Every finding on record at Northwest Nursing Center

Based on observation, record review, and interview, the facility failed to ensure an accident did not occur for a resident during facility transport for 1 (#7) of 1 sampled resident reviewed for accident hazards. The administrator identified eight residents used the facility van for transportation. Findings:On 07/17/25 at 10:59 a.m., the maintenance supervisor demonstrated the process of preparing a resident for transport per wheelchair using the facility van. There were four straps to be connected to the wheelchair at all sides. An undated form titled Policy and Procedure Securing a Wheelchair For Van Transport, read in part, Safety is the top priority when transporting wheelchair users in a wheelchair van. Position the wheelchair in the van as close as possible to the safety straps bolted in the floor. Check that the wheelchair's locks are in place and that four straps with hooks are bolted on the floor, as well as the regular seat belt that goes around the person who is in the wheelchair. Put the seat belt across the individual's lap and chest and fasten it. Adjust the seat belt so that it fits comfortably.An undated face sheet showed Res #7 had diagnoses which included chronic kidney disease stage 4, schizophrenia, seizures, altered mental status, muscle weakness, and abnormalities of gait and mobility.A quarterly assessment, dated 10/15/24, showed Res #7 had a BIMS score of 14 and was not cognitively impaired. The assessment showed the resident required moderate assistance with dressing and transfers.An incident report, dated 11/29/24, showed Res #7 had certain injury. The report showed the resident was being transported to dialysis by the facility van. The report showed a seat belt was in place for transport. The report showed CNA #1 was driving the van and noticed the resident was starting to slide down out of the wheelchair. The report showed CNA #1 pulled the van over and the resident was on the floor. The report showed CNA #1 noted a laceration to the resident's right leg, EMS was called, and the resident was taken to the emergency room by EMS. A nurse note, dated 11/29/24 at 2:31 p.m., showed at 2:00 p.m. Res #7 was being transported to dialysis by facility van. The note showed the resident was observed slumped down in the wheelchair, the staff stopped the van, and the resident was lying on the van floor. The note showed Res #7 was transported by EMS. The note showed the resident received an order to return to the hospital in 10 days to remove the stitches. A nurse note, dated 12/01/24, showed Res #7 continued with focus charting for laceration with sutures to right foot.An In-service Training Report, dated 12/02/24, showed staff were educated to call for assistance and have staff accompany resident during transportation if indicated by charge nurse. A nurse note, dated 12/05/24, showed a wound to the right leg with sutures intact but draining out dark color secretion with a foul odor noted. The note showed the resident complained of pain to the wound site. On 07/17/25 at 10:38 a.m., Res #7 stated the facility provided transportation to dialysis three times a week. The resident stated the staff always placed the seat belt for transport. The resident did not recall sliding or falling out of their wheelchair during transport to dialysis. On 07/17/25 at 11:09 a.m., the maintenance supervisor stated a seat belt was placed around the resident's waist and a shoulder belt from above the left side was connected to the waist belt. The maintenance supervisor stated if the seat belt was placed correctly the resident could not fall out of the chair. On 07/18/25 at 12:10 p.m., CNA #1 was interviewed about the incident with Res #7 on 11/29/24 sliding out of the wheelchair during transport. CNA #1 stated they positioned the wheelchair and connected the straps to the wheelchair. CNA #1stated the LPN/charge nurse #1 placed the seat belt on the resident. The CNA stated they observed in the rearview mirror Res #7 sliding out of their wheelchair, they pulled the van off the road, and Res #7 was found lying on the van floor. CNA #1 stated the seat belt was still connected around the wheelchair. On 07/18/25 at 1:28 p.m., the administrator was asked was the in-service provided to staff sufficient in addressing the incident that occurred on 11/29/24 regarding Res #7 sliding out of the wheelchair during transport. The administrator stated the in-service provided did not address the concern regarding Res #7 sliding out of the wheelchair during transport. On 07/18/2025 at 2:40 p.m., the administrator stated LPN/charge nurse #1 placed the seat belt on Res #7 for transport on 11/29/24. The administrator stated the transportation driver/CNA #1 was responsible for ensuring the resident was secured correctly for transport.

Based on record review and interview, the facility failed to ensure a resident:a. received appropriate care for a dehisced surgical incision for 1 (#54) of 4 sampled residents reviewed for hospitalization; andb. had an order for hospice services for 2 (#75 and #4) of 3 sampled residents reviewed for hospiceThe administrator identified 62 residents resided in the facility and 11 residents received hospice services.Findings: 1. Resident #54's significant change resident assessment, dated 06/26/25, showed the resident had diagnoses which included unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing and limitation of activities due to disability. The assessment showed the resident had moderate cognitive impairment with a BIMS of 10. A physician progress note, dated 07/04/25, showed the resident had a long right lateral knee incision which had multiple dehisced areas. The note showed they would have the staff contact the surgeon's office to make sure they know about the dehisced areas. There was no documentation the facility contacted Resident #54's surgeon to notify them about the dehisced surgical site. A Daily Skilled Nurses Note dated 07/05/25, did not document the resident's surgical site was dehisced. A nursing note, dated 07/13/25 at 9:22 a.m., showed the resident pulled out their trach and was sent to the emergency room for further eval. A nursing note, dated 07/13/25 at 10:30 a.m., showed the resident was observed taking off the dressing from their wound and picking on it with blood in their hands. The note showed the nurse replaced the wound dressing. A hospital record, dated 07/13/25, showed the resident had evidence of wound dehiscence to their surgical site. The record showed the resident had a procedure for the closure of the wound dehiscence on 07/14/25. On 07/17/25 at 2:50 p.m., LPN #3 stated they were familiar with the resident's care. They stated they last cared for the resident on 07/10/25. They stated the resident's surgical site was not open. On 07/18/25 at 12:35 p.m., LPN #2 stated they took care of the resident on 07/08/25. They stated the resident's surgical site was not open. On 07/22/25 at 8:20 a.m., RN #1 stated the first time they noticed the resident's surgical site had opened was on 07/13/25. They stated they cared for the resident on 07/12/25 and the surgical site was not open. On 07/22/25 at 11:40 a.m., the corporate nurse consultant stated the DON was responsible for reviewing physician progress notes. They stated the current DON had started working at the facility on 07/09/25 which was the day they received the 07/04/25 physician progress note. On 07/22/25 at 11:43 a.m., Corporate Nurse Consultant #1 stated the facility should have clarified the physician progress note dated 07/04/25. On 07/22/25 at 11:43 a.m., Corporate Nurse Consultant #1 stated the facility should monitor surgical sites and notify the physician if the site dehisced. 2. A policy titled Hospice Services Facility Agreement, dated 04/14/24, read in part, The facility has the interdisciplinary team to be responsible for working with hospice representatives to coordinate care to the resident provided by facility and hospice staff. A progress note, dated 03/19/25, showed Resident #75 wanted to switch hospice companies. A physician order, dated 03/21/25, showed the resident was ordered to be evaluated by the resident's chosen hospice. A significant change assessment, dated 05/16/25, showed Resident #75 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, and had a life expectancy of less than six months. On 07/23/25 at 6:00 p.m., the administrator was asked when Resident #75 had been originally admitted to hospice services. They stated they did not have an order for the first hospice Resident #75 had been admitted to in February or March 2025, or the hospice company's hard chart. They stated they had coordinated care with the second hospice company Resident #75 had switched to. They stated the first hospice company would routinely make visits to the facility to see the resident between 7:00 p.m. and 11:00 p.m. so there was not a coordination of care with that hospice company. 3. An initial hospice assessment, dated 03/19/25, showed Resident #4 had been assessed by the RN with the hospice company. A significant change assessment, dated 06/11/25, showed Resident #4 had a BIMS score of 14, which indicated the resident was cognitively intact for daily decision making, and had a life expectancy of less than six months. A care plan, reviewed 06/30/25, showed a focus related to hospice services had been initiated on 06/20/25. On 07/18/25 at 8:13 a.m., review of the clinical record did not show Resident #4 had a physician's order for hospice services. A physician order, dated 07/18/25 at 10:54 a.m., showed Resident #4 was admitted to hospice services on 03/19/25. On 07/21/25 at 2:51 p.m., the DON stated they had entered the physician order for hospice services for Resident #4 because there had not been one put into the electronic clinical record. The DON stated they did not know why Resident #4 had not had an order for hospice services. On 07/23/25 at 4:19 p.m., LPN #4 stated they would review the physician orders to determine if a resident was to receive hospice services. They stated if the resident did not have an order for hospice, they would know the resident was on hospice because the hospice companies had hard charts for the residents on services.

Based on record review and interview the facility failed to ensure a comprehensive care plan was developed for 3 (#61, 69, and #73) of 18 sampled residents reviewed for care plans. The administrator identified 62 residents resided in the facility. Findings: 1. An admission assessment, dated 02/20/25, showed Resident #73 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of end stage renal disease. The care area assessment summary showed visual function, ADL function, urinary incontinence/indwelling catheter, psychosocial well-being, activities, falls, nutritional status, pressure ulcer, psychotropic drug use, pain, and return to the community referral were all triggered care areas from the assessment and care planning decisions had been made. The admission assessment showed the care area assessment summary and care planning decisions had been completed by the VP of reimbursement on 02/28/25. A care plan, reviewed 06/09/25, showed a care plan for falls. The care plan did not show the other triggered areas on the admission assessment had been care planned. On 07/23/25 at 9:31 a.m., the VP of reimbursement stated they had completed assessments and the care area summary. They stated they had informed the former DON they needed to develop a comprehensive care plan. The VP of reimbursement stated corporate nurse consultant #1 was responsible to monitor to ensure comprehensive care plans were developed. On 07/23/25 at 9:36 a.m., corporate nurse consultant #1 stated the VP of reimbursement would need to be asked why the comprehensive care plan had not been developed for Resident #73. On 07/23/25 at 9:38 a.m., the administrator stated a previous corporate MDS coordinator was responsible to ensure a comprehensive care plan had been developed for Resident #73. 2. A significant change assessment, dated 06/12/25, showed Resident #61 was severely impaired in cognition for daily decision making by staff assessment, and had limited range of motion on both sides of their upper and lower extremities. A care plan, revised on 07/14/25, did not show the resident had limitation in their upper and lower extremities. On 07/23/25 at 5:24 p.m., the MDS coordinator stated the care plan for Resident #61 had been revised on 07/14/25 and the resident had limited range of motion to both sides of the upper and lower extremities. The MDS coordinator reviewed the resident's significant change assessment and the care plan and stated they should have addressed the limited range of motion on the care plan. A policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, read in part 3. An admission/discharge return anticipated assessment for Resident #69, dated 04/07/25, showed the admission date of 03/29/25. The assessment showed the resident went to the hospital. An undated order summary for Resident #69's showed an admission date of 04/14/25. A review of Resident #69's electronic medical record did not show a comprehensive care plan had been initiated or completed. An undated order summary for Resident #69's showed diagnoses which included acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status. On 07/22/25 at 10:32 a.m., the MDS coordinator stated there was not a comprehensive care plan for the resident. They stated they started in May of this year and had to catch things up. They stated there was no coordinator since February and corporate was doing them during that time.

Based on record review and interview, the facility failed to ensure residents who received dialysis services were assessed before and after dialysis for 1 (#7) of 1 sampled resident reviewed for dialysis.Corporate Nurse Consultant #1 identified two residents who required dialysis.Findings: An undated policy titled End-Stage Renal Disease, Care of a Resident with, read in part, Residents with end-stage renal disease [ESRD] will be cared for according to currently recognized standards of care. An annual assessment, dated 04/12/25, showed Resident #7 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, had a diagnosis of end stage renal disease, and received dialysis. A July 2025 treatment record showed the fistula for Resident #7 was monitored every shift. A care plan, reviewed 07/14/25, showed Resident #7 required dialysis and was scheduled weekly on Monday, Wednesday, and Friday at 1:30 p.m. A Dialysis Communication form, dated 07/18/25, showed vital signs had been obtained for Resident #7 by facility staff. The bottom of the form showed the dialysis center obtained vital signs. On 07/16/25 at 3:13 p.m., review of the assessments, progress notes, and scanned documents in the electronic clinical record, dated 06/01/25-07/16/25, did not show Resident #7 had been assessed before and after dialysis. A Dialysis Communication form, dated 07/21/25, showed vital signs had been obtained by dialysis staff. The form did not have Resident #7's name on it and the facility staff had not documented the pre-dialysis vital signs. On 07/23/25 at 8:34 a.m., Resident #7 stated uh huh when asked if they received dialysis. Resident #7 did not participate further with an interview. On 07/23/25 at 10:44 a.m., LPN #2 stated they obtained vital signs before the resident went to dialysis but was not on shift when they returned. They stated they documented the pre-dialysis vital signs in the dialysis communication book or in a progress note. On 07/23/25 at 10:46 a.m., corporate nurse consultant #1 stated the nurses were to document in the dialysis communication book before and after a resident returned from dialysis. They stated they were to document vital signs and their assessment of the dialysis access site. On 07/23/25 at 11:03 a.m., corporate nurse consultant #1 stated the only form in the dialysis communication book was dated 07/18/25. They stated the facility nurse was to complete the pre-dialysis assessment and the dialysis center was to complete the post-dialysis assessment. They stated the administrator was to monitor to ensure the assessments had been completed. On 07/23/25 at 11:05 a.m., the administrator stated they had completed an audit and noticed the dialysis center did not always return the dialysis communication forms. They stated they had started sending the dialysis communication book with Resident #7 on 07/18/25. On 07/23/25 at 11:15 a.m., corporate nurse consultant #1 stated since 07/18/25 when the dialysis communication book had been implemented the facility had not monitored to ensure pre and post dialysis assessments were being completed.

Based on record review and interview the facility failed to ensure anticoagulant monitoring was in place for a high-risk medication for 1 (#69) of 5 sampled residents reviewed for unnecessary medication. The administrator identified 62 residents resided at the facility, and 30 residents received anticoagulant therapy. Findings: An undated policy titled High Risk Medications-Anticoagulants, read in part, This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systemic approach to managing anticoagulant therapy for efficacy and safety.The resident's plan of care shall alert staff to monitor for adverse consequences. An undated order summary for Resident #69's showed diagnoses which included acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status. A physicians order, dated 03/28/25, showed Apixaban (blood thinner) 5 mg tablet two times a day. This order was discontinued on 04/09/25. A physicians order, dated 04/15/25 showed Apixaban (blood thinner) 5 mg tablet two times a day. This order was discontinued on 06/22/25. Review of Resident #69's electronic medical record showed no order or monitoring for side effects of anticoagulant therapy was completed since the inception of the order dated 03/28/25. On 07/22/25 at 10:02 a.m., LPN #2 stated anticoagulant monitoring was done in the electronic medical record and there was something they had to follow. LPN #2 reviewed Resident #69's order list and was unable to locate. On 07/22/25 at 10:26 a.m., LPN #2 requested assistance from the corporate nurse consultant #1 to locate the monitoring. LPN #2 stated they did not have anything.

