Every finding on record at Shady Rest Care Center

On 07/08/25 past non-compliance immediate jeopardy situations were determined to exist related to the facility's failure to:a. secure Resident #2 during transport in the facility van. On 06/18/25 the van driver had to brake suddenly, and Resident #2 fell forward from the wheelchair hitting their head and right knee on the row of seats in front of them; andb. ensure the safety of Resident #1 who was at risk for elopement. On 06/22/25 at 8:17 p.m., a facility video showed Resident #1 left the facility through the kitchen door and walked North down the alley. At 8:27 p.m., the video showed Resident #1 at the front door of the facility and then they walked South down [NAME] street.Based on observation, record review, and interview, the facility failed to ensure:a. seat belts were in proper working order for 1 (#2) of 3 sampled residents reviewed for transportation safety; and b. prevent the elopement of 1 (#1) of 3 sampled residents reviewed for elopement.The administrator identified 35 residents resided in the facility. Findings:1. A quarterly assessment, dated 05/22/25, showed Resident #2 was cognitively intact with a BIMS of 14. A final Incident Report Form, dated 06/18/25, showed the seatbelt attachment was not in working order and Resident #2 was injured during transportation. A progress note, dated 06/18/25, showed Resident #2 was sent via ambulance to the hospital emergency room for evaluation after complaining of neck pain and right knee pain. A hospital Discharge summary, dated [DATE], showed Resident #2 was diagnosed with a strain of the neck muscles, closed fracture of the nasal bone, closed head injury, and contusion of the right knee. A service repair invoice, dated 06/20/25, showed the lap belt retractor device needed to be replaced. The invoice showed multiple missing tie down pieces for the lap belt were installed. A care plan for Resident #2, revised 06/20/25, read in part, Encourage me to sit up straight when in my w/c [wheelchair], especially if I am in the van. Facility staff will sit in the back with me on any future transports. The equipment in the van will be checked for appropriateness, safety of function. A safety checklist is to be initiated before any transport by staff, going forward.A Quality Assessment and Performance Improvement form, dated 06/19/25, showed 1. Pre-travel safety checklist in place inside transport van; 2. Staff in-service education regarding safety during transport van; 3. Driver suspended pending investigation of situation; and 4. Certified nurse aide/support staff will sit in the back of the van with any resident. Plan of completion date was 06/20/25. On 07/08/25 at 9:34 a.m., Resident #2 stated they were in the van with the maintenance supervisor driving the van. Resident #2 stated the driver nearly missed the exit on the expressway causing them to brake hard. Resident #2 stated they were flung forward hitting their face and right knee on the row of seats in front of them. Resident #2 stated the wheelchair was secured to the floor of the van, but the lap belts did not work. Resident #2 stated the AD was also in the van.On 07/08/25 at 10:07 a.m., the AD stated they were in the van on 06/18/25 during the transport of Resident #2 to a physician's appointment. The AD stated when the van driver attempted to exit off the expressway a car pulled in front of them causing the driver to pump the breaks hard. The AD stated Resident #2 was flung forward hitting their head on the row of seats in front of them. The AD stated the van driver was not on the phone during the transport. On 07/08/25 at 10:19 a.m., the van driver stated the seatbelt for wheelchairs was not working. They stated they had to brake harder than usual, and Resident #2 fell forward. They stated they were not on the phone, although they did use navigation. The van driver stated Resident #2 stated they were fine and declined the emergency room at that time.On 07/08/25 at 10:40 a.m., administrator #1 stated the van was repaired by the safety devise vendor, who also did an in-service with the van driver on using the seat belts. They stated the facility had initiated a safety check list that must be completed before transporting a resident. Administrator #1 stated they monitored this check list. The in-service was not provided by the end of the survey.On 07/08/25 at 11:30 a.m., the van driver stated they had noticed the seatbelt for wheelchair occupants was not working in the middle of May. They stated they reported this to two other administrators at sister facilities. On 07/08/25 at 1:51 p.m., administrator #2 from a sister facility stated they had not received a report from anyone the seatbelts were not working in the facility van. On 07/08/25 at 1:55 p.m., administrator #3 from a sister facility stated they had not received a report from anyone the seatbelts were not working in the facility van. 2. On 06/25/25 at 1:30 p.m., the route Resident #1 walked was observed by car. [NAME] street was observed to be a moderately busy residential street without curbs. On 06/25/25 at 3:32 p.m. the keypad locks were observed on the door from the dining room to the kitchen and on the door from the kitchen to the outside.An admission assessment, dated 05/23/25, showed Resident #1 was moderately impaired for making decisions with a BIMS score of 10. Resident #1 had diagnoses which included hypertension and chronic obstructive pulmonary disease. An elopement assessment, dated 05/23/25, showed Resident #1 was at risk for elopement. A progress note, dated 06/22/25, showed the police called the facility informing them Resident #1 was at a store and requested someone to pick up Resident #1.A care plan for Resident #1, revised 06/23/25, read in part, 1. Assist me to call my wife on the facility phone prn. 2. Encourage me to voice my feelings in a productive manner. 3. If I voice increased desire to leave the facility, help me call my wife, and redirect through conversation, activity. 4. Place on 15 minute checks. 5. When it is noted that I am having episodes of increased paranoia, increase visual checks for my whereabouts, comfort and safety. A Quality Assessment & Performance Improvement form, dated 06/24/25, showed 1. In-service all staff on new door security expectations; 2. At end of shift cook to validate doors are all locked prior to leaving kitchen area; 3. Night charge nurse to check doors at 10 p.m. daily; and 4. In-service all staff to importance of elopement prevention. The plan of completion date was 06/25/25. On 06/25/25 at 12:30 p.m., this surveyor viewed a video which showed on 06/22/25 at 8:17 p.m., Resident #1 leaving the facility through the kitchen door and walking North down the alley. At 8:27 p.m., Resident #1 was observed at the front door of the facility. The resident did not try to re-enter the facility. On 06/25/25 at 12:30 p. m., administrator #1 stated on 06/24/25 the facility put a keypad lock on the door from the dining room to the kitchen and a keypad lock on the door from the kitchen to the outside.On 06/25/25 at 3:30 p.m., LPN #1 stated Resident #1 frequently talked about their family member picking them up to go home. They stated Resident #1 had not eloped before. LPN #1 stated the resident was assessed for injury, but none were noted.

Based on record review, observation, and interview, the facility failed to provide the correct amount of food to residents in accordance with the facility menu. A facility resident roster, dated 08/26/24, documented 34 residents resided in the facility. Findings: A facility food portion policy, dated 01/02/23, documented it was the policy of the facility for food portions served be those written on the menus. A facility Spring/Summer 2024 Diet Spreadsheet, documented a serving of fried potatoes was one half cup. On 08/27/24 at 12:07 p.m., the afternoon meal service was observed. [NAME] #1 was observed filling the plates of each resident. They were observed using tongs to measure and place fried potatoes onto each plate. They were observed using serving spoons marked for specific serving sizes for the other food items. The amount of potatoes going on each plate were easily observed to be of various amounts. On 08/28/24 at 9:26 a.m. [NAME] #1 stated the serving size for the fried potatoes was suppose to be one half cup per serving but they did not have that size of serving spoon. They stated they did not have all the correct sizes of measuring spoons at that time and needed to purchase some. They stated they were not aware of how long they had been without all of the spoons. [NAME] #1 provided the printed menu for the afternoon meal on 08/27/24 that included the serving sizes for each food item. At 10:00 a.m., the Administrator stated they were unaware of the need for the spoons and would order replacements. They stated it was important for resident to get the correct amount of each food item.

Based on record review and interview, the facility failed to provide have a director of food services employed at the facility. A facility resident roster, dated 08/26/24, documented 34 residents resided in the facility. Findings: A facility document, titled [NAME] Rest Active, undated, documented the names and titles of the facility staff. Under the subheading, Dietary the title of CMA/Dietary Manager had no name associated with it. On 08/28/24 at 8:35 a.m., [NAME] #1 stated the facility did not have a dietary manager at that time. They stated the last person in that role had left four or five months prior to the survey. They stated the facility administrator was ordering food for the kitchen and the dietician comes in once or twice a month. They stated they had not accepted any of the responsibilities of the dietary manager. At 8:49 a.m. the Administrator stated the last dietary manager was terminated on 08/19/24 and they had not found a new one yet. They stated they currently had no one performing the duties of the dietary manager.

Based on record review and interview, the facility failed to ensure the residents right to refuse treatment was respected for one (#28) of two residents reviewed for resident's rights. The administrator reported the census was 34. Findings: An undated facility policy titled Resident rights Guidelines for All Nursing Procedures read in part, .Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including . Resident right of refusal (medication and treatments) . Resident #28 had diagnoses which included benign prostate hyperplasia and depression. A physician order, dated 07/21/24, indicated the resident had urinary catheter. A nurse note, dated 07/23/24 at 3:43 am, indicated the resident wanted the catheter removed. A nurse note, dated 07/24/24 at 9:51 am, indicated the resident wanted the catheter removed. A nurse note, dated 07/25/24 at 12:17 pm, indicated the resident wanted the catheter removed. A nurse note, dated 07/30/24 at 2:03 pm, indicated the resident wanted the catheter removed. A nurse note, dated 07/31/24 at 1:57 pm, indicated the resident wanted the catheter removed. A nurse note, dated 08/03/24 2:02 pm, indicated the resident wanted the catheter removed. A nurse note, dated 08/14/24 3:25 am, indicated the resident wanted the catheter removed. A nurse note, dated 08/14/24 2:37 pm, indicated the resident wanted the catheter removed. A nurse note, dated 08/15/24 3:38 am, indicated the resident wanted the catheter removed. A nurse note, dated 08/17/24 4:33 pm, indicated the resident wanted the catheter removed. On 08/26/24 at 12:40 pm, the Resident #28 stated the catheter was very uncomfortable and they would like it removed. They also stated they had spoken to staff about it repeatedly. On 08/27/24 at 1:40 pm, the DON stated the resident has the right to refuse treatment.

Based on observation and interview, the facility failed to ensure a broken window pane was replaced and not covered with a Styrofoam and tape for two (#17 and #24) of twelve sampled resident reviewed homelike environment. A facility resident roster, dated 08/26/24, documented 34 residents resided in the facility. Findings: On 08/28/24 at 10:19 a.m. a white piece of Styrofoam was observed taped to the window next to the bed of Resident #24. The second occupant of the room was Resident #17. They stated the window had been broken by their previous roommate but could not recall the date. They stated they could not see broken window because of the curtain but they wanted it to be fixed. They stated staff was aware of the broken window as they had put on the Styrofoam but they had not returned to fix it properly. At 10:24 a.m., the maintenance supervisor stated the window had been broken the week prior. They stated they were going to fix it but they had not been given any money to replace the window pane. At 10:31 a.m. the corporate nurse stated the use of Styrofoam to replace a broken window was not provide a homelike appearance. They stated they had provided money to the maintenance supervisor that morning to get materials to replace the missing glass.

Based on record review and interview, the facility failed to implement a comprehensive care plan for one (#139) of five sampled residents reviewed for unnecessary medications. A facility resident roster, dated 08/26/24, documented 34 residents resided in the facility. Findings: Resident #139 had diagnoses which included bipolar disorder and anxiety disorder. A physician order, dated 08/09/24, documented the resident was receiving clonazepam (an antianxiety medication) 0.5 mg by mouth twice a day. A physician order, dated 08/09/24, documented the resident was receiving fluoxetine (an antidepressant) 40 mg by mouth daily. A physician order, dated 08/09/24, documented the resident was receiving trazodone (an antidepressant) 50 mg by mouth at bedtime. A review of Resident #139's care plan did not address the use antidepressant or antianxiety medications. On 08/27/24 at 1:40 pm, the DON stated psychotropic medication use should be included on the resident's care plan. On 08/28/24 at 10:30 am, the ADON stated the use of antidepressant and antianxiety medications should be included on the care plan.

Based on record review and interview, the facility failed to ensure a resident's attending physician participated in care plan conferences for one (#6) of twelve sampled resident reviewed for care plans. A facility resident roster, dated 08/26/24, documented 34 residents resided in the facility. Findings: A facility policy, titled Care Planning - Interdisciplinary Team, dated 2001, documented the interdisciplinary team was to include a resident's attending physician. Resident #6 had diagnoses which include chronic obstructive pulmonary disease and chronic kidney disease. A care conference information note, dated 07/16/24, documented a care plan conference for a quarterly assessment had occurred on that date. The list of attendees to the meeting did not include the resident's attending physician. On 08/29/24 at 10:43 a.m., the ADON stated the medical director was the attending physician for Resident #6. They stated medical director had not participated in the resident care plan meeting. They stated they had no documentation the medical director had attended any of the care plan meeting for the resident since January of 2024. They stated they do inform the physician if any issues were talked about during those meetings but they have no documentation of those discussions. They stated the facility policy did require the physician to be present during the care plan process.

Based on observation and interview, the facility failed to ensure dryer lint screens were routinely cleared for two of two dryers observed in the laundry room. The administrator reported the census was 34. Findings: A facility policy titled Policy on Lit [sic] and cleaning under, around, and behind dryer, dated 02/11/1995, read 1. Minimum of every shift and as needed for build-up. 2. The area of the lit [sic] trap, behind the dryer and areas around the dryer. A Dryer Lint Log, dated August 2024, documented the lint screens had been cleared on 17 out of 84 opportunities. On 08/29/24 at 8:57 am, the housekeeping supervisor stated that the lint screens should be cleared at the end of every shift, but they could not get the 2nd shift to clear them, and the 3rd shift often forgot to document clearing the screens.

Based on record review and interview, the facility failed to ensure an admission MDS was completed within 14 days of admission for one (#139) of five residents reviewed for MDS assessments. The administrator reported the facility census was 34. Findings: An undated facility policy titled MDS Completion and Submission Timeframes read in part, .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . Resident #139 was admitted to the facility on [DATE]. An MDS 3.0 assessment summary documented the admission assessment for Resident #139 was in process. On 08/28/24 at 1030 am, the ADON stated the admission MDS for Resident #139 had not been completed and was late.

Based on record review and interview, the facility failed to notify a resident's responsible party when the resident was transferred to a hospital for one (#37) of four sampled resident reviewed for hospitalization s. The DON stated 26 residents had been transferred from the facility in the six months prior to the survey. Findings: A Change in Resident's Condition or Status policy, dated 2001, documented a nurse was to notify a resident's representative when the resident was transferred to a hospital. A progress note, dated 07/30/24 at 10:00 p.m., documented Resident #37 wanted to be sent to a hospital and a medical transport was called. The note did not document if the resident's representative was notified of the transfer. A progress note, dated 07/31/24 at 3:54 p.m., documented Resident #37's family member called the facility to complain they were not made aware the resident had gone to the hospital. On 08/28/24 at 9:07 a.m. The DON stated they recalled the phone call from the family member that was documented in the 07/31/24 progress note. They stated they had reviewed Resident #37's medical record and did not find documentation anyone at the facility had notified the two emergency contacts when the resident transferred to a hospital on 07/31/24. They stated someone should have notified them.

Based on record review and interview, the facility failed to ensure residents receiving psychotropic medications were monitored for side effects for one (#139) of five residents reviewed for unnecessary medications. The corporate nurse reported 23 residents in the facility received psychotropic medications. Findings: Resident #139 had diagnoses which included bipolar disorder and anxiety disorder. A physician order, dated 08/09/24, documented the resident was receiving clonazepam (an antianxiety medication) 0.5 mg by mouth twice a day. A physician order, dated 08/09/24, documented the resident was receiving fluoxetine (an antidepressant) 40 mg by mouth daily. A physician order, dated 08/09/24, documented the resident was receiving trazodone (an antidepressant) 50 mg by mouth at bedtime. A review of the EHR did not document Resident #139 was being monitored for medication side-effects. On 08/27/24 at 1:40 pm, the DON stated all residents receiving psychotropic medications should have side-effect monitoring in place. On 08/28/24 at 10:30 am, the ADON stated medication side-effect monitoring was not in place for resident #139.

Based on observation, record review and interview, the facility failed to provide food that accommodated resident allergies for one (#30) of two residents reviewed for dining. Corporate Nurse #1 reported 32 residents received meals from the kitchen. Findings: An undated facility policy titled Food Allergies and Intolerances read in part, .Residents with food allergies and/or intolerances are identified upon admission and offered foods substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s) . Resident #30 had diagnoses which included congestive heart failure and depression. A physician's order, dated 08/05/24, documented the resident was to receive a regular diet with thin liquids, the order did not document the resident's allergies. The EHR documented the resident was allergic to pork. On 08/26/24 at 9:00 am, Resident #30 was observed eating breakfast in his room, bacon was observed on their plate. On 08/26/24 at 9:00 am, Resident #30 stated they were served bacon this morning and had been served sausage the day before. They stated they had spoken to the staff, but they continued to serve pork products. On 08/28/24 at 8:43 am, [NAME] #1 stated that resident preferences and allergies should be listed on the meal card and whoever was plating the meal should check the card to ensure the residents preferences and allergies were accommodated. Resident #30's meal card indicated he was allergic to pork. On 08/29/24 at 12:10 pm, LPN #1 stated the person plating the food should check the card for allergies and preferences and so should the person who is taking the food to the resident.

Based on observation, record review, and interview, the facility failed to provide comfortable room temperatures for two (#6 and #7) of four sampled residents reviewed for environment. A facility resident roster, dated 08/05/24, documented 37 residents resided at the facility. Findings: A facility indoor temperature policy, dated 05/23/24, documented indoor temperatures at the facility would be maintained between 72 degrees Fahrenheit and 80 degrees Fahrenheit. 1. Resident #6 had diagnoses which included chronic kidney disease and obesity with alveolar hypoventilation (decreased oxygen levels and increased carbon dioxide levels). 2. Resident #7 had diagnoses which included chronic obstructive pulmonary disease and congestive heart failure. On 08/05/24 at 1:52 p.m., Resident #7 stated the temperature in their room made her miserable and had been too hot for at least one month. The temperature in the room was measured by the surveyor and found to be 86.1 degrees Fahrenheit. The resident stated they had informed the administrator and other staff many times but the heat in their room had continued. On 08/05/24 at 1:55 p.m., Resident #6 stated the temperature in their room was too hot. The room temperature was measured by the surveyor and found to be 88.5 degrees Fahrenheit. The resident stated their room had been too hot for about one month. They stated they had informed the administrator and other staff members of the heat many times. On 08/06/24 at 12:04 p.m., CNA #2 stated the hallway and rooms where Residents #6 and #7 reside had been hot for about one month. They stated they were not sure if the administrator was aware of the situation. On 08/06/24 at 12:16 p.m., CNA #3 stated the area of the facility where Residents #6 and #7 reside have been very hot for about three months. They stated they had reported the situation to the administrator several times in those months. On 08/06/24 at 12:46 p.m., CNA #4 stated the rooms and hallway were Resident #6 and #7 reside have been very hot on and off for about one month. They were unsure if the administration had been informed. On 08/06/24 at 1:20 p.m., the Administrator stated they had been informed of the ineffective air conditioning the past Thursday [08/01/24] and had arranged for contractors to work on the air conditioning system. They stated the system was replaced on 08/05/24. They stated they were unaware that part of the building was having problems, and no one reported the issue to them until 08/01/24.

Based on record review and interview, the facility failed to provide written notice of transfer to residents and their representatives prior to each resident's transfer to a hospital for three (#3, 31, and #40) of three sampled residents reviewed for hospitalization s. The Beneficiary Notice - Residents discharged Within the Past Six Months form, documented nine residents had been discharged in the previous six months. Findings: A Transfer or Discharge Notice, revised date December 2016, documented a resident and or their representative would be given a written notice of transfer, as soon as practicable but prior to transfer, if the transfer was required because of the resident's urgent medical needs. 1. Resident #31 had diagnoses which included atrial fibrillation. A progress note, dated 04/26/23, documented the resident was transferred to a hospital for elevated blood pressure and the inability of the resident to move the right side of their body. A progress note, dated 05/06/23, documented the resident was transferred to a hospital for right hip pain following a fall. A review of the resident's electronic clinical record did not find documentation the resident or their representative had received a written notice of transfer before the hospitalization s. 2. Resident #40 had diagnoses which included vascular dementia. A progress note, dated 05/27/23, documented the resident had been sent to a hospital for aggressive behavior including a physical assault on another person. A review of the resident's electronic clinical record did not find documentation the resident or their representative had received a written notice of transfer before the hospitalization . 35474 3. Resident #3 had diagnoses which included hypertension. A progress note, dated 12/13/22, documented the resident was transferred to the hospital for left sided weakness. The progress note documented the resident did not have family to notify of the transfer. A progress note, dated 12/18/22, documented the resident was transferred to the hospital for left sided weakness, nausea, and vomiting. The progress note documented the resident did not have family to notify of the transfer. Review of the electronic clinical record did not reveal the resident was provided written notice of transfer before the hospitalization s. On 07/24/23 at 9:44 a.m., the administrator was asked if residents and their representatives were provided a written notice of transfer when a resident is sent to a hospital. They replied they had not given written notices since the family is called and made aware of those situations. The administrator was asked how long they had worked at that facility. They stated since February of 2022. They were asked if since that time until the present had any written notices of transfer been provided to a resident or their representative. They responded there had been none provided during that time. On 07/26/23 at 3:02 p.m., the social service director and MDS coordinator were asked who was responsible to ensure notifications were provided in writing of transfers. The social service director stated they had not been notifying anyone of transfers but they were going to start notifying family members. They were asked who provided written notification to the residents when they were transferred. The social service director stated they had not been notifying residents. The MDS coordinator stated they notified residents verbally but not in writing of transfers.

