Every finding on record at Pleasant Valley Health Care Center

Based on record review and interview, the facility failed to ensure residents' private information was not released on social media for 3 (#2, 4 and #5) of 3 sampled residents reviewed for privacy.The DON identified 74 residents resided in the facility. Findings:An undated Social Media Policy, read in part, DO NOT use Social Media to post, upload, send, or otherwise share or disclose a photo or video of a resident without prior written permission of the resident or the residents authorized agent as required by applicable law.This prohibition includes photos and videos where the resident is not easily identifiable.An incident report form, dated 07/21/26, showed a caller had informed facility staff that two former facility employees had posted photos and names of Residents #2, #4, and #5 on two social media platforms.On 07/24/26 at 10:20 a.m., licensed practical nurse #2 stated photos and resident information should never be shared on social media without the consent of the resident.On 07/24/26 at 1:10 p.m., certified nurse aide #3 stated photos of residents should not be shared on social media.On 07/24/26 at 1:45 p.m., the DON stated they were not sure when the photos and resident names had been posted on social media. They stated the two employees that had posted the information had been terminated prior to the facility becoming aware of the incident. The DON stated the former employees were in violation of the facility's social media policy.On 07/24/26 at 2:00 p.m., the assistant administrator stated the former employees had failed to ensure the privacy of the residents.

Based on interview, record review, and facility policy review, the facility failed to ensure a fall intervention to toilet a resident every hour was implemented for 1 (Resident #85) of 3 sampled residents reviewed for falls.Findings included: An admission Record indicated the facility admitted Resident #85 on 04/16/2026. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure. Resident #85's Baseline Care Plan, with an admission date of 04/16/2026, indicated the resident required one person physical assistance for toilet use, was always incontinent of urinary continence, frequently incontinent of bowel continence, and had a history of falls. Resident #85's incident report dated 04/16/2026, indicated the resident was on the floor in front of their wheelchair in front of the nurses' station due to an attempt to stand. Per the incident report, the resident slipped, fell, and landed on their buttocks in front of their wheelchair. The incident report indicated the resident had no apparent injuries and stated they needed to go to the bathroom. According to the incident report, after the fall the facility implemented an intervention to toilet the resident every hour. Resident #85's medication administration record (MAR) and treatment administration record (TAR) for the timeframe 04/01/2026 - 04/30/2026 revealed no documented evidence Resident #85 was checked for toilet use every hour. Resident #85's Task List Report revealed no indication certified nursing assistant (CNA) staff checked the resident for toilet use every hour. During an interview on 06/10/2026 at 9:20 AM, Licensed Practical Nurse (LPN) #3 stated all of their residents were checked for incontinence every two hours. LPN #3 stated after Resident #85's fall on 04/16/2026, the resident was to be checked for toileting every hour. LPN #3 stated sometimes every one-hour toileting would be listed on the TAR or the MAR. During an interview on 06/10/2026 at 1:56 PM, LPN #8 stated when a resident was on an every one-hour toileting check it would be documented in the CNA tasks, MAR, or TAR. According to the LPN #8, staff toileted Resident #85 every two hours. During an interview on 06/10/2026 at 2:50 PM, the Director of Nursing (DON) stated the intervention implemented after Resident #85 fell on [DATE] was to toilet the resident every hour. The DON stated that whenever an intervention of every-hour toileting was implemented, the process was to place an order for CNAs on their task sheet. The DON reviewed the task orders for the CNA staff and stated there was not an every-hour toileting order. The DON stated the order could show up on the MAR, TAR, or the task sheet for the CNAs. The DON stated that would be how the CNA staff and nursing staff knew to implement the intervention. The DON acknowledged the intervention to toilet Resident #85 every hour was not implemented. During an interview on 06/11/2026 at 8:25 AM, the Administrator stated fall interventions should be implemented immediately.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure a licensed practical nurse (LPN) knew how to prime an insulin pen for 1 (Resident #7) of 6 residents observed for medication administration.Findings included: An undated facility document titled, Job description for Charge Nurse, specified Job Knowledge: 1. Knowledge of procedures and techniques necessary to administer medications and treatment as prescribed by the physician. An undated facility document titled, Staff education Policy signed by the Director of Nursing (DON), indicated It is the policy of this facility to perform Staff education or in-services based on the required annual in-services by the state and any additional training that is needed by the staff on an as need basis. An admission Record revealed the facility admitted Resident #76 on 11/16/2020. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2026, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #76's Care Plan Report included a focus area revised 06/11/2024, that indicated the resident was at risk for complications related to diabetes mellitus. Interventions directed staff to administer Lantus (insulin) as physician ordered (revised 11/07/2024). Resident #76's Order Summary Report with active orders as of 06/11/2026, revealed an order dated 11/06/2024, for Lantus subcutaneous solution inject 40 units subcutaneously one time a day related to type 2 diabetes mellitus. During medication administration observation on 06/10/2026 at 7:22 AM, LPN #2 did not prime the Lantus insulin pen before she injected 40 units of Lantus insulin into Resident #76's right lower abdominal quadrant. During an interview on 06/10/2026 at 11:49 AM, LPN #2 stated she had no knowledge of how to prime an insulin pen and was not sure how or why the process would be completed. LPN #2 stated if priming was needed, she should have primed the pen before she administered Lantus to Resident #76 on 06/10/2026. LPN #2's LPN/LVN [licensed vocational nurse] Knowledge & Skills Checklist dated 10/06/2025, revealed no evidence of training on how to prime an insulin pen. During an interview on 06/11/2026 at 9:28 AM, the Medical Director stated insulin pens should be primed before administration to get the air out of the needle. During an interview on 06/11/2026 at 10:33 AM, the DON stated she would expect all nurses administering insulin by way of an insulin pen to receive training on insulin administration. During an interview on 06/11/2026 at 11:05 AM, the Administrator stated she deferred her expectation of competency of nurses to prime an insulin pen to the DON.

Based on observation, interview, record review, facility policy review, and the manufacturer's guidelines, the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 3 medication errors out of 34 opportunities, which yielded a medication error rate of 8.82% for 2 (Resident #76 and Resident #7) of 6 residents observed for medication administration. Findings included: A facility policy titled, Medication Administration, revised 06/03/2025, revealed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy specified, 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 1. The manufacturer's guidelines for the Lantus pen, with a copyright date of 2022, indicated, Step 3. Perform a safety test * Dial a test dose of 2 units * Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. * Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. * If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. An admission Record revealed the facility admitted Resident #76 on 11/16/2020. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2026, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #76's Care Plan Report included a focus area revised 06/11/2024 that indicated the resident was at risk for complications related to diabetes mellitus. Interventions directed staff to administer Lantus (insulin) as physician ordered (revised 11/07/2024). Resident #76's Order Summary Report with active orders as of 06/11/2026, revealed an order dated 11/06/2024, for Lantus subcutaneous solution, inject 40 units subcutaneously one time a day related to type 2 diabetes mellitus. During medication administration observation on 06/10/2026 at 7:22 AM, Licensed Practical Nurse (LPN) #2 did not prime the Lantus insulin pen before she injected 40 units of Lantus insulin into Resident #76's right lower abdominal quadrant. During an interview on 06/10/2026 at 11:49 AM, LPN #2 stated she had no knowledge of how to prime an insulin pen and was not sure how or why the process would be completed. LPN #2 stated that if priming was needed, she should have primed the pen before she administered Lantus to Resident #76 on 06/10/2026. During an interview on 06/10/2026 at 12:13 PM, the Director of Nursing (DON) stated she deferred her expectation of priming an insulin pen prior to administration to the Assistant Director of Nursing (ADON). During an interview on 06/10/2026 at 12:19 PM, the ADON stated she expected a nurse to dial the insulin pen to 2-3 units to prime the pen, then push the plunger to get the air out of the line before dialing the ordered dose of insulin to be administered to the resident. The ADON stated priming the insulin pen prior to administration was important to ensure the air bubbles were out and to ensure the resident received the correct dose of insulin. The ADON stated LPN #2 should have primed the insulin pen prior to administration of insulin to Resident #76. During an interview on 06/11/2026 at 9:28 AM, the Medical Director stated insulin pens should be primed before administration to get the air out of the needle. During an interview on 06/11/2026 at 11:05 AM, the Administrator stated she deferred her expectation of priming an insulin pen to the DON. 2. An admission Record revealed the facility admitted Resident #7 on 12/15/2022. According to the admission Record, the resident had a medical history that included diagnoses of essential hypertension and atrial fibrillation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2026, revealed Resident #7 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. Resident #7's Care Plan Report, included a focus area revised 08/14/2022 that indicated the resident had an altered cardiovascular system related to hypertension and hyperlipidemia (high cholesterol). Interventions directed staff to administer amiodarone and diltiazem as the physician ordered. Resident #7's medication administration record (MAR) for the timeframe 06/01/2026 - 06/30/2026, revealed the transcription of an order dated 11/04/2025, for amiodarone hydrochloride (HCL) oral tablet 200 milligrams (mg), give one tablet by way of the percutaneous endoscopic gastrostomy (PEG) tube one time a day related to atrial fibrillation and hold for a systolic blood pressure less than 120 millimeters of mercury (mmHg) or a heart rate less than 60 beats per minute (bpm). The MAR also revealed the transcription of an order dated 11/03/2025, for diltiazem HCL tablet 30 mg, give one table by way of PEG tube two times a day related to hypertension and hold for a systolic blood pressure less than 120 mmHg or a heart rate less than 60 bpm. During medication administration observation on 06/10/2026 at 8:29 AM, Certified Medication Aide (CMA) #10 prepped and administered one tablet of amiodarone HCL 200 mg when Resident #7 had a heart rate of 62 bpm and one tablet of diltiazem HCL 30 mg when the resident had a systolic blood pressure of 101 mmHg. During an interview on 06/10/2026 at 8:56 AM, CMA #10 stated Resident #7 had a systolic blood pressure of 101 mmHg and a pulse (heart rate) of 62 bpm. CMA #10 stated she had been taught to read the resident's physician's orders for hold parameters, but she did not notice the parameters before she administered amiodarone and diltiazem to Resident #7 by way of the resident's PEG tube. CMA #10 stated she should have held the two medications because the resident's blood pressure was outside of the set parameters. During an interview on 06/10/2026 at 10:09 AM, Licensed Practical Nurse (LPN) #3 stated she oversaw CMA #10. LPN #3 stated she had not been made aware that CMA #10 administered Resident #7's medications when the resident's blood pressure was outside the hold parameters. LPN #3 stated t the two medications for the resident's blood pressure with hold parameters should have been held if the resident's blood pressure was 101/61 mmHg. During an interview on 06/11/2026 at 9:28 AM, the Medical Director (MD) stated he was notified Resident #7 was administered amiodarone and diltiazem by CMA #10 when the resident's vital signs were outside the hold parameters. The MD stated that although the medications should have been held, he did not think the medications would pose a significant concern to the resident. During an interview on 06/11/2026 at 10:33 AM, the Director of Nursing (DON) stated CMA #10 should have read the entire order and administered medications according to the physician's orders. The DON stated CMA #10 should have held (not administered) the cardiac (heart) medication. During an interview on 06/11/2026 at 11:05 AM, the Administrator stated she expected staff to read and follow the physician's orders.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's supplemental oxygen tubing was stored in a plastic bag when not in use for 1 (Resident #41) of 1 sampled resident reviewed for respiratory care.Findings included: A facility policy titled, Oxygen Administration, revised 06/03/2025, indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy specified, e. Keep delivery devices covered in plastic bag when not in use. An admission Record indicated the facility admitted Resident #41 on 10/02/2023. According to the admission Record, the resident had a medical history that included a diagnosis of acute respiratory failure with hypoxia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/03/2026, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #41's Care Plan Report included a focus area initiated 03/12/2026, that indicated the resident was at risk for altered respiratory status related to acute respiratory failure with hypoxia. Interventions specified the administration of supplemental oxygen at 2 liters per minute (L/M) by way of nasal canula (NC) per concentrator for shortness of breath (SOB) to maintain the resident's oxygen saturation greater than 90%. Resident #41's Order Summary Report with active orders as of 06/10/2026, revealed an order dated 04/28/2026, for supplemental oxygen at 2 L/M by way of NC per concentrator as needed for SOB to maintain the resident's oxygen saturation level greater than 90%. During an observation on 06/08/2026 at 10:28 AM, 06/09/2026 at 3:54 PM, and 06/10/2026 at 9:47 AM, Resident #41's supplemental oxygen tubing was observed on the floor under the oxygen concentrator in the resident's room. During a concurrent interview and observation on 06/09/2026 at 11:14 AM, Resident #41 they used the supplemental oxygen at night when needed. The surveyor noted Resident #41's supplemental oxygen tubing was on the floor. Resident #41 stated the supplemental oxygen tubing was on the floor, and they were not aware of how the tubing got on the floor as they did not take off the tubing. Resident #41 stated the staff took off their supplemental oxygen and placed the tubing somewhere. During an interview on 06/10/2026 at 3:11 PM, the Director of Nursing stated she expected supplemental oxygen tubing to be stored in a zip lock bag. During an interview on 06/11/2026 at 8:25 AM, the Administrator stated supplemental oxygen tubing should be appropriately stored inside a bag.

On 08/16/24 at 9:35 a.m., the Oklahoma State Department of Health identified the presence of an immediate jeopardy related to the facility failed to evaluate Residents #51 and #18 for the capacity to consent to sexual activity. Resident #18 had known sexually inappropriate behaviors and there was no evidence the facility identified these events as sexual abuse or evaluated the resident's capacity to consent. A Progress Note, dated 06/21/24 at 7:16 p.m., documented Resident #51 was observed with their legs opened and Resident #18 was sitting in front of Resident #51, rubbing on Resident #51's vagina. The nurse told the residents they could not do that. The nurse observed them kissing, went to speak with Resident #51, who was leaned forward while trying to pull their pants down, and Resident #18 had partial of their penis out. The nurse told them they could not do that in the hallway. On 08/16/24, there had been no documentation of evaluation of capacity to consent, care plans or assessments for Residents #51 and #18 regarding sexual activity. On 08/16/24 at 11:10 a.m., the Administrator was notified of the presence of an immediate jeopardy related to residents had not been evaluated for the capacity to consent to sexual activity. A plan of removal was requested. On 08/16/24 at 5:41 p.m., the following POR for abuse was submitted to OSDH for review: A [Name of facility and address withheld] Plan of Removal, read in parts, .1. Al staff are inserviced on sexual behaviors with residents with decreased BIMS and when to report incidents .2. Designee began assessing all BIMS greater than 9 in the facility for any sexual abuse from resident #18. All residents assessed had not had any form of sexual abuse while in the facility .3. Compliance with reporting allegations of abuse/neglect/exploitation policy has been reviewed with all staff. All staff have been inserviced and all new hires will continue to be inserviced upon hire .r. MDS updated Resident #18 care plan for sexual behaviors. Monitoring order in place q [every] shift .5. Designee will review 24 hour reports and will report any new behaviors in M-F morning meetings .6. Nurse Practitioner to eval and treat Resident #51 [amended to be Resident #18]. On this day resident eval to consent to sexual activity and sexual activity [sic] and sexual consent form was completed on Resident #18 and Resident #51 .7. DON reviewed all behavior notes for the past 6 months assessing for any resident to resident sexual abuse. No other instances were found .8. Resident #18 and Resident #51 were educated on sexual activity .Completion Date/Time: 8/16/24 at 1640 [ 4;40 p.m.] .9. Nursing staff will initiate the Evaluation for Sexual Consent Form upon any observed sexual behaviors between residents .Completion Date/Time: Ongoing .10. Follow up regarding Resident #18 sexual consent, family consented to companionship but not the act of sex itself .Follow up regarding [Resident #51]: Family consented to companionship but not the act of sex its self .What are your steps to ensure the residents are evaluated for consent regarding sexual activity? All residents exhibiting sexual behaviors will be screened with the Evaluation for sexual consent form upon noted behaviors, assessment will be performed by witnessing nurse of other designee . On 08/19/24 at 8:25 a.m., the facility was notified the POR was approved. The IJ was lifted, effective 08/19/24 at 11:00 a.m., when all components of the plan of removal had been completed. The deficiency remained at a level of potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure an evaluation was completed to assess the capacity to consent to sexual activity for two (#51 and #18) of five sampled residents reviewed for abuse. The Administrator identified 83 residents resided in the facility. Findings: An Abuse, Neglect and Exploitation policy, dated 07/01/24, received and reviewed on 08/14/24 at 1:42 p.m., read in part, .includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act .Sexual Abuse is non-consensual sexual contact of any type with a resident .Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse .identifying when, how and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded .Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends and other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions . 1. Resident #18 had diagnosis which included unspecified dementia. Resident #18's quarterly assessment dated , 04/20/24, documented Resident #18's cognition was severely impaired. A Behavior Note, dated 09/20/19 at 5:24 p.m., documented, Another resident informed this nurse that resident was in hallway touching penis. List Interventions Attempted: Educated [Resident #18] that resident will need to go inside room in private to do so. A Behavior Note, dated 10/18/19 at 4:49 p.m., documented, ACMA was giving resident eternal feedings when resident got penis out of pants and started touching [themselves]. ACMA asked resident respectfully to wait until after feeding was administered. List Interventions Attempted: ACMA asked resident respectfully to wait until after feeding was administered. This nurse spoke [with] resident and asked if it could wait until after feeding due to being unable to stop feeding. A Behavior Note, dated 10/22/23 at 8:56 p.m., documented, [Resident #18] had penis out during 2030 [8:30 p.m.] smoke break. List Interventions Attempted: CNA [name withheld] firmly told [Resident #18] to put [Resident #18] penis away. A Behavior Note, dated 10/23/23 at 1:01 p.m., documented, During 11 a.m. smoke break resident exposed penis. List Interventions Attempted: CNA/Activities assist [name withheld] instructed resident to put it away now. A Behavior Note, dated 04/21/24 at 10:02 a.m., documented CMA had was finishing feeding [Resident 18] when [Resident 18] ran [Resident 18's] hand up [CMA's] leg and tried to touch [CMAs] private area. List Interventions Attempted: CMA firmly told [Resident #18] to keep [Resident 18's] hands to [themselves]. A Behavior Note, dated 06/21/24 at 7:25 p.m.,, documented, This nurse was coming out of a resident room and [Resident #18] sitting in WC in front of [Resident #51] rubbing on her vagina. This nurse told residents that they can not do that in the hallway and they stopped. This nurse was sitting a [sic] nurses station and seen [Resident #18] and [Resident #51] kissing. This nurse went to talk to residents; [Resident #18] had partial of [their] penis out and Resident #51 was leaning forward trying to pull pants down. This nurse told resident they can not do that in the hallway and [Resident 51] voiced understand and got up and sat in front of nurses station. Resident #18's care plan, dated 08/06/24, did not address sexual activity or prevent the risk of sexual abuse. The clinical record did not contain an assessment Resident #18 had been assessed to ensure the capacity to engage in sexual activity, or sexual activity behaviors. 2. Resident #51 had diagnosis to include Alzheimer's Disease and malignant neoplasm of bronchus and lung. A Quarterly Assessment, dated 06/14/24, documented Resident #51 had clear speech, understands, is understood, has severe cognitive impairment for daily decision making, displayed inattention and disorganized thinking, and required supervision and cues to perform ADLs. A Progress Note, dated 06/21/24 at 7:16 p.m., read in part, .This nurse was coming out of a resident room and seen [Resident #51] sitting in a chair .with legs opened and [Resident #18] was sitting in front of [Resident #51], rubbing on [Resident #51's] vagina. This nurse told residents that the [sic] can not do that and they stopped. This nurse was sitting a nurses station and seen [Resident #51] and [Resident #18] kissing this nurse went to talk to resident and {Resident #51 was leaning forward trying to pull pants down while [Resident #18] had partial of [their] penis out. This nurse told resident they can not do that in the hallway. Resident got up and sat in front of nurses station .interventions Attempted: told resident they were not allowed to do that in hallway . A Care Plan, dated 08/13/24, documented Resident #51 had the potential to be physically aggressive .was aggressive toward another resident. and that a CNA had reported to the nurse at 2:30 p.m., Resident #51 had become physically aggressive to another female resident during lunch. The clinical record did not contain an assessment Resident #51 had been assessed to ensure the capacity to engage in sexual activity, or sexual activity behaviors. The care plan did not contain documentation Resident #51 had interventions in place to address sexual activity or prevent the risk of sexual abuse. No documentation was provided to support the sexual activity between Residents #51 and #18 had been assessed to ensure the resident were cognitively intact to consent to sexual activity. The facility did not provide an incident report or reportable incident to OSDH. On 08/15/24 at 4:24 p.m., the DON was asked to explain the events surrounding the progress note dated 06/21/24 at 4:27 p.m. The DON stated it appeared the nurse came out and seen Resident #51 sitting in a chair with their legs opened and Resident #18 was sitting in a wheelchair and were observed to be engaged in sexual touching. The DON was asked what was the facilities response to this allegation. The DON stated if residents wanted to sexual, they have the right to be as long as it is not in a public place. The DON was asked if a state reportable incident had been completed as a result of this behavior. The DON stated, they understood the residents have a right, so nothing else was put in place. The DON was asked if the care plan was updated an interventions put into place. They stated only what was in the progress note. The DON was asked if Resident #51 or #18 had been able to consent to sexual activities. The DON stated both residents had been assessed to have severely impaired cognitive impairment for daily decision making. The DON was asked if the residents had severe cognitive impairment, how was it determined they could consent to sexual activity. No information was provided. The DON was asked if the residents' care plans had been updated to reflect the sexual behavior. The don stated the care plan was updated on 06/27/24 to monitor for wandering, there is not a care plan for sexual activity. The DON was asked how staff would be able to identify if the residents were able to consent to sexual behaviors. They stated they would refer to the care plan and policies. The DON was asked if the care plan for Resident #51 had been updated. They stated the care plan did not appear to have an update. The DON was asked if this had been the only event of sexual activity for either of the residents. They stated, I don't see anything. 46216

Based on observation, record review, and interview, the facilty failed to ensure staff members assisted residents with eating in a dignified manner for two (#12 and #75) of nine sampled residents observed during meal service in the assisted dining room. The DON identified 15 residents who required feeding assistance resided in the the facility. Findings: A Promoting/Maintaining Resident Dignity During Mealtimes policy, revised 07/04/24, read in part, It is the practice of this facility to treat each resident with respect and dignity .All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes .All staff will be seated, if possible, while feeding a resident . 1. Resident #12 had diagnoses which included vascular dementia and obsessive-compulsive behavior. An Annual Resident Assessment, dated 06/09/24, documented Resident #12 had severe cognitive impairment and was dependent on staff for the task of eating. On 08/13/24 at 12:14 p.m., CMA #3 was observed standing over Resident #12 and giving them a bite of their lunch meal. On 08/13/24 at 12:15 p.m., CMA #3 gave Resident #12 a bite of mechanical soft barbeque chicken while standing over the resident on their right side. CMA #3 gave a drink of a pink liquid and instructed the resident to take a drink while standing over the resident. CMA #3 gave the resident a bite of beans instructing them to take a bite while standing to the right of them. 2. Resident #75 had diagnoses which included unspecified dementia and mild neurocognitive disorder. A Quarterly Resident Assessment, dated 07/27/24, documented Resident #75 had severe cognitive impairment and required supervision or touching assistance for the task of eating. On 08/13/24 at 12:28 p.m., CNA #1 walked over to Resident #75, helped the resident move their tray back towards them, and gave the resident bites of beans while standing to the right side of the resident. On 08/13/24 at 12:30 p.m., CNA #1 continued to stand over Resident #75 feeding them bites of beans and attempting to give them a bite of bread. On 08/13/24 at 12:31 p.m., CNA #1 continued to stand over Resident #75 on their right side giving them a bite of chicken and a bite of beans. There was an empty chair observed to the left of the resident. On 08/13/24 at 12:34 p.m., CNA #1 continued to stand over Resident #75 while feeding them a bite of mechanical textured meat. On 08/13/24 at 12:48 p.m., CNA #1 stated they would make sure if a resident needed assistance with their meal, they would help them. On 08/13/24 at 12:49 p.m., CNA #1 stated they were not aware of any policy on where staff were situated while assisting a resident with eating. On 08/14/24 at 10:09 a.m., the DON stated staff should assist residents with eating when needed. They stated staff should be seated while assisting residents with eating.

Based on observation and interview, the facility failed to ensure information to file a formal complaint to the state agency and ombudsman were readily available to 10 of 10 residents that attended the resident group interview. The Administrator reported the census was 83. Findings: On 08/14/24 at 3:15 p.m., ten residents were asked if they knew their Ombudsman. several of the residents questioned what was an Ombudsman. The residents were introduced, then asked if they were familiar with where information was posted to call the ombudsman if they had a concern or complaint. They stated they did not know but the information may be on the bulletin board on C Hall. The residents were asked if they knew how to report a complaint to the state survey office. They stated they did not know, the information may have been posted on the bulletin board on C Hall. On 08/14/24 at 3:46 p.m., the bulletin board on C Hall was observed to have the information to report a complaint to the state office and posting of the Ombudsman. The forms were near the top of the bulletin board, with the bottom of the forms approximately 5 feet above the floor. On 08/14/24 at 3:50 p.m., the Administrator was asked if the information for residents to file a formal complaint to the state agency or contact the Ombudsman were readily available for all residents to view. They stated the forms needed to be lowered.

