Every finding on record at Ranchwood Nursing Center

Based on record review and interview, the facility failed to ensure the physician and family were notified when a resident had a change of condition for 1 (#6) of 3 sampled residents reviewed for a change of condition which resulted in death. Resident #1 had low blood pressure of 73/47, 81/59 and a pulse of 41 without notification to the physician of the change. The MDS coordinator identified 105 residents resided in the facility.On 04/10/26, an IJ situation was determined to exist related to the facility's failure to notify the physician and family of a change in condition for Resident #6 who was reported to have a low blood pressure and pulse which resulted in death.On 04/10/26 at 11:55 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On 04/10/26 at 11:57 a.m., the administrator and DON were verbally notified of the IJ in existence and provided the IJ template via email at 12:01 p.m.On 04/13/26 at 1:14 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal read in part, Ranchwood Nursing and Rehab Plan of Removal: 04/10/2026 F580- Notification of Physician This POR is in response to the facility's alleged failure to notify the physician and family when a resident experiences a change in condition with abnormal vital signs which places all residents at risk for serious harm, serious injury, serious impairment, or death.The DON was promptly educated on the identification and monitoring of abnormal vital signs and notification of physicians and family members when abnormal vital signs are obtained, or when there is a change in condition as defined by F580 as:An accident involving the resident which results in injury and has the potential for requiring physician intervention;A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life- threatening conditions or clinical complications);A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); orA decision to transfer or discharge the resident from the facility DON was re-educated by Regional Nurse Consultant at 12:15 pm verbalized understanding and has demonstrated competency in recognition of abnormal vital signs.The DON/designee will educate licensed staff on abnormal vital signs and notification of physician for change of condition to be completed on 4/10/2026 at 11:59 pm.No licensed nursing staff will be allowed to work until education on notification of physician is given. Staff not receiving education on 4/10/2026 will receive education prior to the start of their next shift.Medical Director was contacted at 4/10/2026 at 12:55 p.m.An audit of currently recorded vital signs was completed to verify that there are no current residents with vital signs outside of normal limits or parameters provided by the physician.DON/designee will monitor abnormal vital signs as defined by the parameters provided by physicians or those congruent with standards of practice 5 times weekly during morning meeting to identify change of condition and notification of physician. Issues identified will be corrected immediately.Submitted to QAPI for review on 4/10/2026 at 1 pm.The IJ was lifted, effective 04/13/26 at 2:45 p.m., when all components of the plan of removal had been verified as completed. A review of the resident audits was conducted. In-service training regarding notification of changes was reviewed, and staff were interviewed to ensure the in-service training had been completed. The deficient practice remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy . Findings:A physician's note, dated 02/03/26, showed Resident #6 was assessed. The note showed their blood pressure was 110/66 with a pulse of 77. The note showed the physician assessed Resident #6 for dehydration and ordered one liter of intravenous normal saline (a sterile solution of sodium chloride in water often used for dehydration).A comprehensive admission assessment for Resident #6, dated 02/17/26, showed they were admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), acute kidney injury, multi-drug resistant organisms, urinary tract infection, sepsis, and diabetes mellitus.A vital sign log for Resident #6, dated 02/18/26, showed the resident's blood pressure was 73/47 and their oxygen saturation was 84% on room air. There was no documentation in Resident #6's health chart that showed the physician was notified of their change of blood pressure and oxygen saturation. There was no documentation Resident #6 had been seen by the nurse practitioner on 02/18/26.A nurse's note for Resident #6, dated 02/21/26, showed they were unable to be aroused with a blood pressure of 81/59 and a pulse of 41. Resident #6 had three plus pitting edema to both arms and cold, purple fingers. The note showed the physician was notified and ordered a 500cc bolus of normal saline for hydration. The note showed the physician stated if no improvement to send Resident #6 to the emergency room.A vital sign log for Resident #6, dated 02/22/26, showed the resident's pulse was 48. There was no documentation Resident #6 had been seen by the nurse practitioner on 02/22/26.There was no documentation in Resident #6's health chart that showed the physician was notified of their abnormal pulse.A nurse's note for Resident #6, dated 02/23/26, showed the resident was found unresponsive with a pulse of 28 and was sent to the emergency room.An emergency room physician's note for Resident #6, dated 02/23/26, showed the resident had a blood pressure of 71/44, a temperature of 88.2 degrees Fahrenheit, and was ill-appearing. The note showed Resident #6 had a blood glucose level of less than 20. The note showed Resident #6 was verbally and physically unresponsive, critically ill with low blood pressure, and had a high likelihood of death. An e-mail sent by RN #1 as a late entry nurse's note, dated 04/03/26, showed Resident #6 returned to the facility while actively dying. The e-mail showed Resident #6 passed away on 02/24/26 at 5:30 a.m.A Certificate of Death for Resident #6, dated 03/26/26, showed the resident's cause of death was protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure. The Certificate of Death showed a significant condition contributing to Resident #6's death was diabetes mellitus. A policy titled Change of Condition, dated 02/13/23, read in part, Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in a patient's condition or health status.On 04/09/26 at 11:02 a.m., Resident #6's family member stated there had been no communication from the facility regarding Resident #6's physical condition. Resident #6's family member stated on 02/23/26, the emergency room notified them of Resident #6's condition. The family member stated Resident #6 was actively dying, so they approved transfer back to the facility to pass away.On 04/09/26 at 11:51 a.m., LPN #1 stated they would notify the nurse practitioner or physician of a resident's pulse that was less than 60. LPN #1 stated on 02/22/26, they notified the nurse practitioner of Resident #6's low pulse of 48 and documented the pulse rate in Resident #6's health chart. LPN #1 was asked to show the documentation of notification, and they stated they could not find it. LPN #1 stated they did not notify the family of Resident #6's low pulse.On 04/09/26 at 12:51 p.m., the ADON stated they would report a blood pressure less than 110/60 and an oxygen saturation less than 90% to the physician or nurse practitioner. The ADON stated they notified the nurse practitioner for Resident #6's blood pressure of 73/47 and oxygen saturation of 84% on 02/18/26. The ADON stated they could not recall if they spoke with them or left a message and did not recall any orders given by the nurse practitioner. The ADON stated they usually documented notifications in the residents' health chart, but could not remember if they documented the notification on 02/18/26.On 04/10/26 at 10:28 a.m., the nurse practitioner stated they did not recall notification of abnormally low vital signs regarding Resident #6 on 02/18/26 or 02/22/26. The nurse practitioner stated the only notification of change they had received were on the days Resident #6 was seen in person by them.

Based on record review and interview, the facility failed to promptly assess, identify, and intervene when a resident experienced an acute emergent change in condition for 1 (#6) of 3 sampled residents reviewed for changes in conditions when facility staff failed to notify the medical provider of critical emergent vital signs/symptoms and identify hypoglycemia on a resident with known history of diabetes and known recent history and hospitalizations for hypoglycemia resulting in transfer to the acute care hospital and subsequent death.Specifically, the facility failed to:a. Identify, monitor, intervene, and provide continuing assessments for Resident #6 who was admitted with a known history of diabetes and hypoglycemia experiencing signs and symptoms of hypoglycemia.b. Notify the medical provider of, or intervene, for Resident #6's critically abnormal vital signs of a blood pressure of 73/47 and an oxygenation of 84% on [DATE], andc. Notify the medical provider of, or intervene, for Resident #6's critically abnormal vital signs/symptoms of a blood pressure of 81/59, pulse of 41, and unresponsive status on [DATE].These failures led to Resident #6 transferring to the acute care hospital on [DATE] where they were identified to have a blood pressure of 71/44, temperature of 88.2 degrees Fahrenheit, blood glucose of 20, and described as ill-appearing with a high likelihood of death. The resident was identified as actively dying and returned to the facility where they ultimately expired on [DATE].The MDS coordinator identified four residents required monitoring for diabetes type 2 mellitus resided in the facility.On [DATE], OSDH was contacted and confirmed an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to adequately monitor finger stick blood sugars and intervene for Resident #6 who had a diagnosis of diabetes mellitus type 2 and was found unresponsive with hypoglycemia.On [DATE] at 11:55 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On [DATE] at 1:14 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Ranchwood Nursing and Rehab Plan of Removal: [DATE] F684- Monitor Blood glucose The facility's alleged failure to monitor and intervene for a resident who had a diagnosis of diabetes mellitus type 2 places all diabetic residents at risk for serious harm, serious injury, serious impairment, or death.An audit was completed of all residents with diabetes and oral agents to ensure monitoring of hypoglycemia signs and symptoms. Orders in place. Completed on [DATE]DON was promptly educated by Regional Nurse Consultant at 12:15 pm on [DATE] on monitoring for signs and symptoms of diabetes mellitus type 2, appropriate notifications and protocols to intervene. DON verbalized understanding and demonstrated competency.The DON/designee will educate licensed staff on recognizing signs and symptoms of hypoglycemia and protocol to intervene.All residents identified as receiving oral medication for the treatment of hypoglycemia had their blood sugar checked by 11:59 pm on [DATE].Medical Director was contacted at [DATE] at 12:55pm.No licensed nursing staff will be allowed to work until education on hypoglycemic protocol is given. Staff not receiving education on [DATE] will receive education prior to the start of their next shift.DON/designee will monitor clinical records 5 times weekly for changes related to potential hypoglycemia and follow up completedSubmitted to QAPI for review on [DATE] at 1:00 pm.b. intervene for Resident #6 who had low blood pressure, pulse, and oxygen readings with a diagnosis of acute kidney injury and was found unresponsive.On [DATE] at 11:57 a.m., the administrator and DON were verbally notified of the IJ in existence and provided the IJ template via email at 12:01 p.m.On [DATE] at 1:14 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Ranchwood Nursing and Rehab Plan of Removal: [DATE] F684- Change of Condition The facility's alleged failure to monitor and intervene when a resident experiences a change in condition with abnormal vital signs which places all residents at risk for serious harm, serious injury, serious impairment, or death.DON was promptly educated on the identification and monitoring of abnormal vital signs and notification of physicians and family members when abnormal vital signs are obtained, or when there is a change in condition as defined by F580 as:An accident involving the resident which results in injury and has the potential for requiring physician intervention:A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life- threatening conditions or clinical complications);A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); orA decision to transfer or discharge the resident from the facility DON was re-educated by Regional Nurse Consultant at 12:15 pm verbalized understanding and has demonstrated competency in recognition of abnormal vital signs.The DON/designee will educate licensed staff on abnormal vital signs and notification of physician for change of condition, to by [sic] completed by [DATE] 11:59 pm.No licensed nursing staff will be allowed to work until education on hypoglycemic protocol is given. Staff not receiving education on [DATE] will receive education prior to the start of their next shift.All vital signs were reviewed for abnormal results by 11:59 pm on [DATE].Medical Director was contacted at [DATE] at 12:55pm.DON/designee will monitor abnormal vital signs 5 times weekly during morning meeting to identify changes in condition and notification of physician and family. Issues identified will be corrected immediately.Submitted to QAPI for review on [DATE] at 1:00 pm.The IJs were lifted, effective [DATE] at 2:45 p.m., when all components of the plans of removal had been verified as completed. A review of the resident audits was conducted. In-service training regarding notification of changes was reviewed, and staff were interviewed to ensure the in-service training had been completed. The deficient practice remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. Findings:An undated vital sign log showed no finger stick blood sugar monitoring for Resident #6 from [DATE] through [DATE].Medication administration records for Resident #6, dated January and February 2026, showed the resident had taken Metformin (a blood sugar lowering medication) 500mg twice daily and glimepiride (a blood sugar lowering medication) 1mg once daily. The medication administration records showed the resident was prescribed Glutose (a low blood sugar antidote) 15gm gel by mouth and glucagon (a low blood sugar antidote) 1mg emergency kit injected, both as needed as blood sugar check required. There were no parameters on the order to indicate what level of blood sugar would require administration of Glutose or glucagon.A hospital physician's note for Resident #6, dated [DATE], showed the resident had been hypoglycemic (low blood sugar) with a finger stick blood sugar of 36 upon arrival to the emergency room.A care plan for Resident #6, dated [DATE], showed no interventions for acute kidney injury or diabetes mellitus type 2.A physician's note for Resident #6, dated [DATE], showed the resident was assessed. The note showed their blood pressure was 110/66 with a pulse of 77. The note showed the physician assessed the resident for dehydration and ordered one liter of intravenous normal saline (a sterile solution of sodium chloride in water commonly used for dehydration).A hospital discharge summary for Resident #6, dated [DATE], showed the resident had been hospitalized from [DATE] to [DATE] for hypoglycemia.A comprehensive admission assessment for Resident #6, dated [DATE], showed the resident was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, hypertension, and acute kidney injury.A vital sign log for Resident #6, dated [DATE], showed the resident's blood pressure was 73/47 and their oxygen saturation was 84% on room air. There was no documentation in Resident #6's health chart that showed any intervention for their change of blood pressure and oxygen saturation.A nurse's note for Resident #6, dated [DATE], showed the resident was unable to be aroused with a blood pressure of 81/59 and a pulse of 41. Resident #6 had three plus pitting edema (a moderate-to-severe fluid buildup in tissues) to both arms and cold, purple fingers. The note showed the physician was notified and ordered a 500cc bolus of normal saline for hydration. The note showed the physician stated if no improvement to send Resident #6 to the emergency room.A vital sign log for Resident #6, dated [DATE], showed the resident's pulse was 48.There was no documentation in Resident #6's health chart that showed the physician was notified of their abnormal pulse.A nurse's note for Resident #6, dated [DATE], showed the resident was found unresponsive with a pulse of 28 and was sent to the emergency room.An emergency room physician's note for Resident #6, dated [DATE], showed the resident had a blood pressure of 71/44, a temperature of 88.2 degrees Fahrenheit, and was ill-appearing. The note showed the resident had a blood glucose level of less than 20. The physician's note showed Resident #6 was verbally and physically unresponsive, critically ill with low blood pressure, and had a high likelihood of death. A Certificate of Death, for Resident #6, dated [DATE], showed the resident's cause of death was protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure. The cause of death showed significant conditions contributing to Resident #6's death was shown as diabetes mellitus.An e-mail sent by RN #1 to the DON, dated [DATE], showed Resident #6 returned to the facility from the emergency room on [DATE], while actively dying. The e-mail showed Resident #6 passed away on [DATE] at 5:30 a.m.A policy titled Change of Condition, dated [DATE], read in part, The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room. Care-giving staff should describe and document the nature, extent, and severity of symptoms, abnormalities, and condition changes clearly and in sufficient detail to help practitioners distinguish their potential causes and consequences. Document in the medical record the date, time, and name of each physician notified, actions taken, and/or patient's response to treatment. Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in a patient's condition or health status. An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death.On [DATE] at 11:51 a.m., LPN #1 stated they would notify the nurse practitioner or physician of a resident's pulse that was less than 60. LPN #1 stated on [DATE] they notified the nurse practitioner of Resident #6's low pulse of 48 and documented the notification in Resident #6's health chart. LPN #1 was asked to show the documentation of notification, and they stated they could not find it. LPN #1 stated they did not notify the family of Resident #6's low pulse. LPN #1 stated they did not remember monitoring Resident #6's finger stick blood sugar.On [DATE] at 12:51 p.m., the ADON stated they would report a blood pressure less than 110/60 and an oxygen saturation less than 90% to the physician or nurse practitioner. They stated they notified the nurse practitioner for Resident #6's blood pressure of 73/47 and oxygen saturation of 84% on [DATE]. The ADON stated they could not recall if they spoke with the nurse practitioner or left a message and did not recall any orders given by the nurse practitioner. The ADON stated they usually documented notifications in the residents' health chart, but could not remember if they documented the notification on [DATE]. The ADON stated they were unaware of any orders to monitor Resident #6's finger stick blood sugar.On [DATE] at 1:20 p.m., the DON stated there were no physician orders to monitor Resident #6's finger stick blood sugar, but monitoring should have been done since they were diabetic. The DON stated that laboratory orders for kidney monitoring were on an as needed basis. They stated the nurses should have contacting the nurse practitioner to verify when the laboratory tests were needed.On [DATE] at 10:28 a.m., the nurse practitioner stated they did not recall notification of abnormally low vital signs regarding Resident #6 on [DATE] or [DATE]. They stated the only notification of change they had received were on days Resident #6 was seen in person by the nurse practitioner. The nurse practitioner stated they expected the facility to monitor Resident #6's finger stick blood sugar given hospitalizations for hypoglycemia and diagnosis of diabetes mellitus type 2. The nurse practitioner stated the nurses were expected to notify them of blood pressure changes for laboratory tests to be performed.

Based on record review and interview, the facility failed to develop a care plan:a. for a resident who had a diagnosis of diabetes mellitus type 2 and acute kidney injury for 1 (#6) of 3 sampled residents reviewed for care plans. Resident #1 had no care plan for glucose levels and showed the resident's cause of death was protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure. The Certificate of Death showed a significant condition contributing to Resident #6's death was diabetes mellitus.b.to include interventions for weight loss for 1 (#1) of 3 sampled residents reviewed for weight loss.The MDS coordinator identified 105 residents resided in the facility.Findings: 1. A facility policy titled Care Plan Process, dated 03/27/23, read in part, The plan of care identifies the date, problem, goals, measurable and realistic, time frames for achievement, interventions, discipline specific services, resolution/goal analysis, and [sic] discharge option.A care plan for Resident #6, dated 01/22/26, did not identify acute kidney injury or diabetes mellitus type 2 as diagnoses. A comprehensive admission assessment for Resident #6, dated 02/17/26, showed the resident was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2 and acute kidney injury.A nurse's note for Resident #6, dated 02/23/26, showed the resident was found unresponsive with a pulse of 28 and was sent to the emergency room.An emergency room physician's note for Resident #6, dated 02/23/26, showed the resident had a blood pressure of 71/44, a temperature of 88.2 degrees Fahrenheit, and was ill-appearing. The note showed Resident #6 had a blood glucose level of less than 20. The physician's note showed Resident #6 was verbally and physically unresponsive, critically ill with low blood pressure, and had a high likelihood of death. A Certificate of Death, for Resident #6 dated 03/26/26, showed the resident's cause of death was protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure. The Certificate of Death showed a significant condition contributing to Resident #6's death was diabetes mellitus.On 04/10/26 at 8:36 a.m., the DON stated Resident #6 should have had a care plan for monitoring their kidney injury and failure and diabetes mellitus type 2.2. A Nutrition Therapy Assessment for Resident #1, dated 03/25/26, showed recommended interventions of encourage fluid intake with meals and snacks, frozen nutrition treat, and weekly weights.A Physician Order for Resident #1, dated 03/25/26, showed weekly weights on day shift times four weeks or until stable.An undated care plan for Resident #1 did not show the recommended interventions.An undated weight report for Resident #1 showed the resident had a weight loss of 7.7 pounds or 8.5% in 6 months from 10/2025 to 04/2026.A quarterly assessment for Resident #1, dated 01/29/26, showed their BIMS was a 3 indicating severe cognitive impairment and a diagnosis of severe protein calorie malnutrition. On 04/08/26 at 11:04 a.m., the MDS coordinator stated they updated the care plans when a 10% change in weight loss or gain occurred. The MDS coordinator stated the interventions were not updated on Resident #1's care plan.On 04/08/26 at 11:25 p.m., the MDS coordinator stated the interventions shown on the nutrition therapy assessment were appropriate and should have been on the care plan. On 04/08/26 at 11:35 p.m., the DON stated their expectations for updating the care plans would ideally be within 24 hours. They stated the interventions should have been updated on the plan of care.

Based on record review and interview, the facility failed to provide sufficient staff to ensure the highest practicable well-being of each resident. The director of nurses reported 98 residents resided in the facility.The Quality of Care Monthly Report dated December 2025 showed 3 days with insufficient direct care staff for the reported resident census.The Quality of Care Monthly Report dated January 2026 showed 5 days with insufficient direct care staff for the reported resident census.The Quality of Care Monthly Report dated February 2026 showed 1 day with insufficient direct care staff for the reported resident census.A Bath List provided by the facility showed Res. #1 in room [ROOM NUMBER]A was to have baths on Monday and Thursday every week. Facility provided Bath Sheet documents showed Resident #1 had baths on 03/05/26, 03/19/26, and 03/24/26. A Bath List provided by the facility showed Res. #8 in room [ROOM NUMBER]B was to have baths every Tuesday, Thursday and Saturday. Facility provided Bath Sheet documents showed Resident #8 had baths on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A Bath List provided by the facility showed Res. #9 in room [ROOM NUMBER]B was to have baths on Wednesday and Saturday every week. Facility provided Bath Sheet documents showed Resident #9 had a complete bed bath on 01/16/26 and 01/21/26, and had a shower on 03/05/26. On 03/25/26 at 8:45 a.m., CNA #1 stated the residents do not get incontinent care, baths or showers as often as they needed due to staffing. CNA #1 stated they will leave them for the next shift but often they are short staff so they never get done. On 03/25//26 at 10:20 a.m., CNA #2 stated they were short staffed at times and do not have enough people to help with residents that require more than one person transfer. CNA #2 stated residents that require more assistance often do not get baths or showers. On 03/25/26 at 3:10 p.m., the DON stated they did not have additional bath sheets. The DON stated they do not have a good process for bath or shower sheet completion and feels like more have been done than turned in. The DON stated they were not sure how many baths were actually getting done.

