal which documented: "...Plan of Removal of Immediate Jeopardy Steps: 1. Employee (name withheld) was immediately suspended on [DATE] at 8:00 p.m. by Administrator, Kip Cummins and Senior Director of Human Resources until further investigation is finalized. 2. Employee (name withheld) was immediately suspended on [DATE] at 8:20 p.m. by Administrator, Kip Cummins and Senior Director of Human Resources until further investigation is finalized. 3. Resident Abuse Prevention Policy #910 dated [DATE] by Kip Cummins, Administrator and Tammy Roberts, Director of Nursing was reviewed immediately and approved. 4. Re-educate all McMahon-Tomlinson Nursing Center's employees to include Administrator and Director of nursing on Resident Abuse Prevention Policy #910 via mandatory in-service to be started by 9:00 p.m. on [DATE] and be completed by 5:00 p.m. on [DATE]. No employee will be allowed to work in the facility after this date and time without completion of education. 5. Each employee will sign an "Acknowledgement of Abuse Policy and Reporting Requirements" after following re-education on the Resident Abuse Prevention Policy #910 by 5:00 p.m. on [DATE]. No employee will be allowed to work in the facility after this date and time until "Acknowledgement of Abuse Policy and Reporting Requirement" is signed. 6. Each employee will also satisfactorily complete "Abuse Prohibition Management Program Post Test". No employee will be allowed to work in the facility after this date and time until "Abuse Prohibition Management Program Post Test" is completed. 7. The Administrator, the Director of Nursing, or person designated on their behalf will receive and investigate all complaints of abuse immediately. This person will be identified on the staffing schedule to begin at 9:00 p.m. at [DATE]. 8. Immediate Investigation of any alleged abuse will be conducted by the above identified staff member. The report will contain the following: a. Immediate removal of the alleged perpetrator. b. Head to toe evaluation will be completed on the resident involved. c. The date and time the incident took place. d. The circumstances surrounding the incident. e. Where the incident took place. f. The names of any witnesses and their account of the incident; including written statements. g. The residents' account of the incident. h. The employee's account of the incident; written statement. i. Accounts of any other individuals involved (i.e., employee's supervisor, etc.); and 9. All abuse complaints to be immediately communicated to the Administrator, Director of Nursing or person designated on their behalf. 10. Initial reports will be submitted within 24 hours to the OK State Department of Health. 11. An investigation of the facility for abuse and neglect to include interviews with 100% of residents and/or family members will be conducted by 5 p.m. on [DATE]." On [DATE] at 5:00 p.m., the IJ was removed after inservices and post tests were completed and staff were interviewed and determined to be knowledgeable concerning abuse prohibition. The deficiency remained at no actual harm with a potential for more than minimal harm, at a pattern. Based on interview and record review, it was determined the facility failed ~to thoroughly investigate allegations of abuse and ~failed to report to the appropriate State agencies for four (#1,#2, #24 and #25) of four sampled residents reviewed for allegations of abuse. This had the potential to affect all 109 residents residing in the facility. Findings: The facility's Resident Abuse Prevention Policy and Procedure, last reviewed on [DATE], documented "... McMahon-Tomlinson Nursing Center will do everything possible to prevent any type of resident abuse. However, should any resident abuses ever occur, the administrator of the facility or in his absence the persons designated to act on behalf of the facility will be notified immediately, usually by the department director. This notification shall apply at any time, day or night. In addition to this notification, the incident reporting system will be completed by all persons having any knowledge of the incident. The Administrator, Director of Nursing or persons designated to and on their behalf is responsible for investigating any alleged violations of abuse. The investigator is responsible for obtaining any evidence of abuse and must prevent further potential abuse while the investigation is in progress, including immediate suspension of the alleged perpetrator. The investigation and report will include: a. Immediate removal of the alleged perpetrator b. The date and time the incident took place; c. The circumstances surrounding the incident; d. Where the incident took place; e. The names of any witnesses and their account of the incident; including written statements. f. The residents' account of the incident; g. The employees' account of the incident; written statements. h. Accounts of any individuals involved (i.e., employees' supervisor, etc.); and i. Corrective action taken to prevent future occurrences. The Administrator, the Director of Nursing, or person designated on their behalf is responsible for reporting any alleged abuse to officials in accordance with state law immediately with an initial report of the incident and a final report within 5 days. If the alleged violation is verified, the alleged perpetrator will be terminated and the appropriate licensing agencies will be notified. The following agencies are to be notified: a. Oklahoma State Department of Health (Form 283). B. Nurse Aide Registry (Form 718). c. Licensing Boards (if applicable). d. DHS/Local Law Enforcement." 