Every finding on record at Park Place Healthcare and Rehab

Based on observation, record review, and interview, the facility failed to maintain an effective pest management program so the facility was free of pests and rodents. The administrator identified 65 residents resided in the facility. Findings: On 07/21/2026 at 11:28 a.m., an insect was observed crawling on the wall behind the stove during the follow-up visit to the kitchen. On 07/22/26 at 1:40 p.m., resident room [ROOM NUMBER] was observed for cockroaches. One live cockroach was observed on the wall under the sink. A policy titled Pest Control Policy, revised 07/01/26, read in part, The facility shall maintain an ongoing pest management program designed to prevent, identify and control pests throughout the building.all pest sightings, inspections and corrective actions will be documented and monitored until resolved. A pest control invoice from the pest control company, dated 07/20/26, showed the technician's comments were they treated the perimeter of the building, around all windows, door entrances, and the perimeter foundation. On 07/21/2026 at 11:29 a.m., [NAME] # 1 was asked to identify the insect observed crawling on the wall in the kitchen. [NAME] #1 stated the insect was a cockroach, and the kitchen had been sprayed the other day. On 07/22/26 at 1:41 p.m., Resident #38 in room [ROOM NUMBER] stated their room had not been sprayed on 07/20/26. Resident #38 stated they had previously reported to staff the room had cockroaches, but nothing had been done. On 07/22/26 at 1:44 p.m., CNA #1 stated they had observed live cockroach activity in the facility within the last two months, including in residents' rooms. CNA #1 stated cockroach activity in residents' rooms had been reported to the maintenance supervisor. On 07/22/26 at 1:46 p.m., the administrator and regional nurse manager were shown the cockroach found in room [ROOM NUMBER] on the wall, under the sink. The regional nurse manager stated, Yes, that is a roach. On 07/22/26 at 1:53 p.m., the maintenance supervisor stated they had sprayed some resident rooms a few weeks ago for cockroaches but did not have a log or proof that it had been sprayed. On 07/22/26 at 1:55 p.m., the regional nurse manager stated pest control had sprayed the facility on 07/20/26 and all resident rooms were sprayed. The regional nurse manager stated pest control had sprayed for all bugs and did so monthly. On 07/23/26 at 1:43 p.m., the pest control technician stated on 07/20/26, they had performed a routine monthly treatment for the facility. The pest control technician stated they had sprayed the kitchen, activity area, and common areas inside the facility. The pest control technician stated they did not treat any residents' rooms because no concerns had been reported to them. The pest control technician stated they had treated the kitchen area because the facility had previous concerns in the kitchen with cockroaches.

Based on record review and interview, the facility failed to ensure a resident's care plan was updated when the code status changed for 1 (#24) of 3 sampled residents reviewed for advance directives. The administrator identified 65 residents resided in the facility. Findings:A policy titled Comprehensive Person-Centered Care Plans, dated 12/01/16, read in part, The care plan would describe services that would otherwise be provided for the above but were not provided due to the resident exercising his or her rights, including the right refuse treatment. A quarterly assessment for Resident #24, dated 05/02/26, showed the resident admitted to the facility 07/18/24. The assessment showed the resident had a diagnosis of hemiplegia. A care plan for Resident #24, dated 05/11/26, showed the resident had an advance directive and desired to be a full code. A DNR consent form for Resident #24, dated 06/08/26, showed the resident wanted their code status to be DNR. A physician's order for Resident #24, dated 06/17/26, showed the resident's code status was DNR (do not resuscitate). On 07/21/26 at 3:59 p.m., the regional nurse consultant stated Resident #24's care plan should have been updated immediately with the DNR code status, after the DNR form was signed on 06/08/26.

Based on record review and interview, the facility failed to provide adequate supervision to prevent an elopement for 1 (#71) of 1 sampled resident reviewed for elopement. The regional nurse consultant identified one resident at risk for elopement resided in the facility.Findings: A policy titled Wandering and Elopements, dated 03/01/19, read in part, If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A wandering assessment for Resident #71, dated 04/22/26, showed the resident was a moderate risk for wandering. An admission assessment for Resident #71, dated 04/29/26, showed the resident's cognition was moderately impaired with a BIMS score of 10. The assessment showed diagnoses which included paranoid schizophrenia and diabetes mellitus. An incident report for Resident #71, dated 05/09/26, showed the resident exited the building when another resident's family member entered the facility. The report showed the nurse was notified, and they brought the resident back into the facility. The report showed the resident was put on every 15 minute checks until no longer an elopement risk. A wandering assessment for Resident #71, dated 05/09/26, showed the resident was a high risk for wandering. A care plan for Resident #71, dated 05/09/26, showed the resident was to be monitored every 15 minutes until the resident was no longer an elopement risk. An incident report for Resident #71, dated 05/11/26, showed the resident exited the front door of the facility with two nurses following, and the resident was redirected back inside. The report showed the resident was confused and stated, I've been locked up here for seven months. The report showed 15 minute location checks were to be continued until the resident was no longer exit-seeking. A wandering assessment for Resident #71, dated 05/11/26, showed the resident was a high risk for wandering. A care plan for Resident #71, dated 05/11/26, showed to continue every 15 minute checks until no longer exit seeking. A progress note for Resident #71, dated 05/22/26, showed the resident's family requested a referral to behavioral health due to their elopement risk. A progress note for Resident #71, dated 05/22/26, showed the resident exited the front door with staff following behind, but the resident would not go back to the facility. The progress note showed the resident's family picked them up and returned the resident to the facility. The progress note showed the resident's admission profile was added to the elopement book. A wandering assessment for Resident #71, dated 05/22/26, showed high risk for wandering. A 15 minute checks observation log for Resident #71's location, dated 05/24/26, showed no documentation15 minute checks had been completed on the resident from 12:00 a.m. to 4:45 p.m. A progress note for Resident #71, dated 05/24/26, showed the resident was identified out of the building. The progress note showed the facility searched for the resident and was told by other residents that Resident #71 left the facility to find their family member. The progress note showed the facility contacted a family member and the police. An interview letter for Resident #71 by the regional nurse consultant, dated 05/24/26, showed the resident left the facility at approximately 7:17 a.m. on 05/24/26, and returned to the facility at approximately 5:30 p.m. on 05/24/26. The letter showed Resident #71 was re-evaluated and found to be competent to sign self out of the facility as long as the resident had breakfast first, signed out, and informed staff where they were going. On 7/23/26 at 4:06 p.m., CNA #1 stated residents were allowed to sign themselves out if they were okay to do so. CNA #1 stated Resident #71's family was notified when the resident wanted to leave the facility, and the family would come to the facility to talk with the resident. CNA #1 stated Resident #71 went missing one day, and they had looked for the resident for around one hour, and then they were sent home after not finding the resident. On 07/24/26 at 1:30 p.m., the regional nurse consultant stated they were not able to find proof location checks had been completed every 15 minutes for Resident #71 on 05/24/26, before the resident exited the facility around 7:15 a.m. The regional nurse consultant stated the resident's cognition had improved since admission, and they had not been allowed to leave the facility because their family member did not want them to. The regional nurse consultant stated upon Resident #71's return on 05/24/26, the resident was re-evaluated and found to be competent to leave the facility on their own as long as they signed out and informed staff where they were going.

Based on observation, record review, and interview, the facility failed to ensure:a. care plan interventions were implemented to prevent skin breakdown, andb. a resident with wounds received appropriate treatment for 1 (#26) of 3 sampled residents reviewed for pressure ulcers and skin conditions.The wound care nurse identified 12 residents had wounds in the facility. Findings:On 02/12/26 at 10:40 a.m., Resident #26 was observed with three open areas to their coccyx and buttocks during an incontinent care observation.On 02/12/26 at 10:48 a.m., CNA #1 was observed to apply vitamin A&D ointment to Resident #26's wounds.On 02/13/26 at 11:11 a.m., Resident #26 was observed lying on their back on a regular mattress.On 02/17/26 at 9:39 a.m., Resident #26 was observed lying in bed. They had a navy-blue pressure relieving mattress on their bed.An undated facility SKIN MANAGEMENT POLICY, read in part, Any resident with pressure sores will receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing based upon the resident's clinical condition .The CNA staff will monitor skin daily of all resident's during care .and alert their Charge Nurse of any skin change.A physician order for Resident #26, dated 01/23/26, showed weekly skin assessment every Thursday evening night shift.An admission assessment for Resident #26, dated 01/29/26, showed the resident had diagnoses which included unspecified fracture of sacrum and abnormalities of gait and mobility. The assessment showed the resident was at risk for developing pressure ulcers. The assessment showed the resident required supervision or touching assistance with rolling left to right and required substantial or maximal assistance with perineal hygiene. The assessment showed the resident's cognition was intact with a BIMS score of 15.A care plan for skin breakdown for Resident #26, initiated 02/05/26, read in part, Monitor/document/report PRN [as needed] any changes in skin status: appearance, color, wound healing, s/sx [medical abbreviation for signs and symptoms] of infection, wound size, stage .Pressure reducing/relieving mattress to bed .Skin assessment weekly as ordered.A Skin Assessment by Charge Nurse for Resident #26, dated 02/05/26 at 10:58 p.m., showed the resident had no open area and their coccyx was reddened.A bowel and bladder elimination report for Resident #26, dated 02/11/26 and 02/12/26, showed the resident had a total of four loose stools.A Skin Assessment by Charge Nurse for Resident #26, dated 02/12/26 at 10:58 p.m., showed the resident had no open area and their coccyx was reddened.A skin assessment for Resident #26, completed by the wound care nurse on 02/13/26, showed the resident had the following stage two open areas:a. right buttock measuring 1.5 cm by 1.5 cm,b. left buttock measuring 1.5 cm by 1.5 cm, andc. upper cerbe (upper part of the buttocks) measuring 1cm by 0.5 cm.Physician's orders for Resident #26 were reviewed for 02/2026. There were no orders for wound treatment. On 02/13/26 at 1:12 p.m., the wound care nurse stated Resident #26 did not have a wound and was not on their list for the provision of wound care.On 02/13/26 at 1:26 p.m., RN #1 stated they did not remember CNA #1 informing them of the Resident #26's wounds.On 02/12/26 at 10:43 a.m., CNA #1 stated Resident #26 had one open spot on their bottom and not three. They stated they had not taken care of the resident for the last couple of days.On 02/13/26 at 11:12 a.m., Resident #26 stated they were not aware they had three wounds on their buttocks.On 02/13/26 at 12:47 p.m., CNA #1 stated they were to report any skin issues immediately to the nurse. They stated they reported the wound observation to RN #1 after the incontinent care observation on 02/12/26 and on 02/13/26. CNA #1 stated they asked RN #1 if there was anything else they could use for treatment and RN #1 informed them to use the vitamin A&D ointment.On 02/13/26 at 12:52 p.m., CNA #1 stated Resident #26 did not have a pressure relieving mattress on their bed.On 02/13/26 at 12:56 p.m., RN #1 stated the charge nurses were responsible for completing skin assessments when ordered.On 02/13/26 at 12:57 p.m., RN #1 stated Resident #26 only had redness to their bottom. They stated the last time they made an observation of the resident's bottom was last week. They were not sure of the date or time.On 02/13/26 at 1:05 p.m., RN #1 stated the skin breakdown interventions in place for Resident #26 was to educate the resident on skin breakdown, positioning, shift weight in wheelchair, use of moisture barrier, do not massage over bony areas, use of pressure reducing mattress, and weekly skin assessment. On 02/13/26 at 1:06 p.m., RN #1 stated all the residents in the facility had pressure relieving mattresses on their beds including Resident #26.On 02/13/26 at 1:17 p.m., the DON was asked if Resident #26 had a pressure relieving mattress to their bed per the resident's care plan. They stated that could mean pillows or wedges. They stated they were not aware the resident had wounds.On 02/13/26 at 1:18 p.m., the DON stated the 02/12/26 weekly skin assessment showed Resident #26 had no open areas.On 02/17/26 at 9:51 a.m., the wound care nurse stated Resident #26's previous mattress was a regular mattress and not a pressure relieving mattress. They stated they put the air flow pressure reducing mattress on the resident's bed on 02/13/26. They stated not all residents in the facility had a pressure relieving mattress. On 02/17/26 at 9:54 a.m., the wound care nurse stated the Resident #26's wound would be considered facility acquired and having a pressure reducing mattress could have helped in preventing it.On 02/17/26 at 10:50 a.m., the DON stated the facility trained nurses on proper skin assessment which involved assessing all areas of the skin during a weekly skin assessment and CNAs were to report to the charge nurse any skin issues noted during care.

Based on record review and interview, the facility failed to ensure pain medication was administered as prescribed for 1 (#48) of 3 sampled residents reviewed for pain management.The administrator identified 63 residents resided in the facility. Findings: A policy titled Medication Administration, dated 04/2019, read in part, Medications are administered in accordance with prescriber orders. A policy titled Pain Assessment and Management, dated 03/2020, read in part, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management. A care plan for Resident #48, dated 10/10/25, showed the resident had generalized pain. The care plan showed an intervention for pain management was to administer analgesic medications as ordered by the physician. A physician's order for Resident #48, dated 10/10/25, showed the resident was prescribed oxycodone 5 mg (an opioid analgesic) one every six hours as needed for pain. A quarterly assessment for Resident #48, dated 12/20/25, showed the resident had diagnoses which included gout and liver cirrhosis. The assessment showed Resident #48 had a BIMS of 12, which indicated moderate cognitive impairment. A medication administration record for Resident #48, dated 01/2026, showed the resident received oxycodone 5 mg one tablet one time on the 7:00 a.m. to 3:00 p.m. shift. They rated their pain at a four out of 10. Resident #48 received oxycodone 5 mg one time on the 3:00 p.m. to 11:00 p.m. shift on 01/17/26. They rated their pain a six out of 10. There was no documentation showing Resident #48 was administered oxycodone 5 mg on the 11:00 p.m. to 7:00 a.m. shift on 01/17/26 into 01/18/26. A nurse's charting note for Resident #48, dated 01/18/26, showed the resident requested their oxycodone from the nurse on duty and was advised there was no primary nurse to administer narcotics to Resident #48. Resident #48 was offered Tylenol (an analgesic), but Resident #48 stated they could not take Tylenol due to their liver condition. On 02/12/26 at 7:40 a.m., Resident #48 stated they hurt all over and all of the time. They stated they received oxycodone every six hours. Resident #48 stated their liver transplant physician advised them to not take Tylenol, but that was all they have been offered for break through pain. Resident #48 stated they were denied oxycodone in January due to no available staff. On 02/12/26 at 7:50 a.m., CMA #1 stated Resident #48 complained of pain frequently and had been prescribed oxycodone as needed until 02/06/26. They stated Resident #48's oxycodone had been changed to routinely every six hours on 02/05/26. On 02/12/26 at 8:38 a.m., LPN #4 stated Resident #48 requested their as needed oxycodone on 01/18/26, but they were the only nurse on duty for the overnight shift on 01/27/26 into 01/28/26. They stated they refused to accept the keys for the narcotic lockbox for Resident #48's hall and was told by administration they would try to have another nurse help fill the shift. LPN #4 stated they did not know where the keys for the narcotic lockbox for Resident #48's hall were during that shift. LPN #4 stated they offered Resident #48 Tylenol, but they refused. LPN #4 stated Resident #4 rated their pain 10 out of 10, so they called the provider and was told Resident #48 could only have Tylenol if oxycodone was not available. On 02/18/26 at 8:36 a.m., the DON stated it was the facility's policy to administer medications as ordered. They stated Resident #48's oxycodone should have been given and an alternative for Tylenol should have been available.

Based on record review and interview, the facility failed to ensure the direct care staffing hours on the Quality of Care report was accurately reported to CMS during the months of 12/2025 through 01/2026. The administrator identified 63 residents resided in the facility.Findings: The Quality of Care report for the month of December 2025 showed the following was reported to CMS for direct care staffing hours for the 3 p.m. to 11 p.m. shift:a. 12/20/26, a census of 62 and 52.32 direct care staffing hours,b. 12/24/26, a census of 63 and 37.40 direct care staffing hours,c. 12/27/26, a census of 63 and 61.18 direct care staffing hours, andd. 12/28/26, a census of 61 and 61.00 direct care staffing hours. The facility payroll detail report for the month of December 2025 showed the facility had the following for the 3 p.m. to 11 p.m. shift:a. 12/20/26, 91.51 direct care staffing hours,b. 12/24/26, 63.27 direct care staffing hours,c. 12/27/26, 86.99 direct care staffing hours and,d. 12/28/26, 98.69 direct care staffing hours. The Quality of Care report for the month of January 2026 showed the following was reported to CMS for direct care staffing hours for the 3 p.m. to 11 p.m. shift:a. 01/03/26, a census of 65 and 33.75 direct care staffing hours,b. 01/20/26, a census of 66 and 38.21 direct care staffing hours,c. 01/21/26, a census of 66 and 41.11 direct care staffing hours,d. 01/24/26, a census of 65 and 72.50 direct care staffing hours,e. 01/27/26, a census of 64 and 37.83 direct care staffing hours,f. 01/28/26, a census of 64 and 38.44 direct care staffing hours, andg. 01/31/26, a census of 64 and 47.50 direct care staffing hours. The facility payroll detail report for the month of January 2026 showed the facility had the following for the 3 p.m. to 11 p.m. shift:a. 01/03/26, 104.74 direct care staffing hours,b. 01/20/26, 64.10 direct care staffing hours,c. 01/21/26, 65.13 direct care staffing hours,d. 01/24/26, 72.50 direct care staffing hours,e. 01/27/26, 75.80 direct care staffing hours,f. 01/28/26, 64.92 direct care staffing hours, andg. 01/31/26, 76.73 direct care staffing hours. On 02/18/26 at 12:05 p.m., the corporate nursing officer stated the facility had not accurately submitted staffing information to CMS.

