Every finding on record at Perry Green Valley Nursing Center, LLC

Based on record review and interview, the facility failed to ensure a resident did not slide from a wheelchair onto the floor of a facility vehicle while being transported for 1 (#1) of 3 sampled residents reviewed for accident hazards. The administrator stated 61 residents resided at the facility. Findings: A facility policy titled Driving and Motor Vehicle Policy, dated 06/23/14, read in part, Driver is responsible for the safety of all passengers while providing transportation to persons to and from designated locations. If at any time the driver feels he/she is in an unsafe situation for the passenger or the vehicle, driver will have the right to exercise judgment to stop vehicle. [sic]. A care plan problem for Res #1 titled Falls, dated 10/20/23, read in part, Resident at risk for fall r/t [related to] impaired mobility, spinal stenosis, and dementia. An annual minimum data set assessment, dated 03/31/25, showed Res #1 had a brief interview for mental status score of 11 (this indicated the resident had moderate cognitive impairment). The assessment further showed the resident required assistance to stand and transfer to a chair where a staff member would supply more than half of the physical effort, the resident had impaired mobility in one lower extremity, and the resident weighed 282 pounds. A progress note, dated 05/13/25 at 10:42 a.m. (the note was a late note written on 05/14/25 at 10:44 a.m.), showed Res #1 had repositioned themselves and slid out of their wheelchair during a transport. The note further showed a 12 centimeter scratch had been observed on the resident's left buttock with no other injuries being observed. A progress note, dated 05/15/25 at 10:00 a.m., showed staff had found bruising to Res #1's left abdomen that was blue green and yellow in color. A progress note, dated 05/15/25 at 11:46 a.m., showed Res #1 complained of pain in the left lower quadrant of their abdomen that they described as an 8 on a 0 to 10 pain scale (zero represents no pain and 10 the worst pain the person had experienced). The note further showed the resident flinched when the nurse touched the resident's abdomen and an x-ray had then been ordered. A progress note, dated 05/16/25 at 11:21 a.m. (the note was a late note written on 05/20/25 at 10:10 a.m.), showed Res #1 had been sent to a hospital in a private van. A progress note, dated 05/16/25 at 4:15 p.m., showed hospital staff had contacted the facility and informed them Res #1 was moved to another hospital. A hospital Discharge summary, dated [DATE] at 4:19 p.m., showed Res #1 had been assessed at the hospital secondary to a fall in an automobile. The summary showed the resident was found to have a large left abdominal rectal sheath hematoma (a build up of blood inside a major abdominal muscle). On 05/27/25 at 9:39 a.m., CNA #1 was asked to describe the events that occurred on 05/13/25 regarding Res #1's transport. CNA #1 stated they had transported Res #1 to a physician appointment in the community. CNA #1 stated at the appointment the resident kept sliding down in their wheelchair because they would take their feet off the chair's footrests and did not sit up straight. CNA #1 stated they thought the resident was uncomfortable because they had a boot (for medical purposes) on one of their feet. CNA #1 stated they had repositioned the resident in their wheelchair at least twice at the physician's office. CNA #1 stated after the appointment they had secured the resident in the facility van and started back to the facility. CNA #1 stated while in motion on a city street they arrived at a stop sign where Res #1 stated they felt like they were slipping out of their wheelchair. CNA #1 stated they drove into a store parking lot to assist the resident, but the resident slipped out of the wheelchair onto the floor before they could get to them. CNA #1 stated Res #1 was found on the van floor wedged between their wheelchair and the van's front driver and passenger chairs. CNA #1 stated they attempted to put the resident back into their wheelchair, but was unable because of the resident's weight. CNA #1 stated they called for an ambulance and those workers were able to put the resident back in their wheelchair. CNA #1 stated the EMS staff had asked the resident if they wanted to go to a hospital, but the resident refused. CNA #1 stated they proceeded back to the facility where it took four staff members to get the resident back into the building. CNA #1 was asked how many people were supposed to transport the resident. CNA #1 stated they believed it was one. On 05/27/25 at 11:32 a.m., CNA #1 was asked about their decision to transport the resident back from their appointment after observing the residents having difficulty staying in their wheelchair. CNA #1 stated they did not feel it would be a problem since they had successfully transported the resident previously. On 05/30/25 at 11:40 a.m., LPN #1 was asked to describe what they knew of the incident where Res #1 fell in a van. LPN #1 stated CNA #1 did not report the fall to them and they found out about the fall from the resident. LPN #1 stated Res #1 had told them they had slid out of their wheelchair and that they were ok. LPN #1 stated they assessed the resident, and they found a 12 cm scratch on the resident's buttock. LPN #1 stated they did not find any other injuries on the day they fell. LPN #1 stated Res #1 had no history of sliding out of their wheelchair before that day. LPN #1 described Res #1 as a very large man On 05/30/25 at 11:54 a.m., the DON was asked what information they had regarding Res #1 sliding out of their wheelchair in a van. The DON stated they were in an interdisciplinary team meeting when the driver called and stated the resident had slid out of their wheelchair. The DON stated the driver was told to call EMS because of the resident's size. The DON stated once the resident returned to the facility LPN #1 assessed them and found a single scratch and no other injuries. The DON was asked about their thoughts on CNA #1's actions on the day Res #1 had slid from their wheelchair. The DON stated anytime a resident had a fall they expected the staff member to inform the nurse. The DON stated CNA #1 should have probably called someone for assistance once Res #1 started having trouble staying in their wheelchair at the physician's office. The DON stated Res #1 may not have slid out of their wheelchair if other staff had been there to assist during the transfer.

Based on observation and interview, the facility failed to ensure chemicals were secured for three of five halls observed. The DON identified five halls in which residents resided. Findings: On 11/04/24 at 11:39 a.m., the utility room door on hall eight was observed to be unlocked. A bottle of bleach was observed in the unlocked utility room. LPN #4 stated the door was to be closed and locked due to chemicals. On 11/04/24 at 2:44 p.m., a can of disinfectant spray and a tube of Calmoseptine was observed to be unattended on hall seven by the shower room. The disinfectant spray label documented to store the product in an area inaccessible to small children. The Calmoseptine label was observed to document to keep out of reach of children. The door to the shower room was observed to be open. A four ounce bottle of derma daily moisturizing lotion and a box of 50 germicidal disposable wipes were observed to be unsecured and unattended. The labels on the bottle of lotion and the germicidal wipes documented to keep out of reach of children. On 11/04/24 at 2:51 p.m., LPN #3 stated they were supposed to keep the door to the shower room closed and locked and the cart with disinfectant spray was not to be unsecured. On 11/05/24 at 8:05 p.m., the shower room door on hall one was observed to be ajar, unattended, and the key in the door knob. The following items were observed to be unsecured and unattended in the shower room: a. one, four ounce bottle of ultra sure antiperspirant and deodorant. The label documented to keep out of reach of children; b. two, 11 ounce cans of shaving cream. The label documented to keep out of reach of children; and c. four, four ounce bottles of derma daily moisturizing lotion The label documented to keep out of reach of children. On 11/05/24 at 8:08 p.m., the utility room on hall one was observed to be unlocked and unattended. Two, 3.78 liter bottles of bleach were observed unsecured in the utility room. On 11/05/24 at 8:21 p.m., LPN #1 walked by and closed the door. The key to the door was observed to remain in the door knob. On 11/05/24 at 8:28 p.m., LPN #2 stated the door to the utility room was to be kept closed and locked. On 11/05/24 at 8:34 p.m., the utility room on hall seven was observed to be unlocked. The following items were observed to be unsecured in the utility room: a. one gallon bottle of disinfectant cleaner; and b. one bottle of disinfectant with approximately half an inch of liquid. On 11/05/24 at 8:38 p.m., LPN #2 arrived to the utility closet and stated the utility closet was to be closed and locked. On 11/06/24 at 4:57 p.m., the DON stated utility rooms and shower rooms were to be locked to ensure chemicals were secured.