Based on record review and interview, the facility failed to ensure medication was available for administration as ordered for 1 (#1) of 3 sampled residents reviewed for medication administration. The administrator identified 105 residents resided in the facility. Findings:A policy titled Medication Administration, dated 01/2024, read in part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices.A physician order for Resident #1, dated 02/17/25, showed the resident was to receive divalproex (anticonvulsant) 125 mg one tablet by mouth every 12 hours for unspecified dementia.A physician order for Resident #1, dated 06/04/25, showed the resident was to receive levothyroxine (thyroid hormone) 150 micrograms one tablet by mouth at early morning time for hypothyroidism. A 02/2026 MAR for Resident #1 showed:a. levothyroxine was held on 02/07/26 at 6:00 a.m., due to being unavailable,b. levothyroxine was held on 02/08/26 at 6:00 a.m., due to being unavailable,c. levothyroxine was held on 02/12/26 at 6:00 a.m., due to no documentation,d. levothyroxine was held on 02/14/26 at 6:00 a.m., due to being unavailable,e. levothyroxine was held on 02/15/26 at 6:00 a.m., due to being unavailable,f. levothyroxine was held on 02/16/26 at 6:00 a.m., due to being unavailable,g. divalproex was held on 02/15/26 at 9:00 a.m., due to being unavailable, andh. divalproex was held on 02/16/26 at 9:00 a.m., due to being unavailable.On 03/05/26 at 10:11 a.m., CMA #2 stated the process to ensure medications were available was to order medications daily. They stated typically they should order when down to five days or less, and if the medication was not in the building to call the pharmacy and let the nurse know. CMA #2 stated when a medication was not available, they left the medication up on the MAR and would notify the nurse, pharmacy, and then the DON. On 03/05/26 at 10:22 a.m., the DON and regional consultant stated medications should be ordered when down to a seven-day supply and if was not available they were to notify the physician and DON and order STAT from pharmacy. On 03/05/26 at 2:31 p.m., CMA #1 stated H on the MAR indicated hold. Upon review of the MAR for 02/2026 for Resident #1, CMA #1 stated the following:a. levothyroxine was held on 02/07/26 at 6:00 a.m., due to being unavailable,b. levothyroxine was held on 02/08/26 at 6:00 a.m., due to being unavailable,c. levothyroxine was held on 02/12/26 at 6:00 a.m., due to no documentation,d. levothyroxine was held on 02/14/26 at 6:00 a.m., due to being unavailable,e. levothyroxine was held on 02/15/26 at 6:00 a.m., due to being unavailable,f. levothyroxine was held on 02/16/26 at 6:00 a.m., due to being unavailable,g. divalproex was held on 02/15/26 at 9:00 a.m., due to being unavailable, andh. divalproex was held on 02/16/26 at 9:00 a.m., due to being unavailable.CMA #1 stated the medications were not in the building since it was unavailable and needed to be ordered STAT.

Based on observation, record review, and interview, the facility failed to ensure the hall 8 computer on top of the treatment cart was locked and secured to prevent the exposure of resident medical records for 1 of 1 treatment cart observed. The administrator identified 105 residents resided in the facility. Findings:On 03/04/26 at 12:26 p.m., LPN #1 was observed on hall 8 to leave the treatment cart and go inside of a room. The treatment cart had a laptop computer on top that was unlocked with the screen exposed, showing medical records from the electronic medical record. The treatment cart and computer were positioned in front of the room slightly sideways near the wall with the front of the computer screen facing the hallway. On 03/04/26 at 12:27 p.m., an unknown resident was observed to walk up to the cart, face the computer, and talk to LPN #1 from the door, while LPN #1 was inside the room. A policy titled Medication Administration, dated 01/2024, read in part, Resident's health information needs to remain private. The pages of the MAR notebook containing resident health information must remain closed or covered when not in direct use. On 03/04/26 at 12:29 p.m., LPN #1 stated they did not think it was a big deal since they came right back. LPN #1 stated they were not sure how to lock the computer screen.On 03/04/26 at 2:32 p.m., the regional consultant and the DON stated the policy and procedure for securing computers was to minimize the screen or close it when not actively used by staff.

Based on observation, record review, and interview, the facility failed to ensure timely incontinent care was provided for 1 (#3) of 2 sampleds resident observed for incontinent care.The administrator identified 105 residents resided in the facility. Findings:On 03/04/26 at 1:50 p.m., there was a strong odor of urine and an overly urine saturated brief in the trash can observed in Resident #3's room. On 03/04/26 at 1:58 p.m., Resident #3's family member was observed to remove the blanket, sheet, and cloth pad and place on the floor. The bed was observed to have a wet ring in the center of the mattress. A policy titled Perineal Care, dated 04/10/23, read in part, Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection. Dispose of gloves and used supplies and perform hand hygiene. Apply new gloves and place new brief and change linens as needed.A resident admission assessment for Resident #3, dated 02/11/26, showed the resident was cognitively intact with a brief score for mental illness of 14. The assessment showed the resident required partial/moderate assistance with toileting and was dependent for bed mobility. The assessment showed Resident #3 was occasionally incontinent of bladder.On 03/04/26 at 1:52 p.m., Resident #3 stated they were not soiled.On 03/04/26 at 2:00 p.m., Resident #3 stated the staff had gotten them up out of bed just before lunch. On 03/04/26 at 2:03 p.m., CNA #1 stated Resident #3 was in bed when they got to their room around 1:00 p.m. or earlier to get the resident out of bed. They stated when they got the resident out of bed for therapy, they were wet. CNA #1 stated they changed their clothes. CNA #1 verified the sheet on the bed was wet and the linen and pad on the floor was wet. On 03/04/26 at 2:05 p.m., CNA #1 stated they did not make the bed after getting Resident #3 up. On 03/04/26 at 2:09 p.m., the DON stated the process for getting incontinent residents up was for staff to check if the resident was clean and dry and to clean if not and to check every two hours at minimum. The DON stated linens were to be changed as needed when soiled, upon request, and at minimum twice weekly. The DON stated the expectation for when a bed was wet was for the staff to change the bed and resident, for both to be clean and dry.On 03/04/26 at 2:12 p.m., the DON verified they observed the wet linen and the wet ring on Resident #3's bed.

Based on observation, record review, and interview, the facility failed to ensure the treatment cart for hall 8 was secure when staff were not in attendance for 1 of 1 treatment cart observed. The administrator identified 105 residents resided in the facility. Findings:On 03/04/26 at 12:26 p.m., LPN #1 was observed on hall 8 to leave the treatment cart and go inside of a room. The treatment cart was not locked. The treatment cart was positioned in front of the room slightly sideways near the wall with the front of the cart facing the hallway. On 03/04/26 at 12:27 p.m., an unknown resident was observed to walk up to the front of the treatment cart and talk to LPN #1 from the door, while LPN #1 was inside the room. A policy titled Medication Administration, dated 01/2024, read in part, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse.The cart must be clearly visible to the personnel administering medications when unlocked.On 03/04/26 at 12:29 p.m., LPN #1 stated they did not think it was a big deal since they came right back. On 03/04/26 at 2:32 p.m., the regional consultant and the DON stated the policy and procedure for treatment/medication cart storage, was anytime not in attendance of the cart they were to be locked.

Based on observation, record review, and interview, the facility failed to ensure hand hygiene practices were maintained during the provision of perineal care for 1 (#4) of 2 sampled residents observed for incontinent care. The administrator identified 105 residents resided in the facility. Findings:On 03/04/26 at 11:18 a.m., CNA # 2 was observed to begin incontinent care on Resident #4. CNA #2 obtained wipes, performed perineal care to the front, then turned the resident onto their side. Resident #4 had a bowel movement. On 03/04/26 at 11:21 a.m., CNA #2 was observed to wipe the stool off of Resident #4 with a wipe. CNA #2 was observed to wipe stool that was on their left gloved hand onto the pad under the resident. CNA #2 placed a clean brief under Resident #4 and proceeded to touch the wipes package and place them on the resident's table, turned the resident back over, touched the resident, the wipes package, and cleaning solution with the same gloves. CNA #2 did not change their gloves. On 03/04/26 at 11:22 a.m., CNA #2 was observed to fasten Resident #4's clean brief, remove the soiled pad, and place it at the foot of the bed. CNA #2 put clean pants on Resident #4. CNA #2 did not change gloves. On 03/04/26 at 11:24 a.m., CNA #2 was observed to touch Resident #4's covers and draw sheet with the same gloved hands.On 03/04/26 at 11:25 a.m., CNA #2 was observed to remove their gloves, took the trash, and left the room. CNA #2 did not sanitize their hands after removing the gloves or before grabbing the trash. There was no observation the CNA #2 performed hand hygiene. A policy titled Perineal Care, dated 04/22/24, read in part, Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection.Remove feces present.Dispose of gloves and used supplies and perform hand hygiene. Apply new gloves and place new brief and change linens as needed. A 5-day resident assessment for Resident #4, dated 12/26/25, showed the resident was dependent for toileting and bed mobility. The assessment showed Resident #4 was frequently incontinent of bowel and bladder and had active diagnosis of urinary tract infection and septicemia (infection in the blood).On 03/04/26 at 12:30 p.m., CNA #2 stated gloves were to be changed after cleaning stool and after completed with incontinent care. CNA #2 stated they did not think they changed their gloves because they were nervous.

On 09/16/25 at 2:02 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation related to the facility's failure to assess and identify a wound for Resident #128. This likely resulted in an infected diabetic foot ulcer which caused the resident to be admitted to the hospital and resulted in a right below-knee amputation.On 09/16/25 at 2:15 p.m., regional director was notified of the IJ and provided the IJ template.On 09/17/25 at 8:25 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Plan Of Removal 09/16/2025:What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not occur. Resident #128 was discharged . Skin assessment for current residents in house will be completed by 09/16/25 at 11:59 p.m. Weekly skin assessments will be documented in the TAR. DON/designee will provide education to all clinical staff on completion of weekly skin assessments and on the addition of skin assessments to the TAR by 11:59 p.m.Involvement of Medical Director. The Medical Director has been notified of IJ status on 09/16/25.Involvement of QA. An Ad Hoc QAPI meeting was held on 09/16/25 with the Medical Director, Facility Administrator, and Director of Nursing to review the plan of removal. Director of Nursing will track, trend, and analyze audit results and forward results of audits monthly to QAPI Committee for review and/or action.Who is responsible for the implementation of the process? The Administrator/designee will be responsible for the implementation of the new process. The new process/system will be started on 09/16/25 and no licensed staff will be able to return to work until they complete the above stated education.A review of skin assessments, dated 09/16/25, showed all residents in the facility had a head-to-toe skin assessment performed.A review of in-services provided for staff on 09/16/25 and 09/17/25, showed staff were educated on documentation, identification, and notification of wounds.On 09/17/25 after interviews with facility staff, review of skin assessments, and review of in-services, the immediacy was lifted, effective 09/17/25 at 8:34 a.m., when the remainder of staff received in-service training. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to assess and identify a new wound to prevent hospitalization for an infected diabetic ulcer for 1 (#128) of 5 sampled residents reviewed for wounds. The infected diabetic ulcer led to the resident having a right below-knee amputation.The DON identified 109 residents resided in the facility.Findings: A Skin Data Collection policy, dated 07/01/18, showed a licensed nurse would collect data during weekly skin evaluations. A quarterly assessment, dated 05/06/25, showed Resident #128's cognition was intact with a BIMS score of 15. The assessment showed diagnoses of diabetes mellitus and renal failure. The assessment showed no pressure ulcers or skin issues and the resident required supervision for activities of daily living. A skin assessment, dated 06/24/25, showed Resident #128 had no skin issues. An interdisciplinary progress note, dated 07/07/25, showed Resident #128 was observed to be drowsy, with a persistent desire to lie down and sleep. The note showed due to the resident's altered mental status and inability to engage coherently; the resident was transported to the hospital. An emergency room note, dated 07/07/25, showed Resident #128 presented from the nursing home for evaluation of increased confusion. The note showed on arrival the resident was mildly hypotensive but responded well to IV fluids. The note showed there was concern for a possible infected right foot diabetic ulcer. The note showed the resident was admitted to the hospital for further management with podiatry consultation. An emergency room note, dated 07/07/25, showed final diagnoses of altered mental status, sepsis, diabetic foot ulcer, and hypoglycemia for Resident #128. The note showed the plan to be admitted to the hospital. A wound culture report, dated 07/12/25, showed culture collected from the right foot ulcer on 07/08/25 and resulted in growth of methicillin-resistant Staphylococcus aureus. A hospital physician's note, dated 07/13/25, showed a diabetic ulcer on the right plantar was first assessed 07/07/25. A hospital discharge note, dated 07/15/25, showed an assessment and plan for a diabetic foot ulcer to include wound care, patient to remain completely touch down weight bearing to right lower extremity per podiatry, and vancomycin (IV antibiotics) with dialysis on Monday, Wednesday, and Friday through 09/02/25 and flagyl (antifungal) through 08/19/25. A physician's order, dated 07/15/25, showed to: Cleanse right plantar foot with soap and water, normal saline or wound cleanser. Pat dry. Pack wound with Dakins soaked gauze. Cover with dry gauze. Wrap with kerlix and secure with tape. Wrap with Ace bandage. Perform daily on day shift and as needed. An admission skin assessment, dated 07/16/25 at 8:04 a.m., showed the Resident #128 had a skin issue of dry skin. The skin assessment showed no diabetic ulcer to the resident's right foot. A progress note, dated 07/17/25 at 4:00 a.m., showed a head-to-toe assessment of a dry dressing to the right foot. A treatment record, dated 07/15/25 through 07/21/25, showed daily wound care to the resident's right plantar foot was not performed on 07/15/25 and 07/21/25 due to resident being in the hospital. The record showed the daily wound care was not performed on 07/16/25 and 07/18/25 due to the resident had been out to dialysis. A progress note, dated 07/21/25 at 10:20 a.m., showed the resident was confused and unable to appropriately answer questions. The note showed Resident' #128's fingerstick blood sugar was 57. The resident was sent to the emergency room for evaluation and treatment. An emergency room note, dated 07/21/25, showed the Resident #128's family stated the right diabetic foot ulcer was worsening and they were unsure if the nursing home was performing wound care as prescribed. The note showed the family stated the resident had become increasingly confused for the past couple of days, prompting the nursing home to send the resident to the hospital for further evaluation. The emergency room note, dated 07/21/25, showed the resident's right plantar diabetic ulcer appeared grossly infected. The note showed to cefepime (antibiotic) was added to the IV vancomycin (antibiotic) and flagyl (antifungal) due to worsening infection. The note showed wound care team consulted and the resident was admitted to the hospital for further evaluation. A podiatric surgery consultation, dated 07/21/25, showed ulceration #1 right plantar measurements 1.5 cm x 1.5 cm x 0.9 cm. The note showed debridement performed at bedside with wound measurements post debridement of 4.5 cm x 1.6 cm x 1.1 cm. A vascular surgery consultation, dated 07/26/25, showed a non-healing right foot wound and the resident will need either a below the knee or above-the-knee amputation. A postoperative note, dated 07/29/25, showed a right below-knee amputation procedure. On 09/15/25 at 1:35 p.m., the resident's family member stated the resident was taken to the emergency room on [DATE] when a wound was found on the resident's right foot. The family member stated the wound was so deep the bone was almost visible, and the wound was not found until that day in the emergency room. The family member stated the resident was treated for a wound infection in the hospital for several days and then sent back to the nursing home. The family member stated the resident was sent back to the nursing home for less than a week before having to be readmitted to the hospital. The family member stated the last hospital admission resulted in an amputation of the right foot, then the resident was admitted to a hospice house until their passing on 08/06/25. The family member stated a nurse at the nursing home was not taking adequate care of the resident's wound. The family member stated they had called the nursing home and were told an investigation had been conducted related to the resident's wound and changes had been made and staff had been terminated. On 09/15/25 at 2:15 p.m., the regional director stated there were no incident reports related to this resident other than a fall that did not require a state report. On 09/15/25 at 2:57 p.m., the DON reported the issues with skin assessments not being completed accurately had been addressed and the employee had been terminated. The DON reported the resident's wound to the right foot was not documented before the emergency room visit on 07/07/25. The DON reported the resident's last skin assessment before 07/07/25 was completed on 06/24/25. On 09/16/25 at 3:04 p.m., the DON reported the charge nurses were supposed to conduct weekly skin assessments on all residents. The DON reported they were working on a process to ensure skin assessments were conducted every week.

Based on record review and interview, the facility failed to ensure a discharge summary was completed for 1 (#129) of 5 sampled residents reviewed for discharge from the facility. The administrator identified 109 residents resided in the facility.Findings: A quarterly assessment, dated 01/01/25, documented Resident #129 had diagnoses which included paraplegia and anxiety. The assessment showed the resident had a BIMS of 15, which indicated the resident was cognitively intact. The assessment showed the resident was independent with eating and personal hygiene. A social services discharge note, dated 03/21/25, documented resident #129 was discharged from the facility. There was no discharge summary located in the resident's medical record. On 09/17/25 at 10:12 a.m., the corporate nurse consultant reported a discharge summary was not completed for Resident #129.

Based on observation, record review, and interview, the facility failed to accurately assess a resident for smoking safety/privileges for 1 (#32) of 2 sampled residents reviewed for smoking assessments. The administrator identified 15 residents who smoked. Findings: On 09/09/25 at 9:45 a.m., Resident #32 was observed in their room lying in bed. An unidentified staff member was asked by the surveyor to verify if Resident #32 was in the second bed by the window. The staff member stated, yes, and upon looking in on the resident, stated to the resident, you know the drill, give it to me. The resident was observed to hand the staff member their vape, which was held in the resident's hand under their blanket. The staff member reported the resident's smoking/vaping privileges were suspended at one time and staff were supposed to keep the resident's smoking supplies. The staff member stated the resident's family continued to bring the resident vapes and they had several stored in a large baggie, locked in the medication cart. On 09/11/25 at 1:42 p.m., Resident #32 was observed outside in the smoking area/patio with other residents. The resident was observed to be smoking a cigarette independently. A Resident Smoking policy, dated 08/01/22, showed residents who wished to smoke would be evaluated for their ability to safely do so. The policy showed the care plan would be updated quarterly and as necessary to document changes in the resident's smoking status. A quarterly assessment for Resident #32, dated 06/16/25, showed the resident has a BIMS of 15, which indicated the resident was cognitively intact. The assessment showed the resident required substantial to maximal assistance with activities of daily living and ate independently. A care plan for Resident #32, dated 07/02/25, showed the resident tried to keep their vape and other smoking supplies in their pockets or hidden in their chair. The care plan showed the resident accused staff of harassment and theft when they removed smoking supplies from the resident's possession. A physician order, dated 07/12/25, showed Resident #32 would have their smoking privileges suspended due to non-compliance of smoking policies and procedures. The physician order documented a diagnosis of psychosis. A smoking assessment for Resident #32, dated 09/08/25, showed the resident may smoke unsupervised in designated smoking areas and must request smoking materials from staff. On 09/10/25 at 10:15 a.m., the corporate director was asked if there was a smoking assessment for Resident #32 prior to 09/08/25. The corporate director stated they would check. No further assessment prior to 09/08/25 was provided. On 09/11/25 at 1:45 p.m., the ADON was asked about the physician order of 07/12/25, which showed smoking privileges were suspended. The ADON stated they thought the order was written just prior to the resident going out for a psych eval and that may have been part of the reason the resident was sent out. The ADON was asked about the smoking assessment completed on 09/08/25, and if the order should have been changed or discontinued. The ADON stated they did not know and would check with the DON. On 09/11/25 at 3:13 p.m., the DON reported the physician order which suspended Resident #32's smoking privileges was correct and still active. The DON reported the smoking assessment was not correct, as the resident should not be smoking or have any smoking privileges at all, due to not following facility policies.

