Every finding on record at Summers Healthcare, LLC

Based on observation, record review, and interview, the facility failed to ensure food was prepared under sanitary conditions to prevent cross-contamination. The dietary manager identified 2 residents on a pureed diet.On 07/20/26 at 11:38 a.m., the dietary manager was observed pureeing chicken in the food processor/blender work bowl and then pureeing spinach in the same work bowl without washing, rinsing, and sanitizing the work bowl and blade between food items. An undated policy titled Policy and Procedure for Pureeing Food read in part, Foods shall not be mixed together unless required by a standardized recipe .Equipment shall be cleaned and sanitized between uses .Staff shall: Prevent cross-contamination .Sanitize equipment between food items. On 07/20/2026 at 11:42 a.m., the dietary manager stated they have never cleaned the food processor/blender work bowl and blade between foods and was not aware they were supposed to.

On 01/18/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide Resident #1 with an environment that was free from accident hazards. A nurses' note, written 01/03/24 at 5:40pm, documented resident was found with left arm caught in bed rail and the bed rail had fallen on it. A nurses' note, written 01/04/24 at 3:28pm, documented the resident was transferred to the ER following xray of left arm. An ER report, dated 01/04/24, documented resident had a closed fracture of the left distal humerus. On 01/17/24 at 12:10pm, the resident was observed in bed with two upper bed rails raised. On 01/18/24 at 1:10pm, the DON acknowledged no physician's orders and no bed rail risk assessment had been completed. There was no documentation that the risk and benefits of using bed rails had been discussed with the resident's representative and no signed consent had been obtained before bed rails were put in use nor upon her return from the hospital. On 01/18/24 at 5:09 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 01/18/24 at 5:15 p.m., the administrator and the DON were notified of the IJ situation. On 01/23/24 at 4:16 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: 1/18/2024 All residents have the potential to be affected. 1/18/2024 at approximately 1600 all bedrails in the facility were lowered pending Pre-restraining assessment, restraint: side rail utilization assessment, consent from resident/family member for physical restraint and physicians order for the use of bedrails. [Resident #1's] bedrails were lowered, her bed was lowered to the lowest position and pillows were placed to maintain position for her protection. 1/18/2024 at approximately 1800 all residents or their families were educated on the pros and cons of bedrail restraints. Pre-restraining assessments were completed on all residents. Side rail utilization assessments were completed on [five] residents requesting bedrails, which included [Resident #3], [Resident #4], [unnamed resident #1], [unnamed resident #2], [unnamed resident #]. Consents were obtained verbally from [Resident #1's] guardian, [unnamed resident #2's] poa, and [Resident #3] and consent form mailed to them on 1/19/2024. [unnamed resident #1] and [unnamed resident #3] signed their own consents. Physician's orders were obtained for the five residents that requested bedrails be utilized while in bed. Care plans have been updated for [Resident #3], [Resident #4], [unnamed resident #1], [unnamed resident #2], and [unnamed resident #3] to indicate their request for bedrails. The five residents that have requested bedrails will be reassessed quarterly and consents will be updated annually. Residents that have requested some type of bedrail will be visualized for safety and positioning every two hours and as needed while in bed when bedrail is being utilized. All bedrails in the facility that are not being used have been zip tied to prevent use when not authorized by staff and visitors without proper assessments, consents and orders. 1/18/2024 Staff have been educated on the facility policy for restraints: pre-restraining assessment, side rail utilization assessment, consent for side rail and physicians order for side rails. Staff were educated on making sure residents are safe and moved from faulty bed then reporting to maintenance log. Staff were also in-serviced on procedure for reporting faulty bed to maintenance using identifying bed number along with room number and problem that has been identified to maintenance in the maintenance logbook. All beds were reassessed for proper working order. All beds will be assessed monthly for proper working order utilizing a tracking log. The maintenance supervisor or designee will monitor the maintenance log daily or as needed for any beds that are not working properly. The Director of nurses or designee will assess all residents upon admission and quarterly for restraints and consents will be obtained upon admission and annually per facility restraint policy. The QAPI committee will review all new assessments and quarterly assessments monthly and consents for new admissions and annual consents will be reviewed monthly. Care plans will be updated quarterly and on admission. The QAPI committee will review all care plans for residents that have requested bedrails. The Maintenance Supervisor will address any bed or equipment issues quarterly and as needed with the QAPI committee. The Maintenance Supervisor will present bed tracking log to the QAPI committee quarterly or as needed. The immediacy was lifted, effective 01/23/24 at 12 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated with the potential for harm to Resident #1. Based on record review, observation, and interview, the facility failed to identify and eliminate a known and foreseeable accident hazard for one (#1) of three sampled residents reviewed for the use of bed rails. The administrator identified 19 residents resided in the facility. Findings: A Restraints (Physical) policy, undated, read in parts, .General Guidelines for Assessments may include .Potential to injure self . Resident #1 had diagnoses that included gastrostomy, tracheostomy, and ventilator dependent. A quarterly MDS, dated [DATE], documented Resident #1 had severely impaired cognition, limited movement with impaired ROM to upper extremities, and was dependent for all ADL's. A nurses' Note, written 01/03/24 at 5:40 p.m., documented resident was found with left arm caught in bedrail and the bedrail had fallen on it. A nurses' note, written 01/04/24 at 3:28 p.m., documented the resident was transferred to the ER following xray of left arm. An ER report, dated 01/04/24, documented resident had a closed fracture of the left distal humerus. On 01/17/24 at 12:10 p.m., the resident was observed in bed with left arm in a sling and two upper bed rails raised. On 01/18/24 at 9:17 a.m., the DON was asked if a bed rail risk assessment had been completed for Resident #1 and if any new interventions had been put in place to prevent further injury when Resident #1 returned from the hospital. The DON stated no.

Based on interview and record review, the facility failed to have a qualified activity director for 19 of 19 residents who resided at the facility. Findings: On 01/18/24 at 1:10 p.m., the DON was asked if the facility had a certified activity director. She stated not at this time, CMA #1 does activities when they are here and comes in on their days off, the rest of the staff pitches in too. The DON was asked if CMA #1 or any other staff were certified activity directors. They stated no. On 01/18/24 at 3:56 p.m., the Administrator reported the last day the facility had a certified activity person was on 07/31/23.

