Every finding on record at Memory Care Center at Emerald

Based on record review and interview, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 (#64) for 3 sampled residents reviewed for abuse.The administrator identified 58 residents resided in the facility.Findings:A facility policy titled Abuse, Neglect and Exploitation, dated 01/2024, read in part, Resident must not be subject to abuse by anyone, including, but no limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardian, friends, or other individuals. Prevention of abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation. Observe resident behavior and their reactions to other residents, roommates, tablemates.An admission assessment, dated 04/02/26, showed Res #24 had a BIMS score of 6 (a BIMS score of 6 indicated the resident's cognition was severely impaired) and diagnoses that included stroke and dementia. The assessment showed the resident had demonstrated verbal behaviors directed at others in the one to three days of the seven-day look back period. The assessment showed Res #24 did not show any physical behaviors directed at others during the seven-day look back period.An admission assessment, dated 04/28/26, showed Res #64 had a BIMS score of 00 (a BIMS score of 00 indicated the resident's cognition was severely impaired) and had a diagnosis of dementia. The assessment showed the resident did not show any physical or verbal behaviors toward others in the seven-day look back period.A handwritten statement authored by CNA #1, dated 05/16/26, showed CNA #1 had been assisting in a resident room and heard Res #64 make some type of noise. The statement showed CNA #1 entered the common area and observed Res #24 grab Res #64 by the arms and throw Res #64 to the ground.An Alert note, dated 05/16/26 at 3:31 p.m., showed, Res #64 had been shoved to the floor, had been wincing from pain, and had been sent to an acute care hospital.An Incident note, dated 05/16/26 at 4:05 p.m., showed Res #24 was observed aggressively shoving another resident to the floor.An incident report, with an incident date of 05/16/26, showed Res #24 had shoved Res #64 to the ground. The incident report showed Res #64 had been sent to an acute care hospital and found to have had a fracture to their right hip.A hospital discharge record, dated 05/19/26, showed Res #64 had been admitted to the hospital on [DATE] and was diagnosed with a closed displaced fracture of the right femoral neck. The record showed the resident had a surgical procedure to repair the fracture while at the hospital.On 06/02/26 at 3:18 p.m., the administrator stated when the incident occurred with Res #24 and Res #64 on 05/16/26, CNA #1 should not have left the day area to work alone in a resident room. They stated CNA #1 should have asked someone to watch the day area while they assisted the other resident. The administrator stated they have a system where the nurse on the unit and a float nurse aide would watch the day areas so other work could be completed. They stated in this instance CNA #1 had not followed their system for covering the units.

Based on record review and interview, the facility failed to ensure they had a full-time DON for 8 of 30 dates reviewed for the employment of a DON.The administrator identified 58 residents resided in the facility.Findings:An email sent to the facility administrator from the former DON, dated 05/25/26 at 4:11 p.m., showed the facility's DON resigned effective that date.On 05/29/26 at 10:20 a.m., the administrator stated the facility did not have a full-time DON. They stated they did not have anyone who had accepted the responsibilities of the DON position. The administrator stated the former DON had resigned on Monday, 05/25/26 via an email. The administrator stated they had not been able to find a full-time or interim DON since 05/25/26.On 06/02/26 at 3:18 p.m., the administrator stated they had not found anyone to assume the duties of the DON. The administrator stated they were unable to locate a policy regarding the employment of a DON.

Based on observation and interview, the facility failed to ensure drugs and biologicals were kept at proper temperatures in 1 of 1 medication refrigerator. The administrator identified 58 residents resided in the facility. Findings: On 06/02/26 at 11:33 a.m., the medication refrigerator was observed for proper temperature control. The only temperature logs observed were from 2025. There was no temperature log observed for 2026. On 06/02/26 at 11:42 a.m., the ADON stated they had never completed the temperature log or checked the temperature of the refrigerator, and they did not know who was responsible for that task. On 06/02/26 at 3:26 p.m., the administrator stated checking the medication refrigerator temperature and maintaining the temperature logs was a nursing task, but ultimately, they were responsible to ensure tasks were completed. The administrator stated they were uncertain when the task stopped being completed or why. The administrator stated they did not have a policy for medications which require refrigeration.

Based on record review and interview, the facility failed to ensure the OSDH and a local law enforcement agency were notified of allegations of abuse within two hours of the allegations becoming known to the facility for 2 (#3 and #64) of 3 sampled residents reviewed for abuse.The administrator identified 58 residents resided in the facility.Findings:A facility policy titled Abuse, Neglect and Exploitation, dated 01/2024, read in part, In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or (sic) resident property, are reported immediately, but now later than 2 hours after the allegation is made, if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected service where state law provides for jurisdiction in long-term care facilities) in accordance with State law.An incident report for Res #3, with an incident date of 08/19/25, showed an allegation of sexual abuse had been reported to staff by Res #3 on 08/19/25. The attached fax sheet showed the incident report was faxed to the OSDH on 08/20/25 at 2:11 p.m. The incident report showed a law enforcement agency had been contacted about the allegation on 08/20/25 at 11:30 a.m.An incident report for Res #64, with an incident date of 05/16/26, showed Res #64 had been thrown to the ground by Res #24 on 05/16/26. The attached fax sheet showed the incident report was faxed to the OSDH on 05/17/26 at 4:09 p.m. The incident report showed a law enforcement agency had been contacted about the incident on 05/17/26 at 1:50 p.m.On 06/02/26 at 3:10 p.m., the administrator stated they were the facility's abuse coordinator, but the incident reports were written and sent to the OSDH by other staff members. The administrator stated the facility had not sent in the reports to OSDH and law enforcement within two hours as required in the two instances.

Based on record review and interview, the facility failed to ensure influenza and pneumococcal vaccinations were provided for 2 (#8 and #10) of 5 sampled residents reviewed for immunizations.The ADON identified 24 residents were admitted to the facility from 10/31/25 through 03/31/26.Findings:A policy, titled Infection Control Immunizations, dated 03/20/24, read in part,1. Prior to receiving vaccinations, the resident or legal representative will be provided with information and education regarding the benefits and potential side effects of the vaccinations. 2. Provision of such education shall be documented in the resident's medical record. 3. All new residents shall be assessed for current vaccination status upon admission. 1. A quarterly MDS assessment, dated 04/22/26, showed Res #10 was admitted on [DATE] and had a BIMS score of 4 (a BIMS score of 4 indicated the resident's cognition was severely impaired).A review of Res #10's EMR showed no documentation the influenza vaccine or pneumococcal vaccine had been offered or given. 2. A quarterly MDS assessment, dated 05/11/26, showed Res #8 admitted on [DATE] and had a BIMS score of 14 (a BIMS score of 14 indicated the resident's cognition was intact).A review of Res #8's EMR showed no documentation the influenza vaccine or pneumococcal vaccine had been offered or given. On 05/28/26 at 3:02 p.m., the ADON stated the immunization section for Res #8 and #10 in the EMR was not completed and there was no documentation to show if the residents were offered the influenza vaccine or the pneumococcal vaccine.On 05/28/26 at 3:15 p.m., the ADON stated they did not offer the influenza vaccine to the new admits if they admitted after the facility had completed their annual influenza clinic. The ADON stated the facility's influenza clinic was typically in October of every year.

Based on record review and interview, the facility failed to ensure the COVID-19 vaccine was provided for 2 (#8 and #10) of 5 sampled residents reviewed for immunizations.The ADON identified 24 residents were admitted to the facility from 10/31/25 through 03/31/26.Findings:1. A review of Res #8's EMR showed no documentation that any immunizations had been provided to the resident.2. A review of Res #10's EMR showed no documentation that any immunizations had been provided to the resident.A policy titled Infection Control Immunizations, dated 03/20/24, read in part,1. Prior to receiving vaccinations, the resident or legal representative will be provided with information and education regarding the benefits and potential side effects of the vaccinations. 2. Provision of such education shall be documented in the resident's medical record. 3. All new residents shall be assessed for current vaccination status upon admission.On 05/28/26 at 3:02 p.m., the ADON stated they had reviewed the EMR's for Res #8 and Res #10 and had no documentation the residents had been offered or administered the COVID-19 vaccination.