Based on record review, and interview, the facility failed to develop and implement a comprehensive care plan for a. anxiety disorder for 1 (#70) of 5 sampled residents reviewed for unnecessary medication, and b. smoking for 1 (#16) of 3 sampled residents reviewed for smoking.The DON identified 15 residents in the facility were smokers.The DON reported 109 residents resided in the facility.Findings:1. A care plan policy, dated 02/12/20, showed it was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Resident #70's physician's order, dated 03/20/25, showed the resident was to receive, sertraline (antidepressant) 50 mg one time daily for anxiety disorder and unspecified depression.duloxetine hcl (serotonin and norepinephrine reuptake inhibitor) 30 mg one by mouth every 12 hours for anxiety disorder and unspecified depression, andXanax (benzodiazepines) 0.25 mg one by mouth at bedtime for anxiety disorder.A quarterly assessment, dated 08/14/25, showed Resident #70's cognition was intact with a BIMS score of 15. The assessment showed a diagnosis of anxiety disorder and the use of antianxiety medication.A care plan, dated 09/09/25, showed no goals or interventions for Resident #70's anxiety disorder.On 09/17/25 at 12:32 p.m., the regional nurse consultant stated the resident's anxiety diagnoses should have been included in the care plan.2. A Resident Smoking policy, dated 08/01/22, showed the resident's care plan would include the resident's smoking designation (Supervised/Unsupervised) and include the amount of assistance the resident was to receive during smoking.A physician's order for Resident #16, dated 03/18/25, showed supervised smoking as needed for nicotine dependence. An annual assessment, dated 08/09/25, showed severe cognitive impairment with a BIMS score of 07. The assessment showed tobacco use and a diagnosis of nicotine dependence. A smoking risk assessment, dated 09/08/25, showed cigarette use. The assessment showed Resident #16 may smoke independently or with setup assistance and may request smoking material from staff. A care plan, dated 09/09/25, showed no goal or interventions related to smoking. On 09/17/25 at 11:10 a.m., the regional nurse consultant stated smoking should have been included in the resident's care plan.

Based on observation, record review, and interview, the facility failed to: a. revise and update the care plan for Resident #32 when their smoking privileges were suspended, andb. include the resident's legal guardian in the development and review of the care plan for Resident #76. The administrator identified 109 residents resided in the facility. Findings: 1. On 09/09/25 at 9:45 a.m., Resident #32 was observed in their room lying in bed. An unidentified staff member was asked by the surveyor to verify if Resident #32 was in the second bed by the window. The staff member stated, yes, and upon looking in on the resident, stated to the resident, you know the drill, give it to me. The resident was observed to hand the staff member their vape, which was held in the resident's hand under their blanket. The staff member stated the resident's smoking/vaping privileges were suspended at one time and staff were supposed to keep the resident's smoking supplies. The staff member reported the resident's family continued to bring the resident vapes and they had several stored in a large baggie, locked in the medication cart. On 09/11/25 at 1:42 p.m., Resident #32 was observed outside in the smoking area/patio with other residents. The resident was observed to be smoking a cigarette independently. A quarterly assessment for Resident #32, dated 06/16/25, showed the resident had a BIMS of 15, which indicated the resident was cognitively intact. The assessment showed the resident required substantial to maximal assistance with activities of daily living and ate independently. A care plan for Resident #32, dated 07/02/25, showed the resident tried to keep their vape and other smoking supplies in their pockets or hidden in their chair. The care plan showed the resident accused staff of harassment and theft when they removed smoking supplies from the resident's possession. The care plan did not address the resident's smoking privileges had been suspended due to non-compliance of smoking policies and procedures. A physician order, dated 07/12/25, showed Resident #32 would have their smoking privileges suspended due to non-compliance of smoking policies and procedures. The physician order documented a diagnosis of psychosis. On 09/11/25 at 3:13 p.m., the DON reported the physician order which suspended Resident #32's smoking privileges was correct and still active. The DON reported the resident's care plan should have been updated to reflect the resident was not supposed to smoke and does not have smoking privileges. 2. On 09/10/25 at 2:52 p.m., Resident #76's guardian stated they had attended only one care plan meeting, held in March 2025, and that meeting was attended by the social worker only. The guardian stated they had not been invited to the most recent care plan meeting held on 08/22/25. A quarterly assessment, dated 8/15/25, showed Resident #76 has a BIMS of 10, which indicated their cognition was moderately impaired. On 09/15/25 at 9:40 a.m., the social services director stated they conducted the 08/22/25 care plan meeting alone. The social services director stated they forgot to invite the resident's guardian and there was no documentation to show the guardian had been contacted or participated in the meeting.

Based on observation, record review, and interview, the facility failed to: a. ensure incontinent care was provided for 1 (#100), and b. ensure showers were provided for 1 (#127) of sampled 8 residents reviewed for activities of daily living.The DON identified 109 residents resided in the facility.Findings:1. A progress note showed Resident #127 was admitted to the facility on [DATE] and discharged on 04/24/25. Review of bath sheet forms for Resident #127 showed the resident received showers on 04/16/25, 4/20/25 and 04/23/25. There was no documentation to show showers were provided from 04/03/25 to 04/16/25. On 9/10/25 at 2:45 p.m., an unidentified charge nurse stated there was a shower list displayed at the nurse's station indicating the room numbers and the days showers were scheduled. The charge nurse stated once showers were complete, the charge nurse signed off on the sheet. The unidentified charge nurse acknowledged sometimes showers were missed if staff did not show up to work. On 9/10/25 at 4:00 p.m., CNA #1 stated residents sometimes refused showers. Residents were encouraged to shower by discussing the importance of hygiene and if they continued to refuse, it was reported to the charge nurse. CNA #1 stated there was enough staff to provide showers. 2. On 09/11/25 at 10:01 a.m., Resident #100 was observed in bed during a wound care observation. The resident's brief was observed to be soaked with urine, and the resident had a foul odor of urine. The resident's hair was observed to be greasy and unwashed. A care plan, dated 08/05/25, showed Resident #100 was incontinent of bowel and bladder. The care plan showed an intervention was to check and change the resident and keep them clean and dry. An annual assessment, dated 08/09/25, showed Resident #100's cognition was severely impaired with a BIMS score of 07. The assessment showed the resident was frequently incontinent of urine and required partial to moderate assistance with activities of daily living. The assessment showed diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, and dementia. On 09/11/25 at 10:16 a.m., Resident #100 stated they had not received a brief change or a bath. On 09/11/25 at 10:18 a.m., CNA #2 stated they had not been able to perform incontinent care for Resident #100 during this shift. On 09/17/25 at 12:33 p.m., the regional nurse consultant reported incontinent care should be offered to this resident frequently, at least every two hours.

Statement of Deficiency:Based on record review and interview, the facility failed to notify the resident's legal guardian of a change in the resident's condition and treatment for 1 (#76) of 1 sampled resident reviewed for notification. The administrator identified 109 residents resided in the facility. Findings: A facility policy Change of Condition, dated 02/13/23, read in part, Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in the patient's condition or health status. A quarterly assessment for Resident #76, dated 08/15/25, showed a BIMS of 10, which indicated the resident was moderately cognitively impaired. A physician's order dated 08/20/25 showed the resident was to receive Ceftriaxone 2 g, intravenous. There was no documentation to indicate the legal guardian was notified. On 09/10/25 at 2:52 p.m., Resident #76's legal guardian stated they were not notified when the resident was diagnosed with a UTI and the need for IV antibiotic treatment on 08/20/25. On 09/11/25 at 10:00 a.m., the DON reported the resident's guardian should have been notified of the resident's diagnosis and antibiotic treatment.

Based on record review and interview, the facility failed to develop and implement a baseline care plan to provide effective and person-centered care for 1 (#126) of 1 sampled resident reviewed for baseline care plans. The administrator identified nine residents admitted to the facility in the previous 30 days. Findings:A Care Plan - Process policy, dated 03/27/23, read in part, The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process.Initiate a Baseline Care Plan and complete within forty-eight (48) hours of admission based on the physician's orders and nursing evaluation.The Baseline Plan of Care facilitates care until the comprehensive Care Plan is developed. Resident #126 was admitted to the facility on [DATE]. A baseline care plan, dated 09/03/25, showed Resident #126 had diagnoses which included infection and inflammatory reaction due to internal right knee prosthesis, diabetes, hypertension, urge incontinence, and atrial fibrillation. The baseline care plan showed the resident was mildly cognitively impaired and would receive physical therapy to improve function, as well as antibiotic IV therapy. The baseline care plan did not address the resident's incontinence, ADL assistance required, the resident's fall risk, or the resident's wound vac. On 09/08/25 at 1:30 p.m., Resident #126's family member stated the resident had fallen out of bed the previous night on 09/07/25. The family member reported the resident had a new surgical wound to the right leg, as well as a wound vac in place, and did not know what the facility was doing to prevent falls. On 09/09/25 at 11:45 a.m., Resident #126's family member stated the resident had fallen again the previous night. The family member reported staff had told them they would put the bed in the lowest position and get a fall mat for the resident's bedside. The family member stated the resident did not have an injury related to the fall. On 09/10/25 at 9:36 a.m., Resident #126's family member stated since the time of the resident's admission on e week ago, they had issues with finding the resident soaking wet. The family member reported they were at the facility the previous day at 11:45 a.m. and walked with the resident to physical therapy. The family member reported they returned at 6:15 p.m. and found the resident in their recliner, soaking wet with urine up to their neck. The family member stated the resident was in the same pull-up and clothes they had been in earlier in the day. On 09/11/25 at 10:13 a.m., the DON was asked about the resident's baseline care plan, which did not show the resident was at risk for falls, although the resident had recently had surgery to the right leg and had a wound vac in place. The DON reported the resident's fall risk and wound vac should have been included on the baseline care plan. The DON reported ADL assistance, including toileting or incontinent care, should have been included on the baseline care plan.

Based on observation, record review, and interview, the facility failed to ensure care plan interventions were implemented to promote the healing of a pressure ulcer for 1 (#100) of 7 sampled residents reviewed for pressure ulcers. The DON identified 13 residents in the facility had pressure ulcers.Findings: On 09/09/25 at 11:03 a.m., Resident #100 was observed lying on their back in bed. The resident was observed with a gauze bandage on the left foot. The resident's heels were observed on the mattress and not offloaded.On 09/11/25 at 9:25 a.m., Resident #100 was observed in bed lying on their back. The resident's heels were on the mattress and not offloaded.On 09/11/25 at 11:33 a.m., the ADON entered Resident #100's room to provide wound care. The resident was in bed lying on their back and heels were not offloaded. The ADON performed wound care to the left heel per physician's orders. The ADON exited the room after the wound care was performed, and the resident's heels were not offloaded and no pressure relieving devices were in place.On 09/17/25 at 12:08 p.m., Resident #100 was observed in bed; no pillow was observed under their heels. A Prevention of Pressure Ulcers/Injuries policy, dated 07/01/18, showed residents would receive care to maintain skin integrity and prevent pressure ulcers/injuries. The policy showed pillows used to support the entire lower leg may effectively raise the heel from contact with the bed.A quarterly assessment, dated 07/16/25, showed Resident #100's cognition was moderately impaired with a BIMS score of 12. The assessment showed two stage III pressure ulcers that were not present on admission. The assessment showed skin and ulcer/injury treatments:pressure reducing device for bed and chair, pressure ulcer/injury treatment, andapplication of dressing to feet.A physician's order, dated 08/26/25, showed to cleanse the stage III pressure wound of the left heel with normal saline or wound cleanser, pat dry, apply A & D to peri wound, apply hydrogel to wound bed, cover with border island dressing, wrap with gauze roll, and secure with tape.A wound physician's note, dated 09/03/25, showed a stage III pressure wound of the left heel, full thickness, with a duration of greater than 110 days. The note showed the wound size was 1.2 X 0.8 x 0.1 cm. The note showed measurements were exactly the same as the previous visit. The note showed given improvement in the wound with a decrease in ulcer area of 7.7 percent. The note showed the objective was to heal and maintain, and the approach was close monitoring and off-loading.A care plan, dated 09/08/25, showed a stage III pressure ulcer wound to the left heel. The care plan showed an intervention to float the heel when in bed.On 09/17/25 at 11:08 a.m., the regional nurse consultant stated if it was documented in the care plan to offload the resident's heels, then the heels should be offloaded.On 09/17/25 at 12:06 p.m., CNA #3 stated Resident #100's should have had a pillow under their heels to offload them for the pressure ulcer.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for 3 (#1, 2, and #3) of 3 sampled residents reviewed for assistance with activities of daily living. The administrator identified 115 residents resided in the facility. Findings: 1. On 04/07/25 at 1:07 p.m., Res #1 was observed lying in bed. The resident' s hair was kempt. No odors were observed. A policy titled Bathing, revised 02/12/20, read in part, Staff will provide bathing services for residents within standard practice guidelines .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record. Res #1 was admitted with diagnoses which included hemiplegia and hemiparesis. A quarterly assessment, dated 02/13/25, showed Res #1 had a BIMS score of 13 and was cognitively intact. The assessment showed Res #1 was dependent with bathing. The medical record documented Res #1 was to receive a bath/shower weekly on Wednesday and Saturday. There was no documentation for February 2025 Resident #1 received a bath/shower on 02/01/25 (Saturday), 02/05/25 (Wednesday), 02/08/25 (Saturday), 02/12/25 (Wednesday), 02/12/25 (Saturday), 02/19/25 (Wednesday), 02/22/25 (Saturday), and 02/29/25 (Saturday). A bath sheet, dated 02/26/25, showed a shower was not given due to Res #1 vomiting. There was no documentation for March 2025 Resident #1 received a bath/shower on 03/01/25 (Saturday), 03/08/25 (Saturday), 03/12/25 (Wednesday), 03/15/25 (Saturday), 03/19/25 (Wednesday), 03/22/25 (Saturday), 03/26/25 (Wednesday), and 03/29/25 (Saturday). There was no documentation for April 2025 Resident #1 received a bath/shower on 04/02/25 (Wednesday) and 04/06/25 (Saturday). On 04/07/25 at 1:10 p.m., Res #1 stated they usually received a shower if the staff had time to do it. 2. On 04/08/25 at 1:15 p.m., Res #2 was observed sitting in a chair in their room. The resident's hair and clothes were clean and kempt. No odors were observed. Res #2 was admitted with diagnoses which included intellectual disabilities and reduced mobility. An admission assessment, dated 01/10/25, showed Res #2 had a BIMS score of 13 and was cognitively intact. The assessment showed Res #2 required partial to moderate assistance with bathing. The medical record documented Res #2 was to receive a bath/shower weekly on Monday and Thursday. There was no documentation Resident #2 received a bath/shower on 02/03/25 (Monday), 02/06/25 (Thursday), 02/10/25 (Monday), 02/13/25 (Thursday), 02/17/25 (Monday), 02/20/25 (Thursday), and 02/24/25 (Monday). There was no documentation Resident #2 received a bath/shower on 03/20/25 (Thursday), 03/24/25 (Monday), and 03/31/25 (Monday) There was no documentation for April 2025 Resident #2 received a bath/shower on 04/03/25 (Thursday). On 04/08/25 at 1:17 p.m., Res #2 stated they thought they received a shower yesterday. On 04/08/25 at 1:19 p.m., family member #1 stated Res #2 was supposed to receive a shower twice a week, but usually only received a shower once a week. 3. On 04/08/25 at 9:38 a.m., Res #3 was observed lying in bed. The resident's hair and clothes were clean and kempt. No odors observed. Res #3 was admitted with diagnoses which included heart failure and muscle weakness. A quarterly assessment, dated 01/18/25, showed Res #3 had a BIMS score of 8 and was moderately cognitively impaired. The assessment showed Res #3 required substantial to maximum assistance with bathing. The medical record documented Res #3 was to receive a bath/shower weekly on Monday and Thursday. There was no documentation Resident #3 received a bath/shower on 02/03/25 (Monday), 02/06/25 (Thursday), 02/10/25 (Monday), 02/13/25 (Thursday), 02/17/25 (Monday), 02/20/25 (Thursday), and 02/24/25 (Monday). There was no documentation Resident #3 received a bath/shower on 03/03/25 (Monday), 03/06/25 (Thursday), 03/17/25 (Monday), 03/20/25 (Thursday), 03/24/25 (Monday), 03/27/25 (Thursday), and 03/31/25 (Monday). There was no documentation for April 2025 Resident #3 received a bath/shower on 04/03/25 (Thursday). On 04/07/25 at 1:30 p.m. family member #2 stated Res #3 had not received showers regularly. They stated residents having not been bathed was an on-going problem in the facility. On 04/08/25 at 9:40 a.m., Res #3 stated they had not received showers regularly. They stated that they always felt better after a shower, but the staff never showered them on their designated days. Res #3 stated yesterday was their scheduled shower day, but they did not received a shower. On 04/08/25 at 12:00 p.m. the DON stated showers were supposed to be documented on the bath sheets. They stated the bath sheets that were provided were the only ones that could be located for February 2025 until present. On 04/08/25 at 3:15 p.m., the staffing coordinator stated the certified nursing assistants were supposed to give the bath sheets to them after they had completed a shower. They stated no additional bath sheets could be located. The staffing coordinator stated there was no way to ensure the scheduled showers were completed for Res #1, Res #2, and Res #3 without the bath sheet documentation. On 04/08/24 at 3:30 p.m., the administrator stated all completed showers should have been documented on the bath sheets. They stated there was no way to prove Res #1, Res #2, and Res #3 received showers on their scheduled days.

Based on record review and interview, the facility failed to ensure medications were administered according to physician orders for 3 (#1, 2, and #3) of 3 residents sampled for timely administration of medications. The administrator identified 115 residents resided in the facility. Findings: A policy titled Liberalized & Standardized Medication Administration, read in part, The licensed nurse and/or technicians (as allowed by state regulations) are responsible for adhering to the facility's standardized and liberalized medication administration schedules. Liberalized schedules - will allow for medication administration during the defined window of time; these are presented by a descriptor (e.g 'in the morning') or time frame (e.g '0700-0900') on the MAR/EMAR [medication administration record/electronic medication administration record]. Medications scheduled are considered timely as long as they are administered within one and a half hours before or after the defined time or window of time.If the medication is not available, the Director of Nursing or designee will be notified. 1. Res #1 had diagnoses which included hypertensive chronic kidney disease, type II diabetes mellitus, and restless leg syndrome. A quarterly assessment, dated 02/13/25, showed Res #1 had a BIMS score of 13 and was cognitively intact. The assessment showed insulin and hypoglycemic medications were received. Physician orders, dated 03/20/25, showed to administer the following: a. lisinopril (ACE inhibitor) 5 mg daily for hypertensive chronic kidney disease, b. metoprolol (beta-blocker) 25 mg twice daily for hypertensive chronic kidney disease, c. amlodipine (calcium channel blocker) 5 mg daily for hypertensive chronic kidney disease, d. omeprazole (proton pump inhibitor) 40 mg before breakfast for gastroesophageal reflux disease, e. ropinirole (dopamine agonist) 1 mg at bedtime for restless leg syndrome, f. insulin glargine (long-acting insulin) 35 units once daily in the morning for type II diabetes mellitus, and g. insulin glargine 28 units at bedtime for type II diabetes mellitus. A March 2025 Medication Record showed missed doses for the following: a. ropinirole on 03/22/25, b. lisinopril, metoprolol, and omeprazole on 03/23/25, c. insulin glargine 28 units on 03/23/25 and 03/25/25, d. insulin glargine 35 units on 03/23/25 and 03/29/25, and e. amlodipine on 03/23/25 through 03/27/25 and 03/29/25 through 03/30/25. There was no explanation for the missed doses in the medical record. 2. Res #2 had diagnoses which included convulsions, encephalitis, and edema. An admission assessment, dated 01/10/25, showed Res #2 had a BIMS score of 13 and was cognitively intact. The assessment showed antianxiety, diuretic, and anticonvulsant medications were received. Physician orders, dated 02/19/25, showed to administer the following: a. atorvastatin calcium (lipophilic statin) 20 mg at bedtime for hypercholesterolemia, b. metoprolol 50 mg daily for heart disease, c. furosemide (diuretic) 40 mg daily for edema, and d. lisinopril 20 mg daily for heart disease. A physician order, dated 03/20/25, showed to administer levetiracetam (anticonvulsant) 500 mg every 12 hours for seizures. A physician order, dated 03/21/25, showed to administer felbamate (anticonvulsant) 600 mg two tablets with breakfast, lunch, and dinner for encephalitis. A March 2025 Medication Record showed missed doses of the following: a. atorvastatin and levetiracetam on 03/22/25, b. felbamate on 03/22/25 and two missed doses on 03/23/25, c. metoprolol on 03/23/25, d. furosemide on 03/22/25 through 03/24/25 and on 03/26/25, and e. lisinopril on 03/23/25. There was no explanation for the missed doses in the medical record. 3. Res #3 was admitted with diagnoses which included chronic kidney disease, paroxysmal atrial fibrillation, and insomnia. A physician order, dated 06/17/24, showed to administer ferrous sulfate (iron supplement) 325 mg every 12 hours for anemia in chronic kidney disease. A physician order, dated 12/28/24, showed to administer lactulose (osmotic laxative) 30 ml's one time daily for chronic kidney disease. A quarterly assessment, dated 02/13/25, showed Res #3 had a BIMS score of 8 and was moderately cognitively impaired. The assessment showed anticoagulant, diuretic, and antidepressant medications were received. A physician order, dated 02/20/25, showed to administer furosemide 40 mg one time daily for essential hypertension. A physician order, dated 02/24/25, showed to administer budesonide/formoterol (corticosteroid) two puffs every 12 hours for chronic obstructive pulmonary disease. A physician order, dated 03/04/25, showed to administer apixaban (anticoagulant) 5 mg every 12 hours for paroxysmal atrial fibrillation. A physician order, dated 03/07/25, showed to administer trazadone (antidepressant) 150 mg at bedtime for insomnia. A physician order, dated 03/16/25, showed to administer melatonin (sedative) 10 mg at bedtime for insomnia. A physician order, dated 03/28/25, showed to administer albuterol sulfate/ipratropium bromide (bronchodilator) one ampule via nebulization every eight hours for chronic obstructive pulmonary disease. A March 2025 Medication Record showed missed doses of the following: a. apixaban, melatonin, ferrous sulfate, and trazadone on 03/22/25, b. budesonide/formoterol on 03/22/25, 03/24/25, 03/25/25, and 03/26/25, c. furosemide on 03/26/25, and d. lactulose on 03/26/25 and 03/31/25. A Treatment Record, dated 04/01/25 through 04/08/25, showed a missed dose of albuterol sulfate/ipratropium bromide on 04/02/25, 04/04/25, and 04/05/25. There was no explanation for the missed dosages in the medical record. On 04/09/25 at 10:25 a.m., corporate nurse consultant #1 stated the medication record should have showed held if the medications were not given for a specific reason. They stated no explanation was found for the missed doses in question. Corporate Nurse Consultant #1 stated there was no way to know if the missed doses of medication were given or not. On 04/09/25 at 2:45 p.m., the DON stated there was no way to know if the medication doses in question for Res #1, Res #2, and Res #3 were administered. They stated the staff were not documenting appropriately on the medication records.

