Every finding on record at Ponca City Nursing & Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure pureed foods were prepared to meet the needs of the residents for 1 (noon meal) of 1 meal observed during meal preparation.The dietary manger identified seven residents with a pureed diet.Findings:On 07/01/26 at 11:33 a.m., [NAME] #1 was observed to add seven pork chops, two slices of wheat bread, and beef broth to a blender.On 07/01/26 at 11 :36 a.m., [NAME] #1 blended the seven pork chops, two slices of wheat bread, and added two more slices of wheat bread to the blender.On 07/01/26 at 11:43 a.m., [NAME] #1 was observed to puree eight, four-ounce scoops of butter noodles and one slice of wheat bread.On 07/01/26 at 11 :54 a.m., [NAME] #1 was observed to puree eight, four-ounce scoops of mixed vegetables and one slice of wheat bread.A policy titled Therapeutic Diets, dated 03/2026, showed to define therapeutic diets and ensure all residents received diets that were safe and nutritionally adequate.On 07/01/26 at 12:19 p.m., the dietary manager stated residents with a puree diet could not have bread, they mixed it in the puree. The dietary manager stated residents with a puree diet were not getting the right serving size of each item if bread was added to the puree.On 07/02/26 at 1:13 p.m., the administrator stated they did not puree bread by itself because the bread got to stiff. They stated they mixed it in with the other puree items.On 07/02/26 at 1:13 p.m., the administrator stated by adding bread to puree the residents were not getting the correct nutritional value.

Based on observation, record review, and interview, the facility failed to ensure opened perishable food items were dated for 2 (drink and salad refrigerators) of 3 refrigerators.The dietary manager identified 88 residents received meals from the kitchen.Findings:On 06/29/26 at 10:53 a.m., a kitchen visit was made. The drink refrigerator contained three opened gallon containers of 2% milk with no opened on or use by date.On 06/29/26 at 10:55 a.m., the following observations were made during the kitchen visit. The salad refrigerator contained:a. an opened bag of lunch meat with no opened on or use by date,b. a half a container of tea with no opened on or use by date, andc. a half empty 2% milk with no opened on or use by date.A policy titled Food Safety, dated 03/2026, read in part, All food items shall be covered, labeled, and dated.On 06/29/26 at 11:02 a.m., Dietary Aide #1 stated they did not know the milk should be dated and stated the opened tea container belonged to an employee.On 07/02/26 at 11:05 a.m., the dietary manager stated they had new employees and all items should be dated when opened.On 07/02/26 at 12:24 p.m., the dietary manager stated staff drinks should not be stored in the facility refrigerator.

Based on observation, record review, and interview, the facility failed to ensure staff utilized personal protective equipment during the provision of catheter care for 1 (#3) of 6 sampled residents reviewed for incontinent care. The DON identified six residents had indwelling urinary catheters. Findings: On 07/01/26 at 5:08 a.m., Resident #3 was observed to have an indwelling urinary catheter in place. CNA #7 was observed wearing gloves to drain the catheter tubing while the resident was seated on the toilet. CNA #7 then placed the urine filled container onto the edge of the sink. CNA #7 was observed to wipe Resident #3's buttock. Using the same soiled gloves, CNA #7 was observed to place a clean brief and pull up the resident's pants. CNA #7 transferred Resident #3 to their recliner. CNA #7 was observed to comb Resident #3's hair. CNA #7 was observed to doff soiled gloves and throw them in the trash. CNA #7 was not observed to change gloves between clean and dirty tasks and was not observed to utilize a gown. CNA #7 was not observed to wash or sanitize their hands after providing incontinent care. A policy titled Catheter Care, Urinary, dated 08/2022, read in part, Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. Equipment and supplies .Personal protective equipment .gowns, gloves, mask, . as needed).A physician's order for Resident #3, dated 07/28/25, read in part, Enhanced Barrier Precautions: Must wear gown and gloves, (mask if warranted) during high contact resident care activity . every shift.A quarterly assessment for Resident #3, dated 06/04/26 showed the resident had a BIMS score of 9 which indicated moderate cognitive impairment, and an indwelling urinary catheter.A care plan for Resident #3, dated 06/04/26, showed the resident had an indwelling urinary catheter. The intervention read in part, Enhanced Barrier Precautions: Must wear gown and gloves, (mask if warranted) during high contact resident care activity, (dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting.)On 07/01/26 at 5:20 a.m., CNA #7 stated they were supposed to change toilet tissues after each wipe and change their gloves. On 07/01/26 at 5:35 a.m., LPN #1 stated they did not know when infection control training had been completed.On 07/01/26 at 11:45 a.m., the IP stated they conducted rounds and assisted with wound care. The IP stated they completed continuing education with staff and staff also completed training. The IP stated hands must be washed with soap and water if they were visibly soiled. The IP stated staff could use alcohol-based hand gel after changing their gloves. The IP stated a gown and gloves were to be worn during urinary catheter care.

Based on observation, record review, and interview, the facility failed to ensure a resident had fluids at bedside for 1 (#30) of 3 sampled residents reviewed for hydration.The administrator identified 88 residents resided in the facility. Findings:On 06/30/26 at 9:50 a.m., no fluids were observed in Residents #30's room. On 07/02/26 at 8:51 a.m., Resident #30 was observed to have a clear, small, plastic cup in their hand with water. A 5-day scheduled assessment for Resident #30, dated 04/08/26, showed a BIMS score of 14, which indicated the resident's cognition was intact for daily decision making. The assessment showed the resident was independent in their ability to eat and drink.On 06/30/26 at 9:50 a.m., Resident 30 stated they drank from the bathroom sink because they did not want to bother staff. They stated staff did not pass ice or water.On 07/02/26 at 8:56 a.m., CNA #2 stated they were to pass ice and water with hourly rounds and at 10:00 a.m. and 2:00 p.m.On 07/02/26 at 9:02 a.m., CNA #4 stated Resident #30 had a maroon cup in their room for fluids.On 07/02/26 at 9:07 a.m., CNA #2 stated they did not see a maroon cup for fluids in Resident #30's room.On 07/02/26 at 9:30 a.m., the DON stated staff were to offer residents fresh ice and water at 10:00 a.m., 2:00 p.m., 8:00 p.m., during meals, and with all resident assistance.On 07/02/26 at 9:31 a.m., the DON stated it was not acceptable for residents to drink from the bathroom sink. They stated Resident #30 was not on a fluid restriction.

Based on observation, record review, and interview, the facility failed to ensure a resident had a physician's order for oxygen administration for 1 (#87) of 2 sampled residents reviewed for respiratory care.The DON identified 11 residents on oxygen resided in the facility. Findings:On 06/29/26 at 1:48 p.m., Resident #87 was observed on oxygen at a rate of two liters per minute via nasal cannula.On 07/01/26 at 10:39 a.m., Resident #87 was observed to have oxygen on via a nasal cannula.A care plan for Resident #87, dated 06/26/26, showed the resident used oxygen continuously. The care plan showed the resident had a diagnosis of acute respiratory failure with hypoxia.There was no documentation Resident #87 had a physician's order for the use of oxygen.On 07/01/26 at 10:46 a.m., LPN #2 stated Resident #87 was on 2.5 liters of oxygen.On 07/01/26 at 10:48 a.m., LPN #2 stated a physician's order was needed for oxygen administration. They stated Resident #87 did not have an order for oxygen use.On 07/02/26 at 9:28 a.m., the DON stated a physician's order was required for oxygen administration.On 07/02/26 at 9:29 a.m., the DON stated Resident #87 had been on oxygen since 06/25/26.