Based on observation, record review, and interview, the facility failed to ensure:a. dirty linen was not placed on the floor for 1 (#41),b. soiled wipes and a soiled brief were not placed on the bed for 1 (#16),c. gloves were changed appropriately during incontinent care for 3 (#16, 40 and #41) of 4 sampled residents reviewed for activities of daily living, andd. staff worn a gown during incontinent care for 1 (#40) of 4 sampled residents reviewed for EBP.The DON identified 40 residents required assistance with incontinent care and 14 residents had EBP precautions. Findings: 1. On 02/12/26 at 5:46 a.m., CNA #5 was observed to don gloves to perform incontinent care on Resident #41. On 02/12/26 at 5:47 a.m., CNA #5 was observed to open a brief, set it on Resident #41's bedside table, remove the front of the resident's brief and assist them to turn to their left side. Fecal matter was observed on the resident's brief. CNA #5 cleaned the resident with wipes and discarded the dirty brief in the trash bag. With the same gloves, CNA #5 put a new brief and pad under the resident. They removed the old pad and dropped it on the floor. CNA #5 adjusted the resident's brief, bed, flat sheet, and placed the resident's call light and bedside table in reach. CNA #5 did not change their gloves during incontinent care. On 02/12/26 at 5:52 a.m., CNA #5 picked up the pad and trash bag from the floor with the brief and put them in two separate bins on the hallway. CNA #5 then removed their gloves. On 02/12/26 at 5:53 a.m., CNA #5 sanitized their hands with the alcohol-based hand rub. An Infection Prevention and Control Program policy, dated 05/12/23, read in part, Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. A care plan for Resident #41, revised 01/07/26, showed the resident was incontinent of bowel and bladder. The care plan showed to clean perineal area with each incontinent episode. The care plan showed the resident had diagnoses which included dementia and senile degeneration of the brain. On 02/12/26 at 5:56 a.m., CNA #5 stated the process for incontinent care was to inform the resident of the procedure, turn them, wipe the resident, turn them again, and wipe them. They stated dirty linens were to be placed in a bag. CNA #5 stated they already knew they did something wrong the moment they placed the pad on the floor. On 02/12/26 at 5:57 a.m., CNA #5 stated they were supposed to change gloves twice during incontinent care. They stated they did not remember, not changing their gloves. On 02/12/26 at 5:59 a.m., CNA #5 stated they should not touch other surfaces with dirty gloves. They stated they did not have a trash bag in the room to put the dirty pad in it. They stated it is an infection control issue. 2. On 02/12/26 at 5:49 a.m., CNA #7 was observed to don gloves, prepare a clean brief and new bed pad for Resident #16's incontinent care. CNA #7 unfastened Resident #16's brief, which was soiled with urine. CNA #7 tucked the soiled brief between Resident #16's legs, wiped them front to back two times, and placed dirty wipes on the foot of bed on top of the sheet. CNA #7 rolled Resident #16 onto their right side, tucked the soiled brief under the resident, and applied a clean brief under them. CNA #7 placed a clean bed pad in Resident #16's wheelchair. CNA #7 rolled Resident #16 onto their back and pulled the clean brief between their legs. CNA #7 then rolled Resident #16 onto their left side, removed the soiled brief and placed it at the foot of bed on top of the sheet. While still wearing the soiled gloves, CNA #7 handed Resident #16 their stuffed animal. CNA #7 placed the soiled brief and wipes in the trash can and removed the trash bag. CNA #7 was still wearing the same gloves and covered Resident #16 with their sheets and moved the resident's bedside table in closer reach. CNA #7 used the bed remote to raise the head of bed and handed it and the call light to Resident #16. CNA #7 reached into their jacket pocket with gloves still on, grabbed clean gloves and then put them back into their pocket. CNA #7 found the trash bag roll they had inside their jacket packet and replaced the trash bag in the trash can. CNA #7 doffed gloves and exited Resident #16's room, placing the trash bag into the trash barrel. A care plan for Resident #16, dated 11/14/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy. The care plan showed Resident #16 was occasionally incontinent and required staff assistance with perineal care. On 02/12/26 at 6:00 a.m., CNA #7 stated they should have changed gloves after touching Resident #16's dirty brief and before touching anything considered clean. CNA #7 stated they should not have placed the soiled wipes and brief on the bed. CNA #7 stated they should not have touched Resident #16's stuffed animal, clean sheets, bedside table, bed remote, or their call light with the same gloves on that they used to touch the soiled wipes and brief. CNA #7 stated they should not have touched the clean gloves or trash bag roll in their pocket with soiled gloves on. 3. On 02/12/26 at 6:02 a.m., an EBP sign was observed outside of Resident #40's room. Personal protective equipment was located in a hanging organizer on the outside of their door. CNA #7 entered Resident #40's room, utilized hand sanitizer and donned gloves. CNA #7 prepared a clean brief and changed their gloves. CNA #7 unfastened Resident #40's brief and tucked the brief between Resident #40's legs. Resident #40's brief was free of urine. CNA #7 rolled Resident #40 onto their left side and feces was observed in the resident's brief. CNA #7 wiped the resident front to back three times and tucked the soiled brief under Resident #40. A wound dressing was observed clean, dry, and intact to Resident #40's coccyx. CNA #7 applied a clean disposable pad and clean brief under the resident. CNA #7 rolled Resident #40 onto their left side, removed the soiled brief and disposed of it in the trash can. CNA #7 pulled the clean brief under Resident #40, placed the brief between the resident's legs and doffed their gloves. CNA #7 removed a pair of gloves from their jacket pocket and donned them. They placed a pillow between Resident #40's legs, covered them with a blanket, lowered the bed and placed the fall mat on the floor. CNA #7 removed the trash bag, replaced it with a clean one, and doffed gloves. CNA #7 then washed their hands with soap and water. A policy titled Enhanced Barrier Precautions, dated 04/01/24, read in part, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.High contact care activities include: changing briefs or assisting with toileting. A care plan for Resident #40, dated 12/11/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral region and other specified local infections of the skin and subcutaneous tissue. The care plan showed Resident #40 was on enhanced barrier precautions and personal protective equipment was to be used throughout out their stay or until their wounds healed. On 02/12/26 at 6:15 a.m., CNA #7 stated EBP meant to wash their hands or use hand sanitizer, wear gloves and a gown. They stated they did not think about wearing a gown during incontinent care. CNA #7 stated they should have changed their gloves after removing Resident #40's soiled brief. On 02/12/26 at 7:16 a.m., the DON stated the facility's process for incontinent care was to change gloves between clean and dirty surfaces and soiled briefs. They stated for residents on EBP staff were to wear gloves and a gown for incontinent care. They stated CNA #7 should have followed the facility's process.

Based on record review, and interview, the facility failed to ensure the physician was notified when a resident's blood sugar was above 350 for 1 (#2) of 2 sampled residents reviewed for insulin.The administrator identified 63 residents resided in the facility. Findings: A Physician Notification for Resident Change in Condition, policy undated, read in part, The licensed nurse assigned to the resident is responsible for notification of and communication to the medical staff regarding significant changes.Changes in the condition of the resident are determined by assessments utilizing parameters defined by physician orders/instructions. Document in the medical record the date, time and name of each physician notified, actions taken and/or resident's response to treatment. A physician's order for Resident #2, dated 12/31/25, showed Humalog (an insulin medication) 100 unit per milliliter, inject as per sliding scale, for blood sugar level of 350 to 400, give 10 units and notify medical doctor, subcutaneously before meals related to type two diabetes mellitus with unspecified complications. An admission resident assessment for Resident #2, dated 01/07/26, showed the resident had a diagnosis of diabetes. The assessment showed the resident's cognition was intact with a BIMS score of 14. A FSBS INJECTION for 02/2026 for Resident #2 showed 10 units of Humalog insulin was administered on: a. 02/06/26 at 11:00 a.m. with an FSBS of 365, b. 02/08/26 at 7:00 a.m. with an FSBS of 364 and 4:00 p.m. with an FSBS of 359, c. 02/09/26 at 11:00 a.m. with an FSBS of 351, and d. 02/11/26 at 11:00 a.m. with an FSBS of 375. Progress notes and a medication administration record for 02/2026 for Resident #2 were reviewed. There was no documentation the provider was notified of the above FSBS. On 02/10/26 at 9:43 a.m., Resident #2 stated their blood sugar was always high, and the facility did not know how to control it. They stated their usual blood sugar was around 100 to 200 before admission to the facility. Resident #2 stated their blood sugar at the facility went as high as 370. On 02/11/26 at 1:43 p.m., RN #1 stated the process for insulin administration was to obtain the resident's FSBS, document it, and administer the amount of insulin as ordered. On 02/11/26 at 1:44 p.m., RN #1 stated physician notifications of FSBS during insulin administration would be in resident's progress notes. On 02/11/26 at 1:49 p.m., RN #1 stated Resident #2's order showed to notify the physician if FSBS was 350 to 400. On 02/11/26 at 1:52 p.m., RN #1 stated they could not locate documentation the physician was notified of the above FSBS. They stated they have not notified the provider for the FSBS of 375 on 02/11/26 at 11:00 a.m. They stated the provider should have been notified as ordered. On 02/11/26 at 2:02 p.m., the DON stated staff should notify the physician if the order stated to notify the physician.

Based on observation, record review, and interview, the facility failed to comprehensively assess a resident's physical condition and needs for 1 (#10) of 18 sampled residents reviewed for comprehensive assessments.The administrator identified 63 residents resided in the facility. Findings:On 02/11/26 at 8:48 a.m., Resident #10's left hand was observed to be contracted and completely closed into a fist. There were no therapeutic devices in their left hand. Resident #10's left arm was observed to not raise above shoulder height. A policy titled Resident Assessments, dated 11/2019, showed appropriate resident assessments were to be completed.A Physician's Progress Note for Resident #10, dated 11/14/25, showed the resident had left sided weakness. An admission Assessment for Resident #10, dated 11/23/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included renal failure and heart failure. The assessment showed Resident #10 had no impairment to their upper extremities. The assessment showed Resident #10 had a BIMS score of 14, which indicated they were cognitively intact. On 02/11/26 at 8:48 a.m., Resident #10 stated they had no use of their left hand and could not raise their left arm above their shoulders. On 02/12/26 at 9:54 a.m., CNA #2 was asked if Resident #10 had any physical limitations. They stated Resident #10 was unable to use their left hand and their left arm was weak. On 02/12/26 at 10:38 a.m., the MDS coordinator was asked how resident assessment information was collected for the comprehensive assessment. They stated, I read the chart and see the patient myself. The MDS coordinator was asked if Resident #10's comprehensive assessment showed any upper extremity impairments. They stated, No. The MDS coordinator stated Resident #10's assessment should have showed upper extremity impairment for their left-hand contracture and left arm weakness.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan:a. included interventions for limited range of motion for 1 (#10) of 3 sampled resident reviewed for limited range of motion,b. was implemented for offering a meal replacement supplement for 1 (#48) of 3 sampled residents reviewed for nutrition, andc. included the use of a mechanical lift for transfer for 1 (#3) of 5 sampled residents reviewed for accidents.The administrator identified 63 residents resided in the facility and the DON identified six residents used a mechanical lift for transfers. Findings: A policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, read in part, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.The comprehensive person-centered care plan will: describe the services that are furnished or attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; aid in preventing or reducing decline in the resident's functional status and/or functional levels; enhance the optimal functioning of the resident by focusing on a rehabilitative program. 1. On 02/11/26 at 8:48 a.m., Resident #10's left hand was observed to be contracted and completely closed into a fist. There were no therapeutic devices in their left hand. Resident #10's left arm was observed to not raise above shoulder height. A care plan for Resident #10, dated 11/11/25, did not show any problem area related to limited range of motion or contractures. A physician's progress note for Resident #10, dated 11/14/25, showed the resident had left sided weakness. An admission assessment for Resident #10, dated 11/23/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included renal failure and heart failure. The assessment showed Resident #10 had no impairment to their upper extremities. The assessment showed Resident #10 had a BIMS of 14, which indicated they were cognitively intact. On 02/11/26 at 8:48 a.m., Resident #10 stated they had no use of their left hand and could not raise their left arm above their shoulders. They stated there were no therapeutic devices or therapies used to maintain or improve function. On 02/12/26 at 9:54 a.m., CNA #2 stated Resident #10 was unable to use their left-hand and their left arm was weak. CNA #2 stated there were no therapeutic devices or therapies provided to Resident #10, but they needed both. On 02/12/26 at 10:04 a.m., LPN #2 stated Resident #10 did not have an order for therapeutic devices for their left-hand contracture, and no range of motion exercises were provided. On 02/12/26 at 10:11 a.m., CNA #6 stated Resident #10 was not on restorative services and had no therapeutic devices for their left-hand contracture. On 02/12/26 at 10:16 a.m., the DON stated if a resident had limited range of motion or a contracture the resident was admitted to therapy or to their restorative program. The DON stated Resident #10 had not received assistance from the restorative program until today but should have been since admission. They stated a rolled-up wash cloth should have been placed in Resident #10's left hand to prevent further contracture, and staff should have been providing passive range of motion exercises. On 02/12/26 at 10:38 a.m., the MDS coordinator stated Resident #10's care plan did not include their upper extremity impairment, left-hand contracture, or interventions, but should have. 2. On 02/11/26 at 9:16 a.m., Resident #48 was observed lying in bed with their eyes closed. A breakfast tray was untouched sitting on their walker seat. A care plan for Resident #48, dated 10/10/25, showed the resident had a nutritional problem or potential nutritional problem related to protein calorie malnutrition. The intervention was for staff to offer Resident #48 a meal replacement supplement if 50% or less of their meal was consumed. An undated weight log for Resident #48 showed on 12/05/25, the resident weighed 170 pounds. An admission assessment for Resident #48, dated 12/20/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included pancytopenia (a serious blood disorder characterized by dangerously low red blood cells, white blood cells, and platelets), renal insufficiency, and cirrhosis of the liver. The assessment showed Resident #48 had a BIMS of 12, which indicated moderate cognitive impairment. An undated weight log for Resident #48 showed on 01/05/26, the resident weighed 158.5 pounds. A dietician's note for Resident #48, dated 01/20/26, showed the resident had a significant weight loss of 8.8% in one month and 15.3% in six months. The note showed Resident #48's meal intake was poor to fair and ranged from 25 to 50% of meals. The dietician recommended health shakes three times daily with meals. An undated weight log for Resident #48 showed on 02/04/26, the resident weighed 155 pounds. On 02/11/26 at 1:46 p.m., Resident #48 stated they did not receive any meal supplements. They stated, I really like them. I'm not sure why I don't get them anymore. On 02/11/26 at 1:53 p.m., CNA #2 stated Resident #48 did not receive health shakes or additional supplements if meal consumption was 50% or less. They stated Resident #48 never ate much and did not have much of an appetite. On 02/13/26 at 8:52 a.m., the DON stated Resident #48 should have been receiving health shakes when 50% or less of their meals were consumed. 3. On 02/17/26 at 9:23 a.m., CNA #3 and the activities director were observed using the lift to transfer Resident #3 from the Geri chair to their bed and back to the Geri chair because the resident requested to be taken for a smoke break. A significant change in status assessment for Resident #3, dated 01/20/26, showed the resident had diagnoses which included weakness and dementia. The assessment showed the resident was dependent on staff for transfer. The assessment showed the resident had severe cognitive impairment with a BIMS score of 06. A care plan for Resident #3, revised 02/05/26, did not show the use of a mechanical lift for transfers. On 02/10/26 at 12:10 p.m., Resident #3 stated they used a lift for transfers with one staff assistance. On 02/13/26 at 10:22 a.m., CNA #4 stated Resident #3 used a lift for transfers. On 02/17/26 at 9:22 a.m., CNA #3 stated Resident #3 had been using the lift for transfers since they were employed at the facility. On 02/17/26 at 9:30 a.m., the MDS coordinator stated they were responsible for completing care plans. They stated if a resident used a lift for transfers, the nurses would notify them, and they would make observation of the transfer. The MDS coordinator stated they would document lift use on the resident's care plan. On 02/17/26 at 9:33 a.m., the MDS coordinator stated Resident #3's care plan did not address the use of a lift for transfers.

