Every finding on record at Washita Valley Living Center

Based on observation, record review, and interview, the facility failed to ensure proper personal protective equipment was used for 2 (#34 and #87) of 2 sampled residents reviewed for enhanced barrier precautions. The assistant director of nursing reported three residents required enhanced barrier precautions. Findings: 1. On 04/16/25 at 10:12 a.m., Resident #34 was observed in bed with an indwelling catheter in place. LPN #1 gathered catheter care supplies, washed their hands and applied gloves. LPN #1 was observed cleaning the resident's peri area and catheter tubing with a wash rag and peri wash. LPN #1 placed the dirty wash rag in a plastic bag and discarded gloves. LPN #1 was observed performing hand hygiene, reapplying gloves, and rinsing the resident's peri area with a clean wash rag and water. LPN #1 placed the use wash rag in the plastic bag and discarded gloves. LPN #1 was observed carrying the plastic bag with used wash rags to the dirty linen room. LPN #1 was observed performing hand hygiene. LPN #1 was not observed to wear a gown for catheter care. A policy titled Enhanced Barrier Precautions, dated 04/24/24, showed an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy showed high-contact resident activities include device care or use of urinary catheters and feeding tubes. An admission assessment, dated 03/24/25, showed Resident #34 had an indwelling catheter and a diagnosis of urinary tract infection in the last 30 days. The assessment showed the resident's cognition was intact with a BIMS score of 15. A care plan, dated 04/02/25, showed Resident #34 had a catheter with a leg bag and an intervention of cath care every shift. On 04/17/25 at 9:33 a.m., the DON reported the resident was on enhanced barrier precautions and gown and gloves should have been worn for cath care. 2. On 04/16/25 at 10:06 a.m., Resident #87 was observed in bed with a feeding tube in place to the abdomen. On 04/16/25 at 10:06 a.m., LPN #1 was observed gathering supplies for feeding tube site care for Resident #87. LPN #1 was observed to wash their hands and apply gloves. LPN #1 was not observed to don a gown for feeding tube care. LPN #1 was observed attempting to perform feeding tube site care, but the resident refused. LPN #1 was observed discarding their gloves in the trash and washing their hands before leaving the room. On 04/17/25 at 8:59 a.m., Resident #87 was in bed with feeding tube in place. On 04/17/25 at 8:59 a.m., LPN #1 was observed washing their hands and unhooking Resident #87's feeding tube to perform medication administration. LPN #1 was observed to check feeding tube placement and administer medication. LPN #1 was observed reconnecting the tube feeding and restarting the feeding, their gloves thrown in the trash, and their hands washed before exiting the room. A care plan, dated 04/07/25, showed Resident #87 required tube feeding for all nutrition and hydration due to dysphagia related to stroke and being nothing by mouth. An admission assessment, dated 04/08/25, showed Resident #87 had a feeding tube and a swallowing disorder. The assessment showed the resident's cognition was severly impaired with a BIMS score of 01. On 04/17/25 at 9:14 a.m., LPN #1 reported Resident #87 was not on enhanced barrier precautions. LPN #1 reported residents with catheters, any intruding medical device, and wounds required enhance barrier precautions. LPN #1 reported they were wrong and a gown should have been worn for administering Resident #87's medication and when providing feeding tube site care. LPN #1 reported a gown should have also been worn with Resident #34's catheter care. On 04/17/25 at 9:34 a.m. the DON reported Resident #87 should be on enhanced barrier precautions for the feeding tube, and a gown and gloves should be worn for site care and medication administration. The DON reported staff needed to be retrained on the enhanced barrier precaution policy.

Based on record review and interview, the facility failed to ensure the person designated to serve as the dietary supervisor had completed their certification for dietary management. The DON reported 34 residents received food from the kitchen. Findings: A dietary manager policy was not provided by the facility. A review of the dietary supervisor's ServeSafe certification showed a completion date of 02/25/25. There was no documentation the dietary supervisor was certified as a dietary manager. On 04/15/25 at 9:30 a.m., the dietary supervisor reported they had not completed the dietary manager certification training. The dietary manager reported they were unsure how long they had served as the dietary supervisor. The dietary supervisor reported they had been working in dietary for many years on and off. On 04/16/25 at 3:00 p.m., the administrator reported the dietary supervisor's hire date was 03/16/11. The administrator reported the employee had worked as the dietary supervisor on and off since being hired. The administrator reported the dietary supervisor had not been sent to the course for dietary manager training due to having unreliable transportation.

Based on record review and interview, the facility failed to follow a physician order to obtain a follow-up appointment for 1 (#37) of 1 sampled resident reviewed for assistance with medical appointments. The administrator reported 35 residents resided in the facility. Findings: A policy titled Referrals, Social Services, dated December 2008, read in part, Social services personnel shall coordinate most resident referrals with outside agencies .Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician .Social services will document the referral in the resident's medical record. A physician order, dated 12/06/24, showed Resident #37 was to have a follow-up neurology appointment scheduled with (name withheld) in two weeks. A care plan for Resident #37, dated 12/10/24, showed the resident was admitted to skilled services after a hospitalization due to a fall resulting in anterior displaced type 2 dens fracture (cervical neck fracture). The care plan showed the resident would have a follow-up with neurology (name withheld) in two weeks. A discharge summary for Resident #37, dated 01/05/25, showed the resident had been admitted to the facility with diagnoses which included anterior displaced type 2 dens fracture, chronic obstructive pulmonary disease, congestive heart failure, osteoarthritis, peripheral vascular disease, muscle wasting and atrophy, anxiety, depression, and heart disease. The discharge summary showed the resident had a steady decline and passed away on 01/05/25 under hospice care. On 04/21/25 at 10:32 a.m., the DON reported they had reviewed Resident #37's clinical record and could not find where a two week follow-up neurology appointment was scheduled as ordered for the resident. The DON reported the appointment would have fallen during the holidays and the facility had new social services staff, but the appointment should have been scheduled as ordered. .

Based on observation, record review, and interview, the facility failed to ensure pureed food preparation was conducted in a sanitary manner. The dietary supervisor reported four residents were on a pureed diet. Findings: An undated policy titled Puree Food Preparation, showed to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. On 04/15/25 at 12:00 p.m., dietary cook #1 was observed washing the food processor bowl and blade attachment. Dietary [NAME] #1 was observed returning to the food processor and work station, setting down the food processor bowl and blade attachment on the work station. Dietary [NAME] #1 was observed dipping a dish rag into a pail of disinfecting solution with their bare hand, then wiping off the food processor and the work station with the dish rag. Dietary [NAME] #1 was observed returning the dirty dish rag back to the pail of disinfection solution. Dietary [NAME] #1 was observed placing the food processor bowl back onto the food processor and inserting the blade attachment, and touching the inside of the food processor bowl without washing their hands first. Dietary [NAME] #1 was observed putting four pieces of cake into the food processor with a spatula without performing hand hygiene. On 04/15/25 at 12:15 p.m. the dietary supervisor was asked if the cook should have washed their hands after using the dirty rag in the disinfecting solution before continuing the food preparation. The dietary supervisor reported the cook should have washed their hands after using the dish rag. The dietary supervisor reported the cook should discard the cake, re-wash the food processor, wash their hands, and redo the pureed cake food preparation.

