Every finding on record at Trinity Woods, Inc.

Based on observation, interview, facility policy review, and Centers for Disease Control and Prevention (CDC) and the National Institute for Occupational Safety and Health (NIOSH) guidance, the facility failed to ensure staff were fit tested for N95 respirator masks annually. Additionally, the facility failed to maintain sanitary technique and prevent contamination of medication for 4 (Resident #10, #26, #38, and #44) of 5 sampled residents observed for medication administration, when the nurse touched the medications with bare hands, and the facility failed to ensure equipment used for vital sign readings (measurements including body temperature, heart rate, respiratory rate, and blood pressure that indicate the status of the body's vital functions) among multiple residents was disinfected between residents' uses for 3 (Resident #10, #38 and #42) of 3 sampled residents observed for vital sign readings.Findings included: 1. A facility policy titled, COVID [coronavirus disease of 2019, COVID-19] Guidelines, dated 09/30/2024, in the section Personal Protective Equipment indicated, Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard. An undated publication by the Centers for Disease Control and Prevention (CDC) and the National Institute for Occupational Safety and Health (NIOSH) titled, Filtering Out Confusion: Frequently Asked Questions about Respiratory Protection, in the section How Often Must Fit Testing Be Conducted? indicated, In addition to fit testing upon initially selecting a model of respirator, OSHA requires that fit testing be conducted annually, and repeated 'whenever an employee reports, or the employer or the physician or other licensed health care professional makes visual observations of changes in the employee's physical condition that could affect respirator fit.' During an interview on 06/03/2026 at 10:51 AM, the Infection Preventionist (IP) stated she had been at the facility approximately 22 months, fit testing for N95 masks was done before she started her position, but she had not done fit testing for any of the staff. The IP stated the person certified to fit test staff for N95 masks was no longer with the facility. During an interview on 06/03/2026 at 11:07 AM, the Administrator (ADM) stated the facility had not fit tested for N95 masks since the current IP had been in the role. During an interview on 06/03/2026 at 2:02 PM, Licensed Practical Nurse (LPN) #5 stated she had been with the facility since October 2025, and she had not been fit tested for an N95 mask. During an interview on 06/03/2026 at 2:08 PM, Certified Medication Aide (CMA) #7 stated she had been with the facility for a year and a half, and she had not been fit tested for an N95 mask with the facility. During an interview on 06/03/2026 at 2:10 PM, Certified Nursing Assistant (CNA) #8 stated she had been with the facility 11 years, she thought she was last fit tested for an N95 mask three years ago, and she was certain she had not been fit tested for an N95 mask within the past year. During an interview on 06/03/2026 at 1:50 PM, the ADM stated they could not find a list of staff who had been fit tested for N95 masks. 2. A facility policy titled, Administering Medications, revised 01/2016, revealed, 14. Staff shall follow established facility infection control procedures (e.g. [exempli gratia, for example], hand washing, aseptic technique, gloves, isolation precautions, etc. [et cetera, and other similar things]) when these apply to administering medications. A. An admission Record revealed the facility admitted Resident #44 on 10/16/2023. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, overactive bladder, foot drop of the right foot, and osteoarthritis of the knee. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2026, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. A Medication Administration Record [MAR], dated 06/2026, revealed Household Manager (HM) #6 administered Resident #44's morning medications on 06/03/2026, which included the following medications:- aspirin (a platelet aggregation inhibitor), one 325 milligrams (mg) tablet by mouth for deep vein thrombosis (DVT);- Lasix (furosemide, a diuretic), one 40 mg tablet by mouth for edema (swelling from excess fluid); - potassium chloride (a mineral, electrolyte), one Extended Release (ER) 10 milliequivalent tablet by mouth for the prevention of hypokalemia (low potassium) due to diuretics;- sertraline hydrochloride (Zoloft, an antidepressant), one 50 mg tablet for major depressive disorder;- Colace (docusate, a stool softener), one 100 mg capsule by mouth; and- Neurontin (gabapentin, an anticonvulsant for nerve pain), one 100 mg capsule by mouth. An observation of medication administration, on 06/03/2026 at 10:37 AM, revealed HM #6 prepared and administered medications to Resident #44. The observation revealed HM #6 removed Resident #44's oral medications from individual medication bottles and placed the medications into HM #6's ungloved left hand before putting the medications into a medication cup for administration. The observation revealed the medications that HM #6 administered to Resident #44 on 06/03/2026 at 10:37 AM included gabapentin, potassium chloride, furosemide, sertraline, aspirin, and docusate. B. An admission Record revealed the facility admitted Resident #26 on 04/02/2026. According to the admission Record, the resident had a medical history that included diagnoses of metabolic encephalopathy, traumatic subarachnoid hemorrhage with loss of consciousness, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2026, revealed Resident #26 had moderate impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). A Medication Administration Record [MAR], dated 06/2026, revealed on 06/03/2026 Household Manager (HM) #6 administered Resident #26 one amantadine (an antiviral, antiparkinsonian agent) tablet orally for tremors. An observation of medication administration, on 06/03/2026 at 10:48 AM, revealed HM #6 prepared and administered amantadine to Resident #26. The observation revealed HM #6 removed Resident #26's amantadine tablet from a multi-dose medication packaging card into HM #6's ungloved left hand before placing the medication into a medication cup for administration. The observation revealed HM #6 then administered the amantadine to Resident #26. C. An admission Record revealed the facility admitted Resident #38 on 12/15/2025. According to the admission Record, the resident had a medical history that included diagnoses of vitamin deficiency and essential hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2026, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. A Medication Administration Record [MAR], dated 06/2026, revealed Household Manager (HM) #6 administered Resident #38's morning medications on 06/03/2026, which included one 5 milligram (mg) tablet of Norvasc (amlodipine, a calcium channel blocker to lower blood pressure) and a multivitamin/mineral tablet. An observation of medication administration, on 06/03/2026 at 11:00 AM, revealed HM #6 prepared and administered medication to Resident #38. The observation revealed HM #6 removed Resident #38's amlodipine tablet from a multi-dose medication packaging card, and the tablet fell to the surface of the medication cart. The observation revealed HM #6 picked the tablet up from the surface of the cart with her ungloved left hand before placing the medications into a medication cup for administration. HM #6 was then observed to remove Resident #38's multivitamin from a multi-dose medication packaging card into HM #6's left hand before placing the multivitamin into a medication cup for administration. D. An admission Record revealed the facility admitted Resident #10 on 02/27/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory with hypoxia, acute bronchitis, constipation, vitamin deficiency, acute on chronic combined systolic and diastolic heart failure, other seasonal allergies, atrial fibrillation, and chronic kidney disease. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2026, revealed Resident #10 had severe impairment in cognitive skills for daily decision making and had a short-term and long-term memory problem per a staff assessment for mental status (SAMS). A Medication Administration Record [MAR], dated 06/2026, revealed Household Manager (HM) #6 administered Resident #10's morning medications on 06/03/2026, which included:- amiodarone (an antiarrhythmic, one 200 milligram (mg) tablet by mouth related to long lasting persistent atrial fibrillation;- cetirizine (an antihistamine), one 10 mg tablet by mouth for allergies;- torsemide (a diuretic), one 20 mg tablet by mouth for fluid retention:- a chewable multivitamin with minerals for hair, skin, and nails, one tablet by mouth for vitamin deficiency;- docusate sodium (a stool softener), one 100 mg capsule by mouth for constipation;- age-related macular degeneration multivitamin/mineral tablets, one capsule by mouth for vitamin deficiency;- Mucinex (guaifenesin, an expectorant), one extended release (ER) 600 mg tablet by mouth for cough and congestion; and- potassium chloride, 20 MEQ (milliequivalent) for low potassium; and- midodrine HCL (midodrine hydrochloride, for low blood pressure), one 2.5 mg tablet by mouth for syncope (fainting). A medication administration observation, on 06/03/2026 at 11:15 AM, revealed HM #6 prepared and administered medication to Resident #10 including: torsemide, docusate, mucous relief medication, midodrine, potassium chloride, an age-related macular degeneration multivitamin/mineral tablet, a chewable multivitamin with minerals for hair, skin, and nails, cetirizine, and amiodarone. The observation revealed HM #6 removed Resident #10's oral medications from multi-dose medication packaging cards into HM #6's ungloved left hand before placing the medication into a medication cup and transferring the medications to a plastic sleeve for crushing. During an interview on 06/03/2026 at 12:46 PM, HM #6 stated she had been trained to remove medication from the pill pack or bottle and place it directly into the pill cup without touching the medications. HM #6 stated that on the morning of 06/03/2026 she started the medication administration process an hour late, and she began placing the medication into her hand because she thought that would speed up the process. HM #6 stated she should have donned a glove before touching any medications. HM #6 stated she knew that she should not touch resident medications because it could be an infection control concern for the residents. During an interview on 06/04/2026 at 1:12 PM, the Infection Preventionist (IP) stated staff were never to place medications in their bare hands during medication preparation, and pills dropped on the surface of the medication cart should be discarded and another dose should be used for administration. During an interview on 06/04/2026 at 10:34 AM, the Director of Nursing (DON) stated HM #6 should not put pills in HM #6's hand when administering medications to residents because of infection control concerns. 3. A facility policy titled, Standard Precautions, revised 01/2026, revealed, 5b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded. A. An admission Record revealed the facility admitted Resident #42 on 03/06/2026. According to the admission Record, the resident had a medical history that included diagnoses of syncope and collapse, hypokalemia, atrial fibrillation, gastroesophageal reflux disease, vitamin deficiency, depression, anxiety disorder, essential hypertension, esophageal obstruction, constipation, age related osteoporosis, pain, unspecified dementia, and zygomatic (cheekbone) fracture right side. A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2026, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Resident #42's Order Summary Report, dated 06/04/2026, revealed an order that indicated vital signs were to be taken weekly on Sundays, started 06/03/2026. An observation, on 06/03/2026 at 9:37 AM, revealed Household Manager (HM) #6 obtained Resident #42's blood pressure, pulse, oxygen saturation, and temperature readings with a device used for multiple residents. The observation revealed HM #6 did not clean the multiuse device either before or after use. B. An admission Record revealed the facility admitted Resident #38 on 12/15/2025. According to the admission Record, the resident had a medical history that included diagnoses of vitamin deficiency and essential hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2026, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #38's Order Summary Report, dated 06/04/2026, revealed an order that indicated vital signs were to be taken every shift, started 12/15/2026.An observation, on 06/03/2026 at 10:00 AM, revealed Household Manager (HM) #6 obtained Resident #38's blood pressure, pulse, oxygen saturation, and temperature reading with a device used for multiple residents. The observation revealed HM #6 did not clean the equipment either before or after use. C. An admission Record revealed the facility admitted Resident #10 on 02/27/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory with hypoxia, acute bronchitis, constipation, vitamin deficiency, acute on chronic combined systolic and diastolic heart failure, other seasonal allergies, atrial fibrillation, and chronic kidney disease. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2026, revealed Resident #10 had severe impairment in cognitive skills for daily decision making and had a short-term and long-term memory problem per a staff assessment for mental status (SAMS). Resident #10's Order Summary Report, dated 06/04/2026, revealed an order that indicated vital signs were to be taken every shift, started 02/28/2026. During an observation, on 06/03/2026 at 10:20 AM, Household Manager (HM) #6 was observed to obtain Resident #10's blood pressure, pulse, oxygen saturation, and temperature readings with a device used for multiple residents. The observation revealed HM #6 was not observed to clean the equipment either before or after use. During an interview on 06/03/2026 at 12:46 PM, HM #6 stated she had been trained to disinfect the vital sign equipment between residents. HM #6 stated she should have disinfected the vital-sign equipment between each resident but did not think about it at the time. During an interview on 06/04/2026 at 1:12 PM, the Infection Preventionist (IP) stated staff were educated to disinfect vital sign equipment between each resident use, and HM #6 should have disinfected the equipment between residents. During an interview on 06/04/2026 at 10:34 AM, the Director of Nursing (DON) stated HM #6 should have disinfected the vital sign equipment between each resident.

Based on interview, record review, and facility policy review, the facility failed to notify a physician when a resident's vital signs were outside physician-ordered parameters for 1 (Resident #13) of 17 sampled residents. Specifically, a Physician wrote an order to be notified when Resident #13's systolic blood pressure (SBP) was above 160 millimeters of mercury (mm/Hg). The facility measured 35 blood pressure readings from 05/10/2026 through 05/31/2026 that were above 160 mm/Hg for Resident #13 that were not reported to the Physician. Findings included: A facility policy titled, Blood Pressure, Measuring, revised 01/2016, indicated, 4. Hypertension is defined as blood pressure over 140/90 mm/Hg (although the elderly often have persistent systolic readings from 140 to 160 mm/Hg [sic]. 5. Hypertension should be reported to the physician. An admission Record revealed the facility admitted Resident #13 on 05/04/2026. According to the admission Record, the resident had a medical history that included a diagnosis of essential hypertension. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/10/2026, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #13's Care Plan Report, included a problem statement dated 05/14/2026, that indicated the resident had hypertension. Interventions directed staff to notify the doctor if the SBP was over 160 mm/Hg. Resident #13's Order Summary Report, for active orders as of 06/02/2026, included an order dated 05/04/2026 to notify the physician if systolic blood pressure was above 160 mm/Hg. Resident #13's Weights and Vitals Summary for the timeframe from 05/04/2026 through 06/04/2026 included the following blood pressures:162/68 mm/Hg on 05/10/2026 at 08:09 PM173/68 mm/Hg on 05/14/2026 at 8:24 AM166/72 mm/Hg on 05/14/2026 at 10:41 PM168/64 mm/Hg on 05/15/2026 at 8:09 AM168/64 mm/Hg on 05/15/2026 at 3:36 PM165/74 mm/Hg on 05/16/2026 at 8:09 AM165/74 mm/Hg on 05/16/2026 at 8:10 AM165/74 mm/Hg on 05/16/2026 at 6:16 PM162/68 mm/Hg on 05/16/2026 at 8:37 PM170/68 mm/Hg on 05/17/2026 at 8:44 AM170/68 mm/Hg on 05/17/2026 at 8:45 AM170/68 mm/Hg on 05/17/2026 at 11:42 AM163/71 mm/Hg on 05/17/2026 at 9:07 PM169/68 mm/Hg on 05/18/2026 at 9:56 AM169/68 mm/Hg on 05/18/2026 at 9:57 AM169/68 mm/Hg on 05/18/2026 at 9:58 AM167/67 mm/Hg on 05/20/2026 at 7:55 AM167/61 mm/Hg on 05/21/2026 at 8:10 AM197/84 mm/Hg on 05/22/2026 at 8:08 AM163/72 mm/Hg on 05/23/2026 at 9:37 PM174/70 mm/Hg on 05/24/2026 at 9:08 PM174/70 mm/Hg on 05/24/2026 at 9:09 PM162/79 mm/Hg on 05/24/2026 at 9:48 PM169/69 mm/Hg on 05/25/2026 at 11:33 AM169/69 mm/Hg on 05/25/2026 at 11:34 AM169/79 mm/Hg on 05/26/2026 at 8:44 AM169/79 mm/Hg on 05/26/2026 at 8:45 AM169/79 mm/Hg on 05/26/2026 at 8:46 AM166/64 mm/Hg on 05/29/2026 at 7:57 AM166/64 mm/Hg on 05/29/2026 at 5:10 PM185/82 mm/Hg on 05/30/2026 at 8:13 AM185/82 mm/Hg on 05/30/2026 at 1:57 PM162/74 mm/Hg on 05/30/2026 at 9:47 PM162/74 mm/Hg on 05.31/2026 at 8:50 AM162/74 mm/Hg on 05.31/2026 at 8:51 AM During an interview on 06/02/2026 at 2:24 PM, Certified Medication Aide (CMA) #2 stated CMAs gathered vital signs and verbally told the nurse if they were elevated, but that was not documented. She stated that she had collected Resident #13's vital signs, which had been high, but not high enough to report to the nurse. She stated that if there was a threshold for reporting Resident #13's elevated blood pressure, it had not been communicated to the CMAs. During a telephone interview on 06/02/2026 at 3:31 PM, Registered Nurse (RN) #3 stated that nurses notified the physician when Resident #13's SBP was above 160 mm/Hg. RN #3 stated that they also documented the notification, but she was not sure if she had documented her notifications to the physician. During an interview on 06/03/2026 at 8:54 AM, Licensed Practicing Nurse (LPN) #4 stated the medication administration record (MAR) indicated if a vital sign needed to be reported to the physician and staff notified the physician via an encrypted messaging application. LPN #4 stated that the CMAs took the resident's vital signs before administering medications. LPN #4 stated the reporting thresholds were in the MAR. She stated that CMAs should report anything out of clinical range. During an interview on 06/03/2026 at 12:22 PM, the Medical Director stated that the nurses used a Health Insurance Portability and Accountability Act (HIPAA) compliant communication system to report elevated vital signs. He stated that he reviewed his communications for Resident #13 and found no indication of elevated blood pressures. He stated he was not aware of the abnormal blood pressures, and he would expect staff to notify him of blood pressures outside the physician-ordered parameters. During an interview on 06/04/2026 at 9:49 AM, the Director of Nursing (DON) stated that when vital signs were outside of physician-ordered parameters, they were reported via the facility's encrypted communication system to the physician. The DON stated that when a vital sign was outside the parameter, it created an alert. The DON stated that nursing staff used that alert to document the physician notification. During an interview on 06/04/2026 at 10:16 AM, the Administrator stated vital signs outside the physician-ordered parameters were communicated to the physician via the facility's encrypted communication system. The Administrator stated that if staff had to report to the physician, they should know what the thresholds were.

Based on interview, record review, facility document review, and facility policy review, the facility failed to implement a pharmacy recommendation for discontinuation of an antidepressant medication for 1 (Resident #5) of 5 residents reviewed for unnecessary medications. Specifically, the pharmacist recommended to review Resident #5's sertraline 12.5 milligrams (mg) via peg-tube once daily (QD) for depression. The Medical Director (MD) agreed with the recommendation to discontinue the medication, and the facility failed to follow the order to discontinue it.Findings included: A facility policy titled, Medication Utilization and Prescribing Clinical Protocol, reviewed January 2016, revealed, The Physician, Consultant Pharmacist and staff will adjust existing medications based on their efficacy and the continued presence of relevant conditions and risks. Resident #5's admission Record, indicated the facility admitted the resident on 05/22/2022. According to the admission Record, the resident had a medical history that included diagnoses of aphasia (loss of speech due to an injury to the brain), gastrostomy status (a surgical incision into the stomach to allow placement of a tube for food and nutrition), and other recurrent depressive disorders (at least two major depressive episodes with periods of no depression in between them). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2026, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Per the MDS, Resident #5 received antidepressant medication during the assessment's seven-day lookback period. Resident #5's Care Plan Report included a focus area, revised 10/13/2025, that indicated the residents had prescribed antidepressant medication to treat depression. Interventions directed staff to monitor for medication side effects. The care plan further indicated that the last gradual dose reduction (GDR) for the antidepressant medications was on 05/01/2023. Resident #5's Order Summary Report for active orders as of 06/02/2026, included an order dated 09/02/2025, for sertraline (an antidepressant) 12.5 mg via peg-tube (percutaneous endoscopic gastrostomy tube - a tube inserted into the stomach to provide nutrition and medications for people who have trouble with swallowing) QD (quaque die, once daily), PO (per os, by mouth) for depression. Resident #5's Note to Attending Physician/Prescriber, dated 11/26/2025, indicated, Please review the following psychotropic medication for [Resident #5]: Sertraline 12.5 mg via peg-tube once daily for depression. Is the medication still needed at this time or is a trial of discontinuance an option? The physician agreed and indicated, ok to [discontinue] [after] [1 tablet] every other day (QOD) [quaque altera die, every other day] x 7 days, and signed it on 12/15/2025. Resident #5's May 2026 Treatment Administration Record (TAR) contained an order dated 09/02/2025 for sertraline 12.5 mg via peg-tube QD for depression. Resident #5 was administered the medication for 29 of the 31 days in the month. Resident #5's June 2026 TAR contained an order dated 09/02/2025 for sertraline 12.5 mg via peg-tube QD for depression. Resident #5 was administered the medication daily. During an interview on 06/03/2026 at 9:02 AM, the Pharmacy Consultant stated he reviewed all residents' medications monthly and gave recommendations to the facility. Per the Pharmacy Consultant, the Medical Director (MD) then gave orders based on his recommendations and was unsure why Resident #5's recommendation to discontinue the sertraline was not implemented. He stated there was no follow-up done to remove the order from the computer by the facility, thus the medication continued to be provided to the nursing staff for administration. During an interview on 06/03/2026 at 12:24 PM, the MD stated he received the pharmacy recommendations related to each resident's medication regimen monthly, responded to the recommendations, and returned them to the facility. The Physician further stated if he wrote an order in his response to the recommendation, he expected the facility to follow that order. During an interview on 06/03/2026 at 2:50 PM, Household Manager (HM) #1 stated that the unit managers were responsible for updating the orders, and that the recommendation to discontinue Resident #5's sertraline should have been implemented and was unsure as to why it was not followed. During an interview on 06/04/2026 at 8:32 AM, the Director of Nursing (DON) stated that the pharmacy consultant made recommendations and the MD responded to them monthly. The DON further stated that based on the MD's responses, the HM's implemented any new orders, and the DON did not know why Resident #5's sertraline was not discontinued when the MD gave the order to discontinue it in December 2025. During an interview on 06/04/2026 at 10:22 AM, the Administrator stated she expected the pharmacy recommendations to be followed up on, and any new physician orders should be implemented when written.

Based on record review and interview, the facility failed to have a documented water management plan for the prevention of water borne pathogens. The Resident Census and Conditions of Residents report, dated 06/13/23, documented 55 residents resided at the facility. Findings: A review of facility infection control policy and procedures failed to locate documentation of a water management program. On 06/15/23 at 12:13 p.m. the administrator was asked if the facility had a water management program. The administrator replied the facility did not and an organizational officer would work to develop one.

Based on observation, interview, and record review, it was determined the facility failed to provide written information regarding the facility's bed hold policy for three of three residents (#33, #52, and #75) reviewed for transfer/discharge. The facility identified 28 residents were transferred or discharged to the hospital in the last three months. Findings: 1. Resident #52 was admitted to the facility on admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/05/19, documented the resident was severely impaired for daily decision making and required extensive assistance with activities of daily living. The care plan, dated 11/14/19, documented the resident had a tendency to wander and interventions were documented. The physician orders, dated 11/25/19, documented the resident was to be transferred and admitted to the hospital for a possible bowel obstruction. On 12/02/19 at 2:43 PM, the resident was asleep in his bed with his call light within reach. On 12/05/19 at 3:10 PM, the director of nurses (DON) stated the resident's face sheet and medication record were sent to the hospital with the resident. The DON stated the facility did not provide the bed hold policy to the resident or resident's representative at the time of the transfer. 2. Resident #75 was initially admitted on [DATE] with [DIAGNOSES REDACTED]. A five day assessment, dated 10/17/19, documented the resident was severely impaired for daily decision making. The assessment documented the resident required limited to extensive assistance of one person for activities of daily living (ADLs). The care plan, dated 10/23/19, documented the resident was dependent and required assistance with ADLs. The transfer report, dated 11/14/19, documented the resident was up in the wheelchair that morning and started shaking uncontrollably. The record documented the physician was notified. The record documented the resident was transferred to the hospital for evaluation. On 12/05/19 at 3:10 PM, the director of nurses (DON) stated the resident's face sheet and medication record were sent to the hospital with the resident. The DON stated the facility did not provide the resident or the resident's representative with the bed hold policy. 3. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 07/17/19, documented the resident required limited to extensive assistance with activities of daily living (ADLs). The care plan, dated 08/05/19, documented the resident required assistance with ADLs. The assessment, dated 08/21/19, documented the resident was discharged to the hospital. An assessment, dated 08/23/19, documented the resident returned to the facility. On 12/04/19 at 3:35 PM, the resident was in her room, in her recliner, and was watching television. The resident was clean, groomed, and operated the remote control without difficulty. The resident stated she had improved in her ability to complete her ADLs since she came back from the hospital. On 12/04/19 at 4:15 pm, the facility was not able to provide documentation a written bed hold policy had been provided to the resident or the resident's responsibility party upon discharge to the hospital. On 12/04/19 at 4:30 pm, the admissions coordinator and the social services coordinator stated the facility always held a resident's bed until the resident returned. They stated the facility did not provide the bed hold policy upon transfer or discharge since the resident's bed was always held.

Based on observation, interview, and record review, it was determined the facility failed to provide in writing a notice of transfer/discharge for three (#52, #75, #33) of four sampled residents whose transfers/discharges were reviewed. The facility identified 28 residents were transferred or discharged to the hospital in the last three months. Findings: 1. Resident #52 was admitted to the facility on admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 11/05/19, documented the resident was severely impaired for daily decision making and required extensive assistance with activities of daily living. The care plan, dated 11/14/19, documented the resident had a tendency to wander and interventions were documented. The physician orders, dated 11/25/19, documented the resident was to be transferred and admitted to the hospital for a possible bowel obstruction. On 12/02/19 at 2:43 PM, the resident was asleep in his bed with his call light within reach. On 12/05/19 at 3:10 PM, the director of nurses (DON) stated the resident's face sheet and medication record were sent to the hospital with the resident. The DON stated the facility did not send a written notice of transfer or discharge to the resident or the resident's representative. 2. Resident #75 was admitted on [DATE] with [DIAGNOSES REDACTED]. A five day assessment, dated 10/17/19, documented the resident was severely impaired for daily decision making. The assessment documented the resident required limited to extensive assistance of one person for activities of daily living (ADLs). The care plan, dated 10/23/19, documented the resident was dependent and required assistance with ADLs. The transfer report, dated 11/14/19, documented the resident was up in the wheelchair that morning and started shaking uncontrollably. The record documented the physician was notified. The record documented the resident was transferred to the hospital for evaluation. On 12/05/19 at 3:10 PM, the director of nurses (DON) stated the resident's face sheet and medication record were sent to the hospital with the resident. The DON stated the facility did not send a letter to the resident's representative providing a notice of discharge. 3. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 07/17/19, documented the resident required limited to extensive assistance with activities of daily living (ADLs). The care plan, dated 08/05/19, documented the resident required assistance with ADLs. An assessment, dated 08/21/19, documented the resident was discharged to the hospital. An assessment, dated 08/23/19, documented the resident returned to the facility. On 12/04/19 at 3:35 PM, the resident was in her room, in her recliner, and was watching television. The resident was clean, groomed, and operated the remote control without difficulty. The resident stated she had improved in her ability to complete her ADLs since she came back from the hospital. On 12/04/19 at 4:15 pm, the facility was not able to provide documentation a written notice of transfer/discharge had been provided to the resident or the resident's responsibility party upon discharge to the hospital. On 12/04/19 at 4:15 pm, the admissions coordinator and the social services coordinator stated the facility did not completely discharge the resident from the facility when admitted to the hospital. They stated the facility did not provide a notice of transfer/discharge since the resident's record remained open.