Based on record review and interview, the facility failed to ensure medications were accurately coded on assessments for one (#37) of five residents whose assessments were reviewed for medications. The MDS coordinator identified four residents who received clopidogrel (an antiplatelet medication). Findings: Resident #37 had diagnoses which included cerebral infarction. The quarterly assessment, dated 06/20/23, documented the resident received an anticoagulant medication for seven days during the seven day look back period. Review of the June 2023 medication administration record did not reveal the resident had received an anticoagulant medication. On 07/26/23 at 2:44 p.m., the MDS coordinator was asked what anticoagulant medication had been coded on the 06/20/23 quarterly assessment. They reviewed the clinical record and stated clopidogrel. They were asked why they had coded clopidogrel as an anticoagulant. They stated they had always coded any resident ordered clopidogrel as an anticoagulant during the look back period on the assessment.

Based on record review and interview, the facility failed to include a reconciliation of admission and discharge medications in the discharge summary process for one (#39) of three sampled residents reviewed for closed records. The Beneficiary Notice - Residents discharged Within the Past Six Months form, documented nine residents had been discharged in the previous six months. Findings: A Discharge Summary and Plan, policy and procedure, revised December 2016, documented a nurse would reconcile a resident's pre-discharge medications with their post-discharge medications and document the process as part of the discharge summary process. A progress note, dated 05/08/23, documented resident #39 was discharged to another facility. Resident #39's discharge summary, dated 05/08/23, was reviewed for documentation of reconciliation of pre-discharge medications and post-discharge medications. No reconciliation of medications were found. On 07/24/23 at 9:06 a.m., the DON was asked to describe the reason resident #39 was discharged . They stated what had occurred leading up to the discharge. They were then asked if the residents pre-discharge and post-discharge medications had been reconciled in the resident's discharge summary. They stated they the nurses were supposed to reconcile the medications but there was no documentation it was done in the case of resident #39.

Based on observation, record review, and interview, the facility failed to obtain a medication to one (#29) of five sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents, form, dated 07/20/23, documented 35 residents resided in the facility. Findings: Resident #29 had diagnoses which included Diabetes mellitus. A physician's medication order, dated 07/03/23, documented resident #29 was to be administered a Farxiga (medication used to control blood sugar levels) 10 mg tablet once daily during the morning medication pass. A Medication Administration History, record, dated 07/01/23 through 07/27/23, documented resident #29 was not administered Farxiga on 07/26/23 as it was not available. The record further documented a pharmacy would deliver the medication that night. On 07/26/23 at 8:11 a.m., CMA #1 was observed preparing morning medications for resident #29. They reported one medication was not in the medication cart. CMA #1 identified the miss medication as Farxiga 10 mg tablets. They were asked when the resident had last been administered the medication. They reported it had been given the day before. They reported the medication was ordered one week earlier. On 07/27/23 at 9:23 a.m., CMA was asked if resident #29's Farxiga had arrived at the facility. They responded it came the night before and had been administered during the morning medication pass that morning. At 10:13 a.m., the DON was asked to describe the procedure for ordering medications. They responded medications were reordered when a one-week supply was left in the facility. They were asked what was done if a medication order had not arrived before the medication supply had run out. They responded the CMA was to report that information to the charge nurse, ADON, and DON so that steps could be taken to acquire the medication. They were asked if they had been informed of resident #29's unavailable Farxiga on 07/26/23. They stated they had not been informed. At 10:26 a.m., resident #29 was asked if they had been informed of their missing medication on 07/26/23. They stated they had not been informed and was unhappy about missing their medication.

Based on record review and interview, the facility failed to ensure eight hours daily of RN coverage and employ a full-time DON for 19 of 28 days reviewed. The Resident Census and Conditions of Residents form identified 41 residents who resided in the facility. Findings: Review of the RN time detail, dated 12/08/22 through 01/04/23, revealed the facility had not provided eight hours of RN coverage on 12/08/22, 12/09/22, 12/12/22 through 12/19/22, 12/21/22, 12/22/22, 12/26/22 through 12/30/22, 01/02/23, and 01/04/23. The time detail revealed the facility had not had a DON since 12/08/22. On 01/05/23 at 1:18 p.m., the administrator was asked who the DON was for the facility. They stated they had a DON arriving later in the day on 01/05/23. The administrator was asked how the facility had provided eight hours of RN coverage daily. They stated the weekend RN had provided coverage at times. The administrator was asked what they had attempted to obtain a full-time DON and provide eight hours of RN coverage daily. They stated they had posted the job openings on various employment websites. They stated the previous DON had provided their resignation effective 01/05/23 but unexpectedly ended their employment after their shift on 12/07/22. The administrator was asked if agency staffing had been utilized to provide eight hours of RN coverage. They stated, No. The administrator was asked why agency staffing had not been utilized for RN coverage. They stated they did not have money for an agency RN because they were utilizing agency LPNs and CMAs.

Based on record review, observation, and interview, the facility failed to ensure leftover foods were dated and discarded by the use by date and the ice machine was maintained in a sanitary manner. The DON identified 40 residents who received nourishment from the kitchen. Findings: The undated Use of Leftovers policy, read in part, .Leftovers can be used if used within 7 days (day of preparation being day 1) according to the 2013 Federal Food Code and if reheated to 165 [degree] F for a minimum of 15 seconds for hot foods*. Time/temperature control for safety leftovers may be used within 24 hours of preparation or may be frozen for use at a later time . An undated and untitled policy ready in parts, .It is the policy of [NAME] Rest Care Center that ice machines will be cleaned monthly and as needed .All ice will be removed and ice machine cleaned per manufacturer guidelines. Maintenance will keep a log of dates when ice machine has been cleaned . On 11/14/22 at 12:42 p.m., a tour of the kitchen was conducted. The refrigerator was observed to have two plastic containers of an orange substance dated 10/26/22 and 11/02/22, one container labeled applesauce dated 11/10/22, and one container of barbeque pork dated 11/08/22. The dietary manager was asked what the date on the container indicated. They stated it was the date the item was received. They were asked how long leftovers were kept. They stated two to three days. The dietary manager was asked when the containers had been opened. They stated they did not know. They were asked how they monitored to ensure leftovers were discarded by the use by date. They stated they went by when the item had been served on the menu as the date the food had been opened. They were asked where they documented the monitoring of leftover food. They stated they did not document the monitoring. On 11/14/22 at 2:30 p.m., the ice machine was observed with the maintenance supervisor. The deflector panel was observed to contain a black substance when it was wiped with paper towel. On 11/28/22 at 5:54 p.m., the maintenance supervisor was asked how often the ice machine was cleaned. The maintenance supervisor stated they cleaned the mechanical section of the ice machine weekly and the ice storage bin once a month. The maintenance supervisor was asked if they observed discoloration of the parts during the weekly cleaning of the mechanical section. They stated, No. The maintenance supervisor was asked if they observed discoloration of the parts during the monthly cleaning of the ice storage area. They stated, Yes.

Based on record review, observation, and interview, the facility failed to have an effective means of documenting a resident's code status for four (#6, 43, 30, and #40) of four sampled residents who were reviewed for advance directives. The Resident Census and Conditions of Residents form documented 13 residents had advanced directives and 43 residents resided in the facility. Findings: The Advanced Directives policy, revised [DATE], read in parts, .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive . 1. Resident #43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Oklahoma Do-Not-Resuscitate (DNR) Consent Form EMR attachment, dated [DATE], possessed the signature of the resident and the signatures of two witnesses, which indicated the resident was a DNR. A physician order, dated [DATE], documented the resident was a DNR. The nurse's progress note, dated [DATE] at 1:24 p.m., documented the resident was without pulse and CPR was initiated. The note documented CPR was stopped when the code status was determined to be DNR. The resident was pronounced dead by local emergency personal at 1:18 p.m. On [DATE] at 3:11 p.m., LPN #1 was asked about Resident #43. LPN #1 stated staff informed them that Resident #43 was acting funny. The LPN stated when they went to assess the resident, the resident displayed agonal breathing. The LPN stated while assessing, the resident became pulseless and CPR was initiated. The LPN stated Halloween door decorations located on the resident's door blocked their view of the resident's code status. The LPN stated once staff confirmed the resident was a DNR, CPR was stopped. The LPN stated the door decorations were removed the same day they provided CPR to Resident #43. 2. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Oklahoma Do-Not-Resuscitate (DNR) Consent Form EMR attachment, dated [DATE], possessed the mark of the resident and the signatures of three witnesses, which indicated the resident was a DNR. On [DATE] at 4:10 p.m., the name plate on the resident's door indicated the resident was a DNR. On [DATE] at 4:45 p.m., the DON was asked what the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the resident's desired code status was a DNR. The DON was asked the resident's advanced directive indicated. The DON reviewed the DNR, reviewed the resident's care plan, and stated the resident's code status was DNR. 3. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:56 p.m., the resident's electronic medical record was reviewed. The EMR indicated the resident's code status was DNR. Review of the clinical record did not reveal a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:50 a.m., the name plate on the resident's door indicated the resident was a DNR. On [DATE] at 4:42 p.m., the DON was asked what the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated full code. The DON stated the resident had just elected hospice services and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked if there was an advanced directive documented in the resident's electronic medical record. The DON stated the advanced directive had just been uploaded to the resident's electronic medical record a minute ago. The DON was asked what the time frame was for updating a resident's code status. The DON stated it should be done the same day the code status changed. 4. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:40 p.m., the resident's electronic medical record was reviewed. The EMR indicated the resident's code status was DNR. There was an advanced directive, signed by the resident's representative, attached to the electronic medical record. The attached advanced directive did not possess witness signatures. On [DATE] at 11:25 a.m., the name plate on the resident's door indicated the resident was a DNR. On [DATE] at 4:44 p.m., the advanced directive attached in the electronic medical record was reviewed with the DON. The DON was asked if the attached advanced directive was complete. The DON stated the advanced directive was missing the witness signatures. The DON was asked how the staff knew what the resident's code status was without a complete advanced directive. The DON stated the staff would not know.

On 05/19/22 at 2:38 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to identify, implement, monitor, and modify interventions to prevent an extreme weight loss. Record review and interview revealed the resident's weight loss had not been identified, monitored, or intervened by the facility from December 2021 to May 2022. Resident #13 was readmitted in December with a documented weight of 190.3 pounds and a recent weight documented on 05/03/22 of 123.68 pounds. This accounted for a severe weight loss of 33.43% in five months. Documentation from the dietician identified the significant weight loss and informed the facility. No documentation was provided by the facility that interventions had taken place on recommendation of the dietician. At 2:46 p.m., the facility's administrator, and regional consultant nurse were made aware of the IJ situation related to the facility's failure to prevent severe weight loss. A plan of removal of the IJ situation was requested. On 05/20/22 at 10:06 a.m., the regional consultant nurse provided an acceptable plan of removal. The plan of removal documented, Plan of Removal 05/19/2022 Resident at [Risk- Resident #13], and all residents Current Information/Plan in Place 1. Medical Director has been notified about IJ our Plan of Removal with respect to [Resident #13] 15:00 05/19/2022. 2. IJ situation brought to the attention of Administrator at 14:50 05/19/2022. [Resident #13] was sent to ER in [name removed] Hospital at 13:36. Hospital to draw labs 15:00 05/19/2022. 3. All residents except hospice and actively passing residents will be weighed, and weights will be reviewed by nurse consultant to be completed by 2200 05/19/2022. Physician will be notified of weight variances with orders to be obtained and interventions to be implemented and order written, and intervention place on care plan 20:00 05/19/2022. 4. In-services on meal percentages documentation and refusal of meal documentation on 05/19/2022 by nurse consultant for nursing staff to include both in-person and over the phone education of meal percentages, who to notify of refusal being the charge nurse, documentation of meal percentages, with documentation of meal percentages sheet placed in DON/Nurse Consultant for review with a supplement to be given if intake eaten is less than 50% completed 18:00 05/19/2022 6. Nurse Consultant to review all current weights and supplement orders at 22:00 5/19/2022. 7. Dietitian report obtained for visit to facility today 05/19/2022, reviewed by nurse consultant, physician reviewed , copies place in dietary binder, recommendations signed and orders written, and intervention will be implemented and placed on care plans 20:00 05/19/2022. 8. Systems: nurse consultant will review weight weekly and notification to physician with order obtained and actions take with interventions and care plans updated 20:00 05/19/2022. On 05/20/22, interviews were conducted with a total of ten employees who worked different shifts. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. On 05/20/22 at 1:19 p.m., the corporate nurse was informed the IJ had been lifted as of 05/19/22 at 7:30 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review, observation, and interview, the facility failed to assess, monitor, and intervene for severe weight loss of one (#13) of three residents sampled for weight loss. Resident #13 was readmitted in December with a documented weight of 190.3 pounds and a recent weight documented on 05/03/22 of 123.68 pounds. This accounted for a severe weight loss of 33.43% in five months. The Resident Census and Conditions of Residents identified 34 residents lived at the facility. Findings: Resident #13 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's MDS assessments did not document a significant change or weight loss for the resident. Resident #13's care plan, dated 12/14/21, did not document a weight loss or any interventions for weight loss. The care plan was not updated for the need to monitor during meals. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of meal percentages revealed: December 15th through 31st meal percentages were documented 10 out of 51 opportunities as 76-100% 3 times, 51-75% one time, 26-50% three times, 1-25% three times. A progress note, dated 12/16/2021 at 11:00 a.m., read in part, .Ate about 40% breakfast with assistance. Will not eat by himself @ this time . A physician's note, dated 12/16/21, documented a decrease of 20-30 pounds while at home with wife/hospital. No orders were provided. A progress note, dated 12/19/2021 at 1:26 p.m., read in part .Staff assist [name removed] with lunch, good appetite while someone is at bedside . January 1st through 31st meal percentages were documented five out of 93 opportunities as 76-100% two times, 51-75% two times, 26-50% one time. On 01/06/22 the resident's weight was documented as 166.5 pounds. No interventions were documented. This was a 23.8 pound loss from December 2021. An Admission Nutrition Assessment, dated 01/26/22 at 1:55 p.m., read in part, [Resident #13's] weight 166.5 as of 01/06/22 .Requires feeding assistance. Diet is adequate to meet nutritional needs. Noted he was sent out to hospital this morning. Will rec [recommend] d/c [discontinue] heart healthy from diet order at next visit. February 1st through 28th, meal percentages were documented once out of 93 opportunities as 1-25%. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Mech soft and nectar thick liquids. On 02/16/22 resident #13's weight was documented as 170.2 pounds. This was a 20.1 pound loss or 10.5% loss from readmission in December 2021. A dietician note, dated 02/16/22 at 11:09 a.m., documented the resident's weight as 170 pounds as of 02/16/22. A weight increase of 3.7 pounds for one month and a diet as mechanical soft, heart healthy. A progress note, dated 02/25/22 at 1:01 p.m., read in part, .Resident refused to eat lunch, states will drink the fluids but is not going to eat anything at this time .WCTM [will continue to monitor] for any changes or continued behavior . There were no further notes documenting continued monitoring. March meal percentages were not documented out of 93 opportunities. No weights were documented for this month. Resident #13 had a significant weight loss during this month. The facility had not implemented interventions for severe weight loss of 10.5 pounds experienced by Resident #13. A dietary note, dated 03/22/22 at 2:03 p.m., documented, .March wt [weight] not confirmed. Diet: Regular, Mechanical Soft, nectar thickened liquids. Wound R [right] ankle per wound report 3/2. Receives Vit C and Zinc. Rec: Daily MVI [multivitamin] with minerals. No weights were documented for March 2022. April meal percentages were documented three out of 90 opportunities as 76-100% two times, 26-50% one time. A dietary note, dated 04/13/22 at 3:00 p.m., read in part, .Weight 132# [pounds] as of 4/11. Reflects a significant weight loss compared to February. Staff reports that resident has very poor meal intake. He doesn't like thickened liquids. Diet: Regular, Mechanical Soft, nectar thickened liquids .Noted hospice being considered. Will notify physician of significant weight change. If resident does not go on hospice soon, is he a candidate for enteral nutrition support? May meal percentages were documented 11 out of 51 opportunities as 76-100% five times, 51-75% two times, 26-50% two times, 1-25% two times. On 05/03/22 resident #13's weight was documented as 126.68 pounds, which is a 33.43% loss since readmission on 12/14/21. A progress note, dated 05/13/22 at 8:01 p.m., read in part, .[Resident #13] did not want to get OOB [out of bed] for the evening meal today, with two different people asking. States, no, I'm waiting for my wife. The note did not document if the resident was offered a meal in his room or a supplement drink. A progress note, dated 05/16/22 at 6:07 a.m., read in part, .Resident began yelling out at about 0500 [5:00 a.m.], stating he missed his meals, he did not miss his meals .states he wants food now . No documentation provided for resident being offered any food or snack options. There were no documented inteventions for Resident #13 severe weight loss experinced from 12/14/21 through 05/03/22. On 05/18/22 at 3:27 p.m., CNA #3 stated the meal percentages were documented on a clipboard and then entered in the computer by the CNAs. On 05/18/22 at 4:31 p.m., the corporate nurse consultant stated the dietician will be here tomorrow. The nurse stated, I know the doctor saw April recommendations but I need to look for the other ones, I don't think the dietician sends individual recommendations to the doctor but they send the whole report. On 05/19/22 at 8:23 a.m., Res #13 was observed in bed, sitting at a 30 degree angle, a plate was on the over bed table with a half eaten sausage patty, remnants of egg on the plate and on the resident. Staff was not present in the room. Resident #13 required assistance to eat and supervision for choking. On 05/19/22 at 8:43 a.m., CNA #1 stated several residents required assistance with eating. Resident #13 required assistance sometimes. The CNA was asked how they knew which residents required assistance. The CNA stated when it was charted or given in report. The CNA stated breakfast was typically passed by the CNAs but today breakfast was passed by the regional nurse and activities director because they were short a CNA. The CNA was asked if they were able to meet the needs of residents when staff was missing. The CNA stated no. On 05/19/22 at 8:54 a.m., The activities director stated they had assisted residents and helped pass trays to residents, including resident #13's tray. The activities director stated none of which required assistance or supervision while eating. Resident #13 required assistance to eat and for risk of choking due to dysphagia. On 05/19/22 at 8:55 a.m., CNA #2 stated resident #13 required limited assistance with supervision for choking. The CNA was asked how they assisted residents to eat when there were only two aides for the building. The CNA stated, We do the best we can. On 05/19/22 at 9:50 a.m., the registered dietician stated they came once a month and saw everyone. The dietician stated the recommendations to the physician and a summary for the facility were left with the DON. The dietician stated if recommendations were not addressed from the previous month the recommendation would be made again the next month. The dietician was asked to describe the weight loss from December on readmission to the May weight. The dietician stated very significant. The dietician was asked if the weight loss were to continue, what would be the end result. The dietician stated the resident cannot continue like that. On 05/19/22 at 10:49 a.m., the corporate nurse consultant was asked how weights were monitored. The nurse stated a list was given to the previous DON when the consultant nurse arrived. The previous DON did not follow through with the list, weights were not monitored or assess for variance. The corporate nurse was asked if the dietician recommendations were addressed by the physician. The nurse stated they would have to look for them. The corporate nurse was asked when it was noticed the weights were not addressed. The nurse stated the second week in March. The nurse stated the weights were not addressed because the weight report had not been pulled. On 05/25/22 at 1:34 p.m., the administrator was asked how weights were monitored and addressed. The administrator stated that was the responsibility of the DON. The administrator was asked who was responsible to ensure the weights were monitored and addressed. The administrator stated the corporate nurses. The administrator was asked, as the administrator, how did you ensure that you utilized resources to ensure weight loss did not occur. The administrator stated they were not made aware of the weight loss.

