Every finding on record at The Commons

Based on observation, interview, and facility policy review, the facility failed to ensure food was stored properly; failed to ensure staff utilized facial hair restraint/covers when preparing, distributing, and serving food during 2 of 2 meal preparation observations; and failed to ensure staff washed/sanitized their hands when serving meals to residents during 1 of 1 meal service observations. These deficiencies had the potential to affect all residents who received food from the facility kitchen, and all residents who received staff assistance with meals in the dining room.Findings included: 1. A facility policy titled, Dining Services Policies and Procedures Receiving Food and Supplies, revised 06/25/2012, indicated, Food items will be received and handled in accordance with established sanitary practices. The policy further indicated, 7. All foodstuffs are to be dated. During a concurrent initial tour of the kitchen and interview on 06/01/2026 at 10:30 AM, an observation of the walk-in freezer revealed frozen chicken in a stainless-steel pan covered with clear plastic wrap and dated 02/17/2026. The chicken contained areas of pink, light tan, and white discoloration on the top layer. The observation further revealed 19 raw hamburger patties stored in an open, clear plastic bag inside a cardboard box dated 05/27/2026. The hamburger patties had brown, pink, and light tan discoloration around the edges. The Dietary Supervisor (DS) stated that the chicken and hamburger patties were not properly stored and that the hamburger patties were not properly sealed. An observation of the walk-in refrigerator on 06/01/2026 at 10:37 AM revealed a partially opened container of yellow American cheese that was undated and exposed to air and three individual dishes of cake covered with plastic wrap that lacked dates, The observation further revealed two containers of raw chicken dated 05/20/2026 that were surrounded by a thick liquid substance. Further observation revealed white American cheese wrapped in plastic wrap and dated 12/21/2025, a bag of bacon bits with a use-by date of 05/25/2026, a 3-inch by 4-inch piece of butter with a use-by date of 04/08/2026, turkey bologna with a use-by date of 04/08/2026, a container of chopped beef brisket with a use-by date of 05/16/2026, cottage cheese with a use-by date of 05/30/2026, bacon bits in a resealable plastic bag dated 04/20/2026, potato salad with a use-by date of 05/29/2026 stored in a pan covered with plastic wrap, and individual 0.75-ounce cups of cream cheese with a use-by date of 08/22/2025. The DS stated the cheese was not dated or properly sealed, that the containers of chicken were past their discard date, and that the other food items were not discarded in a timely manner. During a concurrent tour of the kitchen and interview with the DS on 06/01/2026 at 11:20 AM, an observation of the tray-line refrigerator revealed white cheese in an almost empty container covered with clear plastic wrap. The cheese had pale, tan discoloration around the sides of the container. The observation also revealed an uncovered, undated container of tartar sauce with dried residue on the interior sidewalls of the container. The DS stated that the food items were not stored properly. During a concurrent tour of the kitchen and interview on 06/04/2026 at 4:00 PM, an observation of the walk-in refrigerator revealed an open, undated bag of Parmesan cheese that was approximately three-quarters full, wrapped in clear plastic wrap, and a sheet pan that was approximately three-quarters full of cake covered with plastic wrap and undated. The DS stated that the food was not stored properly. 2. A facility policy titled, Dining Services Policies and Procedures Dress, Hygiene, and Conduct, with an effective date of effective 01/01/2022 indicated, Hairnets or hair covers must be worn at all times. Facial hair must also be covered with a protective covering. During a kitchen tour on 06/01/2026 at 11:24 AM, Dietary Aide (DA) #10, DA #11, DA #13, [NAME] #16, [NAME] #17, and [NAME] #18 were observed preparing food and handling clean dishes and utensils with facial hair exposed. Their beards and mustaches were not completely covered with a hair restraint/protective covering. During a tour of the kitchen on 06/04/2026 at 4:06 PM, 3 dietary staff members (DAs #10, #11, and #14) were observed in the kitchen preparing food and washing dishes. Their facial hair was not completely covered with a hair restraint. During a lunch meal observation in the main dining room on 06/01/2026 at 11:40 AM, DA #15 was observed wearing a surgical mask, which did not fully cover their facial hair. During an interview on 06/01/2026 at 12:36 PM, DA #15 stated the facility had beard nets, but that he always used a surgical mask instead. He was unsure whether a surgical mask was an appropriate replacement for a facial hair restraint. During an interview on 06/01/2026 at 12:41 PM, the Dietary Supervisor (DS) stated that a surgical mask was not enough to replace a beard net. During an interview on 06/05/2026 at 9:38 AM, the DS stated that all facial hair, including facial hair on the upper lip, should be completely covered. During an interview on 06/05/2026 at 9:41 AM, the Director of Nursing (DON) stated his expectation was that all facial hair, including facial hair on the upper lip, needed to be completely covered. During an interview on 06/05/2026 at 9:55 AM, the Administrator (ADM) stated his expectation was that staff followed facility policy regarding facial hair covering. The ADM stated he had observed staff wearing facial hair coverings that covered only the lower portion of the face and beard area rather than all facial hair.3. A facility policy titled, Hand Hygiene Guideline, with an effective date of 06/2025, indicated, When to perform hand hygiene: Before: direct contact with a resident, preparing or administering medications, handling food or feeding a resident, performing a clean or aseptic procedure. After: contact with a resident, contact with bodily fluids, mucous membranes, non-intact skin, or wound dressings, removing gloves, handing soiled equipment or linen, using the restroom, sneezing coughing, or touching the face. During a lunch meal observation in the main dining room on 06/01/2026 at 11:40 AM, Dietary Aide (DA) #15 used a resident's already unwrapped utensils to cut up their meat at the resident's request. He then returned to the meal counter to continue serving plates without performing hand hygiene. DA #15 was observed with his thumbs inside his waist band pulling his pants up. He did not perform hand hygiene afterwards and returned to serving plates. He was also observed adjusting his surgical mask but did not perform hand hygiene afterwards and returned to serving plates. DA #15 was also observed to pull out a walkie talkie to speak and return to meal service without performing hand hygiene. During the same lunch meal service observation on 06/01/2026 at 11:40 AM, Licensed Practical Nurse (LPN) #5 was observed assisting a resident with cutting their food and feeding them a forkful of food. The observation revealed that LPN #5 then assisted another resident with cutting up their food without sanitizing or washing her hands. LPN #6 was then observed to pick up a resident's used cup, refill it at a water dispense, and return it to the resident. The LPN then returned to helping another resident with feeding assistance without performing hand hygiene. During an interview on 06/01/2026 at 12:36 PM, DA #15 stated that he was not sure what hand hygiene he needed to perform during meal service. However, he stated that he did not sanitize his hands between helping residents, but that he was supposed to. He stated he was not sure whether hand hygiene was needed after using a walkie talkie or pulling up his pants. During an interview on 06/01/2026 at 12:50 PM, LPN #5 stated that hand hygiene required during meal service included using sanitizer between helping every resident. She stated they should sanitize between cutting up food, getting water refills, and feeding if they were switching to help another resident. LPN #5 stated that she helped multiple residents during the meal service and did not sanitize her hands between them but stated she should have. During an interview on 06/01/2026 at 12:41 PM, the Dietary Supervisor (DS) stated that she expected staff to wash their hands after serving every three to five plates or if their hands got something on them. She stated staff would need to wash their hands if they assisted a resident with cutting up their food prior to assisting another resident. The DS stated that staff could use alcohol-based hand sanitizer if they touched anything. but hand washing was preferred. She stated that if staff touched a resident's property, their face, or beard net; pulled up their pants; or touched a walkie talkie, they needed to wash their hands. During an interview on 06/04/2026 at 11:30 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP #8) stated she was responsible for staff infection control training. She stated that she did not meet with dietary aides but provided education regarding handwashing to the dietary manager (DM), who was supposed to educate the dietary staff. The ADON/IP #8 stated that for meal service, staff were to complete hand hygiene between each resident when passing plates and if they touched used dishware, they must complete hand hygiene afterward. During an interview on 06/04/2026 at 11:55 AM, the Director of Nursing (DON) stated she expected staff to use hand hygiene before and after serving a resident. She stated that alcohol-based hand sanitizer was appropriate unless hands were visibly soiled. During an interview on 06/04/2026 at 3:18 PM, the Administrator stated he expected all staff to be observing the hand hygiene policy during meal services.

Based on observation, interview, and record review, and facility policy review, the facility failed to assess a resident for self-administration of medication, failed to obtain a physician's order for self-administration of medication, and failed to obtain a physician's order to keep medication at the bedside for 1 resident (Resident # 34) of 5 residents observed during medication pass.Findings included: A facility policy titled, Self-Administration Of Medications, effective 01/2022, indicated, In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. The policy further indicated, A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. B. If the resident indicates no desire to self-administer medications, this is documented in the appropriate place in the resident's medical record, and the resident is deemed to have deferred this right to the facility. C. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition. The policy further indicated, D. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered. An admission Record revealed that the facility admitted Resident #34 on 08/21/2024 and most recently readmitted the resident on 10/26/2025. According to the admission Record, the resident had a medical history that included a diagnosis of dry eye syndrome of an unspecified lacrimal gland. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/2026 revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS revealed Resident #34 had adequate vision with corrective lenses. Resident #34's Care Plan Report, included a focus area initiated on 09/10/2024, that indicated the resident had a diagnosis of dry eyes. Interventions directed staff to administer Refresh drops per physician orders (initiated 12/05/2024). The Care Plan Report revealed no documentation of any interventions that indicated Resident #34 had been assessed to self-administer medication. A physician's order, dated 04/04/2025, revealed an order for Refresh Ophthalmic solution (an eye drop medication used to treat dry eyes) to be instilled in both eyes four times per day related to dry eye syndrome. The physician's order did not include directions for resident self-administration or instructions for the resident to keep the medication at bedside. Resident #34's June 2026 Medication Administration Record [MAR], revealed staff initialed the entries for Refresh for 06/01/2026 at 8:00 AM through 06/03/2026 at 8:00 AM, indicating that staff had administered the medication four times per day. Resident #34's electronic medical record revealed no documented evidence that an assessment had been completed for self-administration of medication. During an observation and concurrent interview on 06/01/2026 at 11:52 AM, there was a clear plastic cup with two bottles of Refresh eye drops on Resident #34's bedside table. Resident #34 stated the instilled the eye drops independently. During an observation on 06/02/2026 at 1:35 PM, Resident #34 was noted to be sitting in a chair by the bed. The overbed table was across the resident's lap, and the clear cup that contained two bottles of eye drops was on the overbed table and within reach of the resident. During a concurrent observation and interview on 06/03/2026 at 9:35 AM, with Certified Medication Aide (CMA) #3, Resident #34 had two different sized green bottles of eye drops in a plastic cup on the overbed table. CMA #3 handed the resident the larger green bottle of eye drops, and the resident self-administered the Refresh eye drops, placing one drop in each eye. CMA #3 stated that for a resident to self-administer medication, she believed an assessment had to be completed, and the resident's physician had to write an order to keep the medication at the bedside. Per CMA #3, Resident #34 had an order to keep the eye drops at the bedside. During an observation on 06/04/2026 at 10:32 AM, Resident #34 was sitting in a recliner with their eyes closed. The clear cup with the two bottles of Refresh eye drops remained on the resident's bedside table, which was bedside the recliner within reach of the resident. During an interview on 06/04/2026 at 11:56 AM, CMA #7 stated she had worked at the facility for one and one-half years and Resident #34 had eye drops in their room during that time. CMA #7 stated Resident #34 self-administered the eye drops independently and refused to allow staff to administer the eye drops. CMA #7 stated when she started working at the facility, someone told her that Resident #34 was able to keep the eye drops in their room and self-administer them but was unable to remember who had given her that information. CMA #7 stated Resident #34 had an order for the Refresh eye drops, but the order did not include self-administration or the ability to keep the medication at bedside. During an interview on 06/04/2026 at 10:32 AM, Licensed Practical Nurse (LPN) #6 stated before a resident could self-administer medication, staff had to assess the resident to make sure the resident knew how to safely administer the medication, how long to wait between administration times, and how to check the expiration date on the medication. The LPN stated they also had to get a physician's order for the resident to self-administer the medication and to keep the medication at bedside. LPN #6 stated the charge nurse was responsible for completing a self-administration assessment. During an interview on 06/03/2026 at 10:00 AM, Physician #4, who was Resident #34's primary care physician, stated that Resident #34 was not always alert and oriented and was not trustworthy to administer their own medication. Physician #4 stated he was aware that medication sometimes showed up in the resident's room brought in by the resident's family. The physician stated that although he had known for a year that medication appeared in the resident's room, staff had not requested an assessment for medication self-administration, or an order for the eye drops to be kept at bedside. Physician #4 stated he expected the staff to follow the facility's policy for self-administration of medication. During an interview on 06/05/2026 at 1:14 PM, the Director of Nursing (DON) stated that if medication was found in a resident's room, without an order or self-administration assessment, she expected the administrative staff to be notified and the medication removed. The DON stated she was unsure why Resident #34 had eye drops in their room for such a long period of time. The DON stated that if medication were kept in a resident's room, it should be locked so other residents could not get to the medication. During an interview on 06/05/2026 at 2:03 PM, the Administrator stated staff were required to take any medication seen at bedside out of the room. The Administrator stated he was not aware that Resident #34 had eye drops in the room until it was brought to his attention that surveyors had found eye drops at Resident #34's bedside.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified when medication was not available for administration for 1 (Resident #34) of 5 residents observed for medication administration.Findings included: During an interview on 06/05/2026 at 9:20 AM, the Assistant Administrator stated it was common practice to notify the physician if medication was not available; subsequently, the facility did not have a policy regarding physician notification. An admission Record revealed the facility admitted Resident #34 on 08/21/2024. According to the admission Record, the resident had a medical history that included a diagnosis of systolic congestive heart failure. Resident #34's Order Summary Report, for the timeframe from 06/01/2024 through 06/30/2026, included an order dated 04/30/2025 for Lasix oral tablet 20 milligrams (mg) one tablet daily for systolic congestive heart failure. Resident #34's May 2026 Medication Administration Record [MAR] revealed staff documented 9 for Lasix 20 mg for 05/28/2026 through 05/31/2026. Per the MAR, a chart code 9 indicated Other/See Nurse Notes. Resident #34's Nurses Progress Note dated 05/29/2026 indicated a voicemail was left with a hospice company for a refill of Lasix 20 mg. Resident #34's June 2026 MAR revealed staff documented 9 for Lasix 20 mg for 06/01/2026 through 06/03/2026. Per the MAR, a chart code 9 indicated Other/See Nurse Notes. During an observation of medication administration on 06/03/2026 at 9:03 AM, Certified Medication Aide (CMA) #3 prepared and administered Resident #34's medications. CMA #3 stated that Lasix was not available to administer and had been ordered from a pharmacy. CMA #3 stated that the nurse was responsible for notifying the physician when a medication was not available for administration. During an interview on 06/03/2026 at 9:16 AM, Licensed Practical Nurse (LPN) #5 stated if medication was not available, staff needed to contact the physician to see what they wanted to do and if there was something different the physician wanted them to give until the medication was available. LPN #5 stated she was not aware that Lasix was not available for Resident #34. During an interview on 06/03/2026 at 10:03 AM, Physician #4 stated he was not aware Lasix was not available for Resident #34. Physician #4 stated he expected to be notified of any medication that was not available. Per Physician #4, missing the medication was not critical or significant for the resident. During an interview on 06/04/2026 at 3:17 PM, the Director of Nursing (DON) stated she expected the charge nurse to be notified if medication was not available, and the charge nurse should call the pharmacy and notify the physician. The DON stated staff should have contacted Resident 34's physician about Lasix not being available because he may have ordered a different medication. During an interview on 06/04/2026 at 4:01 PM, the Administrator stated he deferred to the DON for physician notification.

Based on interview and record review the facility failed to submit a Preadmission Screening and Resident Review (PASRR) form to the state-designated authority after the addition of a new psychiatric diagnosis for 1 (Resident #10) of 2 residents reviewed for the accuracy of the PASRR.Findings included: During an interview on 06/05/2026 at 1:43 PM, the Assistant Administrator revealed that the facility had no PASRR policy. An admission Record indicated the facility admitted Resident #10 on 01/02/2025. According to the admission Record the resident had a medical history that included diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety (onset 01/02/2025), delusional disorders (onset 02/11/2025), and unspecified depression (onset 03/17/2025). A Level I PASRR Screen, dated 01/13/2025, indicated Resident #10 had a primary diagnosis of unspecified dementia. The screening form indicated the resident had no evidence of a serious mental illness including possible disturbances in orientation or mood. The screening form revealed Resident #10 also had no diagnosis of a depressive disorder, other psychotic disorder, or another mental disorder that may lead to a chronic disability. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/2026, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. The MDS indicated Resident #10 had active diagnoses that included depression and a psychotic disorder. Resident #10's Care Plan Report, included a focus area revised on 01/02/2026, that indicated the resident took medication to help manage their depression and delusional disorder. Interventions initiated on 05/28/2025, directed staff to give the medications as ordered and to monitor for side effects and effectiveness, document the number of behavioral episodes each shift, and record the number of occurrences of demonstrated target behaviors. Resident #10's Order Summary Report, for active orders as of 06/05/2026, included an order dated 02/02/2026 for Seroquel (an antipsychotic medication) 25 milligrams (mg), one-half tablet at bedtime related to the resident's delusional disorder. The order summary report also included an order dated 01/23/2026 for Celexa (an antidepressant medication) 10 mg to be taken at bedtime to help manage the resident's depression. There was no documented evidence that the facility referred Resident #10 to the state-designated authority for review when the resident was diagnosed with a newly evident or possible serious mental disorder. During an interview on 06/04/2026 at 1:20 PM, Assistant Director of Nursing (ADON) #2 stated she functioned as a skilled case manager. ADON #2 stated if a new psychiatric diagnosis was added after the initial submission of a Level 1 PASRR, she called the state agency responsible for PASRR to determine whether a Level II PASRR was required. ADON #2 stated she was unsure what the facility policy or the federal regulations required for a change in the resident's PASRR. During an interview on 06/05/2026 at 1:25 PM, ADON #9 stated that she was aware that a new diagnosis required a new PASRR to be submitted. She stated that the DON was previously responsible for the resubmission of the PASRRs but was not sure who was currently responsible. During an interview on 06/05/2026 at 1:04 PM, the Director of Nursing (DON) stated that either the MDS nurse or the Case Manager was responsible for submitting a new PASRR if a new diagnosis was added. The DON stated she expected the new PASRR to be submitted as soon as the new diagnosis was added. During a telephone interview on 06/04/2026 at 3:02 PM, the Psychiatric Intellectual Disabilities Analyst (PIDA) stated he reviewed Level I PASRRs if they were assigned to him but did not send PASRR determination letters to the facilities. The PIDA stated if a resident was admitted with a Level I PASRR and had a significant change in condition, such as a new diagnosis, then a new Level I PASRR may need to be sent to the state-designated authority responsible for PASRRs. During an interview on 06/05/2026 at 2:11 PM, the Administrator stated it was a collaborative team effort to review PASRRs and submit an updated Level I PASRR if a new diagnosis was obtained.

Based on observation, interview, record review, and facility document review, the facility failed to ensure an indwelling urinary catheter tubing was secured and a urine collection bag was stored in a manner to prevent infection for 1 (Resident #60) of 2 residents with a urinary catheter.Findings included: A facility document titled, Catheter Care Guideline, with an effective date of 03/2025, indicated, Our facility is committed to providing proper catheter care in accordance with current professional standards of practice. The document further indicated the Purpose was, To ensure care aligns with safe and effective management of urinary catheters and reduce the risk of infection and promote resident comfort and dignity. The document also indicated, 3. Daily Catheter Care: e. Position properly to prevent pulling. -May use external anchoring device. The document also revealed, 5. Managing the Drainage Bag: a. Keep the bag below bladder level and secure it properly to prevent pulling. b. Empty the drainage bag regularly, ensuring the spout does not touch any surfaces. An admission Record indicated the facility admitted Resident #60 on 07/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of retention of urine and neuromuscular dysfunction of the bladder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2026, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an indwelling catheter during the assessment's seven-day look-back period. Resident #60's Care Plan Report included a focus statement initiated 04/07/2026 that indicated the resident required an indwelling urinary catheter due to a neurogenic bladder. Interventions included checking the tubing each shift (initiated 04/07/2026) and monitoring the catheter system for any compromise (initiated 05/18/2026). Resident #60's Order Summary Report with active orders as of 06/03/2026, revealed an order dated 03/30/2026 for an indwelling urinary catheter for diagnoses of neurogenic bladder and urinary retention. During an observation on 06/01/2026 at 9:56 AM, Resident #60 was in bed and the collection bag for the indwelling urinary catheter was lying directly on a fall mat on the floor at the resident's bedside. During a concurrent observation and interview on 06/01/2026 at 10:03 AM, the Assistant Director of Nursing/Infection Preventionist (ADON #8/IP) revealed that Resident #60's urinary catheter tubing was not secured but stated that it should be. The ADON/IP #8 stated the urine collection bag should not be directly on the fall mat because that could allow bacteria into the system. During an interview on 06/04/2026 at 3:17 PM, the Director of Nursing (DON) stated that the indwelling urinary catheter tubing should be secured to the resident's leg. The DON stated that securing the urinary catheter tubing helped prevent pulling and dragging the catheter system. The DON stated that for infection control purposes the catheter tubing should be secured, and that the urine collection bag should not be on the floor or the fall mat. During an interview on 06/04/2026 at 4:01 PM, the Administrator stated he deferred to the DON related to securing the indwelling catheter tubing and for the placement of the urine collection bag.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff were trained on the Personal Protective Equipment (PPE) required for contact isolation for 1 (Dietary Aide [DA] #15) of 1 dietary staff reviewed for infection control competencies.Findings included: A facility policy titled, Infection Control and Isolation Guideline, dated July 2025, indicated, To prevent the spread of infectious diseases and promote a safe environment for residents, staff, and visitors utilizing evidence-based infection control and isolation practices in accordance with current Center for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines. The policy also indicated, Transmission-Based Precautions used in addition to Standard Precautions for known or suspected infections. A. Contact Precautions-PPE: Gown and gloves upon room entry. During an observation and concurrent interview on 06/01/2026 at 9:51 AM, DA #15 was observed entering and exiting a resident room that had signage indicating the resident was on contact precautions. DA #15 stated that he had worked at the facility for almost three years, but he did not know what contact precautions were. DA # 15 was unable to identify the facility Contact Precautions sign posted outside the resident room was for or what it meant. He stated that he had not received any training on infection control. During an interview on 06/01/2026 at 12:41 PM, the Dietary Supervisor stated that the dietary aides reported to her. She stated that infection control for dietary aides included computer training, and dietary staff were required to have a food handler card. During an interview on 06/03/2026 at 2:30 PM, the Regional Nurse stated that the facility did not have any documentation or proof that DA #15 had a food handler card, training on infection control, or training on hand hygiene. The Regional Nurse stated that DA #15 had been working without the required dietary training for infection control, food handling, and handwashing. During an interview on 06/04/2026 at 11:30 AM, Assistant Director of Nursing (ADON #8), who was also the infection preventionist, stated she trained staff on infection control. She stated that she did not meet with dietary aides, but she did meet with the Dietary Supervisor and provided education for her to provide to dietary staff. She stated she educated the Dietary Supervisor on hand washing, enhanced barrier precautions, and contact isolation. She stated that contact precautions were indicated by a sign that stated Contact isolation along with a yellow universal precautions sign and that dietary staff should not enter those rooms to prevent any accidental cross contamination. ADON #8 stated that dietary staff were only allowed to enter enhanced barrier rooms. She stated that a dietary aide should not have even been in a contact isolation room. During an interview on 06/04/2026 at 11:55 AM, the Director of Nursing (DON) stated that for contact isolation, she personally always wore a gown and gloves when entering a room and expected the staff to as well. She stated it was to prevent the spread of infection throughout the facility and protect immuno-compromised residents as well. During an interview on 06/04/2026 at 3:18 PM, the Administrator stated infection control training was the responsibility of the infection preventionist. He stated that the dietary department head trained dietary staff on subjects like handwashing techniques, but enhanced barrier precautions training was done by the infection preventionist. He stated anyone entering a room where a resident had additional precautions in place should have been trained on how to don PPE in order to reduce transmission of disease to an at-risk population, and if they did not have the training, they should not have entered the room. He stated that the facility paid for food handler cards for staff but was not sure if DA #15 had received the training. He stated that no one on his current staff recalled training DA #15 on infection control, handwashing, or food handling.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff donned Personal Protective Equipment (PPE) on entering a resident's room with contact isolation precautions for 1 (Resident #45) of 4 residents reviewed for transmission based precautions. Specifically, Dietary Aide (DA) #15 entered and exited Resident #45's room without donning PPE, when the resident was on contact isolation precautions.Findings included: A facility policy titled, Infection Control and Isolation Guideline, effective 07/2025, indicated, Purpose - To prevent the spread of infectious diseases and promote a safe environment for residents, staff, and visitors utilizing evidence-based infection control and isolation practices in accordance with current CDC [Centers for Disease Control and Prevention] and CMS [Centers for Medicare and Medicaid Services] guidelines. The policy also indicated, 2. Transmission-Based Precautions - Used in addition to Standard Precautions for known or suspected infections. A. Contact Precautions, and PPE: Gown and gloves upon room entry. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2026, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an indwelling catheter, a multidrug resistant organism, and a urinary tract infection. Resident #45's Care Plan Report included a focus area, initiated 05/04/2026, that indicated the resident had a urinary tract infection. Interventions directed staff to administer minocycline (a tetracycline antibiotic) as ordered (initiated 05/23/2026). Resident #45's Care Plan Report included a focus area, initiated 10/09/2024 and revised 05/29/2026, that indicated the resident was at risk for infection related to an indwelling catheter and a history of ESBL (extended-spectrum beta-lactamase, enzymes made by some bacteria that break down some antibiotics) resistance. On 06/01/2026 at 9:51 AM, DA #15 was observed entering and exiting Resident #45's room that had signage indicating the resident was on contact precautions. During a concurrent interview, DA #15 stated that he had worked at the facility for almost three years, and he had not received any training on infection control. DA #15 stated he did not know what contact precautions were, and he was not able to identify posted facility signage outside Resident #45's room for Contact Precautions.During an interview on 06/04/2026 at 11:30 AM, Assistant Director of Nursing (ADON) #8, who was the Infection Preventionist (IP), stated that Resident #45 was on contact precautions for ESBL in the urine. The IP stated that for contact precautions staff donned a gown and gloves even for just walking in the room, as staff could never know what their clothes were going to touch. The IP stated a resident's room that was on contact precautions was indicated by a sign that stated the room was to be on contact isolation with a yellow universal precautions emblem. The IP stated staff donned PPE before going into the contact isolation room, they doffed PPE when coming out of the room, and there was a bio-hazard box inside the room to dispose of used PPE. The IP stated, if there was a resident room with yellow universal precautions signage, dietary staff should not go in the room, to prevent any accidental cross contamination. The IP stated dietary staff, as unlicensed individuals, might not be aware of risks. The IP stated that a dietary aide should not have been in a contact isolation room. During an interview on 06/04/2026 at 11:55 AM, the Director of Nursing (DON) stated she always wore a gown and gloves when entering a contact isolation room, and she expected the staff to as well. The DON stated that it was to prevent the spread of the infection throughout the facility and protect immunocompromised residents as well. During an interview on 06/04/2026 at 3:18 PM, the Administrator (ADM) stated anyone going into a contact precautions situation should have been trained on how to don the protective barriers to avoid any transmission of disease to an at-risk population, to keep residents safe, and to keep staff healthy. The ADON stated if a staff member were not trained on contact precautions that staff member should not be going into the contact isolation room, and certified nurse aides would have to go into the room instead.

