Every finding on record at Muskogee Nursing Center

On [DATE] at 5:30 p.m., an IJ situation was determined to exist related to the facility's failure to ensure supervision was provided to prevent Resident #1 from elopement. A quarterly assessment, dated [DATE], showed the resident had moderate cognition impairment with a BIMS of 12. An undated face sheet showed Resident #1 had diagnoses which included dementia, diabetes, and psychosis. A care plan, dated [DATE], for Resident #1 showed the resident was at risk for wandering. A facility incident report, dated [DATE], showed Resident #1 had left the facility and was struck by a car and expired later. On [DATE] at 5:35 p.m., the administrator was notified of the existence of an IJ situation related to the facility's failure to provide supervision to prevent elopement. The IJ template was provided to the administrator. On [DATE] at 3:00 p.m., an acceptable plan of removal was approved by OSDH. The plan of removal, read in part, Muskogee Nursing Center 602 North M St Muskogee OK 74403 [DATE] at1446. Plan of Removal. There are no more wandering residents in the nursing facility at this time that try to get out of the facility [DATE]All residents will have updated wandering risk performed [DATE] and [DATE]If a new admit or resident develops wandering behavior, will advise to be relocated to a sister facility where they have wander guard and lock downs or home of their choice [DATE]One on one will be done on any resident that starts exhibiting wandering behavior until Dr. can assess and faily [sic] and solution made [DATE]If for some reason a resident gets out and wanders off and will not listen to us 911 and family will be called immediately, and staff will stay with resident [DATE]Individual care plans will be performed on all residents and updated when needed for example: if residents start to have wandering tendencies [DATE]Doors will be locked down so a staff member will have to assist anyone coming in or going out [DATE]When family comes to pick resident up, we will have family and resident sign the Sign Out form [DATE]All staff were called in for emergency in-service and educated when someone wants to sign out, for the changes we have made [DATE]Also, if a resident leaves without signing out 911 will be called immediately as well as family [DATE]Code to doors was changed [DATE]Sign posted outside to notify all visitors if no one is up front to let them in to call ###-###-#### [DATE] On [DATE] at 1:00 p.m., the IJ was lifted, effective [DATE], when all components of the plan of removal had been verified as completed. Multiple certified and licensed staff on different shifts were interviewed regarding elopements. Wandering assessments, and staffing were reviewed. The deficient practice remained at an isolated level with potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent elopements for 1 (#1) of 3 sampled residents reviewed for accident hazards. The administrator identified 2 residents were at risk for elopement. Findings:On [DATE] at 10:15 a.m., all doors of the facility were observed to be closed and locked.A muskogee police department case report, dated [DATE] at 8:09 p.m., showed when Resident #1 was struck by a car they rolled onto the hood of the car, and struck the windshield. An EMS run report, dated [DATE], showed CPR was initiated by the paramedic and MPD officer. A [NAME] device (A portable, mechanical system that provided automated chest compressions) was placed on Resident #1 by EMS. Resident #1 was pronounced deceased at the hospital. An undated facility face sheet for Resident #1 showed the resident had diagnoses which included dementia, diabetes, and psychosis. A quarterly assessment for Resident #1, dated [DATE], showed the resident was moderately impaired for daily decision making with a BIMS of 12. A nurses note for Resident #1,dated [DATE], read in part, At approximately 8pm resident insisted on leaving the facility. CNA attempted X2 to redirect resident d/t [due to] it being dark outside. This nurse was made aware and educated resident about safety of walking in the dark with dark clothing on. Resident became agitated and cursed at staff before signing themself out of the facility. Called family member and received voice mail. Then called the family member's spouse with no answer. Called family member a 2nd time and left voice mail to make them aware of the resident behavior. On [DATE] at 2:53 p.m., the administrator stated Resident #1 had left the facility property approximately three times prior to the current incident being investigated. The administrator stated they were told by an ombudsman, residents could not be restricted from leaving the facility because the facility was not a jail. The administrator stated the facility did not have an alert system. The administrator stated the facility had no policy regarding wandering or elopement. The administrator stated the facility had removed the posted code from the exit door, moved the nurse's desk to allow a view of the exit door when the nurse is at the desk, in-serviced all staff to call 911, family and administration if a resident left the facility unsupervised. On [DATE] at 9:19 a.m., CNA #2 stated they saw Resident #1 sign themself out and they told the resident it was not a good idea. CNA #2 stated they followed Resident #1 down the street but did not remember for how far. CNA #2 stated they returned to the facility to care for their other residents and informed the nurse. On [DATE] at 10:17 a.m., the administrator provided a form titled QAPI Quality Assurance Performance Improvement dated [DATE]. On [DATE] at 1:00 p.m., the administrator also provided a form titled QAPI Quality Assurance Performance Improvement dated [DATE]. On [DATE] the administrator provided a form titled, In-Service Bi-Monthly, dated [DATE], Topics discussed: Elopement, CNA charting, doors are to stay locked, one on one will be done on anyone exhibiting wandering behavior.

Based on record review and interview, the facility failed to ensure accurate staffing information for the PBJ reports was provided to CMS for the fourth quarter of 2024. A facility document titled All Residents, dated 01/06/25, documented 38 residents resided at the facility. Findings: A CMS PBJ Staffing Data Report dated 07/01/24 through 09/30/24, documented the facility had not provided the required RN coverage or licensed nurse coverage for the quarter of 2024. A review of the facility daily staffing reports for the fourth quarter of 2024 revealed the facility had been adequately staffed for RN coverage, licensed nurse coverage, and weekend staffing. On 01/08/25 at 10:14 a.m., the administrator stated the information submitted was not accurate and the person who had entered the data had erroneously submitted incorrect information at another one of their facilities on another occasion. On 01/08/25 at 10:32 a.m., the administrator stated they had not been aware the wrong information had been submitted. They stated the employee who had entered the data had recently been let go because they had done the same thing at another facility. They stated the facility did not have a policy or procedure for the entry of PBJ report data.

Based on record review and interview, the facility failed to ensure SNF ABN forms included the required information for two (#43 and #48) of three sampled resident reviewed for skilled services beneficiary review. The DON identified 10 residents that had discharged from part A skilled services in the previous six months to the survey. Findings: 1. A SNF ABN form for Resident #43, dated 09/20/24, was reviewed and found not to have the reasons for non-coverage and estimated cost of those services documented on the form. 2. A SNF ABN form for Resident #48, dated 12/23/24, was reviewed and found not to have the reasons for non-coverage and estimated cost of those services documented on the form. On 01/08/25 at 9:59 a.m., the infection preventionist stated they had been tasked with creating the SNF ABN forms and presenting them to the residents. They stated they were unaware the section about the reason for potential non-payment and estimated cost were required to be included on the form. They stated they understood now the information was needed for the resident and their representatives to make informed decisions about future care. On 01/08/25 at 10:32 a.m., the administrator stated they did not have a policy or procedure for the completion of the SNF ABN forms. They stated the forms were important for the residents to make decisions and should have been completed fully.

Based on record review and interview, the facility failed to ensure licensed nurses were competent to perform tasks of their position by conducting a skills check and documenting the results for each licensed nurse. A facility employee list provided by the DON documented eight licensed nurses worked at the facility. Findings: A review of LPN #1's employee file did not reveal a skills review. On 01/08/25 at 8:56 a.m. the DON stated they had looked at LPN #1's records and did not find a skills check. They stated the former DON had stopped performing skill checks at some point and they would be restarting that process. They stated it was their expectation each licensed nurse would possess the skills to perform their duties. They stated their was no facility policy or procedures regarding skills checks. On 01/08/25 at 9:01 a.m., the administrator stated none of their current licensed nurses had a skills check in their file because the previous DON had not done them. On 01/08/25 at 9:06 a.m., the assistant administrator stated the nurses last skills check had occurred in 2021.

Based on observation and interview, the facility failed to: a. implement an enhanced barrier precaution policy to prevent the spread of multidrug-resistant organisms; and b. ensure a licensed practical nurse performed hand hygiene during tracheostomy care for one (#36) of one sampled resident reviewed for tracheostomy care. The administrator reported the census in the facility was 38 and one resident had a tracheostomy. Findings: 1. On 01/06/25 at 8:45 a.m., a tour of the facility was conducted. No signage was noted indicating enhanced barrier precautions were in place to protect at risk residents. On 01/07/25 at 12:42 p.m., CNA #1 stated the facility did not use EBP. On 01/07/25 at 12:45 p.m., CNA #2 stated they were not familiar with EBP. On 01/08/25 at 09:41 a.m., LPN #1 stated the facility was in the process of implementing enhanced barrier precautions. On 01/08/25 at 10:35 a.m., the infection preventionist stated they are currently not using EBP. b. A facility Trach policy, dated 11/05/24, read in part, Cleaning A Non Disposable Inner Cannula 1. Prepare supplies before cleaning inner cannula. a. Open tracheostomy care kit with supplies. b. Cleanse trach site with 15 ml of normal saline with 5 ml of hydrogen peroxide. c. May open extra splint gauze sponges. 2. DON disposable gloves 3. Remove oxygen source if one is present. 4. Gently remove inner cannula, remove gloves and discard 5. Disposable replacement inner cannula, release lock gently remove inner cannula, Replace with appropriate sized new cannula. Engage lock on inner cannula. 6. Suction outer cannula using sterile and or clean technique. 7. Replace inner cannula into outer cannula reapply oxygen source if needed. A facility Addendum to Trach Cleaning policy, read in part, Procedure: Wash your hands, Set up equipment/trach care kit onto pre cleaned area, [NAME] gloves, Place hydrogen peroxide/sterile water solution into bowl/compartment; Place sterile water into second bowl or compartment, Remove inner cannula while holding the neck plate of trach still, Place inner cannula in peroxide/sterile water solution and soak until crust or mucus plugs are softened or removed, Use the brush or pipe cleaners to clean inside, outside, and the creases of the tube, Look inside the inner cannula to make sure it is clean and clear of mucus, Rinse tube in saline or sterile water, Reinsert into trach while holding neck plate still, Turn the inner cannula until it locks into position, and Double check the locking by pulling the inner cannula forward gently. On 01/08/25 at 8:31 a.m., LPN #1 was observed performing tracheostomy care to Resident #36. LPN #1 was observed to have prepared the material necessary for the care then don gloves. They were not observed cleaning their hands prior to donning the gloves. LPN #1 was observed removing the tracheostomy tubing from the resident and placing it on a clean surface. They then prepared a cleaning solution, applied the solution to gauze, then cleaned around the ostomy site. They discarded the gauze then repeated with new gauze. They then discarded that gauze and began cleaning the tracheostomy tubing. They then placed the tubing into the resident's tracheostomy site and secured it. They then placed a bandage around the tubing on the resident's neck. LPN #1 then removed their gloves they had put on at the beginning of the care. On 01/08/25 at 8:40 a.m., LPN #1 was asked how they thought the care had gone. They stated they believed it had gone well. They were asked how many times during the care did they change their gloves. They stated they had not and should have done so between the dirty and clean steps. They stated they had been nervous. On 01/08/25 at 8:49 a.m., the DON stated they were surprised by LPN #1's performance during the tracheostomy care. They stated it was their expectation the nurses understand the importance of not passing infections and using personal protective equipment. They stated they would be having training with LPN #1 on these issues.

Based on record review and interview, the facility failed to ensure dialysis communication forms were consistently filled out for one (#21) of one sampled resident reviewed for dialysis. The administrator reported three residents in the facility received dialysis services. Findings: A Nursing Home Dialysis Transfer Agreement, signed 01/21/14, read in part, Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer to center. Resident #21 had diagnoses which included end stage renal disease. A physician's order, dated 11/03/21, documented Resident #21 was to receive dialysis every Tuesday, Thursday, and Saturday. Resident #21's 2024 TARs documented they had been transported to dialysis 13 times in November and 13 times in December. Out of 26 opportunities, the resident's health record contained five dialysis communication forms. On 01/08/25 at 9:41 a.m., LPN#1 stated the nurse on duty should ensure a dialysis communication form was sent with the resident to dialysis. They stated once the resident returned from dialysis the form should be given to the business office manage to place in the resident's chart. On 01/08/25 at 10:01 a.m., the business office manager stated the forms do not always make it back from dialysis with the resident. On 01/08/25 at 11:30 a.m., the administrator stated the facility needed to ensure the communication forms made it back to the facility.

Based on record review and interview, the facility failed to ensure a resident with a diagnosis of diabetes and received routine insulin had an HgbA1C lab collected as ordered by a physician for one (#22) of five sampled residents reviewed for unnecessary medications. The DON stated 23 residents at the facility have physician routine orders for HgbA1C tests. Findings: Resident #22 had diagnoses which included type two diabetes. A physician's order, dated 08/12/19, documented Resident #22 was to have HgbA1C labs drawn each January, April, July, and October. A review of the resident's EHR revealed no documentation the resident's HgbA1C had been collected since July 2024. On 01/07/25 at 9:45 a.m., the infection preventionist stated in October 2024 the facility's QA committee had identified through their quality assurance program the HgbA1C labs for Resident #22 had not been done. They were asked since the discovery, how many times had the resident's lab been checked. The infection preventionist stated they had not been checked since identified by the QA committee. They stated the HgbA1C was important to get an accurate measurement of the resident's blood sugar levels and would they would contact the physician for an order to obtain the lab now. On 01/08/25 at 8:49 a.m., the DON stated all lab work needed to be completed as ordered so the providers could make informed decisions about care.

Based on record review and interview, the facility failed to ensure lab work identified by the QA committee as not having been done was collected once the omission was identified for one (#22) of five sampled residents reviewed for unnecessary medications. A facility document titled All Residents, dated 01/06/25, documented 38 residents resided at the facility. Findings: An active physician's order, dated 08/12/19, documented Resident #22 was to have HgbA1C labs drawn each January, April, July, and October. A review of the resident's EHR revealed no documentation the resident's HgbA1C had been collected since July 2024. On 01/07/25 at 9:45 a.m., the infection preventionist stated in October 2024 the QA committee, through their quality assurance program, had identified the previous DON had not been monitoring labs and Resident #22 HgbA1c had not been collected since July 2024. The infection preventionist was asked how many times the resident's labs had been collected since October 2024. They stated the labs had not been collected. They were asked how effective the facility quality assurance had been in that case. They stated it had not been effective for Resident #22. They stated they would contact the physician and get an order for the lab work to be collected.

Based on record review and interview, the facility failed to update COVID-19 Policy and Procedures at least annually. The Administrator reported there were 34 residents residing in the facility. Findings: A COVID-19 Policy and Procedure, revised 12/23/20, stated in parts, .Staff will have their temperature checked 3 times per shift .Dietary staff to wear mask while in kitchen .Nurse's to wear N95 mask while completing breathing treatments .Facility will obtain and record temperatures on all residents qshift .Residents are to be encouraged to stay in their rooms .Residents are to wear face mask anytime they come out of their room . On 11/16/23 at 9:00 a.m., the Administrator stated the above practices documented in their current COVID-19 policy and procedures were no longer in effect and acknowledged the policy had not been updated at least annually.

Based on observation, record review, and interview, the facility failed to ensure staff wore hair nets and beard guards while in the kitchen. The CDM identified 33 residents received services from the kitchen. She identified one resident who solely received nutrition and hydration through a peg tube. Findings: A Personnel Standards policy, undated, read in part, .The following standards have been adopted by the dietary department .Hair nets, covering all of the hair, must be worn at all times while on duty .Facial hair must be covered with a beard guard . On 11/14/23 at 11:22 a.m., Cook #1 was observed with very short hair on their head and the bottom half of their face. They were not observed to have a hair net or beard guard on. On 11/14/23 at 11:48 a.m., DA #1 was observed in the kitchen with longer facial hair observed from side burn to side burn, covering chin, and above top lip. They were not observed to wear a beard guard. On 11/14/23 at 12:00 p.m., Cook #1 and DA #1 were observed assisting with plating lunch and covering trays for delivery. Neither staff were observed wearing a beard guard, and cook was not observed to wear a hair net. On 11/15/23 at 3:18 p.m., DA #1 was observed in the kitchen without a hair net or beard guard. They were observed filling a resident's pitcher. DA #1 alerted CDM the surveyor was at the door. DA #1 was observed to obtain and don a hairnet. On 11/15/23 at 3:19 p.m., the CDM was asked what the policy was regarding staff and hair nets. She stated, We all wear our hair nets. She stated, We have to wear them to come in the kitchen. She was asked what the policy was for wearing beard guards. She stated, Yeah, if they have a beard they are suppose to wear one. She was asked if any of the kitchen staff had a beard. The CDM stated, No. She was asked if DA #1 had a beard. The CDM was observed to look at DA #1 and stated the DA #1 had one. DA #1 was observed to grab another hair net. The CDM stated DA #1 was putting one on.