On [DATE] at 12:20 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to supervise staff to ensure proper application of cardiopulmonary resuscitation (CPR). At 12:57 the facility administrator and corporate nurse were informed of the IJ situation related to the facility's failure to provide CPR by certified staff for a resident. A plan of removal for the IJ situation was requested. On [DATE] at 5:14 p.m., the corporate nurse provided an acceptable plan of removal. The facility's plan of removal documented, .Plan of Removal [DATE] .CPR training will be conducted on [DATE] / [DATE] @ 10 am with [trainers name withheld]. All staff of SRCC will go through CPR training. Conduct a Mock Survey the following week by [DATE] to ensure proper CPR is initiated in an emergency situation. Review all equipment on crash cart, where it is, what it is for, and proper usage. Check list that will be reviewed and look at the cart daily by the charge nurse. Educate all nurses that they should stay at the scene with the resident supervising the staff. Delegate other staff to call 911, paperwork etc. ,d+[DATE] shift if CPR is needed the charge nurse (LPN #2) will be performing CPR, 2- [DATE] shift is agency nurse, the agency is sending the nurses CPR card to us. All charge nurses will be running the code. Today ,d+[DATE] shift [name withheld] / Agency nurse ,d+[DATE] shift. Tomorrow on 6-,d+[DATE]-10 charge nurse (LPN #2) will perform CPR if needed. Audit crash cart weekly to determine all equipment is readily available, performed by DON / ADON / MDS nurse. Full codes - 29. Staff per shift that are CPR certified - 2- / 10 today - x 2 tomorrow ,d+[DATE] - x 2 ,d+[DATE] x 2 will have staff certified tomorrow. Orientation for agency staff is a book that all agencies are aware that sits at the nursing station of information they need to know about in this facility. Don [sic] / ADON will do a walk through with the agency staff prior to working their shift. CPR class Thursday-19. Friday-12. On [DATE] interviews were conducted with six staff member who had responsibilities to conduct CPR. Each verified that they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. The crash cart was found to have been inspected and stocked with supplies required to implement CPR. Documentation that each staff member had been certified in CPR was observed. One staff member who was unable to attend training had been suspended until that time he/she became certified. On [DATE] at 3:50 p.m., the administrator and corporate nurse were informed the IJ had been removed on [DATE] at 3:00 p.m. The deficient practice reamined at a level of isolated harm. Based on interviews and record review it was determined the facility failed to provide supervision of untrained/certified facility staff who performed CPR, for one (#1) of one sampled resident who had no vital signs and was designated a full code. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated [DATE], documented the resident had a code status of full code. A physician order, dated [DATE], documented, .Code Status: Full . A nurse note, dated [DATE] at 8:26 a.m., documented, .Resident was walking with wheelchair back to room. Resident lost balance in front of nurses station and fell backwards hitting her head on the nurses station wall and sliding into a seated position. This nurses witnessed fall and immediately assessed resident. Resident was sitting with head and back against wall with eyes open looking forward. Resident was breathing at this time. Resident begun to groan, this nurse laid resident on her back. Resident stopped breathing, this nurse initiated CPR. 911 WAS CALLED. EMSA arrived and continued CPR. EMSA then transported resident . A review of the employee training records and current certifications for CNA #3 through #5 and CMA #1 contained no documentaiton to indicate the employees had been trained and/or certifeid in CPR. On [DATE] a facility video recording, dated [DATE] at 6:47 a.m., was reviewed. It documented the fall of resident #1 and the staff's response. The following times are those documented in the recording: ~6:48 a.m. resident #1 fell backwards and struck her head and upper back against a wall. The first staff member arrived at the resident's location in approximately 10 seconds; ~6:50 a.m., facility staff began chest compressions; ~6:56 a.m., a simple type face mask connected to an oxygen tank was placed on the resident's face; ~6:58 a.m., community first responders took over chest compressions; and ~6:59 a.m., a bag valve mask was first used by the community first responders. During the recording LPN #2 was observed to leave and return to the scene repeatedly without providing any supervision to ensure CPR was being performed correctly. The staff members observed on the video who applied chest compression did so incorrectly. The chest compressions stopped and started too often, hand placement was incorrect, the depth of the compressions were often too shallow, and the direction of force of the compressions were often misdirected causing the body to rock to the sides with each compression. During the approximate 8 minutes the facility staff performed compressions the resident did not receive any rescue breaths. On [DATE] at 1:27 p.m., CNA #4 was asked how long he had worked at the facility. He stated he had worked since [DATE]. He was asked how long he had been a CNA. He stated three days. He was asked if he was on duty when resident #1 had fallen. He stated he was there. He was asked if he had assisted with CPR for resident #1 that day. He stated he mostly performed chest compressions. He stated he would do between 17 and 21 compressions and then check for a pulse. He was asked what the nurse had been doing while he did compression. He stated she went to look for an ambu bag and mouth barriers. He was asked if those items had been found. He stated they were not on the crash cart and were unavailable during CPR. He was asked what training he had related to caring for an unresponsive persons. He stated he had not had any formal training but learned during on the job training. He was asked what he would do in such a case. He stated he would stay with the resident and check vital signs except to contact the nurse. He was asked to describe his CPR training. He stated he had been trained in CPR and first aid at a previous employer. He was asked if he had a current CPR certification for healthcare providers. He stated he did not. He was asked if he had received CPR training at the facility. He stated they watched instructional videos but nothing with a trainer or a dummy. At 1:46 p.m., CNA #5 was asked how long she had worked at the facility. She stated since [DATE]. She was asked how long she had been a CNA. She stated since 2014. She was asked if she had been on duty the day the resident fell . She stated she had been. She was asked to describe the incident. She stated she did not see the fall but came upon it. She was told by the LPN #2 to assist the resident into the sitting position and once in that position the resident stopped breathing. She stated she knew it was wrong to put the resident in the sitting position as an unconscious person should not be moved. I told the nurse we needed to do CPR and we placed the resident flat on the floor. She was asked who performed the chest compressions. She stated, CNA #4, CNA #3, LPN #2, CMA #1, and herself. She was asked what else other than compressions had been done. She stated they could not find the ambu bag as it was not on the cart. She was asked if there had been a mouth guard. She stated she was not sure. She stated LPN #2 kept looking around for those items while others performed compressions. She was asked if she was CPR certified. She stated she was and had been since 2014. At 2:05 p.m., LPN #2 was asked how long she had worked at the facility. She stated for one month full time and three months as needed. She was asked how long she had been an LPN. She stated three years. She was asked if she had been on duty the day the resident had fallen. She stated she was at the nurses' station where the resident had fallen and had been the first one at the scene. She was asked to describe the incident. She stated the resident had been walking behind her wheelchair when she fell backwards into a half sitting position against the wall. She stated she had slowly turned her and laid her down on the floor. She stated the resident had been unresponsive and she left the scene to get a blood pressure cuff. She heard an aide state the resident had stopped breathing so she checked the resident's code status and then initiated CPR. She was asked if anyone had ever placed the resident in the sitting position on the floor. She stated no and that the resident went from the laying position to the gurney. She was asked if she had viewed the video recording of the incident. She stated she had. She was asked how she was able to supervise the CPR while she was not present during the running of the code. She had no comment. She was asked if she was CPR certified. She stated she was. She was asked if there had been any CPR training at the facility since the resident had fallen. She stated there had been an in-service on [DATE] where they had watched videos on CPR. On [DATE] at 8:25 a.m., CNA #3 was asked how long she had worked at the facility. She stated one year. She was asked how long she had been a CNA. She stated two months. She was asked to describe any training she had received at the facility related to unresponsive persons and CPR. She stated she had none at the facility. She was asked if she was on duty when the resident fell . She stated she had been and had heard the resident fall. She was asked if she participated in CPR. She stated LPN #2 had started chest compressions and she and others took turns. She was asked if she was CPR certified. She stated she had been in the past but it had expired in 2005. She was asked if the resident had received oxygen. She stated at some point they did put an oxygen mask on her. She was asked if anyone had sat the resident up at any time. She stated LPN #2 and CNA #5 had sat the resident up to do vitals. She was asked if LPN #2 had remained with the resident during CPR. She stated the nurse went to look for supplies that were not found on the crash cart. At 8:44 a.m., CMA #5 was asked how long she had worked at the facility. She stated eight months. She was asked how long she had been a CMA. She stated two years. She was asked to describe any training she had received at the facility related to caring for unresponsive persons and CPR. She stated she did not recall any training at the facility on those two subjects. She was asked if she had been on duty when the resident had fallen. She stated she had been. She was asked to describe what had occurred. She stated she had come across the scene and observed the resident laying on the floor. She stated other staff was performing CPR so she went to get the crash cart. She stated that LPN #2 removed an oxygen mask from the cart. She saw CNA # 4 performing compressions. She stated LPN #2 had to run back and forth to find the mask. She was asked if she heard anyone talk about missing equipment. She stated LPN #2 said there had been no bag in the crash cart. She was asked if she was CPR certified. She state she had been but it expired seven months earlier. On [DATE] at 8:37 a.m., the DON was asked how long she had worked at the facility. She stated since [DATE]. She was asked to describe the training the staff received in relation to unresponsive persons and CPR. She stated that CPR inservices had occurred in the facility and the ADON helped with training. She stated they have inservices twice each month. She was asked if she had been aware staff members were not certified in CPR. She stated she had been and they had tried to schedule training for those persons. She was asked if she was responsible for checking to ensure new employees were CPR certified. She stated she did not feel that anyone had ever told her that was one of her responsibilities. She was asked how the facility ensured new employees knew how to perform their duties and where to locate supplies. She stated when she started there was no competency check sheets but she started having new employees shadow current employees for a period of time. She was asked if there was a sign off sheet related to that program. She stated there was not. She was asked if she had any responsibility with the inventory and ordering of supplies such as ambu bags. She stated that was done by the ADON. At 9:08 a.m., the ADON was asked if she assisted with the training of staff. She stated she did so with the DON. She was asked if she had the duty of ensuring staff were certified in CPR. She stated she was not. She was asked if she had been aware that some nursing staff were not CPR certified. She said she became aware after the incident of resident #1. She was asked if she was tasked with keeping supplies available for the nursing staff including the crash cart. She stated she was. She was asked if ambu bags were in the building and were so on the day of resident #1's fall. She stated yes. She was asked why LPN#2 could not find the ambu bags if they were in the building. She stated she thought the LPN had been panicked. She was asked if the nurse stayed to suprvise the code to ensure it was completed correctly. She stated she did not.

On [DATE] at 12:20 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to: ~ provide cardiopulmonary resuscitation (CPR) by trained and certified staff to a resident who had no vital signs. Clinical records revealed the resident was a full code; and ~ have equipment required in the application of CPR available to staff. At 12:57 the facility administrator and corporate nurse were informed of the IJ situation related to the facility's failure to provide CPR by certified staff for a resident. A plan of removal for the IJ situation was requested. On [DATE] at 5:14 p.m., the corporate nurse provided an acceptable plan of removal. The facility's plan of removal documented, .Plan of Removal [DATE] .CPR training will be conducted on [DATE] / [DATE] @ 10 am with [trainers name withheld]. All staff of SRCC will go through CPR training. Conduct a Mock Survey the following week by [DATE] to ensure proper CPR is initiated in an emergency situation. Review all equipment on crash cart, where it is, what it is for, and proper usage. Check list that will be reviewed and look at the cart daily by the charge nurse. Educate all nurses that they should stay at the scene with the resident supervising the staff. Delegate other staff to call 911, paperwork etc. ,d+[DATE] shift if CPR is needed the charge nurse (LPN #2) will be performing CPR, 2- [DATE] shift is agency nurse, the agency is sending the nurses CPR card to us. All charge nurses will be running the code. Today ,d+[DATE] shift [name withheld] / Agency nurse ,d+[DATE] shift. Tomorrow on 6-,d+[DATE]-10 charge nurse (LPN #2) will perform CPR if needed. Audit crash cart weekly to determine all equipment is readily available, performed by DON / ADON / MDS nurse. Full codes - 29. Staff per shift that are CPR certified - 2- / 10 today - x 2 tomorrow ,d+[DATE] - x 2 ,d+[DATE] x 2 will have staff certified tomorrow. Orientation for agency staff is a book that all agencies are aware that sits at the nursing station of information they need to know about in this facility. Don [sic] / ADON will do a walk through with the agency staff prior to working their shift. CPR class Thursday-19. Friday-12. On [DATE] interviews were conducted with six staff member who had responsibilities to conduct CPR. Each verified that they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. The crash cart was found to have been inspected and stocked with supplies required to implement CPR. Documentation that each staff member had been certified in CPR was observed. One staff member who was unable to attend training had been suspended until that time he/she became certified. On [DATE] at 3:50 p.m., the administrator and corporate nurse were informed the IJ had been removed on [DATE] at 3:00 p.m. The deficient practice reamined at a level of isolated harm. Based on interviews and record review it was determined the facility failed to: ~ provide CPR by trained and certified staff members for one (#1) of one sampled resident who had no vital signs and was designated a full code; and ~ have equipment required in the application of CPR available to staff. Findings: An undated policy, titled CPR, documented, .Standard: It is the policy of this facility will provide basic life support, including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services . Policy: Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: Do Not Resuscitate orders is in place .Procedure: CPR certified staff will be available at all times. The staff will maintain current CPR certification for healthcare providers including hand-on skill practice and in-person assessment and demonstration of skills. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated [DATE], documented the resident had a code status of full code. A physician order, dated [DATE], documented, .Code Status: Full . A nurse note, dated [DATE] at 8:26 a.m., documented, Resident was walking with wheelchair back to room. Resident lost balance in front of nurses station and fell backwards hitting her head on the nurses station wall and sliding into a seated position. This nurses witnessed fall and immediately assessed resident. Resident was sitting with head and back against wall with eyes open looking forward. Resident was breathing at this time. Resident begun to groan, this nurse laid resident on her back. Resident stopped breathing, this nurse initiated CPR. 911 WAS CALLED. EMSA arrived and continued CPR. EMSA then transported resident . An incident report on ODH Form 283, documented, .Incident date [DATE] .Incident type Death Other than by Natural Causes .ATTACHMENT 2 .Written statements were gathered from 4 people who were witnesses to the incident. Camera footage was reviewed by (administrator) and (DON), and it was seen that (resident #1) came out of her room that is in front of the nurses station, pushing her wheelchair. She went to turn around and lost her balance and fell backwards, hitting the back of her head on the nurses station. (LPN #2) came around from the nurses station and assessed (resident #1). She laid her down flat on the ground and (CNA #3) called for (CNA #5) to come help. (CMA #1) brought the crash cart. (CNA #4) was present as well. They began CPR and called 911. The fire department came and took over the rescue efforts and then transported (resident #1). On [DATE], (name withheld) of APS came to the facility to complete an investigation. (administrator) and (DON) are currently working to find someone to come and do CPR training with all staff. On [DATE], the facility had an in service over CPR. (administrator) and (DON) plan do [sic] review CPR again on the upcoming in service on [DATE]. (DON) and (MDS #1) are currently working on an updated check list for the crash cart . A review of the employee training records and current certifications for CNA #3 through #5 and CMA #1 contained no documentaiton to indicate the employees had been trained and/or certifeid in CPR. On [DATE] a facility video recording, dated [DATE] at 6:47 a.m., was reviewed. It documented the fall of resident #1 and the staff's response. The following times are those documented in the recording: ~6:48 a.m. resident #1 fell backwards and struck her head and upper back against a wall. The first staff member arrived at the resident's location in approximately 10 seconds; ~6:50 a.m., facility staff began chest compressions; ~6:56 a.m., a simple type face mask connected to an oxygen tank was placed on the resident's face; ~6:58 a.m., community first responders took over chest compressions; and ~6:59 a.m., a bag valve mask was first used by the community first responders. During the recording LPN #2 was observed to leave and return to the scene repeatedly without providing any supervision to ensure CPR was being performed correctly. The staff members observed on the video who applied chest compression did so incorrectly. The chest compressions stopped and started too often, hand placement was incorrect, the depth of the compressions were often too shallow, and the direction of force of the compressions were often misdirected causing the body to rock to the sides with each compression. During the approximate 8 minutes the facility staff performed compressions the resident did not receive any rescue breaths. On [DATE] at 1:27 p.m., CNA #4 was asked how long he had worked at the facility. He stated he had worked since [DATE]. He was asked how long he had been a CNA. He stated three days. He was asked if he was on duty when resident #1 had fallen. He stated he was there. He was asked if he had assisted with CPR for resident #1 that day. He stated he mostly performed chest compressions. He stated he would do between 17 and 21 compressions and then check for a pulse. He was asked what the nurse had been doing while he did compression. He stated she went to look for an ambu bag and mouth barriers. He was asked if those items had been found. He stated they were not on the crash cart and were unavailable during CPR. He was asked what training he had related to caring for an unresponsive persons. He stated he had not had any formal training but learned during on the job training. He was asked what he would do in such a case. He stated he would stay with the resident and check vital signs except to contact the nurse. He was asked to describe his CPR training. He stated he had been trained in CPR and first aid at a previous employer. He was asked if he had a current CPR certification for healthcare providers. He stated he did not. He was asked if he had received CPR training at the facility. He stated they watched instructional videos but nothing with a trainer or a dummy. At 1:46 p.m., CNA #5 was asked how long she had worked at the facility. She stated since [DATE]. She was asked how long she had been a CNA. She stated since 2014. She was asked if she had been on duty the day the resident fell . She stated she had been. She was asked to describe the incident. She stated she did not see the fall but came upon it. She was told by the LPN #2 to assist the resident into the sitting position and once in that position the resident stopped breathing. She stated she knew it was wrong to put the resident in the sitting position as an unconscious person should not be moved. I told the nurse we needed to do CPR and we placed the resident flat on the floor. She was asked who performed the chest compressions. She stated, CNA #4, CNA #3, LPN #2, CMA #1, and herself. She was asked what else other than compressions had been done. She stated they could not find the ambu bag as it was not on the cart. She was asked if there had been a mouth guard. She stated she was not sure. The CNA stated LPN #2 kept looking around for those items while others performed compressions She was asked to describe any training she had received related to unresponsive persons. She stated she thought they did have such training on [DATE] and [DATE] but could not describe it. She was asked if there had been any CPR training. She stated they had watched some videos but had not practiced on a dummy or demonstrated CPR. She was asked if she was CPR certified. She stated she was and had been since 2014. At 2:05 p.m., LPN #2 was asked how long she had worked at the facility. She stated for one month full time and three months as needed. She was asked how long she had been an LPN. She stated three years. She was asked if she had been on duty the day the resident had fallen. She stated she was at the nurses' station where the resident had fallen and had been the first one at the scene. She was asked to describe the incident. She stated the resident had been walking behind her wheelchair when she fell backwards into a half sitting position against the wall. She stated she had slowly turned her and laid her down on the floor. She stated the resident had been unresponsive and she left the scene to get a blood pressure cuff. She heard an aide state the resident had stopped breathing so she checked the resident's code status and then initiated CPR. She was asked if anyone had ever placed the resident in the sitting position on the floor. She stated no and that the resident went from the laying position to the gurney. She was asked if she had viewed the video recording of the incident. She stated she had. She was asked how she was able to supervise the CPR while she was not present during the running of the code. She had no comment. She was asked if she was CPR certified. She stated she was. She was asked if there had been any CPR training at the facility since the resident had fallen. She stated there had been an in-service on [DATE] where they had watched videos on CPR. On [DATE] at 8:25 a.m., CNA #3 was asked how long she had worked at the facility. She stated one year. She was asked how long she had been a CNA. She stated two months. She was asked to describe any training she had received at the facility related to unresponsive persons and CPR. She stated she had none at the facility. She was asked if she was on duty when the resident fell . She stated she had been and had heard the resident fall. She was asked if she participated in CPR. She stated LPN #2 had started chest compressions and she and others took turns. She was asked if she was CPR certified. She stated she had been in the past but it had expired in 2005. She was asked if the resident had received oxygen. She stated at some point they did put an oxygen mask on her. She was asked if anyone had sat the resident up at any time. She stated LPN #2 and CNA #5 had sat the resident up to do vitals. She was asked if LPN #2 had remained with the resident during CPR. She stated the nurse went to look for supplies that were not found on the crash cart. At 8:44 a.m., CMA #5 was asked how long she had worked at the facility. She stated eight months. She was asked how long she had been a CMA. She stated two years. She was asked to describe any training she had received at the facility related to caring for unresponsive persons and CPR. She stated she did not recall any training at the facility on those two subjects. She was asked if she had been on duty when the resident had fallen. She stated she had been. She was asked to describe what had occurred. She stated she had come across the scene and observed the resident laying on the floor. She stated other staff was performing CPR so she went to get the crash cart. She stated that LPN #2 removed an oxygen mask from the cart. She saw CNA # 4 performing compressions. She stated LPN #2 had to run back and forth to find the mask. She was asked if she heard anyone talk about missing equipment. She stated LPN #2 said there had been no bag in the crash cart. She was asked if she was CPR certified. She state she had been but it expired seven months earlier. On [DATE] at 8:37 a.m., the DON was asked how long she had worked at the facility. She stated since [DATE]. She was asked to describe the training the staff received in relation to unresponsive persons and CPR. She stated that CPR inservices had occurred in the facility and the ADON helped with training. She stated they have inservices twice each month. She was asked if she had been aware staff members were not certified in CPR. She stated she had been and they had tried to schedule training for those persons. She was asked if she was responsible for checking to ensure new employees were CPR certified. She stated she did not feel that anyone had ever told her that was one of her responsibilities. She was asked how the facility ensured new employees knew how to perform their duties and where to locate supplies. She stated when she started there was no competency check sheets but she started having new employees shadow current employees for a period of time. She was asked if there was a sign off sheet related to that program. She stated there was not. She was asked if she had any responsibility with the inventory and ordering of supplies such as ambu bags. She stated that was done by the ADON. At 9:08 a.m., the ADON was asked if she assisted with the training of staff. She stated she did so with the DON. She was asked if she had the duty of ensuring staff were certified in CPR. She stated she was not. She was asked if she had been aware that some nursing staff were not CPR certified. She said she became aware after the incident of resident #1. She was asked if she was tasked with keeping supplies available for the nursing staff including the crash cart. She stated she was. She was asked if ambu bags were in the building and were so on the day of resident #1's fall. She stated yes. At 10:10 a.m., the BOM was asked how long she had worked at the facility. She stated since [DATE]. She was asked what items she ensured new staff in the nursing department had prior to hire. She stated she looked for an active license or certification depending on the job and did background checks. She was asked if she had checked to see if new employees were CPR certified. She stated that was not part of her duties. She was asked if she knew who was responsible for that task. She stated she did not know.