Based on record review and interview, the facility failed to ensure an antipsychotic medication was not prescribed for the diagnosis of dementia and ensure an as needed anxiety medication order had a 14-day limit for 1 (#5) of 5 sampled residents reviewed for unnecessary medications.The ADON identified 24 residents were prescribed antipsychotic medications. Findings:A medication order for Res #5, dated 04/16/25, showed the resident was prescribed Seroquel (an antipsychotic medication) 50 mg one tablet by mouth at bedtime for dementia and behaviors.A medication order for Res #5, dated 10/09/25, showed the resident was prescribed diazepam (an antianxiety medication) 5mg/ml oral concentrate give 0.5 ml by mouth every four hours as needed for anxiety. The medication order did not have a discontinue date.A pharmacy consult report for Res #5, dated 10/30/25, showed Res #5's physician was informed psychotropic medication prescribed to be used as needed was required to have a 14-day limit unless the physician gave a written rationale for a longer limit. The consult report did not show a written response from the physician.A MAR for Res #5, dated 05/01/26 through 05/31/26, showed Res #5 was administered 24 doses of Seroquel 50 mg tablets during the month of May 2026. The MAR showed Res #5 had an order for diazepam 5mg/ml oral concentrate give 0.5 ml by mouth every four hours as needed for anxiety.On 06/01/26 at 11:19 a.m., the ADON stated they were familiar with antipsychotic medications. The ADON stated they did not know if antipsychotic medications were approved for the treatment of dementia. The ADON stated Res #5 was prescribed Seroquel because they kicked and squeezed the hands of the staff.On 06/01/26 at 11:29 a.m., the ADON stated Res #5's as needed diazepam medication order should have been limited to 14 days. On 06/02/26 at 3:10 p.m., the administrator stated the nursing department needed to review the medication orders more closely to find these types of issues.

Based on record review and interview, the facility failed to ensure a care plan was revised after multiple incidents of aggression toward others for 1 (#24) of 3 sampled residents reviewed for abuse.The administrator identified 58 residents resided in the facility.Findings:A Care Plan Process policy, dated 09/2019, read in part, A care plan will: Incorporate identified problem areas.A care plan for Res #24, dated 03/31/26, read in part, BEHAVIORS/WANDERING: The resident has behaviors, takes food off other residents (sic) plates, reaches over counter (sic) to get things, doesn't care to be redirected, wanders around on the unit, etc. The care plan showed no interventions related to aggression toward others.An admission assessment, dated 04/02/26, showed Res #24 had a BIMS score of 6 (the BIMS score of 6 indicated the resident's cognition was severely impaired) and diagnoses that included stroke and dementia. The assessment showed the resident had demonstrated verbal behaviors directed at others in the one to three days of the seven-day look back period. The assessment showed Res #24 did not show any physical behaviors directed at others during the seven-day look back period.A Mood/Behavior note, dated 04/15/26 at 6:24 p.m., showed Res #24 had lunged at a staff member when they were not allowed to eat from another resident's plate.A Mood/Behavior note, dated 04/17/26 at 6:23 p.m., showed Res #24 threatened to physically assault a CNA when the staff member removed a cupcake from the resident.A General note, dated 05/12/26 at 4:22 p.m., showed Res #24 was asked to remove their hand from their pants by a staff member. The note showed Res #24 responded by moving within inches of the staff member's face and asking them if they wanted to fight.A Mood/Behavior note, dated 05/13/26 at 9:57 a.m., showed Res #24 was observed lunging at another resident and a staff member had to stand between the residents. The note showed Res #24 was asked to put on clothes by another resident and Res #24 stated to that resident they would physically assault them.An Incident note, dated 05/16/26 at 4:05 p.m., showed Res #24 was observed aggressively shoving another resident to the floor.On 06/01/26 at 1:09 p.m., MDS Coordinator #1 stated they revised the care plan anytime a resident had a change in their condition such as falls, use of antibiotics, or new behaviors. MDS Coordinator #1 stated they knew Res #24's aggressive behaviors toward others had occurred, but for some reason they had forgotten to enter them into the resident's care plan. MDS Coordinator #1 stated they should have revised Res #24's care plan with a focus on aggression and new interventions.On 06/02/26 at 10:34 a.m., CNA #2 stated they had worked with Res #24 since the resident was admitted in March 2026. CNA #2 stated they had not seen Res #24 physically assault anyone but did witness the resident verbally threaten staff and other residents multiple times. They stated they reported those incidents to the nurse on duty.On 06/02/26 at 1:48 p.m., CMA #1 stated they worked with Res #24 routinely since the resident was admitted . CMA #1 stated they had observed Res #24 be verbally abusive toward residents and staff. They stated they reported those incidents to the charge nurses.On 06/02/26 at 3:11 p.m., the administrator stated the MDS coordinator should have created new interventions regarding Res #24's aggressive behaviors.

Based on record review and interview, the facility failed to complete an annual performance review for 1 (CNA #3) of 2 sampled CNAs reviewed for performance reviews. The current staff roster identified 13 CNAs were employed.Findings: The facility was unable to provide the 2025 annual competency for CNA #3 hired on 01/28/24 as identified by CNA #3's employee application. On 06/02/26 at 3:26 p.m., the administrator stated completing annual performance reviews was the DON's responsibility, but the facility was having a hard time keeping a DON. The administrator stated the facility did not have a policy regarding competencies, but they knew the regulations required annual competencies to be completed.

Based on record review and interview, the facility failed to ensure a monthly pharmacy review was conducted for 1 (#5) of 5 sampled residents reviewed for unnecessary medications.The ADON identified 55 residents received medications in the facility.Findings:A MAR for Res #5, dated 01/01/26 through 01/31/26, showed the resident was prescribed 12 medications including aspirin, Celexa, metoprolol, Remeron, Seroquel, apixaban, acetaminophen, and diazepam.On 06/01/26 at 11:29 a.m., the ADON stated they reviewed Res #5's pharmacy consultant reports and were unable to find the January 2026 monthly pharmacy review form.On 06/02/26 at 3:10 p.m., the administrator stated the nursing department was to ensure the pharmacy reviews were completed.

Based on record review and interview, the facility failed to report allegations of abuse to the Oklahoma State Department of Health for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator reported 56 residents resided at the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, dated 11/17, read in part, In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later that 2 hours after the allegation is made .to the administrator of the facility and other officials .in accordance with State law through established procedures. A progress note titled Mood/Behavior, dated 04/28/25 at 8:51 p.m., showed Res #1 had reported to LPN #2 that Res #1 was having a romantic relationship with CNA #1, an unidentified LPN had twice sexually assaulted a resident, and an unidentified CNA was living at Res #1's home and receiving money from Res #1 monthly. LPN #2 further wrote in the note that they had spoken to the ADON and the administrator about the reports. On 05/12/25 at 10:22 a.m. the administrator was asked about LPN #2's progress note, dated 04/28/25 at 8:51 p.m. They stated they were aware of each of the allegations mentioned in the note. They stated they had not reported the incident or participated in the investigation as they had assigned those tasks to the DON. On 05/12/25 at 10:47 a.m., the DON was asked about LPN #2's progress note dated 04/28/25 at 8:51 p.m., that contained Res #1's allegations of sexual abuse and misappropriation. The DON stated she had not seen that progress note by LPN #2 or heard of those allegations before this surveyor showed them, so the allegations had not been reported to state and had not been investigated.