Based on record review and interview, the facility failed to ensure arbitration agreements documented a location agreed upon by both parties. The administrator identified 63 residents who had signed binding arbitration agreements. Findings: The Mediation and Arbitration Agreement, dated 02/05/1951, read in part, Such mediation will be held in Tulsa or Oklahoma County, Oklahoma in a place agreed to by the parties On 11/06/24 at 3:36 p.m., the administrator stated arbitration would take place in either Tulsa or Oklahoma county. The administrator stated if Tulsa or Oklahoma county was not agreed upon by both parties they thought they could change to another location. The administrator stated they did not know why the arbitration agreement did not indicate arbitration could occur in a location agreeable to both parties.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for the use of bed rails prior to installation for four (#17, 30, 115, and #55) of four sampled residents who were reviewed for bed rails. The DON identified 24 residents who utilized bed rails. Findings: 1. Resident #17 had diagnoses which included Parkinson's disease. A physician order, dated 11/02/23, documented half side rails bilaterally for bed mobility. The Care Plan, dated 10/03/24, read in part, 1/2 side rails bilat upper bed for self repositioning. On 11/04/24 at 11:35 a.m., Resident #17's bed was observed to contain half side rails bilaterally. Review of the electronic clinical record did not reveal a consent had been completed for the use of bed rails. 2. Resident #30 had diagnoses which included muscle weakness. A physician order, dated 09/18/24, documented the resident may use half bed rails for position/mobility. Review of the care plan did not reveal the use of the bed rails. Review of the clinical record did not reveal a consent had been completed for the use of bed rails. On 11/04/24 at 11:31 a.m., Resident #30 was observed in bed with half side rails in the up position bilaterally. 3. Resident #115 had diagnoses which included atrial fibrillation. The Baseline Care Plan, dated 10/28/24, did not document the use of half bed rails. Review of the electronic clinical record did not reveal a physician order or consent for the use of bed rails. On 11/04/24 at 1:12 p.m., Resident #115 was observed in bed with half side rails in the up position bilaterally. 4. Resident #55 had diagnoses which included chronic kidney disease. Review of the care plan did not reveal the use of the bed rails. Review of the clinical record did not reveal a consent had been completed for the use of bed rails or a physician's order had been obtained. On 11/04/24 at 2:43 p.m., the resident's bed was observed to have bilateral half bed rails. On 11/06/24 at 11:37 a.m., the DON stated they obtained physician's orders for the use of bed rails, bed rails were applied to the bed, and residents were then assessed for the use of the bed rails. The DON stated they did not obtain consents for the use of bed rails because they were not used as a restraint. The DON stated orders for bed rails for Resident #115 and Resident #55 had not been obtained. 41809

Based on observation, record review, and interview, the facility failed to ensure residents were offered snacks for one (bedtime) of one snack time observed. The DON identified 63 residents who received nourishment from the kitchen. Findings: The undated Resident Meals/Snacks policy, read in part, Staff will pass out optional snacks to residents in-between meals. Residents may also request snacks or simple meals (soups, sandwich, etc.) after dining room hours. On 11/05/24 at 1:37 p.m., seven residents in the resident council meeting stated they were not offered bedtime snacks. On 11/05/24 at 8:04 p.m., the dietary staff were observed in the kitchen. A tour of the facility's nurses stations and resident rooms did not reveal snacks had yet been provided. On 11/05/24 at 8:13 p.m., cook #1 was observed to take a bowl with snacks in it to hall eight. On 11/05/24 at 8:39 p.m., Resident #18 requested a sandwich, chips, and a snack cake from a CNA. Resident #18 stated staff did not offer snacks, but they would ask for them for themselves and their roommate. On 11/05/24 at 8:43 p.m., CMA #1 stated they usually passed out snacks after evening medications were administered. CMA #1 was asked what snacks they had to offer to residents. They stated they had been provided five sandwiches, five bags of chips, and five snack cakes for hall eight. On 11/05/24 at 8:45 p.m., LPN #1 stated they had 24 residents on hall eight. On 11/05/24 at 8:47 p.m., Resident #9 was watching television in their room. They stated they were not offered snacks at bedtime and had not been offered a snack tonight. On 11/05/24 at 8:51 p.m., LPN #1 stated they no longer had access to the kitchen. They stated the other charge nurse may have a key. On 11/05/24 at 8:56 p.m., LPN #2 stated they did not have a key to access the kitchen. On 11/06/24 at 12:23 p.m., cook #1 stated they made approximately six sandwiches, six bags of chips, and six snack cakes for the overnight snacks. They stated they had thought the nurses could get into the kitchen for additional snacks if needed after the kitchen was closed. On 11/06/24 at 12:34 p.m., the dietary manager stated they provided hearty snacks at 8:00 p.m. They stated they had a snack list they followed. They stated they made six sandwiches, six bags of chips, and six cookies in case a resident wanted something overnight. The dietary manager stated if additional food was needed they kept bread and peanut butter in the pantry on the hall. They stated the nursing staff did not have access to the kitchen once it was closed. On 11/06/24 at 12:47 p.m., the DON stated the CMAs were responsible to pass out the snacks provided by the dietary department. The DON stated some residents have scheduled snacks and some residents requested snacks from the staff.

Based on observation, record review, and interview, the facility failed to: a. ensure control measures and testing protocols were in place for monitoring for the potential presence of water-borne pathogen such as Legionella; and b. follow the enhanced barrier precautions policy for a resident on precautions for one (#6) of 16 sampled residents reviewed for infection control. The administrator identified 63 residents resided in the facility. Findings: An Infection prevention and control program policy, revised July 2024, read in part, Water Management: a. Control measures and testing protocols are in place to address potential hazards associated with the facility's water system. An Enhanced Barrier Precautions policy, revised April 2024, read in part, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy also read, '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. The policy also read, All staff receive training on enhanced barrier precautions and high-risk activities upon hire and at least annually. The policy also read, Enhanced barrier precautions (EBP) are indicated for residents with any of the following: wounds .Indwelling medical devices .Infection or colonization. 1. On 11/05/24 at 4:32 p.m., the DON stated they did not know what was in place for prevention of Legionella. On 11/05/24 at 4:40 p.m., the DON stated they spoke with maintenance and they did not know about Legionella. On 11/06/24 at 8:36 a.m., the maintenance director stated they did not check for waterborne pathogens or bacteria. They stated they were not aware of any water testing being done. They stated they did not monitor the water system. They stated the only thing they checked was the water temperature and they knew where the shut off valves were. They stated they did not have a map of the water system. They stated they did not know if any areas of stagnant water concern. They stated they know where to look for leaks based on the location of the valves. 2. Resident #6 had a diagnosis of pressure ulcer stage 3 to left elbow. On 11/06/24 at 9:35 a.m., the wound care nurse was observed during provision of wound care to Resident #6's elbow. The nurse had a nursing student present to assist during the treatment. There was signage on the door for EBP. On 11/06/24 at 9:45 a.m., the wound care nurse was observed to remove the dressing from the residents elbow. They did not have on a gown. On 11/06/24 at 9:46 a.m., the wound care nurse put on the gown after removing the dressing. The nursing student was instructed to hold the resident's arm up while the wound care nurse performed the treatment. The nursing student was not observed to wear a gown. On 11/06/24 at 9:51 a.m., the wound care nurse stated gown and gloves were required for EBP. They stated the requirements for EBP were for anybody that would have close contact with the wound. They stated close contact meant dressing changes, clothing changes, or anything that could get drainage on them. They stated the nursing student did not have on the required PPE and should have since they held the resident's arm. The wound care nurse also stated they should have put on the gown before starting the treatment. 45583

Based on observation, interview, and record review, the facility failed to ensure resident beds were maintained and monitored for the use of bed rails for four (#17, 30, 115, and #55) of four sampled residents who were reviewed for bed rails. The DON identified 24 residents who utilized bed rails. Findings: The Bed Safety and Bed Rails policy, dated August 2022, read in part, Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. 1. Resident #17 had diagnoses which included Parkinson's disease. On 11/04/24 at 11:35 a.m., Resident #17's bed was observed to contain half side rails bilaterally. 2. Resident #30 had diagnoses which included muscle weakness. On 11/04/24 at 11:31 a.m., Resident #30 was observed in bed with half side rails in the up position bilaterally. 3. Resident #115 had diagnoses which included atrial fibrillation. On 11/04/24 at 1:12 p.m., Resident #115 was observed in bed with half side rails in the up position bilaterally. 4. Resident #55 had diagnoses which included muscle weakness and history of falling. On 11/04/24 at 2:43 p.m., the resident's bed was observed to have bilateral half bed rails. On 11/06/24 at 11:38 a.m., the maintenance supervisor stated they installed bed rails as directed by the DON. They stated they repaired bed rails as needed based on staff reports, but did not provide routine safety inspections of the residents' beds or bed rails.