Based on observation and interview, the facility failed to ensure past survey results were readily available to residents to review for 10 of 10 residents that attended the resident group interview. The Administrator reported the census was 83. Findings: On 08/14/24 at 3:15 p.m., ten residents were asked if they knew where the previous survey results were posted and if the reports were readily available to them, without having to request the information The residents stated they did not know they could look at the reports and did not know where to locate the previous reports. On 08/14/24 at 3:46 p.m., the bulletin board on C Hall was observed to have a binder labeled, Survey Results, in a file bin mounted to the wall. The lower part of the bin was approximately five feet above the floor. The binder was attached to a chain that limited the binder to be lowered approximately three feet above the floor. On 08/14/24 at 3:50 p.m., the Administrator was asked if the previous survey results were readily available to the residents to review, without the assistance of staff. They stated the binder may be too high and needed to be lowered or in a different place.

Based on interview and record review, the facility failed to ensure the results of abuse investigations were submitted to the State within 24 hours for three (#15, 44, and #51) of five residents reviewed for abuse. The Administrator identified 83 residents resided in the facility. Findings: Resident #15 had diagnoses which included cognitive communication deficit and chronic kidney disease, stage 3. Resident #15's admission assessment, dated 05/22/24, documented Resident #15's cognition was intact. An Initial State Reportable Incident form, faxed on 07/08/24 at 4:37 p.m., documented CNA# 5 reported to administration Resident #15 had reported to them that on 07/03/24 CNA #4 had called Resident #15 an expletive word in the shower room. A Final State Reportable Incident form, faxed on 07/11/24 at 12:57 p.m., documented CNA #4 was immediately put on a three day suspension for verbal abuse allegation during this investigation. All staff were immediately in-serviced over abuse on 07/08/24. On 08/14/24 at 1:17 p.m., RN #1 stated the facility policy for reporting abuse was to report verbal and physical abuse immediately. On 08/14/24 at 1:34 p.m. the DON stated the incident had occurred on 07/03/24. They stated it was report to OSDH within two hours or sooner. On 08/14/24 at 1:37 p.m., the DON stated the incident had occurred on 07/03/24 and was reported to CNA #4 on 07/05/24, the CNA stated that they had forgotten to report it. The DON stated CNA #4 had not reported in a timely manner. On 08/14/24 at 1:40 p.m., the Administrator stated the CNA had not reported the incident to them until 07/08/24. 21731 2. Resident #44 had diagnoses to include mild intellectual disabilities, vascular dementia, hearing loss, visual loss, behavioral and emotional disorder with childhood onset, schizophrenia, and bipolar. A Quarterly Assessment, dated 07/19/24 documented Resident #44 had moderate cognitive impairment, displayed verbal behavioral symptoms toward others and required some substantial to maximum assistance with ADLs. An Incident Report Form, dated 06/26/24 documented a hospice nurse reported Resident #44 stated a staff member was too rough with Resident #44. The resident had reported they had urinated on themselves in the dining room at lunch and the aide had to take the resident out of the dining room to provide care. Resident #44 stated They just jerked me around . The investigative file, documented the event occurred on 06/26/24. A Xerox Confirmation Report documented the initial report was filed on 06/26/24 at 2:18 p.m. A Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment of Misappropriation of Property form documented the an allegation of abuse had been received on 06/26/24 but the Nurse Aide Registry had not been notified until 07/02/24. On 08/15/24 11:35 a.m., in the presence of the administrator, the DON was asked to clarify items on the incident report, dated 06/26/24. The DON stated a hospice nurse had reported to staff Resident #44 reported an allegation of abuse with the staff were too rough. The DON was asked when was the nurse aide registry notified of the abuse allegation and an investigation had been initiated for the nurse aide. The DON stated we have five days to report. An Incident Report Form, dated 08/18/24, documented at approximately 8:30 p.m., Resident #44 was being provided care alleged a CNA had molested Resident #44. The investigative file, contained a Xerox Confirmation Report, that documented an initial report to OSDH had been sent on 08/20/24 at 7:59 a.m., and the Nurse Aide Registry form documented the Nurse Aide Registry had been notified on 08/20/24. On 08/20/24 at 11:17 a.m., the ADON was asked when did facility staff become aware of the allegation of abuse regarding the event on 08/18/24. They stated, management was made aware just after noon on 08/19/24. The ADON was asked when did the facility send a report to OSDH. The ADON stated on 08/19/24, the charge nurse had been aware but did not report to management. The ADON was asked when did the facility report to the Nurse Aide Registry a CNA had an allegation of abuse. They stated on 08/20/24 just be fore 8:00 a.m. The ADON was asked if the LPN had been reported to their licensing board. The ADON stated, they had not. 3. Resident #51 had diagnosis to include Alzheimer's Disease and malignant neoplasm of bronchus and lung. A Progress Note, dated 09/19/23 at 1:17, read in part, .[resident] yelling and swatting at other resident during activities . The clinical record did not contain an incident report to OSDH or other required agencies. A Progress Note, dated 04/04/24 at 6:03 p.m., read in part, .Resident wanted to sit in chair in front of nurse station. Another resident was sitting in the chair Resident {#51] attempted to pull other resident out of chair while insulting [them] . The clinical record did not contain an incident report to OSDH or other required agencies. A Quarterly Assessment, dated 06/14/24, documented Resident #51 had clear speech, understands, is understood, has severe cognitive impairment for daily decision making, displayed inattention and disorganized thinking, and required supervision and cues to perform ADLs. A Progress Note, dated 06/21/24 at 7:16 p.m., read in part, .This nurse was coming out of a resident room and seen [Resident #51] sitting in a chair .with legs opened and [Resident #18} was sitting in front of [Resident #51], rubbing on [Resident #51's] vagina. This nurse told residents that the [sic] can not do that and they stopped. This nurse was sitting a nurses station and seen [Resident #51 and [Resident #18] kissing this nurse went to talk to resident and {Resident #51 was leaning forward trying to pull pants down while {Resident #18 had partial of [their] penis out. This nurse told resident they can not do that in the hallway. Resident got up and sat in front of nurses station .interventions Attempted: told resident they were not allowed to do that in hallway . The clinical record did not contain an incident report sent to OSDH of a sexual interaction between Resident #51 and Resident #18. The facility did not provide an incident report or reportable incident to OSDH. On 08/13/24 at 11:46 a.m., during the noon meal, Resident #51 was seated a a dining table in the main dining room. Resident #72, entered the area from a side door and approached the table where Resident #51 was seated. Resident #51 began to swing their arms, and hit Resident #72. CNA #1 calmly separated the residents and assisted Resident #51 to another table for the noon meal. 08/13/24 at 2:10 p.m., CNA #1 was asked to verify if they had assisted Resident #51 during the noon meal when an altercation occurred between two female residents. They stated they had separated the residents. They stated they did not know what triggered the event but turned and seen Resident #51 hitting Resident #72. CNA #1 was asked if they had reported the event to anyone. They stated not yet, was trying to charge to they could go home at 2:00 p.m., On 08/15/24 at 4:24 p.m., the DON was asked to explain the events surrounding the progress note dated 06/21/24 at 4:27 p.m. The DON stated it appeared the nurse came out and seen Resident #51 sitting in a chair with their legs opened and Resident #18 was sitting in a wheelchair and were observed to be engaged in sexual touching. The DON was asked if a state reportable incident had been completed as a result of the sexual behavior between two cognitively impaired residents. The DON stated, they understood the residents have a right, so nothing else was put in place. The DON was asked to review the progress notes dated 09/19/23 and 04/02/24 and if the events of resident to resident altercations had been reported to OSDH or other required agencies. They stated they had not. been reported.

2. Resident #44 had diagnoses to include mild intellectual disabilities, vascular dementia, hearing loss, visual loss, behavioral and emotional disorder with childhood onset, schizophrenia, and bipolar. A Quarterly Assessment, dated 07/19/24 documented Resident #44 had moderate cognitive impairment, displayed verbal behavioral symptoms toward others and required some substantial to maximum assistance with ADLs. An Incident Report Form, dated 06/26/24 documented a hospice nurse reported Resident #44 stated a staff member was too rough with Resident #44. The resident had reported they had urinated on themselves in the dining room at lunch and the aide had to take the resident out of the dining room to provide care. Resident #44 stated They just jerked me around . The investigative file, contained documented of two Nurse Aides, a visitor, the resident's room mate, and a hospice nurse were interviewed. There was no documentation other staff or residents in the facility had been interviewed to ensure the safety of all residents. On 08/15/24 11:35 a.m., in the presence of the administrator, the DON was asked how was it determined the allegation was fully investigated. The DON stated they interviewed the resident, the other people that were in the resident room at the time, a hospice nurse , as well as the resident's room mate at the time - which has since passed away. The DON was asked if the alleged CNA involved had access to other residents. The don stated yes and the CNA that had assisted was from another hall. The DON was asked how was the event fully investigated if other residents being provided care from the staff involved were not interviewed, or if other staff were not interviewed. The DON stated, I thought I had a good investigation at the time, with a lot of interviews, but they are not with the information provided to the surveyor. No further information was provided. 3. Resident #51 had diagnosis to include Alzheimer's Disease and malignant neoplasm of bronchus and lung. A Progress Note, dated 09/19/23 at 1:17, read in part, .[resident] yelling and swatting at other resident during activities . The clinical record did not contain an incident report or investigative notes. A Progress Note, dated 04/04/24 at 6:03 p.m., read in part, .Resident wanted to sit in chair in front of nurse station. Another resident was sitting in the chair Resident {#51] attempted to pull other resident out of chair while insulting [them] . The clinical record did not contain an incident report or investigative notes. A Quarterly Assessment, dated 06/14/24, documented Resident #51 had clear speech, understands, is understood, has severe cognitive impairment for daily decision making, displayed inattention and disorganized thinking, and required supervision and cues to perform ADLs. A Progress Note, dated 06/21/24 at 7:16 p.m., read in part, .This nurse was coming out of a resident room and seen [Resident #51] sitting in a chair .with legs opened and [Resident #18} was sitting in front of [Resident #51], rubbing on [Resident #51's] vagina. This nurse told residents that the [sic] can not do that and they stopped. This nurse was sitting a nurses station and seen [Resident #51 and [Resident #18] kissing this nurse went to talk to resident and {Resident #51 was leaning forward trying to pull pants down while {Resident #18 had partial of [their] penis out. This nurse told resident they can not do that in the hallway. Resident got up and sat in front of nurses station .interventions Attempted: told resident they were not allowed to do that in hallway . The clinical record did not contain an incident report or investigative notes. On 08/15/24 at 02:17 p.m., the DON was asked how resident to resident altercations are handled. They stated usually like all other reportable events. The DON was asked if an investigation was initiated for Resident #51. They were asked to provide a copy of the event and items reported. No further information was provided. On 08/15/24 at 4:24 p.m., the DON was asked if the resident to resident altercations on 09/19/23, 04/02/24, and 06/21/24, had been investigated. They stated there was not a report made so there was not an investigation. 35389 Based on record review and interview, the facility failed to: a. ensure an allegation of abuse was fully investigated for two (#14 and #51); and b. prevent the potential for further abuse while an investigation was in progress for one (#44) of five sampled residents reviewed for abuse. The Administrator identified 83 residents resided in the facility. Findings: An Abuse Policy, revised 03/24/22, read in part, .Any allegation of abuse will be investigated by the DON, ADON, administrator or designated representative by use of the Abuse Packet. At a minimum they will .Interview any witnesses to the incident .interview the resident .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident if necessary .Interview the roommate, family members, and visitors as able and necessary .Interview other residents to whom the accused employee provides care or services .Employees of this facility who have been accused of resident abuse will be suspended from duty. This action will remain in effect until the investigation has been completed .Any licensed nurse found unfit for service will be reported to the Oklahoma Board of Nursing . 1. Resident #14 had diagnoses which included cognitive communication deficit, anxiety, and persistent mood disorder. A Quarterly Resident Assessment, dated 05/30/24, documented Resident #14's cognition was intact. An Initial State Reportable Incident form, dated 08/04/24, documented on 08/05/24 at 11:35 a.m. the charge nurse reported that resident #14 told hospice nurse that LPN #3 flipped off Resident #14 and stated [explicit word] on 08/04/24. It documented LPN #3 was placed on suspension. A Final State Reportable Incident form, faxed 08/06/24, documented upon interviewing Resident #14, the resident told the Administrator and the ADON they had asked the nurse to complete wound care and the nurse couldn't because they were unable to locate the key to the wound care cart. It documented the resident was mad because the nurse was careless and lost the key. It documented the resident told the nurse [explicit word] and flipped [them] off because [they] were careless to lose the key. It documented Resident #14 said they shouldn't have said anything because they didn't want to get anyone in trouble. The facility completed a referral to APS, notified the police department who did not feel the need to complete a report, and unsubstantiated the complaint because the resident admitted they were the one who told the nurse (explicit word) and flipped them off. It documented witness statements were attached. The report was completed by the Administrator. The investigation included an interview with Resident #48, LPN #3, ADON, and LPN #4. The statements contained the following information: a. Resident #48's statement, undated, documented they were happy with the care LPN #3 provided them. It documented Resident #48 did not have any issues with LPN #3 and was happy with the care they received. b. Resident #14's interview contained the above information on the final report. c. LPN #3's statement, dated 08/05/24, documented Resident #14 had flipped them off and said (explicit word); d. ADON's statement, dated 08/06/24, documented they were informed on 08/04/24 of the misplaced keys to the wound care cart. It documented the ADON arrived at the facility at 12:00 p.m. and provided the keys to the nurse. It did not document any information regarding the allegation of abuse. e. LPN #4's statement, dated 08/05/24, documented the hospice nurse had reported to them that Resident #14 told them they were flipped off over the weekend, and LPN #4 reported the situation to the Administrator and the ADON. It did not document any other staff members or residents were interviewed regarding the abuse allegation involving LPN #3 and Resident #14. A Follow Up State Reportable Incident form, faxed 08/07/24, documented the following additional information: a. on 08/06/24 at approximately 2:00 p.m., the Ombudsman came to the facility and interviewed Resident #14. It documented the resident told the Ombudsman LPN #3 flipped them off and said (explicit word) to the resident. It documented the resident did not want LPN #3 fired. It documented the Ombudsman and the Administrator went to interview Resident #14 who again reported LPN #3 had flipped them off and said (explicit word) to the resident. It documented the resident did not want the nurse fired and the nurse would remain on suspension with possible termination; b. on 08/07/24 at 11:12 a.m. the Administrator spoke to the Ombudsman who talked with their supervisor and they agreed the facility could bring LPN #3 back because the resident was oriented and the resident did not want the nurse fired; c. on 08/07/24 at 11:45 a.m., the Administrator asked Resident #14 if LPN #3 returned to the facility, would the resident be comfortable with LPN #3 providing wound treatment to the resident. It documented the resident stated yes; and d. 08/07/24 would be LPN #3's third day of suspension. It documented the nurse would return to their regular schedule on 08/10/24. There was no documentation the facility conducted any additional interviews with staff or other residents LPN #3 cared for after they received the follow up information where Resident #14 reported it was LPN #3 who flipped them off and cursed at them. There was no documentation LPN #3 had been reported to the Oklahoma State Board of Nursing for this abuse allegation. There was no documentation any additional interviews were held with LPN #3 regarding the incident prior to them returning to work. On 08/12/24 at 8:43 a.m., Entrance Conference was held with the Administrator was asked to provide a copy of the facility's Abuse Prohibition Policy and Procedures. The Abuse Policy revised 03/24/22 was provided to the survey team. On 08/12/24 at 10:21 a.m., Resident #14 stated their abuse concern was over kinda. They stated there was a nurse at the facility that told them (explicit word) last week. They stated it was LPN #3. They stated the facility spoke with the nurse and were going to fire them. Resident #14 stated they didn't want the employee to lose their job. They stated LPN #3 hadn't been in their room since the incident, but they still saw them in the facility. They stated staff had come in and spoke to Resident #14 about the incident, reprimanded LPN #3, and they believed it went down in their record. They stated they didn't think anyone else was around when LPN #3 did it. On 08/14/24 at 9:59 a.m., CMA #2 stated they would report any allegation of abuse to the DON. On 08/14/24 at 10:06 a.m., CNA #6 stated the facility did not tolerate any yelling, screaming, or getting loud. They stated they were to stay calm and collected and approach each resident nicely. They stated they were to report any allegation of abuse to their charge nurse, their supervisor, or anyone above them. On 08/14/24 at 10:10 a.m., the DON stated staff were to notify the charge nurse, if unavailable notify their supervisor, if unavailable the DON, ADON, or Administrator with any allegation of abuse. On 08/14/24 at 10:13 a.m., the Administrator stated the facility didn't allow any abuse or mistreatment. They stated any allegation of abuse was to be reported immediately and the facility would report it within the two hour maximum window as required. On 08/14/24 at 10:15 a.m., the Administrator and the DON stated they shared the responsibility of investigating allegations of abuse. The DON stated if a nurse reported abuse, they would go investigate by interviewing other residents, the aides on the hall, medication aides, the roommate if applicable, and anyone in the vicinity of the incident. They stated they could also review camera footage. On 08/14/24 at 10:17 a.m., the DON stated if a staff member was involved, it would be the same process and they would usually suspend the staff member during the investigation. On 08/14/24 at 10:18 a.m. the DON stated they would report the staff member to the licensing board while completing the State Reportable. The Administrator stated as they were completing the State Reportable, they would report the staff member. On 08/14/24 at 10:18 a.m., the DON stated once they had completed the investigation and determine whether the event did or did not occur and see what the police said to determine if it was safe for a staff member to return to work. On 08/14/24 at 10:19 a.m., the Administrator stated on the abuse investigation involving Resident #14, a hospice staff member had reported the incident to the facility. They stated the resident had reported to hospice a staff member said (explicit word) and flipped them off. They stated it was reported to the charge nurse who reported it to the ADON and Administrator immediately on 08/05/24. On 08/14/24 at 10:24 a.m., the DON stated the allegation was against LPN #3, they were suspended three days and then returned to work after the Administrator spoke to the Ombudsman who told them what to do. On 08/14/24 10:25 a.m., the Administrator stated they did not notify the licensing board of the allegation of abuse involving LPN #3. On 08/14/24 at 10:26 a.m., the Administrator stated they along with the ADON interviewed the resident, the nurse, and then interviewed another resident that the nurse provided care to. The DON stated they did not see any other resident interviews in there. On 08/14/24, at 10:31 a.m., the Administrator stated they did not think any other staff were interviewed. On 08/14/24 at 10:32 a.m. the Administrator and DON stated they believed another resident who had wounds was interviewed but they could not find it in the investigation. On 08/14/24 at 10:34 a.m. the Administrator stated they completed a follow up report because the Ombudsman came to the facility and spoke with Resident #14. They stated the resident reported staff had flipped them off and said (explicit). The Administrator stated at that point, they along with the Ombudsman went to speak to the resident who reported that the nurse said it to [them]. They stated the resident did not want the staff member fired. On 08/14/24 at 10:37 a.m., the Administrator stated they had spoken with the Ombudsman who stated it was safe to bring the staff member back after their suspension. They stated the Ombudsman reported the resident was oriented, they were there for the residents, and that was what the resident wanted. On 08/14/24 at 10:39 a.m., the DON reported LPN #3 was educated by the DON, ADON and Administrator to take a staff member in with them anytime they were providing care to Resident #14. They stated it was verbal and there was no documentation of the conversation. On 08/14/24 at 1:42 p.m., the Administrator provided a new abuse policy revised 07/01/24.

Based on interview and record review, the facility failed to revise care plans for two (#18 and #51) of 21 residents reviewed for care plans. The Administrator identified 83 residents resided in the facility. Findings: A Care Plan Revisions Upon Status Change policy, revised 07/02/24, read in part, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change .The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change .The care plan will be updated with the new or modified interventions . Resident #18 had diagnosis which included unspecified dementia. Resident #18's quarterly assessment dated , 04/20/24, documented Resident #18's cognition was severely impaired. A Behavior Note, dated 09/20/19 at 5:24 p.m., documented, Another resident informed this nurse that resident was in hallway touching penis. List Interventions Attempted: Educated [Resident #18] that resident will need to go inside room in private to do so. A Behavior Note, dated 10/18/19 at 4:49 p.m., documented, ACMA was giving resident eternal feedings when resident got penis out of pants and started touching [themselves]. ACMA asked resident respectfully to wait until after feeding was administered. List Interventions Attempted: ACMA asked resident respectfully to wait until after feeding was administered. This nurse spoke [with] resident and asked if it could wait until after feeding due to being unable to stop feeding. A Behavior Note, dated 10/22/23 at 8:56 p.m., documented, [Resident #18] had penis out during 2030 [8:30 p.m.] smoke break. List Interventions Attempted: CNA [name withheld] firmly told [Resident #18] to put [Resident #18] penis away. A Behavior Note, dated 10/23/23 at 1:01 p.m., documented, During 11 a.m. smoke break resident exposed penis. List Interventions Attempted: CNA/Activities assist [name withheld] instructed resident to put it away now. A Behavior Note, dated 04/21/24 at 10:02 a.m., documented CMA had was finishing feeding [Resident 18] when [Resident 18] ran [Resident 18's] hand up [CMA's] leg and tried to touch [CMAs] private area. List Interventions Attempted: CMA firmly told [Resident #18] to keep [Resident 18's] hands to [themselves]. A Behavior Note, dated 06/21/24 at 7:25 p.m.,, documented, This nurse was coming out of a resident room and [Resident #18] sitting in WC in front of [Resident #51] rubbing on her vagina. This nurse told residents that they can not do that in the hallway and they stopped. This nurse was sitting a [sic] nurses station and seen [Resident #18] and [Resident #51] kissing. This nurse went to talk to residents; [Resident #18] had partial of [their] penis out and Resident #51 was leaning forward trying to pull pants down. This nurse told resident they can not do that in the hallway and [Resident 51] voiced understand and got up and sat in front of nurses station. On 08/15/24 at 5:36 p.m., Resident #18's care plan was reviewed, there was no documentation of sexual behaviors in the care plan. On 08/19/24 at 2:15 p.m., the DON stated the care plan had last been updated on 08/06/24. 21731 3. Resident #51 had diagnosis to include Alzheimer's Disease and malignant neoplasm of bronchus and lung. A Progress Note, dated 09/19/23 at 1:17, read in part, .[resident] yelling and swatting at other resident during activities . The clinical record did not contain an a care plan to address Resident #51's behaviors. A Progress Note, dated 04/04/24 at 6:03 p.m., read in part, .Resident wanted to sit in chair in front of nurse station. Another resident was sitting in the chair Resident {#51] attempted to pull other resident out of chair while insulting [them] . The clinical record did not contain a care plan to address Resident #51's behaviors. A Quarterly Assessment, dated 06/14/24, documented Resident #51 had clear speech, understands, is understood, has severe cognitive impairment for daily decision making, displayed inattention and disorganized thinking, and required supervision and cues to perform ADLs. A Care Plan, last reviewed on 07/05/24, did not address resident specific behaviors or interventions for behaviors. A Progress Note, dated 06/21/24 at 7:16 p.m., read in part, .This nurse was coming out of a resident room and seen [Resident #51] sitting in a chair .with legs opened and [Resident #18] was sitting in front of [Resident #51], rubbing on [Resident #51's] vagina. This nurse told residents that the [sic] can not do that and they stopped. This nurse was sitting a nurses station and seen [Resident #51 and [Resident #18] kissing this nurse went to talk to resident and [Resident #51] was leaning forward trying to pull pants down while [Resident #18] had partial of [their] penis out. This nurse told resident they can not do that in the hallway. Resident got up and sat in front of nurses station .interventions Attempted: told resident they were not allowed to do that in hallway . The clinical record did not contain a care plan to address Resident #51's behaviors On 08/13/24 at 11:46 a.m., during the noon meal, Resident #51 was seated a a dining table in the main dining room. Resident #72, entered the area from a side door and approached the table where Resident #51 was seated. Resident #51 began to swing their arms, and hit Resident #72. CNA #1 calmly separated the residents and assisted Resident #51 to another table for the noon meal. On 08/15/24 at 4:24 p.m., the DON was asked if Resident #51's care plan addressed behaviors that were displayed by Resident #51. They stated, No.

Based on observation, record review, and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week. The Administrator identified 83 residents resided in the facility. Findings: On 08/14/24 at 10:58 a.m., Human Resource #1, provided the requested RN hours for May, June, and July. Review of the RN time punch details documented, the facility did not have RN coverage for eight consecutive hours on the following dates: a. 05/04/24 - 7.68 hours worked, b. 05/05/24 - 7.72 hours worked, c. 05/12/24 - 7.47 hours worked, d. 05/18/24 - 7.45 hours worked, e. 05/19/24 - 7.43 hours worked, f. 05/27/24 - 7.80 hours worked, g. 06/08/24 - 7.60 hours worked, h. 06/23/24 - 7.67 hours worked, i. 07/05/24 - 4.93 hours worked, j. 07/06/24 - 7.60 hours worked, k. 07/07/24 - 7.53 hours worked, l. 07/13/24 - 7.45 hours worked and, m. 07/26/24 - 7.47 hours worked. On 08/15/24 at 11:37 a.m., Human Resource #1 stated if the facility did not have RN coverage, the DON or ADON would need to come in to cover. On 08/15/24 at 11:48 a.m., Human Resource #1 stated the dates listed above did not meet the 8 consecutive RN hours required.