Based on record review, observation, and interview the facility failed to ensure a system was in place for timely physician responses for lab and diagnostic test results for one (#36) of five residents reviewed for unnecessary medications. The Census and Conditions of Residents form documented 40 residents resided in the facility. Findings: The facility policy Lab and Diagnostic Test Results - Clinical Protocol: read in parts . Physician Responses .Time frames. A physician will respond within an appropriate time frame . within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification. Resident #36 was admitted to the facility on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A lab report, dated 06/07/22, documented high lab value results for a PT/INR test. A hand written note, dated 06/07/22, documented the report was faxed to the physician and signed with a nurse's initial. On 10/03/22 the clinical record documented the resident had high lab results for a PT/INR. A hand written note on the report read: faxed on 10/03/22 by (nurse initials) at 2120. There was no documentation in the clinical record verifying the physician's response or any follow-up to the physician by the nursing staff for the 06/07/22 or the 10/03/22 lab results. On 10/28/22, the DON stated there should have been follow-up to the physician when they did not get a response. She stated according to the policy, the physician should have followed up by the end of the next day. The DON acknowledged the facility did not have a system in place to follow up on labs faxed to the physician.

Based on record review, observation, and interview, the facility failed to ensure: a. medications had not been left on top of the med cart unattended, and; b. medications stored in the medication room and on a medication cart were not outdated. The Resident Census and Conditions of Residents form documented 40 residents resided in the facility. Findings: The facility's policy Administering Medications read in parts, .No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications . and must be inaccessible to residents or others passing by . On 10/27/22 at 8:20 a.m., the medication cart on the north hall was observed to be unattended. The following medications were observed to be on top of the cart: [MEDICATION(S)] 40 mg 1 tab in a bubble pack, a [MEDICATION(S)] inhaler 110 mcg, [MEDICATION(S)]/Dexameth eye drops, and Azo 95 mg a pack of 12. The surveyor remained with the cart for approximately five minutes until a CMA was seen walking from the south hall, up the middle hall, and returned to the cart. On 10/27/22 at 8:30 a.m. CMA #1 was asked if she was the staff member passing medications and she stated, yes. The CMA reported the medications should not have been left on top of the medication cart unattended. On 10/27/22 at 12:35 p.m., the North hall medication room was toured. Expired resident medications, expired house stock medications, and expired medical supplies were identified during the tour. The following resident expired medications, including expiration dates, were observed in the North medication storage room: 1 Xeroform 06/04/22 2 [MEDICATION(S)] Gel 08/19/22 1 Hydrogel 07/16/22 2 Hydrocortisone Cream 09/10/22 5 Triple antibiotic Cream 05/18/22, 05/07/22, 07/16/22, 06/14/22, and 04/01/22 2 [MEDICATION(S)] 09/2022, and 08/2022 2 Eucerin lotion 10/20/21 and 08/27/21 1 [MEDICATION(S)] Cream 04/25/22 1 Muscle Rub 07/07/22 1 Antibacterial soap 10/06/22 1 Iodine 02/28/22 1 Bio freeze spray 06/17/21 2 Santyl 250 units 05/2022 1 Nystan powder 08/09/22 2 [MEDICATION(S)] 20 ml 07/07/22 and 07/29/22 Resident expired medications found on the South medication cart: 2 DM Tussin 04/19/22 and 04/25/22 Expired house stock observed in the North storage room included: Active Ice pain relief 12/2021 2 Packs of Nicotine Gum 2 mg 02/2018 Budros Butt Paste 03/2018 Dakins Hy[DATE]/26/2019 Peroxide 02/2018 Expired medical supplies observed in the North medication storage room included: 26 dressing tape Right Fix 09/22/21 13 comfi tape adhesive tape 03/31/22, 09/21/21, 03/29/20 and 12/29/20 39 Alginate wound dressing 03/2022 19 Hydrogel wound dressing large 12/10/20 30 Silver Alginate 10/18/22 1 Hydrogel wound dressing 10/2021 4 Packing Strips 02/24/22 1 Box Sterile Gloves 06/30/21 On 10/27/22 at 12:30 a.m., LPN #1 reported the facility didn't want to be wasteful so they were keeping the expired medications in case they were needed. On 10/27/22 at 12:45 p.m., the DON reported the expired medications should have been removed and medications should not have been left on the medication cart unattended.

Based on observation, interview and record review, it was determined the facility failed to develop and implement a comprehensive care plan for two (#35 and #18) of five residents whose records were reviewed for Unnecessary Medication, [CONDITION(S)] Medication, and Medication Regimen Review. The facility reported 36 residents resided in the facility. Findings: The facilities policy for Antipsychotic Medication Use documented residents who are admitted from a hospital . The interdisciplinary team will: re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks to consider whether or not the medication can be reduced, tapered, or discontinued. 1. Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A careplan for depression, dated 05/01/19, documented the resident was sent to geri psych on 07/23/20 and returned on 08/12/20 with medication changes. The careplan contained no documentation regarding the use of an antipsychotic medication. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 04/23/21, documented the resident had received an antipsychotic medication for seven days of the look back period. The assessment documented a gradual dose reduction (GDR) had not been attempted. The resident was observed throughout the survey and exhibited no behaviors. On 05/26/21 at 10:15 a.m., certified medication aide #1 could not report any psychotic behaviors for this resident. On 05/26/21 at 10:30 a.m., the assistant director of nursing (ADON) could not find clinical indication for the use of antipsychotic medication for this resident. On 05/26/21 at 3:20 p.m., the director of nurses was informed of the above findings and was in agreement he should have had a clinical indication, and a GDR for the use of the antipsychotic medication. The DON reported the use of an antipsychotic medication should have been care planned. 2. Resident #18 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Area Assessment (CAA), dated 12/31/20, documented the resident was to receive [MEDICATION(S)] 1mg every morning and [MEDICATION(S)] 2mg every night for Unspecified, Mood Disorder. The assessment documented the resident had received an antipsychotic medication. A care plan, dated 05/17/21, contained no documentation regarding the use of an antipsychotic medication. On 05/26/21 11:32 a.m., the minimum data set (MDS) coordinator was asked if the resident had a care plan for the antipsychotic medication. The MDS coordinator reported the resident did not have a care plan for the antipsychotic medication.