Based on observation, interview, and record review, it was determined the facility failed to accurately document the residents' status in the assessments for two (#33 and #51) of 27 sampled residents reviewed for assessments. The facility census and condition report documented 70 residents lived in the facility. Findings: 1. Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 11/07/19, did not document assessments for cognitive patterns, mood, behavior, or primary medical condition. The care plan, dated 11/27/19, documented the resident was a high risk for falls and was frequently restless. On 12/02/19 at 1:11 PM, the resident was observed in her room with a family member. The family member stated the resident fell on Thanksgiving while she was alone in her room. She stated the resident was confused and was not stable to walk unassisted. On 12/04/19 at 10:30 AM, registered nurse (RN) #2 stated she was responsible for the submission assessments. The nurse stated the staff did not complete the assessment sections. 2. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/15/19, documented the resident's memory score, presence of [MEDICAL CONDITION], mood, and behaviors were not assessed. The assessment documented the resident required extensive assistance with most activities of daily living (ADLs). The care plan, dated 11/03/19, documented the resident required assistance with ADLs. On 12/03/19 at 8:00 AM, the resident was in the dining room, sitting in a wheelchair, eating her morning meal, and feeding herself. On 12/04/19 at 3:35 PM, the resident was in her room in her recliner, and was watching television. She was alert, oriented, and smiled. The resident was clean, groomed, and operated the remote control without difficulty. The resident stated she had improved in her ability to complete her ADLs since she came back from the hospital. The resident stated she was able to do most ADLs with little assistance. On 12/04/19 at 10:30 AM, registered nurse (RN) #2 stated the nurse who completed the assessments was terminated two months ago. The nurse stated she had been overseeing the completion of the assessments in addition to her other duties. The nurse stated each section of the assessment was delegated to selected individuals for completion. She stated the person who was assigned the sections for memory and psychosocial needs did not complete the sections. On 12/04/19 at 4:30 PM, RN #1 stated the resident required minimal assistance with ADLs and had improved since her surgery in (MONTH) 2019. The nurse stated the assessment completed in (MONTH) 2019 did not accurately document the resident's ADL abilities.

Based on observation, interview, and record review, it was determined the facility failed to serve food in a sanitary manner for 26 of 26 residents who dined in the[NAME]Hall household. The facility census and condition report documented 69 residents ate food served from household kitchens. Findings: On 12/04/19 at 4:50 PM, certified medication aide (CMA) #1 was serving the noon meal. She was wearing gloves. While preparing plates, the CMA touched the counter, cabinets, threw away trash. Without changing her gloves or washing her hands the CMA picked up and sliced fruit, placed the fruit on plates, and served the food to the residents. The CMA changed her gloves but did not wash her hands. The CMA opened cabinets, opened cans of soup, and opened the microwave. Wearing the same gloves, she removed hamburger buns from the package using her hands and placed the buns on a plate. With the same gloved hands she reached into the potato chip bag, grabbed a handful of potato chips, and placed them on a plate. The plate of food was served to a resident. The CMA continued to serve food without changing her gloves. On 12/05/19 at 12:05 PM, CMA #2 was serving food. She wore gloves while serving. She opened soup cans, turned knobs on the stove, and touched food without changing her gloves. On 12/05/19 at 2:30 PM, CMA #2 stated while serving food, gloves must be changed and hands washed after touching any type of surface besides serving utensils. The food handling policy stated food handlers must wash their hands after engaging in activities that contaminate the hands.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls for two (#23 and #41) of 3 sampled residents reviewed for falls. The facility failed to: a) Assess the residents to determine needs of residents. b) Thoroughly investigate falls to determine underlying causes of falls for the residents. c) Implement preventative interventions to prevent falls for the residents. Resident #23 was on the dementia unit and had advanced dementia with behaviors. The resident sustained [REDACTED]. The resident sustained [REDACTED]. The resident was sent to the hospital. A hospital CT scan documented the resident had an upper arm impacted [MEDICAL CONDITION] neck. Resident #41 was a new admission who was confused, agitated, and had behaviors toward others. The resident fell in his room and hit his head. The resident was transported to the hospital. The hospital discharge summary documented the resident had a [MEDICAL CONDITION]. The risk management report documented 21 residents had experienced falls since (MONTH) 1, (YEAR). Findings: The facility policy for fall prevention documented staff was to complete hourly rounding and check residents for positioning, check to ensure resident possessions were close, check residents for pain, and check residents for potty needs. The policy documented staff were to offer restless residents snacks, fluids, television, or company. The policy documented staff must huddle, complete a fall scene and incident investigation report, and complete an incident report after each fall. The policy documented staff were to evaluate information gathered till the cause of the fall was determined. The policy documented new interventions were to be implemented with each fall or indicate why the current approach was still relevant. 1. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall risk assessment, dated 07/30/18, documented the resident was at moderate risk for falling. The physician orders, dated 07/30/18, did not document the resident was to receive psychoactive medication. A physician order, dated 07/31/18, documented an order for [REDACTED]. The care plan, dated 07/31/18, documented the resident needed assistance with activities of daily living (ADLs) and was at risk for falls. The care plan documented the interventions to prevent falls were for the staff to check on the resident frequently throughout the day and night. The care plan documented the staff were to encourage the resident to wait for staff assistance and keep the call light within his reach. The care plan documented the staff were to ask resident if he was thirsty, hungry, needed toileting, and provide assistance as needed when the resident was restless. The care plan documented the staff were to remind the resident to stand slowly and lock the brakes on his wheelchair. A discharge assessment, dated 08/02/18, documented the resident was discharged from the facility to the hospital. A progress note, dated 08/02/18, at 11:30 AM, documented the resident had extreme behaviors of hitting and yelling at other residents. The note documented the daughter was notified the resident was to transfer to the hospital for a psychiatric evaluation. An entry assessment, dated 08/15/18, documented the resident returned to the facility. The physician orders, dated 08/15/18, documented the resident was to receive [MEDICATION NAME] (an antianxiety medication) every six hours for anxiety and agitation and Quetiapine [MEDICATION NAME] 50 mg (an antipsychotic) one time per day for behaviors. A progress note, dated 08/15/18 at 1:19 PM, documented the resident was combative toward staff and other residents. The note documented the resident was sent to the hospital for evaluation. A progress note, dated 08/15/18 at 5:08 PM, documented the resident arrived back to the facility at 2:42 PM accompanied by his daughter and was pleasantly confused. A progress note, dated 08/15/18 at 5:16 PM, documented the resident was agitated at dinner and displayed aggressive, violent, and verbal behaviors. The note documented [MEDICATION NAME] was administered to the resident. An incident report, dated 08/15/18, documented the staff found the resident on the floor in front of his sink. The report documented the resident could not state what had occurred and complained of pain in his back. The report documented the resident had no apparent injuries and his vital signs were within normal limits. The report documented the resident stated he hit his head. The report documented the doctor was notified and received an order to send the resident to the emergency room . The report documented the family was notified. A fall investigation note, dated 08/16/18 at 01:28 AM, documented the events of the fall. The note did not document details of a fall investigation. A hospital discharge summary, dated 08/20/18, documented the resident had a [DIAGNOSES REDACTED]. A progress note, dated 08/20/18 at 11:55 AM, documented a new order for [MEDICATION NAME] (an antidepressant) 50 mg 1 every 6 as needed for anxiety. A progress note, dated 08/20/18 at 6:21 PM, documented the resident returned to the facility at 2:15 PM accompanied by his son. The note documented the resident was alert and oriented to self. The physician orders, dated 08/20/18, documented the resident was to receive [MEDICATION NAME] (an [MEDICAL CONDITION] medication) 500 mg for behaviors and [MEDICATION NAME] topically every 6 hours for anxiety or agitation. A fall risk assessment, dated 08/20/18, documented the resident was a high risk for falls. The admission assessment, dated 08/30/18, documented the resident was moderately impaired for daily decision making. The assessment documented the resident had physical behaviors towards others and rejected care which interfered with the provision of care. The assessment documented the resident required extensive assistance with transfers, mobility, and other activities of daily living (ADLs). The assessment documented the resident did not walk during the assessment period, was not steady with transfers, had no range of motion impairment, used the wheelchair, and was frequently incontinent of bowel and bladder. The assessment documented the resident had falls before admission. The assessment documented the resident received antipsychotic, antianxiety, antidepressant, and diuretic medications. The care plan, dated 09/17/18, did not document new interventions to prevent falls. On 10/02/18 at 2:12 PM, the resident was observed. The resident was resting in bed. The bed was in low position and the call light was in reach. The resident had a Broda chair and a gait belt in his room. On 10/03/18 at 9:30 AM, the resident was observed in the living area, sitting in a Broda chair, and was in front of the television. No foot support was in place and the resident's feet were dangling. The resident's eyes were closed but he was easily awakened. The resident was not interacting with other residents or staff. On 10/03/18 at 12:00 PM, a family member was interviewed. The family discussed concerns relating to staff supervision, the treatment for [REDACTED]. The family stated the resident fell and hit his head the day he returned from the hospital. The family stated the resident had a bleed in his head. On 10/08/18 at 9:30 AM, the fall investigations were requested. The director of nurses (DON) provided the facility's fall incident report and stated the facility had no other fall investigation information documented. The DON stated an investigation huddle was to be completed at the time of the fall and documented on a form. The DON stated after the information was input into the computer, the form was discarded. The DON reviewed the incident report and stated no huddle or fall investigation information was documented on the report. On 10/08/18 at 3:19 PM, CNA #5 was interviewed regarding fall prevention. The CNA stated the resident was advanced with his dementia. The CNA stated when the resident was first admitted the staff attempted to walk the resident with his walker and it was difficult. She stated the resident would usually sit in his wheelchair and move his feet all the time. The CNA stated the resident had behaviors directed to the staff but not to other residents. The CNA stated the resident resisted care. The CNA stated the family brought a recliner for the resident and he would sit in the recliner in his room reading the Bible by himself. The CNA stated once the resident was in bed, the staff would check on him hourly. On 10/08/18 at 3:30 PM, CNA #4 was interviewed regarding the resident and his fall on 08/15/18. The CNA stated the staff supervised the residents in the television area and checked the residents every 30 to 40 minutes. The CNA stated she did not know who placed the resident in his room that evening. The CNA stated a staff member found him on the floor. The CNA could not state details of the fall. On 10/08/18 at 3:46 PM, LPN #2 was interviewed regarding the events of the resident's fall. The LPN stated the fall was not witnessed. The LPN stated 30 minutes prior to the fall incontinent care had been provided and the resident was placed in his recliner. The LPN stated the resident had not been agitated. The LPN stated the staff performed rounds at least every two hours and sometimes would sit with a resident. On 10/08/18 at 3:57 PM, the director of nurses (DON) was interviewed regarding falls. The DON stated at the time of the fall, the staff on duty was to have a huddle and document the details of the fall on the Fall Scene and Incident Investigation Report (FSII). The FSII report was the initial part of the fall investigation. The DON stated the report would be given to the unit coordinator and the coordinator would input the fall information to the electronic incident report. The DON reviewed the resident's incident report. The DON stated the report required less information than what was on the FSII report and the initial fall investigation details were not documented on the incident report. The DON was not able to provide a thorough investigation report documenting the underlying or root cause of the resident's fall. The DON stated the fall was discussed in the morning meeting and it was determined the resident had to go to the bathroom and that was the cause of his fall. The DON reviewed the admission care plan and the current care plan. The DON stated the care plan was not updated with a new intervention to prevent the resident from falling. 2. Resident #23 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The fall risk assessment, dated 02/19/18, documented the resident scored a 75 which was considered a high fall risk. The physician orders [REDACTED]. The comprehensive assessment, dated 03/04/18, documented the resident was severely impaired for daily decision making and required extensive assistance for activities of daily living. The assessment documented the resident required a wheelchair for mobility and was usually incontinent of bowel and bladder. The assessment documented the resident was taking antianxiety, antidepressant, and hypnotic medication. An incident report, dated 03/05/18 at 5:15 AM, documented the resident fell , was found on the floor next to her bed, and was yelling out. The report documented the nurse gave the resident [MEDICATION NAME] to help with yelling. The report did not document new interventions to prevent falls. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. An incident report, dated 03/05/18 at 6:00 AM, documented the resident was found lying on the floor, on the fall mat, and next to her bed. The resident was sent to the hospital for evaluation. The report did not document new interventions to prevent falls. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. The nurse notes, dated 03/05/18, documented the resident fell two times and was having behaviors. The note documented the resident was sent to the hospital for an evaluation. The care plan, dated 03/05/18, documented the resident required assistance with activities of daily living (ADL), had [MEDICAL CONDITION] with behaviors, was incontinent, and was considered a high fall risk. An incident report, dated 03/17/18 at 10:00 PM, documented the resident fell and was found on the floor in her room. The report documented an X-ray of the right hip was obtained and the results were negative. The report documented hourly rounding was to continue and the staff was to sit with the resident until she fell back asleep that night. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. An incident report, dated 03/21/18 at 7:19 PM, documented the resident was found on her knees by her bed. The report documented hourly rounding was to continue. The report did not document a new intervention to prevent falls. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. An incident report, dated 04/03/18 at 10:00 PM, documented the resident stood up from her wheelchair without assistance and immediately sat on the floor in front of her wheelchair. The report documented the immediate action was for staff to offer activities, food, or fluid. The report documented the staff was to ask the resident the four P's (pain, potty, position, and possession). The facility was not able to provide a completed fall investigation. The offering of food, fluid, and the four P's were not documented on the care plan. An incident report, dated 04/05/18 at 5:45 PM, documented the resident was found on the floor by her wheelchair in her room. The report documented hourly rounding was to continue and provide constant monitoring while awake. The report documented the staff was to place a chair outside the resident's room and monitor while the resident slept. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. The nurse notes, dated (MONTH) 6, (YEAR) to (MONTH) 30, (YEAR), were reviewed. The notes did not document the staff was monitoring the resident while she was sleeping. An incident report, dated 05/25/18 at 1:10 AM, documented the staff witnessed the resident slide out of the bed. The report documented the resident was wet and the floor was wet. The report documented the resident had been toileted at 11:30 PM. The report documented the resident did not sustain an injury from the fall. The facility was not able to provide a completed fall investigation. The care plan did not document a new intervention to prevent future falls. The quarterly assessment, dated 06/04/18, documented the resident was still dependent for daily decision making. The assessment did not document the resident had falls. The care plan, dated 08/22/18, documented the resident had one fall with injury. The care plan did not document new or updated interventions since 03/05/18. The incident report, dated 09/27/18 at 10:00 PM, documented the resident was found lying on the floor behind the door. The report documented the resident was complaining of left arm pain. The report documented the resident was assisted into wheelchair by the staff. The report documented the resident was sent to hospital for x-rays. The nurse notes, dated 9/28/18 at 6:33 AM, documented the resident returned to the facility. The X-ray report, dated 09/28/18, documented there was no acute fracture or a dislocation of the left arm. The nurse notes, dated 09/28/18 at 9:09 AM, documented the resident was complaining of severe pain of the left arm. The notes documented the physician was notified and the resident was sent back to the hospital for an outpatient CT scan. The CT report, dated 09/28/18 at 1:54 PM, documented the resident an impacted minimally displaced [MEDICAL CONDITION] humeral neck. On 10/08/18 at 12:56 PM, the director of nurses (DON) stated the fall investigations should be with the incident reports. The incident reports did not include documentation regarding thorough fall investigations. On 10/08/18 at 3:10 PM, certified nurse aide (CNA) #5 was interviewed. The CNA stated resident #23 would try to get up in the dining area and the staff would assist her back to her chair. The CNA stated she did not sit by the resident's room while the resident slept. The CNA stated she would check on the resident every hour. On 10/08/18 at 4:00 PM, the DON was interviewed regarding how the facility investigated falls. The DON stated the staff on duty at the time of the fall was supposed to fill out a fall safety intervention investigation (FSII) report. The DON states the report was discussed in the morning meeting and the staff tried to figure out the cause of the falls. The DON stated the household LPN coordinator was to transfer the information from the FSII report to the facility incident report. On 10/08/18 at 4:18 PM, the LPN coordinator for Cobb Landing was interviewed. The LPN stated he entered the information on the FSII report regarding the fall and then discarded the FSII report. The LPN stated he did not document all the information on the new report because there was not a place for all the information. The LPN stated during stand up meetings every morning they would look for consistent factors related to the fall. The LPN stated the fall investigation was not documented. The LPN stated after a fall, the facility reviewed the resident's medication. The LPN stated the physician was aware of the resident's fall and had not reviewed her medicine at that time. The LPN stated he was notified when a fall occurred.

Based on observation, interview, and record review, it was determined the facility failed to accurately document falls on the comprehensive assessment for one (#23) of 37 residents whose assessments were reviewed. The census and condition report documented 68 residents lived at the facility. Findings: Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 03/14/18, documented the resident required assistance with activities of daily living (ADL). The care plan documented the resident's dementia with behaviors, impaired cognitive function/dementia, and impaired thought processes. The care plan documented the resident was a high fall risk. The medical records for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), documented the resident had multiple falls and did not sustain an injury with the falls. The quarterly assessment, dated 06/04/18, documented the resident was dependent for daily decision making. The assessment did not document the resident had falls during the assessment period. On 10/02/18 at 2:00 PM, the resident sat in a wheelchair in the hallway. Her left arm was in a sling. The resident's conversation was not appropriate to situation. The resident had non-skid socks and a concave mattress on her bed. On 10/08/18 at 3:18 PM, the assessment coordinator stated she had been in the position for six months. She stated she was behind on the assessments and did not know the assessment did not document the resident's falls accurately.

Based on observation, interview, and record review, it was determined the facility failed to fully develop comprehensive care plans related to the use of psychoactive medication for two (#23 and #26) of 37 sampled residents whose care plans were reviewed. The facility census and condition report documented 52 residents received psychoactive medications. Findings: 1. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 03/29/18, documented the resident was severely impaired for daily decision-making, had depression, delusions, and behaviors. The assessment documented the resident received anti-anxiety and anti-depressant medications. The care plan, dated 03/05/18 documented the resident received antianxiety and antidepressant medications. The care plan did not document the resident specific behaviors, side effects of the medication to monitor and report, or gradual dose reductions. The physician orders [REDACTED]. On 10/02/18 at 2:00 PM, the resident was observed sitting in a wheelchair in the hallway. Her left arm was in a sling. The resident had disorganized thoughts. The resident propelled herself about the unit in her wheelchair. On 10/03/18 at 9:30 AM, the resident was observed in the dining area sitting in her wheelchair. The resident was having difficulty staying awake. Her eyes were closed and her head was bobbing down onto the table. 2. Resident #26 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission assessment, dated 11/10/18, documented the resident was severely impaired for daily decision-making, had depression, and did not have behaviors. The assessment documented the resident received antipsychotic and antidepressant medications. The care plan, dated 12/28/18, did not document the resident received psychoactive medications, the resident's specific behaviors, the side effects to monitor, or the gradual dose reductions. The physician orders [REDACTED]. On 10/03/18 at 10:15 AM, licensed practical nurse (LPN) #1 was observed providing wound care to the resident's shins. The resident expressed thoughts that were not relevant and were disorganized. On 10/09/18 at 11:15 AM, the care plan coordinator stated she started employment on 02/01/18 and began as the assessment and care plan coordinator in (MONTH) (YEAR). The coordinator stated she had been to classes for the completion of the assessments. The coordinator stated she was not aware of the care plans were incomplete for psychoactive medications.

Based on observation, interview, and record review, it was determined the facility failed to ensure nursing staff demonstrated competency and/or skills when providing treatment and care for three (#20, #26, and #41) of 37 residents reviewed for care provision. The facility failed to: a) Complete wound care using correct technique for resident #20. b) Transfer and position residents using correct technique for residents #26 and #41. Findings: 1. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 05/25/18, documented the resident was severely impaired for daily decision making, required extensive assist with the activities of daily living, and did not have skin sores. The care plan, dated 07/25/18, documented the resident was at risk for pressure ulcers and wounds due to her fragile skin. The physician orders [REDACTED]. On 10/03/18 at 10:15 AM, licensed practical nurse (LPN) #1 was observed providing wound care to the resident's shins. Four skin tears were observed on the left shin. The nurse cleansed the wounds using a wet 4 by 4. The nurse wiped back and forth over all four tears multiple times using the same gauze. The LPN completed the dressing change. The nurse removed the dressing from the right shin and the resident had two skin tears. The nurse cleansed the tears with a wet 4 by 4 wiping back and forth over the tears multiple times using the same gauze. On 10/03/18 at 11:00 AM, LPN #1 was interviewed regarding dressing change technique. The nurse stated the site should be wiped once with gauze then the gauze should be discarded. The LPN stated a new gauze should be used with each wipe. 2. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment for 09/07/18 was not completed. The care care plan, dated 09/04/18 documented the resident required assistance with transfers, repositioning, and had a history of [REDACTED]. The care plan documented the staff was to handle the resident's affected extremity gently, supporting it with hands or a pillow since movement of fractured bones was painful and muscle spasms could occur. The care plan documented adequate support diminished soft tissue tension. The care plan documented the staff were to assist the resident to reposition periodically, encourage coughing and deep-breathing exercises. On 10/03/18 at 9:30 AM the resident was observed in a Broda chair and the resident's feet were dangling and were not supported with a foot rest. 3. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 08/30/18, documented the resident was moderately impaired for daily decision making and required extensive assistance with transfers, mobility, and other activities of daily living (ADLs). The care plan, dated 09/17/18, documented the resident required assistance for positioning. The care plan did not document the resident used a Broda chair or the family requested the staff position the resident in the recliner. On 10/03/18 at 12:00 PM, the family was interviewed. The daughter stated the family was not sure the resident was repositioned routinely. The daughter expressed concerns the resident stayed in one position on his bottom for long periods and felt he was in pain due to the resident's grimacing. On 10/04/18 at 8:45 AM, the resident was in his Broda chair in the dining room and was assisted with the morning meal. The resident sat up straight and his feet were not supported with a foot rest. After the morning meal the resident was moved to the television area and was reclined back. The staff did not adjust the resident from side to side and no pillow was placed under his head for neck support. On 10/04/18 at 8:55 AM, the CMA moved the resident to the dining area. The CMA clipped his nails and lotioned his hands but did not reposition the resident in his chair. On 10/04/18 at 9:15 AM, the resident put his left leg up on table without assistance. On 10/04/18 at 9:30 AM, the resident was trying to move about in Broda chair and was grimacing. The resident bent his knees and placed his feet on edge of chair seat. CNA #7 lifted the leg rest but did not reposition the resident's bottom. The resident continued to grimace. On 10/04/18 at 9:50 AM, CMA #1 transported the resident down the hall, stopped, and lowered the leg rest. The CMA did not reposition the resident's bottom. The CMA transported the resident back up the hall and the resident had a grimace on his face. The resident was taken into the television area and transferred to the recliner by LPN #1 and the CM[NAME] The staff lifted the resident under the arms and pulled on back of his pajama bottoms to complete the lift. The resident did not bear weight or assist with the lift. The resident was grimacing and the pajama bottoms were wedged in between his buttocks. On 10/09/18 at 1:47 PM, the LPN coordinator for the unit was interviewed regarding transfer technique. The LPN stated a non-weight resident would be transferred with two persons using a gait belt, a sliding board, or a Hoyer lift. The LPN stated the staff were not to transfer a resident lifting under the resident's arms or with the use of their pants. The LPN stated the staff were to reposition the residents in wheelchairs or Broda chairs every 30 minutes and were to utilize the foot support. Five employee personnel files were reviewed. The files did not document skill checks had been completed for for three of the five employees whose files were reviewed. The facility could not provide documentation for the employees skill checks. On 10/08/18 at 1:28 PM, the administrator (ADM) was interviewed. The ADM stated only two of the five requested skill check sheets had been obtained. The ADM stated a new employee would follow another employee for two weeks after hire. The ADM stated it was the responsibility of the new employee and the employee who was orienting them to turn in the skills check off sheets.

Based on observation, interview, and record review, it was determined the facility failed to update the care plan for four (#20, #23, #41, and #49) of 37 residents whose care plans were reviewed. The facility failed to: a) Update the care plan related to skin tears and wound care for resident #20. b) Update the care plan related to weight loss for resident #23. c) Update the care plan with interventions to prevent falls for residents #23, #41, and #49. The census and condition report documented 68 residents lived at the facility. Findings: 1. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 05/25/18, documented the resident was severely impaired for daily decision making, required extensive assist with transfers, and required total assistance with ambulation, had impairment to both lower extremities, and did not have skin sores. The care plan, dated 07/25/18, documented the resident was at risk for pressure ulcers and wounds due to her fragile skin. The care plan was not updated related to the resident's skin tears and wound care. The physician orders [REDACTED]. On 10/03/18 at 10:15 AM, licensed practical nurse (LPN) #1 was observed providing wound care to the resident's shins. Four skin tears were observed on the left shin. The nurse removed the dressing from the right shin and the resident had two skin tears. 2. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nutritional assessment, dated 02/26/18, documented the resident received a ground diet, thin liquids, and Med Pass 2.0 (a high protein supplement) three times daily. The notes documented the resident's meal intake was fair and her weight was stabilizing. The admission assessment, dated 03/29/18, documented the resident was severely impaired for daily decision-making, required assistance with meals, and weighed 140 pounds. The care plan, dated 07/25/18, documented the resident required set up help with meals. The care plan did not document nutritional needs, identified weight loss, or interventions to prevent weight loss. The weight record, dated 10/01/18, documented the resident weighed 130 pounds. On 10/03/18 at 8:30 AM, the resident was observed in the dining area for the morning meal. The resident received meal assistance. The resident ate a small amount. 3. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment, dated 07/30/18, documented the resident was at moderate risk for falling. The care plan, dated 07/31/18, documented the resident needed assistance with ADLs and was at risk for falls. The care plan documented the interventions to prevent falls were for the staff to check on the resident frequently throughout the day and night. The care plan documented the staff were to encourage the resident to wait for staff assistance and keep the call light within reach. The care plan documented the staff were to ask the resident if he was thirsty, hungry, needed toileting, and provide assistance as needed when the resident was restless. The care plan documented the staff were to remind the resident to stand slowly and lock the brakes on his wheelchair. Physician orders, dated 08/15/18, documented the resident was to receive [MEDICATION NAME] (an antianxiety medication) every six hours for anxiety and agitation and Quetiapine [MEDICATION NAME] 50 mg (an antipsychotic) one time per day for behaviors. An incident report, dated 08/15/18, documented the staff found the resident on the floor in front of his sink. A hospital discharge summary, dated 08/20/18, documented the resident had a [DIAGNOSES REDACTED]. A fall risk assessment, dated 08/20/18, documented the resident was a high risk for falls. The admission assessment, dated 08/30/18, documented the resident was moderately impaired for daily decision making, The assessment documented the resident required extensive assistance with transfers, mobility, and other activities of daily living (ADLs). The assessment documented the resident had falls before admission. The care plan, dated 09/17/18, was not updated to include the resident had a fall with a head injury. The care plan did not document the resident did not bear weight or the way the staff were to transfer the resident. The care plan did not document the resident had a Broda chair and a recliner. The care plan did not document the resident received psychoactive medications. On 10/02/18 at 2:12 PM, the resident was observed. The resident was in bed. The resident had a Broda chair and a gait belt in his room. On 10/03/18 at 12:00 PM, a family member was interviewed. The family discussed concerns relating to staff supervision, the treatment for [REDACTED]. The family stated the resident fell and hit his head the day he returned from the hospital. The family stated the resident had a bleed in his head. On 10/09/18 at 11:15 AM, the assessment/care plan nurse was interviewed. The nurse stated she was the assessment nurse in (MONTH) (YEAR). The nurse stated she attended two trainings for certification. The nurse stated since employees had changed positions, the assessment and care plan completion was behind. The nurse stated the care plans for falls had not been updated and the psychoactive medications were not on the care plans. The nurse stated she was not aware the assessment for resident #23 was not accurate for falls. 4. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Morse fall risk assessment, dated 04/04/18, documented the resident was a moderate risk for falls. The initial care plan, dated 04/05/18, did not document the resident was at moderate risk for falls. A fall investigation progress note, dated 07/04/18 at 4:30 AM, documented the resident had fallen. The note documented the resident was heard calling for help and was found sitting on the floor. The note documented the resident had stated he had tried to go to the bathroom, lost his balance, and fell . The note documented the resident had suffered a skin tear to his left elbow. A fall investigation note, dated 07/05/18 at 3:15 PM, documented monitoring was to be continued to identify any further injury following the resident's fall. The quarterly assessment, dated 07/18/18, documented the resident was moderately impaired for daily decision making. The quarterly assessment documented the resident required limited to moderate assistance with activities of daily living (ADLs). The quarterly assessment documented the resident had one fall after the prior assessment had been completed. The care plan, dated 07/23/18, did not document the resident had a fall. The care plan did not document new interventions to prevent further falls. On 10/02/18 at 12:35 PM, the resident was observed in the dining room. A staff member was assisting the resident into the chair for lunch. The resident appeared very weak and unstable on his feet. On 10/09/18 at 2:00 PM, certified nurse aide (CNA) #6 was interviewed regarding the resident's risk for falls. The CNA stated she was not aware the resident was at risk for falls. On 10/09/18 at 11:15 AM, the care plan coordinator stated she started employment on 02/01/18 and began as the assessment and care plan coordinator in (MONTH) (YEAR). The coordinator stated she had been to classes for the completion of the assessments. The coordinator stated she was not aware the care plans were not updated related to fall interventions.