Based on record review, observation, and interview the facility failed to ensure care plans were updated to include the use of a full body mechanical lift for two (#6 and #7) of three sampled residents who required the use of a full body mechanical lift for transfers. The DON identified eight residents who required the use of a full body mechanical lift for transfers. Findings: Resident #6's care plan for ADLs, dated 07/22/21, read in parts, .extensive 2 person assist for .transfers . A quarterly assessment for resident #6, dated 04/19/22, documented the resident's cognition was severely impaired and was dependent on staff for transfers. Resident #7's care plan for ADLs, dated 09/24/21, read in parts, .extensive 2 person assist for .transfers . A quarterly assessment, dated 03/11/22, documented the resident's cognition was intact and the resident was dependent on staff for transfers. On 05/18/22 at 3:39 p.m., CNA #3 identified resident #6 and #7 as residents who needed to be transferred using the full body mechanical lift. On 05/20/22 at 11:02 a.m., resident #7 was observed in a geri chair with a full body lift sling under them. At 11:14 a.m., the DON stated the care plan for resident #6 and #7 had not been updated to include the use of a full body mechanical lift during transfers. The DON was asked how the staff would know how to transfer the residents if it was not on the care plan. The DON stated they would get the information in report before they started their shift.

Based on record review and interview the facility failed to ensure a resident was transferred with the full body mechanical lift for one (#5) of three sampled residents who required the use of a full body mechanical lift for transfers. The DON identified eight residents who required the use of a full body mechanical lift for transfers. Findings: The facility's policy for Lifting Machine, Using a Mechanical, dated 07/2017, read in parts, .Mechanical lifts may be used for tasks that require .transferring a resident from bed to chair .Lateral transfers . An annual assessment for resident #5, dated 03/17/22, documented the resident had severe cognitive impairment with daily decision making and required extensive assistance for transfers. Resident #5's care plan for ADLs, updated 07/25/21, read in parts, .Resident extensive to total assist for most ADLs .Total 2 person assist for transfers via full lift . An incident report, dated 04/05/22, read in parts, .Resident not in w/c sitting Back .slid out of w/c .CNA's on hall .lowered to floor . On 05/19/22 at 7:24 a.m., CNA #2 stated resident #5 required the use of a full body mechanical lift for transfers. CNA #2 was asked if resident #5 had a fall while being transferred. CNA #2 stated yes, about a month ago, they heard a new employee was trying to transfer the resident without using the mechanical lift. At 9:57 a.m., LPN #1 was asked if resident #5 had fallen during a transfer. LPN #1 stated they had heard that happened. At 5:45 p.m., CNA #1 was asked if they had ever transferred resident #5 without using the full body mechanical lift. CNA #1 stated yes. CNA #1 stated they were trying to transfer resident #5 using the gait belt and resident #5 had to be lowered to the floor. CNA #1 stated the incident was reported to LPN #2 and the other staff on duty knew about the incident. CNA #1 was asked if they knew resident #5 required the mechanical lift for transfers. CNA #1 stated yes, and stated they had called for help but no other staff came to help. At 10:04 a.m., LPN #2 stated resident #5 required the use of a mechanical lift for transfers. LPN #2 was asked about the incident report dated 04/25/22. LPN #2 stated they did not recall what had happened. LPN #2 stated whatever the incident report documented was what happened. LPN #2 was asked if they were aware of resident #5 being transferred without using the mechanical lift and then lowered to the floor. LPN #2 stated they did not recall that incident. On 05/20/22 at 11:07 a.m., the DON stated resident #5 required the use of a full body mechanical lift. The DON stated when a full body mechanical lift was used it required two staff members.

Based on observation, record review, and interview, the facility failed to ensure medications were not held without a physicians' order for one (#15) and a medication was available to be administered for one (#48) of 15 sampled residents observed during medication pass observation. Findings: A policy and procedure, titled, Administering Medications revised April 2019, read in part, .Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . 1. Res #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #15's Physician Order Report', dated 02/14/22 to 03/14/22, documented the resident was to receive [MEDICATION(S)] 25mg extended release, and Losartan 100mg daily at 9:00 a.m. for hypertension. 2. Res #48 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #48's Physician Order Report, dated 02/14/02 to 03/14/22, documented, [MEDICATION(S)] Tears Severe ointment 94-3 %, apply thin ribbon to both eyes three times a day. Dx: Recurrent erosion of cornea, right eye. On 3/9/22 at 1:57 p.m., during medication pass observation, CMA #1 stated, Res #48's tears were not in stock, the medication was not available. On 03/14/22 at 8:33 a.m., during medication pass observation, CMA #1 obtained Res #15's B/P, result documented as 136/52 and pulse 60. She notified LPN #1 of B/P result. LPN #1 instructed CMA #1 to hold Res #15's [MEDICATION(S)] and losartan medications. No physician orders to hold medications were in place at that time. On 03/14/22 at 11:21 a.m., LPN #1 was asked what B/P medications were held for Res #15 this morning. She replied, her [MEDICATION(S)] and Losartan. LPN #1 was asked if there were physician orders or parameters to hold these medications. She stated, No, I don't believe there are. I was going to call the physician and get them. I charted I held them. On 03/14/22 at 1:05 p.m., LPN was asked if she had parameters for all B/P medications. LPN #1 stated, Yes, all but the HCTZ. She takes that for a diuretic. LPN #1 was asked if she had rechecked the resident's blood pressure after she received the physician's order. She stated yes it was 130/74 right after I received the parameter order about 1210 p.m. LPN #1 was asked if she administered the medications that were held. LPN #1 stated No, held until tomorrow. On 03/14/22 at 4:29 p.m., the DON was asked what the standard practice was to notify the physician when a medication is held. She stated within 24 hours. On 03/14/22 at 4:29 p.m., the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked if Res #48 should have missed those doses as documented. She stated, No, there should be a weeks' supply in the house.