On 04/10/19 at 2:36 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) related to the facility's failure to prevent resident to resident abuse by one (#33) of one sampled resident who had abusive/aggressive behaviors. The clinical record documented nine occurrences of the resident's abusive/aggressive behaviors between 10/07/18 and 04/09/19. At 2:36 p.m., the director of nursing (DON), corporate administrator/registered nurse (RN), and corporate licensed practical nurse (LPN) were notified of the IJ situation and were asked to provide a plan of removal. At 5:50 p.m., the corporate LPN provided an acceptable plan of removal. The facility's plan of removal documented: Plan of Removal April 10, 2019 Identify Residents at Risk 1. (Name deleted resident #33) Current Information/Plans in Place 1. Medical Director has been notified about IJ our Plan of Removal with respect to (name deleted resident #33) 2. IJ situation was brought to the attention of the DON at 2:35 pm. (Name deleted resident #33) was placed with nursing staff one-on-one at 2:58 pm. In-service on resident to resident abuse started by DON at 3:40 pm. 3. A sitter schedule will be in place for all three shifts (6 am to 2 pm, 2 pm to 10 pm, 10 pm to 6 am). 4. Attached is a sitter schedule and report sheet which will be monitored daily to see activity of (name deleted resident #33). The sitter will be with (name deleted resident #33) as needed, and provide 1:1 staffing and redirection of any monitoring safety of (name deleted resident #33). This will be documented by the charge nurse and monitored by the DON or designee daily for completeness. 5. Report Sheet will be documented (name deleted resident #33) location, activity, and any behaviors by the charge nurse as follows: (Q (every) 15 minutes x (times) 2 hours, Q 30 minutes x 2 hours, Q 1 hour x 2 hours, Q 2 hours x 2 hours, Q 4 hours x 2 hours, and (name deleted doctor #1) to consult and evaluate for further treatment. 6. (Name deleted doctor #2) will be in communication with the facility for update on (name deleted resident #33) and any changes in condition, and will have (name deleted doctor #1) to consult and evaluate for further treatment and psychosocial well-being of (name deleted resident #33) related to behaviors in respect to the residents at risk. 7. (Name deleted resident #33) was transferred from (name deleted facility) to another facility as suggestion of (name deleted doctor #2), Medical Director at 17:12 (5:12 p.m.) on 04/10/18 (sic 04/10/19). Education/In-Service 1. In-services will be conducted on (MONTH) 10, 2019, starting at 3:40 pm with current staff and DON. 2. Staff on sick leave/vacation will be in-serviced upon their return to work. A list of those staff members will be provided. 3. Staffing will include all of the following departments: a. Administrator b. Nursing/MDS c. Social Services and Activities d. Housekeeping e. Dietary Will identify other residents with aggressive behavior by audit. Expected Time and Date of Completion In-services will begin on (MONTH) 10, 2019, at 3:40 pm for the current staff. Date: 4/10/19 Time: 18:15 pm. (name deleted corporate LPN) The IJ was removed on 04/17/19 at 11:00 a.m. after all components of the plan of removal had been completed. The deficient practice remained at a pattern level with the potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to prevent resident to resident abuse by one (#33) of one sampled resident who displayed abusive/aggressive behaviors. The clinical record documented nine occurrences of the resident's abusive/aggressive behaviors between 10/07/18 and 04/09/19. This had the likelihood to affect all 32 residents who resided in the facility. Findings: Resident #33 had [DIAGNOSES REDACTED]. A psych evaluation note, dated 07/07/18, documented, the resident had mild dementia. The note documented, Reportedly has aggressive bx's (behaviors) & poor impulse control, (no) current evidence of mood or thought D/O (disorder) beyond mild cognitive deficit. A progress note, dated 10/07/18 at 9:11 a.m., documented, Resident cursing and yelling at other residents. Spoke to resident about behavior. Residents states she does this cause she is bored. Resident is trying to start arguments with other residents by coming into the dinning (sic) room and calling them names. During smoke breaks she also makes rude comments to other residents(.) A quarterly assessment, dated 11/09/18, documented the resident was cognitively intact, had verbal behavioral symptoms directed towards others for one to three days of the look back period, and had other behavioral symptoms not directed towards others for one to three days of the look back period. The assessment documented the resident used a wheel chair for mobility and needed no physical help of staff with locomotion on the unit. The care plan, dated 11/09/18, had no documentation of the resident's behaviors. A progress note, dated 11/28/18 at 8:06 a.m., documented, Behavior note: Res. (resident) yelling and cursing dietary staff over breakfast. Educated res. (sic) R/T (related to) verbal abuse. A progress note, dated 12/16/18 at 2:09 p.m., documented, Resident yelling and cursing at staff. Threw lunch try (sic) at staff. Resident being very disrespectful to staff and other residents. A progress note, dated 01/29/19 at 8:27 a.m., documented, Behavior note: Res. yelling, at another resident. for sitting at a table drinking coffee, yelled, 'That's not your spot and you need to move'. When trying to talk to res. she became argumentative, cursing, went to her room and slammed the door. A progress note, dated 02/04/19 at 10:28 a.m., documented, resident overheard screaming at another resident 'get the hell out of my room you f------- b----! I will kick your ass!', (name deleted resident #30) replied back 'IM (sic) not afraid of you' and pro ceded (sic) into the dining room, (name deleted resident #33) followed (name deleted resident #30) and threw a glass of water in her face, this nurse separated the 2, notified DON and PCP (primary care physician). A progress note, dated 02/04/19 at 12:39 p.m., documented by the social service (SS) director, documented, Talked to resident after incident with (name deleted resident #30) and she replied she had told her numerous time to stay out of her room, and that if she continue to come in her room she would kick (name deleted resident #30's) ass, was going to go speak with the nurse and let her know SS/AD (activity director) didn't get to talk to nurse before it happen again, SS/AD talked to (name deleted resident #33) about the reason she threw water on (name deleted resident #30) the second time her (sic) replied was doing a replay for the ladies that was sitting in the dinning room with her. The annual assessment, dated 02/06/19, documented the resident's cognition was intact; required supervision with transfer, ambulation in room and corridor, and locomotion on the unit with no physical assistance from staff; and the resident had no behaviors. A progress note, dated 02/15/19 at 9:26 p.m., documented, Patient yelled at another resident to move this shift. I Charge Nurse on duty talked to her and asked her to please not yell at other residents. A progress note, dated 02/18/19 at 11:30 a.m., documented, In Admin (administrator- previous administrator #2) office this date, yelling that her stuffed animals were 'stolen'(.) Note: the stuffed animals were found by housekeeping under her bed, before she came to the office so she was already aware of this. She then began to scream at this Admin that her coffee cups were 'also stolen', the coffee cups were not stolen and were in the kitchen where they were washed. The cook had tried to return them to (name deleted resident #33) at breakfast and (name deleted resident #33) had refused to take them. (Name deleted resident #33) continued to scream at Admin, I attempted to redirect her x 3. She finally calmed down and left the office. Will discuss with DON and IDT (interdisciplinary) team if she would benefit from seeing facility Psychiatrist to work on anger management. There was no documentation in the resident's clinical record for the possibility to work with the Psychiatrist on anger management at that time. A progress notes, dated 04/01/19 at 7:47 a.m., documented, Resident up in w/c (wheel chair) in d/r (dining room) for lunch, Resident threw a cup full of torn up paper at another Resident (#30) stating it was confetti and an (MONTH) fools joke. Resident was ask (sic) by this Nurse to not do things like that as other Residents many not understand the concept. Resident became hostile with this Nurse and other staff members cursing and yelling at us calling names and continued throughout the day following staff around the facility harassing them. Will continue to monitor. A progress note, dated 04/01/19 at 7:02 p.m., documented, Res. in dinning (sic) room, yelling at dietary staff, r/t refuse eve (evening) meal, requested a bake potatoe (sic), which dietary did cooked (sic) a baked potatoe (sic), res. cursing loud, she stated that it's taking to (sic) long. And as Res. exit dinning (sic) room, cursing, and refuse baked potatoe (sic). Dietary baked the potatoe (sic) in a timely manner. A progress note, dated 04/02/19 at 1:44 p.m., documented, Resident up in D/R this a.m. yelling at other Residents, when this Nurse heard Resident yelling went to D/R to witness Resident trying to pour hot coffee on another Resident (#4), when Res (#33) was interrupted by this Nurse she turned around and started yelling at me and threatened to throw her coffee cup at me and then threw the glass mug at me shattering it all over the floor. Res was told that her outburst and bad behaviors were unacceptable and that she can not continue to behave in these ways, Res then told this Nurse f--- y-- b---- you can't do anything about it. Res then went to her room to get a new mug and back out to the D/R. This nurse suggested sending Res to (name deleted mental health facility), and Res replied by yelling saying that she wasn't going anywhere and we cant (sic) make her. Will continue to monitor. A progress note, dated 04/02/19 at 5:04 p.m., documented, When res. entering dinning (sic) room, she yelled out at another female res. 'Move out of my way you old hag.' Talked to res. r/t yelling and name calling was verbal abuse. Res. stated, 'I just called her an old hag', 'That's not abuse.' On 04/10/19 at 9:59 a.m., an un-named family member told the surveyor about the behaviors of resident #33. The family member stated the facility was doing nothing about the resident. The family member stated the resident was able to bully, verbally abuse, and emotionally abuse residents. On 04/10/19 at 11:06 a.m., certified nurse aide (CNA) #3 stated when the resident has aggressive behaviors to other residents she tells her to go to her room. She stated the resident does not go to her room and says We can't make her.'' She stated they keep other residents away from her. On 04/10/19 at 1:02 p.m., the corporate nurse consultant stated there were not other incident reports of the resident's behaviors besides the one incident report dated 02/04/19. On 04/10/19 at 1:46 p.m., resident #1 stated resident #33 had been mean to her in the past. She stated it had hurt her feelings. She stated she was not afraid of resident #33. On 04/10/19 at 1:56 p.m., resident #9 was asked if resident #33 ever made fun of her or cursed her. The resident stated, oh yes, she did that to everybody. She stated the resident was a rude person all the time. On 04/10/19 at 2:00 p.m., resident #30 stated resident #33 had thrown water on her twice and then a cup of confetti. She stated it was wrong. She stated she was not afraid of the resident. On 04/10/19 at 2:07 p.m., resident #33 was interviewed. The resident was asked if had ever thrown something in the dining room. The resident stated she had thrown a plastic cup that day with ice and tea that day in the dining room because lunch was late. He stated she threw it at the kitchen door. Stated she was a regular b---- and she did not care. Then she stated she had thrown a little bit of coffee on resident #4 because the resident called her a name. She stated she had told the resident to quit blocking the way to the coffee, to quit roosting by the coffee, and other peoples wanted coffee. She stated then she threw her coffee cup at a nurse. The resident was asked if she had ever cussed at another resident. She stated no. Then she stated, oh yes I did say, F------- G-- D--- B----- today. She then stated she had never thrown liquid on anybody. Then with a smile on her face stated, Oh yes, I threw water on resident #30. She was asked how many times did you throw water on the resident. She stated two times. The resident was asked why she threw water on the resident the first time. She smiled and then stated, I was bored. She was asked why she threw water on the resident the second time. The resident continued to smile and then stated, To prove that I did it the first time. On 04/10/19 at 2:10 p.m., resident #17 was asked about the behaviors of resident #33. Resident #17 was observed during the survey sitting at the same dining room table as resident #33. Resident #17 stated what resident #33 does is bad stuff. The resident stated he got scared sitting next to her in the dining room. He stated he was scared for others also. He stated he was afraid she would throw a fork. He stated resident #33 had thrown water and coffee on residents. He stated he got upset when she hurt others.

On 05/14/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to implement their abuse policy by conducting a thorough investigation of an alleged incident of sexual abuse, and protecting the residents from the likelihood of further abuse. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to implement their abuse policy to thoroughly investigate an incident of alleged sexual abuse and to protect the residents. At 5:31 p.m., the administrator and the DON were informed of the IJ related to the facility's failure to implement their abuse policy to thoroughly investigate, and protect residents, and that a plan of removal would be required. They were informed this placed the facility in an extended survey. At 7:05 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal documented, Plan of removal 05/14/15 ALLEGATION OF ABUSE-PLAN OF REMOVAL Allegation of sexual abuse failure to protect, failure to do thorough investigation, failure to follow and implement policy and procedure. At 5/14/15 - 2:50 PM, (Name deleted) C.N.A. was informed that because of the allegation on 4/3/15, he was suspended until the findings of the allegation of sexual abuse could be determined. We will terminate per facility policy. Staff will be inserviced on all three shifts until all staff have been re-educated and re-inserviced as to reporting requirements of abuse, of facility abuse policy and procedure, protection of the residents and how to conduct a thorough investigation, as well as mandatory use of walkie-talkies by all staff, all shifts, for employees who work on the memory unit, and the charge nurse. The administrator (Name deleted), will conduct an organized inservice all staff starting at approximately 7 pm and all staff will be in-serviced by 12 midnight-Thursday, 5/14/15 staff in the facility will be in-serviced first and all other staff will be in-serviced as they come in, each in-service conducted will last for a minimum of 30 minutes. Staffing will be 2 on the Memory unit for 6-2, 2 staff members on 2-10 shift, one caregiver will remain on 10-6 shift this change will begin at approximately 7pm on 5/14/15. The in-service information was attached to the plan of removal. On 05/15/15 at 10:31 a.m., an addendum to the plan of removal on 05/14/15, was received from the administrator. The addendum documented, 5/15/15 ADDENDUM TO PLAN OF REMOVAL 1025 (10:25 a.m) The three persons who could not attend the class/inservice for 5/14/15 were terminated. (Name deleted), LPN 6-2 shift, (Name deleted), MDS/data entry, and (Name deleted), C.N.A. (Name deleted), C.N.A. on (leave), and (Name deleted), C.N.A. (leave). Will be inserviced. prior to returning to the facility, or to work. The employee (Name deleted) C.N.A. 2-10 was notified as of 5/15/15 1005 (10:25 a.m.) that his employment was terminated, could not return to work. 5/15/15 1040 (10:40 a.m.) Addendum to plan of removal (Name deleted) CNA is also PRN & will not be allowed to return to work until such time as she can be thoroughly inserviced. Staff were interviewed on 05/15/15 in regards to their knowledge of the abuse in-service; to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 05/14/15 at 11:15 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a potential for more than minimal harm at a pattern. Based on interview and record review, it was determined the facility failed to implement their abuse policy to thoroughly investigate an incident of alleged sexual abuse that involved one (#1) of five sampled residents whose records were reviewed regarding abuse. The facility also failed to protect residents from the likelihood of further abuse. This had the potential to affect all 38 residents who resided at the facility. Findings: An undated policy, titled Allegation of Abuse and/or Mistreatment, documented, .no tolerance policy for abuse and/or mistreatment of [REDACTED]. Procedure: All suspicions of abuse and/or mistreatment will be immediately reported to the Administrator, including but not limited to: .sexual abuse.remove any immediate threat to the resident to prevent further potential abuse to resident during the investigation. Document protective measures taken.Investigation: shall include but not limited to: 1. Identify the staff member initiating the report of abuse 2. Identify all the individuals involved 3. Obtain statements from witnesses that actually viewed the incident. 4. Obtain resident assessments 5. Document where and when incident occurred 6. Document any evidence of injury or abuse present on the resident's body or in the resident's actions. 7. Interview all staff, residents and visitors .Reporting An initial report shall be submitted to OSDH within 24 hours, with a written report within 5 days. .Allegations of abuse shall be reported to the.licensing authority. .Any employee suspected of abuse or neglect will be removed from direct care of the resident/residents while the investigation is in progress. .Protection during investigation.Thorough investigation.Reporting.Corrective action. 1. Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 04/03/15, documented the resident had a BIMS score of eight. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors; required limited assistance with transfers; required supervision with ambulation; had a [DIAGNOSES REDACTED]. A nurse's note, dated 04/03/15 at 6:25 p.m., documented, R was verbal on unit and asked for cigarette and p declined verbally accused a male CNA put his coc- in all the women back here. A facility incident report, dated 04/03/15, documented, .Allegation verbally R states (CNA #2 Name deleted) is putting his c**k in all the women back here.Incident Type: Behavior - verbal abuse. Steps taken to prevent recurrence: R had refused nicotine patch. There was no documentation to show the resident and other residents were protected after an allegation of sexual abuse had been reported. A state reportable combined initial/final incident report, dated 04/03/15, documented, It was reported to Charge Nurse by CNA (CNA #2 Name deleted) that (resident #1) was very upset because she was out of cigarettes and she wanted to go outside to smoke. When the Charge Nurse (Name deleted-LPN #3) entered the unit to speak with (Name deleted-resident #1) she said to (Name deleted-CNA #2) I know put your cock in all these females back here. I know I am crazy. (Name deleted-CNA #2) was taken on (off) the unit and another female CNA was placed on the unit in his place in order for an investigation to take place. Please include relevant resident history. history of dementia, history of aggressive behaviors, history of violent hitting behaviors, history of verbal aggression and of yelling out derogatory comments to staff when she is upset with them. please include a summary of the investigation (include investigative actions, findings and causative factors) and corrective measures implemented to prevent recurrence. After investigation it was discovered as stated by (Name deleted-Resident #1) I get angry and yell things when I don't get to smoke. Nothing happened. A physician notification, dated 04/03/15, documented, R was declined to go smoke and had refused nicotine patch earlier today and was verbal to our male CNA (Name deleted-CNA #2) accused of putting his coc-in all the women back here-administrator noted(sic) on allegation and no clothing disarray on Resident or staff. DON texted also. A written statement signed by LPN #3, dated 04/03/15, documented, I want to write my statement on (Name deleted-Resident #1) on unit with (word/words not legible) while (Name deleted-LPN #2) on unit passing meds with CNA (Name deleted-CNA #2) on unit and per staff report. (Name deleted-resident #1) asked for a cigarette from (Name deleted-CNA #2).stated I know your putting your c**k in all these females back here, I know I'm crazy. No clothing on R or staff was in disarray. (Name deleted-CNA #2) removed from unit and (Name deleted-CNA #1) replaced instead. (Name deleted-LPN #2) called (Name deleted-administrator #1) and due to no specific female named he stated he will handle the report per (Name deleted-LPN#2). A nurse's note, dated 04/04/15, documented, This nurse read in above charting allegations made against a male CNA. Notified Admin & DON of allegations. DON stated she would contact nurse who charted this. This nurse told male CNA he would be on the main floor not working in the unit at this time, until told otherwise by upper management. On 04/04/15, LPN #4 documented, Investigation into behaviors of yelling @ staff hitting staff & accusing staff of behavior that is inappropriate. Ref. 4/3/15 (Name deleted-CNA #2) putting his c**k in all the women.spoke one on one with (Name deleted-Resident #1) and asked her several questions, she states nothing happened and she gets angry and yells out false statement when she dosen't (sic) get to smoke! A care plan, dated 04/14/15, documented, Problem: .has impaired decision making R/T [MEDICAL CONDITION] Disorder and Anxiety.Goal: .will have positive experiences in daily routine.Approach: .Determine if decisions made by the resident endanger the resident or others. Intervene if necessary.Encourage to verbalize feelings, concerns and fears.Monitor her for confusion or frustration and reassure and assist her as needed for all decisions daily. There was no care plan to address the resident's aggressive behaviors, verbal aggression, and yelling out derogatory comments to staff when she is upset with them, and there were no interventions to prevent behaviors. There was no documentation of the incident on 04/03/15 and no interventions were addressed on the care plan. An April 2015, monthly behavior monitoring form documented the resident had not exhibited any behaviors on 04/03/15. A May 2015, monthly behavior monitoring form documented the resident had not exhibited any behaviors from 05/01/15 through 05/13/15. On 05/14/15 at 9:34 a.m., the DON was asked if they were currently working on any investigations regarding allegations of abuse. She stated, I think everything is done. The allegations and investigations were received from the DON for the past three months. At 1:01 p.m., the DON and administrator #2 were asked if an allegation of sexual abuse on 04/03/15 had been reported. She stated, I believe it was reported to (Name deleted-LPN #3). She called and told us (Administrator #1 and DON). The DON was asked who conducted the investigation. She stated administrator #1 and the corporate nurse and then she (DON) wrapped it up. The DON was asked if CNA #2 had been suspended during the investigation. She stated, I don't believe so. No, not that I know of. The DON was shown the incident report and the investigation. She was asked if that was all the investigation. She stated, Yes. She was asked if any residents had been interviewed during the investigation. She stated, I didn't. The DON was asked if any staff had been interviewed. She stated, Yes, the corporate nurse talked to (Name deleted-CNA #2 ). She stated she (DON) did not interview any staff. The DON was asked if the interview would be with the investigation. She stated, It should be. The investigation was reviewed and no interview with CNA #2 was found or provided. The DON was asked how they had protected the residents when the allegation had been reported and during the investigation. She stated, I think the (administrator #1) told (CNA #2) not to take care of (Name deleted-resident #1). We believe that nothing happened. The DON was asked if the resident was on the memory unit. She stated, Yes. She was asked if the CNA was the only aide on the unit. She stated yes, just like when the charge nurse would just alternate care for (Name deleted-resident #4) if needed. The DON and administrator #2 were asked what their abuse policy and procedures were when an allegation of abuse was reported. The administrator stated, Suspend pending the outcome of the investigation. They were asked if they had followed the abuse procedures. The DON stated, No. Administrator #2 stated, It doesn't look like it to me. The DON was asked if they followed their policy. She stated, I talked to (resident #1). I didn't write out at statement, I just put it on an incident report. I felt like it was done. Administrator #2 stated, They should have interviewed all parties and all staff and looking through (the investigation) I can see they didn't hit on all components of a thorough investigation. It shouldn't be an initial and a final, it looks like it wasn't done. The DON was shown a notification of nurse aide registry form that documented CNA #2 had been suspended on 04/03/15 through 04/07/15. She was asked if that was her hand writing. She stated, Yes. I don't know why I did that. I guess I thought (administrator #1) had suspended him. No, he was not suspended. At 2:22 p.m., CNA #2 was asked if anyone had interviewed him or talked to him about the allegation of sexual abuse on 04/03/15. He stated, The nurse talked to me. He was asked if administrator #1 or the DON spoke with him. He stated, I can't remember. CNA #2 was asked if he was working on the unit on 04/03/15. He stated, Yes. He was asked if he was suspended after the allegation had been reported. He stated, I don't remember. They pulled me off the unit and put me out front (main floor). I finished out my shift. CNA #2 was asked if he was assigned a certain hall or area when he was pulled from the unit to the main floor. He stated, We do the whole area. On 05/15/15 at 10:55 a.m., LPN #1 was asked about the incident regarding the allegation of sexual abuse on 04/03/15. She stated she had read the previous nurse's note (04/03/15) and notified the DON and administrator #1 and quoted what was in the chart. Administrator #1 told her that was not what he had been told happened. LPN #1 was asked if any plans had been implemented regarding the resident's behaviors and the allegation of sexual abuse. She stated, Not that I know of. She was asked if CNA #2 had been scheduled to work on 04/04/15 in the unit. She stated, Yes. I pulled him off the unit. She was asked where the CNA had been placed to work. She stated, Because of what I read in the nurses' notes, I assigned him to the floor (main floor). No one was telling me what to do. I wasn't getting any instructions from anyone. LPN #1 was asked if she was aware CNA #2 was not to be around or take care of two residents who resided on the main floor. She stated, At that time I did not know that. She was asked when she was provided that information. She stated, After this occurred with (resident #1).