Based on observation, record review, and interview, the facility failed to ensure range of motion was provided to residents for 3 (#2, 13, and #61) of 3 sampled residents reviewed for position and mobility.The administrator identified 12 residents had limited range of motion resided in the facility.Findings:1. On 07/15/25 at 11:57 a.m., Resident #2 was in bed and had contracted upper and lower extremities. A quarterly resident assessment, dated 06/16/25, showed Resident #2 had diagnoses which included spastic quadriplegic cerebral palsy and aphasia. The assessment showed the resident's cognition was severely impaired. The assessment showed the resident had impairment on both upper and lower extremities. The assessment showed no passive or active range of motion was perform in the seven days look back period. The assessment showed the resident was dependent on staff assistance for all activities of daily living. There was no documentation Resident #2 received range of motion services. 2. On 07/15/25 at 12:53 p.m., Resident #13 was observed in bed with right side weakness and contracted left hand. A quarterly resident assessment, dated 04/16/25, showed Resident #13 had diagnoses which included nontraumatic intracerebral hemorrhage and muscle spasm. The assessment showed the resident's cognition was severely impaired with a BIMS of 05. The assessment showed the resident had impairment on one side of their upper and lower extremity. It showed no passive or active range of motion was perform in the seven days look back period. The assessment showed the resident was dependent on staff assistance for all activities of daily living. There was no documentation Resident #13 received range of motion services. On 07/22/25 at 2:37 p.m., corporate nurse consultant #1 stated therapy would do a screen and develop a contracture management plan and refer it to restorative to carry out the plan. On 07/22/25 at 2:48 p.m., corporate nurse consultant #1 stated Resident #2 and Resident #13 had not received restorative services for range of motion. They stated the residents above would qualify for range of motion. On 07/22/25 at 3:10 p.m., CNA #4 was asked what care they provided for Resident #2 and Resident #13. They stated they repositioned and changed Resident #2 and Resident #13's pads. They stated they put pillows between Resident #13's legs. CNA #4 did not mention providing active or passive range of motion for Resident #2 and Resident #13. On 07/22/25 at 3:15 p.m., LPN #3 stated they did not perform range of motion on Resident #2 and Resident #13. They stated therapy were the main staff that perform range of motion on residents but nurses and CNAs can do it as well. 3. A significant change assessment, dated 06/12/25, showed Resident #61 was severely impaired in cognition for daily decision making by staff assessment, and had limited range of motion on both sides of their upper and lower extremities. A care plan, revised on 07/14/25, did not show the resident had limitation in their upper and lower extremities. On 07/15/25 at 3:45 p.m., review of the physician orders, care plan, assessments, and scanned documents in the electronic clinical record did not show Resident #61 had been assessed or evaluated for range of motion services. On 07/15/25 at 3:38 p.m., family member #1 stated Resident #61 had refused therapy in the past but would like for them to be assessed for exercises of their joints. On 07/23/25 at 3:41 p.m., the DON stated the nurses periodically assessed for range of motion services. On 07/23/25 at 3:56 p.m., the DON was asked how they ensured residents with limited range of motion did not experience a further decline in range of motion. They stated they did not know. The DON stated they did not have a restorative program at the facility, but they offered physical therapy.

Based on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 3 (#20, 29, and #69) of 18 sampled residents reviewed for baseline care plans.The administrator identified 62 residents resided in the facility. Findings:An undated policy titled Care Plans, read in part, To assure the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. A policy titled Baseline Care Plan, dated 08/01/24, read in part, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality .The baseline care plan will .Be developed within 48 hours of a resident's admission 1.An admission MDS, dated 02/19/25, showed Resident #20 was admitted to the facility on [DATE] with diagnoses to include depression and psychotic disorder other than schizophrenia. A review of Resident #20's medical chart did not show a baseline care plan was developed within 48 hours of admission. On 07/16/2025 at 11:11 a.m., MDS coordinator #1 was asked when a baseline care plan is to be developed by the facility. They stated, Within 48 hours of admission. [Resident #20] was admitted in February and I didn't get their care plan done until May. MDS coordinator #1 was asked if Resident #20 had a baseline care plan in place. They stated, No. 2. An undated order summary for Resident #69 showed diagnoses which included acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status. A review of Resident #69's electronic medical record did not show a baseline care plan had been completed. A resident admission assessment, dated 04/07/25, showed an admission date of 03/29/25. On 07/22/25 at 10:32 a.m., MDS coordinator #1 stated there was not a baseline care plan for the resident. They stated they started in May of this year and had to catch things up. They stated there was no coordinator since February and corporate was doing them during that time. 3. The Baseline Care Plan v1.1-V1, dated 05/19/25, did not show Resident #29 or the resident's representative had been provided a summary of the baseline care plan. The admission assessment, dated 05/23/25, showed Resident #29 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of unspecified dementia. On 07/22/25 at 1:45 p.m., MDS coordinator #1 stated they completed baseline care plans within 48 hours of admission in the electronic clinical record. They stated they had not provided residents or resident representatives with a summary of the baseline care plan. On 07/22/25 at 2:26 p.m., corporate nurse consultant #1 stated baseline care plans were completed within 48 hours of admission and documented in the electronic clinical record. They stated the social services director provided a summary of the baseline care plan to the resident and or resident representative. On 07/23/25 at 8:27 a.m., Resident #29 stated they did not believe they had been provided a summary of their baseline care plan. On 07/23/25 at 9:18 a.m., corporate nurse consultant #1 stated they had spoken with social services, and they said they had not provided a baseline care plan summary to Resident #29 or their representative.

Based on record review and interview, the facility failed to ensure a significant change assessment had been completed when hospice services were elected for 2 (#4 and #75) of 19 sampled residents whose assessments were reviewed.The administrator identified 11 residents on hospice services.Findings: 1. A progress note, dated 03/19/25, showed Resident #75 wanted to switch hospice companies. A physician order, dated 03/21/25, showed Resident #75was ordered to be evaluated by the resident's hospice of choice. A significant change assessment, dated 05/16/25, showed Resident #75 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, had a life expectancy of less than 6 months, and the sections of the assessment had been completed on 06/02/25. On 07/23/25 at 6:00 p.m., the administrator was asked when Resident #75 had been originally admitted to hospice services. They stated they did not have an order for the first hospice Resident #75 had been admitted to, but they had elected the hospice benefit in February or March 2025 with the first hospice company. The administrator stated a significant change assessment should have been completed when Resident #75 had initially elected the hospice benefit.2. On 03/19/25, an initial hospice assessment showed Resident #4 had been assessed by the RN with the hospice company.A significant change assessment, dated 06/11/25, showed Resident #4 had a BIMS score of 14, which indicated the resident was cognitively intact for daily decision making, had a life expectancy of less than 6 months, and the sections of the assessment had been completed on 06/20/25. On 07/22/25 at 1:47 p.m., the MDS coordinator stated they had noticed in June, shortly after beginning the role as MDS coordinator, a significant change assessment had not been completed when Resident #4 had elected the hospice benefit. On 07/23/25 at 4:23 p.m., the administrator stated the significant change assessment for Resident #4 had not been completed when they had elected the hospice benefit because they had been transitioning MDS coordinators at that time.

Based on record review and interview, the facility failed to ensure notification of a bed hold was provided upon transfer for 1 (#73) of 4 sampled residents who were reviewed for hospitalization.The administrator identified 62 residents resided in the facility.Findings:The admission assessment, dated 02/20/25, showed Resident #73 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of end stage renal disease. An entry under the Census section of the electronic clinical record, dated 04/05/25 through 06/15/25, showed Resident #73 was a long-term care resident. A physician order, dated 06/15/25, showed Resident #73 was transferred to the emergency room to be evaluated and treated. A progress note, dated 06/15/25, did not show notification of a bed hold had been provided. On 07/22/25 at 2:46 p.m., LPN #1 stated the administrator or social services director provided bed hold information when a resident was transferred to the hospital. On 07/23/25 at 8:30 a.m., LPN #4 stated they did not know who provided notification of a bed hold upon transfer to the hospital. They stated they thought it was the administrator or the social services director. On 07/23/25 at 8:37 a.m., the administrator stated residents signed information regarding bed holds upon admission. They stated the facility did not provide notification regarding bed holds at the time of a transfer to the hospital.

Based on record review and interview, the facility failed to ensure an annual comprehensive assessment was completed within 366 days of the previous annual comprehensive assessment for 1 (#9) of 19 sampled residents whose assessments were reviewed.The administrator identified 62 residents resided in the facility.Findings: An annual assessment, dated 11/18/24, showed Resident #9 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and a diagnosis of diabetes mellitus. The annual assessment showed it was completed on 12/13/24. An MDS 3.0 NH Final Validation Report, dated 12/13/24, showed the annual assessment for Resident #9, read in part, Assessment Completed Late: An OBRA comprehensive assessment with the Care Area Assessment [Section V] is due every year unless the resident is no longer in the facility. A prior record with an ARD [A2300] within 366 days of the submitted record could not be found. On 07/23/25 at 6:13 p.m., the administrator stated they had not had an MDS coordinator,. They stated they were utilizing the corporate MDS coordinator and assessments were completed late.

Based on record review and interview, the facility failed to ensure assessments were transmitted within 14 days of completion for 1 (#7) of 19 sampled residents whose assessments were reviewed.The administrator identified 62 residents resided in the facility. Findings: A SNF Part A discharge assessment, dated 02/26/25, showed Resident #7 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, Part A skilled services had ended on 02/26/25, and the sections of the assessment were completed on 06/02/25. An MDS 3.0 NH Final Validation Report, dated 06/05/25, showed the SNF Part A discharge assessment for Resident #7, read in part, Assessment Completed Late: Z0500B [assessment completion date] is more than 14 days after A2300 [assessment reference date] On 07/23/25 at 6:13 p.m., the administrator stated the corporate MDS coordinator had been completing assessments, but some were late due to the transition of MDS coordinators in the facility.

Based on observation, record review, and interview, the facility failed to ensure a resident's assessment was accurate for 1 (#20) of 18 sampled residents reviewed for accurate assessments.The administrator identified 62 residents resided in the facility.Findings:A document titled, Transition Plan, dated 11/21/24, showed Resident #20 was discharged from an inpatient behavioral health facility on 11/21/24 with a diagnosis of schizophrenia.A Quarterly MDS, dated 05/22/25, showed Resident #20 was admitted to the facility on [DATE] with diagnoses to include depression and psychotic disorder other than schizophrenia. The MDS showed Resident #20 did not receive antipsychotic medications.A review of Resident #20's MAR for February and March 2025 showed Resident #20 received Paliperidone ER Oral Tablet Extended Release 24Hour (an atypical antipsychotic) 6 MG tablet one time daily for schizophrenia.A review of Resident #20's MAR for March, April, and May 2025 showed Resident #20 received Zyprexa Oral Tablet 5 MG (an atypical antipsychotic) one tablet daily for schizophrenia.On 07/16/25 at 11:08 a.m., the MDS coordinator was asked if Resident #20's most recent MDS, the quarterly MDS, reflected their diagnosis of schizophrenia or the antipsychotic medications they had received. The MDS coordinator stated, No it doesn't. They were asked if the MDS should show a diagnosis of schizophrenia. They stated, Yes, it should because [Resident #20] has it. The MDS coordinator was asked if the MDS showed Resident #20 was receiving an antipsychotic medication. They stated, No, those questions were answered incorrectly.

Based on record review and interview, the facility failed to ensure accurate documentation of a diagnosis on a PASARR form for a mental health illness for 1 (#20) of 13 sampled residents reviewed for the need of a level II screening.The administrator identified 13 residents with mental illness resided in the facility.Findings:A document titled Transition Plan, dated 11/21/24, showed Resident #20 was discharged from an inpatient behavioral health facility on 11/21/24 with a diagnosis of schizophrenia.An admission MDS, dated 02/19/25, showed Resident #20 was admitted to the facility on [DATE] with diagnoses to include depression and psychotic disorder other than schizophrenia. The MDS showed Resident #20 did not receive antipsychotic medications. The MDS showed Resident #20 was not considered by the state level 2 PASARR process to have serious mental illness and/or intellectual disability or a related condition.A Psychiatric Exam, dated 02/20/25, read in part, Patient is on Paliperidone [an atypical antipsychotic] Patient does have a diagnosis of schizophrenia.A review of Resident #20's MAR for February 2025 showed Resident #20 received Paliperidone ER Oral Tablet Extended Release 24Hour 6 MG tablet one time daily for schizophrenia.On 07/16/25 at 11:02 a.m., the MDS coordinator was asked what was the process for identifying whether a state level PASARR 2 needed to be completed. They stated, If they have any diagnoses like bipolar, schizophrenia, or take antipsychotic medications, we call the state for a state level PASARR 2. MDS coordinator #1 was asked what diagnoses Resident #20 had and they stated, MDD [major depressive disorder] and schizophrenia. [Resident #20] has a state level 2 PASARR in progress. A copy of the initiated state level 2 PASARR was requested. MDS coordinator #1 was asked if based on Resident #20's diagnosis of schizophrenia was question #2 on the PASSAR 1 answered correctly. They stated, Absolutely not.On 07/16/25 at 11:50 a.m., MDS coordinator #1 stated, [Resident #20] actually does not have a level 2 PASARR in progress.

Based on record review and interview, the facility failed to ensure a care plan had been revised for 1 (#7) of 19 sampled residents whose care plans were reviewed.The administrator identified 62 residents resided in the facility.Findings: A Nutrition Services Note, dated 04/02/25, showed the dietician discontinued the liquid protein for Resident #7. An annual assessment, dated 04/12/25, showed Resident #7 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, and had a diagnosis of diabetes mellitus. A care plan, reviewed 07/14/25, showed Resident #7 had a nutritional problem and was to receive 30 milliliters of liquid protein each day. On 07/23/25 at 12:24 p.m., the MDS coordinator stated the care plan for Resident #7 had been reviewed on 07/13/25. They stated the nutrition portion of the care plan had not been revised since 09/04/24. They stated the liquid protein should not have still been on the care plan and the care plan had not been fully updated. On 07/23/25 at 12:52 p.m., corporate nurse consultant #1 stated care plans were to be reviewed/revised daily for acute needs and quarterly. They stated they did not know why the care plan for Resident #7 had not been revised to reflect their current needs.

