Every finding on record at Stigler Nursing & Rehab

Based on record review and interview, the facility failed to ensure a RN was in the facility 08/2025 through 09/2025 at least eight consecutive hours a day, seven days a week.The administrator identified 54 residents resided in the facility. Findings: A PBJ [Payroll Based Journal] Staffing Data Report, dated 07/01/25 through 09/30/25, showed no RN hours on 08/25/25, 09/19/25, 09/24/25, and 09/25/25. A form titled DON TIME LOG, dated 08/2025, did not show the DON worked on 08/25/25. The DON stated they were considered the eight hour a day RN coverage Monday through Friday for the facility. A form titled DON TIME LOG, dated 09/2025, did not show the DON worked on 09/19/25, 09/24/25, or 09/25/25. The DON stated they were considered the eight hour a day RN coverage Monday through Friday for the facility. A nurse staff schedule for 02/2026 showed the DON was considered the eight hour a day consecutive RN coverage for the facility Monday through Friday. On 02/11/26 at 2:22 p.m., the DON reviewed the DON time log and stated they must have failed to sign the log when they worked on 08/25/25, 09/19/25, 09/24/25, and 09/25/25. The DON stated they were considered the eight hour a day RN coverage for those days.

Based on record review and interview, the facility failed to ensure residents were provided with advance directive information for 2 (#5 and #10) of 24 sampled residents reviewed for advance directives.The administrator identified 54 residents resided in the facility.Findings: A facility policy titled Health, Medical Condition and Treatment Options, Information Resident of, dated 12/2022, read in part, Residents will be informed of their health, medical condition and options for treatment and/or care.Right to formulate an advance directive upon admission and/or if the resident requests to complete an advance directive after admission. 1. A physician order tab in the electronic medical record showed Resident #5 was admitted to the facility on [DATE]. A review of the electronic health records for Resident #5 showed no advanced directive acknowledgement form. A physician order for Resident #5, dated 02/04/26, showed the resident's code status was do not resuscitate. On 02/11/26 at 1:30 p.m., the administrator stated a signed advance directive acknowledge form was not located for Resident #5. The administrator stated advanced directive information was provided and obtained with admission. The administrator stated the advance directive acknowledgement form for Resident #5 was not part of their clinical record. 2. An undated Advance Directive Acknowledgement form for Resident #10 was not marked to show the resident had executed an advanced directive or had not executed an advanced directive. The form did not have a signature by the resident or resident representative. On 02/10/26 at 9:27 a.m., the administrator stated Resident #10 had been at the facility for several years prior to the current staff managing the facility. On 02/10/26 at 10:47 a.m., the SSD stated no other documents for Resident #10 had been found regarding their advance directive or acknowledgement. On 02/11/26 at 8:04 a.m., the SSD stated they were unable to locate a signed copy of the advance directive or acknowledgement of advance directive for Resident #10.

Based on record review and interview, the facility failed to ensure residents who were discharged from Medicare Part A skilled services, had benefit days remaining, and remained in the facility were issued SNF ABN and NOMNC notices for 1 (#23) of 3 sampled residents reviewed for beneficiary notices. The MDS coordinator identified nine residents discharged from Medicare Part A skilled services with benefit days remaining in the past six months. Findings:A ''SNF Beneficiary Notification Review form, dated 02/10/26, showed Resident #23 was admitted to Part A skilled services on 10/23/25, discharged from Part A skilled services on 12/19/26, and remained in the facility. The form showed Resident #23 was not provided with a SNF ABN or NOMNC notice.On 02/10/26 at 12:55 p.m., the MDS coordinator stated SNF ABN and NOMNC notices were not provided to Resident #23 but should have been per regulations.

Based on observation, record review, and interview, the facility failed to ensure staff served food in a manner that would reduce the risk of cross contamination during one of one kitchen observation. The DM identified 53 residents received meals prepared by the kitchen and one resident who received nutrition via peg tube. Findings: On 02/11/26 at 12:00 p.m., meal service was observed. CNA #1 approached the kitchen window to obtain a meal prepared by the dietary staff. The dietary staff prepared a plate, desert dish, and drinks for the staff to transport to a resident's table. CNA #1 picked up the uncovered meal plate and the desert dish in each hand. There were two drink glasses remaining to be transported. CNA #1 picked up the glasses by the rims using their third, fourth, and fifth fingers of each hand and transported the meal the resident's table. CNA #2 approached the kitchen window to obtain another resident's meal. CNA #2 picked up the uncovered plate and placed the desert dish in the middle of the plate touching the food items. CNA #2 then picked up two drink glasses with the same hand by grasping one glass at the bottom of the glass using their thumb and first finger and grasping the other glass by the rim using their third, fourth, and fifth fingers and transported the meal the resident's table. An undated Food & Nutrition Infection Control policy, read in part, Never touch eating surfaces of plates, inside of bowls, rims of cups or glasses, or food-contact ends of utensils.Do not stack bowls on cups or glasses. On 02/11/26 at 12:02 p.m., CNA #1 stated they should have used a tray to transport the meal from the kitchen window to the residents' table and not handle the residents' glasses by the rims. On 02/11/26 at 12:03 p.m., CNA #2 stated they should not have placed the desert container on the residents' plate touching the food. CNA #2 stated the desert container that touched the food was an infection control concern. On 02/11/26 at 12:03 p.m., the DM stated the facility staff should have used a tray to transport the plate, desert, and drink glasses to the tables. The DM stated the staff should not have handled the glasses by the rim or place desert containers on plate in the food. On 02/11/26 at 12:10 p.m., the DON stated the staff should observe infection control practices when they transported meals to the residents. The DON stated the food containers should not have touched the food and staff should not have handled to glasses by the rims.

Based on observation and interview, the facility failed to ensure walls were kept clean for 1 (room [ROOM NUMBER]) of 1 room observed for infection control concerns.The administrator identified 54 residents resided in the facility. Findings: On 02/05/26 at 1:30 p.m., room [ROOM NUMBER] was observed. There was 3 to 4 inches of the base board pulled away from the bottom of the wall next to the bathroom door. There was a moderate amount of a black substance on the wall under and around the base board. On 02/05/26 at 1:40 p.m., housekeeper #1 stated they had worked at the facility for three months. Housekeeper #1 stated the black substance on the wall looked like mold. They stated it had been that way since they have worked at the facility. Housekeeper #1 stated they had tried to clean it off the wall several times, but it would not come off. On 02/11/26 at 10:46 a.m., the maintenance supervisor stated the black substance looked like mold. They stated they used spackling to adhere the base board back to the wall and around the skirting. They stated the spackling did not remove the mold, only covered it up. They stated it should have been cleaned off the wall.

On 07/31/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #1, who was at risk for elopement, did not elope from the facility. Res #1 admitted to the facility on [DATE] with diagnoses including dementia. Res #1 eloped from the facility on 06/29/24 without staff knowledge and was returned to the facility by a community member. The facility did not complete one-on-one monitoring upon the Res #1's return or initiate environmental interventions for prevention. The care plan was not revised for the Res #1 and staff did not have a consistent plan to monitor and prevent elopement for the resident. On 07/31/24 at 3:00 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to elopement for Res #1. On 07/31/24 at 3:12 p.m., the administrator was notified of the IJ situation. On 08/01/24 at 12:11 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Corrective Action: Plan of Removal On 07/31/24, elopement risk assessments were initiated on all residents with care plans updated to identify any at risk residents. 1. A notification sign will be placed on front door and service door to alert visitors and vendors to not let anyone out without notifying/asking facility staff first. 2. All staff In-Serviced on elopement risk policy, ensuring that identified elopement risk residents are redirected away from doors, properly performing 1:1 monitoring, and location of list of wandering/elopement risk residents and to check list at beginning of shift. 3. MDS Coordinator in-serviced on completion of 48-hour care plans on all new admissions to include but not limited to potential for risk of elopement. 4. HR/BOM in-serviced on all newly hired personnel will be educated on elopement policy, location of list of at risk for elopement residents with an acknowledgement page. 5. Nursing Administration In-Serviced on reviewing elopement risk resident list/any new admissions and updating list accordingly 5 times weekly during clinical meeting. 6. DON/Designee will report any negative findings quarterly to QAPI. 7. Any employee that can't be reached for In-Service will be inactive and taken off of schedule until education is provided. Completed by 10 a.m. 8/1/2024 The IJ was lifted, effective 08/01/24 at 10:00 a.m., when all components of the plan of removal had been completed. The deficiency remained at a level of potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure a resident at risk for elopement did not elope from the facility for one (#1) of three sampled residents reviewed for elopement and failed to ensure treatment carts were locked. The facility assessment documented four residents who were at risk for elopement and five residents who wander. Findings: A Safety and Supervision of Residents policy, revised July 2017, documented in part Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. A Wandering and Elopement policy, revised March 2019, documented in part If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 1. Res #1 admitted to the facility on [DATE] with diagnoses including dementia. A baseline care plan was not completed. A wander risk assessment, dated 06/21/24 documented the resident was at risk for elopement. The 72 hour portion of the wander risk assessment was not completed to include history of wandering prior to admission. A progress note, dated 06/22/24 at 2:32 p.m., documented Res #1 was exit seeking. A progress note, dated 06/23/24 at 5:50 p.m., documented Res #1 was trying to get out of the facility. A progress note, dated 06/24/24 at 8:30 a.m., documented an interview with the Res #1's daughter in which the daughter notified the facility Res #1 was a flight risk. A progress note, dated 06/25/24 at 4:23 a.m., documented Res #1 continued to attempt to get out of the facility. A progress note, dated 06/25/24 at 9:51 a.m., documented Res #1 was attempting to leave the facility. The note documented the staff would continue to check on the Res #1 every two hours. A progress note, dated 06/26/24 at 7:28 p.m., documented Res #1 was attempting to get out the front door. A progress note, dated 06/27/24 at 2:25 a.m., documented Res #1 was attempting to get out the front door. An incident report, dated 06/29/24, documented the Res #1 eloped from the facility because a family member let them out. The incident report documented a sign would be placed on the door to alert visitors to not let anyone out, and the resident would be placed on one-on-one monitoring until a new wander risk assessment was completed. A witness statement, dated 06/29/24, documented the Res #1 was observed outside the facility at 1:55 p.m. A progress note, dated 06/29/24, at 2:54 p.m., documented the Res #1 had left the facility without staff knowledge and had been returned by a community member. The high temperature for the facility's location on 06/29/24 was 97 F. No wander risk assessment was documented after 06/29/24. A care plan, dated 07/03/24, documented Res #1 was at risk for elopement. The interventions documented included: Assess for fall risk, distract Res #1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Res #1 prefers: (not completed), monitor for fatigue and weight loss, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. A HOURLY RESIDENT CHECKS form, dated 06/29/24, documented a single check at 3:07. It did not document a.m. or p.m. There were no other documented checks for 06/29/24. A HOURLY RESIDENT CHECKS form was not provided for 06/30/24 from midnight to 6:15 p.m. A HOURLY RESIDENT CHECKS form was not provided for 07/02/24 from 6:00 a.m. to 6:00 p.m. A HOURLY RESIDENT CHECKS form was not provided for 07/04/24 from 6:00 a.m. to 6:30 p.m. A HOURLY RESIDENT CHECKS form was not provided for 07/05/24 from 6:00 a.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/06/24. A HOURLY RESIDENT CHECKS form was not provided for 07/08/24 from 6:00 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/09/24 from midnight to 6:00 a.m. and 6:00 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/10/24 from midnight to 6:00 a.m. and 4:30 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/11/24 from midnight to 6:00 a.m., from 10:30 a.m. to 3:00 p.m., and from 6:00 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/12/24. A HOURLY RESIDENT CHECKS form was not provided for 07/13/24. A HOURLY RESIDENT CHECKS form was not provided for 07/14/24 from midnight to 6:00 a.m. and from 6:00 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/15/24 from midnight to 6:00 a.m. and from 6:00 p.m. to midnight. No additional forms were provided after this date. On 07/29/24 at 12:00 p.m., the outer front door of the entrance to the facility was observed missing. The hinge was observed hanging from the top of the door frame. A green button to the right of the door granted entry to the facility. No signs for visitors regarding letting anyone out was observed. On 07/29/24 Res #1 was observed wandering the halls and approaching the front door several times from 12:44 p.m. to 1:25 p.m. Staff are not observed redirecting or interacting with Res #1 during this time. On 07/29/24 at 1:07 p.m., staff #1 stated Res #1 was on 15 minute visuals and was supposed to wear bright colors so they can be spotted easily. On 07/29/24 at 1:31 p.m., staff #2 stated Res #1 was reoriented, the staff check the doors to make sure they are locked, and the Res #1 is checked every 2 hours for safety. On 07/31/24 at 11:26 a.m., the staff #3 stated they knew Res #1 was at risk for elopement because they had eloped from their apartment twice before admission. They stated the 15 minute checks were only supposed to be completed during the day because Res #1 was asleep at night. When asked why some of the staff completed them at night they stated they did not have an answer for that. On 07/31/24 at 11:48 a.m., staff #5 stated there were no residents on one-on-one monitoring. They stated the 15 minute checks were not the same as one-on-one monitoring. They stated the 15 minute checks were supposed to be documented 24 hours per day. On 07/31/24 at 12:30 p.m. the staff #3 stated one on one monitoring was not completed. They stated they did not have an answer as to why the other interventions listed were not completed. On 07/31/24 at 12:56 p.m., the staff #3 stated a member of the community was the one who returned the resident to the facility. On 07/31/24 at 1:02 p.m., the staff #3 stated the baseline care plan was not completed. 2. On 07/29/24 at 12:16 p.m., the treatment cart parked on the south side of the nurses station was observed unlocked and unsupervised. The cart remained unlocked and unsupervised until 1:31 p.m. On 07/29/24 at 12:59 p.m., the treatment cart parked on the north side of the nurses station was observed unlocked and unsupervised. On 07/29/24 at 1:31 p.m. staff #2 stated the treatment carts should be locked when they are left. They stated they thought their cart was locked. They were observed locking the medication cart. On 08/01/24 at 11:04 a.m., the treatment cart parked on the south side of the nurses station was observed unlocked and unsupervised. On 08/01/24 at 11:41 p.m., the treatment cart parked on the north side of the nurses station was observed unlocked and unsupervised. On 08/01/24 at 1:00 p.m., the treatment cart parked on the south side of the nurses station was observed unlocked and unsupervised. On 08/01/24 at 1:05 p.m., staff #4 stated treatment carts should be locked when staff walk away from the cart or it is not in use.

Based on record review and interview, the facility failed to ensure RN coverage eight consecutive hours seven days per week. The Resident List Report documented 54 residents resided in the facility. Findings: Timecards from 06/16/24 to 07/31/24 documented RN coverage was not provided for eight consecutive hours on: 06/16/24, 06/17/24, 06/28/24, 07/02/24, 07/03/24, 07/04/24, 07/10/24, 07/13/24, 07/17/24, 07/18/24, 07/27/24, and 07/28/24. On 08/01/24 at 1:15 p.m., staff #4 stated there was not a RN in the building on 07/27/24 and 07/28/24. They stated they were unaware the RN on shift was clocking out before a full eight hours was worked.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for a resident with wounds for one (#1) of three sampled residents whose wound documentation was reviewed. LPN #2 identified ten residents who had wounds. Findings: Res #1 had diagnoses which included paraplegia, end stage renal disease, hepatitis c, diabetes and pressure ulcers. Wound care assessments, dated 05/22/24, documented Res #1 had pressure ulcers to their coccyx, left heel, outer right ankle, outer right foot and spinous process lower. Res #1's comprehensive care plan did not include a care plan for their pressure ulcers. On 05/23/24 at 12:32 p.m., LPN #2 reported they missed the wounds when auditing new physician's orders and reported the wounds should have been care planned.

Based on record review and interview, the facility failed to ensure wound care assessments were accurate for a resident with wounds for one (#1) of three sampled residents whose wound documentation was reviewed. LPN #2 identified ten residents who had wounds. Findings: The Pressure Ulcer Treatment policy, undated, read in part, .Suspected Deep Tissue Injury: Purple or [NAME] localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed . Res #1 had diagnoses which included paraplegia, end stage renal disease, hepatitis c, diabetes and pressure ulcers. A wound care assessment, dated 05/22/24, documented Res #1 had a SDTI (Suspected Deep Tissue Injury) of the spinous process lower. A progress note, dated 05/22/24, documented in part, .Contacted doctor about wound care and obtained orders .where slough and eschar is present on spinous process lower . A wound care assessment, dated 05/22/24, documented Res #1 had a SDTI to the coccyx with Epithelial tissue, granuation tissue, slough and nectrotic tissue present. On 05/23/24 at 12:34 p.m., LPN #2 reported the facility had a dedicated wound care nurse but the position was eliminated recently. LPN #2 reported the wound care assessments for Res #1 were not accurate with regard to staging. LPN #2 reported the wounds that were documented as SDTI should have been documented as unstageable.

Based on observation, record review, and interview the facility failed to update the comprehensive person-centered care plans to reflect the residents' current needs for four (#2, 19, 30, and #46) of 15 sampled residents whose care plans were reviewed. The administrator identified 58 residents resided in the facility. Findings: A Care Planning-Interdisciplinary Team policy, read in part, .This facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . The resident, family members, and/or legal representative are encouraged to participate in the development of and revisions to the resident's care plan . 1) Resident #2's current physician's orders dated 07/31/23, documented may apply oxygen via nasal cannula at 2-4 LPM to keep oxygen saturations above 92%. Resident #2's quarterly assessment dated [DATE] documented the resident had no cognitive impairments and was not on oxygen therapy. On 04/15/24 at 12:15 p.m., an oxygen concentrator and tubing were observed in resident #2's room and the resident reported they would use oxygen if needed. On 04/17/24 at 11:10 a.m., the MDS coordinator reported the oxygen was not captured on the MDS dated [DATE] and stated oxygen therapy was not on the plan of care but should be. They reported the resident had been on oxygen since 07/31/23. 2) Resident #19's physician's orders dated 12/13/22 documented nurse to perform nail care with showers/baths and as needed. The shower sheet dated 04/09/24 documented the resident was already getting ready for bed and did not feel like taking a shower, resident refused to sign. Resident #19's care plan dated 04/13/16 through 05/16/24, documented the resident often refuses showers, will take showers as scheduled, CNA to notify charge nurse if resident refuses showers, staff will encourage resident to take her showers on her scheduled days (Tuesday, Thursday, Saturday), staff will wake resident up at 08:30 every morning to eat breakfast and prepare for shower. On 04/16/24 at 10:09 a.m., Resident #19 reported they refused to sign the shower sheet because it was too late and they were already ready for bed when the staff asked them about a shower. On 04/16/24 at 01:01 p.m., the MDS coordinator was asked about the plan of care for showers. They reported the plan of care changed last week to 7:30 p.m., to 8:30 p.m., at night and the plan of care had not been updated, but they would update it now. 3) Resident #30's physician's orders dated 11/24/22, documented, ensure resident is wearing CPAP at night when sleeping, one time a day related to sleep apnea. The quarterly assessment dated [DATE] documented the resident had no cognitive impairments and had a diagnosis to include sleep apnea and the CPAP was not captured under special procedures. Resident #30's care plan dated 11/02/22 through 04/21/24, documented resident has a diagnosis of sleep apnea, resident will have fewer episodes of sleep apnea, encourage resident to avoid caffeinated drinks before bedtime, provide resident with a quiet room when they are ready to go to sleep. The plan of care did not document the CPAP machine or the maintenance of the equipment. On 04/17/24 at 11:24 a.m., resident #30 reported they wore CPAP at night, the CPAP machine/tubing was observed on the table next to the resident's bed. On 04/17/24 at 11:50 a.m., LPN #2 reported they were aware resident #30 had CPAP, but they did not clean or change the CPAP tubing. They reported they only changed O2 tubing once a week on Thursday. On 04/17/24 at 11:55 a.m., the MDS coordinator was asked if resident #30 had a physician's order for CPAP. They stated they did not know if they were on CPAP. They checked the physician's orders and stated yes there was an order on 11/24/22. They were asked if CPAP was captured on the quarterly MDS dated [DATE]. They stated no, it was blank. They were asked if resident #30 had a plan of care for CPAP. They stated no, it's not on the sleep apnea diagnosis. They reported the last they knew the CPAP was stored in the top of the resident's closet. 4) Resident #46's care plan dated 01/17/24, documented bolus 250 ml of Osmolyte Q 6 hours followed by 100 ml of H20. Resident #46's quarterly assessment dated [DATE], documented, resident's cognition was severely impaired, with seizure disorder, anxiety, and functional quadriplegia. Resident #46's physician's orders dated 03/13/24, documented, Jevity 1.5 every 6 hours 237 cc each feeding. On 04/11/24 at 09:06 a.m., there was no redness around Resident #46's G-tube site and they had a protector (binder) around it to avoid pulling on the tube. On 04/11/24 at 11:54 a.m., ACMA #1 reported resident #46's feeding was scheduled at 12:30 p.m., and they would administer Jevity 1.5. On 04/16/24 at 01:29 p.m., the MDS coordinator was asked when would they update the plan of care. They stated with a new order and quarterly with a new MDS. They were asked when Resident #46's Jevity was ordered and they stated it was ordered on 03/13/24. On 04/16/24 at 03:21 p.m., the IP nurse was asked when they would update a plan of care. They stated usually if a major change or when we find a major change and sometimes things are missed until the quarterly review. They reported they were responsible for the Osmolyte and sometimes more than one of staff would update the plan of care. They reported the plan of care should have been updated when they received the Jevity order. The IP nurse was asked if the protector (binder) around the Resident #46's peg tube was included on the care plan. They reported it was not care planned, but should be care planned.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#1) of four residents sampled for abuse. On 08/06/23 CNA #1 sprayed Res #1 in the face for five seconds while the resident was screaming, yelled at the resident, and then sprayed her in the face again again per witness statement and interview. CNA #1 was terminated for abuse on 08/06/23 and rehired on 09/21/23. The administrator identified 58 residents residing in the facility. Findings: A document titled, [NAME] County Nursing Center, dated 01/11/23, signed by CNA #1, read in part, .Abuse/Incident Reporting/Investigations What is reportable and actions to be taken: 1. Abuse is defined in many ways in the nursing home setting. Abuse can be physical, emotional, mental, verbal, and sexual .4. The most important thing you do is make sure all residents are safe and notify your DON, ADON, and/or Administrator . Res #1 had diagnoses which included dementia, major depression disorder, anxiety disorder, and cerebrovascular disease. A statement by CNA #2, dated 08/06/23, documented while assisting CNA #1 with Res #1's shower, CNA #1 took the spray nozzle and ran it across the resident's hair and then stalled the nozzle on the resident's face for at least five seconds. The statement documented CNA #1 then pulled the sprayer off the resident's face and said [Res #1 name withheld] stop screaming, then when the resident resumed yelling, CNA#1 sprayed her in the face again. A warning notice form, signed by the DON on 08/06/23, documented CNA #1 was terminated and was not eligible for rehire. There was no investigation completed. There was no state notification of the allegation until 10/03/23. On 09/21/23, CNA #1 applied for employment again at the long term care facility and was rehired. Per OKScreen documentation, there was no notification of rehire and no screening conducted upon rehire for 09/21/23. On 10/03/23, the administrator faxed an incident report to the state agency related to the abuse allegation on 08/06/23. An annual assessment, dated 12/26/23, documented Res #1 was severly impaired and required total assistance with all ADLs. On 01/31/24 at 12:54, an interview was conducted with the resident's family member in regard to the abuse allegations. The family member stated they were notified of the shower incident and was informed CNA #1 was terminated. They then stated someone from the facility called them while they were out of town and inform them that CNA #1 was back in the facility working with the residents. The family member stated once they were back in town they came into the facility and voiced their concerns related to CNA #1 working in the facility after being terminated for abusing their parent. The family member stated their parent was confused and totally dependent on others to assist them. The family member also stated that CNA #1 had been reported to the district attorney's office for attacking their grandchild in a local restaurant and charges were pending against CNA #1 for assault and battery. On 02/01/24 at 12:59 p.m., the administrator stated they did not know about the incident on 08/06/23 until 10/03/23. They stated they reported the abuse incident to the state at that time. On 02/01/24 at 1:23 p.m., the DON stated the abuse was reported from CNA #2 and they immediately terminated CNA #1. The DON stated they did not know they were required to report the abuse to the state within two hours of the report given to them. They stated they did not know the regulations so the report was not reported to the state. The DON stated CNA #1 was rehired after being terminated for abuse in August. On 02/01/23 at 209 p.m., CNA #2 stated CNA #1 sprayed Res #1 in the face for about five seconds and then yelled at the resident and cursed them for screaming. CNA #2 stated CNA #1 sprayed the resident in the face again. CNA #2 stated they reported the abuse immediately to the DON and then wrote a statement. On 02/01/23 at 2:15 p.m., the ADON stated CNA #1 was rehired on 09/21/23 after being terminated on 08/06/23.