Based on record review and interview, the facility failed to develop and implement interventions for reducing or discontinuing the use of bed rails and provide ongoing monitoring and evaluation for three (#1, 3, and #4) of three sampled residents with bed rails in use. The administrator identified 19 residents resided in the facility. There were six residents with bed rails in use. 1. Resident #1 had diagnoses that included gastrostomy, tracheostomy, and ventilator dependent. On 01/17/24 at 12:10 p.m., Resident #1 was observed in bed with two upper bed rails raised. 2. Resident #3 had diagnoses that included gastrostomy, tracheostomy, and ventilator dependent. On 01/17/24 at 1:08 p.m., Resident #3 was observed in bed with four bed rails raised. 3. Resident #4 had diagnoses that included gastrostomy and tracheostomy. On 01/17/24 at 12:05 p.m., Resident #4 was observed in bed with two upper bed rails raised. There were no interventions documented on the care plan or implemented for resident #1, #3, nor #4, to reduce or discontinue the use of bed rails. There was no documentation in resident #1, #3, or #4's clinical records showing ongoing monitoring and evaluation of bed rail use was being conducted. On 01/18/24 at 1:10 p.m., the DON was asked if interventions had been put in place to reduce the use or discontinue the use of bed rails for the above-named residents. They stated the residents had been using the bedrails since they have been here. The DON was asked to provide documentation of ongoing monitoring and evaluations for residents with bed rails in use and stated no monitoring or evaluations had been documented.

Based on record review and interview, the facility failed to a. assess the resident for need and safety of bed rail use, b. discuss the risks and benefits of bed rails and obtain informed consent from the resident or the resident's representative, and c. obtain a physician's order for the use of bed rails for three (#1, 3, and #4) of three sampled residents reviewed for restraints. The administrator identified 19 residents resided in the facility. There were six residents with bed rails in use. Findings: A Restraints (Physical) policy, undated, read in parts, .Procedure .1. Assess resident's need for restraint use .Obtain informed consen .Obtain physician's order .Develop or review resident care plan . 1. Resident #1 had diagnoses that included gastrostomy, tracheostomy, and ventilator dependent. On 01/17/24 at 12:10 p.m., Resident #1 was observed in bed with two upper bed rails raised. 2. Resident #3 had diagnoses that included gastrostomy, tracheostomy, and ventilator dependent. On 01/17/24 at 1:08 p.m., Resident #3 was observed in bed with four bed rails raised. 3. Resident #4 had diagnoses that included gastrostomy and tracheostomy. On 01/17/24 at 12:05 p.m., Resident #4 was observed in bed with two upper bed rails raised. There was no documentation in the clinical records of Resident #1, #3, nor #4 of the reason bed rails were being used, risks or benefits of use, informed consent for use, nor a physician's order for the use of bed rails. On 01/18/24 at 1:10 p.m., the DON was asked the facility policy regarding the use of bed rails. They stated bed rails could only be used with a physician's order and resident or family consent. The DON was asked if there was documentation of the reason bed rails were being used, the risks or benefits of use, an informed consent for use, or a physician's order for the use of the bed rails in the clinical records of Resident #1, #3, or #4. They stated no and acknowledged the facility policy had not been followed.

Based on record review and interview, the facility failed to ensure MDS assessments were transmitted timely for three (#152, 104, and #154) of 11 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents report, dated 08/23/23, documented 19 residents resided in the facility. Findings: A MDS 3.0 Validation Report, dated 08/23/23, documented the following comprehensive assessments were not transmitted within 14 days of completion: a. Resident #152's comprehensive assessment, dated 05/19/23, b. Resident #104's comprehensive assessment, dated 12/16/22, and c. Resident #154's comprehensive assessment, dated 01/27/23. On 08/24/23 at 3:00 p.m., the administrator was asked to provide MDS submission reports from April 2023 to August 22, 2023. She stated No, because there was not anyone in facility to do them.

Based on observation and interview the facility failed to ensure food was labeled/dated and outdated foods were properly disposed. This affected 16 residents who received nutritional services from the kitchen. Resident Census and Condition of Residents documented four residents received enteral feeding, and the facility Census was 20. Findings: On 09/19/22 at 10:21 a.m., during a brief initial observation in the kitchen the following food was observed as follows; 1. two packs of frozen turkey breasts (use/sell by date 07/29/22), 2. two packages of bologna (use/sell by date 02/19/22) and, 3. hamburger patties in a clear package, unlabeled and no expiration date. The DS was asked when the turkey breast was stored. The DS stated, That, I don't know I wasn't here when it went in. During observation of the refrigerator in the kitchen, there was six bags of, undated, fajita-blend vegetables. The dry storage room had a large undated bag of cereal. The DS acknowledged there was no date on the bag. On 09/19/22 at 10:47 a.m., in a second storage area an, undated, opened bag of French fries was observed in a freezer. There were three bags of, undated, sealed French fries in plastic packaging. The DS was asked if there was a date. The DS state, I don't see a date on them.

Based on record review and interview the facility failed to document the provision of information and education regarding the risks, benefits, and potential side effects of vaccinations to the resident or legal representative before administering: a. the pneumococcal vaccine for three (#1, #4, and #5) of five residents sampled for immunizations, and b. the influenza vaccine for one (#3) of five residents sampled for immunizations. Resident Census and Condition of Residents documented 20 residents lived at the facility. Findings: Vaccination of Residents policy, revised October 2019, read in part, .1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations .2. Provision of such education shall be documented in the resident's medical record . 1.Resident #1's immunization log documented they received [MEDICATION(S)] vaccine on 07/31/2020. There was no documentation in resident #1's clinical record that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided to them or their legal representative before administering. 2. Resident #3's immunization log documented they received influenza vaccine on 06/02/2020. There was no documentation in resident #3's clinical record that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided to them or their legal representative before administering. 3. Resident #4's immunization log documented they received [MEDICATION(S)] vaccine on 07/31/2020. There was no documentation in resident #4's clinical record that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided to them or their legal representative before administering. 4. Resident #5's immunization log documented they received [MEDICATION(S)] vaccine on 07/31/2020. There was no documentation in resident #5's clinical record that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided to them or their legal representative before administering. On 09/20/22 at 1:20 p.m., DON was asked if residents or their legal representatives were provided information and education regarding the risks, benefits, and potential side effects of vaccinations offered at the facility. The DON stated, Yes, they should be. The DON was asked if the provision of this information was documented in the resident's medical record. She stated yes. After a review of the clinical records with this surveyor, for residents #1, #3, #4, #5, and #7, the DON agreed the information and education regarding the risks, benefits, and potential side effects of the pneumococcal or influenza vaccinations were not present for these residents, as outlined above.