Based on observation, record review, and interview, the facility failed to follow their policy to administer medications via enteral tube for one (#13) of one sampled resident reviewed for medication administration via gastrostomy tube. The Administrator stated 83 residents resided in the facility. The Resident Matrix, dated 08/12/24, documented four residents with a gastric tube resided in the facility. Findings: A Medication Administration via Enteral Tube policy, dated 07/02/24, documented, .flush enteral tube with water per orders prior to administering medications .dilute the solid or liquid medication as appropriate and administer using a clean oral syringe .Flush tube again with water per orders taking into account resident's volume status .repeat with the next medication .flush the tube with a final flush of water . Physician Orders for Resident #13 included: a. On 07/06/23, may crush medications; b. On 08/08/23, clopidogrel bisulfate 75 mg by mouth every day for hypertension; lactulose 10 gm/15 ml give 30 ml by mouth daily; Mylanta maximum strength oral suspension 400-400-40 mg/5 ml give 15 ml by mouth two times a day; c. On 08/14/23, trospium chloride ER 60 mg by mouth every day; d. On 12/05/23, CoQ-10 100 mg by mouth one time a day; docusate 100 mg by mouth every day; e. On 12/18/23, famotidine 40 mg by mouth twice a day; f. On 09/01/23, furosemide 40 mg by mouth every day; g. On 01/25/24, glycolax powder, give 17 gram in orange juice, by mouth every day; h. On 05/02/24, hydroxyzine 50 mg by mouth two times a day; i. On 05/20/24, lorazepam 0.5 mg by mouth two times a day; and j. On 06/12/24, Jevity 1.5 Cal/Fiber one can via gastrostomy tube four times a day, flush with 60 cc of water before and after. On 08/14/24, at 9:00 a.m., CMA #1 was observed to prepare the above orders to be administered to Resident #13. CMA #1 placed the tablets into a medication cup, poured the tablets into a pouch and crushed the medications to a fine powdery substance, and placed the contents into a plastic water cup. No liquids were added into the cup of crushed medications. The lactulose was poured into a medication cup for administration. CMA cleansed their hands, donned gloves and a gown, entered the resident room, and arranged the cups on the bedside table. CMA #1 obtained an eight ounce container of tap water. CMA #1, checked the residual of contents of the gastrostomy tube, removed the plunger from the syringe, placed the syringe into the gastrostomy tube, poured approximately 60 cc of water into the syringe, added water to parts of the Jevity, poured a small amount of the mixture into the syringe and gastrostomy tube, followed by an undetermined amount of dry fine powder substance of the crushed medications, added water, dry crushed medications, Jevity, and repeated the process until the medications and Jevity was been administered through the gastrostomy tube. The tube was then flushed with approximately 60 cc of water. On 08/14/24, at 1:28 p.m., CMA #1 was asked if there was a reason the medications had not been diluted in liquids prior to placing the dry crushed medications in the syringe attached to the gastrostomy tube. CMA #1 stated, I forgot to bring a spoon, CMA #1 stated they were aware the medications could be cocktailed and diluted with water.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 37 medications opportunities were observed, with three errors, for a total error rate of 8.11%. This affected two (#13 and #43) of six residents observed during the medication administration. The Administrator stated 83 residents resided in the facility. Findings: 1. A Physician Order, dated 03/09/24, documented Resident #43 was to be administered a chewable aspirin one time a day for atherosclerotic heart disease. On 08/14/24 at 8:50 a.m., CMA #1 prepared and administered oral medications for Resident #43, to include a chewable aspirin as ordered. CMA placed the chewable aspirin in the same medication cup with other medications for a total of 10 medications. CMA #1 did not provide instruction to Resident #43 regarding the chewable aspirin to be chewed and not swallowed. 2. Physician Orders for Resident #13 included: a. On 07/06/23, may crush medications; b. On 08/08/23, administer Mylanta Maximum Strength oral suspension by mouth two times a day for pneumonitis; and c. On 08/29/23, administer Potassium Chloride ER tablet by mouth one time a day for extremity edema. On 08/14/24 at 9:00 a.m., CMA #1 asked Resident #13 if they preferred their medications to be given by mouth or via gastrostomy tube. Resident #13 requested all medications to be via gastrostomy tube. CMA #1 prepared the medications for Resident #13, and removed the Potassium Chloride ER from the medication cup. CMA #1 stated they needed to obtain Mylanta from the medication room. The CMA went to the medication room in search of the medication, stated the medication must not have been delivered, there was no Mylanta to be offered or administered to Resident #13. On 08/14/24 at 1:28 p.m., CMA #1 was asked why Resident #43 was administered a chewable aspirin and not instructed to chew the tablet as ordered. They stated the resident has always just swallowed it. CMA #1 was asked why resident #1 did not receive the Potassium Chloride as ordered. CMA #1 stated, the medication is coated and cannot be crushed. They were asked if there was an order to hold the medication or to provide a liquid potassium if given through the gastrostomy tube. CMA #1 stated there were no further orders to hold or different form of the medication. Three medication error occurred out of 37 opportunities, which resulted in an error rate of 8.11%.

Based on observation, record review, and interview, the facility failed to: 1. ensure bare hand contact with food did not occur during the lunch meal service. 2. monitor the dish washing machine to ensure proper sanitation was being conducted. Findings: A Food Service policy, undated, read in part, .All staff in the dining room will wash/sanitize hands with any resident contact, touching other surface or contact with your own person before serving a resident meal tray . 1. Resident #75 had diagnoses which included unspecified dementia and mild neurocognitive disorder. A Quarterly Resident Assessment, dated 07/27/24, documented Resident #75 had severe cognitive impairment and required supervision or touching assistance for the task of eating. On 08/13/24 at 12:19 p.m., CNA #1 picked up Resident #75's slice of bread with their bare hands and asked the resident if they wanted a bite. On 08/13/24 at 12:30 p.m., CNA #1 picked up Resident #75's slice of bread with their bare hands and tried to feed it to them. The resident took the piece of bread from CNA #1 and started feeding themselves. On 08/13/24 at 12:49 p.m., CNA #1 stated they would have to ask another staff member the policy for bare hand contact with food. They stated they would make sure they washed and sanitized their hands. On 08/14/24 at 10:08 a.m., the DON stated staff just had to sanitize their hands before touching food with their bare hands. They stated staff were allowed to touch food with their bare hands to butter toast or something like that. 46216 2. On 08/13/24 at 11:20 a.m., dietary aide #1 obtained a chlorine test strip and placed it in the outer basin of the dish machine to moisten the strip. The strip turned a light lavender in color. On 08/13/24 at 11:24 a.m., dietary aide #1 stated it read 10 ppm. They stated it should read between 50-100 ppm. On 08/13/24 at 11:29 a.m., the dietary manager obtained a chlorine test strip and placed it in the outer basin of the dish machine to moisten the strip. The strip again turned a light lavender in color. The dietary manager stated it should read 120 ppm. On 08/13/24 at 11:34 a.m., the dietary manager stated they had called maintenance and they would be on there way. On 08/13/24 at 11:35 a.m., the dietary manager stated they would use paper serving containers and plastic utensils for lunch service as the dishes were not sanitized properly.

Based on observation, record review, and interview, the facility failed to: a. handle soiled linens in a manner that prevented cross contamination for one (#14) of one sampled resident observed during wound care; and b. ensure enhanced barrier precautions were utilized when accessing a resident's gastric tube for one (#13) of one sampled resident observed with a gastric tube. The Administrator identified 83 residents resided in the facility. The Resident Matrix, dated 08/12/24, documented four residents with a gastric tube resided in the facility. Findings: A Laundry Services policy, undated, read in part, .All soiled linen should be bagged or put into carts at the location where used .If laundry barrels are used, all linens should be bagged . An Enhanced Barrier Precautions policy, dated 07/24/24, read in part, .Enhanced barrier precautions .(EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .enhanced barrier precautions .for residents with .feeding tubes .necessary when performing high-contact care activities .donned prior to entering the resident's room activities include .feeding tubes .Additional epidemiologically important MDROs may include .ESBL -producing Enterobacterales . 1. Resident #14 had diagnoses which included cognitive communication deficit, anxiety, and persistent mood disorder. A Quarterly Resident Assessment, dated 05/30/24, documented Resident #14 was cognitively intact, dependent on staff for the task of toileting, and always incontinent of bowel and bladder. On 08/12/24 at 9:56 a.m., CNA #7 provided incontinent care to Resident #14. CNA #7 turned Resident #14 on their right side and large soft brown stool was observed on their buttock and up their back. The resident stated Can you believe it went all the way up my back? On 08/12/24 at 10:00 a.m., CNA #7 stated, That's what you have me for, to help you. Stool was observed on the sling that was located under the resident and on the bottom of their shirt. On 08/12/24 at 10:03 a.m., CNA #7 stated, We will get you a new shirt ok. The CNA removed the resident's soiled shirt and sling, and tossed them on the ground by the foot of the bed. Both items had brown stool on them. On 08/12/24 at 10:07 a.m., CNA #7 removed the sling and black shirt from off the ground, and placed the items on the lid of a yellow soiled linen barrel located outside in the hallway. CNA #7 lifted the items off the lid, lifted the lid, and placed the soiled shirt and sling in the yellow barrel. The CNA failed to place the soiled items in a bag prior to transporting them out of the resident's room. On 08/12/24 at 10:08 a.m., CNA #7 stated if items got wet, they would place them in the yellow barrel. They stated if it had diarrhea on it, they would blow it out. They stated the only diarrhea today was on the resident's brief. On 08/14/24 at 10:10 a.m., the DON stated staff should hold soiled items away from the body and of course wear gloves. 21731 2. Resident #13 had diagnoses to include diffuse large B-cell lymphoma, metastatic cancer, ESBL resistance, gastrostomy status, and chronic kidney disease -Stage 4. Physician Orders, dated 06/27/24 documented Resident #13 was to be admitted to hospice services, medications and nutrition could be administered by mouth or gastrostomy tube. On 08/14/24 at 9:00 a.m., CMA #1 was observed to don gloves and gown, enter Resident #13's room with prepared medications, administer medications and a nutritional supplement, remove the gloves and gown, and begin to clean the work area. Resident #13 stated, they did not believe all of the contents placed in the gastrostomy tube had gone in. CMA #1, washed their hands, donned gloves, and opened the cap of the gastrostomy tube. The CMA was asked if there was a reason they did not don a gown when they returned to check the gastrostomy tube. The CMA stated there was not a gold star on the Resident's door to indicate the need for a gown, as they pointed to a green star on the door. The CMA was asked what was the meaning of the green star. They stated, I don't know. On 08/14/24 at 1:34 p.m., LPN #1 was asked how the medication aides were to know what type of PPE was to be worn while administering medications for a resident with a gastrostomy tube. LPN #1 stated, I don't know. The LPN was asked what was the meaning of the green star on the doors. They stated, I would have to ask. On 08/14/24 at 1:39 p.m., LPN #2, having overheard the conversation with LPN #1, stated the green star is to identify EBP and the medication aides are to wear gloves and a gown prior to providing any care to the resident. LPN #2 stated if there had been a gold star, the staff are to don gloves and gowns prior to entering the resident room. The medication aide should have donned gloves and a gown when they check the gastrostomy tube each time the care was provided to Resident #13.

Based on record review and interview, the facility failed to ensure Resident Assessments were accurately coded for two (#58 and #85) of 21 residents reviewed for assessments. The Administrator identified 83 residents resided in the facility. Findings: 1. Resident #58 had diagnoses which included dysphagia following cerebral infarction. A Physician Order, dated 07/17/23, documented admit to hospice for CVA. An Annual Resident Assessment, dated 07/18/24, did not document hospice care was received while the resident was at the facility. On 08/15/24 at 2:16 p.m., MDS Coordinator #1 stated they started with evaluating the resident's cognition, went through the resident's chart, pain, completed all of their interview questions, and reviewed progress notes and assessments to ensure Resident Assessments were accurately coded. On 08/15/24 at 2:17 p.m., MDS Coordinator #1 stated the life expectancy less than six months section and hospice should be checked yes when a resident received hospice care. They stated Resident #58 was receiving hospice care. On 08/15/24 at 2:19 p.m., MDS Coordinator #1 stated the annual resident assessment for Resident #58 did have life expectancy less than six months marked but did not have hospice marked. 2. Resident #85 had diagnoses which included displaced intertrochanteric fracture of the left femur. A Nurses' Note, dated 06/22/24, documented Resident #85 discharged from the facility to home accompanied by family. A Discharge Resident Assessment, dated 06/22/24, documented Resident #85's discharge status was a short-term general hospital. On 08/16/24 at 9:34 a.m., MDS Coordinator #2 stated Resident #85's skilled days were up and the resident discharged home with family. On 08/16/24 at 9:36 a.m., MDS Coordinator #2 reviewed Resident #85's discharge assessment and stated I put hospital.

Based on record review and interview, the facility failed to ensure physician ordered labs were obtained for one (#14) of 12 sampled residents reviewed for lab services. The Administrator identified 83 residents resided in the facility. Findings: A Laboratory Services policy, reviewed 07/02/24, read in part, .The facility must provide or obtain laboratory services when ordered .The facility is responsible for the timeliness of the services. Resident #14 had diagnoses which included stage four pressure wound of the left heel. Wound Evaluation and Management Summary notes, dated 05/15/24, documented HBA1C recommended. The note was signed by the Wound Care Physician. Wound Evaluation and Management Summary notes, dated 05/22, 05/29, 06/05, 06/12, 06/19, 06/28, 07/17, 07/24, 07/31, 08/07, and 08/14/24 documented the HBA1C was pending. The notes were signed by the Wound Care Physician. There was no documentation the HBA1C was ever obtained. On 08/15/24 at 8:40 a.m., the ADON was asked to clarify the recommendation of a HBA1C on Resident #14's wound care notes. On 08/15/14 at 9:32 a.m., the Administrator stated the Wound Care Physician had put the HBA1C under recommendations not orders so the wound care nurse did not see it. They stated they ordered it today. They stated the facility went ahead and did a QA on the HBA1C that started in May and continued on the wound care notes but was never drawn.

Based on observation and interview, the facility failed to ensure food was stored in a sanitary manner and dishes were dried completely before storing them. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: On 07/12/23 at 11:44 a.m., an initial tour of the kitchen was conducted. The following were observed: a. A scoop was observed stored in a large container which was filled with flour. b. Condensation was on plastic containers which were stacked on a shelf. On 07/12/23 at 11:49 a.m., the DM stated scoops should never be left inside any container which stored food. The DM stated the plastic containers should not have been stacked while drying. The DM stated containers should have been left on a shelf to dry and once completely dry then stacked.

Based on record review and interview, the facility failed to notify the physician of a resident change in condition for one (#67) of four residents who were reviewed for respiratory monitoring. The ''Resident Census and Conditions of Residents report documented 66 residents resided in the facility. Findings: Resident (Res) #67 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the resident was to receive [MEDICATION(S)] nebulization solution every six hours as needed for wheezing. The treatment administration record (TAR) for [DATE] did not document [MEDICATION(S)] nebulization had been administered for wheezing at any time in [DATE]. The Care Plan last reviewed [DATE], read in parts, .at risk for impaired breathing pattern r/t [CONDITION(S)] .obtain chest X-ray r/t temp 100.7 and non productive cough .administer AccuNeb Nebulization Solution 0.63 MG/3 ML ([MEDICATION(S)]) as physician ordered .monitor VITAL SIGNS .monitor/document/report to MD .changes in behavior . The quarterly assessment, dated [DATE], documented the resident was severely cognitively impaired and required extensive assistance with most activities of daily living. The assessment did not document the resident received oxygen therapy. A social service progress note, dated [DATE], documented a resident care plan meeting was conducted. The note documented the resident was eating well, was total care, and the family had no concerns or complaints. A nurse note, dated [DATE] at 8:20 p.m., documented the resident spiked a temperature of 101.4 F. The note documented the resident was COVID-19 tested with a negative result and was given Tylenol (a pain/fever reducing medication). The documentation did not show physician was notified of temparature. A vital sign entry, dated [DATE] at 9:10 p.m., documented a heart rate of 78 beats per minute. A nurse note, dated [DATE] at 9:45 p.m., documented the resident's temperature was 99.1 F. A vital sign entry, dated [DATE] at 3:48 a.m., documented a temperature of 98.2 F. A nurse note, dated [DATE] at 5:54 a.m., documented at 12:00 a.m., the resident was in bed, temperature was 98.2 F, eyes were closed, and aroused to verbal stimuli. The note documented the resident's respirations were even and unlabored with wheezing noted to the upper lobes. The note documented, at 5:40 a.m., a certified nurse aide (CNA) informed the nurse was needed in the resident's room. The note documented the resident was nonresponsive with no blood pressure or respirations and all vital signs had ceased. The note documented the resident's family was notified at 5:50 a.m. and the physician was notified at 6:12 a.m. of the resident's condition. There was no documentation to show that the physician was notified of wheezing. The vital sign record did not documented any oxygen saturation or respiration monitoring during [DATE]. A discharge summary, dated [DATE], documented the resident was deceased and the cause of death was unknown. On [DATE] at 9:32 a.m., licensed practical nurse (LPN) #2 , who worked the night shift, stated she did not know the resident had a breathing treatment order for wheezing. The LPN stated the resident's oxygen saturations on the night shift were running fairly good most of the time. She stated she did not document the resident's oxygen saturations because other residents were sick and she was busy. The LPN stated she did not notify the physician of the resident's wheezing or any respiratory concerns. On [DATE] at 12:55 p.m., certified medication aide (CMA) #1 stated she was asked by CNA #1 to check out Res #67 because something was wrong. The CMA stated the CNA told her right after the evening meal. The CMA stated the resident's face was red and her respirations were labored and heavy. The CMA told the CNA to advise the nurse. On [DATE] at 2:20 p.m., CNA #1 stated she assisted Res #67 with all three meals on [DATE]. The CNA stated the resident ate well for breakfast and lunch, but did not eat well for the evening meal. The CNA stated during the evening meal the resident was not acting normal, had a cough, and she had asked the nurse to check on the resident. The CNA stated around 9:00 p.m. the nurse was in the resident's room and heard the nurse say the resident had rattles with lung sounds. On [DATE] at 9:16 a.m., the physician stated the facility did not notify him of the change of resident's condition. The physician stated he did not know the resident's cause of death, it was difficult to determine based on documentation, and would liked to have seen some respiratory monitoring and documentation completed. The physician stated he expected the staff to administer the breathing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, the facility failed to provide respiratory care and monitoring for one (#67) of three residents sampled for respiratory care. The facility failed to: a. conduct thorough respiratory assessments. b. provide physician ordered respiratory treatments as needed. c. notify the physician of a change in condition. The ''Resident Census and Conditions of Residents'' report documented 66 residents resided in the facility. Findings: Resident (Res) #67 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the resident was to receive [MEDICATION(S)] nebulization solution every six hours as needed for wheezing. The treatment administration record (TAR) for [DATE] did not document [MEDICATION(S)] nebulization had been administered for wheezing at any time in [DATE]. The Care Plan last reviewed [DATE], read in parts, .at risk for impaired breathing pattern r/t [CONDITION(S)] .obtain chest X-ray r/t temp 100.7 and non productive cough .administer AccuNeb Nebulization Solution 0.63 MG/3 ML ([MEDICATION(S)]) as physician ordered .monitor VITAL SIGNS .monitor/document/report to MD .changes in behavior . The quarterly assessment, dated [DATE], documented the resident was severely cognitively impaired and required extensive assistance with most activities of daily living. The assessment did not document the resident received oxygen therapy. A social service progress note, dated [DATE], documented a resident care plan meeting was conducted. The note documented the resident was eating well, was total care, and the family had no concerns or complaints. A nurse note, dated [DATE] at 8:20 p.m., documented the resident spiked a temperature of 101.4 F. The note documented the resident was COVID-19 tested with a negative result and was given Tylenol (a pain/fever reducing medication). A vital sign entry, dated [DATE] at 9:10 p.m., documented a heart rate of 78 beats per minute. A nurse note, dated [DATE] at 9:43 p.m., documented a STAT order was placed for a laboratory influenza test for the resident. A nurse note, dated [DATE] at 9:45 p.m., documented the resident's temperature was 99.1 F. A vital sign entry, dated [DATE] at 3:48 a.m., documented a temperature of 98.2 F. A nurse note, dated [DATE] at 5:54 a.m., documented at 12:00 a.m. the resident was in bed, her temperature was 98.2 F, her eyes were closed, and she aroused to verbal stimuli. The note documented the resident's respirations were even and unlabored with wheezing noted to the upper lobes. The note documented at 5:40 a.m. the certified nurse aide (CNA) informed the nurse she was needed in the resident's room. The note documented the resident was nonresponsive with no blood pressure or respirations and all vital signs had ceased. The note documented the resident's family was notified at 5:50 a.m. and the physician was notified at 6:12 a.m. of the resident's condition. The vital sign record did not documented any oxygen saturation or respiration monitoring on [DATE] and [DATE]. A discharge summary completed [DATE] documented the resident was deceased and the cause of death was unknown. On [DATE] at 9:32 a.m., licensed practical nurse (LPN) #2 stated she did not know the resident had a breathing treatment order for wheezing. The LPN stated the resident's oxygen saturations on the night shift were running fairly good most of the time. She stated she did not document the resident's oxygen saturations because other residents were sick and she was busy. The LPN stated she did not notify the physician of the resident's wheezing or any respiratory concerns. On [DATE] at 12:55 p.m., certified medication aide (CMA) #1 was interviewed related to the resident's change of condition. The CMA stated she was asked by CNA #1 to check out Res #67 because she said something was wrong. The CMA stated the CNA informed her right after the evening meal. The CMA stated the resident's face was red and her respirations were labored and heavy. The CMA stated she did not have a thermometer and told the CNA to advise the nurse. On [DATE] at 2:20 p.m., during an interview with CNA #1, she stated she assisted Res #67 with all three meals on [DATE]. The CNA stated the resident ate well for breakfast and lunch, but did not eat well for the evening meal. The CNA stated during the evening meal the resident was not acting her normal, had a cough, and she had asked the nurse to check on the resident. The CNA stated around 9:00 p.m. the nurse was in the resident's room and heard the nurse say the resident had rattles with lung sounds. On [DATE] at 9:16 a.m., the physician stated the facility did not notify him of the resident's change in condition. The physician stated he did not know the resident's cause of death, it was difficult to determine based on documentation, and would have liked to have seen some respiratory monitoring and documentation completed. The physician stated he would expected the staff to administer the as needed breathing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and interview, the facility failed to provide or obtain lab services to meet the needs of the residents in a timely manner for two (#61 and #67) of two residents reviewed for laboratory services. The facility failed to provide lab services which were ordered as STAT on the weekends. The Resident Census and Conditions of Residents form documented 66 residents resided in the facility. Findings: 1. Resident (Res) #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated [DATE], documented Res #61's basic needs would be met by the staff through the review date. The care plan did not address the issues surrounding the anticoagulant use. A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] solution (an anticoagulant) 0.8 ml subcutaneously every 12 hours for 90 days. A physician order, dated [DATE], documented the facility was to obtain the following lab tests on admission: CBC, CMP, TSH, and lipid test, then repeat the test every six months. A lab report, dated [DATE], documented the CBC, CMP, TSH, and lipid panel had been obtained at 5:22 a.m., and reported to the facility at 3:04 p.m. The results documented the resident's red blood cells (RBC) were low at 3.22 L (reference range of 4.63 - 6.08) and hemoglobin (hgb) was low at 7.3 L (reference range of 13.7 - 17.5 g/dl) On [DATE] at 6:40 p.m., (Friday evening) a nurse note documented Res #61 had a bowel movement described as black tarry stools. The note documented Res #61's physician was notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented Res #61's family and the DON were notified. On [DATE] at 9:41 p.m., a skilled note documented Res #61's bed pan had black tarry stools noted. The note documented the nurse notified the physician who ordered a STAT CBC and occult stool to be obtained. On [DATE] at 1:45 a.m., a skilled note documented Res #61 denied abdominal cramping or pain related to a bloody bowel movement earlier that day. On [DATE] at 7:00 a.m., a skilled note documented Res #61 had no black tarry stools at that time. On [DATE] at 9:15 a.m., (Sunday) a nurse note documented the lab was called regarding the STAT CBC and stool specimen ordered on [DATE]. The note documented the lab did not answer and a message was left for the lab. On [DATE] at 10:10 a.m., a nurse note documented the lab had called and reported the CBC and occult stool would be run on that day. A skilled note, dated [DATE] at 3:15 p.m., documented Res #61 had one black tarry bowel movement during the shift. A nurse note, dated [DATE] at 4:16 p.m., documented a facility nurse contacted the lab regarding the blood and stool specimen and were told the lab was taking it to another lab for processing as their lab tech was not coming in that day. A nurse note, dated [DATE] at 8:59 p.m., documented a lab report for Res #61 had not been received. A five day MDS assessment, dated [DATE], documented Res #61 was moderately impaired in cognition; required set up for eating; limited assistance for locomotion; and extensive assistance with bed mobility, transfers, toilet use, dressing, personal hygiene, and bathing. The assessment documented Res #61 was frequently incontinent of bowel and had a urinary catheter. The assessment documented the resident was receiving an anticoagulant and therapy. A nurse note, dated [DATE] at 5:26 a.m., as a late entry for 3:30 a.m., documented Res #61 had a large amount of tarry liquid stool with a small amount of soft stool. The note documented the nurse contacted Res #61's physician who gave orders to send Res #61 to the hospital. The note documented Res #61 left the facility at 4:05 a.m. and Res #61's family member had been notified. A lab report, reported to the facility on Monday [DATE] at 8:36 a.m., documented the CBC for Res #61 had been collected on [DATE] at 4:23 p.m., received on [DATE] at 5:09 p.m., had been sent to another lab for processing. A lab report, reported to the facility on [DATE] at 2:55 p.m., documented a sample for occult stool was collected on [DATE] at 6:20 p.m., was received on [DATE] at 7:44 a.m., and not processed as it was past stability. The lab report documented the facility was notified of the status of the occult stool test on [DATE] at 2:55 p.m., and were told not to reorder the occult stool test. A nurse note, dated [DATE] at 10:22 a.m., documented the CBC results had been obtained from the lab and Res #61's hgb was 6.0. The note documented the nurse contacted Res #61's family member who reported the resident had received a blood transfusion at the hospital. A history and physical (H/P) report from the receiving hospital dated [DATE] at 6:16 p.m., documented Res #61's hgb level was 6.0 in the hospital's emergency room and he had received two units of packed red blood cells at that time. The H/P documented Res #61 reported to the physician the presence of black stools for the previous five days. The assessment/plan read in part: 1. Acute blood loss [CONDITION(S)] secondary to colon cancer - Hgb 6.0, transfused 2 units PRBCs in ER, repeat hgb 7.7, will transfuse 1 more unit in the event that he may go to OR tomorrow, continue to monitor hgb . On [DATE] at 2:39 p.m., during an interview with the DON regarding obtaining STAT labs, she reported the facility was only able to obtain STAT labs during the week. She stated if the labs were drawn on the weekend, the facility had to fight with the lab to have them run STAT. The DON was asked what process did the facility use to ensure physician ordered STAT labs were obtained in a timely manner on the weekends and she stated if it was a dire situation the facility had to send residents to the hospital as this was their only back up. On [DATE] at 4:56 p.m., the administrator was asked for the facility's policy on labs. The administrator reported she did not think the facility had a lab policy. On [DATE] at 9:19 a.m., Physician #1 reported obtaining STAT labs during the weekends at the facility was difficult. Physician #1 stated a STAT lab turn around time should have been two to four hours. When asked about Res #61's black tarry stools, he stated because the facility had been unable to obtain STAT labs over the weekend, the facility staff had to rely on monitoring vital signs and other symptoms. He stated Res #61 had to be sent to the hospital early on Monday morning ([DATE]). 2. On [DATE] at 9:19 a.m., in regard to obtaining STAT influenza testing, physician #1 stated the ability to obtain STAT lab results within two to four hours was especially important with time sensitive treatments such as [MEDICATION(S)], (an antiviral used to treat the influenza) which needed to be started in 48 hours from onset of symptoms. Physician #1 stated if it took longer than 48 hours to receive STAT influenza tests, [MEDICATION(S)] treatment was pretty much useless. Physician #1 stated it was a good thing the flu outbreak at the facility had been relatively mild as if it had been a normal flu season the outcome could have been severe. On [DATE] at 10:50 a.m., during an interview with the LPN/IP, she stated a recent flu outbreak had started in the facility on [DATE]. The IP stated the flu test turn around time was taking too long and had spoken with Physician #1 about this as several residents started [MEDICATION(S)] greater than 48 hours from the start of their signs and symptoms. At that time, the IP reviewed the list of flu positive residents since the outbreak started and reported seven of the 23 residents, who had tested positive for the flu, had not received confirmation from the lab regarding the positive results which were greater than two days due to the weekends. The IP stated it was not possible to obtain a flu test over the weekend as the lab the facility used would not process STAT flu tests on the weekend. 3. Resident (Res) #67 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE] (Saturday), documented to obtain an influenza A and B test. A nurse note, dated [DATE], documented a STAT order was placed for a laboratory influenza test for the resident. A discharge summary completed [DATE] documented the resident was deceased and the cause of death was unknown. On [DATE] at 10:26 a.m., the director of nurses (DON) stated the documented stat laboratory influenza order for the resident should had been obtained within four hours. On [DATE] at 11:08 a.m., the DON stated the STAT order for the influenza test was not obtained because the laboratory company did not do STAT orders on the weekends. The DON stated the resident passed away before a lab test could be completed the following Monday.