Based on observation, record review, and interview, the facility failed to ensure weight loss was unavoidable by providing meal replacement supplements for 1 (#48) of 3 sampled residents reviewed for nutrition.The administrator identified 63 residents resided in the facility. Findings:On 02/11/26 at 9:16 a.m., Resident #48 was observed lying in bed with their eyes closed. A breakfast tray was untouched sitting on their walker seat.A care plan for Resident #48, dated 10/10/25, showed the resident had a nutritional problem or potential nutritional problem related to protein calorie malnutrition. The intervention was for staff to offer Resident #48 a meal replacement supplement if 50% or less of their meal was consumed.An undated weight log for Resident #48 showed on 12/05/25, the resident weighed 170 pounds.An admission assessment for Resident #48, dated 12/20/25, showed the resident had diagnoses which included pancytopenia (a serious blood disorder characterized by dangerously low red blood cells, white blood cells, and platelets), renal insufficiency, and cirrhosis of the liver. The assessment showed Resident #48 had a BIMS of 12, which indicated moderate cognitive impairment.An undated weight log for Resident #48 showed on 01/05/26, the resident weighed 158.5 pounds. A dietician's note for Resident #48, dated 01/20/26, showed the resident had a significant weight loss of 8.8% in one month and 15.3% in six months. The note showed Resident #48's meal intake was poor to fair and ranged from 25 to 50% of meals. The dietician recommended health shakes three times daily with meals. There was no documentation showing Resident #48 received health shakes. Resident #48 did not receive health shakes three times daily for the following dates:a. 01/21/26,b. 01/22/26,c. 01/23/26,d. 01/24/26,e. 01/25/26,f. 01/26/26,g. 01/27/26,h. 01/28/26,i. 01/29/26,j. 01/30/26,k. 01/31/26,l. 02/01/26,m. 02/02/26,n. 02/03/26,o. 02/04/26,p. 02/05/26,q. 02/06/26,r. 02/07/26,s. 02/08/26,t. 02/09/26,u. 02/10/26, andv. 02/11/26. An undated weight log for Resident #48 showed on 02/04/26, the resident weighed 155 pounds. On 02/11/26 at 1:46 p.m., Resident #48 stated they did not receive any meal supplements. They stated, I really like them. I'm not sure why I don't get them anymore. On 02/11/26 at 1:53 p.m., CNA #2 stated Resident #48 did not receive health shakes or additional supplements if meal consumption was 50% or less. They stated Resident #48 never ate much and did not have much of an appetite.On 02/13/26 at 8:52 a.m., the DON stated Resident #48 should have been receiving health shakes when 50% or less of their meals were consumed.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate was less than five percent for 2 (#53 and #56) of 4 sampled residents observed during medication pass. The facility's medication error rate was 7.41%.The administrator identified 63 residents resided in the facility. Findings:1. On 02/12/26 at 8:03 a.m., CMA #1 was observed to administer one tablet of vitamin D3 25 mcg to Resident #56.An Administering Medications policy, dated 04/2019, read in part, Medications are administered in a safe and timely manner, and as prescribe.A physician's order for Resident #56, dated 07/19/23, showed vitamin D3 50 mcg, give one tablet by mouth in the morning for supplement.On 02/12/26 at 11:29 a.m., CMA #1 stated Resident #56 was supposed to receive vitamin D3 50 mcg. They stated they should have given the resident two tablets of the house stock vitamin D3 25 mcg to equal 50 mcg.On 02/12/26 at 11:31 a.m., CMA #1 stated they did not follow the physician's order.2. On 02/12/26 at 8:37 a.m., CMA #2 was observed to administer one tablet of senna (a laxative medication) to Resident #53.A physician's order for Resident #53, dated 10/16/25, showed senna-lax, give two tablets by mouth one time a day related to constipation.On 02/12/26 at 10:06 a.m., CMA #2 stated they gave Resident #53 one tablet of the senna. They stated it was supposed to be two tablets per the physician's order.On 02/12/26 at 11:47 a.m., the DON stated staff were supposed to follow the rights of medication administration and to use the punch, initial, give method. They stated staff were to follow physician's orders.

Based on observation, record review, and interview, the facility failed to accurately complete a weekly skin assessment for 1 (#26) of 3 sampled residents reviewed for pressure ulcers and skin conditions.The wound care nurse identified 12 residents had wounds in the facility. Findings:On 02/12/26 at 10:40 a.m., Resident #26 was observed with three open areas to their coccyx and buttocks during an incontinent care observation.A physician order for Resident #26, dated 01/23/26, showed weekly skin assessment every Thursday evening night shift.An admission assessment for Resident #26, dated 01/29/26, showed the resident had diagnoses which included unspecified fracture of sacrum and abnormalities of gait and mobility. The assessment showed the resident's cognition was intact with a BIMS score of 15. The assessment showed the resident was admitted on [DATE]. A Skin Assessment by Charge Nurse for Resident #26, dated 02/12/26 at 10:58 p.m., showed the resident had no open area and their coccyx was reddened.A skin assessment for Resident #26, completed by the wound care nurse on 02/13/26, showed the resident had the following stage two open areas:a. right buttock measuring 1.5 cm by 1.5 cm,b. left buttock measuring 1.5 cm by 1.5 cm, andc. upper cerbe (upper part of the buttocks) measuring 1 cm by 0.5 cm.On 02/10/26 at 10:00 a.m., Resident #26 stated they had a small open area on their bottom.On 02/13/26 at 1:18 p.m., the DON stated the 02/12/26 weekly skin assessment showed Resident #26 had no open areas.On 02/13/26 at 3:15 p.m., LPN #1 stated the process for weekly skin assessment was to assess the resident's skin from head to toe.On 02/13/26 at 3:20 p.m., LPN #1 stated to their knowledge they did visualize Resident #26's coccyx and buttocks on the 02/12/26 weekly skin assessment. LPN #1 stated they did not do a complete skin assessment.On 02/17/26 at 10:50 a.m., the DON stated the facility trained nurses on proper skin assessments which involved assessing all areas of the skin during a weekly skin assessment.

Based on observation, record review, and interview, the facility failed to ensure range of motion exercises and equipment for a contracture to maintain or improve mobility for 1 (#10) of 2 sampled residents reviewed for range of motion and mobility.The DON identified two residents had limited range of motion. Findings:On 02/11/26 at 8:48 a.m., Resident #10's left hand was observed to be contracted and completely closed into a fist. There were no therapeutic devices in their left hand. Resident #10's left arm was observed to not raise above shoulder height. A policy titled Restorative Nursing Services, dated 07/2017, read in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence.A physician's progress note for Resident #10, dated 11/14/25, showed the resident had left sided weakness. An admission assessment for Resident #10, dated 11/23/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included renal failure and heart failure. The assessment showed Resident #10 had no impairment to their upper extremities or diagnosis for left-hand contracture. The assessment showed Resident #10 had a BIMS score of 14, which indicated they were cognitively intact. On 02/11/26 at 8:48 a.m., Resident #10 stated they had no use of their left hand and could not raise their left arm above their shoulders. They stated there were no therapeutic devices or therapies used to maintain or improve function. On 02/12/26 at 9:54 a.m., CNA #2 stated Resident #10 was unable to use their left hand, and their left arm was weak. CNA #2 stated there were no therapeutic devices or therapies provided to Resident #10, but they needed both. On 02/12/26 at 10:04 a.m., LPN #2 stated Resident #10 did not have an order for therapeutic devices for their left-hand contracture, and no range of motion exercises were provided. On 02/12/26 at 10:11 a.m., CNA #6 stated Resident #10 was not on restorative services and had no therapeutic devices for their left-hand contracture. On 02/12/26 at 10:16 a.m., the DON stated if a resident had limited range of motion or a contracture the resident was admitted to therapy or to their restorative program. The DON stated Resident #10 had not received assistance from the restorative program until today but should have been since admission. They stated a rolled-up wash cloth should have been placed in Resident #10's left hand to prevent further contracture, and staff should have been providing passive range of motion exercises.

Based on observation, record review, and interview, the facility failed to ensure a weekly skin assessment was accurately documented for 1 (#26) of 3 sampled residents reviewed for pressure ulcers and skin conditions.The wound care nurse identified 12 residents had wounds in the facility. Findings:On 02/12/26 at 10:40 a.m., Resident #26 was observed with three open areas to their coccyx and buttocks during an incontinent care observation.A Charting and Documentation policy, revised 07/2017, read in part, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.A physician's order for Resident #26, dated 01/23/26, showed weekly skin assessment every Thursday evening night shift.An admission assessment for Resident #26, dated 01/29/26, showed the resident had diagnoses which included unspecified fracture of sacrum and abnormalities of gait and mobility. The assessment showed the resident's cognition was intact with a BIMS score of 15.A Skin Assessment by Charge Nurse for Resident #26, dated 02/12/26 at 10:58 p.m., showed the resident had no open area and their coccyx was reddened.A skin assessment for Resident #26, completed by the wound care nurse on 02/13/26, showed the resident had stage two open areas to their cerbe and both buttocks. On 02/13/26 at 3:15 p.m., LPN #1 stated the process for weekly skin assessment was to assess the resident's skin from head to toe.On 02/13/26 at 3:20 p.m., LPN #1 stated to their knowledge they did visualize Resident #26's coccyx and buttocks on the 02/12/26 weekly skin assessment. LPN #1 stated they did not do a complete skin assessment.On 02/17/26 at 10:51 a.m., the DON stated nurses were to document only observed findings on the skin assessment.

Based on observation, record review, and interview, the facility failed to ensure residents were provided with necessary behavioral health care and services for 1 (#10) of 3 sampled residents reviewed for behavioral health care needs.The administrator identified 63 residents resided in the facility. Findings: On 02/11/26 at 8:47 a.m., Resident #10 was observed to be tearful in their room. A physician's order for Resident #10, dated 11/11/25, showed the resident was to receive a psychiatric consultation for mental health needs if criteria was met as needed. An admission assessment for Resident #10, dated 11/23/25, showed the resident had a diagnosis of depression. The assessment showed it was very important for them to participate in activities. The assessment showed no behaviors and their depression screening showed no concerns. The assessment showed Resident #10 had a BIMS of 14, which indicated they were cognitively intact. A physician's order for Resident 310, dated 12/20/25, showed the resident was prescribed fluoxetine 20 mg (an anti-depressant medication) once daily for depression. A review of physician progress notes showed no psychiatric consultations. An activity note for Resident #10, dated 12/29/25, showed the resident did not participate in any activities in December 2025. On 02/11/26 at 8:48 a.m., Resident #10 stated they were depressed and it made them not want to get out of bed. They stated they would miss dialysis because of their depression. On 02/12/26 at 9:57 a.m., CNA #2 stated Resident #10 was easily upset and isolated in their room. On 02/12/26 at 10:02 a.m., LPN #2 stated Resident #10 was not social and stayed in their room. They stated Resident #10 refused dialysis several times. On 02/13/26 at 8:48 a.m., the DON stated any residents on antidepressants with behaviors were sent for a psychiatric consultation. They stated criteria for determining a resident required a psychiatric consultation would be refusing dialysis, isolating in their room, and refusing care. The DON stated Resident #10 should have been seen for psychiatric consultation.

Based on record review and interview, the facility failed to ensure medications were administered according to the physician orders for 1 (#8) of 3 residents sampled for medication administration.The administrator identified 55 residents resided in the facility.Findings:An Administering Medications policy, revised April 2019, read in part, Medications are administered in a safe and timely manner, and as prescribed.The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.A physicians' order, dated 03/15/25, showed atorvastatin calcium tablet (statin) 40 mg, give one tablet at bedtime.A physicians' order, dated 03/15/25, showed gabapentin capsule (anti-convulsant) 300 mg, give one capsule three times a day.A physicians' order, dated 05/06/25, showed carvedilol tablet (beta blocker) 3.125 mg, give two times a day.A physicians' order, dated 05/27/25, showed Zyprexa tablet (anti-psychotic) 10 mg, give one tablet at bedtime.A physicians' order, dated 06/24/25, showed buspirone HCI tablet (anti-anxiety) 5 mg give three times a day.A physicians' order, dated 06/24/25, showed mirtazapine tablet (anti-depressant) 7.5 mg, give one tablet at bedtime.A physicians' order, dated 07/14/25, showed doxepin HCI tablet (anti-depressant) 3 mg, give one tablet at bedtime.A physicians' order, dated 07/15/25, showed Singulair tablet (leukotriene receptor antagonist) 10 mg, give one tablet at bedtime.A physicians' order, dated 08/27/25, showed hydrocodone-acetaminophen tablet (opioid) 10-325 mg, give one tablet three times a day.Resident #8's quarterly assessment, dated 09/03/25, showed residents cognition was intact, with a brief interview for mental illness score of 14.A physicians' order, dated 09/16/25, showed carafate tablet (anti-ulcer) 1 gram, give one tablet four times a day.A September 2025 MAR showed blanks on 09/03/25 for the following:a. atorvastatin calcium tablet 40 mg;b. doxepin HCI tablet 3 mg;c. mirtazapine tablet 7.5 mg;d. Singulair tablet 10 mg;e. Zyprexa tablet 10 mg; andf. carvedilol tablet 3.125 mg.A September 2025 MAR showed blanks on 09/25/25 for the following:a. buspirone tablet 5 mg;b. gabapentin capsule 300 mg;c. carafate tablet 1 gram; andd. hydrocodone-acetaminophen tablet 10-325 mg.There was no explanation for the missed doses in the medical record.On 11/05/25 at 11:15 a.m., certified medication aide #1 stated blanks on the MAR meant either not in facility or not given. They stated it did not appear the above medications were given as ordered.On 11/05/25 at 11:55 a.m., the ADON stated the process for passing medications was to use the PIG (punch, initial, give) method per order time and policy. They stated staff were to ensure they signed it out. On 11/05/25 at 11:57 a.m., the ADON stated according to the MAR the medications above had not been given.