Based on record review and interview, the facility failed to: a. thoroughly investigate allegations of sexual abuse; b. investigate an allegation of misappropriation; and c. initiate precautions to protect residents from the alleged perpetrators for 1 (#1) of 3 sampled residents reviewed for abuse The administrator stated the facility had 56 residents resided at the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, dated 11/17, read in part, When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. An MDS admission assessment, dated 03/16/25, showed in Section C that Res. #1 had been assessed and found to have a BIMS score of 03 which indicated their cognition was severely impaired. A progress note titled Mood/Behavior, dated 04/28/25 at 8:51 p.m., showed Res #1 had reported to LPN #2 that Res #1 was having a romantic relationship with CNA #1, an unidentified LPN had twice sexually assaulted a resident, and an unidentified CNA was living at Res #1's home and receiving money from Res #1 monthly. The note showed they had spoken to the ADON and the administrator about the reports. A progress note titled Mood/Behavior, dated 05/01/25 at 6:35 p.m., showed LPN #1 had been informed by CNA #2 that Res #1 had alleged CNA #1 had stolen credit cards. The note did not show if this allegations were passed on to the administration. On 05/12/25 at 10:22 a.m. the administrator was asked about LPN #2's progress note, dated 04/28/25 at 8:51 p.m. They stated they were aware of each of the allegations mentioned in the note. They stated they had not reported the incident or participated in the investigation as they had assigned those tasks to the DON. When asked about LPN #1's progress note of 05/01/25 at 6:35 p.m., which contained the allegation from Res #1 about their credit cards having been stolen, the administrator stated they were not aware of that note or allegation. On 05/12/25 at 10:47 a.m., the DON was asked about LPN #2's progress note dated 04/28/25 at 8:51 p.m., that contained Res #1's allegations of sexual abuse and misappropriation. The DON stated they had not seen that progress note by LPN #2 or heard of those allegations before this surveyor showed them. They stated they had not conducted any investigation related to the allegations identified in that note. The DON was asked about LPN #1's progress note, dated 05/01/25 at 6:35 p.m. which contained the allegation of stolen credit cards. The DON stated they had never been told about that report so there was no investigation. On 05/12/25 at 11:20 a.m., ADON was asked about LPN #2's progress note dated 04/28/25 at 8:51 p.m. The ADON stated they had been told about the allegations but believed it was the next morning [04/29/25] about 7:00 a.m., when they were told about them. They stated they then informed the DON about the allegations at about 8:00 a.m. On 05/12/25 at 11:32 a.m., the DON was asked if CNA #1 had been suspended at any time after the allegations against them had been made. The DON stated CNA #1 had not been suspended. The DON stated the reason was because when they did find out about CNA #1 having been named by Res #1 as an alleged perpetrator, the administrator told them they had enough information about the allegations to unsubstantiate the allegations. The DON was asked when they discovered CNA #1 had been named. The DON stated it was on 05/02/25. On 05/12/25 at 12:50 p.m., CNA #1 was asked about the allegations Res #1 had made against them. CNA #1 stated they had not been aware the resident had made those accusations. They stated they found out about the allegations against them after Res #1 had been moved to a different hall and they went over there to visit them. CNA #1 stated when they left the hall after the visit, the administrator told them they should not go over there and then about Res #1's allegations. CNA #1 stated they had not been suspended from work because of any allegation from Res #1. CNA #1 stated they had not, and worked each of their scheduled shifts in April and May 2025. On 05/12/25 at 1:37 p.m., LPN #1 was asked about their progress note, dated 05/01/25 at 6:35 p.m. LPN #1 stated it was their understanding that anytime Res #1 had made an allegation, they were to make a note of it. They stated when they were told by CNA #2 of the allegation of stole credit cards, they wrote the note and informed the ADON the next morning. On 05/12/25 at 4:21 p.m., LPN #2 returned the surveyor's telephone call. LPN #2 was asked about their progress note, dated 04/28/25 at 8:51 p.m. They stated the note contained Res #1's multiple allegations about sexual abuse and a staff member getting money from them. They stated they had reported the information to the ADON but did not know what the ADON had done with the information.

Based on record review and interview, the facility failed to protect the resident's right to be free from neglect for one (# 1) of four residents reviewed for neglect. The Administrator reported the facility census was 53. Findings: A facility policy titled Abuse, Neglect and Exploitation, revised 01/24, read in part, .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Neglect, as defined at 483.5, means 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 . Resident #1 had diagnoses which included severe unspecified dementia with anxiety and senile degeneration of the brain. An admission assessment, dated 03/15/24, documented Resident #1 was severely impaired for daily decision making and was able to walk without assistance. A nurse note, dated 05/18/24 at 7:44 pm, documented the CMA on duty notified the nurse that Resident #1 was found laying on the concrete patio in the courtyard, the resident was unresponsive to a sternal rub. The note further documented the staff placed cool wet cloths on the resident and called 911. EMS arrived at approximately 6:50 pm and transported Resident #1 to the hospital. Hospital discharge paperwork, dated 05/24/24, documented Resident #1's diagnoses for hospital admission included heat exhaustion and volume depletion. On 05/31/23 at 9:30 a.m., CNA #1 stated that the courtyard doors should always be locked, and residents shouldn't not be outside without staff. On 05/31/23 at 9:40 a.m., LPN #1 stated staff should always supervise residents when they are outside. On 05/31/23 at 10:00 a.m., RN #1 stated activities staff usually took the residents outside, they also stated residents should always be supervised and dressed appropriately when outside. On 05/31/23 at 10:15 a.m., CNA #2 stated the courtyard doors should not be propped open and staff members should be supervising residents when they are outside. On 05/31/23 at 10:20 a.m., CNA #3 stated the doors should be secure and residents should not be unsupervised when they are in the courtyard. On 05/31/23 at 10:53 a.m., the ADON stated that they had educated staff regarding propping the courtyard doors open, supervising residents when they are outside, and ensuring residents are dressed properly for the environment. They stated that after Resident #1 was found unresponsive in the courtyard EMS was contacted immediately and the resident was sent to the hospital for treatment related to heat exhaustion. On 05/31/23 at 12:40 p.m., LPN #2 stated they were called to the 600-hall courtyard around 6:40 pm on 05/18/24, they further stated when they arrived, they observed Resident #1 laying on the concrete in the direct sun wearing only a pair of pants. LPN #2 stated Resident #1 was unresponsive to sternal rubs and that EMS was notified immediately. LPN #2 stated the door between the courtyard and the 600-hall was propped open with a chair. On 05/31/24 at 12:48 p.m., CNA #4 stated they were called to the 600-hall around 6:30 pm 0n 05/18/24, and that when they arrived, they observed Resident #1 laying outside on the concrete patio. They also stated that the door between the courtyard and 600-hall was propped open. CNA #4 stated the resident was red, soaked with sweat, hot to the touch, and unresponsive. On 05/31/23 at 3:00 p.m., the ADON stated they were unsure how long the resident had been in the courtyard, they stated that a CNA reported they offered the resident a snack approximately two hours before he was found unresponsive in the courtyard. The ADON reported Resident #1 was not being adequately supervised. On 05/31/23 at 3:05 p.m., the Administrator stated that Resident #1 was not being supervised appropriately at the time of the incident.