Based on observation and interview, the facility failed to ensure nurse staffing data was posted in a prominent place accessible to residents, staff, and visitors on 1 (06/02/2026) of 5 days of the survey.Findings included: During an interview on 06/05/2026 at 9:35 AM, the Assistant Administrator stated the facility did not have policy related to posting nurse staffing. During an observation of the facility on 06/02/2026, the survey team was unable to locate a nurse staffing data posting. During an interview on 06/02/2026 at 4:00 PM, the Scheduler stated that while she created the nurse schedule in their electronic system, it did not generate the total nursing hours. She stated it was possible to run such a report, but it would be done by Human Resources. She stated she personally did not run a report for daily staffing, nor did she post staffing anywhere in the facility. During an interview on 06/02/2026 at 4:11 PM, the Payroll Clerk (PC) stated that she utilized their electronic employee software to run daily staffing numbers. She stated that she ran a report to get the patient hours per day (PPD) and sent it daily to the Administrator at the start of her shift. She stated she was never instructed regarding a need for daily staff postings available to the public. During an interview on 06/04/2026 at 11:55 AM, the Director of Nursing (DON) stated she was not aware of any daily staff posting requirements/regulations for hours by discipline and did not know whether anyone had been tasked with posting nurse staffing data. During an interview on 06/04/2026 at 3:18 PM, the Administrator stated that he was not previously aware of a regulation requiring daily staff posting and was unsure whether anyone posted daily staffing hours.

Based on record review and interview, the facility failed to submit payroll based staffing information to CMS as required for the 3rd quarter of 2024. The administrator identified 95 residents resided in the facility. Findings: A PBJ Staffing Data Report - FY Quarter 3 2024, documented there was no data submitted for the third quarter. On 10/31/24 at 10:08 a.m., the administrator stated they did not think anyone had been completing it. They were asked what was the process for ensuring it was accepted. They stated, I don't think it was getting done. 47453

Based on observation, record review and interview, the facility failed to provide ADL care to dependent residents for two (#21 and #64) of three sampled residents reviewed for ADLs. The administrator identified 95 residents resided in the facility. Findings: 1. Resident #21 had diagnoses which included dementia. A Significant Change Assessment, dated 09/09/24, documented Resident #21's daily decision making was severely impaired. It documented the resident was dependent on staff for personal hygiene. On 10/27/24 at 9:41 a.m., Resident #21 was observed seated in their gerichair in their room. Their hair was observed uncombed, and their facial hair was observed to be straggled, and unshaven. On 10/28/24 at 1:34 p.m., Resident #21 was observed in bed. Their hair was observed uncombed, and their facial hair was observed to be straggled, and unshaven. On 10/29/24 at 9:53 a.m., Resident #21 was observed seated in their gerichair in their room. Their hair was observed uncombed, and their facial hair was observed to be straggled, and unshaven. 2. Resident #64 had diagnoses which included dementia. A Quarterly Assessment, dated 09/12/24, documented Resident #64's cognition was severely impaired. It documented the resident had upper extremity impairment to one side. On 10/27/24 at 9:53 a.m., Resident #64 was observed seated in their wheelchair in their room. Their hair was observed uncombed and their facial hair was observed to be unshaven. On 10/28/24 at 1:35 p.m., Resident #64 was observed seated in their wheelchair in their room. Their hair was observed uncombed and their facial hair was observed to be unshaven. On 10/28/24 at 2:30 p.m., Resident #64 was observed being shaved by CNA #4. CNA #4 stated they shaved the male residents as often as they could. On 10/29/24 at 1:38 p.m., the administrator, DON, and corporate #1 was asked what was their expectation for the resident's hair to be combed and shaved. They stated it needed to be brushed in the shower, when they got up, or when it needed it. They stated not all mens hair grows the same and shaving should be completed two to four times a week or when they were looking scruffy. They were asked how staff were aware of how often to provide the care. The DON stated they expected residents to look presentable.

Based on observation, record review, and interview, the facility failed to ensure medications were not left at a resident's bedside for one (#55) of 24 sampled residents observed for bedside medications. The administrator identified 95 residents resided in the facility. Findings: Resident #55 had diagnoses which included dementia. Resident #55 had the following physician orders, dated 08/19/24, documented Vicks Vapor rub 4.8 % - 1.2 % -2.6% topical ointment, apply by topical route two times per day to toenails for nail fungus; nystatin 100,000 unit/gram topical powder apply by topical route two times per day under bilateral breasts for rash; and Aquaphor or equivalent to bilateral lower extremities every day for dryness and itching. There were no self administrating of medications orders. An Annual Assessment, dated 09/12/24, documented Resident #55's cognition was moderately impaired. On 10/27/24 at 12:50 p.m., Resident #55 was observed seated in their wheelchair in their room. Resident #55 was not interviewable. Two medication cups with white cream and one medication cup with a powder substance was observed on the counter near the sink. Resident #55 was observed to be able to propel their wheelchair in their room. On 10/28/24 at 1:37 p.m., the medication cups were observed on the counter near the sink in the resident's room. On 10/29/24 at 9:02 a.m., Resident #55 was observed seated in their wheelchair in their room. They were observed feeding themselves breakfast. The medicine cups containing the creams and powder were observed at the sink. On 10/30/24 at 8:45 a.m., CMA #2 was observed to enter Resident #55's room. The medicine cups containing the creams and powder were observed at the sink. On 10/30/24 at 8:47 a.m., CMA #2 was asked what were in the medicine cups. They stated, Probably remedy powder. They stated the resident had yeast. CMA #2 was observed to don gloves and applied a portion of the powder substance on the resident. CMA #2 was asked if it was normal to leave medicine in the resident's room. They stated the residents can have it if they have a physician's order to leave it. CMA #2 stated they did not know if the resident had an order. On 10/30/24 at 8:49 a.m. LPN #4 was asked if Resident #55 had a physician's order to have medication at bedside. They stated the resident did not have an order and should not have any medication left in their room.

Based on record review and interview, the facility failed to complete a level I PASARR upon admission for two (#19 and #66) of eight residents sampled for level I PASARR completed upon admission. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 57 residents had psych diagnosis. Findings: 1. Resident #19 had diagnoses which included anxiety disorder, other recurrent depressive disorders, and Parkinson's disease. A Comprehensive Assessment, dated 09/06/23, documented Resident #19's cognition was severely impaired. Resident #19's clinical record did not contain documentation a PASARR 1 was completed. On 09/15/23 at 10:01 a.m., the DON was asked to provide a level I PASSAR for Resident #19. The DON stated a level I PASARR was not completed. 2. Resident #66 had diagnoses which included dementia, anxiety, and depression. A Quarterly Assessment, dated 09/01/23, documented Resident #66's cognition was severely impaired. Resident #66's clinical record did not contain documentation a level I PASARR was completed. On 09/13/23 at 2:44 p.m., the DON was asked if a level I PASARR was completed on Resident #66. The DON stated a level I PASARR was not completed.

Based on observation, record review, and interview, the facility failed to ensure the menu was followed for four (#78, 45, 70, and #24) of 10 sampled residents observed for dining services. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility. The DON identified two residents received nutrition and hydration solely through a peg tube. Findings: AWednesday Lunch extended menu, undated, documented bread pudding was to be served for dessert. On 09/13/23 at 12:45 p.m., Resident #78 and #45 had been observed during lunch service. They were not observed to have been served a dessert. On 09/13/23 at 12:47 p.m., CMA #3 was asked what Resident #78 and #45 had been served for dessert. They stated it didn't look like Resident #78 had received a dessert. They stated, I haven't seen the desserts out yet. On 09/13/23 at 1:04 p.m., Resident #70 and #24 were observed sitting at a table in the dining room. They both denied receiving a dessert. On 09/13/23 at 1:17 p.m., the assistant administrator was asked if the lunch service was complete. They stated it was. The assistant administrator was asked when the dessert was served. They stated, Suppose to be directly after meal. The assistant administrator stated, I know some people didn't get served.

Based on observation, record review, and interview, the facility failed to ensure privacy was provided while administering peg tube medication to one (#8) of one sampled resident observed for peg tube medication administration. The DON identified two residents who received nutrition and hydration solely through a peg tube. Findings: A Quality of Care policy, undated, read in part, .Provide utmost Privacy for care delivered . Resident #8 had diagnoses which included gastrostomy status. A Significant Change Assessment, dated 07/03/23, documented Resident #8's cognition was severely impaired. On 09/13/23 at 8:16 a.m., LPN #4 was observed to administer medication via Resident #8's peg tube. LPN #4 was not observed to close the door before providing care. Multiple people were observed walking past Resident #8's room and were observed to look in the room during medication administration. On 09/13/23 at 8:33 a.m., LPN #4 was asked how staff provided privacy during care. LPN #4 stated they should have closed the door.

Based on record review and interview, the facility failed to ensure a resident's comprehensive assessment was completed timely for one (#138) of 22 sampled residents reviewed for MDS assessments. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility. Findings: Resident #138 had diagnoses which included diabetes mellitus type two. A Admission Assessment, dated 08/31/23, was not completed for Resident #138. On 09/14/23 at 12:34 p.m., MDS Coordinator #1 was asked when were admission MDS assessments completed. They stated by the 14th day after admission. MDS Coordinator #1 was asked what the process was to ensure MDS assessments were completed timely. They stated they make out a schedule and the EHR identifies when assessments were due. MDS Coordinator #1 was asked to review Resident #138's assessment. They were asked if the assessment was complete. They stated it was not. MDS Coordinator #1 was asked if the assessment should have been completed. They stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure staff cleaned an insulin vial prior to administration for one (#38) of one sampled resident observed for insulin administration. The DON identified 15 residents received injectable insulin. Findings: Resident #38 had diagnoses which included diabetes mellitus type two. A Physician's Order, dated 08/31/23, documented to administer six units of insulin aspart for a FSBS of 200. On 09/13/23 at 7:27 a.m., LPN #4 was observed to obtain Resident #38's unopened insulin box. LPN #4 was observed to open the box and obtain the insulin vial. LPN #4 was observed to remove the cap on the insulin vial and draw up six units of insulin. LPN #4 was observed to administer the insulin to Resident #38. LPN #4 was not observed to clean the insulin vial prior drawing up the insulin. On 09/13/23 at 7:35 a.m., LPN #4 was asked when staff were to clean the insulin vials. They stated prior to drawing up the insulin. LPN #4 was asked when staff were to clean new, unopened insulin vials. They stated, We just pop the top and draw up the insulin. On 09/13/23 at 2:27 p.m., the DON was asked when were staff to clean a new, unopened, insulin vial. She stated she would clean it after she removed the top.

Based on observation, record review, and interview, the facility failed to ensure a treatment cart was secured for one of three sampled carts observed. A Number of Medication Carts document, undated, documented seven carts were in the facility. Findings: A Medication Cart policy, undated, read in part, .cart must be locked when not in use . On 09/13/23 at 7:45 a.m., CMA #2 was observed at the treatment cart on hall 400. They were observed to push the lock in and go into a resident's room. The lock on the treatment cart was not observed all the way in the cart. There was no staff observed around the cart. On 09/13/23 at 7:47 a.m., LPN #1 was observed to walk by the treatment cart. They were asked what was in the cart. LPN #1 was observed to pull the lock out and open the drawers to the treatment cart without using keys to unlock the cart. Multiple insulin vials, cards of medication, and boxes of breathing treatments were observed in the cart. LPN #1 was asked how staff ensured treatment carts were secured. They stated, Suppose to be locked. LPN #1 was asked if the cart was unlocked prior to opening the drawers to the cart. They stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure a resident received a therapeutic diet as ordered for one (#68) of 10 sampled residents observed for dining services. The RD identified 10 residents received ground meat diets. Findings: Resident #68 had diagnoses which included dementia. A Care Plan, dated 03/15/22, read in part, .nutrition risk .chewing difficult .missing/broken teeth .Diet: Regular .with ground meats .Interventions .Provide diet as prescribed . A Physician's Order, dated 07/03/23, documented Resident #68 was to receive a regular diet with ground meats. On 09/12/23 at 12:43 p.m., Resident #68 was observed to receive a corn dog and tater tots for lunch. The corn dog was not observed to be ground meat per Resident #68's physician's order diet. On 09/12/23 at 12:47 p.m., Resident #68 was observed to pick up the corn dog and bite off a piece of the breading from the corn dog. Resident #68 was observed to try and break off a piece of the meat inside the corn dog with their fingers, but was not successful. Resident #68 put the corn dog back on their plate, removed the breading from their mouth, and put it on their plate. On 09/12/23 at 12:55 p.m., the RD was observed to ask Resident #68 about their lunch meal. Resident #68 was observed to pick up the corn dog, bite off a piece of the breading, chewed on it, then removed it from their mouth, and placed it on their plate. The RD was observed watching Resident #68 during this observation. On 09/12/23 at 12:59 p.m., the RD was asked how staff ensured diets were followed. They stated they have a label that was updated daily, and they checked diet orders in the book next to the serving station. The RD was asked what was considered ground meat. They stated the meat was ground up and gravy could be on it. The RD was asked if a corn dog was considered ground meat. They stated, No. The RD was asked what was Resident #68's physician's ordered diet. They stated they thought it was regular with ground meat. The RD was asked if Resident #68 had problems chewing the corn dog. They stated, [Resident #68] seemed to. They were asked if Resident #68's diet had been followed. They stated, Probably not.

Based on observation, record review, and interview, the facility failed to ensure kitchen equipment, storage shelf, and the ceiling above the food preparation area was maintained to promote sanitation. The DON identified 89 Residents received nutrition from the kitchen. Findings: A Cleaning of Food and Infection Prevention/Control policy, revised 01/2021, read in part, .Non food contact surfaces of equipment .shall be cleaned as often as is necessary to keep equipment free of accumulation of dust, dirt, food particles, and other debris . On 09/12/23 at 8:40 a.m., a tour of the kitchen was conducted. The following observations were made: a. an accumulation of lint, grease, and cob webs on the exhaust vents, and fire suppression system over the fryers and steam table. A sticker documented last service for cleaning hood vents were 01/2023 with next service due in 04/2023, b. an accumulation of grease and lint on the top shelf above the food warmer with Styrofoam clam shells stored on the soiled surface, and c. an accumulation of lint and grease on the cords hanging from the ceiling over the food preparation area. On 09/13/23 at 12:36 p.m., the CDM was shown the lint, cobwebs, and grease accumulation on the above items. The CDM stated the kitchen condition was unacceptable and created a physical hazard for food contamination.

Based on observation, record review, and interview, the facility failed to ensure staff wore a faceshield/goggles while in a COVID-19 positive resident's room for two (#57 and #43) of four sampled residents observed for infection control. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility. The DON identified four residents were COVID-19 positive. Findings: A COVID-19 Prevention, Response and Reporting policy, dated 09/11/23, read in part, .It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 .HCP who enter the room of a resident with .confirmed SARS-CoV-2 infection should adhere to .eye protection . Two Physician's Orders, dated 09/12/23, documented Resident #57 and #43 were on isolation. On 09/14/23 at 7:56 a.m., LPN #1 was observed to don on gown, mask, and gloves and went into Resident #57's and #43's room. LPN #1 was not observed to wear eye shield/goggles. A sign was observed hanging next to the residents' door. The sign, dated 09/12/23, read in part, .NEED TO HAVE ON .EYE SHIELD/GOGGLES . On 09/14/23 at 8:04 a.m., LPN #1 was observed to don on gown, mask, and gloves and went into Resident #57's and #43's room. LPN #1 was not observed to wear eye shield/goggles. On 09/14/23 at 8:30 a.m., LPN #1 was observed to open Resident #57 and #43's door. LPN #1 was observed not wearing eye protection. On 09/14/23 at 8:34 a.m., LPN #1 was asked what PPE staff were to wear in COVID-19 positive resident rooms. They stated staff wore gowns, gloves, and N95 mask. LPN #1 was asked if staff wore eye protection. They stated, No. On 09/14/23 at 8:38 a.m., the IP was asked what PPE staff were to wear when in COVID-19 positive resident rooms. They stated gown, N95 mask, gloves, and faceshield/goggles.

On 08/19/22, an IJ situation was determined to exist due to the facility failing to ensure: a) staff positioned a resident who was on aspiration precautions at a 90 degree angle, b) a staff member was present during meal service, c) staff did not serve toast to a resident who was laying at 30 degree angle who was on aspiration precautions, d) staff provided supervision to ensure residents followed aspiration precautions during a meal service and, e) have a system in place to communicate aspiration precautions to staff. On 08/19/22 Resident #23 was observed to be served breakfast which consisted of toast. The dietary staff gave Resident #23 the toast while they laid down in bed, and did not ensure aspiration precautions were followed. Resident #23 was observed taking large, fast bites of the toast and was coughing between bites. An LPN was observed to assist the resident into their wheelchair and provided setup assistance with breakfast tray, then left the room leaving the resident unsupervised. This resulted in putting Resident #23 at high risk for aspiration. On 08/19/22 at 2:50 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 08/19/22 at 3:05 p.m., the administrator was notified of the IJ situation. On 08/19/22 at 8:03 p.m., an acceptable plan of removal was provided. The plan of removal documented: Plan of Removal for IJ The Commons 08/19/2022 .Plan of removal completion before midnight [08/21/22] .Provide a list of every resident on aspiration precautions .Identify each resident on aspiration precautions with a yellow dot on their door .Educate all staff on what aspiration precautions means and what it entails before returning to work .Educate all staff on yellow dots and what they mean before returning to work .Educate all staff on reading labels and identifying residents with aspiration precautions before returning to work . Educate all staff to look at label/dot and then look at message board in residents closet to ensure dietary orders are being followed before returning to work .Put aspiration precautions on section sheets for direct care staff .Educate all staff on procedures that allows all staff to know if any resident is on aspiration precautions and how to keep them safe before returning to work .Ensure individualized care plans are in place for identified residents with aspiration precautions . Create a policy for identifying aspiration risks in residents with the proper dots and method of notifying staff, include aspiration risk and precautions in our regularly scheduled in-service curriculum .Present the situation and the remedies to QA committee .All residents at risk will have their care plans reviewed and updated to reflect risk of aspiration .Include in all new employee packets education on aspiration precautions and procedures and ongoing reeducation as needed . Weekly audits x4 week then monthly audits x3 months will be done to ensure procedures are being followed adequately .Any staff who are unavailable by the completion date will be in-serviced before returning to work . On 08/22/22 and 08/23/22, observations and interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 08/23/22 at 10:20 a.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 08/23/22 at 7:45 a.m. The deficiency remained at a level of potential harm at a pattern. Based on observation, record review and interview, the facility failed to ensure staff: a) positioned Resident #23 at a 90 degree angle and a staff member was present during a meal service, b) did not serve toast to Resident #23 who was laying at 30 degree angle who was on aspiration precautions, c) provided supervision to ensure Residents #23 and #52 followed aspiration precautions during a meal service and, d) have a system in place to communicate aspiration precautions to staff for two (#23 and #52) of two sampled residents reviewed for accident hazards. The administrator identified 10 residents who were at risk for aspiration precautions. Findings: The facility's Resident Food Services policy, revised 01/2022, read in part, .All food and beverages served will be assessed and determined safe for residents with special dietary needs, including .swallowing/chewing difficulty .Information is written on the meal card, meal ticket, or community specific method of identifying resident's diet order .and/or special nutritional needs .Consults with physician and/or Speech Therapy to address any special food needs . 1. Resident #23 had diagnosis of dysphagia following cerebral infarction. A physician's order, dated 10/22/16, read in part, .Aspiration Precautions . A physician's order, dated 10/22/16, read in part, .Sit up 90 degrees .Eat Slow Rate .Small Sips/bites .Close Supervision .Check for Pocketing on the Right side .Double Swallow .Assist/Feed . Resident #23's care plan, dated 11/27/16, read in part, .[Resident #23] .is at risk for aspiration .Related to .Needs Supervision/cues .Swallowing difficulty . Resident #23's care plan interventions, dated 09/19/17, read in part, .Aspiration precautions. Needs supervision with meal . Resident #23's care plan interventions, dated 03/08/22, read in part, .Provide necessary assistance at meal time . Resident #23's assessment, dated 06/07/22, documented the resident had severely impaired cognition with daily decision making, and required supervision with eating. Resident #23's speech therapy evaluation and plan of treatment report, dated 06/11/22, read in part, .Recommendations .Assist pt achieve 90 degree posture for PO intake. Pt has difficulty maintaining posture. Cue for alternating liquids and solids to encourage liquid intake and assist with clearing residue from oral cavity . On 08/19/22 at 8:40 a.m., dietary aide #1 was observed to deliver Resident #23's breakfast tray to their room. Resident #23 was observed lying in bed, with the head of the bed elevated at approximately 30 degrees. Resident #23 was pointing at the tray. Dietary aide #1 gave the resident the toast while the resident was lying in bed. Dietary aide #1 was observed to leave the resident's room. Resident #23 was observed taking big, fast, bites of toast and coughing between bites. Resident #23 was observed to finish eating the toast and began to transfer self out of the bed. LPN #2 was observed to come into the resident's room and assist the resident up and into their wheelchair. LPN #2 was observed to set resident up in front of the breakfast tray, uncovered the tray, and left the room. Resident #23 was observed eating oatmeal unsupervised in their room. On 08/19/22 at 9:20 a.m., the administrator was asked how staff ensured residents' dietary needs and restrictions were met. They stated they review this in their meetings and the nurses observed. On 08/19/22 at 10:42 a.m., dietary aide #1 was asked what aspiration precautions were. They stated, Kind of choking. Not able to breath. They were asked how often residents were served food while in bed. They stated, Not very often but when they ask, I give it to them. I know [Resident #23] is not supposed to be in the bed eating but [Resident #23] reached for the toast. I know it's not good for [Resident #23] to eat in bed. I told [Resident #23] to push [their] button to get an aide to help [them] up. Dietary aide #1 was asked how staff knew which residents were on aspiration precautions. They stated, That's a good question. To avoid it, I try not to give anything while they are laying down. On 08/19/22 at 10:52 a.m., CNA #2 was asked what precautions were ordered for Resident #23. They stated they weren't sure. They were asked how staff knew which residents were on aspiration precautions. They stated, It's on their chart and the plates when they are served. They were asked who was on aspiration precautions. They stated they weren't sure. CNA #2 was asked what were aspiration precautions. They stated when food went in the wrong way and could get lodged in their throat. They stated to make sure the resident was up at a 90 degree angle. On 08/19/22 at 10:59 a.m., EA #1 was asked how staff knew what precautions the resident had to follow. They stated, On the sticker. We look what the allergy is and what not to give them. They were asked who was on aspiration precautions. They stated they weren't sure. EA #1 was asked what were aspiration precautions. They stated the resident needed to sit up and could choke. They were asked how staff ensured precautions were followed. They stated, From the nurse or aide. On 08/19/22 at 11:06 a.m., dietary aide #2 was asked what aspiration precautions were. They stated, No. They were asked how staff ensured precautions were followed. They stated to look at the sticker. Dietary aide #2 was asked what residents were on aspiration precautions. They stated, I don't know. I look at their label when they get food. On 08/19/22 at 12:05 p.m., LPN #2 was asked what level of assistance did Resident #23 required with meals. They stated it depended on the day. They stated sometimes the resident required set up assistance and sometimes they required more assistance. LPN #2 was asked what were aspiration precautions. They stated if the resident had problems swallowing or choking. They stated they would get speech therapy involved, alter diets and liquids. LPN #2 was asked how staff ensured aspiration precautions were followed. They stated to make sure the resident was sitting up with the correct diet and liquid consistency. They were asked how staff knew which residents were on aspiration precautions. They stated it was in the computer and on their section/report sheet. LPN #2 was asked if Resident #23 was on aspiration precautions. They stated they needed to look in the computer. After LPN #2 was observed looking in the computer, they stated the resident was. LPN #2 was asked if they received any training on aspiration precautions. They stated they did in CNA school and if they had any questions, they would ask the nurse manager or another nurse. On 08/19/22 at 12:15 p.m., CMA #5 was asked how staff knew which residents were on aspiration precautions. They stated, I don't. They were asked to describe a situation where a resident would be fed lying down in bed. They stated, I would not feed a resident lying down because of aspiration risk. An undated meal sticker/label was observed for Resident #23. It did not identify the resident was on aspiration precautions. Other than a physician order, there was no system in place to notify staff of the residents with aspiration precautions. On 08/19/22 at 12:52 p.m., the administrator assistant stated they did not have an aspiration precaution policy. On 08/19/22 at 1:22 p.m. the administrator was asked who served meal trays to the residents. They stated dietary and CNAs. They were asked who all can serve trays to the residents. They stated they have seen nursing staff help. The administrator assistant was asked who assisted the residents with the meals. They stated CNAs and staff, such as dietary and some office staff, that have been through training with the previous dietician. The administrator and administrator assistant were asked what were aspiration precautions. The administrator stated the resident needed to sit up for 30 minutes after eating. The administrator assistant stated they need to sit up while they eat and if the resident needed assistance, they would receive the assistance. The administrator and administrator assistant were asked what resident had aspiration precautions. The administrator assistant stated they would have to go through and look at each chart or ask the nurse. The administrator stated the nurses would know who had aspiration precautions. The administrator assistant stated the dietary, and staff who were working with residents would know. The administrator assistant stated CNA/CMAs have section sheets with diets on them. The administrator assistant was asked to describe the section sheets. They stated the section sheet was something to describe the care the resident needed. They were asked how often the section sheets were updated. They stated weekly and with every change. The administrator assistant was asked if all staff who served and assisted the residents with food have access to residents' precautions. They stated they can look on the food container label. They stated the label consisted of the resident's name, room number, diet order, any specialized order, and allergy. The administrator and administrator assistant were asked how the trained staff were aware of the residents with aspiration precautions. The administrator stated the staff were aware if the resident was getting assistance with feeding, through report, or the section sheet. The administrator assistant stated if the resident was on a specialized diet, such as thickened liquid, pureed, mechanical soft diet, the resident was automatically on aspiration precautions. The administrator assistant was asked how staff would know the resident was on aspiration precautions with a regular diet and thin liquids. They stated the staff still needed to make sure the resident was sitting up. They stated that was universal precautions to prevent anyone from choking. The administrator was asked how did staff ensure aspiration precautions were followed. They stated when the resident received their food, ensure the resident was sitting up and ensured resident was up for 30 minutes after eating. The administrator was asked if it was safe to serve a resident, who had physician ordered aspiration precautions, a piece of toast while in bed with the head of the bed up at approximately 30 degrees. They stated no it wasn't safe. The administrator was asked what risk was to the resident. They stated the resident would be at high risk for aspiration. The administrator was asked what it could indicate if the resident was coughing between bites of the toast. They stated possible aspiration. On 08/19/22 at 1:50 p.m., RN #1 was asked how aspiration precautions were communicated to the staff. They stated when the resident was admitted or with any changes, staff filled out diet forms with any special precautions that included aspiration precautions. On 08/19/22 at 1:52 p.m., the dietary manager stated aspiration precautions were not on the residents' dietary food label. The administrator was observed looking at the printed label for Resident #23 and confirmed aspiration precautions were not on the label. 2. Resident #52 had diagnoses to include dementia, cerebral infarction with [CONDITION(S)], [CONDITION(S)], auditory/visual hallucinations, ataxia; dysphagia; and abnormal posture. A physician's order, dated 10/15/21, documented Resident #52 was to receive liquids with a thin consistency. A physician order, dated 05/17/22, documented Resident #52 was to be served a diet consistency of soft bite size pieces and finger foods as tolerated, with staff supervision to decrease loss of bolus with patient feeding attempts. The order documented the resident was to not be served bacon, hard crusty breads, or large chunks of hard vegetables. The ADL Focus care plan, dated 04/01/21, documented Resident #52 required supervision for eating. Interventions included staff would assist with ADL's as needed. The ADL Focus care plan was last reviewed on 06/30/22. The ADL Focus care plan did not contain interventions for the supervision of meals/eating. The Nutrition Risk Focus care plan, dated 04/01/21, documented Resident #52 was at nutritional risk related to the need for assistance/cues, swallowing difficulty and [CONDITION(S)]. The care plan documented a recent weight loss as evidence the Resident #52 was at nutritional risk. The Nutritional care plan interventions included: provide diet as prescribed; allow eating/drinking at own pace, and assist the resident as needed. The Nutritional Risk Focus care plan was last updated on 07/14/22. The interventions did not address the resident's assessment status and/or the physician orders regarding Resident #52 required supervision with meals. The Resident CNA Documentation History Detail for 06/2022, documented Resident #52 was independent and had not received supervision for 21 meals. Resident #52 had required limited assistance of staff for 2 meals. Seven meals had been refused and one meal did not contain documentation. A quarterly assessment, dated 07/08/22, documented Resident #52 had severe cognitive impairment for daily decision making, and required supervision of one staff for eating. The Resident CNA Documentation History Detail for 07/2022, documented Resident #52 had not received supervision for 35 meals. Resident #52 required limited assistance for two meals. Four meals documented the resident refused. Nineteen meals contained no documentation. The Resident CNA Documentation History Detail, dated from 08/01/22 through 08/22/22, documented the resident did not receive supervision for 23 of 66 meals. One meal documented the meal did not occur. Fifteen meals contained no documentation. On 08/16/22 at 08:45 a.m., resident #52 was in a private room, seated in a recliner. Resident #52 was leaned to the right arm rest of the chair. On 08/17/22 at 01:19 p.m., Resident #52 was seated in a recliner in her room, a meal container was in front of the resident, on an over-bed table. On 08/22/22 at 12:48 p.m., Resident #52 was served the noon meal while seated in a recliner inside a private room. The food container included sliced meat, french fried potatoes, and green beans. The food container was placed on the resident's lap. Resident #52 remained seated semi-reclined in a recliner. Resident #52 was leaned to the right side positioned in a manner with her head on the right arm rest of the recliner. Staff remained in the common areas and other resident rooms. There was no staff in the room with Resident #52. On 08/22/22 at 01:17 p.m., LPN #1 was observed to glance into Resident #52's room while the LPN passed by the doorway. The LPN did not stop or call for assistance for the resident. Resident #52 remained semi-reclined in a recliner with her head leaned over the right arm rest of the chair. Resident #52 had remained alone in a private room, without supervision of meal intake, from 12:48 p.m., until after 1:18 p.m., On 08/22/22 at 01:18 p.m., LPN #1 was asked if LPN #1 had just did look in on Resident #52. LPN #1 stated yes. LPN #1 was asked how much time had passed from when Resident #52 was served the noon meal and a staff member checked on the resident. LPN #1 stated, It was too long. LPN #1 was asked if Resident #52 had been identified as at risk for aspiration and/or required supervision for meals. LPN #1 stated Resident #52 was identified at risk for aspiration but likes to eat in a private room. LPN #1 stated Resident #52 should have been monitored closer.