Based on observation, record review, and interview, the facility failed to implement infection prevention/control protocols by ensuring catheter bags were not on the floor, gloves were changed as indicated during provision of incontinent care, and ensure catheter care was provided as an intervention to prevent [CONDITION(S)]'s for two (#28 and #37) of two sampled residents for catheter care. The DON identified two residents with Foley catheters. Findings: A policy and procedure, titled, Catheter Care, Urinary revised September 2014, read in part .The purpose of this procedure is to prevent catheter-associated urinary tract infections .review the resident's care plan to assess for any special needs of the resident .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor . 1. Resident #28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 01/26/22, documented, resident #28 had moderate cognitive impairment, and required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. Res #28's Care Plan, read in part, .01/19/22 .Resident requires an indwelling urinary catheter R/T urinary retention .Do not allow tubing or any part of the drainage system to touch the floor .Store collection bag inside a protective dignity pouch .provide catheter care Q shift . A Resident Progress Note, dated 03/11/22 at 4:38 a.m., read in part, .Noted with tea-colored to greenish discoloration UO from catheter, decreased output also noted for this shift . A Resident Progress Note, dated 03/11/22 at 11:17 a.m., read in part, .[Nurse practitioner] w/ new telephone order to obtain UA with C&S if indicated d/t resident w/decreased output, tea colored urine, and purulent DC from cath site per night nurse . A Resident Progress Note, dated 03/11/22 at 1:34 p.m., read in part, .Cath clamped approx. 1 hour ago and UA obtained at this time .Urine appeared yellow and cloudy w/thick [MEDICATION(S)] . A Resident Progress Note, dated 03/14/22 at 5:01 a.m., read in part, .Received UA C&S final result as follows: >100,000 cfu/ml of Morganella morganii Carbapenem resistant enterobacteriaceae, resistant organism, contact precaution needed . On 03/14/22 at 09:38 a.m., Res #28 was observed sitting in her recliner, the resident's catheter bag was observed on the floor. Urine is straw color with white sediment in tubing, there is no dignity bag observed over the catheter bag. Res #28 stated, I have a [CONDITION(S)], they are doing the labs to see what I have to take. Res #28 was asked if she was having any pain in her vaginal area. She stated, yesterday I coughed and there was pain down there. She stated she did not have any pain today. She was asked how often she received catheter care. She stated, I don't think it is daily. On 03/14/22 at 10:35 a.m., LPN #1 was asked to observe the resident's #28 catheter. She was asked where the resident's #28 catheter bag was located. She stated, Looks like it's on the floor. LPN #1 was asked where should it be. She stated it should be hung to flow to gravity. LPN#1 was asked if it should be covered with a dignity bag. She stated, At all times. LPN #1 was asked if it was an infection control issue related to the catheter bag lying on the ground. She stated, Yes mam. LPN #1 entered the resident's room and hung the catheter bag on the side of the recliner. On 03/14/22 at 1:47 p.m., LPN #1 was asked if she had completed the catheter/pericare today for the resident #28. She stated, The aides do that. LPN #1 pointed to CMA #2 who was walking towards the nurses desk. CMA #2 was asked if she had completed catheter care on Res #28. She stated, yes when we got her up. She was asked when it would be completed again. She stated when the resident #28 feels like she needs to have a bowel movement. On 03/14/22 at 1:50 p.m., the resident was asked if staff had done catheter care on her today. She stated, No, I think I have had it done twice in the past month. On 03/10/22 at 1:58 p.m., RN #1 was asked if the resident had any [CONDITION(S)]'s. She stated no, not here. On 03/14/22 at 3:50 p.m., the DON was asked who was supposed to be performing catheter care. She stated, The charge nurses. 2. Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 02/03/22, documented Res #37 had moderate cognitive impairment, and needed extensive assistance with bed mobility, transfers, and toilet use. Resident #37's Care Plan read in part .01/27/22 .Resident requires an indwelling urinary catheter R/T DIFFICULTY URINATING .Do not allow tubing or any part of the drainage system to touch the floor .Store collection bag inside a protective dignity pouch .provide catheter care Q shift . A urine sample was obtained on 03/05/22. A lab report (urine culture), dated, 03/09/22 read in part .Organism 1 .Proteus Mirabilis >1000,000 COL/ML . On 03/09/22 at 08:16 a.m., 11:08 a.m., and 12:29 p.m., Res #37's catheter bag was observed on the floor near his bed. No dignity bag was covering the catheter bag. On 03/09/22 at 12:41 p.m., CNA #1 was asked where Res #37's catheter bag was. CNA #1 bent over and pulled the catheter bag out from under the bed. She was asked if it was on the floor. She stated,Yes. No dignity bag was covering the catheter bag. On 03/10/22 at 10:05 a.m., CNA #2 was observed providing peri care for Res #37. Res #37 was lying on his back, CNA #2 was observed wiping/cleaning feces toward Res #37's testicles in an upward motion. She did not change her gloves and continued to roll the resident and change his sheets. CNA #2 assisted another staff member to put a sling under the resident and transferred the resident to a Geri-chair. Catheter care was not observed prior to transferring the resident to his Geri-chair. CNA #2 then removed her gloves into the trash and donned clean gloves. On 03/10/22 at 10:25 a.m., CNA #2 was asked if she changed her gloves after performing peri care and prior to putting new sheets on the bed. She replied, yes. On 03/14/22 at 1:43 p.m., Res #37 was asked if the staff had completed his catheter/peri care today. Res #37 stated he was not sure what the question meant. Res #37 was then asked if the staff had cleaned his penis area and around the catheter site. Res #37 stated, They ain't never done that.

Based on record review, observation, and interview, the facility failed to ensure resident representatives were notified of skin tears for one (#44) of one sampled resident who was reviewed for notification of change, and failed to consult with the physician before a significant blood pressure medication was held for one (#15) of 15 sampled residents observed during the medication pass. The facility identified five residents who had skin tears. The DON identified 49 residents resided in the facility and received medications. Findings: A policy and procedure, titled, Administering Medications revised April 2019, read in part, .Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An event and progress note, dated 03/06/22, documented the resident had a skin tear to his right second toe and had voiced he had ran over his toe with his wheelchair. The note documented the area was measured and cleaned. On 03/09/22 at 09:12 a.m., the resident stated he cut his right second toe on the wheelchair. He stated the wheelchair had been repaired by a maintenance employee. The resident pulled his sock off and a Band-Aid was observed on his second toe. He was asked how often the staff checked on it and applied bandages. He stated the nurse was supposed to come in and check on it. On 03/14/22 at 09:56 a.m., the resident's clinical record was reviewed and did not reveal the resident's responsible party had been notified of the skin tear injury. On 03/14/22 at 10:24 a.m., LPN #2 was asked who notified the resident's responsible party when the resident had a change such as a skin tear injury. She stated the charge nurse. The nurse was asked where the notification was documented; and stated in the progress notes. LPN #2 was asked why the resident's responsible party/family was not notified of the skin tear injury; and stated she did not know. On 03/14/22 at 10:42 a.m., the DON was asked who was responsible to notify the resident's representative of a change in condition; and stated the charge nurse. The DON was asked why they were not notified on the resident's skin tear; and stated the charge nurse did not notify them and it was missed. Res #15 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/14/22 at 8:33 a.m., during medication pass observation, CMA #1 obtained Res #15's B/P, result was 136/52 and pulse 60. LPN #1 instructed CMA #1 to hold Res #15's [MEDICATION(S)] and losartan medications. No orders to hold medications were in place at that time. A Resident progress note, dated 03/14/22 at 9:49 a.m., read in part .Held BP meds this am d/t pulse 60 and BP 136/52 . On 03/14/22 at 11:21 a.m., LPN #1 was asked what B/P medications were held for Res #15 this morning. She stated, her [MEDICATION(S)] and Losartan. LPN #1 was asked if there were physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I was going to call the physician and get them. I charted I held them. On 03/14/22 at 4:29 p.m., the DON was asked what the standard practice was to notify the physician when a medication is held; and stated, that day or within 24 hours.