Based on record review and interview the facility failed to ensure medication was administered according to physician orders for 1 (#69) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 62 residents resided at the facility. Findings: A policy titled Medication Administration, dated 05/01/24, read in part, Administer medication as ordered in accordance with manufacturer specifications .Sign MAR after administration. An undated order summary for Resident #69 showed diagnoses which included acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status. A physician's order, dated 04/19/25, showed Guaifenesin (expectorant) three times a day. A physician's order, dated 04/20/25, showed Ipratropium-Albuterol (bronchodilator to prevent bronchospasm) three times a day for wheezing and sob. A review of Resident #69's medication administration record dated 04/01/25 - through 04/30/25 showed blank boxes for:a. Guaifenesin on 04/19/25 at 8:00 a.m., 2:00 p.m., 8:00 p.m., and on 04/20/25 at 8:00 a.m., 2:00 p.m., 8:00 p.m., andb. Ipratropium-Albuterol on 04/20/25 at 2:00 p.m., 8:00 p.m., and on 04/21/25 at 8:00 a.m., and 2:00 p.m. On 07/22/25 at 10:02 a.m., LPN #2 stated blanks on the medication administration record indicated they missed it. They stated they were supposed to put refused. On 07/22/25 at 10:23 a.m., LPN #2 stated they did not see where the albuterol or the guaifenesin were administered as ordered. The facility failed to ensure a resident with a respiratory diagnosis received supporting medication as ordered.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained:a. during provision of incontinent care for 1 (#13) of 6 sampled residents reviewed for ADL care, andb. appropriate personal protective equipment was worn for a resident on enhanced barrier precautions for 2 (#7 and #13) of 18 sampled residents reviewed for infection control practices. The administrator identified 62 residents resided in the facility, 16 incontinent residents, and 12 residents on EBP. Findings: A policy titled Perineal Care, dated 05/01/24, read in part, It is the policy of this facility to provide perineal care to all incontinent residents .as needed to promote cleanliness and comfort, decrease risk of infection to the extent possible . Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate .Clean the bottom of the scrotum and the anal area .Remove gloves and discard. Perform hand hygiene. Re-apply new set of gloves. Place appropriate incontinent product under resident .Remove gloves and discard. Perform hand hygiene. Reposition as desired ad cover resident. A facility policy titled Enhanced Barrier Precautions, dated 04/01/24, read in part Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves used during high contact resident care activities.An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. 1. An undated order summary for Resident #13's showed diagnoses to include nontraumatic intracranial hemorrhage, muscle wasting and atrophy. A physician's order, dated 01/23/25, showed to cleanse peg tube site daily. A resident assessment, dated 04/16/25, showed a BIMS of 5 indicating severely impaired cognition, always incontinent of bladder and bowel, dependent for toileting mobility, and presence of a feeding tube. There was no order located for enhanced barrier precautions. On 07/23/25 at 9:30 a.m., a laminated EBP sign was observed on the wall next to Resident #13's door. On 07/23/25 at 9:39 a.m., Resident #13 was observed in his room, in bed with a tube feeding. On 07/23/25 at 9:44 a.m., CNA #2 stated Resident #13 was dependent, incontinent, with an hourly check and change, and was on tube feeding. CNA #2 was unable to state for sure when the resident was last checked. Requested to check resident for incontinence. On 07/23/25 at 9:46 a.m., CNA #2 went into Resident #13's room to check if soiled. CNA #2 donned gloves and pulled back the sheet to check brief and observed brief to be wet. CNA #2 stated the resident needed to be changed. Resident #13 was covered back up with sheet, removed gloves, and exited the room to gather supplies. There was no observation of hand hygiene performed. EBP sign remained next to the resident's door. On 07/23/25 at 9:48 a.m., CNA #2 returned to the room, closed the door and curtain, placed trash bag near the bed, and donned gloves. No gown donned. Has clean brief and wipes ready on the bedside table. Resident #13 has bilateral lower extremity contractures. CNA #2 wiped front to back if the perineum with a wipe. Resident had bowel movement and urine soilage. CNA #2 removed the soiled brief by folding it over itself and wiped the remaining stool from the resident, then wiped the gloved hands with a clean wipe, and then applied the clean brief to the residents' bed, turned the resident over, removed a soiled wipe from between the residents' groin and threw it in the trash. The CNA then wiped the gloved hands with another clean wipe and proceeded to turn the resident over and apply the clean brief. CNA #2 removed the green soiled pad and put it on the floor next to the trash and then continued to snap the brief closed, adjusted the residents' gown, removed their gloves and adjusted the cover and head of bed. On 07/23/25 at 9:56 a.m., CNA #2 placed the pad in the bag and the trash in a bag. There was no observation of CNA #2 changing gloves or performing hand hygiene according to standard practice and the standard of care. On 07/23/25 at 9:58 a.m., CNA #2 stated the process for hand hygiene during incontinent care was to wash hands first. When asked when they should change gloves or wash their hands, they stated, When start messing with sheets and call lights and before and after incontinent care or when hands are soiled when may cross contaminate. CNA #2 stated, For me it really depends on the person. Some may change more than others, it is up to the person. CNA #2 stated they did not know what kind of wipes they had wiped their gloved hands with. On 07/23/25 at 10:00 a.m., CNA #2 stated Resident #13 was on EBP for the feeding tube. CNA #2 stated they did not see any PPE. They stated it was not appropriate to put soiled linen on the floor. On 07/23/25 at 10:39 a.m., DON not available. The corporate nurse consultant #1 stated the process for hand hygiene during incontinent care was to wash hands before and after, put on gloves, if soiled ten take off, sanitize and new gloves, then remove gloves and wash hands after. The corporate nurse consultant #1 stated for an incontinent resident on EBP they were expected to wear gown and gloves. They stated the PPE was located on the carts. On 07/23/25 at 10:42 a.m., corporate nurse consultant #1 showed the linen cart where the gowns were stored at the bottom. They stated it was not appropriate to put soiled linen on the floor during incontinent care, and it was not appropriate to wipe gloved hands with a clean wipe used for incontinent care instead of changing gloves or performing hand hygiene. 2. On 07/17/25 at 4:24 p.m., LPN #1 gathered their supplies and prepared a clean area on Resident #7's bedside table. LPN #1 washed their hands and donned a pair of gloves. The LPN did not don a gown per enhanced barrier precautions. LPN #1 used a pair of scissors to remove the old dressing. The LPN placed the scissors back on the clean area prepared. LPN #1 did not clean the scissors. The LPN cleaned the wound with normal saline. LPN #1 used the same scissors used to remove the soiled dressing to cut the collagen strip for the size of the wound. LPN #1 placed an abdominal pad over the collagen and wrapped with a gauze wrap. A care plan, dated 01/19/21, showed Resident #7 had diagnoses which included schizophrenia, mild protein-calorie malnutrition, abnormal gait and mobility, and diabetes mellitus. A physician order, dated 07/17/25, showed the staff was to cleanse the right heel with normal saline, pat dry, apply a collagen sheet and cover with an abdominal pad, and wrap with kerlix and secure with tape daily and as needed. On 07/17/25 at 4:55 p.m., LPN #1 stated they forgot to bring in an alcohol wipe to clean the scissors between dirty and clean dressing areas. The LPN stated they should have been wearing a gown and gloves for the wound care per EBP.

Based on record review and interview, the facility failed to ensure the COVID-19 vaccine was offered to residents for 3 (#4, 29, and #61) of 5 sampled residents reviewed for immunization.The administrator identified 62 residents resided in the facilityFindings:The Vaccination of Residents policy, dated 2001, read in part, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated.1. A care plan, revised 06/09/25, showed Resident #4 was admitted on [DATE].2. Resident #29's admission resident assessment, dated 05/23/25, showed the resident was admitted on [DATE].3. A care plan, dated 07/14/25, showed Resident #61 was admitted on [DATE].There was no documentation the residents above had been offered the COVID-19 vaccine.On 07/23/25 at 6:14 p.m., the infection preventionist stated they had no supporting documentation the residents above had been offered the COVID-19 vaccine.

Based on record review and interview, the facility failed to provide bathing for 1 (#41) of 6 sampled residents reviewed for activities of daily living.The administrator identified 43 residents required assistance with bathing.Findings:An undated facility policy titled Resident Showers, read in part, Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.Resident #41's admission resident assessment, dated 05/29/25, showed the resident had impairment on one side of their upper and lower extremity. The assessment showed the resident required partial to moderate assistance with bathing with the assistance of one person. The assessment showed Resident #41's cognition was intact with a BIMS of 15.A care plan, dated 06/05/25, showed Resident #41 had diagnoses which included cerebral infarction and obesity.A Documentation Survey Report for July 2025 showed Activity itself did not occur or family and/or non facility staff provided care 100% of the time for that activity on:a. 07/05/25,b. 07/12/25, andc. 07/19/25.Resident #41 was identified during resident group meeting held on 07/18/25 at 11:16 a.m. of not receiving their showers as scheduled.On 07/23/25 at 11:53 a.m., CNA #3 stated they looked in the shower book to determine which resident were scheduled for a shower.On 07/23/25 at 11:54 a.m., CNA #3 stated if a resident declined a shower, they informed the nurse, the DON, and administrator. They stated they would document refusal on the shower sheet.On 07/23/25 at 11:56 a.m., CNA #3 stated they would document activity did not occur if the shower was not provided or if the resident refused.On 07/23/25 at 11:57 a.m., CNA #3 stated Resident #41 never refused a shower.On 07/23/25 at 11:58 a.m., CNA #4 stated Resident #41's shower scheduled was every Tuesday, Thursday, and Saturday.On 07/23/25 at 11:59 a.m., CNA #4 stated Resident #41 never refused a shower.On 07/23/25 at 12:10 p.m., the DON stated they could not locate any shower sheets for the above dates to show the resident refused a shower.

Based on record review and interview, the facility failed to ensure an allegation of abuse/mistreatment was reported to the appropriate licensing board in a timely manner for 5 (#23, 40, 53, 72, and #77) of 6 sampled residents reviewed for abuse.The administrator identified 62 residents resided in the facility.Findings:An ABUSE, NEGLECT, EXPLOITATION AND MISAPPROPRIATION OF PROPERTY PROHIBITION policy, dated 2022, read in part, The Health Care Center establishes and implements mechanisms for reporting, investigating, and monitoring the abuse, neglect and misappropriation of property prohibition.1. An annual resident assessment, dated 05/23/25, showed Resident #23 had diagnoses which included weakness and morbid severe obesity due to excess calories. The assessment showed the resident's cognition was intact with a BIMS of 15. 2. An annual resident assessment, dated 06/04/25, showed Resident #40 had diagnoses which included unspecified hearing loss, unspecified ear and repeated falls. The assessment showed the resident had severe cognitive impairment with a BIMS of 00. 3. An annual resident assessment, dated 06/22/25, showed Resident #53 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The assessment showed the resident had severe cognitive impairment with a BIMS of 01. 4. A discharge return not anticipated resident assessment, dated 03/31/25, showed Resident #72 had a diagnosis which included anxiety disorder. The assessment showed the resident's memory was ok. 5. A modification of end of PPS resident assessment, dated 01/15/25, showed Resident #77 had moderate cognitive impairment with a BIMS of 09.A care plan, revised 01/20/25, showed Resident #77 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.An Initial INCIDENT REPORT FORM, dated 01/15/25, showed an allegation of abuse/mistreatment. The report showed on 01/15/25, (staff name withheld) reported allegations of physical and emotional abuse to residents by CNA #5. The report showed CNA #5 was rolling roughly into the wall and slammed Resident #72's food tray down in front of them.The initial incident report form did not document the nurse aide registry was notified of the abuse/mistreatment allegation.A final INCIDENT REPORT FORM, dated 01/17/25, showed an allegation of abuse/mistreatment. The report showed CNA #5 was rolling Resident #23 and Resident #40 roughly into the wall with unprofessional comments and slammed Resident #72's food tray down in front of them. The report showed other residents involved were Resident #53 and Resident #77. The report showed the nurse aide registry was notified of the abuse/mistreatment allegation.The report Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property, dated 01/17/25, showed CNA #5 was reported for abuse/mistreatment allegation.On 07/22/25 at 10:45 a.m., the administrator stated the nurse aide registry should have been notified of the abuse/mistreatment allegation by CNA #5 when the initial incident form was reported to the state agency on 01/15/25.

Based on record review and interview, the facility failed to ensure the influenza vaccine was offered to a resident for 1 (#4) of 5 sampled residents reviewed for immunization.The administrator identified 62 residents resided in the facility.Findings:The Influenza Vaccine policy, dated 2001, read in part, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.A care plan, revised 06/09/25, showed Resident #4 was admitted on [DATE].There was no documentation Resident #4 had been offered an influenza vaccine.On 07/23/25 at 6:14 p.m., the infection preventionist stated they had no supporting documentation Resident #4 had been offered the influenza vaccine.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 01/08/23 related to the facility's failure to ensure an elopement assessment was completed on admission and a resident was free from accident hazards for a resident who had diagnoses of schizoaffective disorder and history of stimulant abuse. The facility failed to prevent Resident #102 from eloping from the facility which had the potential to result in serious injury or harm. On 09/11/23, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent accident hazards related to elopement. The past noncompliance IJ was removed effective 05/09/23 after the facility put measures in place to prevent recurrence. On 01/09/23 staff was in-serviced about the policy and procedure on elopement. The facility performed an elopement community-based drill on 03/20/23 and 03/21/23. The facility completed elopement assessments on all residents by 04/16/23. On 05/09/23 the facility installed a fence around the patio to help keep residents from eloping and protect residents from outside dangers. On 09/08/23 at 8:47 a.m., a fence was observed to be approximately five feet tall with a gate surrounding the back patio area. The gate required a key access on the opposite side of the gate to open. There was also a part on the pole that had to be lifted at the same time in order to open the gate. Based on record review, observation, and interview, the facility failed to ensure an elopement assessment was completed on admission and a resident was free from accident hazards for a resident who had diagnoses of schizoaffective disorder and history of stimulant abuse for one (#102) of three sampled residents reviewed for elopement. The DON identified three residents at risk for elopement resided in the facility. Findings: An Elopement Risk policy, dated 10/11, read in part, .It is the policy of the Facility that on admission, re-admission, significant change, and quarterly, all residents will be assessed for elopement risk .An elopement risk will be completed by nursing . Resident #102 was admitted to the facility on [DATE] and had diagnoses which included schizoaffective disorder, other stimulant abuse in remission, anxiety disorder unspecified, and malignant neoplasm of overlapping sites of the brain. Resident #102's Level 1 PASRR Screening, dated 10/07/22, documented yes for: a. evidence of serious mental illness including possible disturbances in orientation or mood; b. diagnosis of a serious mental illness; and c. recent history of mental illness or been prescribed a psychotropic medication for a possibly undiagnosed mental illness in the absence of a justifiable neurological disorder (within the last two years). It documented per OHCA Resident #102 was cleared to admit and the level two was completed 10/03/22. A Patient Health Questionnaire-9 form, dated 10/13/23, documented moderate depression. It documented Resident #102 experienced the symptoms of feeling down, depressed or hopeless 12-14 days. There was no completed Elopement Risk Assessment on admission located in Resident #102's clinical record. An Admission Resident Assessment, dated 10/22/22, documented level two PASRR condition serious mental illness and Resident #102 had severe cognitive impairment. A Progress Note, dated 01/08/23 at 8:38 p.m., read in part, Focus assessment r/t AWOL: A nursing staff took all resident out for smoke break at [3:30 p.m.] include [sic] this resident. They all came back into the building at [3:55 p.m.]. At [4:30 p.m.] staffs [sic] noticed that this resident is nowhere to be found except for [resident's] walker left outside at smoke area. Staff look/drove around neighborhood, but resident couldn't locate. Head count of other residents initiated immediately. This nurse notified ADON and police. Police case number is .Hospice and case walker [sic] notified. A Discharge Resident Assessment, dated 01/09/23, documented staff assessment for cognitive skills for daily decision making was severely impaired. It documented wandering behavior occurred one to three days. A Social Services Note, dated 01/09/23 at 11:38 a.m., read in part, SSD got report from [Detective #1] that resident was found [at] 12:02 a.m. by Oklahoma County Sheriff Office resident was then taken to [hospital] downtown. Resident #102's hospital records, dated 01/09/23, documented the resident was admitted at 12:36 a.m. on 01/09/23 with principal problem of schizophrenia and active problems of anxiety and suicidal ideations. It documented the resident was brought in by police. It documented the resident came in as EOD for psychosis, poor self-care, and suicidal ideations. It documented the resident was withdrawn. It documented Resident #102 reported history of brain cancer and schizophrenia. It documented Resident #102 reported they heard voices in their head all the time. The resident reported they bother me and if they do not go away, I would rather be dead. It documented the resident reported a headache and constant hallucinations. It documented the mental status examination on admission included paranoid delusions, auditory and visual hallucinations, and suicidal thoughts. It documented the resident was oriented times three with poor attention span and poor concentration. It documented the resident had poor insight, poor judgement, and impaired due to serious and persistent mental illness. It documented the resident was started on an antipsychotic Zyprexa 2.5 mg by mouth twice a day. It documented Resident #102 reported being on hospice and that they were sent to a nursing home and believes they are not giving him the correct medication for treating [resident] appropriately. On 09/08/23 at 8:37 a.m., the Administrator was asked when the 01/08/23 progress note documented Resident #102 was not found. They stated the resident was not found at 4:30 p.m. The Administrator stated they were notified around 5:30 p.m. They stated they along with other staff members came up to the facility and a police report had already been filed. They stated they arrived at the facility at 6:30 p.m. and interviewed staff over the incident. On 09/08/23 at 8:39 a.m., the Administrator was asked what interviews were conducted. They stated they asked staff that took the resident out to smoke where Resident #102 was when they last seen them, and what alerted them the resident wasn't there. On 09/08/23 at 8:42 a.m., the Administrator was asked who notified the detective when Resident #102 went missing. They stated, RN #2. On 09/08/23 at 8:43 a.m., the Administrator was asked how the facility determined Resident #102 was missing. They stated the resident went out to smoke. They stated residents were allowed to sit outside in the evenings. On 09/08/23 at 8:44 a.m., the Administrator was asked to explain how Resident #102 got back outside, as the note documented all of the residents returned inside after smoking on 01/08/23. They stated the code was on the door, and the resident could go outside unsupervised as long as they were not smoking. The Administrator was asked if the facility had identified how Resident #102 left the faciity on [DATE]. They stated the resident just walked away. They stated the resident left their walker on the back patio. On 09/08/23 at 8:46 a.m., the Administrator was asked to show the surveyor the back patio. The Administrator was observed walking to the door at the back of the dining room, punched in a code (which was observed on the top of the keypad) into the keypad, opened the door, and exited to the patio. The Administrator stated Resident #102 had it memorized. On 09/08/23 at 8:47 a.m., the Administrator stated, At that time of course, the fence was not here. They stated, That was added after. The Administrator was asked when the fence was added. They stated, May or June of this year. The Administrator was asked the reason the fence was added. They stated, To add extra security. They stated the facility had homeless people who were coming to the patio plugging things in. They stated also to keep people from wandering after that happened. The Administrator was asked if the gate to the fence was locked. They stated, Yes. The fence was observed to be approximately five feet tall with a gate which required a key access on the opposite side of the gate to open. There was also a part on the pole that had to be lifted at the same time in order to open the gate. The Administrator stated Resident #102 had never left this area until this day. The Administrator stated the resident was allowed to come outside unattended by staff. On 09/08/23 at 8:51 a.m., the Administrator was asked the reason Resident #102 was on hospice services. They stated the resident had cancer but they were unsure of the type. The Administrator was asked the reason Resident #102 was admitted to the facility. They stated the hospice nurse had reported the resident could not remember to take their medications on their own or remember to shower. The Administrator stated the resident did not want to live at the facility. On 09/08/23 at 8:53 a.m., the Administrator was asked if they had any knowledge of the reason the resident left the facility. They stated, No. On 09/08/23 at 8:55 a.m., the Administrator was asked if the facility conducted any in-services after Resident #102 eloped. They stated they did an in-service and an elopement drill facility wide right after. They were asked to provide that information a well as the contact information for the staff present at the time of the elopement. On 09/08/23 at 9:08 a.m., Detective #1 stated Resident #102 was assigned to them. They stated the resident was reported missing on 01/08/23. They stated the department found the resident and took them to a local hospital. On 09/08/23 at 9:22 a.m., the SSD was asked to explain the social service note for Resident #102 dated 01/09/23 at 11:38 a.m. The SSD stated they had been calling looking for the resident. They stated they received a call from Detective #1 stating they had found Resident #102 that night and the resident was taken to the hospital the same night. The SSD was asked if they were familiar with Resident #102. They stated the resident wasn't at the facility long. They stated the resident had brain cancer and ambulated on their own. They stated, I know sometimes [Resident #102] was with it, sometimes [Resident #102] wasn't. They stated the resident had bad headaches which caused a lot of pain. They stated when the resident experienced the headaches, their cognition wouldn't be up to par. On 09/08/23 at 9:25 a.m., the SSD was asked if Resident #102 was able to go outside on their own. They stated they had supervised smoking, but the resident could go outside on their own if they weren't smoking. On 09/08/23 at 9:49 a.m., an attempt was made to call RN #2. The call went straight to voicemail and the staff member did not return the call. On 09/08/23 at 10:00 a.m., the Hospice Assistant Administrator was asked to speak with any staff who were familiar with Resident #102. They stated they were present when the resident was admitted . On 09/08/23 at 10:03 a.m., the Hospice Assistance Administrator was asked the reason Resident #102 admitted to the LTC facility. They stated the resident had people stealing from them in their apartment. They stated the resident wasn't taking their medication when it was needed and needed more assistance with medication. On 09/08/23 at 10:42 a.m., the DON was asked to explain the wandering coding on Resident #102's discharge resident assessment. The DON stated the assessment was completed by Corporate MDS and they wanted to get the Administrator to help answer. On 09/08/23 at 10:45 a.m., the Administrator stated the MDS was coded because the resident had eloped that day. The Administrator stated the resident did not wander. On 09/08/23 at 10:51 a.m., attempted to call CMA #2 identified as being there during the elopement and received message the caller is not accepting calls at this time.

