Every finding on record at Southern Oaks Care Center

Based on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation of the resident's stay and follow-up instructions were completed for 1 (#64) of 2 sampled residents who were reviewed for discharges.The DON identified one resident who had been discharged to another facility in the last three months.Findings: An undated diagnoses list showed Res #64 admitted to the facility on [DATE] with diagnoses of hypertension, chronic obstructive pulmonary disease, hyperlipidemia, and renal insufficiency. A quarterly assessment, dated 11/05/25, showed Res #64's cognition was moderately impaired with a BIMS score of 10. A discharge assessment dated [DATE], showed the resident discharged to an inpatient rehab facility on 12/26/25. A review of the resident's chart did not show a discharge summary. On 03/19/26 at 3:07 p.m., MDS #1 stated there was no discharge summary completed.

Based on record review and interview, the facility failed to ensure assessments were completed for discharge for 1 (#39) of 1 sampled resident reviewed for resident assessments.The DON identified 57 residents resided in the facility.Findings:An undated face sheet, dated 11/13/25, showed Res #57 admitted to the facility. A nurse note, dated 11/14/25, showed Res #57 discharged home against medical advice. An entry assessment was completed and submitted on 11/16/25. A Medicare 5-day assessment was completed on 11/19/25. A review of the resident's chart did not show a discharge assessment had been completed. On 03/19/2026 at 3:04 p.m., MDS #1 stated a discharge assessment should have been completed.

Based on observation, record review and interview, the facility failed to ensure a baseline care plan was completed for 1 (#32) of 15 sampled residents reviewed for baseline care plans.The administrator identified 57 residents resided in the facility.Findings:On 03/17/26 at 11:51 a.m., Res #32 observed in his bed. Res #32 voiced he had been in the facility a few weeks.An undated facility policy titled, Care Plans - Baseline, read in part, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. A Care Plan Report, dated 03/15/26, showed Res #32 was admitted to the facility on [DATE]. The report showed the baseline care plan was initiated on 03/15/26.On 03/17/26 at 11:51 am., Res #32 voiced he had been in the facility a few weeks.On 03/20/26 at 10:04 a.m., the DON stated Res #32 was admitted on [DATE] and did not have a 48 hour care plan until 03/15/26.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan included interventions for behaviors for 1 (#37) of 15 sampled residents whose care plans were reviewed.The DON identified 57 residents resided at the facility. Findings: On 03/17/26 at 11:14 a.m., Res #37 was observed sitting in a chair beside the bed. There was a strong odor of urine in the room. An admission form, dated 05/21/26, showed Res #37 had diagnoses which included dementia and depression. A care plan, dated 05/28/25 did not show interventions for behaviors. A behavior note, dated 02/26/26 at 9:35 p.m., read in part, What was the behavior?: resident is aggressive when asked about showersDid anything worsen the behavior?: yes, asking her to get up.What was the resident doing just prior to the onset of the behavior?: sleepingWhat non-pharmacological approaches were attempted to reduce/resolve the behavior?: tried to explain the importance of a showerWhat were the results of the non-pharmocological interventions?: naDid the behavior resolve?: yesWhat interventions are in place to prevent a recurrance?: naWas there a medical or physical cause for the behavior?: dementiaWhat there a psycosocial reason for the behavior?: dementiaWas there an environmental reason for the behavior?: noWhat there a medication reason for the behavior?: dementiaHas delerium been ruled out as a cause for the behavior?: yesWas the physician notified?: noWas the family/responsible party notified?: noA quarterly assessment, dated 03/03/26, showed the Res was moderately impaired in cognition for daily decision making with a BIMS score of 11.On 03/19/26 at 12:45 p.m., CNA #1 stated Res #37 frequently refused showers and would get agitated when asked to shower. CNA #1 stated would attempt two or three times to get Res #37 to shower and if they were unsuccessful they notified the charge nurse. On 03/19/26 at 12:50 p.m., CNA # 2 stated Res #37 could be hateful. CNA #2 stated they attempted to give Res #37 a shower, but they often refused. CNA #2 stated if the Res refused more than three times they notified the charge nurse who documented it in the progress notes.On 03/19/26 at 12:50 p.m., CNA #3 stated at times Res #37 would not get out of bed and would not allow staff to change their brief or shower them. CNA #3 stated they attempt two or three times to shower Res #37 and if they still refused, they notify the charge nurse. On 03/19/26 at 12:55 p.m., LPN #3 stated if Res #37 refused to shower the CNA's reported this to them and they would attempt to get the resident to shower. LPN #3 stated if they could not get Res #37 to shower, they documented it in the progress notes.On 03/19/26 at 1:00 p.m., MDS coordinator #1 stated Res #37's behavior for agitation and refusing showers did not show in the care plan but it should have been care planned. They stated they needed help and could not keep up with the care plans.

Based on observation, record review, and interview, the facility failed to obtain a physician's order for a catheter for 1 (#55) of 1 sampled resident reviewed for catheters.The DON identified 57 residents resided in the facility.Findings:On 03/17/26 at 12:34 p.m., Res #55 was observed sitting in their wheelchair in the dining room. Res #55's catheter bag was observed attached to the side of the wheelchair in a privacy bag. On 03/18/26 at 10:13 a.m., Res #55 was observed sitting in their wheelchair in their room. Res #55's catheter was observed hanging on the side of their wheelchair draining to gravity. The catheter bag was observed inside a privacy bag. An undated diagnoses list showed Res #55 admitted to the facility with diagnoses which included retention of urine, acute kidney failure, and benign prostatic hyperplasia. An admission assessment, dated 02/15/26, documented the resident had an indwelling catheter. A care plan, revised 02/20/26, showed the resident had an indwelling catheter. A review of the resident's record did not show a physician's order for the catheter. On 03/19/2026 at 3:09 p.m., the DON stated there should have been a physician order for the catheter.

Based on observation, record review, and interview, the facility failed to change and store nebulizer tubing in a sanitary manner for 1 (#4) of 3 sampled residents who were reviewed for respiratory care.The DON identified 57 residents resided in the facility.Findings:On 03/17/26 at 11:00 a.m., Res #4 was observed sitting in a recliner in their room. A nebulizer mask and tubing were observed lying on a sheeted bed mattress directly behind the resident.On 03/18/26 at 10:20 a.m., Res #4 was observed sitting in a recliner in their room. A nebulizer mask and tubing were observed lying on a sheeted bed mattress directly behind the resident.On 03/19/26 at 12:45 p.m., a nebulizer mask and tubing were observed lying on a sheeted bed mattress directly behind Res #4's recliner.An undated medical diagnoses list for Res #4 showed the resident admitted with diagnoses which included simple chronic bronchitis and acute respiratory failure with hypoxia.An Administering Medications through a Small Volume (handheld) Nebulizer policy, revised 10/2010, read in part, Rinse and disinfect the nebulizer equipment according to facility protocol.When equipment is completely dry, store in a safe and sanitary manner.Change equipment and tubing every seven days, or according to facility protocol. A physician order, dated 02/04/26, showed budesonide (anti-inflammatory medication) 0.5 mg/2 milliliters via nebulizer one time a day for shortness of breath.An admission assessment, dated 02/15/26, showed the resident was moderately cognitively impaired with a BIMS score of 12. The assessment showed the resident had no shortness of breath and received respiratory therapy. There were no documented nebulizer mask or tubing changes in the medical record.On 03/17/26 at 11:01 a.m., Res #4 stated they had received breathing treatments with the nebulizer intermittently. Res #4 stated they could not remember if they had received a breathing treatment that day.On 03/18/26 at 10:21 a.m., Res #4 stated they thought the staff had administered a breathing treatment with the nebulizer that morning.On 03/19/26 at 12:50 p.m., LPN #1 was shown Res #4's nebulizer mask and tubing lying on the sheeted mattress. LPN #1 stated the nebulizer equipment was not stored properly. LPN #1 stated the nebulizer mask and tubing should have been stored in a sealed plastic bag after use.On 03/19/26 at 12:55 p.m., LPN #1 was asked when Res #4's nebulizer mask and tubing had been changed. LPN #1 stated they weren't sure because the current tubing had not been labeled and dated. On 03/19/26 at 12:59 p.m., the IP stated the nebulizer mask and tubing should have been stored in a plastic bag to ensure proper infection control. The IP stated they were not sure of the policy but thought the tubing should be changed every 48-72 hours. The assistant director of nursing stated the tubing should have been documented as changed in a progress note or on the treatment administration record.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was maintained in a sanitary manner for 1 (#19), of 2 sampled residents reviewed for oxygen therapy.The DON identified 57 residents resided in the facility. Findings: On 03/18/26 at 9:39 a.m., Res #19 was observed to not use oxygen. The oxygen tubing was observed to be lying on the floor next to Resident #19's bed. On 03/19/26 at 3:10 p.m., Res #19 was sitting in their wheelchair watching television. Res #19's oxygen tubing was observed to be lying on the floor. An undated admission record showed Res #19 had diagnoses which included peripheral vascular disease and dementia. A quarterly assessment, dated 12/18/25, showed the Res was cognitively intact with a BIMS score of 13. An undated policy titled Oxygen Administration, read in part, 8. Keep the oxygen cannula and tubing used PRN [as needed] stored in a clean manner (off the floor). On 03/19/26 at 3:15 p.m., Res #19 stated the staff did not put the oxygen tubing in a plastic bag. On 03/20/26 at 10:02 a.m., infection preventionist #1 stated oxygen tubing should not be on the floor. Infection preventionist stated it should be stored in a plastic bag on the wall. They stated they did not know why it was on the floor.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 (#3) of 5 sampled residents who were reviewed for unnecessary medications.The DON identified 57 residents who receive medications in the facility.Findings:An undated diagnosis list showed Res #3 admitted to the facility with diagnoses which included schizophrenia, anxiety, and depressive disorders. The Consolidated Report from Consultant Pharmacist, dated 11/05/25, read in part, Sertraline 100 mg daily - may we trial a reduction to 50 mg daily. The consultant pharmacist report was not addressed by the physician. On 03/19/26 at 3:15 p.m., the DON stated the physician should have answered the report within 30 days.

Based on observation, record review, and interview, the facility failed to ensure: a. staff remained with residents until medications were taken for four (#7, 8, 16, and #23), and b. medications were administered as ordered for two (#26 and #98) of nine sampled residents reviewed for medications. The DON identified 44 residents resided in the facility. Findings: An Administering Oral Medications policy, dated October 2010, documented to remain with the resident until all medications have been taken. A. On 09/10/24 at 7:43 a.m., Resident #16 was observed at a dining room table eating breakfast. A medication cup, containing medications, was observed on the dining table next to the resident's breakfast tray. Resident #16 was observed to pour the medications into their hand. Ten medications were observed in their hand. On 09/10/24 at 7:44 a.m., Resident #7 was observed at a dining room table eating breakfast. A medication cup, containing medications, was observed on the dining table next to the resident's breakfast tray. On 09/10/24 at 7:46 a.m., Resident #23 was observed at a dining room table eating breakfast. A medication cup, containing medications, was observed on the dining table next to the resident's breakfast tray. Resident #23 was asked when they take their medications. Resident #23 stated they take them while they are eating. On 09/10/24 at 7:47 a.m., Resident #8 was observed at a dining room table eating breakfast. A medication cup, containing medications, was observed on the dining table next to the resident's breakfast tray. Resident #8 was asked when they take their medications. Resident #8 stated they take them after they eat. On 09/10/24 at 7:55 a.m., CMA #1 was asked what the policy was for administering medications. They stated the would click on the resident's name, press which medications they will be giving, chart it, lock the computer, and go to the resident. CMA #1 stated some of the residents like to take their medication while they are eating. CMA #1 was asked the process for a resident to self administer medications. They stated to stand there and watch them. CMA #1 was asked if residents had to have a physician's order to self administer medications. They stated, Yes. CMA #1 was asked if Residents #16, 7, 23, and #8 had orders to self administer medications. They stated, No. B. 1. Resident #26 had diagnoses which included hypertension. A physician's order, dated 08/13/24, documented to administer Hydralazine HCI 25 mg three times a day. A Medication Administration record, dated September 2024, documented '9' for Hydralazine twice on 09/01, twice on 09/02, three times on 09/03, and once on 09/11/24. A '9' indicates see other/progress notes per the MAR legend. There was no documentation found regarding the Hydralazine. On 09/12/24 at 12:50 p.m., CMA #2 was asked what a '9' on the MAR indicated. They stated it could mean there is a new order or it's awaiting delivery. CMA #2 stated it doesn't necessarily mean it's not here. They stated there should be a note if there is a '9.' CMA #2 was made aware of the '9's on Resident #26's MAR. CMA #2 was asked when medications were re-ordered. They stated they re-ordered medications weekly if the resident was on skilled services. CMA #2 stated Resident #26 ended up running out. CMA #2 was asked if the medication had been administered per physician's orders. They stated if the medicine was in the building, yes, and if not, no. B. 2. Resident #98 had diagnoses which included fractured left femur and chronic pain. A Physician's Order, dated 09/03/24, documented to administer Tylenol 325 mg two tablets every four hours as needed for pain. A Medication Administration record, dated September 2024, documented '9' for the Tylenol on 09/04, 09/05, 09/06, 09/09, and on 09/10/24. On 09/12/24 at 1:00 p.m., CMA #2 was made aware of Resident #96's MAR documenting '9' for the Tylenol. They stated at the time they did not have that strength. CMA #2 stated they had to ask administration how they wanted to do that since it was not an OTC they kept at the facility. CMA #2 was asked if the medication had been administered per physician's orders. They stated if the medicine was in the building, yes, and if not, no.

Based on record review and interview, the facility failed to ensure a resident assessment was accurate related to falls for one (#7) of six residents whose resident assessments were reviewed. The resident roster documented a census of 44 residents. Findings: Res #7 had diagnoses which included dementia, weakness, lack of coordination and hemiplegia/hemiparesis following cerebral infarction affecting the left side. A progress note for 06/17/24 at 9:19 p.m. documented Res #7 fell in their room and sustained a laceration to the left side of their head. Res #7 was sent to the hospital for an evaluation. A quarterly resident assessment, dated 07/16/24, documented Res #7 had one fall without injury since the last resident assessment. On 09/12/24 at 1:08 p.m., the DON reported the MDS should have documented a fall with injury. The DON reported the MDS Coordinator relied on a fall report that was inaccurate and did not review the progress notes.

Based on observation, record review, and interview, the facility failed to ensure food temperature monitoring policy was followed during one of one kitchen observations for food temperature monitoring. The Corporate Nurse identified 37 residents received nutrition from the kitchen. Findings: The facilty's Food Temperature policy, undated, read in part, Foods should be served at proper temperature to ensure food safety and palatability. The policy also read, Record reading on Food Temperature Chart (Form 401) at the beginning of tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to proper temperature. Take the temperature of each pan of product before serving. Resident #2 was admitted on [DATE] with diagnoses which included heart failure and unspecified cerebral infarction. A quarterly MDS assessment, dated 06/24/24 documented Resident #2's cognition was intact. On 08/05/24 at 10:30 a.m., Resident #2 was asked about the food. Resident #2 stated that the food was served cold in the dining room so he started eating in his room. On 08/05/24 at 11:45 a.m., during a kitchen observation, green beans were observed on the steam table. [NAME] #1 was asked where they documented the temperature of the green beans. Cook #1 stated they documented the temperature as 155 degrees in a temperature log. [NAME] #1 was asked to provide a copy of the temperature log. On 08/05/24 at 11:46 a.m., [NAME] #1 provided the facilty's Food Temperature Log Holding Table form, dated 08/05/24. The form did not document food temperatures were monitored or recorded for the breakfast and lunch service on 08/05/24. On 08/05/24 at 11:47 a.m , [NAME] #1 was asked where the temperatures from breakfast and Lunch service were recorded since they were not logged in the required form. [NAME] #1 stated they were keeping all the temperatures from breakfast and lunch in their head and had not recorded them in the required log. On 08/05/24 at 11:50 a.m., the CDM overheard the conversation [NAME] #1 had with the surveyor. The CDM stated that if the documentation was not in place, then the temperature monitoring did not occur. The CDM stated that the temperatures should of been recorded at the time they were taken and the policy was not followed.

Based on record review and interview, the facility failed to ensure an alleged incident of sexual abuse was reported to: a. the Oklahoma State Department of health, b. Adult Protective Services, c. the police, d. and the nurse aide registry within two hours of the allegation for one(#1) of three sampled residents reviewed for abuse. The corporate nurse identified 38 residence resided in the facility. Findings: The facilty's Abuse Investigation and Reporting policy, revised 07/2017, read in part, All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of property will be reported by the facility, administrator, or his/her designee. The policy also read, An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours if the alleged violation involves abuse. A OSDH 283 Incident Report Form, dated 07/28/24, documented an alleged incident of sexual abuse occurred on was reported to the Administrator on 07/28/24. A hand written statement, dated 07/28/24, documented, LPN #1 reported incident of alleged sexual abuse on 07/28/24. Two hand written notes, dated 07/28/24, documented CNA #1 and CNA #2 submitted statements of the alleged events on 07/28/24. A facsimile cover sheet, dated 07/30/24, documented, the 283 Incident Report Form, dated 07/28/23 , was sent by FAX on 07/30/24 at 12:51 p.m. to OSDH and {Name of Local Law Enforcement withheld} was notified on 07/30/24 at 12:40 p.m The OSDH form 283 did not document Adult Protective Services and the Nurse Aide Registry were notified. A Notification of Nurse Aide/Non Technical Service Worker Abuse, Neglect, Mistreatment of Misappropriation of Property OSDH form # 718, documented the Nurse Aide Registry was notified by Fax on 08/02/24 at 1:27 p.m. A facsimile cover sheet, dated 08/02/24 at 2:40 p.m., documented, OSDH 283 Incident Report Form final, documented Adult Protective Services and the Nurse Aide Registry was notified. On 08/06/24 at 10:08 a.m., {Name of Staffing Agency with held} Director of Staffing stated CNA #1 worked 07/28/24 and returned to the facility on [DATE] with restrictions. On 08/06/24 at 10:23 a.m., the Corporate nurse was asked what the policy was for reporting sexual abuse. They corp nurse stated that a report should of been done within two hours to OSDH, Adult protective Services, and the police. The Corporate Nurse stated the Nurse aide registry should of been notified within 24 hours. The corporate was asked nurse to identify the noncompliance. They stated the Administrator did not report timely to OSDH, the Nurse Aide Registry, APS, and local law enforcement.

Based on observation, record review, and interview the facility failed to ensure: a. staff did not touch medication which they administered to a resident with their bare hands for one (#18) and b. hands were washed/sanitized in between residents during medication pass for three (#2,18, and #19) of four sampled residents observed during medication pass. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 33 residents resided in the facility. Findings: A Handwashing/Hand Hygiene policy, revised 08/15, read in parts, .This facility considers hand hygiene the primary means to prevent the spread of infection .Use alcohol-based hand rub containing at least 62 [percent] alcohol .Before and after direct contact with residents .Before preparing or handling medications . On 07/14/23 at 7:05 a.m., LPN #2 prepared the following medications for Resident #2: a. duloxetine 30 mg one capsule, b. gabapentin 300 mg one capsule, c. Januvia 100 mg one tablet, d. minocycline 100 mg one capsule, e. potassium chloride 20 MEQ one tablet, f. rosuvastatin 10 mg one tablet, g. torsemide 20 mg one tablet, and h. vitamin D3 2000 units two tablets. LPN #2 did not wash/sanitize their hands prior to preparing the medications for administration. On 07/14/23 at 7:11 a.m., LPN #2 took a cup of water and a cup containing the above medications to Resident #2 who was seated at a table in the dining room. Resident #2 took all medications by mouth. LPN #2 then walked back to their medication cart and began preparing Resident #19's medications without washing/sanitizing their hands. On 07/14/23 at 7:13 a.m., LPN #2 prepared the following medications for resident #19: a. lorazepam 0.5 mg 1 tablet, b. buspirone 5 mg one tablet, c. citalopram 10 mg one tablet, d. furosemide 80 mg one tablet, e. meclizine 25 mg one tablet, f. metolazone 5 mg one tablet, g. Metoprolol 25mg one tablet h. potassium chloride 20 MEQ one tablet, and i. vitamin D3 one tablet. On 07/14/23 at 7:17 a.m., LPN #2 took a cup of water and a cup containing the above medications to Resident #19's room. LPN #2 knocked on the resident's door, entered the room, and handed the medications and water to the resident. Resident #19 took all medications by mouth, and LPN #2 exited the room and returned to the medication cart without washing/sanitizing hands. On 07/14/23 at 7:21 a.m., LPN #2 began preparing medications for Resident #18 without washing or sanitizing their hands. LPN #2 placed one Alkums antacid tablet (calcium carbonate 500mg) in a medication cup, then added one Loratadine 10mg, and one multivitamin to the same medication cup. On 07/14/23 at 7:25 a.m., LPN #2 used their bare hands and removed the Alkums antacid tablet from the medication cup and placed it into a separate medication cup. LPN #2 was asked if they had touched the antacid with their bare hands. They stated, Oh I did, sorry. LPN #2 stated, I should sanitize. LPN #2 then sanitized their hands and continued placing the following medications into the first medication cup: a. gerikot 8.6 mg two tablets, b. docusate sodium 100 mg one tablet, c. atorvastatin calcium 40 mg one tablet, d. clopidogrel 75 mg one tablet, e. furosemide 20 mg one tablet, f. potassium chloride 10 MEQ one tablet, and g. vitamin D 5000 units one tablet. LPN #2 added one Vitamin C 500 mg chewable to the medicine cup which contained the antacid. On 07/14/23 at 7:22 a.m., LPN #2 entered Resident #18's room and attempted to administer the medications. Resident #18 stated they only wanted one brown pill (gerikot) and wanted to wait until after breakfast to take their medications. On 07/14/23 at 7:23 a.m., LPN #2 sanitized their hands and wrote the resident's name on both medicine cups and wrote one senna (gerikot) on the cup containing the medication. On 07/14/23 at 7:29 a.m., LPN #2 placed both medication cups in the top of their medication cart. The surveyor remained with the medication cart. On 07/14/23 at 7:35 a.m., LPN #2 was asked the policy for sanitizing or washing hands when administering medications. They stated, It should be before and after. They stated they could sanitize or wash their hands. They were asked if they sanitized/washed hands in between preparing Resident #2 and Resident #19's medications. They stated, I think I sanitized. They were asked if they washed/sanitized their hands between Resident #19 and Resident #18's medication administration. They stated, I don't think so. On 07/14/23 at 8:24 a.m., LPN #2 wheeled the medication cart to Resident #18's room and sanitized their hands. On 07/14/23 at 8:30 a.m., LPN #2 stated Resident #18 only wanted one senna (gerikot) and removed one from the medicine cup using a spoon and placed it in the sharps container. LPN #2 then took the medication cups into Resident #18's room and the resident took all medications by mouth chewing both the antacid and the Vitamin C. On 07/14/23 at 8:37 a.m., LPN #2 was asked the policy for touching medication with their bare hands. They stated, I don't think we have one.