On 05/14/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to thoroughly investigate an incident of alleged sexual abuse and ensure protection of the residents from the likelihood of further abuse. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to thoroughly investigate an incident of alleged sexual abuse and to protect the residents. At 5:31 p.m., the administrator and the DON were informed of the IJ related to the facility's failure to thoroughly investigate, and protect residents, and that a plan of removal would be required. They were informed this placed the facility in an extended survey. At 7:05 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal documented, Plan of removal 05/14/15 ALLEGATION OF ABUSE-PLAN OF REMOVAL Allegation of sexual abuse failure to protect, failure to do thorough investigation, failure to follow and implement policy and procedure. At 5/14/15 - 2:50 PM, (Name deleted) C.N.A. was informed that because of the allegation on 4/3/15, he was suspended until the findings of the allegation of sexual abuse could be determined. We will terminate per facility policy. Staff will be inserviced on all three shifts until all staff have been re-educated and re-inserviced as to reporting requirements of abuse, of facility abuse policy and procedure, protection of the residents and how to conduct a thorough investigation, as well as mandatory use of walkie-talkies by all staff, all shifts, for employees who work on the memory unit, and the charge nurse. The administrator (Name deleted), will conduct an organized inservice all staff starting at approximately 7 pm and all staff will be in-serviced by 12 midnight-Thursday, 5/14/15 staff in the facility will be in-serviced first and all other staff will be in-serviced as they come in, each in-service conducted will last for a minimum of 30 minutes. Staffing will be 2 on the Memory unit for 6-2, 2 staff members on 2-10 shift, one caregiver will remain on 10-6 shift this change will begin at approximately 7pm on 5/14/15. The in-service information was attached to the plan of removal. On 05/15/15 at 10:31 a.m., an addendum to the plan of removal on 05/14/15, was received from the administrator. The addendum documented, 5/15/15 ADDENDUM TO PLAN OF REMOVAL 1025 (10:25 a.m) The three persons who could not attend the class/inservice for 5/14/15 were terminated. (Name deleted), LPN 6-2 shift, (Name deleted), MDS/data entry, and (Name deleted), C.N.A. (Name deleted), C.N.A. on (leave), and (Name deleted), C.N.A. (leave). Will be inserviced. prior to returning to the facility, or to work. The employee (Name deleted) C.N.A. 2-10 was notified as of 5/15/15 1005 (10:25 a.m.) that his employment was terminated, could not return to work. 5/15/15 1040 (10:40 a.m.) Addendum to plan of removal (Name deleted) CNA is also PRN & will not be allowed to return to work until such time as she can be thoroughly inserviced. Staff were interviewed on 05/15/15 in regards to their knowledge of the abuse in-service; to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 05/14/15 at 11:15 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a potential for more than minimal harm at a pattern. Based on interview and record review, it was determined the facility failed to thoroughly investigate an incident of alleged sexual abuse that involved one (#1) of five sampled residents whose records were reviewed regarding abuse. The facility also failed to protect residents from the likelihood of further abuse. This had the potential to affect all 38 residents who resided at the facility. Findings: An undated policy, titled Allegation of Abuse and/or Mistreatment, documented, .no tolerance policy for abuse and/or mistreatment of [REDACTED]. Procedure: All suspicions of abuse and/or mistreatment will be immediately reported to the Administrator, including but not limited to: .sexual abuse.remove any immediate threat to the resident to prevent further potential abuse to resident during the investigation. Document protective measures taken.Investigation: shall include but not limited to: 1. Identify the staff member initiating the report of abuse 2. Identify all the individuals involved 3. Obtain statements from witnesses that actually viewed the incident. 4. Obtain resident assessments 5. Document where and when incident occurred 6. Document any evidence of injury or abuse present on the resident's body or in the resident's actions. 7. Interview all staff, residents and visitors .Reporting An initial report shall be submitted to OSDH within 24 hours, with a written report within 5 days. .Allegations of abuse shall be reported to the.licensing authority. .Any employee suspected of abuse or neglect will be removed from direct care of the resident/residents while the investigation is in progress. .Protection during investigation.Thorough investigation.Reporting.Corrective action. 1. Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident resided in the memory unit. An admission assessment, dated 04/03/15, documented the resident had a BIMS score of eight. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors; required limited assistance with transfers; required supervision with ambulation; had a [DIAGNOSES REDACTED]. A nurse's note, dated 04/03/15 at 6:25 p.m., documented, R was verbal on unit and asked for cigarette and p declined verbally accused a male CNA put his coc- in all the women back here. A facility incident report, dated 04/03/15, documented, .Allegation verbally R states (CNA #2 Name deleted) is putting his c**k in all the women back here.Incident Type: Behavior - verbal abuse. Steps taken to prevent recurrence: R had refused nicotine patch. There was no documentation to show the resident and other residents were protected after an allegation of sexual abuse had been reported. A state reportable combined initial/final incident report, dated 04/03/15, documented, It was reported to Charge Nurse by CNA (CNA #2 Name deleted) that (resident #1) was very upset because she was out of cigarettes and she wanted to go outside to smoke. When the Charge Nurse (Name deleted-LPN #3) entered the unit to speak with (Name deleted-resident #1) she said to (Name deleted-CNA #2) I know put your cock in all these females back here. I know I am crazy. (Name deleted-CNA #2) was taken on (off) the unit and another female CNA was placed on the unit in his place in order for an investigation to take place. Please include relevant resident history. history of dementia, history of aggressive behaviors, history of violent hitting behaviors, history of verbal aggression and of yelling out derogatory comments to staff when she is upset with them. please include a summary of the investigation (include investigative actions, findings and causative factors) and corrective measures implemented to prevent recurrence. After investigation it was discovered as stated by (Name deleted-Resident #1) I get angry and yell things when I don't get to smoke. Nothing happened. A physician notification, dated 04/03/15, documented, R was declined to go smoke and had refused nicotine patch earlier today and was verbal to our male CNA (Name deleted-CNA #2) accused of putting his coc-in all the women back here-administrator noted(sic) on allegation and no clothing disarray on Resident or staff. DON texted also. A written statement signed by LPN #3, dated 04/03/15, documented, I want to write my statement on (Name deleted-Resident #1) on unit with (word/words not legible) while (Name deleted-LPN #2) on unit passing meds with CNA (Name deleted-CNA #2) on unit and per staff report. (Name deleted-resident #1) asked for a cigarette from (Name deleted-CNA #2).stated I know your putting your c**k in all these females back here, I know I'm crazy. No clothing on R or staff was in disarray. (Name deleted-CNA #2) removed from unit and (Name deleted-CNA #1) replaced instead. (Name deleted-LPN #2) called (Name deleted-administrator #1) and due to no specific female named he stated he will handle the report per (Name deleted-LPN#2). A nurse's note, dated 04/04/15, documented, This nurse read in above charting allegations made against a male CNA. Notified Admin & DON of allegations. DON stated she would contact nurse who charted this. This nurse told male CNA he would be on the main floor not working in the unit at this time, until told otherwise by upper management. On 04/04/15, LPN #4 documented, Investigation into behaviors of yelling @ staff hitting staff & accusing staff of behavior that is inappropriate. Ref. 4/3/15 (Name deleted-CNA #2) putting his c**k in all the women.spoke one on one with (Name deleted-Resident #1) and asked her several questions, she states nothing happened and she gets angry and yells out false statement when she dosen't (sic) get to smoke! A care plan, dated 04/14/15, documented, Problem: .has impaired decision making R/T [MEDICAL CONDITION] Disorder and Anxiety.Goal: .will have positive experiences in daily routine.Approach: .Determine if decisions made by the resident endanger the resident or others. Intervene if necessary.Encourage to verbalize feelings, concerns and fears.Monitor her for confusion or frustration and reassure and assist her as needed for all decisions daily. There was no care plan to address the resident's aggressive behaviors, verbal aggression, and yelling out derogatory comments to staff when she is upset with them, and there were no interventions to prevent behaviors. There was no documentation of the incident on 04/03/15 and no interventions were addressed on the care plan. An April 2015, monthly behavior monitoring form documented the resident had not exhibited any behaviors on 04/03/15. A May 2015, monthly behavior monitoring form documented the resident had not exhibited any behaviors from 05/01/15 through 05/13/15. On 05/14/15 at 9:34 a.m., the DON was asked if they were currently working on any investigations regarding allegations of abuse. She stated, I think everything is done. The allegations and investigations were received from the DON for the past three months. At 1:01 p.m., the DON and administrator #2 were asked if an allegation of sexual abuse on 04/03/15 had been reported. She stated, I believe it was reported to (Name deleted-LPN #3). She called and told us (Administrator #1 and DON). The DON was asked who conducted the investigation. She stated administrator #1 and the corporate nurse and then she (DON) wrapped it up. The DON was asked if CNA #2 had been suspended during the investigation. She stated, I don't believe so. No, not that I know of. The DON was shown the incident report and the investigation. She was asked if that was all the investigation. She stated, Yes. She was asked if any residents had been interviewed during the investigation. She stated, I didn't. The DON was asked if any staff had been interviewed. She stated, Yes, the corporate nurse talked to (Name deleted-CNA #2 ). She stated she (DON) did not interview any staff. The DON was asked if the interview would be with the investigation. She stated, It should be. The investigation was reviewed and no interview with CNA #2 was found or provided. The DON was asked how they had protected the residents when the allegation had been reported and during the investigation. She stated, I think the (administrator #1) told (CNA #2) not to take care of (Name deleted-resident #1). We believe that nothing happened. The DON was asked if the resident was on the memory unit. She stated, Yes. She was asked if the CNA was the only aide on the unit. She stated yes, just like when the charge nurse would just alternate care for (Name deleted-resident #4) if needed. The DON and administrator #2 were asked what their abuse policy and procedures were when an allegation of abuse was reported. The administrator stated, Suspend pending the outcome of the investigation. They were asked if they had followed the abuse procedures. The DON stated, No. Administrator #2 stated, It doesn't look like it to me. The DON was asked if they followed their policy. She stated, I talked to (resident #1). I didn't write out at statement, I just put it on an incident report. I felt like it was done. Administrator #2 stated, They should have interviewed all parties and all staff and looking through (the investigation) I can see they didn't hit on all components of a thorough investigation. It shouldn't be an initial and a final, it looks like it wasn't done. The DON was shown a notification of nurse aide registry form that documented CNA #2 had been suspended on 04/03/15 through 04/07/15. She was asked if that was her hand writing. She stated, Yes. I don't know why I did that. I guess I thought (administrator #1) had suspended him. No, he was not suspended. At 2:22 p.m., CNA #2 was asked if anyone had interviewed him or talked to him about the allegation of sexual abuse on 04/03/15. He stated, The nurse talked to me. He was asked if administrator #1 or the DON spoke with him. He stated, I can't remember. CNA #2 was asked if he was working on the unit on 04/03/15. He stated, Yes. He was asked if he was suspended after the allegation had been reported. He stated, I don't remember. They pulled me off the unit and put me out front (main floor). I finished out my shift. CNA #2 was asked if he was assigned a certain hall or area when he was pulled from the unit to the main floor. He stated, We do the whole area. On 05/15/15 at 10:55 a.m., LPN #1 was asked about the incident regarding the allegation of sexual abuse on 04/03/15. She stated she had read the previous nurse's note (04/03/15) and notified the DON and administrator #1 and quoted what was in the chart. Administrator #1 told her that was not what he had been told happened. LPN #1 was asked if any plans had been implemented regarding the resident's behaviors and the allegation of sexual abuse. She stated, Not that I know of. She was asked if CNA #2 had been scheduled to work on 04/04/15 in the unit. She stated, Yes. I pulled him off the unit. She was asked where the CNA had been placed to work. She stated, Because of what I read in the nurses' notes, I assigned him to the floor (main floor). No one was telling me what to do. I wasn't getting any instructions from anyone. LPN #1 was asked if she was aware CNA #2 was not to be around or take care of two residents who resided on the main floor. She stated, At that time I did not know that. She was asked when she was provided that information. She stated, After this occurred with (resident #1).

