Every finding on record at River Oaks Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure medications were secured/locked when not attended to for 1 (hall 200) of 2 medication/treatment carts observed for medication storage. The administrator identified 69 residents resided in the facility. Findings: On 04/15/25 at 10:19 a.m., a medication cart was observed unlocked on hall 200 in front of room [ROOM NUMBER]. There was no staff present. A policy titled Storage of Medications, dated 01/2022, read in part, Medications and biologicals are stored safely, securely .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication carts and medication supplies are locked when not attended by persons with authorized access. On 04/15/25 at 10:20 a.m., ACMA #1 returned to the cart and was asked if the medication cart was locked. They looked and stated, No, I thought I locked it as the top drawer does not always lock. I just pushed it in and it must have popped open when I walked away. ACMA #1 was asked if it was reported to maintenance. They stated it had not been reported as it happened this morning. ACMA #1 stated they did not normally work on that cart and their pharmacy consultant was currently there and they were going to report it to them. On 04/15/25 at 10:23 a.m., ACMA #1 stated they alerted the pharmacy consultant immediately.

45462 Based on record review, observation, and interview, the facility failed to provide maintenance services necessary to ensure the following: a. a sanitary and comfortable interior for one (#20) of 24 sampled residents reviewed for homelike environment, and b. odors did not linger on one unit (Route 66- Hall 300) of three units observed for odors. The Resident Census and Conditions of Residents report, dated 12/06/22, documented there were 74 residents residing in the facility. There were 27 residents residing on Route 66 - Hall 300. Findings: A Maintenance policy, dated 06/27/06, read in parts, .This facility shall provide a safe, functional, sanitary and comfortable environment for residents .and assure the good repair of the entire facility . 1. Resident #20 had diagnoses which included hypertension and heart disease. A Comprehensive Resident Assessment, dated 06/16/22, documented Resident #20's cognition was moderately impaired. On 12/06/22 at 1:37 p.m., Resident #20 was observed in their room. There was a blanket observed to be rolled up on the floor between the toilet and the wall in their bathroom. The base board was pulled away from the wall and the drywall was wet and deteriorated behind the base board. Resident #20 was asked why the blanket was on the bathroom floor. They stated there had been a leak next to the toilet for about two to three weeks. Resident #20 was asked if staff were aware of the issue. They stated they must be, because they were the ones putting the blankets down. A Completed Work Orders log, dated January 2022 through November 2022, had no documentation of the water leak in Resident #20's bathroom. On 12/07/22 at 12:49 p.m., the Maintenance Supervisor was shown Resident #20's room and asked why the blanket was on the floor. He stated he didn't know why the blanket was there, but the wall looked wet. He was asked if anyone had reported this issue to him. He stated, No, but it looks like I need to get on it. On 12/07/22 at 12:55 p.m., the Administrator was shown Resident #20's bathroom with the rolled up blanket between the toilet and the wall, baseboard pulled away from the wall, and the drywall wet and deteriorated. The Administrator stated she was not aware of the issue and would call the plumber. 2. On 12/06/22 at 10:00 a.m., upon arriving on hall 300, a strong urine odor was noted in the hallway at the nurses' station. On 12/06/22 at 12:00 p.m., a strong urine odor was noted when passing 300 hall nursing station and in the sitting area on hall 300. A strong urine odor could be smelled in the hall outside of room [ROOM NUMBER]. On 12/07/22 at 8:07 a.m., a strong urine odor was noticed in the 300 hall at the nurses' station. RN #1 was observed at nurses' station on hall 300. RN #1 was asked if they smelled an odor in the hallway. They stated, That urine smell may be coming from room [ROOM NUMBER]. I see the housekeepers are in there two to three times a day. That gentleman has a dog and he's not a very clean person. On 12/07/22 at 8:10 a.m., the floor tech was observed cleaning the floor around the nurses' station on hall 300. They were asked if they smelled an odor in the hallway. The floor tech stated, I do not smell anything, but I will check around for a possible cause. On 12/07/22 at 8:46 a.m., there was a very strong urine odor on hall 300 between rooms [ROOM NUMBERS]. On 12/07/22 at 11:07 a.m., the DON was asked about the strong urine odor present around the nurses' station on hall 300. The DON stated they were aware of the lingering odor on Route 66 [hall 300] near the nurses' station. They were asked what the facility policy was on maintaining an odor-free environment. The DON stated, Housekeeping should address problems with odors immediately when present. They were asked what was causing the strong urine odor around the nurses' station on hall 300. The DON stated, There are two residents on that unit that urinate on the floor. When we see the problem we try to address it immediately. All the rooms have individual heaters and that makes it worse. She was asked what was being done to eliminate the problem. The DON stated, We try to educate and investigate as much as we can. We have increased cleaning and changing of residents there. We have increased housekeeping hours on that unit during the week and on the weekends. We moved the DON office to that hall to help monitor and improve opportunities for education. On 12/08/22 at 8:17 a.m., the Administrator stated the tile in rooms [ROOM NUMBERS] had odors trapped in them from the lift station backing up into the rooms the through the toilets. She stated the lift station has been repaired multiple times, but the tile continued to have the odors trapped in it. She stated they had increased housekeeping in those rooms, but due to the smell being trapped in the tile, they were unable to get rid of the odor. 46216