Based on observation, interview, and record review, it was determined the facility failed to ensure dignity and respect were provided to one (#165) of 37 sampled residents who were reviewed for dignity and respect. The facility failed to ensure the staff interacted respectfully with a resident who had dementia. The census and condition report documented 23 residents with dementia lived at the facility. Findings: Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 05/14/18, documented the resident had dementia and a personality disorder with behaviors. The care plan interventions documented the staff were to always be pleasant, patient, and reassuring. The care plan documented the resident would be allowed to verbalize her feelings and to be offered reassurance. The Medication Administration Record [REDACTED]. The record documented the resident had received [MEDICATION NAME] for a personality disorder and [MEDICATION NAME] for anxiety. Progress notes for the month of (MONTH) (YEAR) documented the resident was having behavioral episodes. The notes documented the resident was threatening staff and other residents. The progress notes documented the resident was confused, talked to herself, and was combative toward staff. The progress notes, dated 08/11/18 and 08/17/18, documented the resident had been sent to the hospital for behaviors and a psychiatric evaluation. On 10/03/18 at 12:00 PM, a family member of another resident discussed concerns regarding the night shift staff and how they talked to and about residents. The family member stated resident #165 fell and the staff tried to reason with the resident. The staff were overheard telling the resident she was going to the hospital and the hospital would restrain her. The family member stated the nurse told the other staff the resident was going out to the hospital. In front of the resident a staff member was heard stating yay, yay, party. On 10/09/18 at 6:30 AM, certified nurse aide (CNA) #1 was asked how she would care for a resident with dementia. The CNA stated the staff were to be patient, calm, and not argumentative with the resident. CNA #1 stated the resident was having behaviors such as wandering, was aggressive, argumentative, and refused care. The CNA stated she had not heard anyone speaking badly to the residents. On 10/09/18 at 6:40 AM, license practical nurse (LPN) #2 stated the resident had a personality disorder, would become aggressive, and resisted care. The LPN stated the resident often refused her medication. The LPN stated on 08/23/18 she notified the physician of the resident's behaviors and received an order to send the resident to the hospital for an evaluation. The LPN was asked if she had overheard the staff speak disrespectfully in front of the resident. The LPN stated she had not heard anyone speak disrespectfully or threaten the resident. On 10/09/18 at 9:22 AM, LPN #3 stated the staff should not express happiness when a resident was discharged . The LPN stated someone expressing happiness because a resident was being discharged should not have happened.

Based on observation, interview, and record review, it was determined the facility failed to ensure assessments were updated at least quarterly for three (#22, #23, and #26) of 37 residents reviewed for assessments. The census and condition report documented 68 residents lived at the facility. Findings: 1. Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly assessment, dated 06/01/18, documented the resident was severely impaired for daily decision making. The assessment documented the resident required extensive assistance for activities of daily living (ADL). The next quarterly assessment was due 09/01/18 and was not completed. 2. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 03/05/18, documented the resident had an ADL self care performance deficit. The care plan documented the resident was cognitively impaired. The quarterly assessment, dated 06/04/18, documented the resident was severely impaired for daily decision making. The assessment documented the resident required extensive assistance for activities of daily living. The next quarterly assessment was due 09/04/18 and was not completed. 3. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 06/07/18, documented the resident was severely impaired for daily decision making. The assessment documented the resident required extensive assistance for ADLs. The next quarterly assessment was due 09/07/18 and was not completed On 10/08/18 at 3:18 PM, the minimum data set (MDS) coordinator stated she had been in the position for six months. The MDS coordinator stated she was behind on assessments because she had been going for training. The MDS coordinator stated the previous care plan coordinator would complete the assessments and care plans when she was away from the facility.

Based on record review and interview, it was determined the facility failed to ensure a significant medication ([MEDICATION NAME]) was administered as ordered and not stopped abruptly for three days for one (#132) of 6 residents whose medications were reviewed. A total of eighty residents received medication. Findings; Resident # 132 was admitted to the facility with [DIAGNOSES REDACTED]. A nurse's note, dated 5/22/17, documented, New order received for [MEDICATION NAME] 60 mg daily. Faxed to pharmacy and to start today. Daughter made eye appt for resident; leaving facility at 1400 (2:00 p.m.) for 1500 (3:00 p.m.,) appt. (appointment) Resident has been complaining of eyes hurting for several days now; [MEDICATION NAME] (dry eye drops) ordered BID (twice daily) with little relief. Daughter in room with resident at this time. A physician's telephone order, dated 05/22/17, documented, . [MEDICATION NAME] 60 mg (milligram) daily ~ start today. A hand written medication administration record (MAR) dated May 2017, documented, [MEDICATION NAME] 60 mg daily, starting on 05/22/17. A local pharmacy inventory record, documented, [MEDICATION NAME] 20 mg tablets # 30 were received into the facility on the same day at 11:44 a.m. A nurse's note, dated 5/23/17, documented, Resident returned from eye appointment at approximately 1630 (4:30 p.m.) Daughter with him. Stated they did a biopsy of left side, testing for [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is a serious disorder that causes chronic inflammation of the large and medium arteries of the head, which supply [MEDICATION NAME] blood to portions of the head and brain. This [MEDICAL CONDITION] disease results in an inadequate supply of oxygen and nutrients in the brain and head areas.) Dressing on left side of face; to leave on for 24 hours. Use cold compresses if swelling appears. Sitting in dining room eating dinner at this time. Daughter present. Notified Dr. (name withheld) of information. A physician's telephone order, dated 05/25/17, documented, Increase (up symbol) [MEDICATION NAME] to 80 mg po (by mouth) daily. A local pharmacy inventory record, documented [MEDICATION NAME] 20 mg, #30 tablets were delivered to the facility the same day at 8:11 p.m. The order was hand written onto the May 2017 MAR and documented the medication was administered as ordered beginning 05/26/17 through 05/31/17. A 14 day comprehensive assessment, dated 06/01/17, documented the resident was moderately impaired in cognition, able to make his needs known and required limited to extensive assistance for bed mobility, walking, dressing and toileting. A nurse's note, dated 06/03/17 at 9:42 a.m., documented, Alert and oriented, responds easily to verbal stimuli. Denies pain this a.m. Left elbow dressing changed this a.m. per orders. Staff assist x (times) 1 for dressing, transfers and toileting needs. Up for breakfast in dining area with good appetite this a.m. Resting in bed after breakfast this morning, c/o (complains of) dizziness after standing to walk with walker per daughter request. Daughter at bedside this a.m. A nurse's note, dated 06/04/17 at 2:21 p.m., documented, . Therapy to nurse's desk midmorning to report that elder c/o while ambulating with B/P (blood pressure) at that time of 74/31. Assisted into chair with followup B/P of 102/61. An untimed physician's telephone order, dated 06/04/17, documented, Restart [MEDICATION NAME] 80 mg tonight. A MAR dated June 2017, documented, [MEDICATION NAME] 80 mg po daily - start tonite. The MAR documented the medication was administered as ordered beginning on 06/04/17 through 06/06/17. The same MAR failed to document the administration of the previously ordered Predinsone 80 mg, on 06/01/17, 06/02/17 and on 06/03/17. On 08/01/17 at 2:58 p.m. an interview was conducted with registered nurse (RN) #2. She was asked to review the orders for the [MEDICATION NAME], and the monthly MARs for June 2017 for the resident. After reviewing the records, she was asked if the resident had received the [MEDICATION NAME] 80 mg as ordered on June 1st through June 3rd. She stated the medication had not been given. She was asked if she could explain why the [MEDICATION NAME] was not administered. After sitting quietly for a moment, she stated she recalled the facility had, Changed pharmaceutical companies beginning June 1, and for one reason or another the [MEDICATION NAME] order wasn't picked up by the new pharmacy. She was asked if she knew why the resident was prescribed the [MEDICATION NAME]. She stated it was for his eye problem. On 08/01/17 at 4:34 p.m., an interview was conducted with RN #4 (unit manager). She was asked if she was aware of the missed doses of [MEDICATION NAME]. She stated she had been made aware there had been a problem with the medications not being placed onto the new pharmacy sheets. She further stated she had spoken with the physician and was informed the missed doses would not have any long term affect on the resident. She was asked when the physician had been notified of the missed doses. She stated, It had to be done on Sunday when the med was restarted. She was asked if this type of medication should ever be stopped abruptly. She stated, No. It's a steroid and should not have been stopped abruptly. She was asked if the medication not being given would be considered significant. She stated, Yes. 08/01/17 at 4:39 p.m., an interview was conducted with the QA (quality assurance)nurse. She was asked if she was aware of the significant medication error which had occurred involving the resident. She stated she was aware of the missed doses of [MEDICATION NAME]. She was asked if she could provide the medication error report for the missed doses. She stated, No I can't because there isn't one. She was asked if there should have been a report generated. She stated, There should have been a report made but the unit manager has had to work longer hours than usual and failed to make the report out. She was asked if the steroid medication would be considered a significant medication. She stated, Yes, It is.

Based on observation and interview, it was determined the facility failed to ensure there was sufficient staff to serve meals in a timely manner during meal observations on two units. 78 residents received food from the kitchen. Findings: On 07/30/17 at 11:35 a.m., resident #78 was observed sitting in her wheelchair (w/c) at a table. The resident was documented to require extensive assistance from one staff person for locomotion. the resident resided on Chapman Heights (CH) unit, At 11:42 a.m., resident # 62 was observed to be assisted by staff into the dining room via walker. At 12:12 p.m., staff were observed to begin to serve fruit to the seated residents. Resident #78 had waited 35 minutes and Resident #62 had waited 27 minutes. From 12:05 to 12:12 p.m., the remainder of CH residents who ate in the dining room had arrived. At 12:26 p.m., Residents #78 and #62 were served the first two lunch plates. At least 51 minutes had elapsed since #78 had entered the dining room and 44 minutes since #62 was escorted into the dining area. At 12:48 p.m., the last resident was served in the DR. This was 36 to 43 minutes since entering the dining room. On 08/01/17 at 11:40 a.m., upon entering the dining room on Buehler Place (BP) unit, resident #51 was observed sitting in a reclining positioning chair and resident # 101 was observed sitting in a w/c at a table. At 12:14 p.m., CMA #1 was observed to serve fruit to residents #51 and #101. The residents were in the dining room for 34 minutes before receiving any foods. At 12:22 p.m., a certified nursing assistant (CNA) came into the dining room and began to assist with serving residents and CMA #1 continued to plate the food instead of plating and serving food. On 08/07/17 at 3:30 p.m., unit coordinator #1 was asked about the observed meal services and the delay with meals being served. She stated she had not realized the meal service was taking as long as it was and she probably needed to reevaluate the distribution of staff during meal service.

Based on observation and interview, it was determined the facility failed to ensure: a. the kitchen was clean and sanitary, and b. staff on two (Chapman Heights and Buehler Place) of six units observed during meal service wore hair nets when dishing food onto plates. This had the potential to affect 78 residents identified as receiving oral nutrition from the kitchen and served on the units. The facility identified two residents who received nutrition solely via a feeding tube. Findings: On 07/30/17 at 10:25 a.m., during the initial kitchen tour, the following were observed: ~ loose debris, plastic wrappers on the floor of the walk-in refrigerator, ~ loose debris, multiple reddish brown buildup spotted through the isle, and black buildup along the edges of the floor of the walk-in freezer, ~ two beige three-shelve rolling carts with black buildup on all three shelves, and rust and black buildup around the metal and wheels, ~ one dark gray three-shelve rolling cart with black and gray dust and buildup on the metal around the wheels, ~ buildup of white/gray dust on five cans of plums, three cans of blueberry and one can of strawberry pie filling, and multiple other cans of assorted food products, ~ one 106 ounce can of nacho sliced jalapeno peppers with a large dent measuring approximately five inches long and greater than 1/2 inch depth in the middle of the dent, ~ one one-gallon can of olive oil with a dent towards the top, which traveled completely across the front of the can and was approximately 1/2 inch in depth, ~ three Rubbermaid plastic bins containing rice and oatmeal with lids, all three lids have buildup of gray/blackish, loose debris. The lid on the oatmeal bin did not fit properly, which left a gap opening, and the scoop was stored on top of the middle bin containing rice with buildup and debris on the lid, ~ the double Vulcan ovens at the back of the kitchen had a greasy, brownish/black buildup on the outer doors and windows and on the racks inside both ovens, ~ the Cleveland Hot Chaud at the back of the kitchen had a black greasy buildup around the switch and temperature dials and on the back support legs which came up approximately five to six inches above the top of the appliance, ~ the Star Max grill had brown/white/black greasy buildup on the grates, on the front knobs and on the metal plate behind the knobs, and ~ the double oven stove with ten burners had a black buildup inside the bottom of both ovens. At 11:35 a.m., during the noon meal service on the Chapman Heights unit, certified medication assistant (CMA) #3 was observed dishing food onto plates behind the serving counter. The staff member was not observed to wear a hair net to contain her hair. On 08/01/17 at 9:15 a.m., during breakfast service on the Buehler Place unit, CMA #1 was observed to go behind the service counter and dish a plate of food without wearing a hair net. As she was taking the plate to a resident, she walked past the surveyor and stated, I know I'm suppose to have my hair net on. On 08/02/17 at 8:18 a.m., during the breakfast meal service certified nursing assistant #2 was observed dishing plates of food. She was wearing a hair net but a large amount of her hair was left out in front of the hair net. On 08/07/17 at 10:36 a.m., CMA #3 was asked about her not wearing a hair net when dishing/serving foods. She stated, she was told if her hair was completely pulled back they did not have to wear a hair net. On 08/07/17 at 11:00 a.m., a walk through of the kitchen was made with the director of dining (DOD). All of the findings during the initial tour, with the exception of the rolling carts, were still present. There was only one beige rolling cart present and in addition to the buildup on the shelves and wheels, there was a large crack across the top shelve. The DOD was asked how the staff could sanitize the cart with the crack. He stated the crack must be new and they would get rid of the cart due to the inability to sanitize it properly. He was asked about the other observations present during the initial tour and during the walk through. He stated he was new to the facility and had just found the cleaning schedules to put up for staff to follow. He stated the findings were not acceptable. The DOD was asked about staff not wearing hair nets when dishing food onto plates on the units. The director of nutrition services joined the interview at this point and stated, this was due to her misunderstanding. She had the staff following the county requirements instead of the federal and state requirements.

Based on observation, record review and interview, it was determined the facility failed to ensure one (#133) of five sampled residents did not wait for meal assistance for more than 30 minutes during two meal services observed. This had the potential to affect 67 residents identified by the facility as requiring assistance of staff for eating. Findings: Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 02/15/17 at 4:05 p.m., documented, .Elder is up for all meals via w/c (wheelchair) and eats at least 50% of all meals and drinks adequate amount of fluids. Elder is limited one person assist with ADL's . A quarterly assessment, dated 05/02/17, documented resident #133 was severely impaired in cognition, required limited assistance of one person for locomotion on and off the unit, utilized a wheelchair as a mobility device and required supervision and one person physical assistance with eating. A nurse's note, dated 07/16/17 at 12:06 a.m., documented the resident had a fall in her room. A mobile X-ray result documented a [MEDICAL CONDITION], the resident was sent out for evaluation. The resident returned to the facility on [DATE]. The resident's care plan, last revised on 08/01/17, documented the resident required assistance with her ADL's related to her generalized weakness. Interventions included: ~ supervision with set up assistance to eat her meals and snacks, ~ .Eating-I need assistance with my meal-(type of assist and # of caregivers) (add any assistive devices, plate guard, large grip silver ware ect (sic)) Date Initiated: 04/05/2017 . On 08/01/17 at 9:05 a.m., the resident was observed in her w/c asleep at a dining room table. Her breakfast plate was in front of her with a half eaten slice of toast and a half eaten sausage patty. At 9:40 a.m., certified nurses aide (CNA) #1 was observed to take the resident's plate and coffee, and warm it up in the microwave. She then awakened the resident, sat down next to her, cut up the sausage and began feeding her. This resident was observed to sleep in front of her plate for 35 minutes before being assisted with her meal. At 12:06 p.m., staff was observed to bring the resident into the dining room via w/c and place her at a dining table. At 12:13 p.m., staff placed a bowl of soup in front of resident. At 12:19 p.m., the resident was observed to continue to sleep in her w/c at the table. She was not observed to eat any of her soup. At 12:26 p.m., the resident continued to sleep and had not touched her food or drink. At 12:31 p.m., certified medication assistant (CMA) #1, who was the only staff in the dining room at the time, called out across the dining room Miss (Resident name deleted). At 12:33 p.m., CMA #1 called out across the dining room again Miss (Resident name deleted) and began walking towards the resident, however the staff member was stopped by another resident. At 12:45 p.m., CMA #1 was observed to go over to the resident and awaken her as she spoke to her. At 12:48 p.m., the resident was observed to have eaten approximately one spoonful of fettuccini as she waited for assistance. At 12:50 p.m., CMA #2 was observed to sit down next to the resident with her own lunch, she awakened the resident and began to assist her with her meal. The resident began to eat her meal slowly. The meal was not reheated prior to being served to the resident. At 3:20 p.m., CMA #2 was asked how much the resident had eaten for lunch. She stated she ate less than 50%. On 08/07/17 at 3:30 p.m., unit coordinator #1 was asked about the delay in assistance for the resident. She stated since her [MEDICAL CONDITION] the daughter was usually here at meal times to assist her. She was asked about the meals when the daughter was not there to assist her. She stated she needed to make sure staff assisted her, as she required more assistance since her [MEDICAL CONDITION] as she was more sleepy due to pain medication. The resident had not experienced a weight loss since the fracture and had been placed on supplements for added nutrition.

Based on observation and interview, it was determined the facility failed to follow the menu for pureed diets on one (Chapman Heights (CH)) of six units observed during one of three meal observations. This had the potential to affect 11 residents identified by the facility as receiving mechanically altered diets. Findings: On 07/30/17 at 11:35 p.m., certified medication aide (CMA) #3, was observed preparing the service line for the lunch meal on the CH unit. She was asked what was on the planned menu for lunch. She stated the menu items for lunch were roast beef, roasted potatoes, roasted veggies, fruit and rolls. She further stated soup and salad was optional and was offered for all noon and evening meals. At 11:42 a.m., the following items were observed on the food line for the unit: salad, fruit, tomato soup, roast beef, roasted potatoes, roasted vegetable mix and rolls. At 12:05 p.m., CMA #3 was observed to prepare the pureed diets. She was asked how many pureed diets there were on the unit. She stated there were two which included residents #55 and #63. She was observed to puree two servings of the mixed vegetable mix, fruit and roast beef and then dish the servings onto a plate for one, and into small bowls for the other. She was not observed to puree any of the roasted potatoes or dinner rolls for the two diets. The meals were then served to the two residents at 12:23 p.m., without the potatoes and or the bread. On 08/07/17 at 10:36 a.m., CMA #3 was asked if she had pureed and served roasted potatoes and bread to residents #55 and #63 on 07/30/17 for lunch. She stated, No. She was asked why the residents had not received the roasted potatoes and or bread with their meal. She stated one of the residents did not like potatoes and anytime she had tried to puree bread it came out as a ball. At 11:30 a.m., the director of nutrition services was asked about the lack of bread being served for pureed residents on CH. She stated she was unaware bread was not being served on CH, and was also unaware the resident did not like potatoes. She further stated the facility provided pre-molded bread for its residents on a pureed diet and was available in the kitchen.