Based on observation, interview, and record review, it was determined the facility failed to provide indwelling urinary catheter care per recommended standards for one (#31) of three residents reviewed for indwelling urinary catheter care. The facility reported three residents required the use of indwelling urinary catheter Findings: Resident #31 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised on 07/08/19, documented the resident was at risk for urinary tract infection due to suprapubic catheter. The care plan documented the resident would have decreased risk of catheter related trauma through the review date. The care plan documented for the staff to provide catheter care as ordered, 18 French catheter change every four weeks, and monitor /document intake and output as per facility policy. A quarterly assessment, dated 04/02/21, documented the resident was intact with cognition. The assessment documented the resident required little to no assistance with activities of daily living (ADL). The assessment documented the resident had an indwelling catheter. On 05/25/21 12:59 PM, the DON reported the resident had a suprapubic catheter. On 05/25/21 01:12 PM, the resident reported his catheter was in his penis. The resident stated, They clean those every day. They do not clean mine every day. The resident denied ever refusing to allow staff to clean the catheter. The resident reported the catheter was changed every month. On 05/25/21 01:15 PM, LPN #2 reported the resident had a suprapubic catheter. The LPN reported she was told when she was hired, the resident refused to let staff clean his catheter. On 05/25/21 01:19 PM, CMA #1 reported the resident had an indwelling catheter in his penis. The CMA reported the nurses cleaned the catheters. On 05/25/21 02:20 PM, CNA #2 reported CNAs do not perform catheter care. The CNA reported nurses provided catheter care. She reported when she gave the resident showers, she made sure his catheter was clean. On 05/25/21 04:14 PM, LPN #3 reported the resident performed his own catheter care. The LPN was asked if self-care was charted or care planned . She reported it was not. The DON reported catheter care was not on the treatment sheet or ADL sheet. The DON reported catheter care should have been provided.

Based on observation, interview, and record review, it was determined the facility failed to provide pain management for one (#33) of three residents reviewed for pain. The facility reported 24 residents required pain management. Findings: Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 08/26/19, documented the resident was on pain medication therapy. The goal documented the resident would have decreased risk of any discomfort or adverse side effects from pain medication. The care plan interventions included, administer medications (Tylenol and [MEDICATION(S)]) as ordered, monitor pain every shift, monthly pain assessment to be completed by RN. A 5-day Medicare assessment, dated 04/14/21, documented the resident was intact with cognition. The assessment documented the resident received scheduled pain medication regimen. The assessment documented the resident reported pain or hurting during the last five days of the look back period. The assessment documented the resident reported the frequency of pain almost constantly. The assessment documented the resident reported pain made it difficult to sleep at night and had limited day-to-day activities. A new care plan intervention was initiated on 05/10/21 to place [MEDICATION(S)] on hold until further notice. A 5-day Medicare assessment, dated 05/17/21, documented the resident had cognitive deficit. The assessment documented the resident did not receive scheduled pain medication regimen. The assessment documented the resident did not receive as needed (PRN) pain medication during the five day look back period. The assessment documented the resident reported almost constant pain present during the five day look back period. The assessment documented the resident reported pain made it hard to sleep at night and limited day-to-day activities. The assessment documented the resident numerically rated his pain at eight, on a scale of one to ten, ten being the highest level. On 05/24/21 10:26 AM, the resident reported he had pain. The resident rated pain as an eight on a scale of one to ten. On 05/25/21 08:58 AM, the resident rated pain at 8-9. The resident reported he had not had medication for pain. On 05/25/21 02:35 PM, the minimum data set (MDS) nurse reported she questioned the resident regarding pain for the MDS assessments. The MDS nurse confirmed the resident's response of almost constant pain which made it difficult to sleep or participate in day-to-day activities. The MDS nurse stated, They don't want him on serious pain meds because of the history of addiction. On 05/25/21 02:54 PM, LPN #3 reported the resident did not complain of pain. On 05/25/21 02:55 PM, the resident rated pain at 8-9. The resident reported he hurts all over, no specific location. On 05/25/21 03:10 PM, LPN #4 reported resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN reported the resident does have frequent pain and has been reminded to ask for PRN pain medication. On 05/25/21 04:37 PM, the ADON, and DON reported the resident received [MEDICATION(S)] 5/325mg four times daily until he was admitted to a geri-psych facility at the end of February, 2021. The DON reported the resident returned from geri-psych with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported the resident was hospitalized from 05/05/21 to 05/10/21. She reported the [MEDICATION(S)] was placed on hold pending a consult with nephrology. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No other prn pain medication administration was documented. On 05/26/21 09:31 AM, the resident reported he was in pain. Nursing staff was notified of resident's pain. On 05/26/21 04:30 PM, the DON reported the resident should have had his pain addressed.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident was free from an unnecessary medication for two (#35 and #18) of five residents whose records were reviewed for Unnecessary Medication, [CONDITION(S)] Medication, and Medication Regimen Review. The facility identified 13 residents who received an antipsychotic medication. Findings: The facilities policy for Antipsychotic Medication Use documented residents who are admitted from a hospital . The interdisciplinary team will: re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks to consider whether or not the medication can be reduced, tapered, or discontinued. 1. Resident #35 was admitted to this facility on 01/09/19 with diagnoses which included depression, [CONDITION(S)], diabetes, [CONDITION(S)]-fibrillation, and dementia. A careplan for depression, dated 05/01/19, documented the resident was sent to geri psych on 07/23/20 and returned on 08/12/20 with medication changes. The careplan contained no documentation regarding the use of an antipsychotic medication. A physician's order, dated 08/13/20, documented for the resident was to receive [MEDICATION(S)] 0.25 milligrams (mg) two times a day related to major depressive disorder. A quarterly assessment, dated 04/23/21, documented the resident had received an antipsychotic medication for seven days of the look back period. The assessment documented a gradual dose reduction (GDR) had not been attempted. The clinical record contained no clinical indication for the use of an antipsychotic medication. A review of the residents behavior monthly flowsheets documented the resident had no psychotic behaviors. A medication regimen review from September through December 2020 and January through March 2021 had no gradual dose reduction recommendation documented. The resident was observed throughout the survey and exhibited no behaviors. On 05/26/21 at 10:15 a.m., certified medication aide #1 could not report any psychotic behaviors for this resident. On 05/26/21 at 10:30 a.m., assistant director of nursing (ADON) could not find clinical indication for the use of antipsychotic medication for this resident. On 05/26/21 at 3:20 p.m., the director of nurses was informed of the above findings and was in agreement he should have had a clinical indication, and a GDR for the use of the antipsychotic medication. The DON reported the use of an antipsychotic medication should have been care planned. 2. Resident #18 was admitted on [DATE] with diagnoses which included unspecified disorder of adult personality and behavior, sleep apnea unspecified, localized [CONDITION(S)], obesity unspecified, [CONDITION(S)], [CONDITION(S)], diabetes mellitus, [CONDITION(S)], and hypertension. A physician's order, dated 04/30/19, documented for the resident to receive [MEDICATION(S)] 1 milligram every day for mood/picking related to anxiety disorder. A physician's order, dated 05/01/20, documented for the resident to receive [MEDICATION(S)] 2 milligram at bedtime for unspecified mood disorder. A quarterly assessment, dated 05/08/21, documented the resident was moderately impaired with cognition. The assessment documented no behaviors. The assessment documented the resident received an anti-psychotic, anti-anxiety, and anti-depressant for seven days of the look back period. A care plan, dated 05/17/21, documented the resident used anti-psychotic medication for the diagnosis of depression. The care plan interventions were for the staff to administer as ordered, Abnormal Involuntary Movement Scale (AIMS) assessment to be completed quarterly and as needed, monitor behaviors every shift, and for pharmacist to review medication regimen review monthly and make any recommendations. The clinical record contained no documentation regarding a clinical indication for the use of an anti-psychotic medication. The resident was observed throughout the survey, 05/24/21 through 05/27/21, and no behaviors were observed. On 05/26/21 01:10 p.m., the DON reported the last gradual dose reduction was completed on 04/30/19. The DON reported there should have been a gradual dose reduction attempted or at least discussed. The DON reported there should have been clinical indication for the use of an anti-psychotic medication.