Based on record review, observation, and interview, the facility failed to conduct routine pressure ulcer assessments, follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Census and Conditions of Residents form documented one resident with pressure ulcers. Findings: Res #15's significant change assessment, dated 08/13/22, documented the resident's cognition was moderately impaired, required extensive assistance with ADLs, and had no pressure ulcers. A nurse note, dated 09/06/22, documented the resident had a fluid filled blister to the left heel measuring 2.0 x 4.5 cm. The note documented an order to cleanse the area with wound wash, pat dry, and spray area with skin prep BID until resolved. A physician order, dated 10/05/22, documented to discontinue skin prep and apply Allevyn dressing to left heel and leave in place for seven days. The TAR documented the skin prep treatment was continued after the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's EHR was reviewed and there were no pressure ulcer assessments for over five weeks from the dates of 09/06/22 until 10/13/22. The wound assessment, dated 10/13/22, documented a pressure ulcer on the left heel measured 2.0 x 0.9 cm and had a Allevyn dressing in place. The wound assessment, dated 10/20/22, documented a pressure ulcer on the left heel measured 1.0 x 0.7 cm and had a Allevyn dressing in place. On 10/26/22 at 4:20 p.m., the resident was lying on an air mattress and the resident's left heel was observed to have an Allevyn dressing. The care plan had not been updated with the new pressure ulcer and interventions to included the physician orders, air bed, and heel protectors. On 10/28/22 at 9:55 a.m., LPN #1 was observed providing wound care to the resident's left heel. There was no dressing in place. The pressure ulcer was open, approximately nickel size, and had serosanguinous drainage on the gauge when the wound was cleaned. The LPN applied skin prep to the pressure ulcer and surrounding area. The LPN stated she had no knowledge of the order for the Allevyn dressing. On 10/28/22 at 3:33 p.m., the DON stated the order for the Allevyn dressing did not make it into the resident's EHR. She stated the skin assessments should have been completed weekly and the care plan should have been updated.

Based on record review and interview, the facility failed to submit direct care staffing data to CMS at any time in the past. The Resident Census and Conditions of Residents form documented 33 residents resided in the facility. Findings: The CMS PBJ Staffing Data Report, for quarter three of 2022, documented no data was submitted for the quarter. On 10/27/22 at 9:03 a.m., the vice president of operations stated the facility had never submitted PBJ data. She stated they had contacted their payroll company recently to start submitting the required data.

Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner for the residents. The VPO identified 33 residents as eating meals prepared by the kitchen. Findings: On 11/01/21 at 8:56 a.m., during the initial kitchen tour, a bag of flour was observed in the store room open to air. On 11/01/21 at 9:02 a.m., cook #1 stated the flour should have not been left open. He stated it must have been left that way from last night. On 11/01/21 at 9:04 a.m., a sealed bag of meat in the refrigerator was observed to be unlabeled and undated. There was a bag of hot links dated but open to air in the refrigerator. At that time, cook #1 stated the meat in the bag was left over pork roast. He stated it was not dated or labeled. Cook #1 stated the hot links bag should have been sealed. On 11/03/21 at 11:24 a.m., kitchen staff were observed putting dishes away wet. The DM stated normally the staff let the items air day, but they were nervous because the surveyor was in the kitchen. On 11/03/21 at 11:29 a.m., the DM stated the food in the refrigerator should have been labeled and dated, and nothing in the store room should not have been left open to air. On 11/03/21 at 12:02 p.m., the meal service was observed. The food trays were observed to have water dripping from them as the DM plated the food.

Based on interview and record review, the facility failed to review and revise care plans for three (#3, 16, and #22) of 12 sampled residents whose care plans were reviewed. The Administrator identified 34 residents as residing at the facility. 1. Resident (Res) #3 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, with a start date of 05/07/21, revealed the care plan was not reviewed and/or revised following a 07/22/21 quarterly Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) assessment. On 11/02/21 at 3:45 p.m., the DON stated she completed the assessments and care plan reviews. She stated the resident's care plan had not been updated following the 07/22/21 assessment. She stated she worked on getting the MDS assessments first. She stated she was unaware of any time frames in which to complete care plan reviews and revisions. 2. Resident (Res) #16 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, with a start date of 06/10/21, revealed the care plan was not reviewed and/or revised following an 08/27/21 quarterly MDS assessment. On 11/02/21 at 3:45 p.m., the DON stated she completed the assessments and care plan reviews. She stated the resident's care plan had not been updated following the 07/22/21 assessment. She stated she worked on getting the MDS assessments first. She stated she was unaware of any time frames in which to complete care plan reviews and revisions. 3. Resident (Res) #22 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 05/05/21, had not been reviewed and revised with every assessment. The care plan was not reviewed and revised after the quarterly assessment on 09/29/21. On 11/02/21 at 3:45 p.m., the DON stated she completed the assessments and care plan reviews. She stated she worked on getting the MDS assessments first. She stated she was unaware of any time frames in which to complete care plan reviews and revisions.

Based on interview and record review, the facility failed to notify the physician of changes in condition for two (#6 and #133) of 12 sampled residents whose records were reviewed. Resident #6 experienced an 11.2 pound weight gain in one week, and Resident #133 experienced fingerstick blood sugar levels greater than 400. The facility did not notify the physician. The VPO identified 34 residents as residing at the facility. Findings: The undated FSBS Policy and Procedure policy read in part, .standing order for physician notification is for FSBS less than 70 or greater than 400 . 1. Resident (Res) #6 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no parameters listed for physician notification. Weight Records, dated 10/15/21, documented Res #6 weighed 302.8 lbs. Weight Records, dated 10/22/21, documented Res #6 weighed 314 lbs. This was an increase of 11.2 lbs in one week. A Progress Note, dated 10/22/21 and written by the hospice nurse read in parts, .anterior lobes diminished to auscultation .4+ [CONDITION(S)] to ble educated on keeping feet elevated pt noncompliant. facility weighed pt current weight 314 will notify physician of 11.2 lbs weight gain in 1 week . Review of the clinical record revealed no documentation to show the hospice agency had communicated with the hospice physician or facility staff regarding the hospice physician's instructions related to the weight gain. A Progress Note, dated 10/24/21 at 2:29 p.m., read in parts, .Pt hypoxic with reduced SPO2 with O2 via N/C . Pt is verbally responsive with interrupted and slurred speech patterns. Pulse Ox levels fluctuate between 51-30%. Accessory muscle use [sic] for breathing. Noted SOB-distress noted .Pt did express desire to go to the hospital as he 'would like to see his son one more time', and stated 'I don't want to die today.' Pt transported via EMS to nearest acute care facility . On 11/03/21 at 10:29 a.m., RN #1 stated facility staff obtained weekly weights and she put them into the electronic record. She stated the weight for Res #6 would fluctuate greatly. She stated he was in the hospital presently for an acute exacerbation of his [CONDITION(S)]. RN #1 stated she had notified the hospice nurse of the weight gain. She stated the hospice nurse was supposed to notify the hospice physician. On 11/03/21 at 10:32 a.m., the DON and VPO were asked who was responsible for the care of a resident. They stated, The facility. They were asked what the expectation was of their staff if a resident had an 11.2 lb weight gain in one week. The DON stated she had informed the hospice nurse when she was here of the weight gain. She was asked how she monitored the resident after knowing of the weight gain. She stated the hospice nurse had told her she would get with the doctor and orders would follow. The DON was asked if the hospice nurse had contacted her again. She stated she may have contacted the day or evening nurse. The DON and VPO were asked what staff was supposed to do if they did not have further communication with the hospice agency. The VPO stated they should have notified the facility's physician. She stated, We should have followed up with hospice and our doctor. 2. Resident (Res) #133 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Treatment Administration Records, dated 10/19/21, 10/20/21 at 11:04 a.m., 10/20/21 at 4:19 p.m., and 10/27/21, documented the resident had FSBS greater than 400 on each reading. Res #133's clinical record did not document physician notification for FSBS above 400 on the identified dates. On 11/01/21 at 11:57 a.m., Res #133 stated his FSBS ranged in the high 300s to over 400 sometimes. He stated he did not receive insulin. On 11/02/21 at 4:10 p.m., the DON stated Res #133 was admitted with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated a nursing judgement should have been to notify the physician for FSBS over the 400 range. The DON stated physician standing orders were to notify the physician of FSBS over 400. The DON stated documentation for Res #133 did not show the physician was notified of the FSBS above 400.

Based on observation and interview, the facility failed to implement CDC guidelines for infection control procedures to prevent the transmission of COVID-19 and/or other infections. The facility failed to: a) provide pressure ulcer treatments in a manner to prevent cross contamination for two (#3 and #16) of two sampled residents observed for wound care; and b) provide assistance with meals in a manner to prevent cross contamination for four (#3,11, 82, and #183) of 33 residents who were observed during the meal service. Findings: 1. On 11/01/21 at 12:23 p.m., CNA #1 was observed to deliver a meal tray to Resident (Res) #183. CNA #1 lifted up the head of the resident's bed, touched her own head, and sat on the side of the bed to assist the resident to eat. CNA #1 opened the resident's dresser drawer looking for a straw. CNA #1 stood with her hands in her pants pockets, sat back down on the bed, and started assisting Res #183 to eat again. CNA #1 then touched the resident's hand, arm, and back while assisting Res #183 to sit up on the side of the bed. CNA #1 then sat on the side of the bed and continued to assist Res #183 with eating. Hand hygiene was not observed during this observation. 2. On 11/01/21 at 12:23 p.m., CNA #2 was observed to assist Resident (Res) #82 with the noon meal. He did not perform hand hygiene prior to beginning to assist her. At 12:51 p.m., CNA #2 left the dining room and went to the kitchen window pass. CNA #2 touched his mask, retrieved a glass of tea for Res #82, and returned to the dining room. CNA #2 got up from the table and took another resident out of the dining room. Hand hygiene was not observed. 3. On 11/01/21 at 12:39 p.m., CNA #3 was observed assisting Resident (Res) #3 with the noon meal. CNA #3 placed the food tray on the table, moved the resident's chair, moved a dining room chair for herself to sit on, placed a clothing protector on the resident, moved the food tray belonging to Res #82, adjusted her own chair, and sat down and started feeding Res #3. She did not perform hand hygiene. At 12:52 p.m., CNA #3 stood up, moved Res #11's geriatric chair, and repositioned at another table. CNA #3 then repositioned her own chair, left the dining room, and retrieved a tray. She returned to the dining room and started assisting Res #11. No hand hygiene wass observed at any time. On 11/01/21 at 1:11 p.m., CNA #3 stated she should have sanitized her hands after touching chairs, other residents' trays, and before assisting Res #3 with their meal. On 11/04/21 at 9:17 a.m., the DON/ IP stated the staff should sanitize their hands after each tray delivery and when starting to feed a resident. She stated she monitored by observation but no routine audits had been completed. 4. On 11/01/21 at 9:42 a.m., RN #1 entered the room for Resident (Res) #16 to perform wound care. She donned gloves without performing hand hygiene. She placed the dressing change supplies on the overbed table. She did not clean the table first. RN #1 sprayed gauze pads with wound cleanser and patted the ulcer. She doffed her gloves, and without performing hand hygiene, left the room and retrieved more gloves. She re-entered the room, donned gloves, and applied aliginate to the ulcer and covered it with a [MEDICATION(S)] foam dressing. She doffed her gloves, gathered the used supplies, left the room, and then performed hand hygiene using sanitizer from the hallway dispenser. 5. On 11/03/21 at 9:41 a.m., RN #1 was observed providing wound care for Resident (Res) #3. RN #1 donned gloves, entered the room, placed a trash bag on the bed, and placed clean gauze on the trash bag. RN #1 cleaned the wound with wound cleanser and gauze pads, and without performing hand hygiene, she changed gloves and completed the dressing change. RN #1 then doffed her gloves, gathered the used supplies, and left the resident's room. She performed hand hygiene after leaving the resident's room. On 11/03/21 at 9:51 a.m., RN #1 stated she did not know to perform hand hygiene when she changed her gloves after cleansing the wound. She stated she did not know to clean surfaces used to hold dressing change supplies.

Based on interview and record review, the facility failed to provide written notification of the facility's bed hold policy on transfer for one (#6) of one sampled resident reviewed for transfer requirements. The Administrator identified five residents as being transferred in the last three months. Findings: Resident (Res) #6 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note, dated 10/24/21 at 2:29 p.m., read in parts, .Pt hypoxic with reduced SPO2 with O2 via N/C . Pt is verbally responsive with interrupted and slurred speech patterns. Pulse Ox levels fluctuate between 51-30%. Accessory muscle use for breathing. Noted SOB-distress noted .Pt did express desire to go to the hospital as he 'would like to see his son one more time', and stated 'I don't want to die today.' Pt transported via EMS to nearest acute care facility . On 11/03/21 at 11:46 a.m., the VPO was asked to provide documentation the resident was provided written information related to the facility's bed hold policy when he was transferred to the hospital. She stated the facility was notifying the residents of the bed hold policy on admission, but they were not providing that information when they transferred to the hospital.

Based on interview and record review, the facility failed to complete accurate assessments for one (#9) of 12 sampled residents whose assessments were reviewed. The Administrator identified 34 residents as residing at the facility. Findings: Resident (Res) #22 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 02/12/21, did not document Res #22 was receiving [CONDITION(S)]. A quarterly MDS assessment, dated 08/11/21, did not document Res #22 was receiving [CONDITION(S)]. On 11/01/21 at 11:46 a.m., Res #22 stated he went to [CONDITION(S)] on Tuesday, Thursday, and Saturday every week. On 11/03/21 at 3:16 p.m., the DON stated [CONDITION(S)] was not marked on the assessments. She stated Res #22 had been receiving [CONDITION(S)] as far as she knew since admission.

Based on interview and record review, the facility failed to complete a discharge summary for one (#83) of two residents who were reviewed for discharge requirements. The VPO identified five residents as discharging from the facility in the last 180 days. Findings: Resident (Res) #83 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Note, dated 12/31/20, documented Res #83 discharged from the facility against medical advise. Review of the clinical record revealed no discharge summary, including a recapitulation of his stay at the facility. On 11/03/21 at 11:48 a.m., the VPO was asked to provide the discharge summary. She stated they only had the nurse's note dated 12/31/20 when the resident left. She stated a discharge summary was not completed.