Based on record review, observation, and interview, the facility failed to ensure the physician prescribed about of formula was administered to one (#2) of two sampled resident reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents required tube feedings. Findings: Resident #2 had diagnoses which included aphasia and protein calorie malnutrition. A Resident Assessment, dated 09/12/22, documented the resident received tube feedings. A Physician's Order, dated 10/21/22, read in parts, .Enteral Feed .four times a day Give 1.5 cartons (350 cc) Glucerna 1.5 via peg tube Q 6hrs for PROTIEN [sic] -CALORIE MANLNUTRION [sic] . On 12/07/22 at 8:43 a.m., LPN #1 was observed to pour Glucerna 1.5 into a water pitcher that was marked in ounces and cc's. The amount of formula LPN #1 poured into the water pitcher measured halfway between the 300 cc mark and the 350 cc mark, and halfway between the 10 and 12 ounce mark. LPN #1 was observed to look at the formula and stated, 350, right? LPN #1 was observed to administer the 325 cc's of formula to Resident #2. On 12/07/22 at 9:12 a.m., the DON was asked how staff ensured they administered the physician ordered amount of formula. She stated by checking the orders and measuring the formula using a graduated measuring container. She was made aware of the above observation.

Based on observation and interview the facility failed to ensure clean plates and bowls were stored inverted or covered to prevent exposure to contamination. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 74 residents resided in the facility and two residents received tube feedings. Findings: Title 310. Oklahoma State Department of Health, Chapter 257. Food Establishments, 310:257-7-105. Equipment, utensils, linens, and single-service and single-use articles, read in part, .(b) Clean equipment and utensils shall be stored .(2) Covered or inverted . On 12/07/22 at 10:44 a.m., clean plates were observed in the plate holder with the food surface side up. Additional clean plates and bowls were observed stacked along the side of the steam table with the food surface side up. On 12/07/22 at 10:45 a.m., the Dietary Manager was asked where clean dishes were stored after they were air dried. The Dietary Manager pointed out the clean serving plates uncovered and not inverted stored in the plate holder. They were asked if the dishes were stored properly. The Dietary Manager stated, Yes. They were informed that clean dishes are required to be stored inverted or covered. They stated, I will correct it right away.

Based on observation and interview, the facility failed to ensure the laundry room was maintained in safe operating conditions by not cleaning out the lint traps for two of two dryers observed. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 74 residents resided in the facility. Findings: On 12/08/22 at 11:59 a.m., a tour of the laundry room was conducted. An observation was made of two dryers in the laundry room. There was a build up of half an inch to one inch of lint observed on the floor once the lids to the lint traps were opened. Housekeeper #1, who was present during the observation, stated that they weren't sure when the lint traps were last cleaned. They were asked to provide the cleaning log for the lint traps and were unable to locate the log. The dryer vent lid had a sticker that read it was to be cleaned every day. On 12/08/22 at 12:10 p.m., the Maintenance Supervisor stated there used to be a cleaning schedule posted in the laundry room. A cleaning log was not located. The Maintenance Supervisor stated they cleaned the lint traps every Friday. He was asked how often the lint traps should be cleaned. The Maintenance Supervisor stated they were unsure. On 12/08/22 at 1:26 p.m., the Administrator stated there was not a policy on cleaning the lint traps.

Based on record review and staff interview, the facility failed to ensure a resident's legal representative was notified of a change in condition for one (#1) of three sampled residents reviewed for notification. The ADON identified 76 residents resided in the facility. Findings: A Notification of Change guideline, read in part, .The facility will .notify the resident's legal representative or interested family member of .A significant change in the resident's .status . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress note dated 11/30/21 at 11:27 a.m., read in part, Resident abnormal lab work from bmp reported to [resident #1's doctor] .lab work that resident is in chronic kidney failure and ordered resident to be sent out to ER for further evaluation .[Ambulance service] picked up resident and transporting to [receiving hospital] . There was no documentation the resident's legal representative had been notified. A Progress note dated 12/01/21 at 3:44 p.m., read in part, [Resident #1's legal representative] has been updated that resident is now at [hospital name deleted] .for renal failure . On 12/14/21 at 11:10 a.m., LPN #1 was asked if resident #1's legal representative had been notified when he was sent to the ER. He stated the legal representative had officially been notified the next day on 12/01/21. At 11:17 a.m., the DON was informed that LPN #1 had notified resident #1's legal representative the day of his transfer to the ER. She stated he should have.