On 04/27/17 at 7:30 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's failure to ensure the right to privacy of resident #1 when a staff member used a personal cell phone to videotape the resident as she was masturbating in her room and showed the video to other staff members. This affected one (#1) of three sampled residents whose rights to privacy had been violated. On 04/27/17 at 7:30 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 11/30/16 at 7:45 p.m., the administrator and director of nurses were notified of the IJ situation. On 04/27/17 at 8:18 p.m., the plan of removal was accepted. The plan of removal for the Immediate Jeopardy documented: Inservice Plan: 1. Educate all staff present at this time. 2. Educate night staff when they arrive at 10:30 pm on 4/27/17. 3. Educate day staff as they arrive at 6:30 am on 4/28/17. 4. All OMM (Oklahoma Methodist Manor) staff will be educated in person, or via phone, before the end of the day on 4/28/17. Topics covered on the staff inservices were: ~abuse prevention, specifically mental abuse and humiliation ~video or other camera usage ~abuse reporting requirements ~thorough investigations of abuse and ~resident's right to privacy and dignity. The immediate jeopardy was removed on 04/30/17 at 7:00 p.m., after the plan of removal was carried out. The deficient practice remained at an isolated level of harm. Based on record reviews and interviews, it was determined the facility failed to ensure one (#1) of three sampled residents was provided the right to privacy. CNA #1 used a personal cell phone to videotape the resident as she was masturbating in her room, and showed the video to other staff members. The facility's failure to ensure the right to privacy had the potential to affect all 76 residents residing in the facility. Findings: A policy 'Resident Rights' dated January 2015, documented, .The 1987 Nursing Home Reform Law requires each long-term care community to care for its residents in a manner that promotes and enhances the quality of life of each resident, ensuring dignity, choice and self-determination. Resident's rights include but are not limited to .the right to privacy .the right to choose .the right to be free of restraint and abuse . A policy 'Videotaping, Photographing, and Other Imaging of Residents' dated January 2016, documented, .Residents will be protected from invasion of privacy that might occur from the use of resident photographs, videotapes, digital images, and other visual recordings during resident care or other facility activities without the written consent of the resident . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 08/01/16, and a quarterly assessment, dated 01/31/17, documented the resident had a severe visual impairment, and displayed modified cognitive impairment with decision making. The assessments documented the resident required limited assistance with eating and personal hygiene and extensive assistance with all other activities of daily living. The admission assessment documented activities that were very important to the resident included choosing her clothing and bedtime, listening to music, keeping up with the news, going outside when the weather was nice, participating in religious services and using a phone in private. Activities that were not important at all included doing things with groups of people. The care plan, dated 08/04/16, documented the residents's visual impairment was severe, with no vision or only seeing light, colors, shapes and was not able to follow objects. Interventions included, knock before you enter the room and introduce yourself, tell me why you're coming to see me . A facility incident report alleging abuse/mistreatment, received by the state agency on 04/25/17 at 11:18 a.m., documented, Description of Incident .On April 24, 2017, (name deleted) DON, received two reports from co-workers that CNA (name deleted) allegedly recorded a video, using his smart phone,of a resident with her hand in her pants supposedly masturbating. The co-workers stated that (name deleted) showed them an image on his phone and said he had a video of the resident masturbating. Upon seeing the video, told him it was inappropriate and that he should delete it from his phone. (Name deleted) was called to my office for an interview at which time he confessed to taking the video. (Name deleted)'s employment was immediately terminated . relevant resident history .The [AGE] year old resident, (name deleted), was admitted .7/25/16 with [DIAGNOSES REDACTED].due to her [MEDICAL CONDITION] would not have seen the video recording take place. She has not been informed that the video may have been taken; however, her daughter and POA, (name deleted) has been informed of the incident and the subsequent action we are taking . summary of investigation .While interviewing (name deleted), he admitted to taking and showing the video of the resident to his co-workers a couple of weeks ago. He became very emotional and stated that he realized it was wrong at the time and had subsequently deleted the video a couple of days later,. We believe that no remaining copy of the video exists in any device or form. He then resigned his position and left my office. His employment was immediately terminated . The report documented physician, family, DHS:Adult Protective Services, local law enforcement and the nurse aide registry were notified. On 04/27/17 at 11:15 a.m., the DON was asked about the above incident. The DON stated CNA #1 had called her on Sunday, 04/23/17, because he was upset with CMA #1. The DON told him she would talk to him on the following day. The DON stated on Monday morning, 04/24/17, CMA #1 met with her and LPN #1, the household coordinator on which both CNA #1 and CMA #1 worked, and on which resident #1 resided, to make a formal complaint against CNA #1, stating she felt threatened and disrespected by him. The DON could not recall the specific time of the meeting but stated it was before noon. The DON stated during the conversation with CMA #1, the CMA stated CNA #1 had recently recorded a video on his personal cell phone of resident #1 masturbating while in her room and had showed the video to his co-workers. The DON stated this was the first knowledge she and LPN #1 had of the incident. The DON stated she then immediately met with CNA #1, who provided her with a written a statement detailing his problems with co-workers. The DON stated she asked the CNA if he had video recorded a resident who resided on the household on which he worked. She stated the CNA admitted to taking a video recording a few weeks prior of resident #1 masturbating to show his co-workers so they would believe him. The DON stated the CNA told her he had since deleted the video. The DON stated she told the CNA this had been mistreatment of [REDACTED]. The DON stated she immediately notified the administrator, and an investigation was begun. She stated staff working on the household on which the resident resided were contacted and asked if they had seen or been shown a video of resident #1 masturbating. She stated written statements were obtained from CMA #1 and CNA #2. She stated CNAs #2 and #3 and CMA #1 were the only staff who told her they had knowledge or had seen the video recording on the phone belonging to CNA #1. The DON was asked for evidence of a thorough investigation. She provided a one-page report titled '(Name deleted) Investigation' which summarized the verbal accounts from CNA #1 and CMA #1 about their problems working with each other, and summarized the reports from each about the video recording on the phone belonging to CNA #1 of resident #1 masturbating. The report was signed by the DON and LPN #1. The days and dates on the report were inaccurate, and there was no date or time the report was completed. Attached to the one-page report were written statements from CNA #1, dated 04/23/17, CNA #2, dated 04/24/17, and CMA #1, dated 04/24/17 at 11:50 a.m. The DON also provided an undated/unsigned piece of paper on which eight names were written. To the right side of the names a no, never saw a video, yes, not involved or no was handwritten. There was a yes written beside three names. The DON identified the names with a yes to be CNAs #2, #3 and CMA #1, and indicated those staff had known about/seen the video recording on the personal cell phone belonging to CNA #1. The DON stated the other names on the paper were staff who worked on the household on which the resident resided and had contact with CNA #1. The DON stated local law enforcement was contacted on 04/25/17, the day following the administrator and DON's awareness of the incident. The DON was asked what the facility had done to ensure the incident did not recur. She stated nothing else had been done. She stated a 'Skills Fair', an annual event provided by the facility in which all employees skills were checked, had been conducted a month prior to the incident. She stated part of the 'Skills Fair' included retraining of each employee on the facility's abuse/neglect policy and procedures. She stated in addition, all employees were provided with training upon hire of the facility's abuse/neglect policy and procedures, resident rights and the facility's policy and procedures regarding the use of personal cell phones, photos and video recording upon hire. At 1:00 p.m., LPN #1 was asked about the incident. She stated she had no knowledge of the video recording until the meeting she and the DON had with CMA #1 and CNA #1 on 04/24/17. From 1:20 p.m. to 1:35 p.m., CNAs #2 and #3 were asked if they had any knowledge of any resident being video recorded. They stated approximately two weeks prior, CNA #1 had shown them a video recording during shift change of resident #1 masturbating in her room. They stated they knew that was wrong and knew it was abuse as well as a violation of the resident's privacy, and should have been reported immediately to the household coordinator. They stated they told LPN #1, the household coordinator, about the video recording the next morning. They were asked if CNA #1 continued to work on the household with residents after they had knowledge of the video recording of resident #1. They stated he did continue to work and they wondered why because they knew the CNA should not have been allowed to work with residents. At 1:45 p.m., LPN #1 was asked if any staff had reported knowledge of the video recording prior to the meeting on 04/24/17 with the DON. She stated, No. She stated if she had known of the incident she would have reported it to the DON immediately. She stated a couple of weeks prior, some staff members, which she thought had included CNAs #1, 2 and #3, had asked her what to do about a resident masturbating. She stated she told them it was the resident's right to do that, and to leave the resident alone and shut the door. From 3:15 to 4:00 p.m., the administrator and corporate staff #1 were asked about the incident. The administrator stated he became aware of the video recording incident involving resident #1 on 04/24/17, when the DON notified him during the meeting she and LPN #1 had with CNA #1. He stated the CNA quit and walked out as the DON and LPN #1 were talking to him. They were asked what they had done after they became aware of the incident. They stated the CNA was immediately terminated, and an ODH form 718 'Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property' had been faxed to the state agency on 04/25/17. They stated staff members had been interviewed, and from those interviews determined four staff members, CNAs #2, 3, 4 and LPN #2 may have seen the video. They stated by the next day they recognized a crime on some level may have been committed, and local law enforcement was notified on 04/25/17 at 10:00 a.m. They stated CNA #4 denied any knowledge of the video nor had it been texted to her. They stated LPN #2 notified the administrator on 04/25/17 at 11:54 a.m. via a text to his cell phone that she was quitting effective immediately. The administrator stated he left several voice mail messages with a family member of the resident on 04/24/17 and 04/25/17 asking him/her to return his call after he became aware of the incident. The administrator stated the family member met with him on 04/25/17 at 11:45 a.m., at which time he/she was informed of the incident involving the video recording and the involvement of local law enforcement. He stated he/she was also given a copy of the report that had been sent to the state agency. The administrator was asked for any written evidence of the investigation, and he stated he had nothing written at that time. There was no documentation of staff members that had been interviewed with dates, times, questions that were asked of staff, and there was no documentation residents had been asked about any inappropriate conduct from CNA #1 or any other staff. There was no evidence of a thorough investigation. The administrator was asked what had been done to ensure the the incident did not recur. He stated all employees had just had an in-service about a month prior during the 'Skills Fair', at which time all employees were provided with an in-service on abuse/neglect, so he believed all employees were aware of what abuse/neglect was and what to do when it was suspected. The corporate staff #1 stated the police department in charge of investigating the incident had told the facility to not tinker with this anymore. At 6:15 p.m., CMA #1 was interviewed. She stated she had heard CNAs #2 and #3 talking about the incident involving the video of resident #1 a couple of weeks prior. She stated when she was talking to the DON and LPN #1, the household coordinator, on 04/24/17 about how she felt disrespected and threatened by CNA #1. She stated she told them no one had done anything about the video CNA#1 had taken of resident #1. She stated they told her they were not aware of the incident, and at that time she told them what she had heard. She stated she told them she had not seen the video but had heard about the contents of the video. The CMA was asked about the abuse policy. She stated she was aware she should have reported the incident when she became aware, and was aware CNA #1 should not have been providing resident care pending the outcome of the investigation. She was asked why she had not reported knowledge of the incident at the time she became aware, and she had no answer. On 05/02/17 at 9:13 a.m., LPN #2 was interviewed. She was asked of any knowledge of any resident being video recorded. She stated she observed CNA #1 showing something on his cell phone to CNAs #2 and #3 on 04/24/17 as she was working. She stated she could tell by the look on the CNAs faces it wasn't something she wanted to see, and thought it was some video/picture totally unrelated to residents. She stated she had no idea what was on the phone was about the residents, and had she been aware of the nature of the video, would have taken the phone away from CNA #1 and reported the incident to the administrator and/or DON right away. She stated when the DON called her on 04/24/17 asking about any knowledge of the video, she then realized what had been on the phone. On 05/02/17 at 1:00 p.m., the DON was asked how the facility ensured privacy, dignity and respect for residents. She stated staff were to honor and respect residents' choices in such a way as to not belittle or embarrass them. She stated the video recording of resident #1 was absolutely a violation of the resident's privacy and dignity. A family member returned a call to the surveyor on 05/05/17 at 10:15 a.m., after having left messages requesting to talk about the incident. The family member stated the family had elected not to inform the resident of the incident. The family member stated the resident, had she known of the incident, would have been very embarrassed and humiliated. The family member stated the resident had been a life-long member of the Methodist Church, and this facility was where she always wanted to be if needed. The family member stated if his/her mother were to become aware of the incident, he/she believed she would not feel safe at the facility anymore, and would want to go live somewhere else. He/she stated if the family were to move her, they would have to tell her why they were moving.

On 04/27/17 at 7:30 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure resident #1 was not mentally abused when a staff member used a personal cell phone to videotape the resident as she was masturbating in her room and showed the video to other staff members. This affected one (#1) of three sampled residents whose right to be free of mental abuse was violated. On 04/27/17 at 7:30 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 11/30/16 at 7:45 p.m., the administrator and director of nurses were notified of the IJ situation. On 04/27/17 at 8:18 p.m., the plan of removal was accepted. The plan of removal for the Immediate Jeopardy documented: Inservice Plan: 1. Educate all staff present at this time. 2. Educate night staff when they arrive at 10:30 pm on 4/27/17. 3. Educate day staff as they arrive at 6:30 am on 4/28/17. 4. All OMM (Oklahoma Methodist Manor) staff will be educated in person, or via phone, before the end of the day on 4/28/17. Topics covered on the staff inservices were: ~abuse prevention, specifically mental abuse and humiliation ~video or other camera usage ~abuse reporting requirements ~thorough investigations of abuse and ~resident's right to privacy and dignity. The immediate jeopardy was removed on 04/30/17 at 7:00 p.m., after the plan of removal was carried out. The deficient practice remained at an isolated level of harm. Based on record reviews and interviews, it was determined the facility failed to ensure one (#1) of three sampled residents was free from mental abuse. CNA #1 used a personal cell phone to videotape the resident as she was masturbating in her room, and showed the video to other staff members. The facility's failure to ensure the resident was free from mental abuse had the potential to affect all 76 residents residing in the facility. Findings: A policy 'Resident Rights' dated January 2015, documented, .The 1987 Nursing Home Reform Law requires each long-term care community to care for its residents in a manner that promotes and enhances the quality of life of each resident, ensuring dignity, choice and self-determination. Resident's rights include but are not limited to .the right to privacy .the right to choose .the right to be free of .abuse . A policy 'Videotaping, Photographing, and Other Imaging of Residents' dated January 2016, documented, .Residents will be protected from invasion of privacy that might occur from the use of resident photographs, videotapes, digital images, and other visual recordings during resident care or other facility activities without the written consent of the resident . A policy 'Reporting Abuse to Facility Management' dated January 2016, documented, .Employees .must immediately report any suspected abuse or incidents of abuse, regardless of any time lapse, to the Household Charge Nurse. In the unavailability of the Household Charge Nurse, such reports may be made directly to the Director of Nursing Services or Administrator .Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment . A policy 'Preventing Resident Abuse' dated January 2016, documented, .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED].Timely and thorough investigations of all reports and allegations of abuse .The reporting and filing of accurate documents relative to incidents of abuse .An ongoing review and analysis of abuse incidents; and the implementation of changes to prevent future occurrences of abuse . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 08/01/16, and a quarterly assessment, dated 01/31/17, documented the resident had a severe visual impairment, and displayed modified cognitive impairment with decision making. The assessments documented the resident required limited assistance with eating and personal hygiene and extensive assistance with all other activities of daily living. The admission assessment documented activities that were very important to the resident included choosing her clothing and bedtime, listening to music, keeping up with the news, going outside when the weather was nice, participating in religious services and using a phone in private. Activities that were not important at all included doing things with groups of people. The care plan, dated 08/04/16, documented the residents's visual impairment was severe, with no vision or only seeing light, colors, shapes and was not able to follow objects. Interventions included, knock before you enter the room and introduce yourself, tell me why you're coming to see me . A facility incident report alleging abuse/mistreatment, received by the state agency on 04/25/17 at 11:18 a.m., documented, Description of Incident .On April 24, 2017, (name deleted) DON, received two reports from co-workers that CNA (name deleted) allegedly recorded a video, using his smart phone,of a resident with her hand in her pants supposedly masturbating. The co-workers stated that (name deleted) showed them an image on his phone and said he had a video of the resident masturbating. Upon seeing the video, told him it was inappropriate and that he should delete it from his phone. (Name deleted) was called to my office for an interview at which time he confessed to taking the video. (Name deleted)'S employment was immediately terminated . relevant resident history .The [AGE] year old resident, (name deleted), was admitted .7/25/16 with [DIAGNOSES REDACTED].due to her [MEDICAL CONDITION] would not have seen the video recording take place. She has not been informed that the video may have been taken; however, her daughter and POA, (name deleted) has been informed of the incident and the subsequent action we are taking . summary of investigation .While interviewing (name deleted), he admitted to taking and showing the video of the resident to his co-workers a couple of weeks ago. He became very emotional and stated that he realized it was wrong at the time and had subsequently deleted the video a couple of days later,. We believe that no remaining copy of the video exists in any device or form. He then resigned his position and left my office. His employment was immediately terminated . The report documented physician, family, DHS:Adult Protective Services, local law enforcement and the nurse aide registry were notified. On 04/27/17 at 11:15 a.m., the DON was asked about the above incident. The DON stated CNA #1 had called her on Sunday, 04/23/17, because he was upset with CMA #1. The DON told him she would talk to him on the following day. The DON stated on Monday morning, 04/24/17, CMA #1 met with her and LPN #1, the household coordinator on which both CNA #1 and CMA #1 worked, and on which resident #1 resided, to make a formal complaint against CNA #1, stating she felt threatened and disrespected by him. The DON could not recall the specific time of the meeting but stated it was before noon. The DON stated during the conversation with CMA #1, the CMA stated CNA #1 had recently recorded a video on his personal cell phone of resident #1 masturbating while in her room and had showed the video to his co-workers. The DON stated this was the first knowledge she and LPN #1 had of the incident. The DON stated she then immediately met with CNA #1, who provided her with a written a statement detailing his problems with co-workers. The DON stated she asked the CNA if he had video recorded a resident who resided on the household on which he worked. She stated the CNA admitted to taking a video recording a few weeks prior of resident #1 masturbating to show his co-workers so they would believe him. The DON stated the CNA told her he had since deleted the video. The DON stated she told the CNA this had been mistreatment of [REDACTED]. The DON stated she immediately notified the administrator, and an investigation was begun. She stated staff working on the household on which the resident resided were contacted and asked if they had seen or been shown a video of resident #1 masturbating. She stated written statements were obtained from CMA #1 and CNA #2. She stated CNAs #2 and #3 and CMA #1 were the only staff who told her they had knowledge or had seen the video recording on the phone belonging to CNA #1. The DON was asked for evidence of a thorough investigation. She provided a one-page report titled '(Name deleted) Investigation' which summarized the verbal accounts from CNA #1 and CMA #1 about their problems working with each other, and summarized the reports from each about the video recording on the phone belonging to CNA #1 of resident #1 masturbating. The report was signed by the DON and LPN #1. The days and dates on the report were inaccurate, and there was no date or time the report was completed. Attached to the one-page report were written statements from CNA #1, dated 04/23/17, CNA #2, dated 04/24/17, and CMA #1, dated 04/24/17 at 11:50 a.m. The DON also provided an undated/unsigned piece of paper on which eight names were written. To the right side of the names a no, never saw a video, yes, not involved or no was handwritten. There was a yes written beside three names. The DON identified the names with a yes to be CNAs #2, #3 and CMA #1, and indicated those staff had known about/seen the video recording on the personal cell phone belonging to CNA #1. The DON stated the other names on the paper were staff who worked on the household on which the resident resided and had contact with CNA #1. The DON stated local law enforcement was contacted on 04/25/17, the day following the administrator and DON's awareness of the incident. The DON was asked what the facility had done to ensure the incident did not recur. She stated nothing else had been done. She stated a 'Skills Fair', an annual event provided by the facility in which all employees skills were checked, had been conducted a month prior to the incident. She stated part of the 'Skills Fair' included retraining of each employee on the facility's abuse/neglect policy and procedures. She stated in addition, all employees were provided with training upon hire of the facility's abuse/neglect policy and procedures, resident rights and the facility's policy and procedures regarding the use of personal cell phones, photos and video recording upon hire. At 1:00 p.m., LPN #1 was asked about the incident. She stated she had no knowledge of the video recording until the meeting she and the DON had with CMA #1 and CNA #1 on 04/24/17. From 1:20 p.m. to 1:35 p.m., CNAs #2 and #3 were asked if they had any knowledge of any resident being video recorded. They stated approximately two weeks prior, CNA #1 had shown them a video recording during shift change of resident #1 masturbating in her room. They stated they knew that was wrong and knew it was abuse as well as a violation of the resident's privacy, and should have been reported immediately to the household coordinator. They stated they told LPN #1, the household coordinator, about the video recording the next morning. They were asked if CNA #1 continued to work on the household with residents after they had knowledge of the video recording of resident #1. They stated he did continue to work and they wondered why because they knew the CNA should not have been allowed to work with residents. A weekly schedule for 04/17/17 through 04/23/17 showed CNA #1 worked on household in which resident #1 resided on 04/17/17 through 04/20/17 and on 04/23/17. At 1:45 p.m., LPN #1 was asked if any staff had reported knowledge of the video recording prior to the meeting on 04/24/17 with the DON. She stated, No. She stated if she had known of the incident she would have reported it to the DON immediately. She stated a couple of weeks prior, some staff members, which she thought had included CNAs #1, 2 and #3, had asked her what to do about a resident masturbating. She stated she told them it was the resident's right to do that, and to leave the resident alone and shut the door. From 3:15 to 4:00 p.m., the administrator and corporate staff #1 were asked about the incident. The administrator stated he became aware of the video recording incident involving resident #1 on 04/24/17, when the DON notified him during the meeting she and LPN #1 had with CNA #1. He stated the CNA quit and walked out as the DON and LPN #1 were talking to him. They were asked what they had done after they became aware of the incident. They stated the CNA was immediately terminated, and an ODH form 718 'Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property' had been faxed to the state agency on 04/25/17. They stated staff members had been interviewed, and from those interviews determined four staff members, CNAs #2, 3, 4 and LPN #2 may have seen the video. They stated by the next day they recognized a crime on some level may have been committed, and local law enforcement was notified on 04/25/17 at 10:00 a.m. They stated CNA #4 denied any knowledge of the video nor had it been texted to her. They stated LPN #2 notified the administrator on 04/25/17 at 11:54 a.m. via a text to his cell phone that she was quitting effective immediately. The administrator stated he left several voice mail messages with the resident's family member on 04/24/17 and 04/25/17 asking him/her to return his call after he became aware of the incident. The administrator stated the family member met with him on 04/25/17 at 11:45 a.m., at which time he/she was informed of the incident involving the video recording and the involvement of local law enforcement. He stated he/she was also given a copy of the report that had been sent to the state agency. The administrator was asked for any written evidence of the investigation, and he stated he had nothing written at that time. There was no documentation of staff members that had been interviewed with dates, times, questions that were asked of staff, and there was no documentation residents had been asked about any inappropriate conduct from CNA #1 or any other staff. There was no documentation the resident's physician had been notified. There was no evidence of a thorough investigation. The administrator was asked what had been done to ensure the the incident did not recur. He stated all employees had just had an inservice about a month prior during the 'Skills Fair', at which time all employees were provided with an inservice on abuse/neglect, so he believed all employees were aware of what abuse/neglect was and what to do when it was suspected. The corporate staff #1 stated the police department in charge of investigating the incident had told the facility to not tinker with this anymore. At 6:15 p.m., CMA #1 was interviewed. She stated she had heard CNAs #2 and #3 talking about the incident involving the video of resident #1 a couple of weeks prior. She stated when she was talking to the DON and LPN #1, the household coordinator, on 04/24/17 about how she felt disrespected and threatened by CNA #1. She stated she told them no one had done anything about the video CNA#1 had taken of resident #1. She stated they told her they were not aware of the incident, and at that time she told them what she had heard. She stated she told them she had not seen the video but had heard about the contents of the video. The CMA was asked about the abuse policy. She stated she was aware she should have reported the incident when she became aware, and was aware CNA #1 should not have been providing resident care pending the outcome of the investigation. She was asked why she had not reported knowledge of the incident at the time she became aware, and she had no answer. On 05/02/17 at 9:13 a.m., LPN #2 was interviewed. She was asked of any knowledge of any resident being video recorded. She stated she observed CNA #1 showing something on his cell phone to CNAs #2 and #3 on 04/24/17 as she was working. She stated she could tell by the look on the CNAs faces it wasn't something she wanted to see, and thought it was some video/picture totally unrelated to residents. She stated she had no idea what was on the phone was about the residents, and had she been aware of the nature of the video, would have taken the phone away from CNA #1 and reported the incident to the administrator and/or DON right away. She stated when the DON called her on 04/24/17 asking about any knowledge of the video, she then realized what had been on the phone. On 05/02/17 at 1:00 p.m., the DON was asked how the facility ensured dignity and respect for residents. She stated staff were to honor and respect residents' choices in such a way as to not belittle or embarrass them. She stated the video recording of resident #1 was absolutely a violation of the resident's privacy and dignity. A family member returned a call to the surveyor on 05/05/17 at 10:15 a.m., after having left messages requesting to talk about the incident. The family member stated the family had elected not to inform the resident of the incident. The family member stated the resident, had she known of the incident, would have been very embarrassed and humiliated. The family member stated his/her mother had been a life-long member of the Methodist Church, and this facility was where she always wanted to be if needed. The family member stated if his/her mother were to become aware of the incident, he/she believed she would not feel safe at the facility anymore, and would want to go live somewhere else. He/she stated if the family were to move her, they would have to tell her why they were moving.