Based on record review and interview the facility failed to document the provision of information and education regarding the risks, benefits, and potential side effects of vaccinations to the resident or legal representative when offering the COVID-19 vaccine for five (#1, #3, #4, #5, and #7) of five residents sampled for immunizations. Resident Census and Condition of Residents documented 20 residents lived at the faciity. Findings: Vaccination of Residents policy, revised October 2019, read in part, .1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations .2. Provision of such education shall be documented in the resident's medical record . 1. There was no documentation in resident #1's clinical record that information and education regarding the risks, benefits, and potential side effects of the COVID-19 vaccination had been provided to resident #1 or their legal representative. 2. Resident #3's Social Service progress note, dated 06/07/22, read in part, .I asked [Resident #3's] daughter if she wanted [Resident #3] to receive a covid vaccine, [resident #3's] daughter declined via telephone . There was no documentation in resident #3's clinical record that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided to resident #3 or their legal representative. 3. Resident #4's Social Service progress note, dated 06/07/22, read in part, .I asked [Resident #4's] father if he wanted [Resident #4] to receive a covid vaccine, he declined via telephone . There was no documentation in resident #4's clinical record that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided to resident #4 or their legal representative. 4. Resident #5's Social Service progress note, dated 06/07/22, read in part, .I asked [Resident #5's] daughter if she wanted [Resident #5] to receive a covid vaccine, [resident #5's] daughter declined via telephone . There was no documentation in resident #5's clinical record that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided to resident #5 or their legal representative. 5. Resident #7's Social Service progress note, dated 06/07/22, read in part, .I asked [Resident #7's] POA if they wanted [Resident #7] to receive a covid vaccine, POA declined via telephone . There was no documentation in resident #7's clinical record that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided to resident #7 or their legal representative. On 09/20/22 at 1:20 p.m., DON was asked if residents or their legal representatives were provided information and education regarding the risks, benefits, and potential side effects of vaccinations offered at the facility. The DON stated, Yes, they should be. The DON was asked if the provision of this information was documented in the resident's medical record. She stated yes. After a review of the clinical records with this surveyor, for residents #1, #3, #4, #5, and #7, the DON agreed the information and education regarding the risks, benefits, and potential side effects of the COVID-19 vaccination was not present for these residents.

Based on observation, interview and record review, it was determined the facility failed to implement and maintain their infection control program to prevent the development and transmission of COVID-19. The facility failed to ensure staff utilized personal protective equipment (PPE) as required by the Center for Disease Control (CDC). The administrator identified 25 residents who resided in the facility with four of those residents currently positive for COVID-19. Findings: A facility policy titled, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), documented: It is the policy of (named facility) to minimize exposures to respiratory pathogens .for the COVID-19 and to adhere to Federal and State/Local recommendations (to include, for example: visitation, precautions: including the use of eye protection). .Disposable eye protection will be discarded after use .Facility will provide adequate work supplies to avoid sharing. The CDC guidance titled, Healthcare Workers Eye Protection, documented: .extended use of eye protection is the practice of wearing the same eye protection for repeated close contact encounters with several different patients .If a disposable face shield is reprocessed, it should be dedicated to one HCP (health care provider) . Healthcare Workers Gowns .Disposable gowns generally should NOT be re-used .because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits . repeatedly donning and doffing of contaminated gown may increase risk for HCP self-contamination. On 12/8/20 at 10:00 a.m., an initial tour of facility was conducted. Disposable gowns and disposable face shields were observed draped on each doorway of each resident's room door affixed with a push pin. Staff were observed wearing a surgical mask. At 10:02 a.m., the ACMA (advanced certified medication aide) #1 was observed dragging a disposable gown on the ground and placed it on the doorway of room [ROOM NUMBER]. The ACMA #1 was observed to remove the gown from the doorway of room [ROOM NUMBER] and donned the gown then donned the face shield also draped on the doorway. The ACMA #1 was observed to enter room [ROOM NUMBER]. At 10:06 a.m., the ACMA #1 was observed exiting room [ROOM NUMBER], doffed the gown and placed it back on push pin on the doorway of room [ROOM NUMBER]. The ACMA was observed to then remove the face shield and replaced it on push pin on doorway of room [ROOM NUMBER]. The ACMA was observed to walk down hall to a storage room where she retrieved a bottle of disinfectant, returned to doorway of room [ROOM NUMBER]. The ACMA was observed spraying the doffed gown affixed to the doorway of room [ROOM NUMBER] and sprayed the outside of the face shield also affixed to the doorway of room [ROOM NUMBER]. The ACMA was not observed to perform hand hygiene. At 10:09 a.m., the ACMA stated staff entering a resident room share the disposable gown and disposable face shield hung at doorway. The ACMA stated there was sufficient PPE supplies. At 10:13 a.m., CNA (certified nurse aide) #2 and CNA #3 was observed donning a gown and face shield affixed to doorway of room [ROOM NUMBER] and room [ROOM NUMBER]. Both staff observed entering room [ROOM NUMBER]. At 10:19 a.m., CNA #2 and CNA #3 were observed exiting room [ROOM NUMBER]. Both staff observed doffing gloves, disposable gown and disposable face shield at the doorway of room [ROOM NUMBER]. Staff then placed disposable gown and disposable face shield on the doorway of room [ROOM NUMBER] and 114. CNA #2 observed to pick up the bottle of disinfectant and sprayed the gowns and sprayed the outside of the face shield. CNA #2 then placed the disinfectant back on cart at doorway of room [ROOM NUMBER]. Both staff observed walking down hall to room [ROOM NUMBER] and observed donning gown and face shield affixed to wall and entered room [ROOM NUMBER]. At 11:09 a.m., the administrator and DON (director of nurses) stated the disposable face shield and disposable gown were sprayed and reused by any staff entering room. The administrator stated the facility staff utilized the disposable gowns and disposable face shield until they were torn.