Based on record review and staff interview, it was determined the facility failed to notify the physician and resident's legal representative of falls for one (#1) of three sampled residents whose clinical records were reviewed for incidents. The facility identified 68 residents resided in the facility. Findings: A resident's family or physician notification of change guideline, documented, .Purpose - This is a guideline to know when it may be necessary to notify the resident's family or physician. The facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or interested family member of the following events .An accident involving the resident, that results in injury and has the potential for requiring physician intervention .A significant change in the resident's physical, mental, or psychosocial status .A need to alter treatment significantly .A decision to transfer or discharge the resident from the facility .The facility will inform the resident and, if known, the resident's legal representative . Resident #1 had [DIAGNOSES REDACTED]. A quarterly resident assessment, dated 04/30/16, documented the resident's cognition was intact and he required extensive assistance with transfers and ambulation in his room. He required supervision with locomotion off and on the unit. He utilized a wheelchair for a mobility device. A care plan, revised 06/09/16, documented, .Focus .(Resident) is at risk for injury related to falls d/t (due to) Muscular wasting/Disuse Atrophy, Muscle Spasms, Chronic Pai[DIAGNOSES REDACTED], [MEDICAL CONDITION], Spinal Stenosis, environmental factors .Goal .(Resident) will be free of injury related to falls through the review date .Interventions .(Resident) requires assist with transfers. 1-2 person assist as needed. He uses an electric wheelchair with self releasing belt for sudden starts and stops. He remains able to release seat belt on his own . A nurse's progress note, dated 06/15/16 at 7:09 p.m., documented, .CN (charge nurse) called to room by CMA (certified medication aide). Resident sitting on floor in front of w/c (wheelchair). Resident states, I didn't fall, I got down to grab my shoes and locked up so I couldn't get back up. Resident reassured staff that he had no injuries and was in no pain. Resident assisted to w/c. No redness or bruising noted. Call light in reach . A nurse's progress note, dated 07/09/16 at 7:53 p.m., documented, .Focused assessment r/t (related to) resident c/o (complaints of) dissatisfaction with care rendered. Resident was found lying on floor by this nurse and CMA, no injuries noted, all vss (vital signs stable), no neurological deficits, resident denies head injury, mental status is baseline. Resident has a history of crawling on floor to get from one area of room to another instead of waiting for staff assistance after pushing call light. Resident was re-educated about not attempting to self transfer without staff assistance, did not verbalize understanding. Resident was re-educated about call light, did not verbalize understanding. Resident's speech was slurred and unclear. After 4 attempts at asking resident what he was trying to say, resident stated Gait belt. Resident was educated that gait belts were for ambulation, not trying to lift a person off of the floor. Resident was assisted back to bed by this nurse and CMA. Will continue to monitor . There was no documentation located in the resident's clinical record the physician or resident's legal representative was notified of the incidents that occurred on 06/15/16 and 07/09/16. On 08/30/16 at 4:10 p.m., the ADON was asked if the resident's physician and family/legal representative had been notified of the incidents on 06/15/16 and 07/09/16. She stated, No, I don't see where they were. She was asked if they should have been notified. She stated, Yes. At 4:13 p.m., the ADON was asked what the policy was for physician and family notification. She stated we would notify physician and families of any changes with medications, any falls, when the doctor visits, results of lab, weight loss and anything else like that.

Based on record review and staff and family interviews, it was determined the facility failed to provide a copy of medical records when requested for one (#1) of one sampled resident whose family had requested records in the past six months. The facility identified 68 residents resided in the facility. The facility identified one resident's family/legal representative had requested medical records in the past six months. Findings: A facility Confidentiality and Release of Medical Information from Resident Medical Records policy, last revised 08/19/03, documented, .The release of medical information will occur only to individuals with proper authorization from the resident of whom the medical record pertains or their authorized representative . Requests for medical information are answered upon receipt of the request. The Administrator and the Director of Nursing are notified of any request prior to release . Procedure .Resident Access to their Medical Records: A resident or legal representative has the right to review the medical record and to obtain copies . 1. The resident may submit an oral and written request to review or obtain photocopies of the record. 2. Review: Residents must have access to all their records (including medical, financial, etc. (et cetera))upon request by the resident or the resident's legal representative, within 24 hours (excluding hours occurring during a weekend or holiday) after making such a request. 3. Photocopies: The facility must respond to the resident's request for photocopies within 2 working days of written request. Residents are charged for photocopies. 4. Prepayment for photocopies is preferred. Photocopy fees are based on the community standard and /or state statute. The community standard is based on the fee charged at the library or post office . Resident #1 had [DIAGNOSES REDACTED]. On 08/16/16 at 3:20 p.m., resident #1's legal representative was interviewed. She stated she requested the resident's medical records on 07/18/16 from the facility. She stated she received a letter in the mail approximately one week later from the corporate office stating they had received her request for medical records and she would be receiving a notice for an amount of postage and records at $0.50 per page. She stated she had still not received the copy of the resident's medical record. A monthly social services note, signed 07/18/16, documented, (Resident #1's daughter) had given me a written medical records request and dated it 7/18/17 (sic) not once but twice. Gave the request to the DON (director of nursing). I informed daughter the copies would be 50 cents each. Request sent to corporate and it is being processed. discharged to home with daughter. A letter to resident #1's daughter from the facility's corporate office, dated 08/19/16, documented, .Records Request for Records Pertaining to (resident #1) .The documents you have requested related to the above individual have been copied and are ready to be shipped to you. Please remit $550.00 (4703 pages, including both paper copies and electronic medical records), which represents total charges for copying and shipping .Upon receipt of payment, the requested records will be shipped to you . On 08/30/16 at 3:10 p.m., assistant director of nursing (ADON) was asked what the policy was for access to medical records. She stated if they receive a request, they fax the request to the corporate office. She stated the corporate office would then contact the resident/legal representative to confirm which records they were requesting, pull those records from the facility's electronic medical record and the facility would send the paper chart to the corporate office. She was asked what the policy was on a time frame for providing medical records. She stated they tried to do a three day turn around. At 3:50 p.m., the ADON, who was identified as the person in charge of medical records, was asked if resident #1's legal representative had been provided the requested medical records timely. She stated, I'm not sure when corporate sent them. She stated, I'm not sure what our policy is. She stated, I just know that when we get a request, we try to turn it in to corporate within three days.