On 06/28/22, an IJ situation was determined to exist related to the facility's failure to ensure transportation staff were trained on securing residents in wheelchairs prior to transportation. Staff identified as transporters have not been trained on correct procedures. The facility did not have a policy and procedure for staff to follow and there were no competency checks to ensure wheelchair residents were secured prior to and/or during transportation. On 06/13/22 Resident #1 was not secured in the transportation van and the driver had to suddenly stop causing the resident to fall forward out of the wheelchair sustaining fractures as a result. There was no training of aides that assisted with transportation on securing the residents for safe transport. The aides did not inform management that they continually observed Resident #1 not being secured in the transport van. On 06/28/22 at 12:11 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 12:24 p.m., the administrator was notified of the IJ situation. On 06/28/22 at 8:13 p.m., an acceptable plan of removal was provided. The plan of removal documented: The Commons - [NAME], Oklahoma - 6/28/2022 Immediate Jeopardy .All staff have been in-serviced on Transportation Policy & Procedures and were tested on their knowledge of transport of residents in The Commons van . The following texts have been sent to all staff immediately: 'ATTENTION STAFF: Due to an IJ from State, ALL EMPLOYEES NEED TO COME TO THE FACILITY AT ONE OF THE FOLLOWING IN-SERVICE TIMES: 1:00 PM, 2:30 PM OR 4:00 PM TODAY. This is not debatable. Please come to the facility ASAP.' In-Service was completed on 6/28/2022 at 5[:]13 PM. Staff that are on vacation or medical leave will be in-service prior to returning to work . After the accident, The Commons realized that there was not a Transportation Policy and Procedure in place. Our transport education was subpar and since then we have created and implemented a structured policy and procedure and now all staff have been in-serviced formally. Also, we have implemented during new employee orientation and annually all staff will be educated and re-educated on the transport policy and procedure. Please see attach for policy and procedure, and the formal education . On 06/29/22, interviews were conducted with multiple staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 06/29/22 at 9:06 a.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 06/28/22 at 5:13 p.m. The deficiency remained at a level of actual harm at an isolated incident. Based on record review and interview, the facility failed to ensure transportation staff were trained on securing residents in wheelchairs prior to transportation for one (#1) of three sampled residents reviewed for accidents. Staff identified as transporters have not been trained on correct procedures. The facility did not have a policy and procedure for staff to follow and there were no competency checks to ensure wheelchair residents were secured prior to and/or during transportation. On 06/13/22 Resident #1 was not secured in the transportation van and the driver had to suddenly stop causing the resident to fall forward out of the wheelchair sustaining fractures as a result. There also was no training of aides that assisted with transportation on securing the residents for safe transport. The aides did not inform management that they continual observed Resident #1 not being secured in the transport van. The administrator identified 80 residents resided in the facility and 41 residents went to outside the facility for appointments. Findings: Resident #1 was admitted with diagnoses of multiple [CONDITION(S)], encounter for other orthopedic after care, displaced segmental fracture shaft of right fibula and displaced obliquely fracture shaft of right tibia. Resident #1's care plan, effective 01/07/21, documented the resident was at risk for falls related to loss of ability to balance, muscle weakness, MS and use of DME. Resident #1's quarterly assessment, dated 04/17/22, documented resident was cognitively intact, required assistance with transfers, bed mobility, and dressing. It documented the resident had impaired ROM on one side of upper extremities, and impairment on both sides of lower extremities. It documented the resident required use of a wheel chair. A Progress Note dated 06/13/22 at 5:51 p.m., read in part, .Resident left facility at approximately [2:00 p.m.] for appointment at [doctor's office]. Received call from [doctor's] nurse who stated [Resident #1] had fallen out of [their] wheelchair during transport to appointment, that [Resident #1] was expressing severe neck [and] back pain after falling. [The doctor] sent resident to hospital for X-Rays [and] CT of head. Resident returned to facility at approximately [5:10 p.m.] . A hospital x-ray report, dated 06/13/22, documented Resident #1 had a proximal fibular diaphyseal fracture with communited components and angulated distal tibial obliquely oriented fracture. A transportation check list and transportation policy were created/implemented on 06/14/22. It documented staff who are involved in transportation should all be trained in the correct procedures for transporting people who use wheelchairs. It documented procedures to secure wheelchairs and passengers. The transporter that was involved in the incident on 06/13/22 was the only one who signed the check list. Progress note, dated 06/15/22 at 8:52 p.m., read in part, .Resident is going to [hospital] for surgery on right foot . A hospital operative record, dated 06/16/22, documented pre and post diagnose of displaced right tibial shaft fracture with segmental fibula fracture. It documented the operation was a closed reduction IM nailing right tibia. A statement from the transporter, dated 06/16/22, read in part, On Monday June 13 I and [EA #2] was taking [Resident #1] to a Dr. AppT .A [name deleted] truck .is coming at us head on. The wrong way on a one way street. I have to slam on the brakes to avoid hitting [the truck]. When I did this I feel [sic] a thump in the back. I look back and [Resident #1] is balled up behind the passenger seat. We pull over so I jump out drivers side and [EA #2] gets out passenger side and we get [Resident #1] back in [their] chair. We go ahead and take [Resident #1] to [their] Dr. Appt .So .Dr set up appt at [hospital]. They find that [Resident #1] has a broken shin . A final state incident report, dated 06/22/22, documented Resident #1 was involved in incident. Resident #1 was being transported to a doctor's appointment in the transport van when they were involved in a near miss automobile accident. Another driver was driving down a one-way road the wrong direction which caused the transport van driver to have to slam on the brakes to avoid collision. When the transporter slammed on the brakes, Resident #1 slid out of their electric wheelchair and on to the floor of the van. Resident #1 sustained a displaced distal tibial and a nondisplaced distal fibular fracture on the right leg. Resident #1 was admitted to hospital and underwent surgical repair. Resident #1 was educated to report immediately if staff members do not put seat belt on them during transport. The transporter was educated to securely fasten all wheel chairs and to have residents seat belted in before the vehicle is put in to motion. An un-named document in the state report, dated 06/13/22, read in part, .The interim Administrator visited with [transporter] and found out the following steps were not taken .[Resident #1] uses a motorized wheelchair, and it was not properly belted into the floor of the van .[Transporter] thought because it would not move once turned off that would be adequate .[Resident #1] was not properly seat belted in .[Transporter] thought that it would not fit around [Resident #1]in [their] motorized chair .[Transporter and EA #2] moved resident back into [Resident #1's] wheelchair .[Transporter] did not want [Resident #1] to ride in the floor of the van .[Resident #1] was transported to [their] doctor's appointment and then under the direction of [their] physician sent to hospital . Correct steps that [Transporter] should have followed .All wheelchairs secured .If the motorized wheelchair could not be secured, then a regular wheelchair would have to be used so it could be secure .All passengers .have to be seat belted .The resident should not have been moved without an assessment by trained nurse .Solution .[Transporter] has been in-serviced .Transportation policy and procedure reviewed and revised to avoid further incidents .[Transporter] has reviewed .and has signed acknowledgement of the information . On 06/27/22 at 3:18 p.m. Resident #1 was asked about the incident. They stated, This wouldn't have happened if I was secured properly. On 06/27/22 at 3:30 p.m., the DON identified the transporter as the primary driver and EA #1 as the back up driver. The DON stated the transporter had an incident with a resident and that was when the facility created the transportation policy and check list. The DON stated they know EA #1 had not been in-serviced over this. On 06/27 /22 at 3:36 p.m., EA #1 was asked what training they had been provided. They stated, Honestly nothing. No test. Just put me on their insurance and got my driver's license information. On 06/27/22 at 4:09 p.m., the administrator was asked for training documentation for transportation drivers. On 07/27/22 at 4:16 p.m., the maintenance supervisor stated they trained all the drivers. They stated they went over the four points to secure the wheelchair and applying the seat belt. They stated, I don't know why [transporter] didn't do it that time. On 06/27/22 at 4:37 p.m. EA #2. They repeated what was already documented in the state reportable. They were asked if the wheelchair was secured. EA #2 stated the transporter never secured this resident or would put a seat belt on them. EA #2 stated they had told the transporter, in the past, they needed to secure and put a seat belt on Resident #1. They stated they secured other residents. EA #2 was asked who was responsible to secure the resident and the wheelchair. They stated they would do one side and the transporter would do the other side. EA #2 was asked why they didn't do this with Resident #1. They stated, [Transporter] stated [Resident #1] will be ok. On 06/27/22 at 4:58 p.m. the transporter was asked about the incident. They stated they didn't secure the wheelchair, or put a seat belt on Resident #1. When asked why, the transporter stated Resident #1 sat so low in their motorized wheelchair, the seat belt would have hit Resident #1 in the neck. The transporter stated they thought the motorized wheelchair would not move if it was off. They stated they never secured the motorized wheelchairs. The transporter stated they had been transporting residents for a year and a half and hadn't had any training prior to incident, except they drove with the previous driver. The transporter stated they have not had any training since incident. On 06/27/22 at 5:15 p.m., the administrator was unable to locate education for the transporter, and the back up, EA #1. The administrator stated they had talked to the transporter and they stated the only training they had completed was driving with the previous driver. On 06/28/22 at 10:56 a.m., the administrator stated there was no transportation policy or procedure prior to 06/14/22. 06/28/22 at 11:17 a.m., the administrator was asked who provided training to transport drivers. They stated It was suppose to be [maintenance supervisor]. The administrator was asked who goes with residents during transport. They stated EAs, CNAs, activities, other facility staff that were available, and the driver. The administrator was asked if the staff had been trained on the proper procedures to transport residents. They shook their head no. The administrator was asked who all had been trained. They stated the transporter and EA #2. The administrator was asked if the maintenance supervisor had been trained. They stated, No. The administrator was asked who was responsible for ensuring the residents were secured during transport. They stated the driver but the other person going should have knowledge as well.

On 06/25/21, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from abuse. A staff member alleged that LPN #3 had been refusing/withholding pain medications to resident #9. The allegation was not reported timely to the administrator and a thorough investigation was not conducted. The employee remained working during the investigation and no action was taken against the nurse. The resident had consistent pain at a level of eight and nine without his medications. An allegation of staff being verbally abusive to resident #7 on 02/22/21 was not reported until 02/23/21, one day after the allegation occurred. The residents were not protected as the staff member was allowed to work. The facility documented an incident of resident #5 being physically abused by staff witnessed and reported by staff. The facility failed to protect the resident, complete a thorough investigation and implement corrected measures to prevent further abuse. Resident #8 made an allegation of rape by staff on 06/28/21 and the staff had been allowed to continue to work over six hours after the allegation was made, and Staff witnessed verbal abuse to Resident #6, by an employee and reported it. The allegation was not reported to the administrator timely and a thorough investigation was not conducted. The residents were not protected due to the perpetrator remaining at work and continued to work while the investigation was on going. At 11:04 a.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 11:28 a.m., the Administrator (ADM) was notified of the IJ. An acceptable plan of removal was provided by the administrator on 06/25/21 at 9:55 p.m. It documented the following: All residents will be interviewed 06/25/2021. All staff on shift will be educated on updated policy immediately, and if not currently working will be inserviced by phone call by midnight on 06/25/2021. (see attached) (amended to be 9 am on 06/26/2021) ** if unable to be contacted, we will document date and time, and the staff member will be taken off the schedule until completed** The following texts will be sent to all staff immediately .Surveyors have identified serious deficiencies in Abuse reporting. All staff are required to complete in-service. Someone from The Commons will be calling you before midnight tonight .If you have been not contacted to complete an in-service by midnight, call [director of nursing] or will be removed from the schedule .Beginning IMMEDIATELY-reporting of ANY abuse allegations will be need to be texted or called to [administrator] .[assistant administrator] .This is any time- DAY or NIGHT! If no response to a text, then CALL .All staff that have been identified as not timely reporting abuse will be given a 1 day suspension. [Resident #5] -Staff member with physical abuse allegation will be terminated immediately. At every allegation of abuse, a text will be sent to all staff to remind staff that we take abuse very seriously .An allegation has been reported, this is a reminder NO forms of abuse will be tolerated Administrator, Asst Administrator and DON have learned that a thorough investigation includes resident safe surveys on all halls that the alleged abuser has worked. Handwritten statements from those questioned should be included in an investigation. We have reviewed the different types and examples of abuse and will follow our policies that have been updated. We will in-service all staff members on the attached education. We learned that the witness is the person that has reported the incident during the investigation. We learned that to properly assess the resident we must conduct medical, psychosocial, and mental status assessment at the time, and an assessment each shift for 3 days for 9 occurrences On 06/28/21 at 5:20 a.m., two police officers were observed to be at the front door to the facility. When approached, they stated they had received a call that a resident had been sexually abused. They were asked when they had received the call. One stated, About five minutes ago. At 5:25 a.m., the administrator stated, I need to talk to you guys. She stated, We have a crazy lady who says she was raped and I didn't send the two ladies home. The administrator identified additional allegations of abuse that had been reported over the pervious two days. On 06/28/21, at 6:57 a.m., the ADM was asked what the facility did to further educate the administrative staff on abuse. She stated she looked through the state operations manual and reached out to some of her administrator forums online. She was asked if she shared that information with her administrative staff. She stated they looked up information themselves. She was asked if there was anything specific they educated the administrative staff on. She stated, No, nothing specific. A review of the investigations were made and the facility continued to not protect residents after allegations were made, failed to complete through investigations, and failed to take corrective actions against employees based on the accurate results of the investigations. At 3:30 p.m., the administrator was made aware that an amended plan of removal was needed due to ongoing abuse and neglect allegations not being reported timely, not protecting residents and conducting thorough investigations. An acceptable amended plan of removal was provided by the administrator on 06/29/21 at 7:20 p.m. It documented the following: Plan of AMENDED Removal for IJ's - ALL THESE items will be completed by June 30th, 2021 [By 8:00 p.m.] .Abuse, Neglect, Misappropriation Investigation POLICY was updated .An outside agency will provide in-service on PRN [as needed] pain medication administration for CMA, and Nursing on June 30th. This inservice will focus on neglect, and not withholding medications. All staff that have not been in serviced by June 30th, 8pm may not work until in serviced, by the DON [director of nursing], ADON [assistant director of nursing], or the outside agency. Due to further consideration on 06/28/21 [staff name deleted] was terminated. [CNA #6] and [LPN #3] will be terminated on 06/30/21 . An ADMINISTRATIVE team was formed called the INCIDENT RESPONSE TEAM on June 29th, and includes the Administrator, Assistant Administrator, DON, ADON, and HealthCare Center Resident services Director. The administrator or designee will report to Board of Director any allegation of abuse at regularly scheduled monthly meetings at a minimum. The INCIDENT response team will be in-serviced by an outside source on all aspects of ABUSE - including screening, preventing, identifying, Investigating, protecting, and reporting/response on 06/30/21 with advanced traing on Abuse. To always protect our residents, the INCIDENT response team will meet to collaborate and respond to allegations to ensure all thorough investigation has been completed. On 07/01/21, two LPNs, one RN and three CMAs were interviewed and able to state accurate information related to abuse and neglect and five administrative staff were interviewed and were able to state accurate information related to abuse and neglect. The immediacy was lifted on 06/30/21 at 5:10 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at a level of actual harm at a pattern Based on observation, record review, interviews, it was determined the facility failed to ensure residents were free from abuse and neglect for six (#1, 5, 6, 7, 8 and #9) of six sampled residents reviewed for abuse and neglect. The facility also failed to have an environment that ensured staff were free to report allegations of abuse and neglect without fear of retaliation. This deficient practice resulted in harm to Resident #9 and #7. Resident #9 had constant pain a level of eight and nine (on a scale of 1-10) when LPN #3 had been refusing/withholding pain medications. As a result of not getting his pain medication the resident became upset and mad because of the pain level he was at. An allegation of staff being verbally abusive to resident #7 on 02/22/21 was not reported until 02/23/21, one day after the allegation occurred. The residents were not protected as the staff member was allowed to work. This resulted in harm to Resident #7 when he wheeled himself away from the nurse's station area back down the hall towards his room and sat secluded in the corner the rest of the shift. The facility identified 95 residents resided in the facility. Findings: An employee handbook, dated 03/2020, documented, .The Company actively works to prevent .abuse by .Protecting employees .from adverse action when they do the right thing and report any [MEDICATION(S)] concern regarding .abuse .The Company strictly prohibits retaliation, in any form, against any individual making a report, complaint, or inquiry in good faith .Abuse & Neglect Policy .NO FORM OF ABUSE OR NEGLECT IS TOLERATED AND MUST BE REPORTED IMMEDIATELY .FAILURE TO REPORT ABUSE OR NEGLECT, EVEN SUSPECTED ABUSE OR NEGLECT, LEAVES YOU RESPONSIBLE FOR THE SITUATION .Bullying & Harassment .The Commons will not, in ay instance, tolerate bullying or harassing behavior. Employees found in violation of this policy will be disciplined, up to and including termination .examples of bullying and/or harassment: Verbal .ridiculing .humiliating .Shouting, raising voice at in individual in public .Telephone Calls & Cell Phones .Cell phone use is limited to break time only .Code of Conduct .Disciplinary Procedures .Violations of any of these rules .may result in corrective action being taken, up to and including discharge .Physical or mental abuse of the residents or failure to report physical or mental abuse by others .Social Media .Employees must not post confidential .about .clients .Employees should not disparage any person .based on .disability . An abuse policy, dated 12/08/2020, documented, Reporting Requirements .allegations shall be reported immediately to the administrator, DON and to other officials in accordance with State law. Allegations that involve abuse .must be reported within 2 hours .These allegations must be thoroughly investigated and must prevent further potential abuse while the investigation is in progress .appropriate action must be taken including report to the appropriate licensing board .Prevention .It [sic] the policy of The Commons that each resident will be free from abuse, neglect .All facility staff will be in-serviced upon first employment, and at least annually thereafter, regarding .neglect or abuse .Immediately report any suspicion of abuse, neglect or mistreatment to your immediate supervisor .The supervisor WILL CALL the CELL phone of the ADMINISTRATOR [admin], then the DON .Suspected or substantiated cases must also be reported to respective agencies such as state agencies, law enforcement, physician; families, and/or resident responsible party. The subject of abuse shall be routinely and openly discussed .Investigation .Procedure .1st .Care for, treat and PROTECT the resident-DON, ADON, or house supervisor should do a medical assessment immediately .documenting any injury in detail .Take a statement from the resident .2nd .Isolate the perpetrator .3rd .Immediately notify the Administrator, then DON . 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 01/14/21, documented the resident's cognition was moderately impaired. A care plan, effective date 01/07/21, documented, .Resident is at risk for pain r/t [related to] muscle spasms and chronic pain syndrome .Resident will have pain treated/relieved in a timely manner .Administer medications as prescribed . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 325 mg capsule give 2 tablets by oral route every 6 hours as needed for pain . [MEDICATION(S)] 50 mg tablet give 1 tablet (50 mg) by oral route every 6 hours as needed for pain . A statement from CMA #3, dated 06/26/21 at 12:35 a.m., documented, Generally everyday, on multiple occasions, typically beginning first thing in the morning after the CNA has helped [Resident #9] get up out of bed for the day, he will ask for a pain pill. He will specifically ask for a [MEDICATION(S)] and rate his pain at an 8 out of 10 for leg or butt pain. As protocol, as the CMA, I report the request to the charge nurse, the charge nurse will go to the resident to evaluate the resident and report back to me, the CMA, with guidance to administer a pain med and instruct me with the level of the pain that was reported and the location of th [sic] pain. On many occurrences, [LPN #3], will deny the resident, [Resident's name], pain meds stating 'He just got up, he doesn't need a pain pill' or 'He's going outside to smoke a cigarette, he's not hurting bad enough if he can go outside to smoke' or 'He can't have a pain pill because he hasn't eaten anything yet.' On these occurrences, [Resident] won't receive pain meds until sometimes 10 a.m or as late a 2 p.m. as reflected on the MAR [medication administration record] . An OSDH incident form, dated 06/26/21, documented, .[Resident #9] .Allegations of Abuse/Mistreatment .Description of Incident .Staff reported Nurse not approving PRN pain meds when resident asked for them. Resident is cognitive and needs no family called . A statement from LPN #3, dated 06/27/21 at 12:23 [did not document a.m. or p.m.], documented, Sometimes resident asks for pain pills when it is not time as he had it earlier. Med is scheduled [every] 8 [hours] prn. Resident is offered Tylenol if [MEDICATION(S)] can't be given yet . Safe surveys were conducted with five residents. The questions asked to the residents were not related to receiving pain medications. The facility documented the allegation was unsubstantiated and completed on 06/27/21 at 5:30 p.m. The employee continued to work during the investigation of the alleged neglect. The facility did not complete a through investigation and interview residents and staff to include the alleged victim regarding pain medications being withheld. On 06/28/21 at 12:40 p.m., the administrator and assistant administrator were asked about the conclusion of the investigation. The assistant administrator stated she had made an excel spreadsheet of which nurse had given Tylenol versus the [MEDICATION(S)]. She stated the accused nurse had administered the medications as much as the other nurses. She was asked if there was documentation of the times the resident had requested the [MEDICATION(S)]. She stated she didn't think you could tell when he had requested it. She was asked if there was no documentation of when the resident requested it and the CMA stated LPN #3 withheld the medication, how did they come to the conclusion the allegation was unsubstantiated. She stated she went to the resident and asked him about it. She stated the resident is this nurse's biggest cheerleader. At 1:19 p.m., the ADM provided resident surveys. There were no questions asked to the residents related to staff withholding pain medications. She stated the executive director had made the surveys and thought that the question Do staff members respect your requests and allow you to make decisions regarding your care covered that. On 06/29/21 at 6:35 p.m., the resident was asked if he was in pain. He stated he had pain in his right side, leg and knee. He stated he would rate it consistently at an 8 out of 10. He stated it was usually a 9 in the mornings. He was asked how he felt if he did not get his [MEDICATION(S)] when he requested it. He stated, If I don't get them, I get mad. He was asked if his [MEDICATION(S)] was ever withheld. He stated it was and then stated he would not disclose who the employee was that withheld the medication. At 7:02 p.m., CMA #3 was asked about the allegations made regarding LPN #3 withholding [MEDICATION(S)]. She stated, [MEDICATION(S)] is what he asks for all the time. She stated, It's upsetting to me cause when he asks for something, I have protocol I have to follow. She stated that LPN #3 would give the same responses CMA #3 had put in her statement. She stated she was taught to take their pain as they stated it. She stated LPN #3 would have her administer Tylenol or [MEDICATION(S)] instead of the [MEDICATION(S)]. 2. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 02/18/21, documented the resident's cognition was severely impaired. A state incident report form, dated 02/23/21, documented, .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Administrator was notified today of an allegation of verbal abuse occurring on 02/22/21 from a staff member against a nurse. The nurse is not on the schedule until Thursday. She will not be working until the allegation has been investigated. Investigation is in progress .For 5 day and final reports, please include a summary of the investigation .and corrective measures implemented to prevent recurrence .See attached for investigation: Nurse yelled at resident. She was suspended and counseled on ways to recognize burnout. Also gave her Employee Assistance information . The allegation of abuse was not reported to the administrator until the next day after it occurred. The facility failed to report the allegation of abuse within two hours to the appropriate agencies such as the Oklahoma State Department of Health (OSDH). A written statement by CMA #3, dated 02/23/21, documented, The day of 2-22-21, [resident #7] spent a majority of the day sitting in the North Hall hallway outside of [another resident]s room. At approximately 2 p.m. [resident #7] wheeled himself in his wheelchair up closer to the nurse's station area and parked himself in his wheelchair outside of the wound care nurse's office. Immediately the charge nurse, [LPN #3], stood up and yelled to [resident #7] get the hell out of here, you're not going to sit up here while I'm here. [Resident #7] did raise his hands and yelled at [LPN #3]. I do not know what he yelled at her, his speech is often hard to make out due to health conditions. [LPN #3] then yelled at him again get the hell out of here, you're not going to talk to me that way. After this occurrence, [resident #7] wheeled himself away from the nurse's station area back down the hall towards his room .During this occurrence, [CMA #4] was sitting in a chair beside me and witnessed the entire event . A written statement by CMA #4, dated 02/24/21, documented, On Monday February 22nd I [CMA #4] came into work I was on North Hall. I was sitting at nurses station [resident #7] the resident came strolling up to the Common Area by the nurses station [LPN #3] the nurse told him to turn around and go back he said he has rights She said I dont care Im not gonna [sic] deal with you and he said he wanted to sit up here She screamed at him and said I dont give a dam [sic] your [sic] not sitting up here Im not gonna [sic] deal with your Ass. so [resident #7] sat in the Corner til [LPN #3] left he was very upset the rest of the evening . A written statement by CNA #3, dated 02/24/21, documented, The other day I was in the office getting something when I heard [LPN #3] yelling at [resident #7]. And telling him to go to his room. [Resident #7] started yelling back at her and [LPN #3] got louder and told him she wasn't going to listen to it. Go to your room. [LPN #3] then said Im sick of him acting like this . A written statement by LPN #3, dated 02/24/21 at 5:00 p.m., documented, Missed a call from [administrator (admin)] [at] the Commons. Called back [and] was told there was an allegation against me for yelling [at] a male on North Hall on Monday February 22nd [at] approx [approximately] [2:00 p.m.] .Not only did I yell [at] the man but supposedly I cussed [at] him also per [admin] via the cameras. No Audio .Was also told I told male resident to go away, go down the hall or go to his room. I had asked residents not to sit in the area by wound care Nurse's office as it congests the hallway .May of raised my voice towards the resident . A investigative summary, undated, documented, .Who is/are the reported victim .[resident #7] .Who is/are the reported perpetrator .[LPN #3] .Who witnessed the incident .[CMA #3], [CNA #3], [CMA #4] .What happened .Resident .was in his wheelchair sitting near the nurse's desk. [LPN #3] the nurse came down the hall and started yelling at him to leave the desk .What is the history of the resident(s)? Was the incident foreseeable .The resident has had outbreaks lately, but there is NO reason a staff member should yell at a resident. A staff member should Never yell at resident, but this incident was not foreseeable .What does the victim want to happen .[resident #7] would not discuss the incident, but when asked what he would like to happen, he just shrugged his shoulder .When did the incident happen .Around 2pm on Feb [February] 22nd .When was facility supervisory/management staff first contacted about the incident .On [DATE]rd . An Oklahoma Board of Nursing complaint form, submitted date 02/26/21, documented, .Nurse's Name: [LPN #3] .Did incident include Misconduct or Criminal Behavior .Yes: Patient abuse .Description of Investigation .LPN was suspended pending the investigation and returned to work on 02/26/2021. She received disciplinary action write up for raising her voice at a resident and for conducting herself in a manner contrary to recognized standards. Her employment at the facility is being retained . A time sheet for pay period from 02/14/21 to 02/27/21, documented LPN #3 worked until 6:48 p.m. on 02/22/21. LPN #3 worked approximately 4 hours and 48 minutes after the abuse occurred. The facility failed to protect residents from further abuse during the investigation. The facility failed to report the allegation timely to the administrator and a through investigation was not completed. On 06/23/21 at 2:24 p.m., the admin was asked to describe the incident that happened on 02/22/21 with resident #7. She stated the resident is hard of hearing and LPN #3 stated she didn't yell. She stated she reviewed the cameras, took statements from the witnesses and LPN #3 and discussed the incident with the resident's wife. She was asked when LPN #3 worked on 02/22/21. She stated she didn't know. She was asked when the incident was reported. She stated she was notified on the following day. She was asked what the outcome of her investigation was. She stated it was substantiated that LPN #3 did it. She stated she was suspended and had a write up. She was asked if the facility had a zero tolerance for abuse. She stated, If I say yes, my hand book is wrong. She was asked what was done to protect and prevent this from happening to other residents. She stated they didn't add anything else other than what was in place. She was asked who the staff can report suspected abuse to. She stated, Any authority. She was asked when the staff had witnessed the abuse, did they report timely. She stated, No. She was asked if the staff who witnessed the abuse were inserviced about reporting timely. She stated, Nothing in writing. On 06/24/21 at 1:09 p.m., the DON was asked if verbal abuse happened on 02/22/21 around 2:00 p.m. She stated Yes. She was asked if LPN #3 continued to work after. She stated, Yes. She was asked if LPN #3 continued to work with residents, how were the resident protected. She stated, They couldn't be, because we didn't know about it. She was asked, since the staff failed to report the abuse immediately, were the residents protected. She stated, No. The ADM was asked if the resident was assessed after the incident. She stated, No. The staff members who witnessed the abuse did not immediately report it. As a result, LPN #3 worked with the victim and other residents for approximately four hours and 48 minutes. The facility did not put any corrective measures in place to prevent abuse from reoccurring. As a result, one of the witnesses [CMA #4] had an allegation of verbally abusing a different resident. The facility substantiated allegation and terminated CMA #4 while LPN #3 continued to be employeed by the faciltiy. 3. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 05/02/21, documented the resident's cognitive skills for daily decision making was severely impaired. An initial incident report form, dated 06/07/21, documented, .Resident .Involved .[resident #5] .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Received an allegation of abuse towards a resident by staff member. Staff member suspended pending investigation . A written statement from CMA #2, dated 06/07/21, documented Around [8:30 a.m.] [CNA #2] asked me if I could come help her I told her yes just give me a second because I was in the middle of taking care of another Resident. When I walked into [resident #5]'s room [CNA #2] had ahold [sic] of his Right arm yanking [and] pulling on him while she was slapping at his left leg,-on bare skin-. I yelled at her to stop doing him that way [and] she was like what [and] just kind of dropped him back on the bed, she went to pull on his arm to get him up I told her to just leave that I would take care of him. I brought him out for breakfast [and] told the Charge Nurse .what had just happened. When [LPN #2] talked to [CNA #2] she told her to stay away from direct care of [resident #5]. When I seen [sic] D.O.N .around [10:00 a.m.] I asked if [LPN #2] had talk to her [and] I told [DON] what had happened She told me she was not aware but now she is [and] asked me to write out a statement . A written statement from LPN #2, dated 06/07/21, documented, [CMA #2] came to me and stated I yelled at [CNA #2] because she came out to ask me to help get him [resident #5] up I went into the room where she was and he was mad and hitting at her states she saw her grab his arm and swat at his left leg so I told her to leave and I would finish him, I went to [CNA #2] and asked what happened she said I was just playing and I would never hurt anyone was told by nurse to stay out of room . A written statement from CNA #2, dated 06/07/21, documented, .[resident #5] was awake. So desided [sic] to get him up. got his clothes ready then uncovered him started talking to him while was getting him dressed. I started by putting [sic] his pull-up on the [sic] then i put his pants on. after that I took his hospital gown off. got his shirt ready to put his arm in. then put the arm in as I went to put his head his shirt, I told him not to Bite me. got his head in the whole [sic] [and] pull his shirt down. tried to sit him up By Putting my arm on leg to Push Leg in a sitting position while i have my other hand around upper back to help him sit up. then hollered [sic] at [CMA #2] to help stand him to finish getting dressed. Because he was fighting me. I was patting his .leg to clam [sic] him down to resure [sic] it was ok. then [CMA #2] came in their [sic] saw i was trying to hold him up. then told me Let him lay Back down the [sic] she would get him. then said was abusing him. I Left the room and went the Break room. then the nurse .ask me if i hit him I told her no i was patting him to try come [sic] him down. [LPN #2] told me not go around him again. until told other wise . An investigative summary, undated, documented, .Who is .the reported victim .[resident #5] .who is .reported perpetrator .[CNA #2] .What happened .Allegation that CNA was yanking on Residents arm and slapping his leg .What was done to protect the resident(s) from further harm .Staff member was told not go around the resident until further notice by the nurse on the hall and then was suspended and sent home pending investigation by the DON .What is the history of the resident .Was the incident foreseeable .Resident has a history of being combative to staff when cares are delivered .When did the incident happen .06/07/21, [7:30 a.m.] .When was facility supervisory/management staff first contacted about the incident .[10:00 a.m.] . A final state report, dated 06/08/21, documented, .A skin sweep was completed on the resident by two nurses with no injuries noted .The Accused perpetrator was suspended on 06/07/2021 pending an investigation. On 06/08/2021 she was counseled by the DON and the Administrator. She received verbal education or what could be considered to be abuse. She also completed a Relias Training entitled Understanding Dementia. The accused perpetrator was allowed to return to work on 06/08/2021 . CNA #2's time sheet, dated 06/06/21 to 06/19/21, documented she worked on 06/07/21 from 6:30 a.m. to 10:04 a.m., and from 10:36 a.m. to 11:37 a.m. and on 06/08/21 from 8:27 a.m. to 1:27 p.m., and from 1:57 p.m. to 2:32 p.m. The facility had documented the allegation was unsubstantited even through there was a witness, and failed to complete a thourgh investigation by interviewing other staff members and residents. On 06/24/21 at 12:48 p.m., the DON was asked to describe her investigation process. She stated she would complete an incident report, remove and suspend staff, take statements from other staff on the hall that the incident occurred and complete safe surveys on cognitive residents on the section of the hall the incident occurred. She was asked if staff worked the same hall. She stated not always. She was asked if she considered interviewing other staff and residents on other halls. She stated she has interviewed other staff but not other residents. She was asked when the investigation was started. She stated on 06/07/21 at 10:00 a.m. She was asked when the investigation was completed. She stated late on 06/07/21. She was asked if a thorough investigation was conducted. She stated, I feel it was thorough. She was asked if the resident was assessed after incident for delayed injury. She stated, No. She was asked when CNA #2 had worked on 06/07/21. She stated she left at 10:04 a.m. for lunch and when she returned, she was suspended and sent home. She was asked when she worked on 06/08/21. She stated she was here at 8:30 a.m. to meet with DON and watch Relias training then returned to the floor. She was asked what disciplinary actions CNA #2 received. She stated she watched Relias video about dementia, she was suspended on the 7th and two and a half hours on the 8th. The DON was asked what corrective actions were put in place to prevent further abuse and protect the residents. She stated there were no changes. The DON stated she didn't feel the allegation happened because CNA #2 left the door open and she called the CMA for help. She acknowledged staff did not notify DON or ADM of the incident in a timely manner. LPN #2 did not report incident to the DON immediately and as a result, CNA #2 continued to work with other residents for approximately one and a half to two and a half hours. A thorough investigation was not completed by not interviewing other staff and residents. As a result, it is unknown if other residents had been involved. 4. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A time record for RN #2, dated 06/27/21, documented she worked from 5:33 p.m. to 5:39 a.m. A time record for CNA #5, dated 06/27/21, documented she worked from 10:01 p.m. to 5:39 a.m. A progress note, dated 06/28/21 at 4:23 a.m., documented, .She than [sic] began saying that she was raped by 50 females every 30 minutes .Staff is n [TRUNCATED]