Based on observation, record review, and interview, it was determined the facility failed to provide reasonable assistance in locomotion for one (#15) of 13 sampled residents. The facility's Resident Census and Conditions of Residents documented nine residents ambulated with assistance and/or required assistive devices. Findings: Resident #15 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE], documented the resident was cognitively intact; required extensive assistance for locomotion; and experienced shortness of breath with exertion. The care plan last updated 08/26/19, documented the resident required staff assistance with most of his ADL tasks. Interventions documented, .I prefer to use a w/c for transportation to and from the dining room or any other location outside of my room and I request when they are available that staff push my w/c so I don't become (short of breath). Staff to assist with propelling w/c as needed . On 09/16/19 at 12:52 p.m., resident #15 was observed with his oxygen concentrator in front of his wheelchair as he propelled himself from the dining room to his room. He was short of breath upon arrival to his room. At 12:57 p.m., an unidentified nurse presented to room. As she plugged the oxygen concentrator into the wall outlet, the resident stated, I don't know why they won't help me. The nurse exited the room without responding to resident. At 12:59 p.m., the resident was asked if he had difficulty maneuvering his w/c and oxygen concentrator. He stated, Yes, I have trouble and they never help me. He was asked if he requested assistance from staff. He stated, Yes I have asked but they say it makes me stronger to do it myself. The resident was asked how he felt about that. He stated, I don't even ask them anymore because they won't help and it wipes me out to do it (propel wheelchair and maneuvering concentrator). He stated, It takes me a long time to recover after I have to do it. On 09/17/19 at 8:52 a.m., the resident propelled himself from the dining room to his room with the oxygen concentrator in front of him. Upon arrival to his room, he plugged his oxygen concentrator into the wall outlet. The resident was very short of breath and stated, It takes me 5-10 minutes to recover. At 8:58 a.m., the resident continued to be short of breath. He stated, I'm starting to recover. At 9:00 a.m., the resident stated he feels like he has recovered. At 3:57 p.m., CNA #1 was asked how the resident gets to and from the dining room. She stated we encourage him to walk but he doesn't so we push him to the dining room and he self propels from the dining room back to his room because he becomes impatient for us to finish feeding other residents. She was asked does the resident walk. She stated he walks assisted and uses a portable concentrator. She stated when the resident is assisted to the dining room, his concentrator is off but staff hurry so the oxygen concentrator can be plugged into the outlet. At 4:02 p.m., CMA #1 was asked how the resident gets to and from the dining room. She stated, We push him out and he pushes himself back. We plug the concentrator in when he returns to the room. She was asked how long does the resident wait to have his concentrator plugged in? She stated, We see him go and we follow him and plug the concentrator in. She was asked does he walk. She stated the residents walks with assistance. She was asked what does the resident do for oxygen when he walks. She stated a portable oxygen concentrator is used. She was asked if the resident ever appear short of breath. She stated he becomes short of breath when he walks. She was asked if he becomes short of breath when he self propels in his w/c. She stated, No, he does good with that. At 4:10 p.m., LPN #1 was asked how the resident gets to and from the dining room. She stated staff usually assist to the dining room and he self propels back to his room. She was asked how does the resident manage his concentrator while self propelling. She stated, He puts it between his legs and he plugs the concentrator in when he gets to his room, or staff walking by plug it in. She was asked if the resident walks. She stated, He can or used to but he says he gets too short of breath. She was asked if the resident ever appeared to be short of breath. She stated, Not recently.

Based on observation, record review, and interview, it was determined the facility failed to ensure information was provided to residents/representatives to formulate an advance directive for three (#7, 4, and #14) of three sampled residents whose records were reviewed for advance directives. The facility census was 32. Findings: 1. Resident #7 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE], documented the resident to be severely impaired in cognition for daily decision making. The current physician orders [REDACTED]. The clinical record documented a guardian had been assigned to the resident. A note inside the record documented the guardian had died on [DATE]. The record did not contain information of a new legal guardian had been assigned/determined or if a representative had been offered information to formulate an advance directive. On [DATE] at 3:05 p.m., the social service director was asked if she is involved with review/offering information to resident/representative to formulate an advance directives. She stated she assisted with the admission packet and reviewed the information in the packet with them. She stated she was unfamiliar with information, if there is not an advance directive, she would notify the charge nurse or medical records to follow-up. She was asked if she was aware of resident #7 having an order for [REDACTED]. At 3:30 p.m., the DON was asked if she had any information of resident's advance directive/guardian. She stated, I do not know what is being done but the facility is aware the guardian expired. She was asked what is in the process to update the guardian/advance directive for a resident. She stated the next emergency contact is to go to court to be awarded the guardianship. The plan is for the individual to forward a copy of the new guardianship papers. She was not sure when the court date was to occur. She was asked if this should have been addressed prior to a 2 month span. She stated it could be a problem. She was asked if nursing facility has a policy/practice to follow up with advance directive to be offered. She stated the information is offered on admit and if there is a change of condition. She stated, I do not know if there is a policy, but will look for one. On [DATE] 10:14 a.m., the administrator was asked who was responsible to review if residents had or was to be offered information to formulate an advance directive. She stated, The administrator, director of nurses and social services. She was asked who assisted new admits with the admission packet. She stated, Social services. She was asked how often legal items are reviewed/updated. She stated on admission and should be reviewed with each care plan meeting when family/representatives are together. She was asked where the information would be located. She stated the information should have been documented in the social services notes. She was informed the surveyor was unable to locate such documentation and asked if the resident's record should have been updated at the time the guardian has died . She stated, We looked into that yesterday and I called the lawyer. The lawyer is out of town until next week so we cannot address the issue until then. 2. Resident #4 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE], documented the resident was cognitively intact for daily decision making; and required oxygen/suctioning/[MEDICAL CONDITION] care. The current physician orders [REDACTED]. The current demographic sheet documented the resident's mother was the first emergency contact. There was no documentation to indicate information to formulate an advance directive had been offered to the resident or her representative. Observations made throughout the survey. The resident was alert and oriented. She was non-verbal but able to communicate using her computer or blinking eyes to yes/no questions. 3. Resident #14 was admitted with [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The quarterly assessment dated [DATE], documented the resident had severe impairment of cognitive skills. Demographic sheet documented the resident's wife was the responsible party and emergency contact #1 and the resident was a full code status. There was no documentation the resident/representative was provided information to formulate an advance directive. On [DATE] at 10:00 a.m., the MDS coordinator was asked if the resident or representative had been offered information to formulate an advance directive. She stated the advanced directive information was in the admission packet and felt sure if the resident did not have an advanced directive or did not want to formulate an advanced directive it wasn't printed off. The director of nurses was asked if the resident was at a high risk for something happening that was life threatening. She stated, Yes. She was asked if it would be important to know what the resident's wishes were. She stated, Yes. She was asked if the resident had been informed of her rights to formulate an advanced directive. She stated she didn't know, she would check. No further information was provided.