On 08/13/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure supervision was provided to a resident who smoked and used oxygen that resulted in Resident #20 igniting themselves and received second degree burns to their face.On 08/13/25 at 5:09 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 08/13/25 at 5:23 p.m., the administrator and the DON were notified of the IJ situation and the IJ template was provided.On 08/14/25 at 11:40 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Incident: Resident was smoking while wearing oxygen and accidentally ignited [themself], resulting in burn injuries and immediate life-threatening risk.1. Immediate Action Taken- Oxygen was removed from the resident's vicinity and turned off to eliminate fuel source. Staff responded immediately, extinguishing the fire, and activated emergency medical response, first aid was provided at the facility prior to transport. Resident transferred to the emergency department for burn evaluation/treatment.2. Identification of All Residents at Risk- Facility wide audit within 2 hours to identify all residents who use oxygen and smoke. Each identified resident immediately educated on fire risks and safe practices. Residents using oxygen prohibited from smoking without staff present; oxygen removed at least 10 feet for 10 minutes from ignition source before lighting any smoking material.3. Education- 07/17/2025: All staff and residents were in-serviced on the smoking policy, confiscating smoking materials, lighting equipment and vapes. Fire drills were carried out per CMS and NFPA regulations. Competency verified through verbalization of hazard recognition. 08/13/2025 at 6:50 p.m.: All staff educated on the importance of communications of hazard identification related to smoking and oxygen supervision. Staff is to immediately communicate if a resident is placing themselves in danger.4. Systemic Changes to Prevent Recurrence- Smoking Policy revised to mandate staff removal of oxygen and confirmation of safe distance and time frame before resident smokes. Care plan updated for all residents who smoke. Maintenance to inspect and ensure No Smoking Oxygen in Use is posted and visible in all relevant areas.If a resident is observed attempting to smoke with oxygen in place- Staff will immediately notify licensed nurse on duty- staff will 1:1 resident until licensed nurse arrives.- Licensed nurse will assess respiratory status prior to oxygen removal.- Licensed nurse will remove the oxygen tubing/tank from the resident before smoking in accordance with the facility smoking policy.- Licensed nurse will notify Administrator, Director of Nursing, or designee immediately.Any staff member who observes a resident not following the smoking policy will immediately:- Immediately notify the nurse on duty.- Remain with the resident until the nurse arrives to prevent unsafe action.- Licensed nurse will:Intervene to stop unsafe behavior and secure any smoking materialsNotify the Admin/DON or designee immediatelyDocument the incident and interventions in the resident's medical record.5. Monitoring & QASupervised smoking will continue for all residents.Any non-compliance will be clearly documented with results reported to QAPI: corrective action taken immediately if deviation noted.6. Completion Date for Immediate Jeopardy RemovalAll immediate corrective actions completed by 08/14/25 at 2:00 p.m.The IJ was lifted, effective 08/14/25 at 2:00 p.m., when all components of the plan of removal had been completed. Multiple staff on different shifts were interviewed regarding the in-service they received; and audits were reviewed. In-services and fire drills were reviewed. The revised smoking policy was reviewed. Care plans were reviewed, and no smoking signs were observed in designated areas. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to ensure supervision was provided to a resident who smoked and used oxygen for 1 (#20) of 4 sampled residents reviewed for accidents.The administrator identified 53 residents resided in the facility, 6 residents smoked and wore oxygen frequently/routinely, and 14 residents smoked and had as needed orders for oxygen.Findings:An undated Smoking and Oxygen Use Policy-Long-Term Care Facility, read in part, Residents have the right to smoke if medically cleared; however, safety must be prioritized when oxygen therapy is involved. The facility may limit or revoke smoking privileges for residents who are noncompliant with safety protocols . Residents must be removed from oxygen for at least 10 minutes before smoking. Smoking is only permitted in the designated outdoor smoking areas under staff supervision. Oxygen equipment must be stored away from the smoking area. Staff must verify that the resident has complied with the disconnection time before allowing smoking.An undated order summary showed Resident #20 had diagnoses which include hypoxemia, congestive heart failure, and chronic obstructive pulmonary disease.An evaluation Smoking and Safety, dated 12/14/24, showed Resident #20 had balance problems while sitting or standing. The evaluation did not have any clinical suggestions marked.A physician's order, dated 12/16/24, showed oxygen at 4 liters per minute via nasal cannula three times a day.A care plan, initiated 02/14/25, showed Resident #20 required supervision while smoking and to ensure residents' oxygen was removed and turned off before smoking.A care plan, revised, 05/18/25, showed Resident #20 smoked independently and required supervision while smoking.A care plan, initiated, 07/17/25 and revised on 07/21/25, showed Resident #20 was noncompliant with smoking while oxygen in use, with goal for resident to be free from complications related to noncompliance. The care plan showed only one intervention of the resident placed on 1:1 related to smoking with the use of oxygen, educate resident on importance of not smoking while oxygen in use related to safety. An Initial INCIDENT REPORT FORM, dated 07/17/25, showed serious harm. The report showed the resident went to the front of the building and told the receptionist they were going outside for fresh air. The report showed once resident was outside, they lit a cigarette while they were wearing their oxygen cannula. The report showed the oxygen caught on fire and they were sent to the emergency room for evaluation and treatment.A behavior note, dated 07/17/25 at 12:52 p.m., read in part, Resident observed preparing to go outside to smoke with nasal canula in place. Informed resident of the risk associated with smoking while using oxygen, including fire hazard. Resident was advised not to smoke while on oxygen therapy. Will continue to reinforce safety precautions. Supervisor notified.A facility incident report, dated 07/17/25 at 2:45 p.m., read in part, Resident [#28] came wheeling to the nurses station fast, stated [Resident #20] set [themselves] on fire. [They] were smoking cigarette with [Their] oxygen on. Went to front door found [Resident #20] sitting in wheel chair. Face burn along nose and lips, and neck area. Awake and alert, non-compliant, explained to resident earlier no smoking because of oxygen.An incident note, dated 07/17/25 at 3:56 p.m., read in part, Resident outside smoking with oxygen on and caught face on fire. Noted blackened areas to face and nose. Bottom lip is swollen and small amount of red substance noted. EMSA [emergency medical services authority] here resident transported to [hospital] burn center via stretcher.An After Visit Summary, dated 07/17/25 - 07/19/25, showed Resident #20 had second degree burn of face.A Smoking and Safety, evaluation, dated 07/18/25, showed Resident #20 had poor vision or blindness. It did not have any clinical suggestions or interventions marked.A Smoking and Oxygen use, in-service, dated 07/18/25 showed 8 staff signatures. Resident #20's discharge return anticipated resident assessment, dated 07/30/25, showed the resident's cognition had modified independence with decision making, required supervision to substantial assistance with mobility. The assessment did not show the resident smoked.There was no documentation of staff supervision while resident smoked outside.On 08/12/25 at 8:15 a.m., Resident #20 was asked what happened to their face. They stated, I got burned smoking with oxygen on. They stated there were not any nurses outside when the incident occurred. Resident #20 stated they were outside without any supervision for about 30 minutes. They stated there was somebody outside but they were on their phone. Resident #20 stated a lot of the time people would be out there smoking and no ones with them. They stated they get the code to the door so they go out there and smoke without the staff out there. They stated they get their smoking material from the nurse. On 08/12/25 at 1:38 p.m., the activity assistant stated there were seven designated times for residents to smoke and the residents had to wait at the nurse's station for the designated staff to pass out the cigarettes to them one at a time and the staff has the lighter. The stated they were supervised by either staff staying outside or watching through the window. The activity assistant stated they were aware of the smoking incident with Resident #20 but had no knowledge if they were supervised at the time of the incident. The activity assistant stated there was only one resident to their knowledge that was an independent smoker, and it was not Resident #20. On 08/12/25 at 2:03 p.m., CNA #1 stated the whole building watches for smokers. They stated the residents had a lock box the materials were kept in and it was separated by each resident. CNA #1 stated Resident #20 required encouragement to not smoke due to breathing problems and oxygen. CNA #1 stated the resident was upset the day of the incident. CNA #1 stated the last time they saw Resident #20 that day, they were sitting up front by the tv at the table. CNA #1 stated the resident was always moving around. CNA #1 stated they heard the RN on duty (whom did not return phone calls for interview) state they were sending Resident #20 out because they set themselves on fire. CNA #1 stated it occurred around lunch time, and they had signed themselves out and went out the front and no staff was with them. Unable to speak to the RN that sent resident out to the hospital as they did not answer the phone, and the nurse that made the note of the resident preparing to go outside with oxygen was no longer employed at the facility since the date of the incident. On 08/13/25 at 11:54 a.m., Resident #20's family member #1 stated they did not provide the resident with a lighter and that the last time they had visited Resident #20 was on Saturday the 2nd and had brought snacks only. On 08/13/25 at 12:19 p.m., Resident #20's family member #2 stated they did not provide the resident with any smoking material and they do not purchase the cigarettes for them. They stated they last visited the resident two weeks ago. On 08/13/25 at 12:37 p.m., LPN #2 stated Resident #20 did not normally leave the facility and if they did, it was with their family member. They stated Resident #20 were normally in their room or the tv room and would sit outside for fresh air. LPN #2 stated they were aware of the recent smoking incident, and the resident was currently out of cigarettes and had tried to be sneaky to get from another resident. LPN #2 reviewed the sign out books, dated for 07/11/25 - 07/22/25, for Resident #20's name. LPN #2 stated the resident didn't typically sign out and were always on the back smoking area. The resident sign out book showed the resident had signed out on 07/14/25 at unknown time and another with an unknown date with a time frame of 8:45 a.m., and for 07/14/25 with a family member. LPN #2 stated no resident went out with their cigarettes without staff during smoking time. On 08/13/25 at 1:24 p.m., the administrator and DON were interviewed. The administrator stated after reviewing the nurse note from 07/17/25, their expectation regarding interventions to prevent hazard from smoking while on oxygen was the residents don't have lighters, and the tanks were to be turned completely off on the wheel chair before they were allowed to go smoke. The DON interjected and stated 90% of the time they were the one to remove the tank and put it in the dining room until the resident came back in. The administrator stated the implemented interventions when the resident was observed preparing to go outside to smoke while wearing oxygen was they talked to the resident about the dangers. The administrator stated nothing showed the resident attempted at that moment with that staff member to go outside. The administrator stated Resident #20 was very evasive to staff members and if they said no, the resident would roll around the building until someone that doesn't know. They stated the resident did not say they were going out to smoke, and they did not see any smoking material on them.On 08/13/25 at 1:30 p.m., both the administrator and the DON stated a resident should not be allowed to smoke with the intent they will still be on their oxygen.On 08/13/25 at 1:32 p.m., the administrator stated they did not do any resident safe surveys at the time of the incident on 07/17/25. They stated the incident could have affected other residents. They were unaware of how the resident obtained the smoking material. The administrator stated residents that were mentally capable could check themselves out as they could not keep them trapped in the property and they had the right to leave and had a right to their property and do their due diligence to get them upon their return. The administrator stated no resident was allowed to smoke independently, even independent smokers, and if they sign out it was off property, all had been educated, and Resident #20 had been educated multiple times.On 08/13/25 at 1:34 p.m., the administrator stated Resident #20 could sign themselves out. The administrator stated they did not see where the resident was signed out for 07/17/25. They stated the residents were not required to sign out to get fresh air or while on the property.On 08/13/25 at 3:03 p.m., the administrator stated they ensure resident safety while outside on premises by frequent observations and frequent checks, I can't keep them locked in.On 08/13/25 at 3:07 p.m., CNA #5 stated the last time they were in-serviced regarding the smoking protocol and safety was when they first started in May.The hire date for CNA #5 was 05/05/25 per the employee list with hire dates provided by the administrator.

Based on observation, record review, and interview, the facility failed to ensure a resident was free from abuse for 1 (#8) of 3 sampled residents reviewed for abuse.Findings:On 08/11/25 at 10:10 a.m., Resident #8 was observed sitting in a wheelchair in their room. The resident had a knot and bruising on the right side of their forehead. On 08/11/25 at 11:00 a.m., Resident #4 was observed lying in their bed with their eyes closed. On 08/11/25 at 12:10 p.m., Resident #4 was observed in the dining room with a one-on-one sitter. On 08/12/25 at 9:13 a.m., Resident #4 was observed lying in their bed with their eyes closed. An annual assessment, dated 05/30/25, showed Resident #4 was admitted to the facility on [DATE] with diagnoses to include dementia with agitation, Alzheimer's disease, and major depressive disorder. The assessment showed Resident #4 had a BIMS of 15, which indicated Resident #4 was cognitively intact. An annual, dated 06/03/25, showed Resident #8 was admitted to the facility on [DATE] with diagnoses to include cerebrovascular accident (stroke), anxiety, depression, and schizophrenia. The assessment showed Resident #8 had a BIMS of 14, which indicated Resident #8 was cognitively intact. An Incident Note, dated 08/09/25, read in part, Resident states that the other resident [Resident #4] was sitting in [their] spot in the dining room. [They] told [Resident #8] [they] normally don't sit here. Other resident [Resident #4] stated that [they] was going to sit wherever [they] like and it's not nothing [Resident #8] could do about it. Both residents started passing word between each other. This resident [Resident #4] stated that the other resident [Resident #8] said I would hit you with this cane and this resident [Resident #4] stated and I will stick you with this fork. The other resident [Resident #8] hit this resident [Resident #4] over the head with the cane. Resident has a hematoma on the right side of head. The note showed Resident #4 declined transport to the emergency room for evaluation and neurological checks were initiated by staff. Both residents were separated. A review of Resident #4's electronic medical chart showed neuro checks were provided by licensed staff through 08/10/25 and Resident #4 was seen by a physician on 08/11/25. A document titled 15 Minute Checks, dated 08/11/25, showed Resident #8 was placed on one-on-one supervision on 08/11/25 through 08/12/25. On 08/11/25 at 10:10 a.m., Resident #8 was asked how they received the knot and bruising to the right side of their forehead. Resident #8 stated, I got to the dining room, and [Resident #4] was sitting in my spot; the same spot I've sat in for 6 months. I told [Resident #4] [they] were in my spot. [They] said, 'I don't want to hear that shit, find you somewhere else to sit.' [Resident #4] said 'I'm not getting up,' so that's when the argument started. Resident #8 stated that Resident #4 kept raising [their] cane as if [they] were going to hit Resident #8 with it. Resident #8 stated, I said you better not hit me with that cane. [They] brought it up and hit me in the head on the right side. Resident #8 was asked what the staff's response was to the incident. Resident #8 stated, To my knowledge they got [Resident #4] on one-on-one, but I don't know what that means. [Resident #4] is not allowed to come in here in my room and that's all I know. Resident #8 was asked if a nurse checked them out after they were hit. Resident #8 stated, Yes and my head is really sore and swollen. Resident #8 was asked if staff were giving them anything for pain and they stated, I ask for Tylenol and they give it to me. On 08/12/25 at 1:01 p.m., CMA #3 was asked what they knew about Resident #8's bruising on their head. CMA #3 stated, I wasn't here. Just what I was told is [Resident #8] and [Resident #4] got into an altercation and [Resident #4] hit [Resident #8] with their cane. CMA #3 was asked if Residents #4 and #8 had gotten into an altercation before this incident. CMA #3 stated, No. [Resident #8] just got to this hall last week. CMA #3 was asked what interventions were put into place for the residents. They stated, I'm not sure. On 08/12/25 at 1:06 p.m., CMA #1 was asked what they knew about Resident #8's bruising on their head. CMA #1 stated, I just know what [Resident #8] told me. They said [Resident #4] was sitting in [Resident #8's] spot, told [them] to move and [Resident #8] got hit in the head. CMA #1 was asked what interventions were in put into place for the residents. CMA #1 stated, [Resident #4] is supposed to have a one-on-one sitter, but I don't know for how long. On 08/12/25 at 2:15 p.m., CMA #2 was asked what they knew about Resident #4. They stated, [Resident #4] has moments, but if something doesn't go [their] way or [they're] disagreeing with someone that's when things happen. CMA #2 was asked what interventions were implemented for Resident #4 when they are agitated. CMA #2 stated, Separate [them], walk with [them]. That usually works. Try to meet [their] needs. CMA #2 was asked how many altercations Resident #4 had with other residents. CMA #2 stated, Just had one this past weekend, but I haven't heard anything else. CMA #2 was asked what interventions were implemented after his altercation with Resident #8. They stated, Separation, one-on-one, and [their] family came. On 08/12/25 at 2:34 p.m., a phone call was placed to the nurse on duty during Residents #4 and #8's altercation on 08/09/25. LPN #3 was asked what they knew about the incident. LPN #3 stated, There was a commotion in the dining room. When we made it in there [Resident #8] had a big knot on [their] head and said [Resident #4] had hit them with a cane. LPN #3 identified the aide in the dining room as CNA #2. LPN #3 was asked what interventions were put into place following the incident. LPN #3 stated, We separated them and [Resident #8] sat at the nurse's station with me. On 08/12/25 at 2:52 p.m., a phone call was placed to CNA #2, and they were asked about the incident between Residents #4 and #8. They stated, It happened in the dining room. [Resident #8] didn't want [Resident #4] to sit next to [them] and started throwing a fit. [Resident #4] hit [Resident #8] with a cane, so [Resident #8] grabbed a fork, but was unable to make contact with [Resident #4]. CNA #2 was asked what interventions were put into place following the incident. They stated, The nurses were called and tried calming everyone down and the residents were separated. On 08/12/25 at 3:09 p.m., the DON was asked what they knew about the incident between Residents #4 and #8. They stated, [Resident #4] sat in [Resident #8's] seat and wouldn't move. An argument ensued and [Resident #4] wacked [Resident #8] on the head with [their] cane, causing a knot on [Resident #8's] head. The DON was asked what interventions were put into place following the incident. The DON stated, At that time we talked about the one-on-one, making sure the two residents weren't near each other. The DON stated the staff relocated Resident #4 to a different hall.

Based on record review and interview, the facility failed to ensure the staff informed residents who attended the resident council meetings were informed of where past survey results were located in the facility. Findings:A review of the resident council meeting minutes from January 2025 through July 2025 showed no education to residents regarding the location of past facility survey results.On 08/12/25 at 9:59 a.m., the residents gathered for a resident council interview were asked if they knew where the past facility survey results were located without having to ask staff. The residents stated, No, in unison and shook their heads indicating no.On 08/18/25 at 11:07 a.m., the social services director, who helped organize resident council meetings, was asked how it was communicated to the residents where the past survey results were located. They stated, I don't know that it is communicated. They've never asked. The social services director was asked if they had ever made residents aware of where the results were located. They stated, No.