Based on record review and interview, the facility failed to ensure a resident who preferred individualized activities in their room was provided those activities for one (#53) of 8 sampled residents reviewed for activities. A facility room roster, dated 07/28/24, documented 79 residents resided in the facility. Findings: An Activities and Social Work, dated 11/2022, read in part, When the Care Planning Team develops the resident's activity and social care plan, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. A review of the resident's medical record found no documentation of activities having been provided to Resident #53 in the months of April 2024 and May 2024. An annual minimum data set assessment, dated 03/22/24, documented Resident #53's cognition was intact. On 07/29/24 at 1:19 p.m., Resident #53 stated the staff had not provided them with one-to-one activities in their room. They stated they believed they did not receive activities in their room because they would be charged extra. They stated they would enjoy if someone would spend time with them doing an activity as they were unable to leave the room without much difficulty. On 07/30/24 at 12:32 p.m. the activities director stated they usually attempt to spend two times each week with those wanting visits. They stated they document resident participation in monthly progress notes in the residents' electronic medical record. They stated they did not know why those notes for #53 were not in the medical record and would go look for them. On 07/30/24 at 1:16 p.m., the activities director stated they had looked in the Resident #53's records and was unable to locate the activities documentation for April 2024 and May 2024. They stated they may not have clicked the save and lock button in the system after entering the information.

Based on record review and interview, the facility failed to ensure a physician order was completed for a gradual dose reduction for one (#34) of five sampled residents reviewed for unnecessary medications. The DON identified 53 residents received psychotropic medications. Findings: A Medication and Treatment Orders policy, revised July 2016, read in part,orders for medications and treatments will be consistent with principles of safe and effective order writing. A Tapering Medications and Gradual Drug Dose Reduction policy, revised July 2022, read in part, the residents who use psychotropic medications shall receive gradual dose reductions. The policy also read, in a effort to discontinue these drugs. Resident #34 had diagnoses which included Alzheimer's, depression, and cognitive communication deficit. A Medication Regimen Review, dated 07/16/24, documented Resident #34 received mirtazapine (Remeron) 30 mg at bedtime. Recommendation by pharmacist made to reduce mirtazapine (Remeron) to 15 mg at bedtime. Review was signed by physician on 07/18/24 to reduce mirtazapine (Remeron) to 15 mg at bedtime. A Medication Administration record, dated July 2024, documented Resident #34 continued to receive mirtazapine (Remeron) 30 mg at bedtime. On 07/31/24 at 7:59 a.m., the DON was asked what the facility policy was for adding or changing orders in a residents chart. They stated the nurse that takes the order or notes the order makes the changes in a residents chart. They were then asked to review a pharmacist recommendation on a medication regimen review for Resident #34 dated 07/16/24 for mirtazapine to be reduced to 15 mg every day at bedtime. They were then asked to review the medication administration record for July 2024 and asked if the order for mirtazapine was reduced per physician order signed on 07/18/24, they stated No it was not changed.

Based on observation, record review, and interview, the facility failed to provide treatment and services to treat a contracture for one (#46) of one sampled resident reviewed for range of motion restorative care. The DON identified nine residents with contractures. Findings: The facility's Restorative Nursing Services policy, revised 06/2017, read in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. The policy also read, Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 1. Resident #46 was admitted on [DATE] with diagnoses which included esophagitis and Guillain-Barre syndrome. A annual MDS assessment, dated 07/13/24, documented Resident #46's cognition was intact and had range of motion impairments on the upper extremities and lower extremities on both sides. The Health Record did not document Resident #46 was receiving restorative services. On 07/29/24 at 1:20 p.m., Resident #46 was observed in bed. Resident #46 had contractures to both hands and legs. Resident #46 stated both hand and legs were contracted. Resident #46 was asked if they were receiving therapy or restorative care. Resident #46 stated they wanted restorative care and was not receiving it because they were not eligible due to being on Medicaid. On 07/31/24 at 12:55 p.m., CMA#1 was asked to discuss Resident #46's physical limitations and contractures. They stated Resident #46's hands were contracted and required a lift assist with transfers. On 07/31/24 at 12:59 p.m., LPN#3 was asked to discuss Resident #46's physical limitations or contractures. LPN#3 stated Resident #46 was contracted in their legs bilaterally and both hands. LPN #3 was asked what the policy was for a resident to receive restorative therapy. They stated when there is an order or the resident experienced weight loss, pain, a decline in ADL's , or experienced a fall, the resident would receive restorative care. On 07/31/24 at 1:06 p.m., the DON was asked how the facility determines a resident receives and/or needs restorative care. They stated every resident was evaluated and they try and get a restorative program if they qualify. The DON was asked if Resident #46 was a candidate for restorative care. The DON stated Resident #46 was candidate for restorative care and thought the resident had refused. The DON was asked to provide documentation of the refusal or restorative care Resident #46 was receiving. The DON stated resident #46 should of been receiving restorative care and there was no documentation of a refusal or restorative care being provided.

Based on observation record review, and interview, the facility failed to maintain an adequate call light system for one (#1) of three sampled residents whose call light systems were observed. The Administrator identified 47 residents resided in the facility. Findings: The Call System, Residents policy, dated September 2022, read in part, .Each resident is provided with a means to call staff directly for assistance from his/her bed .and from the floor . Resident #1 had diagnoses which included other atherosclerotic heart disease, h/o pulmonary embolism, type 2 diabetes, syncope and collapse, and age-related physical debility. Resident #1's care plan, admitted [DATE], documented they were at risk for cardiac instability, impaired respiratory integrity, complications of diabetes, and injury related to a fall. Resident #1's resuscitation status was 'Full Code'. On 07/15/24 at 12:25 p.m., Resident #1 was observed in bed eating lunch unassisted and unattended. No call light was observed in the resident's room connected to the wall system. On 07/16/24 at 9:51 a.m., the Administrator reported the facility call system was removed from Resident #1's room and a two-part doorbell aparatus was being used for Resident #1's call system. On 07/16/24 at 12:10 p.m., the push button part of the apparatus was observed zip-tied to the positioning rail attached to Resident #1's bed and the base was observed plugged in an outlet in the [NAME] nurses' station room at the end of the hall. The push button part of the apparatus could only be assessed by the resident when in bed. On 07/16/24 at 12:15 p.m., LPN #1 was asked to perform a test of Resident #1's call system. It was observed that the doorbell would only chime once when pushed by the resident and repeated chimes would require the resident to be able to repeatedly push the button. On 07/16/24 at 12:45 p.m., the DON was made aware of my observations regarding Resident #1's call system. The DON was asked if the call system in place for Resident #1 would be adequate if the resident fell out of bed or experienced a cardiac, respiratory, or serious hypoglycemic or hyperglycemic event and was not able to repeatedly push the call button. The DON acknowledged it would not.