On 03/30/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to report and thoroughly investigate three incidents of alleged sexual abuse and ensure protection of residents from the likelihood of further abuse. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to report and thoroughly investigate three incidents of alleged sexual abuse and to protect the residents. At 5:50 p.m., the administrator, DON, and ADON were informed of the IJ related to the facility's failure to report, thoroughly investigate, and protect residents, and that a plan of removal would be required. They were informed this placed the facility in an extended survey. At 6:35 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal documented, "Plan of removal 03/30/15 Part 1 (CNA #7) is suspended as of 6:13 pm on 3/30/15 while investigation is being done. Part 2 In-service over identifying abuse, protecting resident's from abuse, and reporting all abuse. What is abuse and report all allegations of abuse to Administrator (name deleted). See exhibit A. In-service all staff on 03/30/15 by 10:00 p.m., and any staff not available will be contacted by phone and in-service with a witness and documented. Any staff not available to come in or reached via phone will be in-service prior to them starting their shift." The in-service information was attached to the plan of removal. Staff were interviewed on 03/31/15 in regards to their knowledge of the abuse in-service; to ensure their understanding of all aspects of the plan of removal. At 10:40 a.m., dietary aide #1 was interviewed regarding her knowledge of the abuse in-service. She stated the administrator called her at 10:00 p.m. She was asked if she was in-serviced over the telephone. She stated, "They haven't told me nothing." She stated the dietary manager had told her this morning when she came in that the in-service was to be about abuse. She was asked if she had been in-serviced since she had arrived at work. She stated, "No." At 11:20 a.m., the DON was informed the dietary aide had not been in-serviced regarding abuse and was not aware what the in-service was about. At 4:45 p.m., the DON provided documentation that the dietary aide had been in-serviced on abuse. The IJ was removed effective 03/31/15 at 4:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at widespread. Based on interview and record review it was determined the facility failed to report and thoroughly investigate three incidents of alleged sexual abuse that involved two (#2 and #7) of three sampled residents who were reviewed regarding abuse. The facility also failed to protect residents from the potential of further abuse. This had the potential to affect 35 residents who resided at the facility. Findings: An undated policy, titled Allegation of Abuse and/or Mistreatment, documented, "...no tolerance policy for abuse and/or mistreatment of [REDACTED]. Procedure: All suspicions of abuse and/or mistreatment will be immediately reported to the Administrator, including but not limited to: ...sexual abuse...remove any immediate threat to the resident to prevent further potential abuse to resident during the investigation. Document protective measures taken...Investigation: shall include but not limited to: 1. Identify the staff member initiating the report of abuse 2. Identify all the individuals involved 3. Obtain statements from witnesses that actually viewed the incident. 4. Obtain resident assessments 5. Document where and when incident occurred 6. Document any evidence of injury or abuse present on the resident's body or in the resident's actions. 7. Interview all staff, residents and visitors ...Reporting An initial report shall be submitted to OSDH within 24 hours, with a written report within 5 days... ...Allegations of abuse shall be reported to the...licensing authority... ...Any employee suspected of abuse or neglect will be removed from direct care of the resident/residents while the investigation is in progress... ...Protection during investigation...Thorough investigation...Reporting...Corrective action..." 1. Resident #2 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/16/15, documented the resident had a BIMS score of 10. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident exhibited no behaviors, was totally dependent, and required one to two person assist with activities of daily living. A care plan, updated 01/13/15, did not address that the resident was afraid of CNA #7 and did not want CNA #7 to provide any care to her. The resident's clinical record did not include any documentation that the resident was afraid of CNA #7. There were no incident reports/investigations regarding the alleged incidents found. On 03/30/15, at 3:07 p.m., CNA #3 was asked if she was aware of any allegations of abuse. She stated, "(CNA #7) couldn't go in (residents' #2 and #3) room." She stated the CNA does not work in the area of their rooms and worked in the locked unit only. At 3:20 p.m., CNA #5 was asked if she was aware of any alleged abuse. She stated, "(CNA #7) told me he couldn't go around (resident #2) because of allegations, did not go into detail about." At 3:40 p.m., CMA #1 was asked if she was aware of any allegations of abuse. She stated that recently a family member stated to me there was a problem regarding (resident #2) and (CNA #7). She stated, "I directed her to the administrator." She stated the DON was nearby and she had also called her over to speak to the family member. The CMA was asked if she knew what the problem was. She stated she knew some kind of incident happened and (CNA #7) was not to be near her. She stated she had heard of an incident when she was off work about CNA #7 playing with the resident's breasts. She was asked if she knew if any investigation was done and what had happened. She stated, "They had some kind of meeting and he wasn't supposed to be alone with her." At 5:00 p.m., LPN #2 was asked if she was aware of any allegations of sexual abuse. She stated, "No." She stated she knew that CNA #7 didn't go into resident #2's room. She was asked if she knew why. She stated, "No." She was asked if she had been interviewed by staff regarding why the resident did not want the CNA in her room. She stated, "No." At 6:00 p.m., the activity director was asked if anyone had reported to her any allegations of abuse. She stated, "I know (resident #2) doesn't like CNA #7 around her." She stated the resident's family member had stated to her that she did not want the CNA to take care of her. She stated another resident had also told her that CNA #7 was not to be taking care of her because she was afraid of him. She was asked if she knew why the resident was afraid of the CNA. She stated they had all been aware that he was not supposed to be handling her. She stated she had reported to the administrator that the resident and family were upset regarding CNA #7 and did not want him to provide care for her. On 03/31/15 at 10:22 a.m., LPN #3 was asked if she was aware that CNA #7 was not supposed to provide care for the resident. She stated, "No." She was asked if anyone had told her the resident was afraid of CNA #7. She stated, "No." She was asked as a charge nurse if she should have known the resident was afraid of the CNA. She stated, "Oh yes." 2. Resident #7 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/13/15, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had no behaviors, required limited to extensive assistance of one to two persons with transfers, dressing, eating, was frequently incontinent, and was totally dependent for personal hygiene. The clinical record did not include any documentation regarding the resident being upset regarding CNA #7. On 03/30/15 at 2:50 p.m., CNA #6 was asked if she was aware of any recent allegations of sexual abuse. She stated, "(Resident #7) said that (CNA #7) was trying to hurt him and he didn't want him anywhere near him." She was asked what had occurred. She stated, "Another worker told me that (CNA #7) was trying to touch (resident #7). She was asked if she reported it to anyone. She stated, "I told (LPN#2). She was asked if she knew what was done and if the allegation was investigated. She stated, "I have no idea." She was asked when this had occurred. She stated, "I think it was the week of March 23rd." At 3:07 p.m., CNA #3 was asked if she was aware of any recent allegations of abuse. She stated, "(Resident #7) told her that (CNA #7) tried to touch him and hurt him." She stated the resident kept hollering he's (CNA #7) gay and the charge nurse and CMA came back to the locked unit to the resident's room. She stated the incident had occurred the week of March 23rd. She stated, "I didn't feel like the nurse looked into it." At 3:20 p.m., CNA #5 was asked if she was aware of any recent allegations of abuse. She stated, "(Resident #7) told me (CNA #7) was touching him." She stated the resident had told her to get CNA #7 out of there. She stated the charge nurse that evening (LPN #1) had told the (CNA #7) that if the resident needs anything she would come to the locked unit and take care of it. She was asked when the incident had occurred. She stated, "Maybe a week ago or two." She was asked if anything was done to protect the resident. She stated, "No." She was asked if anyone had spoke to her regarding the incident. "She stated, "No one ever ask me about it after it happened." She stated she was concerned because she had walked in the resident's room when he was yelling and CNA #7 was at the head of the resident's bed and stated the resident was about to fall out of bed. She stated she thought it was odd because the resident did not look like he was about to fall out of bed. She was asked if anything was done to protect the resident. She stated, "There wasn't, he was working every day back there." At 3:40 p.m., CMA #1 was asked if she was aware of a recent incident between the resident and CNA #7. She stated, "I went and did a shower on (resident #7), he was refusing to let CNA #7 do it." She was asked if she knew why he did not want the CNA to do his shower. She stated the resident was very irritated and stated he did not want the CNA taking care of him. On 03/31/15 at 10:50a.m., LPN #1 was asked what had occcurred between the resident and CNA #7. She stated, "I heard (resident #7) yelling, (CNA #7) stepped out with a broom in his hand, (resident #7) was yelling I don't want him in my room. CNA #5 came down and he (the resident) was ok with her. She was asked if she identifed what had occurred as abuse. She stated, "Patients have outbursts." She was asked if she protected the resident. She stated she thought she was by telling the CNA not to go in his room. She was asked if the CNA continued to work alone on the locked unit. She stated, "Yes." LPN #1 was asked if she had reported the incident and started an investigation. She stated she had not, but in hindsight she should have. She was asked when the incident had occurred. She stated, "About a week ago." At 4:35 p.m., the DON and ADON were asked if it had been reported to them resident #2 was afraid of CNA #7 and the CNA was not to be in her room or provide care for her. They both stated, "No." They were asked if they were aware of any allegations regarding the CNA touching the resident's breast or cheek. They both stated, "No." They were asked if they were aware of an incident between resident #7 and CNA #7. They both stated, "No." They were asked why staff were not reporting allegations of abuse. The DON stated, "I don't know, they should tell me. They have several opportunities to tell me." At 4:45 p.m., the administrator, DON, and ADON were asked if they had received any allegations of sexual abuse regarding resident #2 and CNA #7. They all stated, "No." The administrator stated that he knew the resident was afraid of the CNA and had heard the resident was startled when the CNA had come up behind her and started talking. He stated, "I was aware she was afraid and didn't want him anywhere near her." The administrator was asked if it had been reported to him that CNA #7 had touched the resident's breasts or had touched her cheek while she was in the shower. He stated, "No, I hadn't heard that, but he's not to be around her anyway." They were asked if anyone reported any incidents regarding allegations of abuse between resident #7 and CNA #7. They all stated no, and stated they were not aware of the occurrence of any abuse. They were asked why staff were not reporting allegations of abuse. The administrator stated, "No. Have no idea." They were asked why there were not any incident reports or investigations as to why resident #2 was afraid of the CNA, the CNA touching her breasts, or entering the shower room and touching her cheek and why resident #7 did not want the CNA to provide his care. The administrator stated, "I would say it didn't happen." He stated if the incidents occurred then there should have been incidents reports and they should have been investigated.

Based on observation, interviews, and record review, it was determined the facility failed to implement their abuse policy to provide interventions to protect one (#8) of one sampled resident who was involved in a resident to resident altercation. Resident #9 pulled resident #8 from his wheelchair and hit him in his eye, which resulted in an injury to resident #8's eye and upper lip. The facility failed to provide interventions to prevent further abuse to this resident or other residents who were up and about the facility. This had the likelihood to affect 34 of 43 residents who resided in the facility. The facility identified nine residents who were bedfast. This resulted in an Immediate Jeopardy Situation. Findings: Facility Policy & Procedure for Resident Abuse, Neglect, and Misappropriation of Property The facility's undated policy on allegation of abuse and or mistreatment documented, "...All suspicions of abuse and/or mistreatment will be immediately reported the Administrator, including Physical abuse...Patterns and trends Recognizing high risk residents Recognizing high risk situations Changes in a residents behavior, ie, cringing, crying, flinching...Remove any immediate threat to the resident to prevent further potential abuse to the resident during the investigation. Document protective measures taken..." The facility's undated policy on resident to resident abuse documented, "...Facility staff will immediately intervene to halt abusive behavior and initiate appropriate actions to ensure the safety of all residents based on individual occurrence. These actions may include, but not limited to the following: A. Remove abusive resident from other residents... B. Provide one on one immediate supervision until problem behavior alleviated by one of the following: a. Medication b. Family interventions c. Counseling by Mental Health Professional d. Physical restraints may be utilized e. Transfer to facility of physician preference f. Notify local police department if facility is unable to ensure safety of all residents. C. Details of any abusive incidents will be documented in the resident's clinical record. D. Administrator and D.O.N. notification of abusive incident will be per Incident Accident Report completed by licensed nurse at time of occurrence (sic), after notification by telephone of time of incident. E. Administrator or D.O.N. will initiate an immediate investigation of alleged abuse at the time of occurrence, and document findings. Investigation will continue for a minimum of 72 hours. F. The Administrator will notify Ok. State Dept. of Health within 12 hours, by telephone, of any actual abuse. A report of the incident shall be mailed to OSDH with in 5 working days of the incident. IDENTIFYING PROCEDURES: 1. Residents will be identified for behavioral problems that may result in potential for and/or actual harm to other residents on admission to the facility by review of history, any previous documented behavioral problems, current medication, family interviews and physician consultation. Review will be completed by a licensed nurse on day of admission. 2. Residents that develop behavioral problems while in the facility will be identified by staff observation, resident family interviews, RAI assessment, resident council meetings, internal quality assurance and Behavior Risk Assessment. 3. Degree of risk for potential or actual harm will be completed as mandated by state regulations addressing any behavioral problems identified that may result in potential for or actual harm to other residents. PREVENTATIVE MEASURES: 1. Residents identified with potential for or actual harm to other residents will be assessed by a licensed nurse for causative factors. a. Changes in medical condition b. Environmental factors c. Psychological factors d. Adverse reaction to medication e. Social and emotional problems 2. Licensed nurse will notify the attending physician and the responsible party after assessment determines that behavioral problem is present. 3. Facility will provide individualized behavior management and preventative measures not limited to: a. 1-1 counseling b. Diversional activities c. Removal of negative stimuli triggering behavior d. Identify and attempt to eliminate triggers prior to behavioral episode. e. Notify mental health professional for assessment and recommended treatment 4. Nursing will complete a behavior risk assessment for any resident identified at risk for behavioral episodes. Resident exhibiting behavior problems will have a behavior monitor completed. The behavior monitor will be individualized with specific interventions and behavior modifications identified for each residents needs." 1. Resident #9 had [DIAGNOSES REDACTED]. The admission assessment, dated 09/20/11, documented the resident had no behaviors. The October 2011 monthly summary documented the resident had threatened staff and other residents. The November 2011 monthly summary documented the resident could become hostile to staff and other residents, but was getting better at not doing it. The December 2011 monthly summary documented the resident had hostility due to wanting medications he couldn't have. A quarterly assessment, dated 12/29/11, documented the resident had no behaviors. The care plan did not address resident behaviors. A behavioral summary, dated 01/10/12 at 1:15 p.m., documented, "Resident put roommate in head lock while in wheel chair and threw him in the floor when asked why he did that resident stated 'I'm tired of getting cussed at everytime I get up.' Both residents in floor roommate had assistance from staff on getting out of floor the other resident didn't want assistance." For Resident's Response, the facility had circled verbal aggression, others, armed aggression and thrown. For Staff Intervention/Medication, the facility had circled verbal intervention, verbal redirection and physical intercedence. For outcome, the form documented, "Staff intervened and resident went into his room and roommate taken to nurses desk." 2. Resident #8 had [DIAGNOSES REDACTED]. The care plan, dated 07/13/11, documented the resident had impaired cognitive function with difficulty with decision making at times. Interventions included, "Reorient resident as needed, monitor resident for signs of increased confusion/disorientation...Encourage resident participation in activities daily to promote acceptance and prevent wandering/elopement..." A comprehensive assessment for resident #8, dated 11/20/11, documented the resident was moderately impaired in cognitive skills for daily decision making, was not ambulatory, required the use of a wheel chair, required limited assistance with transfers and had no behaviors. On 01/10/12 at approximately 4:00 p.m., the surveyor was at the nurses' station and heard LPN #1 and CMA #1 talking about an altercation that had occurred between two residents earlier that day. They stated resident #9 had grabbed resident #8 and pulled him out of his wheelchair and that resident #8 had a black eye and resident #9 had a scratch down one side of his face after the altercation. At 5:20 p.m., resident #8 was observed leaving the dining room in his wheelchair alone. He was observed to push himself up the north hall to the room of resident #9 and wheeled himself into the doorway of the room. Resident #8 then spoke to resident #9, who was standing inside the room. There was no staff person observed in the room with resident #9. Resident #8 and #9 were observed speaking to each other in a normal tone of voice for approximately one to two minutes. CNA #9 was then observed to walk up the hallway and look at resident #8 in the doorway of the room. The CNA was then observed to push resident #8 to the dining room and leave him there unattended. Resident #9 was observed in his room unattended. There was no staff visible in the hallway or at the nurses' station. Resident #8 remained in the dining room for approximately 1 minute and then he left the dining room alone and wheeled himself back to the room of resident #9. He wheeled his wheelchair inside the room and spoke to resident #9. There was no staff visible in the room, in the hallway or at the nurses' station. Resident #9 then left his room and went to the nurses' station, which was unattended by staff, and stood there. Another resident walked up to resident #9 and asked him if he was all right. The resident then patted him on the arm and stated she would talk to him later and left the nurses' station. There was no staff visible at the nurses' station or in the hallway. Resident #8 was observed to wheel himself back toward the nurses' station and stop at the door of his room. He was unattended by staff. CNAs #9 and #10 were observed in the north hall assisted dining room. No other staff was observed in the area of the north hall or nurses' station. At 6:00 p.m., the administrator and ADON were asked about the altercation that occurred between residents #8 and #9. They both stated that resident #9 had said he grabbed resident #8 and got him in a head lock and hit him in the eye and his eye was black and he had a couple of places on his upper lip. They were asked if they thought resident #9 was cognitively alert and acted willfully when he pulled resident #8 from his wheelchair and hit him. They both stated, "Yes." They were both asked what had been done to protect the residents since the altercation had occurred. The ADON stated she had contacted (hospital name deleted) to transfer resident #9 to the facility for an evaluation regarding his behavior but resident #9 had refused to go. She stated, "I've got him talked into going to (name deleted) now." She was asked when he would be transferred to the other facility. She stated, "I'm going to try to call them." She was asked if she had contacted them. She stated, "Not yet." The administrator and the ADON were asked what measures had been put in place to protect the residents. The ADON stated, "We moved him into another room and I spoke with him and asked him why he did this. He (resident #9) said he (resident #8) was cussing at me and I told him that's no reason to hit." They were asked if there was any staff assigned to monitor resident #9 until he could be transferred. They both stated, "No." They were asked if there was a plan in place to protect the other residents. They both stated, "No." Immediate Jeopardy Identified On 01/10/12, an immediate jeopardy (IJ) situation was identified related to a resident to resident altercation. The facility failed to implement their abuse policy to ensure the residents were protected from a resident that had physically assaulted another resident. At 6:08 p.m., the Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to implement their abuse policy to protect residents from resident to resident abuse. At 6:12 p.m., the administrator and ADON were informed of the IJ situation and asked for a plan of removal. At 7:43 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The plan of removal documented, "6:15 pm Resident, (name deleted) placed 1 on 1 with CNA, (name deleted). CNA instructed to stay with resident @ all times + prevent his contact c other residents 6:30 pm (Hospital name deleted) notified to admit (name deleted) for behaviors. 7:05 pm (Hospital name deleted) unit notified facility, requesting information be faxed. Resident info faxed to (Hospital) Unit. 7:25 pm Received admission agreement from (Hospital) Unit, for taken to (name deleted) for signature/agreement 7:35 pm (Name deleted) signed agreement 7:45 pm (Hospital) Unit notified facility that they will admit him in am @ (Name deleted) will remain 1 on 1 c CNA through night. CNA has been instructed to document (name deleted) actions, behaviors, & any needed interventions, c focus on protecting other residents from harm, every hour. Abuse Prevention in-service training scheduled for 8 pm, 01-10-12. All employees notified to attend. Attendance record will be completed + checked against work schedules to verify all employees receive training. Any employee not attending this in-service will not be allowed to work until training complete, no later than 8 am on 01-11-12. Focus will include res to res altercations & importance of protecting all residents from harm. In-service training @ 8 pm also included: Behavior management program has been implemented including: Behavior Risk Assessments to determine residents @ risk for behavior disturbances, pre-admission screening, continued education for all staff (scheduled quarterly & @ time of hire)" Immediacy Removed The IJ was removed on 01/11/12 at 9:15 a.m., when the last employee was inserviced. The deficient practice remained at a level of potential for more than minimal harm at a pattern that was not an immediate jeopardy. On 01/11/12, staff were interviewed in regards to their knowledge of the inservice, to ensure their understanding of and interventions for resident to resident abuse. The staff verbalized understanding and importance of intervening and reporting immediately. Staff stated that resident #9 had been transferred out of the facility.