Based on record review, and interview, it was determined the facility failed to ensure the physician was notified of a change for one (#1) resident who was reviewed for physician notification. Findings: Resident #6 had [DIAGNOSES REDACTED]. An annual assessment, dated 07/29/19, documented the resident's cognition was moderately impaired; he was independent for bed mobility; and required extensive assist of one person for dressing. It was also documented the resident required extensive assist of two persons for toileting. He was frequently incontinent of bowel and had a suprapubic catheter. A care plan, dated 07/10/19, documented staff were to report to the physician any suspected signs and symptoms of a UTI: cloudiness, deepening of color, foul smelling urine. A nurse's note, date 08/05/19 at 8:00 a.m., documented the resident's urine had sediment A nurse's note, dated 08/06/19 at 8:00 p.m., documented the resident had brownish colored urine with sediment. A nurse's note, dated 08/08/19 at 4:00 p.m., documented the resident had light brown urine with sediment. A nurse's note, dated 08/09/19 at 8:00 a.m., documented the resident had amber colored urine. A nurse's note, dated 08/10/19 at 5:30 p.m., documented the resident had dark tea colored urine. A nurse's note, date 08/11/19 at 5:00 p.m., documented the resident had dark tea colored urine. A nurse's note, dated 08/14/19 at 6:00 p.m., documented the resident had amber urine with sediment. A nurse's note, dated 08/14/19 at 12:20 p.m., documented the resident had light brown urine with sediment. A nurse's note, dated 08/15/19 at 2:00 a.m., documented the resident had light brown urine with sediment and odorous. A nurse's note, dated 08/15/19 at 5:00 p.m., documented the resident had cloudy amber urine with sediment. A nurse's note, dated 08/16/19 at 5:00 a.m., documented the resident had dark brown urine with sediment. A nurse's note, dated 08/31/19 at 6:00 p.m., documented the resident had dark amber urine with large amount of sediment. A nurse's note, dated 09/01/19 at 6:00 p.m., documented the resident had dark amber urine with large amount of sediment. There was no documentation in the clinical record to indicate the physician had been notified of the darkened urine, sediment or urine odor. On 09/18/19 at 3:15 p.m., LPN #1 was asked what the process was for residents with catheters when they have dark urine? She stated, We encourage fluids and we notify the physician. She was asked what was done for resident #6 when the record documented dark brown urine. She stated, He sees the Physician Assistant when he comes in and he addresses it but I know if it isn't documented it didn't happen. She was asked if the resident was encouraged to increase fluids? She stated. Yes, but he often refuses. She was asked the resident had been treated for [REDACTED]. At 6:59 p.m. Resident's catheter tubing was observed to be cloudy with amber urine.

Based on observation, record review and interview it was determined the facility failed to ensure residents were treated with dignity and self-determination for one (#8) of 13 sampled residents who required assistance with transfers. The facility's Resident Census and Conditions of Residents identified 18 residents were dependent or required assistance of staff for transfers. Findings: Resident #8 had [DIAGNOSES REDACTED]. A significant change in status assessment dated [DATE], documented the resident had severe cognitive impairment; required extensive assistance with bed mobility, dressing, and toileting; and limited assistance with transfers/ambulation. The care plan last updated 07/28/19, documented .independent with most ADL task but required staff assistance will receive staff assistance as needed or requested . On 09/16/19 at 11:51 a.m., the resident was assisted into the dining room for the noon meal. At 12:15 p.m., staff served the noon meal to the resident. At 12:52 p.m., the resident was assisted to the day room. At 12:54 p.m., in a loud voice the resident stated, Please, take me back to my room. At 12:56 p.m., the resident repeated her request to return to her room to go to bed. She continued to repeat, .Take me back to my bed. At 12:58 p.m., continued to repeat, Take me back to bed. At 12:59 p.m., the social service director walked by the room, hesitated then continued to walk past the resident. At 1:01 p.m., the resident stated, If I sit here much longer, I can't. An unidentified male staff assisted another resident into the room near resident #8. The male staff did not acknowledge the request from resident #8. At 1:02 p.m., the resident continued to plead for someone to take her to bed. Four additional, dependent residents are seated in the room. At 1:04 p.m., the resident's voice becomes louder and she stated, Please get me back to my bed. She wiped tears from her eyes and stated, I need to go back go bed. Take me back to my bed and I will shut up. Take me back to my bed. At 1:07 p.m., an unidentified CNA and LPN were observed to be standing in the dining room. The LPN walked past the resident in the day room. The television is on a loud volume. The resident is now crying, Please take me back to my bed. The resident wiped her eyes and nose. At 1:09 p.m., the LPN walked past the resident again. At 1:09 p.m., the CNA walked into the dining room. The resident is begging and stated, Please go back to bed. The social service director walked past the resident again. At 1:10 p.m., the social service director walked into the day room in front of the resident, looking for a different channel on the television. She stated she was going to BINGO. At 1:13 p.m., a CMA entered the room. The DON was present. The resident continued to request to go to bed. At 1:17 p.m., the social service director walked by the room again. The resident stated, I want to go back to my room What's the problem? On 09/17/19 at 9:00 a.m., resident #8 is observed in the common area, she requested to return to her room. At 9:01 a.m., the resident stated, I need to go back to bed so I can lay down. A social worker from Valir is visiting another resident in the common area. At 9:08, the resident has constantly stated request to return to her room. No staff are present from 9:01 a.m. until 9:08 a.m., when a CNA brought another resident into the common area. Resident #8 did not say anything while the staff were present. At 9:11 a.m., the resident appeared to be napping in her wheelchair. At 9:16 a.m., the activities director walked past the resident while the resident requested, I want to go back to bed. The activity director stated, I will be right back. At 9:22 a.m., another staff member assisted the resident to her room and provided toileting. The activities director had not returned. The resident had repeatedly requested to go to bed on 2 days. On 09/18/19 at 10:30 a.m., the MDS Coordinator was asked if there was a reason the resident was not taken to her room after meals when she requested to go to bed. She stated, No, if she wanted to go to bed the staff should take her and lay her down.