On 05/28/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from verbal abuse and failure to implement interventions to protect residents from physical abuse. An admission resident assessment, dated 12/18/24, showed Resident #3's cognition was intact (BIMS 15). A quarterly resident assessment, dated 01/15/25, showed Resident #5's cognition was intact (BIMS 15). A quarterly resident assessment, dated 01/25/25, showed Resident #4's cognition was intact (BIMS 13). A facility reported incident, dated 02/28/25, showed an allegation of abuse/mistreatment involving Resident #3, Resident #4, and Resident #5. The reported incident showed at approximately 6:00 p.m., the residents were outside smoking when an alleged altercation involving threats of physical harm occurred between residents. The reported incident showed Resident #3 made verbal threats of physical harm to Resident #5. Resident #4 became upset and allegedly made threats of physical harm to Resident #3. Residents #3 and #4 were immediately separated and placed on 1:1 for the protection of all residents. The reported incident showed residents were placed on 1:1 for the duration of the investigation. The reported incident showed care plans were updated as appropriate. The reported incident showed Resident #3 was sent out for a geri-psych evaluation and their care plan would be revised as needed upon return. The reported incident showed staff were re-educated on the signs and symptoms of abuse, and the policies and procedures for reporting abuse, neglect, and misappropriation. The final facility reported incident was faxed to OSDH on 03/05/25 at 3:50 p.m. There were no updates to Resident #3 or Resident #4's care plan regarding the above incident. The facility did not provide documentation of 1:1 provided for each shift for the duration of the investigation. The facility did not provide documentation of staff having been in-serviced related to abuse, neglect, and misappropriation as documented in the facility reported incident. An incident note, effective 02/28/25 at 7:30 p.m. showed it was reported to LPN #1 Resident #4 verbally threatened another resident with bodily harm. The resident stated, I will kick your [explicit]. Resident #4 separated from other residents until they went to bed. A behavior note, dated 02/28/25 at 8:44 p.m., showed Resident #3 was being observed 1:1 by the previous DON due to an alleged incident of verbal threats of physical harm to another resident. While sitting in this nurse's office, Resident #3 went into their purse and retrieved a small 1 ½ inch knife. The previous DON asked Resident #3 for the knife and the resident refused. The previous DON then informed the resident that it was illegal to posses a knife on the property. Resident #3 then attempted to jab knife at this nurse while simultaneously handing the knife to the previous DON. An incident note, effective 02/28/25 at 9:50 p.m., showed it was reported to LPN #2 Resident #3 was threatening another resident with bodily harm. They stated, ILL [SIC] WILL SET YOU ON FIRE AND HAVE SOMEONE SHOOT YOU IN THE HEAD. The note showed the resident was separated and placed on 1:1 until EMSA arrived. A behavior note, dated 03/01/25 at 8:47 p.m., showed Resident #3 continued to display verbal outbursts including yelling directed towards staff and other residents. A behavior note, dated 03/03/25 at 9:53 a.m., showed staff spoke with Resident #3 regarding their aggressive behaviors and them pulling a knife on the nurse. The resident admitted they did it and agreed to go to the hospital for treatment. On 05/28/25 at 2:02 p.m., LPN #2 stated at the time of the incident on 02/28/25, Resident #3 was very verbally aggressive with other residents and making threats. LPN #2 stated at the time of the incident, Resident #3 stated to Resident #5, I'll beat your [explicit] and burn you up. LPN #2 stated Resident #3 stated they would call a family member to kill Resident #5. They stated Resident #3 was placed on one on one and had additional incidents. LPN #2 stated on one incident Resident #3 pulled a knife on the former DON and the wound care nurse. They stated staff were able to get the knife away and sent the resident out for a psychiatric evaluation. LPN #2 stated Resident #3 had the knife hidden in their purse. On 05/28/25 at 2:07 p.m., LPN #1 stated on 02/28/25 Resident #3 was yelling at Resident #5 and Resident #4 was taking up for Resident #5. They stated the residents were separated and Resident #3 was in the former DONs office when the resident pulled out a knife and acted like they were going to stab the former DON. They stated the facility tried to get Resident #3 sent out for evaluation. On 05/28/25 at 3:51 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/28/25 at 4:00 p.m., the administrator and DON were notified of the IJ situation and provided the IJ template. On 05/30/25 at 5:01 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Deficiency Summary: Resident #3 made verbal threats of physical harm to Resident #5. Resident #4 became upset at Resident #3 and allegedly made verbal threats of physical harm to Resident #3 which had the potential to put Resident #3 and Resident #5 at risk of serious harm or death. This continues to be a hazard for all residents in the facility. 1. Immediate Action Taken: a. Resident #3 and Resident #4 were immediately separated from other residents at the time of incident. b. Resident #3 was immediately placed on 'One on One' with Protection of Resident until [they] was transferred to Geri-Psych for evaluation and treatment. c. Resident #4 was immediately placed on 'One on One' with Protection of Resident until he was evaluated and treated by Geri-Psych. d. Resident #3 and Resident #4 care plans were reviewed and updated. 2. Systemic Changes Implemented: a. Change in Director of Nursing on 4/28/2025. b. QA - The following Performance Improvement Plan (PIPs) were developed through QA: i. Documentation/Charting on 5/9/2025 ii. Care Plans on 5/9/2025 iii. Employee Orientation on 5/9/2025 iv. Grievances on 5/14/2025 v. Clinical concerns on 5/28/2025 c. Staff were educated on 'One on One' with Protection of Resident on 05/28/2025. d. Staff were educated on 'One on One' with Protection of Resident documentation on 05/28/2025. e. Firearm and Weapon Prohibition Policy updated to specifically include knives 3. Education and Training a. In-service of all staff on the following: Completed on 5/28/2025 i. Abuse, Neglect, and Exploitation Policy. - inclusive of threatening behaviors and no weapons including knives. ii. Firearm and Weapon Prohibition Policy Update for residents - includes knives iii. Firearm and Weapon Prohibition Policy Update for staff - includes knives iv. 'One on One' with Protection of Resident. v. 'One on One' with Protection of Resident documentation [sic]. b. In-service of all members of nurse management on the following: Completed on 5/28/2025 i. Care Plan Development. Facility will be in compliance on 5-30-2025 at 8:00 am. On 06/02/25 at 9:46 a.m., CNA #5 stated they had not received any recent training or in-services. They stated they were new and their second day of work was Thursday 05/29/25. They stated they had not received any information regarding 1:1 or weapons. On 06/02/25 at 11:36 a.m., the DON stated CNA #5 was brand new. The DON stated CNA #5 was not on the list of who completed the training for the plan of removal because they were new. On 06/02/25 at 11:38 a.m., the DON stated CNA #5 trained with CNA #3 on 05/28/25 and on 05/29/25. The DON stated CNA #5 would receive the training related to the POR today 06/02/25. On 06/02/25 at 11:58 a.m., the administrator provided documentation of CNA #5 completing abuse training on 05/16/25. The administrator stated CNA #5's hire date was 05/16/25 and they had not been on the floor since Thursday, 05/29/25. In-service sheets for abuse and neglect, no knives, guns, ammunition, explosives, on the premises, and supervising a resident who was on 1:1, were all dated 06/02/25 at 12:30 p.m., and were signed as completed by CNA #5. The IJ was lifted, effective 06/02/25 at 12:30 p.m., when all components of the plan of removal had been verified as completed. This was verified by staff interviews, review of in-service information, and a review of resident records to ensure interventions were in place for residents who exhibited threatening behaviors and what the facility was to do when there was a knife concern. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to: a. ensure residents were free from verbal abuse for 3 (#3, 4 and #5) of 5 sampled residents reviewed for abuse; b. implement interventions to protect residents from potential physical abuse for 1 (#3) of 5 sampled residents reviewed for abuse; and c. ensure residents were free from neglect for 1 (#1) of 5 sampled residents reviewed for abuse. The DON and the regional clinical director identified 51 residents resided in the facility. Findings: A firearm and weapon prohibition policy, dated 2024, read in part, A safe and secure environment is fundamental for fulfilling our company's mission of providing medical care and related health care services. Our company is committed to maintaining a safe workplace that is free of violence.To prevent the unauthorized possession of weapon(s) while on company premises .Any employee who becomes aware of a violation of this policy is required to immediately notify his/her supervisor of such violation .Violation of this policy is considered a serious offense that endangers the safety of our patients, staff, and visitors. Therefore, this offense may result in termination of employment (Staff), discharge from facility (Resident), and criminal prosecution. An abuse, neglect, and exploitation policy, dated 2025, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Establish policies and procedures to investigate any such allegation .Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures .Establish coordination with the QAPI [Quality Assessment and Performance Improvement] program .Employee Training .Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as .Aggressive and/or catastrophic reactions of residents .Outbursts or yelling out .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.Possible indicators of abuse include, but are not limited to .Verbal abuse of a resident overheard .Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning [and] repositioning.Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.Responding immediately to protect the alleged victim .Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed .Increased supervision of the alleged victim and residents .Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator .Providing emotional support and counseling to the resident during and after the investigation, as needed .Revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse .This coordinated effort results in the QAA [Quality Assessment and Assurance] Committee determining .If a thorough investigation is completed .Whether the resident is protected .Whether an analysis was conducted as to why the situation occurred .Risk factors that contributed to the abuse (e.g., history of aggressive behaviors, environmental factors). A facility reported incident, dated 02/28/25, showed an allegation of abuse/mistreatment involving Resident #3, Resident #4, and Resident #5. The reported incident showed at approximately 6:00 p.m., the residents were outside smoking when an alleged altercation involving threats of physical harm occurred between residents. The reported incident showed Resident #3 made verbal threats of physical harm to Resident #5. Resident #4 became upset and allegedly made threats of physical harm to Resident #3. Residents #3 and #4 were immediately separated and placed on 1:1 for the protection of all residents. The reported incident showed residents were placed on 1:1 for the duration of the investigation. The reported incident showed care plans were updated as appropriate. The reported incident showed Resident #3 was sent out for a geri-psych evaluation and their care plan would be revised as needed upon return. The reported incident showed staff were re-educated on the signs and symptoms of abuse, and the policies and procedures for reporting abuse, neglect, and misappropriation. The final facility reported incident was faxed to OSDH on 03/05/25 at 3:50 p.m. The facility did not provide documentation of staff having been in-serviced related to abuse, neglect, and misappropriation as documented in the facility reported incident. The facility did not provide documentation of 1:1 provided for each shift for the duration of the investigation. The daily staffing sheets showed: a. on 03/01/25 1:1 was assigned for Resident #3 and Resident #4 for the 3:00 p.m. to 11:00 p.m. shift. There was no documentation 1:1 was assigned for the 7:00 a.m. to 3:00 p.m. or the 11:00 p.m. to 7:00 a.m. shift; b. on 03/02/25 1:1 was assigned Resident #3 and Resident #4 for the 3:00 p.m. to 11:00 p.m. shift. One staff member was assigned 1:1 for the 7:00 a.m. to 3:00 p.m. shift but it did not document what resident they were assigned to. There was no documentation 1:1 was assigned for the 11:00 p.m. to 7:00 a.m. shift; and c. on 03/03/25 there was no documentation 1:1 was assigned for Resident #4 for the 3:00 p.m. to 11:00 p.m. shift or the 11:00 p.m. to 7:00 a.m. shift. Resident #4 was still in the facility and had not yet been evaluated by mental health services. There were no updates to Resident #3 or Resident #4's care plan regarding the above incident. 1. On 05/28/25 at 2:20 p.m., Resident #3 was observed lying in their bed in their room watching television. The resident began voicing concerns with wanting to get out of the facility. An admission resident assessment, dated 12/18/24, showed Resident #3's cognition was intact (BIMS 15). The assessment showed Resident #3 had diagnoses which included depression, anxiety disorder, and schizophrenia. A behavior note, dated 02/28/25 at 8:44 p.m., showed Resident #3 was being observed 1:1 by the previous DON due to an alleged incident of verbal threats of physical harm to another resident. While sitting in this nurse's office, Resident #3 went into their purse and retrieved a small 1 ½ inch knife. The previous DON asked Resident #3 for the knife and the resident refused. The previous DON then informed the resident that it was illegal to posses a knife on the property. Resident #3 then attempted to jab knife at this nurse while simultaneously handing the knife to the previous DON. An incident note, effective 02/28/25 at 9:50 p.m., showed it was reported to LPN #2 Resident #3 was threatening another resident with bodily harm. They stated, ILL [SIC] WILL SET YOU ON FIRE AND HAVE SOMEONE SHOOT YOU IN THE HEAD. The note showed the resident was separated and placed on 1:1 until EMSA arrived. A behavior note, dated 03/01/25 at 8:47 p.m., showed Resident #3 continued to display verbal outbursts including yelling directed towards staff and other residents. A behavior note, dated 03/03/25 at 9:53 a.m., showed staff spoke with Resident #3 regarding their aggressive behaviors and them pulling a knife on the nurse. The resident admitted they did it and agreed to go to the hospital for treatment. Behavioral health hospital records, dated 03/03/25 through 03/14/25, showed Resident #3's presenting problem was they threatened a staff member with a knife. The records showed the reason for Resident #3's admission was they were a danger to others and had severe mood symptoms. The record showed key factors contributing to admission were increased aggression and violent behavior. 2. A quarterly resident assessment, dated 01/15/25, showed Resident #5's cognition was intact (BIMS 15). The assessment showed Resident #5 had diagnoses which included heart failure and hypertension. An order note, dated 02/28/25 at 9:58 p.m., showed LPN #2 was informed Resident #5 was threatened bodily harm by another resident. The note showed another resident told Resident #5 they would set the resident on fire and have someone shoot them in the head. The note showed the resident was checked for bodily harm. 3. A quarterly resident assessment, dated 01/25/25, showed Resident #4's cognition was intact (BIMS 13). The assessment showed Resident #4 had diagnoses which included hypertension, aphasia following cerebral infarction, parkinsonism, and history of traumatic brain injury. An incident note, effective 02/28/25 at 7:30 p.m., showed it was reported to LPN #1 Resident #4 verbally threatened another resident with bodily harm. The resident stated, I will kick your [explicit]. Resident #4 was separated from other residents until they went to bed. A mental health provider note for Resident #4, dated 03/04/25, read in part, resident reportedly threatened another resident (per another resident) with bodily harm saying 'I will kick your [explicit]'. This was after [they] heard the resident threatening another resident with bodily harm including having someone shoot them. [Resident #4] reports today that [they] would never hurt a woman and [they] has no feeling of wanting to hurt anyone. What [they] was doing, [they] relates, was trying to get this [resident] to hit [them] to show that [they] is violent. [They] reports that this resident often verbally abuses one particular resident and [they] were tired of it.today reports [they] is 'over' the situation that prompted [their] 1:1, and that [they] never intended to hurt anyone and does not want to hurt anyone or end their life.[They] does voice understanding of [their] behaviors and that words have certain outcomes in a tightly ran facility that has to follow many guidelines per state.I do not see the need for 1:1 to continue at this time. The note was signed on 03/04/25 by PA #1. On 05/23/25 at 1:01 p.m., CNA #4 stated they had received abuse education about a month ago. They stated they watched for verbal abuse, physical abuse, and neglect of patient care. They stated they would notify the administrator if abuse/neglect was observed or reported to them. On 05/23/25 at 1:07 p.m., CNA #2 stated they had received education on abuse and neglect. They stated they watched for every form of abuse including yelling, facial expressions, hand motions, anything that made a resident feel uncomfortable. They stated they would notify their charge nurse and DON if abuse/neglect was observed or reported to them. On 05/23/25 at 1:15 p.m., CNA #3 stated they were unsure of the last education they received regarding abuse/neglect. They stated they believed it was around January 2025. They stated they had not observed any signs or symptoms of abuse or neglect in the facility. They stated if abuse was observed or reported to them, they would contact the charge nurse immediately. On 05/23/25 at 1:19 p.m., ACMA #1 stated they had received education on abuse/neglect a couple Fridays ago. They stated they observed for financial, verbal, physical abuse, and misappropriation. They stated they would report any concerns with abuse/neglect to their nurse, DON, and administrator. On 05/23/25 at 1:22 p.m., LPN # 3 stated they had received education related to abuse/neglect multiple times. They stated they observed for emotional, spiritual, and physical abuse. They stated if abuse/neglect was observed or reported to them, they would notify their supervisor, complete an incident report, and ensure everything was documented. On 05/23/25 at 1:24 p.m., LPN #4 stated they had received an in-service last Friday on abuse/neglect. They stated they monitored for resident to resident abuse, staff to resident abuse, and resident to staff abuse. They stated if they observed abuse or it was reported to them, they would first remove the stressor, then report it to the DON and administrator who was the abuse coordinator. On 05/28/25 at 11:22 a.m., Resident #4 stated they had previously had an incident with Resident #3. They stated Resident #3 was cussing at Resident #5 and Resident #4 stated they told Resident #3 to quit. On 05/28/25 at 11:49 a.m., ACMA #1 stated they remembered Resident #3 talking smack on the day of the incident. They stated it was Resident #3 and Resident #5. They stated Resident #4 stepped in and they were talking about viscous stuff, setting people on fire, and killing them. They stated Resident #3 said it to Resident #5. ACMA #1 stated they heard them yelling initially. ACMA #1 stated Resident #3 said [explicit], shut the [explicit] up, I will set your [explicit] on fire. They stated Resident #5 said Don't nobody like your ugly [explicit]. ACMA #1 stated Resident #4 said they would beat Resident #3 up. They stated nobody touched anyone, it was all verbal and heated. ACMA #1 stated they tried to separate them and hollered for the nurse. They stated Resident #3 and #4 were placed on 1:1. ACMA #1 stated the only other staff present at the time no longer worked at the facility. On 05/28/25 at 12:23 p.m., the administrator stated when they were made aware of an allegation of abuse or neglect, they would immediately make sure the residents were safe. They stated staff would notify the abuse coordinator who was the administrator, and they would ensure statements were obtained and the resident was assessed. On 05/28/25 at 12:24 p.m., the administrator stated the responsible party, DON, physician, and depending on what happened, psych services would be notified of an allegation of abuse or neglect. On 05/28/25 at 12:26 p.m., the administrator stated in the abuse allegation involving Residents #3, #4, and #5, the residents were outside smoking and got into a verbal altercation. They stated Resident #4 thought Resident #3 was calling them names. They stated Resident #3 started yelling at Resident #5. The administrator stated Resident #4 approached Resident #3 and told them they were tired of the name calling. The administrator stated staff were present and immediately separated the residents. They stated the physician was notified and Resident #3 and #4 were put on 1:1 observations. On 05/28/25 at 12:29 p.m., the administrator stated they completed an initial reportable incident form and interviewed residents and staff. They stated assessments were completed and the records were reviewed. They stated senior psych services were contacted for an evaluation and medication review. They stated Residents #3, #4, and #5 showed no signs or symptoms of abuse or distress. The administrator stated Resident #3 was admitted for psych services. They stated Resident #3 remained on 1:1 until they were admitted and there were no other incidents. On 05/28/25 at 12:37 p.m., the administrator and the DON were asked to review the behavior note dated 02/28/25 which discussed Resident #3 taking a knife out of their purse and attempting to jab at the former DON. They were asked what the facility did in response to Resident #3's knife incident. The DON stated staff got the knife from the resident. On 05/28/25 at 1:48 p.m., the DON and administrator were asked how the facility was ensuring Resident #3 did not obtain a knife and attempt to use it again. The administrator stated Resident #3 had no family or friends and did not go anywhere. The DON stated staff should not be carrying anything like that on their person or in their purse. The administrator stated they did not know how Resident #3 got a knife. The DON stated they were not at the facility at the time of the incident and did not know how the resident got a knife. On 05/28/25 at 1:51 p.m. the administrator stated they were not in the building at the time of the knife incident. They stated they did not know about the knife incident at the time. They stated they did not recall when they were made aware of the knife incident. On 05/28/25 at 1:52 p.m., the administrator stated they could not answer for who was providing 1:1 for the 7:00 a.m. to 3:00 p.m. or the 11:00 p.m. to 7:00 a.m. shift on 03/01/25. They stated they would look for additional documentation of who was assigned 1:1 for the other dates and to see if the resident had a roommate for the 11:00 p.m. to 7:00 a.m. shift. On 05/28/25 at 2:02 p.m., LPN #2 stated at the time of the incident on 02/28/25, Resident #3 was very verbally aggressive with other residents and making threats. LPN #2 stated at the time of the incident, Resident #3 stated to Resident #5, I'll beat your [explicit] and burn you up. LPN #2 stated Resident #3 stated they would call a family member to kill Resident #5. They stated Resident #3 was placed on one on one and had additional incidents. LPN #2 stated on one incident Resident #3 pulled a knife on the former DON and the wound care nurse. They stated staff were able to get the knife away and sent the resident out for a psychiatric evaluation. LPN #2 stated Resident #3 had the knife hidden in their purse. On 05/28/25 at 2:07 p.m., LPN #1 stated on 02/28/25 Resident #3 was yelling at Resident #5 and Resident #4 was taking up for Resident #5. They stated the residents were separated and Resident #3 was in the former DON's office when the resident pulled out a knife and acted like they were going to stab the former DON. They stated the facility tried to get Resident #3 sent out for evaluation. 4. An admission resident assessment, dated 04/07/25, showed Resident #1 was dependent on staff for toileting hygiene and lower body dressing and required substantial/maximum assistance for oral hygiene, upper body dressing, and personal hygiene. The cognition part of the assessment was incomplete. A facility reported incident, dated 05/16/25, showed an allegation of abuse/mistreatment and an allegation of neglect involving Resident #1 and CNA #6. The reported incident showed Resident #1 stated CNA #6 was mean to them. They stated, When I push my call light the CNA comes in and says what do you want with a mean tone. The reported incident showed Resident #1 told CNA #6 they needed to be changed and CNA #6 stated, I only have to change you every [two] hours and you have to urinate more before I change you. The reported incident showed Resident #1 could only separate their legs partially and stated CNA #6 forcefully pulled their legs apart which caused a great deal of pain. The reported incident showed Resident #1 reported it was not the first time CNA #6 was mean to them and they did not feel safe with CNA #6 in the building. The reported incident showed CNA #6 was terminated effective immediately. The report was completed by the DON. A BIMS evaluation, dated 05/26/25, showed Resident #1's cognition was intact (BIMS score 15). On 05/23/25 at 10:18 a.m., Resident #1 stated they had asked CNA #6 to change them. They stated the CNA informed them We only change you every two hours. Resident #1 stated CNA #6 reported, So I'm not going to change you until five o'clock. Resident #1 stated five o'clock passed so they pushed their call light. They stated CNA #6 came in huffing and puffing and said just because they said they would change them at five did not mean they would be in right at five. CNA #6 stated, I'll change you when I get the chance. Resident #1 stated CNA #6 started hollering and pointing their finger in their face. They stated CNA #6 told them they were not the only resident they had to take care of. Resident #1 stated they left the room and slammed the door. On 05/23/25 at 10:23 a.m., Resident #1 stated CNA #6 came back shortly after and was extremely rough when they changed them. They stated the CNA held their leg down with what felt like Extreme pressure. Resident #1 stated they received a lot of fluid through a feeding tube and urinated frequently. On 05/23/25 at 10:26 a.m., Resident #1 stated the DON had spoken to them again today and asked if they were comfortable with CNA #6 returning to work. Resident #1 stated if CNA #6 did that to them, who else would they do it to. They stated they would hate to find out they mistreated a resident who was unable to speak up for themselves. On 05/23/25 at 1:15 p.m., CNA #3 stated they had been at the facility about four months and were not sure of any abuse/neglect allegations involving Resident #1. On 05/23/25 at 1:19 p.m., ACMA #1 stated they were not aware of any abuse/neglect allegations involving Resident #1. On 05/23/25 at 1:24 p.m., LPN #4 stated Resident #1 was talking with them in their room while they were completing a treatment. They stated the resident reported one of the CNAs only changed them every two hours and would fuss when they had to go in the resident's room. They stated it was a night shift aide. LPN #4 stated they reported it to the DON and were unsure of the findings of the investigation. On 05/23/25 at 1:33 p.m., the DON stated if abuse or neglect was reported to them, they would immediately suspend the staff member involved. They stated they would start the initial state reportable and if applicable notify the nurse aide registry. The DON stated they would have social services go in with a form to at least 50 percent of the residents on the hall and survey them without coaxing them. The DON stated they would then speak with staff and gather all their information before completing the final report. They stated based on the investigation findings, they determined what action to take. The DON stated in regards to the abuse allegation involving Resident #1, they went back and spoke to the resident. The DON stated based on their discussion, they did not feel it would not happen again to another resident if CNA #6 returned to work. The DON stated they terminated CNA #6. The DON stated it was their first time to complete an abuse allegation. On 05/23/25 at 1:36 p.m., the DON stated they monitored for signs of abuse such as missing money, how a resident was spoken to, the way they were cared for, and the way staff were treating residents overall. They stated if a resident stated they needed to be changed, staff were to change them. The DON stated they did not care if the resident was changed two minutes ago, even if the brief was bone dry, they stated it didn't matter because this is the resident's home not theirs. On 05/23/25 at 1:38 p.m., the DON[TRUNCATED]