Based on observation and interview, the facility failed to ensure proper food service sanitation, cleaning and storage requirements were followed. The ADON identified all 56 residents who resided at the facility received food from the kitchen. Findings: An undated, Sanitation of Dining and Food Service Areas policy, read in part, The Dining Service staff will uphold sanitation of the dining areas. The policy also read, All staff will be trained on the frequency of cleaning. The policy also read, Staff will be held responsible for all cleaning tasks. An undated Sanitizing and Disinfectant Solutions policy, read in part, Bleach solution should be at a concentration of greater than or equal to 50 to 100 ppm. An undated Food Storage(Dry, Refrigerated, and Frozen) policy, read in part, All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. On 05/06/24 at 9:50 a.m., a tour of the kitchen was conducted. The following observations were made. a. Cook #1 did not have on a beard guard and had a full beard, b. one opened bag of an orange block of cheese with no date label, c. five packs of boiled eggs in a box. The box did not have a date label of when opened, d. one plastic container almost empty of cheese with no date label, e. one opened bag of mozzarella cheese with no date label, f. one block of butter in a box with no date label on the box when opened, g. one gallon of half empty milk with no date label of when opened, h. one box with three bags of liquid eggs with no date label when opened, i. one opened box of bacon with no date label when opened, j. one jar of almost empty ranch dressing with no date label when opened, k. a red/pink drinking cup with a lid and draw was observed on the bottom shelf next to a box of plastic ware. The metal shelf had black and white substance/debris on it(see photo), l. there were two toasters covered with brown and black crumb substance/debris on both the black trays they were sitting on and on the metal shelves they were stored on(see photo), m. there was black, brown and white debris/substance on the bottom of the metal shelf that stored the pots and pans(see photo). On 05/06/24 at 9:56 a.m., the Cook #1 stated they were not sure and had to brush up on the policy and procedure was for hair nets. They stated they did not have on a beard guard because they were waiting for them to be ordered and had not been instructed on what to do until they arrived. On 05/06/24 at 10:16 a.m., Cook #1 stated the policy and procedure for food storage/labeling was to pull the oldest to the front and label/date when ordered and when arrived. On 05/06/24 at 10:21 a.m., Cook #1 stated that none of the items listed from the refrigerator were dated and did not know why. They acknowledged the crumbs on the toaster and shelf and stated it was not clean. They stated the kitchen was swept and mopped every night and the shelves were cleaned every Wednesday. On 05/06/24 at 10:25 a.m., Cook #1 observed the debris wiped from the shelf of the pots and pans and stated it was dirt. On 05/06/24 at 11:24 a.m., follow up observation found the following. n. black substance splattered on the wall and along the trim around the sink area where the dishes were washed(see photo), o. the low temp dishwasher never reached above 100 degrees(see photo), p. the three sink sanitizer compartment never reached above 10 ppm. On 05/06/24 at 11:25 a.m., Dietary Aide #1 stated the black substance on the wall around the sink next to the dishwasher was black mold. They stated they knew it was because they would scrub it and it would come off then came back. They stated they reported to Food Service Director. On 05/06/24 at 11:52 a.m. the dishwasher was run again for the fourth time and the temperature still under 100 degrees. (see photo for temperature gauge requirement). They stated when that happens they let the Food Service Director know and they call to get it fixed. They stated that they still continue to use it because it takes months to get someone out to fix it. They were to set up the three compartment sink for usage after lunch. On 05/06/24 at 12:16 a.m., observed the three compartment sink observed. The hot water coming out of the faucet was 88 degrees. Dietary Aide #1 stated that when the dishwasher is running then the hot water comes out cool then warms up when the dishwasher stopped. On 05/06/24 at 12:29 p.m., the three compartment sink sanitization was too low at 10 ppm. They stated they never had that happen before and were to contact the Administrator. They also stated that they would have scrubbed the dishes well with washing them. On 05/06/24 at 12:38 p.m., the three compartment sink sanitization was again too low at 10 ppm. The blender used to prepare the mechanical soft and puree food was washed in the dishwasher that had not reached temperature. On 05/06/24 at 12:52 p.m., observed Maintenance supervisor in the kitchen dishwasher area.

Based on record review and interview, the facility failed to ensure the resident's representative completed the resident's code status correctly and were offered the choice to formulate an advanced directive for two (#6 and #48) of three sampled residents reviewed for advanced directives. The administrator identified 56 residents who resided in the facility. Findings: The facility's Admission policy, revised 01/2024, read in part, The facility will review all advance directive information during the admission process to assure that the resident's wishes will be incorporated in the plan of care. The policy also read, The facility allows advance directive information to be given to the resident's representative at the time of admission if the resident is incapacitated, whether or not the resident has executed an advanced directive 1. Resident #6 A document titled, Advance Directive Code (Resuscitate) Status, dated 02/26/24, documented Resident #6's POA had initialed the resident was a full code and a DNR. Resident #6's Social Services Admission Data, dated 02/27/24, documented the resident was able to make their own decisions related to advanced care planning and did not have an advanced directive. On 05/08/24 at 4:10 p.m., the office assistant stated Resident #6 had a POA. They stated the resident's POA had incorrectly initialed both full code and DNR on the code status document. They stated Resident #6 was a full code. They stated they did not have documentation Resident #6 had been offered or declined the opportunity to formulate an advanced directive. On 05/08/24 at 5:15 p.m., the office assistant stated they did not ask any residents if they wanted information to formulate an advanced directive because of their dementia diagnoses. 46216 2. Resident #48 admitted to the facility on [DATE] with diagnoses which included Huntington's disease and unspecified dementia. On 05/07/24 at 2:55 p.m., the BOM was asked if Resident #48 had been offered the choice to formulate advanced directives. On 05/07/24 at 3:20 p.m., the BOM states no advanced directive on file for Resident #48.

Based on observation, record review, and interview, the facility failed to ensure wheelchairs were clean and maintained in good repair for two ( #1 and #25) of three sampled residents who were reviewed for wheelchair maintenance. The Administrator identified 56 residents who resided in the facility. Findings: The facility's Physical Environment: Space and Equipment policy, revised 01/2024, read in part, Inspection of resident care equipment will be completed routinely and as needed to maintain and ensure safe operating conditions. 1. Resident #1's quarterly assessment, dated 04/10/24, documented they ambulated with a manual wheelchair and walker. On 05/06/24 at 11:24 a.m., Resident #1's wheelchair armrests were observed to be torn and had the yellow padding showing. The wheelchair was observed to be dirty. 2. Resident #25's significant change assessment, dated 08/14/23, documented they ambulated with a manual wheelchair. On 05/06/24 at 12:17 p.m., Resident #25's wheelchair armrests were observed to be torn with the yellow padding showing. The wheelchair was observed to be dirty. On 05/08/24 at 2:35 p.m., the ADON stated the CNAs were responsible for notifying the nurse of the need for wheelchair maintenance and the nurse would notify maintenance. The ADON was shown the pictures and the wheelchairs for Resident #1 and #25. They stated they needed to be cleaned and the armrests needed to be repaired. They stated the wheelchair armrests could not be disinfected or cleaned properly because they were torn.

Based on record review and interview, the facility failed to implement their abuse policy related to: a. reporting allegations of abuse and/or neglect to the OSDH and investigating allegations of abuse and/or neglect for three (#6, #9, and #41) of five sampled residents who were reviewed for abuse allegations; and b. abuse training upon hire for seven (#1, 2, 3, 4, 5, 6, and #7) of 25 sampled employee files reviewed for abuse training. The administrator identified 56 residents who resided in the facility. Findings: The facility's Abuse Neglect and Exploitation policy, revised 01/2024, read in part, Ensure that all alleged violations involving abuse .are reported immediately, but not later than two hours after the allegation is made. The policy also read, Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated The policy also read, Neglect means 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. The policy also read, Employee training .New employees should be educated on abuse, neglect, and exploitation during initial orientation. Annual education and training is provided to all existing employees. The policy also read, Investigation of Alleged Abuse, Neglect, and Exploitation .reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. 1. Resident #6 had diagnoses which included dementia and late on-set Alzheimer's Disease. A document titled, Grievance Log, dated 04/18/24, documented Resident #6 reported the staff on the night shift tried to smother them and pulled their call light out of the wall and placed it where they could not reach it. There was not an incident report submitted to the OSDH or documentation an investigation was conducted. On 05/10/24 at 11:43 a.m., the SSD stated they considered the grievance for Resident #6 on 04/18/24 an allegation of abuse and notified the administrator. On 05/10/24 at 11:45 a.m., the administrator stated they considered the statement made by the resident documented on the grievance log an allegation of abuse. They stated the nurse on the night shift had been on the unit and had written a statement. They stated they had not done an investigation or reported the incident to the OSDH because the nurse had been present during the time Resident #6 alleged the abuse happened. 2. Resident #9 had diagnoses which included frontotemporal neurocognitive disorder. Resident #9's quarterly assessment, dated 11/28/23, documented the resident required substantial maximal assist with toileting, dressing, transferring, and was frequently incontinent of urine and bowel. Resident #9's care plan for ADLs, dated 09/12/23, documented the resident required one person assist for toileting, transferring, and personal hygiene. A document titled, Grievance Log, dated 01/05/24, documented there was not a CNA on the hall to provide care for Resident #9 until 5:00 a.m. and the resident had brown ringed (Dried urine on clothing or sheets.) the grievance log also documented the DON had disciplinary action against the aide who refused to help others. On 05/10/24 at 11:33 a.m., the administrator stated the SSD would notify them if they had received an allegation of neglect. The administrator was asked if they considered the grievance made for Resident #9 on 01/05/24 an allegation of neglect. They stated to some degree. On 05/10/24 at 11:40 a.m., the SSD stated they considered the grievance for Resident #9 on 01/05/24 an allegation of neglect and they notified the administrator and the DON. On 05/10/24 at 11:45 a.m., the administrator stated they did not believe the allegation of neglect on 01/05/24 documented on the grievance form had been submitted to the OSDH. On 05/14/24 at 2:25 p.m., the ADON stated brown ringed meant dried urine. They stated Resident #9 required assistance with incontinent care. 46216 3. Resident #41 admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, unspecified, dementia in other disease class, and bipolar disorder. An Incident Note, dated 12/24/23, documented, Resident standing at counter. Resident from [room number withheld] approached counter and this resident stepped closer to [Resident #15] while hitting [Resident #41] hand with [Resident #41] fist. [room number withheld] turned to walk away when this resident turned also. [room number withheld] stuck [Resident #15] foot out in front of [Resident #41] and at this same time pushed [Resident #41] from behind. Resident fell forward hitting [Resident #41] nose on the floor. Noted 0.2 x 0.1 cm laceration to [Resident #41] nose. Small amount of bleeding from nose. Cleaned area with normal saline. ROM WNL. Neuro checks initiated and WNL. One on one with this resident for 1 hr then assisted to bed. Called [family member], left message requesting return call. Notified DON and abd [sic] physician. No state reportables were located for the 12/24/23 incident. On 05/14/24 at 12:29 p.m., the ADON stated they were unable to locate state reportable for the 12/24/23. 45583 4. Employee #1, 2, 3, 4, 5, 6, and #7's personnel files were reviewed. The personnel files did not contain abuse training upon hire. On 05/10/24 at 10:39 a.m., HR stated they did not have information to show abuse training was received by the employee.