Based on observation, record review, and interview, the facility failed to ensure hot water was provided for the residents for approximately a month. The DON identified 58 residents resided in the facility. Findings: An invoice dated 01/09/24, documented two inch pipes were replaced with gas line thread tape to prevent gas leaks. An invoice dated 01/15/24, documented the valve ball fitting was replaced and pipes were replaced again. An invoice dated 01/16/24, documented a water heater connector and pipe had to be replaced. An invoice dated 01/19/24, documented the couple fitting, pipes, copper caps, an adapter, and a lower and upper thermostat were replaced. An invoice dated 01/23/24, documented a lower and upper thermostat was replaced with a water heating element. An invoice dated 01/26/24, documented parts were purchased again to repair the old water heaters. The plumber replaced the water heater pump and the gate valve. Once the pump and gate valve were repaired then the valve that was replaced blew off causing damage again. The pump was replaced with copper adapter, and ball valve was replace. A gate valve was also replaced at this time. An invoice dated 01/27/24, documented a galvanized malleable pipe plug was replaced with a gate valve on the water heaters. Two invoices dated 01/30/24, documented more pipes and connectors, a p-trap fitting, and connectors were replaced on the water heaters. An invoice date 01/31/24, documented two commercial water heaters were purchased and delivered to the facility. On 01/31/24 at 11:07 a.m., an interview was conducted with the COO and they stated there was a problem with both water heaters in the building. Their company had purchased two commercial water heaters and they were going to install them as soon as the electrician was finished with rewiring to upgrade for commercial water heaters. On 01/31/24 at 12:07 p.m., an observation was made for hall #100/200 of shower temperatures at 90.3 to 90.7 F. On 01/31/24 at 1:34 p.m., an interview was conducted with Res #3 and they stated they the water was always cold but they heard there was some new water heaters being put in. On 01/31/24 at 2:18 p.m., an observation was made of the old water heater on #100/200 hallway being removed and an electrician was working to upgrade the wiring for the new commercial water heater. On 02/01/24 at 11:43 a.m., an interview was conducted with Res #2 and they stated they refused to take a shower/bath many times related to the water being ice cold. On 02/05/24 at 1:22 p.m., an interview was conducted with the maintenance man and they stated one water heater was completely rewired and installed and they were working on the other water heater. On 02/05/24 at 1:24 p.m., an observation was made of hall #100/200 shower temperature at 108.0 F. On 02/06/24 at 10:54 a.m., an interview with the activity staff was conducted and they stated the water was never out but the plumber that was working on the old water heaters had to turn the water off and on when working to repair the old water heaters in the past weeks. On 02/07/24 at 11:49 a.m., an interview was conducted with the resident's representative and they stated Res #2 had not been given a shower/bath in almost four weeks. They also stated another family member had to take Res #2 to give them a shower and wash their hair.

Based on observation, record review, and interview the facility failed to ensure residents received bathing as scheduled for four (#1, 2, 3, and #4) of four residents sampled for ADLs. The DON identified 58 residents who resided in the facility. Findings: 1. An annual assessment for Res #1, dated 12/26/23, documented the resident was severely cognitively impaired and required total assistance with ADLs. No recent bathing documentation was in medical record. 2. An annual assessment for Res #2, dated 11/01/23, documented the resident was cognitively intact and was independent with most ADLs. No recent bathing documentation was in medical record. On 02/01/24 at 11:43 a.m., Res #2 stated they refused to take a shower/bath many times related to the water being ice cold. On 02/07/24 at 11:49 a.m. an interview was conducted with a family member of Res #2. They stated the resident had not been given a shower/bath in almost four weeks. They also stated another family member had to take Res #2 to give them a shower and wash their hair. 3. A quarterly assessment for Res #3, dated 11/08/23, documented the resident's cognition was impaired and required total assistance with bathing. No recent bathing documentation was in medical record. On 01/31/24 at 1:38 p.m., the resident stated he had not had a shower as often as he would have liked. The resident stated the water is always cold. 4. A quarterly assessment for Res #4, dated 12/07/23, documented the resident was cognitively intact and required supervision with bathing. No recent bathing documentation was in medical record. On 01/31/24 at 11:07 a.m., an interview was conducted with the COO and they stated there was a problem with the both water heaters in the building. Their company had purchased two commercial water heaters and they were going to install them as soon as the electrician was finished with rewiring to upgrade for commercial water heaters. On 01/31/24 at 2:14 p.m., the DON was asked to provide documentation related to bathing for Res #1, #2, #3, and #4. The DON stated the documentation should be in the shower binder at the nurse station but had just looked for it and could not find any bathing documentation. On 02/05/24 at 1:22 p.m., an interview was conducted with the maintenance man and they stated one water heater was completely rewired and installed and they were working on the other water heater.

Based on record review and interview, the facility failed to ensure all allegations of abuse were reported within two hours and a final report with five days for one (Res #1) of four residents sampled for abuse. The DON identified 58 residents residing in the facility. Findings: A facility policy, titled Abuse and Neglect - Clinical Protocol read in part, .15. The administrator will provide in a written report of the results of all abuse investigations and appropriate actions taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident . A statement by CNA #2, dated 08/06/23, documented while assisting CNA #1 with Res #1's shower, CNA #1 took the spray nozzle and ran it across the resident's hair and then stalled the nozzle on the resident's face for at least five seconds. The statement documented CNA #1 then pulled the sprayer off the resident's face and said [Res #1 name withheld] stop screaming, then when the resident resumed yelling, CNA#1 sprayed her in the face again. On 10/03/23, the administrator faxed an incident report to the state agency. On 02/01/24 at 1:23 p.m., the DON stated they received the abuse allegation statement from CNA #2 on 08/06/23. The DON provided documentation of CNA #1's termination letter with no rehire. The DON stated they did not know they had to file a state reportable within two hours of the allegation. On 02/01/24 at 1:54 p.m., an interview was conducted with the administrator, they stated they did not know about the abuse from CNA #1 until 10/03/23 and as soon as they found out about the abuse they initiated an investigation and reported the abuse to all the appropriated authorities. On 02/01/23 at 2:09 p.m., during a phone interview, CNA #2 stated they were being trained by CNA #1. CNA #2 stated they were helping CNA #1 provide a shower for Res #1. CNA #2 stated that CNA #1 sprayed Res #1 in the face for about five seconds and then yelled and cursed the resident for screaming, then CNA #1 sprayed the resident in the face again. CNA #2 stated she reported the abuse immediately to the charge nurse, ADON, then the DON. CNA #2 stated CNA #1 was terminated and was not to be rehired. CNA #2 stated the administrator knew about the abuse allegation on 08/06/23. CNA #2 stated two weeks later they came to work and CNA #1 was working at the facility again. CNA #2 stated they asked the ADON and the DON about CNA #1 being at work and they said it was above their head.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff were available 24 hours a day who had current certification in CPR for Healthcare Providers (training to include hands-on practice and in-person skills) and maintain their certifications to be able to provide CPR until emergency medical services arrived. The facility failed to have a CPR policy and ensure staff were familiar with facility policies related to CPR. Three of the facility's 15 nurses had CPR certification, one night shift nurse who worked three shifts a week, one weekend nurse, who worked the day shift, and the administrator/RN, who was not on the schedule. No CMAs or CNAs had evidence of CPR certification. On [DATE] at 3:35 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. On [DATE] at 3:41 p.m., the administrator was notified of the IJ situation. On [DATE] at 12:14 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: [NAME] County Nursing Center February 23, 2023 On February 22, 2023 State Surveyors entered the facility to conduct a complaint survey and also an annual survey. Prior to leaving the facility on February 23, 2023 the survey team initiated an IJ template for the facility for failure to ensure that there was a system in place to ensure that there were an adequate number of staff in the facility that were healthcare provider CPR certified for each shift. The facility also failed to ensure that there was a CPR policy in place and to ensure that staff were familiar with the protocols related to providing CPR. 3 of 15 nurses were certified with only part of the facility being covered with at least one CPR certified employee in the facility at all times. All staff were required to be CPR certified upon hire and the instructor that was performing the CPR classes for the facility relocated to a job that did not allow her to continue to train our staff in CPR, therefore most staff CPR certifications expired in [DATE]. We have a nurse on staff that has completed the book work training to be certified as a CPR instructor but we have had difficulty locating an instructor to check her off for her skills and hands on training therefore we have difficulty finding someone to certify our staff in CPR. On February 23, 2023 from 1600 to 1800 Upon being given the IJ template all staff on shift were immediately inserviced by the administrator and the Director of Nursing on what to do in the event someone went into cardiac arrest, the new policies and procedures implemented by the facility regarding protocols for performing CPR, CPR certification requirements and the proper way to determine the residents code status. On February 23, 2023 from 1600 until 1800 by the assistant DON and the infection control preventionist, the remaining nursing staff were called and in serviced by phone on the proper protocols to follow regarding the proper procedures in the event a resident went into cardiac arrest, the new policy and procedures regarding CPR and CPR certification as well as the proper way to determine a residents code status. A Policy regarding CPR was immediately put into place and approved by the medical director administrator and the DON. During the Survey Process we had practical nursing students in the facility doing clinicals and their instructor informed us that she was in fact certified as a CPR instructor and that she was willing to come in on February 24, 2023, to certify the remaining nurses on staff that were not CPR certified. Therefore, All Nurses employed with our facility were instructed to present to the facility on [DATE], for CPR certification from 11 am to 2 pm. This will allow there to be a minimum of 2 Certified staff on shift at night and more than 5 certified staff on shift on days. We also scheduled all CNAs and CMAs to attend CPR training for those that just needed to renew their certification on Saturday and Sunday February 25th and 26th with classes being held from 8 am to 12 pm and 1 pm until 5 pm both days. And the following weekend from 8 am until 4 pm both with classes on both Saturday and Sunday for all staff that have not been certified previously. Another CPR certified employee was called into the facility to work tonight so that affective immediately there would not be any time that there is not several CPR certified staff on shift working ensuring that we had 24-hour coverage of staff that were CPR certified. These steps that were put into place will ensure that the 30 residents who currently reside in the facility that are full codes will be able to be provided care appropriately according to their wishes and code status ensuring that there will be staff always trained in CPR on shift. From this point forward and following the policy that the facility implemented all staff will be required to attend CPR certification with hands on training every 2 years and will be required to obtain or have their CPR certification prior to starting work or within 90 days from their hire date. The facility will comply and will have the immediacy of the deficiency of having numerous CPR certified staff on at all times twenty-four hours a day with all nurses CPR Certified and all remaining staff in-serviced, this correction will be completed by February 24, 2023, at 4pm. After completion of the correction of the immediate jeopardy, all CNAs and CMAs will attend CPR training in the weeks ahead to ensure that all nursing staff are certified. A CPR policy and Procedure was developed and implemented on February 23, 2023, and approved by the medical director, Administrator, and the DON. All staff were in-serviced and educated on the policies and protocols of the new policy by the administrator and the Director of Nurses. All staff verbalized understanding and importance of knowing the policy and procedure for the facility. All resident records also reviewed and updated with code status and if a DNR ensured a DNR was scanned into the medical record. The immediate Jeopardy will be corrected on February 24, 2023, by 4 pm. The IJ was lifted, effective [DATE] at 4:00 pm., when all the components of the plan of removal had been completed. The deficient practice remained at a pattern with potential for harm to Residents. Based on record review, observation, and interview, the facility failed to: a. ensure the availability of staff present 24 hours a day who had current certification in CPR for Healthcare Providers (training to include hands-on practice and in-person skills) and maintained their certifications to be able to provide CPR until emergency medical services arrived and b. have a CPR policy and ensure staff were familiar and trained in basic life support. The administrator identified 30 residents whose code status was full code. Findings: Upon entrance to the facility, on [DATE] at 10:30 a.m., no staff were present in the building who had certification in CPR for Healthcare Providers. On [DATE] at 10:45 a.m., the DON stated the facility did not have a policy related to CPR or CPR certification. She stated, No one is required to be CPR certified. On [DATE] at 4:25 p.m., LPN #1 stated her CPR certification had expired. She stated she was told by administration that she did not need to be certified. LPN #2 stated hers had also expired. LPN #1 and LPN #2 were the only nurses assigned to work the floor that shift. On [DATE] at 5:23 p.m., the IP/LPN stated she had completed her online training but still needed to find a trainer to do the hands on skills part. On [DATE] at 5:27 p.m., the administrator stated she had ACLS, BLS, and PALS certification which expires ,d+[DATE]. On [DATE], during record review, the IP/LPN provided the CPR for Health Care Providers certifications for the administrator/RN, LPN #3, and RN #1. She stated those were the only staff who were CPR certified. On [DATE] at 12:48 p.m., the DON and ADON were asked how the staff know the code status of a resident. The DON stated there was a list at the nurse station. She went and brought back the list of residents who had DNR status. She stated the list had not been updated. She stated it was dated back in 2021. The ADON stated she looked at the top right hand corner of the residents' EHR. During record review there were several residents' EHRs that did not have the code status at the top of their chart. The residents' code status was observed near the door of each resident. On [DATE] from 12:57 p.m. to 2:00 p.m., interviews where conducted with all staff on the halls. There were no staff who voiced they had CPR certification at this time except for two CNAs. The CNAs stated they thought their certification was still good but did not have their card with them. They said the facility had not asked them for their CPR certification card. [DATE] at 3:41 p.m., the administrator stated she did not realize CPR certification was a regulation. She stated the person who had been doing their CPR classes had stopped doing classes last year in June.

On 02/28/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; monitor and evaluate the effectiveness of the interventions; modify the care plan with each fall; conduct a root cause analyses for each fall; and communicate the interventions with all staff. Res #41 had 16 falls in four months with one fall resulting in a fractured hip. Res #41 had sustained a broken hip after six falls and only two falls had steps to prevent recurrence. Res #41 had nine falls after a hip fracture with only two of those falls having interventions to prevent recurrence. The last fall was 02/26/23. Res #24 had five falls in four months, with the forth fall resulting in a fractured hip. Res #34 had eight falls in the last four months with the last fall resulting in a 17 x 2 cm skin tear to arm. The facility failed to consistently put interventions in place to prevent falls for these residents. On 02/28/23 at 1:59 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. On 02/28/23 at 2:07 p.m., the administrator was notified of the IJ situation. On 02/28/23 at 3:58 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: February 28, 2023 On February 28, 2023, surveyors were here for annual survey and issued an IJ template regarding falls. The facility failed to ensure that residents who had fallen had fall interventions put into the resident ' s care plan to prevent the recurrence of falls. The facility failed to monitor the effectiveness of the interventions and modify the care plan with each fall. They also failed to conduct a root cause analyses for each fall and communicate the intervention with all staff. The residents affected were resident #41, 24, and 34, with the potential for all remaining residents to be at risk. The facility will correct this deficient practice by 02/28/2023 at 6 pm by in servicing all nursing staff, RNs, LPNs, CMAs, and CNAs regarding: The facility falls prevention policy. The facility Accident and Incident Policy Newly implemented fall intervention book The importance of reporting changes in resident conditions The facility incident reporting system How to review and update a care plan Perform a new fall risk assessment for all residents in the facility. Updating fall care plans for the 3 residents affected. The facility has implemented a system to consistently ensure interventions are put into place following resident falls. A root cause analyses will be performed on all 3 residents affected. From this day forth the administrator and the Director of Nurses and Compliance Officer will review all incident/accident reports daily to ensure completion with a root cause analysis established. The facility will ensure that all risk management reports have appropriate interventions added after every fall, updating care plans and fall risk assessments when needed if a resident has a fall. This monitoring will be continuous without a stop date. The IJ was lifted, effective 02/28/23 at 6:00 pm., when all the components of the plan of removal had been completed. The deficient practice remained at a pattern with for actual harm to the residents. Based on record review, observation, and interview, the facility failed to: a. ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; b. monitor and evaluate the effectiveness of the interventions; c. modify the care plan with each fall; d. conduct a root cause analyses for each fall; and e. communicate the interventions with all staff for three (#41, 24, and #34) of three sampled residents reviewed for falls. The IP/LPN identified 21 residents who had fallen in the last four months. Findings: 1. Res #41 had diagnoses which included unspecified injury of left hip, Parkinson's disease, dementia, anxiety disorder due to known physiological condition, and pain. An annual MDS assessment, dated 10/25/22, documented the resident's cognition was severely impaired; was independent with bed mobility, transfers, walking, dressing, and toileting; and required limited assistance with hygiene and bathing. The assessment documented the resident's balance was not steady but was able to stabilize without staff assistance. The assessment documented the resident had no impairment in ROM; used a walker and a wheelchair; was always continent of urine and bowel; did not have pain; and had one fall with no injury. The care plan interventions, dated 11/02/21, documented the following: a. Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. b. The resident needs prompt response to all requests for assistance. c. The resident needs a safe environment with floors free from spills and/or clutter; adequate, glare-free light; the bed in low position at night; side rails as ordered, handrails on walls, and personal items within reach. d. Ensure that the resident was wearing appropriate footwear, non-skid socks when ambulating or mobilizing in w/c. A facility incident report, dated 11/21/22 at 3:30 p.m., documented the resident was on his knees in the shower room and wheelchair was not in sight. The resident stated he wanted to use the toilet. The report documented no injuries and the intervention was for the resident to be educated to use wheelchair or when walking to use his walker during ambulation. A facility incident report, dated 11/22/22 at 10:08 p.m., documented the resident was lying on the floor beside his bed. The report documented no injuries and no interventions to prevent recurrence. A facility incident report, dated 12/05/22 at 7:50 a.m., documented the resident was sitting on floor near toilet in the common bathroom. The report documented the resident said his knees gave out when using wheeled walker. The report documented no injuries and no updated interventions. A facility incident report, dated 01/02/23 at 5:05 a.m., documented the resident was sitting on the floor near the foot of his bed. The resident stated he missed a step while walking to the bathroom. The report documented no injuries and no interventions to prevent recurrence. The resident's medical record documented the resident received Part B therapy from 01/06/23 to 01/20/23. A facility incident report, dated 01/18/23 at 12:40 a.m., documented the resident was lying on the floor in his room and the resident said he must have fallen. The report documented no injuries and no interventions to prevent recurrence. A facility incident report, dated 01/21/23 at 9:30 a.m., documented the resident was sitting in his wheelchair in the dayroom; was observed attempting to stand and walk to a recliner; and leaned forward and went to his knees. The report documented no injuries and no updated interventions. A facility incident report, dated 01/23/23 at 11:44 a.m., documented the resident was observed standing up from his w/c while in the dining room, fell backward to floor onto his left side, was sent to the hospital, and sustained a left trochanter hip fracture. The report did not documented any interventions to prevent recurrence. A discharge with return anticipated MDS assessment, dated 01/23/23, documented the resident had two or more falls with no injury and one fall with major injury. The resident's medical record documented the resident received Part A therapy from 01/27/23 to the present time. A facility incident report, dated 01/31/23 at 9:00 p.m., documented the resident was on his knees beside his bed, with no injury, and no interventions to prevent recurrence. A facility incident report, dated 02/02/23 at 4:32 a.m., documented the resident was on his knees on the fall mat, alarm in place but did not go off, and the resident had only been in bed for 10 minutes when found. The report documented no injuries and no steps to prevent recurrence. A facility incident report, dated 02/04/23 at 3:30 p.m., documented the resident was lying on his left side on the fall mat, said he rolled off the bed, with no injuries, and no interventions to prevent recurrence. The care plan intervention, dated 02/06/23, documented the resident needed to use a personal alarm on his bed and chair for personal safety precautions. A quarterly MDS assessment, dated 02/06/23, documented the resident's cognition was severely impaired; had no rejection of care behaviors; required the extensive assistance of two people with bed mobility, transfers, dressing, toileting, and bathing; did not walk; required extensive assistance of one person with mobility in a wheelchair and hygiene; and the assistance of one person with eating. The assessment documented the resident's balance was not steady and required staff assistance to stabilize; had impaired ROM on one lower extremity; was frequently incontinent of urine and bowel; had pain and received PRN pain medication; and had one fall with no injury and one fall with minor injury. A facility incident report, dated 02/07/23 at 6:01 a.m., documented the resident yelled for help, was on his left side next to bed on the mat, and stated his left hip hurt. The report documented the resident's alarm string was attached to the resident but not to the alarm box. The report documented the intervention was to wrap the call light in bright pink tape. The care plan intervention, dated 02/07/23, documented the resident had a current left hip fracture which required surgery and currently attended therapy. A facility incident report, dated 02/10/23 at 6:28 p.m., documented the resident was on knees beside his bed, removed the alarm before getting out of bed, and no injury. The report documented the intervention was to place the body alarm in a place on his clothing where he could not reach and place the resident on one on one. There was no documentation of one on one supervision. The next three facility incident reports, dated 02/12/23, 02/14/23, and 02/22/23, documented the resident was on his knees on the fall mat beside his bed, stated he rolled out of bed with no injuries, and no interventions to prevent recurrence. On 02/24/23 at 3:54 p.m., the resident was observed sitting in a recliner in lobby with feet elevated and grip socks on. The resident stated he had not fell , had not broken anything, was not in therapy, and had no pain. A facility incident report, dated 02/26/23 at 11:30 p.m., documented the nurse was answering the resident's call light and upon entering the room, the resident was sitting on his buttocks with arm upon the recliner and knees up by his chest. The report documented the resident stated he was trying to go to the bathroom and when he stood up he fell and hit his head. The report did not document updated interventions to prevent recurrence. On 02/27/23 at 2:54 pm, an observation was made of the resident's room. The resident was not in his room. The resident's twin bed was in low position with a mat on the floor at bedside. There was a bubbled air mattress overlay on top of the flat mattress. The edges of the overlay tapered off to the edge of the mattress. On 02/27/23 at 2:56 p.m., CNA #3 was asked what interventions she used to keep res from falling. She stated she took the resident to the bathroom every hour. She was asked if that intervention was communicated to her from another staff member. She stated, ''No, It was just something that she did. On 02/27/23 at 4:11 p.m., the DON was asked what the facility was doing to help prevent falls for the resident. She stated the resident was told to use his call light and we try to keep an eye on him. She stated, There is not a lot we can do. She stated it was the nurse's responsibility to came up with an intervention for a fall. She stated the nurse should document the interventions on the incident reports. She was asked about the process of the interventions getting on the care plans. She stated she was not sure and should ask the MDS coordinator for that answer. On 02/27/23 at 4:19 p.m., the MDS coordinator stated the nurses documented the interventions on the incident reports. She stated all falls should have an intervention to help prevent another fall. She stated the nurse also documents the interventions in the residents' progress notes. The MDS coordinator stated the IP/LPN goes through the nurse notes and up- dates the care plans with the interventions. On 02/28/23 at 10:38 a.m., the IP/LPN stated she had recently started to update the plans. She stated they should have an intervention for each fall. She stated if an intervention was documented in the nurse notes, then she added it to the care plan. She said it was the nurse on duty responsibility, when the resident fell , to come up with an intervention. She stated an inservice was conducted in January over falls. She stated a root cause analysis was not being conducted. On 02/28/23 at 11:32 a.m., the administrator stated she did not realize there had not been interventions for most of the falls. She stated the resident was on Part B therapy before he broke his hip and Part A after the hip fracture. She said they had removed his w/c and walker so he would not to get to them without help. She said they had done one on one with him and kept the alarm out of his reach. She stated the nurses were supposed to add an intervention with each fall. The administrator stated they had went over interventions for falls at a recent in-service. She stated the facility had not been doing a root cause analysis. 34945 2. Res #24 had diagnoses which included after care following joint replacement surgery and arthritis in the left knee. A care plan, dated 07/06/22, documented Res #24 was at risk for falls. The care plan documented interventions of keep the call light within reach and encourage the resident to use it; promptly answer all requests for assistance; and educate the resident, family, and care givers about safety reminders and what to do if a fall occurs. The care plan also documented to transfer the resident to the emergency room for a CT scan of the head and left shoulder and an x-ray of the scapula. An incident report, dated 11/06/22, documented the resident fell in the bathroom after the resident's legs gave out. The report documented the resident had not been injured and did not document interventions to prevent recurrence. The care plan was not updated at that time. An incident report, dated 11/08/22, documented the resident fell in the bathroom when his legs gave out. The report documented the resident had a skin tear to the upper right arm measuring 7 x 5 cm, a skin tear to the left hand on the index and middle finger, and a skin tear to the upper back measuring 3 x 4 cm. The report did not document interventions to help prevent future falls and the care plan was not updated. A quarterly assessment, dated 12/03/22, documented the resident was moderately impaired in cognition, independent with bed mobility, walking, locomotion, and toilet use; and limited assistance with transfer, dressing, and hygiene. The assessment documented the resident had fallen with a minor injury. An incident report, dated 12/13/22, documented the resident fell in his room sustaining a skin tear to the right forearm measuring 6 cm and skin tears to three fingers on the left hand. The entry documented the resident could not focus for neuro checks and was sent to the emergency room . The report did not document interventions and the care plan was not updated. An An incident report, dated 01/10/23, documented the resident fell in his room, fractured his hip, and pulled off a toe nail. The report documented the resident was educated to use the call light and wait for assistance prior to getting up. No care plan updates were documented. A discharge with return anticipated assessment, dated 01/10/23, documented the resident had fallen with a minor injury and a fall with a major injury. A medicare 5 day PPS assessment, dated 01/22/23, documented the resident was moderately impaired in cognition and required limited to total assistance with ADLs. An incident report, dated 01/24/23, documented the resident fell in his room while attempting to transfer himself to his wheel chair. The entry documented the resident sustained an abrasion to the left knee. The report did not document any interventions to prevent falls and the care plan was not updated. On 02/28/23 at 9:50 a.m., the resident was observed in his bed sleeping. An unidentified hospice aide was present in the room and stated she had just finished with his cares and the resident was worn out. The call light was observed on the resident's abdomen, the wheel chair was placed at the foot of the bed, a recliner was next to the bed, and a walker was placed on the other side of the recliner. An over the bed table with a urinal placed on it was out of reach of the resident. On 02/28/23 at 9:52 a.m., CNA #1 reported the resident had broke his hip from falling. The CNA stated the resident did not have any interventions to prevent falls prior to the hip fracture. The CNA stated the previous night a bed alarm was put on the resident as he kept trying to get out of bed. The CNA stated they felt the resident needed a fall mat but had not been approved for one yet. On 02/28/23 at 9:56 a.m., the MDS coordinator reported she completed this resident's care plan. She reviewed the resident's falls in November and December of 2022, and January of 2023 and agreed no new interventions to prevent the reoccurrence of falls had been documented on the care plan for Res #24. 3. Res #34 had diagnoses which included dementia, long term use of anticoagulants/antiplatelet, and persistent mood disorder. A care plan, dated 12/21/21, documented the resident was at risk for falls. The care plan documented interventions of anticipate and meet the resident's needs; keep the call light in reach and encourage the resident to use it; encourage the resident to participate in activities which promoted exercise or physician activity for strengthening and improved mobility; and ensure the resident was wearing appropriate foot wear. An annual assessment, dated 07/06/22, documented Res #34 was severely impaired in cognitive skills for daily decision making and was independent with most ADLs but required limited assistance with dressing and extensive assistance with toilet use and personal hygiene. The assessment documented the resident had a fall with minor injury. The only update to the fall care plan was dated 07/22/22. It documented the resident preferred not to wear any type of foot wear including non skid socks or shoes. An incident report, dated 10/07/22, documented the resident had fallen in her room. The report documented as a CNA stood her up to assist her to change her clothing, the resident walked away and tripped over the leg of the bedside table sustaining a 2.5 x 1.5 cm skin tear to the right elbow. There were no documented interventions and the care plan was not updated. An incident report, dated 11/21/22, documented the resident was found uninjured and sitting on the floor in her room calling mama mama after rolling out of bed. The report documented the resident was educated on not lying on the edge of the bed to avoid falling out and the resident voiced understanding. The care plan was not updated. An incident report, dated 11/27/22, documented the resident was lying on her back on the floor. The report documented the resident had become tangled in her catheter tubing and fell . The report did not document any injuries. The report documented the catheter bag was changed to a leg bag. The care plan was not updated. An incident report, dated 12/13/22, documented the staff heard the resident calling out and found the resident on the floor with a 2.5 x 1.5 cm abrasion to the left knee. No interventions were documented and the care plan was not updated. An incident report, dated 12/24/22, documented the resident had been found in the floor with her clothing down around her thighs. The report documented the resident sustained a 1 cm skin tear below the left elbow. The report documented staff were educated to ensure no slip socks were on the resident. The care plan was not updated. An incident report, dated 01/08/23, documented the resident was found in the floor on her back with redness to both knees and the right shoulder. Interventions to help prevent recurrence were not documented and the care plan was not updated. An incident report, dated 01/08/23, documented the resident was found on the floor under her bed with no injuries. The report documented the resident was instructed to use the call light when she needed help. The care plan was not updated. An incident report, dated 01/13/23, documented the resident fell in her room onto a fall mat and was not injured. The report did not document interventions for falls and the care plan was not updated. A quarterly assessment, dated 01/23/23, documented Res #34 was severely impaired in cognitive skills for daily decision making and remained mostly independent with ADLs but required limited assistance with transfer, eating, and toileting; and extensive assistance with dressing. The assessment documented Res #34 had fallen two or more times resulting in injury except major injury. An incident report, dated 01/24/23, documented the resident fell half in and out of her room and received a 2 cm laceration above her right eye, a 2 x 1 cm skin tear to the right elbow, and a 17.5 x 2 cm skin tear from her right shoulder to her right elbow. The report documented the staff were educated on non slick socks and the care plan was not updated. On 02/23/23 at 11:54 a.m., the resident was observed in the dining room at the assistive feeding table. The staff member attending to the resident was observed to leave the dining room briefly and asked another staff member to keep an eye on her. During the time the attending staff member was gone, the resident attempted to rise from her seat several times and was observed to be very unsteady. The other staff member was observed to have the resident sit back down and reassure her. On 02/27/23, between 2:44 p.m. and 2:49 p.m., three CNA's were interviewed regarding fall interventions for Res #34. All three stated the only interventions they were aware of was the fall mat beside the bed and to use a gait belt when ambulating with the resident. On 02/28/23 at 9:15 a.m., the resident was observed to get out of bed, cross her fall mat, and enter the bathroom without staff assistance. A short time later, the resident was observed back in bed. On 02/28/23 at 9:57 a.m., the MDS coordinator stated the nursing staff were to put interventions in to prevent future falls when they completed the incident reports. She stated the DON and IP received the incident reports and then brought them to her to update the care plans.