Based on observation, record review, and interview, it was determined the facility failed to ensure an allegation of abuse was identified for one (#6) of two sampled residents who were investigated for abuse. The facility identified two allegations investigated and reported to the Oklahoma State Department of Health. The facility census was 32. Findings: The facility abuse, neglect, mistreatment and misappropriation of resident property documented, .Abuse is the willful inflection of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the policy of[NAME]Health Services that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse. Additionally the residents will be protected from abuse, neglect, harm while they are residing at[NAME]Health Services. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.[NAME]Health Services will strive to educate staff and other applicable individuals in techniques to protect all parties. D. IDENTIFICATION ABUSE POLICY REQUIREMENTS: It is the policy of[NAME]Health Services that all staff monitor residents and will know hot (sic) to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated . Resident #6 had [DIAGNOSES REDACTED]. An Incident/Accident Report dated 05/18/19 at 12:15 p.m., documented resident #6 had been seated in his w/c at a dining table, talking to a hospice nurse. A female resident approached resident #6 to talk with a hospice nurse. Resident #6 started yelling and hit the female resident in the chest. A second Incident/Accident Report 05/18/19 at 12:15 p.m., documented the resident #5 approached resident #6 as he was being examined/assessed by a hospice nurse. Resident #5 began to speak to the nurse. Resident #6 yelled and hit resident #5 in the chest with his fist. Resident #5 teared up and a small red area was noted on her chest. Resident #5 was taken to her room. The physician, administrator and family were notified. The Incident/Accident Reports or the clinical records, did not contain information the incident had been identified as resident to resident abuse, investigated, or reported to the appropriate agencies. The significant change in status assessment dated [DATE], documented resident #6 had moderate cognitive impairment for daily decision making; displayed verbal behaviors toward others one to three days of the assessment; behaviors interfered with the resident's personal care; behaviors did not affect other residents; and the resident behaviors had not changed in comparison to the last assessment. A care plan last updated on 07/30/19, documented the resident #6 was resistive to care; and at times becomes verbally, and rarely physically, abusive towards staff. The care plan did not contain information of the resident's behavior toward other residents. The current physician orders [REDACTED]. On 09/17/19 at 2:40 p.m., the administrator was asked who was responsible investigating allegations of abuse? She stated she was responsible. The administrator was shown the incident reports on Resident #6 and #5. She was asked if she thought this was a resident to resident altercation? She stated, Yes. She was asked if an abuse investigation had been conducted? She stated, No. She was asked if the incident should have been investigated? She stated , Probably. She stated an algorithm is utilized for the investigations and, .Resident #5 doesn't remember two seconds later . She was asked how did the facility protect residents? She stated, We intervene as soon as possible when we see or hear and altercation. She was asked if the staff were aware of this incident? She stated, I guess so. If the staff see these two residents getting close to one another you intervene. She was asked if an altercation between residents #5 and #6 had ever occurred before. She stated, I am sure it probably has. She stated because residents #5 and #6 are cognitively impaired, she did not need to report to the State Health Department. At 2:50 p.m., the MDS Coordinator was asked if she was aware of the incident reports involving #6 and #5? She stated, I can't say that I have been. I knew of several verbal altercations but did not know of anything physical. She was asked if the behavior for #6 or #5 had been care planned? She reviewed the care plan book and stated, No, (#6) behaviors are not care planned. She was asked how other residents are protected? She stated, The residents are separated immediately, try to get to the root cause. I know (resident #6) tends to yell at (resident #5) anytime she comes around. We try to redirect them to separate areas. If we see a verbal altercation we know it could lead to something physical . At 3:08 p.m., LPN #2 was asked what usually happens when a resident is verbally/physically aggressive. She stated, (Resident #6) can get aggressive when he doesn't want care, we try to give him several times to do it and he gets mad and yells at us. He raises his fist to us and grabs our arms .he doesn't like (Resident #5). He will attempt to swing at (Resident #5) when she goes by. Staff try to keep the two resident apart. At 3:15 p.m., CMA #1 was asked if any of the residents are physically or verbally aggressive? She stated, Yes (Resident #6) and (Resident #5). She was asked if the two residents are physically aggressive? She stated, (Resident #6) is when he thinks someone is trying to attack him, he will make a fist and try to hit but he doesn't initiate it it's only if he feels threatened. She was asked if there were any residents in particular that resident #6 has had altercations with? She stated, (Resident #5), they yell at each other anytime they are around each other. We try to separate them anytime they get close to one another. At 3:23 p.m., CNA #1 was asked if she was aware of any residents who were physically or verbally aggressive. She stated, Yes, (Resident #5) and (Resident #6) are verbal and yell a lot. She was asked who do they yell at? She stated, Staff and residents. She was asked what do you do when you witness this behavior? She stated, I can usually talk him down depending on his mood, me or (LPN #1) are typically able to talk to him. At 3:30 p.m., cook #1 was asked if he was aware of any incident between Resident #6 and Resident #5. He stated, No, I have never seen anything physical them but I think if they got close to each other they might hit. There is always a commotion between them. The staff keep them separated from each other.

Based on observation, record review, and interview, it was determined the facility failed to ensure an allegation of abuse was reported for one (#6) of two sampled residents who were investigated for abuse. The facility identified two allegations investigated and reported to the Oklahoma State Department of Health. Findings: The facility abuse, neglect, mistreatment and misappropriation of resident property documented, .Abuse is the willful inflection of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the policy of[NAME]Health Services that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse. Additionally the residents will be protected from abuse, neglect, harm while they are residing at[NAME]Health Services. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.[NAME]Health Services will strive to educate staff and other applicable individuals in techniques to protect all parties . REPORTING AND RESPONSE . It is the policy of[NAME]Health Services that abuse allegation (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law.[NAME]Health Services will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation for not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and Adulty (sic) Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in this facility. EXTERNAL REPORTING Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual shall report immediately, but not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Initial reporting of allegation: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency . Resident #6 had [DIAGNOSES REDACTED]. An Incident/Accident Report dated 05/18/19 at 12:15 p.m., documented resident #6 had been seated in his w/c at a dining table, talking to a hospice nurse. A female resident approached resident #6 to talk with a hospice nurse. Resident #6 started yelling and hit the female resident in the chest. A second Incident/Accident Report 05/18/19 at 12:15 p.m., documented the resident #5 approached resident #6 as he was being examined/assessed by a hospice nurse. Resident #5 began to speak to the nurse. Resident #6 yelled and hit resident #5 in the chest with his fist. Resident #5 teared up and a small red area was noted on her chest. Resident #5 was taken to her room. The physician, administrator and family were notified. The Incident/Accident Reports or the clinical records, did not contain information the incident had been reported to the appropriate agencies. The significant change in status assessment dated [DATE], documented resident #6 had moderate cognitive impairment for daily decision making; displayed verbal behaviors toward others one to three days of the assessment; behaviors interfered with the resident's personal care; behaviors did not affect other residents; and the resident behaviors had not changed in comparison to the last assessment. A care plan last updated on 07/30/19, documented the resident #6 was resistive to care; and at times becomes verbally, and rarely physically, abusive towards staff. The care plan did not contain information of the resident's behavior toward other residents. The current physician orders [REDACTED]. On 09/17/19 at 2:40 p.m., the administrator was asked who was responsible investigating allegations of abuse? She stated she was responsible. The administrator was shown the incident reports on Resident #6 and #5. She was asked if she thought this was a resident to resident altercation? She stated, Yes. She was asked if an abuse investigation had been conducted? She stated, No. She was asked if the incident should have been investigated? She stated , Probably. She stated an algorithm is utilized for the investigations and, Resident #5 doesn't remember two seconds later . She was asked if an altercation between residents #5 and #6 had occurred before. She stated, I am sure it probably has. She stated because residents #5 and #6 are cognitively impaired, she did not need to report to the State Health Department.