Based on observation, record review, and interview, the facility failed to develop a care plan for oxygen therapy for one (#6) of one sampled resident who received oxygen therapy and limited range of motion with contracture for one (#20) of two sampled residents who had limited range of motion. The ADON identified six residents who utilized oxygen, ten residents who had limited range of motion, and three residents who had contractures. Findings. The facility's Special Needs policy, revised 01/2024, read in part, Comprehensive care plans will be developed based on resident assessments, goals and preferences. 1. Resident #6 had diagnoses which included acute respiratory failure with hypoxia. Resident #6's Monthly Physician's Orders, included oxygen 2 liters via nasal cannula continuously. Resident #6's care plan did not document they utilized oxygen therapy, how often to change the nasal cannula, oxygen safety, or interventions. On 05/06/24 at 12:26 p.m., Resident #6 was observed in their room with oxygen at two liters via nasal cannula. An oxygen concentrator machine with a humidifier bottle and portable oxygen tank was observed in Resident #6's room. On 05/09/24 at 2:06 p.m., the MDS coordinator stated Resident #6's care plan should have included oxygen therapy. They stated the care plan did not document Resident #6 utilized oxygen or interventions for oxygen therapy. 2. Resident #20 Resident #20's care plan was reviewed and did not document they had limited range of motion or contracture to left hand and did not document interventions to prevent the contracture from worsening or how to provide care to the left hand with the contracture. On 05/07/24 at 11:58 a.m., Resident #20's family member stated the resident's hand was contracted. and they were not sure if they had a brace or splint for Resident #20's hand to prevent it from getting worse. On 05/09/24 at 8:54 a.m., Resident # 20's left hand was observed to be closed, there was not a splint or brace in Resident #20's hand. On 05/09/24 at 9:07 a.m., CNA #7 stated Resident #20's left hand was contracted. They stated they at times put a rolled wash cloth in Resident #20's hand. On 05/14/24 at 10:03 a.m., the ADON stated Resident #20's left hand was contracted. They stated the care plan did not document Resident #20's hand was contracted or interventions to prevent it from worsening.

Based on observation, record review, and interview, the facility failed to ensure sufficient staff a. was available to provide incontinent care for one (#9) of one sampled resident who required incontinent care; b. was available to provide supervision during meals for one (#46) of two sampled residents who required supervision with meals; and c. was available to provide a licensed staff member on a 24 hour basis. The ADON identified 40 residents who required assistance with incontinent care, 10 residents who required assistance with meals, and 56 residents who resided in the facility. Findings: 1. Resident #9 had diagnoses which included frontotemporal neurocognitive disorder. Resident #9's care plan for ADLs, dated 09/12/23, documented the resident required one person assist for toileting, transferring, and personal hygiene. Resident #9's quarterly assessment, dated 11/28/23, documented the resident required substantial maximal assist with toileting, dressing, transferring, and was frequently incontinent of urine and bowel. A schedule, dated 01/04/24, documented there were no CNAs assigned to work on the Burgundy hall on night shift. A document titled, Grievance Log, dated 01/05/24, documented there was not a CNA on the hall to provide care for Resident #9 until 5:00 a.m. and the resident had brown ringed (Dried urine stain on linen or clothing.) the grievance log also documented the DON had disciplinary action against the aide who refused to help others. On 05/14/24 at 2:25 p.m., the ADON stated the schedule did not reflect a staff member had been assigned to the burgundy hall. The ADON was asked what brown ringed meant from the grievance log. They stated brown ringed meant dried urine. They stated Resident #9 required assistance with incontinent care every two hours. The ADON stated the CNA from green hall should have assisted the nurse with the residents' care needs on burgundy hall. The ADON stated they were not working at the facility at the time of the grievance and based on the documentation it looked like the aide from green hall refused to assist with resident care on the burgundy hall. 2. Resident #46 had diagnoses which included extrapyramidal and movement disorder, anxiety, and dementia. Resident #46's care plan for ADLs dated 01/11/24 , documented they required set up and supervison with meals. A nurse's note, dated 04/12/24, at 1:32 p.m., documented Resident #46 only ate if they were fed. Resident #46 ate 100% of their breakfast and lunch when they were fed. A nurse's note, dated 04/14/24, at 2:12 p.m., documented Resident #46 required some attention towards feeding and Resident #46 would eat if fed. On 05/09/24 at 8:25 a.m., during breakfast observation, RN #1 and CNA #7 were observed assisting residents with eating. CMA #1 was observed administering medications in the dining room. There were no staff members feeding or sitting with Resident #46 to encourage them to eat and not wander from the dining area. On 05/09/24 at 8:25 a.m., Resident # 46 was observed chewing their food and walking around unit. The residents breakfast was in a bowl, scrambled eggs, a biscuit in one bowl, a bowl of oatmeal, a cup juice and milk. On 05/09/24 at 8:26 a.m., CNA #7 cued Resident #46 to come and eat from across the dining room. On 05/09/24 at 8:29 a.m., Resident # 46 was observed walking to their room. There was no staff with Resident #46. On 05/09/24 at 8:31 a.m., Resident # 46 came out of room and went into another residents room. CNA#7 went to get Resident #46 and encouraged resident to go back to the dining area and eat her breakfast. On 05/09/24 at 8:39 a.m., Resident #46 continued to ambulate around unit and come and get bites of food. The staff did not stay with Resident #46 during the meal to ensure the resident stayed in the dining area and was encouraged to eat. On 05/09/24 at 9:04 a.m., CNA #7 stated Resident #46 ate their bacon, oatmeal, a few bites of their eggs and half of their biscuit. On 05/09/24 at 2:07 p.m., the MDS coordinator stated the care plan documented to provide supervision with meals. They stated a staff member should be next to Resident #46 during meals to provide supervision and prompt the resident to eat. On 05/09/24 at 2:29 p.m., the ADON stated Resident #46 required cuing and supervision with meals. The ADON stated the staff should be seated next to Resident #46 to cue the resident to eat and ensure they do not get up and leave the dining table. The ADON stated the CNA, nurse, float CNA, CMA should assist with meals to ensure each resident is provided supervision and assistance with meals. 3. A document titled, Incident Report Form, dated 05/12/24, documented the facility was without a licensed nurse for 3.5 hours due to the nurse scheduled to work the 7:00 p.m. shift to 7:00 a.m. shift had called in. On 05/13/24 at 1:30 p.m., Resident #1's family member stated they had pushed the call light for assistance at 6:48 p.m. on 05/12/24, and it had not been answered by the time they left at 7:30 p.m. They stated they lowered the resident's bed, and placed the resident's fall mat by their bed before they left. The family member stated they believed the facility did not have enough staff on 05/12/24. On 05/13/24 at 4:17 p.m., the ADON stated the administrator had filled out an incident report and reported the facility had not had a licensed nurse on 05/12/24 for 3.5 hours. They stated they had volunteered to cover the 3.5 hours but were advised they were needed on 05/13/24. The ADON stated the nurses who had been working the day shift left the faciity on [DATE] without a licensed nurse to replace them. They stated the nurse from their sister facilty on campus had been available for emergencies.