Based on record review and interviews the facility failed to ensure that sufficient fluid was administered to maintain proper hydration for one (#3) of three sampled residents receiving enteral feedings. Resident Census and Conditions of Residents report identified seven residents receiving enteral feedings resided in the facility. Findings: Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Discharge - Pt Medication Report from [hospital], dated 04/28/22, read in part, .Tube feeding with Impact Peptide 1.5 at 55ml/hr. Free water at 40ml/hr . The admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Peg tube flush 200ml every shift use water .Intak e and Output every shift . A Laboratory Report, dated 05/3/22, read in part, .Abnormal .Sodium 160 H .Reference Range .136-145 mEq/L . A Nurses Note, dated 05/4/22, documented resident #3 was sent to [hospital] ER for critical lab- sodium 160. A [hospital] History & Physical, dated 05/5/22, read in part, .Addendum 1 .Elevated urine Na+ and osmolality consistent with free water deficit vs central cause .Addendum 2 .Hypovolemic [CONDITION(S)] 2/2 lack of free water flushes administration with tube feeds . On 05/24/22 at 9:00 a.m., Regional Nurse Consultant #1 was asked where resident's intake and output was documented. She responded that they were signed off on the MAR. When asked if intake and output amounts were documented anywhere else in the clinical record, she responded no. Resident #3's MARs for April 2022 and May 2022 had no documentation of intake and output amounts. On 05/25/22 at 3:00 p.m., the DON was asked why the amount of resident #3's prescribed gtube water flush was changed upon his admission to the facility. She stated, A dual chamber feeding pump was not available at the time so his water flushes were changed to bolus 200ml/shift. When asked if this order was changed by the doctor, the DON responded, Yes, he was notified and prescribed the change. She was asked if she had documented the conversation with the doctor and stated, no. On 05/25/22 at 4:55 p.m., Physician #1 was asked if he had given an order, when resident #3 was admitted to the facility, to change his water flushes from 40ml/hr to 200ml/shift. He stated, That should not have happened, nobody called me about that. The gtube flush documented on resident #3's [hospital] discharge orders totaled 960ml of free water a day. The gtube flush documented on resident #3's facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/26/22 at 1:50 p.m., the Cert. Dietary Mgr was asked about her role for new admissions with gtube feedings. She stated that she forwarded nutrition orders for newly admitted residents receiving tube feedings directly to the dietician. On 05/26/22 at 1:54 p.m., the Reg. Dietician was asked about his role for new admissions with gtube feedings. He stated, I am notified by the facility if no tube feeding orders are received from the hospital. If tube feeding orders are received, they will run that until I come in and make recommendations if it does not seem sufficient. When asked if he was contacted about changes in feeding or fluids for resident #3, he responded no. The Reg. Dietician was asked if going from a water flush of 40ml/hr to 200ml/shift would be of any concern. He stated, Yes, I would go a bit higher on flushes. Maybe about 300ml/shift.

Based on record review and interviews the facility failed to prevent the development of pressure ulcers for one (#4) of three sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents report identified 113 residents receiving preventive skin care resided in the facility. Findings: Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Nurses Note, dated 01/19/22, contained no admission skin assessment and did not document that resident #4 had any wounds present on admission. A nurse practitioner Progress Note, dated 01/20/22, did not state that resident #4 had any wounds present on admission. The admission MDS, dated [DATE], documented in section M that resident #4 was at risk of developing pressure ulcers and had no unhealed pressure ulcers, wounds, or skin problems on admission. The Care Plan, initiated 01/19/22, showed no interventions were implemented on admission for resident #4 to prevent the development of pressure ulcers. A Nurses Note, dated 02/10/22, read in part, .observed resident has stage 3 wound to his left ischium measuring 2x2.5x0.2) and a stage 3 wound to right ischium measuring 8.5x8.7x0.2). Notified [physician] and TX Orders . On 02/10/22, interventions were implemented to prevent skin breakdown and documented on resident #4's care plan. A Weekly Wound Sheet, dated 03/14/22, documented resident #4 had developed new wounds to his right heel (measuring 2.6cmx2.1cmx000) and left ankle (measuring 3.4cmx2.3cmx0.1cm). A Weekly Wound Sheet, dated 03/21/22, documented resident #4 had developed a new wound to his scrotum (measuring 1.4cmx1.1cmx0.1cm). On 05/24/22 at 1:13 p.m., resident #4 was observed up in electric wheelchair in his room. When asked if he had any pressure ulcers on admission, he responded, I think my ulcers was there when I came. They could have been healed. I'm not sure. On 05/25/22 at 11:32 a.m., the administrator was asked if skin assessments were done for all residents on admission. She responded, Yes, as part of the admission process. On 05/25/22 at 4:50 p.m., the DON was asked if resident #4 had any open pressure areas on admission. She stated, From what I can see looking back is that they were not recognized until 02/10/22. On 05/26/22 at 4:01 p.m., the DON was asked how risks for pressure ulcers was determined. She stated the facility uses a screening tool. When asked if this screening tool had been used to determine resident #4's risk for pressure ulcers upon admission, she stated, No, it does not appear that one was done on resident #4. She was asked if interventions were put into place for resident #4 on admission to prevent the development of pressure ulcers. Her response was no.

Based on observation, record review and resident, family and staff interviews, it was determined the facility failed to ensure pain medications were ordered and acquired for two (#257 and #261) of three sampled residents reviewed for pain. Resident #261 had an ankle fracture with surgical repair and had pain rated seven out of ten and went three days without pain medication. Resident #257 had a diagnosis of unspecified femur fracture and went nine hours without routine pain medication causing her to cry all night and experience pain rated 10 out of 10. The Resident Census and Conditions of Residents report, dated 07/13/21, documented 116 residents resided in the facility and 32 residents were on a pain management program Findings: An ordering and receiving controlled substances policy, dated February 12, 2020, documented, .Controlled substances are reordered when a 4 day supply remains to allow for transmittal of the require written prescription to the pharmacist . 1. Resident #261 admitted on [DATE] with diagnoses which included closed fracture of the right lower leg and [CONDITION(S)]. Physician's orders, dated 07/17/21, documented, .[MEDICATION(S)] 50 mg tablet ([MEDICATION(S)] HCL) 2 tablet by mouth 2 times per day As Needed PAIN . [MEDICATION(S)] 5 mg-acetaminophen 325 mg tablet ([MEDICATION(S)] [MEDICATION(S)]/acetaminophen) 1 tablet by mouth every 4 hours 7 Days As Needed PAIN . A care plan, dated 07/17/21, documented, .Pain .Related To .Acute Pain .Goal .Resident will report or demonstrate relief of pain every day .Will achieve consistent pain relief at a level acceptable to the resident .Interventions .Administer pain medications as ordered . A physical therapy evaluation, dated 07/19/21, documented a pain assessment of five out of ten when at rest and seven out of ten at with movement to right ankle. On 07/20/21 at 12:30 p.m., a family member stated her mother-in-law had been admitted on [DATE] with an ankle fracture. She stated she had surgery and had plates and screws placed in her leg. She stated she had not received any pain medication since admission. She stated the resident had been calling them everyday complaining of pain. She stated she had just spoken to a staff member who told them receiving the pain medications should not have taken so long. At 12:38 p.m., the resident was observed in bed with right lower leg in a splint. She stated she had fractured two ankle bones. She was asked if she was hurting. She stated, Yes, its been hurting ever since I got here. She was asked to rate her pain. She stated it was a 6-7. She stated, I try to keep it really still. She was asked if she had received any medication for pain. She stated, No, they tell me it's at the pharmacy. She was asked if she had told any of the staff she was in pain. She stated, Yes, many, many times. She stated, They say it's at the pharmacy. She was asked if she had been offered anything at all for pain. She stated, No. She stated she could have used her own pharmacy and had it delivered. She then stated even a few Advil would have helped. At 12:46 p.m., the assistant director of nursing (ADON) #2 was asked if the resident had orders for pain medications on admit. She stated, Yes, [MEDICATION(S)] 5/325 and [MEDICATION(S)]. She was asked if those pain medications were available. She stated, They are not. She was asked when the resident had admitted to the facility. She stated she had admitted on Saturday with an ankle fracture. She was asked if the resident had gone three days with out pain medication. She stated, Yes. She was asked the status on the pain medications. She stated the resident's family member had came and talked to her about not having the pain medications. She stated she had called the doctor today and had asked him to send a script to the pharmacy. She stated the pharmacy still did not have the script. She was asked if the resident had been offered anything for pain. She stated, Yes, Tylenol. She stated, She hasn't been given anything today. The physician's orders did not document an order for Tylenol. A physician's order, dated 07/20/21 at 1:02 p.m., documented, [MEDICATION(S)] 60 mg/2 mL [milliliter] intramuscular solution ([MEDICATION(S)] [MEDICATION(S)]) 1 Solution Intramuscular one time only 1 Days As Needed .Dx : Pain, unspecified . A nurse's note, dated 07/20/21 at 1:07 p.m., documented, [MEDICATION(S)] 60mg given IM [intramuscular] in left gluteus medius. Resident tolerated injection well . On 07/20/21 at 1:12 p.m., the resident was asked if she had been able to sleep with the pain in her ankle. She stated she had slept a few hours one night. She stated they had just given her some kind of a pain shot. At 3:15 p.m., certified occupational therapy assistant #1 was asked how the resident had tolerated therapy. She stated the resident complained of pain to her right ankle at a six out of ten. At 4:18 p.m., ADON #2 was asked the policy for ordering medications and pharmacy delivery. She stated once they send the orders to the pharmacy they usually received the medications within the hour. 2. Resident #257 had diagnoses which included unspecified fracture of lower end of femur. Physician's order, dated 06/19/21, documented, [MEDICATION(S)] 50 mg [milligrams] tablet .1 by mouth as needed every 4 hours As Needed MILD PAIN . acetaminophen (Tylenol) 325 mg tablet .2 by mouth every 6 hours As Needed . A resident assessment, dated 06/23/21, documented the resident's cognition was intact. A care plan, dated 06/25/21, documented, .Pain .Related To .Acute Pain .Goal .Resident will report or demonstrate relief of pain every day .Will achieve consistent pain relief at a level acceptable to the resident .Chronic pain will be managed effectively .Interventions .Administer pain medications as ordered . A physician's order, dated 6/29/21, documented, [MEDICATION(S)]-acetaminophen 10 mg 325 mg tablet .1 tablet by mouth every 4 hours Dx : Pain . A July 2021 medication administration record (MAR) documented the [MEDICATION(S)]-acetaminophen 10/325mg tablet was to be administered at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The record documented the resident had received the [MEDICATION(S)]-acetaminophen 10/325 mg at midnight, 4:00 a.m. and 8:00 a.m. on 07/14/21. The order for Tylenol was not documented on the MAR. A controlled drug record for the [MEDICATION(S)]-acetaminophen 10/325mg documented the medication had last been administered on 07/14/21 at midnight and the pill count after that administration was zero. A physician's order, dated 07/14/21, documented, [MEDICATION(S)] 60 mg/2 ml [milliliter] intramuscular solution .one time only .Dx : Pain . A nurse's note, dated 07/14/2021 at 9:00 a.m., documented, Pain medication ordered stat Received one time order for [MEDICATION(S)] 60mg IM. Gave [MEDICATION(S)] 60 mg IM . On 07/14/21 at 12:51 p.m., the resident was observed in her room sitting up in bed. She stated she had gone all night without pain medication. She was asked how her pain was currently. She stated it was a six out of ten. She was asked how bad her pain was in the night. She stated, I was crying. She stated, It got up to 10. She stated staff had informed her the pain medication did not get re-ordered. She stated, I went to therapy because I felt like I should. She stated, But it was hard getting it done. At 3:28 p.m., certified medication aide (CMA) #2 was asked to provide the controlled drug log. She stated it's not in the book. She stated that meant she was out of the medication. She stated the resident had run out of the [MEDICATION(S)]-acetaminophe last night. At 3:36 p.m., the pharmacy delivered the [MEDICATION(S)]-acetaminophen to the nurse's station. At 3:56 p.m., licensed practical nurse (LPN) #4 was asked who was responsible for ordering medications. She stated the CMA's were. She was asked why they had run out out of her pain medication. She stated, I don't know the answer to that. She was asked when staff were instructed to re-order medications. She stated, When they are within a week of running out. At 4:01 p.m., LPN #3 was asked how the resident had been this morning. She stated, She was complaining of pain. She stated she had been informed they were out of her pain medication and they had stat it out. She stated the pain medication was in the building now. She stated they had given her an injection for pain. She was asked why the resident had run out of medication. She stated, I don't know. At 4:07 p.m., the resident was asked if staff had been offered anything besides the [MEDICATION(S)]-acetaminophen for pain. She stated, I didn't hear them if they did. On 07/15/21 at 7:34 a.m., LPN # 2 was asked if the resident had complained of pain the night of 07/14/21. She stated, She always complains of pain. She stated she had administered the midnight dose of [MEDICATION(S)]-acetaminophen 10/325 mg and that was the last dose she had received before they ran out. She was shown the July '21 MAR that documented the 4:00 a.m. and 8:00 a.m. dose had been signed out. She stated that was an error. She was asked if the resident had been offered anything else for pain relief. She stated she did not have any orders for other pain medications. On 07/15/21 at 10:52 a.m., the administrator was made aware of the above findings. She acknowledged the findings.

Based on record review and resident, family and staff interviews, it was determined the facility failed to ensure physician ordered pain medications had been acquired for one (#261) of three sampled residents reviewed for pain. The resident had an ankle fracture with surgical repair and had pain rated seven out of ten and went three days without pain medication. The Resident Census and Conditions of Residents report, dated 07/13/21, documented 116 residents resided in the facility. Findings: Resident #261 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 50 mg tablet ([MEDICATION(S)] HCL) 2 tablet by mouth 2 times per day As Needed PAIN . [MEDICATION(S)] 5 mg-acetaminophen 325 mg tablet ([MEDICATION(S)] [MEDICATION(S)]/acetaminophen) 1 tablet by mouth every 4 hours 7 Days As Needed PAIN . A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan, dated 07/17/21, documented, .Pain .Related To .Acute Pain .Goal .Resident will report or demonstrate relief of pain every day .Will achieve consistent pain relief at a level acceptable to the resident .Interventions .Administer pain medications as ordered . On 07/20/21 at 12:30 p.m., a family member stated her mother-in-law had been admitted on [DATE] with an ankle fracture. She stated she had surgery and had plates and screws placed in her leg. She stated she had not received any pain medication since admission. She stated the resident had been calling them everyday complaining of pain. She stated she had just spoken to a staff member who told them receiving the pain medications should not have taken so long. At 12:38 p.m., the resident was observed in bed with right lower leg in a splint. She stated she had fractured two ankle bones. She was asked if she was hurting. She stated, Yes, its been hurting ever since I got here. She was asked to rate her pain. She stated it was a 6-7. She stated, I try to keep it really still. She was asked if she had received any medication for pain. She stated, No, they tell me it's at the pharmacy. She was asked if she had told any of the staff she was in pain. She stated, Yes, many, many times. She stated, They say it's at the pharmacy. She was asked if she had been offered anything at all for pain. She stated, No. She stated she could have used her own pharmacy and had it delivered. She stated even a few Advil would have helped. At 12:46 p.m., assistant director of nursing (ADON) #2 was asked if she had orders for pain medications on admit. She stated, Yes, [MEDICATION(S)] 5/325 and [MEDICATION(S)]. She was asked if those pain medications were available. She stated, They are not. She was asked when the resident had admitted to the facility. She stated she had admitted on Saturday with an ankle fracture. She was asked if the resident had gone three days with out pain medication. She stated, Yes. She was asked the status on the pain medications. She stated the resident's family member had came and talked to her about not having the pain medications. She stated she had called the doctor and had asked him to send a script to the pharmacy. She stated the pharmacy still did not have the script. She was asked if the resident had been offered anything for pain. She stated, Yes, Tylenol. She stated, She hasn't been given anything today. The resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Dx : Pain, unspecified A nurse's note, dated 07/20/21 at 1:07 p.m., documented, [MEDICATION(S)] 60mg given IM [intramuscular] in left gluteus medius. Resident tolerated injection well . At 1:12 p.m., the resident was asked if she had been able to sleep with the pain in her ankle. She stated she had slept a few hours one night. She stated they had just given her some kind of a pain shot. At 3:15 p.m., certified occupational therapy assistant #1 was asked how the resident had tolerated therapy. She stated the resident complained of pain to her right ankle at a six out of ten. At 4:18 p.m., ADON #2 was asked the policy for ordering medications and pharmacy delivery. She stated once they send the orders to the pharmacy they usually received the medications within the hour. At 4:20 p.m., the administrator was made aware of the above. She acknowledged the findings.