Based on interview and record review, the facility failed to monitor and intervene for one (#6) of one sampled resident who was reviewed for a change in condition. The resident experienced an 11.2 lbs weight gain in one week. The facility did not monitor or intervene after noting the weight gain, and the resident experienced an acute exacerbation of [CONDITION(S)]. The VPO identified 34 residents as residing at the facility. Findings: Resident (Res) #6 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no parameters listed for physician notification. Weight Records, dated 10/15/21, documented Res #6 weighed 302.8 lbs. Weight Records, dated 10/22/21, documented Res #6 weighed 314 lbs. This was an increase of 11.2 lbs in one week. A Progress Note, dated 10/22/21 and written by the hospice nurse, read in parts, .anterior lobes diminished to auscultation .4+ [CONDITION(S)] to ble educated on keeping feet elevated pt noncompliant. facility weighed pt current weight 314 will notify physician of 11.2 lbs weight gain in 1 week . Review of the clinical record revealed no documentation the facility monitored the resident after having the 11.2 lbs weight increase in one week. There was no documentation to show the hospice agency had communicated with the hospice physician or facility staff regarding the hospice physician's instructions related to the weight gain. A Progress Note, dated 10/24/21 at 2:29 p.m., read in parts, .Pt hypoxic with reduced SPO2 with O2 via N/C. Pt is verbally responsive with interrupted and slurred speech patterns. Pulse Ox levels fluctuate between 51-30%. Accessory muscle use [sic] for breathing. Noted SOB-distress noted .Pt did express desire to go to the hospital as he 'would like to see his son one more time', and stated 'I don't want to die today.' Pt transported via EMS to nearest acute care facility . On 11/03/21 at 10:29 a.m., RN #1 stated facility staff obtained weekly weights and she put them into the electronic record. She stated the weight for Res #6 would fluctuate greatly. She stated he was in the hospital presently for an acute exacerbation of his [CONDITION(S)]. RN #1 stated she had notified the hospice nurse of the weight gain. She stated the hospice nurse was supposed to notify the hospice physician. On 11/03/21 at 10:32 a.m., the DON and VPO were asked who was responsible for the care of a resident. They stated, The facility. They were asked what the expectation was of their staff if a resident had an 11.2 lbs weight gain in one week. The DON stated she had informed the hospice nurse when she was here of the weight gain. She was asked how she monitored the resident after knowing of the weight gain. She stated the hospice nurse had told her she would get with the doctor and orders would follow. The DON was asked if the hospice nurse had contacted her again. She stated she may have contacted the day or evening nurse. The DON and VPO were asked what staff was supposed to do if they did not have further communication with the hospice agency. The VPO stated they should have notified the facility's physician. She stated, We should have followed up with hospice and our doctor.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents and failed to ensure the resident environment remained free of accident hazards for 2 (#27 and #33) of four residents reviewed for accident hazards. Resident #27 fell , sustained a laceration to his head requiring sutures, and sustained a fracture to his right hip. Resident #33 was admitted to the hospital three times after attempting to inflict self harm. The facility failed to: a) Develop comprehensive care plans for the prevention of falls for resident #27 and prevent self harm attempts for the resident #33. b) Provide sufficient and effective supervision for the resident #27 and resident #33 . c) Investigate falls to determine the underlying cause of the falls. d) Identify and implement interventions to prevent falls for the resident. A facility incident report flowsheet documented 26 residents fell in the last three months. Findings: The facility policy for suicidal residents documented a resident at risk for suicide was to be monitored every 15 minutes for changes in behaviors and mood. The policy documented 15 minute monitoring was to be on going until the resident had been transferred out of the facility for a psychiatric evaluation. The policy documented a resident would not be accepted back into the facility if [MEDICAL CONDITION] were present. The facility policy for falls did not document fall prevention measures. The policy documented the nurse was to complete an incident report and to initiate fall interventions for fall prevention. The policy documented the director of nurses (DON) was to review the report to ensure adequate interventions were added and the care plan was updated. The policy documented the nurse was to observe for any changes in the resident's condition and report changes to the physician. The policy documented the staff were to document on the resident's condition every shift for 72 hours after the fall. 1. Resident #33 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 01/10/19, documented the resident was independent for daily decision making. The assessment documented the resident did not have thoughts of self harm. The assessment documented the resident received psychoactive medication. A psychiatry progress note, dated 01/11/19, documented the resident had a physical decline. A care plan, dated 01/13/19, identified the resident had anxiety, depression, and received an antipsychotic medication. An all occurrence report for behaviors, dated 01/30/19, documented the resident had a decreased appetite. The Medication Administration Record [REDACTED]. A nurse note, dated 02/03/19, documented the resident ingested soap and stated he wanted to kill himself. The note documented the resident was sent to a psychiatric hospital for evaluation. The note documented a feeding tube was inserted because the resident did not want to eat. A nurse note, dated 03/04/19, documented the resident returned to the nursing home from a psychiatric facility. The annual assessment, dated 03/18/19, documented the resident was independent for daily decision making and did not have thoughts of self harm. The assessment documented the resident received psychoactive medication. The care plan, dated 03/25/19, identified the resident had anxiety, depression, and received an antipsychotic medication. The care plan did not document the resident had thoughts of self harm or was on a suicide watch. The quarterly assessment, dated 06/11/19, documented the resident was independent for daily decision making. The assessment did not document the resident had behaviors or thoughts of self harm. The assessment documented the resident received psychoactive medication. A nurse note, dated 06/13/19 at 6:41 PM, documented the resident cut his wrist with a safety razor. The note documented the resident stated he did not like his life. The note documented the resident was sent to a hospital for evaluation and treatment. The hospital discharge summary, dated 07/03/19, documented the resident had a history of [REDACTED]. The summary documented the resident had a history of [REDACTED]. The summary documented the resident implied he had other suicide attempts and suicide ideations. The summary documented the resident had [MEDICAL CONDITION] prior to admission and the resident's prognosis was guarded. The nurse note, dated 07/03/19 at 12:00 PM, documented the resident had returned to the facility. A nurse note, dated 07/11/19 at 5:28 PM, documented the resident's roommate stated the resident was trying to cut himself with fingernail clippers. The note documented the resident was placed on one to one care until the ambulance arrived. The note documented the resident stated he did not want to live. The nurse note documented the resident was sent to the hospital for evaluation and treatment. An all occurrence report for behaviors, dated 07/11/19 at 8:12 PM, documented the resident had attention seeking behaviors and a decreased appetite. The nurse note, dated 07/26/19, documented the resident was readmitted to the facility. The note documented the resident had told the doctor he did not want the tube feeding anymore. The note documented the doctor was going to refer the resident to hospice. The physician orders [REDACTED]. A hospice nurse note, dated 07/30/19 at 2:10 PM, documented the resident had paranoia and refused to eat. The note documented the resident stated the food was poison. The note documented the resident went to the bathroom several times daily and tried to have bowel movements because he believed it would rid his body of the toxins. A significant change assessment, dated 08/07/19, documented the resident was moderately impaired for daily decision making and had thoughts of self harm. The care plan, dated 08/13/19, identified the resident had anxiety, depression, and received an antipsychotic medication. The care plan did not document the resident had thoughts of self harm or was on a suicide watch. On 09/16/19 at 12:35 PM, the resident was in the hall way, clean and free of odor. The resident was overheard the telling a staff member he needed to go to hospital because he needed to have surgery. On 09/16/19 at 3:45 PM, the resident was in his room lying in his bed. The resident did not not have any complaints regarding the facility or the staff. The resident was having difficulty focusing on the conversation. A dietary note, dated 09/17/19 at 12:30 PM, documented the resident was observed by staff with his mouth stuffed full of turkey. The note documented the resident was instructed to spit it out and that the resident complied. A nurse note, dated 09/17/19 at 1:24 PM, documented the resident fell . The note documented the resident stated his vision had become blurry and he fell . The note documented the resident stated he hoped the fall would cause enough trauma and harm to kill himself. The note documented earlier in the day the resident had tried to choke himself with food. On 09/19/19 at 1:05 PM, certified medication aide (CMA #1) stated no residents were on suicide watch. On 09/19/19 at 1:30 PM, certified nurse aide (CNA #2) stated none of the residents were on suicide watch. The CNA stated one resident would try to hurt himself at times. On 09/19/19 at 4:00 PM, the corporate administrator stated no residents in the facility were on suicide watch. On 09/19/19 at 4:50 PM, licensed practical nurse (LPN #1) stated there was no residents on suicide precaution in the facility at this time. The LPN stated a resident would be on one to one care when on suicide watch. On 09/23/19 at 11:55 AM, the part-time assistant director of nurses (ADON) stated one resident had attempted to harm himself in the past. The ADON stated a resident on suicide watch would be checked every 15 minutes. The ADON stated the staff should monitor the resident and notify the nurse for changes in his behaviors. The ADON stated the resident was seen by a counselor and a nurse practitioner. The providers let the ADON or the director of nurses know if any changes were made in the resident's care. The ADON stated reports were filed and no other action would be taken. On 09/24/19 at 10:15 AM, the nurse practitioner (NP) stated she had been seeing the resident for a few months. The NP stated the resident needed to be on an on going assessment and the staff should monitor his mood. The NP stated the resident can be fine one day and not the next day. The NP stated she assessed the resident for the effectiveness of medications and made changes as necessary. The NP stated she was not involved with resident counseling. On 09/24/19 at 2:50 PM, the licensed clinical social worker (LCSW) stated he participated in treatment plan for the resident. The LCSW stated he submitted his notes to Community Pathway and did not provide notes to the facility. The LCSW had not make recommendations for monitoring and assessing the resident. The LCSW stated the nursing home could call and get a copy of the treatment plan and notes. The LCSW stated he was instructed to make a short note on a log after seeing the resident. The LCSW stated he would speak briefly to the ADON or DON regarding the session with the resident but was not involved in facility care planing. The LCSW stated the resident was not happy and did not care much about living. The psychotherapy log for community pathways, dated (MONTH) 2019 thru (MONTH) 2019, was reviewed. The log documented the LCSW visited the resident at every two to four days while in the facility. 2. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall risk assessments for (MONTH) (YEAR) through (MONTH) (YEAR) documented the resident was at high risk for falls. An incident report, dated 01/04/19 at 1:10 AM, documented the resident sustained [REDACTED]. The report documented the resident stated he slipped. An investigative report, dated 01/04/19, documented the resident was in bed during hourly checks. The report documented the new intervention to prevent falls was for staff to ensure the resident had non-skid socks on when he went to bed. The facility was not able to provide a care plan with a fall focus care area or with interventions to prevent falls. An incident report, dated 02/18/19 at 3:45 AM, documented the resident attempted to transfer by himself and fell . The report documented the resident sustained [REDACTED]. The report documented the resident stated he was trying to catch a bus and fell . The facility was not able to provide a care plan with a fall focus care area or with interventions to prevent falls. An incident report, dated 03/10/19 at 9:15 AM, documented the resident fell backwards in his wheelchair when another resident attempted to move his locked wheelchair. The investigative report, dated 03/10/19, documented the resident was taken to the lobby after his meal and was cooperative. The report documented another resident moved the resident but did not state why. The report did not document if the fall was witnessed or unwitnessed by the staff. The report documented the peer resident was educated to ask for assistance from staff to help other residents. The facility was not able to provide an updated care plan. An incident report, dated 03/15/19 at 8:10 AM, documented the resident attempted to ambulate by himself in his room, fell , and sustained a quarter size abrasion to his left knee. The report documented the resident was alone at the time of the fall. The report documented a new intervention was for the staff to toilet the resident every hour. The fall investigation report, dated 03/15/19, documented the resident's brief was soiled and a new intervention was for staff to implement a toileting schedule. The facility was not able to provide a care plan with the updated interventions. An incident report, dated 05/05/19 at 6:40 AM, documented the resident was found on the floor in his room by the nurse. The report documented the resident sustained [REDACTED]. The fall investigation report, dated 05/05/19, documented the resident was not able to verbalize and had [MEDICAL CONDITION] activity. The report did not document a new intervention to prevent falls. The facility was not able to provide a care plan with an updated intervention to prevent falls. A significant change assessment, dated 05/16/19, documented the resident was moderately impaired for daily decision making, and required extensive assistance with mobility, transfers, and other ADLs. The assessment documented the resident required assistance to stabilize and was frequently incontinent of bowel and bladder. The assessment documented the resident had one non-injury fall during the look-back period. The care plan, dated 05/23/19, did not document the resident had a focus care area for falls. The care plan documented the resident had [MEDICAL CONDITION] leading to the potential for falls and other injuries. The care plan documented the resident was to ambulate with a wheelchair or with the assistance of two persons. The care plan did not document other interventions to prevent falls. The care plan, dated 06/13/19 at 5:22 PM, documented the resident had a non-injury fall attempting to ambulate by himself. The care plan documented the staff was to continue monitoring the resident every one hour and to place a mat on the floor by his bed. An incident report, dated 07/03/19 at 8:45 AM, documented the resident slid out of his chair. The report documented the resident did not sustain an injury. The investigation report, dated 07/03/19, documented the resident routinely slid down in his chair requiring repositioning and a non-slip pad was to be placed in the resident's wheelchair. The care plan, dated 07/03/19 at 2:44 PM, documented a non-slip pad was to be placed in the resident's wheelchair. An untimed incident report, dated 07/04/19, documented the resident was found on the floor, had a laceration to the right side of his head, and a laceration to the back of his head. The report documented the resident was sent to the emergency department. An emergency transport report, dated 07/04/19 at 2:54 PM, documented the resident had moderate to severe pain with movement. The facility was not able to provide a completed fall investigation report. The care plan for 07/04/19 was not updated with the fall or an new intervention to prevent falls. A nurse note, dated 07/05/19 at 5:15 AM, documented the resident had a laceration to the right side of his forehead with three sutures in place. The note documented the resident grimaced with movement and Tylenol was administered. A nurse note, dated 07/05/19 at 9:35 AM, documented the resident grimaced during turning and an x-ray of his hip was obtained. The note documented the resident had a right [MEDICAL CONDITION] and was transported to the emergency department per physician order. An emergency department hospital records, dated 07/05/19 at 11:12 AM, documented the resident had continued to complain of pain in his right hip. A hospital X-ray report, dated 07/05/19 at 11:16 AM, documented the resident had an acute traumatic [MEDICAL CONDITION] femur neck The hospital transfer record, dated 07/10/19, documented the resident was transferred to another hospital for surgery. A hospital discharge summary, dated 07/13/19, documented the resident was admitted on [DATE] with a right femur fracture. The record documented the resident had right hip surgery on 07/11/19 and was discharged on [DATE]. A nurse note, dated 07/13/19 at 3:27 PM, documented the resident returned to the nursing home. A fall risk assessment was not completed when he returned. The care plan, dated 07/31/19 at 2:44 PM, documented the resident was currently working with therapy for mobility issues. The quarterly assessment, dated 08/12/19, documented the resident was moderately impaired for daily decision making, required extensive assist with ADLS, did not ambulate and was frequently incontinent. The assessment documented the resident did not have any falls during the look-back period. The care plan, dated 08/21/19 at 1:06 PM, documented the floor mat was removed for resident safety. The care plan, dated 08/23/19 at 1:34 PM, documented the restorative program was discontinued while resident received therapy and staff were to continued every one hour resident checks. The care plan, dated 09/05/19, documented the resident had a non-injury fall when the resident attempted to ambulate by himself. The care plan documented the resident was placed on one to one care for two and a half hours till the resident was no longer restless. Then staff resumed every one hour checks. The facility was not able to provide an incident report or an investigation report related to the fall. An incident report, dated 09/16/19 at 1:00 PM, documented the resident fell while transferring from his wheelchair to the couch. The report did not document if staff was assisting or if the fall was witness by staff. The report documented the staff was to monitor for signs and symptoms that the resident was going to transfer from his wheelchair to the sofa. The care plan did not document a new intervention to prevent falls for the fall which occurred on 09/16/19. The nurse notes for 09/16/19 did not document the details of the resident's fall. On 09/16/19 at 9:45 AM, the resident was sitting in his wheelchair in the lobby with his peers. On 09/16/19 at 12:45 PM, the resident was observed sitting on the couch in the lobby. Staff were observed going in and out of the area. On 09/17/19 at 10:05 AM, the resident was in the lobby participating in a group activity. On 09/18/19 at 1:20 PM, the resident was on the couch in the lobby watching television. On 09/19/19 at 10:15 AM, the resident was in the lobby sitting in his wheelchair. 09/19/19 at 10:20 AM, the assessment and care plan nurse for a sister facility was interviewed. She stated the the care plan nurse was the one to remove a focus area from the care plans. She stated the fall care area focus was removed from the care plan on 05/28/19 by another care plan nurse and was not added back onto the care plan. On 09/19/19 at 2:00 PM, certified medication aide (CMA) #1 stated she had worked at the facility for six years. She stated a high fall risk resident had a star placed on the wall by the bed. The CMA stated the resident was a high fall risk. She stated when the resident was out of bed he was always in the lobby and within sight. The CMA stated resident could not walk without assistance. The CMA stated the resident was to be checked hourly and would have been documented on the treatment administration record. 09/19/19 at 2:10 PM, certified nurse aide (CNA) #1 stated she had worked at the facility for one year. She stated the resident was a high risk for falls. She stated the resident was walked to the dining room with the assistance of two persons and a gait belt. The CNA stated the staff was able to watch the resident while he was in the lobby. On 09/19/19 at 3:15 PM, the resident was sitting on the couch in the lobby.