Based on observation, record review, and interview, the facility failed to: a. label and date food in the freezer, b. keep the kitchen equipment clean and have a cleaning schedule, c. log refrigerator and freezer temperatures, d. store prepared pureed food in a manner in which did not require reheating to maintain temperature, e. monitor dishwasher sanitization ppm for low temperature dishwasher, and f. ensure a dirty fan did not blow across prepared drinks and food on the steam table. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 33 residents received food from the kitchen. Findings: A Dietary policy, undated, read in parts, Fans may be used in the food service kitchens to add ventilation to the work area .They are to be installed in/used in non-preparation or service areas. These fans must be kept clean so as not to contaminate food stuffs. They may be used in areas where all foods are in packaged form, such as storeroom or receiving areas . A Food Storage policy, dated 12/22, read in part, Food items should be stored .and prepared in accordance with good sanitary practice .All products should be dated upon receipt and when they are prepared .Food storage areas shall be clean at all times .All foods served will be tempted and logged . A Safety Precautions-Preparation and Service of Foods policy, dated 12/22, read in parts, .To ensure safety, hot foods must be held at 135 degrees F or above .Cover or protect containers to maintain heat and to protect from contamination .Reheating TCS foods to 165 degrees must be accomplished in 2 hours. If unsuccessful, discard product . A Refrigerator-Reach In policy, dated 12/22, read in part, .Sanitation of Equipment Frequency: Daily .wipe up spills on shelves, sides, and floor of refrigerator . On 07/13/23 at 10:14 a.m., an initial tour of the kitchen was conducted with the dietary manager. Observations were made and foods verified by the dietary manager as follows: a. no daily temperature control logs for the refrigerator or the freezer, b. the bottom of the refrigerator had debris pieces on the floor, c. 13 bags of frozen broccoli in the freezer had no date or label, d. frozen peeled potatoes in a plastic bag tied closed had no date or label, e. one and a half plastic bags of uncooked sugar cookies had no date or label, f. a plastic bag of frozen biscuits had no date or label, g. two bags of frozen mini corn dogs had no date or label, h. eight bags of bread and one bag of hamburger buns had no date or label. On 07/13/23 at 10:20 a.m., the dietary manager was asked if there were daily temperature logs for the refrigerator and freezer. They stated they did not currently keep a log on anything. All items in the refrigerator were at the appropriate temperature and the items in the freezer were frozen to touch. The bottom floor of the refrigerator was observed to have debris pieces. The dietary manager was asked when the last time the refrigerator floor was cleaned. They stated about two weeks ago. They were asked how often they were scheduled to be cleaned. They stated they do not use a schedule. On 07/13/23 at 10:23 a.m., the dietary manager was asked what the policy and procedure was for food storage. They stated to date when open. On 07/13/23 at 10:25 a.m., the dietary manager was asked if the items identified were dated and labeled. They stated, No. On 07/13/23 at 11:49 a.m., the dietary manager began to prepare the puree food. They used a serving size from the already prepared stir fry casserole with fried rice from the steam table and added soy sauce and water. The dietary manager made three servings and placed them in three bowls and left them uncovered on the prep table next to the food processor. On 07/13/23 at 11:54 a.m., the dietary manager had finished the three servings of the puree casserole. On 07/13/23 at 12:01 p.m., the dietary manager was asked where the water temperature control logs and sanitization check for the dishwasher was located. The dietary manager stated they had not had to do that since the COVID outbreak was over. They were asked if it was done prior to COVID. They stated they did not know because they were not there. On 07/13/23 at 12:04 p.m., the same three bowls of puree stir fry casserole were still on the prep counter. The dietary manager was asked how they keep the temperature of the food. They stated they warm them up in the microwave when they are ready for it because they did not have anyplace to put them. On 07/13/23 at 12:06 p.m., puree casserole was tempted at 106 degrees. Observed three of the six compartments on the steam table in use. The other three compartments were empty. On 07/13/23 at 12:16 p.m., the dietary manager put all bowls of puree casserole in the microwave for 20 seconds, stirred them, then put them back in for another 10 seconds. On 07/13/23 at 12:19 p.m., the temperature of one bowl of puree was 130 degrees, and another bowl was at 120 degrees. The dietary manager then placed all three back into the microwave for another 10 seconds. On 07/13/23 at 12:23 p.m., the temperature was checked again on one bowl to be at 140 degrees. On 07/13/23 at 12:24 p.m., all three bowls were put in the microwave for another 10 seconds. All were tempted again and read 150 degrees, 157 degrees, and 147 degrees. The bowls were then placed on trays, then covered at the serving line. The puree food was never tempted above 157 degrees, prepared with already cooked food, and was not left to cool prior to serving. On 07/13/23 at 12:30 p.m., a white osculating fan, standing approximately four feet high and approximately six feet from the serving window, was observed facing the serving area and steam table. The fan had dark brown debris on the back of the fan on the wire frame and on the tip of the blades. The dietary manager was asked how often the fan was cleaned. They stated it was brought in two weeks ago and they did not know. On 07/13/23 at 12:31 p.m., the dietary manager was asked if the fan was clean. They stated, No. On 07/13/23 at 1:35 p.m., the dietary manager was asked when they were reheating the food in the microwave, what temperature were they reheating to. They stated, Between 135-155. On 07/13/23 at 4:06 p.m., the Director of Operations stated the sanitization in the dishwasher was not at the right ppm. They stated it was at 10-50 ppm and that they would not use it and will serve meals on paper. On 07/13/23 at 4:08 p.m., the dietary manager and Director of Operations ran a sanitizing test for the dishwasher stating that the sanitizer was not running correctly. The test strip read 50-100 ppm. They stated they wanted it higher than that. The Director of Operations stated they would have the dishwasher company come out and were going to serve the meals on paper ware. The Director of Operations stated that if the dishwasher was not fixed before dinner that they would prepare the three compartment sink to wash the pots and pans. On 07/14/23 at 7:40 a.m., residents were observed using regular plates, cups, and silverware in the dining room. On 07/14/23 at 11:43 a.m., the Director of Operations was asked for the report from the dishwasher repair. They stated they did not receive a report and that they came out and replaced a part. On 07/14/23 at 11:48 a.m., the dietary manager and Director of Operations ran a sanitizing test on the dishwasher with a reading of 100-200 ppm. On 07/14/23 at 1:03 p.m., the service report for the dishwasher documented on 07/13/23 that the straw in the five gallon container was broken, replaced, and dispensing.

Based on record review and interview, the facility failed to ensure residents were offered the opportunity to formulate an Advance Directive for one (#29) of 16 sampled residents reviewed for Advance Directives. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 33 residents resided in the facility. Findings: Resident #29 admitted to the facility on [DATE]. An Advance Directive Preliminary Review record, dated 08/10/21, documented Resident #29 did not have an Advance Directive or Living will and a Yes was circled next to the question do you wish to complete an Advanced Directive. On 07/13/23 at 12:36 p.m., MDS Coordinator #1 was asked the policy for Advance Directives. They stated they were supposed to be offered on admission. They stated they had also added it to their care plan meetings recently to discuss with residents/representatives at least every three months. On 07/13/23 at 12:40 p.m., MDS Coordinator #1 was shown the Advance Directive Preliminary Review form for Resident #29 and was asked if the resident had an Advanced Directive. They stated they would look for it. On 07/13/23 at 2:10 p.m., MDS Coordinator #1 stated they were still working on locating Resident #29's Advance Directive. On 07/13/23 at 4:17 p.m., MDS Coordinator #1 stated Resident #29 never had an Advance Directive.

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in a sanitary manner. The facility has 33 residents who resided in the facility. Findings: 1. On 01/31/22 at 9:15 a.m., an initial tour was conducted in the kitchen. At 9:27 a.m., the eggs observed in the refrigerator were not pasteurized. At that time the DM stated she thought they used pasteurized eggs but those were not marked pasteurized on the box. She stated they only had one resident who ate over easy eggs in the facility. At 9:35 a.m., scoops were observed in the brown and powdered sugar bins touching the product. The DM stated she was not aware scoops could not be left in the bins. At 9:41 a.m., the sanitizer was observed for the dish machine. The strip did not read at the appropriate level of sanitizer. The DM stated it read at 100 this morning when she checked it. She checked it again with the strip having a very light purple tent. On 02/01/22 at 6:30 p.m., the dish machine sanitizer was observed and the reading on the strip was dark purple, 100ppm. The DM stated the service man was out yesterday and said something wasn't right underneath with the sanitizer and he fixed it. She provided a service report. The DM stated a kitchen staff member had changed the sanitizer Sunday evening. A service report for the dish machine, dated 01/31/22 at 11:05 a.m., documented the sanitizer tested at 10ppm, solution on machine was bad, replaced, and then tested at 100ppm. On 02/02/22 at 9:22 a.m., the sanitizer company's service man was spoken to over the phone. He stated the solution that was hooked up to the dish machine when he arrived was not bright yellow like it should have been. He stated the solution can not be left out side or in sun light because the sun dissipates it. He stated the facility had one sitting out side and the one he changed out from the dish machine. He stated when he checked the dish machine the sanitizer ran in fine but the solution was not reading but about 10ppm on the strip. He said he changed the sanitizer solution to a good one and it was reading 100ppm when he left. 2. On 01/31/22 at 11:37 a.m., dining was observed CNA #1 was sitting in a chair by the kitchen window pass to the dining room. CNA #1 stood up adjusted her clothing several times and delivered a meal tray to Res #10. CNA #1 was observed to touch the rims of the drinking glasses when distributing them to Res #11. At 11:43 a.m., CNA #2 was observed touching her hair putting it behind her ear while touching resident drinking glasses by the rims for Res #26. At 11:56 a.m., CNA #1 moved a stool with her hands moved a resident geri chair up to the table. The CNA touched the stool again sat down moved up to the table. Hand hygiene was not observed before opening a straw for Res #16 and placing it in the residents drink. At 12:10 p.m., observed LPN #1 picked up a piece of garlic bread off the floor and then assist Res #29 by pouring the resident water. At 12:21 p.m., CNA #1 stated hand hygiene should be done before and after assisting the residents. On 02/02/22 at 11:07 a.m., the DON stated the staff should use hand hygiene before and after serving meals to the residents. She stated or if staff touch something dirty they should use hand hygiene. On 02/02/22 at 12:33 p.m., CNA #2 stated should use hand hygiene between every person and should perform hand hygiene any time you contaminate your hands.

Based on observation, interview, and record review the facility failed to assess, monitor and intervene for one (#25) of one sampled resident reviewed for [CONDITION(S)]. The MDS coordinator reported 14 residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident (Res) #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 11/10/21, documented the resident had hypertension and to monitor the residents extremities for [CONDITION(S)]. A quarterly MDS assessment, dated 01/03/22, documented the resident was cognitively independent and required supervision with set up help for most ADLs. A weekly summary assessment, dated 01/25/22, documented the resident had no [CONDITION(S)] in the cardiovascular section of the assessment. A dietary note, dated 01/28/22 at 11:14 a.m., documented the resident had a weight gain of 4.4 pounds. On 01/31/22 at 4:41 p.m., Res #25 was observed in his room sitting in a chair with his feet up in another chair. The resident's left foot was observed to be edematous. Res #25 stated he had swelling in his left foot and he was keeping his feet up in the chair. A weekly summary assessment, dated 02/01/22, documented the resident had no [CONDITION(S)] in the cardiovascular section of the assessment. On 02/01/22 at 7:19 p.m., Res #25 stated he had swelling for a couple of weeks in his left foot. LPN #2 assessed the residents left foot at this time. A nurse note, dated 02/01/22 at 7:23 p.m., documented two plus [CONDITION(S)] noted to left foot and placed Res #25 on the list to be seen 02/02/22 by the physician. On 02/02/22 at 12:01 p.m., the DON stated the physician saw the resident today and is ordering the resident a diuretic and wanted the resident to elevate his legs even higher than he had been. The DON stated the nurses should be assessing for [CONDITION(S)]. On 02/02/22 at 12:46 p.m., LPN #1 stated the resident did not keep his feet elevated. He just sits in a chair. She stated he did not have any [CONDITION(S)] yesterday when she assessed him but he did this morning when she saw him.

Based on interview and record review, it was determined the facility failed to develop a comprehensive care plan related to activities for three (#12, #26, and #142) of 18 sampled residents whose care plans were reviewed. This had the potential to affect all 43 residents who resided in the facility. Findings: Resident #12 had [DIAGNOSES REDACTED]. An admission assessment, dated 04/12/19, documented the resident was moderately impaired in cognition, required extensive assistance with transfer, bed mobility, dressing, bathing and toilet use. The assessment documented the resident had limited range of motion in both lower extremities, required a wheelchair for mobility, was always incontinent of urine, and frequently incontinent of bowel. The assessment documented an interview for activity preferences had been conducted with the resident which revealed the following: ~Somewhat important: Books, newspapers, and magazines to read; Do things with groups of people; and Participate in religious services or practices. A care plan, dated 05/13/19, did not include an individualized focus, measurable goal, or interventions in regards to activities. Resident #26 had [DIAGNOSES REDACTED]. An admission assessment, dated 04/18/19, documented the resident was cognitively intact, required extensive assistance with transfers, bed mobility, ambulation, and personal hygiene. The assessment documented the resident required a walker and wheelchair for mobility, and was occasionally incontinent of bowel and bladder. The assessment documented an interview for activity preferences had been conducted with the resident which revealed the following: ~Very important: Do things with groups of people; and Go outside to get fresh air when the weather is good. ~Somewhat important: Have books, newspapers, and magazines to read; Listen to music; Be around animals such as pets; Keep up with the news; and Participate in religious services or practices. A care plan, dated 04/24/19, did not include an individualized focus, measurable goal, or interventions in regards to activities. Resident #142 had [DIAGNOSES REDACTED]. An admission assessment, dated 04/25/19, documented the resident was cognitively intact, required extensive assistance with transfer, bed mobility, and most ADLs (activities of daily living). The assessment documented the resident required a walker for mobility, was always continent of bowel, and occasionally incontinent of bladder. The assessment documented an interview for activity preferences had been conducted with the resident which revealed the following: ~Very important: To go outside to get fresh air when the weather is good. ~Somewhat important: Listen to music; Keep up with the news; Do things with groups of people; and Participate in religious services or practices. A care plan, dated 04/05/19, did not include an individualized focus, measurable goal, or interventions in regards to activities. For residents #12, #26, and #142 their care plans related to activities documented as follows: Focus .This care plan is part of the plan of care for this resident. Please consider the entire chart as part of the plan of care for this resident in conjunction with the care plan . Goal .Continuity of care . Interventions .Please refer to chart as part of the plan of care in addition to the care plan. i.e. (example) EMAR (electronic medication administration record), ETAR (electronic treatment administration record), current orders, code status . On 06/05/19 at 11:41 a.m., the activity director was asked where activity care plans were documented. She stated the MDS (Minimum Data Set) coordinator developed the care plans. At 11:45 a.m., the MDS coordinator was asked who was responsible to develop the activity care plans. She stated she was responsible for development of the care plans but this did not include the activity care plan. She stated she would have to find out where the activity care plans were located. She stated when a resident completed an activity the activity director made a note in the progress notes. She stated, The whole chart would be the activity care plan.

Based on interview and record review, it was determined the facility failed to ensure clinical records were complete and readily accessible for five (#8, #26, #31, #93, and #142) of 18 sampled residents whose clinical records were reviewed. This had the potential to affect all 43 residents who resided in the facility. Findings: Review of the clinical record for residents #8, #26, #31, and #93 revealed lab (laboratory) services were completed. The documentation did not reveal that the physician had reviewed the lab test results. The results had not been signed and/or dated by the physician. On 06/06/19 at 1:51 p.m., the DON (Director of Nursing) and ADON (Assistant Director of Nursing) were asked what the process was when a physician ordered labs. The ADON stated the order was received from the physician, entered into the electronic record, electronically submitted to the lab company who documented when they had completed the order. She stated the lab results were downloaded onto the physician's phone and automatically loaded into the electronic medical record where nursing staff reviewed the results every shift. She stated the abnormal results highlighted yellow for abnormal and red for critically abnormal which alerted staff to notify the physician. The DON was asked who was responsible for ensuring the nursing staff notified the physician of abnormal lab results. She stated she was responsible. On 06/10/19 at 11:51 a.m., the DON was asked where it was documented that the physician reviewed lab results. She stated if the results were critical, the physician would be contacted by text or phone. She was asked where it was documented that the physician had been contacted. She stated it would be documented in the clinical record and if there were no documentation in the record it was a documentation problem. On 06/10/19 at 2:30 p.m., the staff provided documentation of completed laboratory tests that contained physician comments and signature. The DON stated their policy was for the lab company to send the physician the lab results and if the physician made revisions or gave new orders his assistant would contact the facility. She was asked if they had a copy of the lab results with the documentation from the physician. She stated No, we do not keep copies of these, we requested these from the physician. Resident #142 had [DIAGNOSES REDACTED]. A Medicare 5-day assessment, dated 04/25/19, documented the resident was intact in cognition and received [MEDICAL TREATMENT] services. The monthly physician orders, dated (MONTH) 2019, documented the resident was to receive [MEDICAL TREATMENT] Monday, Wednesday, and Friday. A review of the nurse's assessment sheets for [MEDICAL TREATMENT] revealed there were no assessment sheets prior (MONTH) 1, 2019 and out of 14 assessment sheets, only one had been completed. On 06/06/19 at 1:51 p.m., the ADON was asked what the purpose was of the form titled, Communication Sheet for [MEDICAL TREATMENT]. She stated the form was to be completed by staff. She was asked why there were no communication sheets for [MEDICAL TREATMENT] prior (MONTH) 1, 2019 and why the sheets that existed were not completed with the necessary information. She stated she did not know.