On 06/25/21, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to develope and implement an abuse policy and procedure that promoted an environement where allegations of abuse could be made without fear of retailiation, residents were protected/free of abuse and neglect, allegations were reported timely to the administrator and other agencies, allegations were throughly investigated and corrective measuers were taken to prevent further abuse. A staff member alleged that LPN #3 had been refusing/withholding pain medications to resident #9. The allegation was not reported timely to the administrator and a thorough investigation was not conducted. The employee remained working during the investigation and no action was taekn against the nurse. An allegation of staff being verbally abusive to resident #7 on 02/22/21 was not reported until 02/23/21, one day after the allegation occured. The residents were not protected as the staff member was allowed to work. The facility documented an incident of resident #5 being physically abused by staff witnessed and reported by staff. The facility failed to protect the resident, complete a thorough investigation and implement corrected measures to prevent further abuse. Resident #8 made an allegation of rape by staff on 06/28/21 and the staff had been allowed to continue to work over six hours after the allegation was made. Staff witnessed verbal abuse to Resident #6, by an employee and reported it. The allegation was not reported to the administrator timely and a thorough investigation was not conducted. The residents were not protected due to the perpetrator remaining at work and continued to work while the investigtion was on going. At 11:04 a.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 11:28 a.m., the Administrator (ADM) was notified of the IJ. An acceptable, amended plan of removal was provided by the administrator on 06/29/21 at 7:20 p.m. It documented the following: Plan of AMENDED Removal for IJ's - ALL THESE items will be completed by June 30th, 2021 [By 8:00 p.m.] .Abuse, Neglect, Misappropriation Investigation POLICY was updated .An outside agency will provide in-service on PRN [as needed] pain medication administration for CMA, and Nursing on June 30th. This inservice will focus on neglect, and not withholding medications. All staff that have not been in serviced by June 30th, 8pm may not work until in serviced, by the DON [director of nursing], ADON [assistant director of nursing], or the outside agency. Due to further consideration on 06/28/21 [staff name deleted] was terminated. [CNA #6] and [LPN #3] will be terminated on 06/30/21 . An ADMINISTRATIVE team was formed called the INCIDENT RESPONSE TEAM on June 29th, and includes the Administrator, Assistant Administrator, DON, ADON, and HealthCare Center Resident services Director. The administrator or designee will report to Board of Director any allegation of abuse at regularly scheduled monthly meetings at a minimum. The INCIDENT response team will be in-serviced by an outside source on all aspects of ABUSE - including screening, preventing, identifying, Investigating, protecting, and reporting/response on 06/30/21 with advanced traing on Abuse. To always protect our residents, the INCIDENT response team will meet to collaborate and respond to allegations to ensure all thorough investigation has been completed. On 07/01/21, two LPNs, one RN and three CMAs were interviewed and able to state accurate information related to abuse and neglect and five administrative staff were interviewed and were able to state accurate information related to abuse and neglect. The immediate jeopardy deficiency was lifted as of 06/30/21 at 5:10 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at a level of actual harm at a pattern. Based on observation, record review and resident and staff interviews, it was determined the facility failed to develop and implement a policy and procedure for abuse by not: ~ reporting abuse allegations timely, ~ conducting thorough investigations, ~ protecting the residents, ~ implementing corrective measures and ~ ensuring staff were held accountable for their actions for six [#1, 5, 6, 7, 8 and #9] of six sampled residents reviewed for abuse. The facility identified 95 residents resided in the facility. Findings: An employee handbook, dated 03/2020, documented, .The Company actively works to prevent .abuse by .Protecting employees .from adverse action when they do the right thing and report any [MEDICATION(S)] concern regarding .abuse .The Company strictly prohibits retaliation, in any form, against any individual making a report, complaint, or inquiry in good faith .Abuse & Neglect Policy .NO FORM OF ABUSE OR NEGLECT IS TOLERATED AND MUST BE REPORTED IMMEDIATELY .FAILURE TO REPORT ABUSE OR NEGLECT, EVEN SUSPECTED ABUSE OR NEGLECT, LEAVES YOU RESPONSIBLE FOR THE SITUATION .Bullying & Harassment .The Commons will not, in ay instance, tolerate bullying or harassing behavior. Employees found in violation of this policy will be disciplined, up to and including termination .examples of bullying and/or harassment: Verbal .ridiculing .humiliating .Shouting, raising voice at in individual in public .Telephone Calls & Cell Phones .Cell phone use is limited to break time only .Code of Conduct .Disciplinary Procedures .Violations of any of these rules .may result in corrective action being taken, up to and including discharge .Physical or mental abuse of the residents or failure to report physical or mental abuse by others .Social Media .Employees must not post confidential .about .clients .Employees should not disparage any person .based on .disability . An abuse policy, dated 12/08/2020, documented, Reporting Requirements .allegations shall be reported immediately to the administrator, DON and to other officials in accordance with State law. Allegations that involve abuse .must be reported within 2 hours .These allegations must be thoroughly investigated and must prevent further potential abuse while the investigation is in progress .appropriate action must be taken including report to the appropriate licensing board .Prevention .It [sic] the policy of The Commons that each resident will be free from abuse, neglect .All facility staff will be in-serviced upon first employment, and at least annually thereafter, regarding .neglect or abuse .Immediately report any suspicion of abuse, neglect or mistreatment to your immediate supervisor .The supervisor WILL CALL the CELL phone of the ADMINISTRATOR [admin], then the DON .Suspected or substantiated cases must also be reported to respective agencies such as state agencies, law enforcement, physician; families, and/or resident responsible party. The subject of abuse shall be routinely and openly discussed .Investigation .Procedure .1st .Care for, treat and PROTECT the resident-DON, ADON, or house supervisor should do a medical assessment immediately .documenting any injury in detail .Take a statement from the resident .2nd .Isolate the perpetrator .3rd .Immediately notify the Administrator, then DON . 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 01/14/2021, documented the resident's cognition was moderately impaired. A care plan, effective date 01/07/21, documented, .Resident is at risk for pain r/t [related to] muscle spasms and chronic pain syndrome .Resident will have pain treated/relieved in a timely manner .Administer medications as prescribed . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 325 mg capsule give 2 tablets by oral route every 6 hours as needed for pain . [MEDICATION(S)] 50 mg tablet give 1 tablet (50 mg) by oral route every 6 hours as needed for pain . A statement from CMA #3, dated 06/26/21 at 12:35 a.m., documented, Generally everyday, on multiple occasions, typically beginning first thing in the morning after the CNA has helped [Resident #9] get up out of bed for the day, he will ask for a pain pill. He will specifically ask for a [MEDICATION(S)] and rate his pain at an 8 out of 10 for leg or butt pain. As protocol, as the CMA, I report the request to the charge nurse, the charge nurse will go to the resident to evaluate the resident and report back to me, the CMA, with guidance to administer a pain med and instruct me with the level of the pain that was reported and the location of th [sic] pain. On many occurances, [LPN #3], will deny the resident, [Resident's name], pain meds stating 'He just got up, he doesn't need a pain pill' or 'He's going outside to smoke a cigarette, he's not hurting bad enough if he can go outside to smoke' or 'He can't have a pain pill because he hasn't eaten anything yet.' On these occurances, [Resident] won't receive pain meds until sometimes 10 a.m or as late a 2 p.m. as reflected on the MAR [medication administration record] . An OSDH incident form, dated 06/26/21, documented, .[Resident #9] .Allegations of Abuse/Mistreatment .Description of Incident .Staff reported Nurse not approving PRN pain meds when resident asked for them. Resident is cognitive and needs no family called . A statement from LPN #3, dated 06/27/21 at 12:23 [did not document a.m. or p.m.], documented, Sometimes resident asks for pain pills when it is not time as he had it earlier. Med is scheduled [every] 8 [hours] prn. Resident is offered Tylenol if [MEDICATION(S)] can't be given yet . Safe surveys were conducted with five residents. The questions asked to the residents were not related to receiving pain medications. The facility documented the allegation was unsubstantiated and completed on 06/27/21 at 5:30 p.m. On 06/28/21 at 12:40 p.m., the administrator and assistant administrator were asked about the conclusion of the investigation. The assistant administrator stated she had made an excel spreadsheet of which nurse had given Tylenol versus the [MEDICATION(S)]. She stated the accused nurse had administered the medications as much as the other nurses. She was asked if there was documentation of the times the resident had requested the [MEDICATION(S)]. She stated she didn't think you could tell when he had requested it. She was asked if there was no documentation of when the resident requested it and the CMA stated LPN #3 withheld the medication, how did they come to the conclusion the allegation was unsubstantiated. She stated she went to the resident and asked him about it. She stated the resident is this nurse's biggest cheerleader. At 1:19 p.m., the ADM provided resident surveys. There were no questions asked to the residents related to staff withholding pain medications. She stated the executive director had made the surveys and thought that the question Do staff members respect your requests and allow you to make decisions regarding your care covered that. On 06/29/21 at 6:35 p.m., the resident was asked if he was in pain. He stated he had pain in his right side, leg and knee. She stated he would rate it at an 8 out of 10. He stated it was usually a 9 in the mornings. He was asked how he felt if he did not get his [MEDICATION(S)] when he requested it. He stated, If I don't get them, I get mad. He was asked if his [MEDICATION(S)] was ever withheld. He stated it was once. He stated he turned it in and now he gets it. He was asked who the staff member was who withheld the medication. He stated he was not going to tell. At 7:02 p.m., CMA #3 was asked about the allegations made regarding LPN #3 withholding [MEDICATION(S)]. She stated, [MEDICATION(S)] is what he asks for all the time. She stated, It's upsetting to me cause when he asks for something, I have protocol I have to follow. She stated that LPN #3 would give the same responses CMA #3 had put in her statement. She stated she was taught to take their pain as they stated it. She stated LPN #3 would have her administer Tylenol or [MEDICATION(S)] instead of the [MEDICATION(S)]. The facility failed to develope and implement and abuse policy and procedure that allowed fo an accurate a thorough investigation into the allegations abuse. The facility further failed to develope and implement an abuse policy for protecting residents from abuse and negeclt. 2. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 02/18/21, documented the resident's cognition was severely impaired. A state incident report form, dated 02/23/21, documented, .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Administrator was notified today of an allegation of verbal abuse occurring on 02/22/21 from a staff member against a nurse. The nurse is not on the schedule until Thursday. She will not be working until the allegation has been investigated. Investigation is in progress .For 5 day and final reports, please include a summary of the investigation .and corrective measures implemented to prevent recurrence .See attached for investigation: Nurse yelled at resident. She was suspended and counseled on ways to recognize burnout. Also gave her Employee Assistance information . The allegation of abuse was not reported to the administrator until the next day after it occurred. The facility failed to report the allegation of abuse within two hours to the appropriate agencies such as the Oklahoma State Department of Health (OSDH). A written statement by CMA #3, dated 02/23/21, documented, The day of 2-22-21, [resident #7] spent a majority of the day sitting in the North Hall hallway outside of [another resident]s room. At approximately 2 p.m. [resident #7] wheeled himself in his wheelchair up closer to the nurse's station area and parked himself in his wheelchair outside of the wound care nurse's office. Immediately the charge nurse, [LPN #3], stood up and yelled to [resident #7] get the hell out of here, you're not going to sit up here while I'm here. [Resident #7] did raise his hands and yelled at [LPN #3]. I do not know what he yelled at her, his speech is often hard to make out due to health conditions. [LPN #3] then yelled at him again get the hell out of here, you're not going to talk to me that way. After this occurrence, [resident #7] wheeled himself away from the nurse's station area back down the hall towards his room .During this occurrence, [CMA #4] was sitting in a chair beside me and witnessed the entire event . A written statement by CMA #4, dated 02/24/21, documented, On Monday February 22nd I [CMA #4] came into work I was on North Hall. I was sitting at nurses station [resident #7] the resident came strolling up to the Common Area by the nurses station [LPN #3] the nurse told him to turn around and go back he said he has rights She said I dont care Im not gonna [sic] deal with you and he said he wanted to sit up here She screamed at him and said I dont give a dam [sic] your [sic] not sitting up here Im not gonna [sic] deal with your Ass. so [resident #7] sat in the Corner til [LPN #3] left he was very upset the rest of the evening . A written statement by CNA #3, dated 02/24/21, documented, The other day I was in the office getting something when I heard [LPN #3] yelling at [resident #7]. And telling him to go to his room. [Resident #7] started yelling back at her and [LPN #3] got louder and told him she wasn't going to listen to it. Go to your room. [LPN #3] then said Im sick of him acting like this . A written statement by LPN #3, dated 02/24/21 at 5:00 p.m., documented, Missed a call from [administrator (admin)] [at] the Commons. Called back [and] was told there was an allegation against me for yelling [at] a male on North Hall on Monday February 22nd [at] approx [approximately] [2:00 p.m.] .Not only did I yell [at] the man but supposedly I cussed [at] him also per [admin] via the cameras. No Audio .Was also told I told male resident to go away, go down the hall or go to his room. I had asked residents not to sit in the area by wound care Nurse's office as it congests the hallway .May of raised my voice towards the resident . A investigative summary, undated, documented, .Who is/are the reported victim .[resident #7] .Who is/are the reported perpetrator .[LPN #3] .Who witnessed the incident .[CMA #3], [CNA #3], [CMA #4] .What happened .Resident .was in his wheelchair sitting near the nurse's desk. [LPN #3] the nurse came down the hall and started yelling at him to leave the desk .What is the history of the resident(s)? Was the incident foreseeable .The resident has had outbreaks lately, but there is NO reason a staff member should yell at a resident. A staff member should Never yell at resident, but this incident was not foreseeable .What does the victim want to happen .[resident #7] would not discuss the incident, but when asked what he would like to happen, he just shrugged his shoulder .When did the incident happen .Around 2pm on Feb [February] 22nd .When was facility supervisory/management staff first contacted about the incident .On [DATE]rd . An Oklahoma Board of Nursing complaint form, submitted date 02/26/21, documented, .Nurse's Name: [LPN #3] .Did incident include Misconduct or Criminal Behavior .Yes: Patient abuse .Description of Investigation .LPN was suspended pending the investigation and returned to work on 02/26/2021. She received disciplinary action write up for raising her voice at a resident and for conducting herself in a manner contrary to recognized standards. Her employment at the facility is being retained . A time sheet for pay period from 02/14/21 to 02/27/21, documented LPN #3 worked til 6:48 p.m. on 02/22/21. LPN #3 worked approximately 4 hours and 48 minutes after the abuse occurred. The facility failed to protect residents from further abuse during the investigation. The facilty failed to report the allegation timely to the administrator and a through investigation was not completed. On 06/23/21 at 2:24 p.m., the admin was asked to describe the incident that happened on 02/22/21 with resident #7. She stated the resident is hard of hearing and LPN #3 stated she didn't yell. She stated she reviewed the cameras, took statements from the witnesses and LPN #3 and discussed the incident with the resident's wife. She was asked when LPN #3 worked on 02/22/21. She stated she didn't know. She was asked when the incident was reported. She stated she was notified on the following day. She was asked what the outcome of her investigation was. She stated it was substantiated that LPN #3 did it. She stated she was suspended and had a write up. She was asked if the facility had a zero tolerance for abuse. She stated, If I say yes, my hand book is wrong. She was asked what was done to protect and prevent this from happening to other residents. She stated they didn't add anything else other than what was in place. She was asked who the staff can report suspected abuse to. She stated, Any authority. She was asked when the staff had witnessed the abuse, did they report timely. She stated, No. She was asked if the staff who witnessed the abuse were in serviced about reporting timely. She stated, Nothing in writing. On 06/24/21 at 1:09 p.m., the DON was asked if verbal abuse happened on 02/22/21 around 2:00 p.m. She stated Yes. She was asked if LPN #3 continued to work after. She stated, Yes. She was asked if LPN #3 continued to work with residents, how were the resident protected. She stated, They couldn't be, because we didn't know about it. She was asked, since the staff failed to report the abuse immediately, were the residents protected. She stated, No. The ADM was asked if the resident was assessed after the incident. She stated, No. The staff members who witnessed the abuse did not immediately report it. As a result, LPN #3 worked with the victim and other residents for approximately four hours and 48 minutes. The facility did not put any corrective measures in place to prevent abuse from reoccurring. As a result, one of the witnesses [CMA #4] had an allegation of verbally abusing a different resident. The facility substantiated allegation and terminated CMA #4 while LPN #3 continued to be employed by the facility. The facility failed to develope and implement and abuse policy and procedure that allowed fo an accurate a thorough investigation into the allegations abuse. The facility further failed to develope and implement an abuse policy for protecting residents from abuse. 3. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 05/02/21, documented the resident's cognitive skills for daily decision making was severely impaired. An initial incident report form, dated 06/07/21, documented, .Resident .Involved .[resident #5] .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Received an allegation of abuse towards a resident by staff member. Staff member suspended pending investigation . A written statement from CMA #2, dated 06/07/21, documented Around [8:30 a.m.] [CNA #2] asked me if I could come help her I told her yes just give me a second because I was in the middle of taking care of another Resident. When I walked into [resident #5]'s room [CNA #2] had ahold [sic] of his Right arm yanking [and] pulling on him while she was slapping at his left leg,-on bare skin-. I yelled at her to stop doing him that way [and] she was like what [and] just kind of dropped him back on the bed, she went to pull on his arm to get him up I told her to just leave that I would take care of him. I brought him out for breakfast [and] told the Charge Nurse .what had just happened. When [LPN #2] talked to [CNA #2] she told her to stay away from direct care of [resident #5]. When I seen [sic] D.O.N .around [10:00 a.m.] I asked if [LPN #2] had talk to her [and] I told [DON] what had happened She told me she was not aware but now she is [and] asked me to write out a statement . A written statement from LPN #2, dated 06/07/21, documented, [CMA #2] came to me and stated I yelled at [CNA #2] because she came out to ask me to help get him [resident #5] up I went into the room where she was and he was mad and hitting at her states she saw her grab his arm and swat at his left leg so I told her to leave and I would finish him, I went to [CNA #2] and asked what happened she said I was just playing and I would never hurt anyone was told by nurse to stay out of room . A written statement from CNA #2, dated 06/07/21, documented, .[resident #5] was awake. So desided [sic] to get him up. got his clothes ready then uncovered him started talking to him while was getting him dressed. I started by putting [sic] his pull-up on the [sic] then i put his pants on. after that I took his hospital gown off. got his shirt ready to put his arm in. then put the arm in as I went to put his head his shirt, I told him not to Bite me. got his head in the whole [sic] [and] pull his shirt down. tried to sit him up By Putting my arm on leg to Push Leg in a sitting position while i have my other hand around upper back to help him sit up. then hollered [sic] at [CMA #2] to help stand him to finish getting dressed. Because he was fighting me. I was patting his .leg to clam [sic] him down to resure [sic] it was ok. then [CMA #2] came in their [sic] saw i was trying to hold him up. then told me Let him lay Back down the [sic] she would get him. then said was abusing him. I Left the room and went the Break room. then the nurse .ask me if i hit him I told her no i was patting him to try come [sic] him down. [LPN #2] told me not go around him again. until told other wise . An investigative summary, undated, documented, .Who is .the reported victim .[resident #5] .who is .reported perpetrator .[CNA #2] .What happened .Allegation that CNA was yanking on Residents arm and slapping his leg .What was done to protect the resident(s) from further harm .Staff member was told not go around the resident until further notice by the nurse on the hall and then was suspended and sent home pending investigation by the DON .What is the history of the resident .Was the incident foreseeable .Resident has a history of being combative to staff when cares are delivered .When did the incident happen .06/07/21, [7:30 a.m.] .When was facility supervisory/management staff first contacted about the incident .[10:00 a.m.] . A final state report, dated 06/08/21, documented, .A skin sweep was completed on the resident by two nurses with no injuries noted .The Accused perpetrator was suspended on 06/07/2021 pending an investigation. On 06/08/2021 she was counseled by the DON and the Administrator. She received verbal education or what could be considered to be abuse. She also completed a Relias Training entitled Understanding Dementia. The accused perpetrator was allowed to return to work on 06/08/2021 . CNA #2's time sheet, dated 06/06/21 to 06/19/21, documented she worked on 06/07/21 from 6:30 a.m. to 10:04 a.m., and from 10:36 a.m. to 11:37 a.m. and on 06/08/21 from 8:27 a.m. to 1:27 p.m., and from 1:57 p.m. to 2:32 p.m. The facility had documented the allegation was unsubstantiated even through there was a witness, and failed to complete a thorough investigation by interviewing other staff members and residents. On 06/24/21 at 12:48 p.m., the DON was asked to describe her investigation process. She stated she would complete an incident report, remove and suspend staff, take statements from other staff on the hall that the incident occurred and complete safe surveys on cognitive residents on the section of the hall the incident occurred. She was asked if staff worked the same hall. She stated not always. She was asked if she considered interviewing other staff and residents on other halls. She stated she has interviewed other staff but not other residents. She was asked when the investigation was started. She stated on 06/07/21 at 10:00 a.m. She was asked when the investigation was completed. She stated late on 06/07/21. She was asked if a thorough investigation was conducted. She stated, I feel it was thorough. She was asked if the resident was assessed after incident for delayed injury. She stated, No. She was asked when CNA #2 had worked on 06/07/21. She stated she left at 10:04 a.m. for lunch and when she returned, she was suspended and sent home. She was asked when she worked on 06/08/21. She stated she was here at 8:30 a.m. to meet with DON and watch Relias training then returned to the floor. She was asked what disciplinary actions CNA #2 received. She stated she watched Relias video about dementia, she was suspended on the 7th and two and a half hours on the 8th. The DON was asked what corrective actions were put in place to prevent further abuse and protect the residents. She stated there were no changes. The DON stated she didn't feel the allegation happened because CNA #2 left the door open and she called the CMA for help. She acknowledged staff did not notify DON or ADM of the incident in a timely manner. LPN #2 did not report incident to the DON immediately and as a result, CNA #2 continued to work with other residents for approximately one and a half to two and a half hours. A thorough investigation was not completed by not interviewing other staff and residents. As a result, it is unknown if other residents had been involved. The facility failed to develope and implement and abuse policy and procedure that allowed fo an accurate a thorough investigation into the allegations abuse. The facility further failed to develope and implement an abuse policy for protecting residents from abuse. 4. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A time record for RN #2, dated 06/27/21, documented she worked from 5:33 p.m. to 5:39 a.m. A time record for CNA #5, dated 06/27/21, documented she worked from 10:01 p.m. to 5:39 a.m. A progress note, dated 06/28/21 at 4:23 a.m., documented, .She than [sic] began saying that she was raped by 50 females every 30 minutes .Staff is not to go in her room by themselves. This was reported to administration per policy . On 06/28/21 at 5:20 a.m., two police officers were observed to be at the front door to the facility. When approached, they stated they had received a call that a resident had been sexually abused. They were asked when they had received the call. One stated, About five minutes ago. At 5:25 a.m., the administrator stated, I need to talk to you guys. She stated, We have a crazy lady who says she was raped and I didn't send the two ladies home. An OSDH incident report, dated of 06/27/21, documented, .Final .[Resident #8] .Allegations of Abuse/Mistreatment .Description of Incident .Resident makes allegation that she was being raped by 50 people every 30 minutes. She was also saying we were trying to poison her when staff CMA gave her [MEDICATION(S)] .No S/S [signs/symptoms] of physical rape noted .For 5 day and final reports, please include a summary of the investigation .See attached . A report summary, date and time of report completion 06/28/21 at 5:10 p.m., documented, .Who is/are the reported perpetrator(s) .A woman and 50 of them .What happened .Accusation of Rape and bed bugs .What was done to protect the resident(s) from further harm .Staff was to always go in room [ROOM NUMBER] at a time .What was done upon discovery of the incident .Notified Administrator .What is the resident's current physical status .Assessment done at 5PM 06/28/21 .When was facility supervisor/management staff first contacted about the incident .11:47 PM [06/27/21] . A statement from RN #2 documented, .2305-2315 [11:05 p.m. to 11:15 p.m.] Resident began saying that there was bed bugs in her bed. The bed was checked by 2 staff and found no sign of bugs. She than [sic] began saying that she was raped. She has been yelling these allegations. She said that the rapest [sic] is a woman and there is 50 of them every 5 minutes. She cannot really describe them .Staff has been going in her room with 2 people and then after being told by Administration we have been going in with 2 Licensed nurses . A statement from CNA #5, dated 06/28/21 at 12:32 p.m., documented, At 11:14 pm [Resident #8] started yelling .Shortly after she started yelling rape. She said she was raped and that everyone has been raped. She said that she has been raped every 30 minutes by 50 people . A statement, dated 06/28/21, from CNA #7, documented, Resident stated she was being abused and raped repeatedly . A statement, dated 06/28/21, from CMA #5 documented, .On 6-28-2021, resident in RM [resident #8's room number] has been yelling Rape multiple times and saying the police are coming . On 06/28/21 at 6:27 a.m., the ADM stated she had received a text message from the charge nurse last night at 11:14 p.m. that stated the resident's wound vac had alarmed. The ADM was observed to be reading the text messages from the charge nurse as we spoke. She stated when the nurse went in to check the alarm, the resident alleged rape. The administrator stated the nurse had informed her she had told staff not to go in there alone. The administrator stated she told the nurse to go ask when it happened and get a description of what the person looked like. The nurse told the ADM the resident reported a female rapist and 50 people every 30 minutes. The charge nurse told the ADM that the rapist looks like us. The ADM was asked how many staff had worked with the resident last night. She s [TRUNCATED]