Based on observation, interview, and record review it was determined the facility failed to provide care to attain the highest mental well-being for one (#33) of four residents whose psychological needs were reviewed. The resident was admitted to the hospital three times after attempting to inflict self harm. The facility failed to: a) Determine and implement interventions to prevent self harm attempts for the resident. b) Coordinate a plan with direct care staff to ensure the resident's well-being. c) Monitor for changes in the resident's mood and thoughts. The census and condition report documented 35 residents with behavioral health needs resided at the facility. Findings: The facility policy for suicidal residents documented a resident at risk for suicide was to be monitored every 15 minutes for changes in behaviors and mood. The policy documented 15 minute monitoring was to be on going until the resident had been transferred out of the facility for a psychiatric evaluation. The policy documented a resident would not be accepted back into the facility if [MEDICAL CONDITION] were present. Resident #33 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 01/10/19, documented the resident was independent for daily decision making. The assessment documented the resident did not have thoughts of self harm. The assessment documented the resident received psychoactive medication. A psychiatry progress note, dated 01/11/19, documented the resident had a physical decline. A care plan, dated 01/13/19, identified the resident had anxiety, depression, and received an antipsychotic medication. An all occurrence report for behaviors, dated 01/30/19, documented the resident had a decreased appetite. The Medication Administration Record [REDACTED]. A nurse note, dated 02/03/19, documented the resident ingested soap and stated he wanted to kill himself. The note documented the resident was sent to a psychiatric hospital for evaluation. The note documented a feeding tube was inserted because the resident did not want to eat. A nurse note, dated 03/04/19, documented the resident returned to the nursing home from a psychiatric facility. The annual assessment, dated 03/18/19, documented the resident was independent for daily decision making and did not have thoughts of self harm. The assessment documented the resident received psychoactive medication. The care plan, dated 03/25/19, identified the resident had anxiety, depression, and received an antipsychotic medication. The care plan did not document the resident had thoughts of self harm or was on a suicide watch. The quarterly assessment, dated 06/11/19, documented the resident was independent for daily decision making. The assessment did not document the resident had behaviors or thoughts of self harm. The assessment documented the resident received psychoactive medication. A nurse note, dated 06/13/19 at 6:41 PM, documented the resident cut his wrist with a safety razor. The note documented the resident stated he did not like his life. The note documented the resident was sent to a hospital for evaluation and treatment. The hospital discharge summary, dated 07/03/19, documented the resident had a history of [REDACTED]. The summary documented the resident had a history of [REDACTED]. The summary documented the resident implied he had other suicide attempts and suicide ideations. The summary documented the resident had [MEDICAL CONDITION] prior to admission and the resident's prognosis was guarded. The nurse note, dated 07/03/19 at 12:00 PM, documented the resident had returned to the facility. A nurse note, dated 07/11/19 at 5:28 PM, documented the resident's roommate stated the resident was trying to cut himself with fingernail clippers. The note documented the resident was placed on one to one care until the ambulance arrived. The note documented the resident stated he did not want to live. The nurse note documented the resident was sent to the hospital for evaluation and treatment. An all occurrence report for behaviors, dated 07/11/19 at 8:12 PM, documented the resident had attention seeking behaviors and a decreased appetite. The nurse note, dated 07/26/19, documented the resident was readmitted to the facility. The note documented the resident had told the doctor he did not want the tube feeding anymore. The note documented the doctor was going to refer the resident to hospice. The physician orders [REDACTED]. A hospice nurse note, dated 07/30/19 at 2:10 PM, documented the resident had paranoia and refused to eat. The note documented the resident stated the food was poison. The note documented the resident went to the bathroom several times daily and tried to have bowel movements because he believed it would rid his body of the toxins. A significant change assessment, dated 08/07/19, documented the resident was moderately impaired for daily decision making and had thoughts of self harm. The care plan, dated 08/13/19, identified the resident had anxiety, depression, and received an antipsychotic medication. The care plan did not document the resident had thoughts of self harm or was on a suicide watch. On 09/16/19 at 12:35 PM, the resident was in the hall way, clean and free of odor. The resident was overheard the telling a staff member he needed to go to hospital because he needed to have surgery. On 09/16/19 at 3:45 PM, the resident was in his room lying in his bed. The resident did not not have any complaints regarding the facility or the staff. The resident was having difficulty focusing on the conversation. A dietary note, dated 09/17/19 at 12:30 PM, documented the resident was observed by staff with his mouth stuffed full of turkey. The note documented the resident was instructed to spit it out and that the resident complied. A nurse note, dated 09/17/19 at 1:24 PM, documented the resident fell . The note documented the resident stated his vision had become blurry and he fell . The note documented the resident stated he hoped the fall would cause enough trauma and harm to kill himself. The note documented earlier in the day the resident had tried to choke himself with food. On 09/19/19 at 1:05 PM, certified medication aide (CMA #1) stated no residents were on suicide watch. On 09/19/19 at 1:30 PM, certified nurse aide (CNA #2) stated none of the residents were on suicide watch. The CNA stated one resident would try to hurt himself at times. On 09/19/19 at 4:00 PM, the corporate administrator stated no residents in the facility were on suicide watch. On 09/19/19 at 4:50 PM, licensed practical nurse (LPN #1) stated there was no residents on suicide precaution in the facility at that time. The LPN stated a resident would be on one to one care when on suicide watch. On 09/23/19 at 11:55 AM, the part-time assistant director of nurses (ADON) stated one resident had attempted to harm himself in the past. The ADON stated a resident on suicide watch would be checked every 15 minutes. The ADON stated the staff should monitor the resident and notify the nurse for changes in his behaviors. The ADON stated the resident was seen by a counselor and a nurse practitioner. The providers let the ADON or the director of nurses know if any changes were made in the resident's care. The ADON stated reports were filed and no other action would be taken. On 09/24/19 at 10:15 AM, the nurse practitioner (NP) stated she had been seeing the resident for a few months. The NP stated the resident needed to be on an on going assessment and the staff should monitor his mood. The NP stated the resident can be fine one day and not the next day. The NP stated she assessed the resident for the effectiveness of medications and made changes as necessary. The NP stated she was not involved with resident counseling. On 09/24/19 at 2:50 PM, the licensed clinical social worker (LCSW) stated he participated in treatment plan for the resident. The LCSW stated he submitted his notes to Community Pathway and did not provide notes to the facility. The LCSW had not make recommendations for monitoring and assessing the resident. The LCSW stated the nursing home could call and get a copy of the treatment plan and notes. The LCSW stated he was instructed to make a short note on a log after seeing the resident. The LCSW stated he would speak briefly regarding the session with the resident but was not involved in facility care planing. The LCSW stated the resident was not happy and did not care much about living. The psychotherapy log for community pathways, dated (MONTH) thru (MONTH) 2019, was reviewed. The log documented the LCSW visited the resident at every two to four days while in the facility.