Based on observation, record review and resident, family and staff interviews, it was determined the facility failed to ensure pain medications were ordered and aquired for two (#257 and #261) of three sampled residents reviewed for pain. Resident #261 had an ankle fracture with surgical repair and had pain rated seven out of ten and went three days without pain medication. Resident #257 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Census and Conditions of Residents report, dated 07/13/21, documented 116 residents resided in the facility and 32 residents were on a pain management program Findings: 1. Resident #261 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's orders, dated 07/17/21, documented, .[MEDICATION(S)] 50 mg tablet ([MEDICATION(S)] HCL) 2 tablet by mouth 2 times per day As Needed PAIN . [MEDICATION(S)] 5 mg-acetaminophen 325 mg tablet ([MEDICATION(S)] [MEDICATION(S)]/acetaminophen) 1 tablet by mouth every 4 hours 7 Days As Needed PAIN . A care plan, dated 07/17/21, documented, .Pain .Related To .Acute Pain .Goal .Resident will report or demonstrate relief of pain every day .Will achieve consistent pain relief at a level acceptable to the resident .Interventions .Administer pain medications as ordered . On 07/20/21 at 12:30 p.m., a family member stated her mother-in-law had been admitted on [DATE] with an ankle fracture. She stated she had surgery and had plates and screws placed in her leg. She stated she had not received any pain medication since admission. She stated the resident had been calling them everyday complaining of pain. She stated she had just spoken to a staff member who told them receiving the pain medications should not have taken so long. At 12:38 p.m., the resident was observed in bed with right lower leg in a splint. She stated she had fractured two ankle bones. She was asked if she was hurting. She stated, Yes, its been hurting ever since I got here. She was asked to rate her pain. She stated it was a 6-7. She stated, I try to keep it really still. She was asked if she had received any medication for pain. She stated, No, they tell me it's at the pharmacy. She was asked if she had told any of the staff she was in pain. She stated, Yes, many, many times. She stated, They say it's at the pharmacy. She was asked if she had been offered anything at all for pain. She stated, No. She stated she could have used her own pharmacy and had it delivered. She stated even a few advil would have helped. At 12:46 p.m., the assistant director of nursing (ADON) #2 was asked if the resident had orders for pain medications on admit. She stated, Yes, [MEDICATION(S)] 5/325 and [MEDICATION(S)]. She was asked if those pain medications were available. She stated, They are not. She was asked when the resident had admitted to the facility. She stated she had admitted on Saturday with an ankle fracture. She was asked if the resident had gone three days with out pain medication. She stated, Yes. She was asked what the status on receiving the pain medications. She stated the resident's family member had came and talked to her about not having the pain medications. She stated she had called the doctor and had asked him to send a script to the pharmacy. She stated the pharmacy still did not have the script. She was asked if the resident had been offered anything for pain. She stated, Yes, Tylenol. She stated, She hasn't been given anything today. The physician's orders did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's order, dated 07/20/21 at 1:02 p.m., documented, [MEDICATION(S)] 60 mg/2 mL [milliliter] intramuscular solution ([MEDICATION(S)] [MEDICATION(S)]) 1 Solution Intramuscular one time only 1 Days As Needed . Dx : Pain, unspecified . A nurse's note, dated 07/20/21 at 1:07 p.m., documented, [MEDICATION(S)] 60mg given IM [intramuscular] in left gluteous medius. Resident tolerated injection well . At 1:12 p.m., the resident was asked if she had been able to sleep with the pain in her ankle. She stated she had slept a few hours one night. She stated they had just given her some kind of a pain shot. At 3:15 p.m., certified occupational therapy assistant #1 was asked how the resident had tolerated therapy. She stated the resident complained of pain to her right ankle at a six out of ten. At 4:18 p.m., ADON #2 was asked the policy for ordering medications and pharmacy delivery. She stated once they send the orders to the pharmacy they usually received the medications within the hour. 2. Resident #257 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 06/19/21, documented, [MEDICATION(S)] 50 mg [milligrams] tablet .1 by mouth as needed every 4 hours As Needed MILD PAIN . A resident assessment, dated 06/23/21, documented the resident's cognition was intact. A care plan, dated 06/25/21, documented, .Pain .Related To .Acute Pain .Goal .Resident will report or demonstrate relief of pain every day .Will achieve consistent pain relief at a level acceptable to the resident .Chronic pain will be managed effectively .Interventions .Administer pain medications as ordered . A physician's order, dated 6/29/21, documented, [MEDICATION(S)]-acetaminophen 10 mg 325 mg tablet .1 tablet by mouth every 4 hours Dx : Pain . A July 2021 medication administration record (MAR) documented the [MEDICATION(S)]-acetaminophen 10/325mg tablet was to be administered at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The record documented the resident had received the [MEDICATION(S)]-acetaminophen 10/325 mg at midnight, 4:00 a.m. and 8:00 a.m. on 07/14/21. The order for Tylenol was not documented on the MAR. A physician's order, dated 07/14/21, documented, [MEDICATION(S)] 60 mg/2 ml [milliliter] intramuscular solution .one time only .Dx : Pain . A controlled drug record for the [MEDICATION(S)]-acetaminophen 10/325mg documented the medication had last been administered on 07/14/21 at midnight and the pill count after that administration was zero. There had been three doses of the [MEDICATION(S)]-acetaminophen missed. A nurse's note, dated 07/14/2021 at 9:00 a.m., documented, Pain medication ordered stat Received one time order for [MEDICATION(S)] 60mg IM. Gave [MEDICATION(S)] 60 mg IM . On 07/14/21 at 12:51 p.m., the resident was observed in her room sitting up in bed. She stated she had gone all night without pain medication. She was asked how her pain was currently. She stated it was a six out of ten. She was asked how bad her pain was in the night. She stated, I was crying. She stated, It got up to 10. She stated staff had informed her the pain medication did not get re-ordered. She stated, I went to therapy because I felt like I should. She stated, But it was hard getting it done. At 3:28 p.m., certified medication aide (CMA) #2 was asked to provide the controlled drug log. She stated it's not in the book. She stated that meant she was out of the medication. She stated the resident had run out of the [MEDICATION(S)]-acetaminophe last night. At 3:36 p.m., the pharmacy delivered the [MEDICATION(S)]-acetaminophen to the nurse's station. At 3:56 p.m., licensed practical nurse (LPN) #4 was asked who was responsible for ordering medications. She stated the CMA's were. She was asked why they had run out out of her pain medication. She stated, I don't know the answer to that. She was asked when staff were instructed to re-order medications. She stated, When they are within a week of running out. At 4:01 p.m., LPN #3 was asked how the resident had been this morning. She stated, She was complaining of pain. She stated she had been informed they were out of her pain medication and they had stat it out. She stated the pain medication was in the building now. She stated they had given her an injection for pain. She was asked why the resident had run out of medication. She stated, I don't. At 4:07 p.m., the resident was asked if staff had been offered anything besides the [MEDICATION(S)]-acetaminophen for pain. She stated, I didn't hear them if they did. On 07/15/21 at 7:34 a.m., LPN # 2 was asked if the resident had complained of pain the night of 07/14/21. She stated, She always complains of pain. She stated she had administered the midnight dose of [MEDICATION(S)]-acetaminophen 10/325 mg and that was the last dose she had received before they ran out. She was shown the July '21 MAR that documented the 4:00 a.m. and 8:00 a.m. dose had been signed out. She stated that was an error. She was asked if the resident had been offered anything else for pain relief. She stated she did not have any orders for other pain medications. On 07/15/21 at 10:52 a.m., the administrator was made aware of the above findings. She acknowledged the findings.

On 05/10/21, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent the development and worsening of avoidable unstageable pressure ulcers (PU's), to consistently and thoroughly assess the resident's skin, and to notify the physician and intervene in a timely manner for the PU's. The resident did not have a thorough skin assessment on admission on 02/04/21, did not have weekly skin assessments conducted and developed four unstageable pressure ulcers, one to the right lateral ankle, one to the left lateral ankle, one to the right buttock and one to the sacrum. All required surgical debridement. The right lateral ankle required debridement to bone and tendon. The sacrum wounds progressed to two separate full-thickness pressure ulcers measuing 7 x 8 cm (centimeters) and 5 x 6 cm. Both wounds nearly joining each other. The wounds required debridement down to the periosteum (a dense layer of vascular connective tissue which envelopes the bones) of the sacrum. After debridement the wounds joined and measured 15 x 11 cm. The sacral wound required a wound vac. On 05/10/21, the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 4:10 p.m., the administrator was notified of the IJ situation. At 5:34 p.m., an acceptable plan of removal was provided. The plan of removal documented: All licensed nurses will be educated by the DON [director of nursing] and/or an RNC [registered nurse consultant] on the protocol for identification of new wounds, completion of weekly skin data sheets and weekly wound assessments and notification of physician/responsible party by midnight or prior to their next shift if unable to be reached by midnight 5/10/21. A nurse competency for Skin Evaluations/Checks will be completed for each nurse by midnight 5/10/21 or prior to their next shift if unable to be reached by midnight. Weekly skin assessments completed on 5/7/21 will be confirmed as accurate and that the responsible party was notified by midnight 5/10/21 as noted in the record. All new admits for previous 7 days will be assessed and a nurses note completed on findings with a wound assessment completed for any specific wounds noted by midnight 5/10/21. On 05/10/21 at 10:45 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at an isolated level. On 05/11/21, interviews were conducted with the nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated an in-service was provided on 05/10/21. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on record review and staff and family interviews, it was determined the facility failed to ensure: a. avoidable unstageable pressure ulcers and diabetic wounds developed, b. weekly skin monitoring and /or weekly wound assessments were conducted; and c. the physician was notified timely of new or worsening wounds for one (#1) of three sampled residents reviewed for pressure ulcers. The facility identified 12 residents with pressure ulcers. Findings: A skin data policy, dated July 2018, documented, A licensed nurse will collect data during weekly skin evaluations .Weekly the Licensed Nurse performs a head to toe check of the patient's/resident's skin .The licensed nurse should pay attention to .Open areas .Any significant abnormal findings are reported to the patient's/resident's physician and resident or responsible party. Documentation that the check was performed is denoted on the EMR [electronic medical record/medical record. Abnormal findings are to be documented . Resident #1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A skin data note, dated 02/04/21, documented the resident had a wound to the sacrum. There was no description or measurements of the wound. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Venelex topical ointment 2 times per day TO BUTTOCK . An admission assessment, dated 02/08/21, documented the resident was at risk for pressure ulcers and had no unhealed pressure ulcers. It documented the resident required extensive assistance with bed mobility and was incontinent of bowel and bladder. A skin data sheet, dated 02/12/21, documented the resident had a wound to the sacrum. There was no description or measurements of the wound. There was no skin data sheet for the week of 02/19/21. A skin data sheet, dated 02/26/21, documented the resident had rash/redness to the buttocks and a wound to the sacrum. There was no description or measurements of the wounds. There was no skin data sheet for the week of 03/05 and 03/12/21. There was no documentation of the resident's skin was assessed between 02/27/21 and 03/18/21. There was a total of 20 days between skin assessments. A skin data sheet, dated 03/19/21, documented the resident had a wound to the coccyx, the right foot and left foot. There was no description or measurements of the wounds. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Skin Prep Wipes .topically every shift Apply to right and left outer ankles . There was no skin data sheet for the week of 03/26/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] CRM [cream] APPLY TOPICALLY TO every shift cleanse lt. [left] outer ankle with nss [normal saline solution], pat dry, apply and cover with drsg [dressing] of choice q. [every] shift and prn [as needed] .spenco boots bi lat. [bilateral] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Venelex topical ointment every am pm shift TO BUTTOCKS . A skin data sheet, dated 03/31/21, documented the resident had rash/redness to the buttocks. There was no documentation of descriptions or measurements. The resident's ankle wounds were not addressed. This was the most recently documented assessment of the resident's skin since the last documented assessment on 03/19/21, which was 12 days prior. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] topical ointment .Apply by Topical every shift Apply to buttocks . and .[MEDICATION(S)] .100% [percent] topical past .1 Paste topically every am [morning] pm [evening] shift Cleanse area to right outer ankle with NS [normal saline], Pat dry, Apply [MEDICATION(S)] and cover with dry dressing . A wound report, dated 04/02/21, documented, .DIABETIC WOUND OF THE LEFT, LATERAL ANKLE .Wound Size (LxWxD [length times width times depth]) .1 x 0.8 x Not Measurable cm [centimeters] .Exudate .Moderate Serous .DIABETIC WOUND OF THE RIGHT, LATERAL ANKLE .Wound Size .1.8x 1.6 x 0.2 cm .Exudate .Moderate Serous . The report documented the right ankle wound required surgical debridement. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Cleanse Wound every am shift Cleanse wound to right lateral ankle with NSS, pat dry, apply santyl and cover with calcium alginate, cover with folded ABD [abdominal] pad wrap in kerlix daily and prn . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Skin Prep Wipes every am shift skin prep to left ankle daily . and .Cleanse Wound every am shift Cleanse wound to right lateral ankle with NSS, pat dry, apply santyl and cover with calcium alginate, cover with folded ABD pad wrap in kerlix daily and prn . A wound report, dated 04/05/21, documented, .LEFT, LATERAL ANKLE .0.6 x 0.6 x Not Measureable cm .RIGHT, LATERAL ANKLE .2 x 1.6 x 0.4 cm . The report documented the right lateral ankle required surgical debridement. There was no skin data sheet for the week of 04/07/21. A skin data sheet, dated 04/15/21, documented the resident had a wound to other. The skin assessment did not address the resident's left and right ankle wounds and buttocks wound. A wound report, dated 04/19/21, documented, .LEFT, LATERAL ANKLE .1 x 1 x Not Measurable cm .Wound progress .Deteriorated .RIGHT, LATERAL ANKLE .2 x 2 x 0.2 cm .Wound progress .Deteriorated . The right lateral ankle required surgical debridement. A nurse's note, dated 04/21/21 at 6:56 a.m., documented, Resident has stageable wounds on buttocks. There was no documentation the physician had been notified. There was no documentation of a description of the wound or measurements. A nurse's note, dated 04/22/21 at 3:20 a.m., documented, resident has two stageable wounds on coccyx and right buttock. positioned on left side with pillow for support. no drainage noted will make oncoming shift aware. There was no documentation the physician had been notified or of measurements or description of the wounds. A nurse's note, dated 04/23/21 at 7:26 p.m., documented, .night shift reported x [times] 2 sacral wounds and asst.d [assisted] with wound care and measurements with new orders obtained for wound care. [Family representative] made aware of skin changes. A wound report, dated 04/23/21, documented an unstageable pressure ulcer to the right buttocks measuring 4 centimeters (cm) by 3 cm. It documented the wound base was dusky and non-granulating and the surrounding skin had eschar. It documented an unstageable pressure ulcer to the sacrum measuring 4.9cm x 6.9 cm. It documented the wound base was dusky and non-granulating and the surrounding skin had eschar. This was the first documented wound assessment of the buttocks which included a description and measurements. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Santyl 250 unit/gram topical ointment .Apply by Topical every 24 hours irragate [sic] x 2 sacral wounds with dankins solution, pat dry. aqply [sic] santyl to wound bed like butter, fil [sic] wound bed with calcium alginate ag/antimicrobial and cover with bordered drsg/ [dressing] of choice q.d. [every day] and prn [as needed] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound Consult . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Santyl 250 unit/g [gram] Ointment 1 time per day cleanse left lateral ankle with NS, apply santyl and calcium alginate, cover with abd bad [sic] and kerlix . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Santyl 250 unit/gram topical ointment .Apply by Topical 2 times daily after meals irragate [sic] x 2 sacral wounds with dankins solution, pat dry. aqply [sic] santyl to wound bed like butter, fil [sic] wound bed with calcium alginate ag/antimicrobial and cover with bordered drsg/ [dressing] of choice q.d. [every day] and prn [as needed] . A specialty physician wound evaluation, dated 04/30/21, documented, .CHIEF COMPLAINT .Patient has a rash .Focused Wound Exam .UNSTAGEABLE (DUE TO NECROSIS) SACRUM .Pressure .12 x 10.6 x Not Measurable cm .Exudate .Heavy serous .Thick adherent devitalized necrotic tissue .90 [percent] .SURGICAL EXCISION DEBRIDEMENT PROCEDURE .devitalized tissue and necrotic tissue muscle and surrounding fascial fibers were removed at a depth of 2 cm and healthy bleeding tissue was observed .LEFT, LATERAL ANKLE .1.4 x 1 x Not Measurable .Deteriorated .RIGHT, LATERAL ANKLE .3 x 2.8 x 0.2 cm .Periwound .Odor, Maceration .Deteriorated . Both ankles required surgical debridement. Devitalized tissue and necrotic periosteum and friable bone was removed at a depth of 1 centimeter from the right ankle. A nurse's note, dated 05/01/21 at 7:35 a.m., documented, Resident was sent to [hospital] per [physician] on call. Profused bleeding to buttocks. Changed [sic] dressing x 2 .[Family representative] notified . A hospital operative report, dated 05/02/21, documented, .pressure sore over the right lateral malleolus with visible tendon. In the sacral area was noted to be 2 separate full-thickness stage IV pressure sores the largest directly over the sacrum measuring approximately 7 x 8 cm and the other lesion which was nearly joint [sic, joined] to it measuring 5 x 6cm to the right of midline .used the cautery and knife to incise through normal-appearing skin surrounding these 2 large pressure sores. After going through the dermis we used the cautery to go down into the subcutaneous tissues and begin dissecting this area out As we got towards the deep aspect of the wounds we went into the gluteus muscle and portions of the muscle were excised .The open area measured 15 x 11 cm and was down onto the periosteum of the sacrum .The wound VAC sponge was then placed .wound VAC applied . A care plan, updated 05/05/2021, documented, .Care Area/Problem .Skin Breakdown: At risk for/actual .unstageable wound on sacrum .Interventions .Inspect skin daily with care and bathing, and report any changes to charge nurse .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . On 05/06/21 at 11:00 a.m., licensed practical nurse (LPN) #7 was asked what type of assistance the resident had required. He stated she required extensive assistance for everything. He was asked if she had skin breakdown. He stated she had just transferred to his hall when the night shift informed him of the open areas. He stated he had helped with the measurements when the wounds were found. He was shown the wound report, dated 04/23/21, and was asked if those were his measurements. He said they were. He stated he called the doctor and family and initiated wound care orders. He was asked about the ankle wounds. He stated her legs and feet were abducted and she constantly had pressure on them. He stated she was to use Spenco boots to keep her feet off the mattress. At 3:30 p.m., the director of nursing (DON) was shown the wound report, dated 04/23/21 and was asked if it documented the resident had been admitted with two unstageable wounds. She stated, Yes. She stated the resident had redness and rash on admit. At 3:45 p.m., LPN #8 was asked what type of assistance the resident had required. She stated she required extensive assistance due to a history of stroke. She was asked what interventions were in place to prevent skin breakdown. She stated the residents heels were propped up because she had a wound to the right ankle. She was asked if the resident had any other wounds. She stated, Not that I was aware of. She stated they had been putting a barrier ointment on the residents buttocks because they were red. At 4:42 p.m., the wound care physician was asked if there were any concerns the resident's wounds were infected. She stated she was concerned about osteomylitis in the right ankle due to bone being exposed. She stated she took a swab sample and was waiting on the results. She stated both ankle wounds had declined from the first time she saw them on 04/02/21 to 04/30/21. She stated they started as small wounds that only required skin prep. She was asked when she was first aware of the wounds to the coccyx and right buttocks. She stated on 04/30/21. On 05/10/21 at 12:15 p.m., the DON, administrator (ADM) , regional nurse consultant and the clinical operations specialist were interviewed. They were asked what Venelex ointment wound be ordered for. The DON stated it would be used for a stage 1 or stage 2 pressure ulcer. She was asked how frequently skin assessments were to be conducted. She stated they did weekly skin sheets for all residents. They were shown the timeline of the above documentation. They were made aware the missing weekly skin data sheet and not notifying the physician timely of new or worsening wounds. They were asked if the wounds to the sacrum and right buttock and right and left lateral ankles were present on admit. The DON stated she thought they were. The regional nurse consultant stated if a wound grew in size it should be documented as facility acquired. They were asked how staff should document regarding wounds. The DON stated they should document if a wound is found, notify the doctor and family, obtain an order, and tell the wound nurse. She was asked if there was anything else that should be documented. She stated the size, color, drainage and pain. The DON was again asked if the unstageable wounds were present on admission. She stated, I believe so. She stated the nurse noted those on admit. She was asked if the admit note documented any specific information regarding those wounds. She stated, No. A weekly wound report, dated 05/10/21 at 11:48 p.m., documented the facility had identified 17 new skin issues during assessments completed as part of their plan of removal. Ten were identified to be pressure ulcers and seven were documented as other.