Based on observation, record review, and interview, the facility failed to ensure physician's orders were obtained and completed for a skin tear injury for one (#44) of one sampled resident who was reviewed for a non pressure skin condition. The facility identified five residents who had skin tears. Findings: Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An event and progress note, dated 03/06/22, documented the resident had a skin tear to his right second toe and had voiced he had ran over his toe with his wheelchair. The note documented the area was measured and cleaned. On 03/09/22 at 09:12 a.m., the resident stated he cut his right second toe on the wheelchair. They stated the wheelchair had been repaired by a maintenance employee. The resident pulled his sock off and a adhesive covering was observed on his second toe. Resident #44 was asked how often the staff checked on it and applied bandages. He stated the nurse was supposed to come in and check on it. On 03/10/22 at 2:23 p.m., LPN #3 observed the right foot and removed the bandage on his second toe. Dried blood was observed around the toe. The LPN left the room to get supplies for toe treatment. On 03/10/22 at 2:23 p.m, LPN #3 checked the electronic clinical record and stated the resident had ran over it with a wheelchair. The nurse stated there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/10/22 at 2:45 p.m., LPN #3 and LPN #4 performed the skin treatment to the resident's toe. They were asked if either of them had dressed or monitored his toe since 03/06/22 when the injury had occurred. They both stated no. On 03/14/22 at 10:22 a.m., LPN #2 stated the facility's protocol if a resident developed a skin tear was to assess the area, provide basic first aid, notify the physician for new orders, notify the resident's family, and document in the event and progress note area of the electronic record. On 03/14/22 at 10:22 a.m., LPN #2 was asked if she knew why the physician had not been notified regarding the skin tear injury. The nurse stated they did not know the physician had not been notified regarding the skin tear injury; and thought the notification may have occurred during shift change but had not be done. On 03/14/22 at 10:50 a.m., the DON was asked what the protocol was when a resident developed a skin tear. She stated the nurse is to assess, find out what occurred, document a progress note, contact the physician for treatment orders, and update the electronic record with any new orders received. On 03/14/22 at 10:50 a.m., the DON stated she was responsible to ensure treatment orders were obtained when a resident developed a skin tear. She stated usually in the daily meeting she reviewed the incident reports, new orders, and events documented in the electronic record. On 03/14/22 at 10:50 a.m., the DON stated the nurse told her that she had gotten really busy and forgot to contact the physician on 03/06/22. The DON stated she herself had missed the daily meeting on 03/07/22 and the ADON and MDS coordinator had filled in on that day.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident did not experience an avoidable decrease in range of motion which led to contractures of both hands for one (#3) of three sampled residents whose records were reviewed for contractures and a decline in range of motion. This resulted in an actual harm to the resident. The resident experiencing bilateral hand contractures and a decline in the ability to feed herself and a pressure ulcer in the palm of her left hand. The facility identified four residents who had contractures. Findings: A facility policy titled, Resident Mobility and Range of Motion, dated 07/2017, documented: .Residents will not experience an avoidable reduction in range of motion (ROM) .Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM .Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including .contractures .other complications that could cause or contribute to immobility, impaired ROM . Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not have limited range of motion or contractures on admission to the facility. A care plan, dated 05/12/18, documented the resident required limited to extensive assistance for most activities of daily living (ADL). A quarterly assessment, dated 01/11/21, documented the resident had severe cognitive impairment, required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. The resident was dependent on staff for bathing, required supervision and set up assistance for meals and ambulated with the use of a walker and wheelchair. The assessment documented the resident did not have functional limitation in range of motion, and had not received physical and/or restorative therapy within the seven days of the seven day look back period. A nurse's progress note, dated 02/26/21, documented the resident's left hand was assessed and all fingers were contracted and the nurse was not able to open the left hand or place a hand roll between her fingers. A nurse's progress note, dated 03/11/21, documented the resident's fingernails were pressing into the palm of the resident's left hand. The note documented the nurse opened the resident's hand enough to trim the resident's fingernails and place a hand roll. A nurse's progress note, dated 03/31/21, documented the resident's left index, middle, ring and little finger were contracted into the palm of the hand and a wound was observed to the palm. A care plan, dated 04/05/21, documented the resident had bilateral contractures to the hands. The intervention documented to keep palm pillow in hand as directed by the physician. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change assessment, dated 04/12/21, documented the resident had severe cognitive impairment, required extensive assistance with bed mobility, transfers, dressing, personal hygiene and toileting. The resident required limited physical assist of one person for meals and utilized a walker and wheelchair for mobility. The assessment documented the resident had functional limitation in range of motion to both upper extremities, and received occupational therapy from 03/31/21 to 04/05/21. The resident received passive range of motion two days of the seven day look back period. On 04/23/21 at 10:35 a.m., the resident's left hand was observed wrapped with kerlix and her right hand was closed with no hand roll in place. At 10:37 a.m., the DON (director of nurses) was asked about the dressing on the resident's hand. She stated the resident's left hand was contracted and she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 04/27/21 at 10:33 a.m., the resident was sitting in her room her left hand was observed wrapped in kerlix. She did not have a hand roll in her right hand. At 10:39 a.m., certified nurse aide (CNA) #2 was asked about the resident's hands. She stated the resident's hands had gotten worse since she was moved off the hall she was on before COVID-19. She also stated the resident could pull her fingers open in the past but could not open them now. At 11:13 a.m., LPN #1 stated the resident's wound on her left hand was healed and she had orders to do a dressing change for preventative measures. She was observed while she changed the dressing to the resident's left hand. She cleansed the hand with wound wash, applied [MEDICATION(S)] swab and wrapped gauze between fingers and put hand roll in place and wrapped with kerlix. She did not follow the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She used iodine on the hand and placed a hand roll instead of the double rolled wash cloth. The resident's right hand was observed closed without a hand roll in place. She was asked if the resident was supposed to have a hand roll in her right hand. She stated yes. She was asked how long the resident's hands had been contracted. She stated the resident's hands had been contracted since she had started working there approximately 8 months. She stated they were getting worse. On 04/28/21 at 11:26 a.m., restorative aide #1 was asked if he had provided restorative therapy prior to 03/01/21. He stated the last time she received restorative services was sometime before the facility went to electronic charting before 2019. At 12:10 p.m., the resident's family member was asked about the resident's hands. She stated the resident's hands were not contracted in March of 2020. She stated she visited the resident in person in February of 2021 and observed her hands contracted, nails long and pressing into the palms. She was asked if the resident had hand rolls in her hands at the time of her visit. She stated no. The family member then stated she visited on or around 03/17/21 and took a picture of the resident. The picture was dated 03/17/21 and showed the resident's hands closed with no hand rolls or other devices in place. The resident's family member was asked about therapy for the resident's hands. She stated she did not want therapy stopped but she did want hospice services. At 1:00 p.m., the certified occupational therapy assistant (COTA) was asked about the resident's hands. She stated the resident was evaluated on 03/31/21 for occupational therapy. She stated the resident's left hand was contracted and she was able to get the hand opened and the hand was macerated (Maceration occurs when skin has been exposed to moisture, the skin looks soggy, feels soft or appears whiter than usual and may have a white ring around the wound indicating it has had exposure to drainage,) and had a wound in the palm of her hand. She was asked if the resident had a hand roll or other device in place to her left hand at the time of the evaluation. She stated no. She was asked about the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The COTA was asked if the resident received therapy at this time. She stated no, it was stopped because the family wanted the resident put on hospice services. She was asked if the resident could have therapy while she was on hospice. She stated yes.

Based on interview and record review, it was determined the facility failed to: ~ensure a resident with hand contractures received fingernail care; and ~ensure preventative measures had been implemented for a resident with hand contractures to prevent the development of a pressure ulcer. For one (#3) of two sampled residents who were observed and records reviewed for nail care with hand contractures and pressure ulcers. Findings: A facility policy titled, Fingernails/Toenails, Care of, dated 02/2018, documented: .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and prevent infections .Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .Documentation .The following information should be recorded in the resident's medical record .Any difficulties in cutting the resident's nails .Any problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure .If the resident refused the treatment, the reasons why and the intervention taken . A facility policy titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated 04/2018, documented: .The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility .the nurse shall describe and document/report the following .residents mobility status .current treatment including support surfaces . 1. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was cognitively impaired and required extensive assistance of one to two staff members for activities of daily living. A care plan, dated 05/17/18, documented the resident was at risk for pressure ulcers. A nurse's progress note, dated 02/26/21, documented the resident's left hand was assessed and all fingers were contracted and the nurse was not able to open left hand or put a hand roll in between fingers. The DON (director of nurses) stated all residents had skin assessments and nail care on their bath days. The resident's clinical record was reviewed. There were no new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's progress note, dated 03/11/21, documented the resident's fingernails were pressing into the palm of the resident's left hand. The note documented the nurse opened the resident's hand enough to trim the resident's fingernails and placed a hand roll. There was no further documentation of fingernail trimming and use a hand roll for the resident's left hand. A nurse's progress note, dated 03/31/21, documented the resident's left index, middle, ring and little finger were contracted into the palm of the hand and a wound was observed to the palm that measured 0.4 centimeters (cm) by 0.3 cm with yellow wound bed, scant amount of odorous sanguineous drainage (bloody drainage). The note documented the surrounding area of the wound was red and in between the fingers the skin was soft, white and macerated (Maceration occurs when skin has been exposed to moisture, the skin looks soggy, feels soft or appears whiter than usual and may have a white ring around the wound indicating it has had exposure to drainage,) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 04/07/21. A nurse's progress notes, dated 04/01/21 and 04/02/21, documented the wound bed was yellow with mild redness. The notes documented the resident complained of pain at the site of the wound in her left palm. The care plan, dated 04/05/21, documented to keep a palm pillow in the resident's hand as directed by the physician. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .place double rolled washcloth to palm of left hand. Wrap in between fingers with 3-4 inch roll gauze to keep fingers separated. Wrap hand lightly with kerlix/roll gauze to secure washcloth . On 04/28/21 at 10:15 a.m., the director of nursing (DON) was asked about the resident's pressure ulcer to the left hand. She stated the charge nurse discovered the pressure ulcer to the resident's left hand on 03/31/21. She stated wound care was started and a wound care consult was ordered. She was asked who was responsible for trimming the resident's nails. She stated the certified nurses aides were responsible for trimming the resident's nails on their bath days. On 04/28/21 at 12:10 p.m., the resident's family member was asked about the resident's hands. She stated the resident's hands were not contracted in March of 2020. She stated she visited the resident in person in February of 2021 and observed her hands contracted, nails long and pressing into the palms of the hands. She was asked if the resident had hand rolls in her hands at the time of her visit. She stated no. The family member then stated she visited on or around 03/17/21 and took a picture of the resident. The picture was dated 03/17/21 and showed the resident's hands closed with no hand rolls or other pressure relieving devices in place. On 04/28/21 at 1:00 p.m., the certified occupational therapy assistant (COTA) was asked about the resident's hands. She stated the resident was evaluated on 03/31/21 for occupational therapy. She stated the resident's left hand was contracted and she was able to get the hand opened and the hand was macerated and had a wound in the palm of her hand. She was asked if the resident had a hand roll or other device in place to her left hand at the time of the evaluation. She stated no.