Based on record review, observation, and interview, the facility failed to have an effective administration to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to: a. ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued NOMNC notices. b. ensure a significant change assessment was completed when residents experienced a change of status. c. update the comprehensive person centered care plan to reflect the residents' current needs. d. ensure the availability of staff present 24 hours a day who had current certification in CPR for Healthcare Providers, maintained their certifications, have a CPR policy, and ensure staff were familiar with facility policies related to CPR. e. ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; monitor and evaluate the effectiveness of the interventions; modify the care plan with each fall; conduct a root cause analyses for each fall; and communicate the interventions with all staff. f. ensure a physician provided an acceptable rational for not reducing a psychotropic medication and failed to monitor for side effects of the use of psychotropic medications. g. ensure physician ordered lab tests were obtained. h. follow their COVID-19 staff vaccination policy by not ensuring staff who were to be vaccinated received all the vaccinations in the primary series. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: 1. On [DATE] at 2:18 p.m., the MDS coordinator provided an ABN notice and a form titled Determination on Continued Stay notice for Res #6 and #16 who remained in the facility. When asked for the NOMNC notification, she stated the facility provided the ABN and Determination on Continued Stay notice. 2. On [DATE] at 12:49 p.m., the MDS coordinator was interviewed regarding Res #24's significant change assessment. She stated the assessment was late. On [DATE] at 12:51 p.m., the MDS coordinator stated she did not realize Res #41 needed a significant change assessment. 3. On [DATE] at 4:11 p.m., the DON was asked what the facility was doing to help prevent falls for the resident. She stated the resident was told to use his call light and we try to keep an eye on him. She stated, There is not a lot we can do. She stated it was the nurse's responsibility to came up with an intervention for a fall. She stated the nurse should document the interventions on the incident reports. She was asked about the process of the interventions getting on the care plans. She stated she was not sure and should ask the MDS coordinator for that answer. On [DATE] at 4:19 p.m., the MDS coordinator stated the nurses documented the interventions on the incident reports. She stated all falls should have an intervention to help prevent another fall. She stated the nurse also documents the interventions in the residents' progress notes. The MDS coordinator stated the IP/LPN goes through the nurse notes and up-dates the care plans with the interventions. On [DATE] at 10:38 a.m., the IP/LPN stated she had recently started to update the plans. She stated they should have an intervention for each fall. She stated if an intervention was documented in the nurse notes, then she added it to the care plan. She said it was the nurse on duty responsibility, when the resident fell , to come up with an intervention. She stated an inservice was conducted in January over falls. She stated a root cause analysis was not being conducted. On [DATE] at 11:32 a.m., the administrator stated she did not realize there had not been interventions for most of the falls. She stated the resident was on Part B therapy before he broke his hip and Part A after the hip fracture. She said they had removed his w/c and walker so he would not to get to them without help. She said they had done one on one with him and kept the alarm out of his reach. She stated the nurses were supposed to add an intervention with each fall. The administrator stated they had went over interventions for falls at a recent in-service. 4. Upon entrance to the facility, on [DATE] at 10:30 a.m., no staff were present in the building who had certification in CPR for Healthcare Providers. On [DATE] at 10:45 a.m., the DON stated the facility did not have a policy related to CPR or CPR certification. She stated, No one is required to be CPR certified. On [DATE] at 4:25 p.m., LPN #1 stated her CPR certification had expired. She stated she was told by administration that she did not need to be certified. LPN #2 stated hers had also expired. LPN #1 and LPN #2 were the only nurses assigned to work the floor that shift. On [DATE], during record review, the IP/LPN provided the CPR for Health Care Providers certifications for the administrator/RN, LPN #3, and RN #1. She stated those were the only staff who were CPR certified. On [DATE] at 12:48 p.m., the DON and ADON were asked how the staff know the code status of a resident. The DON stated there was a list at the nurse station. She went and brought back the list of residents who had DNR status. She stated the list had not been updated. She stated it was dated back in 2021. The ADON stated she looked at the top right hand corner of the EHR. During record review there were several EHRs that did not have the code status at the top of the chart. The residents' code status was observed near the door of each resident. On [DATE] from 12:57 p.m. to 2:00 p.m., interviews where conducted with all staff on the halls. There were no staff who voiced they had CPR certification at this time except for two CNAs. The CNAs stated they thought their certification was still good but did not have their card with them. They said the facility had not asked them for their CPR certification card. [DATE] at 3:41 p.m., the administrator stated she did not realize CPR certification was a regulation. She stated the person who had been doing their CPR classes had stopped doing classes last year in June. 5. On [DATE] at 4:11 p.m., the DON was asked what the facility was doing to help prevent falls for Res #41. She stated the resident was told to use his call light and we try to keep an eye on him. She stated, There is not a lot we can do. She stated it was the nurse's responsibility to came up with an intervention for a fall. She stated the nurse should document the interventions on the incident reports. She was asked about the process of the interventions getting on the care plans. She stated she was not sure and should ask the MDS coordinator for that answer. On [DATE] at 4:19 p.m., the MDS coordinator stated the nurses documented the interventions on the incident reports. She stated all falls should have an intervention to help prevent another fall. She stated the nurse also documents the interventions in the residents' progress notes. The MDS coordinator stated the IP/LPN goes through the nurse notes and up- dates the care plans with the interventions. On [DATE] at 10:38 a.m., the IP/LPN stated she had recently started to update the plans. She stated they should have an intervention for each fall. She stated if an intervention was documented in the nurse notes, then she added it to the care plan. She said it was the nurse on duty responsibility, when the resident fell , to come up with an intervention. She stated an inservice was conducted in January over falls. She stated a root cause analysis was not being conducted. On [DATE] at 11:32 a.m., the administrator stated she did not realize there had not been interventions for most of the falls. She stated the resident was on Part B therapy before he broke his hip and Part A after the hip fracture. She said they had removed his w/c and walker so he would not to get to them without help. She said they had done one on one with him and kept the alarm out of his reach. She stated the nurses were supposed to add an intervention with each fall. The administrator stated they had went over interventions for falls at a recent in-service. She stated the facility had not been doing a root cause analysis. 6. On [DATE] at 9:56 a.m., the MDS coordinator reported she completed this resident's care plan. She reviewed the resident's falls in November and December of 2022, and January of 2023 and agreed no new interventions to prevent the reoccurrence of falls had been documented on the care plan for Res #24. 7. On [DATE] at 9:54 a.m., the ADON reported the Res #24's clinical record did not document side effect monitoring for the resident's psychotropic medications. She confirmed the physician had not provided an adequate rational for not attempting a reduction in the resident's psychotropic medications on the MRRs or the facility generated reduction requests. 8. On [DATE] at 3:27 p.m., the IP stated the side effect monitoring should have been documented on Res #34's TAR. She stated if it was not there then it was not done. On [DATE] at 3:37 p.m., the ADON agreed the physician had not provided adequate rationale for not reducing the resident's psychotropic medications. She stated the facility had provided all the documentation they had for the MRRs. 9. On [DATE] at 1:39 p.m., the ADON stated there should have been a CBC, CMP, and lipid panel drawn in either October or November of 2022 for Res #34. She stated she did not have a good excuse for missing ordering the labs, she just missed them. 10. On [DATE] at 11:00 a.m., the IP reported the staff members who were partially vaccinated should have completed the series within two months or within 90 days of hire. She stated CNA #2 had received the second vaccination but she had not received a copy of the vaccination card as yet.

Based on record review, observation, and interview, the facility failed to update the comprehensive person centered care plans to reflect the residents' current needs for four (#24, 34, 44, and #45) of 12 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, documented 47 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included after care following joint replacement surgery and arthritis in the left knee. A care plan, dated 07/06/22, documented Res #24 was at risk for falls. The care plan documented interventions of keep the call light within reach and encourage the resident to use it; promptly answer all requests for assistance; and educate the resident, family, and care givers about safety reminders and what to do if a fall occurs. An incident report, dated 11/06/22, documented the resident fell in the bathroom. The report did not document an intervention to prevent recurrence. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 11/08/22, documented the resident fell in the bathroom. The report did not document an intervention to prevent recurrence. As of 02/28/23, there was no documented update to the care plan. A quarterly assessment, dated 12/03/22, documented the resident was moderately impaired in cognition, independent with bed mobility, walking, locomotion, and toilet use; and limited assistance with transfer, dressing, and hygiene. The assessment documented the resident had a fall with a minor injury. An incident report, dated 12/13/22, documented the resident fell in his room. The report did not document an intervention to prevent recurrence. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 01/10/23, documented the resident fell in his room, fractured his hip, and pulled off a toe nail. The report documented the resident was educated to use the call light and wait for assistance prior to getting up. As of 02/28/23, there was no documented update to the care plan. A discharge with return anticipated assessment, dated 01/10/23, documented the resident had a fall with a minor injury and a fall with a major injury. An incident report, dated 01/24/23, documented the resident fell in his room. The report did not document an intervention to prevent recurrence. As of 02/28/23, there was no documented update to the care plan. On 02/28/23 at 9:50 a.m., the resident was observed in his bed sleeping. An unidentified hospice aide was present in the room and stated she had just finished with his cares and the resident was worn out. The call light was observed on the resident's abdomen, the wheel chair was placed at the foot of the bed, a recliner was next to the bed, and a walker was placed on the other side of the recliner. An over the bed table with a urinal placed on it was out of reach of the resident. On 02/28/23 at 9:52 a.m., CNA #1 reported the resident had broke his hip from falling. The CNA stated the resident did not have any interventions to prevent falls prior to the hip fracture. The CNA stated the previous night a bed alarm was put on the resident as he kept trying to get out of bed. The CNA stated they felt the resident needed a fall mat but had not been approved for one yet. On 02/28/23 at 9:56 a.m., the MDS coordinator reported she completed this resident's care plan. She reviewed the resident's falls in November and December 2022, and January of 2023 and agreed no new interventions to prevent the reoccurrence of falls had been documented on the care plan for Res #24. 2. Res #34 had diagnoses which included dementia, long term use of anticoagulants/antiplatelet, and persistent mood disorder. A care plan, dated 12/21/21, documented the resident was at risk for falls. The care plan documented interventions of anticipate and meet the resident's needs; keep the call light in reach and encourage the resident to use it; encourage the resident to participate in activities which promoted exercise or physician activity for strengthening and improved mobility; and ensure the resident was wearing appropriate foot wear. An annual assessment, dated 07/06/22, documented Res #34 was severely impaired in cognitive skills for daily decision making and was independent with most ADLs but required limited assistance with dressing and extensive assistance with toilet use and personal hygiene. The assessment documented the resident had a fall with minor injury. The care area assessment documented falls had triggered for care planning. The last update to the fall care plan, dated 07/22/22, documented the resident preferred not to wear any type of foot wear including non skid socks or shoes. An incident report, dated 10/07/22, documented the resident had fallen in her room. The report did not document an intervention to prevent recurrence. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 11/21/22, documented the resident had a fall in her room. The report documented the resident was educated on not lying on the edge of the bed to avoid falling out and the resident voiced understanding. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 11/27/22, documented the resident was lying on her back on the floor. The note documented the catheter bag was changed to a leg bag. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 12/13/22, documented the staff heard the resident calling out and found the resident on the floor. The report did not document an intervention to prevent recurrence. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 12/24/22, documented the resident had been found on the floor. The note documented staff were educated to ensure no slip socks were on the resident. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 01/08/23, documented the resident was found on the floor. The report did not document an intervention to prevent recurrence. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 01/08/23, documented the resident was found on the floor under her bed. The report documented the resident was instructed to use the call light when she needed help. As of 02/28/23, there was no documented update to the care plan. An incident report, dated 01/13/23, documented the resident fell in her room onto a fall mat. The report did not document an intervention to prevent recurrence. As of 02/28/23, there was no documented update to the care plan. A quarterly assessment, dated 01/23/23, documented Res #34 was severely impaired in cognitive skills for daily decision making and remained mostly independent with ADLs but required limited assistance with transfer, eating, and toileting; and extensive assistance with dressing. The assessment documented Res #34 had fallen two or more times resulting in injury except major injury. An incident report, dated 01/24/23, documented the resident fell near her room. The report documented the staff were educated on non slick socks. As of 02/28/23, there was no documented update to the care plan. On 02/23/23 at 11:54 a.m., the resident was observed in the dining room at the assistive feeding table. The staff member attending to the resident was observed to leave the dining room briefly and asked another staff member to keep an eye on her. During the time the attending staff member was gone, the resident attempted to rise from her seat several times and was observed to be very unsteady. The other staff member was observed to have the resident sit back down and reassure her. On 02/27/23, between 2:44 p.m. and 2:49 p.m., three CNA's were interviewed regarding fall interventions for Res #34. All three stated the only interventions they were aware of was the fall mat beside the bed and to use a gait belt when ambulating with the resident. On 02/28/23 at 9:15 a.m., the resident was observed to get out of bed, cross her fall mat, and enter the bathroom without staff assistance. A short time later, the resident was observed back in bed. On 02/28/23 at 9:57 a.m., the MDS coordinator stated the nursing staff were to put interventions in to prevent future falls when they completed the incident reports. She stated the DON and IP received the incident reports and then brought them to her to update the care plans. 29358 3. Res #41 had diagnoses which included unspecified injury of left hip, Parkinson's disease, dementia, anxiety disorder due to known physiological condition, and pain. An annual MDS assessment, dated 10/25/22, documented the resident's cognition was severely impaired; was independent with most ADLs; had no impairment in ROM; used a walker and a wheelchair; and had one fall with no injury. The care plan, dated 11/02/21, documented the resident was at risk for falls. The interventions were documented as the following: a. Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. b. The resident needs prompt response to all requests for assistance. c. The resident needs a safe environment with floors free from spills and/or clutter; adequate, glare-free light; the bed in low position at night; side rails as ordered, handrails on walls, and personal items within reach. d. Ensure that the resident was wearing appropriate footwear, non-skid socks when ambulating or mobilizing in w/c. A facility incident report, dated 11/21/22 at 3:30 p.m., documented the following: The resident was on his knees in the shower room and wheelchair was not in sight. The resident stated he wanted to use the toilet. No injuries and the intervention was for the resident to be educated to use wheelchair or when walking to use his walker during ambulation. The fall and the intervention were not added to the care plan. The next five resident falls on 11/22/22, 12/05/22, 01/02/23, 01/18/23, and 01/21/23 were not added to the care plan and no new interventions were added. A facility incident report, dated 01/23/23 at 11:44 a.m., documented the resident was observed standing up from his w/c while in the dining room and fell backward to floor onto his left side. The resident sustained a left trochanter hip fracture. The report did not document an intervention to prevent recurrence. There was no documented update to the care plan. A discharge with return anticipated MDS assessment, dated 01/23/23, documented the resident had two or more falls with no injury and one fall with major injury. The resident's medical record documented the resident received Part A therapy from 01/27/23 to the present time. The next three falls on 01/31/23, 02/02/23, and 02/04/23 were not added to the care plan. The care plan intervention, dated 02/06/23, documented the resident needed to use a personal alarm on his bed and chair for personal safety precautions. A facility incident report, dated 02/07/23 at 6:01 a.m., documented the resident yelled for help and was found on his left side next to bed on the mat. The resident's alarm string was attached to the resident but not to the alarm box. The report documented the intervention was to wrap the call light in bright pink tape. The intervention was not added to the care plan. The care plan intervention, dated 02/07/23, documented the resident had a current left hip fracture which required surgery and currently attended therapy. A facility incident report, dated 02/10/23 at 6:28 p.m., documented the resident was on knees beside his bed. the report documented the resident removed the alarm before getting out of bed. The documented intervention was to place the body alarm in a place on his clothing where he could not reach and place the resident on one on one. There was no documentation of one on one supervision. The care plan was not updated with the fall or the interventions. According to incident reports, the next three resident falls on 02/12/23, 02/14/23, and 02/22/23, documented the resident was on his knees on the fall mat beside his bed. The resident stated he rolled out of bed. The reports did not document interventions to prevent recurrence. There was no documented update to the care plan. On 02/24/23 at 3:54 p.m., the resident was observed sitting in a recliner in lobby with feet elevated and grip socks on. The resident stated he had not fallen, had not broken anything, was not in therapy, and had no pain. A facility incident report, dated 02/26/23 at 11:30 p.m., documented the nurse was answering the resident's call light and upon entering the room, the resident was sitting on his buttocks with arm upon the recliner and knees up by his chest. The resident stated he was trying to go to the bathroom and when he stood up he fell . The report did not document an intervention to prevent recurrence. There was no documented update to the care plan. A quarterly MDS assessment, dated 02/06/23, documented the resident's cognition was severely impaired, required the extensive assistance of two people with most ADLs, did not walk. The assessment documented the resident's balance was not steady and required staff assistance to stabilize; had impaired ROM on one lower extremity; and was frequently incontinent of urine and bowel; had pain; and had one fall with no injury and one fall with minor injury. On 02/27/23 at 2:54 pm, an observation was made of the resident's room. The resident was not in his room. The resident's twin bed was in low position with a mat on the floor at bedside. There was a bubbled air mattress overlay on top of the flat mattress. The edges of the overlay tapered off to the edge of the mattress. On 02/27/23 at 2:56 p.m., CNA #3 was asked what interventions she used to keep res from falling. She stated she took the resident to the bathroom every hour. She was asked if that intervention was communicated to her from another staff member. She stated, ''No, It was just something that she did. On 02/27/23 at 4:11 p.m., the DON was asked what the facility was doing to help prevent falls for the resident. She stated the resident was told to use his call light and we try to keep an eye on him. She stated, There is not a lot we can do. She stated it was the nurse's responsibility to came up with an intervention for a fall. She stated the nurse should document the interventions on the incident reports. She was asked about the process of the interventions getting on the care plans. She stated she was not sure and should ask the MDS coordinator for that answer. On 02/27/23 at 4:19 p.m., the MDS coordinator stated the nurses documented the interventions on the incident reports. She stated all falls should have an intervention to help prevent another fall. She stated the nurse also documents the interventions in the residents' progress notes. The MDS coordinator stated the IP/LPN goes through the nurse notes and up-dates the care plans with the interventions. On 02/28/23 at 10:38 a.m., the IP/LPN stated she had recently started to update the plans. She stated they should have an intervention for each fall. She stated if an intervention was documented in the nurse notes, then she added it to the care plan. She said it was the nurse on duty responsibility, when the resident fell , to come up with an intervention. She stated an inservice was conducted in January over falls. She stated a root cause analysis was not being conducted. On 02/28/23 at 11:32 a.m., the administrator stated she did not realize there had not been interventions for most of the falls. She stated the resident was on Part B therapy before he broke his hip and Part A after the hip fracture. She said they had removed his w/c and walker so he would not to get to them without help. She said they had done one on one with him and kept the alarm out of his reach. She stated the nurses were supposed to add an intervention with each fall. The administrator stated they had went over interventions for falls at a recent in-service. 46909 4. Res #44 had diagnoses which included cerebral palsy, and adult failure to thrive, gastrostomy status, and NPO all medications and feeding. A care plan dated 06/07/22, documented tube feeding, Osmolite 1.5 60 cc/hr continuous via pump related to adult failure to thrive. On 01/23/23 at 6:00 a.m., a physician order discontinued Osmolite 1.5 at 60 cc/hr via peg tube with 60 cc/hr flush one time a day related to adult failure to thrive. On 01/23/23 at 6:00 a.m., a physician order read, Osmolite 1.5 continuous at 40 cc/hr via peg tube with 60 cc/hr flush one time a day related to adult failure to thrive. An annual assessment, dated 02/22/23, documented the resident was a total assist with all ADLs and required tube feeding via gastrostomy tube. On 02/28/23 at 12:06 p.m., the MDS coordinator was asked when the care plans were updated. She stated she reads the nursing notes and if there were any changes in the resident's needs then she would update the care plan at that time.