On 11/30/16 at 6:30 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's failures to ensure the residents were free from abuse and protected from abuse for residents #13, #9, #3, #41, #44, and #6. Resident #13 was verbally abused on multiple occasions. Residents #14 and #27 called the resident fat, a [***] , a cow, and said oink oink as the resident would pass by on multiple occasions. The remarks were stated in the common area and were heard by staff and other residents. The staff stated other residents would laugh at her. The staff stated the resident would cry and began to isolate herself. The resident stated she kept herself in her room for fear of harm. The resident stated her family did not come to visit very often due to the situation in the facility. The resident stated she felt she needed to leave the facility. The nurse's notes, dated 11/11/16 at 11:39 a.m., documented the resident discharged from the facility to relocate to another nursing home. On 11/29/16 resident #9 reported allegations of verbal and physical abuse and sexual harassment by residents #39 and #14. The resident stated resident #9 played loud music and had fowl language which included, GD this and GD that. The resident stated resident #39 had pushed her on the shoulder and she reported this to the social service director and the activity coordinator. The resident stated resident #39 told the men not to talk to her because she was a dick sucker and said these things right in front of other residents. The resident stated she had a hard time holding up her head and the comments made her feel uncomfortable around the other men. The resident stated it made her upset and she wanted to cry. The resident stated she reported these comments to the activity person. The resident stated resident #39 had wanted to touch the resident's breast and private areas but she would not let him and now he called her names. The resident stated older people could not go outside because these residents were outside partying. The resident stated when she voiced her concerns the staff ignored the complaints. Staff and resident interviews confirmed the verbally and physically abusive actions of resident #39, #14, and #27. The resident had an increase in inpatient psychiatric evaluations for the year 2016. The admission records documented the resident had four inpatient psychiatric evaluations in 2016. The record documented the resident had one psychiatric evaluation in 2015 and no evaluations in 2014. The resident stated she had requested these evaluations because she felt her life was out of control. On 11/30/16 at 6:30 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 11/30/16 at 6:47 p.m., the Administrator/Owner and the Assistant Administrator were notified of the IJ situation related to failures in multiples areas of abuse prevention and abuse prohibition. On 11/30/16 at 9:25 p.m., the plan of removal for the IJ pertaining to abuse and abuse prohibition was accepted. The plan of removal for the Immediate Jeopardy documented: The resident(s) that were accused of resident to resident abuse were counseled and both opted to leave facility Against Medical Advice. Facility provided transportation and safe accommodations for resident #1, left facility at 7:40pm. Resident #2 chose to be transported to 327 Dayton Muskogee, Ok, left facility at 7:39pm. Res #3 was educated on abuse. Prevention: All staff that is currently on duty will be in-serviced immediately. All other staff will be in-serviced by phone or prior to reporting to work. All staff will be in-serviced on abuse by 11:59pm on 11-30-16. Identification: All staff and residents will be in-serviced to be able to identify abuse by 11:59pm on 11-30-16. Investigation: Administrative staff will interview all residents and staff by 11:59pm on 11-30-16. Reporting to Administrator: All staff and residents will be in-serviced on proper reporting of abuse by 11:59pm on 11-30-16. Protection: All staff and residents will be in-serviced on proper steps to take to protect residents from abuse by 11:59pm on 11-30-16 Training: All staff will be in-serviced on identifying, understanding, and reporting abuse by 11:59pm on 11-30-16. The IJ was removed on 11/30/16 at 10:56 p.m. when all the components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. On 12/01/16 between 9:30 a.m. and 1:00 p.m., interviews were conducted with the nursing staff regarding educational in-services pertaining to abuse and abuse prohibition for the removal of the Immediate Jeopardy. The staff stated an in-service was provided on 11/30/16 before 11:59 p.m. The staff was able to verbalize understanding of the facility's policy for abuse prohibition. The staff were able to verbalize understanding of the types of abuse, the difference between abuse and behaviors, identification of abuse, reporting of abuse, to whom to report abuse, and the steps to take to protect residents from abuse. On 12/01/16 between 9:30 a.m. and 1:00 p.m., the residents were interviewed regarding in-services related to abuse and abuse prohibition. The residents stated the staff provided in-services regarding abuse on the evening of 11/30/16 before 11:59 p.m. The residents were able to verbalize types of abuse, the difference between abuse and behaviors, and stated they were to report abuse to the administrator. Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from abuse and misappropriation of property for 11 (#13, #9, #16, #3, #42, #44, #6, #41, #39, #14, and #27) of 26 residents reviewed for abuse. The facility failed to: a) Protect residents from physical abuse, verbal abuse, sexual harassment, and intimidation for resident #13, #9, #3, #44, #6, #41, #42, and #16. b) Protect the resident from misappropriation of the resident's belongings by other residents for resident #44. c) Train staff to report abuse to the administrator for residents #13, #9, #3, #44, #6, #41, #16, #39, #14, and #27. d) Thoroughly investigate allegations of abuse for residents #13, #9, #3, #44, #6, #41, #42, and #16. Resident #13 was verbally abused on multiple occasions. Residents and staff stated residents #14 and #27 called the resident fat, a [***] , a cow, and said oink oink as the resident would pass by on multiple occasions. Residents and staff stated the remarks were made in the common area and were heard by staff and other residents. The staff stated other residents would laugh at her. The staff stated the resident would cry and began to isolate herself. The resident stated she kept herself in her room for fear of harm. The resident stated her family did not come to visit very often due to the situation in the facility. The resident stated she felt she needed to leave the facility. The nurse's notes, dated 11/11/16 at 11:39 a.m., documented the resident discharged from the facility to relocate to another nursing home. On 11/29/16 resident #9 reported allegations of verbal and physical abuse and sexual harassment by residents #39 and #14. The resident stated resident #9 played loud music and had fowl language which included, GD this and GD that. The resident stated resident #39 had pushed her on the shoulder and she reported this to the social service director and the activity coordinator. The resident stated resident #39 told the men not to talk to her because she was a dick sucker and said these things right in front of other residents. The resident stated she had a hard time holding up her head and the comments made her feel uncomfortable around the other men. The resident stated it made her upset and she wanted to cry. The resident stated she reported these comments to the activity person. The resident stated resident #39 had wanted to touch the resident's breast and private areas but she would not let him and now he called her names. The resident stated older people could not go outside because these residents were outside partying. The resident stated when she voiced her concerns the staff ignored the complaints. Staff and resident interviews confirmed the verbally and physically abusive actions of resident #39, #14, and #27. The resident had an increase in inpatient psychiatric evaluations for the year 2016. The admission records documented the resident had four inpatient psychiatric evaluations in 2016. The record documented the resident had one psychiatric evaluation in 2015 and no evaluations in 2014. The resident stated she had requested these evaluations because she felt her life was out of control. The facility census and condition report documented 37 residents lived in the facility. Findings: The facility policy regarding resident to resident abuse, dated 10/10/12, documented the residents must not be subjected to abuse by anyone including other residents. The policy documented verbal abuse was disparaging or derogatory terms. The policy stated mental abuse included humiliation, harassment, and threats of punishment. The policy documented the procedure for the management of abuse. The policy documented the residents involved in the abusive situation were to be separated, an assessment was to be completed, and the administrator or the director of nursing was to be notified immediately. The policy documented the charge nurse should complete an incident report before the end of the shift. The report documented an investigation was to be completed and referrals made immediately. 1. Resident #13, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 01/06/16, documented the resident was independent with daily decision making. The assessment documented the resident required supervision with activities of daily living (ADLs). The quarterly assessment, dated 09/26/16, documented the resident was independent with daily decision making. The assessment documented the resident required extensive assistance with personal hygiene, toileting, and bathing. The assessment documented the resident required limited assistance with dressing and supervision with all other activities of daily living. A care plan, updated 10/06/16, documented the resident had a [MEDICAL CONDITION] disorder, a [MEDICAL CONDITION] disorder, and was on psychoactive medications. The care plan documented the resident was being monitored for behaviors. The care plan documented the resident required assistance with ADLs. A nurse's note, dated 10/18/16, documented the resident was outside at the north end of the building drinking vodka and beer. A nurse's note, dated 10/18/16, documented the resident wanted to kill herself by slicing her wrist with a compact disc (CD) case. The police were notified and stayed with the resident until the emergency medical services (EMS) arrived. A nurse's note, dated 10/30/16, documented a male peer had insulted the resident as he walked past her. The nurse's note documented the resident had began screaming, cursing, and became calm after venting her anger for ten minutes. The nurse's note documented the nurse had discussed the incident with the resident and then instructed the male peer to apologize and stop the behavior. A nurse's note, dated 11/06/16, documented the resident had called the police on a peer for insulting her and calling her a fat pig. The nurse's note documented the police had talked with the male resident, told him to stay away from her, and to not speak to her. A nurse's note, dated 11/11/16, documented the resident was discharged from the facility to relocate to another nursing facility. On 12/01/16 at 9:15 a.m., the resident was interviewed regarding her move from the facility. The resident stated she had moved from the facility because she was tired of being bullied by resident #27. The resident stated she kept to herself in her room because she was afraid he would do something to her. The resident stated she did not feel safe in that environment. The resident stated she was called fat, a [***] , a cow, and he would say oink, oink when he saw her. The resident stated he would not leave her alone and his verbal abuse was the reason she relocated to another facility. The resident stated she had called the police on 11/05/16 related to the bullying. The resident stated resident #27 had a room located across the hall from her so she just stayed in her room. The resident stated she couldn't go out into the facility at that time. The resident was asked if she had reported the name calling to anyone at the facility. The resident stated she had reported it to LPN #1, RN #1, and the Administrator but nothing had been done. The resident was asked if she had seen anyone drinking alcohol or smoking marijuana at the facility. The resident stated she had seen residents #27, #39, #14, and #46 drinking alcohol and was outside when they were smoking weed. The resident stated she had told the assistant administrator there was a lot going on at the facility which she didn't want to get involved with. The resident stated her family did not visit often at the facility related to the situation with the other resident. The resident was well dressed, had a walker, was sitting in the living room, and was very personable. The resident smiled, did not have behaviors, and was informative. The incident reports from May 2016 through November 2016 were reviewed. The reports did not document incidence or investigations of resident to resident verbal abuse, police calls, or resident drinking. On 12/06/16 at 10:50 a.m., the director of nurses (DON) was asked about the incident reports for name calling and drinking. The DON stated she was not there when the drinking occurred, LPN #2 was on duty, and she thought he wrote the incident reports. The DON stated she was told about the incident when the police were called and about the drinking. The DON stated the facility was told the police could do nothing about the alcohol. The DON stated when the police wouldn't arrest resident #27, resident #13 stated she had a plastic CD case and would break it and kill herself if they didn't do something. The police stayed with the resident and she was sent to the hospital. The DON stated she was not very good with computers and she had put documentation into the computer which sometimes disappeared. The DON stated the last incident she showed for the resident was on 09/17/16. The DON stated an incident report was not completed. 2. Resident #9 (a [AGE] year old resident) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 01/05/16, documented the resident was independent for daily decision-making, was ambulatory, and required minimal assistance with the activities (ADLs). The assessment documented the resident had delusions and verbal behaviors toward others. The assessment documented the resident received anti-psychotic and anti-anxiety medications. The assessment documented the resident was a smoker. The care plan, dated 01/08/16, documented the resident had psychosocial needs and the staff were to praise the resident for her accomplishments, provide one to one interaction as needed, encourage the resident to come out of her room to visit or dine with others. The care plan documented the resident would refuse care and the staff were not to rush the resident. The care plan documented the resident would misplace belongings and accuse others of stealing her belongings. The care plan documented the resident had paranoid delusions, was verbally abusive, and would falsely accuse others. The care plan documented two staff persons were to provide the residents care at all times and were to redirect the resident as much as possible. A nurse's note, dated 09/15/16 at 11:02 a.m., documented the resident stated the president had bugged the facility and knew everything that was happening. A nurse's note, dated 09/29/16 at 7:26 p.m., documented the resident had frequent behaviors, was rude and disrespectful to staff and residents, cursed and picked fights with others, paced most of the shift, talked to herself, and frequently made delusional random statements. The physician's progress note, dated 10/25/16, documented the resident had been doing ok and was very happy that day, had some allergic rhinitis, started the resident on an anti-[MEDICATION NAME], and to continue care. The physician's orders [REDACTED]. The admission/discharge record, dated 11/12/16, documented the resident was discharged to the hospital for a psychiatric evaluation. The nurse's notes, dated 11/28/16 at 3:25 p.m., documented the resident had been evaluated at the hospital and was returning to the facility. The note documented her medications had been changed. On 11/28/16 at 3:45 p.m., several residents were observed outside on the patio smoking and were playing loud pop rock music. One employee was supervising. One male resident stated, Stop looking at me. She's molesting me with her eyes. A nurse's note, dated 11/29/16 at 7:33 a.m., documented the resident was up early, pacing, and was attempting to sell her belongings to buy cigarettes. On 11/29/16 at 9:58 a.m., resident #9 wanted to be interviewed regarding her concerns in the home. The resident stated she had lived in the facility for [AGE] years. The resident was clean, groomed, and showed signs of nervousness by fidgeting with her hands. The resident moved about in her chair during the interview. The resident stated she had concerns about the resident arguments occurring outside on the back patio. The resident stated some residents were young and some were old. The resident stated a male resident (#39) played loud music and used fowl language like GD this and GD that. The resident stated the older residents did not like the loud music but liked to sit out on the patio and talk with other residents. The resident stated resident #39 threatened residents and said he was going to hit them. She stated resident #39 smoked marijuana along with resident #14 and #46. The resident stated resident #46 brought the marijuana into the home. The resident stated resident #39, #14, and # 27 drank alcohol every weekend and sometimes vomited. The resident stated she was afraid of them because of their vulgar talk and the residents were abusive. She stated resident #39 had pushed her on the shoulder. The resident stated she reported the situation to the social service and activity directors. The resident stated resident #39 called her a dick sucker to the other males and told them not to talk to her. The resident stated she had a hard time holding up her head and it made her feel uncomfortable around the other men. The resident stated the remarks made her upset and cry. The resident stated resident #39 wanted to touch her breasts and private parts but she did not let him and now he made those comments. The resident stated the older people could not go outside because these residents were outside partying. The resident stated when the staff were told they, ignored the complaints. The resident stated she requested to go to the Pavilion for psychiatric evaluation because her life was out of control. On 11/29/16 at 10:47 a.m., the resident's physician was interviewed. The physician stated in the past year the atmosphere in the home had been different. The physician stated the home had an increase in independent residents and had been more volatile. The physician stated one male group liked to fight but none of the elderly residents had complained to him about them. The physician stated resident #9 was needy, outspoken, and manipulative but satisfied easily. The physician stated the resident had requested to go to the hospital for psychiatric evaluations. On 11/29/16 at 1:36 p.m., the ombudsman was interviewed. The ombudsman stated neighbors would complain because some residents threw beer cans out in the back alley. The ombudsman stated there were problems with some residents drinking alcohol, reported marijuana use, and one resident had obtained [MEDICATION NAME] with an old written prescription and some of the [MEDICATION NAME] was reported missing. The ombudsman stated the facility had a meeting with residents. The ombudsman stated the residents had been counseled regarding the alcohol, marijuana, medications, and some residents were given discharge notices. On 11/30/16 at 9:00 a.m., CNA #38 was interviewed regarding abuse and abuse prohibition. The CNA stated she had been employed in the facility for eight months. The CNA was able to verbalize knowledge about abuse and stated resident #9 was verbally abused by resident #39. The CNA stated resident #39 would say, If your mouth is open it better be on my dick. The CNA stated resident #9 went in to tell the assistant director of nurses (ADON). The CNA stated she redirected resident #39 and reported the incident to the charge nurse. The CNA stated resident #13 was verbally abused by resident #14 in the common area in front of other residents. The CNA stated resident #14 called her a fat pig and that she was still ugly even with make up on. The CNA stated this occurred on multiple occasions. The CNA stated other CNAs and nurses heard the name calling and derogatory remarks. The CNA stated resident #13 became withdrawn and would cry. The CNA stated resident #13 relocated to another facility. On 11/30/16 at 9:01 a.m., certified nurse aide (CNA) #6 was interviewed regarding abuse and allegations of abuse. The CNA stated resident #39 swore a lot and the staff try to get him to stop. The CNA stated the swearing did bother the other residents. The CNA stated the swearing even bothered her. The CNA stated resident #39 was not able to cease using profanity. The CNA stated when a female resident complained about resident #39 cussing at her and threatening her, she told the resident to ignore the statements and resident #39's opinions didn't matter. The CNA stated they try to stop resident #39 and redirect him. The CNA stated she had seen marijuana a couple of times, reported it to the charge nurse, and reported it to the assistant administrator. The CNA stated she had seen resident #39 drinking on the weekend and she had taken the alcohol away from him, locked the alcohol up in the medication room, and reported it to registered nurse (RN)#1 and the assistant administrator. The CNA stated the assistant administrator and the administrator came to the facility after the incident. The CNA stated the physician was notified and their medications were held. The CNA stated resident #39 would leave, check himself out of the facility, and come back intoxicated. The CNA stated the residents' behaviors started after resident #14 was admitted . On 11/30/16 at 9:10 a.m., social service director (SSD) was interviewed. The SSD stated she had worked in the facility for [AGE] years. The SSD stated she had not seen any male residents verbally abusing female residents. The SSD stated resident #39 hung out outside on the patio. The SSD stated the resident #39 used profanity and the resident stated it is his right to do so. The SSD stated she would tell him to lower his voice and some older people may not want to hear the profanity. The SSD stated resident #39 would say he paid his part of the rent so he could say what he wanted. The SSD stated resident #9 complained resident #39 called her a [***] , that she was a dick sucker, that she suck blankity blank. The SSD stated resident #39 was talking in a low voice, she did not hear what he had stated, and did not report it since she did not think there was a concern. The SSD stated resident #9 made accusations daily in regard to other residents. On 11/30/16 at 9:46 a.m., licensed practical nurse (LPN) #1 was interviewed regarding abuse. The LPN stated she had been employed by the facility for two years. The LPN was able to verbalize knowledge regarding abuse, neglect, sexual harassment, and [MEDICAL CONDITION]. The LPN was not able to clearly define the difference between verbal behaviors and verbal abuse. The LPN stated resident #39 had verbal behaviors and not verbal abuse. The LPN stated she would check into any allegation of abuse and report abuse through her chain of command. The LPN stated the verbal abuse and intimidation witnessed was documented as behaviors and the resident was redirected. The LPN stated she reported the verbal behaviors to the director of nurses but did not report the behaviors to the administrator. The LPN stated resident #9 complained about resident #39 frequently. The LPN was not able to state how she responded to the complaints. The LPN stated she had not witnessed any residents using marijuana in the facility. On 11/30/16 at 10:31 a.m., resident #39 was interviewed. The resident stated he was admitted to the facility after he was hospitalized for [REDACTED]. The resident stated the pancreatitis and diabetes were under control now. The resident stated he knew how to check his blood sugar and prepare and administer his insulin. The resident stated he needed care for his diabetes and insulin injections. The resident stated his application for Living Choices had been completed a month ago and was approved. The resident stated he could stay with his brother. The resident stated his brother lived north of Tulsa, it was too far away, and he did not want to go there. The resident stated he received information on abuse and the facility rules when he was admitted . The resident was able to verbalize knowledge on the different kinds of abuse. The resident stated verbal abuse was cussing, yelling, the use of profanity, and name calling. The resident stated intimidation was getting in someone's face, cussing, or threatening. The resident was asked to describe sexual harassment. The resident stated he could not say those kind of words. The resident stated resident to resident abuse was not tolerated in the facility. The resident was polite and did not use profanity or unbecoming speech throughout the interview. The resident stated taking or borrowing other residents' personal property was not allowed in the facility. The resident denied taking another resident's [MEDICATION NAME]. The resident stated alcohol and marijuana use were not allowed in the facility and he was counseled on the issue. The resident stated he received a thirty day notice and he stated he gave the notice back to the owner. On 11/30/16 at 11:03 a.m., resident #14 was interviewed regarding abuse. The resident stated he was admitted in August 2016 to receive therapy for a history of a compound fracture of his right ankle. The resident stated he received two weeks of therapy and stated therapy ended since he just quit participating. The resident stated he had been in a wheelchair since 2007 and had slight left sided weakness. The resident stated he had a father that lived in town but did not know if he could stay with him or not. The resident stated as soon as he got an apartment he was good to go. The resident stated he was given information on the rules of the facility and information on abuse but stated he did not read it. The resident stated abuse was not allowed in the facility. The resident stated verbal abuse was cussing and raising one's voice. The resident stated emotional abuse was name calling. The resident stated residents were not allowed to take or borrow other residents' property and could not have alcohol or marijuana on the premise. The resident stated he had been issued a 30 day notice. The resident stated he was given notice because he brought alcohol on the premise. The resident stated they were not allowed to have marijuana on the premise and had been caught with it outside on the patio. The resident was in a wheelchair with minimal weakness to his left side. The resident was polite and did not use any profanity during the interview. On 11/30/16 at 11:26 a.m., resident #27 was interviewed regarding abuse. The resident stated he had resided in the home for six months. The resident stated he did not have anywhere to live and came from a private home. The resident stated he had a stroke four years ago with left sided paralysis and used a quad cane for ambulation. The resident stated he required assistance with the activities of daily living. The resident stated he did not receive information on abuse or the rules of the facility when admitted . The resident stated he found out about abuse prohibition and the rules of the facility the hard way when he got counseled. The resident stated abuse was when someone treats you badly, calls you names, tells you to go to hell, cussing at someone, and lying. The resident stated it was not all right to talk to someone and scare them. The resident stated it was wrong to call someone a [***] . The resident stated he tried not to call anyone a [***] but if they were a [***] then he would call them a [***] . The resident ambulated with a quad cane and needed some assistance with transfers to sit and stand. The resident was polite and did not use profanity during the interview. On 11/30/16 at 12:01 p.m., the director of nurses (DON) was interviewed regarding the policy to prevent abuse. The DON stated she had been employed at the facility since 2003. The DON stated the facility had a no tolerance policy regarding abuse and allegations of abuse were to be reported immediately to the supervisor in the employee's chain of command. The DON stated if an allegation of abuse was reported the staff involved would be suspended and then an investigation would be initiated. The DON stated the course of action would be determined based on the results of the investigation. The DON stated the administrator and DON were responsible for abuse prohibition. The DON stated the staff had not reported allegations of abuse involving resident #39 in which the resident called a female resident a whore. The DON stated resident #39 had been told on multiple occasions not to cuss or use profanity. The DON was asked if resident #13 was verbally abused. The DON state resident #13 was called a fat ass. The DON stated the resident left the facility because she did not like the male resident who called her a fat ass. The DON stated the allegation was investigated by talking to the male resident and the other residents who were present at the time. The DON stated no staff reported resident #13 had been verbally abused repeatedly. The DON stated the resident became more outspoken and started cussing more. The DON stated from what she understood, resident #44 did not feel comfortable being in the room with resident #39 any more but could not state the reason. 3. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 04/29/16, documented the resident had depression and currently received [MEDICATION NAME] (an antidepressant medication). The care plan documented the staff were to give all supportive medications, monitor for behaviors such as expressed sadness and tearfulness, monitor for side effects of the medication, and allow the resident to express concerns and offer reassurance. The care plan documented the resident had behaviors of making false accusations concer