Based on record review and interview, the facility failed to report an allegation of verbal abuse from staff for one (#57) of five sampled residents reviewed for abuse. The Census and Conditions of Resident's report, dated 05/04/22, documented 62 residents resided in the facility. Findings: An Abuse policy, dated 2022, read in part, .Reporting .Any employee who becomes aware of an allegation of abuse .shall report the incident to a supervisor, DON or Administrator immediately . Resident #57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 05/03/22, documented the resident was cognitively intact. On 05/05/22 at 10:25 a.m., Resident #57 was asked to describe any instance where staff made them feel afraid, humiliated/degraded, said mean things to you, hurt you or made you feel uncomfortable. They stated they were made to feel humiliated. The resident was asked who made them feel that way. They stated the SSD had a way of really being hard. They stated they went to get cigarettes the other day after the SSD had gone to the store. The Resident stated when they started to ask a question, the SSD stated, Don't you see I have people waiting to get cigarettes. The SSD stated, They've been waiting longer than you have. Resident #57 was asked how that made them feel. They stated, embarrassed, like I was doing something wrong. On 05/10/22 at 1:36 p.m., Resident #57 was asked if feeling humiliated and embarrassed by the SSD had affected her. They stated Yes, I'm afraid to go to him for anything. They stated the SSD tells people I want things right then and there and that's not true. On 05/10/22 at 2:26 p.m., The BOM was asked if resident #57 reported any rudeness from staff or being humiliated by staff. She stated, Yes. They were asked who the staff member was. They stated it was the SSD. They stated Resident #57 was in my office discussing the cigarettes and their money. The SSD was standing behind the resident interrupting, talking over the resident, and saying the resident was not saying things right. The BOM stated the resident was in tears. They stated they sent the SSD out of the office and got the resident's mind off of what had happened. The BOM was asked if she reported the SSD. They stated they asked the resident if they wanted to speak to the administrator. Resident #57 stated yes. The BOM stated they wheeled the resident to the administrator's office, but did not stay with the resident. On 5/10/22 at 2:40 p.m., the administrator was asked if resident #57 reported any rudeness from staff or being humiliated by staff in the past few weeks. They stated no, they did not. On 05/10/22 at 3:30 p.m., the BOM was asked what the policy was for abuse. She stated, If I hear, suspect, or see it, go to the abuse coordinator and they investigate it. The BOM was asked why they did not report Resident #57's verbal abuse by the SSD. They stated, [Resident #57] could speak for [themselves]. On 05/10/22 at 4:09 p.m., the Administrator and corp nurse were asked what the policy was for abuse. The Administrator stated they report all allegations. They were asked when staff were to report allegations of abuse. The Administrator stated staff should report to the supervisor or Administrator immediately. The Administrator was asked what staff were instructed to do if a resident reports a staff member being rude/hateful and being afraid to speak to a staff member. They stated they should report it. The Administrator was asked what staff were instructed to do if a staff member had made a resident upset to the point of crying. They stated, Report that, obviously. The Administrator and corp nurse were informed the BOM had witnessed the SSD become verbally abusive towards Resident #57. They were unaware of the incident.

Based on record review and interview, the facility failed to implement their abuse policy to ensure: a. residents were free from abuse and/or fear of retaliation for three residents (#41, #123, and an anonymous resident), and b. abuse allegations were thoroughly investigated and residents were protected during abuse investigations and corrective measures were implemented for three (#41, 123, and #124) of five sampled residents and a confidential group who were reviewed for abuse. The administrator identified 62 residents resided in the facility. Findings: An Abuse policy, dated 2022, read in part, .MENTAL/PSYCHOLOGICAL ABUSE includes but is not limited to humiliation, harassment .Health Care Center staff will immediately report and protect the resident if an allegation or observation of abuse has occurred .Allegations of abuse .immediately reported to the supervisor, DON and Administrator . Protection .All residents will be immediately protected from harm .Allegation involving staff who has been identified will result in immediate suspension pending investigation .The employee is to immediately leave the area, badge out and exit property .The employee is not to return until requested to do so . Reporting .Any employee who becomes aware of an allegation of abuse .shall report the incident to a supervisor, DON or Administrator immediately . 1. Resident #123 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive resident assessment, dated 09/02/21, documented the resident's cognition was intact. A Grievance/Complaint report, dated 09/13/21, read in part, .individual's name [Resident #123] .Concern reported to: [Previous Administrator] .Res approached Adm. c/o The night nurse last night, instead of helping me clean myself she threw the wipes at me [and] told me to do it myself. Described the employee as short hair, lite complecated [sic] she also was giving me my meds last night . What other action was taken to resolve concern .Employee has had several complaints from staff due to not assisting with care and refuses to answer call [NAME] .Employee will be terminated . There was no documentation an abuse investigation had been conducted. 2. Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 02/04/22, documented the resident's cognition was intact. A Grievance/Complaint report, dated 03/16/22, read in part, .individual's name [#41] .'I asked [CNA #7] to pick up my phone off of the floor', she responded 'That's not my job to pickup your phone' ' called her back into the room and she said 'What Do You Want.' I told her 'You need a Better Attitude.' .What other action was taken to resolve concern .Employee was notified of suspension till [sic] investigation is complete .Was grievance/complaint resolved .[Yes] .Employee with other rudeness reports, will be placed on 60 days Pip . CNA #7's time record, documented they worked full eight hours shifts on 03/16/22 and 03/17/22. There was no documentation an abuse investigation had been conducted. On 05/05/22 at 10:27 a.m., Resident #41 stated a CNA was on a video call while they were assisting them in the bathroom. The resident stated the CNA had their cell phone sitting on the edge of the bathroom counter and they could see the person the CNA was talking to on the video call. The resident stated, It was rude. The resident was asked the name of the CNA. They stated they did not know their name and they were an agency staff member. The resident stated it happened last Saturday, on 04/30/22. The resident was asked if they told anyone about the video call. They stated they did, but could not remember who they told. There was no documentation of the incident in the resident's clinical record. There was no incident report of the incident. On 05/09/22 at 8:36 a.m., the ADON was asked what the policy was regarding abuse. They stated once abuse was reported, it would be reported to the abuse coordinator and an investigation would be initiated. They stated they would ensure resident safety. The ADON was asked what the facility would do if a resident reported staff having video calls during personal care. They stated they would visit with the resident, report to the administrator, and go over the handbook on the phone policy with the staff member. They stated, It's not appropriate. The ADON was asked if they had any resident report staff doing a video call during care. They stated no. The ADON was informed of Resident #41's report and that the resident stated they had reported the incident. The ADON stated they was not aware of the incident. 3. Resident #124 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An OSDH Incident Report form, dated 04/19/22, read in part, .[Resident #124] .Allegations of Abuse/Mistreatment .Description of Incident .On 04/18 it was brought to the attention of the facility that the family had made allegations of abuse against the facility .summary of investigation .On 04/18 It was brought to the attention of the facility that a family member had made allegations of abuse for resident [#124]. The charge nurse on the day of the alleged incident was interviewed by facility and APS and stated the incident did not happen. Safe surveys were completed with no further allegations of abuse or neglect . 4. On 05/04/22 at 1:52 p.m., an anonymous resident stated the SSD can get angry and make you cry. The resident stated they were scared to report the SSD because it could make it worse. 5. On 05/09/22 at 9:54 a.m.,, an anonymous resident group was asked if they knew how to file a grievance. They stated, Yes. They were asked what happened once they filed a grievance. They stated, Nothing. They were asked if they were able to file a grievance without fear of retaliation. They stated if they had a problem with the person present, they can't feel free to say anything. They were asked if they were fearful of any staff. They stated, Depends on what kind of a day they are having. On 05/10/22 at 12:35 p.m., the administrator was asked to provided the abuse investigations and state reportable incident reports for Resident #41, Resident #124, Resident #123, and in-services conducted since January 2021. On 05/10/22 at 4:09 p.m., the Administrator and corp nurse were asked what the policy was for abuse. The Administrator stated they report all allegations. They were asked when staff were to report allegations of abuse. The Administrator stated staff should report to the supervisor or Administrator immediately. The Administrator was asked what the abuse investigation involved. They stated they would conduct interviews, observations, suspend the staff person involved and conduct safe surveys. The Administrator and corp nurse were asked what would be included in a thorough investigation. The corp nurse stated they would conduct a psychosocial and physical assessment of the resident, notify the physician and next of kin, and would interview the resident and any witnesses. The Administrator stated the investigation would be kept with the state reportable incident. The Administrator was asked what staff were instructed to do if a resident reports a staff member being rude/hateful and being afraid to speak to a staff member. They stated they should report it. The Administrator was asked what staff were instructed to do if a staff member had made a resident upset to the point of crying. They stated, Report that, obviously. The Administrator and corp nurse were informed that residents and staff reported the SSD made residents cry, feel humiliated, made them feel as though they were doing something wrong just by asking a question, spoke rudely to them, and they were afraid of the SSD. They were informed the residents feared retaliation if they reported anything. The Administrator and corp nurse were asked if they had located an investigation for resident #41 from the 03/16/22 grievance/complaint. The Administrator stated, No. They were asked if the staff member involved had been sent home and how the residents had been protected. The Administrator stated the staff member involved was no longer employed. She stated, I can't answer that, I wasn't here. She was informed the employee had worked 03/16/22 and 03/17/22. The Administrator and corp nurse were asked if they had located an abuse investigation related to Resident #123. The corp nurse stated, I couldn't' find any IR with her name on it. She was asked if there was an investigation conducted. She stated, I don't see it. They were asked how residents were protected. The corp nurse stated, I really couldn't tell you, I wasn't here. The Administrator and corp nurse were asked what the allegation of abuse was for Resident #123 on 04/19/22. The Administrator stated it had something to do with the resident's door being shut and the light turned off. They stated APS had investigated the complaint. The Administrator was asked if the facility had investigated the allegation of abuse. The corp nurse stated that the resident's family had called APS, and APS reported the complaint to the facility. They stated when the facility was notified, the resident had already been discharged . The corp nurse was asked if an abuse investigation should have been conducted. They stated, Yes.