Based on interview and record review, it was determined the facility failed to complete a pre and post [MEDICAL TREATMENT] assessment for one (#142) of one residents who received [MEDICAL TREATMENT]. The facility identified one resident who received [MEDICAL TREATMENT]. Findings: Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was discharged to home on 06/04/19. A Medicare 5-day assessment, dated 04/25/19, documented the resident was intact in cognition and received [MEDICAL TREATMENT] services. The monthly physician orders, dated (MONTH) 2019, documented the resident was to receive [MEDICAL TREATMENT] Monday, Wednesday, Friday, and was to be weighed daily. A review of the nurse's documentation related to resident #142 receiving [MEDICAL TREATMENT] for 22 opportunities was as follows: ~ Seven days had no documentation that an assessment of the resident's fistula had been completed pre and/or post [MEDICAL TREATMENT]; ~ Two days had no documentation that the resident had received [MEDICAL TREATMENT]; and ~ One day only the resident's pre and post weights were documented. On 06/06/19 at 1:51 p.m., the DON (Director of Nursing) and ADON (Assistant Director of Nursing) were asked what the process was for assessment of a resident receiving [MEDICAL TREATMENT]. The ADON stated the resident was to be weighed pre and post [MEDICAL TREATMENT] and document in the progress notes. She was asked if the process included assessment of the fistula. She stated yes. She was asked what the purpose was of the form titled, Communication Sheet for [MEDICAL TREATMENT]. She stated the form was to be completed by staff. She was asked why there were no communication sheets for [MEDICAL TREATMENT] prior (MONTH) 1, 2019. She stated she did not know. She was asked why the communication sheets for [MEDICAL TREATMENT] had not been completed. She stated she did not know. She was asked why there were several [MEDICAL TREATMENT] days with no documentation of a fistula assessment. She stated she did not know. On 06/10/19 at 1:35 p.m., the ADON was asked why the resident's daily weights were not documented on the TAR (treatment administration record). She stated when the resident was admitted , daily weights were ordered then the order had been changed to weigh before and after [MEDICAL TREATMENT]. She was shown the physician orders, dated (MONTH) 2019, which revealed an order for [REDACTED]. She was asked if they had documented daily weights. She stated No.

Based on interview and record review, the facility failed to monitor and assess a resident's ability to eat independently for one (#205) of one residents who were reviewed for choking. Resident #205 choked while in the dining room eating independently. The resident expired from Asphyia (Choking on Food). The facility identified seven residents who had swallowing difficulties. Findings: A policy titled, Comprehensive Assessments and the Care Delivery Process, dated (MONTH) (YEAR), documented, .Policy Interpretation and Implementation .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions .Information analysis .Define issues, including problems, risk factors, and other concerns .Define conditions and problems that are causing, or could cause, other problems . Resident #205 was admitted to the facility with [DIAGNOSES REDACTED]. A physician order, dated [DATE], documented, Regular diet Regular texture, Protein shakes with meals . An admission assessment, dated [DATE], documented the resident's cognition was severely impaired for daily decision making, she required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. The assessment documented the resident required limited assistance with one person physical assist while eating, had bilateral lower extremity functional limitation in range of motion, and required a wheelchair as a mobility device. The assessment documented the resident was frequently incontinent of bowel and bladder and had no signs and symptoms of a possible swallowing disorder. A care plan, revised [DATE], documented, .Focus .I have a dx [MEDICAL CONDITION].Interventions .Avoid overeating .Encourage the resident to take their time eating . Focus .I require assistance with adls .Interventions .I require assistance to eat . A SNF progress note titled, Incident Note, dated [DATE] at 5:55 p.m., documented, Pt found in dining room sitting in her chair, blue and non responsive. [MEDICATION NAME] maneuver began and 911 called. Crash cart brought to pt side. Connected to O2 and ambu bag used and cpr began. (Name withheld) ambulance arrived and we continued CPR. AED states 'no shock', cpr and ventilation continues. The transcriber of the note was RN #3. An ambulance report titled, Pre-Hospital Care Report, documented: ~Incident date: [DATE]; ~Incident location: (Name withheld) Nursing Home; ~Unit arrived at scene: 18:02 (6:02 p.m.); ~Complaint reported by dispatch: Choking; ~Chief complaint: [MEDICAL CONDITION]; and ~ED Disposition: Expired. The ambulance report documented an endotracheal tube had been placed at 6:02 p.m. A SNF progress note titled, Discharge Summary, dated [DATE] at 6:21 p.m., documented as follows: Diagnosis: [REDACTED]. Where did the resident discharge to?: Via ambulance to (Name withheld) ER . What date and time did they discharge?: 1810 (6:10 p.m.) [DATE] . Method of transport/accompanied by?: (Name withheld) ambulance . Circumstances of transfer: Choking with [MEDICAL CONDITION] . Vitals and Skin Condition on D/C: pt not breathing, automatic cpr machine in process on guerney (Sic), AED said 'no shock' . The transcriber of the note was RN #3. An emergency room note, dated [DATE] at 7:00 p.m., documented, .Physical Examination .Throat: ET tube in place with copious spaghetti and secretions .Cardiovascular: CPR in progress. No palpable pulses .Respiratory: Severe rhonchi in all lung fields patient is being mechanically ventilated .Medical Decision Making .Patient presents to the ER today with a choking episode leading to [MEDICAL CONDITION]. CPR has been progress (Sic) over an hour upon arrival to the emergency department. After pulse check she remained asystole and bedside ultrasound confirmed cardiac standstill. Time of death was called at 1859 (6:59 p.m.) . A State of Oklahoma Certificate of Death, dated [DATE], documented: ~date of death : [DATE]; ~Time of death: 18:59 (6:59 p.m.); ~Cause of death: Asphyxia (Choking on Food); ~Place of Injury: Nursing Home; and ~Describe how injury occurred: Choking on Food. On [DATE] at 10:34 a.m., the DM was asked how her kitchen staff was made aware of residents who had swallowing disorders. She stated the DON and ADON informed her of those who were assisted diners. She stated she was provided a list which was updated as needed. She stated she observed them eating especially if they were new. She stated sometimes families will inform her. She was asked if she was familiar with resident #205. She stated yes. She stated the resident sat in front of the kitchen serving window. She stated she had to be cued at times but usually ate on her own. She was asked if a nurse was required to be in the dining room during meals. She stated yes. She was asked if she had witnessed the incident with resident #205 on [DATE]. She stated she was not but Cook #1 was there. At 10:53 a.m., Cook #1 was asked what she had witnessed on [DATE] in the dining room with resident #205. She stated she had gone to the serving window and observed resident #205 leaning forward. She stated a nurse leaned her back and spaghetti was observed hanging out of her mouth. She stated someone had attempted the [MEDICATION NAME] maneuver but the resident was a large lady. She stated she had never witnessed the resident choking but later was informed the resident had choked on spaghetti before. No incident report was found regarding the resident previously choking on spaghetti. She was asked if a nurse was in the dining room during meals. She stated 75% of the time there was a nurse in the dining room during meals. She was asked if there was a nurse in the dining room the evening of the incident which involved resident #205. She stated yes there was a nurse at the table behind resident #205 but she could not remember who the nurse was. She was asked if there was anyone at the table with the resident when the incident occurred. She stated yes resident #16 was at the table with the resident. On [DATE] at 11:30 a.m., resident #16 was asked if she sat at the table with resident #205 during meals. She stated she was her table partner. She was asked if she had ever witnessed resident #205 choke when she ate. She stated, She would choke everyday. She stated the resident would stuff her mouth full and then use water to get it down. She was asked if she had witnessed the resident choke on [DATE]. She stated that day the resident was very quiet because she usually liked to talk. She stated when she looked up at the resident she was bent over and shaking. She stated she left the table because there was alot of nurses attending to resident #205. She stated she had told the nurse who administers her nightly injection that she wanted resident #205 moved to another table because she stuffed her mouth full and did not know how to eat. She stated she did not want to be responsible for resident #205. On [DATE] at 11:50 a.m., the hospitality aide/activity assistant was asked if she had witnessed the incident that had occurred on [DATE] which involved resident #205. She stated yes she was passing trays during the evening meal. She stated she was getting a tray from the serving window and when she turned around a nurse and aide were sitting resident #205 up who was choking. She stated the resident was not coughing. She was asked if she had ever witnessed the resident choking before. She stated in the past month or so she had noticed the resident was clumsy with her food. She stated, Kind of in and out of it. Loosing focus and grabbing things. She stated she had reported this to her supervisor and to the nurse. She stated the resident had choked on spaghetti before but could not remember when. No incident report was found regarding the resident previously choking on spaghetti. On [DATE] at 12:30 p.m., LPN #1 was asked to recall the incident that occurred on [DATE] which involved resident #205. He stated he was at the nurses' station when a nurse came and told him that the nurse in the dining room needed him immediately. He stated when he got to the dining room resident #205 was in her chair and was blue in color. He stated he attempted the [MEDICATION NAME] Maneuver until the resident became unconscious and she was lowered to the floor. He stated the ADON had came into the dining room and did a fingersweep in the resident's mouth. He stated a little spaghetti was produced with the fingersweep. He stated CPR was initiated until EMS arrived. He stated she was connected to the AED and CPR was continued but twice the AED indicated no shock. She was placed in the ambulance and intubated. He was asked if he had ever witnessed the resident choking before. He stated, We would have to tell her to slow down. She loved to eat. He stated she was continuously eating and one or two other times had choked but did not need the [MEDICATION NAME] or chest compressions. He stated once he saw what she was eating he knew she was choking. He was asked if staff was aware of her tendency to choke. He stated everyone was aware but the resident was very willful and did what she wanted. At 3:14 p.m., RN #1 was asked if she was familiar with resident #205 and the incident that had occurred on [DATE]. She stated she was working in the dining room when the incident occurred. She stated the resident was a self feeder. She stated she had stepped out of the dining room for approximately three minutes to answer a phone call and when she came back into the dining room she noticed the resident was dark blue in color. She stated she attempted the [MEDICATION NAME] maneuver but the resident was too large. She then called for LPN #1 to come to the dining room immediately. She stated LPN #1 performed the [MEDICATION NAME] maneuver without success. She stated they began CPR. She stated it was obvious the resident had choked on spaghetti because a finger sweep was performed which produced alot of spaghetti. She stated EMS had removed spaghetti when trying to intubate the resident. She stated she knew there was something lodged in the resident's throat because when they attempted to use the Ambu bag there was no air exchange. She was asked if the resident had a history of [REDACTED]. She stated, She shoveled food in like she wasn't going to get another meal. She stated LPN #1 had told her the resident had choked before. She stated approximately a week ago LPN #2 had submitted a request for a speech therapy consult for resident #205. On [DATE] at 3:31 p.m., LPN #2 was asked if she was familiar with resident #205 and the incident that had occurred on [DATE]. She stated she was familiar with the resident and was at the facility the day of the occurence. She stated she heard LPN #1 being called to the dining room. She stated she ran to the dining room and RN #1 was with resident #205 who told her, I think she is choking. She stated LPN #1 attempted the [MEDICATION NAME] maneuver, then the ADON did a fingersweep. She stated they began doing CPR on the resident. She stated, She was just blue. She was asked if the resident had a history of [REDACTED]. She stated a week or two ago she observed the resident eating orange sherbet and she would cough when she would take a bite. She stated she had requested a consult for the resident with speech therapy because she coughed alot during meals. She stated the resident's tablemate had told her that resident #205 shoved food in her mouth. No documentation was found regarding the resident coughing during meals. On [DATE] at 3:47 p.m., LPN #3 was asked if she was at the facility on [DATE] during the incident with resident #205. She stated she was standing at LPN #2's office when RN #1 called out to get LPN #1. She stated the resident would shovel food in her mouth, not chew, and fall asleep. She was asked if the resident had a history of [REDACTED]. At 3:55 p.m., the ADON was asked if resident #205 had a history of [REDACTED]. At 4:00 p.m., RN #3 was asked if she had witnessed the incident with resident #205 on [DATE]. She stated she had just came on duty and went into the dining room where the nurses were trying to resuscitate the resident. She was asked if the resident had a history of [REDACTED]. She stated, She would cram a whole sandwich in her mouth without chewing. At 4:26 p.m., RN #2, the MDS coordinator, was asked how she was informed of a resident with swallowing difficulties. She stated staff would tell her if they had observed a resident cough with food or drinking. She was asked if she was aware that resident #205 choked with food or when drinking. She stated no one had informed her of the resident choking until she found out a consult request had been given to speech therapy. She stated with the computer software that the facility used, when staff documented something on a resident certain words would flag for further investigation. She stated nothing had been flagged on resident #205. At 4:38 p.m., the speech/language Pathologist was asked what the protocol was when they received a consult request on a resident. She stated when she receives a consult request she had 24 hours to completed the request. She was asked how often she received her consult request. She stated everyday. She was asked if she had received a consult request for resident #205. She stated yes she had received the request on [DATE]. She stated she had to go out of town to do a consult first and when she arrived back at the facility to see resident #205 the ambulance was leaving with her. At 4:52 p.m., the DON was asked to recall the incident with resident #205 on [DATE]. She stated she was out of town and was called and went back to the facility. She stated she was informed of the entire incident when she arrived at the facility. She was asked if the resident had a history of [REDACTED]. She stated she was never told the resident had choking episodes.

Based on record review and interview, it was determined the facility failed to identify, develop, and implement appropriate interventions to aid in the prevention of choking for one (#205) of one sampled residents who were reviewed for choking. Resident #205 choked while in the dining room eating independently. The resident expired from Asphyia (Choking on Food). The facility identified seven residents who had swallowing difficulties. Findings: A policy titled, Comprehensive Assessments and the Care Delivery Process, dated (MONTH) (YEAR), documented, .Policy Interpretation and Implementation .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions .Information analysis .Define issues, including problems, risk factors, and other concerns .Define conditions and problems that are causing, or could cause, other problems . Resident #205 was admitted to the facility with [DIAGNOSES REDACTED]. A physician order, dated [DATE], documented, Regular diet Regular texture, Protein shakes with meals . An admission assessment, dated [DATE], documented the resident's cognition was severely impaired for daily decision making, she required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. The assessment documented the resident required limited assistance with one person physical assist while eating, had bilateral lower extremity functional limitation in range of motion, and required a wheelchair as a mobility device. The assessment documented the resident was frequently incontinent of bowel and bladder and had no signs and symptoms of a possible swallowing disorder. A care plan, revised [DATE], documented, .Focus .I have a dx [MEDICAL CONDITION].Interventions .Avoid overeating .Encourage the resident to take their time eating . Focus .I require assistance with adls .Interventions .I require assistance to eat . A SNF progress note titled, Incident Note, dated [DATE] at 5:55 p.m., documented, Pt found in dining room sitting in her chair, blue and non responsive. [MEDICATION NAME] maneuver began and 911 called. Crash cart brought to pt side. Connected to O2 and ambu bag used and cpr began. (Name withheld) ambulance arrived and we continued CPR. AED states 'no shock', cpr and ventilation continues. The transcriber of the note was RN #3. An ambulance report titled, Pre-Hospital Care Report, documented: ~Incident date: [DATE]; ~Incident location: (Name withheld) Nursing Home; ~Unit arrived at scene: 18:02 (6:02 p.m.); ~Complaint reported by dispatch: Choking; ~Chief complaint: [MEDICAL CONDITION]; and ~ED Disposition: Expired. The ambulance report documented an endotracheal tube had been placed at 6:02 p.m. A SNF progress note titled, Discharge Summary, dated [DATE] at 6:21 p.m., documented as follows: Diagnosis: [REDACTED]. Where did the resident discharge to?: Via ambulance to (Name withheld) ER . What date and time did they discharge?: 1810 (6:10 p.m.) [DATE] . Method of transport/accompanied by?: (Name withheld) ambulance . Circumstances of transfer: Choking with [MEDICAL CONDITION] . Vitals and Skin Condition on D/C: pt not breathing, automatic cpr machine in process on guerney (Sic), AED said 'no shock' . The transcriber of the note was RN #3. An emergency room note, dated [DATE] at 7:00 p.m., documented, .Physical Examination .Throat: ET tube in place with copious spaghetti and secretions .Cardiovascular: CPR in progress. No palpable pulses .Respiratory: Severe rhonchi in all lung fields patient is being mechanically ventilated .Medical Decision Making .Patient presents to the ER today with a choking episode leading to [MEDICAL CONDITION]. CPR has been progress (Sic) over an hour upon arrival to the emergency department. After pulse check she remained asystole and bedside ultrasound confirmed cardiac standstill. Time of death was called at 1859 (6:59 p.m.) . A State of Oklahoma Certificate of Death, dated [DATE], documented: ~date of death : [DATE]; ~Time of death: 18:59 (6:59 p.m.); ~Cause of death: Asphyxia (Choking on Food); ~Place of Injury: Nursing Home; and ~Describe how injury occurred: Choking on Food. On [DATE] at 10:34 a.m., the DM was asked how her kitchen staff was made aware of residents who had swallowing disorders. She stated the DON and ADON informed her of those who were assisted diners. She stated she was provided a list which was updated as needed. She stated she observed them eating especially if they were new. She stated sometimes families will inform her. She was asked if she was familiar with resident #205. She stated yes. She stated the resident sat in front of the kitchen serving window. She stated she had to be cued at times but usually ate on her own. She was asked if a nurse was required to be in the dining room during meals. She stated yes. She was asked if she had witnessed the incident with resident #205 on [DATE]. She stated she was not but Cook #1 was there. At 10:53 a.m., Cook #1 was asked what she had witnessed on [DATE] in the dining room with resident #205. She stated she had gone to the serving window and observed resident #205 leaning forward. She stated a nurse leaned her back and spaghetti was observed hanging out of her mouth. She stated someone had attempted the [MEDICATION NAME] maneuver but the resident was a large lady. She stated she had never witnessed the resident choking but later was informed the resident had choked on spaghetti before. No incident report was found regarding the resident previously choking on spaghetti. She was asked if a nurse was in the dining room during meals. She stated 75% of the time there was a nurse in the dining room during meals. She was asked if there was a nurse in the dining room the evening of the incident which involved resident #205. She stated yes there was a nurse at the table behind resident #205 but she could not remember who the nurse was. She was asked if there was anyone at the table with the resident when the incident occurred. She stated yes resident #16 was at the table with the resident. On [DATE] at 11:30 a.m., resident #16 was asked if she sat at the table with resident #205 during meals. She stated she was her table partner. She was asked if she had ever witnessed resident #205 choke when she ate. She stated, She would choke everyday. She stated the resident would stuff her mouth full and then use water to get it down. She was asked if she had witnessed the resident choke on [DATE]. She stated that day the resident was very quiet because she usually liked to talk. She stated when she looked up at the resident she was bent over and shaking. She stated she left the table because there was alot of nurses attending to resident #205. She stated she had told the nurse who administers her nightly injection that she wanted resident #205 moved to another table because she stuffed her mouth full and did not know how to eat. She stated she did not want to be responsible for resident #205. On [DATE] at 11:50 a.m., the hospitality aide/activity assistant was asked if she had witnessed the incident that had occurred on [DATE] which involved resident #205. She stated yes she was passing trays during the evening meal. She stated she was getting a tray from the serving window and when she turned around a nurse and aide were sitting resident #205 up who was choking. She stated the resident was not coughing. She was asked if she had ever witnessed the resident choking before. She stated in the past month or so she had noticed the resident was clumsy with her food. She stated, Kind of in and out of it. Loosing focus and grabbing things. She stated she had reported this to her supervisor and to the nurse. She stated the resident had choked on spaghetti before but could not remember when. No incident report was found regarding the resident previously choking on spaghetti. On [DATE] at 12:30 p.m., LPN #1 was asked to recall the incident that occurred on [DATE] which involved resident #205. He stated he was at the nurses' station when a nurse came and told him that the nurse in the dining room needed him immediately. He stated when he got to the dining room resident #205 was in her chair and was blue in color. He stated he attempted the [MEDICATION NAME] Maneuver until the resident became unconscious and she was lowered to the floor. He stated the ADON had came into the dining room and did a fingersweep in the resident's mouth. He stated a little spaghetti was produced with the fingersweep. He stated CPR was initiated until EMS arrived. He stated she was connected to the AED and CPR was continued but twice the AED indicated no shock. She was placed in the ambulance and intubated. He was asked if he had ever witnessed the resident choking before. He stated, We would have to tell her to slow down. She loved to eat. He stated she was continuously eating and one or two other times had choked but did not need the [MEDICATION NAME] or chest compressions. He stated once he saw what she was eating he knew she was choking. He was asked if staff was aware of her tendency to choke. He stated everyone was aware but the resident was very willful and did what she wanted. At 3:14 p.m., RN #1 was asked if she was familiar with resident #205 and the incident that had occurred on [DATE]. She stated she was working in the dining room when the incident occurred. She stated the resident was a self feeder. She stated she had stepped out of the dining room for approximately three minutes to answer a phone call and when she came back into the dining room she noticed the resident was dark blue in color. She stated she attempted the [MEDICATION NAME] maneuver but the resident was too large. She then called for LPN #1 to come to the dining room immediately. She stated LPN #1 performed the [MEDICATION NAME] maneuver without success. She stated they began CPR. She stated it was obvious the resident had choked on spaghetti because a finger sweep was performed which produced alot of spaghetti. She stated EMS had removed spaghetti when trying to intubate the resident. She stated she knew there was something lodged in the resident's throat because when they attempted to use the Ambu bag there was no air exchange. She was asked if the resident had a history of [REDACTED]. She stated, She shoveled food in like she wasn't going to get another meal. She stated LPN #1 had told her the resident had choked before. She stated approximately a week ago LPN #2 had submitted a request for a speech therapy consult for resident #205. On [DATE] at 3:31 p.m., LPN #2 was asked if she was familiar with resident #205 and the incident that had occurred on [DATE]. She stated she was familiar with the resident and was at the facility the day of the occurence. She stated she heard LPN #1 being called to the dining room. She stated she ran to the dining room and RN #1 was with resident #205 who told her, I think she is choking. She stated LPN #1 attempted the [MEDICATION NAME] maneuver, then the ADON did a fingersweep. She stated they began doing CPR on the resident. She stated, She was just blue. She was asked if the resident had a history of [REDACTED]. She stated a week or two ago she observed the resident eating orange sherbet and she would cough when she would take a bite. She stated she had requested a consult for the resident with speech therapy because she coughed alot during meals. She stated the resident's tablemate had told her that resident #205 shoved food in her mouth. No documentation was found regarding the resident coughing during meals. On [DATE] at 3:47 p.m., LPN #3 was asked if she was at the facility on [DATE] during the incident with resident #205. She stated she was standing at LPN #2's office when RN #1 called out to get LPN #1. She stated the resident would shovel food in her mouth, not chew, and fall asleep. She was asked if the resident had a history of [REDACTED]. At 3:55 p.m., the ADON was asked if resident #205 had a history of [REDACTED]. At 4:00 p.m., RN #3 was asked if she had witnessed the incident with resident #205 on [DATE]. She stated she had just came on duty and went into the dining room where the nurses were trying to resuscitate the resident. She was asked if the resident had a history of [REDACTED]. She stated, She would cram a whole sandwich in her mouth without chewing. At 4:26 p.m., RN #2, the MDS coordinator, was asked how she was informed of a resident with swallowing difficulties. She stated staff would tell her if they had observed a resident cough with food or drinking. She was asked if she was aware that resident #205 choked with food or when drinking. She stated no one had informed her of the resident choking until she found out a consult request had been given to speech therapy. She stated with the computer software that the facility used, when staff documented something on a resident certain words would flag for further investigation. She stated nothing had been flagged on resident #205. At 4:38 p.m., the speech/language Pathologist was asked what the protocol was when they received a consult request on a resident. She stated when she receives a consult request she had 24 hours to completed the request. She was asked how often she received her consult request. She stated everyday. She was asked if she had received a consult request for resident #205. She stated yes she had received the request on [DATE]. She stated she had to go out of town to do a consult first and when she arrived back at the facility to see resident #205 the ambulance was leaving with her. At 4:52 p.m., the DON was asked to recall the incident with resident #205 on [DATE]. She stated she was out of town and was called and went back to the facility. She stated she was informed of the entire incident when she arrived at the facility. She was asked if the resident had a history of [REDACTED]. She stated she was never told the resident had choking episodes.