Based on interview and record review, it was determined the facility failed to implement their abuse policy and procedure related to: ~ Protection of a resident during an investigation of abuse by allowing the alleged perpetrator to return to work during the investigation; and ~Not initiating an investigation for an allegation of abuse in a timely manner. For one (#1) of one sampled resident whose records were reviewed for an allegation of abuse. This had the potential to affect all 52 residents who resided in the facility. Findings: A policy, titled Freedom From Abuse, Neglect, and Exploitation Policy and Procedure, documented the administrator or designee should initiate an investigation immediately, and notify the State Department of Health within the specified time frame. The policy documented the ADM would suspend immediately any employee who had been accused of abuse pending the outcome of the investigation. Resident #1 had [DIAGNOSES REDACTED]. A care plan, updated 05/27/20, documented the resident was occasionally incontinent of bladder. The care plan documented the resident usually toileted her self. The care plan documented the staff would assist the resident as needed. A timecard report, dated 06/29/30, documented CNA #1 worked from 1:41 p.m. until 4:15 p.m. A nurse's note, dated 06/30/20 at 3:30 p.m., documented the resident reported to the nurse a nurse's aide poked her twice in the anal area. The nurse asked the resident why she had not reported until today. The resident reported she was confused and had to think about it. The note documented, Will report. An initial state reportable incident report, dated 06/30/20, documented the resident had alleged CNA #1 touched her inappropriately. The report documented the CNA had been suspended pending the investigation. The report documented an investigation had been initiated immediately. A timecard report, dated 06/30/20, documented CNA #1 worked from 1:37 p.m. until 4:15 p.m. On 07/13/20 at 10:15 a.m., upon entry into the facility the DON reported the ADM was not at the facility. The DON reported the ADM had been placed on suspension. On 07/13/20 at 11:18 a.m., CNA #2 reported (on 06/29/20 approximately 11:30 a.m.) the resident had claimed CNA #1 had stuck his finger in her rectum. The CNA reported she immediately went to the ADM with the information. The CNA reported CNA #1 worked the evening shift on 06/29/20. The CNA reported CNA #1 was not suspended until 06/30/20 around 4:30 p.m. On 07/13/20 at 11:59 a.m., the MDS coordinator reported she had advised the therapist on 06/29/20 to report the allegation to the ADM. The MDS coordinator reported she asked the ADM if he had been made aware of the allegation of abuse. The MDS coordinator reported she observed CNA #1 working the floor on 06/29/20 prior to leaving the facility around 4:00 p.m. On 07/13/20 at 12:55 p.m., the owner reported the ADM had been suspended from his duties due to not following the facility abuse policy. The owner reported the ADM had not suspended CNA #1, initiated an investigation, or submitted an incident report to the Oklahoma State Department of Health in a timely manner.

Based on interview and record review, it was determined the facility failed to initiate an investigation for an allegation of abuse within the two hour time frame for one (#1) of one sampled resident whose records were reviewed for an allegation of abuse. This had the potential to affect all 52 residents who resided in the facility. Findings: A policy, titled Freedom From Abuse, Neglect, and Exploitation Policy and Procedure, documented the administrator or designee should initiate an investigation immediately, and notify the State Department of Health within the specified time frame. Resident #1 had [DIAGNOSES REDACTED]. A care plan, updated 05/27/20, documented the resident was occasionally incontinent of bladder. The care plan documented the resident usually toileted her self. The care plan documented the staff would assist the resident as needed. A timecard report, dated 06/29/20, documented CNA #1 worked from 1:41 p.m. until 4:15 p.m. A nurse's note, dated 06/30/20 at 3:30 p.m., documented the resident reported to the nurse CNA #1 poked her twice in the anal area. The nurse asked the resident why she had not reported until today. The resident reported she was confused and had to think about it. The note documented, Will report. An initial state reportable incident report, dated 06/30/20, documented the resident had alleged CNA #1 touched her inappropriately. The report documented the CNA had been suspended pending the investigation. The report documented an investigation had been initiated immediately. A timecard report, dated 06/30/20, documented CNA #1 worked from 1:37 p.m. until 4:15 p.m. On 07/13/20 at 10:15 a.m., upon entry into the facility the DON reported the ADM had been placed on suspension. On 07/13/20 at 11:18 a.m., CNA #2 reported (on 06/29/20 at approximately 11:30 a.m.) the resident had claimed CNA #1 had stuck his finger in her rectum. The CNA reported she immediately went to the ADM with the information. The CNA reported CNA #1 worked the evening shift on 06/29/20. The CNA reported CNA #1 was not suspended until 06/30/20 around 4:30 p.m. On 07/13/20 at 11:59 a.m., the MDS coordinator reported she had advised the therapist on 06/29/20 to report the allegation to the ADM. The MDS coordinator reported she asked the ADM if he had been made aware of the allegation of abuse. The MDS coordinator reported she observed CNA #1 working the floor on 06/29/20 prior to leaving the facility around 4:00 p.m. On 07/13/20 at 12:55 p.m., the owner reported the ADM had been suspended from his duties due to not following the facility abuse policy. The owner reported the ADM had not suspended CNA #1, initiated an investigation, or submitted an incident report to the Oklahoma State Department of Health in a timely manner.

Based on interview and record review, it was determined the facility failed to protect a resident during an investigation of abuse by allowing the alleged perpetrator to return to work during the investigation, and not initiating an investigation for an allegation of abuse in a timely manner gor one (#1) of one sampled resident whose records were reviewed for an allegation of abuse. This had the potential to affect all 52 residents who resided in the facility. Findings: A policy, titled Freedom From Abuse, Neglect, and Exploitation Policy and Procedure, documented the administrator or designee should initiate an investigation immediately, and notify the State Department of Health within the specified time frame. The policy documented the ADM would suspend immediately any employee who had been accused of abuse pending the outcome of the investigation. Resident #1 had [DIAGNOSES REDACTED]. A care plan, updated 05/27/20, documented the resident was occasionally incontinent of bladder. The care plan documented the resident usually toileted her self. The care plan documented the staff would assist the resident as needed. A timecard report, dated 06/29/30, documented CNA #1 worked from 1:41 p.m. until 4:15 p.m. A nurse's note, dated 06/30/20 at 3:30 p.m., documented the resident reported to the nurse a nurse's aide poked her twice in the anal area. The nurse asked the resident why she had not reported until today. The resident reported she was confused and had to think about it. The note documented, Will report. An initial state reportable incident report, dated 06/30/20, documented the resident had alleged CNA #1 touched her inappropriately. The report documented the CNA had been suspended pending the investigation. The report documented an investigation had been initiated immediately. A timecard report, dated 06/30/20, documented CNA #1 worked from 1:37 p.m. until 4:15 p.m. On 07/13/20 at 10:15 a.m., upon entry into the facility the DON reported the ADM was not at the facility. The DON reported the ADM had been placed on suspension. On 07/13/20 at 11:18 a.m., CNA #2 reported (on 06/29/20 approximately 11:30 a.m.) the resident had claimed CNA #1 had stuck his finger in her rectum. The CNA reported she immediately went to the ADM with the information. The CNA reported CNA #1 worked the evening shift on 06/29/20. The CNA reported CNA #1 was not suspended until 06/30/20 around 4:30 p.m. On 07/13/20 at 11:59 a.m., the MDS coordinator reported she had advised the therapist on 06/29/20 to report the allegation to the ADM. The MDS coordinator reported she asked the ADM if he had been made aware of the allegation of abuse. The MDS coordinator reported she observed CNA #1 working the floor on 06/29/20 prior to leaving the facility around 4:00 p.m. On 07/13/20 at 12:55 p.m., the owner reported the ADM had been suspended from his duties due to not following the facility abuse policy. The owner reported the ADM had not suspended CNA #1, initiated an investigation, or submitted an incident report to the Oklahoma State Department of Health in a timely manner.