On 06/25/21, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff reported allegations of abuse immediately after identifying suspected and/or actual abuse had occurred. A staff member alleged that LPN #3 had been refusing/withholding pain medications to resident #9. The allegation was not reported timely to the administrator investigation. An allegation of staff being verbally abusive to resident #7 on 02/22/21 was not reported until 02/23/21, one day after the allegation occurred. The facility documented an incident of resident #5 being physically abused by staff witnessed and reported by staff. The facility failed to protect the resident, complete a thorough investigation and implement corrected measures to prevent further abuse. Staff witnessed verbal abuse to Resident #6, by an employee and reported it to the charge nurse. The charge nurse did not report the allegation to the administrator timely. At 11:04 a.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 11:28 a.m., the Administrator (ADM) was notified of the IJ. An acceptable plan of removal was provided by the administrator on 06/25/21 at 9:55 p.m. It documented the following: All residents will be interviewed 06/25/2021. All staff on shift will be educated on updated policy immediately, and if not currently working will be inserviced by phone call by midnight on 06/25/2021. (see attached) (amended to be 9 am on 06/26/2021) ** if unable to be contacted, we will document date and time, and the staff member will be taken off the schedule until completed** The following texts will be sent to all staff immediately .Surveyors have identified serious deficiencies in Abuse reporting. All staff are required to complete in-service. Someone from The Commons will be calling you before midnight tonight .If you have been not contacted to complete an in-service by midnight, call [director of nursing] or will be removed from the schedule .Beginning IMMEDIATELY-reporting of ANY abuse allegations will be need to be texted or called to [administrator] .[assistant administrator] .This is any time- DAY or NIGHT! If no response to a text, then CALL .All staff that have been identified as not timely reporting abuse will be given a 1 day suspension. [Resident #5] -Staff member with physical abuse allegation will be terminated immediately. At every allegation of abuse, a text will be sent to all staff to remind staff that we take abuse very seriously .An allegation has been reported, this is a reminder NO forms of abuse will be tolerated Administrator, Asst Administrator and DON have learned that a thorough investigation includes resident safe surveys on all halls that the alleged abuser has worked. Handwritten statements from those questioned should be included in an investigation. We have reviewed the different types and examples of abuse and will follow our policies that have been updated. We will in-service all staff members on the attached education. We learned that the witness is the person that has reported the incident during the investigation. We learned that to properly assess the resident we must conduct medical, psychosocial, and mental status assessment at the time, and an assessment each shift for 3 days for 9 occurrences On 06/28/21, six nurse aides (CNA), seven certified medication aides (CMA), six licensed practical nurses (LPN), one registered nurse (RN), seven housekeepers and one maintenance staff from across all shifts, were interviewed and able to state accurate information related to abuse. On 06/28/21, at 6:57 a.m., the ADM was asked what the facility did to further educate the administrative staff on abuse. She stated she looked through the state operations manual and reached out to some of her administrator forums online. She was asked if she shared that information with her administrative staff. She stated they looked up information themselves. She was asked if there was anything specific they educated the administrative staff on. She stated, No, nothing specific. At 3:30 p.m., the administrator was made aware that an amended plan of removal was needed due to ongoing abuse and neglect allegations not being reported timely, not protecting residents and conducting thorough investigations. An acceptable amended plan of removal was provided by the administrator on 06/29/21 at 7:20 p.m. It documented the following: Plan of AMENDED Removal for IJ's - ALL THESE items will be completed by June 30th, 2021 [By 8:00 p.m.] .Abuse, Neglect, Misappropriation Investigation POLICY was updated .An outside agency will provide in-service on PRN [as needed] pain medication administration for CMA, and Nursing on June 30th. This inservice will focus on neglect, and not withholding medications. All staff that have not been in serviced by June 30th, 8pm may not work until in serviced, by the DON [director of nursing], ADON [assistant director of nursing], or the outside agency. Due to further consideration on 06/28/21 [staff name deleted] was terminated. [CNA #6] and [LPN #3] will be terminated on 06/30/21 . An ADMINISTRATIVE team was formed called the INCIDENT RESPONSE TEAM on June 29th, and includes the Administrator, Assistant Administrator, DON, ADON, and HealthCare Center Resident services Director. The administrator or designee will report to Board of Director any allegation of abuse at regularly scheduled monthly meetings at a minimum. The INCIDENT response team will be in-serviced by an outside source on all aspects of ABUSE - including screening, preventing, identifying, Investigating, protecting, and reporting/response on 06/30/21 with advanced traing on Abuse. To always protect our residents, the INCIDENT response team will meet to collaborate and respond to allegations to ensure all thorough investigation has been completed. On 07/01/21, two LPNs, one RN and three CMAs were interviewed and able to state accurate information related to abuse and neglect and five administrative staff were interviewed and were able to state accurate information related to abuse and neglect. The immediate jeopardy deficiency was lifted as of 06/30/21 at 5:10 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at a level of actual harm at a pattern. Based on record review, resident and staff interviews, it was determined the facility failed to ensure staff reported allegations of abuse immediately after identifying abuse/suspected abuse had occurred for four (#5, 6, 7 and #9) of six sampled residents reviewed for abuse. The facility identified 95 residents resided in the facility. Findings: An abuse policy, dated 12/08/2020, documented, Reporting Requirements .allegations shall be reported immediately to the administrator, DON and to other officials in accordance with State law. Allegations that involve abuse .must be reported within 2 hours .These allegations must be thoroughly investigated and must prevent further potential abuse while the investigation is in progress .appropriate action must be taken including report to the appropriate licensing board .Prevention .It [sic] the policy of The Commons that each resident will be free from abuse, neglect .All facility staff will be in-serviced upon first employment, and at least annually thereafter, regarding .neglect or abuse .Immediately report any suspicion of abuse, neglect or mistreatment to your immediate supervisor .The supervisor WILL CALL the CELL phone of the ADMINISTRATOR [admin], then the DON .Suspected or substantiated cases must also be reported to respective agencies such as state agencies, law enforcement, physician; families, and/or resident responsible party. The subject of abuse shall be routinely and openly discussed .Investigation .Procedure .1st .Care for, treat and PROTECT the resident-DON, ADON, or house supervisor should do a medical assessment immediately .documenting any injury in detail .Take a statement from the resident .2nd .Isolate the perpetrator .3rd .Immediately notify the Administrator, then DON . 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 01/14/21, documented the resident's cognition was moderately impaired. A care plan, effective date 01/07/21, documented, .Resident is at risk for pain r/t [related to] muscle spasms and chronic pain syndrome .Resident will have pain treated/relieved in a timely manner .Administer medications as prescribed . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 325 mg capsule give 2 tablets by oral route every 6 hours as needed for pain . [MEDICATION(S)] 50 mg tablet give 1 tablet (50 mg) by oral route every 6 hours as needed for pain . A statement from CMA #3, dated 06/26/21 at 12:35 a.m., documented, Generally every day, on multiple occasions, typically beginning first thing in the morning after the CNA has helped [Resident #9] get up out of bed for the day, he will ask for a pain pill. He will specifically ask for a [MEDICATION(S)] and rate his pain at an 8 out of 10 for leg or butt pain. As protocol, as the CMA, I report the request to the charge nurse, the charge nurse will go to the resident to evaluate the resident and report back to me, the CMA, with guidance to administer a pain med and instruct me with the level of the pain that was reported and the location of th [sic] pain. On many occurrences, [LPN #3], will deny the resident, [Resident's name], pain meds stating 'He just got up, he doesn't need a pain pill' or 'He's going outside to smoke a cigarette, he's not hurting bad enough if he can go outside to smoke' or 'He can't have a pain pill because he hasn't eaten anything yet.' On these occurances, [Resident] won't receive pain meds until sometimes 10 a.m or as late a 2 p.m. as reflected on the MAR [medication administration record] . An OSDH incident form, dated 06/26/21, documented, .[Resident #9] .Allegations of Abuse/Mistreatment .Description of Incident .Staff reported Nurse not approving PRN pain meds when resident asked for them. Resident is cognitive and needs no family called . A statement from LPN #3, dated 06/27/21 at 12:23 [did not document a.m. or p.m.], documented, Sometimes resident asks for pain pills when it is not time as he had it earlier. Med is scheduled [every] 8 [hours] prn. Resident is offered Tylenol if [MEDICATION(S)] can't be given yet . Safe surveys were conducted with five residents. The questions asked to the residents were not related to receiving pain medications. The facility documented the allegation was unsubstantiated and completed on 06/27/21 at 5:30 p.m. The employee continued to work during the investigaion of the alleged negelct. The facility did not complete a through investigation and interview residents and staff to include the alleged victim regarding pain medications being withheld. On 06/28/21 at 12:40 p.m., the administrator and assistant administrator were asked about the conclusion of the investigation. The assistant administrator stated she had made an excel spreadsheet of which nurse had given Tylenol versus the [MEDICATION(S)]. She stated the accused nurse had administered the medications as much as the other nurses. She was asked if there was documentation of the times the resident had requested the [MEDICATION(S)]. She stated she didn't think you could tell when he had requested it. She was asked if there was no documentation of when the resident requested it and the CMA stated LPN #3 withheld the medication, how did they come to the conclusion the allegation was unsubstantiated. She stated she went to the resident and asked him about it. She stated the resident is this nurse's biggest cheerleader. At 1:19 p.m., the ADM provided resident surveys. There were no questions asked to the residents related to staff withholding pain medications. She stated the executive director had made the surveys and thought that the question Do staff members respect your requests and allow you to make decisions regarding your care covered that. On 06/29/21 at 6:35 p.m., the resident was asked if he was in pain. He stated he had pain in his right side, leg and knee. She stated he would rate it at an 8 out of 10. He stated it was usually a 9 in the mornings. He was asked how he felt if he did not get his [MEDICATION(S)] when he requested it. He stated, If I don't get them, I get mad. He was asked if his [MEDICATION(S)] was ever withheld. He stated it was and then stated he would not disclose who the employee was that withheld the medication. At 7:02 p.m., CMA #3 was asked about the allegations made regarding LPN #3 withholding [MEDICATION(S)]. She stated, [MEDICATION(S)] is what he asks for all the time. She stated, It's upsetting to me because when he asks for something, I have protocol I have to follow. She stated that LPN #3 would give the same responses CMA #3 had put in her statement. She stated she was taught to take their pain as they stated it. She stated LPN #3 would have her administer Tylenol or [MEDICATION(S)] instead of the [MEDICATION(S)]. 2. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 02/18/21, documented the resident's cognition was severely impaired. A state incident report form, dated 02/23/21, documented, .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Administrator was notified today of an allegation of verbal abuse occurring on 02/22/21 from a staff member against a nurse. The nurse is not on the schedule until Thursday. She will not be working until the allegation has been investigated. Investigation is in progress .For 5 day and final reports, please include a summary of the investigation .and corrective measures implemented to prevent recurrence .See attached for investigation: Nurse yelled at resident. She was suspended and counseled on ways to recognize burnout. Also gave her Employee Assistance information . The allegation of abuse was not reported to the administrator until the next day after it occurred. The facility failed to report the allegation of abuse within two hours to the appropriate agencies such as the Oklahoma State Department of Health (OSDH). A written statement by CMA #3, dated 02/23/21, documented, The day of 2-22-21, [resident #7] spent a majority of the day sitting in the North Hall hallway outside of [another resident]s room. At approximately 2 p.m. [resident #7] wheeled himself in his wheelchair up closer to the nurse's station area and parked himself in his wheelchair outside of the wound care nurse's office. Immediately the charge nurse, [LPN #3], stood up and yelled to [resident #7] get the hell out of here, you're not going to sit up here while I'm here. [Resident #7] did raise his hands and yelled at [LPN #3]. I do not know what he yelled at her, his speech is often hard to make out due to health conditions. [LPN #3] then yelled at him again get the hell out of here, you're not going to talk to me that way. After this occurrence, [resident #7] wheeled himself away from the nurse's station area back down the hall towards his room .During this occurrence, [CMA #4] was sitting in a chair beside me and witnessed the entire event . A written statement by CMA #4, dated 02/24/21, documented, On Monday February 22nd I [CMA #4] came into work I was on North Hall. I was sitting at nurses station [resident #7] the resident came strolling up to the Common Area by the nurses station [LPN #3] the nurse told him to turn around and go back he said he has rights She said I dont care Im not gonna [sic] deal with you and he said he wanted to sit up here She screamed at him and said I dont give a dam [sic] your [sic] not sitting up here Im not gonna [sic] deal with your Ass. so [resident #7] sat in the Corner til [LPN #3] left he was very upset the rest of the evening . A written statement by CNA #3, dated 02/24/21, documented, The other day I was in the office getting something when I heard [LPN #3] yelling at [resident #7]. And telling him to go to his room. [Resident #7] started yelling back at her and [LPN #3] got louder and told him she wasn't going to listen to it. Go to your room. [LPN #3] then said Im sick of him acting like this . A investigative summary, undated, documented, .When did the incident happen .Around 2pm on Feb [February] 22nd .When was facility supervisory/management staff first contacted about the incident .On [DATE]rd . On 06/23/21 at 2:24 p.m., the admin was asked who the staff could report suspected abuse to. She stated, Any authority. She was asked when the staff had witnessed the abuse, did they report timely. She stated, No. She was asked if the staff who witnessed the abuse were inserviced about reporting timely. She stated, Nothing in writing. On 06/24/21 at 1:09 p.m., the DON was asked if verbal abuse happened on 02/22/21 around 2:00 p.m. She stated Yes. She was asked if LPN #3 continued to work after. She stated, Yes. She was asked if LPN #3 continued to work with residents, how were the resident protected. She stated, They couldn't be, because we didn't know about it. She was asked, since the staff failed to report the abuse immediately, were the residents protected. She stated, No. The staff members who witnessed the abuse did not immediately report it. As a result, LPN #3 worked with the victim and other residents for approximately four hours and 48 minutes. 3. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 05/02/21, documented the resident's cognitive skills for daily decision making was severely impaired. An initial incident report form, dated 06/07/21, documented, .Resident .Involved .[Resident #5] .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Received an allegation of abuse towards a resident by staff member. Staff member suspended pending investigation . A written statement from CMA #2, dated 06/07/21, documented Around [8:30 a.m.] [CNA #2] asked me if I could come help her I told her yes just give me a second because I was in the middle of taking care of another Resident. When I walked into [resident #5]'s room [CNA #2] had ahold [sic] of his Right arm yanking [and] pulling on him while she was slapping at his left leg,-on bare skin-. I yelled at her to stop doing him that way [and] she was like what [and] just kind of dropped him back on the bed, she went to pull on his arm to get him up I told her to just leave that I would take care of him. I brought him out for breakfast [and] told the Charge Nurse .what had just happened. When [LPN #2] talked to [CNA #2] she told her to stay away from direct care of [resident #5]. When I seen [sic] D.O.N .around [10:00 a.m.] I asked if [LPN #2] had talk to her [and] I told [DON] what had happened She told me she was not aware but now she is [and] asked me to write out a statement . A written statement from LPN #2, dated 06/07/21, documented, [CMA #2] came to me and stated I yelled at [CNA #2] because she came out to ask me to help get him [resident #5] up I went into the room where she was and he was mad and hitting at her states she saw her grab his arm and swat at his left leg so I told her to leave and I would finish him, I went to [CNA #2] and asked what happened she said I was just playing and I would never hurt anyone was told by nurse to stay out of room . An investigative summary, undated, documented, .When did the incident happen .06/07/21, [7:30 a.m.] .When was facility supervisory/management staff first contacted about the incident .[10:00 a.m.] . On 06/24/21 at 12:48 p.m., the DON acknowledged staff did not notify DON or ADM of the incident in a timely manner. LPN #2 did not report incident to the DON immediately and as a result, CNA #2 continued to work with other residents for approximately one and a half to two and a half hours. 4. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 02/15/21, documented the resident's cognition was intact. A nurse's note, dated 03/21/21 at 1:44 p.m., documented, Resident observed on floor lying on back . An initial OSDH incident report, dated 03/21/21, documented, .Allegations of Abuse Mistreatment .Description of Incident .Administrator was notified by Activity director that activity aide reported to her in a statement, that she overheard a nurse say Jesus F****** Christ, [Resident #6] really? when she was notified he had fallen. Nurse is not on shift today. The nurse is suspended until investigation is complete . A facsimile (fax) cover sheet, documented the report was sent to the OSDH on 03/22/21 at 4:22 p.m. On 06/24/21 at 1:35 p.m., the DON was asked if was reported timely. She stated she was not notified until the next day. On 06/25/21 at 3:09 a.m., the activity aide was asked who she had reported the incident to. She stated she reported it to her supervisor that day and that her supervisor was going to call the administrator.