Based on interview and record review, it was determined the facility failed to prevent and provide a resolution for misappropriation of residents' property for two (#2 and #3) of three residents reviewed for misappropriation. The facility identified 48 residents who resided in the facility. Findings: A facility policy titled, Missing Property, documented: .A report of missing property will be the responsibility of the Administrator .Every report of missing property is taken seriously and will be investigated resulting in a resolution within one month of the date of report. The administrator will .Update the resident/resident responsible party of the investigation .Find a resolution .Notify the resident/resident responsible party of the resolution .Resolution of missing property can be that property is found, property has been replaced, or property will not be replaced. The administrator will authorize payment for replacement when facility's negligent act or omission has caused the loss . 1. Resident #2 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An MDS (Minimum Data Set), dated 01/12/21, documented the resident was cognitively intact and was independent with activities of daily living (ADL). An Oklahoma State Department of Health (OSDH) incident report, dated 03/02/20, documented the resident reported missing her flowered lamp from her room. The report documented the family, physician, and administration was notified of the missing lamp. The report documented the staff searched for the lamp and it was not found. The report did not document the resolution. On 04/27/21 at 10:11 a.m., the resident was asked if she had missing property. She stated a lamp went missing about a year ago. She was asked about the investigation. She stated they looked for it but never found it. She was asked what the facility did when they could not find the lamp. She stated they did not do anything. She was asked if the lamp was replaced. She stated no. 2. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An MDS, dated [DATE], documented the resident was severely cognitively impaired and required extensive assistance with ADLs. An OSDH incident report, dated 03/24/21, documented the family reported three missing blankets. The report documented the family, physician and administration was notified of the missing blankets. The report documented one blanket was found and returned to the resident. The report documented the facility continued to search for the other missing blankets. The report did not document the resolution. On 04/29/21 at 12:11 p.m., the administrator was asked if the missing blankets for resident #3 had been resolved. She stated no.

Based on observation and interview, it was determined the facility failed to maintain an infection control program and implement measures to provide a safe environment to help prevent the development and transmission of COVID-19 and/or other infections during meal service as evidenced by the following: ~ Meal trays not delivered in a sanitary manner; ~ Dessert containers not covered on the cart when transported down the hall to deliver to residents; and ~ Hands not sanitized at appropriate times while delivering meals. The DON (director of nursing) reported all 42 residents, who resided in the facility, received meal service from the kitchen. Findings: On 2/23/21 at 11:50 a.m., the noon meal pass was observed. The meal cart was observed to contain meal trays with covered dishes, separate uncovered dessert cups, utensils in a large resealable bag, and covered drink glasses. CNAs (certified nurse aides) were observed to reach into the resealable bag to retrieve silverware for each resident. CNA #1 was observed to deliver a meal tray to one resident room, exit the room and deliver a meal tray to the next resident room. No hand hygiene was observed between the resident rooms. CNA #1 was observed to exit a resident's room with wadded up napkins, an empty yogurt container, and an empty oatmeal container. CNA #1 was observed to place the dirty items on the top shelf of the meal cart along with undelivered clean meal items. On 2/23/21 at 11:58 a.m., CNA #1 stated during meal pass hand hygiene was to be performed between residents and after using hand sanitizer three times hands were to be washed. The CNA stated to prevent contamination of the silverware in the resealable bag, she tried to only touch the silverware handles. At 12:05 p.m., CNA #1 was asked why the dessert cups, delivered to the residents, were not covered. She stated they came from the kitchen uncovered. On 2/23/21 at 3:46 p.m., the DON was asked about infection control during meal pass. She stated staff should sanitize hands between residents and dirty items should be kept away from clean items. On 2/24/21 at 12:40 p.m., the dietary manager stated all food should be covered and silverware should be wrapped in a napkin prior to leaving the kitchen.

Based on interview and record review, it was determined the facility failed to ensure the resident's right to receive visitors for one (#1) of four sampled residents whose records were reviewed for visitation. The facility identified 42 residents who resided in the facility. Findings: A policy titled, Phased COVID-19 Reopening Plan-Phases 1-2-3, dated 07/17/20, documented, .The facility's status in the phases of reopening is based on the absence of COVID-19 in the facility for more than 14 days and the color-coded risk level specified for the facility's county . .Phase 1 - orange-moderate risk or red-high risk .Visitation restricted to [MEDICATION NAME] care end-of-life and psycho-social needs visits only . .Phase 2 - yellow-low risk .Limited visits may be allowed to Nursing Homes .Movement to Phase 2 must be followed by resolution of the last resident case of COVID-19 plus 14 days, with no additional symptomatic staff or residents . .Phase 2 Visitation .Visitation limited to [MEDICATION NAME] care situations including: end-of-life; or residents with significant changes in condition including psycho-social or medical issues . The Centers for Medicare and Medicaid Services (CMS) guidance titled, Nursing Home Visitation - COVID-19, dated 09/17/20, documented, .visitation should be person-centered, consider the resident's physical, mental, and psychosocial well-being, and support their quality of life .facilities should accommodate and support indoor visitation, including visits for reasons beyond [MEDICATION NAME] care situations, based on the following guidelines: .There has been no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing .while end-of-life situations have been used as examples of [MEDICATION NAME] care situations, the term [MEDICATION NAME] care situations does not exclusively refer to end-of-life situations .examples of other types of [MEDICATION NAME] care situations include, but are not limited to .a resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss .if a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing home must facilitate in-person visitation consistent with the regulations . A facility letter addressed to residents and family members, dated 02/19/21, documented, .at this time our facility has no positive COVID-19 cases .our county's current COVID risk level is moderate and we are in phase 1 as follows: Visitation is prohibited, except for [MEDICATION NAME] care situations restricted to end-of-life . A facility letter addressed to resident and/or resident representative, dated 02/22/21, documented, .writing to introduce a new program, which starts this month .The essential family caregiver (EFC) program will help to provide care and support from a resident's designated family member .according to the following guidelines: .EFC must be fully-vaccinated for COVID-19 (two weeks after receiving second dose) . On 02/23/21, during the entrance conference, the DON (director of nursing) stated the county color coded risk level for their facility was yellow. A review of the facility's COVID-19 line list revealed their last outbreak testing was completed on 02/15/21. During the survey, resident interviews revealed visitation with family occurred by telephone, electronic media, or through a window. Resident family interviews revealed visitation had occurred by telephone, through the window, and behind the indoor plexiglass. Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/09/20, documented the resident was cognitively intact, had no behaviors, required limited assistance with most ADLs (activities of daily living), and was continent of bowel and bladder. A significant change assessment, dated 01/07/21, documented the resident was moderately impaired in cognition, had a history of [REDACTED]. On 02/24/21 at 12:20 p.m., the DON stated the EFC letter dated 02/22/21 was developed based on guidance from the Centers for Disease Control and Prevention (CDC), CMS, and the Oklahoma State Department of Health (OSDH). She stated the program had not started yet and revisions could be made to the guidelines including the COVID-19 vaccination requirement. A nurse's progress note, dated 02/24/21 at 1:18 p.m., documented, .resident has had a significant decline in ADLs . On 02/24/21 at 2:17 p.m., the DON stated the facility allowed [MEDICATION NAME] care visits for residents who had declined or had a change in status. She was asked if she considered resident #1 to have declined or had a change in status. She stated maybe gradual, but no. On 02/25/21 at 12:25 p.m., the DON stated they had received no response to the EFC letter dated 02/22/21 and no one had requested a [MEDICATION NAME] care visit. She was asked if it was possible that requests for [MEDICATION NAME] care visits could have been effected by the language in the letter sent to resident's families that read [MEDICATION NAME] care visits were restricted to end-of-life. She stated she did not know. She stated resident visitation at the facility had included window visits, iPad, telephone, and the indoor visitation station (plexiglass). She stated they had not allowed indoor visitation other than the plexiglass visitation station because they just completed their last outbreak testing 02/15/21.