On 04/27/17 at 7:30 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's failure to ensure: a) staff did not mentally abuse, b) staff reported knowledge of mental abuse immediately, c) residents were protected from the perpetrator following staff knowledge of mental abuse and d) a thorough investigation of the allegation of mental abuse was completed when the administrator and director of nursing became aware of an allegation of mental abuse. Two staff members, CNAs #2 and #3, were shown a video recording from the personal cell phone of CNA #1, who had video taped resident #1 as she was masturbating in her room. The CNAs did not immediately report the incident to the household co-coordinator and/or director of nursing and/or administrator. One staff member, CMA #1, had knowledge of the video recording approximately two weeks before she reported the incident to the director of nursing. CNA #1 continued to provide direct resident care in the facility on the household in which resident #1 resided during an approximate 2 week time period when CNAs #2 and #3, and CMA #1 were aware of the video recording before it was reported to the director of nursing by CMA #1. After the allegation of abuse was reported to the director of nursing and the administrator, the facility had no evidence of a thorough investigation. The facility's failures affected one (#1) of three sampled residents. On 04/27/17 at 7:30 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 11/30/16 at 7:45 p.m., the administrator and director of nurses were notified of the IJ situation. On 04/27/17 at 8:18 p.m., the plan of removal was accepted. The plan of removal for the Immediate Jeopardy documented: Inservice Plan: 1. Educate all staff present at this time. 2. Educate night staff when they arrive at 10:30 pm on 4/27/17. 3. Educate day staff as they arrive at 6:30 am on 4/28/17. 4. All OMM (Oklahoma Methodist Manor) staff will be educated in person, or via phone, before the end of the day on 4/28/17. Topics covered on the staff inservices were: ~abuse prevention, specifically mental abuse and humiliation ~video or other camera usage ~abuse reporting requirements ~thorough investigations of abuse and ~resident's right to privacy and dignity. The immediate jeopardy was removed on 04/30/17 at 7:00 p.m., after the plan of removal was carried out. The deficient practice remained at an isolated level of harm. Based on record reviews and interviews, it was determined the facility failed to ensure: a) CNA #1 did not mentally abuse one (#1) b) staff reported knowledge of mental abuse immediately for one (#1), c) residents were protected from the alleged perpetrator following staff knowledge of mental abuse for one (#1) and d) thorough investigations of the allegations of abuse were completed when the administrator and/or director of nursing became aware of the allegations for three (#1, 2 and #3) of three sampled residents. These failures had the potential to affect all 76 residents residing in the facility. Findings: A policy 'Resident Rights' dated January 2015, documented, .The 1987 Nursing Home Reform Law requires each long-term care community to care for its residents in a manner that promotes and enhances the quality of life of each resident, ensuring dignity, choice and self-determination. Resident's rights include but are not limited to .the right to privacy .the right to choose .the right to be free of .abuse . A policy 'Videotaping, Photographing, and Other Imaging of Residents' dated January 2016, documented, .Residents will be protected from invasion of privacy that might occur from the use of resident photographs, videotapes, digital images, and other visual recordings during resident care or other facility activities without the written consent of the resident . A policy 'Reporting Abuse to Facility Management' dated January 2016, documented, .Employees .must immediately report any suspected abuse or incidents of abuse, regardless of any time lapse, to the Household Charge Nurse. In the unavailability of the Household Charge Nurse, such reports may be made directly to the Director of Nursing Services or Administrator .Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment . A policy 'Preventing Resident Abuse' dated January 2016, documented, .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED].Timely and thorough investigations of all reports and allegations of abuse .The reporting and filing of accurate documents relative to incidents of abuse .An ongoing review and analysis of abuse incidents; and the implementation of changes to prevent future occurrences of abuse . A policy 'Abuse Investigations' dated January 2016, documented, .All reports of abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum .Interview relevant staff members who have had contact with the resident during the period of the alleged incident .interview other residents to whom the accused employee provides care or services .witness statements will be reduced to writing. Witnesses will be required to sign and date such reports. The individual conducting the investigation may summarize the content of the accounts of non-witnesses interviewed . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 08/01/16, and a quarterly assessment, dated 01/31/17, documented the resident had a severe visual impairment, and displayed modified cognitive impairment with decision making. The assessments documented the resident required limited assistance with eating and personal hygiene and extensive assistance with all other activities of daily living. The admission assessment documented activities that were very important to the resident included choosing her clothing and bedtime, listening to music, keeping up with the news, going outside when the weather was nice, participating in religious services and using a phone in private. Activities that were not important at all included doing things with groups of people. The care plan, dated 08/04/16, documented the residents's visual impairment was severe, with no vision or only seeing light, colors, shapes and was not able to follow objects. Interventions included, knock before you enter the room and introduce yourself, tell me why you're coming to see me . A facility incident report alleging abuse/mistreatment, received by the state agency on 04/25/17 at 11:18 a.m., documented, Description of Incident .On April 24, 2017, (name deleted) DON, received two reports from co-workers that CNA (name deleted) allegedly recorded a video, using his smart phone,of a resident with her hand in her pants supposedly masturbating. The co-workers stated that (name deleted) showed them an image on his phone and said he had a video of the resident masturbating. Upon seeing the video, told him it was inappropriate and that he should delete it from his phone. (Name deleted) was called to my office for an interview at which time he confessed to taking the video. (Name deleted)'s employment was immediately terminated . relevant resident history .The [AGE] year old resident, (name deleted), was admitted .7/25/16 with [DIAGNOSES REDACTED].due to her [MEDICAL CONDITION] would not have seen the video recording take place. She has not been informed that the video may have been taken; however, her daughter and POA, (name deleted) has been informed of the incident and the subsequent action we are taking . summary of investigation .While interviewing (name deleted), he admitted to taking and showing the video of the resident to his co-workers a couple of weeks ago. He became very emotional and stated that he realized it was wrong at the time and had subsequently deleted the video a couple of days later,. We believe that no remaining copy of the video exists in any device or form. He then resigned his position and left my office. His employment was immediately terminated . The report documented physician, family, DHS:Adult Protective Services, local law enforcement and the nurse aide registry were notified. On 04/27/17 at 11:15 a.m., the DON was asked about the above incident. The DON stated CNA #1 had called her on Sunday, 04/23/17, because he was upset with CMA #1. The DON told him she would talk to him on the following day. The DON stated on Monday morning, 04/24/17, CMA #1 met with her and LPN #1, the household coordinator on which both CNA #1 and CMA #1 worked, and on which resident #1 resided, to make a formal complaint against CNA #1, stating she felt threatened and disrespected by him. The DON could not recall the specific time of the meeting but stated it was before noon. The DON stated during the conversation with CMA #1, the CMA stated CNA #1 had recently recorded a video on his personal cell phone of resident #1 masturbating while in her room and had showed the video to his co-workers. The DON stated this was the first knowledge she and LPN #1 had of the incident. The DON stated she then immediately met with CNA #1, who provided her with a written a statement detailing his problems with co-workers. The DON stated she asked the CNA if he had video recorded a resident who resided on the household on which he worked. She stated the CNA admitted to taking a video recording a few weeks prior of resident #1 masturbating to show his co-workers so they would believe him. The DON stated the CNA told her he had since deleted the video. The DON stated she told the CNA this had been mistreatment of [REDACTED]. The DON stated she immediately notified the administrator, and an investigation was begun. She stated staff working on the household on which the resident resided were contacted and asked if they had seen or been shown a video of resident #1 masturbating. She stated written statements were obtained from CMA #1 and CNA #2. She stated CNAs #2 and #3 and CMA #1 were the only staff who told her they had knowledge or had seen the video recording on the phone belonging to CNA #1. The DON was asked for evidence of a thorough investigation. She provided a one-page report titled '(Name deleted) Investigation' which summarized the verbal accounts from CNA #1 and CMA #1 about their problems working with each other, and summarized the reports from each about the video recording on the phone belonging to CNA #1 of resident #1 masturbating. The report was signed by the DON and LPN #1. The days and dates on the report were inaccurate, and there was no date or time the report was completed. Attached to the one-page report were written statements from CNA #1, dated 04/23/17, CNA #2, dated 04/24/17, and CMA #1, dated 04/24/17 at 11:50 a.m. The DON also provided an undated/unsigned piece of paper on which eight names were written. To the right side of the names a no, never saw a video, yes, not involved or no was handwritten. There was a yes written beside three names. The DON identified the names with a yes to be CNAs #2, #3 and CMA #1, and indicated those staff had known about/seen the video recording on the personal cell phone belonging to CNA #1. The DON stated the other names on the paper were staff who worked on the household on which the resident resided and had contact with CNA #1. The DON stated local law enforcement was contacted on 04/25/17, the day following the administrator and DON's awareness of the incident. The DON was asked what the facility had done to ensure the incident did not recur. She stated nothing else had been done. She stated a 'Skills Fair', an annual event provided by the facility in which all employees skills were checked, had been conducted a month prior to the incident. She stated part of the 'Skills Fair' included retraining of each employee on the facility's abuse/neglect policy and procedures. She stated in addition, all employees were provided with training upon hire of the facility's abuse/neglect policy and procedures, resident rights and the facility's policy and procedures regarding the use of personal cell phones, photos and video recording upon hire. At 1:00 p.m., LPN #1 was asked about the incident. She stated she had no knowledge of the video recording until the meeting she and the DON had with CMA #1 and CNA #1 on 04/24/17. From 1:20 p.m. to 1:35 p.m., CNAs #2 and #3 were asked if they had any knowledge of any resident being video recorded. They stated approximately two weeks prior, CNA #1 had shown them a video recording during shift change of resident #1 masturbating in her room. They stated they knew that was wrong and knew it was abuse as well as a violation of the resident's privacy, and should have been reported immediately to the household coordinator. They stated they told LPN #1, the household coordinator, about the video recording the next morning. They were asked if CNA #1 continued to work on the household with residents after they had knowledge of the video recording of resident #1. They stated he did continue to work and they wondered why because they knew the CNA should not have been allowed to work with residents. A weekly schedule for 04/17/17 through 04/23/17 showed CNA #1 worked on household in which resident #1 resided on 04/17/17 through 04/20/17 and on 04/23/17. At 1:45 p.m., LPN #1 was asked if any staff had reported knowledge of the video recording prior to the meeting on 04/24/17 with the DON. She stated, No. She stated if she had known of the incident she would have reported it to the DON immediately. She stated a couple of weeks prior, some staff members, which she thought had included CNAs #1, 2 and #3, had asked her what to do about a resident masturbating. She stated she told them it was the resident's right to do that, and to leave the resident alone and shut the door. From 3:15 to 4:00 p.m., the administrator and corporate staff #1 were asked about the incident. The administrator stated he became aware of the video recording incident involving resident #1 on 04/24/17, when the DON notified him during the meeting she and LPN #1 had with CNA #1. He stated the CNA quit and walked out as the DON and LPN #1 were talking to him. They were asked what they had done after they became aware of the incident. They stated the CNA was immediately terminated, and an ODH form 718 'Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property' had been faxed to the state agency on 04/25/17. They stated staff members had been interviewed, and from those interviews determined four staff members, CNAs #2, 3, 4 and LPN #2 may have seen the video. They stated by the next day they recognized a crime on some level may have been committed, and local law enforcement was notified on 04/25/17 at 10:00 a.m. They stated CNA #4 denied any knowledge of the video nor had it been texted to her. They stated LPN #2 notified the administrator on 04/25/17 at 11:54 a.m. via a text to his cell phone that she was quitting effective immediately. The administrator stated he left several voice mail messages with a family member of the resident on 04/24/17 and 04/25/17 asking him/her to return his call after he became aware of the incident. The administrator stated the family member met with him on 04/25/17 at 11:45 a.m., at which time he/she was informed of the incident involving the video recording and the involvement of local law enforcement. He stated he/she was also given a copy of the report that had been sent to the state agency. The administrator was asked for any written evidence of the investigation, and he stated he had nothing written at that time. There was no documentation of staff members that had been interviewed with dates, times, questions that were asked of staff, and there was no documentation residents had been asked about any inappropriate conduct from CNA #1 or any other staff. There was no documentation the resident's physician had been notified. There was no evidence of a thorough investigation. The administrator was asked what had been done to ensure the the incident did not recur. He stated all employees had just had an inservice about a month prior during the 'Skills Fair', at which time all employees were provided with an inservice on abuse/neglect, so he believed all employees were aware of what abuse/neglect was and what to do when it was suspected. The corporate staff #1 stated the police department in charge of investigating the incident had told the facility to not tinker with this anymore. At 6:15 p.m., CMA #1 was interviewed. She stated she had heard CNAs #2 and #3 talking about the incident involving the video of resident #1 a couple of weeks prior. She stated when she was talking to the DON and LPN #1, the household coordinator, on 04/24/17 about how she felt disrespected and threatened by CNA #1. She stated she told them no one had done anything about the video CNA#1 had taken of resident #1. She stated they told her they were not aware of the incident, and at that time she told them what she had heard. She stated she told them she had not seen the video but had heard about the contents of the video. The CMA was asked about the abuse policy. She stated she was aware she should have reported the incident when she became aware, and was aware CNA #1 should not have been providing resident care pending the outcome of the investigation. She was asked why she had not reported knowledge of the incident at the time she became aware, and she had no answer. On 05/02/17 at 9:13 a.m., LPN #2 was interviewed. She was asked of any knowledge of any resident being video recorded. She stated she observed CNA #1 showing something on his cell phone to CNAs #2 and #3 on 04/24/17 as she was working. She stated she could tell by the look on the CNAs faces it wasn't something she wanted to see, and thought it was some video/picture totally unrelated to residents. She stated she had no idea what was on the phone was about the residents, and had she been aware of the nature of the video, would have taken the phone away from CNA #1 and reported the incident to the administrator and/or DON right away. She stated when the DON called her on 04/24/17 asking about any knowledge of the video, she then realized what had been on the phone. On 05/02/17 at 1:00 p.m., the DON was asked how the facility ensured dignity and respect for residents. She stated staff were to honor and respect residents' choices in such a way as to not belittle or embarrass them. She stated the video recording of resident #1 was absolutely a violation of the resident's privacy and dignity. A family member returned a call to the surveyor on 05/05/17 at 10:15 a.m., after having left messages requesting to talk about the incident. The family member stated the family had elected not to inform the resident of the incident. The family member stated the resident, had she known of the incident, would have been very embarrassed and humiliated. The family member stated his/her mother had been a life-long member of the Methodist Church, and this facility was where she always wanted to be if needed. The family member stated if his/her mother were to become aware of the incident, he/she believed she would not feel safe at the facility anymore, and would want to go live somewhere else. He/she stated if the family were to move her, they would have to tell her why they were moving. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The initial comprehensive admission assessment and the comprehensive care plan were not due to be completed at the time of the investigation. A 'Combined Initial and Final' Incident Report Form, with an incident date of 04/23/17, alleging abuse/mistreatment, documented, Description of incident .On 04/23/17 .(name deleted family member) met with me to report that (the resident), Did not feel safe. (Family member) explained that upon arriving to his father's room, he was sitting on the side of the bed and had used the call light to ask for assistance and no one resonded. (Name deleted family member) stated that he also pressed the call light button and did not receive a response. He stated that after aproximately 15 minutes he went to the nurses station where the staff were congregated and asked for someone to assist his father. Upon entering .room, the staff had found (name deleted resident) incontinent and had become anxious .The staff cleaned (name deleted resident) and apologized for the delay in care. Additionally, (name deleted family member) stated that they had a bad experience with (name deleted CMA) .reported her behavior as rough and rude .being short and unhelpful to him .(name deleted CMA) is not scheduled to work upcoming shifts . summary of the investigation .While giving report during shift change, (name deleted resident) used his call light to request assistance to ambulate to the bathroom. The staff laid the pagers (which notify them of a call light) on a counter top in the dining room verses handing them to their co-worker replacing them on the next shift. The call light system .notes the call light was activated at 1445 and was answered at 1457. During this time, (name deleted resident) was incontinent. (Name deleted family member) has asked that the nurse also be given a pager in case the CMA or CNAs pager is misplaced in the future. This action has been taken .Regarding (name deleted CMA), I contacted her by phone to inform her she was suspended pending an investigation. She denied being rough or rude .I asked that she provide a written statement of her testimony. There were no witnesses of this event. (Name deleted CMA) is a PRN employee and will no longer be scheduled at OMM to fill vacant shifts. Additionally, I will report to the Nurse Aide Registry . The 'Final' Incident Report regarding this incident documented, .summary of investigation .(name deleted CMA) denied being rough or rude with (name deleted resident) .states she was attempting to encourage his independence as a rehab patient and she believes (name deleted resident) misinterpreted what she was saying .(name deleted CMA) has worked at OMM for the past 5 months and there have been no other reports of rude or rough behavior. (Name deleted CMA) was given education related to service-related expectations. (Name deleted CMA will not work on Mabee Point (where resident resides) until (name deleted resident) is discharged . 3. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] documented the resident had moderate cognitive impairment with daily decision making skills and required extensive assistance with transfers, ambulation, dressing, toileting and hygiene. A combined initial and final incident report form alleging abuse/mistreatment, with an incident date of 04/10/17, documented, .On 4/10/17, (name deleted CNA) and co-worker (name deleted CMA) were assisting (name deleted resident). (Name deleted CNA) became frustrated with (name deleted resident) and yelled, Stop it, I'm tired of your[***] (Name deleted CMA) reported the event to the DON on 04/11/17 at which time she immediately met with (name deleted) CNA obtaining her statement and suspending her pending an investigation . summary of the investigation .inteviewed (name deleted CNA) and she admitted to being frustrated and making the statement .(name deleted CNA) was notified to meet with the administrator and I tomorrow (4/13/17) at which time she will be terminated . On 05/02/17 at 11:00 a.m., the DON was asked about the investigation of the incidents with residents #2 and #3. She was asked if other residents and other staff on the households where the residents resided and who the accused staff provided care for, had been interviewed about the accused staff. She stated the there had been no other staff or residents interviewed. She was asked about the thoroughness of the investigation and stated she felt she had done what she needed to do.

On 04/27/17 at 7:30 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's failure to follow their abuse policy. After an allegation of mental abuse was reported to the director of nursing and administrator involving CNA #1 video taping resident #1 as she was masturbating in her room and showing the video to other staff members, the facility did not notify the physician and family timely, did not notify local law enforcement and the state nurse aide registry of the abuse allegation timely, and did not thoroughly investigate the allegation. The facility's failures affected one (#1) of three sampled residents. On 04/27/17 at 7:30 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 11/30/16 at 7:45 p.m., the administrator and director of nurses were notified of the IJ situation. On 04/27/17 at 8:18 p.m., the plan of removal was accepted. The plan of removal for the Immediate Jeopardy documented: Inservice Plan: 1. Educate all staff present at this time. 2. Educate night staff when they arrive at 10:30 pm on 4/27/17. 3. Educate day staff as they arrive at 6:30 am on 4/28/17. 4. All OMM (Oklahoma Methodist Manor) staff will be educated in person, or via phone, before the end of the day on 4/28/17. Topics covered on the staff inservices were: ~abuse prevention, specifically mental abuse and humiliation ~video or other camera usage ~abuse reporting requirements ~thorough investigations of abuse and ~resident's right to privacy and dignity. The immediate jeopardy was removed on 04/30/17 at 7:00 p.m., after the plan of removal was carried out. The deficient practice remained at an isolated level of harm. Based on record reviews and interviews, it was determined the facility failed to: a) notify the physician, family, local law enforcement and the state nurse aide registry timely for one (#1) and b) ensure thorough investigations of the allegations of abuse were completed when the administrator and/or director of nursing became aware of the allegations for three (#1, 2 and #3) of three sampled residents. These failures had the potential to affect all 76 residents residing in the facility. Findings: A policy 'Resident Rights' dated January 2015, documented, .The 1987 Nursing Home Reform Law requires each long-term care community to care for its residents in a manner that promotes and enhances the quality of life of each resident, ensuring dignity, choice and self-determination. Resident's rights include but are not limited to .the right to privacy .the right to choose .the right to be free of .abuse . A policy 'Videotaping, Photographing, and Other Imaging of Residents' dated January 2016, documented, .Residents will be protected from invasion of privacy that might occur from the use of resident photographs, videotapes, digital images, and other visual recordings during resident care or other facility activities without the written consent of the resident . A policy 'Reporting Abuse to Facility Management' dated January 2016, documented, .Employees .must immediately report any suspected abuse or incidents of abuse, regardless of any time lapse, to the Household Charge Nurse. In the unavailability of the Household Charge Nurse, such reports may be made directly to the Director of Nursing Services or Administrator .Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment . A policy 'Preventing Resident Abuse' dated January 2016, documented, .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED].Timely and thorough investigations of all reports and allegations of abuse .The reporting and filing of accurate documents relative to incidents of abuse .An ongoing review and analysis of abuse incidents; and the implementation of changes to prevent future occurrences of abuse . A policy 'Abuse Investigations' dated January 2016, documented, .All reports of abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum .Interview relevant staff members who have had contact with the resident during the period of the alleged incident .interview other residents to whom the accused employee provides care or services .witness statements will be reduced to writing. Witnesses will be required to sign and date such reports. The individual conducting the investigation may summarize the content of the accounts of non-witnesses interviewed . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 08/01/16, and a quarterly assessment, dated 01/31/17, documented the resident had a severe visual impairment, and displayed modified cognitive impairment with decision making. The assessments documented the resident required limited assistance with eating and personal hygiene and extensive assistance with all other activities of daily living. The admission assessment documented activities that were very important to the resident included choosing her clothing and bedtime, listening to music, keeping up with the news, going outside when the weather was nice, participating in religious services and using a phone in private. Activities that were not important at all included doing things with groups of people. The care plan, dated 08/04/16, documented the residents's visual impairment was severe, with no vision or only seeing light, colors, shapes and was not able to follow objects. Interventions included, knock before you enter the room and introduce yourself, tell me why you're coming to see me . A facility incident report alleging abuse/mistreatment, received by the state agency on 04/25/17 at 11:18 a.m., documented, Description of Incident .On April 24, 2017, (name deleted) DON, received two reports from co-workers that CNA (name deleted) allegedly recorded a video, using his smart phone,of a resident with her hand in her pants supposedly masturbating. The co-workers stated that (name deleted) showed them an image on his phone and said he had a video of the resident masturbating. Upon seeing the video, told him it was inappropriate and that he should delete it from his phone. (Name deleted) was called to my office for an interview at which time he confessed to taking the video. (Name deleted)'s employment was immediately terminated . relevant resident history .The [AGE] year old resident, (name deleted), was admitted .7/25/16 with [DIAGNOSES REDACTED].due to her [MEDICAL CONDITION] would not have seen the video recording take place. She has not been informed that the video may have been taken; however, her daughter and POA, (name deleted) has been informed of the incident and the subsequent action we are taking . summary of investigation .While interviewing (name deleted), he admitted to taking and showing the video of the resident to his co-workers a couple of weeks ago. He became very emotional and stated that he realized it was wrong at the time and had subsequently deleted the video a couple of days later,. We believe that no remaining copy of the video exists in any device or form. He then resigned his position and left my office. His employment was immediately terminated . The report documented physician, family, DHS:Adult Protective Services, local law enforcement and the nurse aide registry were notified. On 04/27/17 at 11:15 a.m., the DON was asked about the above incident. The DON stated CNA #1 had called her on Sunday, 04/23/17, because he was upset with CMA #1. The DON told him she would talk to him on the following day. The DON stated on Monday morning, 04/24/17, CMA #1 met with her and LPN #1, the household coordinator on which both CNA #1 and CMA #1 worked, and on which resident #1 resided, to make a formal complaint against CNA #1, stating she felt threatened and disrespected by him. The DON could not recall the specific time of the meeting but stated it was before noon. The DON stated during the conversation with CMA #1, the CMA stated CNA #1 had recently recorded a video on his personal cell phone of resident #1 masturbating while in her room and had showed the video to his co-workers. The DON stated this was the first knowledge she and LPN #1 had of the incident. The DON stated she then immediately met with CNA #1, who provided her with a written a statement detailing his problems with co-workers. The DON stated she asked the CNA if he had video recorded a resident who resided on the household on which he worked. She stated the CNA admitted to taking a video recording a few weeks prior of resident #1 masturbating to show his co-workers so they would believe him. The DON stated the CNA told her he had since deleted the video. The DON stated she told the CNA this had been mistreatment of [REDACTED]. The DON stated she immediately notified the administrator, and an investigation was begun. She stated staff working on the household on which the resident resided were contacted and asked if they had seen or been shown a video of resident #1 masturbating. She stated written statements were obtained from CMA #1 and CNA #2. She stated CNAs #2 and #3 and CMA #1 were the only staff who told her they had knowledge or had seen the video recording on the phone belonging to CNA #1. The DON was asked for evidence of a thorough investigation. She provided a one-page report titled '(Name deleted) Investigation' which summarized the verbal accounts from CNA #1 and CMA #1 about their problems working with each other, and summarized the reports from each about the video recording on the phone belonging to CNA #1 of resident #1 masturbating. The report was signed by the DON and LPN #1. The days and dates on the report were inaccurate, and there was no date or time the report was completed. Attached to the one-page report were written statements from CNA #1, dated 04/23/17, CNA #2, dated 04/24/17, and CMA #1, dated 04/24/17 at 11:50 a.m. The DON also provided an undated/unsigned piece of paper on which eight names were written. To the right side of the names a no, never saw a video, yes, not involved or no was handwritten. There was a yes written beside three names. The DON identified the names with a yes to be CNAs #2, #3 and CMA #1, and indicated those staff had known about/seen the video recording on the personal cell phone belonging to CNA #1. The DON stated the other names on the paper were staff who worked on the household on which the resident resided and had contact with CNA #1. The DON stated local law enforcement was contacted on 04/25/17, the day following the administrator and DON's awareness of the incident. The DON was asked what the facility had done to ensure the incident did not recur. She stated nothing else had been done. She stated a 'Skills Fair', an annual event provided by the facility in which all employees skills were checked, had been conducted a month prior to the incident. She stated part of the 'Skills Fair' included retraining of each employee on the facility's abuse/neglect policy and procedures. She stated in addition, all employees were provided with training upon hire of the facility's abuse/neglect policy and procedures, resident rights and the facility's policy and procedures regarding the use of personal cell phones, photos and video recording upon hire. At 1:00 p.m., LPN #1 was asked about the incident. She stated she had no knowledge of the video recording until the meeting she and the DON had with CMA #1 and CNA #1 on 04/24/17. From 1:20 p.m. to 1:35 p.m., CNAs #2 and #3 were asked if they had any knowledge of any resident being video recorded. They stated approximately two weeks prior, CNA #1 had shown them a video recording during shift change of resident #1 masturbating in her room. They stated they knew that was wrong and knew it was abuse as well as a violation of the resident's privacy, and should have been reported immediately to the household coordinator. They stated they told LPN #1, the household coordinator, about the video recording the next morning. They were asked if CNA #1 continued to work on the household with residents after they had knowledge of the video recording of resident #1. They stated he did continue to work and they wondered why because they knew the CNA should not have been allowed to work with residents. At 1:45 p.m., LPN #1 was asked if any staff had reported knowledge of the video recording prior to the meeting on 04/24/17 with the DON. She stated, No. She stated if she had known of the incident she would have reported it to the DON immediately. She stated a couple of weeks prior, some staff members, which she thought had included CNAs #1, 2 and #3, had asked her what to do about a resident masturbating. She stated she told them it was the resident's right to do that, and to leave the resident alone and shut the door. From 3:15 to 4:00 p.m., the administrator and corporate staff #1 were asked about the incident. The administrator stated he became aware of the video recording incident involving resident #1 on 04/24/17, when the DON notified him during the meeting she and LPN #1 had with CNA #1. He stated the CNA quit and walked out as the DON and LPN #1 were talking to him. They were asked what they had done after they became aware of the incident. They stated the CNA was immediately terminated, and an ODH form 718 'Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property' had been faxed to the state agency on 04/25/17. They stated staff members had been interviewed, and from those interviews determined four staff members, CNAs #2, 3, 4 and LPN #2 may have seen the video. They stated by the next day they recognized a crime on some level may have been committed, and local law enforcement was notified on 04/25/17 at 10:00 a.m. They stated CNA #4 denied any knowledge of the video nor had it been texted to her. They stated LPN #2 notified the administrator on 04/25/17 at 11:54 a.m. via a text to his cell phone that she was quitting effective immediately. The administrator stated he left several voice mail messages with a family member of the resident on 04/24/17 and 04/25/17 asking him/her to return his call after he became aware of the incident. The administrator stated the family member met with him on 04/25/17 at 11:45 a.m., at which time he/she was informed of the incident involving the video recording and the involvement of local law enforcement. He stated he/she was also given a copy of the report that had been sent to the state agency. The administrator was asked for any written evidence of the investigation, and he stated he had nothing written at that time. There was no documentation of staff members that had been interviewed with dates, times, questions that were asked of staff, and there was no documentation residents had been asked about any inappropriate conduct from CNA #1 or any other staff. There was no documentation the resident's physician had been notified. There was no evidence of a thorough investigation. The administrator was asked what had been done to ensure the the incident did not recur. He stated all employees had just had an inservice about a month prior during the 'Skills Fair', at which time all employees were provided with an inservice on abuse/neglect, so he believed all employees were aware of what abuse/neglect was and what to do when it was suspected. The corporate staff #1 stated the police department in charge of investigating the incident had told the facility to not tinker with this anymore. At 6:15 p.m., CMA #1 was interviewed. She stated she had heard CNAs #2 and #3 talking about the incident involving the video of resident #1 a couple of weeks prior. She stated when she was talking to the DON and LPN #1, the household coordinator, on 04/24/17 about how she felt disrespected and threatened by CNA #1. She stated she told them no one had done anything about the video CNA#1 had taken of resident #1. She stated they told her they were not aware of the incident, and at that time she told them what she had heard. She stated she told them she had not seen the video but had heard about the contents of the video. The CMA was asked about the abuse policy. She stated she was aware she should have reported the incident when she became aware, and was aware CNA #1 should not have been providing resident care pending the outcome of the investigation. She was asked why she had not reported knowledge of the incident at the time she became aware, and she had no answer. On 05/02/17 at 9:13 a.m., LPN #2 was interviewed. She was asked of any knowledge of any resident being video recorded. She stated she observed CNA #1 showing something on his cell phone to CNAs #2 and #3 on 04/24/17 as she was working. She stated she could tell by the look on the CNAs faces it wasn't something she wanted to see, and thought it was some video/picture totally unrelated to residents. She stated she had no idea what was on the phone was about the residents, and had she been aware of the nature of the video, would have taken the phone away from CNA #1 and reported the incident to the administrator and/or DON right away. She stated when the DON called her on 04/24/17 asking about any knowledge of the video, she then realized what had been on the phone. On 05/02/17 at 1:00 p.m., the DON was asked how the facility ensured dignity and respect for residents. She stated staff were to honor and respect residents' choices in such a way as to not belittle or embarrass them. She stated the video recording of resident #1 was absolutely a violation of the resident's privacy and dignity. A family member returned a call to the surveyor on 05/05/17 at 10:15 a.m., after having left messages requesting to talk about the incident. The family member stated the family had elected not to inform the resident of the incident. The family member stated the resident, had she known of the incident, would have been very embarrassed and humiliated. The family member stated his/her mother had been a life-long member of the Methodist Church, and this facility was where she always wanted to be if needed. The family member stated if his/her mother were to become aware of the incident, he/she believed she would not feel safe at the facility anymore, and would want to go live somewhere else. He/she stated if the family were to move her, they would have to tell her why they were moving. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The initial comprehensive admission assessment and the comprehensive care plan were not due to be completed at the time of the investigation. A 'Combined Initial and Final' Incident Report Form, with an incident date of 04/23/17, alleging abuse/mistreatment, documented, Description of incident .On 04/23/17 .(name deleted family member) met with me to report that (the resident), Did not feel safe. (Family member) explained that upon arriving to his father's room, he was sitting on the side of the bed and had used the call light to ask for assistance and no one resonded. (Name deleted family member) stated that he also pressed the call light button and did not receive a response. He stated that after aproximately 15 minutes he went to the nurses station where the staff were congregated and asked for someone to assist his father. Upon entering .room, the staff had found (name deleted resident) incontinent and had become anxious .The staff cleaned (name deleted resident) and apologized for the delay in care. Additionally, (name deleted family member) stated that they had a bad experience with (name deleted CMA) .reported her behavior as rough and rude .being short and unhelpful to him .(name deleted CMA) is not scheduled to work upcoming shifts . summary of the investigation .While giving report during shift change, (name deleted resident) used his call light to request assistance to ambulate to the bathroom. The staff laid the pagers (which notify them of a call light) on a counter top in the dining room verses handing them to their co-worker replacing them on the next shift. The call light system .notes the call light was activated at 1445 and was answered at 1457. During this time, (name deleted resident) was incontinent. (Name deleted family member) has asked that the nurse also be given a pager in case the CMA or CNAs pager is misplaced in the future. This action has been taken .Regarding (name deleted CMA), I contacted her by phone to inform her she was suspended pending an investigation. She denied being rough or rude .I asked that she provide a written statement of her testimony. There were no witnesses of this event. (Name deleted CMA) is a PRN employee and will no longer be scheduled at OMM to fill vacant shifts. Additionally, I will report to the Nurse Aide Registry . The 'Final' Incident Report regarding this incident documented, .summary of investigation .(name deleted CMA) denied being rough or rude with (name deleted resident) .states she was attempting to encourage his independence as a rehab patient and she believes (name deleted resident) misinterpreted what she was saying .(name deleted CMA) has worked at OMM for the past 5 months and there have been no other reports of rude or rough behavior. (Name deleted CMA) was given education related to service-related expectations. (Name deleted CMA will not work on Mabee Point (where resident resides) until (name deleted resident) is discharged . 3. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] documented the resident had moderate cognitive impairment with daily decision making skills and required extensive assistance with transfers, ambulation, dressing, toileting and hygiene. A combined initial and final incident report form alleging abuse/mistreatment, with an incident date of 04/10/17, documented, .On 4/10/17, (name deleted CNA) and co-worker (name deleted CMA) were assisting (name deleted resident). (Name deleted CNA) became frustrated with (name deleted resident) and yelled, Stop it, I'm tired of your[***] (Name deleted CMA) reported the event to the DON on 04/11/17 at which time she immediately met with (name deleted) CNA obtaining her statement and suspending her pending an investigation . summary of the investigation .inteviewed (name deleted CNA) and she admitted to being frustrated and making the statement .(name deleted CNA) was notified to meet with the administrator and I tomorrow (4/13/17) at which time she will be terminated . On 05/02/17 at 11:00 a.m., the DON was asked about the investigation of the incidents with residents #2 and #3. She was asked if other residents and other staff on the households where the residents resided and who the accused staff provided care for, had been interviewed about the accused staff. She stated the there had been no other staff or residents interviewed. She was asked about the thoroughness of the investigation and stated she felt she had done what she needed to do.