On 02/24/23 at the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related to medication acquisition and storage. Resident #110 who had a diagnosis of schizophrenia and anxiety had psychoactive medications not provided and documented as on order. The MAR documented the resident did not receive some doses due to medication being on order and then documented other doses were provided. The facility did not have an accurate accounting of the psychoactive medications and what happened to them after Resident #110 was discharged from the facility. Resident #110 was admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety. The facility did not complete a baseline care plan that addressed the mental health diagnoses. The admission orders documented the resident was to receive Risperidone 1 milligram two times a day for schizophrenia and Buspirone 10 milligrams three times a day for anxiety. A review of the progress notes documented the medication was on order and not received from 01/11/23 through 01/15/23. The medication administration record documented Risperidone was not provided as ordered in the morning with notes to indicate the medication was on order. The Buspirone was not administered as ordered also with notes indicating the medication was on order. A review of the pharmacy manifest documented the facility had received 60 tablets of the Risperidone and 42 tablets of Buspirone on 01/11/23 at 11:58 p.m. On 01/15/23 Resident #110 attacked another resident pulling their hair, gouging their eyes and choking them. Resident #110 was arrested when police was called and the victim pressed charges. On 02/24/23 at 1:40 p.m., the Administrator, and Administrator #1 was notified of the existence of the immediate jeopardy. On 02/27/23 at 5:50 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 2/26/2023 1. All resident's medications that are not administered will be properly documented in the progress note and will be documented when the doctor is notified to ensure continuity of care and to prevent harm, abuse, or neglect. 2. All residents in the facility with mental health diagnosis will be audited to ensure proper medication management by ensuring medications are in the building and available to resident according physician order, if medications are not available, the pharmacy and Dr. [Name deleted] will be notified. 3. All resident's medications and orders were audited to ensure residents are receiving the care based off the physician's orders. 4. In-services will be initiated immediately for all licensed staff concerning the process of medication orders and re-ordering and medication unavailable process. 5. In-services will be initiated immediately for all licensed agency staff concerning the process of medication orders, re-ordering, medication unavailable process and missed/refused medication dosages including how to contact the pharmacy and physician of record which was posted in medication room. 6. In-services will be initiated immediately for all licensed staff concerning the process of refilling medication carts, checking in medication upon arrival, checking to see if medications are on hand and notifying pharmacy when medication needs to be refilled. 7. All staff that are not working (i.e. on leave or vacation) currently will be in serviced via phone conversation. If we are unable to be reached by phone, an email or text will be sent to the employee with a return reply to ensure it was received and understood. 8. An audit was initiated immediately and finished within 24 hours concerning medication availability, all medication carts were audited to ensure the physician orders matched the medication available and any discrepancy in medication orders were flagged, corrected and/or a licensed staff notified the physician immediately. 9.The policy on receiving medications has been updated and it is required to have ordered psychotropic medications available to residents within 4 hours. If medications are unavailable, the physician and pharmacy must be notified immediately for a medication order change from the physician or the use of emergency local pharmacy. The pharmacy will now receive a call from the admitting nurse ensuring that the medication orders have been received. 10.The pharmacy consultants will conduct MAR/ Cart audits. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 1. All residents in the facility shall receive a baseline care plan within 48 hours of admission to address the resident's POC. 2. In-services will be initiated immediately for all licensed staff concerning the baseline care plan and comprehensive care plan policy and procedure. 3. An audit will be initiated immediately and finished within 24 hours concerning new admits, readmits, new orders and the baseline care plan completion to ensure all basic care needs are being met. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 On 03/01/23 after interviews, review of all in services and documentation all components of the plan of removal had been completed and the immediacy was lifted effective 03/01/23 at 4:45 p.m. The deficient practice remained at a level of harm. Based on record review, observation and interview, the facility failed to have a system in place for ordering and accounting of medications for three (#110, #39, and #10) of 24 residents reviewed for medications. Resident #110 did not have an accurate accounting of their psychoactive medications for schizophrenia and anxiety and the facility was not able to account for the medications upon discharge from the facility. On 01/15/23 Resident #110 attacked Resident #34 pulling their hair, gouging their eyes and chocking them and was arrested. The resident census and conditions of resident's form dated 02/23/23 documented 23 residents received psychoactive medications. Findings: 1. Resident #110 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. The hospital discharge order summary dated 01/11/23 documented the resident had orders for Risperidone for schizophrenia and Buspirone for anxiety. The medication manifest dated 01/11/23, for Resident #110 documented the facility received 60 tablets of 1 mg Risperidone and 42 tablets of 10 mg Buspirone on 01/11/23 at 11:58 p.m. Resident #110 medication order summery documented the resident was to receive Risperidone 1 mg one tablet by mouth two times a day for schizophrenia, order was first written on 01/11/23; and Buspirone 10 mg three times a day for anxiety. Both orders were first written on 01/11/23, the day of admission. A review of the clinical record contained no base line care plan for the resident to address his diagnoses of schizophrenia and anxiety and the use of Risperidone and Buspirone. The MAR for January 2023 documented Resident #110 was to receive Risperidone in the morning between 9:00 a.m. and 11:00 a.m.; and again between 7:00 p.m. and 11:00 p.m. Resident #110 did not receive their Risperidone in the morning on 01/12/23, 01/13/23, 01/14/23. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their evening medication of Risperidone on 01/12/23; 01/13/23, and 01/14/15. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Risperidone was on order. The MAR for January 2023 documented Resident #110 was to receive Buspirone at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #110 did not receive their Buspirone on 01/11/23 and 8:00 p.m.; 01/12/23 at 8:00 a.m. and 2:00 p.m.; 01/13/23 at 8:00 a.m. and 2:00 p.m., and 01/14/23 at 8:00 a.m. and 2:00 p.m. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their 8:00 p.m. dose of Buspirone on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Buspirone was on order. The MAR documented the residents' medications were not provided on 01/15/23 due to being out of the facility. A report to the Oklahoma State Department of Health, dated 01/15/23, read in parts, .location facility grounds-dining area .suspected criminal act local law enforcement 01/15 .time 8:13am received report [Resident #110] arguing with [Resident #34], which led to [Resident #110] chocking [Resident #34] police arrived [Resident #110] aggressively charged the policy officers .was arrested for assault and battery . There was no documentation in Resident #110 clinical record how the resident medications were disposed of after their arrest on 01/15/23. On 02/16/23 at 3:15 p.m., the family of Resident #110 stated the facility had spoken with her after discharge and told her the medications were not provided because they were not in the facility. The family member further stated when Resident #110 was on their medications they were stable, and added the resident currently was in the process of being admitted to a psychiatric hospital due to being unstable and being suicidal. When asked how long Resident #110 had these mental health diagnoses, they stated since Resident #110 had been young. On 02/17/23 at 8:42 a.m., CMA #2 stated the facility was out of a lot of medication and they did not have them. CMA #2 then stated there was a huge problem with medications not being in the facility to provide to residents. On 02/17/2023 at 12:10 p.m., Resident #34 stated they were in the dining room and they asked Resident #110 if they had come from prison. Resident #34 then stated, [ Resident #110] had grabbed their hair, gauged the eyes and chocked them. Resident #34 also stated Resident #110 had not been at the facility not even a week there had been no problems until that day. On 02/23/23 at 1:30 p.m., the medication destruction area was observed with the DON and no medications or destruction records were located for Resident #110. The DON stated they could not find anything when observing with the surveyor. On 02/24/23 at 9:51 a.m., the DON stated they did not know if the medications were in the building or not. She stated she can only go by the documentation which stated the medications were on order. The DON then stated if the manifest said they were here they should have been provided and I cannot provide any documentation if the medications were sent with Resident #110 to jail or if they ever received them. The DON was asked about effects to Resident #110 without receiving psychoactive medication for schizophrenia and anxiety. The DON stated they could not answer that. On 02/24/23 at 11:10 a.m., the Medical Director, who was also the attending physician, stated Resident #110 would have been kept on his Risperidone and Buspirone when admitted due to them not knowing the resident. Physician #1 Stated if a resident is not receiving his psychoactive medication, they could have no effect or become more aggressive. They were asked if he was aware Resident #110 had not been receiving the medications for schizophrenia and anxiety. The Medical Director stated they did not know and had they known changes would have been looked at. The physician was made aware of the 01/15/23 incident and they stated, That was a significant occurrence and had I known I would have made changes. On 02/23/23 at 12:32 p.m., the pharmacist was asked what effects on residents not having psychoactive medications provided as ordered. The pharmacist stated, they could have more behaviors. They then stated Resident #110 would also have more anxiety without medications. The pharmacist then stated they were not aware they did not receive the medications and why it stated they were on order. The pharmacist further stated the medications had been delivered to the facility, but was not sure what happened to them afterwards. 2. Resident #39 had diagnoses which included conversion disorder with seizures. A review of the current physician's orders documented the resident had the following medications ordered for seizures: Iagabine HCL 4 mg three times a day first started 12/15/21. A review of the MAR's dated January 2023, and February 2023 contained no documentation to indicate the Iagabine had been administered since 01/29/23. A health status progress note, dated 02/20/23 at 3:59 p.m., read in parts, .will d/c Tiagabine since it is on back order over a month and will adjust the remains medication as needed . On 02/17/23 at 8:42 a.m., CMA #2 stated Resident #39 had been out of medications since the first of the year and it was for seizures. On 02/17/23 at 8:45 a.m., CMA #1 stated Resident #39 had an order for Tiagabine 4 mg for seizures and convulsions because the facility did not have the medications. The CMA then stated they did not know why the medications ran out. On 02/24/23 at 10:33 a.m., the DON stated Resident #39 was to receive all her medications and the Iagabine was not discontinued. On 02/24/23 at 11:08 a.m., the Medical Director, who was also the attending physician, stated they would have adjusted the medications to account for the missing anticonvulsant. 46216 3. Resident #10 had diagnoses which included diabetes mellitus due to underlying condition with diabetic amyotrophy, hepatitis C, and unspecified convulsions. A Physician's order for Resident #10, dated 01/26/23, read in parts, .metformin HCI oral tablet 1000 mg .Give 1000 tablet by mouth two times a day for diabetic amyotrophy . A January 2023 TAR documented six of six doses of metformin 1000 mg were not administered. A February 2023 TAR documented 56 of 56 doses of metformin 1000 mg were not administered. On 02/28/23 at 9:32 a.m., ACMA #1 was asked if Resident #10 had metformin on the cart. They stated no. On 02/28/23 at 2:35 p.m., the DON as asked if there was a physician's order for Resident #10 for metformin 1000 mg. She stated yes. She stated the order was placed on 01/26/23 and was to be given twice a day. The DON was asked if the medication had been given in January and February, she stated no it had not been given.

On 02/24/23 at the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related mental health services and treatment for Resident #110 who had a diagnosis of schizophrenia and anxiety and received psychoactive medications. Resident #110 was admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety. The facility did not complete a baseline care plan that addressed the mental health diagnoses. The admission orders documented the resident was to receive Risperidone 1 milligram two times a day for schizophrenia and Buspirone 10 milligrams three times a day for anxiety. A review of the progress notes documented the medication was on order and not received from 01/11/23 through 01/15/23. The medication administration record documented Risperidone was not provided as ordered in the morning with notes to indicate the medication was on order. The Buspirone was not administered as ordered also with notes indicating the medication was on order. A review of the pharmacy manifest documented the facility had received 60 tablets of the Risperidone and 42 tablets of Buspirone on 01/11/23 at 11:58 p.m. On 01/15/23 Resident #110 attacked another resident pulling their hair, gouging their eyes and choking them. Resident #110 was arrested when police was called and the victim pressed charges. On 02/24/23 at 1:40 p.m., the Administrator, and Administrator #1 was notified of the existence of the immediate jeopardy. On 02/27/23 at 5:50 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 2/26/2023 1. All resident's medications that are not administered will be properly documented in the progress note and will be documented when the doctor is notified to ensure continuity of care and to prevent harm, abuse, or neglect. 2. All residents in the facility with mental health diagnosis will be audited to ensure proper medication management by ensuring medications are in the building and available to resident according physician order, if medications are not available, the pharmacy and Dr. [Name deleted] will be notified. 3. All resident's medications and orders were audited to ensure residents are receiving the care based off the physician's orders. 4. In-services will be initiated immediately for all licensed staff concerning the process of medication orders and re-ordering and medication unavailable process. 5. In-services will be initiated immediately for all licensed agency staff concerning the process of medication orders, re-ordering, medication unavailable process and missed/refused medication dosages including how to contact the pharmacy and physician of record which was posted in medication room. 6. In-services will be initiated immediately for all licensed staff concerning the process of refilling medication carts, checking in medication upon arrival, checking to see if medications are on hand and notifying pharmacy when medication needs to be refilled. 7. All staff that are not working (i.e. on leave or vacation) currently will be in serviced via phone conversation. If we are unable to be reached by phone, an email or text will be sent to the employee with a return reply to ensure it was received and understood. 8. An audit was initiated immediately and finished within 24 hours concerning medication availability, all medication carts were audited to ensure the physician orders matched the medication available and any discrepancy in medication orders were flagged, corrected and/or a licensed staff notified the physician immediately. 9.The policy on receiving medications has been updated and it is required to have ordered psychotropic medications available to residents within 4 hours. If medications are unavailable, the physician and pharmacy must be notified immediately for a medication order change from the physician or the use of emergency local pharmacy. The pharmacy will now receive a call from the admitting nurse ensuring that the medication orders have been received. 10.The pharmacy consultants will conduct MAR/ Cart audits. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 1. All residents in the facility shall receive a baseline care plan within 48 hours of admission to address the resident's POC. 2. In-services will be initiated immediately for all licensed staff concerning the baseline care plan and comprehensive care plan policy and procedure. 3. An audit will be initiated immediately and finished within 24 hours concerning new admits, readmits, new orders and the baseline care plan completion to ensure all basic care needs are being met. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 On 03/01/23 after interviews, review of all in services and documentation all components of the plan of removal had been completed and the immediacy was lifted effective 03/01/23 at 4:45 p.m. The deficient practice remained at a level of harm. Based on record review, observation and interview, the facility failed to provide antipsychotic medication to a resident for one (#110) of seven residents reviewed for medications. Resident #110 did not receive his psychoactive medications for schizophrenia and anxiety. On 01/15/23 Resident #110 attacked Resident #34 pulling their hair, gouging their eyes and chocking them. The resident census and conditions of resident's form dated 02/22/23 documented 23 residents received psychoactive medications. Findings: Resident #110 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. The hospital discharge order summary dated 01/11/23 documented the resident had orders for Risperidone for schizophrenia and Buspirone for anxiety. The medication manifest dated 01/11/23, for Resident #110 documented the facility received 60 tablets of 1 mg Risperidone and 42 tablets of 10 mg Buspirone on 01/11/23 at 11:58 p.m. Resident #110 medication order summery documented the resident was to receive Risperidone 1 mg one tablet by mouth two times a day for schizophrenia, order was first written on 01/11/23; and Buspirone 10 mg three times a day for anxiety. Both orders were first written on 01/11/23, the day of admission. A review of the clinical record contained no base line care plan for the resident to address his diagnoses of schizophrenia and anxiety and the use of Risperidone and Buspirone. The MAR for January 2023 documented Resident #110 was to receive Risperidone in the morning between 9:00 a.m. and 11:00 a.m.; and again between 7:00 p.m. and 11:00 p.m. Resident #110 did not receive their Risperidone in the morning on 01/12/23, 01/13/23, 01/14/23. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their evening medications on 01/12/23; 01/13/23, and 01/14/15. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Risperidone was on order. The MAR for January 2023 documented Resident #110 was to receive Buspirone at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #110 did not receive their Buspirone on 01/11/23 and 8:00 p.m.; 01/12/23 at 8:00 a.m. and 2:00 p.m.; 01/13/23 at 8:00 a.m. and 2:00 p.m., and 01/14/23 at 8:00 a.m. and 2:00 p.m. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their 8:00 p.m. dose of Buspirone on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Buspirone was on order. The MAR documented the residents' medications were not provided on 01/15/23 due to being out of the facility. A report to the Oklahoma State Department of Health, dated 01/15/23, read in parts, .location facility grounds-dining area .suspected criminal act local law enforcement 01/15 .time 8:13am received report [Resident #110] arguing with [Resident #34], which led to [Resident #110] chocking [Resident #34] police arrived [Resident #110] aggressively charged the policy officers .was arrested for assault and battery . There was no documentation in Resident #110 clinical record how the resident medications were disposed of after their arrest on 01/15/23. On 02/16/23 at 3:15 p.m., the family of Resident #110 stated the facility had spoken with her after discharge and told her the medications were not provided because they were not in the facility. The family member further stated when Resident #110 was on their medications they were stable, and added the resident currently was in the process of being admitted to a psychiatric hospital due to being unstable and being suicidal. When asked how long Resident #110 had these mental health diagnoses, they stated since Resident #110 had been young. On 02/17/2023 at 12:10 p.m., Resident #34 stated they were in the dining room and they asked Resident #110 if they had come from prison. Resident #34 then stated, [ Resident #110] had grabbed their hair, gauged the eyes and chocked them. Resident #34 also stated Resident #110 had not been at the facility not even a week there had been no problems until that day. On 02/23/23 at 1:30 p.m., the medication destruction area was observed with the DON and no medications or destruction records were located for Resident #110. The DON stated they could not find anything when observing with the surveyor. On 02/24/23 at 9:51 a.m., the DON stated she did not know if the medications were in the building or not. She stated she can only go by the documentation which stated the medications were on order. The DON then stated if the manifest said they were here they should have been provided and I cannot provide any documentation if the medications were sent with him to jail or he ever received them. The DON was asked about effects to Resident #110 without receiving psychoactive medication for schizophrenia and anxiety. The DON stated they could not answer that. On 02/24/23 at 11:10 a.m., the Medical director, who was also the attending physician, stated Resident #110 would have been kept on his Risperidone and Buspirone when admitted due to them not knowing the resident. They stated if a resident is not receiving his antipsychotic medication, they could have no effect or become more aggressive. The Medical Director was asked if he was aware Resident #110 had not been receiving the medications for schizophrenia and anxiety. The physician stated they did not know and had they known changes would have been looked at. The physician was made aware of the 01/15/23 incident and they stated, That was a significant occurrence and had I known I would have made changes. On 02/23/23 at 12:32 p.m., the pharmacist was asked what effects on residents not having antipsychotic medications provided as ordered. The pharmacist stated, they could have more behaviors. They then stated Resident #110 would also have more anxiety without medications. The pharmacist then stated they were no aware they did not receive the psychoactive medications and why it stated they were on order.