1. Resident #1 had [DIAGNOSES REDACTED]. The resident's significant change assessment, dated [DATE], documented the resident had moderately impaired cognition, required total assistance with all activities of daily living and was always incontinent of bowel and bladder. On [DATE] at 4:00 p.m., the DON was asked for any allegations of abuse since [DATE]. At 5:50 p.m., no documentation of any allegations had been presented to the surveyor. At 5:52 p.m., the social services director (SSD) was asked for any allegations of abuse since [DATE]. She presented an allegation of abuse for resident #1. The untitled form, dated [DATE] and signed by the SSD, documented resident #1's son was told by the resident that a black nurse on the night shift had been rough during care. The resident stated the nurse was not heavy set. The resident had not named the staff member. The SSD stated she had notified the charge nurse, the administrator and the director of nursing. No documentation was found in the clinical record of the incident. A review of reportable incidents required by the State were reviewed. The incident was not reported by the facility. At 6:30 p.m., the DON was shown the above findings and asked if any investigation had been conducted for the allegation of abuse. She stated, "There isn't any." The DON stated she was not aware of the allegation. At 8:20 p.m., the administrator was observed on resident #1's unit and escorted a female staff member of African American descent out of the facility. The administrator later stated the staff member had been suspended. The facility had not investigated the allegation of abuse. No staff members had been interviewed about the allegation until [DATE], during the survey. The alleged perpetrator had been allowed to work from [DATE] to [DATE], without an initiation of an investigation and without measures put in place to protect the residents. 2. Resident #2 had [DIAGNOSES REDACTED]. The quarterly assessment, dated [DATE], documented the resident's cognition was severely impaired. He required limited assistance with transfers, he did not ambulate and he required extensive assistance with eating, hygiene and bathing. A Personnel Action Request, dated [DATE], documented a certified nurses aide (CNA) was terminated because she, "was seen rolling resident (#2) very fast and scaring resident, witnesses in dining room." This form was signed by the administrator and the DON. On [DATE] at 9:45 a.m., the DON was asked if she had found any documentation of the investigation on this incident. She stated, "No." She was asked if a State reportable incident was done or if the CNA was reported to the nurse aide registry. She stated, "No we terminated her. We should have reported her so she couldn't be hired somewhere else." At 12:05 p.m., employee #1 stated she had witnessed the above incident and had reported it to the charge nurse. She was asked if anyone had followed up with her. She stated, "No." An untitled form written by the SSD, dated [DATE], documented resident #25 reported a staff member was mean to resident #2. It documented, "He (staff member) does not know how to talk to people. He was saying Turn over! and was talking real mean to him..." On [DATE] at 8:00 p.m., the administrator suspended the employee reported as being mean to resident #2 and the employee left the building. 3. Resident #24 had [DIAGNOSES REDACTED]. The quarterly assessment, dated [DATE], documented the resident's cognition was severely impaired. Transfers, ambulation, dressing and eating were a one person physical assist. She was always incontinent of bladder and occasionally incontinent of bowel. On [DATE], a grievance report was filled out by the SSD. The report documented resident #24's son stated his mother had complained to him 3 to 4 times about rough physical treatment by (name deleted) night nurse. "She was quite afraid of her." On [DATE], a typed written note by the SSD documented she had went to the room of resident #24 after the charge nurse stated the resident had a complaint. The resident was asked if she had a concern about one of the staff members and the resident stated, yes. The resident reported she did not know the name or description of the staff member but had stated the staff member was mean, "She jerks me around and rushes me." The note documented an RN and an LPN