Based on observation and staff interviews, it was determined the facility failed to ensure: ~ food service equipment was kept clean and maintained in good repair, ~ food products were date marked, ~ food products were labeled with product name, ~ toxic items were not stored next to or above food products or single-use article, ~ food products were covered during storage, ~ soiled rags were stored in proper sanitizer solution and ~ assistance with meals was provided in a manner to prevent cross contamination for resident #67. The facility identified 67 residents who received their food from the kitchen. Four residents received nutrition and hydration through a feeding tube. The Resident Census and Conditions report, dated 03/08/16, identified 18 residents who required assistance of one or two staff members with eating. Findings: 1. On 03/07/16 at 7:40 a.m., a tour of the kitchen was conducted. The following observations were made: ~ two opened containers of cottage cheese were not date marked with an open date or a discard date on a shelf in the walk-in cooler, ~ a one gallon container of Kraft ranch dressing was open and had no lid on the container on a shelf in the walk-in cooler, ~ there was an accumulation of lint on fan guards on the condenser in the walk-in cooler, ~ material was peeling off of the racks and there was an accumulation of food and black residue on the racks in the walk-in cooler, ~ there was an accumulation of brown and white residue on the dish machine, drainboards, three compartment sink and shelving in the dish wash area, ~ there were two metal containers of pepper that were not labeled on a shelf on the table located next to the stove, ~ there was a can of cinnamon spice air [MEDICATION NAME] and a container of germicidal wipes stored on a shelf next to two metal containers of pepper on the table located next to the stove, ~ there was an accumulation of black residue on the base of the table mounted can opener, ~ there was an accumulation of lint and grease on the condiment rack next to the ansul system, ~ there were two containers of oven and grill cleaner stored above multiple boxes of steam pan liners, ~ soiled rags were stored in improper sanitizer solution, the sanitizer solution for quaternary ammonia was greater than 400 parts per million (ppm), ~ there was an accumulation of brown residue inside of the ice machine and ~ the shelf below the prep table that contained the pot/pan and utensil rack was dirty with a brown residue/rust. On 03/08/16 at 2:03 p.m., the kitchen observations were discussed with the dietary manager (DM). She was asked what the policy was for date marking . She stated food products should have been date marked when they were received and should have been date marked when the food product was opened. She was asked what policy was for food storage. She stated food products should have been stored to protect them from contamination, stored up off of the floor and sealed. She was asked what the policy was for cleaning food service equipment. She stated equipment should have been cleaned daily and deep cleaned twice a month. She was asked what the policy was on labeling dry products. She stated dry products should have been labeled. She was asked what the policy was for proper storage of chemicals. She stated chemicals should have been stored out of the reach of the residents and away from food. She was asked what the policy was on proper storage of soiled rags. She stated soiled rags should have been stored in proper sanitizer solution. She was asked what the policy was for reporting repairs to maintenance. She stated maintenance concerns should have been reported to maintenance to be repaired or replaced. 2. Resident #67 had [DIAGNOSES REDACTED]. On 03/08/16, at 4:49 p.m., certified nurse aide #1 was observed handing a grilled cheese sandwich to resident #67 with their bare hands. On 03/10/16, at 9:21 a.m., the director of nurses (DON) was asked what the policy was for staff handling resident's food with their bare hands. She stated, They shouldn't handle food with bare hands. We just had an inservice to teach them how to butter bread without touching it. The previous observation of bare hand contact was discussed with the DON. She was asked if the staff member should have touched the resident's food with their bare hands. She stated, No.

Based on observation and staff interview, it was determined the facility failed to ensure: ~ the floor and walls were kept clean, ~ the ceiling and the walls were maintained in good repair and ~ there were no gaps or visible daylight around entry/exit doors, The Resident Census and Conditions report, dated 03/08/16, documented 71 residents resided in the facility. Findings: On 03/07/16 at 7:40 a.m., a tour of the kitchen was conducted. The following observations were made: ~ there was an accumulation of black and white residue on the floor and walls throughout the dishwash area, ~ there was a hole in the wall around the piping below the drain board on the clean dish side of the dish machine, ~ there were multiple holes in the walls and ceiling in the walk-in cooler, ~ there was a hole in the wall around the piping between the can good racks in the dry food storage room, ~ there was a gap and daylight was visible under the back door in the chemical storage room, ~ there was an accumulation of food and black residue on the lower walls and floor inside of the walk-in cooler and ~ material was peeling off of the walls in the chemical storage room. On 03/08/16 at 2:03 p.m., the kitchen observations were discussed with the dietary manager (DM). She was asked what was the policy for cleaning the floor and the walls. She stated the floor should have been swept after every meal and mopped twice a day or as needed. She stated the walls should have been cleaned twice a week or as needed. She was asked what the policy was on reporting repairs to maintenance. She stated once the problem was noticed it should have been reported to maintenance to have been repaired or replaced.

Based on observation and staff interview, it was determined the facility failed to ensure the posted staffing documented the facility's name, the resident census, the actual and total number of hours worked by the nursing staff and was posted in an area prominently visible to the resident and visitors. The Resident Census and Condition report, dated 03/07/16, documented 71 residents resided in the facility. Findings: On 03/07/16 at 8:00 a.m., there was no posted staffing observed during the initial tour. A wet to dry board was observed in use on hall 200, which listed the nursing staff for all three resident halls. The board listed the date, the nurse, the certified medication aide and the certified nurse aides for each hall. The wet to dry board did not list the facility's name, resident census or the total and actual hours worked. On 03/11/16 at 10:37 a.m., the director of nursing (DON) was asked where the posted staffing was located. She went to a wet to dry board on hall 200, which did not document the name of facility, the resident census, or hours for the registered nurses, the licensed practical nurses or the certified nurse aides. The board only documented date, halls (neighborhoods) and staff names and titles The DON was asked if this was in a prominently visible place for residents and visitors. She stated she could move it to the front lobby/living room area.