Based on record review and interview, the facility failed to ensure physician ordered lab tests were obtained for one (#34) of five residents whose labatory orders were reviewed. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: Res #34 had diagnoses which included Alzheimer's disease, diabetes, and protein calorie malnutrition. A physician order, dated 12/31/21, documented the facility was to obtain a CBC, CMP, and lipid panel on readmission and every six months thereafter. A review of the residents clinical records was conducted and labs were drawn on 04/05/22 and as of 02/27/23 no labs were drawn according to physician orders after that time. A quarterly assessment, dated 01/23/23, documented the resident was severely impaired in cognitive skills for daily decision making and was mostly independent with ADLs. A care plan, last reviewed on 01/30/23, documented the facility was to obtain routine labs as ordered and notify the physician of the results. On 02/27/23 at 1:39 p.m., the ADON stated there should have been a CBC, CMP, and lipid panel drawn in either October or November of 2022.

Based on record review and interview, the facility failed to follow their COVID-19 staff vaccination policy and failed to ensure staff received all the vaccinations in the primary series, had an exemption, or were temporarily delayed in completing their vaccinations. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: The facility's COVID-19 Vaccine Policy, updated on 10/31/22, read in part: .Contingency plan for staff who are not fully vaccinated .A part of this contingency plan, a 30-day period, will be put in place starting first day of hire and/or first day of notice to staff member with staff member being informed that per Administration discretion, termination of employment may be enforced if steps have not been taken to complete vaccination series until staff member becomes in compliance . A review of the facilities current staff vaccination matrix documented 97% of the staff had completed the primary series of COVID - 19 vaccination, had an exemption, or was temporarily delayed in completing their vaccinations. The vaccination matrix, filled out by the facility on 02/22/23, documented 97% of staff have completed the primary series, have exemptions, or are temporarily delayed. The IP reported two staff were partially vaccinated and one of those was going tonight to get her second vaccination. On 02/23/23 at 4:00 p.m., the IP reported CNA #2 had received their first COVID -19 vaccine on 08/25/22 and housekeeper #1 had received their first COVID-19 vaccination on 09/31/21. She stated CNA #2 was going to get their second vaccination tonight. The CNA was unavailable for interview. On 02/24/23 at 11:00 a.m., the IP reported the staff members who were partially vaccinated should have completed the series within two months, or within 90 days of hire. She stated CNA #2 had received the second vaccination but she had not received a copy of the vaccination card as yet.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received supervision and/or failed to implement and/or modify interventions to prevent [CONDITION(S)] from hot liquids for one (#27) of three residents who were reviewed for accident hazards. The resident received a second degree burn from spilling hot coffee onto her lap after interventions were not initiated to prevent [CONDITION(S)] from two previous incidents where the resident had spilled hot coffee onto her lap. The facility administrator (adm) identified three residents who were severely impaired with cognition and received their meals in their rooms. Findings: The facility policy related to drink temperature protocols documented alternatives, such as a cup with a screw on lid, if a resident was able to remove the lid. Resident #27 had diagnoses which included [CONDITION(S)] and [CONDITION(S)] affecting the left non-dominate side, dementia, and open wounds on the right and left thighs. A quarterly assessment, dated 06/26/20, documented the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident was independent with eating and required set up assistance only. The assessment documented the resident had range of motion (ROM) impairment on one side of her upper and lower extremities. A care plan, dated 06/26/20, did not document the type of assistance needed for meals. A facility incident report, dated 07/26/20, documented the resident spilled hot coffee on herself and received a one centimeter (cm) blister to her right outer thigh. A nurse note, dated 07/29/20, documented the resident had spilled hot coffee on herself on Sunday (07/26/20). The note documented the resident's leg had developed a red discoloration with a one cm blister in the center. The note documented the resident's physician was notified, and an order was received to apply Duoderm to protect the area. An annual assessment, dated 09/21/20, documented the resident was moderately impaired with cognitive skills for daily decision making, was independent with eating, and required set up assistance for meals. The assessment documented the resident had ROM impairment on one side of her upper and lower extremities. A care plan, reviewed on 09/25/20, did not document interventions to prevent or protect the resident from spills from hot coffee. A quarterly assessment, dated 03/29/21, documented the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident required limited assistance of one staff person with eating. The assessment documented the resident had ROM impairment on one side of her upper and lower extremities. A care plan, dated 03/29/21, did not document interventions to prevent or protect the resident from spilling hot coffee on herself or for assisting the resident with her meals. A nursing incident note, dated 04/21/21, documented a unnamed certified nursing assistant (CNA) was assisting the resident with changing her clothing when they noticed a light pink area to the resident's right leg. The note documented an unnamed nurse assessed the area and was told by the resident she had spilled coffee on herself earlier in the morning. The note documented the physician was notified, and orders were received to apply lotion and monitor the area for blistering. A hot food temperature chart, dated 04/18/21-04/24/21, documented on 04/21/21, the temperature of the hot coffee was 170 degrees Fahrenheit (F) for breakfast, 175 degrees F for the noon meal, and 170 degrees F for the evening meal. A facility incident report, dated 04/21/21, documented the resident had spilled coffee on herself and had a pink area on her right leg. The incident report did not document steps to prevent spills or protect the resident from spilling hot coffee on herself. A nurse note, dated 04/28/21 at 2:42 PM, documented the resident had spilled hot coffee on herself causing redness to her left leg and an open blister to her right inner thigh. The note documented the director of nursing (DON) suggested the resident's coffee be served in a sippy cup. An incident report was not completed for this incident. A hot food temperature chart, dated 04/25/21-04/30/21, documented on 04/28/21, the temperature of the hot coffee was 170 degrees F for breakfast and lunch. The log documented the coffee temperature was 174 degrees F for the evening meal. A physician order, dated 04/28/21, documented a sippy cup was ordered for warm liquids. A physician order, dated 04/29/21, documented the facility was to cleanse the wound with wound wash once a day, pat the area dry, apply triple antibiotic ointment, and cover until resolved. A skin assessment, dated 05/05/21, documented redness to the right inner thigh was the size of a saucer plate related to burn from the coffee spill. The note documented a red area measuring approximately five cm by seven cm was noted to the left inner leg. The note documented blisters. On 05/10/21 at 2:25 PM, the coffee temperature was obtained and measured 165.4 degrees F. The dietary manager reported the facility was going to obtain a new coffee system to make/keep the coffee hotter. On 05/10/21 at 2:49 PM, the resident was observed sitting in her recliner in her room. Licensed practical nurse (LPN) #3 lifted the dressing on the resident's left thigh for observation. The area was red, open and crusty, and appeared to be approximately four by six cm in size. The resident reported she has recently spilled coffee on herself twice. On 05/10/21 at 2:57 PM, CNA #1 confirmed the resident had recently spilled coffee on herself twice. She stated the facility had been providing the coffee to the residents who ate in their rooms in Styrofoam cups. The CNA reported after the last time the resident spilled coffee, the facility switched her to a sippy cup. On 05/10/21 at 3:00 PM, LPN #4 stated she was the nurse on duty the first time the resident spilled coffee on herself. She confirmed the resident had burned herself twice recently by spilling coffee. On 05/10/21 at 3:01 PM, the director of nursing (DON) reviewed the resident's records and reported she had recommended the resident use a sippy cup for her coffee after the resident spilled coffee on herself on 04/28/21. She stated an incident/investigation report had not been completed. The DON reported the resident was to be supervised when eating and confirmed there had been no interventions prior to 04/28/21 to prevent or protect the resident from hot coffee spills. A care plan update, dated 05/10/21, documented the resident was to utilize a sippy cup with a straw to prevent hot coffee spills. The care plan documented the resident had burned herself by spilling hot coffee and was receiving burn treatment to the affected area. The care plan did not document the resident was to be supervised with meals or with hot liquids. On 05/11/21 at 8:24 AM, the resident's son reported his mother has spilled coffee on herself several times while using styrofoam cups in her room. On 05/11/21 at 10:06 AM, the resident's physician reported the resident received a second degree burn to her upper leg from a coffee spill on 04/28/21. On 05/11/21 at 10:44 AM, CNA #2 reported she was aware the staff were to supervise the resident while eating and drinking. She stated sometimes the staff would sit with the resident and sometimes the staff just drop the tray off. She stated the resident was to be supervised while eating related to providing encouragement to eat and drink. On 05/11/21 at 11:00 AM, LPN #1 reported when new information and interventions were received, it was communicated to all staff by means of a communication log. She stated she measured the burn on the resident's left thigh and it measured four cm by seven cm. The communication log was reviewed from 04/21/21 through 05/11/21 and did not document information regarding the resident's coffee spills, [CONDITION(S)], or interventions such as a sippy cup, or supervision with eating. On 05/17/21 at 10:04 AM, the DON reported the care plan did not document the resident required supervision during meals. She stated the care plan should have included supervision and had not been updated to include the use of a sippy cup for hot liquids until 05/10/21.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services to prevent the development of and/or promote healing of pressure ulcers for two (#77 and #91) of three residents sampled for pressure ulcers. The facility failed to thoroughly and consistently assess, monitor, and track wound progression and/or deterioration of pressure ulcers for resident #77. The facility failed to identify and implement interventions for pressure ulcers for resident #91. The facility identified three residents with pressure ulcers. Findings: The facility policy for pressure ulcer/skin breakdown documented the nursing staff and physician would assess and document a residents significant risk factors for developing pressure sores. 1. Resident #77 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order documented the treatment would be done daily and as needed (PRN) related to soiling and displacement of the dressing. The physician orders [REDACTED]. A nurse note, dated 12/28/15 at 4:00 p.m., documented the resident was alert but confused. The note documented the coccyx had a 4 centimeter (cm) x 3 cm x 0.8 cm open area. The nurse notes between 12/28/15 and 02/11/16, were reviewed. There was no documentation to indicate weekly head to toe skin assessments had been conducted for the resident. A nutrition risk assessment, dated 12/28/15, documented the resident was at moderate risk related to nutritional status. A pain evaluation, dated 12/28/15, documented the resident's nonverbal signs of pain were frowning and scowling. The evaluation documented pain was relieved by frequent position changes. A wound care specialist initial evaluation form, dated 01/05/16, documented the resident had a stage four pressure wound of the coccyx. The form documented the wound size as 5 cm x 2.8 cm x 0.9 cm. The form documented the undermining was 1.5 cm at five o'clock. The form documented the exudate was moderate serous. The form documented the granulation tissue was one hundred percent. The form documented a recommendation was made to reposition the resident per facility protocol. A physician order, dated 01/05/16, documented to change the treatment to the coccyx. The order documented to cleanse the wound to the coccyx with normal saline, pat dry, soak kerlix in 50/50 [MEDICATION NAME] and normal saline, pack wound tightly, cover with dry 4x4s, and secure with tape twice a day (BID). The order documented to give Keflex 500 mg BID for 14 days and [MEDICATION NAME] 300 mg BID for 14 days for a wound infection. A dietary progress note, dated 01/05/16, documented a recommendation for one scoop of protein powder three times a day (TID) with meals to aide in wound healing. An initial assessment, dated 01/06/16, documented the resident's cognition was severely impaired. The assessment documented the resident was dependent on staff for bed mobility and transfers with two plus person physical assist. The assessment documented the resident was dependent on staff for all activities of daily living (ADLs). The assessment documented the resident had a functional limitation in range of motion and lower extremity impairment. The assessment documented staff would assess the resident for pain with observation of non-verbal sounds and facial expressions. The assessment documented the resident was at risk for developing a pressure ulcer and had a stage three pressure ulcer upon admission. The assessment documented the resident was on a turning/repositioning program, received nutritional interventions to manage skin problems, and received pressure ulcer care. A nurse note, dated 01/06/16, documented signs and symptoms of pain while performing treatment to the coccyx, PRN pain medication was given with poor results, and the physician was notified. A physician order, dated 01/06/16, documented the resident was to receive [MEDICATION NAME] 150 mg BID PRN for pain. A care plan, dated 01/07/16, documented the resident had a stage three pressure ulcer to his coccyx related to immobility. The care plan documented to administer treatments as ordered and monitor for effectiveness. The care plan documented to follow facility policies/protocols for the prevention/treatment of [REDACTED]. The care plan documented the resident would need assistance to turn and reposition at least every two hours and as needed. The care plan documented the resident had pain related to immobility. The care plan documented to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. The resident's medical record was reviewed and contained no documention regarding turning or repositioning the resident every two hours. A dietary progress note, dated 02/02/16, documented a stage four to the coccyx continued. The note documented there had been no response to the previous registered dietician (RD) request. The note recommended to add one scoop of protein powder TID with meals to aid in wound healing. The note documented this was the second request to add protein powder. A wound care evaluation, dated 02/07/16, documented a stage three wound on the coccyx, which measured 5.10 cm x 2.3 cm x 0.8 cm. The evaluation documented drainage consistency was sanguineous. The evaluation was conducted by physician #1. On 02/10/16 at 10:51 a.m., the resident was observed lying on his bed on his back with his eyes open. He was not observed to respond when spoken to. On 02/10/16 at 11:41 a.m., the resident was observed lying on his bed on his back with his eyes open. On 02/10/16 at 12:27 p.m., the resident was observed lying on his bed on his back as staff fed him his lunch. On 02/10/16 at 3:37 p.m., the resident was observed lying on his bed on his back with his eyes open. On 02/10/16 at 5:00 p.m., the resident was observed lying on his bed on his back with his eyes closed. On 02/10/16 at 6:50 p.m., the resident was observed lying on his bed on his back with his eyes open. The head of his bed was elevated. On 02/10/16 between 10:51 a.m. and 6:50 p.m., the resident was not observed to leave his room. On 02/11/16 at 7:40 a.m., the resident was observed lying on his bed on his back with his eyes closed. On 02/11/16 at 8:21 a.m., the resident was observed lying on his bed on his back with his eyes closed. On 02/11/16 at 8:38 a.m., the resident was observed lying on his bed on his back with his eyes open. On 02/11/16 at 9:23 a.m., the resident was observed lying on his bed on his back with his eyes open. On 02/11/16 at 9:40 a.m., the resident was observed lying on his bed on his back with his eyes open. On 02/11/16 at 9:50 a.m., certified nursing aide (CNA) #2 was observed to ask licensed practical nurse (LPN) #2 if she could help her turn the resident. The CNA told the LPN she needed to get him turned. The LPN told her she was getting ready to do his treatment. On 02/11/16 between 7:40 a.m. and 10:05 a.m., the resident was not observed to leave his room. On 02/11/16 at 10:05 a.m., the surveyor entered the room along with LPN #2, LPN #1, and CNA #2. The resident was observed lying in his bed. The resident was observed to cry out. LPN #2 stated the resident had been medicated for pain an hour ago. She stated the resident was very vocal. On 02/11/16 at 10:10 a.m., LPN #1 was asked how often the resident was seen by the physician. She stated he was seen biweekly for wound measurement. She stated, You'll see why he hollers when you see the wound. She was asked how often the resident was to be repositioned. She reported he was to be repositioned every two hours. The LPN reported it was difficult to keep him on his side. She reported they used pillows as an aide. CNA #2 said the resident kicked his heel protectors off. Two heel protectors were observed at the foot of the bed underneath the covers. On 02/11/16 at 10:15 a.m., the resident was turned onto his side with the assistance of CNA #2, LPN#1, and LPN #2. No dressing was observed over the pressure ulcer on the resident's coccyx. When asked where the previous dressing was, CNA #2 stated it sometimes would get soiled when the resident was incontinent of bowel. LPN #1 measured the pressure ulcer. The LPN stated the pressure ulcer was 4.5 cm x 4 cm x 1 cm. The resident was noted to grimace and cry out. CNA #2 stated, I know it hurts when he is on his back. That is the way we have to feed him. LPN #2 was observed to mix up the [MEDICATION NAME] and sugar for the pressure ulcer. The consistency of the mixture was observed to be thin. On 02/11/16 at 10:20 a.m., the resident continued to cry out. LPN #2 was observed to cleanse the pressure ulcer. The LPN was observed to clean the inside of the pressure ulcer to the outside and back to the inside of the wound. The resident was observed to flinch when the LPN touched the pressure ulcer. The resident continued to cry out and press his weight against staff. LPN #2 used a wooden tongue blade to apply the [MEDICATION NAME] and sugar mixture to the pressure ulcer. The mixture was thin and ran out of the pressure ulcer and down his buttocks. The LPN applied a dressing to the pressure ulcer. The resident continued to cry out. On 02/11/16 at 10:24 a.m., CNA #2 reported the resident was on his back because she had been feeding him his breakfast. The resident continued to cry out and grimace as he was repositioned onto his left side. On 02/11/16 at 10:25 a.m., the resident's feet were observed. When the sheet was removed from the resident's feet, a circular bandage fell to the floor. CNA #2 picked the bandage up and began to dispose of it. The surveyor asked to see the bandage. The bandage was observed to be dated 01/30/16. A circular pressure ulcer was noted on the resident's left medial heel. The pressure ulcer measured approximately 4 cm x 5 cm. A black ring surrounded the ulcer and the skin was intact. No odor or draining was noted. On 02/11/16 at 10:32 a.m., CNA #2 was asked when she first observed the resident that day. The CNA stated she arrived at the facility at about 6:45 a.m. She was asked if there was a dressing in place on the pressure ulcer when she first saw the resident at 8:00 a.m. She stated, No. She was asked if she reported to anyone that the resident did not have a dressing over his pressure ulcer. The CNA reported she mentioned it to LPN #2 right before the dressing change. On 02/11/16 at 10:59 a.m., the director of nursing (DON) was asked if she had been aware the resident had a pressure ulcer on his left heel. The DON reported she was not aware of the pressure ulcer. She was asked how often skin assessments were conducted on residents with pressure ulcers. The DON reported a full body skin assessment should have been conducted on a weekly basis. The DON was asked where the documentation for the skin assessments would be located. The DON reported they should have been in the nurse notes. On 02/11/16 at 11:00 a.m., the DON was asked to describe the resident's left heel. The DON reported she would describe it as unstageable. The DON was asked if a CNA provided care and noticed there was no dressing on a pressure ulcer, what she would expect them to do. The DON reported she expected them to report it to the charge nurse. On 02/11/16 at 12:30 p.m., the DON reported she had found some notes on her desk, which had been documented by RN #1. The notes documented the resident had a 4 cm in diameter area on his left heel with black eschar. On 02/11/16 at 12:38 p.m., the resident was observed lying in his bed on his back. On 02/11/16 at 12:40 p.m., physician #1 was interviewed via telephone. The physician was asked what consistency the [MEDICATION NAME] and sugar solution should be. He reported it needed to be very thick. He reported the resident had received the thick mixture of [MEDICATION NAME] and sugar in the past and had good results with it. He was asked if prior to that day, had he been notified by the staff of a pressure ulcer on the resident's left heel. He reported he had only been notified earlier that day. He was asked what kind of treatment should have been done to the pressure ulcer on his left heel. He reported he should have been in heel protectors. He reported the resident had trouble with his heels in the past. He was asked how often he assessed the pressure ulcer on the resident's coccyx. He reported about every week or so. He was asked if he was aware the resident had not been receiving the protein powder the dietary consultant recommended in January 2016, which he had ordered on [DATE]. He reported he was not aware. On 02/11/16 at 12:45 p.m., the resident was observed lying in his bed on his back. LPN #2 was asked to measure the pressure ulcer on the resident's left heel. Heel protectors were observed to be on top of his feet underneath his sheet. The LPN measured the pressure ulcer and stated it measured 4 cm x 3.8 cm. The LPN put the heel protectors on the resident and stated the physician ordered the heel protectors as the treatment for [REDACTED]. On 02/11/16 at 4:13 p.m., the dietary manager (DM) was asked which residents received protein powder. The DM named four residents who received protein powder. Resident #77 was not one of the residents mentioned. The DM was asked how she was made aware of the dietary consultant's recommendations. She stated the dietary consultant turned the recommendations into the DON and the DON sent the recommendation to the physician. She was asked if she was aware resident #77 had an order for [REDACTED]. On 02/11/16 at 4:22 p.m., the DON was interviewed. The DON reported she had planned to have the RN measure pressure ulcers and make assessments. The DON reported that process did not work out. The DON was asked if the physician was notified of the pressure ulcer on resident #77's heel. The DON reported the physician had not been notified until after it had been brought to their attention. The DON reported she did not think the RN had been measuring the pressure ulcer on his coccyx correctly. The DON reported the RN had provided her a paper which documented the wound on the resident on 01/30/16 and she had just found it that morning. During the interview on 02/11/16 at 4:22 p.m., the DON was asked what the process was for handling recommendations made by the dietary consultant. The DON reported when the dietary consultant was finished with her assessment, she would provide a form to the DON and the administrator (ADM) and both would sign off on it. The DON reported she reviewed it and put it in the physician's notebook for review and approval. The DON was asked why the dietary recommendation made on 01/05/16 had not been implemented. The DON reported she had not been aware the resident was not receiving protein powder. During the interview on 02/11/16 at 4:22 p.m., the DON was asked how staff were monitored to ensure they were completing their job duties and were competent. The DON reported she spent a lot of time talking to nurses. The DON reported she tried to educate them on concerns when the opportunity arose. The DON was asked prior to this incident, had she identified any concerns related to pain during wound treatments. The DON reported she had not. The DON was asked prior to this incident had she identified any concerns related to pressure ulcer processes and systems. She reported she had related to staffing changes. The DON was asked what type of training the floor nurses had received in order to care for wounds. She stated, They are nurses, LPNs, and one RN on weekends. 2. Resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 01/04/16, documented the resident was moderately impaired with decision making skills. The assessment documented the resident was at risk for pressure ulcers. The assessment documented the resident had no unhealed pressure ulcers at stage 1 or above. The care plan, dated 01/06/16, documented the resident was totally dependent on staff for activities of daily living. The care plan documented staff was to encourage good nutrition and hydration in order to promote healthier skin, keep skin clean and dry, and use a draw sheet or lifting device to move the resident. The care plan did not document any updates for a new pressure ulcer. The care plan documented the resident required assistance of one staff to eat. A skilled daily nurse note, dated 01/24/16, had a mark on the form next to pressure ulcer. No other nurse note was documented until 01/26/16. A nurse note, dated 01/26/16 at 1:00 p.m., documented a certified nurse aide (CNA) reported the resident had an open area to the buttock, and upon assessment the nurse noted the resident to have a 3.5 cm x 3 cm open area to the left buttock and 3 cm x 2.5 cm open area to the right buttock. The physician was notified and a new treatment order was received. A physician order, dated 01/26/16, documented to apply [MEDICATION NAME] Cream to bilateral buttocks and cover with a dry dressing daily. A nurse note, dated 02/03/16, documented a call was made to the physician requesting a wound care physician consult for areas to the resident's bilateral buttocks. The note documented the physician approved. No documentation was found in the resident's medical record related to a consult/assessment. A wound care/skin integrity evaluation, dated 02/07/16, documented the male resident was female. The wound note documented wound #1 was on the right medial buttock with an onset date of 12/26/15. The wound note documented the etiology was moisture related skin damage. The wound note documented the size was 5.50 x 2.10 and depth was less than 0.2. The wound note documented hydrogel gauze would promote a moist wound environment. The note documented foam was required to wick excess exudate & moisture away from compromised fragile periwound. The note documented daily dressing changes were required due to frequent incontinent episodes which caused dressings to become loose/dislodged in less than a 24 hour time frame. The wound note documented to clean with normal saline/wound cleanser, apply hydrogel gauze, and cover with bordered foam. The wound note documented the treatment was to be performed daily. The wound note documented the resident was incontinent per report of the staff. The form was signed by the DON. A wound care/skin integrity evaluation, dated 02/07/16, documented the resident was female. The note documented wound 2 to the left medial buttock with an onset date of 12/26/15 with etiology as moisture related skin damage. The wound note documented the size as 6.50 x 2.10 and depth was less than 0.2. The wound note documented hydrogel gauze would promote a moist wound environment. The note documented foam was required to wick excess exudate & moisture away from compromised fragile periwound. The note documented daily dressing changes were required due to frequent incontinent episodes which caused dressings to become loose/dislodged in less than a 24 hour time frame. The wound note documented to clean with normal saline/wound cleanser, apply hydrogel gauze, and cover with bordered foam. The wound note documented the treatment was to be performed daily. The wound note documented the resident was incontinent per report of the staff. The form was signed by the DON. On 02/09/16 at 2:16 p.m., licensed practical nurse (LPN) #3 reported she assessed the resident's buttocks and reported she would say the wounds were stage 2. The LPN reported she did not know if it was a pressure ulcer. On 02/09/16 at 2:41 p.m., LPN #3 reported the wound care specialist said the resident's wounds were not classified as pressure sores. The LPN reported the wound care specialist said the wounds were excoriation from moisture. On 02/10/15 at 1:14 p.m., LPN #2 was observed providing wound treatments for the resident. The LPN measured the wound to the resident's right upper buttock as 7 cm x 4.5 cm and the wound to the left upper buttock as 3.2 cm x 1.5 cm. The LPN was observed to cleanse the wound with normal saline and apply [MEDICATION NAME] cream and apply a clean dry dressing. The LPN was observed to use the same tape to measure both wounds. The resident was observed on a regular mattress. The resident was observed to fall asleep during the treatment. On 2/11/16 at 1:00 p.m., the dietary manager (DM) was interviewed. The DM reported she was not aware the resident had a pressure ulcer. On 2/11/16 at 2:50 p.m., the resident's physician, physician #2, was interviewed via telephone. The physician was asked what was the cause of the resident's wounds. The physician reported the resident was noncompliant with moving and changing positions. The physician reported the two wounds on the resident's upper buttocks were pressure ulcers. On 02/11/16 at 4:18 p.m., the director of nursing (DON) was interviewed. The DON reported residents were assessed from head to toe on admit and if a resident was admitted with a wound, the wound care specialist would see the resident. The DON reported if a certified nurse aide (CNA) observed a new wound, the CNA was to report to the nurse. The DON reported interventions would be put in place for the pressure ulcer. The DON reported interventions for the resident were to be turned and repositioned and kept clean and dry. The DON reported the registered dietician would ask for a list of residents with wounds when she came to the facility and she would make recommendations. The DON reported the weekend registered nurse (RN) was to assess and measure the resident's wounds. The DON reported the weekend RN wrote the wound down but did not report the wound to her.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services to ensure residents maintained their highest levels of well-being for one (#77) of 35 residents sampled for pain. The facility failed to monitor, assess, and treat the resident for pain. During observation of wound care, resident #77 was observed to be in pain. The facility identified a census of 63 residents. Findings: The facility policy for pain documented the physician and staff would identify residents who had pain or who were at risk for pain. The policy documented a review of the residents [DIAGNOSES REDACTED]. The policy documented nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated such as wound care or repositioning. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse note, dated 12/28/15 at 4:00 p.m., documented the resident was alert but confused, non-verbal, and staff would need to anticipate the resident's needs. The note documented the resident had contractures to the right leg and bilateral arms. The note documented the resident had a wound to the coccyx which measured 4 centimeters (cm) x 3cm x 0.8cm. The note documented the resident would require total assist and a Hoyer lift would be used for the resident. A pain evaluation, dated 12/28/15, documented the resident exhibited nonverbal signs of pain of frowning and scowling. The evaluation documented pain was relieved by frequent position changes. An initial assessment, dated 01/06/16, documented the resident's cognition was severely impaired. The assessment documented the resident was dependent on staff for bed mobility and transfers with two plus person physical assist. The assessment documented the resident was dependent on staff for all activities of daily living (ADLs). The assessment documented the resident had a functional limitation in range of motion and had a lower extremity impairment. The assessment documented staff would assess the resident for pain with observation of non-verbal sounds and facial expressions. The assessment documented the resident was on a turning/repositioning program. A nurse note, dated 01/06/16, documented signs and symptoms of pain while performing pressure ulcer treatment to the coccyx. The note documented as-needed (PRN) pain medication was given with poor results and the physician was notified. A physician order, dated 01/06/16, documented the resident was to receive [MEDICATION NAME] 150 milligrams (mg) twice a day (BID) PRN pain. A care plan, dated 01/07/16, documented the resident would require assistance to turn/reposition at least every two hours and more often as needed. The care plan documented the resident had pain related to immobility. The care plan documented staff would need to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. The care plan documented to notify the physician if interventions were unsuccessful or if the resident's pain worsened significantly from previous. A nurse note, dated 01/08/16 at 10:00 a.m., documented [MEDICATION NAME] 50 mg was administered for signs and symptoms of pain. A nurse note, dated 01/09/16 at 1:30 p.m., documented the resident complained of pain and [MEDICATION NAME] was given. The note documented the pain medication was effective. A nurse note, dated 01/12/16 at 9:00 a.m., documented the resident complained of pain and [MEDICATION NAME] was given. The note documented the pain medication was effective. A nurse note, dated 01/16/16 at 11:00 p.m., documented Tylenol was administered for increased pain and a temperature of 99 degrees Fahrenheit. A physician order, dated 01/28/16, documented to change the [MEDICATION NAME] from 50 mg BID to three times a day (TID) PRN for pain. No documentation was located or provided by the facility to indicate the resident had been repositioned every two hours. On 02/10/16 at 10:51 a.m., the resident was observed lying on his bed on his back with his eyes open. On 02/10/16 at 11:41 a.m., the resident was observed lying on his bed on his back with his eyes open. On 02/10/16 at 12:27 p.m., the resident was observed lying on his bed on his back as staff fed him his lunch. On 02/10/16 at 3:37 p.m., the resident was observed lying on his bed on his back with his eyes open. On 02/10/16 at 5:00 p.m., the resident was observed lying on his bed on his back with his eyes closed. On 02/10/16 at 6:50 p.m., the resident was observed lying on his bed on his back with his eyes open. The head of his bed was elevated. On 02/10/16 between 10:51 a.m. and 6:50 p.m., the resident was not observed to leave his room. On 02/11/16 at 7:40 a.m., the resident was observed lying on his bed on his back with his eyes closed. On 02/11/16 at 8:21 a.m., the resident was observed lying on his bed on his back with his eyes closed. On 02/11/16 at 9:40 a.m., the resident was observed lying on his bed on his back with his eyes open. CNA #2 was observed down the hall from the resident's room. The CNA reported she needed to get down to check on resident #77. On 02/11/16 at 9:50 a.m., CNA #2 was observed to ask LPN #2 if she could help her turn the resident. The CNA told the LPN she needed to get him turned. The LPN told the CNA she was getting ready to do his treatment. On 02/11/16 at 10:05 a.m., the surveyor entered the room, along with LPN #2, LPN #1 and CNA #2. The resident was observed lying on his bed. The resident was observed to cry out as everyone entered the room. LPN #2 reported the resident had been medicated for pain an hour ago. The LPN reported the resident was very vocal. On 02/11/16 at 10:10 a.m., LPN #1 was asked how often the resident was seen by the physician. The LPN reported the resident was seen biweekly for wound measurement. The LPN stated, You'll see why he hollers when you see the wound. The LPN was asked how often the resident was to be repositioned. The LPN stated he was to be repositioned every two hours. The LPN stated it was difficult to keep the resident on his side and reported they used pillows as an aide. CNA #2 reported the resident kicked his heel protectors off. Two heel protectors were observed at the foot of the bed underneath the covers. On 02/11/16 at 10:15 a.m., the resident was turned onto his side with the assistance of CNA #2, LPN#1, and LPN #2. There was no dressing observed over the pressure ulcer on the resident's coccyx. When asked where the previous dressing was, CNA #2 stated it sometimes became soiled when the resident was incontinent of bowel. LPN #1 measured the pressure ulcer. The resident was noted to grimace and cry out. CNA #2 stated, I know it hurts when he is on his back. That is the way we have to feed him. On 02/11/16 at 10:20 a.m., the resident continued to cry out. LPN #2 was observed to cleanse the pressure ulcer. The resident was observed to flinch when the LPN touched the pressure ulcer. The resident continued to cry out and press his weight against staff. On 02/11/16 at 10:24 a.m., CNA #2 reported the resident was on his back because she had been feeding him breakfast. The resident continued to cry out and grimace as he was repositioned onto his left side. On 2/11/16 at 10:35 a.m., the Medication Administration Record [REDACTED]. On 02/11/16 at 10:45 a.m., LPN #1 was asked if, in her nursing opinion, the resident was in pain. She stated, Yes. The LPN was asked how she rated the resident's pain. The LPN reported she went by the face chart. The LPN reported the resident was unable to rate his pain. The LPN reported in her opinion, the resident's pain was at a ten. The LPN reported if the scale went higher than a ten, she would rate his pain at more than a ten. On 02/11/16 at 10:47 a.m., CMA #1 was asked if she pre-medicated the resident before his treatments. The CMA stated the nurses would usually ask her to administer pain medication prior to the pressure ulcer treatment, but the resident did not receive something every day. The CMA stated some days she would be on another hall passing medications and would not be able to administer any pain medication prior to the treatment starting. The CMA also reported what the resident received depended on the amount of pain he was exhibiting and at what time the resident had received pain medication previously. The CMA reported some days the resident received Tylenol and some days he received [MEDICATION NAME]. The CMA was asked how she determined whether she administered a Tylenol or a [MEDICATION NAME]. The CMA stated if the resident was not hollering real bad, she would give him a Tylenol and if he had received a [MEDICATION NAME] within the last eight hours, she would give him Tylenol. The CMA reported the resident was moaning early that morning so she administered a [MEDICATION NAME]. On 02/11/16 at 10:50 a.m., LPN #2 was asked if, in her nursing opinion, the resident had been in pain prior to the pressure ulcer treatment. The LPN reported she did not feel like the resident had been in pain. The LPN reported the resident did not cry out any more than usual during the treatment. The LPN reported the resident yelled throughout the day. The LPN was asked if she had asked the resident if he was in pain. The LPN reported she heard LPN #1 ask the resident if he was in pain and the resident told her he was not in pain. On 02/11/16 at 10:59 a.m., the director of nursing (DON) was asked what she would expect her staff to do if a resident exhibited pain during a pressure ulcer treatment. The DON reported she would expect staff to stop doing the treatment. On 02/11/16 at 12:38 p.m., the resident was observed lying in his bed on his back. On 02/11/16 at 3:03 p.m., LPN #2 was interviewed. The LPN was asked why the resident's [MEDICATION NAME] was increased from BID to TID on 01/28/16. The LPN stated the medication was increased because the resident was having pain issues during pressure ulcer care. The LPN was asked who was responsible for making the determination of what type of pain medication the resident would receive, the Tylenol or the [MEDICATION NAME], prior to the pressure ulcer treatment. The LPN reported the nurse would assess the resident then instruct the CMA what to administer to the resident. The LPN reported she had told the CMA to administer [MEDICATION NAME] prior to that morning treatment. The LPN reported she told the CMA she would be doing pressure ulcer care and told her to give the resident [MEDICATION NAME]. The LPN was asked how the nurses ensure residents are medicated for pain prior to pressure ulcer treatments. The LPN reported she double checked with the CMA prior to doing the treatment. On 02/11/16 at 4:22 p.m., the DON was interviewed. The DON was asked, prior to this incident, if she had identified any concerns related to pain during wound treatments. The DON reported she had not. The DON reported she and LPN #2 had discussed resident #77's pain. The DON reported, One thing that everybody needs to do is they need to go ahead and give the pain medication prior to the treatment.