Based on observation, interview, and record review, it was determined the facility failed to ensure dependent residents received individualized activities for three (#1, #4, and #25) of three sampled residents who reviewed for activities. The facility identified 38 residents who were dependent on staff for ambulation. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Monthly activity progress notes, dated 07/29/2017 through 12/29/17, were reviewed. It was documented the resident went to activities of her choice and had a current calendar in her room; enjoyed Bingo, bowling, church services, and beauty shop; and enjoyed watching favorite TV shows while sitting in her recliner. It was also documented the resident's family visited often, and she enjoyed visits with them. A significant change assessment, dated 01/01/18, documented the resident was moderately impaired in cognitive skills for daily decision making and required extensive assistance with ambulation and transfers. It was documented the importance of activity preferences was reported by the resident, and all activities except one were very important to the resident. On 01/17/18 at 10:38 a.m., the resident was asked if she attended any of the activities the facility provided. She stated yes. She stated she went to Bingo three times per week, indoor golf, different group performances, and Bible study when offered. She was asked if she felt like there were enough activities offered. She stated no. She was asked what activities she would like to have. She stated, Movies or something. She was asked if she had told anyone. She stated yes. She stated she had told the administrator about three weeks ago, and he had stated that he did not have a problem with that, but she had not heard anything else about it. On 01/22/18 at 2:00 p.m., the resident was observed sitting in her recliner in her room with the TV on. Bingo was being held in the dining room. On 01/22/18 at 2:10 p.m., the resident was asked if she knew Bingo was being held in the dining room. She stated, No. On 01/22/18 at 2:15 p.m., CNA (Certified Nurse Aide) #2 was asked how residents were made aware of activities. She stated there was a calendar in the residents' rooms, and the CNAs were supposed to remind them. She was asked how she knew what activities a resident liked and didn't like. She stated she knew her residents, but if she did not or they were new, she would look at their care plan. On 01/22/18 at 2:16 p.m., LPN (Licensed Practical Nurse) #3 was asked how she ensured the residents participated in activities. She stated the aides would go to their rooms, remind, encourage them to go and assist them to get to the activities. She stated she monitored the aides to make sure they reminded and assisted the residents that needed help. On 01/22/18 at 3:07 p.m., the AD (Activities Director) was asked who was responsible for informing and reminding the residents about activities scheduled. She stated she was. She was asked how she let them know. She stated they all had a calendar of activities in their rooms for the month and she tried to go to each room prior to an activity to remind them. She stated sometimes she used the radio and asked staff to let them know and assist them as needed. The AD was asked what activities resident #1 attends. She stated activities including bingo, Ernie and Friends, sometimes bowling, Sunday school, and watching TV. She was asked if the resident had ever asked to have more movies. She stated no. She stated the resident had said she would like to watch more shows like CSI as she liked crime shows. She was asked if they ever watched movies. She stated they have not played movies in quite sometime because she could not get enough people to come. She stated she thought the residents might be more interested in something else. The AD was asked if she was aware resident #1 had not attended bingo today. She stated she was not aware. On 01/23/18 at 9:20 a.m., the resident was asked why she did not attend Bingo on the previous day. She stated, Oh, I didn't even think about it. CNA #4, who was with the resident, stated, I didn't tell her about it yesterday, because I was just too busy. I try to remind the residents when activities are taking place. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 10/09/17, documented resident was cognitively intact and had been interviewed for activity preferences. It was documented it was very important to the resident to have books, newspapers, and magazines to read; listening to music; to be around animals and participating in religious services. It was documented it was somewhat important to the resident to keep up with the news; do things with groups of people; and to do her favorite activities. It was documented the resident required extensive assistance with transfers, dressing, and toilet use, and used a wheelchair for mobility. The resident's care plan, dated 04/06/17 and last revised 01/15/18, documented a problem related to the resident's risk for increased depression and/or social isolation. The goal was the resident would report participation in a satisfying activity program. Interventions included one on one activities with the activities director as needed; an activity calendar in her room each month; assisting the resident to and from activities of choice; providing care, activities, and a daily scheduled that resembled the resident's prior lifestyle; and staff to assist resident with participation in activities as needed. A progress note, dated 09/27/17, documented the resident was .brought to activities and has a current calendar in her room. She does come to beauty shop, fruit w/ friends and sometimes bingo. She does like to stroll around the nursing home in her wheelchair and visit with other residents. Family visits often and she enjoys seeing them. No new changes . A progress note, dated 10/31/17, documented the resident was . brought to activities and has a current calendar in her room. She does come to beauty shop, fruit w/ friends, bingo and holiday parties/birthday parties. She also likes to wheel around the nursing home and visit with other residents. No new changes in activities. A progress note, dated 11/30/17, documented the resident was . brought to activities and has a current calendar in her room. She does come to beauty shop, bingo and holiday parties/birthday parties. She also likes to wheel around the nursing home and visit with other residents. No new changes in activities. A progress note, dated 12/31/17, documented the resident was .brought to activities and has a current calendar in her room. She does come to beauty shop, fruit w/ friends, bingo and holiday parties/birthday parties. She also likes to wheel around the nursing home and visit with other residents. Her family visits often and she enjoys seeing them. No new changes in activities. On 01/17/18 the resident was not observed participating in any activities during the morning. On 01/18/18 at 10:24 a.m., the resident was not observed in exercise activity. On 01/18/18 at 2:33 p.m., the resident was not observed at fruit with friends activity. The resident was observed intermittently from 01/16/18 through 01/18/18 and on 01/22/18. No observations were made of the staff engaging the resident in any activity. On 01/22/18 at 3:17 p.m., the AD was asked what activities resident #4 participated in. She stated she came to the birthday parties, music entertainment, fruit with friends and bingo. She stated the resident had sat with her and they played bingo together. The AD stated the resident liked to be on the go. She stated she had sat and talked with her. She stated the resident had a really low attention span. She stated she walked next to the resident if she was wheeling. The AD was asked if she did one on one activities with the resident. She stated any quality attention she gave the resident she considered a one-on-one. On 01/23/18 at 9:12 a.m., the AD was asked what activities resident #4 had participated in during the last seven days. She stated she believed the resident came to fruit with friends on January 18th. She stated she was pretty sure resident #4 had come to beauty shop on the 16th. She stated she did not know about the 20th and 21st music specials. She was asked what one on one activities she had done with the resident. She stated she had sat and read to the resident. She was asked if she had documentation for that. She stated just in her monthly charting. The AD was asked what the as needed meant on the care plan intervention for one on one activities. She stated it meant prn. She stated they needed to change that to three times a week because prn was not good. She was asked how she ensured the resident had received one on one activities three days per week, as she stated she provided for the resident. She stated she was the person who provided the one on one activities, so she had tried to get in to their rooms at least three times per week. She stated she did not keep a list of them or a chart to check them off. She was asked how she knew when she had provided one on one activities. She stated she had tried to go by her memory, but she could not give specific times. She further stated she knew she did not do activities on Thursdays because that was when they did their care plan meetings. She was asked how others would be able to know when she had provided one on one activities. She stated they would not be able to tell that, only by her word. She was asked if she had enough time to complete the activities and social service duties. She stated, I try. She was asked if she needed help to ensure the resident's received activities. She stated yes. 3. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 08/04/17, documented the resident was severely impaired in cognitive skills for daily decision making with a BIMS (brief interview for mental status) of 01 and that the resident had been interviewed for activity preferences. It was documented the resident had answered not very important for every activity. It was also documented the resident required limited assistance with transfers, ambulation, dressing, and toilet use and ambulated with the use of a walker. The care plan, last reviewed on 11/07/17, documented the resident was at risk for social isolation and showing signs and symptoms of depression. The goal was the resident would participate in activities of choice and show no signs of social isolation and decreased signs of depression. Interventions included one on one activities with the activity director as needed, assisting the resident to and from activities of choice, involving the resident with those who have shared interests, and reminding the resident of upcoming events. An activity progress note, dated 11/07/17, documented, .comes to activities of her choice and has current calendar in room .enjoys doing more independent activities in her room .I spend time each week visiting with her and taking walks with her and she enjoys that .states, she's not much of a game player. I have recently started bring her coffee and cookies and she really enjoys that . An activity progress note, dated 11/30/17 at 10:00 a.m., documented, .comes to activities of her choice and has current calendar in room .enjoys doing more independent activities in her room .I spend time each week visiting with her and taking walks with her and she enjoys that. I bring her coffee and cookies and she really enjoys that . An activity progress note, dated 12/31/17 at 12:34 p.m., documented, .comes to activities of her choice and has current calendar in room .enjoys doing more independent activities in her room .I spend time each week visiting with her and taking walks with her and she enjoys that. I bring her coffee and cookies and she really enjoys that . On 01/16/18 at 10:12 a.m., the resident was observed asleep in her bed. On 01/16/18 at 2:29 p.m., the resident was observed asleep in her bed. On 01/17/18 at 9:16 a.m., the resident was observed sitting in her recliner. She was asking to go home and see her mother. On 01/17/18 at 9:48 a.m., the resident was observed sitting in her recliner. She was folding a blanket on her lap. On 01/17/18 at 10:33 a.m., the resident was observed sitting in her recliner with her eyes closed. On 01/17/18 at 11:31 a.m., the resident was observed asleep in her bed. On 01/18/18 at 8:43 a.m., the resident was observed sitting on the edge of her bed. She was reaching for her walker, which was sitting nearby. On 01/18/18 at 10:24 a.m., four residents were observed in an exercise activity in the common area near the director of nursing office. The director of nursing was asked to identify the names of the residents in the activity, which she did. Resident #25 was observed sitting in her recliner in her room at this time. On 01/18/18 at 1:21 p.m., the resident was observed asleep in her bed. On 01/18/18 at 2:28 p.m., the resident was observed asleep in her bed. On 01/18/18 at 2:33 p.m., a fruit with friends activity was observed in the dining room. Five residents were in attendance. Resident #25 was asleep in her bed at this time. On 01/22/18 at 8:30 a.m., the resident was observed asleep in her bed. The resident was observed intermittently from 01/16/18 through 01/18/18 and on 01/22/18. No observations were made of the staff engaging the resident in any activity. On 01/22/18 at 2:10 p.m., CNA #1 was asked what activities the resident participated in. She stated bingo, church music, and Ernie and friends. She was asked how often the resident participated in activities. She stated about three times a week, unless she did not feel good. She stated it was hard to get her to come out of her room. She was asked how she had assisted the resident regarding activities. She stated she had walked behind her with her walker to activities and she had reminded her when the activities were. On 01/22/18 at 2:16 p.m., LPN #2 was asked how she ensured the residents participated in activities. She stated the aides would go to their rooms and remind and encourage them to go and assist them to get to the activities. She monitored the aides to make sure they reminded and assisted the residents that needed help. She was asked what activities resident #25 participated in. She stated mostly meals and the beauty shop. On 01/22/18 at 3:11 p.m., the AD was asked how she provided activities to a resident with poor cognition. She stated she played music, physical stimulation, spending time with them with touch, like putting lotion on their hands and arms. She stated if they could hear well she would play music and read to them. She did a lot of one-on-one. She was asked who was responsible for making sure the residents received activities. She stated she was. She was asked how she knew what activities they preferred. She stated when they first came to the facility, they did an assessment of what activities they used to do and what they enjoyed to do now and what they never liked to do. The AD was asked how she provided activities to a resident who did not like to come out of their room. She stated she went into their room and did audio books, one on one activities. She was asked how often she provided one on one activities. She stated at least three times a week. She was asked where she documented the one on one activities. She stated she had never documented one on one activities, she just put it on the monthly charting. The AD was asked what activities she had provided for resident #25. She stated she had taken her coffee and cookies and she had walked with her, sat and talked with her, nails, and hair. She stated the resident got bored with reading and she did not like to watch TV or listen to music. She was asked how often she provided the resident with an activity. She stated three times per week. On 01/23/18 at 9:01 a.m., the RN (Registered Nurse) #1/MDS (Assessment Coordinator) was asked how she determined who to interview for activity preferences on an MDS. She stated she tried to interview the resident first, if the resident was unable to answer appropriately she would ask the family or staff. She was asked if a resident had a BIMS score of 01, would she interview them or the family. She stated she would interview the resident if they were able to answer the questions appropriately. She was asked why she had interviewed the resident for activity preferences on 08/04/17 when she had a BIMS of 01. She stated the resident had not been able to remember the memory words for the BIMS score, but she had determined she was able to answer the activity questions. She was asked if the resident's answers were a true indication of the resident's activity preferences. She stated, Yes, I believe so. On 01/23/18 at 9:12 a.m., the AD was asked what activities resident #25 had participated in the last seven days. She stated she believed she had came to fruit with friends on the 18th. She stated she did not know about the 20th and 21st because she was not here on those days, so she would not know if they went to the music specials. She stated resident #25 had not been to any of the group activities. She was asked if she was sure resident #25 went to the fruit with friends activity on the 18th. She stated yes, but she had been in care plan meetings that day, so she had somebody else doing the activity for her. She stated, So I am not for sure. The AD was asked what one on one activities the resident had been involved in the last seven days. She stated she had sat with the resident one day and talked with her. She was asked when the activity had occurred. She stated it was on Tuesday, but she was unsure of the exact time. She was asked if she had documentation of the one-on-one activities with the resident. She stated no, she only had the monthly charting. The AD was asked what the as needed meant on the care plan intervention for one on one activities. She stated it meant prn. She stated they needed to change that to three times a week because prn was not good. She was asked how she ensured the resident had received one-on-one activities three days per week, as you stated you provided for the resident. She stated she was the person who provided the one on one activities, so she had tried to get in to their rooms at least three times per week. She stated she did not keep a list of them or a chart to check them off. She was asked how she knew when she had provided one on one activities. She stated she had tried to go by her memory, but she could not give specific times. She further stated she knew she did not do activities on Thursdays because that was when they did their care plan meetings. She was asked how others would be able to know when she had provided one on one activities. She stated they would not be able to tell that, only by her word. She was asked if she had enough time to complete the activities and social service duties. She stated, I try. She was asked if she needed help to ensure the resident's received activities. She stated yes.