Based on record review and staff interview, it was determined the facility failed to administer medications as ordered by the physician for one (#1) of three sampled residents reviewed for medication administration. The facility identified 79 residents resided in the facility. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A census entry, dated 01/22/16, documented the resident was admitted to the facility at 4:07 p.m. A physician's orders [REDACTED]. .FSBS (fingerstick blood sugar) before meals and at bedtime related to TYPE 1 DIABETES MELLITUS WITH HYPERGLYCEMIA . Advair Diskus Aerosol Powder Breath Activated 100-50 MCG (microgram)/DOSE .1 puff inhale orally two times daily related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION . Aloe Vera Gel Apply to affected area topically four times a day for dry skin . Aspirin Tablet Chewable 81 MG (milligrams) Give 81 mg by mouth at bedtime related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS . Carvedilol Tablet 12.5 MG Give 12.5 mg by mouth every 12 hours related to ESSENTIAL (PRIMARY) HYPERTENSION . Chlorzoxazone Tablet 500 MG Give 1 tablet by mouth two times a day related to LOW BACK PAIN . Cyclosporine Emulsion 0.05 % (percent) Instill 1 drop in both eyes two times a day related to DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS . Gabapentin Capsule 300 MG Give 600 mg by mouth at bedtime related to other IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY . Insulin Glargine Solution 100 UNIT/ML (milliliter) Inject 10 unit (sic) subcutaneously one time a day related to TYPE 1 DIABETES MELLITUS WITH HYPERGLYCEMIA . Ipratropium Bromide Solution 0.02 % 1 vial inhale orally via nebulizer every 4 hours related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION .PNEUMONIA, UNSPECIFIED ORGANISM . Levalbuterol HCI (hydrochloride) Nebulization Solution 0.63 MG/3ML 1 vial inhale orally via nebulizer every 4 hours related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION .PNEUMONIA, UNSPECIFIED ORGANISM . Potassium Chloride ER (extended release) Tablet Extended Release 20 MEQ (milliequivalent) Give 20 mEQ by mouth two times a day related to ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE . Simvastatin Tablet 40 MG Give 40 mg by mouth at bedtime related to [DIAGNOSES REDACTED], UNSPECIFIED . Tamsulosin HCI capsule 0.4 MG Give 1 capsule by mouth at bedtime related to ENLARGED PROSTATE WITH LOWER URINARY TRACT SYMPTOMS . The January 2016 medication administration records(MARS), treatment administration records (TARS)and injection/insulin/FSBS administration records for resident # 1 were reviewed. The evening doses of the above medications and treatments were not documented as given on 01/22/16. The facility provided documentation the pharmacy received the facility medication order for resident #1 on 01/22/16 at 7:55 p.m. The pharmacy documented the medication start date was 01/22/16. The pharmacy packing slips documented the facility received the resident's medications and treatments on 01/22/16. On 03/01/16 at 10:20 a.m., the director of nursing (DON) was asked what the policy was for ordering medications for a new resident. She stated the staff reviewed the hospital discharge orders, put the orders into the computer, printed out the orders, had a second nurse review the orders, and then faxed them to the pharmacy. She stated all medications were delivered in the evening between 9:00 p.m. and 11:00 p.m. She was asked what the policy was if a medication was needed before that time. She stated they would order it from the pharmacy next door. She was asked if any medications for resident #1 were ordered from the pharmacy next door. She stated, No. She was asked if they should have been. She stated, Yes. She was asked what an acceptable amount of time was for new medications to be delivered to the facility. She stated as quickly as possible. She stated, If they STAT (immediately) medications, they get them within an hour. She was asked if any medications for resident #1 had been ordered STAT. She stated, No. She was asked to review resident #1's admission orders [REDACTED]. She was asked what the policy was on administering medications to a new resident. She stated, To follow physician's orders [REDACTED]. She was asked if the physician's orders [REDACTED].#1. She stated, Yes, because the nurse that put them in the computer marked them off for 01/22/16 and marked them to be started on 01/23/16. She was again directed to the hospital discharge orders which documented discharge medications and treatments that were to be given that evening. She was asked if the physician's orders [REDACTED]. She stated, No. The nurse should have put the orders in to start on 01/22/16. She was asked if the resident received any medications on 01/22/16. She stated, No.

Based on record review and staff interviews, it was determined the facility failed to implement their abuse policy to ensure pre-employment reference checks were conducted and new employees were in-serviced on abuse/abuse reporting during the orientation process for five of five employee whose files were reviewed. The Census and Conditions report, dated 04/06/15, documented 73 residents resided in the facility. Findings: The Resident Abuse, Neglect and Misappropriation of Property policy, revised 06/05/14, documented, "Screening /Prevention...All potential employees will be screened for previous history of abuse by OSBI (Oklahoma Stated Bureau of Investigation) checks...and other reference checks... Training/Prevention...All employees will be in-serviced on abuse / reporting abuse during the orientation process following employment..." On 04/08/15 at 12:15 p.m., five employee files were reviewed. These files were on three CNAs (certified nurses aides), one housekeeper and one dietary cook. No reference checks were documented in all five files. No documentation the employees had been in-serviced on abuse was located in all five files. At 1:00 p.m., the regional RN (registered nurse) was asked if she could locate the reference checks on the employees. She was also asked if she could locate the documentation the employees had received the abuse orientation following employment. She stated the abuse orientation was on the Silverchair program (a computer based training program). She stated she would get a copy of the employees' Silverchair files. The regional RN stated it was the responsibility of office personnel #1 to call the references. She stated she would get her to find the reference checks. At 1:30 p.m., the regional RN stated the abuse training had been accidentally dropped from the Silverchair requirements. She was asked if this meant the newly hired employees had no abuse orientation. She stated, "Not the newest ones." The office personnel #1 was asked if she could locate the reference checks in the employee files. She reviewed the files and stated, "They should be in the records but aren't" She then pointed to a blank reference check form. She was asked if she called the references. She stated, "No."