On 07/21/15 a past-noncompliance immediate jeopardy (IJ) was determined to exist related to the facility's failure to provide adequate supervision and have a system in place to effectively and consistently identify residents at risk for elopement and prevent elopement for a resident who had previously exited the building independently. The facility was aware resident #1 had previously exited the building by entering the code to an exit door. The resident exited the building unsupervised for a second time, obtained an employee's vehicle, and drove several miles from the nursing home. According to a police report the resident skidded 39 feet before she struck a fence with the vehicle. On 07/21/15 the Oklahoma State Department of Health (OSDH) was notified and verified the past-noncompliance IJ situation. The deficient practice was determined to be past-noncompliance related to the facility identifying the immediate jeopardy situation and implementing interventions to prevent recurrence of the situation. The facility conducted an inservice related to resident elopement on 07/09/15. The resident was placed on direct one on one observation until the elopement security system was installed on 07/13/15. Signs were placed on the door to alert visitors to please not let residents outside as they left the facility. An elopement book was initiated with resident picture identification and information in the case of an elopement. On 07/21/15 at 5:10 p.m., the administrator and director of nursing (DON) were notified of the past noncompliance immediate jeopardy situation which constituted substandard quality of care. Based on observation, interview, and record review, it was determined the facility failed to provide adequate supervision to prevent elopement and have a system in place to effectively and consistently identify residents at risk for elopement for two (#1 and #4) of three residents sampled for elopements. The facility's failure to provide adequate supervision resulted in an elopement for the two residents. The failure to provide adequate supervision for resident #1 resulted in the resident exiting the facility unsupervised then exited the building unsupervised a second time, which resulted in the resident taking a vehicle, driving away from the nursing home, and through a fence. Findings: The facility policy for missing residents documented the staff would make every effort to prevent residents from leaving the facility unsupervised or unattended. 1. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An elopement risk assessment, dated 06/18/15, documented the resident was independent with walking in her room and in the corridor. The assessment documented the resident stated, I want to go home. The assessment documented the resident had a recent move to the facility. The assessment documented the resident had dementia. The assessment documented, Resident displayed no observable signs of wanting to leave facility. The assessment documented there was no risk of elopement. An admission assessment, dated 06/23/15, documented the resident had short and long term memory problems. The assessment documented the resident was severely impaired with skills for daily decision making. The assessment documented the resident had difficulty focusing her attention and had disorganized thinking that changed in severity. The assessment did not document a behavior of wandering. The assessment documented the resident required extensive assistance of two persons for transfer. The assessment documented the resident had not walked in the past seven days. The assessment documented the resident required extensive assistance of one person for locomotion. The care plan, dated 06/24/15, documented the resident had altered communication due to a [DIAGNOSES REDACTED]. An incident report, dated 06/30/15 at 12:00 p.m., documented the resident had removed her safety alarm, gone down the 400 hall, pushed the door security code in, and stepped outside. The incident report documented the certified medication aide (CMA) got the resident before she went anywhere. The incident report documented interventions to prevent recurrence were the staff was educated to attach the safety alarm out of the resident's reach and staff was to check the resident's location frequently. A nurse note, dated 06/30/15 at 12:00 p.m., documented the resident had removed her safety alarm while on the 400 hall. The nurse note documented the resident pushed the door security code in and stepped outside. The note documented the certified medication aide (CMA) got the resident before she went anywhere. The nurse note documented the staff were educated to attach the safety alarm out of the resident's reach and to check the residents location frequently. A nurse note, dated 07/02/15 at 9:20 p.m., documented the resident had been up ambulating about the facility carrying a bag with personal belongings. The note documented several attempts were made before the resident was redirected to her room and accepted she was staying in the facility. The nurse note documented the resident received therapy for strengthening and endurance. A nurse note, dated 07/03/15 at 6:00 a.m. to 6:00 p.m., documented a personal alarm was in place to alert staff to the resident trying to leave the facility. An incident report, dated 07/03/15, documented at approximately 4:30 p.m., staff discovered the resident was not in the facility. The incident report documented after a thorough search was conducted the police were notified. The report documented within an hour the police department notified the facility the resident had stolen a car and driven the car through a fence. The incident report documented the resident was transported to the local hospital for evaluation. The incident report documented the resident experienced a small bump on her head. The incident report documented the resident's ambulatory ability had greatly improved and the resident was mobile through out the facility. The incident report documented the resident had been wanting to leave the facility for the past six days prior to the elopement incident. The incident report documented the resident took a vehicle that belonged to a facility employee. The incident report documented when the resident returned she would be constantly in view with one on one observance until the alarm equipment to prevent elopements was received. A written voluntary statement, dated 07/03/15 at 6:15 p.m. and signed by licensed practical nurse (LPN) #1, documented she was unable to locate the resident at approximately 4:50 p.m. The LPN documented she had last spoken with the resident at approximately 4:30 p.m. when the resident was requesting to leave the facility. The LPN documented the staff redirected the resident to the day room at which time the staff began serving supper in the dining room. The LPN documented the staff was also on the floor taking care of residents. The care plan had not been updated to reflect the elopement incidents. A written voluntary statement, dated 07/03/15 at 6:15 (a.m. or p.m. not documented) and signed by staff member #1, documented the resident asked, If I knew the fastest way out of here? The staff member documented the resident was told to go to the nurse station and ask one of the women behind the desk. A nurse note, dated 07/04/15 at 8:50 p.m., documented one on one visual checks were initiated. Nurse notes/visual check documentation, dated 07/03/15 through 07/13/15, documented the resident was observed with one on one observation. A follow-up incident report sent to OSDH, dated 07/13/15, documented the elopement alarm system had been installed in the facility. The report documented the resident had a transponder placed on her and the equipment had been tested and was working properly. A nurse note, dated 07/13/15 at 8:30 p.m., documented the alarm security system to prevent elopement was intact. On 07/20/15 at 6:00 p.m., the director of nurses (DON) was interviewed regarding the resident's elopement. The DON reported the resident took the alarm off when she eloped on 07/03/15. The DON reported the resident was observed at 4:00 p.m. The DON reported she met the ambulance about 6:05 p.m. on the road where the resident drove through the fence. On 07/21/15 at 8:45 a.m., the administrator was interviewed regarding interventions after the resident was returned to the facility. The administrator reported after the resident left the facility the first time she placed the code to the door on the top instead of the front of the key pad. The administrator reported she also put signs up to let visitors know not to let residents out of the facility. The administrator reported she came to the facility and talked to everyone after the incident. The administrator reported after the second incident occurred when the resident drove the car she ordered an elopement alarm system. On 07/21/15 at 12:54 p.m., certified nurse aide #2 (CNA) was interviewed regarding supervision of the resident prior to the resident driving the car. The CNA reported she was told to keep the alarm on the resident and to keep an eye on the resident. The CNA reported no one had explained why she was supposed to keep an eye on the resident. On 07/21/15 at 1:50 p.m., CNA #1 was interviewed regarding supervision of the resident. The CNA reported before the incident (when the resident drove the car), the staff kept an eye on the resident and tried to place the alarm so the resident couldn't reach it. The CNA reported after the incident of the resident driving the car, the staff watched the resident one on one. On 07/21/15 at 3:05 p.m., licensed practical nurse (LPN) #1 was interviewed regarding supervision of the resident. The CNA reported the resident knew the combination to the door to get out of the facility. The LPN reported she observed the resident leave the facility. The LPN reported the CNA was able to get to the resident first. The LPN reported the resident was walking. The LPN reported the staff was always trying to find a way to keep the alarm on the resident but she was smart enough to take it off. The LPN reported the resident had exited the facility the first time from the 400 hall exit door. On 07/21/15 at 3:21 p.m., CNA #3 was interviewed regarding supervision of the resident. The CNA reported after the incident of the resident driving the car, the resident was placed with one on one supervision. The CNA reported the staff tried to keep an alarm on the resident prior to the resident leaving the facility. The CNA reported the staff was not able to place the alarm anywhere the resident could not reach it. On 07/21/15 at 3:38 p.m., CNA #4 was interviewed regarding supervision of the resident. The CNA reported after the incident with the resident driving the car, the resident was placed with one on one supervision. The CNA reported the resident roamed the halls during the days. The CNA reported the resident had a chair alarm but would remove it. On 07/21/15 at 3:50 p.m., CNA #5 was interviewed regarding supervision of the resident. The CNA reported the resident had gotten into the parking lot one morning. The CNA reported the resident had a chair alarm prior to the resident taking the car but she would frequently take the alarm off. 2. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A comprehensive assessment had not been completed. A temporary care plan, dated 07/20/15, documented the resident was alert and oriented. The care plan documented the resident was able to walk independently. The care plan documented the resident was able to perform activity of daily living needs independently. An elopement risk assessment, dated 07/02/15, documented the resident displayed no signs of leaving the facility. The assessment documented the resident was not at risk of elopement. A nurse note, dated 07/08/15 (no time), documented the CMA notified the RN the resident was not in her room to administer medications. The note documented a search was initiated. An incident report, dated 07/08/15 at 8:00 a.m., documented a CMA notified the registered nurse (RN) the resident was not in the facility. The incident report documented the facility started searching for the resident. The steps taken to prevent recurrence was one on one observation at all times when the resident was in the facility. An initial incident report to OSDH, dated 07/08/15, documented the CMA notified the RN the resident could not be located within the facility for her morning medications. The report documented the administrator, DON, primary care physcian, and family were notified. The incident report documented a search was initiated immediately. The incident report documented after several contacts were made the resident was located at an inn in another town. The incident report documented the resident arrived back in the facility at 7:45 p.m. with the DON and a LPN. The incident report documented the resident would be placed on one-to-one observation. A written voluntary statement signed by LPN #3, dated 07/08/15 (no time), documented the resident came down the hall around midnight upset over another resident yelling out. The voluntary statement documented the LPN had last seen the resident around 3:00 a.m. walking down to the resident's room. A nurse note, dated 07/08/15 (no time), documented the resident was released to facility custody and returned to the facility with the DON and a LPN at 7:45 p.m. On 07/20/15 at 4:20 p.m., the assistant director of nurses (ADON) was interviewed regarding the elopement. The ADON reported she came to work at 6:00 a.m. the morning of the elopement. She stated a little before 8:00 a.m., the CMA asked the ADON if she had seen the resident because she wasn't in her room. On 07/20/15 at 5:55 p.m., the DON was interviewed regarding the elopement. The DON reported she thought a staff member had observed the resident between 3:30 a.m. and 4:00 a.m. the morning the resident eloped. The DON reported on 07/03/15 she had put signs on the door for visitors to be careful to not let residents out of the facility. The DON reported she had no reason to think the resident was a risk for elopement. The DON reported the resident went out to smoke independently. The DON reported the resident had never attempted to leave the facility. The DON stated the facility conducted smoking and elopement risk assessments on admission. The DON reported the staff was to make rounds every two hours. The DON reported the resident was independent and did not want the staff to open her door every two hours. The DON reported she had notes up for the staff to make rounds at shift change. The DON reported rounds were not made on the morning of 07/08/15 at shift change. The DON was asked what interventions she had put in place to prevent further elopements. The DON reported she had taken pictures of all the residents to put in a book with elopement assessments so she would have the information available if someone else eloped. The DON provided documentation of an inservice related to elopement that was conducted on 07/09/15. On 07/21/15 at 5:21 a.m., CNA #7 was interviewed regarding the elopement. The CNA reported she had not worked the night of the elopement. The CNA reported the staff was supposed to make rounds at 11:00 p.m., 1:00 a.m., 3:00 a.m., and 5:00 a.m. The CNA reported the staff was to check on everyone every two hours. On 07/21/15 at 5:37 a.m., CNA #6 was interviewed regarding the elopement. The CNA reported she was working at the time the resident left the facility. The CNA was asked if the facility had asked her for a statement of what happened. The CNA reported the facility had not asked her for a statement. The CNA reported the facility did not interview her as to the last time she had observed the resident on the date of the elopement. The CNA reported the staff was supposed to make rounds at 11:00 p.m., 1:00 a.m., 3:00 a.m., and 5:00 a.m. On 07/21/15 at 6:25 a.m., LPN #4 was interviewed regarding the staff making rounds. The LPN reported staff was supposed to make rounds at 11:00 p.m., 1:00 a.m., 3:00 a.m., and 5:00 a.m. The LPN reported the staff were supposed to visually look at everyone. On 07/21/15 at 8:45 a.m., the administrator was interviewed regarding the incident. The administrator reported the resident had been evaluated for elopement risk. The administrator reported the resident would sit outside and smoke and there was no indication of her wanting to leave. The administrator reported adult protective services was responsible for the resident but had not given the facility any indication the resident was at risk for an elopement. On 07/21/15 at 10:00 a.m., the assistant director of nurses (ADON) was interviewed regarding making rounds on the day of the elopement. The ADON stated she didn't make rounds that day at 6:00 a.m. when she started work. On 07/21/15 at 10:10 a.m., LPN #3 was interviewed related to the elopement. The LPN reported she had worked the night the elopement occurred. The LPN reported she had observed the resident in the hall at approximately 3:00 a.m. The LPN reported the resident was going to bed. The LPN stated, I don't know if they looked in the resident's room at 5:00 a.m. The LPN stated, We didn't do a round that morning at 6:00 a.m.