Based on record review and interview, the facility failed to ensure licensed nurse, and certified nurse aides received competency/skills checks for four (LPN #1, CNA # 2, CNA #3, and CNA #4) of five employee files reviewed for competency/skills checks. The administrator identified 56 residents resided in the facility. Findings: A Nursing Services and Sufficient Staff policy, dated 02/23, read in part, It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The policy also read, The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care. The policy also read, The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care. 1. LPN #1 was hired on 12/13/23. Review of the employee file for LPN #1 did not reveal a competency/skills check had been completed. 2. CNA #2 was hired on 09/02/23. Review of the employee file for CNA #2 did not reveal a competency/skills check had been completed. 3. CNA #3 was hired on 09/05/23. Review of the employee file for CNA #3 did not reveal a competency/skills check had been completed. 4. CNA #4 was hired on 11/29/23. Review of the employee file for CNA #3 did not reveal a competency/skills check had been completed. On 05/10/24 at 11:58 a.m., the ADON stated they did not have the skills check offs for CNA #2, 3, 4, and LPN #1. They were asked if they did annual skills check offs. They stated, We should be.

On 03/30/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; conduct a root cause analyses for each fall; monitor and evaluate the effectiveness of the interventions; and modify the care plan with each fall. Res #14 had 23 falls in the last five months. Of the 23 falls, 19 did not have updated interventions to help prevent future falls. Res #14's last fall resulted in a fractured hip. The care plan had not been updated since 11/15/22. Res #57 had sustained six falls in three weeks. The third fall resulted in a fractured arm and the last two did not have updated interventions to help prevent future falls. Res #57's last fall was 03/19/23 and the care plan had not been up updated since 03/01/23. Res #25 had 16 falls in last four months. Ten of the falls did not have updated/new interventions to help prevent further falls. The care plan was last updated 07/14/22. The facility failed to provide adequate supervision and interventions to help prevent falls for these residents. On 03/30/23 at 2:28 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. On 03/30/23 at 2:50 p.m., the administrator was notified of the IJ situation. On 03/31/23 at 9:35 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Meeting Date: 3/30/2023 Meeting Attendees: Medical Director ADMIN DON ADON MDS SSD HR Identified Opportunity for Improvement/Deficient Practice: Free from Accidents Hazards/Supervision/Devices Quality Assurance and Performance Improvement 1. Immediate Corrective Action for those affected by the deficient practice: #57 Root Cause, At Risk meeting, Fall Assessment, Care plan updated the facility IDT completed a AT RISK FALL review for Res #57 to identify current interventions for appropriateness and discussion on effectiveness of fall interventions and additional recommendation are being followed for pommel cushion in wheelchair, signage in room for reminders to ask for assistance, dysum in wheelchair. #25 Root Cause, At Risk meeting, Fall Assessment, Care plan updated the facility IDT completed a AT RISK FALL review for Res #25 to identify current interventions for appropriateness and discussion on effectiveness of fall interventions and additional recommendation are being followed for dysum in wheelchair, fall mat, signage in room, [NAME] [sic] cushion in wheelchair, signage in room for reminders. Care planned resident scoots off bed and sits on fall mat. #14 No longer lives in facility 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: ***All licensed nursing staff including agency staff are educated on the fall policy protocol with a focus document in fall investigation, fall risk, pain, skin and change of condition. Immediate initiation. Assure that no one works their assigned shift until educated on this policy. Interdisciplinary team (Social Services, ADON, Therapy, and MDS) educated on At Risk. AT RISK FALLS meeting to review residents who have had a fall. This education reviewed focused on completing a thorough root cause evaluation, trending and tracking for residents with frequent falls and evaluation as an interdisciplinary group (IDT) to determine effectiveness of the current interventions implemented and success of interventions implemented. Complete fall assessments on all residents Audit to falls in past 30 days ensure care plan updated with new interventions Educate CNA to find fall interventions Kardex Orientation for Emerald staff and/or agency to review Kardex for fall interventions and updates 3. Measures put into place/systematic changes to ensure the deficient practice does not recur The leadership will reinforce the post fall root cause evaluation is completed immediately and intervention implementation care plan revisions as indicated with new appropriate interventions to prevent further fall. The DON or designee will review in daily clinical meeting that the documentation of post fall event and follow up post fall for 72 hours is complete and thorough. Leadership will ensure Kardex is updated to reflex new fall interventions Clinical stand-up review falls and care plan updates Education will be followed by review in the daily clinical meeting of all fall events to determine compliance and competency for ongoing fall events and any identified issue immediately reeducation will be completed to continue to improve the system changes implemented with the Quarterly Education to License Nurses on fall protocol and documentation 4. Plan to monitor performance to ensure solutions are sustained. Random audit of care plans of falls will occur Weekly audit X 4 weeks for 1 month, then monthly X3 Daily audit in clinical start up to assure fall protocol is accurate in PCC, care plan, and kardex On-going quarterly review of falls and care plan The plan of correction reviewed in Ad hoc QAPI The plan of correction will be reviewed monthly by the QAPI committee for the next 3 months and longer if needed. The Ad [NAME] committee reviewed the immediate corrective training with Licensed Nurse and facility leadership team. No policy revisions are needed currently as. The Facility Administrator will continue to complete ongoing information gathering to determine any additional system changes ongoing. Completion will done on 03/31/2023, at 01:00 PM [NAME] C. [NAME], Admin. The IJ was lifted, effective 04/03/23 at 5:30 p.m., when all the components of the plan of removal had been completed. The deficient practice remained at a pattern with potential for harm to the residents. Based on record review, observation, and interview, the facility failed to: a. ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; b. monitor and evaluate the effectiveness of the interventions; c. update the care plan with each fall; and d. conduct a root cause analyses and/or evaluate the cause for each fall for four (#14, 17, 25, and #57) of four sampled residents reviewed for falls. The MDS coordinator provided a fall log which documented 37 residents had fallen in the last four months. Findings: The facility's Fall Protocols Policy, dated 10/21/19, read in parts, .An incident investigation will be completed to determine root cause of fall and/or if the event was isolated in nature. Immediate preventive measures will be implemented prior to end of shift based on the incident investigation findings .The fall shall be reviewed at the next interdisciplinary meeting to assure that the interventions are appropriate and to evaluate the need for any additional preventative measures and to verify appropriate intervention has been implemented .The care plan will be revised for any new fall prevention interventions .Fall intervention book will be updated immediately with fall intervention for staff reference. Tasks for ADL documentation will be added as indicated .Interdisciplinary Team to review all documentation and findings related to previous falls and discuss with resident/family and physician . 1. Record review of Res #14's clinical record revealed 29 falls in an eight month period from 11/26/21 through 07/22/22. Res #14's significant change assessment, dated 10/20/22, documented the resident's cognition was moderately impaired; had no behaviors; required the limited assistance of one person with bed mobility and locomotion on the unit with a w/c; limited assistance of two people with transfers; and no ROM impairments. The assessment documented the resident had diagnoses which included dementia and impulse disorder and had no falls since the last assessment on 10/11/23. The care plan, last updated on 07/14/22, documented the resident was at risk for falls related to dementia and impaired safety awareness. The care plan listed the following interventions: a. a safe environment with even floors free from spills and clutter, b. adequate glare free light, c. a working and reachable call light, d. the bed in low position at night, e. side rails as ordered, f. handrails on walls, g. personal items within reach. h. therapy to work with resident and modify therapy times to resident preference to assist with participation success. i. assist with transfers to/from surfaces as needed to the degree needed. j. keep assistive devices within reach. k. assist resident to and from meals. l. obtain UA r/t frequent falls (5/27/22), unsteady gait, and confusion. m. fall 07/12/22 - when resident is visibly tired escort resident to bed to avoid falling. An incident report, dated 10/30/22, documented Res #14 had a fall in another's resident room ambulating self out of w/c. The report documented Res #14 was laying in the floor near the door. The report documented the resident sustained a small red bump with a cut to the right side of the forehead. There were no interventions documented to help prevent further falls and the care plan was not updated. A nurse note, dated 11/03/22, documented the resident fell this morning in the common area with no injuries. There was no documentation of interventions or care plan revision. An incident report, dated 11/14/22, documented