Based on observation, interview, and record review, it was determined the facility failed to: ~ perform thorough skin and pressure ulcer assessments; ~ identify pressure ulcers; and ~ ensure pressure ulcers were dressed for two (#3 and #6) of four sampled residents who were reviewed for pressure ulcers. Resident #3 developed a facility acquired unstageable pressure ulcer to the right lateral malleolus of an undetermined age. There was no documenation to show the facility had knowledge of the pressure ulcer. The facility identified seven residents as having pressure ulcers. Findings: 1. Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/11/17, documented the resident was at risk for pressure ulcers but did not have any. It was documented the resident had short and long term memory problems; was moderately impaired in cognitive skills for daily decision making; was always incontinent of bowel and bladder; and was not on a toileting program. The resident's care plan, updated 12/2017, documented the resident was at risk for skin breakdown due to bowel and bladder incontinence. The goal was the resident's skin would remain clean, dry, and intact without evidence of breakdown through the next review date. Approaches included to monitor for incontinence every two hours and as needed; repositions as needed; and maintain the resident's dignity at all times during provision of incontinent care. The care plan documented the resident was at risk for falls. The goal was the resident would be free of falls through the next review date. Approaches included to monitor for changes that might warrant increased supervision and assistance and to reinforce the need to use the call light for assistance. Review of the clinical record revealed documentation, dated 12/30/17, the resident was found by housekeeping staff on the floor of her room. It was documented the resident was face down and lying in a puddle of blood. It was documented the resident was bleeding from her forehead. A physician's telephone order, dated 12/31/17, documented the resident returned from the hospital with sutures in place and orders for an antibiotic for ten days. An acute care plan update, dated 12/30/17, documented the resident had a fall with injury. The goal was the resident would remain free of injuries due to falls through the next review. Approaches included to notify physician; monitor for 72 hours if warranted; neurological checks for 72 hours if warranted; monitor at frequent intervals, reposition for comfort/safety; toileting plan four times per day;p and reassess environment and equipment. Weekly skin integrity check forms, dated 01/12/18, 02/02/18, and 02/09/18, documented the resident's skin was clear of any breakdown. On 02/13/18 at 9:33 a.m., the resident was observed in her room, sitting in her wheelchair. The room was dark, the resident's eyes were closed, and her head was hanging down. At 10:19 a.m., the resident remained in her room, and the room was dark. She was awake and sitting in her wheelchair. At 2:55 p.m., the resident was observed in her room, sitting in her wheelchair. The lights were out. At 3:31 p.m., the resident was in her room, and the lights were on. The resident stated, I'm so bored. Do something please? On 02/14/18 at 9:24 a.m., the resident was observed in her room, sitting in her wheelchair. At 10:19 a.m., the activities director entered the resident's room and propelled her wheelchair to the dining room where an activity was being held. At 10:45 a.m., the resident was brought back to her room. She continued to sit in her wheelchair. At 11:03 a.m., a CNA entered the resident's room and pushed her wheelchair into the hallway. At 11:05 a.m., the resident was taken to the dining room for the noon meal. Resident #3 remained in the dining room until 11:50 a.m., when she was taken back to her hall and left in front of the door to her room. At 11:55 a.m., the resident propelled herself into the room. At 11:58 a.m., CNA #1 entered the resident's room. He was asked what he was doing. He stated he was going to check the resident and put her into bed. The resident had not been checked for incontinence from 9:24 a.m. until 11:58 a.m., a period of two hours and 34 minutes. CNA #1 removed the resident's pants and brief. The resident was soiled with feces. Her brief was twisted and bunched up in the perineal area. The feces was dried on the resident's buttocks. Without washing his hands before gloving, CNA #1 provided incontinent care for the resident. Small pellets of dried feces fell on to the incontinent pad that was on the resident's bed. Using his gloved hand, CNA #1 swept the small pellets onto the floor. After providing the incontinent care, CNA #1 did not remove the gloves that were worn while providing the care or wash/sanitize his hands. He placed a new brief on the resident, adjusted her bed linens, adjusted the head of the bed and the height of the bed, and gave the resident her call light. He moved the resident's clothing, her wheelchair, and the overbed table. He then removed his gloves, picked up a trash bag, turned the light off, and exited the room. CNA #1 did not wash or sanitize his hands before leaving the room. During the care, resident #3 was observed to have a tannish-white colored scabbed wound on her lateral right ankle. The peri-wound was red. Reddish, purple discolored areas were noted on the tops of the second and third toes on the right foot. The areas were approximately 0.25 cm round. The resident's right heel was noted to be red. On the center of the left medial foot, another wound was noted. The wound had a tannish white colored scab, and the peri-wound was red. A reddish purple discolored area, approximately 0.25 cm round, was noted on the top of the second toe on the left foot. At 12:10 p.m., as CNA #1 entered the hall from the room of resident #3, resident #9 asked to be toileted. Using his left hand, CNA #1 propelled resident #9 towards her room. He placed the trash from resident #3 into the soiled utility room, and pushed resident #9 into her room. Without washing or sanitizing his hands, CNA #1 donned a new pair of gloves and transferred resident #9 onto the toilet. At 12:13 p.m., CNA #1 removed his gloves, opened the door, and asked for incontinent wipes to be brought to the resident's room. He obtained a new pair of gloves. At 12:14 p.m., CNA #1 removed his gloves, left the room, and went to Hall 100 to obtain wipes. He had not washed or sanitized his hands. At 12:15 p.m., CNA #1 donned new gloves and re-entered the resident's room, along with CNA #2. CNA #2 assisted resident #9 with cleaning herself. At 12:17 p.m., CNA #1 transferred resident #9 into her bed, adjusted her bed linens, adjusted the height and head of the bed, and provided the resident her call light. At 12:20 p.m., CNA #1 removed his gloves and washed his hands. On 02/14/18 at 12:22 p.m., CNA #1 was asked what time he had arrived at work. He stated 7:00 a.m. He was asked how often resident #3 was supposed to be checked for incontinence. He stated, Every two hours. He was asked when the resident had last been checked before the observation. He stated, 9:00 a.m. CNA #1 was asked why the resident had not bee checked before 11:58 a.m. He stated she was one of the ones the staff knew when she was incontinent. CNA #1 was asked when he had washed his hands. He stated he had washed them when he had left the dining room. He was asked if he had washed or sanitized his hands during the care for resident #3 or before beginning care for resident #9. He stated no. He stated he had changed his gloves. On 02/14/18 at 2:05 p.m., LPN #1 was asked if the resident had any alterations in her skin integrity, such as pressure ulcers, venous ulcers, or any type of breakdown. She stated, Not that I am aware of. She stated the resident did not have any treatments and she was not seen by the wound doctor. She was asked if the resident had a history of [REDACTED]. LPN #1 was asked if she ever saw the resident's skin. She stated periodically. She stated she knew the resident had some bruising. At 2:21 p.m., LPN #1 was asked to observe the resident's skin. She was asked what the areas on the second and third toes on the right foot were. She stated they were areas of discoloration. She stated the area on the second toe looked like dry skin and felt like a scab. She was asked what the area was on the resident's right lateral ankle. She stated, Looks like that could be a pressure ulcer. She touched the area, and the resident winced. LPN #1 asked the resident if the area hurt. She stated, Once in a while. LPN #1 was asked to describe and measure the area. She stated it was a white, yellow, tan scabbed area. She measured the scabbed area and stated it was 1 cm x 0.7 cm. She was asked to measure the area included the red periwound. She stated the area was 2 cm x 1.5 cm. LPN #1 was asked if the area was a new wound. She stated it did not appear too terribly new to her. LPN #1 was asked what the area was on the resident's left medial foot. She stated it looked like an old pressure ulcer. She was asked to measure the area. She stated it was 2.5 cm x 1.9 cm. When she touched the area to measure it, the resident pulled back on her foot. LPN #1 asked the resident if the area hurt. She stated, Yes. LPN #1 stated, I would say it is an old sore almost completely healed. LPN #1 was asked what the area was on the top of the second toe on the left foot. She stated it was redness. LPN #1 was asked if all the areas should have been listed on the skin assessments. She stated, Yes. On 02/14/18 at 2:33 p.m., the DON was asked to observe the areas and inform the surveyor of what they were. She observed the area on the medial aspect of the left foot and stated it was a pressure ulcer. She stated she did not know if it was a callus or starting to be something. She stated the areas on the second toe on the left foot was a scab. The DON stated the area on the right lateral ankle was a scabbed area. She asked the resident if the area hurt. She stated, A little bit. The DON stated, It might be pressure just because of where it is. The DON was asked if the resident's shoe touched the area on the left medial foot. She stated, Yes. She stated the right ankle was probably bumping against the wheel of the resident's wheelchair. The DON was asked if the areas appeared new. She sated, No. She stated the area to the right lateral ankle was not there when she last completed a skin sweep. She was asked when the skin sweep had been completed. She stated, Right after Christmas. She stated the nurses checked the skin weekly. She was asked if the aides should have reported the areas. She stated, Yes. The DON was asked if the areas were unidentified and unstageable pressure ulcers. She stated, Yes. A wound physician note, dated 02/14/18 at 6:45 p.m., documented, .pt has recurrence of right lateral ankle pressure ulcer, no open wound, covered in scab, pt also has stage 1 pressure ulcer of right heel and healed pressure ulcer of left medial foot. Her wound are mildly painful .Wound #5 .is currently classified as a unstageable/unclassified wound with etiology of pressure ulcer and is located on the right lateral malleolus. The wound measures 1 cm length x 0.5 cm width .limited to skin breakdown. There is a none present amount of drainage noted. The periwound skin appearance did not exhibit: callus, crepitus, excoriation, induration, rash, scarring, dry/scaly, maceration, atrophie blanche, cyanosis, ecchymosis, hemosiderin staining, mottled, pallor, rubor, [DIAGNOSES REDACTED] . Wound #6 .is currently classified as a .Stage I wound with etiology of pressure ulcer and is located on the right calcaneous. The wound measures 3 cm length x 4 cm width . A physician's telephone order, dated 02/14/18, documented, .Skin prep to toes BID .Skin prep to (left) inner foot BID .[MEDICATION NAME] to (right) outer ankle (every) shift .Encourage to offload ankles (and) use pillows or blankets . On 02/20/18 at 11:23 a.m., the DON was asked how she determined that toileting four times daily was an appropriately intervention for the resident. She stated the staff was trying to figure out the root cause of the fall. She stated she could not remember if the resident was wet or not when she fell . She was asked how she determined that four times daily was the right amount to toilet the resident. She stated the IDT group had came up with the intervention to try and toilet the resident to help reduce falls and one of the aides had said that if she was toileted at certain periods, such as after meals and before bed, it might help to reduce falls. The DON was asked if she had completed any type of assessment to determine if this was the resident's voiding pattern. She stated, No. She stated that was when the aides said she was incontinent. The DON was asked how she monitored the aides to ensure they were providing proper incontinent care and following infections control measures. She stated random checks were done. She stated she and the ADON both worked the floor and knew who was doing a good job. The DON was asked when skills competencies were verified. She stated, Well, we have been trying. She stated she had some of them and others she did not. The DON was asked when hands should be washed when providing incontinent care. She stated, Before, during, sometimes three or four times, and of course after. The DON was asked if the wound on the left medial foot was a healed press ulcer, when did it begin, where was the documentation of the wound, and why was it not listed on the skin assessment sheets. She stated she would have to look to see if there had been a pressure ulcer before. No documentation was provided by the end of the survey. On 02/20/18 at 11:44 a.m., the DON was asked how the care plan related to incontinence had been implemented when the resident had not been checked for incontinence for over two hours. She stated the aide had been late in implementing the care plan. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders, dated 01/19/18, documented the resident's pressure ulcer was to be treated with calcium alginate and covered every day. A physician's telephone order, dated 01/19/18, documented the resident's pressure ulcer was to be treated with silver alginate and covered every other day. Treatment records, dated 01/20/18 through 02/05/18, documented the resident received the treatments as ordered by the physician. It was documented the resident discharged from the facility on 02/06/18. On 02/14/18 at 3:11 p.m., LPN #2 was asked if the resident had a pressure ulcer on admission. He stated, Yes. He was asked if he had ever observed the ulcer without a dressing. He stated, Yes. He was asked how often that had occurred. He stated he had came in two or three times and the dressing was not on the pressure ulcers. He stated the aides would tell him they were trying to get the resident up, but he did not have a dressing on the ulcer. On 02/14/18 at 2:30 p.m., the DON was informed it had been reported the resident did not have a dressing on his pressure ulcer two to three times. She stated the nurse had not notified her of the situation.