On 02/24/23 at the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related significant medication errors. Resident #110 who had a diagnosis of schizophrenia did not receive their psychoactive medications. Resident #110 was admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety. The facility did not complete a baseline care plan that addressed the mental health diagnoses. The admission orders documented the resident was to receive Risperidone 1 milligram two times a day for schizophrenia and Buspirone10 milligrams three times a day for anxiety. A review of the progress notes documented the medication was on order and not received from 01/11/23 through 01/15/23. The medication administration record documented Risperidone was not provided as ordered in the morning with notes to indicate the medication was on order. The Buspirone was not administered as ordered also with notes indicating the medication was on order. A review of the pharmacy manifest documented the facility had received 60 tablets of the Risperidone and 42 tablets of Buspirone on 01/11/23 at 11:58 p.m. On 01/15/23 Resident #110 attacked another resident pulling their hair, gouging their eyes and choking them. Resident #110 was arrested when police was called and the victim pressed charges. On 02/24/23 at 1:40 p.m., the Administrator, and Administrator #1 was notified of the existence of the immediate jeopardy. On 02/27/23 at 5:50 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 2/26/2023 1. All resident's medications that are not administered will be properly documented in the progress note and will be documented when the doctor is notified to ensure continuity of care and to prevent harm, abuse, or neglect. 2. All residents in the facility with mental health diagnosis will be audited to ensure proper medication management by ensuring medications are in the building and available to resident according physician order, if medications are not available, the pharmacy and Dr. [Name deleted] will be notified. 3. All resident's medications and orders were audited to ensure residents are receiving the care based off the physician's orders. 4. In-services will be initiated immediately for all licensed staff concerning the process of medication orders and re-ordering and medication unavailable process. 5. In-services will be initiated immediately for all licensed agency staff concerning the process of medication orders, re-ordering, medication unavailable process and missed/refused medication dosages including how to contact the pharmacy and physician of record which was posted in medication room. 6. In-services will be initiated immediately for all licensed staff concerning the process of refilling medication carts, checking in medication upon arrival, checking to see if medications are on hand and notifying pharmacy when medication needs to be refilled. 7. All staff that are not working (i.e. on leave or vacation) currently will be in serviced via phone conversation. If we are unable to be reached by phone, an email or text will be sent to the employee with a return reply to ensure it was received and understood. 8. An audit was initiated immediately and finished within 24 hours concerning medication availability, all medication carts were audited to ensure the physician orders matched the medication available and any discrepancy in medication orders were flagged, corrected and/or a licensed staff notified the physician immediately. 9.The policy on receiving medications has been updated and it is required to have ordered psychotropic medications available to residents within 4 hours. If medications are unavailable, the physician and pharmacy must be notified immediately for a medication order change from the physician or the use of emergency local pharmacy. The pharmacy will now receive a call from the admitting nurse ensuring that the medication orders have been received. 10.The pharmacy consultants will conduct MAR/ Cart audits. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 1. All residents in the facility shall receive a baseline care plan within 48 hours of admission to address the resident's POC. 2. In-services will be initiated immediately for all licensed staff concerning the baseline care plan and comprehensive care plan policy and procedure. 3. An audit will be initiated immediately and finished within 24 hours concerning new admits, readmits, new orders and the baseline care plan completion to ensure all basic care needs are being met. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 On 03/01/23 after interviews, review of all in services and documentation all components of the plan of removal had been completed and the immediacy was lifted effective 03/01/23 at 4:45 p.m. The deficient practice remained at a level of harm. Based on record review, observation and interview, the facility failed to provide psychoactive, seizure, or diabetic medications and be free of significant medication errors for three (#110, #39 and #10) of seven residents reviewed for medications. Resident #110 did not receive his psychoactive medications for schizophrenia and anxiety. On 01/15/23 Resident #110 attacked Resident #34 pulling their hair, gouging their eyes and chocking them. The resident census and conditions of resident's form dated 02/22/23 documented 23 residents received psychoactive medications. Findings: A Medication Administration policy, revised on 03/08/23, read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the stat, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection 1. Resident #110 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. The hospital discharge order summary dated 01/11/23 documented the resident had orders for Risperidone for schizophrenia and Buspirone for anxiety. The medication manifest dated 01/11/23, for Resident #110 documented the facility received 60 tablets of 1 mg Risperidone and 42 tablets of 10 mg Buspirone on 01/11/23 at 11:58 p.m. Resident #110 medication order summery documented the resident was to receive Risperidone 1 mg one tablet by mouth two times a day for schizophrenia, order was first written on 01/11/23; and Buspirone 10 mg three times a day for anxiety. Both orders were first written on 01/11/23, the day of admission. A review of the clinical record contained no base line care plan for the resident to address his diagnoses of schizophrenia and anxiety and the use of Risperidone and Buspirone. The MAR for January 2023 documented Resident #110 was to receive Risperidone in the morning between 9:00 a.m. and 11:00 a.m.; and again between 7:00 p.m. and 11:00 p.m. Resident #110 did not receive their Risperidone in the morning on 01/12/23, 01/13/23, 01/14/23. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their evening medications on 01/12/23; 01/13/23, and 01/14/15. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Risperidone was on order. The MAR for January 2023 documented Resident #110 was to receive Buspirone at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #110 did not receive their Buspirone on 01/11/23 and 8:00 p.m.; 01/12/23 at 8:00 a.m. and 2:00 p.m.; 01/13/23 at 8:00 a.m. and 2:00 p.m., and 01/14/23 at 8:00 a.m. and 2:00 p.m. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their 8:00 p.m. dose of Buspirone on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Buspirone was on order. The MAR documented the residents' medications were not provided on 01/15/23 due to being out of the facility. A report to the Oklahoma State Department of Health, dated 01/15/23, read in parts, .location facility grounds-dining area .suspected criminal act local law enforcement 01/15 .time 8:13am received report [Resident #110] arguing with [Resident #34], which led to [Resident #110] chocking [Resident #34] police arrived [Resident #110] aggressively charged the policy officers .was arrested for assault and battery . There was no documentation in Resident #110 clinical record how the resident medications was disposed of after their arrest on 01/15/23. On 02/16/23 at 3:15 p.m., the family of Resident #110 stated the facility had spoken with her after discharge and told her the medications were not provided because they were not in the facility. The family member further stated when Resident #110 was on their medications they were stable, and added the resident currently was in the process of being admitted to a psychiatric hospital due to being unstable and being suicidal. When asked how long Resident #110 had these mental health diagnoses, they stated since Resident #110 had been young. On 02/17/23 at 12:10 p.m., Resident #34 stated they were in the dining room and they asked Resident #110 if they had come from prison. Resident #34 then stated, [ Resident #110] had grabbed their hair, gauged the eyes and chocked them. Resident #34 also stated Resident #110 had not been at the facility not even a week there had been no problems until that day. On 02/24/23 at 9:51 a.m., the DON stated she did not know if the medications were in the building or not. She stated she can only go by the documentation which stated the medications were on order. The DON then stated if the manifest said they were here they should have been provided and I cannot provide any documentation if the medications were sent with him to jail or he ever received them. The DON was asked about effects to Resident #110 without receiving psychoactive medication for schizophrenia and anxiety. The DON stated they could not answer that. On 02/24/23 at 11:10 a.m., the Medical Director, who was also the attending physician, stated Resident #110 would have been kept on his Risperidone and Buspirone when admitted due to them not knowing the resident. Physician #1 Stated if a resident is not receiving his psychoactive medication, they could have no effect or become more aggressive. He was asked if he was aware Resident #110 had not been receiving the medications for schizophrenia and anxiety. The physician stated they did not know and had they known changes would have been looked at. The physician was made aware of the 01/15/23 incident and they stated, That was a significant occurrence and had I known I would have made changes. On 02/23/23 at 12:32 p.m., the pharmacist was asked what effects on residents not having psychoactive medications provided as ordered. The pharmacist stated, they could have more behaviors. They then stated Resident #110 would also have more anxiety without medications. The pharmacist then stated they were no aware they did not receive the medications and why it stated they were on order. The pharmacist then stated this would be a significant medication error. 2. Resident #39 had diagnoses which included conversion disorder with seizures. A review of the current physician's orders documented the resident had the following medications ordered for seizures: Iagabine HCL 4 mg three times a day first started 12/15/21. A review of the MAR's dated January 2023, and February 2023 contained no documentation to indicate the Iagabine had been administered since 01/29/23. A health status progress note, dated 02/20/23 at 3:59 p.m., read in parts, .will d/c Tiagabine since it is on back order over a month and will adjust the remains medication as needed . On 02/24/23 at 10:33 a.m., the DON stated Resident #39 was to receive all her medications and the Iagabine was not discontinued. The DON asked if an anticonvulsant being missed would result in a significant medication error. The DON nodded her head up and down to indicate yes and made no additional comments. On 02/24/23 at 11:08 a.m., Physician #1 stated they would have adjusted the medications to account for the missing anticonvulsant. 46216 3. Resident #10 had diagnoses which included diabetes mellitus due to underlying condition with diabetic amyotrophy, hepatitis C, and unspecified convulsions. A Physician's order for Resident #10, dated 01/26/23, read in parts, .metformin HCI oral tablet 1000 mg .Give 1000 tablet by mouth two times a day for diabetic amyotrophy . A January 2023 TAR documented six of six doses of metformin 1000 mg were not administered. A February 2023 TAR documented 56 of 56 doses of metformin 1000 mg were not administered. On 02/28/23 at 9:32 a.m., ACMA #1 was asked if Resident #10 had metformin on the cart. They stated no. On 02/28/23 at 2:35 p.m., the DON as asked if there was a physician's order for Resident #10 for metformin 1000 mg. She stated yes. She stated the order was placed on 01/26/23 and was to be given twice a day. The DON was asked if the medication had been given in January and February, she stated no it had not been given. On 02/28/23 at 2:54 p.m., the DON and ACMA #3 were observed to look through the medication cart and stated there was no medication for Resident #3 in the medication cart. On 02/28/23 at 3:00 p.m., the DON and ACMA #3 were asked it there was any metformin for Resident #10 in the medication room. Both staff members went to the medication room, looked through his medications and stated no. DON was asked if there was any metformin for Resident #10 in the discontinued medications bin, she stated yes. Four blister packs were observed to be in the bin. One 30 count blister pack contained 4 remaining metformin pills, one 30 count blister pack contained 30 remaining metformin pills, one 30 count blister pack contained 30 remaining metformin pills, one 30 count blister pack contained 22 remaining metformin pills. On 02/28/23 at 3:05 p.m. the DON stated that the MAR was used to audit the medication carts, the medication did not appear on the MAR, so the medication was pulled from the cart.