On 03/20/15 at 12:00 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to prevent, investigate, assess the resident, protect, report to the physician, family, and OSDH following allegations of resident to resident sexual abuse. Two residents had nurse notes documenting abuse allegations. The facility failed to investigate the allegations of abuse and assess the residents involved in the allegations. The facility failed to notify the physician, the family, and the OSDH following abuse allegations. On 03/20/15 at 12:35 p.m., the OSDH verified an immediate jeopardy situation existed related to the facility's failure to prevent, investigate, assess, protect, and report, following allegations of abuse. On 03/20/15 at 12:45 p.m., the administrator and director of nursing (DON) were informed of the IJ situation related to the facility's failure to identify abuse, prevent abuse and protect residents after allegations of abuse. The facility also failed to investigate the allegations of abuse and assess the residents involved in the allegations. The facility also failed to notify the physician, the family, and the OSDH following abuse allegations The administrator and the DON were informed the immediate jeopardy situation constituted substandard quality of care. The administrator and the DON verbalized understanding. On 03/20/15 at 8:00 p.m., the administrator and the DON provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: "Plan for removal of I.J. related to allegations of sexual misconduct 1. Conduct assessments of residents identified at risk and/or perpetrators including vital signs, document any discoloration e.g. bruising-marks-areas of redness-trauma- rashes- notify physician, ADM-DON, if abnormalities found for further instruction. To be completed by 03/22/2015. 2. Complete staff interviews regarding witnessing of sexual misconduct between residents. To be completed by 03/20/2015. 3. Complete inservice of all staff currently employed at Haskell County Nursing Center on sexual abuse- abuse to include accurate assessment of residents, notification of physician, administrator and/or DON/ADON, investigation methods, accurate documentation, interventions, and reporting to long term care protective health. Also, educated on abuse policy to include the seven components, screening, training, prevention, identification, protection, investigation, reporting/responses. To be completed by 03/20/2015. Employees who are on extended leave will be inserviced on sexual abuse-abuse as outlined in #3 prior to returning to work. All new employees will receive training prior to working on floor will be inserviced on sexual abuse-abuse as outlined in #3 4. Provide for safety of residents from sexual misconduct. a) Staff has been trained on behaviors to be alert for. Effective 03/20/2015. b) Residents have been identified to be at risk for sexual misconduct to include wanderers and disabled, such as bed-fast residents. Effective 03/20/2015. c) Residents have been identified who may be potential perpetrators of sexual misconduct through inappropriate behaviors with staff. Effective 03/20/2015. d) Residents who have been identified either at risk or potential perpetrators will be assessed by physician on record in conjunction with house psychiatrist to review physical/mental status- make recommendations. Physician on record will complete health assessment by 03/24/2015. House Psychiatrist will complete evaluations by 03/26/2015. e) Staff will monitor identified at risk residents to curtail inappropriate unwanted visits to residents room. Charge nurses will conduct 30 minute rounds on 400 hall, effective immediately and document on monitor log. Charge nurses will immediately notify the Administrator and DON if behaviors or sexual misconduct has been identified by charge nurse. Effective 03/20/2015. DON or designee will monitor logs for accuracy; daily x2 weeks, 1x week for 4 weeks, biweekly for 2 months, monthly thereafter f) Staff will accurately document behaviors and update careplans with any additional behaviors and interventions. Effective immediately. g) One staff member will remain on 400 hall at all times. Effective immediately. 5) Behaviors of Identified residents will be added to QA monitoring to be done as follows: By Director of Nursing and or Assistant Director of Nursing or designee. One time a week for 4 weeks Biweekly for 2 months and monthly thereafter this information will be recorded on QA monitoring form and presented at quarterly QA meetings. Effective immediately. 6) Careplans for all identified at risk and/or perpetrators will be updated to accurately reflect behaviors and interventions for safety of residents. To be completed by 03/23/2015" Surveyors interviewed staff on all shifts to verify their knowledge of the facility's policy related to prevent, investigate, assess, protect, and report following allegations of abuse. The staff verbalized an understanding of the facility's policy related to investigation, assessment, protection, and reporting following allegations of abuse. On 03/23/15 at 5:00 p.m., the facility was informed the IJ was removed, effective 03/20/15 at 6:00 p.m., when all components of the plan of removal had been implemented and staff verbalized an understanding of inservices related to prevention, investigation, assessment, protection, and reporting, following allegations of abuse. The deficiency remained at the level of actual harm at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from resident to resident sexual abuse for four (#2, #3, #4, and #5) of eight residents sampled for abuse and neglect. The facility failed to: a) Identify abuse, prevent abuse, and protect residents following allegations of sexual abuse for residents #4, and #5. b) Investigate the allegations of abuse and assess the residents involved in the allegations for residents #2, #3, #4, and #5. c) Notify the physician, the family, and the OSDH following abuse allegations for residents #2, #3, #4, and #5. The facility identified a census of 56 residents. Findings: The facility policy on abuse documented the facility believed all residents entrusted into their care had an inherit right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The policy documented the facility would not use, condone, or tolerate any form of abuse towards residents, including but not limited to sexual abuse. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 02/10/15, documented the resident's cognition was intact. The assessment documented the resident was independent with activity of daily living needs and ambulation. The assessment documented no behaviors. The care plan, updated on 02/12/15, documented the resident had developed a bond with a staff member. An intervention on the care plan was to monitor the resident for inappropriate [MEDICATION NAME] with other female staff or residents and remove female residents if behaviors manifested. The care plan documented the resident's physician would be notified for consult on medication review and/or adjustments. A nurse note, dated 03/03/15 at 5:11 p.m., documented licensed practical nurse (LPN) #1 observed the resident to be hugging another resident and placed his hand on the other resident's buttocks. A nurse note, dated 03/10/15 at 3:16 p.m., documented LPN #2 saw the resident hugging another resident with his hand up the back of the other resident's shirt. The note documented the other resident was taken to another part of the facility. The nurse note documented the resident was placed on 72 hour charting for behavior monitoring. A nurse note, dated 03/11/15 at 11:13 p.m., documented at 7:00 p.m., the resident had a female resident in a room. The note documented the female resident was lying down on a bed and the resident was standing over her with both hands under her shirt rubbing her breast. The note documented the female resident was taken to her room. The note documented a certified nurse aide (CNA) had witnessed the incident. The incident report book was reviewed and no incident report was observed documenting the observations in the nurse notes dated 03/03/15, 03/10/15, and 03/11/15. On 03/18/15 at 7:00 p.m., LPN #3 was interviewed regarding allegations of resident to resident sexual abuse. The LPN reported she had heard rumors from staff but had never witnessed any resident to resident sexual abuse. The LPN reported it was documented one resident was found touching another resident. The LPN reported no knowledge of whether the incident was reported. On 03/19/15 at 3:14 p.m., LPN #4 was interviewed regarding the nurse note dated 03/11/15 at 11:13 p.m. The LPN reported CNA #1 reported the incident to the LPN. The LPN reported she didn't tell anyone. The LPN documented the incident in the nurse notes. The LPN reported the female resident involved was resident #4. The LPN reported she had never witnessed the behavior between resident #2 and resident #4. On 03/19/15 at 6:04 p.m., LPN #1 was interviewed regarding the nurse note dated 03/03/15. The LPN reported the hug was mutual between the two residents and she didn't feel like it was sexual in nature. The LPN reported it was like the resident was dropping his hands to release the hug. The LPN stated she did not report the incident to the DON or ADON. On 03/20/15 at 3:05 p.m., the resident was interviewed in his room and reported he enjoyed living at the facility. The resident reported he got along with everyone in the facility and he loved his women. The resident stated staff would "get on to me, but what can they do?" 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/27/14, documented the resident was severely impaired with cognitive skills. The admission assessment documented the resident required no assistance with transfers, dressing, or eating. The admission assessment documented the resident was able to ambulate without assistance. The assessment documented no behaviors. A care plan, updated on 01/01/15, documented the resident frequently wandered throughout the facility, in and out of other resident rooms, and would lie down on other residents' beds. The care plan documented interventions to re-orient the resident and to assist the resident from other residents' rooms as needed. The care plan documented staff was to monitor where the resident was in the facility. The care plan documented the staff would encourage the resident to attend activities to keep the resident occupied. A nurse note, dated 03/09/15 at 4:00 p.m., documented the resident was observed wandering and staff was to keep the resident out of rooms she should not be in. On 03/18/15 at 5:45 p.m., the resident was interviewed in her room. The resident reported she loved the other residents and she was not afraid of any residents. On 03/18/15 at 8:10 p.m., the DON was interviewed. The DON reported she was aware of a female resident who went into the male residents' rooms. The DON stated no one had ever reported a female resident was in danger from a male resident. The medical record of resident #2 was reviewed and contained documentation in the nurse notes of sexual misconduct directed toward resident #4. The nurse notes documented the events were dated 03/03/15, 03/10/15, and 03/11/15. The medical record of resident #4 was reviewed and did not contain documentation of the incidents with resident #2. The medical record did not contain documentation the resident was assessed following the incidents. The medical record did not document new interventions were put into place in the care plan. The medical record did not document the resident's family, physician, or the OSDH was notified. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 01/21/15, documented the resident received [MEDICAL CONDITION] medications. The care plan was not updated to reflect sexual behaviors. The quarterly assessment, dated 03/04/15, documented the resident's cognition was intact. The assessment documented the resident experienced [MEDICAL CONDITION] 12 to 14 days during the assessment period. The assessment documented no behaviors. The assessment documented the resident required limited to extensive assistance with activity of daily living needs. A nurse note, dated 03/07/15 at 1:41 p.m., documented the resident took another resident in his room and put his hands down the other resident's pants. The note documented the other resident was taken out of the room. The note documented resident #3 would continue to be monitored and would be placed on 72 hour charting. The note documented the events occurred at 10:00 a.m. The incident report book was reviewed and no incident report was observed documenting the observation in the nurse notes dated 03/07/15. On 03/19/15 at 2:28 p.m., LPN #2 was interviewed regarding the allegation of resident to resident sexual abuse. The LPN reported a CNA reported the incident. The LPN stated she reported the incident to the ADON and she was told to put the resident on 72 hour charting for behaviors. The LPN reported the resident was talked to. The LPN reported the female resident was resident #5. The LPN reported having no idea an incident report should have been completed. On 03/19/15 at 3:25 p.m., the ADON was interviewed regarding the nurse note dated 03/07/15 at 1:41 p.m. The ADON reported she had no recollection of the event described in the nurse note. The ADON stated if the allegation of abuse had been reported to her, she would have had the LPN fill out an incident report. The ADON stated the incident should have been reported to the OSDH. On 03/20/15 at 11:30 a.m., the resident was observed in the dining room at a table with two female residents. No behaviors were observed. 4. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/29/14, documented the resident had severe impairment in cognitive skills. The quarterly assessment documented the resident had short term and long term memory problems. The assessment documented the resident exhibited wandering behaviors 4 to 6 days during the assessment period. The quarterly assessment documented the resident required extensive assistance with transfers, dressing, eating, bathing, and hygiene. The quarterly assessment documented the resident was always incontinent of bowel and bladder. A care plan, dated 04/02/14, documented the resident required interventions related to altered mental status caused by dementia. The care plan documented interventions for the resident's inability to speak. The care plan documented the facility staff was to ensure the resident attended activities that may have been of interest to the resident as the resident could no longer express their own choice of activities. The care plan documented interventions for care related to incontinence of bowel and bladder. The medical record of resident #3 was reviewed and contained documentation resident #5 had gone into the room of resident #3 on 03/07/15. The record documented resident #3 put his hands down resident #5's pants. On 03/19/15 at 2:28 p.m, the ADON was interviewed. The ADON reported the resident was assessed following the allegation of sexual abuse The medical record of resident #5 did not contain documentation of the incident or an assessment of the resident on 03/07/15. On 03/19/15 at 1:30 p.m., the director of nursing (DON) was interviewed. The DON reported the staff should have notified the DON or assistant director of nursing (ADON) regarding any allegations of resident to resident sexual abuse. The DON reported the incidents should have been investigated immediately. The DON stated any allegations of abuse should have been reported to the resident's physician, family, and OSDH. On 03/24/15 at 10:35 a.m., the administrator was interviewed. The administrator reported any allegations of resident to resident abuse should have been reported to the charge nurse. The Administrator reported the charge nurse was always to report allegations of abuse to the DON, ADON, or the administrator. The administrator reported any allegations should always have been investigated immediately. The DON reported the victim should always have been assessed; interventions put in place; and the physician, family, and OSDH should have been notified. On 03/24/15 at 10:40 a.m. the resident was observed sitting in a wheelchair in the dining room. The resident was rolling about using her feet. The resident was unable to answer questions.

On 03/20/15 at 12:00 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to follow their abuse policy for allegations of resident to resident abuse. Two residents had nurse notes documenting abuse allegations. The facility to prevent resident to resident sexual abuse; identify abuse; protect residents from abuse; investigate abuse allegations; or report to the physician, family and the OSDH following allegations of resident to resident abuse. On 03/20/15 at 12:35 p.m., the OSDH verified an immediate jeopardy situation existed related to the facility's failure to follow their policy to prevent resident to resident sexual abuse; identify abuse; protect residents from abuse; investigate abuse allegations; or report to the physician, family, and the OSDH following allegations of resident to resident abuse. On 03/20/15 at 12:45 p.m., the administrator and director of nursing (DON) were informed of the IJ situation related to the facility's failure to follow their policy to prevent resident to resident sexual abuse, identify abuse, protect residents from abuse, investigate abuse allegations, or report to the physician, family and the OSDH following allegations of resident to resident abuse. The administrator and the DON were informed the immediate jeopardy situation constituted substandard quality of care. The administrator and the DON verbalized understanding. On 03/20/15 at 8:00 p.m., the administrator and the DON provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: "Plan for removal of I.J. related to allegations of sexual misconduct 1. Conduct assessments of residents identified at risk and/or perpetrators including vital signs, document any discoloration e.g. bruising-marks-areas of redness-trauma- rashes- notify physician, ADM-DON, if abnormalities found for further instruction. To be completed by 03/22/2015. 2. Complete staff interviews regarding witnessing of sexual misconduct between residents. To be completed by 03/20/2015. 3. Complete inservice of all staff currently employed at Haskell County Nursing Center on sexual abuse- abuse to include accurate assessment of residents, notification of physician, administrator and/or DON/ADON, investigation methods, accurate documentation, interventions, and reporting to long term care protective health. Also, educated on abuse policy to include the seven components, screening, training, prevention, identification, protection, investigation, reporting/responses. To be completed by 03/20/2015. Employees who are on extended leave will be inserviced on sexual abuse-abuse as outlined in #3 prior to returning to work. All new employees will receive training prior to working on floor will be inserviced on sexual abuse-abuse as outlined in #3 4. Provide for safety of residents from sexual misconduct. a) Staff has been trained on behaviors to be alert for. Effective 03/20/2015. b) Residents have been identified to be at risk for sexual misconduct to include wanders and disabled, such as bed-fast residents. Effective 03/20/2015. c) Residents have been identified who may be potential perpetrators of sexual misconduct through inappropriate behaviors with staff. Effective 03/20/2015. d) Residents who have been identified either at risk or potential perpetrators will be assessed by physician on record in conjunction with house psychiatrist to review physical/mental status- make recommendations. Physician on record will complete health assessment by 03/24/2015. House Psychiatrist will complete evaluations by 03/26/2015. e) Staff will monitor identified at risk residents to curtail inappropriate unwanted visits to residents room. Charge nurses will conduct 30 minute rounds on 400 hall, effective immediately and document on monitor log. Charge nurses will immediately notify the Administrator and DON if behaviors or sexual misconduct has been identified by charge nurse. Effective 03/20/2015. DON or designee will monitor logs for accuracy; daily x2 weeks, 1x week for 4 weeks, biweekly for 2 months, monthly thereafter f) Staff will accurately document behaviors and update careplans with any additional behaviors and interventions. Effective immediately. g) One staff member will remain on 400 hall at all times. Effective immediately. 5) Behaviors of Identified residents will be added to QA monitoring to be done as follows: By Director of Nursing and or Assistant Director of Nursing or designee. One time a week for 4 weeks Biweekly for 2 months and monthly thereafter this information will be recorded on QA monitoring form and presented at quarterly QA meetings. Effective immediately. 6) Careplans for all identified at risk and/or perpetrators will be updated to accurately reflect behaviors and interventions for safety of residents. To be completed by 03/23/2015" Surveyors interviewed staff on all shifts to verify their knowledge of the facility's policy related to prevent, investigate, assess, protect, and report following allegations of abuse. The staff verbalized an understanding of the facility's policy related to investigation, assessment, protection, and reporting following allegations of abuse. The deficiency remained at the level of actual harm at a pattern level. On 03/23/15 at 5:00 p.m., the facility was informed the IJ was removed, effective 03/20/15 at 6:00 p.m., when all components of the plan of removal had been implemented and staff verbalized an understanding of inservices related to the facility's policy on prevention, investigation, assessment, protection, and reporting following allegations of abuse. Based on observation, interview, and record review, it was determined the facility failed to implement the facility abuse policy and procedure for four (#2, #3, #4, and #5) of eight residents sampled for abuse and neglect. The facility failed to follow their policy to prevent resident to resident sexual abuse; identify abuse; protect residents from abuse; investigate abuse allegations; or report to the physician, family and the OSDH following allegations of resident to resident abuse. The facility identified a census of 56 residents. Findings: The facility policy on abuse documented the facility believed all residents entrusted into their care had an inherit right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The policy documented the facility would not use, condone, or tolerate any form of abuse towards residents, including but not limited to sexual abuse. The policy documented the facility would prevent abuse by assessment, care planning and monitoring. The policy documented the facility would identify occurances of abuse, protect residents from further harm, conduct a thorough investigation and document the findings. The policy documented the facility would report to the state agency and to all other agencies as required. The facility policy on abuse documented the facility believed all residents entrusted into their care had an inherit right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The policy documented the facility would not use, condone, or tolerate any form of abuse towards residents, including but not limited to sexual abuse. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 02/10/15, documented the resident's cognition was intact. The assessment documented the resident was independent with activity of daily living needs and ambulation. The assessment documented no behaviors. The care plan, updated on 02/12/15, documented the resident had developed a bond with a staff member. An intervention on the care plan was to monitor the resident for inappropriate [MEDICATION NAME] with other female staff or residents and remove female residents if behaviors manifested. The care plan documented the resident's physician would be notified for consult on medication review and/or adjustments. A nurse note, dated 03/03/15 at 5:11 p.m., documented licensed practical nurse (LPN) #1 observed the resident to be hugging another resident and placed his hand on the other resident's buttocks. A nurse note, dated 03/10/15 at 3:16 p.m., documented LPN #2 saw the resident hugging another resident with his hand up the back of the other resident's shirt. The note documented the other resident was taken to another part of the facility. The nurse note documented the resident was placed on 72 hour charting for behavior monitoring. A nurse note, dated 03/11/15 at 11:13 p.m., documented at 7:00 p.m., the resident had a female resident in a room. The note documented the female resident was lying down on a bed and the resident was standing over her with both hands under her shirt rubbing her breast. The note documented the female resident was taken to her room. The note documented a certified nurse aide (CNA) had witnessed the incident. The incident report book was reviewed and no incident report was observed documenting the observations in the nurse notes dated 03/03/15, 03/10/15, and 03/11/15. On 03/18/15 at 7:00 p.m., LPN #3 was interviewed regarding allegations of resident to resident sexual abuse. The LPN reported she had heard rumors from staff but had never witnessed any resident to resident sexual abuse. The LPN reported it was documented one resident was found touching another resident. The LPN reported no knowledge of whether the incident was reported. On 03/19/15 at 3:14 p.m., LPN #4 was interviewed regarding the nurse note dated 03/11/15 at 11:13 p.m. The LPN reported CNA #1 reported the incident to the LPN. The LPN reported she didn't tell anyone. The LPN documented the incident in the nurse notes. The LPN reported the female resident involved was resident #4. The LPN reported she had never witnessed the behavior between resident #2 and resident #4. On 03/19/15 at 6:04 p.m., LPN #1 was interviewed regarding the nurse note dated 03/03/15. The LPN reported the hug was mutual between the two residents and she didn't feel like it was sexual in nature. The LPN reported it was like the resident was dropping his hands to release the hug. The LPN stated she did not report the incident to the DON or ADON. On 03/20/15 at 3:05 p.m., the resident was interviewed in his room and reported he enjoyed living at the facility. The resident reported he got along with everyone in the facility and he loved his women. The resident reported staff would "get on to me, but what can they do?" 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/27/14, documented the resident was severely impaired with cognitive skills. The admission assessment documented the resident required no assistance with transfers, dressing or eating. The admission assessment documented the resident was able to ambulate without assistance. The assessment documented no behaviors. A care plan, updated on 01/01/15, documented the resident frequently wandered throughout the facility, in and out of other resident rooms, and would lie down on other residents' beds. The care plan documented interventions to re-orient the resident and to assist the resident from other residents' rooms as needed. The care plan documented staff was to monitor where the resident was in the facility. The care plan documented the staff would encourage the resident to attend activities to keep the resident occupied. A nurse note, dated 03/09/15 at 4:00 p.m., documented the resident was observed wandering and staff was to keep the resident out of rooms she should not be in. On 03/18/15 at 5:45 p.m., the resident was interviewed in her room. The resident reported she loved the other residents and she was not afraid of any residents. On 03/18/15 at 8:10 p.m., the DON was interviewed. The DON reported she was aware of a female resident who went into the male residents' rooms. The DON stated no one had ever reported a female resident was in danger from a male resident. The medical record of resident #2 was reviewed and contained documentation in the nurse notes of sexual misconduct directed toward resident #4. The nurse notes documented the events were dated 03/03/15, 03/10/15, and 03/11/15. The medical record of resident #4 was reviewed and did not contain documentation of the incidents with resident #2. The medical record did not contain documentation the resident was assessed following the incidents. The medical record did not document new interventions were put into place in the care plan. The medical record did not document the resident's family, physician, or the OSDH was notified. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 01/21/15, documented the resident received [MEDICAL CONDITION] medications. The care plan was not updated to reflect sexual behaviors. The quarterly assessment, dated 03/04/15, documented the resident's cognition was intact. The assessment documented the resident experienced [MEDICAL CONDITION] 12 to 14 days during the assessment period. The assessment documented no behaviors. The assessment documented the resident required limited to extensive assistance with activity of daily living needs. A nurse note, dated 03/07/15 at 1:41 p.m., documented the resident took another resident in his room and put his hands down the other resident's pants. The note documented the other resident was taken out of the room. The note documented resident #3 would continue to be monitored and would be placed on 72 hour charting. The note documented the events occurred at 10:00 a.m. The incident report book was reviewed and no incident report was observed documenting the observation in the nurse notes dated 03/07/15. On 03/19/15 at 2:28 p.m., LPN #2 was interviewed regarding the allegation of resident to resident sexual abuse. The LPN reported a CNA reported the incident. The LPN stated she reported the incident to the ADON and she was told to put the resident on 72 hour charting for behaviors. The LPN reported the resident was talked to. The LPN reported the female resident was resident #5. The LPN reported having no idea an incident report should have been completed. On 03/19/15 at 3:25 p.m., the ADON was interviewed regarding the nurse note, dated 03/07/15 at 1:41 p.m. The ADON reported she had no recollection of the event described in the nurse note. The ADON stated if the allegation of abuse had been reported to her she would have had the LPN fill out an incident report. The ADON stated the incident should have been reported to the OSDH. On 03/20/15 at 11:30 a.m., the resident was observed in the dining room at a table with two female residents. No behaviors were observed. 4. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/29/14, documented the resident had severe impairment in cognitive skills. The quarterly assessment documented the resident had short term and long term memory problems. The assessment documented the resident exhibited wandering behaviors 4 to 6 days during the assessment period. The quarterly assessment documented the resident required extensive assistance with transfers, dressing, eating, bathing, and hygiene. The quarterly assessment documented the resident was always incontinent of bowel and bladder. A care plan, dated 04/02/14, documented the resident required interventions related to altered mental status caused by dementia. The care plan documented interventions for the resident's inability to speak. The care plan documented the facility staff was to ensure the resident attended activities that may have been of interest to the resident as the resident could no longer express their own choice of activities. The care plan documented interventions for care related to incontinence of bowel and bladder. The medical record of resident #3 was reviewed and contained documentation resident #5 had gone into the room of resident #3 on 03/07/15. The record documented resident #3 put his hands down resident #5's pants. On 03/19/15 at 2:28 p.m, the ADON was interviewed. The ADON reported the resident was assessed following the allegation of sexual abuse The medical record of resident #5 did not contain documentation of the incident or an assessment of the resident on 03/07/15. On 03/19/15 at 1:30 p.m., the director of nursing (DON) was interviewed. The DON reported the staff should have notified the DON or assistant director of nursing (ADON) regarding any allegations of resident to resident sexual abuse. The DON reported the incidents should have been investigated immediately. The DON stated any allegations of abuse should have been reported to the resident's physician, family, and OSDH. On 03/24/15 at 10:35 a.m., the administrator was interviewed. The administrator reported any allegations of resident to resident abuse should have been reported to the charge nurse. The Administrator reported the charge nurse was always to report allegations of abuse to the DON, ADON, or the administrator. The administrator reported any allegations should always have been investigated immediately. The DON reported the victim should always have been assessed, interventions put in place, and the physician, family, and OSDH should have been notified. On 03/24/15 at 10:40 a.m. the resident was observed sitting in a wheelchair in the dining room. The resident was rolling about using her feet. The resident was unable to answer questions.