On 06/25/21, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a thorough investigation had been conducted and appropriate corrective actions were taken for allegation of abuse. A staff member alleged that LPN #3 had been refusing/withholding pain medications to resident #9. The allegation was not reported timely to the administrator and a thorough investigation was not conducted. The employee remained working during the investigation and no action was taekn against the nurse. An allegation of staff being verbally abusive to resident #7 on 02/22/21 was not reported until 02/23/21, one day after the allegation occurred. The residents were not protected as the staff member was allowed to work. The facility documented an incident of resident #5 being physically abused by staff witnessed and reported by staff. The facility failed to protect the resident, complete a thorough investigation and implement corrected measures to prevent further abuse. Resident #8 made an allegation of rape by staff on 06/28/21 and the staff had been allowed to continue to work over six hours after the allegation was made. Staff witnessed verbal abuse to Resident #6, by an employee and reported it. The allegation was not reported to the administrator timely and a thorough investigation was not conducted. The residents were not protected due to the perpetrator remaining at work and continued to work while the investigtion was on going. At 11:04 a.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 11:28 a.m., the Administrator (ADM) was notified of the IJ. An acceptable plan of removal was provided by the administrator on 06/25/21 at 9:55 p.m. It documented the following: All residents will be interviewed 06/25/2021. All staff on shift will be educated on updated policy immediately, and if not currently working will be inserviced by phone call by midnight on 06/25/2021. (see attached) (amended to be 9 am on 06/26/2021) ** if unable to be contacted, we will document date and time, and the staff member will be taken off the schedule until completed** The following texts will be sent to all staff immediately .Surveyors have identified serious deficiencies in Abuse reporting. All staff are required to complete in-service. Someone from The Commons will be calling you before midnight tonight .If you have been not contacted to complete an in-service by midnight, call [director of nursing] or will be removed from the schedule .Beginning IMMEDIATELY-reporting of ANY abuse allegations will be need to be texted or called to [administrator] .[assistant administrator] .This is any time- DAY or NIGHT! If no response to a text, then CALL .All staff that have been identified as not timely reporting abuse will be given a 1 day suspension. [Resident #5] -Staff member with physical abuse allegation will be terminated immediately. At every allegation of abuse, a text will be sent to all staff to remind staff that we take abuse very seriously .An allegation has been reported, this is a reminder NO forms of abuse will be tolerated Administrator, Asst Administrator and DON have learned that a thorough investigation includes resident safe surveys on all halls that the alleged abuser has worked. Handwritten statements from those questioned should be included in an investigation. We have reviewed the different types and examples of abuse and will follow our policies that have been updated. We will in-service all staff members on the attached education. We learned that the witness is the person that has reported the incident during the investigation. We learned that to properly assess the resident we must conduct medical, psychosocial, and mental status assessment at the time, and an assessment each shift for 3 days for 9 occurrences On 06/28/21, six nurse aides (CNA), seven certified medication aides (CMA), six licensed practical nurses (LPN), one registered nurse (RN), seven housekeepers and one maintenance staff from across all shifts, were interviewed and able to state accurate information related to abuse. At 6:57 a.m., the ADM was asked what the facility did to further educate the administrative staff on abuse. She stated she looked through the state operations manual and reached out to some of her administrator forums online. She was asked if she shared that information with her administrative staff. She stated they looked up information themselves. She was asked if there was anything specific they educated the administrative staff on. She stated, No, nothing specific. The facility reported resident #8 made an allegation of rape by staff on 06/28/21 and the staff contnued to work over six hours after the allegation. A staff member alleged that LPN #3 had been refusing/withholding pain medications to resident #9. The allegation was not reported timely to the administrator and a thorough investigation was not conducted. At 3:30 p.m., the administrator was made aware that an amended plan of removal was needed due to ongoing abuse and neglect allegations without protecting residents and conducting thorough investigations. An acceptable plan of removal was provided by the administrator on 06/29/21 at 7:20 p.m. It documented the following: Plan of AMENDED Removal for IJ's - ALL THESE items will be completed by June 30th, 2021 [By 8:00 p.m.] .Abuse, Neglect, Misappropriation Investigation POLICY was updated .An outside agency will provide in-service on PRN [as needed] pain medication administration for CMA, and Nursing on June 30th. This inservice will focus on neglect, and not withholding medications. All staff that have not been in serviced by June 30th, 8pm may not work until in serviced, by the DON [director of nursing], ADON [assistant director of nursing], or the outside agency. Due to further consideration on 06/28/21 [staff name deleted] was terminated. [CNA #6] and [LPN #3] will be terminated on 06/30/21 . An ADMINISTRATIVE team was formed called the INCIDENT RESPONSE TEAM on June 29th, and includes the Administrator, Assistant Administrator, DON, ADON, and HealthCare Center Resident services Director. The administrator or designee will report to Board of Director any allegation of abuse at regularly scheduled monthly meetings at a minimum. The INCIDENT response team will be in-serviced by an outside source on all aspects of ABUSE - including screening, preventing, identifying, Investigating, protecting, and reporting/response on 06/30/21 with advanced traing on Abuse. To always protect our residents, the INCIDENT response team will meet to collaborate and respond to allegations to ensure all thorough investigation has been completed. On 07/01/21, two LPNs, one RN and three CMAs were interviewed and able to state accurate information related to abuse and neglect and five administrative staff were interviewed and were able to state accurate information related to abuse and neglect. The immediate jeopardy deficiency was lifted as of 06/30/21 at 5:10 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at a level of actual harm at a pattern. Based on record review, resident and staff interviews, it was determined the facility failed to: ~ ensure a thorough investigation had been completed and ~ implement appropriate corrective actions when abuse had been idenitified for six (#1, 5, 6, 7, 8 and #9) of six sampled residents reviewed for abuse. The facility identified 95 residents resided in the facility. Findings: An abuse policy, dated 12/08/2020, documented, Reporting Requirements .allegations shall be reported immediately to the administrator, DON and to other officials in accordance with State law. Allegations that involve abuse .must be reported within 2 hours .These allegations must be thoroughly investigated and must prevent further potential abuse while the investigation is in progress .appropriate action must be taken including report to the appropriate licensing board .Prevention .It [sic] the policy of The Commons that each resident will be free from abuse, neglect .All facility staff will be in-serviced upon first employment, and at least annually thereafter, regarding .neglect or abuse .Immediately report any suspicion of abuse, neglect or mistreatment to your immediate supervisor .The supervisor WILL CALL the CELL phone of the ADMINISTRATOR [admin], then the DON .Suspected or substantiated cases must also be reported to respective agencies such as state agencies, law enforcement, physician; families, and/or resident responsible party. The subject of abuse shall be routinely and openly discussed .Investigation .Procedure .1st .Care for, treat and PROTECT the resident-DON, ADON, or house supervisor should do a medical assessment immediately .documenting any injury in detail .Take a statement from the resident .2nd .Isolate the perpetrator .3rd .Immediately notify the Administrator, then DON . 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 01/14/21, documented the resident's cognition was moderately impaired. A care plan, effective date 01/07/21, documented, .Resident is at risk for pain r/t [related to] muscle spasms and chronic pain syndrome .Resident will have pain treated/relieved in a timely manner .Administer medications as prescribed . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 325 mg capsule give 2 tablets by oral route every 6 hours as needed for pain . [MEDICATION(S)] 50 mg tablet give 1 tablet (50 mg) by oral route every 6 hours as needed for pain . A statement from CMA #3, dated 06/26/21 at 12:35 a.m., documented, Generally every day, on multiple occasions, typically beginning first thing in the morning after the CNA has helped [Resident #9] get up out of bed for the day, he will ask for a pain pill. He will specifically ask for a [MEDICATION(S)] and rate his pain at an 8 out of 10 for leg or butt pain. As protocol, as the CMA, I report the request to the charge nurse, the charge nurse will go to the resident to evaluate the resident and report back to me, the CMA, with guidance to administer a pain med and instruct me with the level of the pain that was reported and the location of th [sic] pain. On many occurrences, [LPN #3], will deny the resident, [Resident's name], pain meds stating 'He just got up, he doesn't need a pain pill' or 'He's going outside to smoke a cigarette, he's not hurting bad enough if he can go outside to smoke' or 'He can't have a pain pill because he hasn't eaten anything yet.' On these occurrences, [Resident] won't receive pain meds until sometimes 10 a.m. or as late a 2 p.m. as reflected on the MAR [medication administration record] . An OSDH incident form, dated 06/26/21, documented, .[Resident #9] .Allegations of Abuse/Mistreatment .Description of Incident .Staff reported Nurse not approving PRN pain meds when resident asked for them. Resident is cognitive and needs no family called . A statement from LPN #3, dated 06/27/21 at 12:23 [did not document a.m. or p.m.], documented, Sometimes resident asks for pain pills when it is not time as he had it earlier. Med is scheduled [every] 8 [hours] prn. Resident is offered Tylenol if [MEDICATION(S)] can't be given yet . Safe surveys were conducted with five residents. The questions asked to the residents were not related to receiving pain medications. The facility documented the allegation was unsubstantiated and completed on 06/27/21 at 5:30 p.m. The employee continued to work during the investigation of the alleged neglect. The facility did not complete a thorough investigation and interview residents and staff to include the alleged victim regarding pain medications being withheld. On 06/28/21 at 12:40 p.m., the administrator and assistant administrator were asked about the conclusion of the investigation. The assistant administrator stated she had made an excel spreadsheet of which nurse had given Tylenol versus the [MEDICATION(S)]. She stated the accused nurse had administered the medications as much as the other nurses. She was asked if there was documentation of the times the resident had requested the [MEDICATION(S)]. She stated she didn't think you could tell when he had requested it. She was asked if there was no documentation of when the resident requested it and the CMA stated LPN #3 withheld the medication, how did they come to the conclusion the allegation was unsubstantiated. She stated she went to the resident and asked him about it. She stated the resident is this nurse's biggest cheerleader. At 1:19 p.m., the ADM provided resident surveys. There were no questions asked to the residents related to staff withholding pain medications. She stated the executive director had made the surveys and thought that the question Do staff members respect your requests and allow you to make decisions regarding your care covered that. On 06/29/21 at 6:35 p.m., the resident was asked if he was in pain. He stated he had pain in his right side, leg and knee. She stated he would rate it at an 8 out of 10. He stated it was usually a 9 in the mornings. He was asked how he felt if he did not get his [MEDICATION(S)] when he requested it. He stated, If I don't get them, I get mad. He was asked if his [MEDICATION(S)] was ever withheld. He stated it was and then stated he would not disclose who the employee was that withheld the medication. At 7:02 p.m., CMA #3 was asked about the allegations made regarding LPN #3 withholding [MEDICATION(S)]. She stated, [MEDICATION(S)] is what he asks for all the time. She stated, It's upsetting to me because when he asks for something, I have protocol I have to follow. She stated that LPN #3 would give the same responses CMA #3 had put in her statement. She stated she was taught to take their pain as they stated it. She stated LPN #3 would have her administer Tylenol or [MEDICATION(S)] instead of the [MEDICATION(S)]. 2. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 02/18/21, documented the resident's cognition was severely impaired. A state incident report form, dated 02/23/21, documented, .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Administrator was notified today of an allegation of verbal abuse occurring on 02/22/21 from a staff member against a nurse. The nurse is not on the schedule until Thursday. She will not be working until the allegation has been investigated. Investigation is in progress .For 5 day and final reports, please include a summary of the investigation .and corrective measures implemented to prevent recurrence .See attached for investigation: Nurse yelled at resident. She was suspended and counseled on ways to recognize burnout. Also gave her Employee Assistance information . The facility failed to report the allegation of abuse within two hours to the appropriate agencies such as the Oklahoma State Department of Health (OSDH). A written statement by CMA #3, dated 02/23/21, documented, The day of 2-22-21, [resident #7] spent a majority of the day sitting in the North Hall hallway outside of [another resident]s room. At approximately 2 p.m. [resident #7] wheeled himself in his wheelchair up closer to the nurse's station area and parked himself in his wheelchair outside of the wound care nurse's office. Immediately the charge nurse, [LPN #3], stood up and yelled to [resident #7] get the hell out of here, you're not going to sit up here while I'm here. [Resident #7] did raise his hands and yelled at [LPN #3]. I do not know what he yelled at her, his speech is often hard to make out due to health conditions. [LPN #3] then yelled at him again get the hell out of here, you're not going to talk to me that way. After this occurrence, [resident #7] wheeled himself away from the nurse's station area back down the hall towards his room .During this occurrence, [CMA #4] was sitting in a chair beside me and witnessed the entire event . A written statement by CMA #4, dated 02/24/21, documented, On Monday February 22nd I [CMA #4] came into work I was on North Hall. I was sitting at nurses station [resident #7] the resident came strolling up to the Common Area by the nurses station [LPN #3] the nurse told him to turn around and go back he said he has rights She said I dont care Im not gonna [sic] deal with you and he said he wanted to sit up here She screamed at him and said I dont give a dam [sic] your [sic] not sitting up here Im not gonna [sic] deal with your Ass. so [resident #7] sat in the Corner til [LPN #3] left he was very upset the rest of the evening . A written statement by CNA #3, dated 02/24/21, documented, The other day I was in the office getting something when I heard [LPN #3] yelling at [resident #7]. And telling him to go to his room. [Resident #7] started yelling back at her and [LPN #3] got louder and told him she wasn't going to listen to it. Go to your room. [LPN #3] then said Im sick of him acting like this . A written statement by LPN #3, dated 02/24/21 at 5:00 p.m., documented, Missed a call from [administrator (admin)] [at] the Commons. Called back [and] was told there was an allegation against me for yelling [at] a male on North Hall on Monday February 22nd [at] approx [approximately] [2:00 p.m.] .Not only did I yell [at] the man but supposedly I cussed [at] him also per [admin] via the cameras. No Audio .Was also told I told male resident to go away, go down the hall or go to his room. I had asked residents not to sit in the area by wound care Nurse's office as it congests the hallway .May of raised my voice towards the resident . A investigative summary, undated, documented, .Who is/are the reported victim .[resident #7] .Who is/are the reported perpetrator .[LPN #3] .Who witnessed the incident .[CMA #3], [CNA #3], [CMA #4] .What happened .Resident .was in his wheelchair sitting near the nurse's desk. [LPN #3] the nurse came down the hall and started yelling at him to leave the desk .What is the history of the resident(s)? Was the incident foreseeable .The resident has had outbreaks lately, but there is NO reason a staff member should yell at a resident. A staff member should Never yell at resident, but this incident was not foreseeable .What does the victim want to happen .[resident #7] would not discuss the incident, but when asked what he would like to happen, he just shrugged his shoulder .When did the incident happen .Around 2pm on Feb [February] 22nd .When was facility supervisory/management staff first contacted about the incident .On [DATE]rd . An Oklahoma Board of Nursing complaint form, submitted date 02/26/21, documented, .Nurse's Name: [LPN #3] .Did incident include Misconduct or Criminal Behavior .Yes: Patient abuse .Description of Investigation .LPN was suspended pending the investigation and returned to work on 02/26/2021. She received disciplinary action write up for raising her voice at a resident and for conducting herself in a manner contrary to recognized standards. Her employment at the facility is being retained . A time sheet for pay period from 02/14/21 to 02/27/21, documented LPN #3 worked til 6:48 p.m. on 02/22/21. LPN #3 worked approximately 4 hours and 48 minutes after the abuse occurred. The facility failed to protect residents from further abuse during the investigation. The facility failed to report the allegation timely to the administrator and a thorough investigation was not completed. On 06/23/21 at 2:24 p.m., the admin was asked to describe the incident that happened on 02/22/21 with resident #7. She stated the resident is hard of hearing and LPN #3 stated she didn't yell. She stated she reviewed the cameras, took statements from the witnesses and LPN #3 and discussed the incident with the resident's wife. She was asked when LPN #3 worked on 02/22/21. She stated she didn't know. She was asked when the incident was reported. She stated she was notified on the following day. She was asked what the outcome of her investigation was. She stated it was substantiated that LPN #3 did it. She stated she was suspended and had a write up. She was asked if the facility had a zero tolerance for abuse. She stated, If I say yes, my hand book is wrong. She was asked what was done to protect and prevent this from happening to other residents. She stated they didn't add anything else other than what was in place. She was asked who the staff can report suspected abuse to. She stated, Any authority. She was asked when the staff had witnessed the abuse, did they report timely. She stated, No. She was asked if the staff who witnessed the abuse were in serviced about reporting timely. She stated, Nothing in writing. On 06/24/21 at 1:09 p.m., the DON was asked if verbal abuse happened on 02/22/21 around 2:00 p.m. She stated Yes. She was asked if LPN #3 continued to work after. She stated, Yes. She was asked if LPN #3 continued to work with residents, how were the resident protected. She stated, They couldn't be, because we didn't know about it. She was asked, since the staff failed to report the abuse immediately, were the residents protected. She stated, No. The ADM was asked if the resident was assessed after the incident. She stated, No. The staff members who witnessed the abuse did not immediately report it. As a result, LPN #3 worked with the victim and other residents for approximately four hours and 48 minutes. The facility did not put any corrective measures in place to prevent abuse from reoccurring. As a result, one of the witnesses [CMA #4] had an allegation of verbally abusing a different resident. The facility substantiated allegation and terminated CMA #4 while LPN #3 continued to be employed by the facility. The facility failed to complete a through and accurate investigation into the allegation of verbal abuse. 3. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 05/02/21, documented the resident's cognitive skills for daily decision making was severely impaired. An initial incident report form, dated 06/07/21, documented, .Resident .Involved .[Resident #5] .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Received an allegation of abuse towards a resident by staff member. Staff member suspended pending investigation . A written statement from CMA #2, dated 06/07/21, documented Around [8:30 a.m.] [CNA #2] asked me if I could come help her I told her yes just give me a second because I was in the middle of taking care of another Resident. When I walked into [resident #5]'s room [CNA #2] had ahold [sic] of his Right arm yanking [and] pulling on him while she was slapping at his left leg,-on bare skin-. I yelled at her to stop doing him that way [and] she was like what [and] just kind of dropped him back on the bed, she went to pull on his arm to get him up I told her to just leave that I would take care of him. I brought him out for breakfast [and] told the Charge Nurse .what had just happened. When [LPN #2] talked to [CNA #2] she told her to stay away from direct care of [resident #5]. When I seen [sic] D.O.N .around [10:00 a.m.] I asked if [LPN #2] had talk to her [and] I told [DON] what had happened She told me she was not aware but now she is [and] asked me to write out a statement . A written statement from LPN #2, dated 06/07/21, documented, [CMA #2] came to me and stated I yelled at [CNA #2] because she came out to ask me to help get him [resident #5] up I went into the room where she was and he was mad and hitting at her states she saw her grab his arm and swat at his left leg so I told her to leave and I would finish him, I went to [CNA #2] and asked what happened she said I was just playing and I would never hurt anyone was told by nurse to stay out of room . A written statement from CNA #2, dated 06/07/21, documented, .[resident #5] was awake. So desided [sic] to get him up. got his clothes ready then uncovered him started talking to him while was getting him dressed. I started by putting [sic] his pull-up on the [sic] then i put his pants on. after that I took his hospital gown off. got his shirt ready to put his arm in. then put the arm in as I went to put his head his shirt, I told him not to Bite me. got his head in the whole [sic] [and] pull his shirt down. tried to sit him up By Putting my arm on leg to Push Leg in a sitting position while i have my other hand around upper back to help him sit up. then hollered [sic] at [CMA #2] to help stand him to finish getting dressed. Because he was fighting me. I was patting his .leg to clam [sic] him down to resure [sic] it was ok. then [CMA #2] came in their [sic] saw i was trying to hold him up. then told me Let him lay Back down the [sic] she would get him. then said was abusing him. I Left the room and went the Break room. then the nurse .ask me if i hit him I told her no i was patting him to try come [sic] him down. [LPN #2] told me not go around him again. until told other wise . An investigative summary, undated, documented, .Who is .the reported victim .[resident #5] .who is .reported perpetrator .[CNA #2] .What happened .Allegation that CNA was yanking on Residents arm and slapping his leg .What was done to protect the resident(s) from further harm .Staff member was told not go around the resident until further notice by the nurse on the hall and then was suspended and sent home pending investigation by the DON .What is the history of the resident .Was the incident foreseeable .Resident has a history of being combative to staff when cares are delivered .When did the incident happen .06/07/21, [7:30 a.m.] .When was facility supervisory/management staff first contacted about the incident .[10:00 a.m.] . A final state report, dated 06/08/21, documented, .A skin sweep was completed on the resident by two nurses with no injuries noted .The Accused perpetrator was suspended on 06/07/2021 pending an investigation. On 06/08/2021 she was counseled by the DON and the Administrator. She received verbal education or what could be considered to be abuse. She also completed a Relias Training entitled Understanding Dementia. The accused perpetrator was allowed to return to work on 06/08/2021 . CNA #2's time sheet, dated 06/06/21 to 06/19/21, documented she worked on 06/07/21 from 6:30 a.m. to 10:04 a.m., and from 10:36 a.m. to 11:37 a.m. and on 06/08/21 from 8:27 a.m. to 1:27 p.m., and from 1:57 p.m. to 2:32 p.m. The facility had documented the allegation was unsubstantiated even through there was a witness, and failed to complete a thorough investigation by interviewing other staff members and residents. On 06/24/21 at 12:48 p.m., the DON was asked to describe her investigation process. She stated she would complete an incident report, remove and suspend staff, take statements from other staff on the hall that the incident occurred and complete safe surveys on cognitive residents on the section of the hall the incident occurred. She was asked if staff worked the same hall. She stated not always. She was asked if she considered interviewing other staff and residents on other halls. She stated she has interviewed other staff but not other residents. She was asked when the investigation was started. She stated on 06/07/21 at 10:00 a.m. She was asked when the investigation was completed. She stated late on 06/07/21. She was asked if a thorough investigation was conducted. She stated, I feel it was thorough. She was asked if the resident was assessed after incident for delayed injury. She stated, No. She was asked when CNA #2 had worked on 06/07/21. She stated she left at 10:04 a.m. for lunch and when she returned, she was suspended and sent home. She was asked when she worked on 06/08/21. She stated she was here at 8:30 a.m. to meet with DON and watch Relias training then returned to the floor. She was asked what disciplinary actions CNA #2 received. She stated she watched Relias video about dementia, she was suspended on the 7th and two and a half hours on the 8th. The DON was asked what corrective actions were put in place to prevent further abuse and protect the residents. She stated there were no changes. The DON stated she didn't feel the allegation happened because CNA #2 left the door open and she called the CMA for help. She acknowledged staff did not notify DON or ADM of the incident in a timely manner. LPN #2 did not report incident to the DON immediately and as a result, CNA #2 continued to work with other residents for approximately one and a half to two and a half hours. A thorough investigation was not completed by not interviewing other staff and residents. As a result, it is unknown if other residents had been involved. 4. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A time record for RN #2, dated 06/27/21, documented she worked from 5:33 p.m. to 5:39 a.m. A time record for CNA #5, dated 06/27/21, documented she worked from 10:01 p.m. to 5:39 a.m. A progress note, dated 06/28/21 at 4:23 a.m., documented, .She than [sic] began saying that she was raped by 50 females every 30 minutes .Staff is not to go in her room by themselves. This was reported to administration per policy . On 06/28/21 at 5:20 a.m., two police officers were observed to be at the front door to the facility. When approached, they stated they had received a call that a resident had been sexually abused. They were asked when they had received the call. One stated, About five minutes ago. At 5:25 a.m., the administrator stated, I need to talk to you guys. She stated, We have a crazy lady who says she was raped and I didn't send the two ladies home. An OSDH incident report, dated of 06/27/21, documented, .Final .[Resident #8] .Allegations of Abuse/Mistreatment .Description of Incident .Resident makes allegation that she was being raped by 50 people every 30 minutes. She was also saying we were trying to poison her when staff CMA gave her [MEDICATION(S)] .No S/S [signs/symptoms] of physical rape noted .For 5 day and final reports, please include a summary of the investigation .See attached . A report summary, date and time of report completion 06/28/21 at 5:10 p.m., documented, .Who is/are the reported perpetrator(s) .A woman and 50 of them .What happened .Accusation of Rape and bed bugs .What was done to protect the resident(s) from further harm .Staff was to always go in room [ROOM NUMBER] at a time .What was done upon discovery of the incident .Notified Administrator .What is the resident's current physical status .Assessment done at 5PM 06/28/21 .When was facility supervisor/management staff first contacted about the incident .11:47 PM [06/27/21] . A statement from RN #2 documented, .2305-2315 [11:05 p.m. to 11:15 p.m.] Resident began saying that there was bed bugs in her bed. The bed was checked by 2 staff and found no sign of bugs. She than [sic] began saying that she was raped. She has been yelling these allegations. She said that the rapest [sic] is a woman and there is 50 of them every 5 minutes. She cannot really describe them .Staff has been going in her room with 2 people and then after being told by Administration we have been going in with 2 Licensed nurses . A statement from CNA #5, dated 06/28/21 at 12:32 p.m., documented, At 11:14 pm [Resident #8] started yelling .Shortly after she started yelling rape. She said she was raped and that everyone has been raped. She said that she has been raped every 30 minutes by 50 people . < [TRUNCATED]