Based on observation, interviews, and record review, it was determined the facility failed to provide interventions to protect one (#8) of one sampled resident who was involved in a resident to resident altercation. Resident #9 pulled resident #8 from his wheelchair and hit him in his eye, which resulted in an injury to resident #8's eye and upper lip. The facility failed to provide interventions to prevent further abuse to this resident or other residents who were up and about the facility. This had the likelihood to affect 34 of 43 residents who resided in the facility. The facility identified nine residents who were bedfast. This resulted in an Immediate Jeopardy Situation. Findings: Facility Policy & Procedure for Resident Abuse, Neglect, and Misappropriation of Property The facility's undated policy on allegation of abuse and or mistreatment documented, "...All suspicions of abuse and/or mistreatment will be immediately reported the Administrator, including Physical abuse...Patterns and trends Recognizing high risk residents Recognizing high risk situations Changes in a residents behavior, ie, cringing, crying, flinching...Remove any immediate threat to the resident to prevent further potential abuse to the resident during the investigation. Document protective measures taken..." The facility's undated policy on resident to resident abuse documented, "...Facility staff will immediately intervene to halt abusive behavior and initiate appropriate actions to ensure the safety of all residents based on individual occurrence. These actions may include, but not limited to the following: A. Remove abusive resident from other residents... B. Provide one on one immediate supervision until problem behavior alleviated by one of the following: a. Medication b. Family interventions c. Counseling by Mental Health Professional d. Physical restraints may be utilized e. Transfer to facility of physician preference f. Notify local police department if facility is unable to ensure safety of all residents. C. Details of any abusive incidents will be documented in the resident's clinical record. D. Administrator and D.O.N. notification of abusive incident will be per Incident Accident Report completed by licensed nurse at time of occurrence (sic), after notification by telephone of time of incident. E. Administrator or D.O.N. will initiate an immediate investigation of alleged abuse at the time of occurrence, and document findings. Investigation will continue for a minimum of 72 hours. F. The Administrator will notify Ok. State Dept. of Health within 12 hours, by telephone, of any actual abuse. A report of the incident shall be mailed to OSDH with in 5 working days of the incident. IDENTIFYING PROCEDURES: 1. Residents will be identified for behavioral problems that may result in potential for and/or actual harm to other residents on admission to the facility by review of history, any previous documented behavioral problems, current medication, family interviews and physician consultation. Review will be completed by a licensed nurse on day of admission. 2. Residents that develop behavioral problems while in the facility will be identified by staff observation, resident family interviews, RAI assessment, resident council meetings, internal quality assurance and Behavior Risk Assessment. 3. Degree of risk for potential or actual harm will be completed as mandated by state regulations addressing any behavioral problems identified that may result in potential for or actual harm to other residents. PREVENTATIVE MEASURES: 1. Residents identified with potential for or actual harm to other residents will be assessed by a licensed nurse for causative factors. a. Changes in medical condition b. Environmental factors c. Psychological factors d. Adverse reaction to medication e. Social and emotional problems 2. Licensed nurse will notify the attending physician and the responsible party after assessment determines that behavioral problem is present. 3. Facility will provide individualized behavior management and preventative measures not limited to: a. 1-1 counseling b. Diversional activities c. Removal of negative stimuli triggering behavior d. Identify and attempt to eliminate triggers prior to behavioral episode. e. Notify mental health professional for assessment and recommended treatment 4. Nursing will complete a behavior risk assessment for any resident identified at risk for behavioral episodes. Resident exhibiting behavior problems will have a behavior monitor completed. The behavior monitor will be individualized with specific interventions and behavior modifications identified for each residents needs." 1. Resident #9 had [DIAGNOSES REDACTED]. The admission assessment, dated 09/20/11, documented the resident had no behaviors. The October 2011 monthly summary documented the resident had threatened staff and other residents. The November 2011 monthly summary documented the resident could become hostile to staff and other residents, but was getting better at not doing it. The December 2011 monthly summary documented the resident had hostility due to wanting medications he couldn't have. A quarterly assessment, dated 12/29/11, documented the resident had no behaviors. The care plan did not address resident behaviors. A behavioral summary, dated 01/10/12 at 1:15 p.m., documented, "Resident put roommate in head lock while in wheel chair and threw him in the floor when asked why he did that resident stated 'I'm tired of getting cussed at everytime I get up.' Both residents in floor roommate had assistance from staff on getting out of floor the other resident didn't want assistance." For Resident's Response, the facility had circled verbal aggression, others, armed aggression and thrown. For Staff Intervention/Medication, the facility had circled verbal intervention, verbal redirection and physical intercedence. For outcome, the form documented, "Staff intervened and resident went into his room and roommate taken to nurses desk." 2. Resident #8 had [DIAGNOSES REDACTED]. The care plan, dated 07/13/11, documented the resident had impaired cognitive function with difficulty with decision making at times. Interventions included, "Reorient resident as needed, monitor resident for signs of increased confusion/disorientation...Encourage resident participation in activities daily to promote acceptance and prevent wandering/elopement..." A comprehensive assessment for resident #8, dated 11/20/11, documented the resident was moderately impaired in cognitive skills for daily decision making, was not ambulatory, required the use of a wheel chair, required limited assistance with transfers and had no behaviors. On 01/10/12 at approximately 4:00 p.m., the surveyor was at the nurses' station and heard LPN #1 and CMA #1 talking about an altercation that had occurred between two residents earlier that day. They stated resident #9 had grabbed resident #8 and pulled him out of his wheelchair and that resident #8 had a black eye and resident #9 had a scratch down one side of his face after the altercation. At 5:20 p.m., resident #8 was observed leaving the dining room in his wheelchair alone. He was observed to push himself up the north hall to the room of resident #9 and wheeled himself into the doorway of the room. Resident #8 then spoke to resident #9, who was standing inside the room. There was no staff person observed in the room with resident #9. Resident #8 and #9 were observed speaking to each other in a normal tone of voice for approximately one to two minutes. CNA #9 was then observed to walk up the hallway and look at resident #8 in the doorway of the room. The CNA was then observed to push resident #8 to the dining room and leave him there unattended. Resident #9 was observed in his room unattended. There was no staff visible in the hallway or at the nurses' station. Resident #8 remained in the dining room for approximately 1 minute and then he left the dining room alone and wheeled himself back to the room of resident #9. He wheeled his wheelchair inside the room and spoke to resident #9. There was no staff visible in the room, in the hallway or at the nurses' station. Resident #9 then left his room and went to the nurses' station, which was unattended by staff, and stood there. Another resident walked up to resident #9 and asked him if he was all right. The resident then patted him on the arm and stated she would talk to him later and left the nurses' station. There was no staff visible at the nurses' station or in the hallway. Resident #8 was observed to wheel himself back toward the nurses' station and stop at the door of his room. He was unattended by staff. CNAs #9 and #10 were observed in the north hall assisted dining room. No other staff was observed in the area of the north hall or nurses' station. At 6:00 p.m., the administrator and ADON were asked about the altercation that occurred between residents #8 and #9. They both stated that resident #9 had said he grabbed resident #8 and got him in a head lock and hit him in the eye and his eye was black and he had a couple of places on his upper lip. They were asked if they thought resident #9 was cognitively alert and acted willfully when he pulled resident #8 from his wheelchair and hit him. They both stated, "Yes." They were both asked what had been done to protect the residents since the altercation had occurred. The ADON stated she had contacted (hospital name deleted) to transfer resident #9 to the facility for an evaluation regarding his behavior but resident #9 had refused to go. She stated, "I've got him talked into going to (name deleted) now." She was asked when he would be transferred to the other facility. She stated, "I'm going to try to call them." She was asked if she had contacted them. She stated, "Not yet." The administrator and the ADON were asked what measures had been put in place to protect the residents. The ADON stated, "We moved him into another room and I spoke with him and asked him why he did this. He (resident #9) said he (resident #8) was cussing at me and I told him that's no reason to hit." They were asked if there was any staff assigned to monitor resident #9 until he could be transferred. They both stated, "No." They were asked if there was a plan in place to protect the other residents. They both stated, "No." Immediate Jeopardy Identified On 01/10/12, an immediate jeopardy (IJ) situation was identified related to a resident to resident altercation. The facility failed to ensure the residents were protected from a resident that had physically assaulted another resident. At 6:08 p.m., the Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to protect residents from resident to resident abuse. At 6:12 p.m., the administrator and ADON were informed of the IJ situation and asked for a plan of removal. At 7:43 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The plan of removal documented, "6:15 pm Resident, (name deleted) placed 1 on 1 with CNA, (name deleted). CNA instructed to stay with resident @ all times + prevent his contact c other residents 6:30 pm (Hospital name deleted) notified to admit (name deleted) for behaviors. 7:05 pm (Hospital name deleted) unit notified facility, requesting information be faxed. Resident info faxed to (Hospital) Unit. 7:25 pm Received admission agreement from (Hospital) Unit, for taken to (name deleted) for signature/agreement 7:35 pm (Name deleted) signed agreement 7:45 pm (Hospital) Unit notified facility that they will admit him in am @ (Name deleted) will remain 1 on 1 c CNA through night. CNA has been instructed to document (name deleted) actions, behaviors, & any needed interventions, c focus on protecting other residents from harm, every hour. Abuse Prevention in-service training scheduled for 8 pm, 01-10-12. All employees notified to attend. Attendance record will be completed + checked against work schedules to verify all employees receive training. Any employee not attending this in-service will not be allowed to work until training complete, no later than 8 am on 01-11-12. Focus will include res to res altercations & importance of protecting all residents from harm. In-service training @ 8 pm also included: Behavior management program has been implemented including: Behavior Risk Assessments to determine residents @ risk for behavior disturbances, pre-admission screening, continued education for all staff (scheduled quarterly & @ time of hire)" Immediacy Removed The IJ was removed on 01/11/12 at 9:15 a.m., when the last employee was inserviced. The deficient practice remained at a level of potential for more than minimal harm at a pattern that was not an immediate jeopardy. On 01/11/12, staff were interviewed in regards to their knowledge of the inservice, to ensure their understanding of and interventions for resident to resident abuse. The staff verbalized understanding and importance of intervening and reporting immediately. Staff stated that resident #9 had been transferred out of the facility.

Based on observations, interviews and record reviews, it was determined the facility failed to provide supervision and failed to identify and implement interventions to aid in the prevention of falls for 4 (#3, #4, #8, and #10) of 7 sampled residents who had experienced falls. This resulted in actual harm for resident #8 when he suffered a fracture of the right femur after a fall and resident #4 when he suffered a hematoma to the right outer eyebrow and temple area after a fall and multiple bruising after a fall. The facility's census and condition report identified 4 residents who had experienced falls. Findings: A Fall prevention policy documented, "It is the policy of Shady Rest Care Center to identify residents at risk for falls and to implement a fall prevention approach to reduce the risk of falls and possible injury. The Fall Prevention Approach is incorporated with the facility's Quality Improvement and Safety Committees... Any resident experiencing a pattern of falls (2 or more during a 30-day period) or an injury from a fall will be referred for a falls assessment to be completed by the nurse or therapist... Residents will be assessed at least quarterly and following any change in condition... Based on the results of the falls assessment, the interdisciplinary team will determine the best approach to implement for fall prevention, adjust the care plan..." 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report, dated 06/15/11 at 2:40 a.m., documented, "...Description of incident: Residents roommate notified CNA resident was sitting on edge of bed and slid to floor. Resident had gotten self up & was sitting on bed...no injuries...suggested safety precautions to prevent recurrence: encourage resident to ask for assistance when sitting on bed to get up..." A care plan, dated 07/12/11, documented, "...Problem: High risk for falls related to history of falls. Goal: Resident will be without falls or injury daily x 90 days. Intervention: 2. Keep environment free of clutter as much as possible...5. Ensure adequate lighting...8. Frequent visual checks on resident if unable to utilize call light while in bed. A falls care area assessment, dated 07/12/11, documented, "...History of Falling:...hx of falls. All seem to occur at bedside while trying to go to BR or changing clothes...Physical performance Limitations:...Resident unable to stand or ambulate without assist. Uses w/c for mobility or as (sic) an aid to assist with ambulation...Internal Risk Factors:...Occasional incontinence of B/B..Has upper and lower extremity weakness...Analysis of Findings: (blank)..." A nurse's note, dated 07/15/11 at 10:30 p.m., documented, "...Residents (sic) roommate came to nurses (sic) station and informed this nurse resident had fallen in (sic) floor. This nurse went to residents room. Resident sitting on side of bed. When asked if he had fallen stated, 'Yes'...no injuries..." No interventions to prevent further falls were documented in the nurses' notes. The fall care plan was not updated to include the fall that occurred on 07/15/11. A nurse's note, dated 08/03/11 at 10:45 p.m., documented, "...called to residents room by roommate...Resident fell and hit his head on dresser by bed....assessment made, no open areas, red areas or bleeding noted...Noted a dime size bump to (lower) mid back of head..." No interventions to prevent further falls were documented in the nurses' notes. The fall care plan was not updated to include the fall that occurred on 08/03/11. An incident report, dated 08/16/11 at 6:00 a.m., documented, "...description of incident: Resident found sitting on floor in his room next to bedside - stated w/c had tipped over c him...suggested safety precautions to prevent recurrence: call for assist when transferring to w/c..." The nurses' notes regarding the fall on 08/16/11 did not document interventions to prevent further falls. The fall care plan was not updated to include the fall that occurred on 08/16/11. An incident report, dated 09/12/11 at 3:30 a.m., documented, "...description of incident: Resident found laying (sic) in living room floor, resting quietly c eyes closed. Resident states he slid out of his chair to the floor...no injuries...suggested safety precautions to prevent recurrence: Though resident attempting to fluctuate (sic) through facility, urge him to rest in bed instead. Persistance..." The nurses' notes regarding the fall on 09/12/11 did not document interventions to prevent further falls. The fall care plan was not updated to include the fall that occurred on 09/12/11. An incident report, dated 10/29/11 at 2:45 a.m., documented, "...Description of Incident: Resident on hands & knees crawling to bed attempting to get up. Pants wet. Was trying to walk to bathroom. No injuries found...Suggested safety precautions to prevent recurrence: Encouraged to use c/l and ask for assistance..." An incident report, dated 10/29/11 @ 6:15 a.m., documented, "...incident type: Incident resulting in injury...Description of Incident: Resident found lying in floor beside bed in front of tv stand. Sweat pants wet and floor noted to be wet. Reports hitting head but doesn't know on what. No evidence of injury on head...Resident c/o severe pain on Rt hip...sent to hospital for eval. Sent back with orders for fall precautions...Report of portable shows subcaptal fracture of the right femur...resident transferred back to hospital...admitted and scheduled for surgery...Corrective measures will include encouraging resident to ask for increased assistance and increased incontinence checks..." Nurses' notes regarding the two falls on 10/29/11 did not document interventions to prevent further falls. The fall care plan was not updated to include the two falls that occurred on 10/29/11. A 14-day assessment, dated 11/20/11, documented the resident had a BIMS score of 9, which indicated the resident was moderately impaired with cognitive skills for daily decision making. The resident was not ambulatory, needed limited assistance with toilet use, was frequently incontinent of urine, occasionally incontinent of bowel, and had no history of falls. On 01/12/12 at 4:25 p.m., the DON and ADON were asked if the facility had a restorative program. The DON and ADON stated, "No." They were informed about the resident's eight falls in the last six months with the only intervention for the resident was to use the call light. They were asked if the resident could use the call light. The ADON stated, "I think he can, he just wants to do things on his own." They were asked if a bowel and bladder program would help the resident. The ADON stated, "Yes, it would have helped." They were asked if they had kept the resident safe. The DON stated, "A lot more we could be doing to keep them (residents) safe." 2. Resident #4 had a [DIAGNOSES REDACTED]. A physical therapy note, dated 07/27/11 through 08/26/11, documented the plan of treatment for [REDACTED]. An occupational therapy initial assessment note, dated 07/26/11 through 08/25/11, documented the resident was a fall risk. A nurse's note, dated 07/29/11, documented, "...resident stated that he slid out of w/c transferring self from w/c...to bed...resident stated, "I fell on the floor on knees...Light red marks & small indention on knees...resident ambulates self c w/c to dinning (sic) room..." An admission assessment, dated 08/01/11, documented the resident had a BIMS score of 11, which indicated the resident was moderately impaired with cognitive skills for daily decision making, the resident required limited/one person physical assistance with transfers, the resident was unsteady during transitions and walking, the resident was occasionally incontinent of bowel and bladder, and the resident had experienced two falls with injury since admission or prior to the assessment. A CAA, dated 08/01/11, documented, "...History of Falling...previous falls...time of day...location of falls...usually on 2-10 shift Resident falls while transferring self...difficulty maintaining standing position..." A nurse's note, dated 08/01/11, documented, "1430 (2:30 p.m.) res found on floor states he fell off the bed...1800 (6:00 p.m.) Res states his back is now hurting...2100 (9:00 p.m.) res returns from (name deleted-hospital)...(No) findings from CT scan & X-ray of back...N O for Neuro (checks) Q shift..." A fall care plan, dated 08/03/11, documented, "Problem: High risk for falls related to history of falls et unsteady balance...Goal: Resident will be without falls or injury daily x 90 days...Intervention: ...Assess resident for ability to use call light to call for assistance...physical and/or occupational therapy referral as indicated...Address fall risk factor for resident: identify resident as fall risk with staff with identification stickers...Frequent visual checks on resident if unable to utilize call light while in bed..." The fall care plan failed to address the resident had experienced two falls since admission on 07/25/11. An incident report, dated 09/26/11, documented, "...Residents (sic) roommate came to nurses (sic) station stated resident on floor and unable to get up...I fell trying to get up...(no) injuries...Suggested safety precautions to prevent recurrence: Encouraged to use c/l c (no) success. Unknown what else to do. Maybe bed alarm..." The fall care plan had not been updated to include the fall that had occurred on 09/26/11 and to address the use of a bed alarm or to address the resident not using the call light to ask for assistance. No new interventions were addressed for the prevention of further falls. A monthly nurse's summary, dated October 2011, documented, "...Resident will transfer self & attempt to walk by himself in room. Very unsteady. Will not ask for help..." A nurse's note, dated 10/05/11, documented, "...Resident found lying on left side, partially sitting, on bathroom floor - Resident stated he fell ...No injuries stated or noted...will continue to monitor. Encouraged to ask for assistance..." The fall care plan had not been updated to include the fall that had occurred on 10/05/11. The care plan did not address the resident attempting to go to the bathroom without assistance and interventions for toileting. The care plan did not address how the staff were to monitor the resident and did not address the resident not using the call light to ask for assistance. No new interventions were addressed for the prevention of further falls. A fall risk assessment, dated 10/16/11, documented, "Intermittent confusion...3 or more falls in past 3 months...chairbound - and/or assist with elimination...Gait/Balance...not able to perform function..." A monthly nurse's summary, dated November 2011, documented, "...Resident will transfer self (without) assist & attempt to ambulate (without) assist. Ambulates very unsteady gait...Will not ask for assist..." A quarterly assessment, dated 11/01/11, documented the resident had a BIMS score of 11, which indicated the resident was moderately impaired with cognitive skills for daily decision making, the resident required limited/one person physical assistance with transfers, the resident was unsteady during transitions and walking, the resident was occasionally incontinent of bowel and bladder, and the resident had experienced two falls with no injury since admission or prior to the assessment. A care plan conference summary, dated 11/02/11, documented, "Impaired cognitive function, poor decision making without assistance, requires assistance...Incontinence B&B risks such as...Increased risk for falls c recent fall hx r/t (decreased) cognitive (illegible) and balance difficulties..." A physician's notification, dated 11/03/11, documented, "...May we get an order for [REDACTED].?" A physician's orders [REDACTED]. A physician's orders [REDACTED]. There were no physical therapy notes in the resident's clinical record and none were provided. An incident report, dated 11/20/11, documented, "...multi. bruising to shoulders, back , abd...bruising unknown origin. Resident states, "I fell ." When asked when he fell . Resident states, "Yesterday." Noted...6cm x 4cm purplish bruise to (R) shoulder...1cm x 4cm bluish bruising to (L) side of abd...9cm x 4cm oblong purplish/blue bruising to (L) side of mid back...3 1/2cm x 0.5cm grazed area just next to large bruising to mid back. All bruises are of unknown origin...Suggested safety precautions to prevent recurrence: If from fall encouraged to ask for assistance..." The fall care plan had not been updated to include the fall that had occurred on 11/20/11. The care plan did not address the resident attempting to go to the bathroom without assistance and interventions for toileting. The care plan did not address how the staff were to monitor the resident and did not address the resident not using the call light to ask for assistance. No new interventions were addressed for the prevention of further falls. An incident report, dated 11/24/11, documented, "...resident found lying on floor next to bed c head next to dresser stated, "Yes, I hit my head."...Stated, "I hit the back of my head." (No) reddness (sic)-(No) scratches - (No) bumps (No) bruising at this time...Suggested safety precautions to prevent recurrence: encouraged resident to use call light for assistance..." The fall care plan had not been updated to include the fall that had occurred on 11/24/11. The care plan did not address the resident attempting to go to the bathroom without assistance and interventions for toileting. The care plan did not address how the staff were to monitor the resident and did not address the resident not using the call light to ask for assistance. No new interventions were addressed for the prevention of further falls. A monthly nurses' summary, dated December 2011, documented, "...Resident will transfer self in & out of bed. Attempts to walk by himself & will usually fall. Ambulates c very unsteady gait...Refuses to ask for assist..." An incident report, dated 12/16/11, documented, "CNA called nurse to room noted resident lying on (L) side c head toward bathroom. Urine on floor by feet (No) injuries found...Suggested safety precautions to prevent recurrence: (low) bed for safety refuses to ask for help. Numerous falls..." A nurse's note, dated 12/16/11, documented, "...Urine in floor at feet...States, "Going to bathroom." The fall care plan had not been updated to include the fall that had occurred on 12/16/11. The care plan did not address the resident attempting to go to the bathroom without assistance and interventions for toileting. The care plan did not address how the staff were to monitor the resident, did not address the resident not using the call light to ask for assistance, and the use of a low bed. No new interventions were addressed for the prevention of further falls. An incident report, dated 12/20/11, documented, "...Res slid out of chair on floor...tiny scratch on (L) elbow...Suggested safety precautions to prevent recurrence: encourage to ask for assistance - low bed..." The fall care plan had not been updated to include the fall that had occurred on 12/20/11. The care plan did not address the resident falling from his chair and appropriate interventions related to the fall. No new interventions were addressed for the prevention of further falls. An incident report, dated 12/27/11, documented, "...Found res lying on back at foot of bed, naked from the waist down, urine in floor...hematoma RT outer eyebrow & temple...Suggested safety precautions to prevent recurrence: reoriented to call light, visual checks q 15 min..." A nurse's note, dated 12/27/11, documented, "...urine in floor res states was trying to go to the bathroom..." The fall care plan had not been updated to include the fall that had occurred on 12/27/11. The care plan did not address the resident attempting to go to the bathroom without assistance and interventions for toileting. The care plan did not address how the staff was to monitor the resident every 15 minutes and for how long of a period of time, and did not address the resident not using the call light to ask for assistance. An incident report, dated 12/28/11, documented, "...Resident found lying on floor on L side next to bedside table...(No) injuries R/T this fall...Suggested safety precautions to prevent recurrence: to encourage resident to request assistance c needs - call light within reach..." The fall care plan had not been updated to include the fall that had occurred on 12/28/11. The care plan did not address if the 15 minute visual checks were implemented. The care plan did not address how the staff was to monitor the resident every 15 minutes and for how long of a period of time, and did not address the resident not using the call light to ask for assistance. A fall risk assessment, dated 01/05/12, documented, "Intermittent confusion...3 or more falls in past 3 months...ambulatory/incontinent but uses w/c d/t falls...Gait/Balance...(blank)..." The fall risk assessment failed to address the six falls in which injuries had been sustained and four falls with no injury, from the time of admission on 07/25/11 through 12/28/11. The assessment did not address the reason why the resident had fallen and no interventions were addressed to prevent further falls. On 01/10/12 at 10:45 a.m., the resident was observed alone in his room. The resident was sitting on the edge of his bed with his wheelchair next to him. No staff were visible. On 01/11/12 at 3:07 p.m., the resident was observed alone in his room. He was attempting to get out of his bed unassisted. The call light was not on and no staff were visible. On 01/12/12 at 4:00 p.m., the DON, ADON, administrator, and the nurse consultant were informed of the resident's 10 falls in which four injuries had resulted, from the time of admission on 07/25/11 through 12/28/11. They were asked if the resident used his call light. The ADON stated, "No. He wants to get up on his on." She was asked if an assessment had been done regarding the use or non use of the call light. She stated, "No." The DON and ADON were asked if the resident's refusal to use the call light should have been addressed on the care plan. The ADON stated, "Yes." They were asked if a fall assessment had been done after the resident had fallen to determine the reason for the falls and to implement an intervention. The DON stated, "No." The ADON was asked if the falls and new interventions had been addressed on the fall care plan. She stated, "No. It should have been." The ADON was asked if the resident had received the physical therapy that had been ordered in November 2011. She stated, "It would be on the care plan." She was informed the physical therapy was not addressed on the care plan and no notes were in the resident's clinical record. She stated, "I didn't write it on the care plan." The ADON stated the physical therapy should have been addressed on the care plan. The ADON was asked if they had a bowel and bladder program or a toileting program. She stated, "No. Not one implemented." She was asked if that would have been an intervention to prevent the falls the resident had experienced. She stated, "Yes." The DON and the ADON were asked if they were keeping the residents safe. The DON stated, "A lot more we can be doing to keep them safe." 3. Resident #10 had [DIAGNOSES REDACTED]. A fall risk assessment, dated 10/11/11, documented, "...History of Falls (past 3 months)...1 - 2 falls...ambulatory/continent...Total score...14..." A total score of 10 or above represented the resident was at high risk for falls. A fall care plan, dated 10/13/11, documented, "Problem: High risk for falls related to unsteady balance...Goal: Resident will be without falls or injury x 90 days...Intervention: ...Assess resident for ability to use call light to call for assistance...Address fall risk factor for resident: identify resident as fall risk with staff with identification stickers...Frequent visual checks on resident if unable to utilize call light while in bed..." An admission assessment, dated 10/24/11, documented the resident had a BIMS score of 3, which indicated the resident was severely impaired with cognitive skills for daily decision making, the resident required extensive assistance with transfers, the resident was unsteady during transitions and walking, the resident was always incontinent of bowel and bladder, the resident had not experienced any falls since admission and one fall prior to the assessment, and did not use a physical restraint. A nurse's note, dated 10/26/11, documented, "...resident hollering help. Went to residents (sic) room noted resident lying on back at foot of bed. Gown wet. Floor wet. Water pitcher lying at residents (sic) feet. Resident states, "I fell ."...area long & approximately 1/4 inch wide c small amt of bleeding..." A fall care plan, dated 10/27/11, documented, "Problem: At risk for injuries from falls as the resident has recent history of falls...Goal: Will have no injury from falls during the next 90 days...Interventions: Monitor resident to ensure he stays in his w/c...Take time out each shift to assist resident in ambulation...Monitor resident for balance and steadiness...Take resident to BR frequently (q 2 hours) and assess if resident needs something to eat or drink...Attempt to anticipate needs to prevent resident from getting out of w/c and increase risk of fall..." A nurse's note, dated 10/29/11, documented, "...Ambulates c slow unsteady gait. Encouraged to use w/c to prevent fall..." A nurse's note, dated 10/30/11, documented, "...Ambulates c slow unsteady gait. Encouraged to have staff assist c Ambulation. Uses mobility when resident stays in it..." A nurse's note, dated 10/31/11, documented, "...Ambulates c slow shuffling unsteady gait. Encouraged to use w/c, but usually gets up out of chair..." A nurse's note, dated 11/02/11, documented, "...Uses w/c for main mobility but does not stay in it. Has to be watched d/t falls..." A nurse's note, dated 11/08/11, documented, "...T.O. D/C Lap buddy. Start use of quick-release restraint for safety R/T residents not able to understand he will fall upon standing..." The fall care plan had not been updated to address the use of a quick-release restraint as an intervention to prevent falls. The care plan had not been updated to address the problem of the use of a physical restraint, the alternatives that had been attempted, a new goal, and interventions for the use of the physical restraint. A 30-day assessment, dated 11/08/11, documented the resident had a BIMS score of 0, which indicated the resident was severely impaired with cognitive skills for daily decision making, the resident required extensive assistance with transfers, the resident was unsteady during transitions and walking, the resident was always incontinent of bowel and bladder, and the resident had not experienced any falls with since admission, and did not use a physical restraint. A nurse's note, dated 11/10/11, documented, "...Resident found lying in floor in dining room under kitchen table on back - (No) injuries..." A nurse's note, dated 11/15/11, documented, "...Res in w/c...in main DR tried to stand up and fell to floor on buttocks...small bruise to tailbone area..." The fall care plan had not been updated to address the resident's fall and the bruise he had sustained. The care plan did not address the reason the resident had fallen and no new interventions had been addressed to prevent further falls and keep the resident safe. A nurse's note, dated 11/16/11, documented, "1600 (4:00 p.m.) ...N.O. may use lap buddy while up in WC for safety... 2000 (8:00 p.m.) ...lap buddy in place for safety..." A physician's orders [REDACTED]. The fall care plan had not been updated to address the use of a lap buddy restraint as an intervention to prevent falls. The care plan had not been updated to address the problem of the use of a physical restraint, what alternatives had been attempted before the use of a physical restraint, a new goal, and interventions for the use of the physical restraint. A nurse's note, dated 11/24/11, documented, "...Uses w/c c lap buddy for main mobility d/t very unsteady on feet & numerous falls..." A nurse's note, dated 11/25/11, documented, "...res found sitting in floor facing the side of bed...no apparent injury..." The fall care plan had not been updated to address the resident's fall while in his room. The care plan did not address the reason the resident had fallen and no new interventions had been addressed to prevent further falls and keep the resident safe. A monthly nurse's summary, dated 11/2011, documented, "...Restraints: (Left Blank)..." A nurse's note, dated 12/11/11, documented, "...Uses w/c c waist restraint for safety..." A monthly nurse's summary, dated 12/2011, documented, "...Restraints: When: ...In bed...In w/c...Type: (low) bed...fast release waist belt...Reason: Safety..." A fall risk assessment, dated 01/05/12, documented, "...History of Falls (past 3 months)...3 or more...chair bound...Total score...12..." A total score of 10 or above represented the resident was at high risk for falls. The assessment did not address the reason for the resident's falls or the use of a physical restraint. A nurse's note, dated 01/08/12, documented, "...Uses w/c for main mobility c quick release waist belt for safety..." The current monthly physician's orders [REDACTED]. On 01/11/12 at 3:10 p.m., the resident was observed in the lobby area. He was in his wheelchair with a waist belt in place. On 01/12/12 at 10:50 a.m., the resident was observed in the assisted dining room in his wheelchair. The resident was asleep and the waist belt was in place. At 4:00 p.m., the DON and ADON were asked if a fall assessment had been done after the resident had fallen to determine the reason for the falls and to implement an intervention. The DON stated, "No." The ADON was asked if the falls and new interventions had been addressed on the fall care plan. She stated, "No. It should have been." The DON was asked who reviewed the current physician's orders [REDACTED]. She stated, "I do." She was asked why there wasn't a current physician's orders [REDACTED]. She stated, "I must have missed it." The DON and the ADON were asked if they were keeping the residents safe. The DON stated, "A lot more we can be doing to keep them safe." 4. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 11/05/11 at 12:35 a.m., documented, "...Resident resting off & on. Gets up & wandering down hallway into others room...ambulates ADLib c slow unsteady gait @ times..." An untimed nurse's note, dated 11/05/11, documented, "...ambulates into other rooms unaware of need to toilet - assistance required try staff to BR - easily distracted @ this time." Nurses' notes, dated 11/07/11 at 3:00 a.m. and 7:00 p.m., documented the resident ambulated at will with a slow unsteady gait. Nurses' notes, dated 11/08/11, 11/09/11, and 11/10/11, documented the resident ambulated at will with a slow steady gait. A nurse's note, dated 11/10/11 at 5:35 p.m., documented, "...Res up roaming halls - redirected out of other residents rooms without difficulty." Nurses' notes, dated 11/13/11 and 11/14/11, documented the resident was up ad lib with a steady gait. A nurse's note, dated 11/15/11 at 2:00 a.m., documented the resident was in another resident's room. A physician's notification, dated 11/15/11, documented, "...Res is frequently up all night long wandering into other residents rooms and trying to go out doors, can we please have an order for [REDACTED]." A nurse's note, dated 11/16/11 at 1:50 a.m., documented, "...res taken to BSC q 1 1/2 hrs to help prevent res using peers rooms for toileting c effective results..." At 11:25 a.m., a nurse's note documented a new order for Restoril 30 mg po q hs for insomnia. A 14-day assessment, dated 11/16/11, documented the resident had a BIMS score of 0 which indicated the resident had severe impairment with cognitive skills for daily decision making, had wandering behaviors that occurred daily, and unable to determine if the resident had a fall any time in the last month prior to admission or any time in the last 2 - 6 months. The nurses' notes, dated 11/17/11, 11/18/11, 11/19/11, 11/20/11, and 11/21/11, documented the resident was ambulatory ad lib with a steady gait. A care plan, dated 11/21/11, documented, "...Problem: Risk for injury from falls due to unstable gait. Goal: Resident will be free from injury/falls during the next 90 days. Intervention: 1. Make sure call light is within reach. 2. Keep environment clutter free...Frequent visual checks." A monthly summary, dated Nov. 2011, documented, "...Resident wanders up & down hallways & in & out of other residents' rooms..." A nurses's note, dated 12/11/11 at 11:24 a.m., documented, "Dr. notified by CNAs that resident not sitting at meal times and not getting adequate nutritional intake because of it...N.O. for quick-release lap buddy only at meal times to enhance nutrition..." A nurse's note, dated 12/12/11 at 2:30 p.m., documented, "DC'd quick release lap buddy." A nurse's note, dated 12/14/11 at 3:00 p.m., documented, "resident lethargic through out shift - eyes will open half way - flicks tongue back & forth...new order to change Restoril 30 mg from routine at hs to PRN at hs..." A physician's orders [REDACTED]." An incident report, dated 12/26/11 at 11:15 a.m., documented, "...Resident found in dining room floor in front of w/c...resident scoots self to the edge of w/c & pushes self c hands on arms of w/c out of w/c (sic)...suggested safety precautions to prevent recurrence:...family wanted to know why resident didn't have a lap buddy on - no order for lap buddy." The incident report did not address interventions to prevent future falls. A nurse's note did not address any interventions to prevent falls. An incident report, dated 12/26/11 at 3:49 p.m., documented, "...Resident found lying in dining room floor, on left side, again, sort of snoozing no head injury noted, no pain stated...suggested safety precautions to prevent recurrence:...(blank)." The incident report did not address interventions to prevent future falls. A nurse's note documented the fall but did not address interventions to prevent future falls. An incident report, dated 12/26/11 at 4:15 p.m., documented, "...res found on floor appears to have slipped out of chair...suggested safety precautions to preve