On 05/18/17 an Immediate Jeopardy (IJ) was determined to exist due to the facility's failure to prevent physical and verbal abuse for resident #4 related to a certified nursing assistant (CNA) jerking the resident's arm and another CNA speaking disparagingly to resident #4. A hospice incident report documented a facility aide was helping the hospice aide transfer resident #4 in the shower room. The report documented the hospice aide stated the facility aide jerked the resident's arm during care. The report documented the hospice aide stated another facility aide entered the shower room and became irritated with the resident because she was smacking and stated, Stop that. It pisses everyone off and she is doing that on purpose. The IJ situation was verified with the Oklahoma State Department of Health. On 05/18/17 at 2:50 p.m., the administrator (ADM) and the director of nurses (DON) were notified of the IJ situation regarding allegations of abuse. On 05/18/17 at 7:02 p.m., the plan of removal was accepted for the Immediate Jeopardy pertaining to abuse. The Plan of Removal for Immediate Jeopardy documented: The two staff members accused of alleged abuse will suspended as of 05/18/17. When a staff member is accused of abuse they will be suspended until further investigation is completed. When abuse is alleged, it will be reported to the ADM, DON, or assistant director of nurses (ADON) immediately. Abuse allegations will remain anonymous to protect the privacy of employees and residents. The abuse policy will be enforced and proper steps taken: Nurse Aid Registry, Oklahoma Board of Nursing, Oklahoma State Department of Health, Adult Protective Services, or Local Law Enforcement will be notified of the abuse allegations. The facility will in-service all staff that are in house on the abuse policy and how to identify abuse immediately. The staff that is not in house will be notified via telephone by 11:00 p.m. on 05/18/17 and if unable to be reached will be removed from the schedule until the in-service is completed. Another in-service will be performed for abuse on 05/30/17. The facility will interview staff to see if they have witnessed abuse by 11:00 p.m. on 05/18/17. The facility will interview cognitive residents to see if they have been abused or witnessed any abuse by 11:00 p.m. on 05/18/17. The ADM will perform the investigation on the alleged staff member of abuse. The employee will not be brought back to work until the investigation is completed. The abuse policy will be updated 05/18/17 to include the Center for Medicare and Medicaid Services (CMS) video and picture taking guidelines and the new abuse guidelines including head injury reporting within two hours. Weekly quality assurance (QA) meetings will be done with the DON, ADM, ADON, minimum data set coordinator (MDS)/care plan staff, and infection control officer for four weeks and then it will resume quarterly. The infection control nurse will interview a sample of five residents and five staff members to see if any abuse allegations have occurred. This will be done weekly for four weeks. The facility policy on abuse will be reviewed and revised as necessary. On 05/18/17 at 7:02 p.m., a copy of the policy and procedure was provided by the ADM. The policy documented the new regulations for abuse provided by CMS. The policy documented the video and picture taking requirements. On 05/18/17 at 10:40 p.m., the immediate jeopardy was removed when all components of the plan of removal had been completed. On 05/19/17 interviews were conducted with staff regarding in-services for education pertaining to content for Immediate Jeopardy removal. The staff stated an in-service was provided the previous day in the facility and some staff stated they had been in-serviced via the telephone. The staff was able to verbalize understanding of information provided in the in-service pertaining to the plan of removal. On 05/19/17 interviews were conducted with residents regarding abuse. The residents stated they had been interviewed regarding abuse the previous evening. The deficient practice remained at a pattern level with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to prevent abuse and failed to ensure residents were protected from further abuse for one (#4) of three sampled residents reviewed for abuse. The facility failed to: a) Prevent physical and verbal abuse from occurring for resident #4. A hospice incident report documented a facility aide was helping the hospice aide transfer resident #4 in the shower room. The report documented the hospice aide stated the facility aide jerked the resident's arm during care. The report documented the hospice aide stated another facility aide entered the shower room and became irritated with the resident because she was smacking and stated, Stop that. It pisses everyone off and she is doing that on purpose. b) Protect residents from potential abuse by allowing staff accused of alleged abuse to continue to work in the facility without conducting thorough investigations and following policy and procedures. The facility identified three allegations of abuse in the last three months. The facility identified 90 residents resided at the facility. Findings: The facility policy on abuse documented the facility would maintain an abuse free environment. The policy documented the facility would screen, train, prevent, identify, investigate, protect, and report abuse. The policy documented staff would be taught during orientation and during the yearly in-service they were obliged to report abuse immediately to the administrator (ADM). The policy documented residents and families would be made aware of how and to whom they could report concerns, incidents, and grievances without fear of retribution. The policy documented the staff would be supervised by licensed nursing staff so that they would be able to identify inappropriate behaviors such as using derogatory language, rough handling, and ignoring residents while giving care. The policy documented the staff would be trained to identify signs of abuse and to report to the licensed nursing staff. The policy documented any allegation of abuse would be investigated by the ADM and the director of nursing (DON). The policy documented the ADM and DON would at a minimum review the residents medical record looking for events leading up to the incident, interview the person reporting the incident, interview any witnesses to the incident, interview the resident if cognitive ability permitted, interview staff members on all shifts who have had contact with resident during the period of the alleged incident, interview the resident; roommate family members, and visitors as able and necessary, interview other residents to whom the accused employee provides care or services, and review all events leading up to the incident. The written report would be completed that identifies the person responsible for reporting the incident. The ADM would notify the Oklahoma State Department of Health by faxing the incident report and Adult Protective Services within 24 hours. The policy documented staff would be suspended until an investigation was completed. The policy documented all forms of abuse would be reported to the licensed practical nurse who then must report to the DON/ADM. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 09/01/16, documented the resident was severely impaired for daily decision making. The assessment documented the resident required limited to extensive assistance with activities of daily living. A care plan, dated 09/20/16, documented the resident had an activity of daily living self care performance deficit related to dementia. A personnel action, dated 11/03/16, documented CNA #2 had improper conduct. The form documented a resident had complained the CNA was rude and did not want the CNA back in her room. The form documented the nurse had also made the CNA aware of the smell on the hall. The form documented the CNA stated, Well everybody[***]. Is there anything else you want me to fix? The form documented the CNA was disrespectful to the nurse. The form did not have documentation of an investigation or an incident report related to the allegation. A termination form, dated 01/24/17, documented CNA #1 was accused of alleged abuse by a resident and the resident's family. The form did not have documentation of an investigation or an incident report related to the allegation A significant change assessment, dated 04/25/17, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance for activities of daily living. A hospice incident report, dated 05/03/17, documented a facility aide was helping the hospice aide transfer resident #4 in the shower room. The report documented the hospice aide stated the facility aide jerked the resident's arm and told the resident to Stand. You know you can stand. The report documented the hospice aide stated another facility aide entered the shower room and became irritated with the resident because she was smacking and stated, Stop that. It pisses everyone off and she is doing that on purpose. The report documented the hospice nurse had left a message for the DON regarding the incident. An initial state incident report, dated 05/04/17, documented an allegation of abuse for resident #4. The report documented an allegation of abuse was reported to the facility. The report documented the hospice DON and the hospice aide reported the allegation of abuse to the facility social services director. The report documented the hospice aide stated CNA #2 jerked the resident's arm and the resident yelled out, and CNA #1 told the resident to stop smacking her mouth that it pissed everybody off. The report documented both aides were suspended until further investigation was completed. A complaint form, dated 05/05/17, documented the social services director had received a call from the hospice DON reporting allegations of verbal abuse. The complaint form documented the RN stated a hospice aide had reported two of the facility aides had verbally abused a resident. The complaint form documented the RN stated she did not know the aides' names. The complaint form documented the social services director stated she asked the hospice DON and hospice aide to come to the facility to talk with her about the allegations of abuse. The complaint form documented the two facility aides had been suspended until the investigation was completed. A probation letter, dated 05/08/17, documented CNA #1 would be on probation for four weeks starting 05/09/17 to 06/06/17. The letter documented the CNA would be supervised for all resident interactions and would not have any interactions with resident #4. The letter documented the CNA would be removed from the bath aide position during the probation time. The letter documented the CNA verbalized understanding of the terms of the probation and by signing the letter agreed to the terms of the probation. The letter was signed 05/08/17. A probation letter documented CNA #2 would be on probation for four weeks starting 05/09/17 to 06/06/17. The letter documented the CNA would be supervised for all resident interactions and would not have any interactions with resident #4. The letter documented the CNA verbalized an understanding of the terms of the probation and by signing the letter agreed to the terms of the probation. The letter was not dated. On 05/15/17 at 10:05 a.m., the ADON stated she was looking for the state incident reports. The ADON stated the DON usually took care of the state incident reports but was out of the facility. The ADON stated she found some of the incident reports in a notebook and some in a basket. The ADON stated she did not know where the other incident reports would be kept. The ADON called the OSDH to confirm transmittal of the state incident reports. The ADON stated she had just received a fax from the OSDH for the incident dated 05/05/17 regarding resident #4 requesting the investigation, the reporting of the two CNAs to the State Nurse Aide board, determination of the allegations being unsubstantiated/substantiated, and the final incident report. The ADON stated she thought the DON had submitted the final report to the state. The ADON stated an investigation had not been completed by the facility, the aides had not been reported to the State Nurse Aide board, and the final five day report had not been sent to the OSDH. On 05/16/17 at 12:05 p.m., licensed practical nurse (LPN) #1 was asked if she had witnessed abuse in the facility. The LPN stated she had heard staff being harsh with the residents. On 05/16/17 at 12:12 p.m., LPN #3 stated the two aids on probation should have had another CNA with them at all times. On 05/16/17 at 12:23 p.m., LPN #2 stated she had offered to help monitor the two aids on probation for allegations of abuse but had not been assigned to monitor them. The LPN stated she monitored the aids by popping in on them. On 05/16/17 at 2:45 p.m., the ADON stated CNA #1 and CNA #2 had not been reported to the state nurse aide board for the allegations of abuse. The ADON stated the two CNAs were still working in the facility. On 05/16/17 at 3:25 p.m., the social services director stated she had not had complaints about CNA #2. The social services director stated she had complaints about CNA #1 related to verbal abuse. The social services director stated CNA #1 was terminated prior to this incident and the DON decided to bring her back. On 05/16/17 at 3:50 p.m., the ADM was interviewed. The ADM stated CNA #1 and CNA #2 had continued to work at the facility but had no contact with resident #4. The ADM stated he thought the DON had taken care of the incident related to the report of the allegations of abuse. A shift schedule for 05/16/17 documented CNA #1 was scheduled as a bath aid. An employee termination form, dated 05/16/17, documented CNA #1 was terminated related to alleged abuse. The termination form documented it was decided it would be in the best interest of the residents' safety to terminate the employee. An employee termination form, dated 05/16/17, documented CNA #2 was terminated related to alleged abuse. The termination form documented it was decided it would be in the best interest of the residents' safety to terminate the employee. On 05/17/17 at 12:15 p.m., the resident was observed sitting in the dining room in her wheelchair. The resident was clean and well groomed. The resident responded to simple questions and required assistance with eating and drinking. On 05/17/17 at 5:18 p.m., the ADON stated the probation letter for CNA #1 documented the CNA would not work as a bath aid. The ADON was asked to review the shift schedule for CNA #1. The ADON stated the CNA was scheduled as a bath aide and was providing showers to the residents while on probation. On 05/17/17 at 5:28 p.m., the social services director stated CNA #1 had worked as a bath aide since her probation had started. On 05/18/17 at 9:00 a.m., the ADON was asked how abuse training was provided to the facility staff. The ADON stated staff were provided videos on abuse upon hire before they went to the floor. The ADON stated she did not know how often abuse training was provided and did not document extra in-services for abuse. On 05/18/17 at 9:35 a.m., the infection control nurse stated Adult Protective Services had not been contacted related to allegations of abuse. On 05/18/17 at 9:35 a.m., the DON called the facility requesting to speak to the surveyors about the allegation of abuse related to resident #4. The DON stated the charge nurses were to document all initial incidents to her and she would perform the follow up investigation and submit the final report to the state. The DON stated the aides were interviewed regarding the allegations of abuse and an initial report was submitted to the state. The DON stated she did submit a report regarding the allegations of abuse. The DON stated CNA #1 and CNA #2 were suspended until a determination had been made. The DON stated the five day state incident report would have contained documentation of the investigation. The DON stated the CNAs were on a four week probation. The DON stated she verbally spoke with the aides and it was a he said, she said situation and there was no way to know if abuse had occurred. The DON stated no other staff or residents had been interviewed regarding the allegations of abuse. The DON stated she did not know if abuse had or had not occurred. The DON stated she did not report the allegations of abuse to the the State Nurse Aid board as there was no hard proof abuse had occurred. The DON stated the facility was short staffed so she had decided to let CNA #1 give showers while on probation. The DON stated she did not document the decision to let the CNA give showers, and that it was a verbal discussion. The DON stated she could not guarantee the CNAs were supervised at all times. The DON stated the investigation had been performed by the social services director and the infection control nurse. The DON stated she had not viewed any documentation regarding the allegation of the abuse investigation. The DON was asked about the termination regarding CNA #1 on 01/24/17. The DON stated she had re-hired CNA #1 after terminating her on 01/24/17 because everyone at the facility liked her. The DON stated she was giving her a chance. The DON stated she had talked with a resident's family at that time and they wanted the CNA arrested on the spot. The DON stated the CNA was accused by the resident and the resident's family of pushing the resident down onto the bed. The resident was not named. The DON stated she did not report the allegation of abuse to the OSDH or the State Nurse Aide board. No investigation related to the incident could be provided by the facility. The DON stated she just fired her because it made the family happy. On 05/18/17 at 11:40 a.m., the ADM stated he had left the allegations of abuse to the DON for investigating and reporting but ultimately it was his responsibility. The ADM stated a few of the abuse allegations were new to him. The ADM stated he had been called regarding the allegation of abuse for resident #4. The ADM stated with his and the DON's guidance, CNA #1 and CNA #2 had been suspended until Monday. The ADM stated he had left the investigation up to the DON. The ADM stated they had dropped the ball on some areas of the investigation. The ADM stated no complaints had been received from the residents and he felt the probation had been followed. The ADM stated they had only followed the abuse policy in some areas. The ADM stated allegations of abuse were problems when CNA #1 was previously employed with the facility. The ADM could not say if the allegations were reported to the OSDH, the State Nurse Aid board, or if an investigation had been performed. The ADM stated CNA #1 was re-hired without him knowing. The ADM stated he relied on the DON to notify him and for her to follow up on allegations of abuse. The ADM stated the DON was not following the policy. The ADM stated there was a communication problem between him and the DON. The ADM stated all allegations of abuse should have been reported to him and were not. The ADM stated all head injuries, a change in plane, breaks, a skin tear, and a hematoma to the head should have been reported to the OSDH. On 05/18/17 at 11:50 a.m., the ADON stated CNA #1 was terminated from the facility on 01/24/17 and re-hired on 04/04/17. The ADON stated the employee's file was reviewed and no documentation was found regarding the reason for termination. Employee files were reviewed. A personnel action, dated 11/03/16, documented CNA #2 had improper conduct. The form documented a resident had complained the CNA was rude and did not want the CNA back in her room. The form documented the nurse had also made the CNA aware of the smell on the hall. The form documented the CNA stated, Well everybody[***] is there anything else you want me to fix? The form documented the CNA was disrespectful to the nurse. The form did not document, and the facility could not provide, any investigation or reporting related to the incident. An employee file contained a termination form, dated 1/24/17, which documented CNA #1 was accused of alleged abuse by a resident and the resident's family. The form did not document, and the facility could not provide, any investigation or reporting related to the incident. On 05/18/17 at 1:02 p.m., LPN #2 stated she could not confirm all baths given by CNA #1 were supervised. The LPN stated the DON had called her into her office and verbally spoke with her regarding supervising the CNA when giving showers. The LPN stated she was told it would be ok as long as the CNA was not alone with residents for extended periods of time. The LPN stated she was not always available to go with the CNA to provide care. The LPN stated she was not sure if resident care was provided with another staff member or provided alone by CNA #1. The LPN stated she worked the six to two shift and the CNA worked the eight to five shift. The LPN stated she did not know who supervised the CNA during the time she was not in the facility. The LPN stated she supervised the CNA as much as possible but no one was assigned to supervise the CNA at all times. The LPN stated she could not guarantee the CNA did not have contact with resident #4. The LPN stated CNA #2 worked directly under her and she felt comfortable saying another CNA was with her during all resident care.