Based on observation, record review and staff interview, it was determined the facility failed to ensure: ~ soiled rags were stored in a sanitizer solution, ~ clean dishes were air dried, ~ can goods were free of dents, ~ bottles of chemicals were properly labeled, ~ containers of dry ingredients were labeled, ~ the handsink was accessible at all times, ~ a box of foam cups was stored up off of the floor, ~ employees washed their hands for at least 15 seconds and ~ employees washed their hands after handling soiled dishes and before handling clean dishes. The facility identified 71 residents who received their meals from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: A facility dietary policy, documented, "...Dry Storage of Dishes And Utensils...Dishes and utensils will not be stored wet... Canned Fruits...Dented or bulging cans should be placed on damaged goods shelf and returned for credit... Toxic Substance Storage...All containers containing toxic substances will be clearly marked as to their contents... Dry Storage Of paper Products...Paper supplies will be stored in a safe and orderly manner..." A facility universal handwashing policy, documented, "...The single most important step in the prevention of infection is hand washing...This can happen when touching resident's supplies, equipment, linens, etc. Nursing home residents are susceptible to the spread of infection because they are frequently already ill and in a weakened state...Proper Hand washing Technique...Wash hands for approximately 15 seconds using friction..." On 04/06/15 at 8:05 a.m., a tour of the kitchen was conducted. The following observations were made: ~ multiple clean drinking glasses were stored stacked wet in a glass storage rack in the dry storage room, ~ a box of foam cups was stored on the floor in the dry/food storage room, ~ two institutional size cans of pears had dents on the side of the cans and an institutional size can of jalapeno peppers had a dent along the top seam of the can and the top was bulging in the dry/food storage area, ~ a soiled rag was stored on the prep table next to the oven, ~ two metal containers containing a white and black substance were not labeled in the cook area and ~ a spray bottle containing a red liquid was labeled bleach. At 9:55 a.m., during a tour of the dining room, dietary cook #2 was observed using the handsink to fill multiple pitchers with water. At 10:35 a.m., brunch was observed. The following observations were made: ~ two soiled rags were stored on the food prep table located below the utensil/dish hanging rack, ~ the dietary aide #1 was observed placing a food tray on the handsink, blocking the handsink from being used for handwashing purposes and ~ the dietary cook #1 was observed washing her hands at the handsink for five seconds. At 10:50 a.m., pureed food preparation was observed. The dietary cook #1 was observed placing the soiled food processor bowl on a soiled dish rack and placed the dish rack in the dish machine to be washed, rinsed and sanitized. After handling the soiled dish/dish rack she then proceeded to handle clean dishes on the clean side of the dish machine and did not wash her hands. On 04/07/15 at 8:34 a.m., dietary aide #1 was observed using the handsink to fill multiple pitchers with water. At 8:35 a.m., a tour of the kitchen was conducted with the dietary manager (DM). The DM was asked what was the handwashing policy on how long employees are required to wash their hands at the handsink and when to wash their hands. She stated hands are supposed to be washed for at least 25 seconds and hands should be washed prior to handling clean dishes. She was asked what was the policy for use of the handsink to fill pitchers with water or store trays on top of. She stated they usually use the three compartment sink if it is clean but they will use the handsink. She was asked what was the policy for storage of soiled rags. She stated soiled rags are supposed to be stored in a sanitizer solution. She was asked what was the policy for storage of clean dishes after being washed. She stated dishes are supposed to be air dried and not stored wet. She was asked what was the policy for dented cans. She stated dented cans are supposed to be thrown away. She was shown the spray bottle of red liquid that was labeled bleach. She was asked if the red liquid was bleach. She said the red liquid was oven/grill cleaner. She was asked if dry ingredients were supposed to be labeled. She stated. "Yes."

Based on observation, record review and staff interview, it was determined the facility failed to ensure residents' manual wheelchairs were maintained in good repair for one (#7) of nine sampled residents whose manual wheelchairs were observed. The Resident Census and Conditions report, dated 04/06/15, documented 73 residents resided in the facility. The director of nursing (DON) identified 40 residents who had manual wheelchairs. Findings: A facility maintenance policy, documented, "...The facility shall maintain all essential mechanical, electrical, and resident care equipment in safe operating order...Procedure...In the event that an item is in need of repair, the defect should be reported to the maintenance department...the maintenance department will repair them promptly...If the skill to repair is beyond the ability of facility staff, an outside vendor will be called in case of emergency, or Grace Living Center Home Office will be called for repair if the item can be scheduled into the Home Office program..." Resident #7 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/06/15, documented the resident utilized a wheelchair as a mobility device. On 04/06/15 at 10:20 a.m., the resident's manual wheelchair was observed. The arms on the wheelchair were torn. The foam padding was exposed and the areas were taped with paper tape. On 04/08/15 at 8:50 a.m., the DON was shown the arms of the manual wheelchair resident #7 was sitting in. She stated that is was time for the resident's wheelchair to be fixed.