On 01/14/20, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a cognitively impaired female resident (resident #2) was not abused by another resident (resident #1). The facility documented incidents of resident #1 being found in bed with resident #2, who was cognitively impaired. She was diagnosed with alcohol dementia and Alzheimer's disease. On one occasion resident #2 was observed pulling her pants up after being caught in bed with resident #1. The facility did not document prompt notification of the administrator, investigation of possible sexual abuse and how they protected the resident or other residents from potential further sexual abuse by resident #1. The facility moved resident #2 to a different room which was discovered by resident #1 the following day. The facility listed they would do frequent checks on the resident, but failed to document this occurred routinely as ordered by the physician. Additionally, CNA observed resident #2 providing resident #1 oral sex and reported the observation to her charge nurse. This encounter was never investigated. The administration staff stated the encounter was merely a rumor and had never been observed. During the survey the resident was observed for over two hours and the facility never conducted a visual check on the resident. At 5:09 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 5:35p.m., the Administrator was notified of the IJ. An acceptable plan of removal was provided by the divisional director of clinical operations at 6:55 p.m. It documented the following: IMMEDIATE JEOPARDY PLAN OF REMOVAL 01-14-21 1. Resident #1 was placed on 1:1 observations with a nursing staff member to ensure the safety of other residents at 5:45pm until alternate placement can be secured. 2. All residents will have Safe Survey completed by 9pm to ensure no other complaints of abuse are noted. If an allegation is made, an initial state report will be filed and an investigation completed and steps to protect the resident during the investigation will be initiated. 3. An inservice will be done with Admin [administrator], DON [director of nursing], ADON's [assistant directors of nursing] on Abuse Policy, Event Management Protocols and Abuse Reporting by the Divisional Director of Clinical Operations by 8pm. This training shall include all steps of the abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuses training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences. 4. An in-service will be done on Abuse /Sexual Abuse w [with]/post-test completed by all department staff by 11pm 1/14/21. In-servicing will be done in-person or by phone; if they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. This training shall include all steps of abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuse training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences. 5. An initial state report was completed for Resident #1 and the investigation initiated, police notified and police report filed with family/physician notified. On 01/15/21, during interviews with staff, one certified nurse aide and one non-certified nurse aide stated they had been handed a packet containing in-service information and told to read it and take a test. A non-certified nurse aide stated she had just been handed a test about mishandling residents. A housekeeping supervisor stated she had been handed a packet containing the in-service information and instructed to in-service her staff. The facility still had approximately 35 staff who needed in-serviced or re-educated. At 3:30 p.m., the divisional director of clinical operations was made aware that an amended plan of removal was needed due to the number of staff not in-serviced. At 3:42 p.m., an acceptable amendment to the plan of removal was provided by the director of clinical operations. It documented the following: IMMEDIATE JEOPARDY PLAN OF REMOVAL 01-14-21 .An in-service will be done on Abuse /Sexual Abuse w [with]/post-test completed by all department staff by 11pm 1/15/21. In-servicing will be done in-person or by phone; if they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. This training shall include all steps of abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuse training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences . On 01/19/21, 17 nurse aides, three licensed practical nurses, three housekeepers and two registered nurses, from across all shifts, were interviewed and able to state accurate information related to abuse. The immediate jeopardy deficiency was lifted as of 01/15/21 at 10:52 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at a level of actual harm at a pattern. Based on observation, record review and staff interviews, it was determined the facility failed to ensure resident #1did not sexually abuse one (#2) of five sampled residents reviewed for sexual abuse. The facility identified 111 residents who resided in the facility and three who had sexually inappropriate behaviors. Findings: A facility abuse policy, dated 06/23/17, documented: .The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property . Abuse Coordinator: Licensed Facility Administrator . The facility must prohibit and prevent abuse .All facility staff members have a duty to ensure that all alleged violations involving abuse .are reported to the Administrator .Upon receiving an allegation of abuse .the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation .if the allegation is reportable, report such allegation to the State Regulatory Agency .not later than 2 hours after the allegation is made . Training .The facility will conduct staff member training regarding abuse .During each new staff member's orientation .the facility at a minimum provide training on the following topics .Activities that constitute abuse .Procedures for reporting incidents of abuse .Dementia management and resident abuse prevention . Investigation .The Abuse Coordinator will immediately begin an investigation .Resident(s) and responsible party interviews .Staff interviews and written statements .Methods to support the individual and detect and prevent further victimization .protect residents by removing immediate threats and potential harm . 1. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly resident assessment, dated 10/30/20, documented the resident's cognition was moderately impaired and she was independent with ambulation. An incident report, documented an incident reported on 11/07/20 at 1:22 a.m., documented, .Type of incident .possible sexual encounter .Witnesses .Yes .What time was this observed .from 2330-0100 [11:30 p.m. to 1:00 a.m.] in resident room .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Independent ambulation .Description of Incident .resident had male from across hall in rom and in bed .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .In house observation .room change to opposite end of building .DON Signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrator's name .11/22/2020 23:40 [11:40 p.m.] . A care plan, updated 11/07/20, documented, .Cognitive Deficit .Related To .Alzheimer's .Alcohol induced dementia .Evidence By .Short-term memory loss .Will recognize family at time of visit over the next 90 days .Monitor for any changes in decline in cognitive status .Offer resident two simple choices to reduce the stress of decision making .Allow ample time to absorb and respond to information .11/11/20 .Socially Inapproriate [sic] .Related To .11-7-2020 Having a man in her room in her bed .Resident will verbalize understanding of need to control socially inappropriate behavior over the next 90 days .11-7-202 room change to opposite end of building .Redirect as needed . A nurse's note, dated 11/09/20 at 7:31 a.m., documented, Resident was seen in another male resident's bed pulling up her pants. Re-directed and explained to her why these behaviors are not ok. Resident then seemed ashamed and said that it wouldn't happen again. Will continue to monitor . An incident report, dated 11/09/20, documented, .Witnessed - Yes .Cognitive status - Moderately impaired .Cognition varies throughout the day .Independent ambulation .Location of incident - Resident Room - Bed .Description of Incident .Resident was seen in another male resident's bed pulling up her pants. Redirected and explained to her why these behaviors are not ok. Resident then seemed ashamed and said that it wouldn't [sic] happen again. Will continue to monitor .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .After IDT [interdisciplinary team] huddle: frequent visual checks on male [resident #1's initials] redirection of both residents .DON [director of nurses] signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrators name] 11/22/2020 23:28 [11:38 p.m.] . A nurse's note, dated 11/11/20 at 10:25 p.m., documented, Resident monitored by staff with frequent visuals and supervised smoking r/t [related to] possible sexual encounter . An incident report, dated 11/11/20, which documented the incident had reported on 11/07/20 at 1:22 a.m., documented, .Type of incident .possible sexual encounter .Witnesses .Yes .What time was this observed .from 2330-0100 [11:30 p.m. to 1:00 a.m.] in resident room .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Independent ambulation .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .In house observation .room change to opposite end of building .DON Signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrator's name .11/22/2020 23:40 [11:40 p.m.] . 2. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 08/26/20, documented the resident had moderately impaired cognition. A nurse's note, dated 11/08/20 at 7:42 p.m., documented, Resident was seen and redirected x [times] 2 for going into female room across hall [resident #2's initials]. He was found in her bed as well. Redirected and reminded that he could not in females room. He stated to staff 'they were grown adults and not making baby.' He has remained in his room in bed resting and no other attempts. Will make oncoming shift aware . A nurse's note, dated 11/09/20 at 7:25 a.m., documented Resident was going into another female resident's room. Later during shift resident was observed with that resident in his bed pulling up her pants. Redirected both residents and explained why they couldn't be doing these behaviors. Will continue to monitor . An incident report, dated 11/09/20 at 7:25 a.m., documented, .Type of incident - Sexual behaviors .Witnessed - Yes .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Psychosocial status - Impaired judgement .Independent ambulation .Action taken - MD [medical doctor] Notified .Other Intervention - Redirected .Description of Incident Resident was going into another female resident' room. Later during the shift resident was observed with that female resident in his bed pulling up her pants. Redirected both residents and explained why they couldn't be doing these behaviors. Will continue to monitor .Supervisor Investigation .Medication review by MD .Administrators Signature [facility administrators name] Completed By [facility administrators name] 11/22/2020 23:11 [11:11 p.m.] . A nurse's note, dated 11/10/20 at 4:42 p.m., documented, Dr. [name deleted] in facility this pm. Notified of ongoing behaviors with a female resident . A nurse's note, dated 11/11/20 at 9:02 a.m., documented, Will do every 15 minute visual checks due to inappropriate sexual behavior. A care plan, onset date 11/11/20, documented, .Socially Inappropriate .Related To .11-7-2020 was in female residents room .Interventions .11-7-2020 frequent visual checks . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Frequent visual checks every shift Reason: inappropriate sexual behavior Frequency: every 15 minutes . An incident report, dated 11/11/20, documented, .Type of incident - sexual behavior .Incident Date/Time -11/07/2020, 23:30 [11:30 p.m.] .Type of Injury - Other - in woman room .What time and where was this observed .from 2330 [11:30 p.m.] - 0100 [1:00 a.m.] going into 910 .Description of Incident resident going into females room .Comments intervention; frequent visual checks .DON Signature [facility DON's name] .Administrators Signature [facility administrator's name] Completed By [facility administrator's name] 11/22/2020 23:12 [11:12 p.m.] . On 01/14/21 from 9:00 a.m. through 11:12 a.m., no staff were observed conducting every fifteen minute check for resident #1. At 10:17 a.m., licensed practice nurse (LPN) #1 was asked if she had witnessed any sexual encounter between residents #1 and #2. She stated she had not witnessed any, but had been told to watch for it by making frequent checks on resident #1. She was asked if she had concerns about sexual behaviors from resident #1. She stated, I do She was asked if female residents were at risk. She stated, Yes. LPN #1 was asked if resident #2 was cognitively intact to make safe decisions. She stated, I'm going to say, no. At 10:40 a.m., the DON was asked what the policy was for allegations of abuse. She stated to report it to the administrator, follow-up, do an investigation, report to state, do safe surveys and interviews. She was asked who she would interview. She stated she would interview the persons in the allegations. She was asked how she would keep the resident safe. She stated by removing the resident from the situation. The DON was shown the nurse's notes from 11/08 and 11/09/20. She was asked if those could have been allegations of sexual abuse. She stated, Yes. She was asked if either incidents were investigated. She stated, No, [Facility administrator] said since it's not witnessed, there was no need. She was asked if they only investigated claims of abuse that were witnessed. She stated, No. The DON was asked if an investigation should have been conducted. She stated, Yes. She was asked if there was a State reportable for the incidents. She stated, No. She was asked if resident #2 was able to safely consent for herself. She stated, No. After reviewing the incident times, the DON was asked if the every fifteen minute visual checks for resident #1 had been effective. She stated, Probably not. She was asked how they knew other residents weren't affected by the sexual abuse if investigations had not been conducted. She stated, We don't. She was asked if resident #1 was a threat to other residents. She stated, Yes. At 12:45 p.m., certified nurse aide (CNA) #1 was asked if she had seen any sexual encounters between resident #1 and #2. She stated she had. She stated she was passing snacks one afternoon around 2:30 p.m. and walked into resident #1's room and resident #2 was performing oral sex on him. She stated she left the room and went immediately and informed the charge nurse. She was asked if administration had been made aware. She stated she assumed so because the next day the resident had been moved to the other end of the building. At 1:15 p.m., the DON was asked if she was aware of resident #2 performing oral sex to resident #1. She stated, I don't think it was ever witnessed. She stated, It was kind of a rumor. She was asked if she were informed of a rumored sexual encounter would you investigate it. She stated, Yes. She was asked if there was an incident report, a state reportable or an investigation. She stated, No. At 3:40 p.m., the administrator (ADM) was asked the policy for resident abuse. She stated everyone was supposed to report, do an incident report, notify family of both parties, investigate by taking statements from witnesses, talk to residents involved, conduct safe surveys and do a state reportable within two hours. The ADM was asked if she was aware of the 11/08/20 at 6:41 a.m. incident when resident #1 was found in resident #2's bed. She stated, I was told she was walking out of his room, but nothing witnessed. She was asked if she was aware of the 11/09/20 incident when resident #1 was observed with resident #2 in his bed pulling up her pants. She stated, Only thing I was told was she was walking out of his room. The ADM was asked if she was aware oral sex had taken place between resident #1 and #2. She stated, We heard of rumors of it, but no staff witnessed it. She was asked if she only investigated allegation of abuse she witnessed. She stated, No. She was asked if it should have been investigated even though it had not been witnessed. She stated, Yes. She was asked if she was aware of interventions in place for resident #1. She stated they had conducted medication reviews and every fifteen minute checks. She was made aware of the above observation of over two hours between visual checks. She acknowledged the findings. At 4:00 p.m., CNA #1 was asked to describe what she observed take place between resident #1 and resident #2. She stated she entered the resident's room and observed feet standing under the curtain. She said she pulled back the curtain and observed resident #2 on her knees with her hands around the base of resident #1's penis and the head of the resident's penis in her mouth. CNA #1 stated she immediately left the room and notified the charge nurse. No documentation of an investigation of the encounter was provided by the facility. CNA #1 could not remember the name of the charge nurse she reported her observation to.

On 01/14/20, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a cognitively impaired female resident (resident #2) was not abused by another resident (resident #1). The facility documented incidents of resident #1 being found in bed with resident #2, who was cognitively impaired. She was diagnosed with alcohol dementia and Alzheimer's disease. On one occasion resident #2 was observed pulling her pants up after being caught in bed with resident #1. The facility did not document prompt notification of the administrator, investigation of possible sexual abuse and how they protected the resident or other residents from potential further sexual abuse by resident #1. The facility moved resident #2 to a different room which was discovered by resident #1 the following day. The facility listed they would do frequent checks on the resident, but failed to document this occurred routinely as ordered by the physician. Additionally, CNA observed resident #2 providing resident #1 oral sex and reported the observation to her charge nurse. This encounter was never investigated. The administration staff stated the encounter was merely a rumor and had never been observed. During the survey the resident was observed for over two hours and the facility never conducted a visual check on the resident. At 5:09 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 5:35p.m., the Administrator was notified of the IJ. An acceptable plan of removal was provided by the divisional director of clinical operations at 6:55 p.m. It documented the following: IMMEDIATE JEOPARDY PLAN OF REMOVAL 01-14-21 1. Resident #1 was placed on 1:1 observations with a nursing staff member to ensure the safety of other residents at 5:45pm until alternate placement can be secured. 2. All residents will have Safe Survey completed by 9pm to ensure no other complaints of abuse are noted. If an allegation is made, an initial state report will be filed and an investigation completed and steps to protect the resident during the investigation will be initiated. 3. An inservice will be done with Admin [administrator], DON [director of nursing], ADON's [assistant directors of nursing] on Abuse Policy, Event Management Protocols and Abuse Reporting by the Divisional Director of Clinical Operations by 8pm. This training shall include all steps of the abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuses training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences. 4. An in-service will be done on Abuse /Sexual Abuse w [with]/post-test completed by all department staff by 11pm 1/14/21. In-servicing will be done in-person or by phone; if they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. This training shall include all steps of abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuse training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences. 5. An initial state report was completed for Resident #1 and the investigation initiated, police notified and police report filed with family/physician notified. On 01/15/21, during interviews with staff, one certified nurse aide and one non-certified nurse aide stated they had been handed a packet containing in-service information and told to read it and take a test. A non-certified nurse aide stated she had just been handed a test about mishandling residents. A housekeeping supervisor stated she had been handed a packet containing the in-service information and instructed to in-service her staff. The facility still had approximately 35 staff who needed in-serviced or re-educated. At 3:30 p.m., the divisional director of clinical operations was made aware that an amended plan of removal was needed due to the number of staff not in-serviced. At 3:42 p.m., an acceptable amendment to the plan of removal was provided by the director of clinical operations. It documented the following: IMMEDIATE JEOPARDY PLAN OF REMOVAL 01-14-21 .An in-service will be done on Abuse /Sexual Abuse w [with]/post-test completed by all department staff by 11pm 1/15/21. In-servicing will be done in-person or by phone; if they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. This training shall include all steps of abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuse training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences . On 01/19/21, 17 nurse aides, three licensed practical nurses, three housekeepers and two registered nurses, from across all shifts, were interviewed and able to state accurate information related to abuse. The immediate jeopardy deficiency was lifted as of 01/15/21 at 10:52 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at level or actual harm at a pattern. Based on observations, interviews and record reviews, it was determined the facility failed to implement their abuse policy to ensure: 1. allegations and observations of sexual abuse by resident #1 were reported to the administrator and the OSDH, investigated and residents were protected from potential further abuse for one (#2) of five sampled residents who were reviewed for abuse; 2. a thorough investigation of alleged sexual abuse was documented for one (#4) of five sampled residents who were reviewed abuse; and 3. abuse training was completed on hire for one (registered nurse #1) of five employee files reviewed for abuse. The facility identified 111 residents resided in the facility and three had sexually inappropriate behaviors. Findings: A facility abuse policy, dated 06/23/17, documented: .The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property . Abuse Coordinator: Licensed Facility Administrator . The facility must prohibit and prevent abuse .All facility staff members have a duty to ensure that all alleged violations involving abuse .are reported to the Administrator .Upon receiving an allegation of abuse .the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation .if the allegation is reportable, report such allegation to the State Regulatory Agency .not later than 2 hours after the allegation is made . Training .The facility will conduct staff member training regarding abuse .During each new staff member's orientation .the facility at a minimum provide training on the following topics .Activities that constitute abuse .Procedures for reporting incidents of abuse .Dementia management and resident abuse prevention . Investigation .The Abuse Coordinator will immediately begin an investigation .Resident(s) and responsible party interviews .Staff interviews and written statements .Methods to support the individual and detect and prevent further victimization .protect residents by removing immediate threats and potential harm . 1. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly resident assessment, dated 10/30/20, documented the resident's cognition was moderately impaired and she was independent with ambulation. An incident report, documented an incident reported on 11/07/20 at 1:22 a.m., documented, .Type of incident .possible sexual encounter .Witnesses .Yes .What time was this observed .from 2330-0100 [11:30 p.m. to 1:00 a.m.] in resident room .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Independent ambulation .Description of Incident .resident had male from across hall in rom and in bed .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .In house observation .room change to opposite end of building .DON Signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrator's name .11/22/2020 23:40 [11:40 p.m.] . A care plan, updated 11/07/20, documented, .Cognitive Deficit .Related To .Alzheimer's .Alcohol induced dementia .Evidence By .Short-term memory loss .Will recognize family at time of visit over the next 90 days .Monitor for any changes in decline in cognitive status .Offer resident two simple choices to reduce the stress of decision making .Allow ample time to absorb and respond to information .11/11/20 .Socially Inapproriate [sic] .Related To .11-7-2020 Having a man in her room in her bed .Resident will verbalize understanding of need to control socially inappropriate behavior over the next 90 days .11-7-202 room change to opposite end of building .Redirect as needed . A nurse's note, dated 11/09/20 at 7:31 a.m., documented, Resident was seen in another male resident's bed pulling up her pants. Re-directed and explained to her why these behaviors are not ok. Resident then seemed ashamed and said that it wouldn't happen again. Will continue to monitor . An incident report, dated 11/09/20, documented, .Witnessed - Yes .Cognitive status - Moderately impaired .Cognition varies throughout the day .Independent ambulation .Location of incident - Resident Room - Bed .Description of Incident .Resident was seen in another male resident's bed pulling up her pants. Redirected and explained to her why these behaviors are not ok. Resident then seemed ashamed and said that it wouldn't [sic] happen again. Will continue to monitor .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .After IDT [interdisciplinary team] huddle: frequent visual checks on male [resident #1's initials] redirection of both residents .DON [director of nurses] signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrators name] 11/22/2020 23:28 [11:38 p.m.] . A nurse's note, dated 11/11/20 at 10:25 p.m., documented, Resident monitored by staff with frequent visuals and supervised smoking r/t [related to] possible sexual encounter . An incident report, dated 11/11/20, which documented the incident had reported on 11/07/20 at 1:22 a.m., documented, .Type of incident .possible sexual encounter .Witnesses .Yes .What time was this observed .from 2330-0100 [11:30 p.m. to 1:00 a.m.] in resident room .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Independent ambulation .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .In house observation .room change to opposite end of building .DON Signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrator's name .11/22/2020 23:40 [11:40 p.m.] . On 01/14/21 from 9:00 a.m. through 10:41 a.m., no staff were observed conducting every fifteen minute check for resident #1. At 10:17 a.m., licensed practice nurse (LPN) #1 was asked if she had witnessed any sexual encounter between residents #1 and #2. She stated she had not witnessed any, but had been told to watch for it by making frequent checks on resident #1. She was asked if she had concerns about sexual behaviors from resident #1. She stated, I do She was asked if female residents were at risk. She stated, Yes. LPN #1 was asked if resident #2 was cognitively intact to make safe decisions. She stated, I'm going to say, no. At 10:40 a.m., the director of nursing (DON) was asked what the policy was for allegations of abuse. She stated to report it to the administrator, follow-up, do an investigation, report to state, do safe surveys and interviews. She was asked who she would interview. She stated she would interview the persons in the allegations. She was asked how she would keep the resident safe. She stated by removing the resident from the situation. The DON was shown the nurse's notes from 11/08 and 11/09/20. She was asked if those could have been allegations of sexual abuse. She stated, Yes. She was asked if either incidents were investigated. She stated, No. [Facility administrator] said since it's not witnessed, there was no need. She was asked if they only investigated claims of abuse that were witnessed. She stated, No. The DON was asked if an investigation should have been conducted. She stated, Yes. She was asked if there was a State reportable for the incidents. She stated, No. She was asked if resident #2 was able to safely consent for herself. She stated, No. After reviewing the incident times, the DON was asked if the every fifteen minute visual checks for resident #1 had been effective. She stated, Probably not. She was asked how they knew other residents weren't affected by the sexual abuse if investigations had not been conducted. She stated, We don't. She was asked if resident #1 was a threat to other residents. She stated, Yes. At 12:45 p.m., certified nurse aide (CNA) #1 was asked if she had seen any sexual encounters between resident #1 and #2. She stated she had. She stated she was passing snacks one afternoon around 2:30 p.m. and walked in to resident #1's room and resident #2 was performing oral sex on him. She stated she left the room and went immediately and informed the charge nurse. She was asked if administration had been made aware. She stated she assumed so because the next day the resident had been moved to the other end of the building. At 1:15 p.m., the DON was asked if she was aware of resident #2 performing oral sex to resident #1. She stated, I don't think it was ever witnessed. She stated, It was kind of a rumor. She was asked if she were informed of a rumored sexual encounter would you investigate it. She stated, Yes. She was asked if there was an incident report, a state reportable or an investigation. She stated, No. At 3:40 p.m., the administrator (ADM) was asked the policy for resident abuse. She stated everyone was supposed to report, do an incident report, notify family of both parties, investigate by taking statements from witnesses, talk to residents involved, conduct safe surveys and do a state reportable within two hours. The ADM was asked if she was aware of the 11/08/20 at 6:41 a.m. incident when resident #1 was found in resident #2's bed. She stated, I was told she was walking out of his room, but nothing witnessed. She was asked if she was aware of the 11/09/20 incident when resident #1 was observed with resident #2 in his bed pulling up her pants. She stated, Only thing I was told was she was walking out of his room. The ADM was asked if she was aware oral sex had taken place between resident #1 and #2. She stated, We heard of rumors of it, but no staff witnessed it. She was asked if she only investigated allegation of abuse she witnessed. She stated, No. She was asked if it should have been investigated even though it had not been witnessed. She stated, Yes. She was asked if she was aware of interventions in place for resident #1. She stated they had conducted medication reviews and every fifteen minute checks. She was made aware of the above observation of an hour and forty one minutes between visual checks. She acknowledged the findings. 2. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 08/26/20, documented the resident had moderately impaired cognition. A nurse's note, dated 11/08/20 at 7:42 p.m., documented, Resident was seen and redirected x [times] 2 for going into female room across hall [resident #2's initials]. He was found in her bed as well. Redirected and reminded that he could not in females room. He stated to staff 'they were grown adults and not making baby.' He has remained in his room in bed resting and no other attempts. Will make oncoming shift aware . A nurse's note, dated 11/09/20 at 7:25 a.m., documented Resident was going into another female resident's room. Later during shift resident was observed with that resident in his bed pulling up her pants. Redirected both residents and explained why they couldn't be doing these behaviors. Will continue to monitor . An incident report, dated 11/09/20 at 7:25 a.m., documented, .Type of incident - Sexual behaviors .Witnessed - Yes .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Psychosocial status - Impaired judgement .Independent ambulation .Action taken - MD [medical doctor] Notified .Other Intervention - Redirected .Description of Incident Resident was going into another female resident' room. Later during the shift resident was observed with that female resident in his bed pulling up her pants. Redirected both residents and explained why they couldn't be doing these behaviors. Will continue to monitor .Supervisor Investigation .Medication review by MD .Administrators Signature [facility administrators name] Completed By [facility administrators name] 11/22/2020 23:11 [11:11 p.m.] . A nurse's note, dated 11/10/20 at 4:42 p.m., documented, Dr. [name deleted] in facility this pm. Notified of ongoing behaviors with a female resident . A nurse's note, dated 11/11/20 at 9:02 a.m., documented, Will do every 15 minute visual checks due to inappropriate sexual behavior. A care plan, onset date 11/11/20, documented, .Socially Inappropriate .Related To .11-7-2020 was in female residents room .Interventions .11-7-2020 frequent visual checks . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Frequent visual checks every shift Reason: inappropriate sexual behavior Frequency: every 15 minutes . An incident report, dated 11/11/20, documented, .Type of incident - sexual behavior .Incident Date/Time -11/07/2020, 23:30 [11:30 p.m.] .Type of Injury - Other - in woman room .What time and where was this observed .from 2330 [11:30 p.m.] - 0100 [1:00 a.m.] going into 910 .Description of Incident resident going into females room .Comments intervention; frequent visual checks .DON Signature [facility DON's name] .Administrators Signature [facility administrator's name] Completed By [facility administrator's name] 11/22/2020 23:12 [11:12 p.m.] . On 01/14/21 from 9:00 a.m. through 11:12 a.m., no staff were observed conducting every fifteen minute check for resident #1. At 10:17 a.m., licensed practice nurse (LPN) #1 was asked if she had witnessed any sexual encounter between residents #1 and #2. She stated she had not witnessed any, but had been told to watch for it by making frequent checks on resident #1. She was asked if she had concerns about sexual behaviors from resident #1. She stated, I do She was asked if female residents were at risk. She stated, Yes. LPN #1 was asked if resident #2 was cognitively intact to make safe decisions. She stated, I'm going to say, no. At 10:40 a.m., the DON was asked what the policy was for allegations of abuse. She stated to report it to the administrator, follow-up, do an investigation, report to state, do safe surveys and interviews. She was asked who she would interview. She stated she would interview the persons in the allegations. She was asked how she would keep the resident safe. She stated by removing the resident from the situation. The DON was shown the nurse's notes from 11/08 and 11/09/20. She was asked if those could have been allegations of sexual abuse. She stated, Yes. She was asked if either incidents were investigated. She stated, No, [Facility administrator] said since it's not witnessed, there was no need. She was asked if they only investigated claims of abuse that were witnessed. She stated, No. The DON was asked if an investigation should have been conducted. She stated, Yes. She was asked if there was a State reportable for the incidents. She stated, No. She was asked if resident #2 was able to safely consent for herself. She stated, No. After reviewing the incident times, the DON was asked if the every fifteen minute visual checks for resident #1 had been effective. She stated, Probably not. She was asked how they knew other residents weren't affected by the sexual abuse if investigations had not been conducted. She stated, We don't. She was asked if resident #1 was a threat to other residents. She stated, Yes. At 12:45 p.m., certified nurse aide (CNA) #1 was asked if she had seen any sexual encounters between resident #1 and #2. She stated she had. She stated she was passing snacks one afternoon around 2:30 p.m. and walked into resident #1's room and resident #2 was performing oral sex on him. She stated she left the room and went immediately and informed the charge nurse. She was asked if administration had been made aware. She stated she assumed so because the next day the resident had been moved to the other end of the building. At 1:15 p.m., the DON was asked if she was aware of resident #2 performing oral sex to resident #1. She stated, I don't think it was ever witnessed. She stated, It was kind of a rumor. She was asked if she were informed of a rumored sexual encounter would you investigate it. She stated, Yes. She was asked if there was an incident report, a state reportable or an investigation. She stated, No. At 3:40 p.m., the administrator (ADM) was asked the policy for resident abuse. She stated everyone was supposed to report, do an incident report, notify family of both parties, investigate by taking statements from witnesses, talk to residents involved, conduct safe surveys and do a state reportable within two hours. The ADM was asked if she was aware of the 11/08/20 at 6:41 a.m. incident when resident #1 was found in resident #2's bed. She stated, I was told she was walking out of his room, but nothing witnessed. She was asked if she was aware of the 11/09/20 incident when resident #1 was observed with resident #2 in his bed pulling up her pants. She stated, Only thing I was told was she was walking out of his room. The ADM was asked if she was aware oral sex had taken place between resident #1 and #2. She stated, We heard of rumors of it, but no staff witnessed it. She was asked if she only investigated allegation of abuse she witnessed. She stated, No. She was asked if it should have been investigated even though it had not been witnessed. She stated, Yes. She was asked if she was aware of interventions in place for resident #1. She stated they had conducted medication reviews and every fifteen minute checks. She was made aware of the above observation of over two hours between visual checks. She acknowledged the findings. At 4:00 p.m., CNA #1 was asked to describe what she observed take place between resident #1 and resident #2. She stated she entered the resident's room and observed feet standing under the curtain. She said she pulled back the curtain and observed resident #2 on her knees with her hands around the base of resident #1's penis and the head of the resident's penis in her mouth. CNA #1 stated she immediately left the room and notified the charge nurse. No documentation of an investigation of the encounter was provided by the facility. CNA #1 could not remember the name of the charge nurse she reported her observation to. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 06/17/20 at 2:27 p.m., documented, Behavior - Resident displaying aggressive behavior today, throughout various times of the day resident was stating that different female staff was coming into room and being inappropriate in a sexual manor [sic], stating that a 'woman is in my bed touching me on my private parts, where my wife and I touch each other' . A state reportable incident, dated 06/17/20, documented, .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Resident states that different female staff and other females are being inappropriate in a sexual manor [sic] during his bath today, but resident did not receive a bath today. Then stating that a 'woman is in my bed touching me on my private parts, where my wife and I touch each other' the resident would state the same things to different staff when no one is in his bed with him. Resident refused his bath from all female and male CNA today .Investigation started . Summary of investigation .Resident has been displaying behaviors of coming out of room and walking down hall, confused staff yelling and screaming at different staff. Dr [doctor] has ordered for attempt to get lab and UA [urine analysis] to rule out UTI [urinary tract infection]. Resident initially said that someone touched him inappropriately during his bath today and that a lady was in his bed touching him. Upon investigation resident refused his bath from all staff today, no bath or personal care was given such as dressing, resident dresses self. Staff and room-mate confirm there was never a lady in his room with him at all. Resident interview changed story from saying people are being inappropriate with him to he is upset because people are saying he is being inappropriate with them. Reassured resident that no one feels he has done anything wrong .Unable to substantiate any abuse, behaviors and confusion related to infection .[facility administrator's name] Reporting Party . On 01/15/20 at 12:26 p.m., the administrator was shown the state reportable incident and was asked if any further interviews were conducted with other residents or staff related to the allegations. She stated, Yes. She stated, Let me go ask my ADONs [assistant directors of nursing] for any paperwork. At 2:02 p.m., the ADM stated, I cannot find anything else for [resident #4]. She was asked if a thorough investigation had been conducted for resident #4's allegations of sexual abuse. She stated, Yes. 4. Registered nurse #1's date of hire was 07/20/20. Her employee file did not contain documentation of abuse training upon hire. On 01/19/21 at 10:55 a.m., the DON was asked to provide documentation of abuse training. At 11:12 a.m., the corporate registered nurses provided a list of on-line in-services completed by RN #1. She stated abuse was due on 01/31/21. She was asked if new employees were provided abuse training. She stated they should be on orientation. At 11:45 a.m., the administrator stated she did abuse and neglect training with new hires. She provided an in-service sign in sheet for abuse dated 07/24/20. She stated RN #1 should have been on this, but she's not. She was asked if they should have provided abuse training prior to working. She stated, Yes.