Based on observation, interview and record review, it was determined the facility failed to ~ monitor and intervene for pain during pressure ulcer treatment for one (#101) of three sampled residents sampled who were observed during pressure ulcers treatment. The resident verbalized a pain score of 8.5 out of 10 before the treatment began and staff continued with the treatment. The resident showed signs and symptoms of increased pain and verbalized she had increased pain during the treatment and staff did not reassess or stop the treatment, ~ monitor and assess the fistula site for one (#50) of one sampled resident who was reviewed for [MEDICAL TREATMENT] services, ~ ensure the physician was notified when a resident had refused several medications on a daily basis and failed to provide pharmacy services to ensure any irregularities were reported to the physician for one (#17) of five sampled residents who were reviewed for unnecessary medications; and ~ follow the physician's orders [REDACTED].#33) of four residents who had orders for weights. The Resident Census and Conditions report, dated 08/28/17, documented 63 residents resided in the facility. Findings: 1. Resident #101 was admitted to the facility, on 08/14/17, with [DIAGNOSES REDACTED]. A review of the clinical record revealed no admission assessment had been completed for the resident. The weekly skin integrity checks dated 08/14/17, 08/15/17 and 08/21/17, documented wound/skin condition present/no new change of condition. Documentation already established on all existing wound/skin conditions. A nurses note, dated 08/15/17, documented an assessment had been completed for skin integrity. It documented, Right foot heel 2.2 wide x 3.4 vertical thick callous on great toe skin peeling to skin on bottom side & top of foot. Left foot 1.4 x 0.9 x 0.1 open red with serous drainage present to foot plantar side. Total foot cool to touch. Easily palpated pulses bilaterally. Left thigh 22.3 x 15.4 x 0.1. Red beefy tissue with occasional spots of slough. Left lower buttocks 6.2 deep x 8 wide x 7.5 verticle. Upper 7.7 x 2.2 x 0.1 . c/o (complain of) discomfort with treatment otherwise at rest tolerable. A progress note details form dated 08/16/17 documented: pressure ulcer (PU) of left ischial, stage 4, 8 centimeters (cm) x 9 cm x 4 cm; PU buttock, unstageable, 13 cm x 11 cm x 0.2 cm; PU left posterior upper leg, stage 4, 18 cm x 15 cm x 1 cm; diabetic wound left heel Grade 1 1 cm x 1 cm. The treatment administration record (TAR), dated August 2017, documented once daily wound care from 08/17/17 thru 08/23/17. The TAR did not document specific wound care times but documented the care had been performed during the 3:00 p.m.-11:00 p.m. shift. The TAR documented the following treatments, Left ishial wound-cleanse with normal saline, pack with gauze soaked with Dakins solution in wound bed and cover with wound bed and cover with border gauze dressing. Do not use excessive amount of tape. Left buttock-cleanse with normal saline, pack with gauze soaked with Dakins solution in wound bed and cover with border gauze dressing. Do not use excessive amount of tape. Left posterior upper leg-cleanse with normal saline, pack with gauze soaked with Dakins solution in wound bed and cover with border gauze dressing. Do not use excessive amount of tape. Apply [MEDICATION NAME] to left heel every shift. Keep pressure relief/offload pressure ulcer prevention. The Medication Administration Record [REDACTED]. Due to the TAR not documenting specific wound care times, it could not be determined how much time had elapsed between the administration of the pain medication and the performance of the wound treatment. A physicians progress note, dated 08/23/17, documented the following for the resident's wounds: ~ a left ischial stage 4 pressure ulcer 8 cm in length x 6 cm in width x 4 cm in depth, ~ the buttock had a chronic unstageable pressure ulcer 7 cm in length x 6 cm in width x 0.1 cm in depth; and ~ the left, posterior upper leg had a chronic stage 4 pressure ulcer 19 cm in length x 13 cm in width x 0.5 cm in depth. A physicians order, dated 08/23/17, documented a clarification order to cleanse wounds to left upper leg and left upper buttock,with saline solution and cover wound with gauze soaked in Dakin solution twice a day (BID). No specific orders regarding pain management with wound care were documented. On 08/24/17 at 11:10 a.m., the assistant director of nursing (ADON) was observed performing pressure ulcer care for the resident. She donned gown and gloves and entered the room. She asked resident to rate her pain. The resident stated eight and a half. The ADON then procedeed to perform wound care on the left posterior hip/thigh, left buttock and coccyx/sacrum. As the ADON cleansed the two right buttock the resident was observed to have a facial grimace, moaned and stated, Oh, that hurts. The ADON was not observed to assess the resident's pain after she verbalized increased pain. The ADON continued with the wound care and covered the hip/thigh wound with another border dressing. She removed her gloves, washed her hands and donned clean gloves. The ADON then removed the dressing from the left heel, cleansed the area with [MEDICATION NAME] left the wound open to air. She changed her gloves and sanitized her hands. She did not assess the resident's pain before exiting the room. On 08/24/17at 3:15 p.m., the ADON was asked if she had performed the wound care of resident #101 that morning. She stated, yes. She was asked if the wound treatment had been painful for the resident. She stated she had asked the resident her the pain level and she had rated it as an eight before the wound care. She was asked what she had done at the time she rated her pain as an eight. She stated, Well, she already had her pain med so there wasn't anything else to do. At 4:01 p.m., LPN #2 was asked what her procedure was for wound care. She stated since it hurts, she always made sure she gave the resident a pain pill 30 minutes to an hour before. She was asked if she then assessed what the resident's pain level was. She stated yes, some days seven or eight and on good days five or six. She stated when the wound was touched the pain level went to a seven to eight. She further stated the resident usually received pain medication as needed before the treatment. LPN #2 was asked if she scheduled the resident's wound care according to the time the resident could have her pain pill. She stated she tried. LPN #2 was asked if before doing wound care she asked the resident what her pain rating was. She stated six or seven. She was asked what the resident pain level was after the resident had received her pain medication. She stated it was a two or three. She further stated, when she got to the tunneling wound the pain was about a five because she had to pack that one. She stated with the tunneling wound the resident did show signs and symptoms of pain and stated the resident stated, Yeah that hurts. She stated she tried to be gentle. LPN #2 was asked if she had spoken to the resident's physician. She stated she had not spoken to the physician. She stated the resident told her she had already spoken to the physician and she was going to increase the resident's pain medication. She was asked if she reported this to the day shift. She stated the day shift was aware of this and was supposed to write a new order for pain medication. She looked in the resident's chart and stated no, it had not been done yet. LPN #2 was asked what she would do if she if before a dressing change the resident reported her pain was an eight. She stated she would check to see when the resident had last received her pain medication. She stated if the resident could not receive more pain medication, she would call the physician. She was asked if she would you continue to do the dressing change. She stated she would wait a little bit. She further stated the treatment had to be done on her shift. She stated, I would maybe see if the resident had Tylenol ordered and maybe try to distract her. LPN #2 was asked what the resident's tolerable pain level was. She stated a six. She was asked if she had asked the resident if that was what it was. She stated she had not. She stated she could tell by the resident's facial expressions. She stated the resident was pretty good about voicing her needs. On 08/28/17 at 4:35 p.m., the resident was asked, if she had been medicated before they provided her wound care. She stated not always. She stated it depended on when she had last received pain medication. She stated if pain medication had not been given recently they would medicate her. She was asked it the pain medication was effective. She stated it helped take the edge off the pain so she can bear it. She was asked if staff asked her if the pain medication had been effective before beginning her wound care. She stated yes. She was asked if the pain increased when they did the wound care. She stated, Oh yes. She was asked how bad the pain was. She stated about a nine sometimes. She stated, The girls try to be real easy but it's got to be done. She was asked if she told them the pain has reached that level and what they did. She stated they said they were sorry and would give me something as soon as they could. She was asked what pain level is tolerable for you. She stated, I've been tolerating it. I cry and make noise. I've ask them about giving me [MEDICATION NAME]. I've asked doctor and she said ok, but it hasn't happened yet. She stated it was not in the record yet. She stated the physician was asked about a week ago. She stated she had not seen the physician again since she had asked. She stated she would ask the physician when she came back. At 4:57 p.m., the DON and the administrator were asked what the facility policy and procedure was for handling pain during pressure ulcer treatment. The DON stated they should be asking the resident's pain level before treatment and during the treatment. She was asked if the resident complained of severe pain during the treatment what should the staff do. The DON stated the nurse should cover the wound the best they could and call the physician to see what they could do. The DON was asked what should be done if the resident's pain was not addressed in a timely manner. She stated she would expect them to take care of it when it happened and if they could not they should have let her know. 2. Resident # 50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 06/14/17, documented the resident was cognitively intact and received a therapeutic diet. It documented the resident required extensive assistance with activities of daily living. The care plan, dated 06/14/17, documented the resident was at risk for fluid volume overload, altered nutrition complication related to [MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. The goal was the resident would have minimal to no complications related to end stage [MEDICAL CONDITION]. Approaches included [MEDICAL TREATMENT] three times a week as per physician orders; monitor, document and report to physician, as needed signs and symptoms of shortness of breath, chest pains, increased blood pressure, itchy skin, nausea and vomiting, signs of infected shunt site, monitor and assess resident's shunt site for signs and symptoms of infection, bruit and thrill, notify [MEDICAL TREATMENT] and physician as needed, observe and encourage resident to maintain fluid restrictions as per physician orders, administer medication as per physician orders. Obtain pre and post [MEDICAL TREATMENT] weights, monitor labs and notify physician of abnormalities as needed. The Medication Administration Record [REDACTED]. A review of the nurses' notes, from 06/02/17 through present revealed no documentation the fistula site had been assessed. On 08/23/17 at 10:45 a.m., the resident was asked when she had [MEDICAL TREATMENT]. She stated she went to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays. She stated the facility had not sent any papers with her and the [MEDICAL TREATMENT] center sometimes sent papers back with her. She stated she was on a fluid restriction but had chosen not to follow it but was going to start doing a better job. She was asked how often the facility assessed her fistula site. She stated the facility had not assessed her left upper arm fistula site at any time. She denied any concerns with the fistula. The resident stated she had not receive any medication such as epoetin at [MEDICAL TREATMENT]. At 4:15 p.m., LPN #4 was asked how long she had worked in the facility. She stated she had worked there about six months and on that hall for about two weeks. She was asked what she did when the resident returned from [MEDICAL TREATMENT]. She stated she did the residents fingerstick blood sugar. She was asked do you assess her fistula. She stated she was assessing the graft all the time. She was asked where do you document the assessment. She stated, I don't. She was asked what the resident's care plan documented was supposed to be done. She stated she had not read the care plan yet. She was asked where the care plans were located. She stated, Mostly I think they would be in the chart. On 08/24/17 at 10:41 a.m., registered nurse (RN) #1 was asked what is your procedure for the resident before she goes to [MEDICAL TREATMENT]. She stated the resident had a finger stick and [MEDICATION NAME] before she went to [MEDICAL TREATMENT]. She was asked if she assessed the fistula. She stated there was nothing on the treatment sheet but she did look at it. She was asked how she ensured other nurses were assessing the site. She stated she did not have an answer for that. She stated it should be ordered. She stated the resident used to have a big dressing on it. She stated yesterday was the first day she had seen the graft site open. At 10:57 a.m., the DON was asked what kind of specialized care the resident required. She stated to check the shunt, wounds and diet. She was asked how they how monitored to ensure appropriate care was given. She stated she talked to staff about that. She stated she had not assessed every single patient. She stated she had asked staff to bring issues to her attention. She further stated she was in the process of doing skills checks lists, but they had not all been done. 3. Resident #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 04/15/17, documented the resident was moderately impaired in cognitive skills for daily decision making, was independent in functional status, and received antipsychotic, antianxiety, and antidepressant medications on seven of the preceding seven days. The care plan, dated 04 /15/17, documented a problem related to the risk for side effects from antidepressant medications. The goal was the resident would have no injury related to medication usage/side effects through the next review date. Interventions were to administer the medication as orders; observe for, document, and report any adverse side effects to the physician and to discuss potential side effects of the medications with the resident and their family. The care plan also documented the resident was at risk for side effects from antianxiety medication use. The goal was the resident would have no injury related to the medication usage or side effects through the next review date. Interventions were to administer the medication as ordered; monitor and record target behaviors of paranoia, delusions, and pacing and to discuss potential side effects of the drug with the resident and family. The care plan also documented the resident was at risk for side effects from antipsychotic drug use. The goal was the resident would have no injury related to medication usage or side effects through the next review date. Interventions were to discuss the side effects of the drug with the resident and family; administer medications as ordered by the physician and to monitor target behaviors of paranoia, delusions and pacing. The MAR, dated May 2017, documented the resident had refused [MEDICATION NAME] and [MEDICATION NAME] every morning from 05/06/17 through 05/31/17. She had refused aspirin 05/10/17 through 05/26/17 and 05/29/17 through 05/31/17. She had refused vitamin D3 05/08/17 through 05/31/17. Physician orders, dated 06/2017, documented the resident was to receive the following routine medications: [REDACTED] ~ [MEDICATION NAME] 15 mg, give 1/2 tablet at bedtime for depression; ~ [MEDICATION NAME] 5 mg every day for dementia; ~ [MEDICATION NAME] 50 mg, take three tablets every morning for depression; ~ Aspirin 81 mg every day for heart health; ~ [MEDICATION NAME] 40 mg every day for gastro-[MEDICAL CONDITION] reflux disease; and ~ [MEDICATION NAME] 10 mg every day for [MEDICAL CONDITION]. The MAR, dated June 2017, documented she had refused [MEDICATION NAME] am and pm doses, [MEDICATION NAME], aspirin, [MEDICATION NAME], VD3 and [MEDICATION NAME] 06/01/17 through 06/30/17. Physician orders, dated 07/2017 documented the resident was to receive the following routine medications: [REDACTED] ~ [MEDICATION NAME] 15 mg, give 1/2 tablet at bedtime for depression; ~ [MEDICATION NAME] 10/325 mg three times daily for pain; ~ [MEDICATION NAME] 10 mg three times daily for anxiety; ~ [MEDICATION NAME] 5 mg twice daily for dementia; ~ Vitamin D3 5,000 units every day; ~ [MEDICATION NAME] 5 mg every day for dementia; ~ [MEDICATION NAME] 50 mg, take three tablets every morning for depression; ~ Aspirin 81 mg every day for heart health; ~ [MEDICATION NAME] 40 mg every day for gastro-[MEDICAL CONDITION] reflux disease; and ~ [MEDICATION NAME] 10 mg every day for [MEDICAL CONDITION]. The MAR, dated July 2017, documented she had refused [MEDICATION NAME], [MEDICATION NAME] and VD3 07/01/17 through 07/31/17. Physician orders, dated 08/2017 documented the resident was to receive the following routine medications: [REDACTED] ~ [MEDICATION NAME] 15 mg, give 1/2 tablet at bedtime for depression; ~ [MEDICATION NAME] 10/325 mg three times daily for pain; ~ [MEDICATION NAME] 10 mg three times daily for anxiety; ~ [MEDICATION NAME] 5 mg twice daily for dementia; ~ Vitamin D3 5,000 units every day; ~ [MEDICATION NAME] 5 mg every day for dementia; ~ [MEDICATION NAME] 50 mg, take three tablets every morning for depression; ~ Aspirin 81 mg every day for heart health; ~ [MEDICATION NAME] 40 mg every day for gastro-[MEDICAL CONDITION] reflux disease and ~ [MEDICATION NAME] 10 mg every day for [MEDICAL CONDITION]. The MAR, dated August 2017, documented she had refused [MEDICATION NAME], [MEDICATION NAME] and VD3 08/01/17 through 08/23/17. On 08/28/17 at 11:24 a.m., certified medication aide (CMA) #2 was asked about the documentation on the MAR indicated [REDACTED]. She was asked if the resident had always refused all of her morning medications. She stated yes, except for her pain medication and baby aspirin. She was asked what she was supposed to do when a resident refused medications. She stated she reported to the nurse if they refused and the nurse was supposed to contact the doctor. She was asked if she had reported it to the nurse every day the resident had refused. She stated she had reported it to one nurse. She was asked if she had reported it to the nurse that day when the resident refused. She stated she had not report it that day. She was asked how long the resident had been refusing the medications. She stated for months. At 11:30 a.m., CMA #3 was asked if the resident had been refusing her medications. She stated yes, and she had told all the nurses. At 11:42 a.m., the DON was asked what was expected of the staff when a resident refused their medication. She stated the medication aide should notify the charge nurse and the charge nurse should notify the physician. She further stated they had many residents that refused their medications and the physician did not want to be called for some residents every time they refused medications. She was asked if resident #17 had refused her medications all the time. She stated she did not know. The DON was asked who was responsible for monitoring administration of medications. She stated it should be discussed between the CMAs and the administrative nurses should all be involved. She was asked who was responsible for monitoring to ensure the residents received their medication. She stated, indirectly she and her designees should be monitoring. She further stated she would like to have had her systems in place, but she had not had time to do that. At 12:36 p.m., the physician was asked if he had been notified the resident had been consistently refusing her medications, with exception of the aspirin, [MEDICATION NAME] and [MEDICATION NAME]. He stated no, he had not been notified. At 3:15 p.m., the consultant pharmacist was asked if he looked at the MAR indicated [REDACTED]. He stated he tried to, but it depended on the availability. He was asked if he had reviewed the MAR for resident #17. He stated he would not be able to say whether he did or not. He was asked if he had knowledge the resident had refused several of her medications on a daily basis in recent months. He stated he may have had a conversation. He further stated many times he was reviewing the active orders. He was asked if he could explain why he could not recall anything specific about this resident if review of the MAR indicated [REDACTED]. He stated there could have been dialogue involved making him think he did not need to make a comment. He further stated he did not know for sure. 4. Resident #33 had [DIAGNOSES REDACTED]. The care plan, dated 04/25/17, documented .Weigh me as per order or facility protocol . An admission assessment, dated 06/21/17, documented the resident was cognitively intact in skills for daily decision making. He required limited assistance of one staff member for transfer, dressing, personal hygiene and bathing. He required supervision with setup only for eating. He required extensive assistance of one staff member for toileting. He was occasionally incontinent of bowel and bladder. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The weight records were reviewed. No documentation of daily weights were located . On 08/24/17 at 3:20 p.m., RN#1 was asked who was responsible for obtaining the resident's weights. She stated, The restorative aide. She was asked how did the staff member know what weights and frequency of weights were ordered. She stated, all new admissions were weighed once a week for four weeks and skilled residents were weighed weekly and were on a list in the front of the weight book. She was asked who was responsible for making sure the residents were being weighed according to the physician's orders [REDACTED]. She was asked where were the weights would be documented. She stated, In the weight book. She was asked what the physician had ordered for the weights for the resident. Looking at the physician's orders [REDACTED]. She was asked where would the resident's daily weights be documented. She stated, In the weight book. She was asked was the resident getting the daily weights as the physician had ordered. She stated, No, he is not receiving daily weights.