On 06/28/21, an Immediate Jeopardy (IJ) situation was determined to exist related to facility failed to have an effective administration to implement an abuse program for ~thoroughly investigating allegations of abuse and neglect; ~ protecting residents during investigations of abuse and neglect; ~ ensure residents were free from abuse and neglect; and ~ staff could report allegations without fear of reprisal. A staff member alleged that LPN #3 had been refusing/withholding pain medications to resident #9. The allegation was not reported timely to the administrator and a thorough investigation was not conducted. The employee remained working during the investigation and no action was taekn against the nurse. An allegation of staff being verbally abusive to resident #7 on 02/22/21 was not reported until 02/23/21, one day after the allegation occurred. The residents were not protected as the staff member was allowed to work. The facility documented an incident of resident #5 being physically abused by staff witnessed and reported by staff. The facility failed to protect the resident, complete a thorough investigation and implement corrected measures to prevent further abuse. Resident #8 made an allegation of rape by staff on 06/28/21 and the staff had been allowed to continue to work over six hours after the allegation was made. Staff witnessed verbal abuse to Resident #6, by an employee and reported it. The allegation was not reported to the administrator timely and a thorough investigation was not conducted. The residents were not protected due to the perpetrator remaining at work and continued to work while the investigation was on going. On 06/28/21 at 3:03 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 3:30 p.m., the Administrator (ADM) was notified of the IJ. An acceptable, plan of removal was provided by the administrator on 06/29/21 at 7:20 p.m. It documented the following: An ADMINISTRATIVE team was formed called the INCIDENT RESPONSE TEAM on June 29th, and includes the Administrator, Assistant Administrator, DON, ADON, and HealthCare Center Resident services Director. The administrator or designee will report to the Board of Director any allegation of abuse at regularly scheduled monthly meetings at a minimum. The INCIDENT response team will be in-serviced by an outside source on all aspects of ABUSE - including screening, preventing, identifying, Investigating, protecting, and reporting/response on 06/30/2021 with advanced training on ABUSE. To always protect our residents, the INCIDENT response team will meet to collaborate and respond to allegations to ensure a thorough investigation has been completed. On 07/01/21, the administrative staff were interviewed and were able to state the seven components of abuse. The immediate jeopardy deficiency was lifted as of 06/30/21 at 5:10 p.m. when all elements of the plan of removal and the amended plan of removal had been implemented. The deficient practice remained at a level of actual harm at a pattern. Based on observation, record review and staff interview it was determined the facility failed to have an effective administration to implement an abuse program for: ~ thoroughly investigating allegations of abuse and neglect; ~protecting residents during investigations of abuse and neglect; ~ensuring residents were free from abuse for six (#1, 5, 6, 7, 8 and #9) of six sampled residents reviewed for abuse; and ~ have an envrironement were staff could report allegations of abuse/negelect without fear of reprisal. The facility Censeus was Findings: 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 01/14/21, documented the resident's cognition was moderately impaired. A care plan, effective date 01/07/21, documented, .Resident is at risk for pain r/t [related to] muscle spasms and chronic pain syndrome .Resident will have pain treated/relieved in a timely manner .Administer medications as prescribed . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 325 mg capsule give 2 tablets by oral route every 6 hours as needed for pain . [MEDICATION(S)] 50 mg tablet give 1 tablet (50 mg) by oral route every 6 hours as needed for pain . A statement from CMA #3, dated 06/26/21 at 12:35 a.m., documented, Generally every day, on multiple occasions, typically beginning first thing in the morning after the CNA has helped [Resident #9] get up out of bed for the day, he will ask for a pain pill. He will specifically ask for a [MEDICATION(S)] and rate his pain at an 8 out of 10 for leg or butt pain. As protocol, as the CMA, I report the request to the charge nurse, the charge nurse will go to the resident to evaluate the resident and report back to me, the CMA, with guidance to administer a pain med and instruct me with the level of the pain that was reported and the location of th [sic] pain. On many occurrences, [LPN #3], will deny the resident, [Resident's name], pain meds stating 'He just got up, he doesn't need a pain pill' or 'He's going outside to smoke a cigarette, he's not hurting bad enough if he can go outside to smoke' or 'He can't have a pain pill because he hasn't eaten anything yet.' On these occurances, [Resident] won't receive pain meds until sometimes 10 a.m or as late a 2 p.m. as reflected on the MAR [medication administration record] . An OSDH incident form, dated 06/26/21, documented, .[Resident #9] .Allegations of Abuse/Mistreatment .Description of Incident .Staff reported Nurse not approving PRN pain meds when resident asked for them. Resident is cognitive and needs no family called . A statement from LPN #3, dated 06/27/21 at 12:23 [did not document a.m. or p.m.], documented, Sometimes resident asks for pain pills when it is not time as he had it earlier. Med is scheduled [every] 8 [hours] prn. Resident is offered Tylenol if [MEDICATION(S)] can't be given yet . Safe surveys were conducted with five residents. The questions asked to the residents were not related to receiving pain medications. The facility documented the allegation was unsubstantiated and completed on 06/27/21 at 5:30 p.m. The employee continued to work during the investigaion of the alleged negelct. The facility did not complete a through investigation and interview residents and staff to include the alleged victim regarding pain medications being withheld. On 06/28/21 at 12:40 p.m., the administrator and assistant administrator were asked about the conclusion of the investigation. The assistant administrator stated she had made an excel spreadsheet of which nurse had given Tylenol versus the [MEDICATION(S)]. She stated the accused nurse had administered the medications as much as the other nurses. She was asked if there was documentation of the times the resident had requested the [MEDICATION(S)]. She stated she didn't think you could tell when he had requested it. She was asked if there was no documentation of when the resident requested it and the CMA stated LPN #3 withheld the medication, how did they come to the conclusion the allegation was unsubstantiated. She stated she went to the resident and asked him about it. She stated the resident is this nurse's biggest cheerleader. At 1:19 p.m., the ADM provided resident surveys. There were no questions asked to the residents related to staff withholding pain medications. She stated the executive director had made the surveys and thought that the question Do staff members respect your requests and allow you to make decisions regarding your care covered that. On 06/29/21 at 6:35 p.m., the resident was asked if he was in pain. He stated he had pain in his right side, leg and knee. She stated he would rate it at an 8 out of 10. He stated it was usually a 9 in the mornings. He was asked how he felt if he did not get his [MEDICATION(S)] when he requested it. He stated, If I don't get them, I get mad. He was asked if his [MEDICATION(S)] was ever withheld. He stated it was and then stated he would not disclose who the employee was that witheld the medication. At 7:02 p.m., CMA #3 was asked about the allegations made regarding LPN #3 withholding [MEDICATION(S)]. She stated, [MEDICATION(S)] is what he asks for all the time. She stated, It's upsetting to me because when he asks for something, I have protocol I have to follow. She stated that LPN #3 would give the same responses CMA #3 had put in her statement. She stated she was taught to take their pain as they stated it. She stated LPN #3 would have her administer Tylenol or [MEDICATION(S)] instead of the [MEDICATION(S)]. 2. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 02/18/21, documented the resident's cognition was severely impaired. A state incident report form, dated 02/23/21, documented, .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Administrator was notified today of an allegation of verbal abuse occurring on 02/22/21 from a staff member against a nurse. The nurse is not on the schedule until Thursday. She will not be working until the allegation has been investigated. Investigation is in progress .For 5 day and final reports, please include a summary of the investigation .and corrective measures implemented to prevent recurrence .See attached for investigation: Nurse yelled at resident. She was suspended and counseled on ways to recognize burnout. Also gave her Employee Assistance information . The allegation of abuse was not reported to the administrator until the next day after it occurred. The facility failed to report the allegation of abuse within two hours to the appropriate agencies such as the Oklahoma State Department of Health (OSDH). A written statement by CMA #3, dated 02/23/21, documented, The day of 2-22-21, [resident #7] spent a majority of the day sitting in the North Hall hallway outside of [another resident]s room. At approximately 2 p.m. [resident #7] wheeled himself in his wheelchair up closer to the nurse's station area and parked himself in his wheelchair outside of the wound care nurse's office. Immediately the charge nurse, [LPN #3], stood up and yelled to [resident #7] get the hell out of here, you're not going to sit up here while I'm here. [Resident #7] did raise his hands and yelled at [LPN #3]. I do not know what he yelled at her, his speech is often hard to make out due to health conditions. [LPN #3] then yelled at him again get the hell out of here, you're not going to talk to me that way. After this occurrence, [resident #7] wheeled himself away from the nurse's station area back down the hall towards his room .During this occurrence, [CMA #4] was sitting in a chair beside me and witnessed the entire event . A written statement by CMA #4, dated 02/24/21, documented, On Monday February 22nd I [CMA #4] came into work I was on North Hall. I was sitting at nurses station [resident #7] the resident came strolling up to the Common Area by the nurses station [LPN #3] the nurse told him to turn around and go back he said he has rights She said I dont care Im not gonna [sic] deal with you and he said he wanted to sit up here She screamed at him and said I dont give a dam [sic] your [sic] not sitting up here Im not gonna [sic] deal with your Ass. so [resident #7] sat in the Corner til [LPN #3] left he was very upset the rest of the evening . A written statement by CNA #3, dated 02/24/21, documented, The other day I was in the office getting something when I heard [LPN #3] yelling at [resident #7]. And telling him to go to his room. [Resident #7] started yelling back at her and [LPN #3] got louder and told him she wasn't going to listen to it. Go to your room. [LPN #3] then said Im sick of him acting like this . A written statement by LPN #3, dated 02/24/21 at 5:00 p.m., documented, Missed a call from [administrator (admin)] [at] the Commons. Called back [and] was told there was an allegation against me for yelling [at] a male on North Hall on Monday February 22nd [at] approx [approximately] [2:00 p.m.] .Not only did I yell [at] the man but supposedly I cussed [at] him also per [admin] via the cameras. No Audio .Was also told I told male resident to go away, go down the hall or go to his room. I had asked residents not to sit in the area by wound care Nurse's office as it congests the hallway .May of raised my voice towards the resident . A investigative summary, undated, documented, .Who is/are the reported victim .[resident #7] .Who is/are the reported perpetrator .[LPN #3] .Who witnessed the incident .[CMA #3], [CNA #3], [CMA #4] .What happened .Resident .was in his wheelchair sitting near the nurse's desk. [LPN #3] the nurse came down the hall and started yelling at him to leave the desk .What is the history of the resident(s)? Was the incident foreseeable .The resident has had outbreaks lately, but there is NO reason a staff member should yell at a resident. A staff member should Never yell at resident, but this incident was not foreseeable .What does the victim want to happen .[resident #7] would not discuss the incident, but when asked what he would like to happen, he just shrugged his shoulder .When did the incident happen .Around 2pm on Feb [February] 22nd .When was facility supervisory/management staff first contacted about the incident .On [DATE]rd . An Oklahoma Board of Nursing complaint form, submitted date 02/26/21, documented, .Nurse's Name: [LPN #3] .Did incident include Misconduct or Criminal Behavior .Yes: Patient abuse .Description of Investigation .LPN was suspended pending the investigation and returned to work on 02/26/2021. She received disciplinary action write up for raising her voice at a resident and for conducting herself in a manner contrary to recognized standards. Her employment at the facility is being retained . A time sheet for pay period from 02/14/21 to 02/27/21, documented LPN #3 worked til 6:48 p.m. on 02/22/21. LPN #3 worked approximately 4 hours and 48 minutes after the abuse occurred. The facility failed to protect residents from further abuse during the investigation. The facilty failed to report the allegation timely to the administrator and a through investigation was not completed. On 06/23/21 at 2:24 p.m., the admin was asked to describe the incident that happened on 02/22/21 with resident #7. She stated the resident is hard of hearing and LPN #3 stated she didn't yell. She stated she reviewed the cameras, took statements from the witnesses and LPN #3 and discussed the incident with the resident's wife. She was asked when LPN #3 worked on 02/22/21. She stated she didn't know. She was asked when the incident was reported. She stated she was notified on the following day. She was asked what the outcome of her investigation was. She stated it was substantiated that LPN #3 did it. She stated she was suspended and had a write up. She was asked if the facility had a zero tolerance for abuse. She stated, If I say yes, my hand book is wrong. She was asked what was done to protect and prevent this from happening to other residents. She stated they didn't add anything else other than what was in place. She was asked who the staff can report suspected abuse to. She stated, Any authority. She was asked when the staff had witnessed the abuse, did they report timely. She stated, No. She was asked if the staff who witnessed the abuse were in serviced about reporting timely. She stated, Nothing in writing. On 06/24/21 at 1:09 p.m., the DON was asked if verbal abuse happened on 02/22/21 around 2:00 p.m. She stated Yes. She was asked if LPN #3 continued to work after. She stated, Yes. She was asked if LPN #3 continued to work with residents, how were the resident protected. She stated, They couldn't be, because we didn't know about it. She was asked, since the staff failed to report the abuse immediately, were the residents protected. She stated, No. The ADM was asked if the resident was assessed after the incident. She stated, No. The staff members who witnessed the abuse did not immediately report it. As a result, LPN #3 worked with the victim and other residents for approximately four hours and 48 minutes. The facility did not put any corrective measures in place to prevent abuse from reoccurring. As a result, one of the witnesses [CMA #4] had an allegation of verbally abusing a different resident. The facility substantiated allegation and terminated CMA #4 while LPN #3 continued to be employed by the facility. 3. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly resident assessment, dated 05/02/21, documented the resident's cognitive skills for daily decision making was severely impaired. An initial incident report form, dated 06/07/21, documented, .Resident .Involved .[resident #5] .Incident Type .Allegations of Abuse/Mistreatment .Description of Incident .Received an allegation of abuse towards a resident by staff member. Staff member suspended pending investigation . A written statement from CMA #2, dated 06/07/21, documented Around [8:30 a.m.] [CNA #2] asked me if I could come help her I told her yes just give me a second because I was in the middle of taking care of another Resident. When I walked into [resident #5]'s room [CNA #2] had ahold [sic] of his Right arm yanking [and] pulling on him while she was slapping at his left leg,-on bare skin-. I yelled at her to stop doing him that way [and] she was like what [and] just kind of dropped him back on the bed, she went to pull on his arm to get him up I told her to just leave that I would take care of him. I brought him out for breakfast [and] told the Charge Nurse .what had just happened. When [LPN #2] talked to [CNA #2] she told her to stay away from direct care of [resident #5]. When I seen [sic] D.O.N .around [10:00 a.m.] I asked if [LPN #2] had talk to her [and] I told [DON] what had happened She told me she was not aware but now she is [and] asked me to write out a statement . A written statement from LPN #2, dated 06/07/21, documented, [CMA #2] came to me and stated I yelled at [CNA #2] because she came out to ask me to help get him [resident #5] up I went into the room where she was and he was mad and hitting at her states she saw her grab his arm and swat at his left leg so I told her to leave and I would finish him, I went to [CNA #2] and asked what happened she said I was just playing and I would never hurt anyone was told by nurse to stay out of room . A written statement from CNA #2, dated 06/07/21, documented, .[resident #5] was awake. So desided [sic] to get him up. got his clothes ready then uncovered him started talking to him while was getting him dressed. I started by putting [sic] his pull-up on the [sic] then i put his pants on. after that I took his hospital gown off. got his shirt ready to put his arm in. then put the arm in as I went to put his head his shirt, I told him not to Bite me. got his head in the whole [sic] [and] pull his shirt down. tried to sit him up By Putting my arm on leg to Push Leg in a sitting position while i have my other hand around upper back to help him sit up. then hollered [sic] at [CMA #2] to help stand him to finish getting dressed. Because he was fighting me. I was patting his .leg to clam [sic] him down to resure [sic] it was ok. then [CMA #2] came in their [sic] saw i was trying to hold him up. then told me Let him lay Back down the [sic] she would get him. then said was abusing him. I Left the room and went the Break room. then the nurse .ask me if i hit him I told her no i was patting him to try come [sic] him down. [LPN #2] told me not go around him again. until told other wise . An investigative summary, undated, documented, .Who is .the reported victim .[resident #5] .who is .reported perpetrator .[CNA #2] .What happened .Allegation that CNA was yanking on Residents arm and slapping his leg .What was done to protect the resident(s) from further harm .Staff member was told not go around the resident until further notice by the nurse on the hall and then was suspended and sent home pending investigation by the DON .What is the history of the resident .Was the incident foreseeable .Resident has a history of being combative to staff when cares are delivered .When did the incident happen .06/07/21, [7:30 a.m.] .When was facility supervisory/management staff first contacted about the incident .[10:00 a.m.] . A final state report, dated 06/08/21, documented, .A skin sweep was completed on the resident by two nurses with no injuries noted .The Accused perpetrator was suspended on 06/07/2021 pending an investigation. On 06/08/2021 she was counseled by the DON and the Administrator. She received verbal education or what could be considered to be abuse. She also completed a Relias Training entitled Understanding Dementia. The accused perpetrator was allowed to return to work on 06/08/2021 . CNA #2's time sheet, dated 06/06/21 to 06/19/21, documented she worked on 06/07/21 from 6:30 a.m. to 10:04 a.m., and from 10:36 a.m. to 11:37 a.m. and on 06/08/21 from 8:27 a.m. to 1:27 p.m., and from 1:57 p.m. to 2:32 p.m. The facility had documented the allegation was unsubstantiated even through there was a witness, and failed to complete a thorough investigation by interviewing other staff members and residents. On 06/24/21 at 12:48 p.m., the DON was asked to describe her investigation process. She stated she would complete an incident report, remove and suspend staff, take statements from other staff on the hall that the incident occurred and complete safe surveys on cognitive residents on the section of the hall the incident occurred. She was asked if staff worked the same hall. She stated not always. She was asked if she considered interviewing other staff and residents on other halls. She stated she has interviewed other staff but not other residents. She was asked when the investigation was started. She stated on 06/07/21 at 10:00 a.m. She was asked when the investigation was completed. She stated late on 06/07/21. She was asked if a thorough investigation was conducted. She stated, I feel it was thorough. She was asked if the resident was assessed after incident for delayed injury. She stated, No. She was asked when CNA #2 had worked on 06/07/21. She stated she left at 10:04 a.m. for lunch and when she returned, she was suspended and sent home. She was asked when she worked on 06/08/21. She stated she was here at 8:30 a.m. to meet with DON and watch Relias training then returned to the floor. She was asked what disciplinary actions CNA #2 received. She stated she watched Relias video about dementia, she was suspended on the 7th and two and a half hours on the 8th. The DON was asked what corrective actions were put in place to prevent further abuse and protect the residents. She stated there were no changes. The DON stated she didn't feel the allegation happened because CNA #2 left the door open and she called the CMA for help. She acknowledged staff did not notify DON or ADM of the incident in a timely manner. LPN #2 did not report incident to the DON immediately and as a result, CNA #2 continued to work with other residents for approximately one and a half to two and a half hours. A thorough investigation was not completed by not interviewing other staff and residents. As a result, it is unknown if other residents had been involved. 4. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A time record for RN #2, dated 06/27/21, documented she worked from 5:33 p.m. to 5:39 a.m. A time record for CNA #5, dated 06/27/21, documented she worked from 10:01 p.m. to 5:39 a.m. A progress note, dated 06/28/21 at 4:23 a.m., documented, .She than [sic] began saying that she was raped by 50 females every 30 minutes .Staff is not to go in her room by themselves. This was reported to administration per policy . On 06/28/21 at 5:20 a.m., two police officers were observed to be at the front door to the facility. When approached, they stated they had received a call that a resident had been sexually abused. They were asked when they had received the call. One stated, About five minutes ago. At 5:25 a.m., the administrator stated, I need to talk to you guys. She stated, We have a crazy lady who says she was raped and I didn't send the two ladies home. An OSDH incident report, dated of 06/27/21, documented, .Final .[Resident #8] .Allegations of Abuse/Mistreatment .Description of Incident .Resident makes allegation that she was being raped by 50 people every 30 minutes. She was also saying we were trying to poison her when staff CMA gave her [MEDICATION(S)] .No S/S [signs/symptoms] of physical rape noted .For 5 day and final reports, please include a summary of the investigation .See attached . A report summary, date and time of report completion 06/28/21 at 5:10 p.m., documented, .Who is/are the reported perpetrator(s) .A woman and 50 of them .What happened .Accusation of Rape and bed bugs .What was done to protect the resident(s) from further harm .Staff was to always go in room [ROOM NUMBER] at a time .What was done upon discovery of the incident .Notified Administrator .What is the resident's current physical status .Assessment done at 5PM 06/28/21 .When was facility supervisor/management staff first contacted about the incident .11:47 PM [06/27/21] . A statement from RN #2 documented, .2305-2315 [11:05 p.m. to 11:15 p.m.] Resident began saying that there was bed bugs in her bed. The bed was checked by 2 staff and found no sign of bugs. She than [sic] began saying that she was raped. She has been yelling these allegations. She said that the rapest [sic] is a woman and there is 50 of them every 5 minutes. She cannot really describe them .Staff has been going in her room with 2 people and then after being told by Administration we have been going in with 2 Licensed nurses . A statement from CNA #5, dated 06/28/21 at 12:32 p.m., documented, At 11:14 pm [Resident #8] started yelling .Shortly after she started yelling rape. She said she was raped and that everyone has been raped. She said that she has been raped every 30 minutes by 50 people . A statement, dated 06/28/21, from CNA #7, documented, Resident stated she was being abused and raped repeatedly . A statement, dated 06/28/21, from CMA #5 documented, .On 6-28-2021, resident in RM [resident #8's room number] has been yelling Rape multiple times and saying the police are coming . On 06/28/21 at 6:27 a.m., the ADM stated she had received a text message from the charge nurse last night at 11:14 p.m. that stated the resident's wound vac had alarmed. The ADM was observed to be reading the text messages from the charge nurse as we spoke. She stated when the nurse went in to check the alarm, the resident alleged rape. The administrator stated the nurse had informed her she had told staff not to go in there alone. The administrator stated she told the nurse to go ask when it happened and get a description of what the person looked like. The nurse told the ADM the resident reported a female rapist and 50 people every 30 minutes. The charge nurse told the ADM that the rapist looks like us. The ADM was asked how many staff had worked with the resident last night. She stated, Two. She stated she had instructed the nurse to inform the family and physician and to assess the resident. She stated the resident refused to be assessed. The administrator stated she told the nurse, You can't rape someone you can't get close to. She was asked who the two staff were that had been working with the resident. She stated it was a CNA and an RN. The ADM was asked how she protected the residents once she was made aware of the allegation of rape. She stated, I told her to go in with two, always two. She was asked what the facility policy was for protecting residents if there was an allegation of abuse. She stated, Let me find the policy. She located the policy and began reading it. She stated, Immediately remove them, suspend. She was asked if either of the two staff had been suspended. She stated, Not at the time. She stated, I came and did it later. She was asked what time she suspended them. She stated, I don't know, I was with the police. She was asked if her policy for suspending employees for allegations of abuse had been followed. She stated, No. On 06/29/21 at 11:30 a.m., the investigation regarding resident #8 allegation of rape was reviewed with the ADM. She stated she based her report on the staff statements. Reviewed with the ADM her interview from 06/28/21, where she reported the charge nurse texted her that the resident described the perpetrators as looks like us and that the investigative report documented the resident was unable to give a description. The ADM stated, Yes, referring to the discrepancies in information. She was asked if she was concerned about the discrepancies. She stated, What does the report say. Reviewed her interview from yesterday that she stated the nurse reported to her the description the resident stated looks like us and the report documented the resident was unable to describe the perpetrator. There was no response given. The two employees remained working at the facility all night after the allegation of rape and the resident identifying the RN and CNA as the ones who raped her. The facility failed to have an accurate a thorough investigation into the allegations. 5. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 02/15/21, documented the resident's cognition was intact. A time record, dated 03/21/21, documented LPN #1 worked from 5:42 a.m. to 3:21 p.m. A nurse's note, dated 03/21/21 at 1:44 p.m., documented, Resident observed on floor lying on back . An initial OSDH incident report, dated 03/21/21, documented, .Allegations of Abuse Mistreatment .Description of Incident .Administrator was notified by Activity director that activity aide reported to her in a statement, that she overheard a nurse say Jesus F****** Christ, [Resident #6] really? when she was notified he had fallen. Nurse is not on shift today. The nurse is suspended until investigation is complete . A facsimile (fax) cover sheet, documented the report was sent to the OSDH on 03/22/21 at 4:22 p.m. There was no documentation in the resident's clinical record of the alleged abuse against the resident. The facility did not report the allegation of abuse to the Oklahoma State Department of Health within the required two hours. A time record for LPN #1 documented she worked on 03/23/21 from 5:42 a.m. to 2:34 p.m. A final OSDH report, faxed to OSDH on 03/23/21 at 6:38 p.m., documented the following .For 5 day and final reports, please include a summary of the investigation .Face Sheet attached, investigation attached . Safe surveys were conducted with three residents on 03/23/21. The following questions were asked: 1. Do you feel like when you turn on your call light, you get everything you need taken care of? 2. Have you heard staff using inappropriate language? 3. Has staff ever yelled or spoken harsh to you? 4. If you feel like your needs aren't met, do you know who to talk to? No negative answers were documented. LPN #1 reamained working after the allegation of verbal abuse had been made and throughout the invesitigation. There were no written staff statements from the reporting staff member, the p [TRUNCATED]

Based on observation, interview and record review, it was determined the facility failed to provide adequate supervision to prevent a resident from eloping and ensure interventions were implemented as ordered to aid in the prevention of elopement for two (#1 and #2) of nine sampled residents who were identified to be at risk for elopement. Resident #1 walked outside into the facility parking lot and sustained a fall resulting in a nasal fracture. This resulted in actual harm to the resident. The director of nursing (DON) identified two additional residents who were at risk for elopement. Findings: A facilty policy titled, "Policy for Wander Guard Alarm Placement" documented, "Once a resident has been determined by nursing to be an elopement risk, the following will occur: A wander guard will be placed on the resident and the POA (power of attorney) notified of the placement. Care Plan will reflect wander guard placement. Resident will be reassessed for removal of wander guard pending decline in condition, no longer at risk, leaves facility to hospital or on leave of absence. Restorative therapy will be notified of referrals for wander guard placement needs/risks." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan dated [DATE], documented; "Problem; personal safety at risk for injury, r/t (related to) impaired cognitive skills, at risk for leaving facility unattended. Goals; (Resident) will remain in faciltiy, injury free this quarter. Interventions: Place wander guard on resident. Check wander guard for working properly." A quarterly assessment, dated [DATE], documented the resident was cognitively intact without behaviors and required limited supervision with most activities of daily living. The assessment further documented the resident was not steady, but able to stabilize without assistance when moving from a seated to a standing position, walking, turning around, moving on and off the toilet and when performing surface to surface transfers. A facility incident report, dated [DATE], at an estimated time of 7:25 p.m. documented, "Resident was sitting near the nurses desk on north hall. When staff were down the hall resident left her walker and exited the facility. Staff was notified that resident had made it to the south parking lot when she had fallen face first in the parking lot. Sent to ER (emergency room ) ...CT (cat scan) of facial bones/nasal sinuses--Comminuted FX (fracture) of nasal bone & nasal septum. ..." A nurses note, dated [DATE] at 10:50 p.m., documented, "Resident was sitting near nurses desk and had been stating she needed to go and fix her son something to eat, and feed her cats. When staff was away from the desk, (Resident) left her walker and exited the building making it to the south parking (lot) where she fell , receiving injuries to her face. Staff was notified and on arrival EMS (emergency medical services) already had her on the stretcher and in the back of ambulance. A bystander called EMS before notifying staff. Another passer-by came into the facility and asked for a wet towel for a person bleeding in parking lot. When staff arrived EMS stated that there was no reason to notify Nurse or house supervisor and they were transporting her to hospital." The note was electronically signed by registered nurse (RN) #1, the house supervisor. A second nurses note, dated [DATE] at 3:27 a.m., documented, "Returned from hospital by ambulance. Entire face including forehead, eyes, nose, lips and chin swollen and dark red. nasal passage packed with guaze and guaze 4 x 4 held in place under nose with strap around ears..." Nurses' notes reviewed following the incident documented the following entries. [DATE] at 6:45 a.m., "still reaching for nasal dressing without remembering why its there. Nurse staying at bedside to keep her from pulling it out and bleeding again. ..she made digging gestures with both hands to show how much she wanted to pull at the dressings on her nose and face." [DATE] at 1:48 p.m., "...dressing was laying on the floor -with guaze -res(Resident) will not leave in place ...cautioned res. not to pick her nose. noted- res face very discolored-nose swollen as well as lip." [DATE] at 11:10 p.m., "she did not complain of pain but grimaced when face touched. gave Norco (oral pain medication)..." [DATE] at 4:15 a.m., "...facial bruising, swelling and discoloration continue complains of headache and general discomfort. Norco ,[DATE] mg given for pain." [DATE] at 9:51 a.m., " ...purple discoloration of nose, under her eyes, eye lids, cheeks, above her lips and extends down her neck-slight red seepage (sic) noted from rt nare-left packing remains intact. Res has appt with (name withheld) to have packing removed." Facility staffing patterns were reviewed for the shift on [DATE]. The records documented RN #2, certified medication aide (CMA) #3 and certified nursing assistants (CNAs) #2 and #4, were on duty at the time of the elopement. Time clock records documented three of the four direct care staff workers on the North hall clocked out at the following times. CMA #3 at 6:52 p.m. RN #2 at 6:55 p.m. CNA #4 at 6:58 p.m. In addition to the above staff, the house supervisor (RN #1) was also documented as clocking out and off duty at 6:53 p.m., on the evening of the elopement. Three of the four staff assigned to the North hall and the house supervisor were not clocked in and on duty during the approximate time the resident eloped. On [DATE] at 1:30 p.m., LPN #1 was observed at the nursing station on the North hall. He was asked how he knew which of his residents were at risk for eloping and used a electronic monitoring device. He stated, "The off-going nurse reports to the on-coming nurse which residents are at risk and who has monitors." He was asked how many of his residents were at risk and had Wander guard devices on. He stated, "Three that I'm sure of without looking, but we have a record here at the desk where I can check." He was asked how often the placement of the Wander guard was documented. He stated, "They have doctors orders which come up on the treatment record and this reminds us to check, sometimes its daily, sometimes it once a shift." He was asked if he had ever cared for Resident #1. He stated, "No. This is my second day working on the `North hall." At 1:35 p.m., CMA #2 was interviewed and asked how she knew which residents were at risk for elopement and or used an electronic monitoring device for wandering. She stated, "The nurses tells us who is at risk and wears the bracelets, plus the restorative comes around and makes sure the bracelets are working." She was asked if the restorative aide (RA) monitored the devices for placement on the residents. She stated she wasn't sure she only knew they kept a book for the monitors (Wander Guard Bracelets). The CMA was asked if resident #1 wore a wander guard bracelet. She stated she did. She was asked where the monitor was located on the resident. She stated she had never seen the device actually on the resident but had seen it hanging on her walker. She was asked if the resident was able to ambulate without her walker. She stated she was, but didn't think she could go too far. At 1:40 p.m., CNA #1 was interviewed and asked if she had ever seen the resident with a wander guard on her body. She stated, "She had one, but it was on her walker." She was asked if the resident was able to ambulate without her walker. She stated she was but generally did not. On [DATE] at 2:45 p.m., the RA was interviewed and asked what her responsibilities were in regards to wander guards. She stated in order to keep track of the actual devices a log book was created so they would know the location of each device. She was asked what other information the log contained. She stated, "Who has a device, when it was assigned and when it expires." A facility binder titled "Code Alert Book" contained hand written entries on blank pages which documented the names of residents who were assigned wander guard bracelets. The first sheet in the binder documented, "Updated [DATE] Code Alerts." The entries on the page documented information pertaining to 12 different residents. The information included the location of where the wander guard were placed on the residents. Resident #1 was not listed in the documentation. A second sheet in the binder documented three entries. The last entry documented, Resident #1's name, an identification number for the actual device and when the device expired. The entry further documented the device was on the resident's walker. A third sheet in the binder documented,"Updated Code Alerts [DATE]." The entries on the page documented information pertaining to 11 different residents and the location of the assigned wander guards. Resident #1's name was included in the list in two separate entries. The first entry documented the device was on her ankle. The second entry dated [DATE], documented the device was on the right ankle, the day of the elopement. The RA was asked about the entry. After reviewing the entry she stated, "I must have put the wrong date on this one." The RA then added, "The book isn't designed to track where the monitor is on the resident, it's so we can keep up with the actual device. The nurses are responsible for the rest." At 3:10 p.m., RN #2 was interviewed and asked about the incident. She verified she was on duty that day and the resident had become very restless after dinner and wanted her keys so she could leave. She stated she contacted the residents family to come sit with the resident to try and calm her down or redirect her. She stated the family member did come to visit, after which time she left to go on break. She was asked what time she left for her break. She stated, "Around 6:45 p.m." She was asked where the resident was at that time, she stated with her granddaughter. She was then asked what time she returned from her break. She stated around 7:25 p.m., at which time someone entered the building and was asking for help to assist a person outside, who was bleeding. She then stated once she reached the scene in the parking lot, the emergency personal had loaded Resident #1 onto a gurney for transport to an emergency department. She was asked how long she thought the resident had been outside unsupervised. She stated it could not have been more than 5 minutes. She was asked if she knew how the resident had gotten outside. She stated she wasn't sure but it was possible she used the door near the nurses desk. She was asked if the door had a monitor on it for the wander guard, she stated it should have, "They all do." She was asked if the resident was wearing a wander guard. She stated, "Yes, she has one, but it was on her walker." 2. Resident #2 was admitted to the facilty with [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was cognitively intact, able to make her needs known and exhibited no behaviors. The assessment further documented the resident required supervision with all activities of daily living. A social services (SS) note, dated [DATE] at 8:31 a.m., documented, "Resident came into the SS office talking about her husband and she wanted to leave. SS explained that her husband is deceased . She insisted that he visits her at night..." A nurses note, dated [DATE] at 11:24 p.m., documented, "resident state she was leaving facility to walk to "chicken coop to meet her son and his kids." her son is dead. she stated chicken coop was like a storage area about 2 blocks from here. she became agitated and resistant to redirection. a wander guard to her ankle had been tried-she was able to remove and stated she would do so again. ... facility DON aware of above. assigned EA (environmental aide) to supervise resident this shift restlessness. ..." A facility incident report dated [DATE] at 4:00 p.m., documented, "Received a call from Dollar General which is aprox (approximately) ,[DATE] (one half) block from this facility, from a family member who remembered (Resident) from when his family member was at the facility. he notified us, and the Med aid from south, (CMA #1) drove to the dollar general and picked her up. The resident stated she needed to go to help her husband who was at home taking care of their 4 small children... Measure to prevent Recurrence: wander Guard placed to keep resident safe and not allow her to leave facility without family or staff." A physicians telephone order, dated [DATE] at 6:12 p.m., documented, "Check placement of wander guard every shift." On [DATE] at 3:20 p.m. the DON was interviewed regarding the elopements. She was asked if she knew how the residents had exited the building. She stated possible through the door at the nurse station on the North hall. She further stated, "She (resident #1) went out the door and walked away. A passer-by saw her fall, called 911 and then came inside to get help." She was asked if the resident had been injured in the fall. She stated, "When she returned to the facility that night she had nasal packings and dark bruises to her face and knees." She was asked who was monitoring the resident at the time of the elopement. She stated, "The staff on the hall. The nurses must have walked off down the hall for a moment and she got up and walked out the door." She was then asked if she thought a resident who was agitated and restless should have been left alone by the staff. The DON stated the resident had spent time with her granddaughter and was thought to be ok as she was left eating ice cream at the nurses desk. She was asked if the resident was documented to have been an elopement risk. She stated she was. She was asked if the resident was wearing a monitoring device to assist in the prevention of elopement. She stated, "Yes, she has wander guard but it was attached to her walker. She has never tried to leave before and she never went anywhere without her walker." She was asked if it was the facility's policy for wander guard devices to be physically on the resident. The DON stated, "Not necessarily. Sometimes the resident has physical limitations that don't allow the bracelets to be put on an extremity." She was asked if resident #1 had any of these type of limitations. She stated she did not. She further stated resident #3 actually cut her device off with scissors, because she didn't like it. The DON was then asked what could have been done differently for resident #1. She stated, "To have the bracelet on her, and not the walker."