Based on observation, interview, and record review, it was determined the facility failed to ensure three (#1, #22 and #115) of three sampled residents who were reviewed for resident council concerns were informed in advance of upcoming resident council meetings. The facility identified 71 residents who resided in the facility. Findings: On 01/18/18 at 1:23 p.m., resident #1 was observed sitting in her wheelchair at the nurses' desk on Hall 700. She was overheard having a conversation with another resident about the time the AD (Activity Director) had said she would be back and what time the Resident Council Meeting was scheduled for. On 01/18/18 at 1:30 p.m., the resident council meeting minutes were reviewed for the past six months. It was documented only residents from Hall 800 had any complaints or attended the meetings. On 01/18/18 at 2:00 p.m., a group meeting of ten alert and cognitively intact residents was held. Nine were from Hall 800, and one was from another hall. The residents in attendance were asked if any residents from the other halls ever attended the meetings. One resident stated they could come if they wanted to. Another resident stated she thought they should advertise the meeting better. Another resident stated she thought the slope in between the buildings might make it hard for some residents to come. They were asked if the meetings were always held on Hall 800 in the dining room. They all stated yes. On 01/22/18 at 2:27 p.m., resident #1 was asked if she knew what a resident council meeting was. She stated yes. She was asked if she could remember if they had one last week. She stated it was cancelled or at least that is what she was told. She was asked if she was invited or reminded of when and where the meetings were going to be held. She stated, No, not usually. She stated she might hear another resident talk about it, but she was not reminded about it. She was asked if she would attend the meetings if she was invited and reminded about the meetings. She stated, Yes. On 01/22/18 at 3:14 p.m., the AD was asked how the residents were made aware of the resident council meetings. She stated she generally walked around and let the residents know or announced over the radio to the staff to have them let the residents know. She was asked if she had ever heard a resident state they wanted to come but did not know when or where it was being held. She stated no. She was asked why the meeting was held on the 800 hall. She stated because it was more private, and the residents felt more comfortable talking about issues. On 01/23/18 at 10:20 a.m., the DON (Director of Nursing) was asked why the resident council meetings were held on Hall 800. She stated because it was more private and the residents felt like they could talk more freely. She was asked if she was aware only the residents from Hall 800 attended the meetings. She stated no. She was asked if she had ever heard a resident complain about not being invited the meetings. She stated no. On 01/23/18 at 11:59 a.m., resident #115 was asked if she had ever heard of or if she was ever invited to a Resident Council Meeting. She stated, No. On 01/23/18 at 2:25 p.m., resident #22 was asked if she had ever heard or been invited to a Resident Council Meeting. She stated she had heard of them. She was asked if she was told when and where they were going to have one. She stated, No. She was asked if she would attend if she was invited and reminded of the time and place to be held. She stated, Yes.