the resident had a fall in the lounge area. The report documented Res #14 was laying on right side 15 feet from the transfer surface with no injuries. The last update documented on the care plan was on 11/15/22 with the intervention to contact hospice to obtain newer model wheelchair. An incident report, dated 11/21/22, documented the resident fell in the hallway after going 15 feet from the w/c transfer surface with no injuries. The intervention was to have direct supervision of the resident while in the hallway. The care plan was not updated with the intervention. A nurse note, dated 11/29/22, documented the resident fell in the living room next to the w/c with no injuries. There were no interventions documented or care plan updated. A nurse note, dated 12/07/22, documented the resident fell in the common area by the doorway of the room. The note documented an incontinent episode on the floor with no injuries. The intervention was to instructed staff to toilet resident swiftly after meals. The care plan was not up-dated with the intervention. A nurse note, dated 12/13/22, documented day one of three for status post fall with no delayed injury. There was no summary of the event, interventions, or update to care plan documented. A nurse note, dated 12/21/22, documented the resident fell in another resident's room with no injuries. There were no interventions of update to the care plan. An incident report, dated 12/26/22, documented the resident had a fall in the dining room. The note documented the resident slipped out of the high back w/c onto buttocks and right side. The report documented a small cut on right hand fourth digit and the intervention was to adjust the anti-slip pad in the resident's w/c. The care plan was not updated. A nurse note, dated 12/28/22, documented the resident fell in another resident room and sustained a small laceration to the back of their head and an intention in the wall where their head hit. The note documented the intervention was hospice gave new medication for aggression and yelling out. The care plan was not updated. An incident report, dated 12/30/22, documented the resident fell in their room in front of w/c next to the floor mat. The report documented the resident sustained a scrape to the knee. No interventions were documented and the care plan was not updated. An incident report, dated 01/06/23, documented the resident fell in his room next to the entry with no injury. The report documented there were no new interventions because safety interventions were already in place. The report documented the bed was in lowest setting, light on in room, and fall mat and call light in place. The care plan was not updated with the fall. A quarterly assessment, dated 01/17/23, documented the resident's cognition was severely impaired; required extensive assistance of two people for bed mobility and transfers; did not walk; and had no ROM impairment. The assessment documented the resident had two or more falls with no injuries. A nurse note, dated 01/20/23 at 9:49 p.m., documented the resident had a witnessed fall on the previous day shift with no injuries. There was no summary of the event, interventions, or update to care plan documented. An incident report, dated 01/23/23, documented the resident fell in the lounge area after walking 10 feet from transfer surface. The report documented a one inch skin tear to the right thumb. There were no interventions or care plan update documented. A nurse note, dated 02/03/23, documented the resident continued on fall follow-up from previous shift with no injuries. There was no summary of the event, interventions, or update to care plan documented. An incident report, dated 02/06/23, documented the resident had a fall in the dining room with no injuries. There were no interventions documented or care plan updated. An incident report, dated 02/09/23, documented the resident fell in the activity attempting to transfer without assistance to the w/c. The report stated staff could not get to the resident in time. The report documented a re-injured laceration to right thumb on palm side and was sent to the ER. There were no interventions documented or update to care plan. A nurse note, dated 02/24/23 at 2:56 p.m., documented it was day two of three status post fall with no delayed injury. There was no summary of the event, interventions, or update to care plan documented. The fall log documented a fall on 03/02/23 at 4:08 p.m. A nurse note, dated 03/04/23, documented day two of three related to previous incident with no injuries. There was no summary of the event, interventions, or update to care plan documented. A nurse note, dated 03/06/23, documented the resident had a fall by their bed onto the mat with no injuries. Interventions documented cares offered every two hours and call light within reach. An incident report, dated 03/06/23, could note be opened to view on the EHR. No new interventions or care plan update was documented. A nurse note, dated 03/11/23, documented the aide reported the resident was on the floor and had an abrasion to the left side of the forehead that was bleeding. No interventions or care plan up-date documented. An incident report, dated 03/18/23, documented the resident had a fall in the hallway and sustained a small cut on right side of the forehead. The report documented the intervention was to encourage the resident to stay in the w/c. The intervention was not appropriate because of the impaired cognition of the resident and the care plan was not updated. A nurse note, dated 03/20/23, documented the resident stood up the dining room area and fell on to floor unobserved. The report documented the resident complained of left hip pain. The note documented the resident was sent to the hospital. No interventions or care plan up-date was documented. A nurse note, dated 03/23/23, documented the resident had returned from the hospital after left hip surgery. On 03/30/23 at 10:25 a.m., CNA #5 stated Res #14 was a fall risk and total care. She stated the resident fell two weeks ago when he stood up from his chair on the night shift and fell and broke a hip. She stated the resident passed last night. She stated he would try to get up by himself so we tried to keep an eye on him the best we could. On 03/29/23 at 10:30 a.m., the resident was observed lying on his bed. CMA #1 at that time stated the resident was on hospice services, had a recent fall with a hip fracture, and she was not aware of the interventions for falls for the resident. On 03/30/23 at 12:30 p.m., the MDS coordinator was asked about the fall care plan not being updated. She stated the facility had recently had a QAPI meeting to bring all care-plans up to accuracy. She stated the DON would relay the fall happening to the IDT and then it went to the care plan from there. On 03/30/23 at 12:58 p.m., the interim DON was questioned about the process which happens after a fall occurred. She stated she had been at the facility for two weeks. She stated when a fall happens the nurse was notified. She stated there was an assessment of the resident completed, family and physician notified, look at what inventions were all ready in place, and come up with new ones. She stated there should have been a new intervention for each new fall. She stated the nurse should do something temporary then come up with long term plan and document the interventions. She stated the care plan should be updated. She stated an incident report should also be filled out and a nurse note documented. On 03/30/23 at 2:30 p.m., the administrator was asked about the process of what happens after a fall. He stated when there was a fall, it is discussed every morning at stand up meeting. He stated interventions were discussed as to what was used in the past and what should be used in the future. He stated the team has round table discussions and we sometimes have to reevaluate. He stated he was not realize the care plan had not been updated. He stated he thought that had been taken care of. He stated there was a root cause analysis conducted as to why there were so many falls. He stated we found the core people were not there and agency did not know the residents well enough and the interventions. The administrator stated there should be an incident report for each fall, along with a nurse note. The administrator was asked if he and the administration went over the incident reports and was there a place to sign that they had reviewed them. He stated he was informed of the falls but did not read over the reports and there was not a place to sign off on the reports after reviewing. 38495 2. Res #25 had diagnoses which included TIA, CHF, and Alzheimer's disease. A care plan, last revised on 12/06/22, documented, the resident was at risk for falls related to progressive neuro-cognitive disorder, Alzheimer's,/dementia. The care plan documented the resident's gait/balance instability, impulsiveness, and poor safety awareness will continue to decline as the disease progresses over time contributing to unpreventable falls. The care plan documented the resident had preference of sitting or laying in the floor and will intentionally move from bed to floor. The care plan documented the following interventions: a. Anticipate and meet my needs as I do not make my needs known, b. Assist with application of non-skid footwear, and c. Direct me to a common area for increased supervision. A fall scene investigation report, dated 10/31/22, was in the EHR but the report could not be viewed. The fall log, provided by the facility, documented a fall on 11/17/22. There was not an incident report or a nurse note regarding the fall in the EHR. A nurse note, dated 12/04/22, documented the resident was found in their room on the fall mat with no injuries. The note documented, .Resident is care planned to the floor .'' A fall scene investigation report, dated 12/05/22, documented the resident's wheelchair and floor mat were pushed away from the bed. The interventions documented were frequent checks, bed in lowest position, and fall mat in place. The care plan was not updated with the new interventions. The fall log documented a fall on 12/11/22. There was not an incident report or nurse note regarding the fall. A nurse note, dated 12/12/22, documented