On 10/30/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure an allegation of sexual abuse was investigated in a thorough and timely manner and residents were protected during the investigation. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 12:50 p.m., the Regional Clinical Director, the Regional Director, the Administrator, and the DON were made aware of the Immediate Jeopardy situation. On 10/30/14 at 5:55 p.m. an acceptable plan of removal was presented to the survey team. The plan of removal documented: "This plan of correction is being submitted in compliance with specific regulatory requirements and preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the facts alleged or conclusion set forth on the statement of deficiencies. The following plan constitutes our abatement of the immediate jeopardy deficiencies cited on 10/30/14: 1. Reeducation was conducted by DON/Designee with all nursing staff regarding checking on residents every 2 hours minimally regardless of cognitive or toileting status. This was initiated on 10/19/14 at 7 a.m. This will be completed by 10/30/14 at 11 pm. 2. Reeducation regarding elopement (including specific time frames, identifying residents at risk, elopement drills, and who to report to) was initiated by DON with all staff on 10/23/14 at 2pm. This will be completed by 10/30/14 at 11 pm. 3. Staff member on duty the day of the alleged incident and fitting the description of the alleged perpetrator was interviewed and suspended pending investigation on 10/30/14 at 1:30 pm. 4. The obtaining of all staff member interviews commenced on 10/30/14 at approximately 12:30 pm. This will be completed by 10/30/14 at 11 pm. 5. Reeducation about Northwest Nursing Center's abuse policies and procedures, including reporting to the Administrator immediately and investigating abuse timely by answering who, what, when, where, and why was initiated by DON with all staff on 10/27/14 at approximately 2pm. This will be completed by 10/30/14 at 11pm. 6. Reeducation was conducted by RVPO with Administrator regarding abuse policies and procedures, including reporting and investigating abuse timely on 10/30/14 at approximately 2pm. 7. Any staff member not completing an interview or any required reeducation listed above, will not be allowed to return to work until interview and/or reeducation is completed. Please accept this plan of correction as the center's written credible allegation of compliance such that the alleged deficiency cited has been or will be corrected by the date or dates indicated." The IJ was removed on 10/30/14 at 7:15 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on clinical record review, review of policy and procedures, staff and resident interviews, and review of police reports, it was determined the facility failed to ensure a thorough and timely investigation was conducted and residents were protected during the investigation, following an allegation of sexual abuse for one (#1) of three sampled residents whose clinical records were reviewed for abuse allegations. The facility became aware on 10/23/14 that resident #1, who had eloped from the facility on 10/18/14, had made an allegation of being sexually assaulted. An investigation was not initiated until 10/25/14, and then only to contact the OKCPD and an emergency room physician. Further investigation was not initiated until 10/29/14. This had the potential to affect all 48 residents who resided in the facility. Findings: A facility policy, with an effective date of 09/12, titled Resident Abuse - Staff to Resident, documented: "...Procedure: Staff to resident Abuse/Neglect (alleged or actual) 1. Remove the resident from danger immediately. Supervisor will immediately release employee from their duties and instruct them to return when Department Manager can meet with them... 4. Notification MUST be made to the following of all residents involved in the incident. a. Attending physician b. Responsible party c. Initial notification to state agency per state specific guidelines. 5. If after initial immediate investigation, the administrative staff finds that there is any possibility that staff to resident abuse did occur, the employee involved will be suspended until the investigation is completed. 6. A DOCUMENTED investigation by the Administrator, Director of Nursing or their designee, MUST be initiated within twenty-four (24) hours of their knowledge of the alleged incident. This investigation includes talking with the resident involved, all staff involved (directly or indirectly), any family involved, other residents involved and any visitors involved or anyone with first hand knowledge. Obtain written statements as deemed necessary. Involvement is defined as direct or indirect knowledge... 10. The State Department of Health is to be notified immediately by the Administrator, Director of Nursing or their designee of the facility's knowledge of any alleged incident of staff to resident abuse/neglect, and a written follow-up of the investigation must be sent within five (5) working days or per state guidelines...." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/06/14, documented the resident could usually make herself understood and could usually understand others. The resident scored a 13 on the brief interview for mental status which indicated she was cognitively intact. She was independent with locomotion on and off the unit, dressing, and transfers. An untimed nurse's note, dated 10/19/14, documented: "Resident was last seen @ approx 8:30 p.m. Propelled self down hallway. @ approx 5:30 a.m. OKC police came to facility and stated resident was at her previous home before this facility. Officer (name deleted, #2) stated 'she appears to be in stable condition just a little tired'. Immediately her room was checked. The bedcovers were untouched, her w/c was against the windowed wall & the window was slightly ajar & easily maneuvable (sic). There were (sic) not a screen on her window. The officer stated she was ambulating c walker assist. He also later informed us that she refused to return to the facility. The ADON was called within minutes of being aware the resident was not in the facility. Dr. (name deleted) notified. Attempted to notify family but no one answered phone. Left message to contact facility ASAP!" An Oklahoma City Police Department Crime Report, completed by Reporting Officer #1, dated 10/20/14 at 9:28 p.m., documented the officer had responded to a rape call which involved the resident. The report documented the resident had climbed out of the window of her nursing home in the late evening of 10/18/14. At around 5:00 a.m. she had been located by (officer #2 name deleted) at an area of NW63rd and May Avenue. The officer had taken her to a friend's house. The report documented the friend contacted the resident's daughter and the daughter came to his house and took the resident to her home. The report documented: "...Prior to going home, (the resident's daughter) stopped by (resident #1's) nursing home to get her medication. (The daughter) said she joked about leaving (resident #1) at the nursing home and she became very upset and adamantly refused to go inside the facility. (The daughter) said this is not normal for (resident #1). (The daughter) said (resident #1) has lived at her current facility for the past three years and never had any problems. (The daughter) said since she got (resident #1), she said she did not seem okay and believed something may have happened to her which caused her aversion to the nursing home. (The daughter) said she began asked (resident #1) if someone hurt her and (resident #1) would avoid the question by looking away. (The daughter) said (resident #1) eventually began crying when (the daughter) asked more specific questions about possibly being assaulted. (The daughter) said she decided on 10-20-14 to take (resident #1) to the hospital around 1700 (5:00 p.m.) hours for an evaluation. (The daughter) said at (hospital #1), it was determined (resident #1) had a concussion...After being cleared from the hospital, (the daughter) took (resident #1) back to her apartment. Once there, she and (friend #2) took (resident #1) into a bedroom away from (the daughter's) children. Once in the room, (friend #2) and (the daughter) asked (resident #1) if someone had hurt her and she replied 'yes'. They then asked her if someone tried to rape her. (Resident #1) again replied 'yes'. Due to the limited speech, the best I could determine from (resident #1) was that she was vaginally raped on or about 10-18-14 by a white make (sic) who works at the nursing facility... Once the rape was over and the suspect was gone, (resident #1) later dragged herself out of the bedroom window and took off walking with a physical therapy walker. It was shortly after this that officers located her and later took her to her friend's house..." The police report contained a description of the alleged suspect which had been provided by the resident. The report documented she was taken to a local hospital and a SANE exam was conducted. The report had been typed on 10/21/14 at 3:24 a.m. and had been approved on 10/27/14. An interdisciplinary progress note, dated 10/23/14, completed by the Administrator, documented: "Ombudsman (name deleted #1) came to facility f/u on (resident #1's) elopement. She stated the friend (name deleted) had called another Ombudsman (name deleted #2) when OKCPD brought (resident #1) to his home. At some point, (resident #1) alleged rape. (Ombudsman #2) notified (Ombudsman #1) which led her to make visit to NWNC. She stated at this point it wasn't alleged that the rape occurred @NWNC & that no police report had been made so there was really nothing for NWNC to do at this time. I notified my supervisor (name deleted) of above." An interdisciplinary progress note completed by the Administator, dated 10/25/14 at 4:30 p.m., documented: "Received message to return call to RDC (name deleted). Was informed at that time that (resident #1) had presented to (Hospital #3) ER & was alleging rape & that CM (case manager) had notified our sister facility (name deleted) stating they needed emergency placement for (resident #1) - she couldn't return to NWNC because she had been raped. - My supervisor (name deleted) was also notified. I was directed to contact ER & OKCPD for info & to begin investigation of allegation. I contacted DON (name deleted) who had also been notified of allegation. (DON name deleted) notified OKCPD who stated they had no report of an alleged rape &@ this point there was really nothing they could do. I spoke w/ER (physician name deleted). He stated family did mention (resident #1) was alleging rape. He did not perform rape kit as he was aware she had not been @ NWNC for a week. He did state that she had been treated somewhere since leaving NWNC as she was taking antibiotics. He was not going into any rape allegation as it was not reported to him, he was treating for possible [MEDICAL CONDITION]" An interdisciplinary progress note completed by the Administrator, dated 10/27/14 at 1:10 p.m., documented: "...Ombudsman (name deleted) @ facility. She stated she believes NWNC has done all we can do in this case. NWNC was informed of allegation of rape by her on 10/23/14. She spoke to (resident #1's) dtr on 10/23 & 10/24 & dtr. never mentioned a possible rape, there has been 0 report to OKCPD or to NWNC Administration..." An interdisciplinary progress note completed by the Administrator, dated 10/28/14 at 2:30 p.m., documented: "Received call from OKCPD Detective (name deleted), sex crimes division stating an allegation of rape on (resident #1) had been reported on 10/20/14 by (resident's daughter). She questioned my knowledge of (resident #1's) stay at NWNC & her elopment (sic) from facility on 10/19/14. She requested my documentation be emailed to her @ (e-mail address deleted). Her phone # (number deleted). She stated (resident #1) had had a SANE exam done & she would start with those results for her investigation. As of now she had no suspect, no description & no gender of alleged rapist." On 10/29/14 at 10:00 a.m., the Administrator was asked to provide state reportable incidents for the current year. She stated she had two on her desk that she was currently working. An OSDH form 283, titled Incident Report Form, documented an incident date of 10/28/14. The report documented it was an initial report and the incident type was an allegation of abuse/mistreatment, a suspected criminal act and a missing resident. For the summary of the investigation the form documented: On 10/28/14 approx 1430 (2:30 p.m.), administrator received a call from OKCPD (detective name deleleted with the sex crimes division) stating an allegation of rape on (resident #1) had been reported on 10/20/14 by (resident #1's daughter). She stated at this point she did not have a suspect, no date or time of alleged rape, no description, no gender. She did state a S.A.N.E. exam had been done & her investigation is pending the results of that test. Facility completing head to toe assessments on disoriented/confused residents & investigation to follow...." She was asked to provide all the documentation she had of the rape allegation investigation, including statements from staff or residents. Documentation provided included statements on 10/20/14 from the Housekeeping Supervisor and the Director of Maintenance regarding the elopement and the window in the resident's room. An In-Service Education Program sheet which documented the subject of discussion was, "Abuse Reporting", dated 10/27/14, documented 21 staff members attended the inservice. Information provided by the facility documented there were currently 64 employees, excluding the DON and the Administrator, who were conducting the inservice. The documentation did not contain any information that staff had been interviewed to attempt to identify a possible perpetrator. A written statement from staffing employee #1, dated 10/28/14, documented, "I (staffing employee #1) have been doing the staffing for about six years I don't staff a male cna on hall one I keep the male cna's on hall two because it is a male hall and we only have one or two male cna's at a time in the time I have been doing the staffing..." The administrator provided a paper which documented head to toe assessments were completed for residents who were disoriented, not alert and oriented x3, or who were unable to verbalize. Ten residents were listed. Nine had results documented of an assessment. The paper was dated 10/29/14. On 10/29/14 at 1:40 p.m., the resident's daughter was contacted. The daughter stated the resident had told her on 10/20/14 that she had been sexually assaulted at the nursing home. She stated the police had been contacted and the resident had been taken to the hospital for a SANE exam. The daughter was asked if a police report had been filed at that time. She provided the surveyors with the police report number. On 10/30/14 at 8:45 a.m., the resident was interviewed. She stated she had crawled out her window at the nursing home at approximately 11:00 p.m. She stated she had the police take her to a friend's house. She was asked why she didn't want to go back to the nursing home. She stated she was afraid because she had been sexually assaulted by a male at the nursing home. She was asked what she did after the assault. She stated she went in her wheelchair to the nurses station and told a male nurse about the other male who touched her. She stated she then went back to her room, got her stuff, and climbed out the window. On 10/30/14 at 12:35 p.m., the administrator was asked if any staff had been interviewed regarding the rape allegation. She stated, "No." She was asked what interventions had been put in place to protect the other residents during the investigation. She stated no one had been suspended because they did not have a physical description of the alleged perpetrator.

On 10/30/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to implement their abuse policies to ensure an allegation of sexual abuse was investigated in a thorough and timely manner and residents were protected during the investigation. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 12:50 p.m., the Regional Clinical Director, the Regional Director, the Administrator, and the DON were made aware of the Immediate Jeopardy situation. On 10/30/14 at 5:55 p.m. an acceptable plan of removal was presented to the survey team. The plan of removal documented: "This plan of correction is being submitted in compliance with specific regulatory requirements and preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the facts alleged or conclusion set forth on the statement of deficiencies. The following plan constitutes our abatement of the immediate jeopardy deficiencies cited on 10/30/14: 1. Reeducation was conducted by DON/Designee with all nursing staff regarding checking on residents every 2 hours minimally regardless of cognitive or toileting status. This was initiated on 10/19/14 at 7 a.m. This will be completed by 10/30/14 at 11 pm. 2. Reeducation regarding elopement (including specific time frames, identifying residents at risk, elopement drills, and who to report to) was initiated by DON with all staff on 10/23/14 at 2pm. This will be completed by 10/30/14 at 11 pm. 3. Staff member on duty the day of the alleged incident and fitting the description of the alleged perpetrator was interviewed and suspended pending investigation on 10/30/14 at 1:30 pm. 4. The obtaining of all staff member interviews commenced on 10/30/14 at approximately 12:30 pm. This will be completed by 10/30/14 at 11 pm. 5. Reeducation about Northwest Nursing Center's abuse policies and procedures, including reporting to the Administrator immediately and investigating abuse timely by answering who, what, when, where, and why was initiated by DON with all staff on 10/27/14 at approximately 2pm. This will be completed by 10/30/14 at 11pm. 6. Reeducation was conducted by RVPO with Administrator regarding abuse policies and procedures, including reporting and investigating abuse timely on 10/30/14 at approximately 2pm. 7. Any staff member not completing an interview or any required reeducation listed above, will not be allowed to return to work until interview and/or reeducation is completed. Please accept this plan of correction as the center's written credible allegation of compliance such that the alleged deficiency cited has been or will be corrected by the date or dates indicated." The IJ was removed on 10/30/14 at 7:15 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on clinical record review, review of policy and procedures, staff and resident interviews, and review of police reports, it was determined the facility failed to implement their abuse policies to ensure a thorough and timely investigation was conducted and residents were protected during the investigation following an allegation of sexual abuse for one (#1) of three sampled residents whose clinical records were reviewed for abuse allegations. The facility became aware on 10/23/14 that resident #1, who had eloped from the facility on 10/18/14, had made an allegation of being sexually assaulted. An investigation was not initiated until 10/25/14, and then only to contact the OKCPD and an emergency room physician. Further investigation was not initiated until 10/29/14. This had the potential to affect all 48 residents who resided in the facility. Findings: A facility policy, with an effective date of 09/12, titled Resident Abuse - Staff to Resident, documented: "...Procedure: Staff to resident Abuse/Neglect (alleged or actual) 1. Remove the resident from danger immediately. Supervisor will immediately release employee from their duties and instruct them to return when Department Manager can meet with them... 4. Notification MUST be made to the following of all residents involved in the incident. a. Attending physician b. Responsible party c. Initial notification to state agency per state specific guidelines. 5. If after initial immediate investigation, the administrative staff finds that there is any possibility that staff to resident abuse did occur, the employee involved will be suspended until the investigation is completed. 6. A DOCUMENTED investigation by the Administrator, Director of Nursing or their designee, MUST be initiated within twenty-four (24) hours of their knowledge of the alleged incident. This investigation includes talking with the resident involved, all staff involved (directly or indirectly), any family involved, other residents involved and any visitors involved or anyone with first hand knowledge. Obtain written statements as deemed necessary. Involvement is defined as direct or indirect knowledge... 10. The State Department of Health is to be notified immediately by the Administrator, Director of Nursing or their designee of the facility's knowledge of any alleged incident of staff to resident abuse/neglect, and a written follow-up of the investigation must be sent within five (5) working days or per state guidelines...." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/06/14, documented the resident could usually make herself understood and could usually understand others. The resident scored a 13 on the brief interview for mental status which indicated she was cognitively intact. She was independent with locomotion on and off the unit, dressing, and transfers. An untimed nurse's note, dated 10/19/14, documented: "Resident was last seen @ approx 8:30 p.m. Propelled self down hallway. @ approx 5:30 a.m. OKC police came to facility and stated resident was at her previous home before this facility. Officer (name deleted, #2) stated 'she appears to be in stable condition just a little tired'. Immediately her room was checked. The bedcovers were untouched, her w/c was against the windowed wall & the window was slightly ajar & easily maneuvable (sic). There were (sic) not a screen on her window. The officer stated she was ambulating c walker assist. He also later informed us that she refused to return to the facility. The ADON was called within minutes of being aware the resident was not in the facility. Dr. (name deleted) notified. Attempted to notify family but no one answered phone. Left message to contact facility ASAP!" An Oklahoma City Police Department Crime Report, completed by Reporting Officer #1, dated 10/20/14 at 9:28 p.m., documented the officer had responded to a rape call which involved the resident. The report documented the resident had climbed out of the window of her nursing home in the late evening of 10/18/14. At around 5:00 a.m. she had been located by (officer #2 name deleted) at an area of NW63rd and May Avenue. The officer had taken her to a friend's house. The report documented the friend contacted the resident's daughter and the daughter came to his house and took the resident to her home. The report documented: "...Prior to going home, (the resident's daughter) stopped by (resident #1's) nursing home to get her medication. (The daughter) said she joked about leaving (resident #1) at the nursing home and she became very upset and adamantly refused to go inside the facility. (The daughter) said this is not normal for (resident #1). (The daughter) said (resident #1) has lived at her current facility for the past three years and never had any problems. (The daughter) said since she got (resident #1), she said she did not seem okay and believed something may have happened to her which caused her aversion to the nursing home. (The daughter) said she began asked (resident #1) if someone hurt her and (resident #1) would avoid the question by looking away. (The daughter) said (resident #1) eventually began crying when (the daughter) asked more specific questions about possibly being assaulted. (The daughter) said she decided on 10-20-14 to take (resident #1) to the hospital around 1700 (5:00 p.m.) hours for an evaluation. (The daughter) said at (hospital #1), it was determined (resident #1) had a concussion...After being cleared from the hospital, (the daughter) took (resident #1) back to her apartment. Once there, she and (friend #2) took (resident #1) into a bedroom away from (the daughter's) children. Once in the room, (friend #2) and (the daughter) asked (resident #1) if someone had hurt her and she replied 'yes'. They then asked her if someone tried to rape her. (Resident #1) again replied 'yes'. Due to the limited speech, the best I could determine from (resident #1) was that she was vaginally raped on or about 10-18-14 by a white make (sic) who works at the nursing facility... Once the rape was over and the suspect was gone, (resident #1) later dragged herself out of the bedroom window and took off walking with a physical therapy walker. It was shortly after this that officers located her and later took her to her friend's house..." The police report contained a description of the alleged suspect which had been provided by the resident. The report documented she was taken to a local hospital and a SANE exam was conducted. The report had been typed on 10/21/14 at 3:24 a.m. and had been approved on 10/27/14. An interdisciplinary progress note, dated 10/23/14, completed by the Administrator, documented: "Ombudsman (name deleted #1) came to facility f/u on (resident #1's) elopement. She stated the friend (name deleted) had called another Ombudsman (name deleted #2) when OKCPD brought (resident #1) to his home. At some point, (resident #1) alleged rape. (Ombudsman #2) notified (Ombudsman #1) which led her to make visit to NWNC. She stated at this point it wasn't alleged that the rape occurred @NWNC & that no police report had been made so there was really nothing for NWNC to do at this time. I notified my supervisor (name deleted) of above." An interdisciplinary progress note completed by the Administator, dated 10/25/14 at 4:30 p.m., documented: "Received message to return call to RDC (name deleted). Was informed at that time that (resident #1) had presented to (Hospital #3) ER & was alleging rape & that CM (case manager) had notified our sister facility (name deleted) stating they needed emergency placement for (resident #1) - she couldn't return to NWNC because she had been raped. - My supervisor (name deleted) was also notified. I was directed to contact ER & OKCPD for info & to begin investigation of allegation. I contacted DON (name deleted) who had also been notified of allegation. (DON name deleted) notified OKCPD who stated they had no report of an alleged rape &@ this point there was really nothing they could do. I spoke w/ER (physician name deleted). He stated family did mention (resident #1) was alleging rape. He did not perform rape kit as he was aware she had not been @ NWNC for a week. He did state that she had been treated somewhere since leaving NWNC as she was taking antibiotics. He was not going into any rape allegation as it was not reported to him, he was treating for possible [MEDICAL CONDITION]" An interdisciplinary progress note completed by the Administrator, dated 10/27/14 at 1:10 p.m., documented: "...Ombudsman (name deleted) @ facility. She stated she believes NWNC has done all we can do in this case. NWNC was informed of allegation of rape by her on 10/23/14. She spoke to (resident #1's) dtr on 10/23 & 10/24 & dtr. never mentioned a possible rape, there has been 0 report to OKCPD or to NWNC Administration..." An interdisciplinary progress note completed by the Administrator, dated 10/28/14 at 2:30 p.m., documented: "Received call from OKCPD Detective (name deleted), sex crimes division stating an allegation of rape on (resident #1) had been reported on 10/20/14 by (resident's daughter). She questioned my knowledge of (resident #1's) stay at NWNC & her elopment (sic) from facility on 10/19/14. She requested my documentation be emailed to her @ (e-mail address deleted). Her phone # (number deleted). She stated (resident #1) had had a SANE exam done & she would start with those results for her investigation. As of now she had no suspect, no description & no gender of alleged rapist." On 10/29/14 at 10:00 a.m., the Administrator was asked to provide state reportable incidents for the current year. She stated she had two on her desk that she was currently working. An OSDH form 283, titled Incident Report Form, documented an incident date of 10/28/14. The report documented it was an initial report and the incident type was an allegation of abuse/mistreatment, a suspected criminal act and a missing resident. For the summary of the investigation the form documented: On 10/28/14 approx 1430 (2:30 p.m.), administrator received a call from OKCPD (detective name deleleted with the sex crimes division) stating an allegation of rape on (resident #1) had been reported on 10/20/14 by (resident #1's daughter). She stated at this point she did not have a suspect, no date or time of alleged rape, no description, no gender. She did state a S.A.N.E. exam had been done & her investigation is pending the results of that test. Facility completing head to toe assessments on disoriented/confused residents & investigation to follow...." She was asked to provide all the documentation she had of the rape allegation investigation, including statements from staff or residents. Documentation provided included statements on 10/20/14 from the Housekeeping Supervisor and the Director of Maintenance regarding the elopement and the window in the resident's room. An In-Service Education Program sheet which documented the subject of discussion was, "Abuse Reporting", dated 10/27/14, documented 21 staff members attended the inservice. Information provided by the facility documented there were currently 64 employees, excluding the DON and the Administrator, who were conducting the inservice. The documentation did not contain any information that staff had been interviewed to attempt to identify a possible perpetrator. A written statement from staffing employee #1, dated 10/28/14, documented, "I (staffing employee #1) have been doing the staffing for about six years I don't staff a male cna on hall one I keep the male cna's on hall two because it is a male hall and we only have one or two male cna's at a time in the time I have been doing the staffing..." The administrator provided a paper which documented head to toe assessments were completed for residents who were disoriented, not alert and oriented x3, or who were unable to verbalize. Ten residents were listed. Nine had results documented of an assessment. The paper was dated 10/29/14. On 10/29/14 at 1:40 p.m., the resident's daughter was contacted. The daughter stated the resident had told her on 10/20/14 that she had been sexually assaulted at the nursing home. She stated the police had been contacted and the resident had been taken to the hospital for a SANE exam. The daughter was asked if a police report had been filed at that time. She provided the surveyors with the police report number. On 10/30/14 at 8:45 a.m., the resident was interviewed. She stated she had crawled out her window at the nursing home at approximately 11:00 p.m. She stated she had the police take her to a friend's house. She was asked why she didn't want to go back to the nursing home. She stated she was afraid because she had been sexually assaulted by a male at the nursing home. She was asked what she did after the assault. She stated she went in her wheelchair to the nurses station and told a male nurse about the other male who touched her. She stated she then went back to her room, got her stuff, and climbed out the window. On 10/30/14 at 12:35 p.m., the administrator was asked if any staff had been interviewed regarding the rape allegation. She stated, "No." She was asked what interventions had been put in place to protect the other residents during the investigation. She stated no one had been suspended because they did not have a physical description of the alleged perpetrator.