On 11/30/16 at 6:30 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's failures to thoroughly investigate and report allegations of abuse and failure to prevent further abuse for residents #13, #9, #3, #41, #6, and #44. Resident #13 was verbally abused on multiple occasions. Residents #14 and #27 called the resident fat, a [***] , a cow, and said oink oink as the resident would pass by on multiple occasions. The remarks were stated in the common area and were heard by staff and other residents. The staff stated other residents would laugh at her. The staff stated the resident would cry and began to isolate herself. The resident stated she kept herself in her room for fear of harm. The resident stated her family did not come to visit very often due to the situation in the facility. The resident stated she felt she needed to leave the facility. The nurse's notes, dated 11/11/16 at 11:39 a.m., documented the resident discharged from the facility to relocate to another nursing home. On 11/29/16 resident #9 reported allegations of verbal and physical abuse and sexual harassment by residents #39 and #14. The resident stated resident #9 played loud music and had fowl language which included, GD this and GD that. The resident stated resident #39 had pushed her on the shoulder and she reported this to the social service director and the activities coordinator. The resident stated resident #39 told the men not to talk to her because she was a dick sucker and said these things right in front of other residents. The resident stated she had a hard time holding up her head and the comments made her feel uncomfortable around the other men. The resident stated it made her upset and she wanted to cry. The resident stated she reported these comments to the activities person. The resident stated resident #39 had wanted to touch the resident's breast and private areas but she would not let him and now he called her names. The resident stated older people cannot go outside because these residents were outside partying. The resident stated when she voiced her concerns the staff ignored the complaints. Staff and resident interviews confirmed the verbally and physically abusive actions of resident #39, #14, and #27. The resident had an increase in inpatient psychiatric evaluations for the year 2016. The admission records documented the resident had four inpatient psychiatric evaluations in 2016. The record documented the resident had one psychiatric evaluation in 2015 and no evaluations in 2014. The resident stated she had requested these evaluations because she felt her life was out of control. On 11/30/16 at 6:30 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 11/30/16 at 6:47 p.m., the Administrator/Owner and the Assistant Administrator were notified of the IJ situation related to failures in multiples areas of abuse prevention and abuse prohibition. On 11/30/16 at 9:25 p.m., the plan of removal for the IJ pertaining to abuse and abuse prohibition was accepted. The plan of removal for the Immediate Jeopardy documented: The resident(s) that were accused of resident to resident abuse were counseled and both opted to leave facility Against Medical Advice. Facility provided transportation and safe accommodations for resident #1, left facility at 7:40pm. Resident #2 chose to be transported to 327 Dayton Muskogee, Ok, left facility at 7:39pm. Res #3 was educated on abuse. Prevention: All staff that is currently on duty will be in-serviced immediately. All other staff will be in-serviced by phone or prior to reporting to work. All staff will be in-serviced on abuse by 11:59pm on 11-30-16. Identification: All staff and residents will be in-serviced to be able to identify abuse by 11:59pm on 11-30-16. Investigation: Administrative staff will interview all residents and staff by 11:59pm on 11-30-16. Reporting to Administrator: All staff and residents will be in-serviced on proper reporting of abuse by 11:59pm on 11-30-16. Protection: All staff and residents will be in-serviced on proper steps to take to protect residents from abuse by 11:59pm on 11-30-16 Training: All staff will be in-serviced on identifying, understanding, and reporting abuse by 11:59pm on 11-30-16. The IJ was removed on 11/30/16 at 10:56 p.m. when all the components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. On 12/01/16 between 9:30 a.m. and 1:00 p.m., interviews were conducted with the nursing staff regarding educational in-services pertaining to abuse and abuse prohibition for the removal of the Immediate Jeopardy. The staff stated an in-service was provided on 11/30/16 before 11:59 p.m. The staff was able to verbalize understanding of the facility's policy for abuse prohibition. The staff were able to verbalize understanding of the types of abuse, the difference between abuse and behaviors, identification of abuse, reporting of abuse, to whom to report abuse, and the steps to take to protect residents from abuse. On 12/01/16 between 9:30 a.m. and 1:00 p.m., the residents were interviewed regarding in-services related to abuse and abuse prohibition. The residents stated the staff provided in-services regarding abuse on the evening of 11/30/16 before 11:59 p.m. The residents were able to verbalize types of abuse, the difference between abuse and behaviors, and stated they were to report abuse to the administrator. Based on observation, interview, and record review, it was determined the facility failed to thoroughly investigate and report allegations of abuse and failed to prevent futher abuse for 11 (#13, #9, #16, #3, #42, #44, #6, #41, #39, #14, and #27) of 26 residents reviewed for abuse. The facility failed to: a) Report allegations and observations of abuse to the administrator for residents #13, #9, #3, #44, and #41. b) Protect residents from abuse for resident #13, #9, #3, #44, #6, #41, #42, and #16. c) Train staff to differentiate between resident behaviors and abusive actions for residents #13, #9, #3, #44, #6, #41, #42, #16, #39, #14, and #27. d) Thoroughly investigate and report allegations of abuse for residents #13, #9, #3, #44, #6, #41, #42, and #16. Resident #13 was verbally abused on multiple occasions. Residents #14 and #27 called the resident fat, a [***] , a cow, and said oink oink as the resident would pass by on multiple occasions. The remarks were stated in the common area and were heard by staff and other residents. The staff stated other residents would laugh at her. The staff stated the resident would cry and began to isolate herself. The resident stated she kept herself in her room for fear of harm. The resident stated her family did not come to visit very often due to the situation in the facility. The resident stated she felt she needed to leave the facility. The nurse's notes, dated 11/11/16 at 11:39 a.m., documented the resident discharged from the facility to relocate to another nursing home. On 11/29/16 resident #9 reported allegations of verbal and physical abuse and sexual harassment by residents #39 and #14. The resident stated resident #9 played loud music and had fowl language which included, GD this and GD that. The resident stated resident #39 had pushed her on the shoulder and she reported this to the social service director and the activities coordinator. The resident stated resident #39 told the men not to talk to her because she was a dick sucker and said these things right in front of other residents. The resident stated she had a hard time holding up her head and the comments made her feel uncomfortable around the other men. The resident stated it made her upset and she wanted to cry. The resident stated she reported these comments to the activity person. The resident stated resident #39 had wanted to touch the resident's breast and private areas but she would not let him and now he called her names. The resident stated older people could not go outside because these residents were outside partying. The resident stated when she voiced her concerns the staff ignored the complaints. Staff and resident interviews confirmed the verbally and physically abusive actions of resident #39, #14, and #27. The resident had an increase in inpatient psychiatric evaluations for the year 2016. The admission records documented the resident had four inpatient psychiatric evaluations in 2016. The record documented the resident had one psychiatric evaluation in 2015 and no evaluations in 2014. The resident stated she had requested these evaluations because she felt her life was out of control. The facility census and condition report documented 37 residents lived in the facility. Findings: The facility policy regarding resident to resident abuse, dated 10/10/12, documented the residents must not be subjected to abuse by anyone including other residents. The policy documented verbal abuse was disparaging or derogatory terms. The policy stated mental abuse included humiliation, harassment, and threats of punishment. The policy documented the procedure for the management of abuse. The policy documented the residents involved in the abusive situation were to be separated, an assessment was to be completed, and the administrator or the director of nursing was to be notified immediately. The policy documented the charge nurse should complete an incident report before the end of the shift. The report documented an investigation was to be completed and referrals made immediately. 1. Resident #13, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 01/06/16, documented the resident was independent with daily decision making. The assessment documented the resident required supervision with activities of daily living (ADLs). The quarterly assessment, dated 09/26/16, documented the resident was independent with daily decision making. The assessment documented the resident required extensive assistance with personal hygiene, toileting, and bathing. The assessment documented the resident required limited assistance with dressing and supervision with all other activities of daily living. A care plan, updated 10/06/16, documented the resident had a [MEDICAL CONDITION] disorder, a [MEDICAL CONDITION] disorder, and was on psychoactive medications. The care plan documented the resident was being monitored for behaviors. The care plan documented the resident required assistance with ADLs. A nurse's note, dated 10/18/16, documented the resident was outside at the north end of the building drinking vodka and beer. A nurse's note, dated 10/18/16, documented the resident wanted to kill herself by slicing her wrist with a compact disc (CD) case. The police were notified and stayed with the resident until the emergency medical services (EMS) arrived. A nurse's note, dated 10/30/16, documented a male peer had insulted the resident as he walked past her. The nurse's note documented the resident had began screaming, cursing, and became calm after venting her anger for ten minutes. The nurse's note documented the nurse had discussed the incident with the resident and then instructed the male peer to apologize and stop the behavior. A nurse's note, dated 11/06/16, documented the resident had called the police on a peer for insulting her and calling her a fat pig. The nurse's note documented the police had talked with the male resident, told him to stay away from her, and to not speak to her. A nurse's note, dated 11/11/16, documented the resident was discharged from the facility to relocate to another nursing facility. On 12/01/16 at 9:15 a.m., the resident was interviewed regarding her move from the facility. The resident stated she had moved from the facility because she was tired of being bullied by resident #27. The resident stated she kept to herself in her room because she was afraid he would do something to her. The resident stated she did not feel safe in that environment. The resident stated she was called fat, a [***] , a cow, and he would say oink, oink when he saw her. The resident stated he would not leave her alone and his verbal abuse was the reason she relocated to another facility. The resident stated she had called the police on 11/05/16 related to the bullying. The resident stated resident #27 had a room located across the hall from her so she just stayed in her room. The resident stated she couldn't go out into the facility at that time. The resident was asked if she had reported the name calling to anyone at the facility. The resident stated she had reported it to LPN #1, RN #1, and the Administrator but nothing had been done. The resident was asked if she had seen anyone drinking alcohol or smoking marijuana at the facility. The resident stated she had seen residents #27, #39, #14, and #46 drinking alcohol and was outside when they were smoking weed. The resident stated she had told the assistant administrator there was a lot going on at the facility which she didn't want to get involved with. The resident stated her family did not visit often at the facility related to the situation with the other resident. The resident was well dressed, had a walker, was sitting in the living room, and was very personable. The resident smiled, did not have behaviors, and was informative. The incident reports from May 2016 through November 2016 were reviewed. The reports did not document incidence or investigations of resident to resident verbal abuse, police calls, or resident drinking. On 12/06/16 at 10:50 a.m., the director of nurses (DON) was asked about the incident reports for name calling and drinking. The DON stated she was not there when the drinking occurred, LPN #2 was on duty, and she thought he wrote the incident reports. The DON stated she was told about the incident when the police were called and about the drinking. The DON stated the facility was told the police could do nothing about the alcohol. The DON stated when the police wouldn't arrest resident #27, resident #13 stated she had a plastic CD case and would break it and kill herself if they didn't do something. The police stayed with the resident and she was sent to the hospital. The DON stated she was not very good with computers and she had put documentation into the computer which sometimes disappeared. The DON stated the last incident she showed for the resident was on 09/17/16. The DON stated an incident report was not completed. 2. Resident #9 (a [AGE] year old resident) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 01/05/16, documented the resident was independent for daily decision-making, was ambulatory, and required minimal assistance with the activities (ADLs). The assessment documented the resident had delusions and verbal behaviors toward others. The assessment documented the resident received anti-psychotic and anti-anxiety medications. The assessment documented the resident was a smoker. The care plan, dated 01/08/16, documented the resident had psychosocial needs and the staff were to praise the resident for her accomplishments, provide one to one interaction as needed, encourage the resident to come out of her room to visit or dine with others. The care plan documented the resident would refuse care and the staff were not to rush the resident. The care plan documented the resident would misplace belongings and accuse others of stealing her belongings. The care plan documented the resident had paranoid delusions, was verbally abusive, and would falsely accuse others. The care plan documented two staff persons were to provide the residents care at all times and were to redirect the resident as much as possible. A nurse's note, dated 09/15/16 at 11:02 a.m., documented the resident stated the president had bugged the facility and knew everything that was happening. A nurse's note, dated 09/29/16 at 7:26 p.m., documented the resident had frequent behaviors, was rude and disrespectful to staff and residents, cursed and picked fights with others, paced most of the shift, talked to herself, and frequently made delusional random statements. The physician's progress note, dated 10/25/16, documented the resident had been doing ok and was very happy that day, had some allergic rhinitis, started the resident on an anti-[MEDICATION NAME], and to continue care. The physician's orders [REDACTED]. The admission/discharge record, dated 11/12/16, documented the resident was discharged to the hospital for a psychiatric evaluation. The nurse's notes, dated 11/28/16 at 3:25 p.m., documented the resident had been evaluated at the hospital and was returning to the facility. The note documented her medications had been changed. On 11/28/16 at 3:45 p.m., several residents were observed outside on the patio smoking and were playing loud pop rock music. One employee was supervising. One male resident stated, Stop looking at me. She's molesting me with her eyes. A nurse's note, dated 11/29/16 at 7:33 a.m., documented the resident was up early, pacing, and was attempting to sell her belongings to buy cigarettes. On 11/29/16 at 9:58 a.m., resident #9 wanted to be interviewed regarding her concerns in the home. The resident stated she had lived in the facility for [AGE] years. The resident was clean, groomed, and showed signs of nervousness by fidgeting with her hands. The resident moved about in her chair during the interview. The resident stated she had concerns about the resident arguments occurring outside on the back patio. The resident stated some residents were young and some were old. The resident stated a male resident (#39) played loud music and used fowl language like GD this and GD that. The resident stated the older residents did not like the loud music but liked to sit out on the patio and talk with other residents. The resident stated resident #39 threatened residents and said he was going to hit them. She stated resident #39 smoked marijuana along with resident #14 and #46. The resident stated resident #46 brought the marijuana into the home. The resident stated resident #39, #14, and # 27 drank alcohol every weekend and sometimes vomited. The resident stated she was afraid of them because of their vulgar talk and the residents were abusive. She stated resident #39 had pushed her on the shoulder. The resident stated she reported the situation to the social service and activity directors. The resident stated resident #39 called her a dick sucker to the other males and told them not to talk to her. The resident stated she had a hard time holding up her head and it made her feel uncomfortable around the other men. The resident stated the remarks made her upset and cry. The resident stated resident #39 wanted to touch her breasts and private parts but she did not let him and now he made those comments. The resident stated the older people could not go outside because these residents were outside partying. The resident stated when the staff were told they, ignored the complaints. The resident stated she requested to go to the Pavilion for psychiatric evaluation because her life was out of control. On 11/29/16 at 10:47 a.m., the resident's physician was interviewed. The physician stated in the past year the atmosphere in the home had been different. The physician stated the home had an increase in independent residents and had been more volatile. The physician stated one male group liked to fight but none of the elderly residents had complained to him about them. The physician stated resident #9 was needy, outspoken, and manipulative but satisfied easily. The physician stated the resident had requested to go to the hospital for psychiatric evaluations. On 11/29/16 at 1:36 p.m., the ombudsman was interviewed. The ombudsman stated neighbors would complain because some residents threw beer cans out in the back alley. The ombudsman stated there were problems with some residents drinking alcohol, reported marijuana use, and one resident had obtained [MEDICATION NAME] with an old written prescription and some of the [MEDICATION NAME] was reported missing. The ombudsman stated the facility had a meeting with residents. The ombudsman stated the residents had been counseled regarding the alcohol, marijuana, medications, and some residents were given discharge notices. On 11/30/16 at 9:00 a.m., CNA #38 was interviewed regarding abuse and abuse prohibition. The CNA stated she had been employed in the facility for eight months. The CNA was able to verbalize knowledge about abuse and stated resident #9 was verbally abused by resident #39. The CNA stated resident #39 would say, If your mouth is open it better be on my dick. The CNA stated resident #9 went in to tell the assistant director of nurses (ADON). The CNA stated she redirected resident #39 and reported the incident to the charge nurse. The CNA stated resident #13 was verbally abused by resident #14 in the common area in front of other residents. The CNA stated resident #14 called her a fat pig and that she was still ugly even with make up on. The CNA stated this occurred on multiple occasions. The CNA stated other CNAs and nurses heard the name calling and derogatory remarks. The CNA stated resident #13 became withdrawn and would cry. The CNA stated resident #13 relocated to another facility. On 11/30/16 at 9:01 a.m., certified nurse aide (CNA) #6 was interviewed regarding abuse and allegations of abuse. The CNA stated resident #39 swore a lot and the staff try to get him to stop. The CNA stated the swearing did bother the other residents. The CNA stated the swearing even bothered her. The CNA stated resident #39 was not able to cease using profanity. The CNA stated when a female resident complained about resident #39 cussing at her and threatening her, she told the resident to ignore the statements and resident #39's opinions didn't matter. The CNA stated they try to stop resident #39 and redirect him. The CNA stated she had seen marijuana a couple of times, reported it to the charge nurse, and reported it to the assistant administrator. The CNA stated she had seen resident #39 drinking on the weekend and she had taken the alcohol away from him, locked the alcohol up in the medication room, and reported it to registered nurse (RN)#1 and the assistant administrator. The CNA stated the assistant administrator and the administrator came to the facility after the incident. The CNA stated the physician was notified and their medications were held. The CNA stated resident #39 would leave, check himself out of the facility, and come back intoxicated. The CNA stated the residents' behaviors started after resident #14 was admitted . On 11/30/16 at 9:10 a.m., social service director (SSD) was interviewed. The SSD stated she had worked in the facility for [AGE] years. The SSD stated she had not seen any male residents verbally abusing female residents. The SSD stated resident #39 hung out outside on the patio. The SSD stated the resident #39 used profanity and the resident stated it is his right to do so. The SSD stated she would tell him to lower his voice and some older people may not want to hear the profanity. The SSD stated resident #39 would say he paid his part of the rent so he could say what he wanted. The SSD stated resident #9 complained resident #39 called her a [***] , that she was a dick sucker, that she suck blankity blank. The SSD stated resident #39 was talking in a low voice, she did not hear what he had stated, and did not report it since she did not think there was a concern. The SSD stated resident #9 made accusations daily in regard to other residents. On 11/30/16 at 9:46 a.m., licensed practical nurse (LPN) #1 was interviewed regarding abuse. The LPN stated she had been employed by the facility for two years. The LPN was able to verbalize knowledge regarding abuse, neglect, sexual harassment, and [MEDICAL CONDITION]. The LPN was not able to clearly define the difference between verbal behaviors and verbal abuse. The LPN stated resident #39 had verbal behaviors and not verbal abuse. The LPN stated she would check into any allegation of abuse and report abuse through her chain of command. The LPN stated the verbal abuse and intimidation witnessed was documented as behaviors and the resident was redirected. The LPN stated she reported the verbal behaviors to the director of nurses but did not report the behaviors to the administrator. The LPN stated resident #9 complained about resident #39 frequently. The LPN was not able to state how she responded to the complaints. The LPN stated she had not witnessed any residents using marijuana in the facility. On 11/30/16 at 10:31 a.m., resident #39 was interviewed. The resident stated he was admitted to the facility after he was hospitalized for [REDACTED]. The resident stated the pancreatitis and diabetes were under control now. The resident stated he knew how to check his blood sugar and prepare and administer his insulin. The resident stated he needed care for his diabetes and insulin injections. The resident stated his application for Living Choices had been completed a month ago and was approved. The resident stated he could stay with his brother. The resident stated his brother lived north of Tulsa, it was too far away, and he did not want to go there. The resident stated he received information on abuse and the facility rules when he was admitted . The resident was able to verbalize knowledge on the different kinds of abuse. The resident stated verbal abuse was cussing, yelling, the use of profanity, and name calling. The resident stated intimidation was getting in someone's face, cussing, or threatening. The resident was asked to describe sexual harassment. The resident stated he could not say those kind of words. The resident stated resident to resident abuse was not tolerated in the facility. The resident was polite and did not use profanity or unbecoming speech throughout the interview. The resident stated taking or borrowing other residents' personal property was not allowed in the facility. The resident denied taking another resident's [MEDICATION NAME]. The resident stated alcohol and marijuana use were not allowed in the facility and he was counseled on the issue. The resident stated he received a thirty day notice and he stated he gave the notice back to the owner. On 11/30/16 at 11:03 a.m., resident #14 was interviewed regarding abuse. The resident stated he was admitted in August 2016 to receive therapy for a history of a compound fracture of his right ankle. The resident stated he received two weeks of therapy and stated therapy ended since he just quit participating. The resident stated he had been in a wheelchair since 2007 and had slight left sided weakness. The resident stated he had a father that lived in town but did not know if he could stay with him or not. The resident stated as soon as he got an apartment he was good to go. The resident stated he was given information on the rules of the facility and information on abuse but stated he did not read it. The resident stated abuse was not allowed in the facility. The resident stated verbal abuse was cussing and raising one's voice. The resident stated emotional abuse was name calling. The resident stated residents were not allowed to take or borrow other residents' property and could not have alcohol or marijuana on the premise. The resident stated he had been issued a 30 day notice. The resident stated he was given notice because he brought alcohol on the premise. The resident stated they were not allowed to have marijuana on the premise and had been caught with it outside on the patio. The resident was in a wheelchair with minimal weakness to his left side. The resident was polite and did not use any profanity during the interview. On 11/30/16 at 11:26 a.m., resident #27 was interviewed regarding abuse. The resident stated he had resided in the home for six months. The resident stated he did not have anywhere to live and came from a private home. The resident stated he had a stroke four years ago with left sided paralysis and used a quad cane for ambulation. The resident stated he required assistance with the activities of daily living. The resident stated he did not receive information on abuse or the rules of the facility when admitted . The resident stated he found out about abuse prohibition and the rules of the facility the hard way when he got counseled. The resident stated abuse was when someone treats you badly, calls you names, tells you to go to hell, cussing at someone, and lying. The resident stated it was not all right to talk to someone and scare them. The resident stated it was wrong to call someone a [***] . The resident stated he tried not to call anyone a [***] but if they were a [***] then he would call them a [***] . The resident ambulated with a quad cane and needed some assistance with transfers to sit and stand. The resident was polite and did not use profanity during the interview. On 11/30/16 at 12:01 p.m., the director of nurses (DON) was interviewed regarding the policy to prevent abuse. The DON stated she had been employed at the facility since 2003. The DON stated the facility had a no tolerance policy regarding abuse and allegations of abuse were to be reported immediately to the supervisor in the employee's chain of command. The DON stated if an allegation of abuse was reported the staff involved would be suspended and then an investigation would be initiated. The DON stated the course of action would be determined based on the results of the investigation. The DON stated the administrator and DON were responsible for abuse prohibition. The DON stated the staff had not reported allegations of abuse involving resident #39 in which the resident called a female resident a whore. The DON stated resident #39 had been told on multiple occasions not to cuss or use profanity. The DON was asked if resident #13 was verbally abused. The DON state resident #13 was called a fat ass. The DON stated the resident left the facility because she did not like the male resident who called her a fat ass. The DON stated the allegation was investigated by talking to the male resident and the other residents who were present at the time. The DON stated no staff reported resident #13 had been verbally abused repeatedly. The DON stated the resident became more outspoken and started cussing more. The DON stated from what she understood, resident #44 did not feel comfortable being in the room with resident #39 any more but could not state the reason. 3. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 04/29/16, documented the resident had depression and currently received [MEDICATION NAME] (an antidepressant medication). The care plan documented the staff were to give all supportive medications, monitor for behaviors such as expressed sadness and tearfulness, monitor for side effects of the medication, and allow the resident to express concerns and offer reassurance. The care plan documented the resident had behaviors of making false accusations concerning staff and residents. The ca