On 04/20/17 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to thoroughly investigate an allegation of sexual abuse and failed to ensure residents were protected from further abuse during the investigation. At 2:25 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. At 2:30 p.m., the administrator and corporate staff member were notified of the IJ situation related to the facility's failure to thoroughly investigate an allegation of sexual abuse and failed to ensure residents were protected from further abuse during the investigation. At 7:25 p.m., an acceptable plan of removal was provided. The plan of removal documented, .Interviews of all residents with safe survey (see attached form) will be completed by 04-20-2017 at 4:00 PM by DON, ADON and MDS. Training of all staff in the areas (sic) abuse, including identification, investigation, reporting, protection, screening, training, prevention by 04-20-2017 at 3:00 PM and lasted for 30 minutes for all current staff by the corporate staff (Operations Director) and no other staff will be permitted to work until they have been in-serviced before their next scheduled shift by phone contact or in person. The information for in-service covered is attached. The in-serviced staff was asked if they had ever witnessed abuse including but not limited to physical, sexual, or mental abuse. Interviews with staff will be conducted one on one by the corporate staff, DON, ADON, Admin or MDS that ask the specific question: To your knowledge has any resident ever touched another resident in an inappropriate manner while a resident at Southern Oaks? (If yes, who did you report this to and please explain). These interviews will be completed by 2pm on 04-21-2017. Interviews will be conducted with residents in a private setting and will ask the specific question: 'Has anyone ever touched you in an inappropriate manner while a resident at Southern Oak?' 'What is your response? (sic) These interviews will be completed by 2:00 PM on 04-21-2017. An attempt will be made to contact the C.N.A. (name withheld Or who was the C.N.A.) by 04-21-2017 at 2 PM. DON or designee will: Daily review of all incidents including allegations of sexual abuse will be done with IDT by 04-20-2017 and ongoing (sic) Reviews will include protection of residents during investigations of sexual abuse (sic) Training for staff will continue on abuse including protective measures on an ongoing basis by the DON, ADON, MDS, Corporate Staff or Administrator and will include new hires on 04-20-2017 and on-going (sic) Actions will be completed by: 04-21-2017 2:00 PM and no staff will be permitted to work until they have completed the training and this training will (sic) before the start of their next worked shift. All current working staff will be interviewed about (sic) as of 02:00 PM (sic) on 04-21-2017 (sic) Administrator or designee will monitor abuse identification, screening, protection, training, and prevention and overall system as follows: Daily review allegations and incidents with investigation review with the IDT (Interdisciplinary team) for abuse and allegations of abuse and preventative measures to prevent abuse and to protect all residents (sic) Review of residents with allegations and incidents will be conducted daily and the information carried through the Quality Assurance Performance Improvement Process . The immediate jeopardy was removed on 04/21/17 at 2:00 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern level of actual harm. Based on interview and record review, it was determined the facility failed to thoroughly investigate an allegation of sexual abuse and failed to ensure residents were protected from further abuse during the investigation for three (#10, #11, and #57) of four sampled residents who were reviewed for abuse. The facility failed to prevent sexual abuse perpetrated by resident #14 against residents #10, #11, and #57. This had the potential to affect all 67 residents. A typed nurse's statement documented the nurse talked to resident #11 about the incident and the resident became upset. The statement documented the resident began to cry after the nurse left the room and said, I wish he wouldn't have done that. Findings: An undated policy, titled Abuse Prohibition Management Program, documented, .When either a reportable incident or actual abuse occurs, the facility must: ~report the incident or abuse; ~conduct and document a thorough investigation of each incident; ~complete an appropriate assessment of the residents involved; and ~implement a plan of action designed to prevent recurrence . If a resident begins to exhibit inappropriate behavior, the facility must assess the resident and promptly intervene, taking appropriate action to protect other residents even if no allegation of abuse is made .appropriate actions include steps such as additional supervision for aggressive residents and appropriate medical/psychiatric evaluation and treatment .the facility must reassess the aggressor's behavior and adjust the care plan accordingly. The facility must take specific steps to control the aggressor's behavior and to protect other residents .sexual activity involving a resident without specific decision-making capacity over sexual matters is a reportable incident and must be addressed .the facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior .the individual conducting the investigation will, as a minimum: Conduct all interviews in the presence of a witness .interview any witnesses to the incident .interview the resident .interview staff members on all shifts who have had contact with the resident during the 48-72 hour period prior to the time of the incident .interview the accused individual .each interview will be conducted separately and in a private location .witness reports will be reduced to writing .witnesses will be required to sign and date such reports .the investigator will compile a written report of the results of the investigation .a copy of the Resident Abuse Report Form must be attached to the investigator's report . 1. Resident #10 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/30/17, documented the resident was moderately impaired in cognition for daily decision making, did not exhibit any mood or behavior problems, and required assistance with activities of daily living. An OSDH Incident Report form, dated 04/08/17, documented resident #14 was observed fondling the left breast and vaginal area of resident #10 after the evening meal. Resident #10 was assessed for injury and distress. The staff placed Resident #14 under direct visual observation and the local police department was notified. A typed statement signed by LPN #5, dated 04/08/17 at 7:15 p.m., documented, .I went and interviewed, (resident #10) about her being touched by another resident. I asked her if anybody had given her a hug, said hi or touched her? She said 'I don't know about that.' I asked her if someone gave her a hug. She said, 'No.' I asked her if someone said hi to her. She said, 'Yes.' I asked her if someone touched her she said, 'Yes.' I asked her if she could tell me where someone touched her. She just stared at me so I asked if they touched her head, shoulder, legs or a private part. She didn't say anything but did raise her pelvis up. I asked her if when she was touched if she felt uncomfortable. She said, 'Yes.' I asked if she wanted it to happen and she said 'I don't know about that.' No, 'I don't know about that.' I asked her if she could tell me anymore and she said, 'No.' .(8:08 p.m.) Later I went back in there and asked her if she had been touched before like what had happened in the dining room by the same person? She just stared at me so I asked her again if anyone had touched her like what had happened before (sic) she said, 'Yes.' .I asked if she could tell me where she had been touched before. She just stared at me. .I asked her the question again and she just stared at me the same way. She didn't verbalize a body part or move when I gave her examples as before. .I asked her if she needed to tell me anything else and she said 'No' . A staff interview form for CNA #6, dated 04/20/17 at 8:40 p.m., documented the question if staff had any knowledge of any resident inappropriately touching another resident at the facility. The handwritten response documented, .(Resident #14) touched (resident #10) in the (sic) happened on my last night (sic) .who did you report this to .(name withheld) (LPN #4). She was walking out of the dining room and I told her what happened .She denies talking to (DON or ADON) .she said she wrote a statement . A staff interview form for CNA #5, dated 04/21/17 at 1:27 p.m., documented the question if staff had any knowledge of any resident inappropriately touching another resident. The handwritten response documented, .(resident #14) to (resident #10) referring to incident on 04-08-17 . No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview with the resident. 2. Resident #11 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/05/17, documented the resident was moderately impaired in cognition for daily decision making and required assistance with activities of daily living. An OSDH Incident Report form, dated 04/08/17, documented, .Note that during the course of this investigation, (resident #14) remained under direct visual observation/supervision by staff at all times, and advised that he was to have no contact with female residents. Subsequently, during dinner meal, resident rose to leave the dining room and as walking by table of co-resident (resident #11) in act of defiance, bent down and kissed her on the lips, and brushed her left breast with his hand while within view of supervising staff, who were unable to reach resident in time to stop him. (Resident #11) reported that this did make her 'uncomfortable', but denied injury . A typed statement signed by LPN #5, dated 04/09/17, documented, .I called (DON) and (DON) had me go talk to (resident #11) about what had happened. Resident became upset and stated, 'I don't want to get him in trouble so I guess it is ok' and she began to get upset. I told her it was ok she did nothing wrong but I just wanted her to feel comfortable and make sure she was ok. Resident began to cry after I left the room and saying, 'I didn't mean to get anybody in trouble. I wish he wouldn't have done that. (DON and ADON) were contacted about what (resident #11) said . An undated staff interview form, timed at 7:50 p.m., documented the question if staff had any knowledge of any resident who had inappropriately touched another resident. The response from the maintenance supervisor documented, .(resident #14) kissing (resident #11) when placing bib on her .also observed same behavior approximately 6 months ago, had brought up in stand-up .stated his opinion on not being appropriate . No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview with the resident. 3. Resident #57 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/09/17, documented the resident was severely impaired in cognition for daily decision making and required assistance with activities of daily living. A handwritten statement by CNA #4, dated 04/20/17, documented, .On Feb. 14, I (name withheld) was passing dinner hall tray (sic) down 100 hall. When I started down the hall I found (resident #14) with one hand on (resident #57's) shoulder and the other hand down her pants. (Resident #57) was saying no no, stop stop it. I told (resident #14) to come here to separate them. I went right to my charge nurse (LPN #6) and told her what had just happened. (LPN #6) said that she dose (sic) not know how to chart that or what to chart. We will have to go to the DON in the morning. The next morning [DATE]th I and (LPN #6) (sic) went to (DON) to report what I had seen . On 04/21/17 at 9:57 a.m., an interview with resident #57, conducted by the DON, documented, Has anyone ever touched you in a inappropriate manner . The resident responded, yes. No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview of the resident following the allegation. 4. Resident #14 had [DIAGNOSES REDACTED]. A care plan, updated 11/07/16, documented, .Focus .I have a (sic) verbally abusive behaviors . Interventions .Intervene as necessary to protect the rights and safety of others . Focus .I have a dx of depression . Interventions .Find a diversional activity that I enjoy doing such as walking around the parking lot for exercise, passing out bibs to other residents, reading, watching westerns,listening to western music . A quarterly assessment, dated 01/24/17, documented the resident was independent in cognition for daily decision making, exhibited no mood or behavior problems, and was independent with ambulation. A progress note, dated 04/08/17 at 8:43 p.m., documented, Behavior Note .What was the behavior? (Resident #14) was witnessed inappropriately touching another resident in the dining room. The incident was witnessed by a staff member . Did anything worsen the behavior? NA . What was the resident doing just prior to the onset of the behavior? taking bibs off of residents . What non-pharmacological approaches were attempted to reduce/resolve the behavior? asked resident not to hand out bibs or collect them by (name withheld) (DON) . Did the behavior resolve? NA . What interventions are in place to prevent a recurrence? Resident is on hourly checks and is no longer able to hand out or pick up bibs . Has [MEDICAL CONDITION] been ruled out as a cause for the behavior? Yes . Was the physician notified? yes . Was the family/responsible party notified? yes . A typed statement signed by LPN #5, dated 04/09/17, documented, .(Resident #14) was warned that he was not supposed to put clothes protectors on other residents after the allegation the evening before about touching a female resident inappropriately. Resident still place bibs on female residents during lunch. He was reminded to not be placing bibs on other residents and he returned to his chair. He again later during the lunch meal got up and continued to place bibs on other female residents. He was again told he cannot do that and I was going to call (DON) and let her know of the situation. He became mad and starting picking up bibs that had not been placed on other residents and stormed out of the dining room. DON and ADON notified of the situation (sic). Was told to keep a close eye on the resident and again talk to the resident and tell him he cannot touch another resident in any way. (Name withheld) RN talked with the resident and he said he understood. During the evening meal resident got up to leave the dining room and on his way out he stopped at (resident #11's) table gave her a sideways hug placing his hand on her breast and gave her a kiss on the side of her mouth and left. We again told him that his actions were in appropriate (sic) and could not happen and I would have to contact (name withheld) DON about the situation. Resident went on to his room. I called (DON) and (DON) had me go talk to (resident #11) about what had happened. Resident became upset and stated, 'I don't want to get him in trouble so I guess it is ok' and she began to get upset. I told her it was ok she did nothing wrong but I just wanted her to feel comfortable and make sure she was ok. Resident began to cry after I left the room and saying, 'I didn't mean to get anybody in trouble. I wish he wouldn't have done that.' (DON and ADON) (sic) were contacted about what (resident #11) said. They advised me to bring (resident #14) up to the nurse's station and keep an eye on him and to contact (geri-psych) to see if they had a opening for him. Resident was asked to come to nurse's station which he did. (LPN #3) contacted (resident #14's family member) after (DON) advised us to call him. I contacted (geri-psych) and they were not able to accept him at this time but they advised for us to keep an eye on the resident and to call the police. DON (sic) was notified of what (geri-psych) had advised and that they were unable to accept him. (sic) (DON) (sic) said to continue to keep an eye on the resident. (Resident #14) is currently in his room . A progress note, dated 04/09/17 at 5:45 p.m., documented, Behavior Note .What was the behavior? resident was witnessed inappropriately touching another resident in the dining room. The incident was witnessed by myself and another staff member . What was the resident doing just prior to the onset of the behavior? eating his dinner. When he finished his dinner he went up to the female resident . What non-pharmacological approaches were attempted to reduce/resolve the behavior? resident had been talked to by the DON and the police about his actions on the previous day . What were the effects of the non-pharmacological interventions? non effective . Did the behavior resolve? no . What interventions are in place to prevent recurrence? Resident is on hourly checks . Was the physician notified? yes by DON . Was the family/responsible party notified? yes by LPN . A progress note, dated 04/10/17 at 9:37 a.m., documented, .Misc. Note .Emergency Care Plan meeting held with (resident #14) and nephew .nephew present with permission of resident .The care plan meeting was held due to witnessed inappropriate touching to female residents breasts. (Resident #14) admitted to touching inappropriately but stated that one female thanked him for touching her. ADON stated to him that she had talked with the females and they were very upset and did not like him to touch them. At that time (resident #14) agreed that this was an an issue and that in was (sic) willing to go to treatment for [REDACTED]. On 04/19/17 at 9:40 a.m., the administrator was asked to provide the investigation documentation for the allegation of abuse for resident #14 and #10. On 04/19/17 at 10:10 a.m., the ADON provided the investigation information. The investigation information included copies of a resident room roster which was identified as documentation of interviews with all the residents. She stated residents with asterisks by the name were involved in the incident. The residents identified were #10 and #11. The investigation information included a handwritten note at the top of the resident room roster which documented female resident interviews were conducted on 04/10/17. The interviews revealed 41 of 45 female residents denied experiencing inappropriate touch from another resident. There was no documentation for four of the female residents listed on the room roster. The investigation information included a form from the local fire and police department dispatch log, dated 04/08/17 at 8:00 p.m., which documented, .DON @ (Name withheld) need to speak to officer .8:07 p.m., arrived at scene .8:25 p.m .everything had been taken care of . The investigation information included a form titled, weekend nursing assignment, dated 04/08/17, which documented a handwritten statement, .(Resident #14) verbal staff interviews .witness to inappropriate behavior . The ADON stated the form documented 15 of 22 staff were interviewed and denied to have ever witnessed inappropriate touching of resident to resident. The investigation information included a typed statement signed by LPN #5, dated 04/09/17, which documented: .(Resident #14) was warned that he was not supposed to put clothes protectors on other residents after the allegation the evening before about touching a female resident inappropriately. Resident still place bibs on female residents during lunch. He was reminded to not be placing bibs on other residents and he returned to his chair. He again later during the lunch meal got up and continued to place bibs on other female residents. He was again told he cannot do that and I was going to call (DON) and let her know of the situation. He became mad and starting picking up bibs that had not been placed on other residents and stormed out of the dining room. DON and ADON notified of the situation (sic). Was told to keep a close eye on the resident and again talk to the resident and tell him he cannot touch another resident in any way. (Name withheld) RN talked with the resident and he said he understood. During the evening meal resident got up to leave the dining room and on his way out he stopped at (resident #11's) table gave her a sideways hug placing his hand on her breast and gave her a kiss on the side of her mouth and left. We again told him that his actions were in appropriate and could not happen and I would have to contact (name withheld) DON about the situation. Resident went on to his room. I called (DON) and (DON) had me go talk to (resident #11) about what had happened. Resident became upset and stated, 'I don't want to get him in trouble so I guess it is ok' and she began to get upset. I told her it was ok she did nothing wrong but I just wanted her to feel comfortable and make sure she was ok. Resident began to cry after I left the room and saying, 'I didn't mean to get anybody in trouble. I wish he wouldn't have done that.' (DON and ADON) (sic) were contacted about what (resident #11) said. They advised me to bring (resident #14) up to the nurse's station and keep an eye on him and to contact (geri-psych) to see if they had a opening for him. Resident was asked to come to nurse's station which he did. (LPN #3) contacted (resident #14's family member) after (DON) advised us to call him. I contacted (geri-psych) and they were not able to accept him at this time but they advised for us to keep an eye on the resident and to call the police. DON (sic) was notified of what (geri-psych) had advised and that they were unable to accept him. (sic) (DON) (sic) said to continue to keep an eye on the resident. (Resident #14) is currently in his room . On 04/19/17 at 4:34 p.m., the DON was asked to provide all documentation regarding the incidents involving residents #14, #10, and #11. On 04/19/17 at 5:25 p.m., the ADON was asked who was responsible for investigating complaints and allegations of abuse. She stated it was usually her. On 04/19/17 at 5:30 p.m., the ADON provided copies of a hourly log used to document resident #14's location beginning 04/08/17 at 8:00 p.m. through 04/11/17 at 8:00 a.m. On 04/20/17 at 11:10 a.m., the DON and ADON were asked if there was a facility incident report completed for the allegation involving residents #14 and #10. The ADON stated the facility utilized the OSDH Incident Report form. The DON was asked what the time was when the incident occurred involving resident #14 and #10. She stated she was unable to locate a incident report, but thought it had occurred during supper time. The DON was asked who resident #10's table mates were. She identified resident #57. The DON and ADON were asked if the residents were interviewed. The ADON stated she had interviewed everyone. She was asked when the interviews were conducted. She stated on 04/09/17. She was informed the resident roster had been dated for 04/10/17. She stated the interviews were conducted the Monday after the incidents, which occurred on 04/08 and 04/09/17. The ADON was asked who the CNA was identified in the state reportable as witnessing the incident which occurred 04/08/17. She stated the LPN was the witness, and would have to look at notes. She stated CNA#6. The DON and ADON were asked for any documentation of the encounter with the local police officer who visited the facility. The ADON reported the officer had spoken to resident #14, the DON, and herself. She stated there was no documentation. On 04/20/17 at 11:40 a.m., the ADON was asked were staff and resident interviews documented. She stated interviews were conducted in person and documented on scrap paper. She stated they were discarded after information was included in the incident report summary. She was asked who was interviewed. She stated only those directly involved in the incident were interviewed. At 11:43 a.m., the corporate RN stated not everyone was interviewed due to the confidentiality of the investigation. The ADON was asked who the facility's designated abuse coordinator was. She stated the administrator. On 04/20/17 at 11:45 a.m., the administrator was asked what was involved with an abuse investigation. She stated when an allegation was reported the facility would immediately notify the resident's physician and family. Unless directly involved, the facility did not obtain additional interviews so as to protect the complainant and others. The facility then started the process of investigation while residents were being monitored. She was asked if an investigation had been conducted regarding resident #14 and #11. She stated the LPN on duty had interviewed resident #11 and determined the resident had not been comfortable with resident #14 touching her. She was asked if the incident had been reported to the state agency. She stated the investigative information obtained in the incident involving residents #11 and #14 had been included in the final report sent to the state agency which involved residents #10 and #14. On 04/20/17 at 11:50 a.m., the DON was asked what the facility policy was regarding abuse. She stated the facility had a policy but she needed to review it.