Based on observation and interview, it was determined the facility failed to store food in accordance with professional standards. The facility reported 51 residents lived in the facility and received their meals from the dietary department. Findings: On 02/10/19 at 2:58 p.m., a tour of the dietary department was conducted. A box of potatoes was stored on the floor in the storage room. The refrigerator contained a bowl of chicken noodle soup dated 01/24/19, a bowl of tomato soup dated 01/21/19, and a Ziploc bag containing fried bologna with no date. The refrigerator also contained a pitcher of an unknown substance red in color and a bowl of unknown substance purple in color. On 02/10/19 at 3:15 p.m., cook #1 reported the chicken noodle soup and tomato soup should have been removed. The cook reported the other items should have been labeled and dated. On 02/13/19 at 2:55 p.m., the dietary manager reported the areas would be addressed.

Based on record review and interview, it was determined the facility failed to ensure controlled medications were destroyed and witnessed by the pharmacist and the DON during the months of October, November, and December of 2017, and two of two glucometers were calibrated per the manufacturer's instructions. The ADM reported 43 residents resided in the facility. Findings: A facility policy and procedure titled, Discarding and Destroying Medications documented, .Include the signature(s) of at least two witnesses . Destruction of a controlled substance must render it 'non-retrievable,' meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted . The medication disposition record will contain the following information .Signature of witnesses. 1. On 01/10/18 at 11:50 a.m., the DON was asked for the facility medication destruction records. The medication destruction records did not contain two witnessed signatures for the months of October, November, and December of 2017. The medication destruction record designated for a pharmacist and the DON to witness the waste of the scheduled medications. At that time, the DON reported she was new to the facility and was not aware the scheduled medications were not witnessed by the pharmacist and the DON. The DON reported the ADON had witnessed the scheduled medication waste and had not signed as a witness to the destruction of the medications. The DON reported the issue would be corrected. On 01/10/18 at 2:15 p.m., the ADM was notified of the findings. The ADM reported the issue would be addressed. 2. On 01/09/18 at 11:00 a.m., LPN #1 was interviewed. The LPN was asked when were the glucometers to be calibrated. The LPN reported the night shift calibrated the glucometers. The LPN was asked for the glucometer calibration log. The LPN reported she did not know where the glucometer log was maintained but would locate the log. On 01/10/18 at 1:00 p.m., the DON was interviewed. The DON reported the facility had two glucometers in use. The DON reported a glucometer calibration log had not been maintained by the facility and the issue would be addressed.

Based on observation, record review, and interview, it was determined the facility failed to ensure sanitary conditions were maintained in the dietary department. The dietary manager reported 43 residents received meals from the dietary department. Findings: On 01/08/18 at 9:40 a.m., a tour of the facility's dietary department was conducted. The following observations were made. A drawer contained an employment application, an order for [REDACTED]. A dietary aide was observed to spray foam cleanser on a counter on which the silverware holder was sitting. Serving ladles and tongs were suspended over the counter. Both the silverware and the serving utensils were in potential areas of contamination by the chemical. A container with disinfectant water was observed in the kitchen and was not observed to be utilized by the dietary aide. A dietary aide was observed to not have a hair net properly in place. The aide's hair was loose from her head band and the hair net was inching upward on her head. The dietary manager instructed the aide to ensure her hair was covered. During the dining observation on 01/08/18 at 12:30 p.m., the tray covers for the hall trays were observed to be stained and some of the covers appeared to have black greasy areas. On 01/09/18 at 9:45 a.m., during the group meeting, the residents reported the tray covers were stained. On 01/10/18 at 12:30 p.m., a test tray was provided for the surveyor. The tray cover was stained, and black, greasy streak marks were observed on the inside and outside of the cover. The black streaks were wiped with a napkin and were removable. At 12:40 p.m., the ADM was asked to observe the tray cover. On 01/10/18 at 2:20 p.m., the dietary manager was informed of the dietary observations. The dietary manager reported she would not store paperwork in the utensil drawer, and she would educate the staff on the other items. The dietary manager reported the tray cover stains would be addressed. On 01/11/18 at 10:00 a.m., the ADM was informed of the dietary findings. The ADM reported he planned to change the segmented meal trays to dinner plates and to obtain new plate covers.

Based on observation, record review, and interview, it was determined the facility failed to ensure prefilled insulin syringes were labeled with the resident's name and dated when opened, a syringe was labeled with the resident's name, the date, and the contents of the unidentified solution, and medications had not expired. The ADM reported 43 residents resided at the facility. Findings: On [DATE] at 9:50 a.m., during a medication pass, on the North Hall, an unlabeled 60 ml syringe was observed inside the medication cart. LPN #2 was asked what the unlabeled syringe contained. The LPN reported he/she had filled the syringe with an acetic acid solution for irrigation and had not labeled the syringe with the resident's name, contents, or the date. An undated 1000 ml container of acetic acid irrigation solution was observed inside the medication cart. The LPN reported he/she had opened the container that a.m. and failed to date the irrigation solution. On [DATE] at 10:00 a.m., both emergency carts were observed to contain one vial of expired [MEDICATION NAME]. The medication cart on the North Hall contained two prefilled syringes of [MEDICATION NAME]which were not labeled with a residents' name or the date opened. The South Hall medication cart contained one [MEDICATION NAME]syringe not labeled or dated. The South Hall medication room refrigerator contained 16 vials of expired [MEDICATION NAME] injections for a resident who was no longer in the facility. On [DATE] at 2:15 p.m., the DON was interviewed. The DON was asked if she expected the nursing staff to pre-fill and not label an irrigation syringe. The DON reported a syringe should not be filled until ready for use. The DON was asked should pre-filled insulin syringes be labeled with a resident's name and dated when opened. The DON reported yes. The DON was asked if there should be expired medication in the facility. The DON reported no. The DON reported the issues would be addressed.