Based on observation, interview and record review, it was determined the facility failed to ensure a care plan was updated and revised to address appropriate activities for one (#11) of one sampled bed bound residents. The Census and Conditions report, dated 02/03/14, documented one resident to be bed bound. Findings: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 11/28/13, documented the resident to be comatose, to need extensive assistance of two people for his ADLs (activities of daily living) and impairment of both upper and lower extremities. Social Services Notes A social services note, dated 05/03/13, documented, "...Can follow you c (with) eyes but unable to speak..." A social services note, dated 06/02/13, documented, "...(resident #11) cont. (continue) to be confined to his apt (apartment) due to his condition. Startles very easily..." A social services note, dated 08/02/13, documented, "...Cont to be bed bound..." A social services note, dated 09/01/13, documented, "...Cont. to follow staff c his eyes..." A social services note, dated 02/05/14, documented, "We provide stimulation for (resident #11) c a mobile above bed, music playing. He is visited daily by staff and talked to, also roommate (sic) talks & sings to him...AD (activities director) does PROM (passive range of motion) c (resident #11) working on restorative while putting lotion on hands & arms." Nurse's Notes Nurses' notes, dated 01/25/14 at 12:00 p.m. and 6:00 p.m. and 02/02/14 at 10:00 a.m., documented the resident to be awake and alert and the call light was in reach. Care Plan A care plan, dated 09/02/13, documented, "At risk for isolation, alteration in psychosocial well-being due to TBI ([MEDICAL CONDITION]), unable to participate in structured activities...Take (resident #11) to activities involving music or entertainment. If restlessness noted reduce stimuli..." Activity Notes Activity notes, dated 12/02/13 through 12/31/13, documented the activities director visits (resident #11) frequently and does activities with him in his room. On 02/04/14 at 11:45 a.m., resident was observed for a medication pass. When CMA (certified medication aide) #1 called the resident by name he opened his eyes. The resident was observed in bed on an air mattress with the head of the bed raised to a 35-40 degree angle. Both his hands were contracted and both his arms were extremely hard for the CMA to move. On 02/05/14 at 3:20 p.m., LPN (licensed practical nurse) #2 was asked if resident #11 was ever placed in his geri chair and taken out of his room. He stated, "No." At 3:25 p.m., CNA (certified nursing aide) was asked if resident #11 was ever placed in his geri chair and taken out of his room. She stated, "No, it's to hard to get him up." At 3:30 p.m., LPN #1 was asked if resident #11 was ever placed in his geri chair and taken out of his room. She stated, "No, he is too heavy to move." On 02/06/14 at 11:10 a.m., RN (registered nurse) #1 was asked if resident #11 was ever placed in his geri chair. She stated, "No, just on special occasions. We use to get him up, but it is harder now, even with the the Hoyer." At 11:30 a.m., resident #11 was observed in his bed with his eyes open staring straight ahead. At 12:30 p.m. the activities director was asked if resident #11 was ever placed in his geri chair. She stated, "He doesn't tolerate it well." She was asked what happens when he is in his chair. She stated, "He spits up and chokes. He doesn't like being in the geri chair." She was asked when was the last time he was up in his geri chair. She stated about a month ago. 02/06/14 at 1:15 p.m., the ADON #2 (assistant director of nursing) was asked about the careplan which documented when resident #1 was to be up in his geri chair. She stated the portion of the care plan that documented the resident is to be up in his geri chair was left on the care plan for when he needs to be up in his geri chair as needed. The DON (director of nursing) stated it was too dangerous for the resident to get him up in his geri chair. She stated his doctor has wanted to amputate the resident's hands due to the risk of them "breaking off." The DON was asked for documentation of this. She provided a doctors report, dated 07/28/11, which documented the condition of the resident's joint deformities. She was asked for any recent documentation on the resident's condition. She stated there was not any.

Based on interview and record review, it was determined the facility failed to ensure the clinical record accurately documented the current status of one (#11) of 15 sampled residents whose records were reviewed. The Census and Condition report, dated 02/03/14, documented 75 residents resided in the facility. Findings: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 09/02/13, documented, "At risk for isolation, alteration in psychosocial well-being due to TBI ([MEDICAL CONDITION]), unable to participate in structured activities...Take (resident #11) to activities involving music or entertainment. If restlessness noted reduce stimuli..." The last comprehensive assessment, dated 11/28/13, documented the resident to be comatose, to need extensive assistance of two people and impairment of both upper and lower extremities. On 02/04/14 at 11:45 a.m., resident was observed for a medication pass. When CMA (certified medication aide) #1 called the resident by name he opened his eyes. The resident was observed in bed on an air mattress with the head of the bed raised to a 35-40 degree angle. Both his hands were contracted and both his arms were extremely hard for the CMA to move. On 02/05/14 at 3:25 p.m., CNA (certified nursing aide) was asked if resident #11 was ever put in his geri chair and taken out of his room. She stated, "No, it's too hard to get him up." At 3:30 p.m., LPN #1 was asked if resident #11 was ever put in his geri chair and taken out of his room. She stated, "No, he is to heavy to move." On 02/06/14 at 11:10 a.m., RN (registered nurse) #1 was asked if resident #11 was ever placed in his geri chair. She stated, "No, just on special occasions. We use to get him up, but it is harder now, even with the the Hoyer." At 11:30 a.m., resident #11 was observed in his bed with his eyes open staring straight ahead. At 12:30 p.m. the activities director was asked if resident #11 was ever placed in his geri chair. She stated, "He doesn't tolerate it well." She was asked what happens when he is in his chair. She stated, "He spits up and chokes. He doesn't like being in the geri chair." She was asked when was the last time he was up in his geri chair. She stated about a month ago. At 1:15 p.m., the ADON #2 (assistant director of nursing) was asked about the careplan which documented when resident #1 was to placed in his geri chair. She stated the portion of the care plan that documented the resident is to be up in his geri chair was left on the care plan for when he needs to be up in his geri chair as needed. The DON (director of nursing) stated it was too dangerous for the resident to get him up in his geri chair. She stated his doctor has wanted to amputate the resident's hands due to the risk of them "breaking off." The DON was asked for documentation of this. She provided a doctors report, dated 07/28/11, which documented the condition of the resident's joint deformities. She was asked for any recent documentation on the resident's condition. She stated there was not any.