On 10/30/14, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to be administered in a manner to promote residents' highest practicable well-being. The facility administration failed to ensure abuse policies were implemented; allegations of sexual abuse were promptly and thoroughly investigated; residents were protected following allegations of abuse; and adequate supervision was provided to prevent elopements. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 12:50 p.m., the Regional Clinical Director, the Regional Director, the Administrator, and the DON were made aware of the Immediate Jeopardy situation. On 10/30/14 at 5:55 p.m., an acceptable plan of removal was presented to the survey team. The plan of removal documented: "This plan of correction is being submitted in compliance with specific regulatory requirements and preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the facts alledged or conclusion set forth on the statement of deficiencies. The following plan constitutes our abatement of the immediate jeopardy deficiencies cited on 10/30/14: 1. Reeducation was conducted by DON/Designee with all nursing staff regarding checking on residents every 2 hours minimally regardless of cognitive or toileting status. This was iniated on 10/19/14 at 7 a.m. This will be completed by 10/30/14 at 11 pm. 2. Reeducation regarding elopement (including specific time frames, identifying residents at risk, elopement drills, and who to report to) was initiated by DON with all staff on 10/23/14 at 2pm. This will be completed by 10/30/14 at 11 pm. 3. Staff member on duty the day of the alleged incident and fitting the description of the alleged perpetrator was interviewed and suspended pending investigation on 10/30/14 at 1:30 pm. 4. The obtaining of all staff member interviews commenced on 10/30/14 at approximately 12:30 pm. This will be completed by 10/30/14 at 11 pm. 5. Reeducation about Northwest Nursing Center's abuse policies and procedures, including reporting to the Administrator immediately and investigating abuse timely by answering who, what, when, where, and why was initiated by DON with all staff on 10/27/14 at approximately 2pm. This will be completed by 10/30/14 at 11pm. 6. Reeducation was conducted by RVPO with Administrator regarding abuse policies and procedures, including reporting and investigating abuse timely on 10/30/14 at approximately 2pm. 7. Any staff member not completing an interview or any required reeducation listed above, will not be allowed to return to work until interview and/or reducation is completed. Please accept this plan of correction as the center's written credible allegation of compliance such that the alleged deficiency cited has been or will be corrected by the date or dates indicated." The IJ was removed on 10/30/14 at 7:15 p.m. when all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on clinical record review, review of policy and procedures and staff and resident interviews, it was determined the facility failure to be administered in a manner to promote residents' highest practicable well-being. The facility administration failed to ensure abuse policies were implemented; allegations of sexual abuse were promptly and thoroughly investigated; residents were protected following allegations of abuse; and adequate supervision was provided to prevent elopements. This had the potential to affect all 53 residents who resided in the facility. Findings: 1. The facility failed to ensure a thorough and timely investigation was conducted and residents were protected during the investigation, following an allegation of sexual abuse for one (#1) of three sampled residents whose clinical records were reviewed for abuse allegations. The facility became aware on 10/23/14 that resident #1, who had eloped from the facility on 10/18/14, had made an allegation of being sexually assaulted. An investigation was not initiated until 10/25/14, and then only to contact the OKCPD and an emergency room physician. Further investigation was not initiated until 10/29/14. See F225 2. The facility failed to implement their abuse policies to ensure a thorough and timely investigation was conducted and residents were protected during the investigation following an allegation of sexual abuse for one (#1) of three sampled residents whose clinical records were reviewed for abuse allegations. The facility became aware on 10/23/14 that resident #1, who had eloped from the facility on 10/18/14, had made an allegation of being sexually assaulted. An investigation was not initiated until 10/25/14, and then only to contact the OKCPD and an emergency room physician. Further investigation was not initiated until 10/29/14. See F226 3. The facility failed to provide adequate supervision to prevent elopement for one (#1) of two sampled residents whose records were reviewed for elopement and who had a history of [REDACTED]. This resulted in an Immediate Jeopardy situation for resident #1 who was found by police after she had fallen in the parking lot of a convenience store two blocks away from the faciltiy at 5:00 a.m. This resulted in actual harm to the resident who sustained a concussion. See F323

On 10/30/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide adequate supervision to prevent elopement of one resident. The facility was unaware the resident had eloped from the facility on 10/18/14 at approximately 11:00 p.m., until police notified them the resident had been found on 10/19/14 at 5:00 a.m. at a convenience store two blocks from the facility. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 12:50 p.m., the Regional Clinical Director, the Regional Director, the Administrator, and the DON were made aware of the Immediate Jeopardy situation. On 10/30/14 at 5:55 p.m. an acceptable plan of removal was presented to the survey team. The plan of removal documented: "This plan of correction is being submitted in compliance with specific regulatory requirements and preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the facts alleged or conclusion set forth on the statement of deficiencies. The following plan constitutes our abatement of the immediate jeopardy deficiencies cited on 10/30/14: 1. Reeducation was conducted by DON/Designee with all nursing staff regarding checking on residents every 2 hours minimally regardless of cognitive or toileting status. This was initiated on 10/19/14 at 7 a.m. This will be completed by 10/30/14 at 11 pm. 2. Reeducation regarding elopement (including specific time frames, identifying residents at risk, elopement drills, and who to report to) was initiated by DON with all staff on 10/23/14 at 2pm. This will be completed by 10/30/14 at 11 pm. 3. Staff member on duty the day of the alleged incident and fitting the description of the alleged perpetrator was interviewed and suspended pending investigation on 10/30/14 at 1:30 pm. 4. The obtaining of all staff member interviews commenced on 10/30/14 at approximately 12:30 pm. This will be completed by 10/30/14 at 11 pm. 5. Reeducation about Northwest Nursing Center's abuse policies and procedures, including reporting to the Administrator immediately and investigating abuse timely by answering who, what, when, where, and why was initiated by DON with all staff on 10/27/14 at approximately 2pm. This will be completed by 10/30/14 at 11pm. 6. Reeducation was conducted by RVPO with Administrator regarding abuse policies and procedures, including reporting and investigating abuse timely on 10/30/14 at approximately 2pm. 7. Any staff member not completing an interview or any required reeducation listed above, will not be allowed to return to work until interview and/or reducation is completed. Please accept this plan of correction as the center's written credible allegation of compliance such that the alleged deficiency cited has been or will be corrected by the date or dates indicated." The IJ was removed on 10/30/14 at 7:15 p.m. when all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on clinical record review, staff and resident interview, and review of policies and procedures, it was determined the facility failed to provide adequate supervision to prevent elopement for one (#1) of two sampled residents whose records were reviewed for elopement and who had a history of [REDACTED]. This resulted in an Immediate Jeopardy situation for resident #1 who was found by police after she had fallen in the parking lot of a convenience store two blocks away from the faciltiy at 5:00 a.m. Findings: A facility policy titled Guide to the Elopement Risk Assessment documented, "1. Upon admission, a resident's potential for elopement will be determined by risk factors which may include, but not limited to: *History of wandering/or elopement *New admission with adjustment difficulties or desire to return home *Dementia *Alcohol or drug abuse *Psychiatric illness *Restlessness, irritability *Acute or chronic confusion/disorientation *Anxiety *Former lifestyle that included frequent walking... 3. Interventions will be developed and entered on the interim plan of care for all residents identified as being an elopement risk... 5. A protected list of names, photographs and face sheets of residents identified at risk for elopement will be kept current and accessible to facility staff..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An OSDH form 283 Incident Report form documented: "...Incident Date 08-13-2013... Missing Resident... Description of Incident...Resident was sitting up in her wheelchair in the parking lot. At an identerminable time the resident left the parking lot and was spotted by staff member when she was at the end of the parking lot. The charge nurse went outside to get the resident and return her to the facility. By the time the staff member reached the resident she was at the corner of NW 61st and Ross...Resident is now care planned for elopement. Her picture has been added to the elopement book. Resident now will be supervised for all outdoor activity..." An Elopement Risk Care Plan, dated 08/13/13, documented the resident had a history of [REDACTED]. The approaches and interventions included elopement risk assessment per protocol, observe for exit seeking behaviors/patterns, encourage and assist to activities when exit seeking, increased monitoring 1:1 monitoring if indicated, picture ID and face sheet in wander books, and assess for wandering/elopement patterns. The care plan had not been updated since initiated. An Elopement Risk Assessment, dated 12/04/13, documented the resident was not an elopement risk. No other elopement risk assessment was provided by the facility. A quarterly assessment, dated 06/06/14, documented the resident could usually make herself understood and could usually understand others. She was independent with locomotion on and off the unit, dressing, and transfers. A nurse's note, dated 10/19/14 (untimed), documented: "Resident was last seen @ approx 8:30 p.m. Propelled self down hallway. @ approx 5:30 a.m. OKC police came to facility and stated resident was at her previous home before this facility. Officer (name deleted, #2) stated 'she appears to be in stable condition just a little tired'. Immediately her room was checked. The bedcovers were untouched, her w/c was against the windowed wall & the window was slightly ajar & easily maneuvable (sic). There were (sic) not a screen on her window. The officer stated she was ambulating c walker assist. He also later informed us that she refused to return to the facility. The ADON was called within minutes of being aware that resident was not in the facility. Dr. (name deleted) notified. Attempted to notify family but no one answered phone. Left message to contact facility ASAP!" A nurse's note, dated 10/19/14, signed by the DON, documented: "5:30 a.m. Received call from (name deleted) LPN notifying me that resident (name deleted) had been picked up by police @ 63rd & N. May at the (name deleted) convenient store. Resident (name deleted) was refusing to come back to the facility & directed police to take her to friends house (name deleted) who is resident's 2nd emergency contact. Instructed nurse to perform facility wide check and account for all other residents..." A nurse's note, dated 10/19/14, signed by the DON, documented: "6 am Upon arrival to facility all staff interviewed. CNA's assigned to (name deleted) state that when they got here at 11 her door was closed as it usually is. State they do not wake (name deleted) or her roommate as they both toilet themselves and typically sleep through the night. Upon entering residents room it was noted that her bed was made, w/c was pushed up against window & screen was off window. Window slid open easily. The walker resident occasionally uses was not in room. No staff recall seeing (name deleted) propelling down hallways after shift changed at 11 p.m..." A handwritten statement, dated 10/19/14, and signed by CNA #1, documented, "(Name deleted) is self sufficient and goes to the rest room on her on (sic) so I don't check on her during bed check at 1 am, 3 am, or 5 am." On 10/30/14 at 11:20 a.m., a telephone interview was conducted with CNA #1. She was asked if she was working the 11 p.m., to 7 a.m., shift on 10/18/14 when the resident eloped. She stated she was. She was asked if she was assigned to the resident's hall that night. She stated she came on at 11 p.m. and she went down the hall to check on residents when she arrived. She was asked if she saw the resident at 11:00 p.m. She stated the resident's door was closed. She was asked if she saw the resident at any time during the shift. She stated, "No, we don't check on her, she does for herself." She was asked how often the nurse checks on the resident. She stated the nurse would check when she did the census each night. She was asked if she was aware the resident had eloped in the past. She stated, "Yes." She stated the resident had been out in the parking lot in the past. She was asked if she had been instructed by anyone, including the resident, not to go in at night and check on the resident. She stated, "No." On 10/30/14 at 8:35 a.m., the resident was interviewed regarding her elopement from the facility. The resident had a history of [REDACTED]. She was asked if she had ever told facility staff to not check on her during the night. She stated, "No." She was asked what time she left the facility. She stated she left through the window of her room at around 11:00 p.m. on 10/18/14. She stated she eloped because she had been sexually assaulted at the facility around 8 p.m. or 9 p.m. that night. She stated she was trying to walk to her friend's house. She stated it took her a long time but she finally made it to a nearby convenience store. While she was at the convenience store, she stated she fell and hit her head. She stated she did not remember anything else until the police arrived around 5:00 a.m. and took her to her friend's house.