Based on observation, record review, and interview, it was determined the facility failed to ensure assessments were transmitted in an appropriate time frame for one (#140) of 12 residents reviewed. The ADM reported 43 residents lived in the facility. Findings: 1. On 01/08/18 at 11:00 a.m., the ADM and the MDS coordinator were informed the survey computer system documented the facility had a different resident roster than the one the facility had provided. The ADM reported he had a couple of different MDS coordinators and DONs since he had come to the facility last year. They were informed resident #140 had a discharge assessment in August 2017 and no re-entry assessment was in the system. The MDS coordinator reported a quarterly assessment had been completed for the resident. 2. Resident #140 was admitted on [DATE] and had [DIAGNOSES REDACTED]. On 01/08/18 at 10:00 a.m., the resident was observed to be lying in the bed with her eyes closed. On 01/09/18, during the investigations for the resident, a discharge assessment, dated 08/16/17, was the only assessment located in the survey computer system. No re-entry assessment was located in the system. The resident was due a quarterly assessment since that date. On 01/10/18 at 9:30 a.m., the MDS coordinator provided the surveyor with the quarterly assessment, dated 11/22/17. The MDS coordinator was asked for the transmission verification for the assessment. The MDS coordinator reviewed the transmission records and reported she could not find the documentation. The MDS coordinator reported she would access the government Internet site to verify the assessment had been received. On 01/11/18 at 9:00 a.m., the MDS coordinator showed the surveyor the facility's computer system which documented the assessment had been transmitted. She reported the quarterly assessment had not shown up on the government's website and she transmitted the assessment again.

Based on record review and interview, it was determined the facility failed to ensure assessments were signed and certified by a registered nurse (RN) for 15 (#6, 11, 13, 15, 19, 24, 26, 32, 33, 35, 37, 38, 140, 147, and #193) of 15 residents reviewed for assessment accuracy and completion. The ADM reported 43 resident lived in the facility. Findings: On 01/10/18, during the investigation phase of the survey, the assessments for the sample residents were reviewed. The assessments, provided by the facility, contained no documentation the RN verified the assessments' completion. On 01/11/18 at 9:51 a.m., the MDS coordinator was asked for the signature page or documentation of the RN who verified the assessment for resident #140. The MDS coordinator reported no signature pages had been completed for the resident or any resident. The MDS coordinator reported she had only been doing the assessments for a month and the DON was new to her position also. On 01/11/18 at 11:00 a.m., the ADM reported a former DON had been hired part-time to help the facility get caught up on the assessments. The ADM reported he had a couple of MDS coordinators and DONs since he came to the facility last year.

Based on observation, record review, and interview, it was determined the facility failed to develop complete comprehensive care plans for four (#6, #19, #35, and #37) of 12 residents whose comprehensive care plans were reviewed. The ADM reported 43 residents lived in the facility. Findings: 1. Resident #37 was admitted on [DATE] with diagnoses which included [MEDICAL CONDITION], malignant neoplasm of lung, bilateral BKA, chronic systolic heart failure, CAD, poor nutrition, [MEDICAL CONDITION], depression, and type II diabetes mellitus. A physician's orders [REDACTED]. A baseline care plan, dated 12/15/17, documented the resident was receiving [MEDICATION NAME] injections. An admission assessment, dated 12/18/17, documented the resident's cognitive function as zeros on the brief interview for mental status. The assessment documented the resident exhibited mild depression and verbal behavioral symptoms towards others which occurred four to six days in the look-back period, but less than daily. The assessment documented the resident rejected care daily in the look-back period. The assessment documented the resident was independent with no physical help for bed mobility and eating. The assessment documented the resident required extensive assistance with transfer, dressing, personal hygiene, and required total assistance for bathing. The assessment documented the resident had an indwelling urinary catheter and was always incontinent of bowel. The assessment documented the resident had received an anticoagulant for four days in the look-back period. The resident's January 2018 Injections form documented the resident was receiving the [MEDICATION NAME] injections as ordered. On 01/08/18 at 12:02 p.m., the resident was observed lying in bed with his call light and water within reach. The resident was alert and oriented. The resident could answer questions with clear speech. The resident reported he had been taking a blood thinner medication and would have to check to see if he was still taking the medication. The resident's comprehensive care plan was reviewed. The resident's care plan contained no entry the resident was on the anticoagulant. The resident's January 2018 treatment forms were reviewed and the forms contained no documentation to monitor the resident for any signs of bleeding tendencies such as bleeding gums, bruising, or blood in the urine or stools. On 01/10/18 at 2:30 p.m., the MDS coordinator was shown the resident's care plan and asked if the anticoagulant use with interventions should have been included in the resident's comprehensive care plan. The MDS coordinator reported yes. 2. Resident #6 was admitted on [DATE] with diagnoses which included dementia with behavioral disturbance, diverticulitis, hypertension, mood disorder, and anxiety. A nurse's note, dated 09/30/17, documented the resident was admitted to the facility and demonstrated confusion and wandering behaviors. A nurse's note, dated 10/01/17, documented the resident was confused and trying to leave the facility. A physician's history and physical report, dated 10/02/17, documented [MEDICATION NAME] (antipsychotic) was added to help calm the resident due to the prn antianxiety medication was not helping with the resident's agitation. The report documented the resident was admitted for skilled services from the hospital after experiencing diverticulitis and bloody diarrhea. An admission assessment, dated 10/07/17, documented the resident was moderately impaired in cognition, exhibited no symptoms of depression, and exhibited signs of delusion with no other behaviors. The assessment documented the resident required limited assistance with ADLs. The resident's care plans, with no date of initiation, documented the following: 1) The resident required the use of [MEDICAL CONDITION] medication for depression and anxiety. 2) The resident required limited-moderate-extensive assistance with ADLs, with mobility and wheelchair use checked as the areas addressed. 3) Supplements. The care plan documented no reason for supplements, such as weight loss or laboratory values, and no goal was documented. 4) Diarrhea and/or vomiting. 5) Therapy, not marked as to which therapy was to be provided, and with no goals or interventions documented. The care plan contained an entry, dated 10/09/17, which documented the resident had a speech evaluation. 6) High risk for falls related to unsteady gait and dementia, dated 10/09/17. The interventions were to have call light in reach, room free of clutter, walker/wheelchair in reach, encourage resident to use call light to request assistance, and ensure proper footwear. An entry, dated 10/22/17, documented the resident experienced a fall and for therapy to work on safety awareness and transfers. An entry, dated 10/25/17, documented the resident experienced a fall and to encourage the resident to go to bed at night and for the staff to apply non-skid socks on resident at night. A nurse's note, dated 11/06/17, documented the resident asked people for a ride home and which door was unlocked so she could go home. A nurse's note, dated 11/08/17 at 8:00 p.m., documented the resident had exhibited exit seeking behaviors all shift. A nurse's note, dated 11/11/17, documented the resident was confused and kept going to the front door to get out. A nurse's note, dated 11/13/17, documented the resident tried to use the phone to call for a ride home and tried to get out of the back door. A mental health visit report, dated 11/22/17, documented the resident had continuous, worsening present illness of moderate severity. The report form documented the treatment plan was discussed with staff. The care plan did not address the resident's dementia, wandering, and exit seeking behaviors. On 01/11/18 at 11:53 a.m., the DON was shown the care plan which did not address the resident's exit seeking behaviors and dementia. The DON was asked if the care plan should have addressed these areas. The DON stated, Yes. 3. Resident #35 was admitted [DATE] with diagnoses which included dementia with behavioral disturbances, [MEDICAL CONDITION], and hypertension. A hospital discharge summary, dated 09/19/17, documented the resident experienced acute [MEDICAL CONDITIONS], behavioral problems, and [MEDICAL CONDITION]. A quarterly assessment, dated 12/26/17, documented the resident was severely impaired in cognition, exhibited mild depression symptoms, and exhibited physical and verbal behaviors on one to three days of the look back period. The assessment documented the resident required assistance with ADLs. The resident's care plans, with no date of initiation, documented the following problems: overactive bladder, altered nutrition, rash, therapy, risk for skin breakdown, and urinary tract infection. The resident's care plan did not address the resident's antipsychotic medications, dementia, and behaviors. A nurse's note, dated 11/30/17, documented the resident exhibited combative behaviors and a urinalysis was ordered by the physician. The December 2017 physician's orders [REDACTED]. The physician's orders [REDACTED]. A nurse's note, dated 12/26/17, documented the resident was combative towards the staff. A urinary tract infection was diagnosed and an antibiotic was started. On 01/10/18 at 4:37 p.m., the MDS coordinator was asked if the resident's care plan should have addressed the resident's dementia diagnosis, behaviors, and [MEDICAL CONDITION] medications. The MDS coordinator reported yes. 4. Resident #19 was admitted to the facility on [DATE] with diagnoses which included [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] reflux disease, and [MEDICAL CONDITION]. An admission assessment, dated 11/07/17, documented the resident was cognitively intact and required extensive assistance of one person for transfers, dressing, and toileting. The assessment documented the resident required physical help in part of bathing. The assessment documented the resident experienced impairment on one side of both upper and lower extremities. The assessment documented the resident was occasionally incontinent of bowel and bladder. An undated comprehensive care plan did not document the resident had a [MEDICAL CONDITION] disorder and [MEDICAL CONDITION] precautions were not addressed. On 01/08/18 at 10:30 a.m., the resident was observed in his wheelchair in the hallway. The resident was observed to have facial hair. The resident reported he was waiting to go outdoors to smoke. On 01/09/18 at 2:30 p.m., the DON was interviewed. The DON was asked if the care plan should have included the resident's [MEDICAL CONDITION] disorder, precautions, and the anticonvulsant medication. The DON reported she was new to the facility and the care plan would be reviewed and updated.