Based on record review and interview, it was determined the facility failed to ensure a resident was seen by their attending physician every thirty days for the first ninety days after admission for one (#1) of 13 sampled residents whose physician visits were reviewed. The facility identified 20 residents who were seen by physician #1. Findings: Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE] for skilled nursing care. Physician visits were documented for 10/04/13, 10/24/13 and 11/02/13. On 02/05/14 at 10:45 a.m., the ADON #1 (assistant director of nursing) was asked for documentation that the resident was seen by her physician in December 2013. At 10:55 a.m., the ADON stated, "We missed the December visit."

Based on observation, interview and record review, it was determined the facility failed to ensure: ~ cooking/serving utensils were clean and free of debris; ~ the cook's fingernails were short; ~ food temperatures were maintained on the steam table at 135 degrees and ~ glasses of milk were maintained at or below 41 degrees Fahrenheit. The facility identified 64 residents who consumed food prepared in the kitchen. The facility identified two residents who received hydration and nutrition solely through feeding tubes. Findings: The Dining Services Policies and Procedures, documented, "Dress, Hygiene and Conduct...Fingernails must be kept short, clean and unpolished..." On 03/25/13 at 8:20 a.m., a tour of the kitchen was conducted. One fryer strainer, one sifter and one three ounce and one four ounce slotted scoops had dried debris on them. One manual vegetable peeler and two spatulas (one with a black handle, one with a brown handle) had dried debris on them. The two spatulas were observed to have a build up of debris where the blade attached to the handle. The two drawers on the prep table where these utensils were kept had dried debris in them under the blue mesh in the bottom of the drawer. The corporate director of dietary was asked if this was acceptable practice. He stated "No". On 03/25/13 at 9:00 a.m., the cook was observed to have long fingernails that were thick and yellow. She was observed to pick up plates, utensils and serving utensils with ungloved hands during breakfast preparation. At 9:00 a.m., it was observed the steam table temperatures were not being conducted. The mechanical soft sausage was not on the steam table, but was sitting in a bowl off to the side of the steam table. The cook was asked about taking the food temperatures and the cook stated she takes the temperatures of the food hourly. This was not observed during the breakfast meal. At 9:05 a.m., the cook was asked to take the temperatures of the food off the steam table being served to the residents in the dining room. The sausage was 80 degrees Fahrenheit; the biscuits and gravy were 112 degrees Fahrenheit; and the eggs were 80 degrees Fahrenheit. At 9:30 a.m., the cook had called that the hall trays were ready to be delivered. These trays were observed to have been sitting out covered with plastic wrap for approximately 45 minutes. The sausage temperature was 78 degrees, the milk was 57 degrees and the milk with ice in it was 42 degrees. The milk products had not been kept in cold storage. At 11:05 a.m., the corporate dietary manager was asked about their policy for taking food temperatures. He stated they were supposed to do it. At 11:10 a.m., the corporate RD/LD (registered dietician/licensed dietician) was asked about their fingernail policy and if she had noticed the cook's fingernails. The corporate RD/LD stated the cook wore gloves most of the time. She was also asked what temperature were the foods to be maintained at on the steam table. She stated 135 degrees. On 3/26/13 at 2:15 p.m., the dietary manager was asked about their fingernail policy. She stated the aids are to keep them short and with no polish. At 2:20 p.m., the cook was asked about her nails. She stated they are hard to cut due to being thick. She stated her nails had been thick and discolored all of her life and she had never been to the doctor to see if anything was wrong with them. On 3/27/13 at 10:00 a.m., the medical records director was asked for the policy on required temperatures of food being served to the residents. At 10:30 a.m., she stated there was not a policy. ADON #1 (assistant director of nursing) stated she had called their corporate office and they stated there was not a policy on taking food temperatures. At 10:35 a.m., the dietary manager was asked for the policy on taking food temperatures. At 10:40 a.m., the dietary manager provided a form, Hot Holding Maintain 135 F and above, which documented, "~ keep foods covered as much as possible while on the steam table ~ use thermometers to check the temperature of foods to be sure they are kept above 135 degrees ~ stir foods frequently while serving." She also provided a form, Cold Holding Maintain 41 F and less, which documented, "~ use thermometers to monitor cold food temperatures in display units and buffets ~ provide sufficient space in cold storage facilities for good circulation." She also brought copies of the daily hot temperature chart. These were observed to document only one temperature taken per meal.

Based on observation, interview, and record review, it was determined the facility failed to ensure the outside courtyard and exterior environment were maintained in good repair and free of animal waste. Sixty five of sixty eight residents had access to the outside courtyard and the exterior environment. Findings: The administrative policies and procedures, titled Animals-Residential, dated 07/16/01, documented, "...4. Provisions will be made for cleaning any areas contaminated by the animals such as urination, excrement..." On 03/26/13 at 3:20 p.m., a tour of the outside environment and courtyard was conducted. The following observations were made: ~ The outside courtyard had accumulations of dog and cat feces on the lawn areas, in the flower beds, and on the patio surfaces. ~ The soffit panels located on the northeast side of the facility, outside resident room #106 and two locations on the west side of hall 300 had gaps where birds, animals or insects could enter the attic space. ~ There were three loose air conditioning grills on the south side of hall 300. A fourth grill had a missing fin creating a hole in the grill. The loose grills/damaged grills could allow access to the interior of the building by mice or other vermin. ~ The inside courtyard patio surfaces were uneven and had gaps between the cement blocks. A 16 square foot area of the patio under the large tree had been dislodged by tree roots. A request was made for policies that dealt with the outside environment but none were provided. On 03/26/13 at 4:00 p.m., the admissions coordinator was shown the above observations. She agreed the cement blocks and the soffits needed to be repaired. She stated, "We will get out here and scoop all the dog and cat poop."