Based on record review and interview the facility failed to ensure that newly ordered medications were initiated in a timely manner for two (#1 and #2) of four sampled residents whose records were reviewed for medications being administered as ordered. The Resident Census and Conditions of Residents report, dated 02/06/23, documented 75 residents resided in the facility. Findings: A Medication Administration and General Guidelines policy, edited 2021, read in part, .Medications are administered .in accordance with State Regulations using good nursing principles and practices . 1. Resident #1 had diagnoses that included COPD and chronic pain syndrome. An Order Summary Report, dated 02/02/23, read in parts, .OxyCONTIN Oral Tablet ER .20 MG .Give 1 tablet by mouth every 12 hours .Percocet Oral Tablet 7.5-325 MG .Give 1 tablet by mouth every 8 hours as needed for Pain . A Telephone/Verbal Order, dated 02/03/23 at 11:00 a.m., read in parts, .HYDROcodone-Acetaminophen Oral Tablet 5-325 MG .Give 1 tablet by mouth every 6 hours as needed for Pain . A [Pharmacy] Drug Delivery Manifest, dated 02/03/2023 at 2:51 p.m., read in parts, Patient: [Res #1] .OXYCOD.APAP TAB 7.5-325 .Received By: [CMA #1] .Delivery Date/Time: 2-3-23 . A [Pharmacy] Drug Delivery Manifest, dated 02/03/2023 at 6:41 p.m., read in parts, Patient: [Res #1] .OXYCONTIN TAB 20MG ER .Received By: [RN #1] .Delivery Date/Time: 2-3-23 11:55 pm . The MAR, dated 2/1/2023-2/28/2023, documented scheduled doses of OxyCONTIN Oral tablet ER were not administered at 9:00 p.m. on 02/02/23, at 9:00 a.m. on 02/03/23, nor at 9:00 p.m. on 02/03/23; no PRN doses of HYDROcodone-Acetaminophen Oral tablets 7.5-325mg were administered on 02/02/23 nor 02/03/23; and no PRN doses of HYDROcodone-Acetaminophen Oral tablets 5-325mg were administered on 02/03/23. On 02/06/23 at 2:12 p.m., Res #1 was observed sitting on his bed. Res #1 was asked if they had been receiving their medications as ordered since their admission to the facility on [DATE]. Res #1 reported they missed three scheduled doses of pain medication and was not offered PRN pain medication for their chronic pain for 2 days when first admitted . Res #1 stated, I had to get irate with them. Res #1 was asked how this made them feel. They stated, Not my best, but it's okay now. On 02/07/23 at 11:38 p.m., the DON was asked how often the pharmacy delivered medications to the facility. She stated routine medications orders and re-orders were delivered every evening with the routine pharmacy delivery. The DON was asked how orders for narcotic pain medications were handled for newly admitted residents. She stated, I tell the pharmacy to stat them and they get here in three to four hours. The DON was asked why OxyCONTIN Oral Tablet ER 20mg and Percocet Oral Tablet 7.5-325mg had not been received from the pharmacy in three to four hours and Res #1 did not receive pain medication for chronic pain until the 2nd day after admission. The DON stated, I don't know. We may have needed to re-do the script. 2. Resident #2 had diagnoses that included dementia without behavioral disturbance and dysphagia. A Telephone/Verbal Order, dated 12/17/22, read in part, .New Order .Start Date: 12/17/2022 [9:00 a.m.] .Ciprofloxacin HCL Tablet 500 MG Give 1 tablet by mouth two times a day for UTI for 10 Days . The MAR, dated 12/1/2022-12/31/2022, documented Ciprofloxacin HCL Tablet 500mg was not administered at 9:00 a.m. and 6:00 p.m. as ordered on 02/17/23, 02/18/23, 02/19/23, 02/20/23, 02/21/23, and 02/22/23; nor at 9:00 a.m. on 02/23/23. On 02/07/23 at 11:38 p.m., the DON was asked how new orders for antibiotic medications were handled. She stated, We stat those and in three to four hours, they are here. The DON was shown the February 2023 MAR documenting ABT prescribed for Res #2 on 02/17/23 had not been started before 02/23/23. She was asked why the medication had not been started as ordered. The DON stated, That's a good question, I can't tell you.

Based on record review and interview the facility failed to ensure bathing was provided for dependent residents for two (#2 and #4) of four sampled dependent residents reviewed for bathing. The Resident Census and Conditions of Residents report, dated 02/06/23, documented 75 residents resided in the facility, 60 residents required assistance of one or two staff for bathing, and 15 residents were dependent on staff for bathing. Findings: A Charting and Documentation policy, revised July 2017, read in parts, .All services provided to the resident .shall be documented in the resident's medical record .The following information is to be documented in the resident medical record: .c. Treatments or services performed . A Bath, Shower/Tub procedure, revised February 2018, read in parts, .Documentation .1. The date and time the shower/tub bath was performed .5. If the resident refused the shower/tub bath, the reason(s) .Reporting .1. Notify the supervisor if the resident refuses the shower/tub bath . 1. Resident #2 had diagnoses that included dementia without behavioral disturbance and dysphagia. Res #2 Care Plan, revised 02/05/23, read in part, .requires assistance with her activities of daily living .needs your help to take a bath .please monitor her bathing schedule, if hospice staff is unable to provide her personal care, NH staff will do so . An ADL: Bathing Task Sheet, for dates 01/06/23-02/06/23, documented Res #2 received a bath on 02/06/23 representing one shower was given in the 30 days that were reviewed. On 02/06/23 at 3:40 p.m., RN #2 was asked how they monitor if baths were completed by hospice aides. RN #2 stated, If hospice is not here by 2 p.m., we do it. RN #2 was asked if baths completed by hospice or the facility staff would be documented. They stated, Yes, in the EHR. RN #2 was asked to review the EHR for Res #2 and verified no baths had been documented for Res #2 for the last 30 days. 2. Resident #4 had diagnoses that included dementia without behavioral disturbance and dysphagia. Res #4 Care Plan, revised 01/22/23, read in part, .BATHING .twice weekly and as needed .requires assistance from 1 person for bathing needs . An ADL: Bathing Task Sheet, for dates 01/07/23-02/06/23, documented Res #2 received a bath on 01/16/23, 01/26/23, and 01/30/23 representing three baths were given in the 30 days that were reviewed. On 02/06/23 at 2:20 p.m., Res #4 was observed in their room up in chair accompanied by family members. Family stated they were not sure what days resident received baths. On 02/06/23 at 3:40 p.m., RN #2 was asked who had assigned baths to the dayshift staff on the unit today. She stated, I don't know. It could have been the night nurse. RN #2 was asked how they monitor if baths were completed by staff as assigned. RN #2 stated, The staff tells me if residents refuse. On 02/06/23 at 3:43 p.m., RN #2 was asked why Res #4's name had been crossed off the bath list. They stated, Someone must have given [them] a shower. CNA #1, CNA #2, and CNA #3 were asked if either of them had given Res #4 a shower today and they all stated no. CNA #1, CNA #2, and CNA #3 were the only CNA's assigned to Res #4's unit during this day shift. Res #4 had not received a bath. On 02/07/23 at 11:38 a.m., the DON was asked to review the ADL record in the EHR for Res #2 and Res #4. The DON agreed the documentation did not indicate baths had been provided to these two dependent residents according to their POC.