On 11/30/16 at 6:30 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's failures to implement abuse prevention policies and procedures to ensure residents were free from abuse for residents #13, #9, #3, #41, #6, and #44. Resident #13 was verbally abused on multiple occasions. Residents #14 and #27 called the resident fat, a [***] , a cow, and said oink oink as the resident would pass by on multiple occasions. The remarks were stated in the common area and were heard by staff and other residents. The staff stated other residents would laugh at her. The staff stated the resident would cry and began to isolate herself. The resident stated she kept herself in her room for fear of harm. The resident stated her family did not come to visit very often due to the situation in the facility. The resident stated she felt she needed to leave the facility. The nurse's notes, dated 11/11/16 at 11:39 a.m., documented the resident discharged from the facility to relocate to another nursing home. On 11/29/16 resident #9 reported allegations of verbal and physical abuse and sexual harassment by residents #39 and #14. The resident stated resident #9 played loud music and had fowl language which included, GD this and GD that. The resident stated resident #39 had pushed her on the shoulder and she reported this to the social service director and the activities coordinator. The resident stated resident #39 told the men not to talk to her because she was a dick sucker and said these things right in front of other residents. The resident stated she had a hard time holding up her head and the comments made her feel uncomfortable around the other men. The resident stated it made her upset and she wanted to cry. The resident stated she reported these comments to the activity person. The resident stated resident #39 had wanted to touch the resident's breast and private areas but she would not let him and now he called her names. The resident stated older people could not go outside because these residents were outside partying. The resident stated when she voiced her concerns the staff ignored the complaints. Staff and resident interviews confirmed the verbally and physically abusive actions of resident #39, #14, and #27. The resident had an increase in inpatient psychiatric evaluations for the year 2016. The admission records documented the resident had four inpatient psychiatric evaluations in 2016. The record documented the resident had one psychiatric evaluation in 2015 and no evaluations in 2014. The resident stated she had requested these evaluations because she felt her life was out of control. On 11/30/16 at 6:30 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 11/30/16 at 6:47 p.m., the Administrator/Owner and the Assistant Administrator were notified of the IJ situation related to failures in multiples areas of abuse prevention and abuse prohibition. On 11/30/16 at 9:25 p.m., the plan of removal for the IJ pertaining to abuse and abuse prohibition was accepted. The plan of removal for the Immediate Jeopardy documented: The resident(s) that were accused of resident to resident abuse were counseled and both opted to leave facility Against Medical Advice. Facility provided transportation and safe accommodations for resident #1, left facility at 7:40pm. Resident #2 chose to be transported to 327 Dayton Muskogee, Ok, left facility at 7:39pm. Res #3 was educated on abuse. Prevention: All staff that is currently on duty will be in-serviced immediately. All other staff will be in-serviced by phone or prior to reporting to work. All staff will be in-serviced on abuse by 11:59pm on 11-30-16. Identification: All staff and residents will be in-serviced to be able to identify abuse by 11:59pm on 11-30-16. Investigation: Administrative staff will interview all residents and staff by 11:59pm on 11-30-16. Reporting to Administrator: All staff and residents will be in-serviced on proper reporting of abuse by 11:59pm on 11-30-16. Protection: All staff and residents will be in-serviced on proper steps to take to protect residents from abuse by 11:59pm on 11-30-16 Training: All staff will be in-serviced on identifying, understanding, and reporting abuse by 11:59pm on 11-30-16. On 12/01/16 between 9:30 a.m. and 1:00 p.m., interviews were conducted with the nursing staff regarding educational in-services pertaining to abuse and abuse prohibition for the removal of the Immediate Jeopardy. The staff stated an in-service was provided on 11/30/16 before 11:59 p.m. The staff was able to verbalize understanding of the facility's policy for abuse prohibition. The staff were able to verbalize understanding of the types of abuse, the difference between abuse and behaviors, identification of abuse, reporting of abuse, to whom to report abuse, and the steps to take to protect residents from abuse. On 12/01/16 between 9:30 a.m. and 1:00 p.m., the residents were interviewed regarding in-services related to abuse and abuse prohibition. The residents stated the staff provided in-services regarding abuse on the evening of 11/30/16 before 11:59 p.m. The residents were able to verbalize types of abuse, the difference between abuse and behaviors, and stated they were to report abuse to the administrator. On 11/30/16 at 10:56 p.m., the IJ was removed when all the components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to implement policies and procedures to prevent abuse for 11 (#13, #9, #16, #3, #42, #44, #6, #41, #39, #14, and #27) of 26 residents reviewed for abuse. The facility failed to: a) Protect residents from abuse for resident #13, #9, #3, #44, #6, #41, #42, and #16. b) Train staff to differentiate between resident behaviors and abusive actions for residents #13, #9, #3, #44, #6, #41, #42, #16, #39, #14, and #27. c) Train staff to report abuse to the administrator for residents #13, #9, #3, #44, #6, #41, #16, #39, #14, and #27. d) Thoroughly investigate allegations of abuse for residents #13, #9, #3, #44, #6, #41, #42, and #16. Resident #13 was verbally abused on multiple occasions. Residents #14 and #27 called the resident fat, a [***] , a cow, and said oink oink as the resident would pass by on multiple occasions. The remarks were stated in the common area and were heard by staff and other residents. The staff stated other residents would laugh at her. The staff stated the resident would cry and began to isolate herself. The resident stated she kept herself in her room for fear of harm. The resident stated her family did not come to visit very often due to the situation in the facility. The resident stated she felt she needed to leave the facility. The nurse's notes, dated 11/11/16 at 11:39 a.m., documented the resident discharged from the facility to relocate to another nursing home. On 11/29/16 resident #9 reported allegations of verbal and physical abuse and sexual harassment by residents #39 and #14. The resident stated resident #9 played loud music and had fowl language which included, GD this and GD that. The resident stated resident #39 had pushed her on the shoulder and she reported this to the social service director and the activities coordinator. The resident stated resident #39 told the men not to talk to her because she was a dick sucker and said these things right in front of other residents. The resident stated she had a hard time holding up her head and the comments made her feel uncomfortable around the other men. The resident stated it made her upset and she wanted to cry. The resident stated she reported these comments to the activity person. The resident stated resident #39 had wanted to touch the resident's breast and private areas but she would not let him and now he called her names. The resident stated older people could not go outside because these residents were outside partying. The resident stated when she voiced her concerns the staff ignored the complaints. Staff and resident interviews confirmed the verbally and physically abusive actions of resident #39, #14, and #27. The resident had an increase in inpatient psychiatric evaluations for the year 2016. The admission records documented the resident had four inpatient psychiatric evaluations in 2016. The record documented the resident had one psychiatric evaluation in 2015 and no evaluations in 2014. The resident stated she had requested these evaluations because she felt her life was out of control. The facility census and condition report documented 37 residents lived in the facility. Findings: The facility policy regarding resident to resident abuse, dated 10/10/12, documented the residents must not be subjected to abuse by anyone including other residents. The policy documented verbal abuse was disparaging or derogatory terms. The policy stated mental abuse included humiliation, harassment, and threats of punishment. The policy documented the procedure for the management of abuse. The policy documented the residents involved in the abusive situation were to be separated, an assessment was to be completed, and the administrator or the director of nursing was to be notified immediately. The policy documented the charge nurse should complete an incident report before the end of the shift. The report documented an investigation was to be completed and referrals made immediately. 1. Resident #13, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 01/06/16, documented the resident was independent with daily decision making. The assessment documented the resident required supervision with activities of daily living (ADLs). The quarterly assessment, dated 09/26/16, documented the resident was independent with daily decision making. The assessment documented the resident required extensive assistance with personal hygiene, toileting, and bathing. The assessment documented the resident required limited assistance with dressing and supervision with all other activities of daily living. A care plan, updated 10/06/16, documented the resident had a [MEDICAL CONDITION] disorder, a [MEDICAL CONDITION] disorder, and was on psychoactive medications. The care plan documented the resident was being monitored for behaviors. The care plan documented the resident required assistance with ADLs. A nurse's note, dated 10/18/16, documented the resident was outside at the north end of the building drinking vodka and beer. A nurse's note, dated 10/18/16, documented the resident wanted to kill herself by slicing her wrist with a compact disc (CD) case. The police were notified and stayed with the resident until the emergency medical services (EMS) arrived. A nurse's note, dated 10/30/16, documented a male peer had insulted the resident as he walked past her. The nurse's note documented the resident had began screaming, cursing, and became calm after venting her anger for ten minutes. The nurse's note documented the nurse had discussed the incident with the resident and then instructed the male peer to apologize and stop the behavior. A nurse's note, dated 11/06/16, documented the resident had called the police on a peer for insulting her and calling her a fat pig. The nurse's note documented the police had talked with the male resident, told him to stay away from her, and to not speak to her. A nurse's note, dated 11/11/16, documented the resident was discharged from the facility to relocate to another nursing facility. On 12/01/16 at 9:15 a.m., the resident was interviewed regarding her move from the facility. The resident stated she had moved from the facility because she was tired of being bullied by resident #27. The resident stated she kept to herself in her room because she was afraid he would do something to her. The resident stated she did not feel safe in that environment. The resident stated she was called fat, a [***] , a cow, and he would say oink, oink when he saw her. The resident stated he would not leave her alone and his verbal abuse was the reason she relocated to another facility. The resident stated she had called the police on 11/05/16 related to the bullying. The resident stated resident #27 had a room located across the hall from her so she just stayed in her room. The resident stated she couldn't go out into the facility at that time. The resident was asked if she had reported the name calling to anyone at the facility. The resident stated she had reported it to LPN #1, RN #1, and the Administrator but nothing had been done. The resident was asked if she had seen anyone drinking alcohol or smoking marijuana at the facility. The resident stated she had seen residents #27, #39, #14, and #46 drinking alcohol and was outside when they were smoking weed. The resident stated she had told the assistant administrator there was a lot going on at the facility which she didn't want to get involved with. The resident stated her family did not visit often at the facility related to the situation with the other resident. The resident was well dressed, had a walker, was sitting in the living room, and was very personable. The resident smiled, did not have behaviors, and was informative. The incident reports from May 2016 through November 2016 were reviewed. The reports did not document incidence or investigations of resident to resident verbal abuse, police calls, or resident drinking. On 12/06/16 at 10:50 a.m., the director of nurses (DON) was asked about the incident reports for name calling and drinking. The DON stated she was not there when the drinking occurred, LPN #2 was on duty, and she thought he wrote the incident reports. The DON stated she was told about the incident when the police were called and about the drinking. The DON stated the facility was told the police could do nothing about the alcohol. The DON stated when the police wouldn't arrest resident #27, resident #13 stated she had a plastic CD case and would break it and kill herself if they didn't do something. The police stayed with the resident and she was sent to the hospital. The DON stated she was not very good with computers and she had put documentation into the computer which sometimes disappeared. The DON stated the last incident she showed for the resident was on 09/17/16. The DON stated an incident report was not completed. 2. Resident #9 (a [AGE] year old resident) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 01/05/16, documented the resident was independent for daily decision-making, was ambulatory, and required minimal assistance with the activities (ADLs). The assessment documented the resident had delusions and verbal behaviors toward others. The assessment documented the resident received anti-psychotic and anti-anxiety medications. The assessment documented the resident was a smoker. The care plan, dated 01/08/16, documented the resident had psychosocial needs and the staff were to praise the resident for her accomplishments, provide one to one interaction as needed, encourage the resident to come out of her room to visit or dine with others. The care plan documented the resident would refuse care and the staff were not to rush the resident. The care plan documented the resident would misplace belongings and accuse others of stealing her belongings. The care plan documented the resident had paranoid delusions, was verbally abusive, and would falsely accuse others. The care plan documented two staff persons were to provide the residents care at all times and were to redirect the resident as much as possible. A nurse's note, dated 09/15/16 at 11:02 a.m., documented the resident stated the president had bugged the facility and knew everything that was happening. A nurse's note, dated 09/29/16 at 7:26 p.m., documented the resident had frequent behaviors, was rude and disrespectful to staff and residents, cursed and picked fights with others, paced most of the shift, talked to herself, and frequently made delusional random statements. The physician's progress note, dated 10/25/16, documented the resident had been doing ok and was very happy that day, had some allergic rhinitis, started the resident on an anti-[MEDICATION NAME], and to continue care. The physician's orders [REDACTED]. The admission/discharge record, dated 11/12/16, documented the resident was discharged to the hospital for a psychiatric evaluation. The nurse's notes, dated 11/28/16 at 3:25 p.m., documented the resident had been evaluated at the hospital and was returning to the facility. The note documented her medications had been changed. On 11/28/16 at 3:45 p.m., several residents were observed outside on the patio smoking and were playing loud pop rock music. One employee was supervising. One male resident stated, Stop looking at me. She's molesting me with her eyes. A nurse's note, dated 11/29/16 at 7:33 a.m., documented the resident was up early, pacing, and was attempting to sell her belongings to buy cigarettes. On 11/29/16 at 9:58 a.m., resident #9 wanted to be interviewed regarding her concerns in the home. The resident stated she had lived in the facility for [AGE] years. The resident was clean, groomed, and showed signs of nervousness by fidgeting with her hands. The resident moved about in her chair during the interview. The resident stated she had concerns about the resident arguments occurring outside on the back patio. The resident stated some residents were young and some were old. The resident stated a male resident (#39) played loud music and used fowl language like GD this and GD that. The resident stated the older residents did not like the loud music but liked to sit out on the patio and talk with other residents. The resident stated resident #39 threatened residents and said he was going to hit them. She stated resident #39 smoked marijuana along with resident #14 and #46. The resident stated resident #46 brought the marijuana into the home. The resident stated resident #39, #14, and # 27 drank alcohol every weekend and sometimes vomited. The resident stated she was afraid of them because of their vulgar talk and the residents were abusive. She stated resident #39 had pushed her on the shoulder. The resident stated she reported the situation to the social service and activity directors. The resident stated resident #39 called her a dick sucker to the other males and told them not to talk to her. The resident stated she had a hard time holding up her head and it made her feel uncomfortable around the other men. The resident stated the remarks made her upset and cry. The resident stated resident #39 wanted to touch her breasts and private parts but she did not let him and now he made those comments. The resident stated the older people could not go outside because these residents were outside partying. The resident stated when the staff were told they, ignored the complaints. The resident stated she requested to go to the Pavilion for psychiatric evaluation because her life was out of control. On 11/29/16 at 10:47 a.m., the resident's physician was interviewed. The physician stated in the past year the atmosphere in the home had been different. The physician stated the home had an increase in independent residents and had been more volatile. The physician stated one male group liked to fight but none of the elderly residents had complained to him about them. The physician stated resident #9 was needy, outspoken, and manipulative but satisfied easily. The physician stated the resident had requested to go to the hospital for psychiatric evaluations. On 11/29/16 at 1:36 p.m., the ombudsman was interviewed. The ombudsman stated neighbors would complain because some residents threw beer cans out in the back alley. The ombudsman stated there were problems with some residents drinking alcohol, reported marijuana use, and one resident had obtained [MEDICATION NAME] with an old written prescription and some of the [MEDICATION NAME] was reported missing. The ombudsman stated the facility had a meeting with residents. The ombudsman stated the residents had been counseled regarding the alcohol, marijuana, medications, and some residents were given discharge notices. On 11/30/16 at 9:00 a.m., CNA #38 was interviewed regarding abuse and abuse prohibition. The CNA stated she had been employed in the facility for eight months. The CNA was able to verbalize knowledge about abuse and stated resident #9 was verbally abused by resident #39. The CNA stated resident #39 would say, If your mouth is open it better be on my dick. The CNA stated resident #9 went in to tell the assistant director of nurses (ADON). The CNA stated she redirected resident #39 and reported the incident to the charge nurse. The CNA stated resident #13 was verbally abused by resident #14 in the common area in front of other residents. The CNA stated resident #14 called her a fat pig and that she was still ugly even with make up on. The CNA stated this occurred on multiple occasions. The CNA stated other CNAs and nurses heard the name calling and derogatory remarks. The CNA stated resident #13 became withdrawn and would cry. The CNA stated resident #13 relocated to another facility. On 11/30/16 at 9:01 a.m., certified nurse aide (CNA) #6 was interviewed regarding abuse and allegations of abuse. The CNA stated resident #39 swore a lot and the staff try to get him to stop. The CNA stated the swearing did bother the other residents. The CNA stated the swearing even bothered her. The CNA stated resident #39 was not able to cease using profanity. The CNA stated when a female resident complained about resident #39 cussing at her and threatening her, she told the resident to ignore the statements and resident #39's opinions didn't matter. The CNA stated they try to stop resident #39 and redirect him. The CNA stated she had seen marijuana a couple of times, reported it to the charge nurse, and reported it to the assistant administrator. The CNA stated she had seen resident #39 drinking on the weekend and she had taken the alcohol away from him, locked the alcohol up in the medication room, and reported it to registered nurse (RN)#1 and the assistant administrator. The CNA stated the assistant administrator and the administrator came to the facility after the incident. The CNA stated the physician was notified and their medications were held. The CNA stated resident #39 would leave, check himself out of the facility, and come back intoxicated. The CNA stated the residents' behaviors started after resident #14 was admitted . On 11/30/16 at 9:10 a.m., social service director (SSD) was interviewed. The SSD stated she had worked in the facility for [AGE] years. The SSD stated she had not seen any male residents verbally abusing female residents. The SSD stated resident #39 hung out outside on the patio. The SSD stated the resident #39 used profanity and the resident stated it is his right to do so. The SSD stated she would tell him to lower his voice and some older people may not want to hear the profanity. The SSD stated resident #39 would say he paid his part of the rent so he could say what he wanted. The SSD stated resident #9 complained resident #39 called her a [***] , that she was a dick sucker, that she suck blankity blank. The SSD stated resident #39 was talking in a low voice, she did not hear what he had stated, and did not report it since she did not think there was a concern. The SSD stated resident #9 made accusations daily in regard to other residents. On 11/30/16 at 9:46 a.m., licensed practical nurse (LPN) #1 was interviewed regarding abuse. The LPN stated she had been employed by the facility for two years. The LPN was able to verbalize knowledge regarding abuse, neglect, sexual harassment, and [MEDICAL CONDITION]. The LPN was not able to clearly define the difference between verbal behaviors and verbal abuse. The LPN stated resident #39 had verbal behaviors and not verbal abuse. The LPN stated she would check into any allegation of abuse and report abuse through her chain of command. The LPN stated the verbal abuse and intimidation witnessed was documented as behaviors and the resident was redirected. The LPN stated she reported the verbal behaviors to the director of nurses but did not report the behaviors to the administrator. The LPN stated resident #9 complained about resident #39 frequently. The LPN was not able to state how she responded to the complaints. The LPN stated she had not witnessed any residents using marijuana in the facility. On 11/30/16 at 10:31 a.m., resident #39 was interviewed. The resident stated he was admitted to the facility after he was hospitalized for [REDACTED]. The resident stated the pancreatitis and diabetes were under control now. The resident stated he knew how to check his blood sugar and prepare and administer his insulin. The resident stated he needed care for his diabetes and insulin injections. The resident stated his application for Living Choices had been completed a month ago and was approved. The resident stated he could stay with his brother. The resident stated his brother lived north of Tulsa, it was too far away, and he did not want to go there. The resident stated he received information on abuse and the facility rules when he was admitted . The resident was able to verbalize knowledge on the different kinds of abuse. The resident stated verbal abuse was cussing, yelling, the use of profanity, and name calling. The resident stated intimidation was getting in someone's face, cussing, or threatening. The resident was asked to describe sexual harassment. The resident stated he could not say those kind of words. The resident stated resident to resident abuse was not tolerated in the facility. The resident was polite and did not use profanity or unbecoming speech throughout the interview. The resident stated taking or borrowing other residents' personal property was not allowed in the facility. The resident denied taking another resident's [MEDICATION NAME]. The resident stated alcohol and marijuana use were not allowed in the facility and he was counseled on the issue. The resident stated he received a thirty day notice and he stated he gave the notice back to the owner. On 11/30/16 at 11:03 a.m., resident #14 was interviewed regarding abuse. The resident stated he was admitted in August 2016 to receive therapy for a history of a compound fracture of his right ankle. The resident stated he received two weeks of therapy and stated therapy ended since he just quit participating. The resident stated he had been in a wheelchair since 2007 and had slight left sided weakness. The resident stated he had a father that lived in town but did not know if he could stay with him or not. The resident stated as soon as he got an apartment he was good to go. The resident stated he was given information on the rules of the facility and information on abuse but stated he did not read it. The resident stated abuse was not allowed in the facility. The resident stated verbal abuse was cussing and raising one's voice. The resident stated emotional abuse was name calling. The resident stated residents were not allowed to take or borrow other residents' property and could not have alcohol or marijuana on the premise. The resident stated he had been issued a 30 day notice. The resident stated he was given notice because he brought alcohol on the premise. The resident stated they were not allowed to have marijuana on the premise and had been caught with it outside on the patio. The resident was in a wheelchair with minimal weakness to his left side. The resident was polite and did not use any profanity during the interview. On 11/30/16 at 11:26 a.m., resident #27 was interviewed regarding abuse. The resident stated he had resided in the home for six months. The resident stated he did not have anywhere to live and came from a private home. The resident stated he had a stroke four years ago with left sided paralysis and used a quad cane for ambulation. The resident stated he required assistance with the activities of daily living. The resident stated he did not receive information on abuse or the rules of the facility when admitted . The resident stated he found out about abuse prohibition and the rules of the facility the hard way when he got counseled. The resident stated abuse was when someone treats you badly, calls you names, tells you to go to hell, cussing at someone, and lying. The resident stated it was not all right to talk to someone and scare them. The resident stated it was wrong to call someone a [***] . The resident stated he tried not to call anyone a [***] but if they were a [***] then he would call them a [***] . The resident ambulated with a quad cane and needed some assistance with transfers to sit and stand. The resident was polite and did not use profanity during the interview. On 11/30/16 at 12:01 p.m., the director of nurses (DON) was interviewed regarding the policy to prevent abuse. The DON stated she had been employed at the facility since 2003. The DON stated the facility had a no tolerance policy regarding abuse and allegations of abuse were to be reported immediately to the supervisor in the employee's chain of command. The DON stated if an allegation of abuse was reported the staff involved would be suspended and then an investigation would be initiated. The DON stated the course of action would be determined based on the results of the investigation. The DON stated the administrator and DON were responsible for abuse prohibition. The DON stated the staff had not reported allegations of abuse involving resident #39 in which the resident called a female resident a whore. The DON stated resident #39 had been told on multiple occasions not to cuss or use profanity. The DON was asked if resident #13 was verbally abused. The DON state resident #13 was called a fat ass. The DON stated the resident left the facility because she did not like the male resident who called her a fat ass. The DON stated the allegation was investigated by talking to the male resident and the other residents who were present at the time. The DON stated no staff reported resident #13 had been verbally abused repeatedly. The DON stated the resident became more outspoken and started cussing more. The DON stated from what she understood, resident #44 did not feel comfortable being in the room with resident #39 any more but could not state the reason. 3. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 04/29/16, documented the resident had depression and currently received [MEDICATION NAME] (an antidepressant medication). The care plan documented the staff were to give all supportive medications, monitor for behaviors such as expressed sadness and tearfulness, monitor for side effects of the medication, and allow the resident to express concerns and offer reassurance. The care plan documented the resident had behaviors of making false accusations concerning staff and residents. The care plan documented the resident l