On 03/02/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to implement interventions to prevent PU/PI development for Resident #21 who was admitted without PU/PIs, but who had multiple co-morbidities and was totally dependent on staff, placing Resident #21 at increased risk for PU/PI development; and failed to provide ongoing skin assessments for the same resident. Resident #21 developed an avoidable unstageable PU/PI on their right heel. Resident # 21 admitted on [DATE] to the facility with hospice care. Admission skin assessment documented no skin concerns to heels. Resident had a Physician's order, revised on 09/05/22 for weekly skin assessments every Sunday. Residents record documented weekly skin assessments were conducted on 10/02/22, 10/23/22, 11/13/22, 12/25, 01/08, 01/29, 02/19, and 02/26. The facility missed a total of 17 Physician's ordered skin assessments since admission. No concerns to right heel were documented in these assessments. No other documentation of PU/PI in residents record documented concerns with right heel. On 03/01/23 during observation surveyor observed a golf ball sized, dark colored area to Resident #21's right heel. On 03/02/23, LPN #1 stated Resident #21 had no skin issues other than a few scattered bruises to his abdomen. Surveyor accompanied LPN #1 into Resident #21's room to conduct a skin assessment. LPN #1 assessed Resident #21's right heel and stated He has a black spot on his right heel, I just found it. Wound care consultant verified it was an unstageable PU/PI, measuring 2 cm. by 3.1 cm. Resident #21 with co-morbidities which included diabetes type 2 and heart disease this puts the resident at a higher risk for infection, increased pain, and loss of limb. The lack of assessing, monitoring, and intervening places dependent residents at risk for avoidable PU/PI. On 03/02/23 at 4:22 p.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 03/02/23 at 4:44 p.m., the Administrator were notified of the IJ situation. On 03/03/23 at 3:36 p.m., a plan of removal was submitted to The Oklahoma State Department of Health. The plan of removal was reviewed and given acceptance to move forward with the plan of removal date of 03/03/23 at 4:00 p.m. The plan of removal sent via email documented: 1. All residents in the facility shall receive a skin sweep immediately to assess and determine a baseline for pressure injury. If a resident refuses a skin assessment it will be documented in PCC, the doctor will be notified, and the nursing staff will follow physician's order for further evaluation or treatment. 2. All residents will have an order for skin assessments upon admission, readmission and weekly thereafter. 3. In-services will be initiated by clinical staff immediately for all licensed staff including but not limited to CNAs, CMAs, LPNs and RNs regarding skin assessments and resident shower policies. 4. In-services were added to the agency in-service book located at the front reception area and all agency employees must read and sign stating they understand both policies and procedures related to resident showers and skin assessments prior to working their shift on the floor. 5. Formal Letter written and sent to Hospice Agencies informing the agency that a book of in- services and education is located in front of their hospice notebook and all licensed hospice employees must read and sign stating they understand policy and procedures related to skin assessments and resident showers prior to providing care. 6. All staff that are not working currently will be in-serviced via phone conversation. If they are unable to be reached by phone, an email or text will be sent to the employee regarding the in-service. Employees who were unable to be reached will need to complete both in-services regarding resident showers and skin assessments prior to beginning their next shift. 7. An audit was initiated immediately and finished within 2 hours concerning the current skin integrity of each resident (who allowed skin sweeps). Any findings and/or concerns were documented in PCC, the physician was notified, and the resident was added to the wound team's list for further assessment and treatment. Initiation Date: 3/2/2023 Completion Date: 4:00 PM on 03/03/2023 On 03/03/23, staff were interviewed regarding training/updates in regard to the Skin assessment policy and protocol. Staff stated they had received in person and/or phone calls from various members of administrative nursing employees and verbalized understanding of the information provided in the in-service pertaining to the plan of removal. On 03/03/23 at 4:21 p.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 03/03/23 at 4:00 p.m. The deficiency remained at a isolated level of actual harm. Based on record review, observation and interview, the facility failed to ensure: a. Weekly skin monitoring and/or weekly wound assessments were conducted and b. Adequate wound care/treatment was initiated timely for one (#21) of one sampled resident reviewed for pressure ulcers. This resulted in actual harm to Resident #21 who developed a pressure injury which worsened to an avoidable deep tissue injury. The Resident Census and Conditions of Residents form, dated 02/22/23, documented 55 residents resided in the facility. Findings: A Skin Audits by Nursing Assistants policy, revised on 03/08/23, read in parts, .It is our policy to communicate changes in skin condition to appropriate personnel as part of our systematic approach for pressure injury prevention and management. This policy establishes responsibilities of nursing assistants in communicating changes in skin condition .Nursing assistants shall inspect the skin surface during bath/shower and report to the resident's nurse immediately .Nursing assistants shall also report changes in skin condition that are noted during any care procedure . A Skin Integrity - Foot Care policy, revised on 03/08/23, read in parts, .It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice,, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot .The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from resident's medical conditions . A Skin Assessment policy, revised on 03/08/23, read in parts, .It is our policy to perform full body skin assessment as part of our systematic approach to pressure injury prevention and management .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .Documentation of skin assessment date and time of assessment .observations .type of wound .describe wound .resident refused and why .other information as indicated or appropriate . Resident #21 had diagnoses which included diabetes mellitus type 2 without complications and heart disease. A Physician's Order dated 09/05/22, documented, Perform weekly skin assessment every SUNDAY on 3-11 shift - CHART UNDER SKIN OBSERVATION TOOL. An Admission assessment dated , 09/09/22 documented Resident #21's cognition was fully intact, and they required extensive assistance with bed mobility and bathing. The assessment also documented Resident #21 had no pressure ulcers. An undated Care Plan, read in parts, .I am at risk for potential .pressure ulcer development .Follow facility policies/protocols for the prevention/treatment of skin breakdown .I need extensive assistance to turn/reposition at least every 2 hours and as needed . A Skin Observation Tool, dated 02/26/23, read in parts, .Res with scattered bruising to bilateral abd, insulin site. Bilat feet pitting, 2+ edema to BLE . On 03/02/23 at 8:01 a.m., LPN #2, was asked if Resident #21 had any skin issues. They stated he had no skin issues, only a few scattered bruises to his abdomen, heels were red and very dry skin. On 03/02/23 at 8:08 a.m., LPN #2 was asked if they could assess Resident #21's skin. LPN # stated Resident #21 had a black spot on their right heel, I just found it. LPN #2 stated I haven't done a skin assessment on him since my three days here. On 03/02/23 at 8:14 a.m., LPN #2 states they will notify wound care. They stated the only treatment was for Cetaphil to Resident #21's legs. They stated they knew his feet were red but hadn't seen a black area. On 03/02/23 at 11:22 a.m., the Wound Care Consultant observed the area, they stated it was a deep tissue injury measuring 2.0 cm by 3.1 cm. On 03/03/23 at 10:28 a.m., the DON #1 stated shower sheets were used to document the skin assessments. They stated skin assessments were ordered to be done weekly.

On 02/24/23, the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related to the facility neglecting to provide Resident #110's medications for the treatment of schizophrenia and anxiety. Resident #110 was admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety. The facility did not complete a baseline care plan that addressed the mental health diagnoses. The admission orders documented the resident was to receive Risperidone 1 milligram two times a day for schizophrenia and Buspirone 10 milligrams three times a day for anxiety. A review of the progress notes documented the medication was on order and not received from 01/11/23 through 01/15/23. The medication administration record documented Risperidone was not provided as ordered in the morning with notes to indicate the medication was on order. The Buspirone was not administered as ordered. There were notes indicating the medication was on order. A review of the pharmacy manifest documented the facility had received 60 tablets of the Risperidone and 42 tablets of Buspirone on 01/11/23 at 11:58 p.m. On 01/15/23, Resident #110 attacked another resident, pulled their hair, gouged their eyes and choked them. Resident #110 was arrested when police were called and the victim pressed charges. On 02/24/23 at 1:40 p.m., the Administrator #1, and Administrator #2 was notified of the existence of the immediate jeopardy. On 02/27/23 at 5:50 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 2/26/2023 1. All resident's medications that are not administered will be properly documented in the progress note and will be documented when the doctor is notified to ensure continuity of care and to prevent harm, abuse, or neglect. 2. All residents in the facility with mental health diagnosis will be audited to ensure proper medication management by ensuring medications are in the building and available to resident according physician order, if medications are not available, the pharmacy and Dr. [Name deleted] will be notified. 3. All resident's medications and orders were audited to ensure residents are receiving the care based off the physician's orders. 4. In-services will be initiated immediately for all licensed staff concerning the process of medication orders and re-ordering and medication unavailable process. 5. In-services will be initiated immediately for all licensed agency staff concerning the process of medication orders, re-ordering, medication unavailable process and missed/refused medication dosages including how to contact the pharmacy and physician of record which was posted in medication room. 6. In-services will be initiated immediately for all licensed staff concerning the process of refilling medication carts, checking in medication upon arrival, checking to see if medications are on hand and notifying pharmacy when medication needs to be refilled. 7. All staff that are not working (i.e. on leave or vacation) currently will be in serviced via phone conversation. If we are unable to be reached by phone, an email or text will be sent to the employee with a return reply to ensure it was received and understood. 8. An audit was initiated immediately and finished within 24 hours concerning medication availability, all medication carts were audited to ensure the physician orders matched the medication available and any discrepancy in medication orders were flagged, corrected and/or a licensed staff notified the physician immediately. 9.The policy on receiving medications has been updated and it is required to have ordered psychotropic medications available to residents within 4 hours. If medications are unavailable, the physician and pharmacy must be notified immediately for a medication order change from the physician or the use of emergency local pharmacy. The pharmacy will now receive a call from the admitting nurse ensuring that the medication orders have been received. 10.The pharmacy consultants will conduct MAR/ Cart audits. Initiation Date: 2/24/2023 Completion Date: 11:59 PM on 2/28/2023 1. All residents in the facility shall receive a baseline care plan within 48 hours of admission to address the resident's POC. 2. In-services will be initiated immediately for all licensed staff concerning the baseline care plan and comprehensive care plan policy and procedure. 3. An audit will be initiated immediately and finished within 24 hours concerning new admits, readmits, new orders and the baseline care plan completion to ensure all basic care needs are being met. Initiation Date: 2/24/2023 Completion Date: 11:59 PM on 2/28/2023 On 03/01/23 after interviews, review of all in services, and documentation, all components of the plan of removal had been completed and the immediacy was lifted effective 03/01/23 at 4:45 p.m. The deficient practice remained at a level of isolated harm. Based on record review, observation, and interview, the facility neglected to provide antipsychotic medication to a resident for one (#110) of seven residents reviewed for medications. Resident #110 did not receive their antipsychotic medications for schizophrenia and anxiety. On 01/15/23, Resident #110 attacked Resident #34, pulled their hair, gouged their eyes, and chocked them four days after admission. The Resident Census and Conditions of Resident's, form, dated 02/22/23 documented 23 residents received psychoactive medications. Findings: An Abuse, Neglect and Exploitation, policy, dated 01/01/23, read in parts, .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Resident #110 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. The hospital discharge order summary dated 01/11/23 documented the resident had orders for Risperidone for schizophrenia and Buspirone for anxiety. The medication manifest dated 01/11/23, for Resident #110 documented the facility received 60 tablets of 1 mg Risperidone and 42 tablets of 10 mg Buspirone on 01/11/23 at 11:58 p.m. Resident #110's medication order summary documented the resident was to receive: Risperidone 1 mg one tablet by mouth two times a day for schizophrenia, and Buspirone 10 mg three times a day for anxiety. Both orders were first written on 01/11/23, the day of admission. A review of the clinical record contained no baseline care plan for the resident to address his diagnoses of schizophrenia and anxiety and the use of Risperidone and Buspirone. The MAR for January 2023 documented Resident #110 was to receive risperdone in the morning between 9:00 a.m. and 11:00 a.m.; and again between 7:00 p.m. and 11:00 p.m. Resident #110 did not receive their Risperidone in the morning on 01/12/23, 01/13/23, 01/14/23. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their evening medications on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Risperidone was on order. The MAR for January 2023 documented Resident #110 was to receive Buspirone at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #110 did not receive their Buspirone on 01/11/23 at 8:00 p.m., 01/12/23 at 8:00 a.m. and 2:00 p.m.; 01/13/23 at 8:00 a.m. and 2:00 p.m., and 01/14/23 at 8:00 a.m. and 2:00 p.m. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their 8:00 p.m. dose of Buspirone on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Buspirone was on order. The MAR documented the residents' medications were not provided on 01/15/23 due to being out of the facility. A report to the Oklahoma State Department of Health, dated 01/15/23, read in parts, .location facility grounds-dining area .suspected criminal act local law enforcement 01/15 .time 8:13am received report [Resident #110] arguing with [Resident #34], which led to [Resident #110] chocking [Resident #34] police arrived [Resident #110] aggressively charged the policy officers .was arrested for assault and battery . There was no documentation in Resident #110 clinical record how the resident medications was disposed of after their arrest on 01/15/23. On 02/16/23 at 3:15 p.m., the family of Resident #110 stated the facility had spoken with them after discharge and told them the medications were not provided because they were not in the facility. The family member further stated when Resident #110 was on their medications they were stable, and added the resident currently was in the process of being admitted to a psychiatric hospital due to being unstable and being suicidal. When asked how long Resident #110 had these mental health diagnoses, they stated since Resident #110 had been young. On 02/17/2023 at 12:10 p.m., Resident #34 stated they were in the dining room and they asked Resident #110 if they had come from prison. Resident #34 then stated, [ Resident #110] had grabbed their hair, gouged their eyes and chocked them. Resident #34 also stated Resident #110 had not even been at the facility for even a week. There had been no problems until that day. On 02/23/23 at 1:30 p.m., the medication destruction area was observed with DON #1 and no medications or destruction records were located for Resident #110. DON #1 stated they could not find anything remaining medication for destruction. On 02/24/23 at 9:51 a.m., DON #1 stated she did not know if the medications were in the building or not. She stated she can only go by the documentation which stated the medications were on order. DON #1 then stated that If the manifest said they were here they should have been provided and I cannot provide any documentation if the medications were sent with him to jail or he ever received them. DON #1 was asked about possible adverse effects to Resident #110 without receiving antipsychotic medication for schizophrenia and anxiety. DON #1 stated they could not answer that. DON #1 had no comment when asked if not providing the psychoactive medications fits the definition of neglect. On 02/24/23 at 11:10 a.m., the medical director stated Resident #110 would have been kept on his Risperidone and Buspirone when admitted due to them not knowing the resident. The medical director stated that If a resident is not receiving his antipsychotic medication, they could have no effect or become more aggressive. He was asked if he was aware Resident #110 had not been receiving the medications for schizophrenia and anxiety. The medical director stated they did not know and had they known changes would have been looked at. The medical director was made aware of the 01/15/23 incident and they stated, That was a significant occurrence and had I known I would have made changes. On 02/23/23 at 12:32 p.m., the pharmacist was asked what effects on residents not having psychoactive medications provided as ordered. The pharmacist stated, they could have more behaviors. They then stated Resident #110 would also have more anxiety without medications. The pharmacist then stated they were not aware they did not receive the medications and why it stated the medications were on order.

Based on record review and interview, the facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for one (#37) of one resident reviewed for dialysis treatment. The Resident Census and Condition of Residents form, dated 02/22/23, documented two residents received dialysis services. Findings: An undated Hemodialysis policy, read in parts, .This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis .The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: The ongoing assessment of resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before .and after dialysis treatments, including .monitoring for complications, implementation of appropriate interventions .Ongoing communication and collaboration with the dialysis facility regarding care and services .The facility will monitor for and identify changes in the resident's behavior that may impact the administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes .The licensed nurse will communicate to the dialysis facility .Timely medication administration .Physician/treatment orders, laboratory values, and vital signs .Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, .after dialysis and monitoring intake and output .The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications .The facility will ensure that the physician's orders for dialysis include .The type of access for dialysis .and location .dialysis schedule .The neurologist name and phone number .dialysis facility name and phone number .Transportation arrangements to and from the dialysis facility .medication administration or withholding of specific medications prior to dialysis treatments .Any fluid restriction if ordered by the physician . Resident #37 had diagnoses which included end stage renal disease, malignant neoplasm of the urethra, embolism and thrombosis of iliac artery, ventricular fibrillation, and atrial fibrillation. A resident assessment dated , 12/02/23, documented Resident's cognition was mildly impaired and he required extensive assistance with bed mobility, transfers, toileting, and baths. No documentation of a physician's order to receive dialysis was observed in Resident #37's EHR. No documentation of a physician's order to receive before and after dialysis weights in Resident #37's EHR. No documentation of physician's orders were located for monitoring of labs and intake/output in Resident #37's EHR. A Physician Order, dated 11/30/22, read in part, .Weekly Weights one time a day every Thu . A Diet Order, dated 01/05/23, documented resident was to receive fluid restriction of 1000ml/d. The order was not place in Resident #37's EHR. On 02/23/23 at 3:19 p.m., the DON stated that prior to last week there was no communication book. Resident #37 had two Dialysis Communication Records in his dialysis binder, dated 02/22/23 and 02/28/23. An Alert Note, dated 03/01/23 at 10:43 a.m., read in parts, .Resident sister in facility at 0900 requesting that resident be sent to ER as not feeling well. Resident has missed dialysis x2, last seen on 2/21. Resident very sluggish, HR decreased. [Named} Physician notified with new order .send resident to ER . An Alert Noted, dated 03/01/23 at 3:17 p.m., read in parts, .resident has been admitted to ICU. Resident sister very upset at this nurse that I was not aware that resident did not receive dialysis on Tuesday .reason why resident had not receive dialysis .resident did not have .sling . Transfer Orders for Receiving Facility, dated 03/06/23, read in parts, .Your discharge diagnosis is: Sepsis .ESRD needing dialysis . On 03/06/23 at 12:25 p.m., LPN #1 stated their was a paper copy of an order that Resident #37 was to receive weekly weights and also on Tuesdays and Saturdays. LPN # stated that resident was not being weighed as ordered. Review of Resident #37's weights documented 48 of 54 opportunities to obtain weights were missed. On 03/06/23 at 12:27 p.m., LPN #1 stated there was no order or documentation for port care. On 03/06/23 at 12:28 p.m., LPN #1 stated there was not an order for dialysis schedule, no order for fluid restrictions, no order or documentation of monitoring intake and output. When asked if Resident #37 should have orders for monitoring output and intake, fluid restrictions, and lab monitoring.

Based on observation, record review, and interview, the facility failed to ensure an effective administration to prevent multiple system failures. A. The facility neglected to provide antipsychotic medication to a resident for one (#110) of seven residents reviewed for medications. Resident #110 did not receive his antipsychotic medications for schizophrenia and anxiety. On 01/15/23 Resident #110 attacked Resident #34 pulling their hair, gouging their eyes and chocking them four days after admission. B. The facility failed to provide bathing assistance for seven (#17, 35,42,43,163,27 and #7 ) of seven sampled residents reviewed for bathing. C. The facility failed to ensure: a. Weekly skin monitoring and/or weekly wound assessments were conducted and b. Adequate wound care/treatment was initiated timely for one (#21) of one sampled resident reviewed for pressure ulcers. This resulted in actual harm to Resident #21 who developed a pressure injury which worsened to an avoidable deep tissue injury. D. The facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for one (#37) of one resident reviewed for dialysis treatment. E. The facility failed to provide antipsychotic medication to a resident for one (#110) of seven residents reviewed for medications. Resident #110 did not receive his psychoactive medications for schizophrenia and anxiety. On 01/15/23 Resident #110 attacked Resident #34 pulling their hair, gouging their eyes and chocking them. F. The facility failed to provide psychoactive, seizure, or diabetic medications and be free of significant medication errors for three (#110, #39 and #10) of seven residents reviewed for medications. G. The facility failed to provide the daily nutritional and special dietary needs for one (#17) of one resident reviewed for special dietary need. H. The facility failed to ensure menus: A. Were followed, B. Reflect the input of resident and resident group, C. Meets the nutritional needs of the residents, and D. Were posted and accessible by residents. The Resident Census and Conditions of Residents form identified 55 residents who resided in the facility. On 03/10/23 at 2:27 p.m., the administrator #1 and administrator #2 were asked who was responsible to monitor to ensure quality of care concerns were identified and corrected. They stated, The administrator and DON. On 03/10/23 at 2:29 p.m., the administrator #1 and #2 were asked why the QA/QAPI plans had not been effective. The Administrator #1 stated, No one followed up on it. On 03/10/23 at 2:30 p.m., the administrator #1 and #2 were asked if effective monitoring was in place would administration already been aware of the quality of care concerns identified by the survey team. They stated, Yes. On 03/10/23 at 2:31 p.m., the administrator #1 and #2 were asked what type of oversight occurred for quality of care concerns identified by the survey team. The administrator #1 stated, It was identified prior to survey as administration was made aware by DON #1 on 02/01/23. The administrator #2 stated, We found out on the first and [named] DON #1 came in and the previous administrator left and administrator #1 came in.