Based on record review and interview, it was determined the facility failed to ensure diabetic residents received insulin as ordered by the physician for one (#77) of five sampled residents who were reviewed for unnecessary medications. The facility identidied 15 residents who received insulin. Findings: Resident #77 had [DIAGNOSES REDACTED]. Physician orders, dated ,[DATE], documented the resident was to have his FSBS (Fingerstick Blood Sugar) checked at 7:00 a.m., 12:00 p.m., 5:00 p.m., and 8:00 p.m. everyday. The physician was to be notified of a FSBS greater than 300 or less than 50. Humalog (a fast acting insulin used to treat type 2 diabetes) was to be administered as follows: .INJECT SQ (subcutaneous) PER SLIDING SCALE FSBS ,[DATE] = 1 UNIT ,[DATE] = 2 UNITS ,[DATE] = 3 UNITS ,[DATE] = 4 UNITS ,[DATE] = 5 UNITS ,[DATE] = 6 UNITS ,[DATE] = 7 UNITS ,[DATE] = 8 UNITS ,[DATE] = 9 UNITS ,[DATE] = 10 UNITS ,[DATE] = 11 UNITS ,[DATE] = 12 UNITS ,[DATE] = 13 UNITS ,[DATE] = 14 UNITS ,[DATE] = 15 UNITS ,[DATE] = 16 UNITS ,[DATE] = 17 UNITS . [MEDICATION NAME] (a long acting insulin) was to be administered routinely every night at bedtime. The diabetic medication administration record (MAR), dated ,[DATE], contained no documentation to indicate the 8:00 p.m. dose of Humalog was administered on [DATE], from [DATE] through [DATE] or from [DATE] through [DATE]. On [DATE] at 12:00 p.m., the MAR documented 12 U (units) of Humalog was administered. There was no documentation to indicate the FSBS was performed as ordered. On [DATE] at 12:00 p.m., the MAR documented the FSBS was 413 and 18 U of Humalog was administered as a one time dose. There was no order for the 18 U found in the clinical record. On [DATE] at 7:00 a.m., the MAR documented the FSBS was 394 and 17 U of Humalog was administered as a one time dose. There was no order for the 17 U found in the clinical record. At 5:00 p.m., the MAR documented the FSBS was 249 and a line was drawn through the dose of Humalog documented as administered. There was no documentation to indicate the amount of Humalog administered to the resident. At 8:00 p.m., the MAR documented the FSBS was 334 and 10 U of Humalog was administered as a one time dose. There was no order for the 10 U found in the clinical record. On [DATE] at 12:00 p.m., the MAR documented the FSBS was 381 and 18 U of Humalog was administered as a one time dose. There was no order for the 18 U found in the clinical record. On [DATE] at 7:00 a.m., the MAR documented the FSBS was 369 and 17 U of Humalog was administered as a one time dose. There was no order for the 17 U found in the clinical record. A physician's orders [REDACTED]. A physician's orders [REDACTED]. On [DATE] at 8:00 p.m., the MAR documented the FSBS was 265 and 4 U of Humalog was administered. According to the physician's orders [REDACTED]. On [DATE] at 7:00 a.m., the MAR documented the FSBS was 221 and 4 U of Humalog was administered. According to the physician's orders [REDACTED]. On [DATE] at 7:00 a.m., the MAR documented the FSBS was 314 and 8 U of Humalog was administered. According to the physician's orders [REDACTED]. At 12:00 p.m., the MAR documented the FSBS was 364 and 18 U of Humalog was documented as having been administered. A one time order for 21 U of Humalog for the FSBS of 364 was also received and documented on the MAR as administered. On [DATE] at 8:00 p.m., the MAR documented the FSBS was 201 and 6 U of Humalog was administered. According to the physician's orders [REDACTED]. On [DATE] at 12:00 p.m., the MAR documented the FSBS was 237 and 6 U of Humalog was administered. According to the physician's orders [REDACTED]. On [DATE] at 12:02 p.m., the director of nursing (DON) was asked to review the resident's MARs and physician's orders [REDACTED]. She was asked if the orders were followed to administer 18 U at 12:00 p.m. with an additional 21 U. She stated if the physician had meant to administer 39 units then the order would have indicated it. After reviewing the documentation for ,[DATE] and ,[DATE], the DON was asked if the physician orders [REDACTED]. She stated there was a problem and some education needed to be done.

Based on observations, record review and interview, it was determined the facility failed to ensure transmission based precautions were implemented for one (#48) of one sampled resident who was reviewed for transmission based precautions. The facility identified four residents who resided in the facility and were on transmission based precautions. Findings: A transmission based precaution policy, dated 02/12/18, documented: Transmission-Based Precautions are .to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . Contact Precautions Use Contact Precautions for patients with known or suspected infections that represent an increaed risk for contact transmission . The policy specified personal protective equipment (PPE), including gloves and gowns, was to be used for all interactions involving contact with the resident or the resident's environment. The donning of PPE was to be completed upon entrance and PPE was to be properly discarded before exiting the resident's room to contain pathogens. The rooms were to be cleaned daily with a focus on frequently touched surfaces. An annual assessment for resident #48, dated 07/01/19, documented the resident was moderately impaired in cognitive skills for daily decision making and required limited assistance with activities of daily living (ADL). He was frequently incontinent of bladder and occasionally incontinent of bowel. A nurse's note, dated 08/23/19, documented the resident was to be on isolation precautions due to [MEDICAL CONDITIONS] ([MEDICAL CONDITION]). A care plan, revised on 08/23/19, documented the resident had [MEDICAL CONDITION] and contact precautions were initiated per the facility's protocol. Staff was to ensure the resident was clean and dry, assist him with hand washing as needed and provide frequent safety checks. It was also documented staff was to monitor the flow and number of visitors. On 8/27/19 at 8:23 a.m., no gloves were available for use prior to entering the resident's room. No biohazard containers were observed for disposal upon exiting the resident's room. The resident was observed in his room lying in bed with dried feces on his hands, forearms, right leg, and clothing. Flies were observed on the resident's soiled clothing and bed linens. Dried feces was observed smeared on the bathroom door and toilet seat. At 8:40 a.m., CNA #3 was asked where staff was to dispose of their contaminated PPE after they had provided care to the resident. She stated trash was placed in the box with the red bag and linens were placed in the box with the yellow bag located in the resident's bathroom. She was asked if staff walked back through the resident's room after disposing of their PPE in his bathroom, would they have been re-contaminated. She stated, yes. At 8:48 a.m., CNA #4 was observed replacing PPE supplies, including gowns, gloves and alcohol based hand sanitizer. She was asked what precautions had been put in place for the resident. She stated, I don't know. She was asked if alcohol based hand hygiene was effective for [MEDICAL CONDITION]. She stated, I don't know. On 08/28/19 at 2:00 p.m., licensed practical nurse (LPN) #2 was observed donning PPE upon entering the room for medication administration. She was observed to discard the gown, gloves and shoe covers in the container located in the resident's room. She was asked what precautions had been put in place to ensure contamination outside the room would not occur. She stated contact precautions for [MEDICAL CONDITION]. She was asked if her PPE was discarded properly to prevent the spread of [MEDICAL CONDITION]. She stated, No. On 08/29/19 at 1:47 p.m., the director of nursing (DON) was asked how staff was to dispose of their PPE following care. She stated in the red and yellow boxes in the bathroom. The staff should then wash their hands prior to exiting the room. The DON was asked if the staff would have ensured proper precautions if they removed their shoe covers then walked back through the resident's room to exit. She stated, she did not know.