On 04/20/17 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy to ensure residents were protected from sexual abuse and to ensure allegations of abuse were thoroughly investigated. At 2:25 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. At 2:30 p.m., the administrator and corporate staff member were notified of the IJ situation related to the facility's failure to protect residents from sexual abuse. At 7:25 p.m., an acceptable plan of removal was provided. The plan of removal documented, .Interviews of all residents with safe survey (see attached form) will be completed by 04-20-2017 at 4:00 PM by DON, ADON and MDS. Training of all staff in the areas (sic) abuse, including identification, investigation, reporting, protection, screening, training, prevention by 04-20-2017 at 3:00 PM and lasted for 30 minutes for all current staff by the corporate staff (Operations Director) and no other staff will be permitted to work until they have been in-serviced before their next scheduled shift by phone contact or in person. The information for in-service covered is attached. The in-serviced staff was asked if they had ever witnessed abuse including but not limited to physical, sexual, or mental abuse. Interviews with staff will be conducted one on one by the corporate staff, DON, ADON, Admin or MDS that ask the specific question: To your knowledge has any resident ever touched another resident in an inappropriate manner while a resident at Southern Oaks? (If yes, who did you report this to and please explain). These interviews will be completed by 2pm on 04-21-2017. Interviews will be conducted with residents in a private setting and will ask the specific question: 'Has anyone ever touched you in an inappropriate manner while a resident at Southern Oak?' 'What is your response? (sic) These interviews will be completed by 2:00 PM on 04-21-2017. An attempt will be made to contact the C.N.A. (name withheld Or who was the C.N.A.) by 04-21-2017 at 2 PM. DON or designee will: Daily review of all incidents including allegations of sexual abuse will be done with IDT by 04-20-2017 and ongoing (sic) Reviews will include protection of residents during investigations of sexual abuse (sic) Training for staff will continue on abuse including protective measures on an ongoing basis by the DON, ADON, MDS, Corporate Staff or Administrator and will include new hires on 04-20-2017 and on-going (sic) Actions will be completed by: 04-21-2017 2:00 PM and no staff will be permitted to work until they have completed the training and this training will (sic) before the start of their next worked shift. All current working staff will be interviewed about (sic) as of 02:00 PM (sic) on 04-21-2017 (sic) Administrator or designee will monitor abuse identification, screening, protection, training, and prevention and overall system as follows: Daily review allegations and incidents with investigation review with the IDT (Interdisciplinary team) for abuse and allegations of abuse and preventative measures to prevent abuse and to protect all residents (sic) Review of residents with allegations and incidents will be conducted daily and the information carried through the Quality Assurance Performance Improvement Process . The immediate jeopardy was removed on 04/21/17 at 2:00 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern level of actual harm. Based on interview and record review, it was determined the facility failed to implement their abuse policy to ensure female residents were protected from sexual abuse and allegations of sexual abuse were thoroughly investigated for three (#10, #11, and #57) of four sampled residents reviewed for abuse. The facility failed to prevent sexual abuse perpetrated by resident #14 against residents #10, #11, and #57. This had the potential to affect all 67 residents. A typed nurse's statement documented the nurse talked to resident #11 about the incident and the resident became upset. The statement documented the resident began to cry after the nurse left the room and said, I wish he wouldn't have done that. Findings: An undated policy, titled Abuse Prohibition Management Program, documented, .When either a reportable incident or actual abuse occurs, the facility must: ~report the incident or abuse; ~conduct and document a thorough investigation of each incident; ~complete an appropriate assessment of the residents involved; and ~implement a plan of action designed to prevent recurrence . If a resident begins to exhibit inappropriate behavior, the facility must assess the resident and promptly intervene, taking appropriate action to protect other residents even if no allegation of abuse is made .appropriate actions include steps such as additional supervision for aggressive residents and appropriate medical/psychiatric evaluation and treatment .the facility must reassess the aggressor's behavior and adjust the care plan accordingly. The facility must take specific steps to control the aggressor's behavior and to protect other residents .sexual activity involving a resident without specific decision-making capacity over sexual matters is a reportable incident and must be addressed .the facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior .the individual conducting the investigation will, as a minimum: Conduct all interviews in the presence of a witness .interview any witnesses to the incident .interview the resident .interview staff members on all shifts who have had contact with the resident during the 48-72 hour period prior to the time of the incident .interview the accused individual .each interview will be conducted separately and in a private location .witness reports will be reduced to writing .witnesses will be required to sign and date such reports .the investigator will compile a written report of the results of the investigation .a copy of the Resident Abuse Report Form must be attached to the investigator's report . 1. Resident #10 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/30/17, documented the resident was moderately impaired in cognition for daily decision making, did not exhibit any mood or behavior problems, and required assistance with activities of daily living. An OSDH Incident Report form, dated 04/08/17, documented resident #14 was observed fondling the left breast and vaginal area of resident #10 after the evening meal. Resident #10 was assessed for injury and distress. The staff placed Resident #14 under direct visual observation and the local police department was notified. A typed statement signed by LPN #5, dated 04/08/17 at 7:15 p.m., documented, .I went and interviewed, (resident #10) about her being touched by another resident. I asked her if anybody had given her a hug, said hi or touched her? She said 'I don't know about that.' I asked her if someone gave her a hug. She said, 'No.' I asked her if someone said hi to her. She said, 'Yes.' I asked her if someone touched her she said, 'Yes.' I asked her if she could tell me where someone touched her. She just stared at me so I asked if they touched her head, shoulder, legs or a private part. She didn't say anything but did raise her pelvis up. I asked her if when she was touched if she felt uncomfortable. She said, 'Yes.' I asked if she wanted it to happen and she said 'I don't know about that.' No, 'I don't know about that.' I asked her if she could tell me anymore and she said, 'No.' .(8:08 p.m.) Later I went back in there and asked her if she had been touched before like what had happened in the dining room by the same person? She just stared at me so I asked her again if anyone had touched her like what had happened before (sic) she said, 'Yes.' .I asked if she could tell me where she had been touched before. She just stared at me. .I asked her the question again and she just stared at me the same way. She didn't verbalize a body part or move when I gave her examples as before. .I asked her if she needed to tell me anything else and she said 'No' . A staff interview form for CNA #6, dated 04/20/17 at 8:40 p.m., documented the question if staff had any knowledge of any resident inappropriately touching another resident at the facility. The handwritten response documented, .(Resident #14) touched (resident #10) in the (sic) happened on my last night (sic) .who did you report this to .(name withheld) (LPN #4). She was walking out of the dining room and I told her what happened .She denies talking to (DON or ADON) .she said she wrote a statement . A staff interview form for CNA #5, dated 04/21/17 at 1:27 p.m., documented the question if staff had any knowledge of any resident inappropriately touching another resident. The handwritten response documented, .(resident #14) to (resident #10) referring to incident on 04-08-17 . No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview with the resident. 2. Resident #11 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/05/17, documented the resident was moderately impaired in cognition for daily decision making and required assistance with activities of daily living. An OSDH Incident Report form, dated 04/08/17, documented, .Note that during the course of this investigation, (resident #14) remained under direct visual observation/supervision by staff at all times, and advised that he was to have no contact with female residents. Subsequently, during dinner meal, resident rose to leave the dining room and as walking by table of co-resident (resident #11) in act of defiance, bent down and kissed her on the lips, and brushed her left breast with his hand while within view of supervising staff, who were unable to reach resident in time to stop him. (Resident #11) reported that this did make her 'uncomfortable', but denied injury . A typed statement signed by LPN #5, dated 04/09/17, documented, .I called (DON) and (DON) had me go talk to (resident #11) about what had happened. Resident became upset and stated, 'I don't want to get him in trouble so I guess it is ok' and she began to get upset. I told her it was ok she did nothing wrong but I just wanted her to feel comfortable and make sure she was ok. Resident began to cry after I left the room and saying, 'I didn't mean to get anybody in trouble. I wish he wouldn't have done that. (DON and ADON) were contacted about what (resident #11) said . An undated staff interview form, timed at 7:50 p.m., documented the question if staff had any knowledge of any resident who had inappropriately touched another resident. The response from the maintenance supervisor documented, .(resident #14) kissing (resident #11) when placing bib on her .also observed same behavior approximately 6 months ago, had brought up in stand-up .stated his opinion on not being appropriate . No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview with the resident. 3. Resident #57 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/09/17, documented the resident was severely impaired in cognition for daily decision making and required assistance with activities of daily living. A handwritten statement by CNA #4, dated 04/20/17, documented, .On Feb. 14, I (name withheld) was passing dinner hall tray (sic) down 100 hall. When I started down the hall I found (resident #14) with one hand on (resident #57's) shoulder and the other hand down her pants. (Resident #57) was saying no no, stop stop it. I told (resident #14) to come here to separate them. I went right to my charge nurse (LPN #6) and told her what had just happened. (LPN #6) said that she dose (sic) not know how to chart that or what to chart. We will have to go to the DON in the morning. The next morning [DATE]th I and (LPN #6) (sic) went to (DON) to report what I had seen . On 04/21/17 at 9:57 a.m., an interview with resident #57, conducted by the DON, documented, Has anyone ever touched you in a inappropriate manner . The resident responded, yes. No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview of the resident following the allegation. 4. Resident #14 had [DIAGNOSES REDACTED]. A care plan, updated 11/07/16, documented, .Focus .I have a (sic) verbally abusive behaviors . Interventions .Intervene as necessary to protect the rights and safety of others . Focus .I have a dx of depression . Interventions .Find a diversional activity that I enjoy doing such as walking around the parking lot for exercise, passing out bibs to other residents, reading, watching westerns,listening to western music . A quarterly assessment, dated 01/24/17, documented the resident was independent in cognition for daily decision making, exhibited no mood or behavior problems, and was independent with ambulation. A progress note, dated 04/08/17 at 8:43 p.m., documented, Behavior Note .What was the behavior? (Resident #14) was witnessed inappropriately touching another resident in the dining room. The incident was witnessed by a staff member . Did anything worsen the behavior? NA . What was the resident doing just prior to the onset of the behavior? taking bibs off of residents . What non-pharmacological approaches were attempted to reduce/resolve the behavior? asked resident not to hand out bibs or collect them by (name withheld) (DON) . Did the behavior resolve? NA . What interventions are in place to prevent a recurrence? Resident is on hourly checks and is no longer able to hand out or pick up bibs . Has [MEDICAL CONDITION] been ruled out as a cause for the behavior? Yes . Was the physician notified? yes . Was the family/responsible party notified? yes . A typed statement signed by LPN #5, dated 04/09/17, documented, .(Resident #14) was warned that he was not supposed to put clothes protectors on other residents after the allegation the evening before about touching a female resident inappropriately. Resident still place bibs on female residents during lunch. He was reminded to not be placing bibs on other residents and he returned to his chair. He again later during the lunch meal got up and continued to place bibs on other female residents. He was again told he cannot do that and I was going to call (DON) and let her know of the situation. He became mad and starting picking up bibs that had not been placed on other residents and stormed out of the dining room. DON and ADON notified of the situation (sic). Was told to keep a close eye on the resident and again talk to the resident and tell him he cannot touch another resident in any way. (Name withheld) RN talked with the resident and he said he understood. During the evening meal resident got up to leave the dining room and on his way out he stopped at (resident #11's) table gave her a sideways hug placing his hand on her breast and gave her a kiss on the side of her mouth and left. We again told him that his actions were in appropriate (sic) and could not happen and I would have to contact (name withheld) DON about the situation. Resident went on to his room. I called (DON) and (DON) had me go talk to (resident #11) about what had happened. Resident became upset and stated, 'I don't want to get him in trouble so I guess it is ok' and she began to get upset. I told her it was ok she did nothing wrong but I just wanted her to feel comfortable and make sure she was ok. Resident began to cry after I left the room and saying, 'I didn't mean to get anybody in trouble. I wish he wouldn't have done that.' (DON and ADON) (sic) were contacted about what (resident #11) said. They advised me to bring (resident #14) up to the nurse's station and keep an eye on him and to contact (geri-psych) to see if they had a opening for him. Resident was asked to come to nurse's station which he did. (LPN #3) contacted (resident #14's family member) after (DON) advised us to call him. I contacted (geri-psych) and they were not able to accept him at this time but they advised for us to keep an eye on the resident and to call the police. DON (sic) was notified of what (geri-psych) had advised and that they were unable to accept him. (sic) (DON) (sic) said to continue to keep an eye on the resident. (Resident #14) is currently in his room . A progress note, dated 04/09/17 at 5:45 p.m., documented, Behavior Note .What was the behavior? resident was witnessed inappropriately touching another resident in the dining room. The incident was witnessed by myself and another staff member . What was the resident doing just prior to the onset of the behavior? eating his dinner. When he finished his dinner he went up to the female resident . What non-pharmacological approaches were attempted to reduce/resolve the behavior? resident had been talked to by the DON and the police about his actions on the previous day . What were the effects of the non-pharmacological interventions? non effective . Did the behavior resolve? no . What interventions are in place to prevent recurrence? Resident is on hourly checks . Was the physician notified? yes by DON . Was the family/responsible party notified? yes by LPN . A progress note, dated 04/10/17 at 9:37 a.m., documented, .Misc. Note .Emergency Care Plan meeting held with (resident #14) and nephew .nephew present with permission of resident .The care plan meeting was held due to witnessed inappropriate touching to female residents breasts. (Resident #14) admitted to touching inappropriately but stated that one female thanked him for touching her. ADON stated to him that she had talked with the females and they were very upset and did not like him to touch them. At that time (resident #14) agreed that this was an an issue and that in was (sic) willing to go to treatment for [REDACTED]. On 04/19/17 at 9:40 a.m., the administrator was asked to provide the investigation documentation for the allegation of abuse for resident #14 and #10. On 04/19/17 at 10:10 a.m., the ADON provided the investigation information. The investigation information included copies of a resident room roster which was identified as documentation of interviews with all the residents. She stated residents with asterisks by the name were involved in the incident. The residents identified were #10 and #11. The investigation information included a handwritten note at the top of the resident room roster which documented female resident interviews were conducted on 04/10/17. The interviews revealed 41 of 45 female residents denied experiencing inappropriate touch from another resident. There was no documentation for four of the female residents listed on the room roster. The investigation information included a form from the local fire and police department dispatch log, dated 04/08/17 at 8:00 p.m., which documented, .DON @ (Name withheld) need to speak to officer .8:07 p.m., arrived at scene .8:25 p.m .everything had been taken care of . The investigation information included a form titled, weekend nursing assignment, dated 04/08/17, which documented a handwritten statement, .(Resident #14) verbal staff interviews .witness to inappropriate behavior . The ADON stated the form documented 15 of 22 staff were interviewed and denied to have ever witnessed inappropriate touching of resident to resident. On 04/19/17 at 4:34 p.m., the DON was asked to provide all documentation regarding the incidents involving residents #14, #10, and #11. On 04/19/17 at 5:25 p.m., the ADON was asked who was responsible for investigating complaints and allegations of abuse. She stated it was usually her. On 04/19/17 at 5:15 p.m., CNA #2 was asked if the facility had assigned staff to do one on one close supervision with a resident. He stated recently and identified resident #14. He was asked what was meant by one on one close supervision. He stated staff was to be within arms reach of the resident at all times, and resident #14 was not to be around female residents. He was asked when one on one close supervision had been started for resident #14. He stated he was not sure, but it continued until the resident was transferred out of the facility. He was asked where the one on one close supervision was documented. He stated the CNAs did not document. He was asked how one on one close supervision was documented. He stated the CNAs reported to the nurse and he thought the nurse documented in the progress notes. On 04/19/17 at 5:30 p.m., the ADON provided copies of a hourly log used to document resident #14's location beginning 04/08/17 at 8:00 p.m., through 04/11/17 at 8:00 a.m. On 04/20/17 at 11:10 a.m., the DON and ADON were asked if there was a facility incident report completed for the allegation involving residents #14 and #10. The ADON stated the facility utilized the OSDH Incident Report form. The DON was asked what the time was when the incident occurred involving resident #14 and #10. She stated she was unable to locate an incident report, but thought it had occurred during supper time. The DON was asked who resident #10's table mates were. She identified resident #57. The DON and ADON were asked if the residents were interviewed. The ADON stated she had interviewed everyone. She was asked when the interviews were conducted. She stated on 04/09/17. She was informed the resident roster had been dated for 04/10/17. She stated the interviews were conducted the Monday, after the incidents, which had occurred on 04/08/17 and 04/09/17. The ADON was asked who the CNA was identified in the state reportable as witnessing the incident which occurred 04/08/17. She stated the LPN was the witness, and would have to look at notes. She stated CNA#6. The DON and ADON were asked for any documentation of the encounter with the local police officer who visited the facility. The ADON reported the officer had spoken to resident #14, the DON, and herself. She stated there was no documentation. On 04/20/17 at 11:40 a.m., the ADON was asked were staff and resident interviews documented. She stated interviews were conducted in person and documented on scrap paper and discarded after information was included in the incident report summary. She was asked who was interviewed. She stated only those directly involved in the incident were interviewed. At 11:43 a.m., the corporate RN stated not everyone was interviewed due to the confidentiality of the investigation. The ADON was asked who the facility's designated abuse coordinator was. She stated the administrator. On 04/20/17 at 11:45 a.m., the administrator was asked what was involved with an abuse investigation. She stated when an allegation was reported the facility would immediately notify the resident's physician and family. Unless directly involved, the facility did not obtain additional interviews so as to protect the complainant and others. The facility then started the process of investigation while residents were being monitored. On 04/20/17 at 11:48 a.m., the ADON was asked what time residents were in the dining room for lunch. She stated lunch was served at 11:30 a.m., and most residents were there before then. She was asked if resident #14 was monitored in the dining room on 04/09/17 from 11:00 a.m. to 12:00 p.m. She stated she was not on duty and could not say if resident was under direct supervision. She was asked why it was documented that resident #14 still placed clothing protectors on female residents at lunch. She stated LPN #5 would have to be interviewed. She was asked what the facility did to protect the female residents. She stated resident #14 was watched closely, and after the second incident, he was to be within arms reach of staff. She was asked how the facility had provided protection for resident #11. She stated staff had been present but unable to prevent resident to resident contact. She was asked if an investigation had been conducted regarding resident #14 and #11. She stated the LPN on duty had interviewed resident #11 and determined the resident had not been comfortable with resident #14 touching her. She was asked if the hourly monitoring was effective in preventing resident #14 from touching other female residents. She stated he was in constant visual observation of staff. She was asked if the incident had been reported to the state agency. She stated the investigative information obtained in the incident involving residents #11 and #14 had been included in the final report sent to the state agency which involved residents #10 and #14. On 04/20/17 at 11:50 a.m., the DON was asked what the facility policy was regarding abuse. She stated the facility had a policy but she needed to review it. On 04/24/17 at 6:02 p.m., the DON was asked who was responsible for resident safety. The DON stated all the staff were responsible. She was asked if she thought the incidents were documented correctly. She stated, No. She was asked if the facility had provided safety for the residents. She stated, No.