On 05/18/17 an Immediate Jeopardy (IJ) was determined to exist due to the facility's failure to: a) Thoroughly investigate physical and verbal abuse for resident #4 related to allowing two staff members to return to work before a thorough investigation was completed. b) Prevent further potential abuse while an investigation was being completed. A hospice incident report documented a facility aide was helping the hospice aide transfer resident #4 in the shower room. The report documented the hospice aide stated the facility aide jerked the resident's arm during care. The report documented the hospice aide stated another facility aide entered the shower room and became irritated with the resident because she was smacking and stated, Stop that. It pisses everyone off and she is doing that on purpose. The IJ situation was verified with the Oklahoma State Department of Health. On 05/18/17 at 2:50 p.m., the administrator (ADM) and the director of nurses (DON) were notified of the IJ situation regarding allegations of abuse. On 05/18/17 at 7:02 p.m., the plan of removal was accepted for the Immediate Jeopardy pertaining to abuse. The Plan of Removal for Immediate Jeopardy documented: The two staff members accused of alleged abuse will suspended as of 05/18/17. When a staff member is accused of abuse they will be suspended until further investigation is completed. When abuse is alleged, it will be reported to the ADM, DON, or assistant director of nurses (ADON) immediately. Abuse allegations will remain anonymous to protect the privacy of employees and residents. The abuse policy will be enforced and proper steps taken: Nurse Aid Registry, Oklahoma Board of Nursing, Oklahoma State Department of Health, Adult Protective Services, or Local Law Enforcement will be notified of the abuse allegations. The facility will in-service all staff that are in house on the abuse policy and how to identify abuse immediately. The staff that is not in house will be notified via telephone by 11:00 p.m. on 05/18/17 and if unable to be reached will be removed from the schedule until the in-service is completed. Another in-service will be performed for abuse on 05/30/17. The facility will interview staff to see if they have witnessed abuse by 11:00 p.m. on 05/18/17. The facility will interview cognitive residents to see if they have been abused or witnessed any abuse by 11:00 p.m. on 05/18/17. The ADM will perform the investigation on the alleged staff member of abuse. The employee will not be brought back to work until the investigation is completed. The abuse policy will be updated 05/18/17 to include the Center for Medicare and Medicaid Services (CMS) video and picture taking guidelines and the new abuse guidelines including head injury reporting within two hours. Weekly quality assurance (QA) meetings will be done with the DON, ADM, ADON, minimum data set coordinator (MDS)/care plan staff, and infection control officer for four weeks and then it will resume quarterly. The infection control nurse will interview a sample of five residents and five staff members to see if any abuse allegations have occurred. This will be done weekly for four weeks. The facility policy on abuse will be reviewed and revised as necessary. On 05/18/17 at various times the staff were in-serviced in the facility and via telephone on the facility policy for abuse. On 05/18/17 at 7:02 p.m., a copy of the policy and procedure was provided by the ADM. The policy documented the new regulations for abuse provided by CMS. The policy documented the video and picture taking requirements. On 05/18/17 at 10:40 p.m., the last employee was in-serviced in the facility. The immediate jeopardy was removed when all components of the plan of removal had been completed. On 05/19/17 interviews were conducted with staff regarding in-services for education pertaining to content for Immediate Jeopardy removal. The staff stated an in-service was provided the previous day in the facility and some staff stated they had been in-serviced via the telephone. The staff was able to verbalize understanding of information provided in the in-service pertaining to the plan of removal. On 05/19/17 interviews were conducted with residents regarding abuse. The residents stated they had been interviewed regarding abuse the previous evening. The deficient practice remained at a pattern level with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to ensure alleged violations of abuse were reported, thoroughly investigated, and/or residents were protected from further potential abuse while an investigation was in progress for two (#4 and #6) of three sampled residents reviewed for abuse. The facility failed to: a) Thoroughly investigate physical and verbal abuse for resident #4 related to allowing two staff members to return to work before a thorough investigation was completed. b) Prevent further potential abuse while an investigation was being completed. c) Report allegations of abuse for resident #4. The facility failed to report allegations of abuse to the State Nurse Aid Registry, Adult Protective Services, and submit the final investigation to the Oklahoma State Department of Health. d) Ensure staff were educated to report allegations of abuse without fear of retribution for resident #6. Two staff members failed to report allegations of abuse to the licensed staff for investigation. A hospice incident report documented a facility aide was helping the hospice aide transfer resident #4 in the shower room. The report documented the hospice aide stated the facility aide jerked the resident's arm during care. The report documented the hospice aide stated another facility aide entered the shower room and became irritated with the resident because she was smacking and stated, Stop that. It pisses everyone off and she is doing that on purpose. The facility identified three residents with allegations of abuse in the last three months. The facility identified 90 residents resided at the facility. Findings: The facility policy on abuse documented the facility would maintain an abuse free environment. The policy documented the facility would screen, train, prevent, identify, investigate, protect, and report abuse. The policy documented staff would be taught during orientation and during the yearly in-service they were obliged to report abuse immediately to the administrator (ADM). The policy documented residents and families would be made aware of how and to whom they could report concerns, incidents, and grievances without fear of retribution. The policy documented the staff would be supervised by licensed nursing staff so that they would be able to identify inappropriate behaviors such as using derogatory language, rough handling, and ignoring residents while giving care. The policy documented the staff would be trained to identify signs of abuse and to report to the licensed nursing staff. The policy documented any allegation of abuse would be investigated by the ADM and the director of nursing (DON). The policy documented the ADM and DON would at a minimum review the residents medical record looking for events leading up to the incident, interview the person reporting the incident, interview any witnesses to the incident, interview the resident if cognitive ability permitted, interview staff members on all shifts who have had contact with resident during the period of the alleged incident, interview the resident; roommate family members, and visitors as able and necessary, interview other residents to whom the accused employee provides care or services, and review all events leading up to the incident. The written report would be completed that identifies the person responsible for reporting the incident. The ADM would notify the Oklahoma State Department of Health by faxing the incident report and Adult Protective Services within 24 hours. The policy documented staff would be suspended until an investigation was completed. The policy documented all forms of abuse would be reported to the licensed practical nurse who then must report to the DON/ADM. 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 09/01/16, documented the resident was severely impaired for daily decision making. The assessment documented the resident required limited to extensive assistance with activities of daily living. A care plan, dated 09/20/16, documented the resident had an activity of daily living self care performance deficit related to dementia. A personnel action, dated 11/03/16, documented certified nursing assistant (CNA) #2 had improper conduct. The form documented a resident had complained the CNA was rude and did not want the CNA back in her room. The form documented the nurse had also made the CNA aware of the smell on the hall. The form documented the CNA stated, Well everybody[***]. Is there anything else you want me to fix? The form documented the CNA was disrespectful to the nurse. The form did not document, and the facility could not provide, any investigation or reporting related to the incident. A termination form, dated 01/24/17, documented CNA #1 was accused of alleged abuse by a resident and the resident's family. The form did not have documentation of an investigation or an incident report related to the allegation. A significant change assessment, dated 04/25/17, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance for activities of daily living. A hospice incident report, dated 05/03/17, documented a facility aide was helping the hospice aide transfer resident #4 in the shower room. The report documented the hospice aide stated the facility aide jerked the resident's arm and told the resident to Stand. You know you can stand. The report documented the hospice aide stated another facility aide entered the shower room and became irritated with the resident because she was smacking and stated, Stop that. It pisses everyone off and she is doing that on purpose. The report documented the hospice nurse had left a message for the DON regarding the incident. An initial state incident report, dated 05/04/17, documented an allegation of abuse for resident #4. The report documented an allegation of abuse was reported to the facility. The report documented the hospice DON and the hospice aide reported the allegation of abuse to the facility social services director. The report documented the hospice aide stated CNA #2 jerked the resident's arm and the resident yelled out, and CNA #1 told the resident to stop smacking her mouth that it pissed everybody off. The report documented both aides were suspended until further investigation was completed. A complaint form, dated 05/05/17, documented the social services director had received a call from the hospice DON reporting allegations of verbal abuse. The complaint form documented the RN stated a hospice aide had reported two of the facility aides had verbally abused a resident. The complaint form documented the RN stated she did not know the aides' names. The complaint form documented the social services director stated she asked the hospice DON and hospice aide to come to the facility to talk with her about the allegations of abuse. The complaint form documented the two facility aides had been suspended until the investigation was completed. A probation letter, dated 05/08/17, documented CNA #1 would be on probation for four weeks starting 05/09/17 to 06/06/17. The letter documented the CNA would be supervised for all resident interactions and would not have any interactions with resident #4. The letter documented the CNA would be removed from the bath aide position during the probation time. The letter documented the CNA verbalized understanding of the terms of the probation and by signing the letter agreed to the terms of the probation. The letter was signed 05/08/17. A probation letter documented CNA #2 would be on probation for four weeks starting 05/09/17 to 06/06/17. The letter documented the CNA would be supervised for all resident interactions and would not have any interactions with resident #4. The letter documented the CNA verbalized an understanding of the terms of the probation and by signing the letter agreed to the terms of the probation. The letter was not dated. On 05/15/17 at 10:05 a.m., the ADON stated she was looking for the state incident reports. The ADON stated the DON usually took care of the state incident reports but was out of the facility. The ADON stated she found some of the incident reports in a notebook and some in a basket. The ADON stated she did not know where the other incident reports would be kept. The ADON called the OSDH to confirm transmittal of the state incident reports. The ADON stated she had just received a fax from the OSDH for the incident dated 05/05/17 regarding resident #4 requesting the investigation, the reporting of the two CNAs to the State Nurse Aide board, determination of the allegations being unsubstantiated/substantiated, and the final incident report. The ADON stated she thought the DON had submitted the final report to the state. The ADON stated an investigation had not been completed by the facility, the aides had not been reported to the State Nurse Aide board, and the final five day report had not been sent to the OSDH. On 05/16/17 at 12:05 p.m., licensed practical nurse (LPN) #1 was asked if she had witnessed abuse in the facility. The LPN stated she had heard staff being harsh with the residents. On 05/16/17 at 12:12 p.m., LPN #3 stated the two aids on probation should have had another CNA with them at all times. On 05/16/17 at 12:47 p.m., the ADON stated the charge nurses were responsible for the initial state incident reports and the DON was responsible for the five day final incident reports. The ADON stated incidents should have been investigated within 24 hours, documented the investigation on the state incident report, and faxed the final report to the state within five days. On 05/16/17 at 2:40 p.m., the infection control nurse (ICN) stated an allegation of abuse should have be investigated within 24 hours. The ICN stated any kind of injury should be reported when a resident hits their head. On 05/16/17 at 2:45 p.m., the ADON stated CNA #1 and CNA #2 were not reported to the state nurse aid board for allegations of abuse. The ADON stated the two CNAs were still working in the facility. On 05/16/17 at 3:25 p.m., the social services director stated she had not had complaints about CNA #2. The social services director stated she had complaints about CNA #1 related to verbal abuse. The social services director stated CNA #1 was terminated prior to this incident and the DON decided to bring her back. On 05/17/17 at 12:15 p.m., the resident was observed sitting in the dining room in her wheelchair. The resident was clean and well groomed. The resident responded to simple questions and required assistance with eating and drinking. On 05/18/17 at 9:35 a.m., the infection control nurse stated Adult Protective Services had not been contacted related to allegations of abuse. On 05/18/17 at 9:35 a.m., the DON called the facility requesting to speak to the surveyors about the allegation of abuse related to resident #4. The DON stated the charge nurses were to document all initial incidents to her and she would perform the follow up investigation and submit the final report to the state. The DON stated the aides were interviewed regarding the allegations of abuse and an initial report was submitted to the state. The DON stated she did submit a report regarding the allegations of abuse. The DON stated CNA #1 and CNA #2 were suspended until a determination had been made. The DON stated the five day state incident report would have contained documentation of the investigation. The DON stated the CNAs were on a four week probation. The DON stated she verbally spoke with the aides and it was a he said she said situation and there was no way to know if abuse had occurred. The DON stated no other staff or residents had been interviewed regarding the allegations of abuse. The DON stated she did not know if abuse had or had not occurred. The DON stated she did not report the allegations of abuse to the the State Nurse Aid board as there was no hard proof abuse had occurred. The DON stated the facility was short staffed so she had decided to let CNA #1 give showers while on probation. The DON stated she did not document the decision to let the CNA give showers, it was a verbal discussion. The DON stated she could not guarantee the CNAs were supervised at all times. The DON stated the investigation had been performed by the social services director and the infection control nurse. The DON stated she had not viewed any documentation regarding the allegation of the abuse investigation. The DON was asked about the termination for regarding CNA #1 on 01/24/17. The DON stated she had re-hired CNA #1 after terminating her on 01/24/17 because everyone at the facility liked her. The DON stated she was giving her a chance. The DON stated she had talked with a residents family at that time and they wanted the CNA arrested on the spot. The DON stated the CNA was accused by the resident and the resident's family of pushing the resident down onto the bed. The resident was not named. The DON stated she did not report the allegation of abuse to the OSDH or the State Nurse Aide board. No investigation related to the incident could be provided by the facility. The DON stated she just fired her because it made the family happy. On 05/18/17 at 11:40 a.m., the ADM stated he had left the allegations of abuse to the DON for investigating and reporting but ultimately it was his responsibility. The ADM stated a few of the abuse allegations were new to him. The ADM stated he had been called regarding the allegation of abuse for resident #4. The ADM stated with his and the DON's guidance CNA #1 and CNA #2 had been suspended until Monday. The ADM stated he had left the investigation up to the DON. The ADM stated they had dropped the ball on some areas of the investigation. The ADM stated no complaints had been received from the residents and he felt the probation had been followed. The ADM stated they had only followed the abuse policy in some areas. The ADM stated allegations of abuse were a problem when CNA #1 was previously employed with the facility. The ADM could not say if the allegations were reported to the OSDH, the State Nurse Aid board, or if an investigation had been performed. The ADM stated CNA #1 was re-hired without him knowing. The ADM stated he relied on the DON to notify him and for her to follow up on allegations of abuse. The ADM stated the DON was not following the policy. The ADM stated there was a communication problem between him and the DON. The ADM stated all allegations of abuse should have been reported to him and were not. The ADM stated all head injuries, a change in plane, breaks, a skin tear, and a hematoma to the head should have been reported to the OSDH. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 03/10/17, did not document the resident's cognitive status. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident wandered but had no behaviors. The care plan, dated 03/27/17 documented the resident had impaired cognitive function related to dementia or impaired thought processes related to [MEDICAL CONDITION]. On 05/15/17 at 10:05 a.m., ADON stated she was looking for the state incident reports. The ADON stated the DON usually took care of the state incident reports but was out of the facility. The ADON stated she found some of the incident reports in a notebook and some in a basket. The ADON stated she did not know where the other incident reports would be kept. The ADON called the OSDH to confirm transmittal of the state incident reports. The ADON stated she had just received a fax from the OSDH for the incident dated 05/05/17 regarding resident #4 requesting the investigation, the reporting of the two CNAs to the State Nurse Aide board, determination of the allegations being unsubstantiated/substantiated, and the final incident report. The ADON stated she thought the DON had submitted the final report to the state. The ADON stated an investigation had not been completed by the facility, the aides had not been reported to the State Nurse Aide board, and the final five day report had not been sent to the OSDH. The ADON stated the OSDH had not received any state incident reports for resident #6. On 05/17/17 at 6:15 p.m., CNA #3 stated she had reported allegations of verbal/physical abuse to the DON and ADM regarding resident #6 but nothing had been done about it. The CNA stated LPN #4 had grabbed the residents arm and snatched her out of another resident's room. The CNA stated she heard CNA #4 say, I'm tired of seeing you going in and out of f .ing residents rooms. On 05/18/17 at 9:00 a.m., the ADON was asked how abuse training was provided to the facility staff. The ADON stated staff were provided videos on abuse upon hire before they went to the floor. The ADON stated she did not know how often abuse training was provided and did not document extra in-services for abuse. On 05/18/17 at 3:30 p.m., the resident was observed wandering down different halls and standing outside the ADM's office. The resident was confused and requesting to go home.

On 09/18/13 at 4:30 p.m., an Immediate Jeopardy (IJ) situation was identified and confirmed by the Oklahoma State Department of Health regarding the facility failure to assess and monitor for a change in condition for a resident with [MEDICAL CONDITION] provide training for the care and management for residents with a trach. On 09/18/13 at 5:20 p.m., the administrator and director of nurses were notified of the IJ situation. On 09/18/13 at 7:15 p.m., an acceptable plan of removal of the immediacy was received by the survey team. The plan of removal of the immediacy documented: "The policy and procedure will be modified to include assessment of the stoma site, peri-[MEDICATION NAME] skin, for redness, excessive heat, inner cannula for thick or purelent drainage or odor,[MEDICAL CONDITION] for fit, irritation around collar, skin breakdown at or around site. STOMA SITE: _____Skin is free of redness _____Skin is warm and dry at the site _____Trach collar fits appropriately _____Drainage is clear _____Skin is intact at stoma site and peri-[MEDICATION NAME] area _____Inner cannula is clean patent The nurses were re-inserviced on 09/18/13 and the inservice was completed by 7:00 p.m. Nurses were instructed to assess & document-monitor any resident being admitted or readmitted or any change of conditions. QA will be done within the week & all above will be discussed. Documentation will be monitored by DON or designee QD x 30 days & then every other day x 2 w." The amended policy documented [MEDICAL CONDITION] would be done every shift. On 09/24/13, the IJ was removed effective 09/18/13 at 7:00 p.m. after verification of completion of the plan of removal. The nurses were knowledgeable of assessment and monitoring for change of condition related [MEDICAL CONDITION]. The nurses stated the inservice provided by the facility on 09/18/13 also included assessment and monitoring for change of condition for residents with indwelling urinary catheters and feeding tubes. The nurses stated there were currently no residents in the facility with [MEDICAL CONDITION] they had been admitted to the hospital previously. The nurses stated none of the residents with an indwelling urinary catheter or feeding tube had experienced a change of condition since 09/18/13. The nurses stated one ambulatory resident had experienced a fall with injury and was sent to the hospital for treatment. The chart was reviewed and determined an assessment had been completed at the time of the transfer to the hospital and upon the resident's return to the facility. The IJ was removed but the deficient practice remained at substandard quality of care at a pattern. Based on record review and interview, it was determined the facility failed to provide necessary care and services to maintain the highest practicable well-being for one (#5) of five sampled residents reviewed for highest practicable well-being. The facility failed to: a) thoroughly assess the resident's change of condition prior to the resident's being discharged to the hospital. The facility failed to record a respiratory assessment before and after treatment including the resident's tolerance to the procedure and description of sputum and [MEDICAL CONDITION]. The facility failed to record an assessment of the resident's urinary status at the time the indwelling urinary catheter was routinely changed and prior to the resident's being discharged to the hospital. Resident #5 was admitted to the hospital with [REDACTED]. The resident's [DIAGNOSES REDACTED]. b) have a physician's orders [REDACTED]. c) have a policy for monitoring respiratory assessments and [MEDICAL CONDITION] care. d) develop a comprehensive care plan for management and care of the [MEDICAL CONDITION], the indwelling urinary catheter, the feeding tube, and prevention of pressure sores. e) provide training to nursing staff for [MEDICAL CONDITION] care. f) consistently record the changing of the inner cannula as ordered by the physician. g) consistently record [MEDICAL CONDITION] as ordered by the physician. h) consistently record the oxygen saturation levels as ordered by the physician. The facility failed to record the use of the flow by oxygen. The facility identified two residents with tracheostomies both of which were in the hospital at the time of the investigation. Findings: The policy for trachesotomy care provided a general protocol for [MEDICAL CONDITION] care but did not identify assessment and monitoring of respiratory status including description of sputum or change in the resident's condition. The policy for change in a resident's condition or status documented the charge nurse would notify the resident's attending physician when a significant change in the resident's condition had occurred. The policy documented a significant change impacted more than one area of the resident's health status. The policy documented the charge nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The policy for [MEDICAL CONDITION] tube feeding via continuous pump documented the physician's orders [REDACTED]. The policy documented the facility was to ensure that equipment and devices were working properly by performing callibrations and checks as instructed by the manufacturer or the facility. The policy documented the person performing the procedure should record the following information in the resident's medical record: the date and time the procedure was performed, the amount and type of enteral feeding, the name and title of the person who performed the procedure, all assessment data obtained during the procedure, how the resident tolerated the procedure, what interventions were taken if the resident refused the procedure, and the signature and title of the person recording the data. The policy documented the supervisor and attending physician should be notified of any complications. The policy for insertion of an indwelling urinary catheter documented the following information should be documented in the resident's medical record: the date and time the procedure was performed, the name and title of the individual who performed the procedure, all assessment data (character, color, clarity, etc.) obtained during the procedure, the size of the catheter inserted and the amount of fluid used to inflate the balloon, how the resident tolerated the procedure, and the signature and title of the person recording the data. The policy documented the physician should be notified of any abnormalities. The policy documented to report other information in accordance with facility policy and professional standards of practice. A policy for tracheal suctioning was not provided by the facility. The policy for oropharyngeal/nasopharyngeal suctioning documented frequency of the suctioning was determined by presence of mucus, saliva or drainage and patency of airway. The policy documented guidelines for documentation included the date and time of the procedure, amount, color, and consistency of material suctioned, condition of the resident's mouth, oropharynx, nasopharynx, frequency of suctioning, and notification to physician of a change in the resident's condition. The policy documented the care plan should include instructions unique to the resident, necessary monitoring and observation of the resident's respiratory function, monitoring for dehydration, and monitoring for congestion. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital history and physical, dated 03/01/13, documented the resident had multiple hospitalization s from December 2012 through February 2013. The report documented the resident was admitted for respiratory care, jejunostomy feeding, and improvement in debility and nutritional status. The report documented the resident's problems included [MEDICAL CONDITION] with permanent tracheotomy due to tracheal stenosis, history of repeated episodes of aspiration pneumonia requiring jejunostomy for feedings, status [REDACTED]. The resident's admission orders [REDACTED]> 100. The orders did not document an order for [REDACTED]. The admission nurse's note, dated 04/02/13, documented the resident had an indwelling urinary catheter that was patent and draining clear amber urine and the catheter would be discontinued. The note documented the resident had [MEDICAL CONDITION] feeding tube. A telephone order, dated 04/03/13, documented an order to discontinue the indwelling urinary catheter. A nurse's note, dated 04/04/13, documented, "Late entry Foley cath was removed on 04/03/13 (without) difficulty clear yellow urine in bag will monitor for urine output." A nurse's note, dated 04/04/13 at 10:00 a.m., documented, "Foley cath reinserted per sterile technique 16F/10cc D.T (due to) (low) output when reinserting had 400 cc clear yellow residual urine... Res (resident) penis had split to posterior side of penis (no) bleeding or dng (drainage) noted." A nutritional assessment, dated 04/04/13, documented the resident required a feeding tube and received Nepro at 50 ml/hr and auto flush water at 50 ml/hr. The assessment documented the resident would receive 872 cc of fluids from the supplement and needed an additional 1200 cc of water to maintain the resident's hydration status at 97%. The admission comprehensive assessment, dated 04/15/13, documented the resident's cognition was severely impaired for daily decision making. The assessment documented the resident was dependent on staff for activities of daily living (ADLs). The assessment documented the resident required a feeding tube, an external urinary catheter, a trach, had oxygen therapy, and was suctioned. The assessment documented the resident was at risk for pressure sores and the presence of a stage III pressure sore on admission to the facility. A pressure sore risk assessment, dated 04/16/13, documented the resident was at high risk for developing pressure sores. The care plan, dated 04/16/13, documented the resident had to be fed through a feeding tube with a goal of receiving adequate intake of nutrition and hydration. The care plan documented approaches including monitoring of the continuous feeding pump to ensure settings were per physician's orders [REDACTED]. The care plan, dated 04/16/13, documented the resident was dependent on staff for all ADLs. The care plan documented approaches including to provide total assistance for bathing (bed bath), grooming, and personal hygiene. The care plan did not address oral care for the resident. The care plan, dated 04/16/13, documented the resident had two stage II pressure sores with approaches including application of treatment daily, to keep skin clean, dry, and from pressure every shift, monitor skin daily and report potential problems to the nurse, provide care every two hours and as needed after each episode of incontinence, and a low air loss mattress on the bed. The care plan had a line drawn through the problem and approaches and documented "resolved 07/15/13." The care plan, dated 04/16/13, documented to monitor [MEDICAL CONDITION] and for the resident to remain free from choking and to cleanse the area [MEDICAL CONDITION] "with per physician orders" (sic) and assess skin condition every shift. The care plan did not identify specific areas for concern related to the management of [MEDICAL CONDITION] suctioning and assessment of the resident's respiratory status. The care plan, dated 04/16/13, did not address the resident's need for a urinary catheter or measures for management of the catheter to prevent infection. A physician's progress note, dated 07/02/13, documented the resident's temperature was 98.6 degrees Fahrenheit (F), blood pressure 115/72, heart rate 83, and respirations 20. The column "NL (normal limits)" was checked for head, eyes, ears, nose, throat, and neck. Ronchi was written by lungs and soft was written by abdomen. Rectal and genitalia had def written next to them. The note documented to continue with current plan of care. A nurse's note, dated 07/30/13, documented thick white secretions had been suctioned from the resident'[MEDICAL CONDITION] the resident received O2 through the flow by tubing. A nurse's note, dated 07/31/13, documented the resident's O2 saturation was 95% and O2 was provided through the flow by tubing. The note documented the resident had been suctioned due to thick white secretions from the trach. The licensed practical nurse (LPN) sheet for the month of July 2013 documented: a) the boxes by the entry "change inner cannula every other day-clean daily" were blank for the entire month. b) the boxes by the entry "[MEDICAL CONDITION] 1/2 peroxide and 1/2 normal saline daily" were blank for the entire month. c) the entry "trach care every shift" was initialed on every shift every day of the month. d) the boxes by the entry "Tracheotomy (with) flow by on 28% prn (as needed) to keep O2 sats 92% or > dx tracheal stenosis PRN" were blank for the entire month. e) the boxes by the entry "cleanse peg site with soap and water, pat dry, apply dressing daily and as needed" were blank for the entire month. The boxes by the entry "keep head of bed elevated 45 degrees or higher because of risk of aspiration FYI" was blank every day of the month. f) the boxes by the entry for low air loss mattress "FYI" (for your information) were blank for the entire month. A weekly pressure ulcer record, dated 07/31/13, documented the resident had a stage II pressure sore area on the sacrum/right buttock related to shearing. The report documented a [MEDICATION NAME] dressing was applied and was to be changed every three days. The monthly physician's orders [REDACTED]. (hr) with 300 cubic centimeters (cc) of water every six hours, check the residual of the feeding and hold if > 100, (04/14/13) cleanse peg site with soap and water, pat dry, apply dressing daily and as needed, (06/03/13) Foley catheter 16F to bedside change monthly on the 15th and as needed, and Foley cath care every shift. The orders did not document an order for [REDACTED]. A nurse's note, dated 08/01/13 at 10:00 a.m., documented the resident had "copious" amount of blood and blood clots coming out of the resident's trach, the physician was notified, and the resident was sent to the hospital. A nurse's note, dated 08/05/13 at 2:45 p.m., documented the resident returned from the hospital. The note documented a dressing was present on the resident's buttocks with no other open areas noted at that time. The note documented the presence of an indwelling urinary catheter with clear yellow urine and the feeding tube was patent. The note documented [MEDICAL CONDITION] intact without drainage. The physician's orders [REDACTED]. The new orders did not have orders [MEDICAL CONDITION], suctioning, catheter care, or care related to the feeding tube. The orders were signed by the attending physician but were not dated. A nurse's note, dated 08/06/13 at 6:35 a.m., documented the resident's temperature was 98.1 degrees F and the O2 sats were 95% and the heart rate was 85. The note documented the resident had dark red sputum when suctioned and the resident would continue to be monitored. The note [MEDICAL CONDITION] had been performed as ordered. A weekly pressure ulcer record, dated 08/06/13, documented the pressure sore on the sacrum/right buttock measured 8 centimeters (cm) x 11 cm with scant amount serosanguineous drainage with odor. The assessment documented the surrounding skin color was dark brown with peeling. The assessment documented the pressure sore could not be staged. The assessment documented the resident had returned from a hospital stay. The next nurse's note, dated 08/07/13 at 7:15 a.m., documented, "Sending to (name deleted hospital) for (increased) bloody sputum during suctioning." A nurse's note, dated 08/07/13 (in error) at 5:20 p.m., documented the resident had returned to the facility and required O2 to the trach. The note documented the resident's vital signs had been taken and the peg tube was intact. The physician's orders [REDACTED]. The new orders did not have orders [MEDICAL CONDITION], suctioning, catheter care, or care related to the feeding tube. The orders were signed by the attending physician but were not dated. A nurse's note, dated 08/13/13 11-7, documented the resident's vital signs had been taken, the resident was turned every two hours, and clear sputum had been obtained on suction of the trach. A weekly pressure ulcer record, dated 08/13/13, documented the resident had returned from the hospital (08/07/13-08/12/13) and the pressure sore on the sacrum/right buttock was a stage II and measured 8 cm x 11 cm without odor. The record documented the wound bed was red and moist and the surrounding tissue was pink. The record documented the treatment was [MEDICATION NAME] covered with a bordered foam dressing. A physician's progress note, dated 08/13/13, documented the resident's temperature was 98.0 degrees F, blood pressure 92/55, heart rate 93, and respirations 20. The column "NL (normal limits)" was checked for head, eyes, ears, nose, throat, and neck. Ronchi was written by lungs and soft was written by abdomen. Regular was written by cardiovascular. Rectal and genitalia had def written next to them. Neurological had tremor written next to it. The note documented to continue with current plan of care. A nurse's note, dated 08/16/13 7-3, documented, "Resident had returned to facility on 08/12/13 at 2:50 p.m. Completed [MEDICATION NAME] (antibiotic) yesterday. (No) adverse reactions were noted. [MEDICAL CONDITION] done, suctioned small amt (amount) clear/white sputum prn (as needed). Repos (repositioned) q (every) 2 (hours), HOB (head of bed) (elevated) 45 (degrees), Wound care to buttocks per orders. Peg patent (with) cont (continuous) feeding per orders will cease priority charting @ this x (time)." A weekly pressure ulcer record, dated 08/19/13, documented the pressure sore on the sacrum/right buttock was stage II and measured 7.9 cm x 8.1 cm without odor. The record did not document the treatment. A weekly pressure ulcer record, dated 08/27/13, documented the pressure ulcer on the sacrum/right buttock was a stage II and measured 7.0 cm x 5.5 cm with light drainage without odor. The record documented "add [MEDICATION NAME]". The record documented the resident had a stage II pressure sore on the left buttock which measured 1.5 cm x 1.7 cm with scant amount of drainage and no odor. The treatment was [MEDICATION NAME]. The record documented the resident had a stage II pressure sore on the left hip which measured 1.2 cm x 1.8 cm with small amount of drainage with no odor. The treatment was [MEDICATION NAME]. The acute care plan, dated 08/27/13, documented a stage II pressure ulcer on the left hip. The care plan documented interventions which included treat with [MEDICATION NAME] daily, observe clean technique with each dressing change, consult with physician to obtain new orders as needed, monitor and document wound dimension and description no less than every week, and the use of a low air loss mattress on the bed. The next nurse's note, dated 08/28/13, documented, "Res [MEDICATION NAME] (changed) back to BID (twice daily) routine per (name deleted doctor)." The LPN sheet for the month of August 2013 documented: a) the boxes by the entry "change inner cannula every other day-clean daily" were blank for the entire month. b) the boxes by the entry "[MEDICAL CONDITION] 1/2 peroxide and 1/2 normal saline daily" were blank for the entire month. c) the entry "trach care every shift" was initialed on every shift until 08/22/13. The sheet had blanks on 11 day and/or evening shifts from 08/23/13 through 08/31/13. d) the boxes by the entry "Tracheotomy (with) flow by on 28% prn (as needed) to keep O2 sats 92% or > dx tracheal stenosis PRN" were blank for the entire month. The boxes by the entry "[MEDICATION NAME] (breathing treatment) three times daily" were blank 14 times from 08/21/13 through 08/30/13. e) the boxes by the entry "O2 sats every shift" had 13 blanks from 08/13/13 through 08/31/13. f) the boxes by the entry "cleanse peg site with soap and water, pat dry, apply dressing daily and as needed" were blank for the entire month. g) the boxes by the entry "Foley cath care every shift" showed DC (discontinue) on 08/15/13. The boxes were blank from 08/16/13 to 08/27/13 and six shifts from 08/27/13 through 08/31/13. The entry "change F/C (Foley catheter) & BSD (bedside drainage bag) monthly and prn" was initialed 08/27/13. The entry "change the bag on the 30th on the night shift" was blank. The procedure was not documented in the nurses' notes. h) the boxes by the entry for low air loss mattress "FYI" (for your information) were blank for the entire month. i) the boxes by the entry "Keep head of bed elevated 45 degrees or higher because of risk of aspiration" were blank for the entire month. The tube feeding sheet for August 2013 documented: a) check residual every 6 hours hold if > 100 ml-18 blanks from 08/13/13 through 08/31/13. b) water 50 ml/hr auto flush (each shift)-16 blanks from 08/13/13-08/31/13. c) Nepro 55 ml/hr per peg (each shift)-13 blanks from 08/13/13-08/31/13. A telephone order, dated 09/03/13, documented an order to have the wound physician consult for the resident's wound care. The wound care specialist initial evaluation, dated 09/04/13, documented the resident had [DIAGNOSES REDACTED]. The evaluation documented the resident had a stage III pressure sore on the coccyx which measured 13 cm x 7 cm and had moderate serous drainage. The evaluation documented the resident had an unstageable pressure sore on the left hip which measured 0.7 cm x 1.3 cm. The evaluation documented the wound was unstageable due to a thick adherent black necrotic tissue covered 100% of the wound. The evaluation documented recommendations which included to off load the wound and reposition per facility policy, a group 2 mattress, multivitamin daily, Vitamin C 500 milligrams (mg) twice daily, and Zinc Sulfate 220 mg daily for 14 days. The evaluation documented the wound care specialist would follow up in seven days. The weekly pressure ulcer record, dated 09/04/13, documented the pressure sore on the coccyx and right buttock (previously documented as the sacrum and right buttock) was a stage III with a moderate amount of serous drainage without odor. The record documented a new order to apply Santyl and Calcium Alginate covered with a bordered foam dressing daily and as needed. The record documented the pressure sore on the left hip was unstageable due to 100% eschar and measured 0.7 cm x 1.3 cm. The record documented a new order for Sure Prep daily. The nurse's note, dated 09/08/13 at 10:45 a.m. (previous note documented on 08/28/13), documented, "Resident has thick dark green secretions with a strong odor. Urine is tea colored. Send to hosp (hospital) for eval (evaluation) & treatment. Wound care performed before resident left as well [MEDICAL CONDITION]." The note did not document the resident's vital signs or other pertinent information about the resident's change of condition. The note did not document the time the resident left the facility. A facility resident transfer/emergency room record, dated 09/08/13, documented, "Reason for transfer-dark green secretions [MEDICAL CONDITION] thick and has a odor. Urine tea colored. BP 131/89 P 102 R 21 T 98.5 O2 sats 91 Attachments Face sheet Current MARs (medication administration records)... Skin/Decubitus: on coccyx...ADL status Ttl bathing, dressing, personal hygiene, eating, transfers, ambulation, able to communicate- somewhat occ...bowel control (last BM 09/08/13)..." The transfer record did not include the time the resident left the facility or the resident's condition at that time. The tube feeding sheet for September 2013 documented: a) check residual every 6 hours hold if > 100 ml-six blanks from 09/01/13 through 09/08/13. b) water 50 ml/hr auto flush (each shift)-four blanks on 09/05/13 and 09/06/13. c) Nepro 55 ml/hr per peg (each shift)-blank from 09/01/13 through 09/08/13. The LPN sheet for the month of September 2013 documented: a) the entry "trach care every shift" had two blanks on 09/03/13 and 09/04/13. b) the boxes by the entry "Tracheotomy (with) flow by on 28% prn (as needed) to keep O2 sats 92% or > dx tracheal stenosis PRN" were blank for the entire month. c) the boxes by the entry "O2 sats every shift" had three blanks from 09/01/13 through 09/08/13. d) the boxes by the entry "cleanse peg site with soap and water, pat dry, apply dressing daily and as needed" were blank two times from 09/01/13 through 09/08/13. e) the boxes by the entry "Foley cath care every shift" were blank two times from 09/01/13 through 09/08/13. f) the boxes by the entry for low air loss mattress "FYI" (for your information) were blank for the entire month. g) the boxes by the entry "Keep head of bed elevated 45 degrees or higher because of risk of aspiration FYI" were blank for the entire month. The ADL flow sheet for September 2013 documented the resident had received a bed bath on 09/05/13. The ADL sheet did not document oral care provided for the resident. The hospital physical exam, dated 09/08/13 at 11:43 a.m., documented the resident was being evaluated due to thick green secretions from the trach. The note documented the nursing home staff reported the thick green secretions had not been present the previous day. The note documented the resident's pulse was 108, respirations 29, and BP 96/80. The note documented a 5 cm diameter decubitus on the lateral left hip, 25 cm diameter of skin breakdown in various stages over the sacrum, skin breakdown on the posterior scrotum, 5 cm x 7 cm area of hair loss with a small area of skin breakdown on the posterior aspect of his head. The note documented the resident had dark green dried mucous in the bilateral supraclavicular notches (top of shoulder areas). The note documented the resident had an indwelling urinary catheter in place with very dark urine. The note documented the abnormal lab results for the urinalysis documented the presence of protein, a large number of red blood cells, a large number of white blood cells, and a large amount of bacteria. The note documented the resident's initial [DIAGNOSES REDACTED]. The hospital emergency room nurse note, dated 09/08/13 at 2:04 p.m., documented the resident's pulse was 117, respirations 32, and blood pressure 82/49. The note documented the paramedic reported the resident being hypotensive, suctioned continuously, and fluid resuscitated en route. The note documented the resident was dry and his mouth was stuck closed with dried mucous and mouth saliva. The note documented the resident had purulent drainage in his eyes. The note documented upon arrival to the hospital the resident had crackles in the lungs and a productive cough, was hypotensive with an irregular pulse, diarrhea some of which had dried on the resident's rectum, a feeding tube with a "very dirty" dressing and an old dressing stuck to his abdomen by the tube entrance which was also "very dirty". The note documented there was no documentation of feedings on the MAR indicated [REDACTED]. The note documented the resident had an indwelling urinary catheter with bloody dark yellow urine with the urine in the drainage bag being "very odorferous". The note documented the resident had a possible deep tissue injury to the right heel. The note documented the resident's penis was "red and was split into the shaft of the penis with raw tissue and appeared to be infected". The note documented the resident had a large hematoma on the back of his head. The note documented the resident was not able to verbalize pain but winced when the back of the head was touched. The note documented on arrival to the emergency room EMS (emergency medical services) reported a "very foul odor" coming from the resident's decubitus wound. The note documented the resident had dirty tape on his right AV which was "apparently from a blood draw" at some time and had the admission bracelet on his left arm from a previous hospital stay in August. A hospital consult note, dated 09/10/13, documented the resident had a previous [DIAGNOSES REDACTED] that had been exacerbated by the use of a Foley catheter. The note documented the skin appeared well healed with no new excoriations or abrasions on the penis. The note documented no infection or leaking of urine around the catheter was noted. The note documented the long standing use of a Foley off the side of the bed to gravity had created a mechanical shearing of the preexisting [DIAGNOSES REDACTED] or created a splitting of the bottom of the surface of the penis. The resident was not at the facility at the time of the investigation. On 09/17/13 at 3:30 p.m., the director of nurses (DON) was asked when the nurses charted on the residents. The DON stated it was the facility policy to chart by exception so if the resident had a change such as a fall or an antibiotic the resident was put in priority charting for 72 hours. The DON was asked to look at the chart for the resident and determine what the assessment for the change of condition had been at the time the resident was discharged to the hospital. The DON looked at the nurses' notes and stated all she could see was the resident had dark green sputum and tea colored urine. The DON was asked if an assessment of the resident's condition would be documented any other place. The DON stated maybe on the transfer sheet which was given to EMS. A copy of the transfer was not available in the resident's chart at that time. The DON was asked if the facility kept a copy of the transfer sheet to which she replied, "I am trying to train the nurses to document so the reader can track what is going on with the resident." A copy of the transfer sheet for 09/08/13 was provided to the surveyor prior to the completion of the investigation. On 09/18/13 at 12:10 p.m., licensed practical nurse (LP