Based on observation, record review, and interview, it was determined the facility failed to provide the necessary care to attain or maintain the highest practicable well-being for two (#8 and #10) of 13 residents sampled for assessment and monitoring. The facility failed to: a) Assess and monitor resident #8 after a fall with complaints of pain symptoms. Nurses' notes, dated 05/17/14, documented the resident was transferred to the hospital and returned to the facility. The notes documented the resident had an immobilizer to her left shoulder due to an "ebolsion." The facility identified 18 residents who had fallen in the last six months. b) Assess and monitor resident #10 following a capillary blood glucose (CBG) out of parameters. The facility identified 15 residents with physician orders [REDACTED]. The facility policy on acute change condition documented the facility would promptly notify the resident's attending physician when there had been an accident or incident involving a resident. The policy documented the staff would monitor and document the residents' progress. The facility policy on blood glucose monitoring documented to monitor a resident every 10-15 minutes during a hyperglycemic state. The policy documented all findings, interventions, and physician notifications would be documented in the nurse's notes. 1. Resident # 8 was admitted to the facility on 01/15/14 with [DIAGNOSES REDACTED]. An admission assessment, dated 01/26/14, documented the resident was severely impaired with cognitive skills. The assessment documented the resident was independent with bed mobility, transfers, and ambulation. The assessment documented the resident was occasionally incontinent with bowel and bladder. The assessment documented the resident had experienced a fall with no injury prior to admission. A quarterly assessment, dated 04/27/14, documented the resident was severely impaired with cognitive skills. The assessment documented the resident was independent with bed mobility and transfers. The assessment documented the resident was occasionally incontinent with bowel and bladder. The assessment documented the resident had experienced one fall without injury prior to the last assessment. A care plan, updated on 04/27/14 documented the resident had an altered mental status at times related to dementia. An incident report, dated 05/16/14 at 3:00 a.m., documented "Yelling for help. Upon entering room found resident sitting in floor. Complained of (c/o) left shoulder pain when touched not when rotated." The incident report documented the resident's physician had been notified via fax. The incident report documented the steps taken to prevent recurrence were to instruct the resident to use the call light when getting out of the bed. A nurse note, dated 05/16/14 at 3:00 a.m., documented the resident was yelling for help. The nurse note documented the resident was found sitting in the floor by the door naked. The nurse note documented the resident was confused and could not explain what had happened. The nurse note documented the resident was very agitated and complained of shoulder pain when touched but denied pain when rotated. The nurse note documented no other injuries were noted. The nurse note documented the resident was instructed to use the call light when getting out of the bed to prevent falls. The nurse note documented the resident's physician was notified via fax due to non-emergent. A nurse note, dated 05/16/14 at 4:00 a.m., documented the resident continued to complain of shoulder pain and pain medication was administered. A nurse note, dated 05/16/14, no time, documented the resident continued to complain of soreness in the left shoulder to touch. The note documented, "Rotates left shoulder without complaints of pain." An incident report, dated 05/17/14 at 5:45 p.m., documented the resident was found on her back on the floor beside the bed. The incident report documented the resident complained of shoulder pain. The incident report documented no swelling or discoloration to the left shoulder. The incident report documented the resident was sent to the emergency room for evaluation. The steps to prevent recurrence were documented as the staff were to check the whereabouts of the resident every hour and a body alarm was to be placed on the resident. A nurse note, dated 05/17/14 at 5:45 p.m., documented the resident was found on her back on the floor beside her bed. The nurse note documented the resident was complaining of left shoulder pain. The nurse note documented the resident was tearful. The nurse note documented the resident's physician was notified and new orders were received to send the resident to the emergency room for evaluation. A nurse note, dated 05/17/14 at 6:05 p.m., documented the resident was sent to the emergency room via emergency medical services for evaluation. A nurse note, dated 05/17/14 at 8:45 p.m., documented the resident returned to the facility. The nurse note documented the resident had an immobilizer to her left shoulder due to an "ebolsion." The nurse note documented the resident was to be administered [MEDICATION NAME] 600 milligrams by mouth three times daily and to follow up with her physician. The nurse note documented the resident's bed was placed in the low position and staff was instructed to check on the resident frequently. A care plan, updated 05/17/14, documented the resident was at risk for complications from a fall. The care plan documented the resident complained of left shoulder pain and was sent to the emergency room for evaluation. On 12/02/14 at 2:15 p.m., the resident was observed propelling herself in a wheelchair in the hallway. On 12/03/14 at 3:30 p.m., the director of nursing (DON) was interviewed regarding physician notification after the resident sustained [REDACTED]. The DON reported it was not appropriate to send a fax to the physician. The DON reported the resident should have been assessed for the pain and then reassessed to see whether the pain medication was effective. The DON reported the resident's physician should have been notified when the resident continued to complain of pain. On 12/04/14 at 5:30 p.m., the resident was observed propelling herself in a wheelchair in the hallway. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 06/25/14, documented the resident had long term and short term memory problems and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with all activities of daily living. The assessment documented the resident received daily insulin injections. The annual assessment, dated 09/22/14, documented the resident had long term and short term memory problems and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with all activities of daily living. The assessment documented the resident received daily insulin injections. The care plan, dated 09/23/14, documented the resident was on a controlled carbohydrate diet. The care plan did not address obtaining CBGs or insulin injections. The resident's treatment sheets were reviewed. A treatment sheet, dated 10/02/14 at 1:06 p.m., documented the resident had a CBG result of 567. The nurse notes were reviewed and did not contain documentation of an entry on 10/02/14. The resident's Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. On 12/02/14 at 11:22 a.m., staff was observed performing a CBG for the resident. The CBG reading was observed to be 379. On 12/02/14 at 12:40 p.m., the resident was observed being administered 22 units of [MEDICATION NAME] R insulin by staff. On 12/03/14 at 10:40 a.m., the director of nursing (DON) was asked if the resident had been reassessed following the CBG result of 567 on 10/02/14. The DON reported it would not be on the treatment administration record if the CBG had been repeated. The DON reported it would be documented in the nurse notes. On 12/04/14 at 10:35 a.m., the DON reported she had not found documentation of repeating the CBG following the reading of 567.

Based on observation, record review, and interview, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#3 and #8) of six sampled residents reviewed for falls. The facility failed to provide interventions to prevent the future occurrence of falls. Nurses' notes, dated 05/17/14, documented resident #8 was transferred to the hospital and returned to the facility. The notes documented the resident had an immobilizer to her left shoulder due to an "ebolsion." The facility identified 18 residents with falls in the past six months. Findings: The facility policy on fall prevention documented the purpose of the protocol was to provide the safest environment for the residents while helping them to function at their highest level. The policy documented the nursing staff would be responsible for resident assessment, documentation, and proper monitoring. The policy documented the nursing staff would initiate fall precautions for the residents. 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 01/26/14, documented the resident was severely impaired with cognitive skills. The assessment documented the resident had a memory problem. The assessment documented the resident was independent with bed mobility, transfers, and ambulation. The assessment documented the resident was occasionally incontinent with bowel and bladder. The assessment documented the resident had experienced a fall with no injury prior to admission. A quarterly assessment, dated 04/27/14, documented the resident was severely impaired with cognitive skills. The assessment documented the resident had a memory problem. The assessment documented the resident was independent with bed mobility and transfers. The assessment documented the resident was occasionally incontinent with bowel and bladder. The assessment documented the resident had experienced one fall without injury prior to the last assessment. An incident report, dated 05/16/14 at 3:00 a.m., documented "Yelling for help. Upon entering room found resident sitting in floor. Complained of (c/o) left shoulder pain when touched not when rotated." The incident report documented the resident's physician had been notified via fax. The incident report documented the steps taken to prevent recurrence were to instructed the resident to use the call light when getting out of the bed. A nurse note, dated 05/16/14 at 3:00 a.m., documented the resident was yelling for help. The nurse note documented the resident was found sitting in the floor by the door naked. The nurse note documented the resident was confused and could not explain what had happened. The nurse note documented the resident was very agitated and complained of shoulder pain when touched but denied pain when rotated. The nurse note documented no other injuries were noted. The nurse note documented the resident was instructed to use the call light when getting out of the bed to prevent falls. The nurse note documented the resident's physician was notified via fax due to non-emergent. A nurse note, dated 05/16/14 at 4:00 a.m., documented the resident continued to complain of shoulder pain and pain medication was administered. A nurse note, dated 05/16/14, no time, documented the resident continued to complain of soreness in the left shoulder to touch. The note documented, "Rotates left shoulder without complaints of pain." An incident report, dated 05/17/14 at 5:45 p.m., documented the resident was found on her back on the floor beside the bed. The incident report documented the resident complained of shoulder pain. The incident report documented no swelling or discoloration to the left shoulder. The incident report documented the resident was sent to the emergency room for evaluation. The steps to prevent recurrence were documented as the staff were to check the whereabouts of the resident every hour and a body alarm was to be placed on the resident. A nurse note, dated 05/17/14 at 5:45 p.m., documented the resident was found on her back on the floor beside her bed. The nurse note documented the resident was complaining of left shoulder pain. The nurse note documented the resident was tearful. The nurse note documented the resident's physician was notified and new orders were received to send the resident to the emergency room for evaluation. A nurse note, dated 05/17/14 at 6:05 p.m., documented the resident was sent to the emergency room via emergency medical services for evaluation. A nurse note, dated 05/17/14 at 8:45 p.m., documented the resident returned to the facility. The nurse note documented the resident had an immobilizer to her left shoulder due to an "ebolsion." The nurse note documented the resident was to be administered ibuprofen 600 milligrams by mouth three times daily and to follow up with her physician. The nurse note documented the resident's bed was placed in the low position and staff was instructed to check on the resident frequently. A care plan, updated 05/17/14, documented the resident was at risk for complications from a fall. The care plan documented the resident complained of left shoulder pain and was sent to the emergency room for evaluation. An incident report, dated 06/07/14 at 11:50 p.m., documented the resident was found sitting in the floor between the bed and the floor. The incident report documented the resident had a three centimeter laceration the her forehead. The incident report documented the resident was sent to the emergency room . The documented steps to prevent recurrence were to make sure the resident's personal alarm was in place. A nurse note dated 06/07/14 at 11:50 p.m., documented the resident was sitting in the floor between her bed and the wall. The nurse note documented blood was noted on the resident's forehead. The nurse note documented no other wounds or bruises were noted. The nurse noted documented first aide was given to the resident and neurological checks were normal. A care plan, updated on 06/07/14, documented the resident was at risk for complications from a fall. The care plan documented the resident had three centimeter laceration to her forehead. A nurse note, dated 06/08/14 at 12:20 a.m., documented the resident's physician, family, and emergency medical services were notified. The nurse note documented the resident was transported to the emergency room for evaluation. A nurse note, dated 06/08/14 at 3:20 a.m., documented the resident returned to the facility with three staples to her forehead. The nurse note documented the resident was to follow-up with her physician. The nurse note documented the resident's neurological checks were normal. A nurse note, dated 06/08/14 at 2:15 p.m., documented the staff heard the resident yelling. The nurse note documented the resident was found lying on the floor half on the mat. The nurse noted documented the resident was yelling her legs were hurting. The nurse note documented the resident could not turn or sit up due to the pain. The nurse note documented the resident was placed on her back and her vital signs were taken. A nurse note, dated 06/08/14 at 2:20 p.m., documented the resident's physician was contacted and emergency medical services (EMS) was notified. A nurse note, dated 06/08/14 at 2:40 p.m., documented. EMS arrived and transported the resident to the emergency room . A nurse note, dated 06/08/14, documented the facility received a report the resident had a hip fracture and two pelvic fractures. A care plan, updated on 06/08/14, documented the resident was at risk for complications from a fall. The care plan documented the resident complained of left leg pain and was sent to the emergency room . A care plan, updated 06/14/14, documented the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. On 12/02/14 at 11:30 a.m., the director of nursing (DON) was asked if other interventions had been put in place besides to ask the resident to use the call light and the placement of the personal alarm prior to the hip fracture. The DON reported she did not see any on the care plan. The DON reported the resident had been reminded to wear non skid shoes. The DON was asked if the resident would know to wear the shoes before ambulating. The DON reported, "No, the staff would have to make sure the resident was wearing them." On 12/02/14 at 2:15 p.m., the resident was observed propelling herself in a wheelchair in the hallway. On 12/02/14 at 5:40 p.m., the director of nursing was asked if the incident reports were reviewed. The DON reported the incident reports were discussed in the stand-up meetings. The DON reported the fall interventions started with the nurses because they were the ones present when the falls occurred. The DON was asked if the falls for the resident had been investigated. The DON reported the facility was not able to determine what caused the resident's fall. The DON reported the resident was alone when the falls occurred. The DON reported the resident did not know what happened. The DON reported the facility did not have a staff member assigned to investigate falls at the current time. On 12/03/14 at 5:07 p.m., the DON was asked how the facility determined what interventions were put in place for the residents to prevent recurrence of falls. The DON reported the nurses were supposed to keep track so the same interventions were not used. The DON reported if the resident continued to fall the interventions were not working. On 12/04/14 at 5:30 p.m., the resident was observed propelling herself in a wheelchair in the hallway. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 05/11/14, documented the resident was severely impaired in cognition and required limited to extensive assistance with activity of daily living needs. The assessment documented the resident was ambulatory. The assessment documented the resident had not fallen since the previous assessment. An incident report, dated 06/30/14 at 9:50 a.m., documented the resident slipped while in the bathroom and "may have" a bruise on the left coccyx. Interventions included to advise the resident to turn on the call light in her room for assistance, use the call light in her bathroom for assistance and use the walker at all times. The care plan, updated on 07/05/14, documented the resident fell on [DATE]. The care plan documented to treat as ordered and monitor for swelling, pain, limited range of motion, bruises, lacerations, change in level of consciousness or behavior and report to the physician promptly. The care plan documented to monitor for side effects from medication, labs, appetite as a cause for falls. The care plan documented to ensure call light was in reach and answered promptly and monitor resident for steadiness and balance. The care plan, dated 08/11/14, documented the resident was at risk for falls. The care plan documented approaches included bed rails would be kept down, call light and water would be kept within easy reach while the resident was in the room, and encourage the resident frequently not to get up fast and to stand up slowly. Other approaches included ensure bed was in the lowest position with wheels locked, ensure walker or wheelchair was kept within the resident's reach, monitor and observe every two hours and as needed, monitor for unsteady gait and assist as needed, and pharmacy consultations monthly. An incident report, dated 08/26/14 at 2:00 a.m., documented the resident was found laying on her left side in the floor and complained of pain to the left arm with no visible redness or swelling. The incident report documented a skin tear to the resident's left elbow. Interventions were to orient the resident to the call light and encourage her to use it. The care plan, updated on 08/26/14, documented the resident was at risk for complications from a fall and at risk for a repeat fall. The care plan documented the resident was sent to a local hospital for an x-ray of her left wrist the following a.m. The care plan documented a skin tear to the residents left elbow. The care plan documented to treat as ordered and monitor for swelling, pain, limited range of motion, bruises, lacerations, change in level of consciousness or behavior and report to the physician promptly. The care plan documented to monitor for side effects from medication, labs, appetite as a cause for falls. The care plan documented to ensure call light was in reach and answered promptly and monitor resident for steadiness and balance. An incident report, dated 11/08/14 at 9:00 a.m., documented the resident was found in the floor in front of the sink. The incident report documented the resident had tenderness to the right elbow and left knee and coccyx. The incident report documented the resident reported she had lost her balance. The incident report documented the resident was barefoot and unsteady. Interventions included the resident was advised to use the call light at all times, nonslip foot socks at all times while up, and evaluate for unsteady gait. The care plan, updated on 11/08/14, documented the resident had fallen and was at risk for a repeat fall. The care plan documented interventions included the resident was advised to use the call light for assistance and neurological checks for 24 hours. The care plan documented a treatment for [REDACTED]. The care plan documented to treat as ordered and monitor for swelling, pain, limited range of motion, bruises, lacerations, change in level of consciousness or behavior and report to the physician promptly. The care plan documented to monitor for side effects from medication, labs, appetite as a cause for falls. The care plan documented to ensure call light was in reach and answered promptly and monitor resident for steadiness and balance. The significant change assessment, dated 11/09/14, documented the resident was severely impaired in cognition, required limited to extensive assistance with all activity of daily living needs, and ambulation did not occur. The assessment documented the resident had sustained two falls since the previous assessment. On 12/01/14 at 4:51 p.m., the resident was observed in the dining room in her wheelchair. The resident was feeding herself her evening meal. The resident had a gait belt around her waist. On 12/02/14 the director of nursing (DON) was interviewed regarding falls. The DON reported interventions should start with the least restrictive and the resident should be evaluated for the reason for the fall. The DON reported the same intervention should not be used over and over. The DON reported the nurses should keep track of the fall interventions but the facility did not have a person who was responsible for that anymore.