On 04/27/17 at 7:30 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure resident #1 was treated with dignity and respect when a staff member used a personal cell phone to videotape the resident as she was masturbating in her room and showed the video to other staff members. This affected one (#1) of three sampled residents whom the facility failed to ensure was treated in a dignified manner. On 04/27/17 at 7:30 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 11/30/16 at 7:45 p.m., the administrator and director of nurses were notified of the IJ situation. On 04/27/17 at 8:18 p.m., the plan of removal was accepted. The plan of removal for the Immediate Jeopardy documented: Inservice Plan: 1. Educate all staff present at this time. 2. Educate night staff when they arrive at 10:30 pm on 4/27/17. 3. Educate day staff as they arrive at 6:30 am on 4/28/17. 4. All OMM (Oklahoma Methodist Manor) staff will be educated in person, or via phone, before the end of the day on 4/28/17. Topics covered on the staff inservices were: ~abuse prevention, specifically mental abuse and humiliation ~video or other camera usage ~abuse reporting requirements ~thorough investigations of abuse and ~resident's right to privacy and dignity. The immediate jeopardy was removed on 04/30/17 at 7:00 p.m., after the plan of removal was carried out. The deficient practice remained at an isolated level of harm. Based on record reviews and interviews, it was determined the facility failed to ensure one (#1) of three sampled residents was treated in a dignified manner. CNA #1 used a personal cell phone to videotape the resident as she was masturbating in her room, and showed the video to other staff members. The facility's failure to ensure dignity had the potential to affect all 76 residents residing in the facility. Findings: A policy 'Resident Rights' dated January 2015, documented, .The 1987 Nursing Home Reform Law requires each long-term care community to care for its residents in a manner that promotes and enhances the quality of life of each resident, ensuring dignity, choice and self-determination. Resident's rights include but are not limited to .the right to privacy .the right to choose .the right to be free of restraint and abuse . A policy 'Videotaping, Photographing, and Other Imaging of Residents' dated January 2016, documented, .Residents will be protected from invasion of privacy that might occur from the use of resident photographs, videotapes, digital images, and other visual recordings during resident care or other facility activities without the written consent of the resident . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 08/01/16, and a quarterly assessment, dated 01/31/17, documented the resident had a severe visual impairment, and displayed modified cognitive impairment with decision making. The assessments documented the resident required limited assistance with eating and personal hygiene and extensive assistance with all other activities of daily living. The admission assessment documented activities that were very important to the resident included choosing her clothing and bedtime, listening to music, keeping up with the news, going outside when the weather was nice, participating in religious services and using a phone in private. Activities that were not important at all included doing things with groups of people. The care plan, dated 08/04/16, documented the residents's visual impairment was severe, with no vision or only seeing light, colors, shapes and was not able to follow objects. Interventions included, knock before you enter the room and introduce yourself, tell me why you're coming to see me . A facility incident report alleging abuse/mistreatment, received by the state agency on 04/25/17 at 11:18 a.m., documented, Description of Incident .On April 24, 2017, (name deleted) DON, received two reports from co-workers that CNA (name deleted) allegedly recorded a video, using his smart phone,of a resident with her hand in her pants supposedly masturbating. The co-workers stated that (name deleted) showed them an image on his phone and said he had a video of the resident masturbating. Upon seeing the video, told him it was inappropriate and that he should delete it from his phone. (Name deleted) was called to my office for an interview at which time he confessed to taking the video. (Name deleted)'s employment was immediately terminated . relevant resident history .The [AGE] year old resident, (name deleted), was admitted .7/25/16 with [DIAGNOSES REDACTED].due to her [MEDICAL CONDITION] would not have seen the video recording take place. She has not been informed that the video may have been taken; however, her daughter and POA, (name deleted) has been informed of the incident and the subsequent action we are taking . summary of investigation .While interviewing (name deleted), he admitted to taking and showing the video of the resident to his co-workers a couple of weeks ago. He became very emotional and stated that he realized it was wrong at the time and had subsequently deleted the video a couple of days later,. We believe that no remaining copy of the video exists in any device or form. He then resigned his position and left my office. His employment was immediately terminated . The report documented physician, family, DHS:Adult Protective Services, local law enforcement and the nurse aide registry were notified. On 04/27/17 at 11:15 a.m., the DON was asked about the above incident. The DON stated CNA #1 had called her on Sunday, 04/23/17, because he was upset with CMA #1. The DON told him she would talk to him on the following day. The DON stated on Monday morning, 04/24/17, CMA #1 met with her and LPN #1, the household coordinator on which both CNA #1 and CMA #1 worked, and on which resident #1 resided, to make a formal complaint against CNA #1, stating she felt threatened and disrespected by him. The DON could not recall the specific time of the meeting but stated it was before noon. The DON stated during the conversation with CMA #1, the CMA stated CNA #1 had recently recorded a video on his personal cell phone of resident #1 masturbating while in her room and had showed the video to his co-workers. The DON stated this was the first knowledge she and LPN #1 had of the incident. The DON stated she then immediately met with CNA #1, who provided her with a written a statement detailing his problems with co-workers. The DON stated she asked the CNA if he had video recorded a resident who resided on the household on which he worked. She stated the CNA admitted to taking a video recording a few weeks prior of resident #1 masturbating to show his co-workers so they would believe him. The DON stated the CNA told her he had since deleted the video. The DON stated she told the CNA this had been mistreatment of [REDACTED]. The DON stated she immediately notified the administrator, and an investigation was begun. She stated staff working on the household on which the resident resided were contacted and asked if they had seen or been shown a video of resident #1 masturbating. She stated written statements were obtained from CMA #1 and CNA #2. She stated CNAs #2 and #3 and CMA #1 were the only staff who told her they had knowledge or had seen the video recording on the phone belonging to CNA #1. The DON was asked for evidence of a thorough investigation. She provided a one-page report titled '(Name deleted) Investigation' which summarized the verbal accounts from CNA #1 and CMA #1 about their problems working with each other, and summarized the reports from each about the video recording on the phone belonging to CNA #1 of resident #1 masturbating. The report was signed by the DON and LPN #1. The days and dates on the report were inaccurate, and there was no date or time the report was completed. Attached to the one-page report were written statements from CNA #1, dated 04/23/17, CNA #2, dated 04/24/17, and CMA #1, dated 04/24/17 at 11:50 a.m. The DON also provided an undated/unsigned piece of paper on which eight names were written. To the right side of the names a no, never saw a video, yes, not involved or no was handwritten. There was a yes written beside three names. The DON identified the names with a yes to be CNAs #2, #3 and CMA #1, and indicated those staff had known about/seen the video recording on the personal cell phone belonging to CNA #1. The DON stated the other names on the paper were staff who worked on the household on which the resident resided and had contact with CNA #1. The DON stated local law enforcement was contacted on 04/25/17, the day following the administrator and DON's awareness of the incident. The DON was asked what the facility had done to ensure the incident did not recur. She stated nothing else had been done. She stated a 'Skills Fair', an annual event provided by the facility in which all employees skills were checked, had been conducted a month prior to the incident. She stated part of the 'Skills Fair' included retraining of each employee on the facility's abuse/neglect policy and procedures. She stated in addition, all employees were provided with training upon hire of the facility's abuse/neglect policy and procedures, resident rights and the facility's policy and procedures regarding the use of personal cell phones, photos and video recording upon hire. At 1:00 p.m., LPN #1 was asked about the incident. She stated she had no knowledge of the video recording until the meeting she and the DON had with CMA #1 and CNA #1 on 04/24/17. From 1:20 p.m. to 1:35 p.m., CNAs #2 and #3 were asked if they had any knowledge of any resident being video recorded. They stated approximately two weeks prior, CNA #1 had shown them a video recording during shift change of resident #1 masturbating in her room. They stated they knew that was wrong and knew it was abuse as well as a violation of the resident's privacy, and should have been reported immediately to the household coordinator. They stated they told LPN #1, the household coordinator, about the video recording the next morning. They were asked if CNA #1 continued to work on the household with residents after they had knowledge of the video recording of resident #1. They stated he did continue to work and they wondered why because they knew the CNA should not have been allowed to work with residents. At 1:45 p.m., LPN #1 was asked if any staff had reported knowledge of the video recording prior to the meeting on 04/24/17 with the DON. She stated, No. She stated if she had known of the incident she would have reported it to the DON immediately. She stated a couple of weeks prior, some staff members, which she thought had included CNAs #1, 2 and #3, had asked her what to do about a resident masturbating. She stated she told them it was the resident's right to do that, and to leave the resident alone and shut the door. From 3:15 to 4:00 p.m., the administrator and corporate staff #1 were asked about the incident. The administrator stated he became aware of the video recording incident involving resident #1 on 04/24/17 when the DON notified him during the meeting she and LPN #1 had with CNA #1. He stated the CNA quit and walked out as the DON and LPN #1 were talking to him. They were asked what they had done after they became aware of the incident. They stated the CNA was immediately terminated, and an ODH form 718 'Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property' had been faxed to the state agency on 04/25/17. They stated staff members had been interviewed, and from those interviews determined four staff members, CNAs #2, 3, 4 and LPN #2 may have seen the video. They stated by the next day they recognized a crime on some level may have been committed, and local law enforcement was notified on 04/25/17 at 10:00 a.m. They stated CNA #4 denied any knowledge of the video nor had it been texted to her. They stated LPN #1 notified the administrator on 04/25/17 at 11:54 a.m. via a text to his cell phone that she was quitting effective immediately. The administrator stated he left several voice mail messages with a family member of the resident on 04/24/17 and 04/25/17 asking him/her to return his call after he became aware of the incident. The administrator stated the resident's family member met with him on 04/25/17 at 11:45 a.m., at which time he/she was informed of the incident involving the video recording and the involvement of local law enforcement. He stated he/she was also given a copy of the report that had been sent to the state agency. The administrator was asked for any written evidence of the investigation, and he stated he had nothing written at that time. There was no documentation of staff members that had been interviewed with dates, times, questions that were asked of staff, and there was no documentation residents had been asked about any inappropriate conduct from CNA #1 or any other staff. There was no evidence of a thorough investigation. The administrator was asked what had been done to ensure the the incident did not recur. He stated all employees had just had an inservice about a month prior during the 'Skills Fair', at which time all employees were provided with an inservice on abuse/neglect, so he believed all employees were aware of what abuse/neglect was and what to do when it was suspected. The corporate staff #1 stated the police department in charge of investigating the incident had told the facility to not tinker with this anymore. At 6:15 p.m., CMA #1 was interviewed. She stated she heard CNAs #2 and #3 talking about the incident involving the video of resident #1. She stated when she was talking to the DON and LPN #1, the household coordinator, on 04/24/17 about how she felt disrespected and threatened by CNA #1. She stated she told them no one had done anything about the video CNA#1 had taken of resident #1. She stated they told her they were not aware of the incident, and at that time she told them what she had heard. She stated she told them she had not seen the video but had heard about the contents of the video. The CMA was asked about the abuse policy. She stated she was aware she should have reported the incident when she became aware, and was aware CNA #1 should not have been providing resident care pending the outcome of the investigation. She was asked why she had not reported knowledge of the incident at the time she became aware, and she had no answer. On 05/02/17 at 9:13 a.m., LPN #2 was interviewed. She was asked of any knowledge of any resident being video recorded. She stated she observed CNA #1 showing something on his cell phone to CNAs #2 and #3 on 04/24/17 as she was working. She stated she could tell by the look on the CNAs faces it wasn't something she wanted to see, and thought it was some video/picture totally unrelated to residents. She stated she had no idea what was on the phone was about the residents, and had she been aware of the nature of the video, would have taken the phone away from CNA #1 and reported the incident to the administrator and/or DON right away. She stated when the DON called her on 04/24/17 asking about any knowledge of the video, she then realized what had been on the phone. On 05/02/17 at 1:00 p.m., the DON was asked how the facility ensured privacy, dignity and respect for residents. She stated staff were to honor and respect residents' choices in such a way as to not belittle or embarrass them. She stated the video recording of resident #1 was absolutely a violation of the resident's privacy and dignity. A family member returned a call to the surveyor on 05/05/17 at 10:15 a.m., after having left messages requesting to talk about the incident. The family member stated the family had elected not to inform the resident of the incident. The family member stated the resident, had she known of the incident, would have been very embarrassed and humiliated. The family member stated his/her mother had been a life-long member of the Methodist Church, and this facility was where she always wanted to be if needed. The family member stated if his/her mother were to become aware of the incident, he/she believed she would not feel safe at the facility anymore, and would want to go live somewhere else. He/she stated if the family were to move her, they would have to tell her why they were moving.

On 05/16/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to thoroughly investigate allegations of mistreatment/neglect or abuse, failure to report allegations of mistreatment/neglect or abuse to administration, failure to protect residents from further mistreatment/neglect or abuse for multiple residents and failure to provide an environment where residents and staff members were able to report mistreatment/neglect or abuse without fear of reprisal. On 05/16/13 the IJ situation was verified with the Oklahoma State Department of Health. At 4:12 p.m., the CEO, administrator, and DON were notified of the IJ situation. On 05/16/13 at 8:39 p.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: "Plan of Removal. May 16, 2013 On May 16, 2013 Oklahoma Methodist Manor was notified by surveyors from the Oklahoma State Department of Health that it as being (sic) cited for 3 deficiencies that constitute Immediate Jeopardy for Not Preventing Abuse Not Investigating Abuse Not Reporting Abuse Not Following Abuse Policy Immediate Interventions 1. The Administrator and Director Of Nursing will fully review and be familiar with Oklahoma Methodist Manor's Abuse Prevention, Investigation and Reporting Policy. This review will be complete by 6:00pm on May 16, 2013. 2. Starting at 8:00pm on Thursday, May 16 and every hour thereafter until 1:00pm on Friday, May 17 (when all interviews are completed), the Administrator or Director of Nursing will conduct monitoring rounds in all Households. All rounds will be documented. 3. (Name deleted), Director of Nursing; (name deleted), Cobb Landing Program Coordinator; and (name deleted), Priddy Harbor Household Coordinator, will conduct inservice education regarding Abuse Prevention and Reporting with all staff present. Every staff member of the Healthcare Households will receive this inservice education prior to working their very next shift and prior to any resident contact. This inservice education will begin no later than 7:00pm on May 16, 2013 and will be completed by 1:00pm on May 17, 2013. Of note, staff member (name deleted), CNA (name withheld) is on vacation and will be educated prior to her return to duty. The education will include: a. Oklahoma Methodist Manor's policy on Abuse and Neglect b. How to use the 'Potential Resident Abuse Report Form' c. Specific responsibilities of the person reporting the allegation: i. If CNA or CMA, will: 1. Report to Charge Nurse 2. Fill out the 'Potential Resident Abuse Report Form' and give to Charge Nurse 3. Follow up the following day to ensure report is being investigated. ii. If LPN or RN, will: 1. Report to Director of Nursing 2. If a specific staff person is identified in the allegation, the LPN or RN will remove that individual from the facility 3. Fill out the 'Potential Resident Abuse Report Form' and give to Director of Nursing 4. Follow up the following day to ensure report is being investigated. iii. If Director of Nursing, will: 1. Report to Administrator 2. The Director of Nursing will ensure that any specific staff person identified in the allegation has been removed from the facility and that the investigation has been initiated. 3. Fill out the 'Potential Resident Abuse Report Form' and give to Administrator 4. Follow up the following day to ensure report is being investigated. iv. If Administrator, will: 1. Review the allegation, the completed 'Potential Resident Abuse Report Form' and will ensure investigation and reporting is complete. v. Upon any allegation of Abuse or Neglect, an incident report and State Report will be completed in accordance with policy and state regulations. d. Follow up on reports to ensure allegations are reported and investigated e. The resident experience during bathing f. The resident experience during dressing and undressing g. The resident experience, and proper protocol, for incontinence care h. The prevention and reporting of 'roughness' or any type of 'bulling' behavior i. Resident use of the call light system, and call light cord placement j. Sensitivity toward a resident's fearfulness to report abuse, and our policy prohibiting and form of retaliation 4. The Director of Assisted Living (name withheld), will audit every resident's call light for proper placement and operation. This audit and system test will be competed by 7:00pm on May 16, 2013. Any light found to be misplaced will immediately be placed within reach of the resident. Any malfunctioning equipment will immediately be replaced with functioning equipment. 5. RN consultant (name withheld) has been engaged to provide immediate support in investigating and supporting corrective action. 6. We will conduct an exhaustive investigation to identify any and all allegations of abuse. a. We will interview all staff members in the Chapman Heights, Priddy Harbor and Buehler Place households and random staff members from other households. These interviews began at 3:00 pm on May 16, 2013 and will be completed by 1:00 p.m. on May 17, 2013. b. We will conduct resident interviews with all residents in the Chapman Heights, Priddy Harbor and Buehler Place households, and selected residents from other households. These interviews began at 4:30pm on May 16, 2013 and will be completed by 1:00p.m. on May 17, 2013. c. Additional Staff, Residents and Family Members will be interviewed as necessary as the investigation proceeds. d. We will contact every responsible party in the Chapman Heights, Priddy Harbor and Buehler Place households informing them of the abuse prevention program and inquiring about any possible incidents of abuse or neglect. This will be completed by 1:00 p.m. on May 17, 2013. e. All allegations of abuse identified during the investigation will be reported and fully investigated in accordance with Oklahoma Methodist Manor policy. Any individual who is identified in an allegation of abuse/neglect will be suspended pending full investigation." On 05/17/13 at 11:25 a.m., the administrator provided documentation to show he made rounds on all households to ensure residents were protected until all staff were inserviced. The IJ was removed when the facility provided evidence that all components of the plan of removal had been completed on 05/17/13 at 1:29 p.m. The deficient practice remained at a pattern level of actual harm. Based on observation, interview and record review, it was determined the facility failed to ensure allegations of mistreatment/neglect and/or abuse were thoroughly investigated, residents were protected from further mistreatment/neglect and/or abuse, and allegations of mistreatment/neglect and/or abuse were reported to administration for five (#3, #5, #6, #8, and #9) of nine sampled residents reviewed for abuse. Residents #3, 5 and #6 resided on Chapman Heights, resident #9 resided on Buehler Place, and resident #8 on Priddy Harbor. The facility identified 16 residents who resided on Chapman Heights, 16 residents who resided on Priddy Harbor, 14 residents who resided on Buehler Place, and a total of 77 residents who resided in the facility. The facility failed to ensure residents and staff were able to report allegations of abuse without fear of reprisal. Findings: The policy dated, revised January 2009, titled, "Abuse investigation policy statement, documented: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation... Should an accident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the DON, or his/her designee, will to (sic) investigate the alleged incident... The Administrator will provide to the person in charge of the investigation a completed copy of the 'Potential Resident Abuse Report Form'... The individual conducting the investigation will, as a minimum...Review the completed 'Potential Resident Abuse Report Form'...Review the resident's medical record to determine events leading up to the incident...Interview the person(s) reporting the incident...Interview any witnesses to the incident...Interview the resident (as medically appropriate)...Interview the resident's Attending physician as needed to determine the resident's current level of cognitive function and medical condition...Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident...Interview the resident's family members, and visitors...Interview other residents to whom the accused employee provides care or services...Review all events leading up to the alleged incident... Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be attached to the 'Resident Abuse Investigation Report Form.')... While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator... Employees of this facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator. To provide general guidelines for resident rights while caring for the resident...Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: Preventing, recognizing and reporting abuse Abuse and Neglect - Clinical Protocol The nurse will assess the individual and document related findings. Assessment data will include...Injury assessment (bleeding, bruising, deformity, swelling etc.)...All current medications, especially anticoagulants, NSAID's, [MEDICATION NAME] platelet inhibitors...Vital signs...Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior)...History of any tendency towards bruising...All active diagnoses...Any recent labs... The nurse will report findings to the physician. As needed, the physician will assess the resident to verify or clarify such findings, especially if the cause or source of the problem is unclear... As part of the initial assessment, the physician will help identify individuals who have a history of being abused or neglected, or those who might have been abused or neglected: for example, individuals admitted from home or the hospital with multiple pressure ulcers and severe under-nutrition... 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish... 'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...As needed, the physician will evaluate the resident or have them sent for evaluation; for example, to rule out sexual assault or fracture, or to assess the location and potential causes of bruises... The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes... The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect... The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations... The Medical Director will advise facility management and staff about systems to ensure the basic medical, functional, psychosocial needs are being met and that potentially preventable or treatment conditions affecting function and quality of life are addressed appropriately... Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion..." The facility's inservice log manual was reviewed and there was no documentation for employees receiving Abuse and Neglect inservices. 1. Resident #8, who resided on Priddy Harbor, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan, dated January 2013, documented: "...Personal Hygiene Please Assist me with my personal hygiene: ...Please make sure my teeth are clean especially when I go to bed..." Bathing - I prefer a WHIRLPOOL Whirlpool bath... I like to have a BATH 3 times a week... Facility LIFTS used for transfers... ...Dental Care I have my own natural teeth. Things you can do to help me: ...Help me brush my teeth every day..." A social service note, dated 01/15/13, documented, "Resident also said she has been feeling bad about herself due to 'I just can't do for myself'." A quarterly assessment, dated 04/16/13, documented the resident was cognitively intact, required extensive assistance with all ADLs, had limited ROM in the lower extremities, and had no falls. An update to the care plan, dated 04/16/13, documented, "...Occassionaly (sic) incont (incontinent) of urine R/T use of diuretics." A nurse's note, dated 05/11/13 at 8:00 a.m., documented, "While resident was getting a bath her 2nd toe was seen to be bleeding. Nurse was notified and bandage was applied..." On 05/15/13 at 10:08 a.m., the resident stated, "I prayed for you to come. I was hoping someone from state would come." She stated, "This is the best facility and the worst help." She stated a staff member she did not know gave her a shower on 05/11/13. She stated the person did not know how to push her in her wheelchair and her right foot was being dragged on the floor all the way to the shower room. She stated it took off the top layer of my toe. She stated the nurse had applied a dressing. She stated, "I had to wait on the lift this morning. I couldn't wait anymore so I just peed in bed." The resident was re-visited at 1:00 p.m. She stated staff was hateful, always in a hurry, and rough. The resident's family member was present and stated she had spoken with administration in regards to the resident's care. She stated, "I would like to see (the resident) get more than two whirlpools a week." The resident stated, "When you're scared they will hurt you, I wait for someone that knows what they're doing to be here." The family member stated, "I would like to see them brush her teeth more often." The resident stated, "I don't like for them to brush my teeth. They are rough." On 05/15/13 at 3:20 p.m., LPN #1 was asked if she reported the incident regarding the toe of resident #8 that was injured when staff pushed her in her wheelchair. She stated, "I reported it to the DON." On 05/16/13 at 3:06 p.m., an observation of the resident's right foot was completed with the assistance of LPN #8. A blood blister was noted on the top of the right great toe extending under the nail. A pea size wound was present on the top of the right second toe, at the distal joint, with serosanguinous drainage. The second toe was swollen and extremely bruised. A blood blister was present on the cuticle area of the 3rd toe. LPN #8 was asked if an x-ray had been obtained. She stated, "It didn't look this bad this morning." She proceeded to call the physician and obtained an order for [REDACTED]. 2. Resident #3, who resided on Chapman Heights, had current [DIAGNOSES REDACTED]. A significant change in status assessment, dated 03/19/13, documented the resident had a severe impairment in cognition, had total dependence in transfers, and was incontinent of bladder and bowel. The care plan, dated March 2013, documented, "...cognitive loss/dementia...always be patient, pleasant and reassuring when I'm confused...explain all procedures to me using simple terms...Personal hygiene...Make sure my hair is brushed when I get out of bed or anytime it needs...Incontinence...I am incontinent of bowel and bladder and I need changed frequently...assist me with incontinent care prn...ADLs...bed mobility extensive assist of one caregiver...transfers use a lift 2 staff members..." On 05/15/13 at 5:30 p.m., resident #3 was asked if staff had been mean to her. She stated, "Yes." The resident stated staff had slapped the bottom of her swollen feet. She stated it had been a while ago and she was sleeping a lot then. She stated staff had told her to shut up. She was asked if she reported the staff to anyone. She stated, "No." She was asked if she was afraid of the staff. The resident did not reply. At 6:10 p.m., the resident was asked if she could remember when staff told her to shut up and slapped the bottom of her feet. She stated, "No. It's all foggy. Wish I could help." 3. Resident #6, who had resided on Chapman Heights, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated September 2012, documented the resident was severely impaired cognitively, required extensive assistance with all ADLs, and had a history of [REDACTED]. The quarterly assessment, dated 12/25/12, documented the resident was severely impaired in cognition and needed extensive assistance with all ADLs. An update to the care plan, dated 01/29/13, documented, "light bruise between eyes - possibly from glasses..." The facility's state reportable file was reviewed for the unknown injury and a head injury related to the bruise between the eyes. There was not a reportable in the facility file. On 05/16/13 at 1:10 p.m., the DON was asked if any abuse had been reported to her since November 2012. She stated there was a concern regarding a transfer of a resident and the resident broke her toe. She was asked how she investigated bruising of unknown origin. She stated, "I take statements of staff on duty." She was asked if she talked with residents. She stated, "At times." She was asked if she considered the bruising between the resident's eyes as potential abuse. She stated, "I talked to five staff on two shifts." She was asked if she interviewed any residents. She stated, "I didn't write that down." She was asked if she interviewed residents on the same hall as the resident. She stated, "I don't know." She was asked who was she to interview according to the facility's abuse policy. No answer was given. At 3:39 p.m., CNA #2 was asked if she had been aware of any staff to resident abuse. She stated, "Yes, only on Chapman Hall. One day we were short staff and (CMA #1) was in the shower room with (resident #6). As I opened the door, the resident's legs were up in the air and the CMA was pulling her pants off. Her feet had dressings on and her feet fell to the floor. The resident screamed out and the CMA pushed her in the shower." She was asked if she reported the incident and to whom. She stated, "Yes. I reported to the administrator, (CMA #5), and the human resources director." There was no documentation of an investigation of the allegation of abuse. 4. Resident #9, who resided on Buehler Place, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly assessment, dated 02/04/13, documented the resident was cognitively intact, needed moderate to extensive assistance with all ADLs, and had no falls. The care plan, dated August 2012, documented the resident had cognitive loss due to difficulty with recall at times, required assistance with ADLs, was occasionally incontinent, had a history of [REDACTED]. An e-mail from a family member to the DON, dated 01/17/13, documented "...After you left, (resident name deleted) and I continued to talk. We discussed specifically the problems (resident name deleted) is having with one caregiver, (CNA #7 name deleted) has threatened (resident name deleted) with retribution if she reports performance concerns to you or others in administration. (Resident name deleted) feels a real sense of danger of retribution from (CNA #7 name deleted). (Resident name deleted) also described several occasions where (CNA #7 name deleted) forced her to do things she was very uncomfortable with, such as having to stand on her own during transfers. I can only categorize this behavior as bullying...Whatever steps you take, they should result in (CNA #7 name deleted) no longer being around (resident name deleted) or in Buehler so as to effectively remove the threat and (resident name deleted) fear of retaliation..." A hand written note, dated 01/18/13, documented, "Admin, DNS, HC meet c (resident name deleted) (Administrator name deleted) asked her about concerns c transfers 'almost falling' The aide stood behind chair & told her to pull herself up - (resident) said I can't do that - Aide said yes you can I stood up and I almost fell ...(CNA name deleted) other concerns w/c to toilet feels rushed too much 12 high risk" An e-mail from the family member to the administrator, dated 01/21/13, documented, "...First, it is wholly consistent with the notion that (resident name deleted) has real sense of fear from retaliation for her to not be completely transparent with you regarding her concerns with (CNA #7 name deleted). Not surprisingly, (resident name deleted) is less forthcoming with you than with me. I think it is unfair to characterize this as uncertainty on her part. Her tears when I was talking with her speak volumes to me. (DON name deleted) can confirm the spontaneous emotion (resident name deleted) had when the three of us met and were discussing these very issues..." An Oklahoma State Department of health incident report form, final faxed on 01/25/13, documented, "Received email from grandson that (resident name deleted) verbalized to him concerns regarding a C.N.A. 'forcing' her to do things she was uncomfortable with, such as having to stand on her own during transfers. (Resident name deleted) also has feelings of possible retribution from aide if she reports her concerns... Interview with caregiver named...Many times when caregiver attempts to help (resident name deleted) will try to do too much on her own and not wait for appropriate help. She was then placed on suspension. Meeting with (resident name deleted) was completed on January 18, 2013. She explained that her concern with one of her caregivers was during a w/c to bed transfer when the care giver instructed her to stand up on her own, using only the transfer bar on the bed. The aide did help her get into bed and no injury occurred during this transfer. She had concerns with transfers in general and was in agreement to have therapy intervene and review assistance needed and technique. (Resident name deleted) denied being afraid of this care giver or anyone else. She agreed to work together with this caregiver and other caregivers along with therapy to improve her transfers. Administrator e-mail grandson of above conversation and of our plan with therapy services. Grandson wrote back with continued concerns about (resident name deleted) working with this one caregiver... Interviews completed with other residents in household with no reports of concerns with cares provided including with transfers and allowing residents to do as much for themselves as possible. Caregiver and (resident name deleted) have not worked together since investigation started on January 17, 2013..." The state reportable form had no documentation of interviewing staff or obtaining written statements by the staff related to the investigation of allegations of abuse. On 05/16/13 at 5:00 p.m., the DON was asked for all state reportable incident reports for the past year and this was the only reportable sent to the state. The DON was asked for further documentation related to the investigation and she stated there was no documentation. The DON was asked if there were written statements from staff and she stated, "No." She was asked which staff were interviewed related to the allegation and she said she was not sure. On 05/17/13 at 1:15 p.m., the resident was interviewed and she confirmed the above information. She stated she wished she was stronger and was able to be independent. 5. Resident #5, who resided on Chapman Heights, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A (name withheld) Hospice care plan, dated 01/21/13, documented a problem, "...Physical condition/generalized weakness..." The goal was, "...To understand limitations r/t generalized weakness related to terminal diagnosis...Patient environment will be safe..." Interventions included, "...Teach safety measures and instruct in use of needed appliances...Assess patient's ability to perform ADL's, observe for weakness..." A care plan, dated 01/22/13, documented a problem, "...Anticipatory grieving..." The goal was, "...Improve coping evidenced by patient/CG discussing feelings..." Interventions included, "...Encourage patient/CG to express feelings and provide emotional support... A quarterly assessment, dated 04/23/13, documented the resident was cognitively intact, was not verbally or physically abusive, and did not exhibit socially inappropriate or disruptive behavioral symptoms. It was documented the resident was totally dependent on staff with transfers and toilet use, and required extensive assistance with bed mobility, dressing, and bathing. On 05/15/13 at 12:38 p.m. CNA #5 was asked if she had reported any allegations of abuse. She stated, "(Resident #5) told me (CNA #8) was rough with her during incontinent care. I told an LPN, I don't know who." She was asked when this occurred. She stated, "May have been in February." On 05/15/13 at 1:14 p.m., resident #5 was asked how she was treated by staff when receiving care. She stated, "(CNA #8) came into my room and didn't even tell me who she was." The resident stated, "I didn't know who she was at first." She stated while she changed my brief, "She pushed on my pelvis so hard I thought it was going to break." When asked when this had occurred she stated, "Several weeks ago." She stated, "She never talks very nice to me. I can't get it why she talks to me that way. I try to be nice to them." She was asked if she had informed anyone of the incident. She stated she had told the charge nurse, CMA/Household Coordinator #5. She stated the charge nurse told her CNA #8 was not to come into her room without having another staff member with her. She stated, "But she does." She stated she had two call lights. One was a pendant which she preferred because she can not use her hands well enough to use her hand held call light. She stated, "The one on the chain, I either can't find it or it's across the room." She stated they get mad at her for using her call light. She stated one night a former employee, who she couldn't remember his name, came into her room and told her, "think of everything you want and tell me so I won't have to keep answering your call light." She stated, "I'm afraid to say anything because they will have it out for me and won't answer my light." The resident required oxygen per nasal cannula. She stated it was sore behind her ears and she asked staff to place gauze under the tubing. She stated, "Some will do it and some won't." The resident stated at another time she was trying to eat a Hershey bar and could not use her hands well so she got chocolate under her fingernails, which were long. She stated, "CMA #1 came in and started ranting and raving that she was going to cut my nails off." On 05/15/13 at 1:20 p.m., in a confidential interview, a resident refused to talk about the staff unless her privacy was protected 100%. The resident was informed that her privacy was protected unless a court order was obtained for the records. The resident stated she would not talk to the surveyor. On 05/15/13 at 2:55 p.m., CMA #1 was asked if she knew of any staff to resident abuse. She stated, "We have some people who tell staff how to care for them and staff get upset because they know how to do their job." On 05/15/13 at 3:39 p.m., CNA #2 stated resident #7 was very demanding during lunch and CMA #1 and CNA #9 ignored her. She stated CMA #5 refused to do incontinent care on a resident with [MEDICAL CONDITION]. On 05/15/13 at 4:00 p.m., in a confidential interview with a CNA, reported she was afraid of the staff. She stated that CMA #1 and CNA #8 told her, "If you say any thing, we will slash your tires and follow you home." At 5:45 p.m., CNA #8 was asked if she had ever witnessed any staff to resident abuse. She stated staff can be "short" with residents at times. When asked what she meant by "short", she stated, "Like rushing the conversation." When asked about the incident that occurred while changing resident #5's brief, she stated resident #5 was asleep and while changing her brief she may have pushed on her stomach a little too much but the resident did not make a noise. She stated she was not aware of the incident until the next day when (CMA/Household Coordinator) informed her. She stated, "I wasn't trying to hurt her." On 05/16/13 at 10:08 a.m., CMA/Household Coordinator #5 was asked if the incident of CNA #8 providing care to resident #5 was reported to her. She stated, "Yes." She stated CNA #8 had placed excessive pressure on resident #5's vaginal area. She stated she spoke to resident #5 and informed the resident that the CNA was not to come back into her room without another staff member present. When asked if she had documented the incident, she stated, "No." When asked how she had monitored to ensure the CNA was following her order, she did not respond. She was then informed that the CNA had been going back into the resident's room without another staff member present. She stated, "We have had staff issues." On 05/16/13 at 10:31 a.m., CNA #8 was asked if she had been aware of staff to resident abuse. She stated, "I don't think it is intentional but some residents don't want certain people to take care of them especially (CMA #1). I worked with her and I see. Its always been an issue. She had been addressed to be more gentle." She was asked if she had reported the abuse. She stated, "Yes, to my supervisor." She was asked if she had been aware of a staff member telling a resident to shut up. She stated, "CMA #1 is a naturally loud person. The facility is aware of CMA #1 and her roughness." She stated, "The abuse is more when the facility is short staffed." She was asked if she reported to her supervisor. She stated, "Yes, I complained to the supervisors. Staff and residents are afraid to complain." She was asked if there was anything else she wanted to say. She stated, "There are call lights that go off and staff will see who it is and then they ignore the resident." Personnel files for CMA #1 and CNA #8 were reviewed. There was no documentation of counseling or reprimands. At 11:00 a.m., CMA #2 was asked if she had ever witnessed any staff to resident abuse. She stated she had not witnessed any verbal abuse but resident #5 had complained of CMA #1 being "rough". She stated she reported the incident to the charge nurse who is