Based on observation, record review, and interview, it was determined the facility failed to ensure an allegation of abuse was investigated for one (#6) of two sampled residents who were investigated for abuse. The facility census was 32. The facility identified two allegations investigated and reported to the Oklahoma State Department of Health. Findings: The facility abuse, neglect, mistreatment and misappropriation of resident property documented, .Abuse is the willful inflection of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the policy of[NAME]Health Services that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse. Additionally the residents will be protected from abuse, neglect, harm while they are residing at[NAME]Health Services. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.[NAME]Health Services will strive to educate staff and other applicable individuals in techniques to protect all parties. D. IDENTIFICATION ABUSE POLICY REQUIREMENTS: It is the policy of[NAME]Health Services that all staff monitor residents and will know hot (sic) to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated. E. INVESTIGATION ABUSE POLICY REQUIREMENTS: It is the policy of[NAME]Health Services that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. PR[NAME]EDURE: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: 1. Who was involved 2. Resident's statements 1. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. 3. Resident's roommate statements (if applicable) 4. Involved staff and witness statements of events. 5. A description of the resident's behavior and environment at the time of the incident 6. Injuries present including a resident assessment 7. Observation of resident and staff behaviors during the investigation 8. Environmental consideration REPORTING AND RESPONSE ABUSE POLICY REQUIREMENTS It is the policy of[NAME]Health Services that abuse allegation (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law.[NAME]Health Services will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation for not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and Adulty (sic) Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in this facility. EXTERNAL REPORTING Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual shall report immediately, but not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Initial reporting of allegation: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency . Resident #6 had [DIAGNOSES REDACTED]. An Incident/Accident Report dated 05/18/19 at 12:15 p.m., documented resident #6 had been seated in his w/c at a dining table, talking to a hospice nurse. A female resident approached resident #6 to talk with a hospice nurse. Resident #6 started yelling and hit the female resident in the chest. A second Incident/Accident Report 05/18/19 at 12:15 p.m., documented the resident #5 approached resident #6 as he was being examined/assessed by a hospice nurse. Resident #5 began to speak to the nurse. Resident #6 yelled and hit resident #5 in the chest with his fist. Resident #5 teared up and a small red area was noted on her chest. Resident #5 was taken to her room. The physician, administrator and family were notified. The Incident/Accident Reports or the clinical records, did not contain information the incident had been investigated. The significant change in status assessment dated [DATE], documented resident #6 had moderate cognitive impairment for daily decision making; displayed verbal behaviors toward others one to three days of the assessment; behaviors interfered with the resident's personal care; behaviors did not affect other residents; and the resident behaviors had not changed in comparison to the last assessment. A care plan last updated on 07/30/19, documented the resident #6 was resistive to care; and at times becomes verbally, and rarely physically, abusive towards staff. The care plan did not contain information of the resident's behavior toward other residents. The current physician orders [REDACTED]. On 09/17/19 at 02:40 p.m. the administrator was asked who was responsible investigating allegations of abuse? She stated she was responsible. The administrator was shown the incident reports on Resident #6 and #5. She was asked if she thought this was a resident to resident altercation? She stated, Yes. She was asked if an abuse investigation had been conducted? She stated, No. She was asked if the incident should have been investigated? She stated , Probably. She stated an algorithm is utilized for the investigations and, Resident #5 doesn't remember two seconds later .

Based on record review, and interview, it was determined the facility failed to ensure assessments were completed at least quarterly for four (#12, 16, 3 and #13) of four residents whose records were reviewed for frequency of assessments. The facility census was 32. Findings. On 09/17/19 at 3:20 p.m., in the presence of the DON and administrator, a request was made for the MDS coordinator to provide documentation of transmitted assessments for residents #12, 16, 3, and #13. 1. The electronic record for resident #12 documented the following assessment reference dates: ~08/17/19, for a quarterly assessment, ~05/07/19, for an annual assessment, and ~02/06/19, for a quarterly assessment. The transmission of assessments report documented an assessment dated [DATE] was submitted on 09/17/19, and .Record submitted late; the submission date is more than 14 days after . 2. The electronic record for resident #16 documented the following assessment reference dates: ~08/12/19, for a quarterly assessment, ~05/12/19, for a quarterly assessment, and ~02/09/19, for a quarterly assessment. The transmission of assessments report documented an assessment dated [DATE] was submitted 09/17/19, and .Record Submitted Late: The submission date is more than 14 days after . 3. The electronic record for resident #3 documented the following assessment reference dates: ~08/03/19, for a quarterly assessment, ~05/03/19, for an annual assessment, and ~02/02/19, for a quarterly assessment. The transmission of assessments report documented an assessment dated [DATE] was submitted on 09/17/19, and .Record Submitted Late: The submission date is more than 14 days after . 4. The electronic record for resident #13 documented the following assessment reference dates: ~08/10/19, for a significant change of status assessment, ~05/12/19, for a quarterly assessment, and ~02/09/19, for a quarterly assessment. The transmission of assessments report documented an assessment dated [DATE] was submitted on 09/17/19, and .Record Submitted Late: The submission date is more than 14 days after . On 09/17/19 at 4:13 p.m., the MDS coordinator was asked why the records of transmission documented the assessments were submitted late. She stated, I just got behind and now getting caught up. She was asked to clarify if the assessments had been completed and not transmitted or if the assessments were not transmitted in a timely manner. She stated, The assessments were completed late.