On 01/14/20, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a cognitively impaired female resident (resident #2) was not abused by another resident (resident #1). The facility documented incidents of resident #1 being found in bed with resident #2, who was cognitively impaired. She was diagnosed with alcohol dementia and Alzheimer's disease. On one occasion resident #2 was observed pulling her pants up after being caught in bed with resident #1. The facility did not document prompt notification of the administrator, investigation of possible sexual abuse and how they protected the resident or other residents from potential further sexual abuse by resident #1. The facility moved resident #2 to a different room which was discovered by resident #1 the following day. The facility listed they would do frequent checks on the resident, but failed to document this occurred routinely as ordered by the physician. Additionally, CNA observed resident #2 providing resident #1 oral sex and reported the observation to her charge nurse. This encounter was never investigated. The administration staff stated the encounter was merely a rumor and had never been observed. During the survey the resident was observed for over two hours and the facility never conducted a visual check on the resident. At 5:09 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 5:35p.m., the Administrator was notified of the IJ. An acceptable plan of removal was provided by the divisional director of clinical operations at 6:55 p.m. It documented the following: IMMEDIATE JEOPARDY PLAN OF REMOVAL 01-14-21 1. Resident #1 was placed on 1:1 observations with a nursing staff member to ensure the safety of other residents at 5:45pm until alternate placement can be secured. 2. All residents will have Safe Survey completed by 9pm to ensure no other complaints of abuse are noted. If an allegation is made, an initial state report will be filed and an investigation completed and steps to protect the resident during the investigation will be initiated. 3. An inservice will be done with Admin [administrator], DON [director of nursing], ADON's [assistant directors of nursing] on Abuse Policy, Event Management Protocols and Abuse Reporting by the Divisional Director of Clinical Operations by 8pm. This training shall include all steps of the abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuses training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences. 4. An in-service will be done on Abuse /Sexual Abuse w [with]/post-test completed by all department staff by 11pm 1/14/21. In-servicing will be done in-person or by phone; if they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. This training shall include all steps of abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuse training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences. 5. An initial state report was completed for Resident #1 and the investigation initiated, police notified and police report filed with family/physician notified. On 01/15/21, during interviews with staff, one certified nurse aide and one non-certified nurse aide stated they had been handed a packet containing in-service information and told to read it and take a test. A non-certified nurse aide stated she had just been handed a test about mishandling residents. A housekeeping supervisor stated she had been handed a packet containing the in-service information and instructed to in-service her staff. The facility still had approximately 35 staff who needed in-serviced or re-educated. At 3:30 p.m., the divisional director of clinical operations was made aware that an amended plan of removal was needed due to the number of staff not in-serviced. At 3:42 p.m., an acceptable amendment to the plan of removal was provided by the director of clinical operations. It documented the following: IMMEDIATE JEOPARDY PLAN OF REMOVAL 01-14-21 .An in-service will be done on Abuse /Sexual Abuse w [with]/post-test completed by all department staff by 11pm 1/15/21. In-servicing will be done in-person or by phone; if they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. This training shall include all steps of abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuse training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences . On 01/19/21, 17 nurse aides, three licensed practical nurses, three housekeepers and two registered nurses, from across all shifts, were interviewed and able to state accurate information related to abuse. The immediate jeopardy deficiency was lifted as of 01/15/21 at 10:52 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at level of actual harm at a pattern. Based on record review and staff interviews, it was determined the facility failed to ensure allegations and observations of sexual abuse by resident #1 were reported to the administrator and state agency for one (#2) of five sampled residents reviewed for abuse. The facility identified 111 residents resided in the facility and three had sexually inappropriate behaviors. Findings: A facility abuse policy, dated 06/23/17, documented: .The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property . Abuse Coordinator: Licensed Facility Administrator . The facility must prohibit and prevent abuse .All facility staff members have a duty to ensure that all alleged violations involving abuse .are reported to the Administrator .Upon receiving an allegation of abuse .the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation .if the allegation is reportable, report such allegation to the State Regulatory Agency .not later than 2 hours after the allegation is made . 1. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly resident assessment, dated 10/30/20, documented the resident's cognition was moderately impaired and she was independent with ambulation. An incident report, documented an incident reported on 11/07/20 at 1:22 a.m., documented, .Type of incident .possible sexual encounter .Witnesses .Yes .What time was this observed .from 2330-0100 [11:30 p.m. to 1:00 a.m.] in resident room .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Independent ambulation .Description of Incident .resident had male from across hall in rom and in bed .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .In house observation .room change to opposite end of building .DON Signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrator's name .11/22/2020 23:40 [11:40 p.m.] . A care plan, updated 11/07/20, documented, .Cognitive Deficit .Related To .Alzheimer's .Alcohol induced dementia .Evidence By .Short-term memory loss .Will recognize family at time of visit over the next 90 days .Monitor for any changes in decline in cognitive status .Offer resident two simple choices to reduce the stress of decision making .Allow ample time to absorb and respond to information .11/11/20 .Socially Inapproriate [sic] .Related To .11-7-2020 Having a man in her room in her bed .Resident will verbalize understanding of need to control socially inappropriate behavior over the next 90 days .11-7-202 room change to opposite end of building .Redirect as needed . A nurse's note, dated 11/09/20 at 7:31 a.m., documented, Resident was seen in another male resident's bed pulling up her pants. Re-directed and explained to her why these behaviors are not ok. Resident then seemed ashamed and said that it wouldn't happen again. Will continue to monitor . An incident report, dated 11/09/20, documented, .Witnessed - Yes .Cognitive status - Moderately impaired .Cognition varies throughout the day .Independent ambulation .Location of incident - Resident Room - Bed .Description of Incident .Resident was seen in another male resident's bed pulling up her pants. Redirected and explained to her why these behaviors are not ok. Resident then seemed ashamed and said that it wouldn't [sic] happen again. Will continue to monitor .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .After IDT [interdisciplinary team] huddle: frequent visual checks on male [resident #1's initials] redirection of both residents .DON [director of nurses] signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrators name] 11/22/2020 23:28 [11:38 p.m.] . A nurse's note, dated 11/11/20 at 10:25 p.m., documented, Resident monitored by staff with frequent visuals and supervised smoking r/t [related to] possible sexual encounter . An incident report, dated 11/11/20, which documented the incident had reported on 11/07/20 at 1:22 a.m., documented, .Type of incident .possible sexual encounter .Witnesses .Yes .What time was this observed .from 2330-0100 [11:30 p.m. to 1:00 a.m.] in resident room .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Independent ambulation .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .In house observation .room change to opposite end of building .DON Signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrator's name .11/22/2020 23:40 [11:40 p.m.] . 2. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 08/26/20, documented the resident had moderately impaired cognition. A nurse's note, dated 11/08/20 at 7:42 p.m., documented, Resident was seen and redirected x [times] 2 for going into female room across hall [resident #2's initials]. He was found in her bed as well. Redirected and reminded that he could not in females room. He stated to staff 'they were grown adults and not making baby.' He has remained in his room in bed resting and no other attempts. Will make oncoming shift aware . A nurse's note, dated 11/09/20 at 7:25 a.m., documented Resident was going into another female resident's room. Later during shift resident was observed with that resident in his bed pulling up her pants. Redirected both residents and explained why they couldn't be doing these behaviors. Will continue to monitor . An incident report, dated 11/09/20 at 7:25 a.m., documented, .Type of incident - Sexual behaviors .Witnessed - Yes .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Psychosocial status - Impaired judgement .Independent ambulation .Action taken - MD [medical doctor] Notified .Other Intervention - Redirected .Description of Incident Resident was going into another female resident' room. Later during the shift resident was observed with that female resident in his bed pulling up her pants. Redirected both residents and explained why they couldn't be doing these behaviors. Will continue to monitor .Supervisor Investigation .Medication review by MD .Administrators Signature [facility administrators name] Completed By [facility administrators name] 11/22/2020 23:11 [11:11 p.m.] . A nurse's note, dated 11/10/20 at 4:42 p.m., documented, Dr. [name deleted] in facility this pm. Notified of ongoing behaviors with a female resident . A nurse's note, dated 11/11/20 at 9:02 a.m., documented, Will do every 15 minute visual checks due to inappropriate sexual behavior. A care plan, onset date 11/11/20, documented, .Socially Inappropriate .Related To .11-7-2020 was in female residents room .Interventions .11-7-2020 frequent visual checks . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Frequent visual checks every shift Reason: inappropriate sexual behavior Frequency: every 15 minutes . An incident report, dated 11/11/20, documented, .Type of incident - sexual behavior .Incident Date/Time -11/07/2020, 23:30 [11:30 p.m.] .Type of Injury - Other - in woman room .What time and where was this observed .from 2330 [11:30 p.m.] - 0100 [1:00 a.m.] going into 910 .Description of Incident resident going into females room .Comments intervention; frequent visual checks .DON Signature [facility DON's name] .Administrators Signature [facility administrator's name] Completed By [facility administrator's name] 11/22/2020 23:12 [11:12 p.m.] . On 01/14/21 from 9:00 a.m. through 11:12 a.m., no staff were observed conducting every fifteen minute check for resident #1. At 10:17 a.m., licensed practice nurse (LPN) #1 was asked if she had witnessed any sexual encounter between residents #1 and #2. She stated she had not witnessed any, but had been told to watch for it by making frequent checks on resident #1. She was asked if she had concerns about sexual behaviors from resident #1. She stated, I do She was asked if female residents were at risk. She stated, Yes. LPN #1 was asked if resident #2 was cognitively intact to make safe decisions. She stated, I'm going to say, no. At 10:40 a.m., the DON was asked what the policy was for allegations of abuse. She stated to report it to the administrator, follow-up, do an investigation, report to state, do safe surveys and interviews. She was asked who she would interview. She stated she would interview the persons in the allegations. She was asked how she would keep the resident safe. She stated by removing the resident from the situation. The DON was shown the nurse's notes from 11/08 and 11/09/20. She was asked if those could have been allegations of sexual abuse. She stated, Yes. She was asked if either incidents were investigated. She stated, No, [Facility administrator] said since it's not witnessed, there was no need. She was asked if they only investigated claims of abuse that were witnessed. She stated, No. The DON was asked if an investigation should have been conducted. She stated, Yes. She was asked if there was a State reportable for the incidents. She stated, No. She was asked if resident #2 was able to safely consent for herself. She stated, No. After reviewing the incident times, the DON was asked if the every fifteen minute visual checks for resident #1 had been effective. She stated, Probably not. She was asked how they knew other residents weren't affected by the sexual abuse if investigations had not been conducted. She stated, We don't. She was asked if resident #1 was a threat to other residents. She stated, Yes. At 12:45 p.m., certified nurse aide (CNA) #1 was asked if she had seen any sexual encounters between resident #1 and #2. She stated she had. She stated she was passing snacks one afternoon around 2:30 p.m. and walked into resident #1's room and resident #2 was performing oral sex on him. She stated she left the room and went immediately and informed the charge nurse. She was asked if administration had been made aware. She stated she assumed so because the next day the resident had been moved to the other end of the building. At 1:15 p.m., the DON was asked if she was aware of resident #2 performing oral sex to resident #1. She stated, I don't think it was ever witnessed. She stated, It was kind of a rumor. She was asked if she were informed of a rumored sexual encounter would you investigate it. She stated, Yes. She was asked if there was an incident report, a state reportable or an investigation. She stated, No. At 3:40 p.m., the administrator (ADM) was asked the policy for resident abuse. She stated everyone was supposed to report, do an incident report, notify family of both parties, investigate by taking statements from witnesses, talk to residents involved, conduct safe surveys and do a state reportable within two hours. The ADM was asked if she was aware of the 11/08/20 at 6:41 a.m. incident when resident #1 was found in resident #2's bed. She stated, I was told she was walking out of his room, but nothing witnessed. She was asked if she was aware of the 11/09/20 incident when resident #1 was observed with resident #2 in his bed pulling up her pants. She stated, Only thing I was told was she was walking out of his room. The ADM was asked if she was aware oral sex had taken place between resident #1 and #2. She stated, We heard of rumors of it, but no staff witnessed it. She was asked if she only investigated allegation of abuse she witnessed. She stated, No. She was asked if it should have been investigated even though it had not been witnessed. She stated, Yes. She was asked if she was aware of interventions in place for resident #1. She stated they had conducted medication reviews and every fifteen minute checks. She was made aware of the above observation of over two hours between visual checks. She acknowledged the findings. At 4:00 p.m., CNA #1 was asked to describe what she observed take place between resident #1 and resident #2. She stated she entered the resident's room and observed feet standing under the curtain. She said she pulled back the curtain and observed resident #2 on her knees with her hands around the base of resident #1's penis and the head of the resident's penis in her mouth. CNA #1 stated she immediately left the room and notified the charge nurse. No documentation of an investigation of the encounter was provided by the facility. CNA #1 could not remember the name of the charge nurse she reported her observation to.