had talked to the resident and the resident's roommate was interviewed. The note documented, "The son's claims of rough treatment were unfounded, but to avoid more conflict between (resident's name deleted) and (name deleted staff member), (name deleted staff member) was removed from caring for (resident's name deleted)." This was the only documentation found in relation to an investigation. On [DATE], the resolution section of the grievance report was filled out and signed by the SSD. It documented, "I talked to resident (#24) and told her the (name deleted) night nurse would no longer be caring for her..." A thorough investigation was not conducted. No measures were put in place to protect the residents. The incident had not been reported to the State. The resident expired on [DATE]. On [DATE] at 1:08 p.m., the SSD stated, "I write up a grievance and if it's abuse I give it to the director of nurses. I leave it up to nursing to determine if it is a State reportable. I will not do that in the future." 4. Resident #25 was admitted with [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented his cognition was intact, he did not ambulate, and required assistance from staff for transfers, bathing, and toileting. A review of the grievance/complaint log kept by the SSD, dated [DATE], documented the resident had made a complaint to the SSD concerning staff were rough in handling him. The complaint log, dated [DATE], documented disposition of the complaint as "resolved." The facility incident reports were requested for review. No documentation of an investigation of this allegation of abuse was presented. The resident's clinical record was reviewed. The nurses' notes from admit to present date did not document any complaints from the resident or any abuse investigation. On [DATE] at 9:45 a.m., an interview was conducted with the abuse coordinator (Administrator) concerning the investigation of an alleged abuse complaint. He stated, "I depend on the DON to handle it if it's a State reportable." At 10:00 a.m., the DON was interviewed and asked for documentation of an investigation of alleged abuse for this resident. She stated she couldn't find one. At 1:55 p.m., an interview with the resident was conducted and he was asked if any staff member had talked with him concerning the "rough handling." He stated, "No." The resident would not name the staff member who he had reported to the SSD. He stated the staff member was rough and went too fast when providing care. He stated he wanted her to take care of him, but wanted her to slow down.

Based on interview and record review, it was determined the facility failed to ensure that one (#1) of three sampled residents received only those medications prescribed by their physician. This caused harm to the resident. This had the potential to affect all 112 residents residing in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. The residents quarterly assessment, dated 09/07/14, documented the resident was moderately impaired, did not ambulate, required extensive assist with transfers, dressing, eating, personal hygiene and she was totally dependent for toileting. A nurse's note, dated 08/17/14, documented the resident was transported to a local hospital emergency room (ER) due to a high blood pressure and greenish colored fluid coming from her feeding tube. At 12:30 p.m., a nurse's note documented at 11:00 a.m., an employee from the local ER contacted the facility to speak with the registered nurse on duty because the resident had on a [MEDICATION NAME] (narcotic pain medication) and the resident had no physician's orders for it. At 12:45 p.m., a nurse's note documented an employee from the local ER stated the resident had a [MEDICATION NAME] 50 mcg (micrograms), located on her chest and the patch was initialed by an agency nurse who had worked at the facility on 08/16/14 at 1:00 p.m. The resident's respiration's were 2 breaths a minute. The [MEDICATION NAME] was removed and [MEDICATION NAME] (a reversal drug used to counteract the effects of narcotics) was given. The resident had to be resuscitated. At 1:30 p.m. a nurse's note documented they received a call from the emergency room to transfer the resident back to the facility. The report given by the ER said the resident was to have no narcotics for 48 hours. On 08/17/14, a medication error report was filled out by a facility registered nurse. It documented the agency nurse worked on 08/16/14, and signed out the [MEDICATION NAME] 50 mcg for the roommate of resident #1. On 09/30/14 at 11:00 a.m., the director of nurses (DON) was interviewed and asked about what their resident identification system was. She stated the nurses were supposed to identify the residents by their photo in their chart. She stated the agency nurse had not looked at the residents photo to correctly identify her. At 2:45 p.m., the DON stated a narcotic count of the resident's roommate's [MEDICATION NAME]es had been conducted and was off by one.