On 04/20/17 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect residents from sexual abuse. At 2:25 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. At 2:30 p.m., the administrator and corporate staff member were notified of the IJ situation related to the facility's failure to protect residents from sexual abuse. At 7:25 p.m., an acceptable plan of removal was provided. The plan of removal documented, .Interviews of all residents with safe survey (see attached form) will be completed by 04-20-2017 at 4:00 PM by DON, ADON and MDS. Training of all staff in the areas (sic) abuse, including identification, investigation, reporting, protection, screening, training, prevention by 04-20-2017 at 3:00 PM and lasted for 30 minutes for all current staff by the corporate staff (Operations Director) and no other staff will be permitted to work until they have been in-serviced before their next scheduled shift by phone contact or in person. The information for in-service covered is attached. The in-serviced staff was asked if they had ever witnessed abuse including but not limited to physical, sexual, or mental abuse. Interviews with staff will be conducted one on one by the corporate staff, DON, ADON, Admin or MDS that ask the specific question: To your knowledge has any resident ever touched another resident in an inappropriate manner while a resident at Southern Oaks? (If yes, who did you report this to and please explain). These interviews will be completed by 2pm on 04-21-2017. Interviews will be conducted with residents in a private setting and will ask the specific question: 'Has anyone ever touched you in an inappropriate manner while a resident at Southern Oak?' 'What is your response? (sic) These interviews will be completed by 2:00 PM on 04-21-2017. An attempt will be made to contact the C.N.A. (name withheld Or who was the C.N.A.) by 04-21-2017 at 2 PM. DON or designee will: Daily review of all incidents including allegations of sexual abuse will be done with IDT by 04-20-2017 and ongoing (sic) Reviews will include protection of residents during investigations of sexual abuse (sic) Training for staff will continue on abuse including protective measures on an ongoing basis by the DON, ADON, MDS, Corporate Staff or Administrator and will include new hires on 04-20-2017 and on-going (sic) Actions will be completed by: 04-21-2017 2:00 PM and no staff will be permitted to work until they have completed the training and this training will (sic) before the start of their next worked shift. All current working staff will be interviewed about (sic) as of 02:00 PM (sic) on 04-21-2017 (sic) Administrator or designee will monitor abuse identification, screening, protection, training, and prevention and overall system as follows: Daily review allegations and incidents with investigation review with the IDT (Interdisciplinary team) for abuse and allegations of abuse and preventative measures to prevent abuse and to protect all residents (sic) Review of residents with allegations and incidents will be conducted daily and the information carried through the Quality Assurance Performance Improvement Process . The immediate jeopardy was removed on 04/21/17 at 2:00 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern level of actual harm. Based on interview and record review, it was determined the facility failed to ensure residents were free from sexual abuse for three (#10, #11, and #57) of four sampled residents reviewed for abuse and neglect. The facility failed to prevent sexual abuse perpetrated by resident #14 against residents #10, #11, and #57. The facility identified 45 female residents. A typed nurse's statement documented the nurse talked to resident #11 about the incident and the resident became upset. The statement documented the resident began to cry after the nurse left the room and said, I wish he wouldn't have done that. Findings: An undated policy, titled Abuse Prohibition Management Program, documented, .Our facility will not condone resident abuse, neglect or mistreatment or misappropriation of resident property (collectively Resident Abuse) by anyone, including staff members, other residents .or other individuals .Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault .Our facility will protect residents from harm during investigations of abuse allegations .during abuse investigations, residents will be protected from harm by the following measures: If the alleged abuse involves another resident, the accused resident's representative and attending physician will be informed of the alleged abuse incident and that the accused resident will not be permitted to make visits to other residents rooms unattended. If necessary, the accused resident's family members may be required to provide assistance in meeting this requirement .If a resident begins to exhibit inappropriate behavior, the facility must assess the resident and promptly intervene, taking appropriate action to protect other residents even if no allegation of abuse is made. Failure to do so is a deficient practice that may constitute neglect. Appropriate actions include steps such as additional supervision for aggressive residents and appropriate medical/psychiatric evaluation and treatment .the facility must reassess the aggressor's behavior and adjust the care plan accordingly. The facility must take specific steps to control the aggressor's behavior and to protect other residents .sexual activity involving a resident without specific decision-making capacity over sexual matters is reportable incident and must be addressed .The facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior . 1. Resident #10 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/30/17, documented the resident was moderately impaired in cognition for daily decision making, did not exhibit any mood or behavior problems, and required assistance with activities of daily living. An OSDH Incident Report form, dated 04/08/17, documented resident #14 was observed fondling the left breast and vaginal area of resident #10 after the evening meal. Resident #10 was assessed for injury and distress. The staff placed Resident #14 under direct visual observation and the local police department was notified. A typed statement, signed by LPN #5, dated 04/08/17 at 7:15 p.m., documented, .I went and interviewed, (resident #10) about her being touched by another resident. I asked her if anybody had given her a hug, said hi or touched her? She said 'I don't know about that.' I asked her if someone gave her a hug. She said, 'No.' I asked her if someone said hi to her. She said, 'Yes.' I asked her if someone touched her she said, 'Yes.' I asked her if she could tell me where someone touched her. She just stared at me so I asked if they touched her head, shoulder, legs or a private part. She didn't say anything but did raise her pelvis up. I asked her if when she was touched if she felt uncomfortable. She said, 'Yes.' I asked if she wanted it to happen and she said 'I don't know about that.' No, 'I don't know about that.' I asked her if she could tell me anymore and she said, 'No.' .(8:08 p.m.) Later I went back in there and asked her if she had been touched before like what had happened in the dining room by the same person? She just stared at me so I asked her again if anyone had touched her like what had happened before (sic) she said, 'Yes.' .I asked if she could tell me where she had been touched before. She just stared at me. .I asked her the question again and she just stared at me the same way. She didn't verbalize a body part or move when I gave her examples as before. .I asked her if she needed to tell me anything else and she said 'No' . A staff interview form for CNA #6, dated 04/20/17 at 8:40 p.m., documented the question if staff had any knowledge of any resident inappropriately touching another resident at the facility. The handwritten response documented, .(Resident #14) touched (resident #10) in the (sic) happened on my last night (sic) .who did you report this to .(name withheld) (LPN #4). She was walking out of the dining room and I told her what happened .She denies talking to (DON or ADON) .she said she wrote a statement . A staff interview form for CNA #5, dated 04/21/17 at 1:27 p.m., documented the question if staff had any knowledge of any resident inappropriately touching another resident. The handwritten response documented, .(resident #14) to (resident #10) referring to incident on 04-08-17 . No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview with the resident. 2. Resident #11 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/05/17, documented the resident was moderately impaired in cognition for daily decision making and required assistance with activities of daily living. An OSDH Incident Report form, dated 04/08/17, documented, .Note that during the course of this investigation, (resident #14) remained under direct visual observation/supervision by staff at all times, and advised that he was to have no contact with female residents. Subsequently, during dinner meal, resident rose to leave the dining room and as walking by table of co-resident (resident #11) in act of defiance, bent down and kissed her on the lips, and brushed her left breast with his hand while within view of supervising staff, who were unable to reach resident in time to stop him. (Resident #11) reported that this did make her 'uncomfortable', but denied injury . A typed statement signed by LPN #5, dated 04/09/17, documented, .I called (DON) and (DON) had me go talk to (resident #11) about what had happened. Resident became upset and stated, 'I don't want to get him in trouble so I guess it is ok' and she began to get upset. I told her it was ok she did nothing wrong but I just wanted her to feel comfortable and make sure she was ok. Resident began to cry after I left the room and saying, 'I didn't mean to get anybody in trouble. I wish he wouldn't have done that. (DON and ADON) were contacted about what (resident #11) said . An undated staff interview form, timed at 7:50 p.m., documented the question if staff had any knowledge of any resident who had inappropriately touched another resident. The response from the maintenance supervisor documented, .(resident #14) kissing (resident #11) when placing bib on her .also observed same behavior approximately 6 months ago, had brought up in stand-up .stated his opinion on not being appropriate . No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview with the resident. 3. Resident #57 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/09/17, documented the resident was severely impaired in cognition for daily decision making and required assistance with activities of daily living. A handwritten statement by CNA #4, dated 04/20/17, documented, .On Feb. 14, I (name withheld) was passing dinner hall tray (sic) down 100 hall. When I started down the hall I found (resident #14) with one hand on (resident #57's) shoulder and the other hand down her pants. (Resident #57) was saying no no, stop stop it. I told (resident #14) to come here to separate them. I went right to my charge nurse (LPN #6) and told her what had just happened. (LPN #6) said that she dose (sic) not know how to chart that or what to chart. We will have to go to the DON in the morning. The next morning [DATE]th I and (LPN #6) (sic) went to (DON) to report what I had seen . On 04/21/17 at 9:57 a.m., an interview with resident #57, conducted by the DON, documented, Has anyone ever touched you in a inappropriate manner . The resident responded, yes. No documentation was found in the resident's clinical record regarding the incident/allegation, assessment, or interview of the resident following the allegation. 4. Resident #14 had [DIAGNOSES REDACTED]. A care plan, updated 11/07/16, documented, .Focus .I have a (sic) verbally abusive behaviors . Interventions .Intervene as necessary to protect the rights and safety of others . Focus .I have a dx of depression . Interventions .Find a diversional activity that I enjoy doing such as walking around the parking lot for exercise, passing out bibs to other residents, reading, watching westerns,listening to western music . A quarterly assessment, dated 01/24/17, documented the resident was independent in cognition for daily decision making, exhibited no mood or behavior problems, and was independent with ambulation. A progress note, dated 04/08/17 at 8:43 p.m., documented, Behavior Note .What was the behavior? (Resident #14) was witnessed inappropriately touching another resident in the dining room. The incident was witnessed by a staff member . Did anything worsen the behavior? NA . What was the resident doing just prior to the onset of the behavior? taking bibs off of residents . What non-pharmacological approaches were attempted to reduce/resolve the behavior? asked resident not to hand out bibs or collect them by (name withheld) (DON) . Did the behavior resolve? NA . What interventions are in place to prevent a recurrence? Resident is on hourly checks and is no longer able to hand out or pick up bibs . Has [MEDICAL CONDITION] been ruled out as a cause for the behavior? Yes . Was the physician notified? yes . Was the family/responsible party notified? yes . A typed statement signed by LPN #5, dated 04/09/17, documented, .(Resident #14) was warned that he was not supposed to put clothes protectors on other residents after the allegation the evening before about touching a female resident inappropriately. Resident still place bibs on female residents during lunch. He was reminded to not be placing bibs on other residents and he returned to his chair. He again later during the lunch meal got up and continued to place bibs on other female residents. He was again told he cannot do that and I was going to call (DON) and let her know of the situation. He became mad and starting picking up bibs that had not been placed on other residents and stormed out of the dining room. DON and ADON notified of the situation (sic). Was told to keep a close eye on the resident and again talk to the resident and tell him he cannot touch another resident in any way. (Name withheld) RN talked with the resident and he said he understood. During the evening meal resident got up to leave the dining room and on his way out he stopped at (resident #11's) table gave her a sideways hug placing his hand on her breast and gave her a kiss on the side of her mouth and left. We again told him that his actions were in appropriate (sic) and could not happen and I would have to contact (name withheld) DON about the situation. Resident went on to his room. I called (DON) and (DON) had me go talk to (resident #11) about what had happened. Resident became upset and stated, 'I don't want to get him in trouble so I guess it is ok' and she began to get upset. I told her it was ok she did nothing wrong but I just wanted her to feel comfortable and make sure she was ok. Resident began to cry after I left the room and saying, 'I didn't mean to get anybody in trouble. I wish he wouldn't have done that.' (DON and ADON) (sic) were contacted about what (resident #11) said. They advised me to bring (resident #14) up to the nurse's station and keep an eye on him and to contact (geri-psych) to see if they had a opening for him. Resident was asked to come to nurse's station which he did. (LPN #3) contacted (resident #14's family member) after (DON) advised us to call him. I contacted (geri-psych) and they were not able to accept him at this time but they advised for us to keep an eye on the resident and to call the police. DON (sic) was notified of what (geri-psych) had advised and that they were unable to accept him. (sic) (DON) (sic) said to continue to keep an eye on the resident. (Resident #14) is currently in his room . A progress note, dated 04/09/17 at 5:45 p.m., documented, Behavior Note . What was the behavior? resident was witnessed inappropriately touching another resident in the dining room. The incident was witnessed by myself and another staff member . What was the resident doing just prior to the onset of the behavior? eating his dinner. When he finished his dinner he went up to the female resident . What non-pharmacological approaches were attempted to reduce/resolve the behavior? resident had been talked to by the DON and the police about his actions on the previous day . What were the effects of the non-pharmacological interventions? non effective . Did the behavior resolve? no . What interventions are in place to prevent recurrence? Resident is on hourly checks . Was the physician notified? yes by DON . Was the family/responsible party notified? yes by LPN . A progress note, dated 04/10/17 at 9:37 a.m., documented, .Misc. Note .Emergency Care Plan meeting held with (resident #14) and nephew .nephew present with permission of resident .The care plan meeting was held due to witnessed inappropriate touching to female residents breasts. (Resident #14) admitted to touching inappropriately but stated that one female thanked him for touching her. ADON stated to him that she had talked with the females and they were very upset and did not like him to touch them. At that time (resident #14) agreed that this was an an issue and that in was (sic) willing to go to treatment for [REDACTED]. On 04/19/17 at 4:34 p.m., the DON was asked to provide all documentation regarding the incidents involving residents #14, #10, and #11. At 5:15 p.m., CNA #2 was asked if the facility had assigned staff to do one on one close supervision with a resident. He stated recently and identified resident #14. He was asked what was meant by one on one close supervision. He stated staff was to be within arms reach of the resident at all times, and resident #14 was not to be around female residents. He was asked when one on one close supervision had been started for resident #14. He stated he was not sure, but it continued until the resident was transferred out of the facility. He was asked where the one on one close supervision was documented. He stated the CNAs did not document. He was asked how one on one close supervision was documented. He stated the CNAs reported to the nurse and he thought the nurse documented in the progress notes. On 04/20/17 at 11:40 a.m., the ADON was asked who was the facility's designated abuse coordinator was. She stated the administrator. On 04/20/17 at 11:45 a.m., the administrator was asked what was involved with an abuse investigation. She stated when an allegation was reported, the facility would immediately notify the resident's physician and family. She stated unless directly involved, the facility did not obtain additional interviews so as to protect the complainant and others. The administrator stated the facility then started the process of investigation while residents were being monitored. On 04/20/17 at 11:48 a.m., the ADON was asked what time residents were in the dining room for lunch. She stated lunch was served at 11:30 a.m., and most residents were there before then. She was asked if resident #14 was monitored in the dining room on 04/09/17 from 11:00 a.m. to 12:00 p.m. She stated she was not on duty and could not say if the resident was under direct supervision. She was asked why it was documented resident #14 still placed clothing protectors on female residents at lunch. She stated (LPN #5) would have to be interviewed. She was asked what the facility did to protect the female residents. She stated resident #14 was watched closely, and after the second incident, he was to be within arms reach of staff. She was asked how the facility had provided protection for resident #11. She stated staff had been present but unable to prevent resident to resident contact. She was asked if an investigation had been conducted regarding resident #14 and #11. She stated the LPN on duty had interviewed resident #11 and determined the resident had not been comfortable with resident #14 touching her. She was asked if the hourly monitoring was effective in preventing resident #14 from touching other female residents. She stated he was in constant visual observation of staff. On 04/20/17 at 11:50 a.m., the DON was asked what was the facility policy was regarding abuse. She stated the facility had a policy but she needed to review it.