Based on observations, record review and interview, it was determined the facility failed to ensure an effective system was in place for the identification of advance directives and code status for two (#12 and #67) of two sampled residents whose records were reviewed for advance directives. This had the potential to affect all 96 residents who resided in the facility. Findings: 1. Resident #12 had [DIAGNOSES REDACTED]. An Advance Directive for Health Care, dated 01/30/17, was signed by the resident and on file in the clinical record. An Oklahoma DNR consent form, dated 05/08/18, was signed by the resident and on file in the clinical record. An Advance Directive Acknowledgement form, dated 02/27/19, was found in the clinical record and signed by the resident's power of attorney. It documented the resident had not executed an advance directive. An Oklahoma Do-Not-Resuscitate (DNR) Consent Form, undated and unsigned, was found in the clinical record with the admission paperwork. It was not completed and a line was drawn across the form with declined handwritten across the line. A social service progress note, dated 02/27/19, documented, .admitted .for SNF (skilled nursing facility) services .is a DNR & has advance Directive . A social services admission evaluation, dated 03/02/19, documented the resident was a DNR and a copy of the DNR had been obtained. An admission assessment, dated 03/06/19, documented the resident was cognitively intact. On 08/27/19 at 5:25 p.m., the director of nursing (DON) was asked the resident's DNR status. She stated, Full code. The DON was asked how the resident's full code status was indicated to the staff. She stated by the green dots on the outside of her clinical record and on her nameplate outside the door to her room. The DON then made reference to the DNR forms in the resident's clinical record and stated the form which was declined was more current than the other. She was asked how she knew it was more current when the form was not dated. She stated it was from the facility's admission packet and was completed with the advance directive acknowledgement form. The other form was faxed from the hospital. The DON was asked how the code status would be known from checking the DNR forms. She stated the dated DNR form also had a faxed date prior to the facility's form. The DON was asked to review the resident's advance directive and the advance directive acknowledgement form which indicated the resident did not have an advance directive. She was asked if the resident had an advance directive. She then acknowledged the resident had an advance directive on file in the clinical record. The DON was asked to review the social service progress note and admission evaluation. She was asked why it would have been documented the resident was a DNR and had an advance directive if the resident was a full code and did not have an advance directive. She stated, I don't know. The DON was asked if the documentation was clear as to the resident's code status and whether she had an advance directive. She stated, No. 2. Resident #67 had [DIAGNOSES REDACTED]. An Oklahoma DNR consent form, dated 08/21/16, was signed by the resident and on file in the clinical record. A social service progress note, dated 10/08/18, documented, .arrived at 3:50 pm .DNR .are in chart and in file . A social services admission evaluation, dated 10/09/18, documented the resident was a DNR and a copy of the DNR had been obtained. A face sheet, printed on 08/19/19, documented the resident did not have an advance directive and was a full code status. Red dots were observed on the outside of the clinical record and on the nameplate outside the door to her room. On 08/27/19 at 11:55 a.m., licensed practical nurse #1 was asked what the red dots indicated. She stated a red dot indicated the resident was a DNR and a green dot indicated they were a full code. On 08/28/19 at 11:11 a.m., the DON was asked what paperwork was sent with a resident when they go to the hospital. She stated, the medication administration records, treatment administration records, advance directive and the face sheet. The DON was asked to review the resident's clinical record. She was then asked the code status of the resident. She stated, DNR. She was asked the code status documented on the face sheet. She stated, Full code.

Based on observations, record review and interview, it was determined the facility failed to provide assistance with dressing, toileting and grooming for one (#48) of three sampled residents who were reviewed for activities of daily living (ADL). The facility identified 82 residents who required assistance with activities of daily living. Findings: Resident #48 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An annual assessment, dated 07/01/19, documented the resident was moderately impaired in cognitive skills for daily decision making and required limited assistance with ADLs. He was frequently incontinent of bladder and occasionally incontinent of bowel. A care plan, dated 07/05/19, documented the resident required assistance with a few of his ADLs. Staff was to assist him to maintain his dignity, ensure he would be dressed in clean and dry clothing and his bed was clean and dry. They were to toilet the resident before meals, before bed and at least once through the night to ensure he was clean and dry. A psychiatric consultation progress note, dated 07/12/19, documented the staff had reported the resident was playing with his feces. This was documented as a behavior related to dementia. The plan of care was for staff to redirect and offer additional peri-care. A nurse's note, dated 08/06/19, documented the resident was to be on isolation precautions due to [MEDICAL CONDITIONS]. On 8/27/19 at 8:23 a.m., the resident was observed in his room lying in bed with dried feces on his hands, forearms, right leg, and clothing. Flies were observed on the resident's soiled clothing and bed linens. Dried feces was observed smeared on the bathroom door and toilet seat. On 8/28/19 at 2:00 p.m., the resident was observed resting in his room with his eyes closed and flies around him. Cornbread crumbs were observed on the resident's bed, bedside table, floor and clothing. Spilled milk and pudding were observed on the bedside table. A brown colored dried substance was observed on the resident's call cord and wall. On 8/29/19 at 8:30 a.m., the resident was observed sitting in a wheelchair in his room as he listened to music with headphones covering his ears. His face was unshaven and his clothing was soiled with food. The bed had been made and food droppings were observed on the blanket. Cookie crumbs and pasta noodles with red sauce were observed on the floor. The resident's drinking cup and bedside table were observed with dried food. A dried brown colored substance remained on the call light cord and wall behind his recliner. Flies were observed throughout the room. At 10:45 a.m., certified nursing assistant (CNA) #1 and CNA #2 were asked if the resident required assistance with ADLs. They both stated yes. They were asked how much assistance he required. They stated he required assistance of one person with toileting due to incontinence. CNA #1 and CNA #2 were asked if the resident refused care. CNA #1 stated no. CNA #2 stated the resident would occasionally refuse with the male CNAs but another staff member would come assist if that occurred. The CNAs were asked if the resident had a decline in his ADL functional status. They stated a minimal decline. They were asked what interventions were implemented due to the decline. They stated more frequent checks were made and the staff was to encourage participation in self care. At 1:47 p.m., the director of nursing (DON) was asked if the resident required assistance with ADLs. She stated yes. She was asked how much assistance he required. She stated he required limited assistance of one person. She was asked if the resident had ever refused care. She stated no. The DON was notified of the observations which had been made of the resident. She stated she was sorry.