Based on observation, interview, and record review, it was determined the facility failed to ensure the residents were provided with adequate supervision to prevent falls for four (#3, #6, #8, and #14) of six sampled residents reviewed for falls. The facility failed to: a) adequately investigate the residents' falls to determine the cause of the falls for residents #3, #6, and #8. b) implement interventions to prevent falls for residents #3, #6, and #8. c) re-evaluate the interventions to prevent falls which were implemented for residents #3, #6, and #8. d) develop new interventions when the previous interventions were ineffective for residents #3, #6, and #8. e) implement measures to prevent wandering behaviors and promote safety for resident #14. Resident #6 experienced a broken hip. The facility identified 65 residents lived in the facility and had falls in the previous seven months. Findings: The facility fall policy documented a fall risk assessment would be completed for all residents when admitted to the facility, quarterly, and with any significant change in the resident's condition. The policy documented the staff was to be trained on identification of fall risks, fall prevention, and would be informed of the residents at high risk for falls. The policy documented if a resident had a pattern of falls or an injury from a fall, the staff was to notify the physician, seek emergency treatment if necessary, notify the resident's responsible party, complete a fall investigation check list, complete a fall risk assessment, and revise the resident's care plan. 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's fall risk assessment, dated 04/17/13, documented the resident had a score of 20. The assessment documented a score of 10 or greater reflected the resident was a high risk for falls. An incident report, dated 04/23/13 at 12:25 a.m., documented the resident was found on the floor. The report documented the resident rolled out of bed, sustained a skin tear to his right elbow, sustained a hematoma to his forehead, and was confused. The report documented an intervention to prevent falls was to place a concave mattress on the resident's bed. A fall investigation check list was not completed. The care plan was not revised to include the fall and the new intervention to prevent falls. The comprehensive assessment, dated 04/29/13, documented the resident was moderately impaired with daily decision making and required moderate assistance with the activities of daily living. The assessment documented the resident had a history of [REDACTED]. The assessment documented the resident received psychoactive medications and oxygen therapy. The care plan, dated 05/01/13, documented the resident was at high risk for falls. The care plan documented the interventions to prevent falls were to check the resident for needs every two hours, keep the resident's room door open and monitor when passing by the resident's room, keep call light within the resident's reach, answer call light in a timely manner, and encourage resident to ask and wait for assistance. An incident report, dated 05/27/13 at 8:00 p.m., documented the resident was confused, had fallen, and had called 911. The staff found the resident on the floor sitting on the fall mat next to the bed. The resident stated his legs were too weak to walk. The resident did not sustain an injury. A fall investigation check list was not completed. The report documented an intervention to prevent falls was for the certified nurse aide (CNA) to confirm the resident understood how to use the call light. The care plan was not revised to include the fall and the new intervention to prevent falls. An incident report, dated 06/14/13 at 4:10 a.m., documented the resident was found on the floor by his bed. The report stated the resident rolled out of bed, was alert, and sustained no injury. The report documented an intervention to prevent falls was to ensure the pressure alternating mattress was adjusted to the right setting. A fall investigation check list was not completed. The care plan was revised to include the fall and the new intervention. An incident report, dated 06/24/13 at 6:30 a.m., documented the resident rolled out of bed while reaching for the urinal. The report documented the resident was alert and sustained no injury. The report documented an intervention to prevent falls was to ensure the bedside table was placed close to the resident's bed. A fall investigation check list was not completed. The care plan was updated to include the fall and the intervention. An incident report, dated 06/24/13 at 1:00 p.m., documented the resident was sitting on the side of the the bed for a meal and slid off the mattress onto the fall mat. The resident was alert, confused, and sustained skin tears to both knees. The report documented an intervention to prevent falls was to transfer the resident to the wheelchair before meals. A fall investigation check list was not completed. The care plan documented the resident was attempting to transfer from the bed to a wheel chair. The care plan was revised with the new fall intervention. An incident report, dated 07/09/13 at 11:45 a.m., documented the resident was found on the floor, on his knees, and his arms on the bed. The report documented the resident was alert, confused, and sustained no injury. The report documented an intervention to prevent falls was to move the residents bed against the wall. A fall investigation check list was not completed. The care plan was not revised to include the fall and the new intervention. An incident report, dated 07/17/13 at 1:20 p.m., documented the resident was found on the floor next to the bed. The report stated the resident stated had slid off bed and woke up on the floor. The report documented the resident was oriented to self, was confused, and sustained no injury. The report documented an intervention to prevent falls was to place a concave mattress on the resident's bed. A fall investigation check list was not completed. The care plan was not revised to include the fall and the intervention to place the concave mattress on the resident's bed. On 08/20/13 at 1:25 p.m., the resident was in his room, sitting on the side of the bed and eating lunch. A concave mattress was on the resident bed and a fall mat was on the floor next to the resident's bed. The resident's bed was in the low position. On 08/23/13 at 10:00 a.m., CNA #1 was interviewed regarding the facility's fall prevention program. The CNA stated the nurses tell the CNAs which residents are fall risks and leaves are placed on the resident's name outside of the resident's room. The CNA stated when a resident was at high risk for falls the CNA would take the resident to the bathroom upon wakening and every two hours, take the resident to activities, keep the residents bed in low position, place a fall mat by the residents bed, and walk the hall and monitor the resident. The CNA stated walking the halls was completed more often than every two hours. The CNA was asked what fall interventions were implemented to prevent resident #3 from falling. The CNA stated the low bed, fall mat, and monitoring were the fall interventions implemented for the resident. The CNA stated the resident's legs were contractured and the resident did not want therapy because therapy hurt. On 08/24/13 at 6:15 p.m., the director of nurses (DON) and the assistant director of nurses (ADON) were interviewed regarding the resident's falls and the facility's fall policy. The DON stated a fall investigation was completed after a resident had a fall. The DON stated the resident's medications would be reviewed, the arrangement of the resident's room would be reviewed, and the nurses would be interviewed. The interdisciplinary team would review the falls every morning. The DON stated the cause of a fall was determined by the information gathered. The DON stated the staff do not complete a fall investigation but they were to document everything that was pertinent to the fall. The DON was asked what caused resident #3 to fall. The DON stated the cause was not determined. The DON and ADON were not able to say what interventions had been implemented to prevent the resident's falls. The DON stated the evaluation of the fall interventions was an ongoing process. The DON stated the fall investigations and fall interventions needed to be improved. 2. Resident #6 was admitted to the facility on [DATE]. The current [DIAGNOSES REDACTED]. A comprehensive assessment, dated 10/04/12, documented the resident was severely impaired for daily decision making and required minimal assistance with the activities of daily living. The assessment documented the resident was ambulatory, had no falls, no pain, and received psychoactive medications. The fall risk assessment, dated 01/07/13, documented the resident had a fall risk score of 16. The assessment documented a score of 10 or greater reflected the resident was a high risk for falls. An incident report, dated 02/27/13 at 4:45 p.m., documented the resident had a non-injury fall and was found sitting on her buttocks in the facility entry. The report documented the resident was confused. The incident report and the care plan did not document new interventions to prevent falls. An incident report, dated 03/04/13 at 3:45 p.m., documented the resident was found in her room on the floor in front of the recliner. The report documented the resident was alert, confused, and had swelling to her right knee. The report documented the resident's daughter was notified and the daughter stated the swelling was a chronic problem. An X-ray was obtained. The incident report and the care plan did not document new interventions to prevent falls. An incident report, dated 03/07/13 at 4:30 p.m., documented the resident slid out of the wheelchair onto the floor. The report documented the resident was awake, alert, and had no apparent injury. The incident report and the care plan did not document new interventions to prevent falls. A fall investigation check list and fall risk evaluation were not completed after the fall. An x-ray report, dated 03/15/13, documented the resident had mild to moderate degenerative arthritis and osteopenia of the right hip. An incident report dated 03/21/13 at 6:30 p.m., documented the resident was walking, fell , and hit her head on the wall. The report document the resident was awake, alert, and had no apparent injuries. The report documented the resident was sent to the emergency room for evaluation due to a sluggish left pupil. The incident report and the care plan did not document new interventions to prevent falls. A fall investigation check list and a fall risk assessment were not completed after the fall. A report was submitted to the Oklahoma State Department of Health (OSDH). A quarterly fall risk evaluation was completed on 03/28/13. An incident report, dated 05/01/13 at 5:30 p.m., documented the resident slid out of the Geri-chair while in the dining room. The report documented the resident was awake, oriented to person, and sustained a bruise on her right arm. The report documented to make sure resident was properly positioned in the Geri-chair as a new intervention to prevent falls. The resident's care plan did not document the resident's fall or the new fall intervention. A fall investigation check list and a fall risk evaluation were not completed. A quarterly fall risk evaluation was completed on 06/27/13. An incident report dated 07/16/13 at 1:45 p.m., documented the resident attempted to stand up from a dining room chair. The report documented the resident was holding onto another chair to pull herself up, the chair fell over, and the resident fell on to her left side. The report documented the resident was confused, disoriented, complained of intense pain to her right shoulder and left hip, and was admitted to the hospital with [REDACTED]. The resident's care plan did not document the resident's fall or new interventions to prevent falls. The fall investigation check list was not completed. A quarterly fall risk evaluation was completed on 07/17/13. An incident report, date 07/25/13 at 2:30 p.m., documented the resident's roommate witnessed the resident was sitting in a recliner, attempted to stand, and fell to the floor. The report documented the resident was confused, able to move her left leg, and did not hit her head. The report documented an x-ray was obtained and the resident was given pain medication. The report documented new fall interventions were to take the resident to activities, to check the resident frequently, to place the resident on the falling leaf fall prevention program, and to wrap the call light with reflective green duck tape. The resident's care plan was not revised to include the resident's fall and the new interventions to prevent falls. The fall investigation check list and a fall risk evaluation were not completed. The physician's orders [REDACTED]. The care plan, dated 08/01/13, documented the resident was at risk for falls. The care plan interventions to prevent falls included: 1. The staff was to remind the resident not to stand without assistance. 2. The staff was to monitor the resident closely. 3. The staff was to keep the resident's room door open and monitor resident each time the staff passed by. 4. The staff was to keep the resident's call light within reach. 5. The staff was to answer the call light in a timely manner. 6. The resident was to use a wheelchair for all locomotion. 7. The staff was to monitor the resident for the side effects of psychoactive medications. 8. The staff was to monitor and report any changes in the resident's cognition. An incident report, dated 08/13/13 at 7:06 p.m., documented the resident was found lying on the floor on her right side and the resident's wheelchair was on its side next to the resident. The report documented the resident was alert, confused, was guarding her left lower extremity, and was unable to say what had happened. The report documented the resident was currently on 30 minute safety checks. The resident's care plan was not revised to include the resident's fall or new interventions to prevent falls. The fall investigation check list and a fall risk evaluation was not completed. The nurse's note, dated 08/16/13 at 11:00 a.m., documented the resident was found on the floor in the dining room after an exercise activity. The notes documented the resident was alert, sustained a small laceration to the left side of her face, and was transferred to the hospital. The resident's care plan documented the resident would not be left in an activity unattended. The fall investigation check list and a fall risk evaluation were not completed. The resident's records documented the resident's falls had occurred while ambulating or attempting to stand from a chair. The records did not show documentation the resident had fallen while trying to get out of bed. On 08/20/13 at 10:20 a.m., the resident was lying in her bed with her eyes closed. The call light was clipped to her pillow. The bed was in the low position. The resident had a purple yellow bruise to the left side of her face and eye. There was a one inch suture site to the resident's left temple. The resident was odor free and her hair was clean. A nurse's note, dated 08/21/13 at 6:50 a.m., documented the resident was found lying on her right side in front of her bathroom. The note documented there was a large amount of blood at her head. The note documented the resident was awake, alert, pupils were equal and reactive and grips were equal, vital signs were within normal limits, and the resident complained her head hurt. The notes documented the resident was transferred to the hospital. On 08/23/13 at 10:00 a.m., CNA #1 was interviewed regarding the facility's fall prevention program. The CNA stated the nurses tell the CNAs which residents are fall risks and leaves are placed on the resident's name outside of the resident's room. The CNA stated when a resident was at high risk for falls the CNA would take the resident to the bathroom upon wakening and every two hours, take the resident to activities, keep the residents bed in low position, place a fall mat by the residents bed, and walk the hall and monitor the resident. The CNA stated walking the halls was completed more often than every two hours. On 08/23/13 at 6:15 p.m., the director of nurses (DON) and the assistant director of nurses (ADON) were interviewed regarding the resident's falls and the facility's fall policy. The DON stated a fall investigation was completed after a resident had a fall. The DON stated the resident's medications would be reviewed, the arrangement of the resident's room would be reviewed, and the nurses would be interviewed. The interdisciplinary team would review the falls every morning. The DON stated the cause of a fall was determined by the information gathered. The DON stated the staff do not complete a fall investigation but they were to document everything that was pertinent to the fall. The DON was asked what caused resident #6 to fall. The DON stated the resident was used to walking all around the facility and wanted to continue walking even after her hip fracture. The DON stated the resident was not able to understand she was not able to walk on her own. The assistant director of nurses (ADON) was asked what interventions were implemented to keep the resident from falling. The ADON stated the resident received continuous visual monitoring at the nurses' desk when the resident was out of bed. The DON stated the evaluation of the fall interventions was an ongoing process. The DON stated the fall investigations and fall interventions needed to be improved. 3. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 02/14/13, documented the resident's cognition was severely impaired for daily decision making. The assessment documented the resident wandered daily. The assessment documented the resident was ambulatory without assistance and required limited assistance with activities of daily living (ADLs). The elopement risk assessment, dated 02/04/13, documented the resident was disoriented to place, was cognitively impaired, had poor decision making skills, and had a history of [REDACTED]. The care plan, dated 02/14/13, documented the resident's cognition was impaired. The care plan documented the resident required cues and supervision with ADLs and was at risk for falls due to wandering without a sense of knowing where he was going. The interventions included to monitor the resident closely, keep the resident's door open, and keep the call light within the resident's reach. The care plan did not identify measures to prevent the resident from wandering into other residents' rooms or measures to maintain the resident's safety related to the wandering. On 08/20/13 at 11:30 a.m., the resident was observed ambulating independently in the dining room. On 08/21/13 at 10:00 a.m., during the group meeting, several residents in attendance voiced concerns that the resident came into their rooms. On 08/21/13 at 1:00 p.m., the resident was observed in the kitchen. The kitchen door was open and the resident walked in. The staff promptly assisted the resident out of the kitchen and shut the door. On 08/23/13 at 5:00 p.m., the director of nurses (DON) was asked how the staff kept the resident out of the rooms of other residents. The DON stated some of the other residents had Velcro stop signs across their door which kept the resident from entering the room. The DON was asked when the resident most usually went into the other residents' rooms. The DON stated the resident mostly wandered at night because he was usually with a staff member during the day. The DON stated the resident had a short attention span but the staff tried to keep him busy during the day. The DON stated there were certain activities and toys the resident enjoyed and they tried to encourage his participation as much as possible. The DON was asked how the staff monitored the resident's safety related to the wandering behaviors. The DON stated the staff just kept an eye on the resident and redirected him when necessary. The DON stated the resident was easily redirected. The DON stated the resident did not bother the other residents' things when he went into the rooms. The DON stated she was not sure if the resident had an actual purpose for entering the other rooms because he had difficulty communicating his needs to the staff. 4. Resident #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The incident/accident report, dated 05/07/13, documented the resident had a non injury fall. The report documented steps to prevent recurrence of falls were to have the certified nurse aides (CNAs) check the resident more frequently and to use a high/low bed and mat. The care plan documented the fall but did not document the interventions. The incident/accident report, dated 05/13/13, documented the resident was found on the floor and had sustained a hematoma and laceration to the face. The report documented steps to prevent recurrence of falls were to have CNAs increase frequency of bed checks for resident. The care plan documented the resident's fall and half side rail for safety but did not document the increased frequency of monitoring. The fall assessment, dated 07/10/13, documented the resident was at high risk for falls. The quarterly assessment, dated 07/11/13, documented the resident was moderately impaired, required supervision, and was totally dependent on one person for activities of daily living. The assessment documented no falls since admission to facility. The care plan, dated 07/12/13, did not document the resident's problem with falls. On 08/21/13 at 9:10 a.m., the resident was observed on an air mattress in bed. The half rail was in the up position to the head area of the bed. There was not a fall mat on the floor to the side of the bed. On 08/23/13 at 6:00 p.m., the director of nurses (DON) was interviewed regarding the interventions to prevent falls. The DON stated monitoring the resident more closely was not an effective intervention because the staff did not document the times the resident was being monitored. The DON stated the resident was moved to a room closer to the nurses' station.