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident remained free of accidents and injury for one (#1) of three sampled residents reviewed for accidents. The facility failed to use a mechanical lift to transfer the resident from the bed to the chair. The resident sustained [REDACTED]. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 06/07/12, documented the resident was severely impaired for daily decision making, was totally dependant with activities of daily living, and was totally dependant for bed mobility. The care plan, updated 06/14/12, documented the resident required a mechanical lift for transfers from the bed to the chair. The care plan documented to inform the resident prior to performing any task to prevent the resident's anxiety. The care plan documented for the staff to introduce themselves to the resident before entering the room due to the resident's blindness. A nurse's note, dated 07/03/12 at 2:30 p.m., documented the resident slipped to the floor while transferring. The nurse's note did not document the physician had been notified of the incident. A nurse's note, dated 07/07/12 at 10:00 a.m., documented the resident was refusing to take a shower. The note documented the resident's legs were discolored - purplish. The note documented the resident yelled out in pain when the nurse touched the leg. The note documented both of the resident's ankles and feet were swollen. A telephone order, dated 07/07/12, documented to obtain an X-ray of the left knee and the left ankle secondary to severe pain, bruising, and swelling. On 08/08/12 at 12:50 p.m., the resident was observed laying in bed being fed the lunch meal by the certified nurse aide (CNA). The resident stated, "I hurt in my legs. They dropped me and broke my leg." On 08/08/12 at 1:15 p.m., the restorative aide (RA) was interviewed regarding the incident on 07/03/12. The RA stated, "It was time to obtain the monthly weights. It was getting late in the day. I was told to hurry and finish so I could clock out. The mechanical lift was being used by another CNA, and I decided to get another CNA and do a two person transfer to get the resident into the weight chair. When we went to stand the resident up, she had a loose bowel movement and her feet slipped out from under her. At that time, I instructed the CNA to lower the resident to the floor with me. After the resident was on the floor, I went to get the licensed practical nurse (LPN) that was on duty. The LPN came to the room and assessed the resident. After the resident was assessed, we placed her back into the bed." On 08/08/12 at 1:50 p.m., the director of nurses (DON) was interviewed regarding the injury of resident. The DON stated she was working the floor on 07/07/12 and was asked to go to the resident's room to assess her because she was complaining of pain in the lower left leg. The DON stated the leg was discolored and had edema. The DON was asked if this incident was reported to the physician when it initially occurred. The DON stated the incident was not reported to the physician the day it occurred. The DON was asked when the incident was reported to the Oklahoma State Department of Health. The DON stated, "I completed the incident report on 07/07/12. That was the day I was informed of the injury." The DON stated, "I was working the floor on 07/07/12 and was asked to go to the resident's room to assess her because she was complaining of pain in the lower left leg. The leg was discolored and had edema. After I assessed her, I called the physician to request an X-ray of the resident's left lower leg. The results of the mobile X-ray were sent to the physician on 07/07/12." The DON was asked when this incident should have been reported to Oklahoma State Department of Health. The DON stated the incident should have been reported on 07/03/12, the day of the injury. On 08/08/12 at 3:00 p.m., the resident's physician was interviewed regarding the incident on 07/03/12 involving the resident. The physician stated he was not notified of the incident until 07/07/12 when the DON contacted him asking for an X-ray. On 08/08/12 at 3:20 p.m., the DON was interviewed regarding the care plan for the resident. The DON stated the resident was only supposed to be transferred with a mechanical lift. The DON was asked if the plan of care was followed while transferring the resident on 07/03/12. The DON stated no the care plan was not followed. On 08/08/12 at 3:30 p.m., the CNA was interviewed regarding the resident's left lower leg. The CNA stated, "I was assisting the RA that day. It was time to weigh the resident. The RA asked me to help her transfer the resident to the weight chair. I went into the room and we sat the resident up on the side of the bed, and stood her up. The resident's feet slipped out from under her and we had to assist her to the floor. I had no idea the resident's legs were so straight and she could not stand. I did not know until after this happened that the resident was supposed to be moved with a mechanical lift. I had only been here two weeks." On 08/09/12 at 9:10 a.m., a physician with the bone and joint clinic was interviewed regarding the resident's injuries. The physician stated the resident had fractures of both ankles. The physician stated the fractures were possibly a week old. The physician stated the fractures were minimally displaced lateral malleolar fractures. On 08/09/12 at 9:50 a.m., the DON was interviewed regarding the nurse's note entry from 07/03/12. The DON stated she was initially unaware the licensed practical nurse did not make a timely entry regarding the resident's injury. The DON stated the entry should have included the fact that it was a late entry. The DON stated, "I did not know how to address the situation." On 08/09/12 at 10:30 a.m., the RA was asked how the resident was supposed to be transferred. The RA stated, "I am not sure what the care plan said about transferring the resident."