Based on interview and record review, it was determined the facility failed to ensure residents received insulin injections per the physician's order for two (#1 and #3) of four sampled residents who were reviewed for insulin administration. The facility identified 18 residents who received insulin in the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order, dated 05/02/18, documented to administer [MEDICATION NAME] 100 u/ml (units/milliliter) 35 units twice daily at 7:00 a.m. and 8:00 p.m. A physician's order, dated 05/02/18, documented to administer Humalog 100 u/ml 25 units before meals. The resident's care plan, dated 05/21/18, documented a problem related to diabetes. The goal was the resident's risk for complications related to diabetes would be minimized. Interventions included for nursing to administer insulin per orders. A nurse's note, dated 05/31/18 on the 7:00 a.m. - 7:00 p.m. shift, documented the resident had no refusal of care, glucose monitoring continued related to diabetes and insulin administered per orders. Review of the clinical record revealed the following: ~ 05/31/18- the resident did not receive [MEDICATION NAME] 35 units at 7:00 a.m. The resident did not receive Humalog 25 units before breakfast. The resident did not receive Humalog 25 units before lunch. The resident did not receive Humalog 25 units before dinner. On 08/07/18 at 5:00 p.m., licensed practical nurse (LPN) #1 was asked what the process was for checking blood sugars and administering insulin. She stated they checked the blood sugar then verified the orders for the insulin dose and administered the insulin per orders. She was asked where they documented the administration of insulin. She stated in the treatment administration record and the diabetic flow sheet. She was asked how many injections per day resident #1 was ordered to receive on 05/31/18. She stated five. She was asked if the resident had received five doses of insulin on 05/31/18 based on the documentation. She stated, No. At 6:32 p.m., the director of nursing (DON) was asked how many insulin injections the resident was ordered to receive per day on 05/31/18. She stated he should have received five injections. She was asked if the resident had received five doses of insulin on 05/31/18 based on the documentation. She stated the injections were not documented. She was asked what it indicated when something was not documented in the clinical record. She stated it was not done. She was asked if the staff had followed the orders for administering insulin to the resident. She stated, No. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order, dated 04/05/18, documented to administer [MEDICATION NAME] 100 u/ml 8 units at bedtime. A physician's order, dated 04/05/18, documented to administer Humalog 100 u/ml per sliding scale before meals and at bedtime. The resident's care plan, dated 04/22/18, documented a problem related to diabetes. The goal was the resident's risk for complications of diabetes would be minimized. Interventions included for nursing to administer insulin per orders. Review of the clinical record revealed the following: ~ 06/07/18- the resident did not receive [MEDICATION NAME] 8 units at bedtime, ~ 06/14/18- the resident did not receive [MEDICATION NAME] 8 units at bedtime. The record contained no documentation a fingerstick blood sugar test was performed at bedtime or that the resident received any sliding scale insulin at bedtime; ~ 07/02/18- the record contained no documentation a fingerstick blood sugar test was performed before breakfast or that the resident received any sliding scale insulin before breakfast. On 08/07/18 at 6:20 p.m., LPN #2 was asked how much Levimir insulin the resident was ordered to receive. She stated eight units at bedtime. She was asked if the resident had received [MEDICATION NAME]on 06/07/18. She stated it was not documented. She was asked if the resident had received [MEDICATION NAME]on 06/14/18. She stated it was not documented. She was asked if the resident had a fingerstick blood sugar test performed on 06/14/18 at bedtime or on 07/02/18 before breakfast or if she had received sliding scale insulin before breakfast. She stated a fingerstick blood sugar or an insulin injection was not documented at those times. She was asked why the resident had not received insulin per the physician's order. She stated she did not know. At 6:42 p.m. the DON was asked how she monitored the staff to ensure the residents received their insulin and had their fingerstick blood sugar test performed per orders. She stated the administrative nurses had been monitoring daily for the staff reporting blood sugars outside of parameters to the physician since the most recent survey. She was asked how much [MEDICATION NAME]the resident was ordered to receive. She stated eight units at bedtime. She was asked if the resident had received [MEDICATION NAME]on 06/07/18. She stated, No. She was asked if the resident had received [MEDICATION NAME]on 06/14/18. She stated, No. She was asked if the resident had a fingerstick blood sugar test performed on 06/14/18 at bedtime and on 07/02/18 before breakfast or if she had received sliding scale insulin before breakfast on 07/02/18. She stated, No. She was asked if the staff had followed the physician order related to the administration of insulin. She stated, No. She was asked why the resident had not received insulin per the physician's orders. She stated, I don't know.