On 05/24/12 at 5:00 p.m., an Immediate Jeopardy (IJ) situation was identified in providing care and services to maintain the highest practicable physical, mental, and psychosocial well-being. The facility failed to assess, monitor, and intervene for a low blood sugar for resident #1 who became unresponsive after receiving 30 units of [MEDICATION NAME] insulin. The Oklahoma State Department of Health was notified and verified the existence of the IJ related to the failure to provide services to maintain the highest practicable well being. On 05/24/12 at 5:35 p.m., the administrator, director of nurses (DON), and consultant nurse were notified of the IJ related to the facility's failure to assess, monitor, and intervene for low blood sugar which resulted in substandard quality of care and placed the facility in a partial extended survey. On 05/24/12 at 8:30 p.m., an acceptable plan of removal of immediacy was presented to the survey team and accepted. The plan of removal documented: "1) Standing orders received from Medical Director for Insulin Administration when FSBS (Finger Stick Blood Sugar) less than 100. 2) Charge nurse responsible for administering insulin to this resident will be instructed immediately regarding the new policy. Done by phone 18:20 (6:20 p.m.). 3) All new orders for insulin will be reviewed by 2 charge nurses before being implemented. 4) A review will be completed of all residents receiving insulin to determine other residents that may be impacted. All charge nurses will be inserviced on the new policy by 3 pm on 05/25/12 or removed from the schedule until they are inserviced." At 10:00 p.m., an amendment to the plan of removal was provided to the surveyor. The amendment documented: "5) Time for inservice completion to be changed to 11:30 pm on 05/24/12. Any nurse not inserviced by then will be removed from the schedule until inservice completed." Removal of Immediate Jeopardy On 05/29/12 at 4:13 p.m., resident #8 was observed being given a supplement for blood sugar that was 68. LPN #4 stated the resident did not receive her routine insulin because the blood sugar was low. The LPN stated she would recheck the resident's blood sugar in 1 hour. The resident's condition was not observed to be in acute distress. At 5:18 p.m., LPN #3 stated resident #9 had a blood sugar at 4:30 p.m. of 128 which was somewhat low for the resident and the insulin would not be given until the resident had eaten the evening meal. The resident's condition was not observed to be in acute distress. At 5:20 p.m., LPN #3 stated resident #10 had a blood sugar at 4:30 p.m. of 252. The LPN stated the resident did not have routine insulin ordered to be given at 4:30 p.m. but had an order for [REDACTED]. Staff interviews were conducted on 05/29/12 in regard to their knowledge of the inservice to ensure their understanding of monitoring blood sugar levels and notifying the physician for a change in condition. The IJ was removed effective 05/24/12 at 11:30 p.m., when the last inservice had been completed and the policy had been revised, staff interviews were conducted and staff could verbalize understanding of the changes in the policy for monitoring low blood sugar. The deficient practice remained at an isolated level of actual harm that was not an immediate jeopardy. Based on observation, record review, and interview, it was determined the facility failed to provide care and services to ensure the resident maintained the highest practicable well-being for one (#1) of seven residents sampled for maintaining highest well-being. The facility failed to assess, monitor, and/or intervene when: 1) resident #1 complained of not feeling well after receiving insulin. The resident became unresponsive after receiving 30 units of [MEDICATION NAME]and upon arrival of the ambulance, the resident's blood sugar was 12. 2) resident #1 complained of "intermittent" pain. 3) resident #1 complained of trouble breathing. The resident remained in the hospital at the time of the investigation. The facility identified 16 residents who received insulin. Findings: The facility policy for diabetic monitoring documented the process for obtaining a blood sample for finger stick blood sugar monitoring. The policy documented the physician's orders [REDACTED]. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The orders included [MEDICATION NAME] 50 milligrams (mg) every six hours for pain and [MEDICATION NAME] 0.25 mg three times a day as needed (prn) for anxiety. The admission nurse's note, dated 05/19/12 at 5:30 p.m., documented the resident was accompanied by the ambulance attendants and family. The note documented the resident was alert and oriented. The note documented the resident's blood pressure was 117/67, pulse 100, respirations 22, and temperature 96.8 degrees Fahrenheit. The note documented the resident's oxygen saturation was 98%. The note documented the resident complained of intermittent pain. The note did not document if the blood sugar was checked at that time. The meal intake percentage sheet for 05/19/12 documented the resident had consumed 60% of the evening meal. The record documented the resident had eaten 70% of the breakfast meal. The medication administration record (MAR) for May 2012 did not document an admission blood sugar check or administration of evening insulin on 05/19/12. A nurse's note, dated 05/20/12 at 1:00 a.m., documented the resident complained of trouble breathing. The note documented the resident's pulse oxygen saturation was 98%. The note documented a prn breathing treatment was administered and a prn FSBS was performed with the results being 190. The meal intake percentage sheet for 05/20/12 documented the resident had eaten 70% of the breakfast meal. The note documented the 05/20/12 7:30 a.m. finger stick blood sugar results were 84. The MAR documented the resident received 30 units of [MEDICATION NAME] 70/30 insulin at 7:30 a.m. The MAR documented initials of certified medication aide (CMA) #1 to indicate the 9:00 a.m. medications had been given prior to the resident being transferred to the hospital. A nurse's note, dated 05/20/12 at 10:15 a.m., documented, "Res (resident) awake/alert for bkfst (breakfast). requesting pain med; pain med adm (administered). Res then noted (with) uncontrolled jerking movements of (upper) body only. Became non-responsive (with) chest rub ineffective. Resp. (respirations) labored, using accessory muscles. O2 @ 4 L/M (liters/minute) via N/C (nasal/cannula). EMSA (emergency medical services) notified for transport to (name deleted hospital) ER (emergency room ). Family notified." The ambulance record, dated 05/20/12, documented the call requesting the ambulance transport the resident to the hospital at 9:59 a.m. and the ambulance was dispatched at 10:01 a.m. The record documented the paramedic assessed the resident at 10:06 a.m. and determined the resident was unresponsive. The record documented the paramedic checked the resident's blood sugar at 10:21 a.m. and the glucose level was 12. The record documented the paramedic administered [MEDICATION NAME] 50% intravenously. The record documented the resident's oxygen (O2) saturation was 82% at 10:30 a.m. The record documented the ambulance arrived at the hospital emergency room at 10:47 a.m. The hospital emergency room record, dated 05/20/12, documented the resident was placed in the triage room of the emergency room at 10:51 a.m. and was seen by the physician at 11:15 a.m. A section of the emergency room record documented, "...additional notes: insulin and a [MEDICATION NAME] they did not give him no other (sic) medications nor did they feed him dinner last night or breakfast this morning..." The medication cards received from the pharmacy were observed to determine which medications the resident had received. The cards indicated one pill had been removed from 11 routine medications. No pills had been removed from the card of pain medication or anxiety medication. The count sheets for the pain medication and anxiety medication indicated no medications had been signed out. On 05/24/12 at 4:00 p.m., licensed practical nurse (LPN) was contacted by telephone for an interview regarding the change of condition for the resident on 05/20/12. The LPN stated she had checked the resident's blood sugar at 7:15 a.m. per physician's orders [REDACTED]. The LPN stated she administered 30 units of [MEDICATION NAME] 70/30 insulin at that time according to the physician's orders [REDACTED]. The LPN stated she asked certified medication aide (CMA) #1 to administer the pain medication. The LPN stated the CMA had stated she had given the resident the pain medication. The LPN stated she was not sure if the resident had eaten breakfast. The LPN stated at 7:30 the resident complained of not feeling well. The LPN stated soon after the resident complained of not feeling well she observed his arms over his head and uncontrolled jerking movements were noted in only the upper part of his body. The LPN stated she checked the resident's vital signs. The LPN stated the resident was not responding so she performed a sternal rub which was not effective. The LPN stated she had checked the resident's oxygen saturation and the result was 89% while using 4 L/M of O2. The LPN stated the ambulance was called and arrived quickly. The LPN stated the ambulance left with the resident at approximately 7:40 a.m. The LPN was asked if she had rechecked the resident's blood sugar before the ambulance arrived. The LPN stated she had not checked the resident's blood sugar since he had been given the 30 units insulin. The LPN stated she could not be sure the resident had eaten breakfast. The LPN was asked to explain the nurse's note entry on 05/20/12 at 10:15 a.m. The LPN stated that was the time she sat down to document the events. On 05/24/12 at 4:25 p.m., CMA #1 was contacted by telephone for an interview regarding the resident's change of condition. The CMA was asked what time she had given the resident pain medication and what medication had been given. The CMA stated she had not given the resident pain medication because no one had told her he was in pain. The CMA stated she had taken the resident's blood pressure and because it was ok she gave the resident his routine morning medications. The CMA was asked what time she had given his medications. The CMA stated it had probably been close to 10:00 a.m. The CMA stated the resident had been alert at that time and did not exhibit symptoms of being sick as far as she could tell. The CMA stated it had probably been about 30 minutes later when CNA #1 had told the nurse the resident was having problems. The CMA stated the nurse (LPN #1) and the CNA (#1) returned to the resident's room and found the resident unresponsive. The CMA stated the nurse took the resident's vital signs and determined they were ok but called the ambulance at that time. At 4:40 p.m., an attempt was made to contact CNA #1 by telephone but the number was not working. At 6:35 p.m., LPN #1 was interviewed a second time after the facility had called her and informed the surveyors they would be putting her on speaker phone so she could tell the surveyors exactly what had been done when the resident had a change of condition. The administrator, DON, assistant director of nurses (ADON), and consultant nurse were in the room as well as the survey team. The LPN stated she had administered the resident's insulin around 7:15 a.m. The LPN stated the resident had complained of not feeling well around 7:30 a.m. and was sent to the hospital around 7:40 a.m. When the LPN was informed the ambulance records indicated the call had been received after 9:45 a.m. the LPN stated she did not think it had been that late when he was sent to the hospital. On 05/24/12 at 7:25 p.m., LPN #2 was interviewed by phone, after the facility had contacted her and informed the surveyors that she also had knowledge of the resident's change of condition and transport to the hospital. The consultant nurse stated the LPN would be put on speaker phone. The administrator, DON, ADON, and consultant nurse were present as well as the survey team. LPN #2 stated she had clocked in on 05/20/12 at 7:20 a.m. and the LPN (#1) was in the process of "shipping" the resident out to the hospital. The LPN stated the nurse assigned to that hall (LPN #1) had already taken the resident's vital signs. The LPN was asked what she knew about the resident's condition at that time. The LPN stated the other nurse had not said what his condition was. The LPN stated the ambulance had arrived quickly and it had probably been between 7:30 a.m. and 7:45 a.m. because she (LPN #2) had been on her way down the hall to do the finger sticks on her assigned halls. At 7:40 p.m., LPN #1 came to the facility and was interviewed for a third time. The administrator, DON, ADON, and consultant nurse were present as well as the survey team. The LPN was asked how she could be sure she had been getting the resident ready to go to the hospital at 7:30 a.m. on 05/20/12. The LPN stated she had just finished doing the finger stick blood sugars and administering insulin to four residents. The LPN was asked how she became aware the resident was having problems. The LPN stated an aide on the floor reported the resident was not going to eat until he got pain medication because he was hurting. The LPN stated she went and asked the CMA to give the resident a pain pill. The LPN stated initially the CMA had stated it would be approximately 20 minutes before she could give the resident a pain pill. The LPN stated she told the CMA to go ahead and give the resident his pain pill at that time. The LPN stated the CMA left the hall where she had been passing medications to other residents and took the resident a pain pill. The LPN stated the CMA told her she had given the pain pill. The LPN was asked what medication the CMA had given and where it had been documented. The LPN stated she did not know. The LPN stated she was thinking that he had [MEDICATION NAME] ordered. When the LPN was asked to look at the physician's orders [REDACTED]. The LPN stated she went back into the resident's room she thought within 5 minutes to make sure the resident was going to eat. The LPN stated she had witnessed the resident become unresponsive after observing him slinging his arms wildly over his head and uncontrolled jerking movements in the upper part of his body were observed at that time. The LPN was asked how much the resident had eaten. The LPN stated she had observed the resident's tray at his bedside when he was complaining of not feeling well, but she stated she could not be positive he had eaten. The LPN stated the resident's tray had not been her priority at that time because she was concerned about the resident. The LPN was asked if the resident had been symptomatic for low blood sugar at that time. The LPN stated she did not feel the resident was symptomatic. The LPN was asked when the physician had been notified. The LPN stated she had faxed the physician at the time she had completed her charting.

Based on observation, record review, and interview, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for one (#1) of three sampled residents reviewed for elopement and falls. Resident #1 left the facility unattended and fell cutting her upper lip and breaking two front teeth. The facility identified seven residents who were at risk for elopement. Findings: The facility policy for elopement documented all residents identified at risk for elopement would be monitored on a schedule determined by the interdisciplinary team and appropriate interventions to prevent elopement would be implemented. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical for the resident prior to admission documented the resident had been referred by another facility due to the resident's exit seeking behavior. The report documented the resident actually left the facility unattended. The hospital report documented the resident exhibited increased agitation when the facility tried to redirect the resident. The report documented the resident had reportedly had increased difficulty sleeping, increased short term memory impairment, wandering behavior, and agitation. The admission resident data collection, dated 04/11/12, documented the resident ambulated independently. The assessment documented the resident was oriented to person. The admission physician's orders [REDACTED]. The orders documented to encourage the resident to remain active and attend activities. The elopement risk and assessment tool, dated 04/11/12, documented the resident was at high risk for elopement. The assessment documented the resident had eloped from a previous nursing home. The assessment documented the resident had been found wandering on another hall looking for her room. The assessment documented the facility would implement safety checks every 30 minutes. An initial care plan had not been completed for the resident at the time of admission. A flow sheet for monitoring the resident every 30 minutes to ensure the resident was in the building was implemented on 04/12/12 at 4:30 p.m. and was consistently documented every 30 minutes until 04/21/12. The flow sheet was blank from 3:00 p.m. through 10:30 p.m. on 04/21/12. The flow sheet documented initials on 04/22/12 consistently every 30 minutes until 8:00 p.m. at which time it was documented the resident was out of the facility. A police incident report, dated 04/22/12, documented a call had been received at 7:21 p.m. regarding a female laying in the driveway and bleeding from her mouth. An ambulance report, dated 04/22/12, documented a call had been received at 7:22 p.m. regarding an elderly woman that had fallen in the driveway and was bleeding. The report documented bystanders had seen the elderly female walking with an unsteady gait down the street prior to the fall. The report documented the female had a laceration to the upper lip and broken tooth pieces were observed on the pavement near the female but no teeth were missing. The report documented that a police officer at the scene had contacted the nursing home to determine if the female was a resident from the facility. The report documented the facility had identified the female as a resident and attendants were informed a staff member would meet them at the emergency room (ER). The report documented the nursing home staff did not go to the ER so no information was obtained regarding the resident's meds, allergies [REDACTED]. The nursing home transfer record from the hospital, dated 04/22/12, documented orders which included to follow up with the dentist in the a.m., bed alarm, head injury precautions for 48 hours, and Lortab 2.5/500 milligrams 1 or 2 tablets every four hours as needed for pain. An incident report, dated 04/22/12, documented the time of the incident was 7:50 p.m. and was an unobserved fall outside. The report documented the resident had been taken to the ER for evaluation and treatment. The report documented the physician had been notified (time left blank) and the family had been notified at 7:55 p.m. regarding the incident. The report documented the resident had gone missing unknown until the police officer called the facility at 7:45 p.m. to determine if the facility knew the female that had fallen. The report documented the facility verified the resident resided at the nursing home and two staff members were sent to the location to verify it was the resident. The report documented the resident had missing teeth related to the incident. The time of the completion of the incident report was documented as 7:05 p.m. The incident was signed by the director of nurses and administrator on 04/23/12. A nurse's note, dated 04/22/12 at 11:15 p.m., documented the resident had gone missing unknown until the police had called and asked if the facility knew the resident. The note documented the police had stated the resident had been seen walking down the street by a neighbor who witnessed the resident fall. The previous note on 04/22/12 had been entered in the clinical record at 5:15 p.m. A nurse's note, dated 04/23/12 at 12:00 a.m., documented the resident had returned from the ER via the private vehicle of a family member. The note documented the orders included to place a bed alarm on the resident's bed. A nurse's note, dated 04/23/12 at 11:12 a.m., documented, "LE (late entry) F/U (follow up) after incident...Resident observed ambulating (up) and (down) hallways after dinner. @ 1935 (7:35 p.m.) this nurse observed resident walking (up towards nursing station on E hall. Another nurse (name deleted), observed resident walking around nurses station. (Name deleted nurse) was sitting @ nurse's station and said resident came to her requesting to have toothbrush recharged. @ 1945 (7:45 p.m.) (name deleted) police called asked if we know (name deleted resident). CMA's (certified medication aides) x 2 went to 1380 Indiana St (street) and verified the resident who was already in the ambulance. EMS (emergency medical services) told CMA's that several teeth were broken, and asked them if they were taking her to (name deleted) hospital to be eval (evaluated) and tx (treated)." The admission assessment, dated 04/23/12, documented the resident's cognition was severely impaired and the resident had some memory with cueing. The assessment documented the resident ambulated independently and wandered 4-6 days out of the previous seven days and placed the resident at risk of getting to a dangerous place. The assessment documented the resident had severe pain almost constantly which interfered with sleep and limited the day to day activities. A care plan was not initiated for the resident at that time. A nurse's note, dated 04/23/12 at 3:45 p.m., documented the resident ambulated independently and continually went to the exit door in an attempt to get out of the facility. Another resident's visitor accidentally let the resident out the door and a staff member brought the resident back inside the facility. On 04/30/12 at 6:15 p.m., on the front door of the facility a red and white stop sign was observed on the door. The sign documented, "Do Not let residents out the door without checking first." A tour of the facility was conducted to determine if doors were locked and the resident safety was maintained. The facility had six halls and each hall had an exit door. Beginning at 6:30 p.m., the following observations were made. 1) The door at the end of B hall lead out to a fenced area. The keypad did not have the exit code posted. One resident sitting in the hall stated she did not know the number to get out and had to get a staff member to go out with her. The gate to the fenced yard, accessible from B hall, was open and lead to an open driveway with an entrance to the street. 2) The door at the end of C hall lead out to an open paved area and the smoke area. Six residents went outside to smoke after one of the residents entered the door code on the keypad. 3) The door at the end of A hall exited to the fenced area. A sign on the door documented, "To exit facility enter code on the keypad at right-1081." The second gate to the fenced area was open at that time. 4) Doors off of halls D, E, and F exited to open yard area with access to the parking lot and the street. On 04/30/12 at 7:15 p.m., resident #1 was observed ambulating from E hall (where she resided), passed the nurses' station, and down B hall which was in a straight line from E hall. The resident ambulated approximately 3/4 of the way down the hall and turned around and walked down E hall to the sitting room at the end of the hall. The resident did not go to the door at that time. The resident had passed four nurses at the nurses' station who made no comment about the resident ambulating down the hall. At 7:50 p.m., the resident was observed in her bed and no staff was observed in the hall. At 7:58 p.m., the director of nurses (DON) was asked how the staff ensured the safety of the resident. The DON stated the resident was monitored and visualized by the nurse every 30 minutes. The DON stated wander guard bracelets were not in use at that time. The DON was asked how the resident had gotten out of the facility when the incident occurred. The DON stated no one really knew. The DON stated the resident had been asking multiple visitors to let her out. The DON was asked when the every 30 minute checks had been initiated. The DON stated the checks had been started right after the resident's admission to the facility. The DON was asked to provide the resident's care plan. The DON stated the resident did not have a care plan completed at that time because she had not been in the facility 21 days. The DON was asked what other measures had been implemented to ensure the resident did not elope from the facility. The DON stated the staff tried to encourage the resident to participate in activities and tried to ensure she was happy and comfortable. The DON was asked if the resident was alert and oriented. The DON stated the resident was not completely oriented. The DON was asked if she had talked to the resident about the incident. The DON stated they had asked the resident how she got out of the facility but the resident wouldn't answer the question. The DON was asked what measures had been implemented since the incident. The DON stated nothing different had been done since the resident eloped. The DON was asked if a bed alarm was placed on the resident's bed after the return from the ER as ordered by the hospital physician. The DON stated the alarm had not been placed on the resident's bed because she did not stay in bed. On 04/30/12 at 8:25 p.m., the DON was asked when the nurse documented the late entry for the incident. The DON stated the nurse documented the incident the next day. The DON was asked why the nurse had not documented in the nurse's notes until the next day. The DON stated she imagined the nurse had been frazzled because the day had been very busy prior to the incident occurring. At 9:15 p.m., the resident was observed in her room dressed in her street clothes with her tennis shoes on and tied. At 9:23 p.m., the resident was observed ambulating on hall E opening the doors to other residents' rooms on the hall. At 9:30 p.m., the resident was observed sitting in the chair in her room. A personal alarm was attached to the resident's blouse at that time. At 9:33 p.m., the DON was asked when the alarm had been placed. The DON stated the alarm had been placed a little earlier. The DON was asked if the placement of the alarm had occurred after being questioned by the surveyor about safety measures. The DON stated the alarm was placed after the surveyor was questioning the resident's safety. The DON stated they had tried a personal alarm prior to the investigation but the resident had repeatedly taken the alarm off. IMMEDIATE JEOPARDY IDENTIFIED On 04/30/12 at 9:45 p.m., an Immediate Jeopardy (IJ) situation was identified in accident hazards. The facility failed to implement measures to promote resident safety related to elopement which resulted in a fall with injury for resident #1. At 9:50 p.m., Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ in accident hazards. At 10:00 p.m., the DON and owner were notified of the IJ in accident hazards related to elopement which placed the facility in a partial extended survey. On 04/30/12 at 11:20 p.m., the facility submitted an acceptable plan of removal of immediacy. FACILITY PLAN OF REMOVAL OF IMMEDIACY The facility plan of removal documented: "1) All employees will be inserviced regarding which residents are wander risks & what the elopement policy requires of staff. This will be completed by 3 pm on 05/01/12. 2) Safety alarm has been attached to (name deleted resident) to alert staff when she arises from chair or bed, beginning to move around. A staff member will be stationed outside the door to monitor activity outside the room, & will watch resident to ensure she remains inside the building until further safety measures are initiated. 3) DON or ADON (assistant director of nurses) will confer with physician on 5/1/12 for an order to transfer resident to a geri psych unit for medication evaluation & if order received contact (name deleted facility) for care as this facility has treated her before. (Note: plan number three had been marked through with an x.) 4) All exit doors will be labeled with signs informing visitors of the need to never let anyone out without first checking with the nurse to ensure it's okay. This will be completed by 11:15 p.m. on 04/30/12. 5) Wander Guard bracelets will be obtained & initiated for (name deleted resident). These will be ordered on [DATE] & put in place when received. Others in need of this will be determined by severity of wander risk. 6) Activities Director will meet with (name deleted resident) on 5/1/12 in an attempt to determine what activities might interest resident & encourage participation in activities of choice. Activity care plan will be completed by 10 am 5/1/12. 7) Elopement Policy will be reviewed by administrator DON & ADON on 5/1/12 @ 9 am for effectiveness & needed changes will be made @ that time. 8) Time changes on checks for eve D/T sundowners-q (every) 10 min visual check from 7 pm-10 pm 9) Resident (name deleted) care plan addressing elopement risk will be completed on 5/1/12 by 12 noon." On 05/01/12 at 11:00 a.m., an amendment to the plan of removal was presented to the surveyor. The changes included the residents at risk for elopement would be discussed in the monthly Quality Assurance meetings to review the effectiveness of the treatment plan for those residents. IMMEDIACY REMOVED On 05/01/12 beginning at 11:30 a.m. until 6:00 p.m., the resident was observed in her room with one one supervision. Staff interviews were conducted on 05/01/12 in regard to their knowledge of the inservice, to ensure their understanding of the safety monitoring and measures implemented to prevent elopement. All staff interviewed responded appropriately. The IJ was removed effective 05/01/12 at 6:00 p.m., when the last inservice had been completed, staff interviews were conducted, and the facility received the copy of the invoice for purchase of wander guard bracelets. The deficient practice remained at a level of actual harm that was not immediate jeopardy at a pattern. The administrator and DON presented the survey team with copies of inservices, a resident care plan, revised policy for elopement, and other documents related to elopement and accident hazards. Signs were observed on all exit doors cautioning visitors to check with the nurse before letting a resident outside.