Based on observation, interview, and record review, it was determined the facility failed to identify and implement interventions to aid in the healing and/or prevention of pressure ulcers for two (#1 and #8) of three sampled residents who were reviewed for pressure ulcers. This resulted in actual harm for resident #1 when her pressure ulcers failed to progress towards healing and for resident #8 when there was no treatment initiated or interventions implemented when the pressure ulcer was first identified. The facility identified three residents as having pressure ulcers. Findings: The facility's policy on the prevention of pressure ulcers, dated 08/2005, documented, "...Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation...to that area and subsequent destruction of tissue...Pressure ulcers are often made worse by continual pressure, heat, moisture...decline in nutrition and hydration status...Identify risk factors for pressure ulcer development...For a person in a chair:...Change position at least every hour...Use foam, gel or air cushion as indicated to relieve pressure...The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate...Place resident on a minimum of a q 2 hour check and change program...Residents who are able to cooperate and understand should be taught to shift weight every 15 minutes while sitting in a chair...Avoid use of wheelchairs with sling seats for prolonged periods. Consider the need for pressure relief/reducing device...Change position at least every hour and use foam, gel or air cushion as indicated to relieve pressure...Check resident for incontinence at least q 2 hours and clean skin when soiled..." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/02/13, documented the resident was severely cognitively impaired and was totally dependent on staff for bed mobility, transfers, and locomotion on and off the unit. It was documented the resident used a wheelchair for mobility. It was also documented the resident was always incontinent of bladder and bowel. It was documented the resident was at risk for developing pressure ulcers. The resident's care plan, updated 08/02/13, documented a problem, "...I am at risk for pressure ulcers..." The goal was, "...I will be free of pressure ulcers x 90 days..." Approaches were, "...I will have access to adequate hydration...I will have preventative txs administered as ordered...I will be reminded of activities that are available." A care plan update, dated 09/16/13, documented a problem, "Skin Breakdown (right)/(left) buttock Stage I." The goal was, "Resolve 1-29-14." The approaches were, "Tx per ordered, turn q 2 (hours), keep clean/dry." A nurse's note, dated 10/16/13 at 4:30 a.m., documented, "...change in skin condition. Res has open wound to bilat buttocks. Wound care protocol tx in place..." Review of the clinical record revealed no documentation of the measurements or stages of the pressure ulcers. There was no documentation of what the "wound care protocol" was. Review of the resident's care plan revealed no documentation to show the care plan had been updated to reflect the pressure ulcers. There was no goal, and there were no approaches. A weekly pressure ulcer QI log, dated 10/18/13, documented the resident had pressure ulcers to her right and left buttocks. Each pressure ulcer measured 0.3 x 0.3 x 0.1 cms. It was documented the ulcers were facility acquired. Interventions were documented as the application of dressings and the application of ointments or medications. A nurse's note, dated 10/20/13 at 11:15 a.m., documented, "...area still red. Looks closed but for tiny (1-2mm) area still open. Wound care protocol continues (with) Tena to surrounding area..." A physician's telephone order, dated 10/22/13, documented, "...clean wounds (x2) to (right and left) buttocks c WC. Pat dry apply foam dsg (and) TAO (and) cover qd until healed..." A weekly pressure ulcer QI log, dated 11/01/13, documented the right buttock pressure ulcer was 0.3 x 0.3 x 0.1 cms. It was documented the left buttock pressure ulcer was 0.3 x 0.3 x 0.1 cms. A weekly pressure ulcer QI log, dated 11/08/13, documented the right buttock pressure ulcer was 0.3 x 0.3 x 0.1 cms. It was documented the left buttock pressure ulcer was 0.3 x 0.3 x 0.1 cms. On 11/12/13 at 11:53 a.m., the resident was observed seated in her wheelchair. There was no pressure relieving device in the wheelchair. On 11/13/13 at 9:45 a.m., the resident was observed seated in her wheelchair. The wheelchair had a sling seat. There was no pressure relieving device in the wheelchair. On 11/13/13 at 9:53 a.m., CNA #4 was asked if the resident was incontinent of bowel and bladder. She stated, "Yes." She was asked if the resident had pressure ulcers. She stated, "She has two small spots." She was asked how often she checked residents for incontinence. She stated, "Every two hours." On 11/13/13 at 10:25 a.m., the resident was observed in her wheelchair in the day room. At 10:59 a.m., the resident was moved to the dining room. The resident remained in the dining room until 12:25 p.m., when she was taken to her room. She remained seated in her wheelchair. At 12:55 p.m., the resident was taken from her room to the day room for a residents' group meeting. She remained in the meeting until approximately 1:45 p.m. The resident had remained in her wheelchair, without being checked for incontinence and without a pressure relieving device, for four hours. At no time did staff encourage the resident to reposition or offer to put the resident to bed. At 2:00 p.m., the resident was observed in the shower. CNAs #2 and #3 were asked if the resident's brief was wet. They stated it was wet but not "drenched." While in the shower, the resident was incontinent of a large amount of urine. CNAs #2 and #3 provided the resident a shower. The resident's buttocks were not washed. The aides did not observe the resident's buttocks. They were asked if the resident had a pressure ulcer. They stated no. On 11/13/13 at 3:15 p.m., LPN #2 was asked how she monitored the aides to ensure they were delivering quality care to the residents. She stated she was on the hall so she just oversaw their work, and she made rounds. LPN #2 was asked how often residents should be checked for incontinence. She stated every two hours and as needed. On 11/13/13 at 3:21 p.m., the DON was asked how she monitored to ensure the staff was providing quality care. She stated she completed rounds, talked with the residents, walked up and down the halls, and monitored actions. The DON was asked what the policy was for checking for incontinence. She stated it was every two hours. She was asked what the policy was on repositioning. She stated it was every two hours or different if ordered by the physician. On 11/13/13 at 4:45 p.m., LPN #2 was observed performing a dressing change on the resident's pressure ulcers. The resident was lying in bed with no dressings on the pressure ulcers. LPN #2 was asked when the dressings were removed. She stated the dressings had been removed when the nurses were informed the surveyor wanted to see the dressing changes. LPN #2 was asked who removed the dressings. She stated LPN #1 had removed them after the resident was brought back from the shower (The resident showered at approximately 2:00 p.m.). LPN #2 was asked if the resident had been incontinent of bladder with the dressings off. She stated, "Yes." The pressure ulcer to the right buttock was located near the center of the distal end of the buttock, near the buttock crease. LPN #2 was asked to describe the pressure ulcer to the right buttock. She stated it was a stage II pressure ulcer, with the edges intact, and yellow slough in the middle. LPN #2 completed the dressing change to the right buttock pressure ulcer. LPN #2 was asked what caused the pressure ulcers. She stated, "I don't know I could say what caused them." She was asked if the facility had attempted to determine the cause. She stated, "Yes." LPN #2 was asked what reason the facility came up with. She stated she would have to look it up. LPN #2 began applying the resident's incontinent brief. She was asked if she was done. She stated, "Yes." LPN #2 was asked if the resident had one or two pressure ulcers. She rolled the resident to the right, looked at the left buttock and stated, "Looks healed to me, but I will fax the doctor." An opening, approximately 0.25 cm round, was noted in the center of the distal portion of the left buttock, near the buttock crease. LPN #2 was asked if the area was open. She stated, "I can't really tell but I will put a dressing on it. It's red." A pressure ulcer record, dated 11/14/13, documented the right buttock pressure ulcer was 1.5 cms in diameter, with an erythemic periwound that measured 3 x 2 cms. It was documented the wound was improving. The left buttock pressure ulcer was documented as being .25 cm in diameter with an erythemic periwound that measured 2 cms. It was documented the wound was improving. On 11/14/13 at 9:25 a.m., LPN #1 was asked if the resident was at increased risk for developing pressure ulcers. She stated, "Yes." She was asked what interventions were in place to aid in the healing and prevention of pressure ulcers. She stated, "Change frequently, get off of bottoms, turn side to side, off any place pressure is added." On 11/14/13 at 9:41 a.m., CNA #1 was asked what interventions were in place to help the resident's pressure ulcers heal and prevent new ones. She stated, "Not leave her in her chair, keep her clean and dry." CNA #1 was asked how often the resident should be checked for incontinence. She stated, "Check after breakfast, right before lunch. Every two hours." On 11/14/13 at 1:58 p.m., the DON and ADON were asked what type of breakdown the resident had. The DON stated they were classified as stage II pressure ulcers. She was asked when they were first identified. She stated, "Around the end of October." She was asked what caused the pressure ulcers. She stated, "(Resident #1) will not get up for activities. There are days that she will. She is requesting to go back to bed all the time. We encourage her to come out for activities." The DON was asked what interventions had been implemented to aid in the healing and prevention of pressure ulcers. She stated, "We got a treatment. We follow the treatment orders, cue her when eating, health shakes ordered." She stated risk factors had been identified on the care plan. The DON was asked what type of cushioning or pressure relieving devices were in the resident's wheelchair. She stated, "I would have to look. We did order some gel cushions a week or so ago." The DON was asked how long the resident stayed up in her wheelchair. She stated, "She is able to tell you yes or no. It's her choice." The ADON was asked if the pressure ulcers were healing. He stated, "They have been maintaining. No worse or better." The ADON was asked why there was no pressure relieving device in the resident's wheelchair. He stated, "We can get one." The ADON was asked who identified the interventions to aid in the healing and prevention of pressure ulcers. He stated, "We talk about it with therapy. It is a team responsibility." The ADON was asked why there were no measurements or descriptions of the pressure ulcers when they were first identified. He stated it was determined there was an issue with pressure ulcer documentation in October. He stated staff had been inserviced on the proper documentation and that he was now in charge of the skin program. The DON was asked if the resident's care plan had been updated to include the pressure ulcers, with a goal and approaches identified. She stated, "No." She was asked why the care plan was not updated. She stated it was during a transition between people completing the care plans. She stated, "We do update the care plans." 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden scale for predicting pressure ulcer risk, dated 06/05/13, documented a total score of 14 indicating the resident was at moderate risk for developing a pressure ulcer. A physician's orders [REDACTED]. A weekly summary form completed by a member of the nursing staff, dated 06/05/13, documented resident #8 required supervision with bed mobility, was occasionally incontinent of bowel, and frequently incontinent of bladder. The skin condition section of the weekly summary form, ulcers and other skin problems, were marked N/A. Skin treatments regarding pressure relieving devices and nutrition/hydration was left blank. The assessment form did indicate the resident was in physical and occupational therapy. Subsequent weekly summaries reviewed revealed pressure relieving devices and nutrition/hydration interventions were not addressed. Daily skilled nurses' notes, dated 06/06/13 through 06/30/13, documented the resident had decreased movement of bilateral lower extremities. A care plan, dated 06/14/13, did not include a focus, goal, or interventions related to the prevention of pressure ulcers. A Braden scale for predicting pressure ulcers risk, dated 06/30/13, documented a total score of 16 which indicated the resident was at risk for developing pressure ulcers. Daily skilled nurses' notes, dated 07/01/13 through 08/15/13, documented the resident had decreased movement of bilateral lower extremities. A skilled nursing note, dated 08/16/13, documented the resident required extensive assistance with bed mobility, toileting, and transfers. The nursing note documented, "...Swelling and dark purple bruise noted...back of R heel...c/o burning pain in RLE and foot..." Review of the care plan revealed no documentation to show the care plan was updated to include a problem or focus related to the skin. There was no documentation of any interventions to aid in the healing or prevention of pressure ulcers. There was no documentation to show the facililty notified the physician of the bruising and burning pain. A skilled nursing note, dated 08/23/13, documented, "...Blister (with) breakdown bruising on R heel. Faxed dr. for script for [MEDICATION NAME] TID..." Review of the resident's care plan revealed no documentation to show the care plan was updated to include the blister, bruising, or treatment intervention of [MEDICATION NAME] three times daily. A significant change in status assessment, dated 08/30/13, documented the resident was at risk for pressure ulcers and had no unhealed pressure ulcers at stage 1 or higher. Other areas of the assessment regarding skin conditions was left blank. A nurse's note, dated 08/30/13 at 12:10 a.m., documented, "...(right) heel purple c hematoma (and) large blister to (right) heel. Floated res heels on pillow..." A nurse's note, dated 08/30/13 at 8:45 a.m., documented, "...res c/o foot pedals on wc states they get in her way..." A weekly summary, dated 09/03/13, documented, "...Blister on R heel...Treatment in place..." Turning/repositioning was documented as a skin treatment. A physician facsimile order, dated 09/10/13, documented, "...Nursing Summary...R heel black and nacrotic (sic), area size of half dollar...Please advise..." It was documented the physician would check the wound the following day. A nursing home visit charge ticket, dated 09/11/13, documented, "...Pressure sore R heel...Plan...Tx pressure ulcer...Antibiotic oint (and) padding dressing...Con't pain meds..." A physician order, dated 09/11/13, documented, "...Place R foot in foam boot..." A care plan, dated 09/11/13, documented, "...Focus...R heel wound...Goal...Resolve...Tx per order...Float heel while in bed...Foam boot..." A quarterly assessment, dated 09/12/13, documented the resident had a BIMS of seven indicating cognition was severely impaired. The assessment documented the resident required extensive assistance with transfer, dressing, and toilet use. A physician's telephone order, dated 10/17/13, documented, "...Cleanse (right) heel c antibacterial cleanser - rinse c sterile saline (and) apply [MEDICATION NAME] oitment BID. Cover c sterile [MEDICATION NAME] (and) kling..." A weekly pressure ulcer QI log, dated 10/18/13, documented the pressure ulcer was unstageable and measured 6 cm x 5 cm. It was documented a treatment of [REDACTED]. It was documented the pressure ulcer was not acquired at the facility. A weekly pressure ulcer QI log, dated 10/25/13, documented the pressure ulcer was unstageable and measured 6 cm x 5 cm. It was documented a treatment of [REDACTED]. It was documented the pressure ulcer was not acquired at the facility. A weekly pressure ulcer QI log, dated 11/01/13, documented the pressure ulcer was unstageable and measured 6 cm x 5 cm. It was documented a treatment of [REDACTED]. It was documented the pressure ulcer was not acquired at the facility. A physician's orders [REDACTED]. A weekly pressure ulcer QI log, dated 11/08/13, documented the pressure ulcer was unstageable and measured 6 cm x 5 cm. It was documented a treatment of [REDACTED]. It was documented the pressure ulcer was not acquired at the facility. On 11/14/13 at 10:55 a.m., LPN #4 was observed completing a dressing change to the right heel on resident #8. The foam boot and dressing were removed from the right foot. A moderate amount of serous drainage was noted on the [MEDICATION NAME] dressing and no odor was detected. The wound measured 2.5cm x 3.0cm with depth not measured. An open pink wound bed was noted without slough. On 11/14/13 at 1:58 p.m., the DON and ADON were asked who identified the interventions to aid in the healing and prevention of pressure ulcers. The ADON stated, "We talk about it with therapy. It is a team responsibility." The ADON was asked why there were no measurements or descriptions of the pressure ulcers when they were first identified. He stated it was determined in October that there was an issue with pressure ulcer documentation. He stated staff had been inserviced on the proper documentation and that he was now in charge of the skin program. The DON was asked if the resident's care plan had been updated to accurately reflect the pressure ulcers, with a goal and approaches identified. She stated, "No." She was asked why the care plan was not updated. She stated it was during a transition between people completing the care plans. She stated, "We do update the care plans." On 11/14/13 at 3:30 p.m. the ADON was asked if the resident's wound was acquired in the facility and when was it first noted. He stated the resident had the wound on admission. He stated the resident had gone to the hospital and came back and on re-admission, the wound was brought to his attention. The ADON reviewed his documentation and stated she was not readmitted with the wound because the resident had gone to the emergency room and was only gone for four hours. He stated he was first made aware of the wound on 08/31/13. The ADON was asked where the wound documentation, including measurements, assessments, and monitoring, was documented. He stated when the last ADON left, the wound documentation ceased.

Based on observation, interview, and record review, it was determined the facility failed to implement interventions to aid in the prevention of weight loss for eight (#1, #3, #4, #5, #11, #12, #15, and #22) of ten sampled residents who were reviewed for weight loss. This resulted in actual harm for resident #1 who experienced a 15.86% severe weight loss in six months. The facility's Census and Conditions report identified no residents as having an unplanned significant weight loss. Findings: The facility's policy on weight assessment and intervention, dated 04/2007, documented, "...The nursing staff and the Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for our residents...If the weight change is desirable, this will be documented and no change in the care plan will be necessary...Interventions for undesirable weight loss should focus first on food...Liquid nutritional supplements, per facility formulary, may be considered if resident caloric intake remains inadequate to stabilize or increase weight. Interdisciplinary team members should consider possible interventions relevant to their discipline..." The facility's undated policy on best practices for nutrition intervention documented, "...All residents will be screened for nutritional risk upon admission, annually and when there is a significant change in condition. A clinically appropriate intervention will be implemented within 5 days so that the resident's risk can be addressed in a timely fashion...In addition, these interventions will be care planned...Weight loss - significant, unplanned...4-oz health shake with meals...care plan...Low [MEDICATION NAME]/[MEDICATION NAME] Lab Value...Add health shakes for moderate depletion and eating over 50%...Add health shakes in between meal supplementation for severe depletion...care plan..." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nutritional quarterly review/risk assessment update, dated 03/13/13 and signed by the RD, documented, "...3/13/13 wt review 204.6#. (Down 5.4% in 1 mo. PO intake (decreased) somewhat (and) refuses meal replacement. (Not) snacking as much either, per DM. Has had personal turmoil recently (and)...If further significant wt (decrease) occurs, will consider supp..." A nutrition risk assessment, dated 04/04/13 and signed by the RD, documented the resident was at moderate nutritional risk. It was documented, "...Res a moderate nutr risk (secondary to) (increased) BMI. Has had sig wt loss last month. Also wt trending (down). If further significant wt loss occurs, will consider supplementation..." Facility weight records, dated 05/02/13, documented the resident weighed 191.6 lbs (pounds or #). A nutritional quarterly review/risk assessment, dated 05/03/13 and signed by the RD, documented, "...Suggest health shakes (with) meals - Still 50 (plus) # over weight but intake (down) drastically..." A nutrition risk assessment, dated 06/06/13, documented, "...185.6#. (Down) 7.8% in 3 mo. (Down) 15.3% in 6 mo. Res going down hill rapidly - (not) eating as well. Can suggest Med Pass 2.0 2 oz TID..." A weight review, dated 07/08/13 and signed by the RD, documented, "...182.1# wt cont to trend (down). (Down) 15.8% in 6 mo. (Decrease) in function, PO intake. To be moved to asst. dining..." A weight review, dated 08/08/13 and signed by the RD, documented, "...180.2# (Down) 11.9% in 6 mo. Wt continues to trend down...Seems to be having difficulty feeding self - may need to be fed. Will speak (with) nursing..." A physician's telephone order, dated 09/04/13, documented, "...Med Pass - 2 oz @ (10:00 a.m., 2:00 p.m., and 8:00 p.m.)..." A dietary progress note, dated 09/06/13 and signed by the RD, documented, "...174#, (down) 15% in 6 mo. Eating (less than) 50% or less...Now (receiving) 2 oz Med Pass TID since 9/4 - to (sic) early to (check) efficacy. Also, [MEDICATION NAME] (increased) last mo (secondary to) (increased) [MEDICAL CONDITION]. Feel wt (decrease) may be due, in part, to that..." A dietary progress note, dated 10/04/13 and signed by the RD, documented, "...168.2#, (down) 12.2% in 6 mo. Eating varied amts w/ refusals. Wanted to lose wt but continues to do so. Per DON, res' mental status continues to decline. Had some stg 1 to bilat buttocks in mid 9/13 - now resolved. [MEDICATION NAME] added 8/21, along (with) (increase) in [MEDICATION NAME]. Suggest (increase) Med Pass to 4 oz TID..." A physician's telephone order, dated 10/04/13, documented, "...Increase Med Pass supplement to 4 oz PO TID @ (10:00 a.m., 2:00 p.m., and 8:00 p.m.)..." A nurse's note, dated 10/23/13 on the 6-2 shift, documented, "...low meal intake. Normal for res. Health shake (and) Med Pass offered. Cont c cueing (and) assist c feeding when res permits..." A nurse's note, dated 10/24/13 on the 6-2 shift, documented, "...low meal intake. Normal for res. Health shake (and) Med Pass offered. Cont c cueing (and) assist c feeding when res permits..." A nurse's note, dated 10/24/13 at 9:30 p.m., documented, "...low meal intake. Normal for res. Health shake (and) Med Pass given. Cont c cueing (and) assist c feeding when res permits..." A nurse's note, dated 10/25/13 at 4:40 p.m., documented, "...low meal intake. Normal for res. Health shake (and) Med Pass offered. Cont c cueing (and) assist c feeding when res permits..." Facility weight records, dated 10/31/13, documented the resident weighed 161.2 lbs. This was a 30.4 lb or 15.86% severe weight loss in six months. Meal intake records, dated 10/2013, documented out of 93 meals, the resident consumed the following: ~ refused - nine meals; ~ 0 - 25% - 22 meals; ~ 26 - 50% - 31 meals; ~ 51 - 75% - 23 meals; and ~ 76- 100% - eight meals. A quarterly nutritional review/risk assessment, dated 11/01/13 and signed by the RD, documented the resident weighed 161.2 lbs. It was documented by the RD that the resident had a 13.1% weight loss in six months. It was also documented the resident had wounds to the left and right buttocks. Recommendations included health shakes with meals. A physician's telephone order, dated 11/01/13, documented, "...Health shakes (with) meals PO...Multivitamin (with) minerals (one) PO qd..." A quarterly assessment, dated 11/02/13, documented the resident was moderately cognitively impaired, required limited assistance with eating, and had no weight loss of 5% or more in the last month or loss of 10% in the last six months. It was documented the resident was not on a physician-prescribed weight loss regimen. A nurse's note, dated 11/02/13 on the 6-2 shift, documented, "...(decreased) meal intake x 2, normal for this resident. Health shake (and) Med Pass offered. Monitoring to continue - cueing (and) feeding assist as allowed by res..." Laboratory test results, dated 11/05/13, documented the resident's [MEDICATION NAME] level was 10 mg/dL. Normal range was 16 - 45. The resident's care plan, last updated 11/07/13, documented a problem, "...I have a decreased appetite..." The goal was, "...I will maintain my wt x 90 days..." Approaches were, "1. supplement per orders. 2. meds per order. 3. weights per order." The care plan did not address the resident's severe weight loss or interventions related to monitoring, assisting, encouraging, or cueing. A nurse's note, dated 11/07/13 at 9:00 p.m., documented, "...new order noted for [MEDICATION NAME] 15 mg po @ hs for appetite stimulant..." A physician's telephone order, dated 11/07/13, documented, "[MEDICATION NAME] 15 mg po (one) tab @ HS for appetite stimulant..." A nurse's note, dated 11/09/13 on the 2-10 shift, documented, "...(decreased) meal intake. health shakes given c meal per dr orders..." A nurse's note, dated 11/11/13 on the 2-10 shift, documented, "...low meal intake. Health shake given c meals..." Meal intake records, dated 11/01/13 through 11/11/13, documented out of 33 meals, the resident consumed the following: ~ not available - one; ~ refused - two meals; ~ 0 - 25% - eight meals; ~ 26 - 50% - seven meals; ~ 51 - 75% - eight meals; ~ 76 - 100% - seven meals. Review of the clinical record revealed no documentation to show the resident was provided a health shake with every meal, as ordered by the physician. There was no documentation of how much of the health shake was consumed if it was offered. On 11/12/13 at 11:00 a.m., the surveyor observed the service of the noon meal. No health shakes were observed to leave the kitchen for any resident. On 11/12/13 at 11:53 a.m., the resident was observed eating her noon meal. The resident was not provided a health shake. The resident used a regular spoon to eat her meal. Her fingers had arthritic changes, and she held the spoon with the tips of her fingers. No staff was observed to encourage the resident to eat or to offer assistance. The resident consumed approximately 50% of her meal. On 11/12/13 at 4:51 p.m., the resident was observed eating her evening meal. The meal consisted of chicken noodle soup, cottage cheese, ice cream, orange juice, and Dr. Pepper. The resident was not served a health shake. The resident was observed tipping her bowl of soup to the side and bending down to drink it out of the bowl. No staff was observed to encourage the resident to eat or to offer assistance. On 11/13/13 at 9:45 a.m., the resident was observed seated in her wheelchair. She was asked if it was difficult to hold her spoon when she ate. She shook her head yes. Review of the resident's meal ticket for the noon meal on 11/13/13 revealed no documentation to show the resident was to receive a health shake. On 11/14/13 at approximately 7:10 a.m., the surveyor observed the delivery of the morning meal. Three health shakes were observed on the chilling refrigerator table in the kitchen. No health shakes were observed to be served to any resident with the delivery of the morning meal. On 11/14/13 at 8:17 a.m., the resident was observed seated in the dining room. She was observed trying to pick up a six ounce glass of water with her fingertips. After three attempts, the resident was able to take a drink of water. At 8:19 a.m., the resident's meal tray was delivered. No health shake was delivered to the resident. On 11/14/13 at 9:25 a.m., LPN #1 was asked if the resident had a weight loss. She stated it was her understanding the resident had lost weight over a period of months. LPN #1 was asked what interventions had been put into place to aid in the prevention of weight loss. She stated, "Encourage, nutritional shakes between and with meals, feed sometimes." LPN #1 was asked where the delivery of the nutritional shakes was documented. She stated, "In dietary." She was asked who was responsible for giving the health shakes to the resident. She stated, "I don't know how to answer that because we're all together in the dining room." On 11/14/13 at 9:41 a.m., CNA #1 was asked how she knew if a resident was supposed to get a health shake with meals. She stated if a resident did not eat, you were supposed to offer one. She stated, "Some come out with the trays." On 11/14/13 at 10:14 a.m., the RD was asked if she had identified any concerns with dietary recommendations not being implemented. She stated she would have to look back, but if she had concerns, she would have gone to the DON. The RD was asked where it was documented residents were receiving health shakes. She stated it was documented in the meal intake section and included with the total meal intake. The RD was asked why resident #1 did not receive her health shake as ordered by the physician. She stated she did not know why. She stated a communication slip should be sent to the kitchen, and she would check to see if there was one. The RD was asked why there was a discrepancy in the weight loss percentage that she had calculated and that the surveyor calculated. She stated she had used a different weight list. The weight list was provided. The surveyor re-calculated the weight loss percentage using the weights provided by the RD. It was determined the weight loss in six months was 15.86%. On 11/14/13 at 10:50 a.m., the DON and corporate nurse were asked how much weight the resident had lost in the last six months. The DON stated she had lost 30.4 lbs. The DON was asked what interventions had been put into place to aid in the prevention of weight loss. She stated the resident had been started on Med Pass three times per day, health shakes with meals, vitamins, and [MEDICATION NAME]. She stated labs had been drawn. The DON was asked who monitored to ensure interventions were implemented. She stated the blue copies of physician orders [REDACTED]. The DON was asked where it was documented the resident received the health shakes as ordered by the physician. She stated the consumption of the health shakes was included in the whole meal intake. The DON was asked whose responsibility it was to deliver the health shakes to the resident. She stated, "The kitchen brings it out or sends it out." The DON was asked why the resident was not receiving the health shakes. She stated, "I didn't look at her table. I can't answer that." She stated, "I will have to check with the kitchen." The DON was asked what kind of changes had occurred with the resident's hands. She stated they were arthritic changes. The DON was asked who monitored to see if the resident needed assistance with eating. She stated the nurses and aides in the dining room did. The DON was asked what the process was for implementing recommendations made by the RD. She stated the RD wrote out the recommendation and it was sent to the physician for approval. She stated the facility would follow the physician's orders [REDACTED]. The DON was asked if any concerns had been identified with the process for implementing the interventions. She stated, "The process seems to be pretty smooth." She stated interventions were usually implemented as soon as the kitchen received the communication slip. On 11/14/13 at approximately 11:00 a.m., the RD reported she could not find the communication slip for the resident. The RD was asked why no resident had received health shakes as ordered by the physician. She stated it had been discovered that the meal tickets had not been printed correctly. She stated only the front side of the meal tickets had been copied and the back side was where it was documented if the resident was supposed to receive a health shake. On 11/14/13 at approximately 5:00 p.m., the DON stated she had spoke with the physician. She stated the physician had said he knew his documentation was lacking but the resident's weight loss had began as a planned weight loss. She stated the resident had been drinking many colas in one day and had expressed the desire to lose weight. The DON was asked if the weight loss had been care planned as intentional, with goals and interventions identified. She stated, "No." The DON was asked if the weight loss had been intentional, why had the recommendations for an appetite stimulant, vitamins, and health shakes been accepted. She stated it was because the weight loss started out as planned but the resident just kept losing weight. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility weight records, dated 05/02/13, documented the resident weighed 150.6 lbs. A quarterly assessment, dated 09/02/13, documented the resident had long and short term memory losses and was severely impaired in cognitive skills for daily decision making. It was documented the resident required supervision with eating and had no weight loss. The resident's care plan, last updated 09/02/13, did not address weight loss as a problem. Facility weight records, dated 10/01/13, documented the resident weighed 135.4 lbs. This was a loss of 15.2 lbs or 10% in five months. A dietary progress note, dated 10/04/13 and signed by the RD, documented, "...recent hospitalization ...Pureed diet (with) poor to fair intake (and) some refusals...refuses to be fed. Need to reinstate 4 oz Med Pass TID (and) (health) shakes (with) meals..." A physician's telephone order, dated 10/04/13, documented, "...Reinstate 4 oz Med Pass TID po...Health shakes (with) meals..." The resident's care plan was not updated to include weight loss as a problem. There was not a goal, and there were no approaches. Facility weight records, dated 10/31/13, documented the resident weighed 133.6 lbs. This was a 17 lbs or 11% weight loss in six months. A quarterly assessment, dated 11/01/13, documented the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months. A dietary progress note, dated 11/01/13 and signed by the RD, documented, "...133.6#...(down) 13.5% in 6 mo. PO intake @ x's is poor. Puree diet (with) Med Pass 4 oz reinstated 10/4/13. Only (down) 1.8# in 1 mo..." A physician's telephone order, dated 11/06/13, documented, "...D/C from hospice services...as of 11/1/13..." On 11/12/13 at 11:55 a.m., the resident was observed during the noon meal. The resident was not served a health shake. One staff member was observed to encourage the resident to eat one time. On 11/12/13 at 5:01 p.m., the resident was observed during the evening meal. The resident was not served a health shake. No one was observed to encourage the resident to eat. On 11/14/13 at 7:10 a.m., the surveyor observed the delivery of the morning meal. No health shakes were served from the kitchen. On 11/14/13 at 8:28 a.m., the resident was observed during the morning meal. The resident was not served a health shake. The DON encouraged the resident to eat but he refused. LPN #4 brought the resident a health shake and stated, "See if you can't drink all that." The resident consumed all the health shake. At 9:00 a.m., CNA #1 asked the resident if he would like another health shake. He stated, "Yep." On 11/14/13 at 10:35 a.m., the DON was asked how much weight the resident had lost. She stated he had lost 17 lbs in six months. She was asked what interventions were in place to help prevent weight loss. She stated the facility offered different alternatives for food, and the resident received supplements and health shakes. The DON was asked who monitored to ensure the interventions were implemented. She stated staff had to document the percentage of food ate by each resident, and staff walked through the dining room, talking with residents. The DON was asked why the resident was not served the ordered health shake. She stated, "I would have to look at dietary to see if it was sent out with the meals." The DON was asked why the weight loss was not addressed on the resident's care plan as a problem with goals and approaches identified. She stated, "It should be addressed on his care plan." 3. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nutrition risk assessment, dated 11/01/13 and signed by the RD, documented, "...Res @ (increased) nutr. risk (secondary to) ostomy, abnormal lab...Can suggest (health) shakes (with) meals for (wound) healing..." A dietary recommendation, dated 11/01/13, documented, "...Recommendation:...health shakes (with) meals..." On 11/12/13 at 11:00 a.m., the surveyor observed the service of the noon meal. No health shakes were observed to leave the kitchen for any resident. On 11/14/13 at approximately 7:10 a.m., the surveyor observed the delivery of the morning meal. Three health shakes were observed on the chilling refrigerator table in the kitchen. No health shakes were observed to be served to any resident with the delivery of the morning meal. On 11/14/13 at 10:14 a.m., the RD was asked if she had identified any concerns with dietary recommendations not being implemented. She stated she would have to look back, but if she had concerns, she would have gone to the DON. On 11/14/13 at approximately 11:00 a.m., the RD was asked why no resident had received health shakes as ordered by the physician. She stated it had been discovered that the meal tickets had not been printed correctly. She stated only the front side of the meal tickets had been copied and the back side was where it was documented if the resident was supposed to receive a health shake. 4. Resident #5 had current [DIAGNOSES REDACTED]. A nutrition risk assessment, dated 05/13/13, documented, "...Res is a (sic) increased nutr risk...sig 3 mo wt gain which is planned...Recg supplement..." The care plan, updated on 10/01/13, documented, "...Focus:..My weight is slowly trending down...Interventions: Assistance as I require it with meals. Provide and serve supplements as ordered..." A quarterly assessment, dated 10/04/13, documented the resident had a BIMS score of 3, which indicated the resident was severely impaired in cognition for daily decision making, needed supervision with eating, and did not have a weight loss or weight gain. The current physician's orders [REDACTED]. On 11/12/13, the noon and dinner meals were observed. The resident was not served nor offered a health shake during these meal times. On 11/14/13 at 11:10 a.m., the DON and registered dietician were asked why resident #5 had not received a health shake with meals as the physician ordered. The DON stated, "She tends not to eat them." They were asked if the resident should have been offered a health shake. She stated, "Yes, at anytime throughout the meal." The DON was asked if the care plan documented the resident refused health shakes. She stated, "Not that specifically." 5. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated 08/20/13, documented the resident had a BIMS score of ten which indicated the resident was moderately impaired in cognition for daily decision making, was totally dependent for ADLs, needed extensive assistance with eating, and did not have a weight loss or gain. On 11/12/13, the lunch and dinner meals were observed. The resident did not receive a health shake with both meals. On 11/14/13 the breakfast meal was observed. The resident did not receive a health shake. On 11/14/13, the DON was asked why resident #11 was at the feeding table. She stated, "She had a significant stroke a while back, and she is just now getting more alert. It has been very slow." She was asked why the resident had not received a health shake as ordered by the physician. The DON was shown the resident's dietary intake documentation which did not have a dietary shake documented. She stated, "Ok." 6. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 01/14/13, documented the focus of "...I am at risk for increased weight loss... The goal was, "...I will remain comfortable..." The intervention was "Health shakes as ordered." Facility's weight records, dated 05/2013, documented the resident weighed 117 lbs. The annual assessment, dated 08/27/13, documented the resident had behaviors, depression, was non-ambulatory, and required assistance with all ADLs. Facility weight records, dated 09/2013, documented the resident weighed 112.4 lbs. The physician's orders [REDACTED]. Facility weight records, dated 11/2013, documented the resident weighed 111.2 lbs. On 11/12/13, during the noon and evening meals, the resident was observed. She did not receive a health shake. On 11/13/13, during the noon meal, the resident did not receive a health shake. On 11/14/13 at 10:50 a.m., the DON was asked if any concerns had been identified with the process for implementing dietary interventions. She stated, "The process seems to be pretty smooth." She stated interventions were usually implemented as soon as the kitchen received a communication slip. 7. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. An annual assessment, dated 10/22/13, documented the resident needed minimal assistance with ADLs, was cognitively impaired, and was depressed. A [MEDICATION NAME] laboratory result, dated 10/17/13, documented the [MEDICATION NAME] was 17. Normal level range was 18 - 45. The resident was observed with his meals at lunch and supper on 11/12/13 and breakfast on 11/14/13. The resident did not receive the large portions of meat. On 11/13/13 at 11:00 a.m., cook #1 was asked if any resident received large or double portions of food and she stated, "No." She was asked if a protein powder supplement was given to residents. She stated, "No. We don't have protein powder in the kitchen." 8. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility weight records, dated 08/2013, documented the resident weighed 119.2 lbs. A physician's orders [REDACTED]. A quarterly assessment, dated 10/21/13, documented the resident required extensive assistance with ADLs, was incontinent of bowel, mood score of 15 related to depression, no skin issues, and had an indwelling catheter. The care plan, updated 10/21/13, addressed a focus of nutritional status. The interventions were an appetite stimulant, offer snacks, and provide health shakes with all meals. Facility weight records, dated 10/2013, documented dthe resident weighed 114.8 lbs. Resident #4 was observed during the breakfast meals on 11/13/13 and 11/14.13. She ate in her room. The resident ate an average of 50% of her meals and did not receive a health shake. The resident stated she did not have much of an appetite. On 11/14/13 at 10:50 a.m., the DON was asked if any concerns had been identified with the process for implementing dietary interventions. She stated, "The process seems to be pretty smooth." She stated interventions were usually implemented as soon as the kitchen received a communication slip.