Based on interview and record review, it was determined the facility failed to ensure residents had fingerstick blood sugar tests performed per the physician's orders [REDACTED].#1 and #3) of four sampled residents who were reviewed for fingerstick blood sugar testing. The facility identified 35 residents who received fingerstick blood sugar testing in the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's care plan, dated 05/21/18, documented a problem related to diabetes. The goal was the resident's risk for complications related to diabetes would be minimized. Interventions included for nursing to monitor the fingerstick blood sugar as prescribed. A nurse's note, dated 05/31/18 on the 7:00 a.m. - 7:00 p.m. shift, documented the resident had no refusal of care, glucose monitoring continued related to diabetes and insulin administered per orders. Review of the clinical record revealed the following: ~ 05/31/18- the record contained no documentation a fingerstick blood sugar test performed before breakfast, before lunch, or before dinner. On 08/07/18 at 7:30 p.m., the director of nursing (DON) was asked if the staff had followed the orders for performing fingerstick blood sugar testing on 05/31/18. She stated, No. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's care plan, dated 04/22/18, documented a problem related to diabetes. The goal was the resident's risk for complications of diabetes would be minimized. Interventions included for nursing to monitor the fingerstick blood sugar as prescribed. Review of the clinical record revealed the following: ~ 06/14/18- the record contained no documentation a fingerstick blood sugar test was performed at bedtime; and ~ 07/02/18- the record contained no documentation a fingerstick blood sugar test was performed before breakfast. On 08/07/18 at 6:20 p.m., licensed practical nurse #2 was asked if the resident had a fingerstick blood sugar test performed on 06/14/18 at bedtime or on 07/02/18 before breakfast. She stated a fingerstick blood sugar was not documented at those times. She was asked why the resident had not received fingerstick blood sugar tests per the physician's orders [REDACTED]. At 6:42 p.m. the DON was asked how she monitored the staff to ensure the residents received their insulin and had their fingerstick blood sugar test performed per orders. She stated the administrative nurses had been monitoring daily for the staff reporting blood sugars outside of parameters to the physician since the most recent survey. She was asked if the resident had a fingerstick blood sugar test performed on 06/14/18 at bedtime and on 07/02/18 before breakfast. She stated, No. She was asked if the staff had followed the physician's orders [REDACTED]. She stated, No. She was asked why the resident had not had a fingerstick blood sugar test performed per the physician's orders [REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to: ~ Implement interventions to aid in the prevention of falls for one (#7) of four sampled residents who were reviewed for falls. The facility identified 55 residents as having falls in the last three months; and ~ Ensure family members received training to assist with passing beverages in the dining room during meal services. This had the potential to affect 84 of 84 residents who ate meals in the dining room. Findings: 1. Resident #7 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 02/06/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for transfers; and had two or more falls with injury since the previous assessment. The resident's care plan, last updated 05/09/18, documented the resident was at risk for falls related to weakness, physical impairments, and cognition loss. The goal was interventions would reduce the risk for serious injury from falling through the next review day. Interventions included to be sure the call light was within reach and encourage/remind the resident to use even though the resident's memory was poor and she did not remember to use the call light; to educate caregivers about safety reminders; and provide frequent visual checks for safety and security. A physician's orders [REDACTED]. A nurse's note, dated 05/12/18 at 3:00 p.m., documented, .has experienced episodes of rambling speech, irritability, pupils reactive .recent order for [MEDICATION NAME] initiated 5/10/18, (physician name withheld) notified, (no) N.O. @ this time . A nurse's note, dated 05/12/18 at 6:35 p.m., documented, .CMA notified this nurse resident had fallen face first out of wc. Resident noted laying on stomach on floor in front of wc .raised area to middle of forehead c bruising to raised area et bruising to (right) side of forehead, small superficial abrasion to bridge of nose et forehead .(No) further visible injury noted .resident continues rambling speech et irritability .DON, PCP, et hospice notified. N.O. to dc [MEDICATION NAME] .patch removed from behind (right) ear . A nurse's note, dated 05/12/18 at 9:05 p.m., documented, .Neuro checks cont resident in wheelchair in lobby .this nurse went to answer a call light, heard noise from lobby, upon enter (sic) lobby, resident was on her (right) side, resident did get x 2 skin tears, held pressure to stop bleeding, one under (right) eye, the other on (right) side of forehead. measurements 4 cm x 2 cm, under (right) eye 1 cm x 0.5 cm. steri-strips x 6 in place to (right) side of forehead. Steri-strips x 2 in place below the (right) eye . On 05/23/18 at 8:41 a.m., the resident was observed in the west lobby. Her wheelchair was not locked, and there was no staff present in the lobby. At 8:59 a.m., 9:08 a.m., 9:13 a.m., 9:25 a.m., and 9:28 a.m., the resident was observed to lean forward from a seated position in her wheelchair. No staff was present in the lobby. On 05/23/18 at 9:32 a.m., CNAs #7 and #8 were observed transferring the resident using a mechanical lift. The resident's wheelchair was not locked. On 05/23/18 at 1:50 p.m., LPN #2 was asked if the resident was at risk for falls. She stated yes. She was asked what interventions were in place to help prevent falls. She stated the resident used a fall mat, concave mattress, and nonskid socks. She stated staff used a mechanical lift with her, and the staff was educated on fall prevention. LPN #2 was asked why the resident suffered the second fall on 05/12/18. She stated she was not really sure, and she did not know where the resident was at the time of the falls. She stated, She should not have been in a wheelchair. She stated the resident should have been in a recliner or in her bed since it was at 9:00 p.m. LPN #2 was asked why the resident was left alone since the nurse had assessed the resident might be suffering from adverse consequences of the [MEDICATION NAME]. She stated she did not know. ' LPN #2 was asked if wheelchairs should be locked when residents were in them and the chairs were not in motion. She stated, Yes. On 05/29/18 at 2:54 p.m., the DON was asked why the resident suffered the second fall on 05/12/18. She stated she could not answer that. She stated her biggest question was why the resident was still up at 9:05 p.m. The DON was asked what was going on with the resident at the time. She stated the nurse felt like the resident was having a reaction to the [MEDICATION NAME], and the resident was increasingly restless that evening. She stated the nurses had called her about the resident's condition. The DON was asked why the resident was left in the wheelchair after already having a fall and a potential reaction to the [MEDICATION NAME]. She stated she could not answer that. She was asked what she would have expected staff to do at the time. She stated staff should have assessed the resident's pain needs and assisted her to bed. She stated they should have figured out some way to do one on one with the resident. The DON was asked if the resident received injuries with the second fall. She stated the resident received two skin tears under her right eye and another on the right side of her forehead. 2. On 05/21/18, serving of the noon meal was observed. Facility staff was observed serving food and beverages. On 05/21/18 at 3:20 p.m., a family member of resident #59 stated residents sometimes sat in the dining room for up to two hours waiting to be fed. She stated it happened at all meals. She stated sometimes the residents' food was cold, and some residents left when they got tired of waiting. She stated weekends were the worst. The family member stated staff allowed herself and the family of resident #10 to help with the drinks when the surveyors were not in the building. She stated they were not allowed to help if the surveyors were there. The family member stated the aides were supposed to come from the floor to help with the serving of food and drinks. On 05/23/18 at 4:51 p.m., a family member of resident #38 told the surveyor the residents had been in the dining room since 4:15 p.m. and there was no staff available to serve meals or drinks. The family member stated some of the residents came early, but the dinner meal was supposed to be served at 4:30 p.m. She stated beverages were not being offered. She stated this happens often. She stated she and some other family member had helped get the beverages out in the past because staff was not there. She stated facility staff had told them they could not do that when State was at the facility. She was asked how she knew what fluids any specific resident needed. She stated it came from experience of being there. She stated she asked questions and sometimes there was a sign on the wall or table that indicated a resident might need thickened liquids. The family member was asked if she ever thickened any liquids for residents. She stated, Yes. She was asked how she knew how to do that. She stated she would ask a staff member, and if a staff member was not present, she would either go to the kitchen and ask or just wait. The family member was asked if there were others who assisted with the beverages. She stated other families helped too. She stated, Everybody who assists here, if they have any doubts, we would not serve. She stated the last thing they wanted to do was cause a problem for someone. On 05/24/18 at 11:47 a.m., a family member for resident #93 stated she was at the facility for meals several days per week. She was asked if she assisted the residents with getting their beverages. She stated, Yes. She stated she had got fluids from the kitchen staff and passed them, but she did not do it very often. She was asked why she passed the beverages. She stated she had become close with some of the people and she loved doing things for them. She was asked if she had received any training from the facility. She stated no. On 05/30/18 at 10:20 a.m., the dietary manager was asked if families helped to pass beverages at meal times. She stated yes. She stated she had tried to stop it, but the administrator had said they had been trained and were aware not to touch the tops of glasses, how to use the ice scoop, and to ask about the fluid requirements for any new admissions. She was asked why they were helping. She stated, They want to. The dietary manager was asked what kind of training the family members had received. She stated, That's a good question. She was asked if she had any documentation of any training the families might have received. She stated, No. I've never witnessed any training. The dietary manager was asked if there was enough staff to get the beverages out in a timely manner. She stated that 15 minutes before a service time, the drink aide and cook aide went out and started passing drinks. She stated the aides were to come from the floor, and the cook aide was to go back to the kitchen. She stated the drink aide would then start taking meal orders and the aides were to start passing drinks. She was asked when the aides were to arrive in the dining room. She stated, Whenever they are available. She stated it could range from the time the meal was supposed to start to 15 minutes after. She stated the nurses and aides were under the impression they did not have to be in the dining room until a quarter after the hour of meal service, so they lolly gag until then. On 05/30/18 at 10:36 a.m., the administrator was asked to provide documentation the family members had been trained to deliver beverages in the dining room. She stated there was none. She stated, They just kind of know from being in the dining room. She was asked why the families were delivering beverages. She stated they did it mainly to help out and they enjoyed it. She stated, There were a couple of complaints of meal services on the weekends.