Based on observation, record review, and staff and resident interview, it was determined the facility failed to prevent mistreatment, by failing to ensure incontinent care was not provided while a resident, who could not bear her weight, was suspended by her armpits with a sit to stand lift for one (#6) of two sampled residents observed using the sit to stand lift. The resident complained of pain throughout the procedure and requested staff to stop. Staff continued to provide incontinent care until finished. This had the potential to affect 20 residents identified by the facility who needed the sit to stand lift. Findings: A facility policy, titled, Abuse Recognition, Prevention and Reporting, documented, "... No form of abuse or neglect is tolerated in this facility and must be reported immediately. Abuse: (Is) the willful infliction of injury... with resulting physical harm, pain or mental anguish..." Resident # 6 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/30/11, documented the resident was moderately impaired in cognitive skills for daily decision-making, required extensive assistance with transferring and was incontinent of bowel and bladder. The assessment also documented the resident was not ambulatory and was only able to stabilize with human assistance when moving from a seated to standing position, when moving on and off the toilet and during surface to surface transfers. A care plan, last updated on 07/01/11, documented, "...Problem:(Res) requires extensive assistance c all care...Approach: sit to stand lift...peri care after every incontinent episode and prn...Comment: Res able to use sit to stand lift for transfers..." A nurse's note, dated 08/25/11 at 11:45 a.m., documented, "...Personal care giver wanted assistance to transfer resident on 08/24/11 at 4:30 p.m. from w/c to personal vehicle... Sitter than (sic) took resident out north door & proceeded to transfer resident personally c no one present; resident not standing well. Slipping back to sit down. Staff member rushed out to assist sitter c transfer into vehicle..." On 09/21/11 at 10:00 a.m., CNA #1 was observed as she provided incontinent care for the resident. She placed a strap around the resident's upper back and secured the velcro closure in front, just under the resident's breasts. She attached the strap to the sit to stand lift and slowly lifted the resident to a semi-standing position. The resident was not able to stand completely and held her knees in a slightly bent position. The CNA began providing care. The resident had been incontinent of urine. Within a minute after the care began, the resident started to sink down, and was unable to support any of her weight on her own. The strap gradually moved up until it was under the resident's armpits. The resident was suspended by the armpits as the incontinent care began. The resident started saying, "It hurts!" In response, the CNA stated, "Just a minute. I need to clean you up." The resident began saying, "Help!" The CNA continued to provide incontinent care for approximately another seven minutes while the resident repeated, "Stop! Come on! (and) It hurts!" The resident was suspended by the armpits for the duration of the incontinent care as she was unable to maintain any weight bearing on her own. The CNA finished the incontinent care and returned the resident to the wheelchair. The resident was asked if that hurt her. She stated, "Yes." The CNA was asked why she performed incontinent care while the resident was suspended in the sit to stand lift. She stated, "I was taught to do it this way when I started working here." She was asked who trained her. She stated, "Another CNA." She was asked if she should have transferred the resident to the bed to provide incontinent care. She stated, "Yes." On 09/22/11 at 3:00 p.m., the restorative aide was asked how it was determined when a sit to stand lift could be used. She stated residents needed to be able to bear at least 50 percent of their own weight to use the sit to stand lift for a transfer. She was asked if the resident could bear 50 percent of her weight. She stated, "Yes." She was asked how long the resident could bear 50 percent of her own weight. She stated, "Long enough to transfer her from one surface to another." She was asked if the resident could maintain 50 percent weight bearing during a seven minute peri care procedure. She stated she could not.

Based on observations, review of policy and procedure, review of clinical records, and staff and resident interview, it was determined the facility failed to implement it's policy and procedure to: a. prevent mistreatment during the use of a sit to stand lift for one (#6) of one sampled resident who used the sit to stand lift. This caused the resident pain and resulted in actual harm for the resident. This had the potential to affect 20 residents identified by the facility who needed the sit to stand lift; and b. thoroughly investigate an allegation of misappropriation for one (#24) of one sampled resident with an allegation of misappropriation. This had the potential to affect four residents identified by the facility with allegations of misappropriation in the last four months. Findings: A facility policy statement, titled, Abuse Prevention, documented, "...Our facility will not condone resident abuse by anyone, including staff members... In an effort to prevent the possibility of abuse, this facility will:... Conduct in-service training on how to prevent abuse and on the proper procedures to follow when abuse is suspected. In-service training will also include signs to watch for in employees that may lead to abuse... The facility has in place set procedures to follow in the event of an abuse allegation..." A facility policy titled, Abuse Investigation, documented, "...All reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source shall be promptly and thoroughly investigated... 4. All allegations will be investigated... 8. Take a statement from the victim... 12. Make a list of all employees on the shift during which the alleged incident occurred... 13. Using the Resident Abuse Report Form take statements from each one of the shift personnel or other potential witnesses (family members, roommates, etc... 14. Document all interviews. Obtain clear, concise but complete description of what the allegation is from the complainant or other reporter... 15. Interview the alleged perpetrator...Take a statement...Document your interview and the responses given... 16. Utilizing the Resident Abuse Investigation Report Form, assemble and summarize data accumulated during the internal investigation... 1. Resident # 6 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/30/11, documented the resident was moderately impaired in cognitive skills for daily decision-making, required extensive assistance with transferring and was incontinent of bowel and bladder. The assessment also documented the resident was not ambulatory and was only able to stabilize with human assistance when moving from a seated to standing position, when moving on and off the toilet and during surface to surface transfers. A care plan, last updated on 07/01/11, documented, "...Problem:(Res) requires extensive assistance c all care...Approach: sit to stand lift...peri care after every incontinent episode and prn...Comment: Res able to use sit to stand lift for transfers..." A nurse's note, dated 08/25/11 at 11:45 a.m., documented,"...Personal care giver wanted assistance to transfer resident on 08/24/11 at 4:30 p.m. from w/c to personal vehicle... Sitter than (sic) took resident out north door & proceeded to transfer resident resident personally c no one present; resident not standing well. Slipping back to sit down. Staff member rushed out to assist sitter c transfer into vehicle..." On 09/21/11 at 10:00 a.m., CNA #1 was observed as she provided incontinent care for the resident. She placed a strap around the resident's upper back and secured the velcro closure in front, just under the resident's breasts. She attached the strap to the sit to stand lift and slowly lifted the resident to a semi-standing position. The resident was not able to stand completely and held her knees in a slightly bent position. The CNA began providing care. The resident had been incontinent of urine only. Within a minute after the care began, the resident started to sink down, and was unable to support any of her weight on her own. The strap gradually moved up until it was under the resident's armpits. The resident was suspended by the armpits as the incontinent care began. The resident started saying, "It hurts!" In response, the CNA stated, "Just a minute. I need to clean you up." The resident began saying, "Help!" The CNA continued to provide incontinent care for approximately another seven minutes while the resident repeated, "Stop! Come on! (and) It hurts!" The resident was suspended by the armpits for the duration of the incontinent care as she was unable to maintain any weight bearing on her own. The CNA finished the incontinent care and returned the resident to the wheelchair. The resident was asked if that hurt her. She stated, "Yes." The CNA was asked why she performed incontinent care while the resident was suspended in the sit to stand lift. She stated, "I was taught to do it this way when I started working here." She was asked who trained her. She stated, "Another CNA." She was asked if she should have transferred the resident to the bed to provide incontinent care. She stated, "Yes." On 09/22/11 at 3:00 p.m., the restorative aide was asked how it was determined when a sit to stand lift could be used. She stated residents needed to be able to bear at least 50 percent of their own weight to use the sit to stand lift for a transfer. She was asked if the resident could bear 50 percent of her weight. She stated, "Yes." She was asked how long the resident could bear 50 percent of her own weight. She stated, "Long enough to transfer her from one surface to another." She was asked if the resident could maintain 50 percent weight bearing during a seven minute peri care procedure. She stated she could not. 2. Resident #24 was admitted to the facility with [DIAGNOSES REDACTED]. The February 2011 medication administration record documented the resident did not receive any narcotic pain medication for the entire month. A comprehensive pain assessment form for a cognitively intact resident, dated 02/17/11, documented, "...mental status: alert, answered questions readily...resident denied pain & no s/s @ time of assessment. Body relaxed, resident cheerful..." The March 2011 medication administration record documented the resident did not receive any narcotic pain medication for the entire month. The MAR also documented the resident had a "0" on a 1-10 pain scale on every shift every day during the month of March 2011. A comprehensive pain assessment form for a cognitively intact resident, dated 03/10/11, documented the resident denied pain and had not received any pain medications during the month. A physician's telephone order, dated 03/20/11, documented, "[MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME]) 1 tablet PO Q 4 HRS PRN pain Give as: 5-325 [MEDICATION NAME]([MEDICATION NAME] sodium) 1 tablet PO Q 4 HRS PRN pain..." The April 2011 medication administration record documented the resident did not receive any pain medication for the entire month. The MAR also documented the resident had a "0" on a 1-10 pain scale on every shift every day during the month of April 2011. A care plan, updated on 04/05/11, did not document any problems or interventions for pain. The May 2011 MAR documented the resident received [MEDICATION NAME] 5-325 mg one tablet on 05/13/11 at midnight for "complaints of aching all over." This dose was signed out as given by RN #1. The resident's pain was assessed to be a "4" on a 1-10 pain scale. The MAR also documented the resident received [MEDICATION NAME] 5-325 mg one tablet on 05/14/11 at 1:15 a.m. for "c/o generalized discomfort." This dose was also signed out as given by RN #1. The resident's pain was assessed to be a "2" on a 1-10 pain scale. An individual narcotic record for [MEDICATION NAME] documented two tablets of [MEDICATION NAME] 5-325 mg were signed out by RN #1 on 05/20/11 at 11:00 p.m. There was no documentation the medication was given on the May 2011 medication administration record. There were no nurses' notes documented for the resident on any dates [MEDICATION NAME] was given. The only complaints of pain were documented on the 10:00 p.m. to 6:00 a.m. shift during May 2011. All other shifts documented the resident's pain at "0". An incident report form to the OSDH, dated 05/24/11, documented, "...Administrator was asked to visit c resident and her daughter in res. room. Resident made me aware that she had not taken pain medication for over a month. She asked to review her May (2011 medication administration record) sheets. She reported to me that there were narcotics signed out on her med sheet that she never received. Administrator noted (RN #1) initials. (RN #1) suspended from her staff position until after drug screen is completed..." An attached narrative from the administrator, dated 05/25/11, documented, "Part C... (Summary of the Investigation)... (RN #1) was taken to (hospital name deleted) ER the night of May 24th, 2011 and drug tested for multiple drugs as standard drug protocol requires. Her drug test returned Negative and she made us aware that she has a prescription for [MEDICATION NAME] for her shoulder...CMAs on different shifts brought this alleged situation to light...Director of Nurses, Nurse Manager, nor me found misappropriation of resident's medications. (Administrator's signature)." On 09/23/11 at 8:05 a.m., the administrator was asked about the investigation into the allegation made by the resident regarding misappropriation of narcotics. She stated the resident asked her why the staff kept asking her if she was getting pain medication at night. The resident stated she hadn't taken any pain medication and wanted to look at her medication administration record. The administrator stated the resident denied ever receiving pain medication at night as documented on the MAR. She was asked if the resident was cognitively aware. She stated, "Yes. Very aware. She used to work in the health care field." She was asked if there were notes documenting interviews with the resident, the family, the alleged perpetrator and other staff who may have knowledge of the circumstances. She stated there was no documentation of interviews or of the investigation. She was asked if anyone had been asked to write a statement. She stated, "No." She was asked if any other residents under the nurse's care had been interviewed about their pain and pain medication administration. She stated she didn't believe so. She was asked if there had been any review of documents including the resident's past medication administration records, nurse's notes regarding the resident's pain, the nurse's administration of narcotics to other residents, or audits of narcotic records. She stated they had looked at the resident's May 2011 records. She was asked if any other residents' records had been reviewed for narcotic administration. She stated she did not think so. She was asked if RN #1 was supervised on the night shift. She stated she was not. She was asked if the nurse's practice was being monitored by administration. She stated,"No." She was asked how she concluded there was no misappropriation of narcotics. She stated, "We determined there was a medication error and we dealt with that." A review of September 2011 prn narcotic administration records for all residents cared for by RN #1 on Hall 500 revealed: 1. RN #1 administered various prn narcotics on the night shift to seven out of eight (#7, 18, 28, 29, 30, 31, and #32) residents with prn narcotic orders. No other night shift nurse administered narcotics to these residents in the month of September 2011. 2. RN #1 administered prn [MEDICATION NAME] on the night shift to six out of six (#7, 28, 29, 30, 31, and #32) residents with prn [MEDICATION NAME] orders. No other night shift nurse administered [MEDICATION NAME] to these residents in the month of September 2011. 3. RN #1 was the only staff person from all three shifts to administer prn [MEDICATION NAME] to three (#28, 29 and #31) residents and 4. RN #1 was the only night shift nurse who treated pain with narcotics on the residents who resided on Hall 500.

Based on observation, review of clinical record, and staff and resident interviews, it was determined the facility failed to assess, monitor, and intervene in the management of pain for two (#1 and #12) of 14 sampled residents who required pain management. This had the potential to effect 32 residents identified by the facility who received pain management. Findings: 1. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 06/08/10, documented, "Problem: (Resident) c/o or shows evidence of pain less than daily 12-17-10 (Resident) is on routine pain medication. Goal: (Resident) will show evidence of relief from any episodes of pain 12/17/10 (Resident) will show evidence of relief from any episodes of pain. Approach: 1) Medicate as ordered with [MEDICATION NAME]. Monitor and record response. 2) Assess for cause of pain and attempt to eliminate. 3) Position for comfort. 4) Alternate relief measures (e.g. backrub, relaxation exercises, guided imagery). Comment: DC [MEDICATION NAME] 12-17-10 [MEDICATION NAME] 50 mg tablet po tid 12-17-10 [MEDICATION NAME] 7.5 mg tablet po bid give with food 12-17-10 Tylenol 325 mg give 1 or 2 tab po q 4 hours prn pain or (increased) temp." A significant change assessment, dated 09/30/10, documented the resident had modified independence in cognitive skills for daily decision making and had moderate pain less than daily. A quarterly assessment, dated 12/03/10, documented the resident was moderately impaired in cognitive skills for daily decision making. It also documented the resident was able to express her ideas and wants and was able to understand others. The resident was on a scheduled pain medication regimen and had no complaints of pain in the last five days. The monthly physician's orders [REDACTED]. The January 2011 MARs, documented, the resident's [MEDICATION NAME] 7.5 mg tablet was circled as not given on: 01/06/11 at 8:00 a.m. and 8:00 p.m. 01/07/11 at 8:00 a.m. 01/08/11 at 8:00 a.m. and 8:00 p.m. 01/09/11 at 8:00 a.m. and 8:00 p.m. 01/10/11 at 8:00 a.m. 01/11/11 at 8:00 a.m. and 8:00 p.m. 01/12/11 at 8:00 a.m. and 8:00 p.m. 01/13/11 at 8:00 a.m. and 8:00 p.m. and 01/14/11 at 8:00 a.m. The January 2011 MARs documented the resident's [MEDICATION NAME] 7.5 mg tablet was blank on: 01/07/11 at 8:00 p.m. and 11/10/11 at 8:00 p.m. The back of the January 2011 MARs documented, "1-13 Med on order. Nurse notified." A Fax to the physician, dated 01/14/11, documented, "...It was noted pt has not had her [MEDICATION NAME] in 9 days bid. Will get this in the bldg (building) today. CMAs didn't report not having it..." On 01/27/11 at 6:05 p.m., the resident was asked if she knew she had gone without her [MEDICATION NAME] for nine days in January. She stated she was not aware that she had gone without it. She then stated, "I did notice that my legs and hips were hurting a lot more. I wasn't getting it?" She was asked what she would rate her pain when she was hurting during that time. She stated she would rate the pain a 9 on a scale of 1 to 10. The resident then asked, "Am I getting it now? It doesn't hurt as much. It feels better." She was asked what she would rate her pain now. She stated she would rate the pain a 5 on a scale of 1-10. At 6:15 p.m., CMA #2 was asked if she worked on the resident's hall and was she aware the resident had not received her [MEDICATION NAME]. She stated she first worked the hall on 01/13/11. She stated she couldn't locate the [MEDICATION NAME] 7.5 mg for the resident, so she informed the charge nurse and charted it on the back of the MAR. At 6:20 p.m., nurse manager #1 was asked why the resident had not received her [MEDICATION NAME] for 17 doses. She stated the CMA reordered the resident's [MEDICATION NAME] on 12/30/10, but the fax didn't go through to the pharmacy, so they didn't get the information to send it out to the facility. She stated the resident ran out of [MEDICATION NAME] on 01/06/11. She was asked why the medication was not given for nine days. She stated she didn't know why it wasn't ordered, but thought the CMA who worked during that period just kept pushing off the reordering of the medication and didn't give it. 2. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, last updated on 12/27/10 documented the resident had evidence of pain. The care plan also documented, "Goal: Resident will show evidence of relief from any episodes of pain within 60 minutes of onset this quarter... Approach: Medicate as ordered...monitor and record response...assess for cause of pain and attempt to eliminate...position for comfort...alternate relief measures (e.g. backrub, relaxation exercises, guided imagery...)" An annual assessment, dated 01/10/11, documented the resident had independent cognitive skills for daily decision-making and was on a pain management regimen. The assessment documented she had almost constant pain which she rated as "severe." A monthly physician's orders [REDACTED]. A MAR for December 2010 documented the resident did not receive [MEDICATION NAME] as ordered on [DATE] at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. The MAR indicated not available" for those doses. The MAR indicated [REDACTED]. The December MAR indicated 0" for every shift, every day for the entire month of December. On 01/26/11 at 10:40 a.m., the resident was asked if she recalled 12/28/10 when she did not receive the [MEDICATION NAME] as ordered. She stated, "Yes. I didn't get my pain medication for 12 or 13 hours." She was asked to describe her pain during that time. She stated the pain was "worse" than usual. She was asked to rate the pain at that time. She stated, "It was an 8." She stated when she received the [MEDICATION NAME], her pain was rated as "4." She was asked what the facility told her about the pain medication. She stated, "They told me someone didn't order it like they were supposed to." She was asked how the absence of pain medication affected her that day. She stated, "I didn't want to read or watch TV. I just wanted to lie still." She was asked what the facility provided instead of the [MEDICATION NAME]. She stated, "They gave me plain Tylenol once that day." At 4:45 p.m., LPN #8 was asked why the pain medication was not refilled for the resident in time to avoid missing doses. She stated she did not know. She was asked if it would be usual for the resident to rate her pain as "0." She stated, "No."

Based on observation, review of clinical record and staff interview, it was determined the facility failed to prevent an actual harm severe weight loss of 5.4% in one month and 14.7% in six months for one (#6) of four sampled residents with a severe weight loss. This had the potential to effect ten residents identified by the facility as having a severe weight loss in the past six months. Findings: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 02/25/10 and last updated 11/10/10, documented, "Problems: ...Supervision for locomotion on & off unit & eating... Approach: 1) (Resident) eats meals on the sunporch can feed self after tray set up..." There was no care plan which addressed nutrition and significant weight loss. A facility weight record titled, Resident Weights, documented the following weights: 07/15/10: 102.0 lbs 08/15/10: 101.0 lbs 09/15/10: 93.0 lbs 10/15/10: 93.0 lbs 11/15/10: 93.0 lbs 12/15/10: 92.0 lbs 01/01/11: 98 lbs 01/15/11: 87 lbs The resident had an 11.2% weight loss between 01/01/11 and 01/15/11 and 14.7% weight loss in the past six months. A form, titled Dietitian's Recommendation's to Physician, dated 09/22/10, documented, "Health shakes tid for wt loss. 8-15-10 wt 101# 9-15-10 wt 93#." The dietary recommendation was signed by the physician. A form, titled Medical Nutrition Therapy Progress Notes, documented, "...9-30-10. Wt 93# - Significant wt loss for past 30 days. On 9-22-10 ordered health shakes tid." A form, titled Dietary Monthly Summary, documented, "...September 2010: No dietary changes. No new labs. 9-1 wt 99#. 9-15 wt (down) 93#. Staff states appetite has decreased. Will start her on health shakes tid for wt loss + Dr notified by fax. No new labs. October 2010: No dietary changes. No new labs. 10-1 wt 94# + 10-15 wt 93#. November 2010: Appetite remains small consuming R (refusal) - 100% of meals. She continues to eat meals on the sunporch where staff continues to encourage meal + fluid intake. 11-1 wt 92# + 11-15 wt 93#." A quarterly assessment, dated 11/16/10, documented the resident was severely impaired in cognitive skills for daily decision making and required supervision with set up help only with meals. A form, titled Dietary Monthly Summary, documented, December 2010: No dietary changes. No new labs. 12-1 wt 89# + 12-15 wt 92#." A nurse's note, dated 12/21/10 at 6:00 p.m., documented, "...Received report resident had emesis x3..." A nurse's note, dated 12/22/10 at 6:00 a.m., documented, "Now having diarrhea stools." A nurse's note, dated 12/23/10 at 9:00 p.m., documented, "Diarrhea conts." A nurse's note, dated 12/25/10 at 9:00 p.m., documented, "(No) diarrhea this shift." A nurse's note, dated 12/26/10 at 3:55 a.m., documented, "N/c (no complaints) of n/v. No diarrhea reported tonight..." There was no monthly dietary summary for the month of January 2011. A form, titled Dietary Sheet, for January 2011 documented the resident's average intake for the following meals: Breakfast: 89% Lunch: 42% Supper: 36%. On 01/27/11 at 9:30 a.m., the CDM was asked how the resident's intake was. She stated the resident never sat still and wouldn't sit still for meals. She stated they tried to give the resident finger foods and health shakes. The CDM was asked if a resident presented with a significant weight loss, how would she proceed. She stated she would first check the resident's physician orders [REDACTED]. She stated she would then fax the physician to notify of the weight loss and ask for health shakes as a supplement. She was asked what would she do if the resident was already on health shakes. She stated she would visit with the nurses, get suggestions, then fax the physician and request either med pass or a super donut. She stated she would fax the physician immediately upon receiving the resident's weights showing a significant weight loss. The CDM was asked if she had notified the physician of the resident's severe weight loss in January 2011. She stated, "No." She was asked if she was aware the resident had had a severe weight loss in January 2011. She stated she was not aware the resident had lost weight so she did not notify the physician or make any recommendations. At 9:55 a.m., CNA #3 was asked if he had noticed if the resident's intake had been declining. He stated, "Yes it is getting worse. She's eating less and less." He was asked if she was declining overall. He stated, "No, she's just not eating." He then stated he felt the resident was having trouble swallowing liquids. He stated the resident would just stop eating when she would start to cough. At 10:00 a.m., LPN #4 was asked if the resident was eating less recently. She stated, "She seems to be eating less." The LPN stated the resident had some dysphagia and would choke at times. She stated a swallow study had been discussed with the family, but they wanted to wait and see. She stated the resident needed more help with meals on some days. The LPN stated she was not aware if the resident's physician had been notified of the weight loss.