Based on observation, interview, and record review, it was determined the facility failed to adequately supervise residents to prevent accidents for two (#13 and #14) of five sampled residents with falls. The facility identified 42 residents with falls from February to May. Findings: The facility fall risk management policy & procedure documented that if a resident experienced a pattern of falls (two or more in a 30 day period), the director of nurses or the assistant director of nurses (or designee) would revise the care plan accordingly. 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 07/29/10, documented the resident's falls from August 2011 through May 2011 under the comment section of the care plan. No new interventions were updated with every new fall. A quarterly assessment, dated 04/25/11, documented the resident had short and long term memory deficits and was moderately impaired for decision making. The assessment documented the resident required extensive assistance with transfers, bed mobility, ambulation. The assessment documented the resident had fallen since the last assessment. The incident report log, for the year 2011, documented the resident was involved in nine falls in less than five months. On 05/13/11 at 11:40 a.m., licensed practical nurse (LPN) #3 was asked if new interventions were added to the care plan after each fall to prevent recurrence. The LPN stated she had not updated the care after each fall with a new intervention. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A resident assessment dated , 03/26/11, documented a brief interview for mental status summary score of 00 (severely impaired). The assessment documented the resident was nonambulatory and required extensive assistance for activities of daily living (ADLs), had two no injury falls, had two injury falls, and one major injury fall since the prior assessment. A care plan, dated 07/22/10 and updated 03/29/11, documented, "...I am at risk for impaired cognition...I have a recent [DIAGNOSES REDACTED]." The care plan approaches, dated 07/22/10 and updated 03/29/11, documented, "...monitor me closely for early intervention, keep my door open and monitor me each time you pass my room, keep my call light in reach and answer in a timely manner, remind me not to stand without assist or use of walker...check to assure I have my personal safety device on and in working condition..." The care plan, dated 07/22/10 and updated 03/29/11, documented, "...02/05/11 - non-inj (injury) fall, 02/11/11 - Fall with head injury..." The care plan did not document the use of a mat on the floor, the side rails, or the geri-chair. An incident report, dated 02/02/11, documented the resident fell from his wheelchair. The description of the incident documented the resident removed the lap buddy, tried to get up, and slid to the floor. No injury was noted. The preventive measures documented the resident was to have the lap buddy in place at all times while the resident was in the wheelchair, the staff was to instruct the resident the lap buddy was not to be removed, and the resident should notify the staff if assistance was needed. An incident report, dated 02/05/11, documented the resident fell from his wheelchair. The description of the incident documented the resident wheeled himself to D hall and was found on the floor in the room next to the bed. No injury was noted. The preventive measures documented the the resident was to have the personal alarm and lap buddy on at all times while in the wheel chair. No new interventions were documented. An incident report, dated 02/11/11, documented the resident fell from his wheelchair. The description of the incident documented the resident took off the lap buddy, stood up from the wheelchair, and fell and hit his head on the piano. The preventive measures documented the resident was to have the personal alarm at all times and have the lap buddy in place while up in the wheelchair. No new interventions were documented. An incident report, dated 02/23/11, documented the resident fell from the wheelchair. The description of the incident documented the resident removed the lap buddy, tried to get out of the wheel chair, and fell on his bottom. The resident received a small skin tear to his left index finger. The preventive measures documented the the resident was to have the personal alarm and lap buddy on at all times while in the wheelchair. No new interventions were documented. An incident report, dated 03/07/11, documented the resident was found on the floor. No injury was noted. The resident was assisted into the wheelchair. The lap buddy and personal alarm were put in place. The preventive measures documented the the resident was to have the personal alarm and lap buddy on at all times while in the wheelchair. The post fall investigation, dated 03/07/11, documented there was a mat on the floor. The care plan did not document the use of a lap buddy, a personal alarm, a mat on the floor, a bed alarm, the side rails, or the geri-chair. An incident report, dated 04/02/11, documented the nurse assessed a purple colored area to the resident's right thigh that was large in size and of unknown origin. The report did not document preventive measures. On 05/13/11 at 4:35 p.m., the director of nursing (DON) was asked if new interventions to prevent falls had been put in place after each fall. The DON stated, "I strive to but it's not perfect." The DON was asked if new interventions should have been put in place after each of the resident's falls. She stated, "It has been difficult to find something else to do for him."

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to ensure safety for two (#8 and #10) of three sampled residents who smoked. This constituted an Immediate Jeopardy situation. The facility identified eight residents who smoked. Findings. The facility smoking policy, dated 04/14/09, documented the residents were allowed to smoke in the designated smoking area outside at the end of C-hall under the shed. The policy documented that smoking materials would be maintained at the nurses' station and/or activity department and provided as requested. The policy documented that a resident who desired to maintain their own smoking materials must be alert and oriented and have a physician's orders [REDACTED]. The policy documented alert, ambulatory residents did not require one on one supervision while smoking. 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Resident Smoking Assessment Form, updated 07/13/11, documented the resident was physically able to securely hold a cigarette, was able to hold cigarette lighting materials, and extinguish the cigarette without assistance. The assessment documented the resident was able to move to designated smoking area without staff assistance, and extinguish a burning cigarette if it had fallen on his/her own body or others. The assessment documented the resident to be an independent smoker and able to maintain own smoking material. A quarterly assessment, dated 08/12/11, documented the resident did not have cognitive impairment and required assistance with activities of daily living (ADLs). The assessment documented the resident had limitations in range of motion in the upper extremities on one side and both sides in the lower extremities. A care plan, last updated 08/12/11, did not address smoking or smoking safety. On 08/23/11 at 12:00 p.m., the surveyor observed certified nurse aide (CNA) #3 push the resident in the wheelchair outside the facility's front door. The CNA then returned inside the facility leaving the resident outside near the circle drive. At 12:10 p.m., the surveyor observed the resident remove a cigarette from a package and attempt to place it in his mouth. The resident slumped his head down. The resident dropped the unlit cigarette to the ground. The resident then removed a second cigarette and attempted to place it to his mouth. The resident slumped his head down. The resident dropped the second unlit cigarette. The resident reached to the ground and picked up the unlit cigarette. At 12:20 p.m., the surveyor observed the resident place an unlit cigarette to his mouth. The resident removed a lighter from the bag tied to the right side of his chair. The resident slumped his head down. At 12:25 p.m., the surveyor observed the resident light the cigarette. At 12:27 p.m., the surveyor observed the resident drop the lit cigarette to the ground. The resident leaned over and picked the cigarette up. The resident slumped his head. At 12:28 p.m., the surveyor observed the resident place the lit cigarette on the right arm rest of his wheel chair and placed his hand into the bag on the side of his wheelchair. At 12:29 p.m., the surveyor observed the resident remove his hand from the bag and knock the lit cigarette to the ground. At 12:30 p.m., the surveyor observed CNA #4 walk up to the resident from the parking area, stop and pick up the lit cigarette and the unlit cigarette, and handed them to the resident. At 12:32 p.m., the surveyor observed the resident throw the lit cigarette onto the ground toward the parking area. At 12:36 p.m., the surveyor observed the resident drop a package of cigarettes to the ground. At 12:38 p.m., the surveyor observed CNA #3 exit the facility and push the resident in the wheelchair further away from entrance and return inside the facility. The resident was parked behind a large shrub and no longer visible to staff inside the facility. At 12:40 p.m., the surveyor observed the resident light a cigarette. The resident slumped his head down. The resident then dropped the lit cigarette from his mouth to the ground. At 12:41 p.m., the resident picked up the lit cigarette and continued smoking. At 12:42 p.m., the surveyor observed two staff members, including CNA #3, walk from the side of the building and begin talking to the resident. CNA #3 returned inside the facility. The other staff member sat on the curb near the resident and asked him why he couldn't hold his head up and if he had stayed up all night. The surveyor was not able to hear resident's responses. At 12:44 p.m., the surveyor observed the resident throw the lit cigarette onto the ground and the staff member pushed the resident into the facility. On 08/23/11 at 12:45 p.m., an interview was conducted with resident #10. The resident stated he had burnt himself with dropped cigarettes two or three times recently. The resident's head slumped down three different times during the interview. The surveyor observed burn holes in the resident's shirt. On 08/23/11 at 12:50 p.m., the director of nurses (DON) entered the surveyor work room and stated, "I need to get his (resident #10) chart. He's not acting right today. His blood pressure has dropped. He really needs to go to the hospital. I am going to call his mother to see if she wants to come up to convince him to go to the hospital." At 1:35 p.m., the surveyor observed burn marks and holes in the resident's wheelchair cushion. Burn holes were observed in all of the resident's shirts and jackets hanging in the closet. At 1:36 p.m., the resident's mother stated, "He usually goes out to smoke by himself. I used to do his laundry but stopped because he doesn't take care of his clothes and they are covered in cigarette burns. You won't find any burn holes in his pants because I just replaced the old ones because they all had holes in them." IMMEDIATE JEOPARDY IDENTIFIED On 08/23/11, an Immediate Jeopardy (IJ) situation was identified in accident hazards due to the facility's failure to provide supervision and monitoring for resident #10 to ensure the resident's safety while smoking. On 08/23/11, at 1:40 p.m., the Oklahoma State Department of Health (OSDH) verified the Immediate Jeopardy (IJ) situation. On 08/23/11 at 1:45 p.m., the facility administrator was notified of the IJ situation related to the facility's failure to provide supervision to ensure residents' safety during smoking. The director of nursing (DON) and facility owner were present at that time. At 2:00 p.m., the DON stated, "He has had a change in condition today. We have been watching him all day. We have watched him. We did assessments. His vital signs were good. We just continued to monitor him. He could answer questions appropriately and was alert to person, place and time." 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A Resident Smoking Assessment Form, dated 05/27/11, documented the resident was not able to hold cigarette lighting materials without assistance. The assessment documented the resident was not able to extinguish a burning cigarette if it had fallen to his own body or others. The assessment documented the resident was not able to move to the designated smoking area without staff assistance. The assessment documented the resident would need to be supervised while smoking. The quarterly assessment, dated 06/27/11, documented the resident did not have cognitive impairment and required total assistance for ADLs. The assessment documented the resident had limited range of motion on both sides in the upper and lower extremities. The care plan, dated 06/28/11, documented the resident required supervision during smoking. On 08/23/11 at 2:25 p.m., the resident was observed by the surveyor smoking alone outside the exit at the end of C hall. The resident stated he was allowed to keep cigarettes and lighters in his room. The resident stated he could go out and smoke whenever he wanted. The resident stated he usually had someone with him in the smoke hut. The surveyor observed the resident drop a lit cigarette to the ground. The resident's right first finger and thumb were dark yellow and brown from nicotine stains. The resident was observed unsupervised during the smoking time. PLAN OF REMOVAL OF IMMEDIACY On 08/23/11 at 5:50 p.m., the DON provided the survey team with an acceptable plan of removal for the immediate jeopardy. The plan of removal documented: "Resident at risk was transferred to (name deleted hospital) for evaluation related to decline in condition, at 1:30pm (sic) on 08/23/11. New smoking assessment will be completed upon his return from the hospital. Direct threat will be removed by all smokers being required to be supervised. Cigarettes and smoking paraphernalia will be maintained at the nurse's desk and smokers can come to the nurse's desk for a cigarette every 2 hours. A staff member will be assigned each shift as the smoker's supervisor and will go out to the smoke shed with smokers during even hours between 8am (sic) and 8pm (sic) except during meal times to allow smoking. Smoker's supervisor will stay with smokers and observe for safety until all cigarettes extinguished. Administrator, DON &/or ADON (assistant director of nurses) will spot check randomly throughout the day x 30d (days) or until compliance achieved, if longer, then randomly on a weekly basis indefinitely to ensure proper supervision is being provided. Results of spot checks will be discusses (sic) at QA meeting monthly with any concerns being brought to Administrator immediately. All smokers care plans will be update (sic) by 08/24/11 for smoking safety. Immediacy of threat will be reduced as outlined above. Severity of threat will be reduced as outlined above. Staff will be in-serviced immediately regarding the change in policy and procedure as noted above. Staff in-servicing will be completed by 08/24/11 by 7pm (sic) by DON or ADON. Facility has ordered smoke aprons for smokers at risk and these will be used as deemed necessary, expected delivery date of 08/24/11." IMMEDIACY REMOVED The IJ was removed on 08/24/11 at 6:00 p.m., after the last employee inservice was completed, smoking assessments were updated, and care plans were updated. The deficient practice remained at a pattern for potential for actual harm that was not an IJ.

Based on observation, interview, and record review, it was determined the facility failed to implement measures to address weight loss for one (#16) of 16 sampled residents whose weights were reviewed. Resident #16 had a significant weight loss of 24 pounds in eight months. The facility census and condition report identified 14 residents with an unplanned weight loss. Findings: The facility policy and procedure for weight loss documented the residents were weighed monthly and the weights were reviewed by the dietary manager, director of nurses, and care plan coordinator. The policy documented the dietary manager referred a weight loss of three pounds or greater to the registered dietician and recommendations were made to the physician. The policy documented the dietary manager would follow up on recommendations to ensure all were addressed. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. The annual assessment, dated 11/20/10, documented the resident's cognition was severely impaired. The assessment documented the resident fed herself independently. The assessment documented the resident weighed 134 pounds and had not had a significant weight loss. The care plan, dated 11/24/10, documented the resident was at risk for impaired nutrition and hydration and fed herself. The interventions included to encourage adequate nutrition with every meal, to keep fluids readily available, to encourage adequate fluid intake, and to notify the physician of significant changes. The annual nutritional assessment, dated 11/30/10, documented the resident had a potential for weight loss, fed herself in her room, had good to fair food intake, had adequate fluid intake, and was at an acceptable weight. A physician's progress note, dated 11/30/10, documented the resident's weight was 134 pounds. The note did not document changes in the treatment plan. The November 2010 diet sheet documented the resident ate less than 50% of the meals 23 times. The documentation did not include a replacement for those meals. The diet sheet documented the resident refused the ordered ice cream with supper 29 times. The diet sheet documented the resident ate less than 50% of the ordered high calorie pudding with lunch six times. The ice cream and pudding were ordered in July 2010. The December 2010 diet sheet documented the resident ate less than 50% of the meals 44 times. The documentation did not include a replacement for those meals. The diet sheet documented the resident refused the ordered ice cream with supper 31 times and refused the ordered high calorie pudding with lunch 31 times. The most current lab report, dated 12/07/10, documented the resident's levels of protein and [MEDICATION NAME] (used to determine nutritional status of the body) were 6.8 (normal range for protein 6.1-8.2) and 3.7 (normal range for [MEDICATION NAME] 3.7-4.7). A physician's progress note, dated 01/11/11, documented the resident's weight was 130 pounds. The note did not document changes in the treatment plan. A physician's orders [REDACTED]. disease. The January 2011 diet sheet documented the resident ate less than 50% of the meals 52 times. The documentation did not include a replacement for those meals. The diet sheet documented the resident refused or ate less than 50% of the ordered ice cream with supper 31 times and refused the ordered high calorie pudding with lunch 31 times. The quarterly assessment, dated 02/16/11, documented the resident's cognition was severely impaired. The assessment documented the resident fed herself independently. The assessment documented the resident reported feeling down, depressed, or hopeless several days out of the past 14 days and had a poor appetite nearly every day. The assessment documented the resident weighed 122 pounds and had not had a significant weight loss. The assessment documented the resident received hospice services. A comment, dated 02/21/11, on the 11/24/10 care plan documented the resident had a poor appetite and had lost eight pounds in 30 days. The care plan did not include interventions to prevent further weight loss. A physician's progress note, dated 02/22/11, documented the resident's weight was 122 pounds. The note did not document changes in the treatment plan. The February 2011 diet sheet documented the resident ate less than 50% of the meals 28 times. The documentation did not include a replacement for those meals. The diet sheet documented the resident refused the ordered ice cream with supper 28 times and refused the ordered high calorie pudding with lunch 28 times. A dietary progress note, dated 03/21/11, documented the resident's weight was 117 pounds, the resident had lost 5 pounds in the past month, and had lost 10.7% during the past three months. The note documented the resident was on hospice. The note documented the resident received high protein pudding. The note documented no changes had been made to the treatment plan and the resident's weight would be monitored. The note was signed by the registered dietitian. The March 2011 diet sheet documented the resident ate less than 50% of the meals 57 times. The documentation did not include a replacement for those meals. The diet sheet documented the resident ate less than 50% or refused the ordered ice cream with supper 31 times refused or ate less than 50% of the ordered high calorie pudding with supper 31 times. A physician's progress note, dated 04/06/11, did not document a weight for the resident. The note did not document changes in the treatment plan. A dietary progress note, dated 04/21/11, documented the resident weighed 114 pounds and had lost 3 pounds in the past month. The note documented the resident was on hospice and her food intake was variable. The note documented the resident's weight would be monitored and the treatment plan remained the same. The note was signed by the registered dietitian. The April 2011 diet sheet documented the resident ate less than 50% of the meals 51 times. The documentation did not include a replacement for those meals. The diet sheet did not document if the ordered ice cream and high calorie pudding had been served to the resident during the entire month. The May 2011 diet sheet documented the resident ate less than 50% of the meals 15 times from 05/01/11 through 05/13/11. The documentation did not include a replacement for those meals. The diet sheet did not document if the ordered ice cream and high calorie pudding had been served to the resident during the entire month. The facility resident weight list documented the following weights: October 2010 136 pounds November 2010 134 pounds December 2010 131 pounds January 2011 130 pounds February 2011 122 pounds March 2011 117 pounds April 2011 114 pounds May 2011 112 pounds. The weight loss beginning in February represented a significant weight loss of greater than 5% in one month, greater than 7.5% in three months, and/or greater than 10% in six months. On 05/13/11 at 1:05 p.m., registered nurse (RN) #1 was asked how often the resident was weighed. The RN stated the resident was weighed monthly. On 05/13/11 at 1:40 p.m., the assistant director of nurses (ADON) was asked what measures had been implemented to prevent the resident's weight loss. The ADON stated the resident's daughter started bringing food from home about the time the resident was placed on hospice to see if the resident's appetite would improve. The ADON stated they had tried different supplements but the resident wouldn't take them. The ADON was asked if the resident would be considered at the end of life because of receiving hospice services. The ADON stated, "I wouldn't say she was in the end of life stage yet." On 05/13/11 at 2:10 p.m., licensed practical nurse (LPN) #3 was interviewed regarding the resident's weight loss. The LPN stated the resident's roommate had passed away in February and since that time the resident did not want to do anything. The LPN stated the resident's appetite began to decrease and the resident wanted to eat in her room more. On 05/13/11 at 2:15 p.m., the director of nurses (DON) was interviewed regarding the resident's weight loss and measures implemented to prevent further weight loss. The DON stated the resident had some kind of cognitive incident and everything changed about the resident. The DON stated it was about the same time the resident began falling and losing weight. The DON did not identify measures that had been implemented to prevent weight loss and did not specify if the effectiveness of the measures had been evaluated. The DON was asked if the physician was notified of the resident's weight loss. The DON stated the notification to the physician should be in the nurses' notes or on telephone orders if new orders were received. On 05/13/11 at 2:25 p.m., LPN #3 was asked to look at the resident's care plan for interventions to prevent weight loss. The LPN stated she had made an entry in February which documented the resident had lost eight pounds in the previous 30 days but had not included interventions to prevent further weight loss. On 05/13/11 at 3:45 p.m., the dietary manager was interviewed regarding the resident's weight loss. The dietary manager stated the resident refused everything they had tried and told the staff she did not have an appetite. The dietary manager stated the resident received high calorie pudding for lunch every day and ice cream at supper. On 05/13/11 at 3:45 p.m., the dietary manager was asked to identify some of the measures they normally tried on other residents who were at risk for losing weight. The dietary manager stated sometimes they used supercereal or double milk. The dietary manager stated she was not sure if those things had been tried for the resident. The dietary manager stated she did not have documentation of what had been tried. On 05/13/11 at 3:45 p.m., the dietary manager stated she did not make dietary recommendations on her own but left that to the dietitian. The dietary manager was asked if she felt like the resident would be considered at the end of life because she was receiving hospice services. The dietary manager stated she would not consider the resident to be at the end of life because she was still able to do some things for herself. The dietary manager stated the resident would not let the staff assist her with eating. The dietary manager stated she had recently been told they could document the intake of the pudding and the ice cream in with the percentage of the meal intake so they were not documenting them separately any longer. On 05/13/11 at 4:30 p.m., the resident was observed in her room at the far end of the hall. The resident was in the bed by the window with her eyes closed. The resident was thin and her clothing was loose fitting. A take out container of food was on the bedside table. The tray contained fried okra, one chicken nugget that had not been eaten, and a scoop of mashed potatoes and gravy with a few bites missing. A portion of a second chicken nugget was on top of the mashed potatoes. On 05/13/11 at 5:45 p.m., the resident was awake and sat up on the bed when the surveyor entered the area next to the bed. The resident was asked if she had eaten supper to which the resident replied she was not hungry. The resident's words were jumbled and she had difficulty getting the words out. On 05/16/11 at 12:00 p.m., the resident was observed lying in bed with her eyes closed. On 05/16/11 at 12:05 p.m., a dietary aide was asked where the resident would be served her lunch. The dietary aide stated the resident's tray would be sent to her room. On 05/16/11 at 12:36 p.m., the resident's tray was on an over-bed table and the resident was observed sitting on the side of the bed with her back to the door. The lid on the Styrofoam bowl which contained a dessert was not removed at the time the tray was served. The plastic lid covering the tea was not removed at the time the tray was served. The resident ate a few bites of the food that was on her tray but kept going back to the container of ice cream. On 05/16/11 at 12:40 p.m., the surveyor entered the area next to the resident's bed and asked the resident how her meal tasted. The resident stated the food tasted pretty good but she was getting full. She told the surveyor she did not like broccoli and preferred small meals because she had never been a big eater. The food on the resident's tray included broccoli, rice, a baked or steamed chicken breast, bread pudding, ice cream, and a slice of white bread. The resident's diet card did not identify broccoli as an item of dislike. On 05/16/11 at 12:42 p.m., a certified nurse aide (CNA) brought the resident a container of chocolate pudding and removed the lid. The resident ate a few small bites of the pudding. On 05/16/11 at 1:12 p.m., CNA #1 came in to the resident's room and stated to the resident "You haven't eaten very much. Would you like for me to get you a milkshake?" The CNA was asked if the resident was offered assistance with eating. The CNA stated she did not normally work that hall, but she thought the resident fed herself and did not want to be assisted. The surveyor asked the CNA if she would attempt to feed the resident so the resident's response could be evaluated. The CNA picked up the ice cream container and said to the resident "would you eat a few more bites for me?" The resident complied with the request and ate the remainder of the ice cream which was approximately 5 or 6 bites.