On 10/23/14 at 10:05 a.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to fully investigate allegations of abuse reported by residents and Licensed Practical Nurse (LPN #1) in regard to Certified Nurse Aide (CNA #1). The facility also failed to take appropriate actions to protect all residents. At 10:15 a.m., the existence of an IJ was verified with the team coordinator who was present on the survey and verified with the Oklahoma State Department of Health (OSDH). At 10:17 a.m., the facility administrator was notified of the existence of an IJ pertaining to the failure to fully investigate and protect all residents from abuse. On 10/23/14 at 1:30 p.m. the facility submitted an acceptable plan of removal. The facility's plan of removal documented: "Washita Valley Living Center 10/23/14 Plan of correction. All Allegations reported an investigation will be done. 1. Notification of how to report incident of abuse to Administrator and posted at each nursed (sic) station. 2. All allegations will be reported to Administrator immediately at the time of incident and statement from all witness will be done before shift is over and turned into the Administrator. 3. Administrator will immediately interview all residents and staff involved in the allegation. 4. Interview all staff in reference to employee if they have every (sic) witness (sic) any behavior of employee due to allegation. 5. Review all information and make decision if employee will return to work or be terminated. 6. Incident report to state. 7. In-Service to all staff in reference how to report abuse and what is abuse. 8. Employee was terminated and OSDH (Oklahoma State Department of Health) and Nurse Aide Registry (notified). 9. All employee's not able to be in-service today due to wrong phone or left message will be inserviced before returning to work, Administrator and Director of Nurses or Assist Director of Nurses will In-Service before staff before returning to work." On 10/23/14, at 5:50 p.m., the IJ was removed after inservices were completed and staff were interviewed and determined to be knowledgeable concerning the information presented in the inservice. The deficient practice remained at a level of actual harm that was not immediate jeopardy, at a pattern. Based on record review and interviews, it was determined the facility failed to fully investigate allegations of abuse reported by two (#7 and #47) of 27 sampled residents and Licensed Practical Nurse (LPN #1) in regard to Certified Nurse Aide (CNA #1). The facility also failed to take appropriate actions to protect all residents. This had the potential to affect all 51 residents residing in the facility. Findings: The facility's policy on abuse documented, "Our goal at Washita Valley Living Center is to ensure that residents are free from any type of abuse. If you suspect abuse or mistreatment of [REDACTED]. We encourage you to report any allegation of abuse as soon as the incident occurs. We are mandated to investigate and notify the appropriate state authorities in a timely manner... ABUSE PREVENTION AND POLICY AND PROCEDURE 1. Screening... 2. Training... 3. Prevention... 4. Identification *Staff to work together to identify any patterns or trends that could constitute abuse. 5. Investigation... *Facility staff will gather information for review from witnesses and/or people that may have information pertinent to the investigation. 6. Protection *The facility staff will insure residents are protected from harm during the investigation process. *Any staff member accused of abuse will be suspended and/or terminated immediately pending the outcome of the investigation... 7. Reporting/Response *Alleged violations and all substantiated incidents will be reported to the state and to other agencies as required. *Staff will take corrective action as necessary. *Staff will analyze data to determine if changes are indicated in policy and procedure to help prevent further occurrence..." 1. Resident #7 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/29/14, documented she was dependent on staff with all activities of daily living and was always incontinent of bowel and bladder. On 10/20/14 at 3:23 p.m., resident #7 stated CNA #1 was rough at times when caring for her and others. She stated she had reported it to other CNA's and the administrator. 2. Resident #47 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 10/09/14, documented her cognition was intact. She was dependent on staff for transfers. She required limited assistance with dressing. She was independent with eating. She required extensive assistance with personal hygiene and bathing and was always continent of bowel. She was frequently incontinent of urine. On 10/23/14 at 10:00 a.m., resident #47 stated CNA #1 had purposely put her call light over by her curtain one evening, out of her reach. CNA #1's employee file was reviewed. The file included the following documentation: A facility 'Performance Deficiency Notice', dated 09/17/14, documented CNA #1 was given a written verbal warning for, "c/o (complaint of) roughness reported via North hall x's (times) 4 residents. Four residents reported during (changing) and repositioning roughness. Discussed (with) (CNA #1) complaints of roughness. Encouraged to slow down take her time (with) residents. Be careful of tone being used. Follow direction of charge nurse (with) 0 (zero) underminding behavior...Suspension x's 3 days if reported once more." The notice was signed by the Assistant Director of Nurses (ADON) and CNA #1. A letter was written on a 'Nurse's Note' form by Licensed Practical Nurse (LPN #1). It was dated 10/03/14. It documented, "To whom it may concern, re: (CNA #1) Residents continue to complain of (CNA #1) 'man-handling' them & cont. (continue) to make rude abuse comments towards residents. After being told to stay out of (2 sets of first and last initials were written) rooms, she cont. to go in there, when I was available to assist in those rooms instead of her. In an emergent situation with (first and last initial written) she refused to assist with anything. Stated she didn't know how to & just sit on his bed when he was having classic s/s (signs and symptoms) of stroke. She refuses to follow any of the rules. One night (initials) asked for pain medicine & Biofreeze she told him there were 5 women dying & the nurse didn't have time to mess (with) him. Her putting (initials) call light out of reach is abuse. She constantly has an attitude & is unprofessional Night before last, (initials) needed a pain pill & asked (CNA #1) to ask me for it. Instead of telling me, I found a note on the nurse's station. By the time I found the note & got her the medicine her pain was out of hand." Signed by LPN #1. A 'Performance Deficiency Notice', dated 10/03/14, documented CNA #1 received a written warning. The reason for the discipline warning was documented as, "Continue to get reports from residents and charge nurse." The facts leading up to filing of the report documented, "Still receiving complaint on repositioning roughness with resident. Still not following direction from charge nurse. Moving employee to 2-10 shift to work and on 30 day probation if not resolved at anytime it will be immediate termination." The notice also documented, "If not correct within 30 day termination will be enforced." This was signed by the administrator and CNA #1. CNA #1 was not suspended for three days as the 09/17/14, 'Performance Deficiency Notice' documented. On 10/23/14 at 8:47 a.m., the administrator was interviewed concerning the above situation. She stated she had spoke with resident #7 and stated the resident had told her CNA #1 had turned her too fast. "No injury was reported, just she is too fast. (CNA #1) was taken off that wing." The administrator was in agreement abuse had been alleged and had not been investigated. She stated she was not aware of the alleged incidents on 10/03/14. She stated CNA #1 was not scheduled to return to work until Friday 10/24/14 for the 2:00 p.m. to 10:00 p.m. shift. At 11:32 a.m., the Director of Nurses (DON) was interviewed concerning the above situation. She stated she was not aware of the note written by LPN #1 in regard to CNA #1. She stated, "I knew there was complaints of (CNA #1) being rough with the residents. (Resident #7) complained she turned her into the side rail. She said she had not done it intentionally. Her voice was just harsh. Other residents had complained of (CNA #1) talking in a harsh tone. (Assistant Director of Nurses-ADON) and the administrator had called (CNA #1) in and had a meeting with her and wrote her up. Inservice day was after (LPN #1) had left note for the administrator. The administrator stated more complaints came and (CNA #1) would be taken off the night shift. As a DON I should have seen it. I should have asked questions." At 12:19 p.m., the ADON stated she came up the evening of 09/17/14, in regard to complaints on CNA #1 and spoke to resident #7 and resident #47. "They stated (CNA #1) was rough in assisting to move them. I didn't feel it was abuse being reported."