Based on record review and interview, it was determined the facility failed to have an effective quality assessment and assurance (QA & A) program that identified concerns and implemented actions to correct the concerns. The facility identified 95 residents as residing in the facility. Findings: 1. Based on observation, interview, and record review, it was determined the facility failed to have sufficient staff to meet the needs of the residents. This had the potential to affect 95 of 95 residents who resided at the facility. Please refer to F-725. 2. Based on observation, interview, and record review, it was determined the facility failed to ensure five (#67, #84, #148, #149, and #150) of five sampled residents with allegations of intimidation and abuse were free from intimidation, verbal abuse, and/or physical abuse. Please refer to F-600. 3. Based on observation, interview, and record review, it was determined the facility failed to conduct thorough investigations of allegations of intimidation and abuse for four (#84, #148, #149, and #150) of five sampled residents whose allegations were reviewed. Please refer to F-610. 4. Based on observation, interview, and record review, it was determined the facility failed to provide incontinent care in a timely manner, offer fluids, and/or assist with oral care for three (#7, #31, and #94) of three residents who were reviewed for activities of daily living. Please refer to F-677. 5. Based on observation, interview, and record review, it was determined the facility failed to implement interventions to prevent falls for one (#7) of four sampled residents who were reviewed for falls and ensure family members received training to assist with passing beverages in the dining room during meal services. Please refer to F-689. 6. Based on interview and record review, it was determined the facility failed to answer call lights in a timely manner for 12 (#1, #6, #15, #27, #43, #50, #52, #55, #61, #72, #80, and #94) of 16 residents who were interviewed about call lights. The facility identified 94 residents as capable of using the call light. Please refer to F-558. On 05/30/18 at 2:16 p.m., the administrator and DON were asked if, prior to the survey, they had identified any concerns related to abuse allegations and abuse investigations. The administrator stated, No. They were asked if, prior to the survey, they had identified any concerns related to sufficient staffing and answering call lights. The administrator stated, Yes. She stated they had identified a concern with call lights being answered in a timely manner. She was asked what the results of the monitoring were. She stated the call lights were being answered more timely. She was asked when this took place. She stated it had been a resident council concern for the last two months and staff had been inserviced each time.

Based on observation, interview, and record review, it was determined the facility failed to ensure two (#94 and #95) of 24 sampled residents were treated with dignity. The facility identified 95 residents as residing at the facility. Findings: The Resident's Rights Policy, dated 11/2016, documented, . the resident has a right to a dignified existence .The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. All activities and interactions with residents by any staff .must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's, goals, preferences, and choices. When providing care and services, staff must respect each resident's individuality, as well as honor and value their input . 1. Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission assessment, dated 04/12/18, documented the resident was cognitively intact; had an indwelling urinary catheter; was totally dependent on staff for transfers; and required extensive assistance with toileting. It was documented the resident was occasionally incontinent of bowel. On 05/21/18 at 11:10 a.m., the resident was observed in her room. She did not have an indwelling urinary catheter. The resident stated the catheter had been removed. At 11:28 a.m., resident #94 was asked if she felt like there was enough staff in the facility for residents to get the care and assistance they needed without have to wait a long time. She stated she had to wait a long time for call lights to be answered. She stated she waited over an hour on the previous evening before her call light was answered. She was asked if she had an incontinent episode while waiting on the previous evening. She stated no, and she would have been really angry if she had. The resident stated she had accidents on other occasions when staff had taken too long to answer the call lights. The resident was asked if she felt like the facility treated her with respect and dignity. She stated she felt undignified when staff so long to answer call lights, causing her to have a accident in her pants. On 05/29/18 at 2:50 p.m., the DON was asked how she thought a resident would feel if they were not assisted to the bathroom in a timely manner, and it caused the resident to have an incontinent episode. She stated, Not very good. 2. Resident #95 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was severely cognitively impaired for daily decision making. A significant change assessment, dated 05/02/18, documented the resident was dependent on staff for all activity of daily living and required extensive assist with mobility. The resident's care plan, dated 05/20/18, documented a problem related to the resident's [DIAGNOSES REDACTED].identify yourself at each interaction .Face when speaking and make eye contact .reduce any distractions .understands consistent, simple, directive sentences .require approaches that maximize involvement in daily decision making and activity such as: limiting choices, use cueing .simple direct instructions. Monitor/document/report .refusal of assistance with care and combativeness . On 05/21/18 at 11:57 a.m., CNAs #4 and #7 approached the resident in the day area where she had been observed sitting in a recliner with her eyes closed. At the same time as CNA #4 stated they were there to get her up to take her to the dining room for lunch, she started to remove the resident's blanket. The resident resisted and began to holler out as she reached for her blanket and snatched it back. The resident and CNA #4 continued to struggle with the blanket while the CNA #4 continued to tell her she needed to get up and go eat lunch. The resident continued to resist care. CNA #4 stated, .I'm not going to do anything for you .I'm not going to get my eyes scratched out today . The resident was left in the recliner. The resident was not observed to have eaten lunch. On 05/30/18 at 9:10 a.m., CNA #5 was asked if she was familiar with the resident. She stated yes. She was asked if the resident had ever refused care and/or became combative. She stated not really. She stated she had in the past but not recently. She was asked if she had ever observed another staff member to treat the resident with disrespect. She stated no. On 05/30/18 at 09:15 a.m., LPN #5 was asked if she was familiar with the resident. She stated yes. She was asked if the resident ever refused care and/or became combative. She stated yes. She stated in the past when the resident would have a [DIAGNOSES REDACTED]. She was asked if she had observed that behavior in the resident recently. She state, no, but she was currently being treated with an antibiotic for a urinary tract infection. She was asked if she had ever observed another staff member to treat the resident with disrespect. She stated no, not really. LPN #5 was asked what she would do if a resident with dementia refused care. She stated she would encourage the resident to cooperate by explaining what she needed the resident to do. If the resident still refused, she would document it and depending on what care was refused, she would notify the charge nurse for the unit, DON, the physician and the family as required. She was asked if a resident should ever told they were not going to receive care because of their behavior. She stated, No, never. On 05/30/18 at 10:12 a.m., the DON was asked what she would do if she were told or observed a staff member treating a resident in a demeaning and/or disrespectful way. She stated if told, she would start an investigation, and if she observed it herself, she would go directly to them and have them come to my office. She stated depending on the situation, they might be suspended and/or let go at that time. The DON was informed of the observation on 05/21/18. She stated the employee had been terminated.