Based on observation, record review, and interviews, it was determined the facility failed to have a quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies, which would in turn ensure the nursing staff provided nursing and related services to enable residents to achieve and maintain their highest practicable well-being. The facility failed to identify and implement a plan of action to correct systems failures related to: a. protection of the residents after a resident to resident altercation had occurred which resulted in an immediate jeopardy situation. b. supervision and implementation of measures to prevent falls for 4 (#3, #4, #8, and #10) of 7 sampled residents with falls. c. not establishing a quality assurance committee that met quarterly. This had the potential to affect 43 of 43 residents who resided in the facility. Findings: 1. The facility failed to provide interventions to protect one (#8) of one sampled resident who was involved in a resident to resident altercation. Resident #9 pulled resident #8 from his wheelchair and hit him in his eye, which resulted in an injury to resident #8's eye and upper lip. The facility failed to provide interventions to prevent further abuse to this resident or other residents who were up and about the facility. This had the likelihood to affect 34 of 43 residents who resided in the facility. The facility identified nine residents who were bedfast. This resulted in an Immediate Jeopardy Situation. Refer to F-225 and F-226. 2. The facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for 4 (#3, #4, #8, and #10) of 7 sampled residents who had experienced falls. A. Resident #8 experienced 8 falls in 6 months with 2 falls resulting in actual harm of a fractured femur and 1 head injuries. B. Resident #4 experienced 10 falls in 5 months. With 4 of the 10 falls the resident sustained [REDACTED]. C. Resident #10 experienced 4 falls within 2 months, resulting in a skin tear and bruising to the tailbone. Refer to F323. On 01/12/12 at 7:40 p.m., the DON was asked if the facility had an established QA committee. The administrator stated, "We don't have an established QA committee." She was asked why. She stated, "I don't know. Can't tell you." The DON, ADON, nurse consultant, and the administrator were asked what systems were in place to identify residents who were at risk for high behaviors. The DON stated, "Through H&P and on admit and review their history." The DON was asked how the facility identified residents who were at high risk for falls. She stated, "Initial fall assessments, H&P, and initial pre-screening." The DON was asked if they should have an established QA committee and QA meetings. The DON stated, "Yes."

Based on observation, interview and record review, it was determined the facility failed to ensure 1 (#3) of 1 sampled resident who required restorative care, received the care and services to prevent a decrease in physical functioning, which caused the resident to go from independently ambulating to a wheel chair with a lap buddy within a month of residing in the facility causing the resident actual harm. The facility's Resident Census and Condition report identified 14 residents with contractures, 9 residents bedfast, 26 residents in a chair most of the time, and 5 residents who ambulated with assistance or an assistive device. Findings: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 11/05/11 at 12:35 a.m., documented, "...Resident resting off & on. Gets up & wandering down hallway into others room...ambulates ADLib c slow unsteady gait @ times..." An untimed nurse's note, dated 11/05/11, documented, "...ambulates into other rooms unaware of need to toilet - assistance required try staff to BR - easily distracted @ this time." Nurses' notes, dated 11/07/11 at 3:00 a.m. and 7:00 p.m., documented the resident ambulated at will with a slow unsteady gait. Nurses' notes, dated 11/08/11, 11/09/11, and 11/10/11, documented the resident ambulated at will with a slow steady gait. A nurse's note, dated 11/10/11 at 5:35 p.m., documented, "...Res up roaming halls - redirected out of other residents rooms without difficulty." Nurses' notes, dated 11/13/11 and 11/14/11, documented the resident was up ad lib with a steady gait. A nurse's note, dated 11/15/11 at 2:00 a.m., documented the resident was in another resident's room. A physician's notification, dated 11/15/11, documented, "...Res is frequently up all night long wandering into other residents rooms and trying to go out doors, can we please have an order for [REDACTED]. A nurse's note, dated 11/16/11 at 1:50 a.m., documented, "...res taken to BSC q 1 1/2 hrs to help prevent res using peers rooms for toileting c effective results..." At 11:25 a.m., a nurse's note documented a new order for [MEDICATION NAME] 30 mg po q hs for [MEDICAL CONDITION]. A 14-day assessment, dated 11/16/11, documented the resident had a BIMS score of 0 which indicated the resident had severe impairment with cognitive skills for daily decision making, had wandering behaviors that occurred daily, and the facility was unable to determine if the resident had a fall any time in the last month prior to admission or any time in the last 2 - 6 months. The nurses' notes, dated 11/17/11, 11/18/11, 11/19/11, 11/20/11, and 11/21/11, documented the resident was ambulatory ad lib with a steady gait. A care plan, dated 11/21/11, documented, "...Problem: Risk for injury from falls due to unstable gait. Goal: Resident will be free from injury/falls during the next 90 days. Intervention: 1. Make sure call light is within reach. 2. Keep environment clutter free...Frequent visual checks." A monthly summary, dated Nov. 2011, documented, "...Resident wanders up & down hallways & in & out of other residents' rooms..." A nurses's note, dated 12/11/11 at 11:24 a.m., documented, "Dr. notified by CNAs that resident not sitting at meal times and not getting adequate nutritional intake because of it...N.O. for quick-release lap buddy only at meal times to enhance nutrition..." A nurse's note, dated 12/12/11 at 2:30 p.m., documented, "DC'd quick release lap buddy." A nurse's note, dated 12/14/11 at 3:00 p.m., documented, "resident lethargic through out shift - eyes will open half way - flicks tongue back & forth...new order to change [MEDICATION NAME] 30 mg from routine at hs to PRN at hs..." A physician's orders [REDACTED]." An incident report, dated 12/26/11 at 11:15 a.m., documented, "...Resident found in dining room floor in front of w/c...resident scoots self to the edge of w/c & pushes self c hands on arms of w/c out of w/c (sic)...suggested safety precautions to prevent recurrence:...family wanted to know why resident didn't have a lap buddy on - no order for lap buddy." The incident report did not address interventions to prevent future falls. A nurse's note did not address any interventions to prevent falls. An incident report, dated 12/26/11 at 3:49 p.m., documented, "...Resident found lying in dining room floor, on left side, again, sort of snoozing no head injury noted, no pain stated...suggested safety precautions to prevent recurrence:...(blank)." The incident report did not address interventions to prevent future falls. A nurse's note documented the fall but did not address interventions to prevent future falls. An incident report, dated 12/26/11 at 4:15 p.m., documented, "...res found on floor appears to have slipped out of chair...suggested safety precautions to prevent recurrence: quick realse (sic) seat belt..." A nurse's note, dated 12/26/11 at 9:30 p.m., documented, "N.O received Lap Buddy to be wedge in wheelchair for residents safety (PT/OT to eval/Treat Thus lap buddy will not be utilized much longer." A physician's orders [REDACTED]." There was not a PT/OT evaluation found in the resident's medical record after 12/26/11. There was no restorative documentation found in the resident's medical record. A fall risk assessment had not been completed after the falls on 12/26/11. The fall care plan was not updated to include the three falls that occurred on 12/26/11. Physician orders, dated 12/01/11 through 01/31/12, did not document an order for [REDACTED]. On 01/09/12 at 8:15 a.m., the resident was observed in the north dining room in a wheelchair with a lap buddy on. The resident was not able to remove the lap buddy. At 12:55 p.m., the resident was observed in a wheelchair at lunch. She did not have a lap buddy. On 01/10/12 at 9:45 a.m., the resident was observed in the doorway of her room in a wheelchair with a lap buddy. CNA #3 and CNA #4 were asked if the resident was able to walk. CNA #4 stated, "It depends on what kind of day she has. She can stand." They were asked why the resident had a lap buddy on. CNA #3 stated, "She is in a lap buddy for safety reasons." They were asked if the resident could remove it on command. CNA #3 and CNA #4 stated, "No." They were asked how long the resident had been in a wheelchair. CNA #4 stated, "For a month." At 9:58, CNA #5 was asked if the facility had any restorative aids. She stated, "Anyone can walk a resident." She was asked if the resident received PT or restorative. She stated, "The resident declined." She was asked if the resident could walk. She stated, "No, not now." At 10:35 a.m., the DON was asked if the facility had a restorative program. She stated, "No." At 10:40 a.m., the PTA and OTA were asked if the resident had received physical therapy. The PTA stated, "She had an order for [REDACTED]." At 4:12 p.m., the resident was observed in the corner of the assisted dining room in a wheelchair with a lap buddy on. At 5:07 p.m., CNA #6 wheeled the resident from the dining room to the resident's room. She returned the resident to the dining room with a lap buddy on. The CNA was asked why she had taken the resident to her room and returned her to the dining room with a lap buddy on. She stated, "Because we just found out she has an order for [REDACTED]. CNA #7 took the lap buddy off the resident. She was asked why she took the lap buddy off the resident. She stated, "Because it is to be taken off while she eats." On 01/12/12 at 3:15 p.m., the activity director was asked what were the activities for the resident. She stated, "She walked a lot when she first came. She would fold clothes and sweep. Then she got sick and she was just zonked." She was asked what activities the resident has now. She stated, "I bring her out to the dining room sometimes. She sleeps so much, she will sleep sitting in her chair." They were asked if the facility had completed pre-restraint assessments on the residents who had a lap buddy or lap belt. The DON stated, "No, I didn't know we had a restraint assessment." At 5:02 p.m., the ADON and DON were told of the documentation of the resident's four falls in one day then the facility received a physician's orders [REDACTED]. They were asked if the lap buddy was a physical restraint for the resident. The ADON and DON stated, "Yes." They were asked if there was a medical [DIAGNOSES REDACTED]." At 4:25 p.m., the DON and ADON were asked if the resident could ambulate. The ADON stated, "I watched her and she was not steady. I felt like she was at risk to fall." The ADON was asked who updated care plans. She stated, "The DON and me."