the resident was attempting to transfer himself from his bed to the wheel chair and slid to the floor with no injuries. There was no intervention documented to prevent recurrence. A fall scene investigation report, dated 12/15/22, documented resident was lying on his left side next to their bed. The report did not document an intervention to prevent recurrence. A fall scene investigation report, dated 12/16/22 at 11:00 a.m., documented resident's wheelchair was approximately five feet behind the resident and the wheels were unlocked. The conclusion was the resident fell out of bed and crawled to the door due to being over sedated and confused. The interventions documented was to discontinue routine narcotic medication and encouraged to follow cueing from signage in the resident's room. The care plan was not updated with the new interventions. A nurse note, dated 12/16/22 at 2:10 p.m., documented this nurse walked by the resident's room and noted the resident sitting up on his buttocks against his bed with no injuries. The resident stated I was trying to get in my wheelchair. The intervention documented to move the resident out to the common area to supervise for remainder of shift. A fall scene investigation report, dated 12/20/22, documented the resident was found on the floor in the room. The interventions documented were a fall mat in place and frequent checks. No new interventions were documented and the care plan was not updated. A fall scene investigation report, dated 12/25/22, documented the resident was sitting on the fall mat with back against the bed facing the door and wheelchair. The intervention documented was to distract the resident with activities and coffee. The care plan was not updated. A fall scene investigation report, dated 01/03/23, documented the resident was observed laying on the floor in front of his wheel chair in front of bathroom door. The intervention documented was to toilet the resident after meal service. The care was not updated. The fall log documented a fall on 01/05/23. A nurse note, dated 01/05/23, documented the resident continued on fall follow up with neuro checks and no injuries. The was not an incident report or interventions to help prevent further falls were documented. A annual assessment, dated 01/23/23, documented the resident was severely impaired with cognition, required extensive assistance with ADLs, and had no falls. A fall scene investigation report, dated 01/25/23, documented the resident was found on the floor on the fall mat. The intervention was that the resident will have non skid socks on while in bed and remind resident to ask for help. The care plan was not updated. A fall scene investigation report, dated, 02/10/23, documented the resident was found on the fall mat. No interventions documented to help prevent further falls. The fall log documented a fall on 03/26/23. There was not an incident report or nurse note regarding a fall. On 03/30/23 at 9:19 a.m., the MDS coordinator stated the resident's care plan had not been updated with the falls. She stated they had QAPI' d bringing the care plans up to date. On 03/30/23 at 10:25 a.m., CNA #5 stated she transfers the resident on and off the toilet. She stated he was a fall risk and the interventions were to keep his bed in a low position and a fall mat by his bed. On 03/30/23 at 10:29 a.m., Res #25 was observed on the bed sleeping, positioned on his left side with the bed in low position and a fall mat was on the floor. On 03/30/23 at 10:37 a.m., CMA #1 stated the nurse usually told her when a resident was a high fall risk. She stated she would usually try and check on the high fall risk residents more often. On 03/30/23 at 10:40 a.m., LPN #1 stated she would look at the resident's history for falls, assessments and the resident's medications. She stated the process for falls was if the fall was not witnessed 72 hour charting on the resident would start, an incident repot should be completed, a note, and notify families, physician, and the hospice if on hospice. She stated the MDS person should be informed of the falls. LPN #1 stated she would let the DON know verbally if she was in the facility and administration. A risk management form should be completed. LPN #1 stated depending on the situation an unwitnessed fall happened, they would start neuro checks and if an injury occurred they would send them out. She stated management in stand up meetings would do the interventions for the residents' falls. 46909 3. Res #57 was admitted to the facility on [DATE] and had diagnoses which included right femur fracture, Parkinson's disease, dementia with mild agitation, and neuropathy. A fall scene investigation report, dated 02/28/23, documented Res #57 was found on the floor by his chair, with no injuries. Interventions documented would be to monitor resident, re-orient, and continue with therapy. A care plan, initiated on 03/01/23, documented the resident was at risk for falls. The care plan documented the following interventions. a. Anticipate and meet the resident's needs. b. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. c. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. d. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. e. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. f. Follow facility fall protocol. g. Occupational therapy - evaluate and treat as ordered or PRN. h. Physical therapy - evaluate and treat as ordered or PRN. An admission assessment, dated 03/05/23, documented the resident was severely impaired and needed extensive assistance with ADLs. The assessment also documented the resident did not have any falls with injuries. The fall log documented a fall on 03/14/23 at 1:45 p.m., for Res #57. There was no nurse note or incident report completed on this day related to a fall. There were no interventions updated on the care plan. A nurse note, dated 03/15/23 at 3:04 a.m., documented neuro checks post fall with no changes with status, ROM within normal limits, no complaints of pain or delayed injury related to fall. An incident nurse note, dated 03/16/23 at 2:25 p.m., documented day three of three post fall follow-up, ROM within normal limits, and denies pain or discomfort. An incident nurse note, dated 03/16/23 at 7:53 p.m., documented the resident was complaining of the left shoulder hurting and stated he believed it was fractured. A nurse note, dated 03/16/23 at 8:23 p.m., documented the resident was transferred to the nearest hospital. A hospital emergency record, dated 03/16/23 at 8:39 p.m., documented the nursing home staff stated the resident had an unwitnessed fall sometime today and then started complaining of left shoulder pain tonight. The hospital record documented swelling was noted on the left shoulder and X-rays were obtained of the shoulder and elbow which demonstrated an acute fracture of the left humeral head. The record documented the resident was placed in a shoulder immobilizer, given a prescription for Norco, and follow-up instructions with a physician. A fall scene investigation report, dated 03/17/23 at 4:10 a.m., documented the resident was found on the floor with no complaints of pain. The intervention was for the resident to be in eye watch at all times and increase activities. The care plan was not updated with the interventions. A nurse note, dated 03/18/23 at 9:19 p.m., documented the resident was sitting in the common area in his w/c and stood up. The note documented the CNA asked the resident to sit back down and when the resident sat back down he slid out of the w/c, with no injury. No interventions were documented for this fall. A nurse note, dated 03/19/23 at 3:08 p.m., documented the resident was found lying on the floor next to his bed with no injuries. No interventions were documented for this fall. On 03/27/23 at 3:00 p.m., an observation was made of the resident sitting in a wheelchair, with a sling on his left arm, in the common area with other residents. On 03/29/23 at 11:30 a.m., the MDS coordinator stated all the falls were documented under the forms tab, with fall screening assessment tool attached. She also stated she had been working the floor and had not updated the resident's care plan. She stated the care plans were addressed in the quality assurance meeting and they would all be brought up to date. On 03/30/23 at 10:25 a.m., LPN #2 stated the resident had fallen in the bathroom on 03/14/23 and she did an assessment on the same day and the resident did not complain of any pain any where on his body but she did start neuro checks on the resident. She also stated an agency nurse was working the next two days and when she came back to work and the resident had a sling on his arm. 4. Res #17 had diagnoses which included Alzheimer's disease, dementia, anxiety, atrial fibrillation, and history of urinary tract infections. A nurse note, dated 12/12/22, documented Res #17 was found on the floor by a CNA with a .golf ball size knot . on the back of their head. The resident was transferred to the local hospital and admitted for closed head injury. No interventions to prevent recurrence was documented and a care plan was not in place at that time. A nurse note, dated 03/10/23, documented Res #17 was found on the floor in their room. She was transferred to the local hospital and admitted with a displaced intertrochanteric fracture of the left femur. On 03/14/23 a care plan was initiated for risk of falls. The care plan documented the following interventions: a. Anticipate and meet the resident's needs. b. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. c. Occupational Therapy evaluate and treat as ordered or PRN. d. Physical Therapy evaluate and treat as ordered or PRN. e. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. A quarterly assessment, dated 03/19/23, documented the resident severely impaired and needed extensive assistance with ADLs. She was frequently incontinent of bladder and occasionally incontinent of bowel. The assessment also documented the resident did not have any falls with injuries. On 03/30/23 at 12:30 p.m., the MDS coordinator stated she was working on the floor and did not have the time to do update the care plan. She stated the care plans were addressed in the quality assurance meeting and they would all be brought up to date.