On 05/16/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to implement their abuse policies to ensure allegations of mistreatment/neglect or abuse were thoroughly investigated, reported to administration and residents were protected from further mistreatment/neglect and/or abuse for multiple residents and failure to provide an environment where residents and staff members were able to report mistreatment/neglect or abuse without fear of reprisal. On 05/16/13 the IJ situation was verified with the Oklahoma State Department of Health. At 4:12 p.m., the CEO, administrator, and DON were notified of the IJ situation. On 05/16/13 at 8:39 p.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: "Plan of Removal. May 16, 2013 On May 16, 2013 Oklahoma Methodist Manor was notified by surveyors from the Oklahoma State Department of Health that it as being (sic) cited for 3 deficiencies that constitute Immediate Jeopardy for Not Preventing Abuse Not Investigating Abuse Not Reporting Abuse Not Following Abuse Policy Immediate Interventions 1. The Administrator and Director Of Nursing will fully review and be familiar with Oklahoma Methodist Manor's Abuse Prevention, Investigation and Reporting Policy. This review will be complete by 6:00pm on May 16, 2013. 2. Starting at 8:00pm on Thursday, May 16 and every hour thereafter until 1:00pm on Friday, May 17 (when all interviews are completed), the Administrator or Director of Nursing will conduct monitoring rounds in all Households. All rounds will be documented. 3. (Name deleted), Director of Nursing; (name deleted), Cobb Landing Program Coordinator; and (name deleted), Priddy Harbor Household Coordinator, will conduct inservice education regarding Abuse Prevention and Reporting with all staff present. Every staff member of the Healthcare Households will receive this inservice education prior to working their very next shift and prior to any resident contact. This inservice education will begin no later than 7:00pm on May 16, 2013 and will be completed by 1:00pm on May 17, 2013. Of note, staff member (name deleted), CNA (name withheld) is on vacation and will be educated prior to her return to duty. The education will include: a. Oklahoma Methodist Manor's policy on Abuse and Neglect b. How to use the 'Potential Resident Abuse Report Form' c. Specific responsibilities of the person reporting the allegation: i. If CNA or CMA, will: 1. Report to Charge Nurse 2. Fill out the 'Potential Resident Abuse Report Form' and give to Charge Nurse 3. Follow up the following day to ensure report is being investigated. ii. If LPN or RN, will: 1. Report to Director of Nursing 2. If a specific staff person is identified in the allegation, the LPN or RN will remove that individual from the facility 3. Fill out the 'Potential Resident Abuse Report Form' and give to Director of Nursing 4. Follow up the following day to ensure report is being investigated. iii. If Director of Nursing, will: 1. Report to Administrator 2. The Director of Nursing will ensure that any specific staff person identified in the allegation has been removed from the facility and that the investigation has been initiated. 3. Fill out the 'Potential Resident Abuse Report Form' and give to Administrator 4. Follow up the following day to ensure report is being investigated. iv. If Administrator, will: 1. Review the allegation, the completed 'Potential Resident Abuse Report Form' and will ensure investigation and reporting is complete. v. Upon any allegation of Abuse or Neglect, an incident report and State Report will be completed in accordance with policy and state regulations. d. Follow up on reports to ensure allegations are reported and investigated e. The resident experience during bathing f. The resident experience during dressing and undressing g. The resident experience, and proper protocol, for incontinence care h. The prevention and reporting of 'roughness' or any type of 'bulling' behavior i. Resident use of the call light system, and call light cord placement j. Sensitivity toward a resident's fearfulness to report abuse, and our policy prohibiting and form of retaliation 4. The Director of Assisted Living (name withheld), will audit every resident's call light for proper placement and operation. This audit and system test will be competed by 7:00pm on May 16, 2013. Any light found to be misplaced will immediately be placed within reach of the resident. Any malfunctioning equipment will immediately be replaced with functioning equipment. 5. RN consultant (name withheld) has been engaged to provide immediate support in investigating and supporting corrective action. 6. We will conduct an exhaustive investigation to identify any and all allegations of abuse. a. We will interview all staff members in the Chapman Heights, Priddy Harbor and Buehler Place households and random staff members from other households. These interviews began at 3:00 pm on May 16, 2013 and will be completed by 1:00 p.m. on May 17, 2013. b. We will conduct resident interviews with all residents in the Chapman Heights, Priddy Harbor and Buehler Place households, and selected residents from other households. These interviews began at 4:30pm on May 16, 2013 and will be completed by 1:00p.m. on May 17, 2013. c. Additional Staff, Residents and Family Members will be interviewed as necessary as the investigation proceeds. d. We will contact every responsible party in the Chapman Heights, Priddy Harbor and Buehler Place households informing them of the abuse prevention program and inquiring about any possible incidents of abuse or neglect. This will be completed by 1:00 p.m. on May 17, 2013. e. All allegations of abuse identified during the investigation will be reported and fully investigated in accordance with Oklahoma Methodist Manor policy. Any individual who is identified in an allegation of abuse/neglect will be suspended pending full investigation." On 05/17/13 at 11:25 a.m., the administrator provided documentation to show he made rounds on all households to ensure residents were protected until all staff were inserviced. The IJ was removed when the facility provided evidence that all components of the plan of removal had been completed on 05/17/13 at 1:29 p.m. The deficient practice remained at a pattern level of actual harm. Based on observation, interview and record review, it was determined the facility failed to implement their abuse policies to ensure allegations of mistreatment/neglect and/or abuse were thoroughly investigated, residents were protected from further mistreatment/neglect and/or abuse, and allegations of mistreatment/neglect and/or abuse were reported to administration for five (#3, #5, #6, #8, and #9) of nine sampled residents reviewed for abuse. Residents #3, 5 and #6 resided on Chapman Heights, resident #9 resided on Buehler Place, and resident #8 on Priddy Harbor. The facility identified 16 residents who resided on Chapman Heights, 16 residents who resided on Priddy Harbor, 14 residents who resided on Buehler Place, and a total of 77 residents who resided in the facility. The facility failed to ensure residents and staff were able to report allegations of abuse without fear of reprisal. Findings: The policy dated, revised January 2009, titled, "Abuse investigation policy statement, documented: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation... Should an accident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the DON, or his/her designee, will to (sic) investigate the alleged incident... The Administrator will provide to the person in charge of the investigation a completed copy of the 'Potential Resident Abuse Report Form'... The individual conducting the investigation will, as a minimum...Review the completed 'Potential Resident Abuse Report Form'...Review the resident's medical record to determine events leading up to the incident...Interview the person(s) reporting the incident...Interview any witnesses to the incident...Interview the resident (as medically appropriate)...Interview the resident's Attending physician as needed to determine the resident's current level of cognitive function and medical condition...Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident...Interview the resident's family members, and visitors...Interview other residents to whom the accused employee provides care or services...Review all events leading up to the alleged incident... Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be attached to the 'Resident Abuse Investigation Report Form.')... While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator... Employees of this facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator. To provide general guidelines for resident rights while caring for the resident...Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: Preventing, recognizing and reporting abuse Abuse and Neglect - Clinical Protocol The nurse will assess the individual and document related findings. Assessment data will include...Injury assessment (bleeding, bruising, deformity, swelling etc.)...All current medications, especially anticoagulants, NSAID's, [MEDICATION NAME] platelet inhibitors...Vital signs...Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior)...History of any tendency towards bruising...All active diagnoses...Any recent labs... The nurse will report findings to the physician. As needed, the physician will assess the resident to verify or clarify such findings, especially if the cause or source of the problem is unclear... As part of the initial assessment, the physician will help identify individuals who have a history of being abused or neglected, or those who might have been abused or neglected: for example, individuals admitted from home or the hospital with multiple pressure ulcers and severe under-nutrition... 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish... 'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...As needed, the physician will evaluate the resident or have them sent for evaluation; for example, to rule out sexual assault or fracture, or to assess the location and potential causes of bruises... The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes... The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect... The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations... The Medical Director will advise facility management and staff about systems to ensure the basic medical, functional, psychosocial needs are being met and that potentially preventable or treatment conditions affecting function and quality of life are addressed appropriately... Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion..." The facility's inservice log manual was reviewed and there was no documentation for employees receiving Abuse and Neglect inservices. 1. Resident #8, who resided on Priddy Harbor, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan, dated January 2013, documented: "...Personal Hygiene Please Assist me with my personal hygiene: ...Please make sure my teeth are clean especially when I go to bed..." Bathing - I prefer a WHIRLPOOL Whirlpool bath... I like to have a BATH 3 times a week... Facility LIFTS used for transfers... ...Dental Care I have my own natural teeth. Things you can do to help me: ...Help me brush my teeth every day..." A social service note, dated 01/15/13, documented, "Resident also said she has been feeling bad about herself due to 'I just can't do for myself'." A quarterly assessment, dated 04/16/13, documented the resident was cognitively intact, required extensive assistance with all ADLs, had limited ROM in the lower extremities, and had no falls. An update to the care plan, dated 04/16/13, documented, "...Occassionaly (sic) incont (incontinent) of urine R/T use of diuretics." A nurse's note, dated 05/11/13 at 8:00 a.m., documented, "While resident was getting a bath her 2nd toe was seen to be bleeding. Nurse was notified and bandage was applied..." On 05/15/13 at 10:08 a.m., the resident stated, "I prayed for you to come. I was hoping someone from state would come." She stated, "This is the best facility and the worst help." She stated a staff member she did not know gave her a shower on 05/11/13. She stated the person did not know how to push her in her wheelchair and her right foot was being dragged on the floor all the way to the shower room. She stated it took off the top layer of my toe. She stated the nurse had applied a dressing. She stated, "I had to wait on the lift this morning. I couldn't wait anymore so I just peed in bed." The resident was re-visited at 1:00 p.m. She stated staff was hateful, always in a hurry, and rough. The resident's family member was present and stated she had spoken with administration in regards to the resident's care. She stated, "I would like to see (the resident) get more than two whirlpools a week." The resident stated, "When you're scared they will hurt you, I wait for someone that knows what they're doing to be here." The family member stated, "I would like to see them brush her teeth more often." The resident stated, "I don't like for them to brush my teeth. They are rough." On 05/15/13 at 3:20 p.m., LPN #1 was asked if she reported the incident regarding the toe of resident #8 that was injured when staff pushed her in her wheelchair. She stated, "I reported it to the DON." On 05/16/13 at 3:06 p.m., an observation of the resident's right foot was completed with the assistance of LPN #8. A blood blister was noted on the top of the right great toe extending under the nail. A pea size wound was present on the top of the right second toe, at the distal joint, with serosanguinous drainage. The second toe was swollen and extremely bruised. A blood blister was present on the cuticle area of the 3rd toe. LPN #8 was asked if an x-ray had been obtained. She stated, "It didn't look this bad this morning." She proceeded to call the physician and obtained an order for [REDACTED]. 2. Resident #3, who resided on Chapman Heights, had current [DIAGNOSES REDACTED]. A significant change in status assessment, dated 03/19/13, documented the resident had a severe impairment in cognition, had total dependence in transfers, and was incontinent of bladder and bowel. The care plan, dated March 2013, documented, "...cognitive loss/dementia...always be patient, pleasant and reassuring when I'm confused...explain all procedures to me using simple terms...Personal hygiene...Make sure my hair is brushed when I get out of bed or anytime it needs...Incontinence...I am incontinent of bowel and bladder and I need changed frequently...assist me with incontinent care prn...ADLs...bed mobility extensive assist of one caregiver...transfers use a lift 2 staff members..." On 05/15/13 at 5:30 p.m., resident #3 was asked if staff had been mean to her. She stated, "Yes." The resident stated staff had slapped the bottom of her swollen feet. She stated it had been a while ago and she was sleeping a lot then. She stated staff had told her to shut up. She was asked if she reported the staff to anyone. She stated, "No." She was asked if she was afraid of the staff. The resident did not reply. At 6:10 p.m., the resident was asked if she could remember when staff told her to shut up and slapped the bottom of her feet. She stated, "No. It's all foggy. Wish I could help." 3. Resident #6, who had resided on Chapman Heights, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated September 2012, documented the resident was severely impaired cognitively, required extensive assistance with all ADLs, and had a history of [REDACTED]. The quarterly assessment, dated 12/25/12, documented the resident was severely impaired in cognition and needed extensive assistance with all ADLs. An update to the care plan, dated 01/29/13, documented, "light bruise between eyes - possibly from glasses..." The facility's state reportable file was reviewed for the unknown injury and a head injury related to the bruise between the eyes. There was not a reportable in the facility file. On 05/16/13 at 1:10 p.m., the DON was asked if any abuse had been reported to her since November 2012. She stated there was a concern regarding a transfer of a resident and the resident broke her toe. She was asked how she investigated bruising of unknown origin. She stated, "I take statements of staff on duty." She was asked if she talked with residents. She stated, "At times." She was asked if she considered the bruising between the resident's eyes as potential abuse. She stated, "I talked to five staff on two shifts." She was asked if she interviewed any residents. She stated, "I didn't write that down." She was asked if she interviewed residents on the same hall as the resident. She stated, "I don't know." She was asked who was she to interview according to the facility's abuse policy. No answer was given. At 3:39 p.m., CNA #2 was asked if she had been aware of any staff to resident abuse. She stated, "Yes, only on Chapman Hall. One day we were short staff and (CMA #1) was in the shower room with (resident #6). As I opened the door, the resident's legs were up in the air and the CMA was pulling her pants off. Her feet had dressings on and her feet fell to the floor. The resident screamed out and the CMA pushed her in the shower." She was asked if she reported the incident and to whom. She stated, "Yes. I reported to the administrator, (CMA #5), and the human resources director." There was no documentation of an investigation of the allegation of abuse. 4. Resident #9, who resided on Buehler Place, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly assessment, dated 02/04/13, documented the resident was cognitively intact, needed moderate to extensive assistance with all ADLs, and had no falls. The care plan, dated August 2012, documented the resident had cognitive loss due to difficulty with recall at times, required assistance with ADLs, was occasionally incontinent, had a history of [REDACTED]. An e-mail from a family member to the DON, dated 01/17/13, documented "...After you left, (resident name deleted) and I continued to talk. We discussed specifically the problems (resident name deleted) is having with one caregiver, (CNA #7 name deleted) has threatened (resident name deleted) with retribution if she reports performance concerns to you or others in administration. (Resident name deleted) feels a real sense of danger of retribution from (CNA #7 name deleted). (Resident name deleted) also described several occasions where (CNA #7 name deleted) forced her to do things she was very uncomfortable with, such as having to stand on her own during transfers. I can only categorize this behavior as bullying...Whatever steps you take, they should result in (CNA #7 name deleted) no longer being around (resident name deleted) or in Buehler so as to effectively remove the threat and (resident name deleted) fear of retaliation..." A hand written note, dated 01/18/13, documented, "Admin, DNS, HC meet c (resident name deleted) (Administrator name deleted) asked her about concerns c transfers 'almost falling' The aide stood behind chair & told her to pull herself up - (resident) said I can't do that - Aide said yes you can I stood up and I almost fell ...(CNA name deleted) other concerns w/c to toilet feels rushed too much 12 high risk" An e-mail from the family member to the administrator, dated 01/21/13, documented, "...First, it is wholly consistent with the notion that (resident name deleted) has real sense of fear from retaliation for her to not be completely transparent with you regarding her concerns with (CNA #7 name deleted). Not surprisingly, (resident name deleted) is less forthcoming with you than with me. I think it is unfair to characterize this as uncertainty on her part. Her tears when I was talking with her speak volumes to me. (DON name deleted) can confirm the spontaneous emotion (resident name deleted) had when the three of us met and were discussing these very issues..." An Oklahoma State Department of health incident report form, final faxed on 01/25/13, documented, "Received email from grandson that (resident name deleted) verbalized to him concerns regarding a C.N.A. 'forcing' her to do things she was uncomfortable with, such as having to stand on her own during transfers. (Resident name deleted) also has feelings of possible retribution from aide if she reports her concerns... Interview with caregiver named...Many times when caregiver attempts to help (resident name deleted) will try to do too much on her own and not wait for appropriate help. She was then placed on suspension. Meeting with (resident name deleted) was completed on January 18, 2013. She explained that her concern with one of her caregivers was during a w/c to bed transfer when the care giver instructed her to stand up on her own, using only the transfer bar on the bed. The aide did help her get into bed and no injury occurred during this transfer. She had concerns with transfers in general and was in agreement to have therapy intervene and review assistance needed and technique. (Resident name deleted) denied being afraid of this care giver or anyone else. She agreed to work together with this caregiver and other caregivers along with therapy to improve her transfers. Administrator e-mail grandson of above conversation and of our plan with therapy services. Grandson wrote back with continued concerns about (resident name deleted) working with this one caregiver... Interviews completed with other residents in household with no reports of concerns with cares provided including with transfers and allowing residents to do as much for themselves as possible. Caregiver and (resident name deleted) have not worked together since investigation started on January 17, 2013..." The state reportable form had no documentation of interviewing staff or obtaining written statements by the staff related to the investigation of allegations of abuse. On 05/16/13 at 5:00 p.m., the DON was asked for all state reportable incident reports for the past year and this was the only reportable sent to the state. The DON was asked for further documentation related to the investigation and she stated there was no documentation. The DON was asked if there were written statements from staff and she stated, "No." She was asked which staff were interviewed related to the allegation and she said she was not sure. On 05/17/13 at 1:15 p.m., the resident was interviewed and she confirmed the above information. She stated she wished she was stronger and was able to be independent. 5. Resident #5, who resided on Chapman Heights, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A (name withheld) Hospice care plan, dated 01/21/13, documented a problem, "...Physical condition/generalized weakness..." The goal was, "...To understand limitations r/t generalized weakness related to terminal diagnosis...Patient environment will be safe..." Interventions included, "...Teach safety measures and instruct in use of needed appliances...Assess patient's ability to perform ADL's, observe for weakness..." A care plan, dated 01/22/13, documented a problem, "...Anticipatory grieving..." The goal was, "...Improve coping evidenced by patient/CG discussing feelings..." Interventions included, "...Encourage patient/CG to express feelings and provide emotional support... A quarterly assessment, dated 04/23/13, documented the resident was cognitively intact, was not verbally or physically abusive, and did not exhibit socially inappropriate or disruptive behavioral symptoms. It was documented the resident was totally dependent on staff with transfers and toilet use, and required extensive assistance with bed mobility, dressing, and bathing. On 05/15/13 at 12:38 p.m. CNA #5 was asked if she had reported any allegations of abuse. She stated, "(Resident #5) told me (CNA #8) was rough with her during incontinent care. I told an LPN, I don't know who." She was asked when this occurred. She stated, "May have been in February." On 05/15/13 at 1:14 p.m., resident #5 was asked how she was treated by staff when receiving care. She stated, "(CNA #8) came into my room and didn't even tell me who she was." The resident stated, "I didn't know who she was at first." She stated while she changed my brief, "She pushed on my pelvis so hard I thought it was going to break." When asked when this had occurred she stated, "Several weeks ago." She stated, "She never talks very nice to me. I can't get it why she talks to me that way. I try to be nice to them." She was asked if she had informed anyone of the incident. She stated she had told the charge nurse, CMA/Household Coordinator #5. She stated the charge nurse told her CNA #8 was not to come into her room without having another staff member with her. She stated, "But she does." She stated she had two call lights. One was a pendant which she preferred because she can not use her hands well enough to use her hand held call light. She stated, "The one on the chain, I either can't find it or it's across the room." She stated they get mad at her for using her call light. She stated one night a former employee, who she couldn't remember his name, came into her room and told her, "think of everything you want and tell me so I won't have to keep answering your call light." She stated, "I'm afraid to say anything because they will have it out for me and won't answer my light." The resident required oxygen per nasal cannula. She stated it was sore behind her ears and she asked staff to place gauze under the tubing. She stated, "Some will do it and some won't." The resident stated at another time she was trying to eat a Hershey bar and could not use her hands well so she got chocolate under her fingernails, which were long. She stated, "CMA #1 came in and started ranting and raving that she was going to cut my nails off." On 05/15/13 at 1:20 p.m., in a confidential interview, a resident refused to talk about the staff unless her privacy was protected 100%. The resident was informed that her privacy was protected unless a court order was obtained for the records. The resident stated she would not talk to the surveyor. On 05/15/13 at 2:55 p.m., CMA #1 was asked if she knew of any staff to resident abuse. She stated, "We have some people who tell staff how to care for them and staff get upset because they know how to do their job." On 05/15/13 at 3:39 p.m., CNA #2 stated resident #7 was very demanding during lunch and CMA #1 and CNA #9 ignored her. She stated CMA #5 refused to do incontinent care on a resident with [MEDICAL CONDITION]. On 05/15/13 at 4:00 p.m., in a confidential interview with a CNA, reported she was afraid of the staff. She stated that CMA #1 and CNA #8 told her, "If you say any thing, we will slash your tires and follow you home." At 5:45 p.m., CNA #8 was asked if she had ever witnessed any staff to resident abuse. She stated staff can be "short" with residents at times. When asked what she meant by "short", she stated, "Like rushing the conversation." When asked about the incident that occurred while changing resident #5's brief, she stated resident #5 was asleep and while changing her brief she may have pushed on her stomach a little too much but the resident did not make a noise. She stated she was not aware of the incident until the next day when (CMA/Household Coordinator) informed her. She stated, "I wasn't trying to hurt her." On 05/16/13 at 10:08 a.m., CMA/Household Coordinator #5 was asked if the incident of CNA #8 providing care to resident #5 was reported to her. She stated, "Yes." She stated CNA #8 had placed excessive pressure on resident #5's vaginal area. She stated she spoke to resident #5 and informed the resident that the CNA was not to come back into her room without another staff member present. When asked if she had documented the incident, she stated, "No." When asked how she had monitored to ensure the CNA was following her order, she did not respond. She was then informed that the CNA had been going back into the resident's room without another staff member present. She stated, "We have had staff issues." On 05/16/13 at 10:31 a.m., CNA #8 was asked if she had been aware of staff to resident abuse. She stated, "I don't think it is intentional but some residents don't want certain people to take care of them especially (CMA #1). I worked with her and I see. Its always been an issue. She had been addressed to be more gentle." She was asked if she had reported the abuse. She stated, "Yes, to my supervisor." She was asked if she had been aware of a staff member telling a resident to shut up. She stated, "CMA #1 is a naturally loud person. The facility is aware of CMA #1 and her roughness." She stated, "The abuse is more when the facility is short staffed." She was asked if she reported to her supervisor. She stated, "Yes, I complained to the supervisors. Staff and residents are afraid to complain." She was asked if there was anything else she wanted to say. She stated, "There are call lights that go off and staff will see who it is and then they ignore the resident." Personnel files for CMA #1 and CNA #8 were reviewed. There was no documentation of counseling or reprimands. At 11:00 a.m., CMA #2 was asked if she had ever witnessed any staff to resident abuse. She stated she had not witnessed any verbal abuse but resident #5 had complained of CMA #1 being "rough". She stated she reported the inc