On 01/14/20, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a cognitively impaired female resident (resident #2) was not abused by another resident (resident #1). The facility documented incidents of resident #1 being found in bed with resident #2, who was cognitively impaired. She was diagnosed with alcohol dementia and Alzheimer's disease. On one occasion resident #2 was observed pulling her pants up after being caught in bed with resident #1. The facility did not document prompt notification of the administrator, investigation of possible sexual abuse and how they protected the resident or other residents from potential further sexual abuse by resident #1. The facility moved resident #2 to a different room which was discovered by resident #1 the following day. The facility listed they would do frequent checks on the resident, but failed to document this occurred routinely as ordered by the physician. Additionally, CNA observed resident #2 providing resident #1 oral sex and reported the observation to her charge nurse. This encounter was never investigated. The administration staff stated the encounter was merely a rumor and had never been observed. During the survey the resident was observed for over two hours and the facility never conducted a visual check on the resident. At 5:09 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 5:35p.m., the Administrator was notified of the IJ. An acceptable plan of removal was provided by the divisional director of clinical operations at 6:55 p.m. It documented the following: IMMEDIATE JEOPARDY PLAN OF REMOVAL 01-14-21 1. Resident #1 was placed on 1:1 observations with a nursing staff member to ensure the safety of other residents at 5:45pm until alternate placement can be secured. 2. All residents will have Safe Survey completed by 9pm to ensure no other complaints of abuse are noted. If an allegation is made, an initial state report will be filed and an investigation completed and steps to protect the resident during the investigation will be initiated. 3. An inservice will be done with Admin [administrator], DON [director of nursing], ADON's [assistant directors of nursing] on Abuse Policy, Event Management Protocols and Abuse Reporting by the Divisional Director of Clinical Operations by 8pm. This training shall include all steps of the abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuses training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences. 4. An in-service will be done on Abuse /Sexual Abuse w [with]/post-test completed by all department staff by 11pm 1/14/21. In-servicing will be done in-person or by phone; if they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. This training shall include all steps of abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuse training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences. 5. An initial state report was completed for Resident #1 and the investigation initiated, police notified and police report filed with family/physician notified. On 01/15/21, during interviews with staff, one certified nurse aide and one non-certified nurse aide stated they had been handed a packet containing in-service information and told to read it and take a test. A non-certified nurse aide stated she had just been handed a test about mishandling residents. A housekeeping supervisor stated she had been handed a packet containing the in-service information and instructed to in-service her staff. The facility still had approximately 35 staff who needed in-serviced or re-educated. At 3:30 p.m., the divisional director of clinical operations was made aware that an amended plan of removal was needed due to the number of staff not in-serviced. At 3:42 p.m., an acceptable amendment to the plan of removal was provided by the director of clinical operations. It documented the following: IMMEDIATE JEOPARDY PLAN OF REMOVAL 01-14-21 .An in-service will be done on Abuse /Sexual Abuse w [with]/post-test completed by all department staff by 11pm 1/15/21. In-servicing will be done in-person or by phone; if they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. This training shall include all steps of abuse policy, including resident rights, protection of residents, duty to report internally and applicable agencies, including OSDH, screening potential facility employees, abuse training, and prevention of abuse, neglect, exploitation, misappropriation of resident property, thorough investigations, and identification of events and occurrences . On 01/19/21, 17 nurse aides, three licensed practical nurses, three housekeepers and two registered nurses, from across all shifts, were interviewed and able to state accurate information related to abuse. The immediate jeopardy deficiency was lifted as of 01/15/21 at 10:52 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at a level of actual harm at a pattern. Based on observations, interviews and record reviews, it was determined the facility failed to ensure: 1. allegations of sexual abuse by resident #1 were investigated and residents were protected from further sexual abuse for (#2) of five sampled residents reviewed for abuse; and 2. allegations of sexual abuse were thoroughly investigated for one (#4) of five sampled residents reviewed for abuse. The facility identified 111 residents resided in the facility and three had sexually inappropriate behaviors. Findings: A facility abuse policy, dated 06/23/17, documented, .The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property . Abuse Coordinator: Licensed Facility Administrator . The facility must prohibit and prevent abuse .All facility staff members have a duty to ensure that all alleged violations involving abuse .are reported to the Administrator .Upon receiving an allegation of abuse .the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation .if the allegation is reportable, report such allegation to the State Regulatory Agency .not later than 2 hours after the allegation is made . Investigation .The Abuse Coordinator will immediately begin an investigation .Resident(s) and responsible party interviews .Staff interviews and written statements .Methods to support the individual and detect and prevent further victimization .protect residents by removing immediate threats and potential harm . 1. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly resident assessment, dated 10/30/20, documented the resident's cognition was moderately impaired and she was independent with ambulation. An incident report, documented an incident reported on 11/07/20 at 1:22 a.m., documented, .Type of incident .possible sexual encounter .Witnesses .Yes .What time was this observed .from 2330-0100 [11:30 p.m. to 1:00 a.m.] in resident room .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Independent ambulation .Description of Incident .resident had male from across hall in rom and in bed .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .In house observation .room change to opposite end of building .DON Signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrator's name .11/22/2020 23:40 [11:40 p.m.] . A care plan, updated 11/07/20, documented, .Cognitive Deficit .Related To .Alzheimer's .Alcohol induced dementia .Evidence By .Short-term memory loss .Will recognize family at time of visit over the next 90 days .Monitor for any changes in decline in cognitive status .Offer resident two simple choices to reduce the stress of decision making .Allow ample time to absorb and respond to information .11/11/20 .Socially Inapproriate [sic] .Related To .11-7-2020 Having a man in her room in her bed .Resident will verbalize understanding of need to control socially inappropriate behavior over the next 90 days .11-7-202 room change to opposite end of building .Redirect as needed . A nurse's note, dated 11/09/20 at 7:31 a.m., documented, Resident was seen in another male resident's bed pulling up her pants. Re-directed and explained to her why these behaviors are not ok. Resident then seemed ashamed and said that it wouldn't happen again. Will continue to monitor . An incident report, dated 11/09/20, documented, .Witnessed - Yes .Cognitive status - Moderately impaired .Cognition varies throughout the day .Independent ambulation .Location of incident - Resident Room - Bed .Description of Incident .Resident was seen in another male resident's bed pulling up her pants. Redirected and explained to her why these behaviors are not ok. Resident then seemed ashamed and said that it wouldn't [sic] happen again. Will continue to monitor .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .After IDT [interdisciplinary team] huddle: frequent visual checks on male [resident #1's initials] redirection of both residents .DON [director of nurses] signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrators name] 11/22/2020 23:28 [11:38 p.m.] . A nurse's note, dated 11/11/20 at 10:25 p.m., documented, Resident monitored by staff with frequent visuals and supervised smoking r/t [related to] possible sexual encounter . An incident report, dated 11/11/20, which documented the incident had reported on 11/07/20 at 1:22 a.m., documented, .Type of incident .possible sexual encounter .Witnesses .Yes .What time was this observed .from 2330-0100 [11:30 p.m. to 1:00 a.m.] in resident room .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Independent ambulation .Notified To .Physician .Family .Supervisor . Supervisor Investigation of Events and Interventions .In house observation .room change to opposite end of building .DON Signature [facility DON's name] .Administrators Signature [facility administrators name] .Completed By [facility administrator's name .11/22/2020 23:40 [11:40 p.m.] . 2. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 08/26/20, documented the resident had moderately impaired cognition. A nurse's note, dated 11/08/20 at 7:42 p.m., documented, Resident was seen and redirected x [times] 2 for going into female room across hall [resident #2's initials]. He was found in her bed as well. Redirected and reminded that he could not in females room. He stated to staff 'they were grown adults and not making baby.' He has remained in his room in bed resting and no other attempts. Will make oncoming shift aware . A nurse's note, dated 11/09/20 at 7:25 a.m., documented Resident was going into another female resident's room. Later during shift resident was observed with that resident in his bed pulling up her pants. Redirected both residents and explained why they couldn't be doing these behaviors. Will continue to monitor . An incident report, dated 11/09/20 at 7:25 a.m., documented, .Type of incident - Sexual behaviors .Witnessed - Yes .Location of incident - Resident Room - Bed .Cognitive status - Moderately impaired .Psychosocial status - Impaired judgement .Independent ambulation .Action taken - MD [medical doctor] Notified .Other Intervention - Redirected .Description of Incident Resident was going into another female resident' room. Later during the shift resident was observed with that female resident in his bed pulling up her pants. Redirected both residents and explained why they couldn't be doing these behaviors. Will continue to monitor .Supervisor Investigation .Medication review by MD .Administrators Signature [facility administrators name] Completed By [facility administrators name] 11/22/2020 23:11 [11:11 p.m.] . A nurse's note, dated 11/10/20 at 4:42 p.m., documented, Dr. [name deleted] in facility this pm. Notified of ongoing behaviors with a female resident . A nurse's note, dated 11/11/20 at 9:02 a.m., documented, Will do every 15 minute visual checks due to inappropriate sexual behavior. A care plan, onset date 11/11/20, documented, .Socially Inappropriate .Related To .11-7-2020 was in female residents room .Interventions .11-7-2020 frequent visual checks . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Frequent visual checks every shift Reason: inappropriate sexual behavior Frequency: every 15 minutes . An incident report, dated 11/11/20, documented, .Type of incident - sexual behavior .Incident Date/Time -11/07/2020, 23:30 [11:30 p.m.] .Type of Injury - Other - in woman room .What time and where was this observed .from 2330 [11:30 p.m.] - 0100 [1:00 a.m.] going into 910 .Description of Incident resident going into females room .Comments intervention; frequent visual checks .DON Signature [facility DON's name] .Administrators Signature [facility administrator's name] Completed By [facility administrator's name] 11/22/2020 23:12 [11:12 p.m.] . On 01/14/21 from 9:00 a.m. through 11:12 a.m., no staff were observed conducting every fifteen minute check for resident #1. At 10:17 a.m., licensed practice nurse (LPN) #1 was asked if she had witnessed any sexual encounter between residents #1 and #2. She stated she had not witnessed any, but had been told to watch for it by making frequent checks on resident #1. She was asked if she had concerns about sexual behaviors from resident #1. She stated, I do She was asked if female residents were at risk. She stated, Yes. LPN #1 was asked if resident #2 was cognitively intact to make safe decisions. She stated, I'm going to say, no. At 10:40 a.m., the DON was asked what the policy was for allegations of abuse. She stated to report it to the administrator, follow-up, do an investigation, report to state, do safe surveys and interviews. She was asked who she would interview. She stated she would interview the persons in the allegations. She was asked how she would keep the resident safe. She stated by removing the resident from the situation. The DON was shown the nurse's notes from 11/08 and 11/09/20. She was asked if those could have been allegations of sexual abuse. She stated, Yes. She was asked if either incidents were investigated. She stated, No, [Facility administrator] said since it's not witnessed, there was no need. She was asked if they only investigated claims of abuse that were witnessed. She stated, No. The DON was asked if an investigation should have been conducted. She stated, Yes. She was asked if there was a State reportable for the incidents. She stated, No. She was asked if resident #2 was able to safely consent for herself. She stated, No. After reviewing the incident times, the DON was asked if the every fifteen minute visual checks for resident #1 had been effective. She stated, Probably not. She was asked how they knew other residents weren't affected by the sexual abuse if investigations had not been conducted. She stated, We don't. She was asked if resident #1 was a threat to other residents. She stated, Yes. At 12:45 p.m., certified nurse aide (CNA) #1 was asked if she had seen any sexual encounters between resident #1 and #2. She stated she had. She stated she was passing snacks one afternoon around 2:30 p.m. and walked into resident #1's room and resident #2 was performing oral sex on him. She stated she left the room and went immediately and informed the charge nurse. She was asked if administration had been made aware. She stated she assumed so because the next day the resident had been moved to the other end of the building. At 1:15 p.m., the DON was asked if she was aware of resident #2 performing oral sex to resident #1. She stated, I don't think it was ever witnessed. She stated, It was kind of a rumor. She was asked if she were informed of a rumored sexual encounter would you investigate it. She stated, Yes. She was asked if there was an incident report, a state reportable or an investigation. She stated, No. At 3:40 p.m., the administrator (ADM) was asked the policy for resident abuse. She stated everyone was supposed to report, do an incident report, notify family of both parties, investigate by taking statements from witnesses, talk to residents involved, conduct safe surveys and do a state reportable within two hours. The ADM was asked if she was aware of the 11/08/20 at 6:41 a.m. incident when resident #1 was found in resident #2's bed. She stated, I was told she was walking out of his room, but nothing witnessed. She was asked if she was aware of the 11/09/20 incident when resident #1 was observed with resident #2 in his bed pulling up her pants. She stated, Only thing I was told was she was walking out of his room. The ADM was asked if she was aware oral sex had taken place between resident #1 and #2. She stated, We heard of rumors of it, but no staff witnessed it. She was asked if she only investigated allegation of abuse she witnessed. She stated, No. She was asked if it should have been investigated even though it had not been witnessed. She stated, Yes. She was asked if she was aware of interventions in place for resident #1. She stated they had conducted medication reviews and every fifteen minute checks. She was made aware of the above observation of over two hours between visual checks. She acknowledged the findings. At 4:00 p.m., CNA #1 was asked to describe what she observed take place between resident #1 and resident #2. She stated she entered the resident's room and observed feet standing under the curtain. She said she pulled back the curtain and observed resident #2 on her knees with her hands around the base of resident #1's penis and the head of the resident's penis in her mouth. CNA #1 stated she immediately left the room and notified the charge nurse. No documentation of an investigation of the encounter was provided by the facility. CNA #1 could not remember the name of the charge nurse she reported her observation to. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 06/17/20 at 2:27 p.m., documented, Behavior - Resident displaying aggressive behavior today, throughout various times of the day resident was stating that different female staff was coming into room and being inappropriate in a sexual manor [sic], stating that a 'woman is in my bed touching me on my private parts, where my wife and I touch each other' . A state reportable incident, dated 06/17/20, documented, .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Resident states that different female staff and other females are being inappropriate in a sexual manor [sic] during his bath today, but resident did not receive a bath today. Then stating that a 'woman is in my bed touching me on my private parts, where my wife and I touch each other' the resident would state the same things to different staff when no one is in his bed with him. Resident refused his bath from all female and male CNA today .Investigation started . Summary of investigation .Resident has been displaying behaviors of coming out of room and walking down hall, confused staff yelling and screaming at different staff. Dr [doctor] has ordered for attempt to get lab and UA [urine analysis] to rule out UTI [urinary tract infection]. Resident initially said that someone touched him inappropriately during his bath today and that a lady was in his bed touching him. Upon investigation resident refused his bath from all staff today, no bath or personal care was given such as dressing, resident dresses self. Staff and room-mate confirm there was never a lady in his room with him at all. Resident interview changed story from saying people are being inappropriate with him to he is upset because people are saying he is being inappropriate with them. Reassured resident that no one feels he has done anything wrong .Unable to substantiate any abuse, behaviors and confusion related to infection .[facility administrator's name] Reporting Party . On 01/15/20 at 12:26 p.m., the administrator was shown the state reportable incident and was asked if any further interviews were conducted with other residents or staff related to the allegations. She stated, Yes. She stated, Let me go ask my ADONs [assistant directors of nursing] for any paperwork. At 2:02 p.m., the ADM stated, I cannot find anything else for [resident #4]. She was asked if a thorough investigation had been conducted for resident #4's allegations of sexual abuse. She stated, Yes.

Based on record review and interview, it was determined the facility failed to ensure ~ CNAs did not neglect to report falls when they occur to the charge nurse, ~ a full assessment was completed every shift after a fall with injury for one (#7) of three sampled residents with falls with injury. Findings: Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The comprehensive resident assessment, dated 01/25/11, documented the resident required extensive assistance with transfers, ambulation, hygiene and bathing. She required limited assistance with dressing. It documented she was occasionally incontinent of bladder. An incident report, dated 02/17/11, documented, "c/o pain Rt foot - Lt foot - Rt knee - contusion unknown origin to Lt foot c swelling noted - res unable to recall origin of injury." A shift report, dated 02/17/11, documented, "3-11...(resident #7) IR unknown etiology - contusion (L) foot c/o pain. Rt Knee (and) L foot x-ray complete awaiting result." A shift report, dated 02/18/11, documented, "7-3...(resident #7) IR Fx R fibula, keep elevated 2 person c gait belt total lift - N/O non weight bearing, ortho consult [MEDICATION NAME] 5/500 q 4-6(hour) PRN/ monitor pain." On 02/18/11, a radiology report documented, "...There is a nondisplaced [MEDICAL CONDITION] right fibula...No fracture seen in the left. Soft tissue swelling and [MEDICAL CONDITION] is present in both ankles. Impression: Nondisplaced distal right fibula fracture." A handwritten note on the bottom of the page documented, "02/18/11 R non weight bearing (and) ortho consult - [MEDICATION NAME] 5/500 Q 4-6 (hours) PRN." A nurses' note, dated 02/18/11, documented, "145p (1:45 p.m.) Daughter in facility (and) notified of N/O's in bed c BLE (up). Discoloration to L foot remains, [MEDICAL CONDITION] to B feet..." A shift report, dated 02/19/11, documented, "11/7...(resident #7 - IR/Fx R tibia - keep elevated - non wt bearing - 2 person assist c gait belt or total lift." A shift report, dated 02/19/11, documented, "7-11..(resident #7) IR broken ankle." A shift report, dated 02/20/11, documented, "11/7...(resident #7) IR broke ankle" A shift report, dated 02/20/11, documented, "7-11...(resident #7) IR broken foot." A shift report, dated 02/21/11, documented, "11/7...(resident #7) IR broke ankle - Drs appt this am." A shift report, dated 02/21/11, documented, "11/7...(resident #7) monitor - broken ankle/foot Tx." A shift report, dated 02/21/11, documented, "7-3...(resident #7) monitor B feet." A shift report, dated 02/21/11, documented, "3-11..(resident #7) monitor B feet." A nurses' note, dated 02/21/11, documented, "215p (2:15 p.m.) In bed this shift c BLE (up) on pillow. Bed bath given...Discoloration to L foot remains..." A shift report, dated 02/22/11, documented, "7-3...(resident #7) Monitor Bilat feet Tx to Dr 2/23." There was no documentation of a full assessment from 02/17/11 after the incident report until 02/21/11, for the left and right foot and right knee after the injury. On 02/21/11, a non-pressure skin condition report documented, "1.4 x 0.8 x utd - wound bed black/brown (eschar) - Surrounding skin color purple. Comments: noted firm blackened area to top of L lat'l foot c swelling (and) purplish discoloration." The initial / final investigation report, faxed to OSDH on 02/22/11, documented, "...CNA #5 stated that she had toileted (Resident #7) during her shift at approximately 9 a.m. and during the transfer from the toilet, the resident became unstable and she lowered her to the floor, sliding her down her own leg to a sitting position with the residents legs straight out in front of her....she did not report it to her charge nurse." On 02/23/11 at 9:00 a.m., the DON and the wound nurse looked at the wound on the resident's left foot. She stated she had looked at the foot on Friday (02/18/11) evening and it did not look like this. There was only a small bruise about a quarter size and there was no swelling. On 02/25/11 at 3:30 p.m., a family member of resident #7 was asked if she was notified of the fracture. She stated she was the one on that evening (02/17/11) that pointed out the swelling, bruising, and the blackened area on the left foot to the CNA. The CNA stated she was wondering what happened to her foot. The survey team was shown a picture message (MMS), dated 02/18/11 at 3:18 p.m., which verified the left foot to have swelling, bruising, and the firm blackened area to the top left lateral foot was apparent on 02/18/11. At 4:40 p.m., the administrator and the DON were asked if they had looked at the residents foot prior to today. They stated they went down there on Friday evening and looked at it. There was a deep purple bruise and it was slightly swollen. They were asked how the injury was discovered. The DON stated after the CNA went to the charge nurse, she notified the doctor for orders to do an x-ray, and she filled out an incident report. The DON was informed of the lack of documentation for the assessment of the foot, and that the resident was on a blood thinner. The staff were also informed of the picture message that was shown to the surveyors which verified what the left foot looked like on Friday (02/18/11). The DON stated the nurses would have to had looked at the foot each time they put the ace wrap on her feet. They put them on in the morning and take them off in the evening. The nurses' notes were reviewed by the corporate RN and the DON. The corporate nurse stated the staff needs to document and be more specific.