Based on observation, interview, and record review, it was determined the facility failed to: A. Assess and monitor resident's pain and ensure pain medication was administered prior to painful pressure ulcer treatments for one (#8) of three sampled residents whose pressure ulcer treatments were observed. This resulted in actual harm for resident #8. The facility's census and condition report identified three residents with pressures ulcers. B. Provide bowel incontinence care and urinary catheter care in a manner that prevented infection for one (#3) of three sampled residents with urinary catheters. The facility identified three residents as having urinary catheters. Findings: The facility's policy on suprapubic catheter care, dated 09/2005, documented, "...The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract...Wash and dry your hands thoroughly...Put on disposable gloves...Remove gloves...Wash and dry your hands...Reposition the bed covers..." The facility's policy on infection control standard precautions, dated 12/2007, documented, "...Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another...Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments..." The facility's clinical protocol regarding pain, dated 04/2007, documented, "...Assessment and Recognition...Includes a review of known [DIAGNOSES REDACTED]. and consequences of pain at regular intervals..." The facility's policy and procedure for administering pain medications, dated 04/2007, documented, "...The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering non-narcotic or narcotic [MEDICATION NAME] the resident's care plan to assess for any special needs of the resident...Be familiar with the physiologic and behavioral signs of pain...Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained...Obtain subjective information from the resident...Location...Pain intensity...Pain quality...Onset and duration...Aggravating factors...Alleviating factors...Accompanying symptoms....Objective information...Behavioral responses to pain...Facial wrinkling/grimacing...Crying or moaning...Administer pain medications as ordered..." 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 06/14/13, documented, "...Focus...I have chronic pain...Goals...I will not have an interruption in normal activities due to pain through review date... Interventions...Anticipate my need for pain relief and respond immediately to any complaint of pain... Medications as my Dr. has ordered document response..." A skilled nursing note, dated 08/16/13, documented, "...Swelling and dark purple bruise noted...back of R heel...c/o burning pain in RLE and foot..." A skilled nursing note, dated 08/23/13, documented, "...Blister (with) breakdown bruising on R heel..." A significant change in status assessment, dated 08/30/13, documented the resident had received scheduled pain and PRN pain medication. The assessment documented the resident had experienced frequent pain with intensity rated eight on a scale of one to ten. A weekly summary, dated 09/03/13, documented, "...Blister on R heel...Treatment in place..." A physician facsimile order, dated 09/10/13, documented, "...Nursing Summary...R heel black and nacrotic (sic), area size of half dollar...Please advise..." A nursing home visit charge ticket, dated 09/11/13, documented, "...Pressure sore R heel...Plan...Tx pressure ulcer...Antibiotic oint (and) padding dressing...Con't pain meds..." A physician order, dated 09/11/13, documented, "...Place R foot in foam boot..." The care plan, dated 09/11/13, documented, "...Focus...R heel wound...Goal...Resolve...Tx per order...Float heel while in bed...Foam boot..." A quarterly assessment, dated 09/12/13, documented the resident had a BIMS of seven indicating cognition was severely impaired. The assessment documented the resident required extensive assistance with transfers, dressing, and toilet use. A physician's orders [REDACTED]. A physician's orders [REDACTED]...2 Tabs (100 MG) by Mouth Every 6 Hrs. As Needed For Pain Not To Exceed 6 Tabs/24 Hrs..." A pain evaluation, dated 10/29/13, documented the resident had a [DIAGNOSES REDACTED]. The evaluation documented frequent aching pain of the right heel with nonverbal/noncognitive signs of grimacing/distorted face, frowning/scowling, wrinkled brow, turned down mouth, and moaning. A physician's orders [REDACTED]. On 11/14/13 at 10:55 a.m., LPN #4 was observed completing a dressing change to the right heel of the resident. The foam boot and dressing were removed from the right foot. A moderate amount of serous drainage was noted on the [MEDICATION NAME] dressing, and no odor was detected. The wound measured 2.5cm x 3.0cm with depth not measured. An open pink wound bed was noted without slough. LPN #4 took a 4x4 sponge saturated with wound cleanser and began wiping the wound in a circular motion. As she began to cleanse the wound the resident began to flinch, wrinkle her brow, and moan stating, "Oh." The LPN asked, "Are you Ok?" The resident was observed in discomfort. The LPN applied the [MEDICATION NAME] and dressing. As the LPN left to wash her hands, the surveyor asked the resident if she had been given pain medication prior the dressing change. She stated, "No but I could have it if I ask for it. I don't like to take pills but I would now." At 11:10 a.m., the LPN returned and the resident asked, "You think I deserve a pain pill?" The LPN asked the resident on a scale of one to ten how she would rate her pain. The resident stated, "Five." The LPN stated, "I'll go tell the med aides, Ok?" The resident stated, "Oh!" She was breathing heavy with a grimacing look on her face. LPN #4 was asked if she assessed for pain prior to dressing changes. She stated, "Usually not." She was asked what she would do if a resident was in pain during a dressing change. She stated, "Continue, I feel it's best to get it done." She stated if she did not cover the wound, bacteria would enter the wound. She was asked what she would do next time a resident was experiencing pain. She stated next time she would give pain medication ahead of time and wait 30 minutes. LPN #4 was asked if she knew what the facility's protocol was for pain and dressing changes. She stated, "No ma'am, I do not." At 4:04 p.m., the DON was asked what the facility's policy was regarding assessing pain related to pressure ulcer dressing changes. She stated pain was assessed anytime there was signs and symptoms of pain. She stated the policy was general and depends on the resident. She was asked what she expected staff to do if a resident began exhibiting signs of pain during a dressing change. She stated, "Call on other staff, call the medication aide, or do position changes." She stated, "Stop immediately until the pain is relieved." She was asked what the current standard of practice was related to pain management with pressure ulcers and dressing changes. She stated, "Alleviate the pain before the procedure." She was asked how she monitored her staff to ensure residents' pain was managed. She stated she would do rounds, she talked to residents, and had came in on different shifts. She was asked when she last observed a staff member during a dressing change. She stated, "A week, maybe." The DON was informed of the dressing change observation and the pain the resident was experiencing during the procedure. She was also made aware that the LPN did not assess for pain prior a dressing change. She stated, "That nurse needs a little re-education." 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital admission history and physical, dated 09/09/13, documented, "...Urinalysis shows a clear yellow specimen...3+ blood, 2+ blood, 2.0 urobilinogen, 3+ leukocyte esterase, 20 to 30 white blood cells per high power field, 3 to 6 red blood cells and 2+bacteria..." A hospital discharge summary, dated 09/11/13, documented, "...Final Diagnosis: [REDACTED]. A urinalysis with culture and sensitivity, dated 10/26/13, documented the following: Blood - 1+ (normal - negative); Leukocyte Esterase - 3+ (normal - negative); [MEDICATION NAME] - positive (normal - negative); RBCs - 10-20 (normal - none); and WBCs - greater than 150 (normal - none). It was documented the specimen had greater than 100,000 CFU/ML of gram negative rods and had morganella morganii. A significant change assessment, dated 11/01/13, documented the resident had long and short term memory problems and was severely cognitively impaired for daily decision making. It was documented the resident was always incontinent of bowel. On 11/13/13 at 9:42 a.m., the resident was observed in the day room, seated in his chair. He remained there until 11:55 a.m. At that time, the resident was taken to the dining room. At 12:55 p.m., the resident was taken back to the day room. At 2:42 p.m., the resident remained in the day room. For a total of five hours, the resident remained up in his chair and was not checked for bowel incontinence. On 11/13/13 at 2:45 p.m., CNA #4 was asked when the resident was last checked for incontinence. She stated, "We laid him down after breakfast. It was before lunch. It was early." She stated, "My partner checked him." CNA #4 was asked when she checked the resident. She stated, "After lunch." She was asked where the resident was when he was checked for incontinence. She stated, "In the chair." CNA #4 was asked how she checked the resident for incontinence while he was up in the chair. She stated, "I checked his brief." She was asked how she checked the brief. CNA #4 stated, "I guess you can't." On 11/13/13 at 2:48 p.m., CNAs #5 and #6 were observed performing incontinent and urinary catheter care for the resident. The CNAs entered the room, washed their hands, and applied gloves. CNA #6 obtained one washcloth from the resident's bathroom. CNA #5 left the room without removing her gloves and returned with a mechanical lift. She entered the room with gloves on. CNAs #5 and #6 transferred the resident to his bed using the lift. Without changing their gloves or sanitizing their hands, the CNAs began to provide care. The resident's brief was loosened. Smears of dried bowel movement were noted on each side of the gathered edges of the brief that were located near the resident's rectal area. The CNAs were asked if the smears were bowel movement. CNA #6 stated, "Yes." Particles of a light brown substance, too numerous to count and approximately the size of large grains of sand, were noted on the resident's buttocks, groin, and scrotal areas. CNA #6 was asked what the substance was. She stated, "When he has a BM, it's real sandy. It's hard to get off." The resident was lying on his right side. CNA #6 moistened the washcloth with peri wash and washed the right buttock, the left buttock, and the rectal area without folding the cloth. The resident was rolled to his back. CNA #6 sprayed the washcloth again with peri wash. She wiped the resident's urinary catheter four times, without folding the cloth. A brown substance, approximately 0.25 cms round, was noted on the catheter tubing. CNA #6 scraped the substance off. Using the same washcloth, CNA #6 folded the cloth, sprayed it with peri wash, and wiped the catheter five more times, wiping in an up and down motion. CNA #6 then folded the cloth, sprayed it with peri wash, and wiped the left groin twice and then the right groin. The light brown particles were observed in the groin folds on each side. A new brief was placed on the resident. Without sanitizing her hands or changing gloves, CNA #6 readjusted the resident's bed linens and pillow, pulled up the half side rails, and placed the resident's call light on his bed. At 3:09 p.m., CNA #6 was asked why she used only one washcloth to perform the care. She stated she thought about it half way through the procedure and knew she should have used more wash cloths. CNA #5 was asked why she did not change her gloves after retrieving the mechanical lift. She stated she should have. CNA #6 was asked if any one at the facility had ever observed her performing incontinent care and catheter care. She stated, "No." CNA #6 was asked how the catheter should be cleaned. She stated in one motion, down the catheter. She was asked what the purpose of changing gloves and washing or sanitizing her hands was. She stated it was to prevent infection. On 11/13/13 at 3:15 p.m., LPN #2 was asked how she monitored the CNAs to ensure they were delivering quality care. She stated she was on the hall so she just oversaw them and made rounds. LPN #2 was asked what the policy was for performing incontinent checks. She stated, "Every two hours and as needed." She was asked what the expectation was if a resident refused to be checked. She stated staff should try a different approach or get someone else to try. She was asked if the resident refused to have incontinent checks done. She stated, "Not usually." On 11/13/13 at 3:21 p.m., the DON was asked what the facility's policy was for checking for incontinence. She stated, "Every two hours." The DON was asked how the staff checked the resident for incontinence since he was up in the chair for five hours. She stated, "They should have checked him." The DON was asked if skills proficiency checks were completed for the CNAs prior to them being allowed to work independently with residents. She stated, "No."