On 06/12/12 an immediate jeopardy (IJ) situation was determined to exist regarding the facility's failure to ensure residents' safety in the area of resident to resident abuse and/or resident to resident altercations. Resident #1 exhibited sexual behavior towards a resident, slapped another resident, pushed another resident down to the floor, and four residents stated they were afraid of resident #1. On 06/12/12, the Oklahoma State Department of Health (OSDH) was notified and verified the immediate jeopardy situation related to the facility's failure to provide supervision to prevent accidents and/or protect residents. On 06/12/12 at 3:15 p.m., the administrator was informed of the IJ situation which also constituted substandard quality of care related to the facility's failure to provide supervision to prevent accidents. On 06/12/11 at 9:30 p.m., the administrator provided the survey team with an acceptable plan of removal which stated: "June 12, 2012 3:15 p.m. (Name deleted) administrator for (Name deleted) Nursing Center received notice from OSDH surveyors of an Immediate Jeopardy related to 'supervision to prevent potential/actual accidents.'" The facility will ensure that residents remain free of accident hazards by providing them with supervision and/or interventions to prevent reoccurrence. Interventions will be resident specific and will be continually monitored for effectiveness. Residents with behavior issues will be discussed with the QA committee. If a resident exhibits any type of behavior problems, staff will place the resident on 72 hour charting to monitor the behavior. Staff will evaluate the time, environment and situation when the behavior occurred and provide interventions accordingly. The behavior medication regimen will be evaluated with the physician. If the behavior continues and interventions are unsuccessful, the facility will consult with the physician for a possible Geri-psych evaluation or alternate placement of the resident. The resident in question related to the IJ situation received orders on 6/11/12 to transfer to (Name deleted) geripsych unit in (Name deleted) Ok. Received notification from staff at (Name deleted) that they could accept her on 6/12/12 around 11 a.m. and that they would transport her. The resident was transferred to (Name deleted) on 6/12/12 at approximately 1:00 p.m. by representatives from that facility. 6/12/12 12:30 p.m. the DON spoke with (Name deleted), (Name deleted) daughter, and gave her the information from the ombudsman on two different facilities with Alzheimer's units and informed her that arrangements needed to be made to transfer the resident to one of them. All staff will be in-serviced on resident to resident abuse by Thursday June 13, 2012. All staff will be required to take a quiz over the in-service and will be required to achieve a 100% on the quiz. The quiz will be re-administered until the staff member meets the requirements. In-services will be conducted Q 6 months with all staff over abuse. The DON/designee will conduct random audits of all staff to determine their knowledge of the abuse policy. Immediate in-services will be conducted if an employee fails the random audit." Surveyors interviewed staff on all shifts, including week-end staff, to verify their knowledge to prevent accidents related to residents who required supervision. The staff verbalized an understanding of the importance of supervision related to the prevention of accidents. On 06/14/11 at 5:50 p.m., the facility was informed the IJ was removed, effective 06/13/11 at 10:00 p.m., when the last staff member had been in-serviced and the staff verbalized an understanding of the inservices. The deficiency remained at the level of actual harm that was not an immediate jeopardy with more than a very limited number of residents affected. Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for five (#1, #2, #3, #4, and #6) of six sampled residents who required supervision to prevent accidents. The facility failed to provide supervision to: a) protect resident #4 from sexual behavior from resident #1. b) protect resident #2 from being slapped on the head by resident #1. c) protect resident #6 from being pushed down to the floor by resident #1. d) ensure residents were free from fear of resident #1. Four residents reported they were afraid of resident #1. The facility identified 61 residents who resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 03/09/12 at 7:30 p.m., documented the resident was going from door to door in the facility trying to open them. The nurse's note documented the resident would become very agitated when staff informed her that she couldn't open the doors. A nurse's note, dated 03/10/12 at 8:35 p.m., documented the resident was going in and out of other residents' rooms. The nurse's note documented the resident was very agitated with staff when asked to leave other residents' rooms. The nurse's note documented at one point when the certified nurse aide (CNA) told the resident she was in the wrong room the resident pinched and shoved the CNA while yelling at the CNA. A nurse's note, dated 03/11/12 at 12:30 a.m., documented the resident was going in and out of other residents' rooms, disturbing their sleep, and upsetting them. A nurse's note, dated 03/13/12 at 3:40 a.m., documented the resident was in another resident's room. The nurse's note documented when the CNA went into the room, resident #1 was standing in front of the other resident's television. The nurse's note documented the resident was holding the television remote and the other resident's television screen was busted. A nurse's note, dated 03/13/12 at 5:30 a.m., documented the resident was up all night wandering in and out of residents' rooms. A nurse's note, dated 03/15/12 at 2:00 a.m., documented the resident was in another resident's room in an extra bed. The nurse's note documented the nurse explained to the resident that she had a bed in her room. The nurse's note documented the resident stated, "I don't care and in the morning I'm going kill everyone on 400 hall." The nurse's note documented the resident held up her hand in the shape of a firearm and made "pow-pow-pow" noises. A nurse's note, dated 03/16/12 at 4:15 a.m., documented the resident was found in another resident's room. The nurse's note documented when the staff tried to bring the resident out of the room, she became agitated. The nurse's note documented the resident started hitting and kicking the nurse. The nurse's note documented the other nurse and CNAs tried to redirect the resident without success. The nurse's note documented the resident was up wandering again. Nurses' notes, dated 03/16/12 at 8:00 a.m. and 8:15 p.m., documented the resident continued to wander in and out of other residents' rooms. A nurse's note, dated 03/16/12 at 11:45 p.m., documented the resident wandered into another resident's room. The nurse's note documented when the CNA explained that the resident couldn't be in other residents' rooms without their permission, the resident became very angry and agitated, stating, "I'm gonna hit you." The nurse's note documented the resident had her fist drawn back. A nurse's note, dated 03/17/12 at 5:05 p.m., documented the resident stated she needed to call the police station. The nurse's note documented the resident stated, "I called the sheriff's office and reported that I'm not sure what's wrong but I feel like I wanna knock someone in the head." The admission assessment, dated 03/18/12, documented the resident was usually understood by others and sometimes understood others. The assessment documented the resident had short and long term memory problems. The assessment documented the resident was severely impaired with cognitive skills. The assessment documented the resident experienced signs and symptoms of delirium related to inattention, disorganized thinking, difficulty following what was said, incoherence, and illogical flow of ideas. The assessment documented the signs and symptoms of delirium were continuously present and did not fluctuate. The assessment documented the resident experienced delusions, including misconceptions beliefs that were firmly held and contrary to reality. The assessment documented the resident experienced physical behavioral symptoms directed toward others such as hitting, pushing grabbing, and/or abusing others sexually. The assessment documented the resident experienced verbal behavioral symptoms directed toward others such as threatening others and screaming or cursing at others. The assessment documented the behavioral symptoms occurred on a daily basis. The assessment documented the resident's behavior significantly intruded on the privacy or activity of others. The assessment documented the resident wandered daily. The assessment documented the wandering behavior placed the resident at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy or activities of others. The assessment documented the resident was independent with ambulation and all activity of daily living needs. Nurses' notes, dated 03/18/12 at 3:00 a.m. and 7:00 p.m., documented the resident was wandering in and out of other residents' rooms. The care plan, dated 03/19/12, documented the staff would monitor the resident when wandering to ensure she was not going in other residents' rooms. The care plan documented the resident had conflicts with family, friends, roommate, other residents, and/or staff. The care plan documented the resident would "holler" at staff and other residents. The care plan documented the facility would notify the doctor if the behavior persisted and she couldn't be redirected by the staff. The care plan documented the resident had outbursts of inappropriate accusations towards staff, but did not address physical behaviors directed toward others, including other residents. A nurse's note, dated 03/20/12 at 6:45 p.m., documented the nurse was called to another resident's room by the CNA. The nurse's note documented upon entering the room the resident was found standing over another resident with a razor in her hand. The nurse's note documented when the nurse tried to explain to the resident that she was in the wrong room the resident became agitated and told the nurse she had better back off before she knocked her head off. A nurse's note, dated 03/20/12 at 7:30 p.m., documented the resident was wandering in and out of other residents' rooms. A nurse's note, dated 03/20/12 at 10:00 p.m., documented the resident was wandering in and out of other residents' rooms waking them up and trying to get other residents out of bed. The nurse's note documented the resident became very agitated and threatened to hit the nurse when she tried to redirect the resident. A nurse's note, dated 03/21/12 at 3:20 a.m., documented the resident continued to wander in and out of other residents' rooms waking them up. The nurse's note documented when the CNA tried to stop the resident from taking supplies off the linen cart, the resident struck the CNA with a box of gloves. A nurse's note, dated 03/21/12 at 7:00 a.m., documented the resident was in the dining room eating out of other residents' plates. The nurse's note documented the resident refused to stop despite multiple attempts by various staff to redirect. The nurse's note documented the resident was agitated and the other residents verbalized fear of resident #1 as the resident continued to go in and out of other residents' rooms and to go through the other residents' belongings. A nurse's note, dated 03/21/12 at 8:30 a.m., documented the physician was notified of all the previous behavior problems. A new order was received to send the resident to a Geri psych unit for evaluation. The care plan, updated 03/21/12, documented the resident had been sent to a psych unit on 03/21/12 and returned on 04/02/12. A medical evaluation, dated 03/22/12, documented the resident was sent to the Geri psych facility secondary to abnormal behavior. The evaluation documented the resident had recently become combative with the staff. The report documented the resident was caught trying to shove a resident who was on Coumadin. The report documented, "According to the nursing home staff other residents are afraid of this patient. The patient has a history of hitting and kicking staff. Nursing home staff reports that her home health nurse stated that she was violent at home prior to being placed in the nursing home in the month of 03/2012." A nurse's note, dated 04/02/12 at 2:10 p.m., documented the resident was readmitted to the facility. A nurse's note, dated 04/02/12 at 7:05 p.m., documented the resident was wandering in and out of other residents' rooms. A nurse's note, dated 04/05/12 at 6:30 a.m., documented the resident was in the dining room touching all cups and silverware. The nurse's note documented the resident was very difficult to redirect. The nurse's note documented the resident stuck her entire arm in a freshly made pitcher of tea. A nurse's note, dated 04/05/12 at 9:45 a.m., documented the resident was wandering in and out of residents' rooms. The nurse's note documented the resident became very argumentative with staff and another resident. A nurse's note, dated 04/05/12 at 11:45 a.m., documented the resident was in the dining room going through other residents' silverware. The nurse's note documented when the resident was asked to stop the resident held a fork up in a stabbing motion. A nurse's note, dated 04/05/12 at 6:45 p.m., documented the resident was wandering in and out of other residents' room and taking other residents' belongings. The nurse's note documented the resident became very agitated with staff when they tried to redirect her. Nurses' notes, dated 04/07/12 at 9:00 a.m. and 6:45 p.m., documented the resident wandered in and out of other residents' rooms. A nurse's note, dated 04/09/12 at 1:00 p.m., documented the resident was wandering in and out of residents' room on the 400 hall. The nurse's note documented the nurse assisted the resident back to her own room. The nurse's note documented the resident immediately went to her roommate's side and began going through her roommate's belongings. The nurse's note documented the roommate began yelling at the resident. A nurse's note, dated 04/09/12 at 1:30 p.m., documented the administrator and DON were informed of the behavior between the resident and her roommate. The nurse's note documented the resident was moved to another room. The care plan, updated 04/09/12, documented the resident was moved to another room due to a conflict with the roommate. A nurse's note, dated 04/10/12 at 7:30 a.m., documented the resident was attempting to get in bed with a male resident. The nurse's note documented the nurse assisted the resident to her own room and bed. A nurse's note, dated 04/11/12 at 12:30 a.m., documented the resident was very combative with staff going in and out of other residents' rooms. The nurse's note documented the resident was trying to pull another resident up from a chair. The nurse's note documented the staff intervened before the resident could physically touch the other resident. The nurse's note documented the resident was cursing at staff and asked a CNA for a knife to cut another CNA. The nurse's note documented the resident stated, "I need a knife so I can cut her up." The nurse's note documented the resident was hitting and slapping the CNA. A nurse's note, dated 04/11/12 at 7:00 a.m., documented the physician was notified of the combative and wandering behavior during the previous night. A new order was received for Seroquel 50 milligrams (mg) at bedtime. The care plan, updated 04/11/12, documented a new order for Seroquel 50 milligram (mg) at bedtime was added. A nurse's note, dated 04/11/12 at 7:30 p.m., documented the resident was sitting on the sofa in the day room kicking at another resident in a wheelchair. The nurse's note documented the resident became argumentative with staff when trying to redirect. A nurse's note, dated 04/12/12 at 3:00 a.m., documented the resident came behind a CNA and grabbed the CNA's hair, pulling it, and yelling for the CNA to go outside with her to fight. A nurse's note, dated 04/12/12 at 1:05 p.m., documented the resident was assisted with a shower after an incontinent episode. The nurse's note documented the resident pushed the nurse in the chest and punched the second nurse in the right arm. The nurse's note documented the incident was reported to the DON and the administrator. Nurses' notes, dated 04/12/12 at 8:00 p.m. and 11:55 p.m., documented the resident was wandering in and out of residents' rooms. A nurse's note, dated 04/27/12 (No time documented) documented the physician added a [DIAGNOSES REDACTED]. A nurse's note, dated 04/27/12 at 11:10 p.m., documented the resident was in and out of other residents' rooms. The nurse's note documented when attempting to redirect the resident, the resident drew her fist back in a hitting motion. The nurse's note documented the resident was very difficult to redirect. The nurse's note documented several attempts were made before the resident left the other resident's room. A nurse's note, dated 05/01/12 at 1:00 a.m., documented the resident was, "Sitting on couch c (with) another resident and she had her hand in the male residents pants c (with) her hand around male residents penis." The nurse's note documented the residents were separated with no further incident. An incident report, dated 05/01/12 at 1:00 a.m., documented the resident was sitting on the couch with a male resident. The incident report documented resident #1 had her hand in the male resident's (Resident #4) pants with her hand around his penis. The incident report documented the resident was not objecting to the behavior. The incident report documented steps taken to prevent recurrence were the residents were redirected and separated without further incident. The incident report documented staff were to monitor closely. The report did not document the physician or family were notified. The incident report was signed by the DON and the administrator. A nurse's note, dated 05/01/12, (No time documented) documented the resident was ambulating in and out of other residents' rooms. The nurse's note documented the resident was cursing loudly to other residents. The nurse's note documented the resident stated, "I hope you drop dead." The nurse's note documented the resident attempted to strike a housekeeper. A care plan, updated 05/15/12, documented the resident wandered in and out of rooms. The care plan documented the facility spoke with the resident's family and the resident's daughters and two sisters would come up in the morning and evening and visit with the resident. The resident council minutes were reviewed for 05/21/12 at 2:00 p.m. The resident council minutes documented the residents had a complaint about a certain resident getting into their beds, using their restroom, and taking their things. A nurse's note, dated 05/28/12 at 6:30 a.m., documented the resident was found by a CNA in another resident's room wandering around. The nurse's note documented the resident only had her shirt on. The nurse's note documented when the CNA tried to get the resident to go back to her room to put on pants, the resident became combative hitting the CNA. The nurse's note documented the physician was notified. A nurse's note, dated 05/29/12 at 12:35 p.m., documented the resident was attempting to go in another resident's room. The nurse's note documented the restorative aide attempted to explain to the resident that she couldn't go in other residents' rooms. The nurse's note documented the resident became verbally abusive and struck the restorative aide in the back and attempted to strike at another resident. A nurse's note, dated 05/30/12 at 10:15 a.m., documented the resident was sitting in a recliner in another resident's room. The nurse's note documented the staff attempted multiple times to redirect the resident out of the room. The nurse's note documented the resident attempted to strike at the nurse's leg. The care plan (No date) documented the resident was placed on every hour checks. The care plan documented, "Staff must document the resident's location every hour." A document, dated 06/02/12, documented observation of the resident's location every hour. A nurse's note, dated 06/03/12 at 8:00 p.m., documented the resident was going in and out of other residents' rooms. The nurse's note documented when the CNA tried to redirect the resident the resident became combative, punching the CNA in the head. A nurse's note, dated 06/03/12 at 8:30 p.m., documented the resident was found in another resident's room trying to get in bed. The certified medication aide (CMA) explained to the resident she had her own room and bed to lay in and she would show the resident where it was. The nurse's note documented the resident became combative hitting the CMA in the arm and screaming, "You better leave me alone." A nurse's note, dated 06/04/12 at 8:00 p.m., documented the resident came up behind another resident (Resident #2) and slapped the other resident in the head. The nurse's note documented staff members witnessed this incident. The nurse's note documented resident #1 struck the other resident "Hard." The nurse's note documented the medical director came to the nursing home to see another patient and assessed resident #1. The medical director gave orders to increase the Seroquel 50 mg to 100 mg at bedtime. The care plan, updated 06/04/12, documented the resident struck another resident in the head. The care plan documented the family was called. The care plan documented the facility spoke with the ombudsman and the ombudsman spoke with the family. A nurse's note, dated 06/05/12 at 10:45 a.m., documented the staff spoke with the resident's daughters regarding the resident's behavior and discussed options with them. The care plan, updated 06/05/12, documented the family brought in beads and earrings to occupy the resident. A nurse's note, dated 06/06/12 at 9:00 a.m., documented the resident was digging in the trash on the treatment cart and the CMA attempted to redirect the resident. The nurse's note documented the resident spit a large amount of saliva on the CMA. A final report on the incident involving resident #1 and resident #2, dated 06/08/12, documented the administrator and director of nurses investigated the incident and found intentional resident to resident abuse. The report documented on 06/04/12 resident #1 walked up behind resident #2 and slapped resident #2 in the back of the head. The report documented the incident was witnessed by two staff members. The report documented the residents were separated and the charge nurse assessed resident #2. The report documented the physician was notified of the incident and increased some of resident #1's medications. The report documented both families were notified and the family of resident #1 came up to sit with resident #1. The report documented corrective actions included to place the resident on every hour monitoring, that the behavior medication was increased, that family would sit with resident #1 more frequently, that the resident's family would talk with the activity director and give her some suggestions on activities for the resident. The report documented the administrator and the DON spoke with the ombudsman and the ombudsman spoke with the resident's family about Alzheimer's units and possibly transferring the resident. The report documented staff were instructed to monitor the resident closely and redirect as needed. The report documented the resident's behavior had improved since the incident and she had not struck at another resident. A nurse's note, dated 06/08/12 at 12:20 p.m., documented resident #1 was found in another resident's room wearing the other resident's clothes. The nurse's note documented it was very difficult to redirect the resident out of the room. A nurse's note, dated 06/08/12 at 2:20 p.m., documented the resident was in the dining room attempting to take a violin away from a band member playing music. The nurse's note documented the resident resisted when redirected. A nurse's note, dated 06/09/12 at 5:05 p.m., documented the resident was ambulating down the hall holding the hand of another resident, causing him to stumble and almost lose his balance. The nurse's note documented the nurse attempted to redirect resident #1 without success. The nurse's note documented the resident stated, "I'll kill you!" The nurse's note documented after one on one with resident #1 she began to calm down and the nurse was able to escort the other resident back to the day room. The nurse's note documented when the nurse returned to assist resident #1 to sit down, resident #1 had gone to the medication room and grabbed a CMA and was trying to rip the CMA's shirt off. The nurse's note documented three staff members were finally able to get the resident off the CMA. A nurse's note, dated 06/09/12 at 5:55 p.m., documented resident #1 was in another resident's room, sitting on the bed, while the other resident was in the wheelchair. The nurse's note documented the other resident's spouse was visiting. The nurse's note documented the resident was not being mean, but was rubbing on the other resident and patting him. A nurse's note, dated 06/10/12 at 7:00 p.m., documented the nurse heard yelling coming from the dining room. The nurse's note documented when the nurse entered the dining room resident #1 was standing over another resident that was sitting in the floor. The nurse's note documented resident #1 was very agitated, stating, "I hate her" and pointed to the resident sitting in the floor. The nurse's note documented the medical director was notified. The care plan, updated 06/10/12 documented the resident struck another resident and knocked the other resident down. The care plan documented the family was called to sit with resident #1. A nurse's note, dated 06/11/12 at 11:45 a.m., documented the medical director was in the facility and observed the resident's behavior as the resident refused to be redirected and became very combative with staff and other residents. The nurse's note documented a new order was received to transfer the resident to a Geri psych unit for an evaluation. The care plan, updated 06/11/12, documented a Geri-psych consult was ordered. On 06/12/12 at 9:50 a.m., a group meeting was conducted with seven alert and oriented residents. The residents voiced concerns about resident #1 getting into their rooms and taking things. The residents reported resident #1 would get into other residents' beds. Four residents in the group reported they were afraid of resident #1. On 06/12/12 at 10:40 a.m., the resident was observed sitting in a chair in the front lobby watching the television. On 06/12/12 at 11:15 a.m., CNA #2 was interviewed. The CNA reported resident #1 was sometimes aggressive. The CNA reported she tried to monitor the resident a little more than the others but they couldn't keep up with the resident. The CNA reported she had not been told anything different to do related to monitoring resident #1. On 06/12/12 at 11:30 a.m., certified medication aide (CMA) #1 was asked if the nurses communicated with her regarding residents' behavior. The CMA stated, "Not usually." The CMA reported the nurses communicated with each other. The CMA was asked if she had been instructed to monitor the location of resident #1. The CMA reported she had not been instructed to monitor the location of resident #1 any more than any of the other residents. A nurse's note, dated 06/12/12 at 1:00 p.m., documented the resident was transferred to the Geri psych unit. On 06/12/12 at 1:30 p.m., the DON was interviewed regarding the behaviors of resident #1. The DON reported she was aware of the resident hitting the CNAs. On 06/12/12 at 3:15 p.m., an interview was conducted with the administrator regarding the incidents involving resident to resident abuse. The administrator stated, "What more could we have done?" The administrator reported the facility had sent resident #1 to a Geri-psych unit. The administrator reported the facility had called the family. The administrator was asked if the facility could meet the needs of resident #1. The administrator stated, "No." The administrator reported the facility had just found a unit that would accept the resident. The administrator asked what she was supposed to do. The administrator asked if she should put the resident out in the street. The administrator reported the Ombudsman was helping the facility find placement for resident #1. On 06/12/12 at 7:40 p.m., licensed practical nurse (LPN) #1 was interviewed. LPN #1 reported she had gotten resident #1 out of other residents' rooms. The LPN reported she had witnessed aggressive behavior from the resident. The LPN reported she had observed the resident hitting and shoving residents. The LPN reported resident #1 had shoved resident #6 on the evening of 06/10/12. On 06/12/12 at 7:55 p.m., certified nurse aide (CNA) #1 reported she had observed the resident hit resident #2. The CNA reported resident #2 wasn't even looking at resident #1. The CNA reported when resident #1 was aggressive, she had to monitor the resident every hour. The CNA reported the resident continued to have behaviors even when she was being monitored. On 06/13/12 at 2:10 p.m., the physician was interviewed. The physician was asked if he had been notified of the incidents involving resident #1. The physician reported he did not want to be notified of every incident. The physician was asked if he had been notified of the incident that involved the male resident with resident having her hand in the male resident's pants. The physician reported he did not remember being notified of that incident. On 06/14/12 at 3:50 p.m., CNA #3 was interviewed regarding the behavior of resident #1. The CNA reported resident #1 had been in bed with a male resident. The CNA was asked the identity of the male resident. The CNA reported the male resident was resident #3. On 06/14/12 at 3:55 p.m., CNA #4 was interviewed regarding the behavior of resident #1. The CNA reported resident #1 had slapped her in the face. The CNA reported the resident had also punched her in the stomach several times. The CNA reported the resident had hurt her. The CNA stated she had reported the incidents to the charge nurse. The CNA reported resident #3 was "Scared to death" of resident #1. CNA #4 reported the wife of resident #3 had been spending the night with him because he was afraid of resident #1. On 06/14/12 at 4:20 p.m., CNA #5 was interviewed regarding the behavior of resident #1. The CNA reported resident #1 had "hit a lot of residents." On 06/14/12 at 4:30 p.m., CNA #6 was interviewed regarding the behavior of resident #1. The CNA reported resident #1 had slapped other residents. The CNA also reported the resident had hit CNAs. The CNA reported resident #1 would flirt with male residents. When asked what she meant by that statement, the CNA stated the resident would rub the legs of male residents.