On 05/16/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to prevent mistreatment/neglect and/or abuse for multiple residents, and to ensure residents and staff were able to report allegations of abuse without fear of reprisal. On 05/16/13 the IJ situation was verified with the Oklahoma State Department of Health. At 4:12 p.m., the CEO, administrator, and DON were notified of the IJ situation. On 05/16/13 at 8:39 p.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: "Plan of Removal. May 16, 2013 On May 16, 2013 Oklahoma Methodist Manor was notified by surveyors from the Oklahoma State Department of Health that it as being (sic) cited for 3 deficiencies that constitute Immediate Jeopardy for Not Preventing Abuse Not Investigating Abuse Not Reporting Abuse Not Following Abuse Policy Immediate Interventions 1. The Administrator and Director Of Nursing will fully review and be familiar with Oklahoma Methodist Manor's Abuse Prevention, Investigation and Reporting Policy. This review will be complete by 6:00pm on May 16, 2013. 2. Starting at 8:00pm on Thursday, May 16 and every hour thereafter until 1:00pm on Friday, May 17 (when all interviews are completed), the Administrator or Director of Nursing will conduct monitoring rounds in all Households. All rounds will be documented. 3. (Name deleted), Director of Nursing; (name deleted), Cobb Landing Program Coordinator; and (name deleted), Priddy Harbor Household Coordinator, will conduct inservice education regarding Abuse Prevention and Reporting with all staff present. Every staff member of the Healthcare Households will receive this inservice education prior to working their very next shift and prior to any resident contact. This inservice education will begin no later than 7:00pm on May 16, 2013 and will be completed by 1:00pm on May 17, 2013. Of note, staff member (name deleted), CNA (name withheld) is on vacation and will be educated prior to her return to duty. The education will include: a. Oklahoma Methodist Manor's policy on Abuse and Neglect b. How to use the 'Potential Resident Abuse Report Form' c. Specific responsibilities of the person reporting the allegation: i. If CNA or CMA, will: 1. Report to Charge Nurse 2. Fill out the 'Potential Resident Abuse Report Form' and give to Charge Nurse 3. Follow up the following day to ensure report is being investigated. ii. If LPN or RN, will: 1. Report to Director of Nursing 2. If a specific staff person is identified in the allegation, the LPN or RN will remove that individual from the facility 3. Fill out the 'Potential Resident Abuse Report Form' and give to Director of Nursing 4. Follow up the following day to ensure report is being investigated. iii. If Director of Nursing, will: 1. Report to Administrator 2. The Director of Nursing will ensure that any specific staff person identified in the allegation has been removed from the facility and that the investigation has been initiated. 3. Fill out the 'Potential Resident Abuse Report Form' and give to Administrator 4. Follow up the following day to ensure report is being investigated. iv. If Administrator, will: 1. Review the allegation, the completed 'Potential Resident Abuse Report Form' and will ensure investigation and reporting is complete. v. Upon any allegation of Abuse or Neglect, an incident report and State Report will be completed in accordance with policy and state regulations. d. Follow up on reports to ensure allegations are reported and investigated e. The resident experience during bathing f. The resident experience during dressing and undressing g. The resident experience, and proper protocol, for incontinence care h. The prevention and reporting of 'roughness' or any type of 'bulling' behavior i. Resident use of the call light system, and call light cord placement j. Sensitivity toward a resident's fearfulness to report abuse, and our policy prohibiting and form of retaliation 4. The Director of Assisted Living (name withheld), will audit every resident's call light for proper placement and operation. This audit and system test will be competed by 7:00pm on May 16, 2013. Any light found to be misplaced will immediately be placed within reach of the resident. Any malfunctioning equipment will immediately be replaced with functioning equipment. 5. RN consultant (name withheld) has been engaged to provide immediate support in investigating and supporting corrective action. 6. We will conduct an exhaustive investigation to identify any and all allegations of abuse. a. We will interview all staff members in the Chapman Heights, Priddy Harbor and Buehler Place households and random staff members from other households. These interviews began at 3:00 pm on May 16, 2013 and will be completed by 1:00 p.m. on May 17, 2013. b. We will conduct resident interviews with all residents in the Chapman Heights, Priddy Harbor and Buehler Place households, and selected residents from other households. These interviews began at 4:30pm on May 16, 2013 and will be completed by 1:00p.m. on May 17, 2013. c. Additional Staff, Residents and Family Members will be interviewed as necessary as the investigation proceeds. d. We will contact every responsible party in the Chapman Heights, Priddy Harbor and Buehler Place households informing them of the abuse prevention program and inquiring about any possible incidents of abuse or neglect. This will be completed by 1:00 p.m. on May 17, 2013. e. All allegations of abuse identified during the investigation will be reported and fully investigated in accordance with Oklahoma Methodist Manor policy. Any individual who is identified in an allegation of abuse/neglect will be suspended pending full investigation." On 05/17/13 at 11:25 a.m., the administrator provided documentation to show he made rounds on all households to ensure residents were protected until all staff were inserviced. The IJ was removed when the facility provided evidence that all components of the plan of removal had been completed on 05/17/13 at 1:29 p.m. The deficient practice remained at a pattern level of actual harm. Based on observation, interview and record review, it was determined the facility failed to prevent mistreatment/neglect and/or abuse for five (#3, #5, #6, #8, and #9) of nine sampled residents review for abuse. Resident #3, 5 and #6 resided on Chapman Heights, resident #9 resided on Buehler Place, and resident #8 on Priddy Harbor. The facility identified 16 residents who resided on Chapman Heights, 16 residents who resided on Priddy Harbor, 14 residents who resided on Buehler Place, and a total of 77 residents who resided in the facility. The facility failed to ensure residents and staff were able to report allegations of abuse without fear of reprisal. Findings: The policy dated, revised January 2009, titled, "Abuse investigation policy statement, documented: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation... Should an accident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the DON, or his/her designee, will to (sic) investigate the alleged incident... The Administrator will provide to the person in charge of the investigation a completed copy of the 'Potential Resident Abuse Report Form'... The individual conducting the investigation will, as a minimum...Review the completed 'Potential Resident Abuse Report Form'...Review the resident's medical record to determine events leading up to the incident...Interview the person(s) reporting the incident...Interview any witnesses to the incident...Interview the resident (as medically appropriate)...Interview the resident's Attending physician as needed to determine the resident's current level of cognitive function and medical condition...Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident...Interview the resident's family members, and visitors...Interview other residents to whom the accused employee provides care or services...Review all events leading up to the alleged incident... Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be attached to the 'Resident Abuse Investigation Report Form.')... While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator... Employees of this facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator. To provide general guidelines for resident rights while caring for the resident...Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: Preventing, recognizing and reporting abuse Abuse and Neglect - Clinical Protocol The nurse will assess the individual and document related findings. Assessment data will include...Injury assessment (bleeding, bruising, deformity, swelling etc.)...All current medications, especially anticoagulants, NSAID's, [MEDICATION NAME] platelet inhibitors...Vital signs...Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior)...History of any tendency towards bruising...All active diagnoses...Any recent labs... The nurse will report findings to the physician. As needed, the physician will assess the resident to verify or clarify such findings, especially if the cause or source of the problem is unclear... As part of the initial assessment, the physician will help identify individuals who have a history of being abused or neglected, or those who might have been abused or neglected: for example, individuals admitted from home or the hospital with multiple pressure ulcers and severe under-nutrition... 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish... 'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...As needed, the physician will evaluate the resident or have them sent for evaluation; for example, to rule out sexual assault or fracture, or to assess the location and potential causes of bruises... The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes... The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect... The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations... The Medical Director will advise facility management and staff about systems to ensure the basic medical, functional, psychosocial needs are being met and that potentially preventable or treatment conditions affecting function and quality of life are addressed appropriately... Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion..." The facility's inservice log manual was reviewed and there was no documentation for employees receiving Abuse and Neglect inservices. 1. Resident #8, who resided on Priddy Harbor, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan, dated January 2013, documented: "...Personal Hygiene Please Assist me with my personal hygiene: ...Please make sure my teeth are clean especially when I go to bed..." Bathing - I prefer a WHIRLPOOL Whirlpool bath... I like to have a BATH 3 times a week... Facility LIFTS used for transfers... ...Dental Care I have my own natural teeth. Things you can do to help me: ...Help me brush my teeth every day..." A social service note, dated 01/15/13, documented, "Resident also said she has been feeling bad about herself due to 'I just can't do for myself'." A quarterly assessment, dated 04/16/13, documented the resident was cognitively intact, required extensive assistance with all ADLs, had limited ROM in the lower extremities, and had no falls. An update to the care plan, dated 04/16/13, documented, "...Occasionally (sic) incont (incontinent) of urine R/T use of diuretics." A nurse's note, dated 05/11/13 at 8:00 a.m., documented, "While resident was getting a bath her 2nd toe was seen to be bleeding. Nurse was notified and bandage was applied..." On 05/15/13 at 10:08 a.m., the resident stated, "I prayed for you to come. I was hoping someone from state would come." She stated, "This is the best facility and the worst help." She stated a staff member she did not know gave her a shower on 05/11/13. She stated the person did not know how to push her in her wheelchair and her right foot was being dragged on the floor all the way to the shower room. She stated it took off the top layer of my toe. She stated the nurse had applied a dressing. She stated, "I had to wait on the lift this morning. I couldn't wait anymore so I just peed in bed." The resident was re-visited at 1:00 p.m. She stated staff was hateful, always in a hurry, and rough. The resident's family member was present and stated she had spoken with administration in regards to the resident's care. She stated, "I would like to see (the resident) get more than two whirlpools a week." The resident stated, "When you're scared they will hurt you, I wait for someone that knows what they're doing to be here." The family member stated, "I would like to see them brush her teeth more often." The resident stated, "I don't like for them to brush my teeth. They are rough." On 05/15/13 at 3:20 p.m., LPN #1 was asked if she reported the incident regarding the toe of resident #8 that was injured when staff pushed her in her wheelchair. She stated, "I reported it to the DON." On 05/16/13 at 3:06 p.m., an observation of the resident's right foot was completed with the assistance of LPN #8. A blood blister was noted on the top of the right great toe extending under the nail. A pea size wound was present on the top of the right second toe, at the distal joint, with serosanguinous drainage. The second toe was swollen and extremely bruised. A blood blister was present on the cuticle area of the 3rd toe. LPN #8 was asked if an x-ray had been obtained. She stated, "It didn't look this bad this morning." She proceeded to call the physician and obtained an order for [REDACTED]. 2. Resident #3, who resided on Chapman Heights, had current [DIAGNOSES REDACTED]. A significant change in status assessment, dated 03/19/13, documented the resident had a severe impairment in cognition, had total dependence in transfers, and was incontinent of bladder and bowel. The care plan, dated March 2013, documented, "...cognitive loss/dementia...always be patient, pleasant and reassuring when I'm confused...explain all procedures to me using simple terms...Personal hygiene...Make sure my hair is brushed when I get out of bed or anytime it needs...Incontinence...I am incontinent of bowel and bladder and I need changed frequently...assist me with incontinent care prn...ADLs...bed mobility extensive assist of one caregiver...transfers use a lift 2 staff members..." On 05/15/13 at 5:30 p.m., resident #3 was asked if staff had been mean to her. She stated, "Yes." The resident stated staff had slapped the bottom of her swollen feet. She stated it had been a while ago and she was sleeping a lot then. She stated staff had told her to shut up. She was asked if she reported the staff to anyone. She stated, "No." She was asked if she was afraid of the staff. The resident did not reply. At 6:10 p.m., the resident was asked if she could remember when staff told her to shut up and slapped the bottom of her feet. She stated, "No. It's all foggy. Wish I could help." 3. Resident #6, who had resided on Chapman Heights, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated September 2012, documented the resident was severely impaired cognitively, required extensive assistance with all ADLs, and had a history of [REDACTED]. The quarterly assessment, dated 12/25/12, documented the resident was severely impaired in cognition and needed extensive assistance with all ADLs. On 05/16/13 at 1:10 p.m., the DON was asked if any abuse had been reported to her since November 2012. She stated there was a concern regarding a transfer of a resident and the resident broke her toe. At 3:39 p.m., CNA #2 was asked if she had been aware of any staff to resident abuse. She stated, "Yes, only on Chapman Hall. One day we were short staff and (CMA #1) was in the shower room with (resident #6). As I opened the door, the resident's legs were up in the air and the CMA was pulling her pants off. Her feet had dressings on and her feet fell to the floor. The resident screamed out and the CMA pushed her in the shower." She was asked if she reported the incident and to whom. She stated, "Yes. I reported to the administrator, (CMA #5), and the human resources director." There was no documentation of an investigation of the allegation of abuse. 4. Resident #9, who resided on Buehler Place, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly assessment, dated 02/04/13, documented the resident was cognitively intact, needed moderate to extensive assistance with all ADLs, and had no falls. The care plan, dated August 2012, documented the resident had cognitive loss due to difficulty with recall at times, required assistance with ADLs, was occasionally incontinent, had a history of [REDACTED]. An e-mail from a family member to the DON, dated 01/17/13, documented "...After you left, (resident name deleted) and I continued to talk. We discussed specifically the problems (resident name deleted) is having with one caregiver, (CNA #7 name deleted) has threatened (resident name deleted) with retribution if she reports performance concerns to you or others in administration. (Resident name deleted) feels a real sense of danger of retribution from (CNA #7 name deleted). (Resident name deleted) also described several occasions where (CNA #7 name deleted) forced her to do things she was very uncomfortable with, such as having to stand on her own during transfers. I can only categorize this behavior as bullying...Whatever steps you take, they should result in (CNA #7 name deleted) no longer being around (resident name deleted) or in Buehler so as to effectively remove the threat and (resident name deleted) fear of retaliation..." A hand written note, dated 01/18/13, documented, "Admin, DNS, HC meet c (resident name deleted) (Administrator name deleted) asked her about concerns c transfers 'almost falling' The aide stood behind chair & told her to pull herself up - (resident) said I can't do that - Aide said yes you can I stood up and I almost fell ...(CNA name deleted) other concerns w/c to toilet feels rushed too much 12 high risk" An e-mail from the family member to the administrator, dated 01/21/13, documented, "...First, it is wholly consistent with the notion that (resident name deleted) has real sense of fear from retaliation for her to not be completely transparent with you regarding her concerns with (CNA #7 name deleted). Not surprisingly, (resident name deleted) is less forthcoming with you than with me. I think it is unfair to characterize this as uncertainty on her part. Her tears when I was talking with her speak volumes to me. (DON name deleted) can confirm the spontaneous emotion (resident name deleted) had when the three of us met and were discussing these very issues..." An Oklahoma State Department of health incident report form, final faxed on 01/25/13, documented, "Received email from grandson that (resident name deleted) verbalized to him concerns regarding a C.N.A. 'forcing' her to do things she was uncomfortable with, such as having to stand on her own during transfers. (Resident name deleted) also has feelings of possible retribution from aide if she reports her concerns... Interview with caregiver named...Many times when caregiver attempts to help (resident name deleted) will try to do too much on her own and not wait for appropriate help. She was then placed on suspension. Meeting with (resident name deleted) was completed on January 18, 2013. She explained that her concern with one of her caregivers was during a w/c to bed transfer when the care giver instructed her to stand up on her own, using only the transfer bar on the bed. The aide did help her get into bed and no injury occurred during this transfer. She had concerns with transfers in general and was in agreement to have therapy intervene and review assistance needed and technique. (Resident name deleted) denied being afraid of this care giver or anyone else. She agreed to work together with this caregiver and other caregivers along with therapy to improve her transfers. Administrator e-mail grandson of above conversation and of our plan with therapy services. Grandson wrote back with continued concerns about (resident name deleted) working with this one caregiver... Interviews completed with other residents in household with no reports of concerns with cares provided including with transfers and allowing residents to do as much for themselves as possible. Caregiver and (resident name deleted) have not worked together since investigation started on January 17, 2013..." The state reportable form had no documentation of interviewing staff or obtaining written statements by the staff related to the investigation of allegations of abuse. On 05/16/13 at 5:00 p.m., the DON was asked for all state reportable incident reports for the past year and this was the only reportable sent to the state. The DON was asked for further documentation related to the investigation and she stated there was no documentation. The DON was asked if there were written statements from staff and she stated, "No." She was asked which staff were interviewed related to the allegation and she said she was not sure. On 05/17/13 at 1:15 p.m., the resident was interviewed and she confirmed the above information. She stated she wished she was stronger and was able to be independent. 5. Resident #5, who resided on Chapman Heights, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A (name withheld) Hospice care plan, dated 01/21/13, documented a problem, "...Physical condition/generalized weakness..." The goal was, "...To understand limitations r/t generalized weakness related to terminal diagnosis...Patient environment will be safe..." Interventions included, "...Teach safety measures and instruct in use of needed appliances...Assess patient's ability to perform ADL's, observe for weakness..." A care plan, dated 01/22/13, documented a problem, "...Anticipatory grieving..." The goal was, "...Improve coping evidenced by patient/CG discussing feelings..." Interventions included, "...Encourage patient/CG to express feelings and provide emotional support... A quarterly assessment, dated 04/23/13, documented the resident was cognitively intact, was not verbally or physically abusive, and did not exhibit socially inappropriate or disruptive behavioral symptoms. It was documented the resident was totally dependent on staff with transfers and toilet use, and required extensive assistance with bed mobility, dressing, and bathing. On 05/15/13 at 12:38 p.m. CNA #5 was asked if she had reported any allegations of abuse. She stated, "(Resident #5) told me (CNA #8) was rough with her during incontinent care. I told an LPN, I don't know who." She was asked when this occurred. She stated, "May have been in February." On 05/15/13 at 1:14 p.m., resident #5 was asked how she was treated by staff when receiving care. She stated, "(CNA #8) came into my room and didn't even tell me who she was." The resident stated, "I didn't know who she was at first." She stated while she changed my brief, "She pushed on my pelvis so hard I thought it was going to break." When asked when this had occurred she stated, "Several weeks ago." She stated, "She never talks very nice to me. I can't get it why she talks to me that way. I try to be nice to them." She was asked if she had informed anyone of the incident. She stated she had told the charge nurse, CMA/Household Coordinator #5. She stated the charge nurse told her CNA #8 was not to come into her room without having another staff member with her. She stated, "But she does." She stated she had two call lights. One was a pendant which she preferred because she can not use her hands well enough to use her hand held call light. She stated, "The one on the chain, I either can't find it or it's across the room." She stated they get mad at her for using her call light. She stated one night a former employee, who she couldn't remember his name, came into her room and told her, "think of everything you want and tell me so I won't have to keep answering your call light." She stated, "I'm afraid to say anything because they will have it out for me and won't answer my light." The resident required oxygen per nasal cannula. She stated it was sore behind her ears and she asked staff to place gauze under the tubing. She stated, "Some will do it and some won't." The resident stated at another time she was trying to eat a Hershey bar and could not use her hands well so she got chocolate under her fingernails, which were long. She stated, "CMA #1 came in and started ranting and raving that she was going to cut my nails off." On 05/15/13 at 1:20 p.m., in a confidential interview, a resident refused to talk about the staff unless her privacy was protected 100%. The resident was informed that her privacy was protected unless a court order was obtained for the records. The resident stated she would not talk to the surveyor. On 05/15/13 at 2:55 p.m., CMA #1 was asked if she knew of any staff to resident abuse. She stated, "We have some people who tell staff how to care for them and staff get upset because they know how to do their job." On 05/15/13 at 3:39 p.m., CNA #2 stated resident #7 was very demanding during lunch and CMA #1 and CNA #9 ignored her. She stated CMA #5 refused to do incontinent care on a resident with [MEDICAL CONDITION]. On 05/15/13 at 4:00 p.m., in a confidential interview with a CNA, reported she was afraid of the staff. She stated that CMA #1 and CNA #8 told her, "If you say any thing, we will slash your tires and follow you home." At 5:45 p.m., CNA #8 was asked if she had ever witnessed any staff to resident abuse. She stated staff can be "short" with residents at times. When asked what she meant by "short", she stated, "Like rushing the conversation." When asked about the incident that occurred while changing resident #5's brief, she stated resident #5 was asleep and while changing her brief she may have pushed on her stomach a little too much but the resident did not make a noise. She stated she was not aware of the incident until the next day when (CMA/Household Coordinator) informed her. She stated, "I wasn't trying to hurt her." On 05/16/13 at 10:08 a.m., CMA/Household Coordinator #5 was asked if the incident of CNA #8 providing care to resident #5 was reported to her. She stated, "Yes." She stated CNA #8 had placed excessive pressure on resident #5's vaginal area. She stated she spoke to resident #5 and informed the resident that the CNA was not to come back into her room without another staff member present. When asked if she had documented the incident, she stated, "No." When asked how she had monitored to ensure the CNA was following her order, she did not respond. She was then informed that the CNA had been going back into the resident's room without another staff member present. She stated, "We have had staff issues." On 05/16/13 at 10:31 a.m., CNA #8 was asked if she had been aware of staff to resident abuse. She stated, "I don't think it is intentional but some residents don't want certain people to take care of them especially (CMA #1). I worked with her and I see. Its always been an issue. She had been addressed to be more gentle." She was asked if she had reported the abuse. She stated, "Yes, to my supervisor." She was asked if she had been aware of a staff member telling a resident to shut up. She stated, "CMA #1 is a naturally loud person. The facility is aware of CMA #1 and her roughness." She stated, "The abuse is more when the facility is short staffed." She was asked if she reported to her supervisor. She stated, "Yes, I complained to the supervisors. Staff and residents are afraid to complain." She was asked if there was anything else she wanted to say. She stated, "There are call lights that go off and staff will see who it is and then they ignore the resident." Personnel files for CMA #1 and CNA #8 were reviewed. There was no documentation of counseling or reprimands. At 11:00 a.m., CMA #2 was asked if she had ever witnessed any staff to resident abuse. She stated she had not witnessed any verbal abuse but resident #5 had complained of CMA #1 being "rough". She stated she reported the incident to the charge nurse who is no longer employed at the facility. On 05/16/13 at 1:10 p.m., the DON was asked what was the facility's policy regarding abuse. She stated, "If something is uncomfortable with you, you are to report." She was asked who was to be contacted regarding allegations of abuse. She stated, "Charge nurse, DON, or administrator." She was asked if the residents had known who to report allegations of abuse to. She stated, "During resident council they are informed." She was asked, what if a resident has not attended the resident council meetings. She stated, "Social service person is to inform them." She was asked if that was documented. She stated, "I don't know." On 05/16/13 at 1:41 p.m., the DON was asked if she had a file on reprimands or counseling of staff. She stated, "No." The DON was asked if she had any complaints of staff that were rough with residents or staff that refused to do incontinent care. She stated, "No." On 05/16/13 at 2:10 p.m., the administrator was asked if he had more than the one allegation of abuse. He stated, "No." We have had in our Chapman Household, a family member state they have been abusive to her mother by the way they talk to her. He was asked if this was an allegation of abuse. He did not reply. The administrator stated, "We had family members say staff was abusive in Chapman." He was asked if he had investigated the a