Based on record review, and interview, it was determined the facility failed to have a qualified activities director. This had the potential to affect 32 residents that resided in the facility. Findings: On 09/18/19 at 3:05 p.m., the activities director was asked how long she had been employed as the activities director. She stated she had started in housekeeping and about a year ago transferred to activities/social services. She was asked if she had been provided training for her new job description. She stated, No, but I was provided three days of orientation with the prior activities director. She was asked if she was currently enrolled in a class to provide training for activities director. She stated, No. On 09/19/19 at 10:04 a.m., the administrator asked how long the activities director had been employed. She stated she started in housekeeping and but transferred to activities less than a year ago. The administrator was asked if the facility had provided the required class/training for the activities director. She stated, Not yet. She was asked if there was a goal for the activities director to complete a class/required training. She stated, Around her anniversary date due to the cost of the class. The administrator was asked to provide the date of new assignment of the activities director At 10:42 a.m., the administrator provided a list of employees and their hire dates. The documentation indicated the activities director was assigned to the current position on 10/22/18.

Based on observation, record review, and interview, it was determined the facility failed to implement their abuse policy for one (#6) of two sampled residents who were investigated for abuse. The facility census was 32. The facility identified two allegations investigated and reported to the Oklahoma State Department of Health. Findings: The facility abuse, neglect, mistreatment and misappropriation of resident property documented, .Abuse is the willful inflection of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the policy of[NAME]Health Services that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse. Additionally the residents will be protected from abuse, neglect, harm while they are residing at[NAME]Health Services. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.[NAME]Health Services will strive to educate staff and other applicable individuals in techniques to protect all parties. D. IDENTIFICATION ABUSE POLICY REQUIREMENTS: It is the policy of[NAME]Health Services that all staff monitor residents and will know hot (sic) to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated. E. INVESTIGATION ABUSE POLICY REQUIREMENTS: It is the policy of[NAME]Health Services that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. PR[NAME]EDURE: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: 1. Who was involved 2. Resident's statements 1. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. 3. Resident's roommate statements (if applicable) 4. Involved staff and witness statements of events. 5. A description of the resident's behavior and environment at the time of the incident 6. Injuries present including a resident assessment 7. Observation of resident and staff behaviors during the investigation 8. Environmental consideration REPORTING AND RESPONSE ABUSE POLICY REQUIREMENTS It is the policy of[NAME]Health Services that abuse allegation (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law.[NAME]Health Services will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation for not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and Adulty (sic) Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in this facility. EXTERNAL REPORTING Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual shall report immediately, but not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Initial reporting of allegation: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency . Resident #6 had [DIAGNOSES REDACTED]. An Incident/Accident Report dated 05/18/19 at 12:15 p.m., documented resident #6 had been seated in his w/c at a dining table, talking to a hospice nurse. A female resident approached resident #6 to talk with a hospice nurse. Resident #6 started to yell and hit the female resident in the chest. A second Incident/Accident Report 05/18/19 at 12:15 p.m., documented the resident #5 approached resident #6 as he was being examined/assessed by a hospice nurse. Resident #5 began to speak to the nurse. Resident #6 yelled and hit resident #5 in the chest with his fist. Resident #5 teared up and a small red area was noted on her chest. Resident #5 was taken to her room. The physician, administrator and family were notified. The Incident/Accident Reports or the clinical records, did not contain information the abuse policy had been implemented to identify resident to resident abuse, an investigation initiated, or the event reported to the appropriate agencies. The significant change in status assessment dated [DATE], documented resident #6 had moderate cognitive impairment for daily decision making; displayed verbal behaviors toward others one to three days of the assessment; behaviors interfered with the resident's personal care; behaviors did not affect other residents; and the resident behaviors had not changed in comparison to the last assessment. A care plan last updated on 07/30/19, documented the resident #6 was resistive to care; and at times becomes verbally, and rarely physically, abusive towards staff. The care plan did not contain information of the resident's behavior toward other residents. The current physician orders [REDACTED]. On 09/17/19 at 2:40 p.m., the administrator was asked who was responsible investigating allegations of abuse? She stated she was responsible. The administrator was shown the incident reports for resident #6 and #5. She was asked if she thought this was a resident to resident altercation? She stated, Yes. She was asked if an abuse investigation had been conducted? She stated, No. She was asked if the incident should have been investigated? She stated , Probably. She stated an algorithm is utilized for the investigations and, .Resident #5 doesn't remember two seconds later . She was asked how did the facility protect residents? She stated, We intervene as soon as possible when we see or hear and altercation. She was asked if the staff were aware of this incident? She stated, I guess so. If the staff see these two residents getting close to one another you intervene. She was asked if an altercation between residents #5 and #6 had occurred before. She stated, I am sure it probably has. She stated because residents #5 and #6 are cognitively impaired, she did not need to report to the State Health Department. At 2:50 p.m., the MDS Coordinator was asked if she was aware of the incident reports involving #6 and #5? She stated, I can't say that I have been. I knew of several verbal altercations but did not know of anything physical. She was asked how other residents are protected? She stated, The residents are separated immediately, try to get to the root cause. I know (resident #6) tends to yell at (resident #5) anytime she comes around. We try to redirect them to separate areas. If we see a verbal altercation we know it could lead to something physical . At 3:08 p.m., LPN #2 was asked what usually happens when a resident is verbally/physically aggressive. She stated, (Resident #6) can get aggressive when he doesn't want care .he gets mad and yells at us. He raises his fist to us and grabs our arms .he doesn't like (Resident #5) .He will attempt to swing at (Resident #5) when she goes by. Staff try to keep the two resident apart. At 3:15 p.m., CMA #1 was asked if any of the residents are physically or verbally aggressive? She stated, Yes, and identified residents #6 and #5. She was asked if there were any residents in particular that resident #6 has had altercations with? She stated, (Resident #5), they yell at each other anytime they are around each other. We try to separate them anytime they get close to one another. At 3:23 p.m., CNA #1 was asked if she was aware of any residents who were physically or verbally aggressive. She stated, Yes, (Resident #5) and (Resident #6) are verbal and yell a lot. She was asked who do they yell at? She stated, Staff and residents. She was asked what do you do when you witness this behavior? She stated, I can usually talk him down depending on his mood, me or (LPN #1) are typically able to talk to him. At 3:30 p.m., cook #1 was asked if he was aware of any incident between Resident #6 and Resident #5. He stated, No, I have never seen anything physical them but I think if they got close to each other they might hit. There is always a commotion between them. The staff keep them separated from each other.