On 10/23/14 at 10:05 a.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to follow their 'Abuse Prevention Policy & Procedure' and fully investigate allegations of abuse reported by residents and Licensed Practical Nurse (LPN #1) in regard to certified nurse aide (CNA) #1, and failed to take appropriate actions to protect all residents. At 10:15 a.m., the existence of an IJ was verified with the team coordinator who was present on the survey and verified with the Oklahoma State Department of Health (OSDH). At 10:17 a.m., the facility administrator was notified of the existence of an IJ pertaining to the failure to fully investigate and protect all residents from abuse. On 10/23/14, at 1:30 p.m. the facility submitted an acceptable plan of removal. The facility's plan of removal documented: "Washita Valley Living Center 10/23/14 Plan of correction. All Allegations reported an investigation will be done. 1. Notification of how to report incident of abuse to Administrator and posted at each nursed (sic) station. 2. All allegations will be reported to Administrator immediately at the time of incident and statement from all witness will be done before shift is over and turned into the Administrator. 3. Administrator will immediately interview all residents and staff involved in the allegation. 4. Interview all staff in reference to employee if they have every (sic) witness (sic) any behavior of employee due to allegation. 5. Review all information and make decision if employee will return to work or be terminated. 6. Incident report to state. 7. In-Service to all staff in reference how to report abuse and what is abuse. 8. Employee was terminated and OSDH (Oklahoma State Department of Health) and Nurse Aide Registry (notified). 9. All employee's not able to be in-service today due to wrong phone or left message will be inserviced before returning to work, Administrator and Director of Nurses or Assist Director of Nurses will In-Service before staff before returning to work." On 10/23/14, at 5:50 p.m., the IJ was removed after inservices were completed and staff were interviewed and determined to be knowledgeable concerning the information presented in the inservice. The deficient practice remained at a level of actual harm that was not immediate jeopardy, at a pattern. Based on record review and interviews, it was determined the facility failed to follow their 'Abuse Prevention Policy & Procedure' and fully investigate allegations of abuse reported by residents and Licensed Practical Nurse (LPN #1) in regard to certified nurse aide (CNA) #1, and failed to take appropriate actions to protect all residents. This had the potential to affect all 51 residents residing in the facility. Findings: The facility's policy on abuse documented, "Our goal at Washita Valley Living Center is to ensure that residents are free from any type of abuse. If you suspect abuse or mistreatment of [REDACTED]. We encourage you to report any allegation of abuse as soon as the incident occurs. We are mandated to investigate and notify the appropriate state authorities in a timely manner... ABUSE PREVENTION AND POLICY AND PROCEDURE 1. Screening... 2. Training... 3. Prevention... 4. Identification *Staff to work together to identify any patterns or trends that could constitute abuse. 5. Investigation... *Facility staff will gather information for review from witnesses and/or people that may have information pertinent to the investigation. 6. Protection *The facility staff will insure residents are protected from harm during the investigation process. *Any staff member accused of abuse will be suspended and/or terminated immediately pending the outcome of the investigation... 7. Reporting/Response *Alleged violations and all substantiated incidents will be reported to the state and to other agencies as required. *Staff will take corrective action as necessary. *Staff will analyze data to determine if changes are indicated in policy and procedure to help prevent further occurrence..." 1. Resident #7 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/29/14, documented she was dependent on staff with all activities of daily living and was always incontinent of bowel and bladder. On 10/20/14 at 3:23 p.m., resident #7 stated CNA #1 was rough at times when caring for her and others. She stated she had reported it to other CNA's and the administrator. 2. Resident #47 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 10/09/14, documented her cognition was intact. She was dependent on staff for transfers. She required limited assistance with dressing. She was independent with eating. She required extensive assistance with personal hygiene and bathing and was always continent of bowel. She was frequently incontinent of urine. On 10/23/14 at 10:00 a.m., resident #47 stated CNA #1 had purposely put her call light over by her curtain one evening, out of her reach. CNA #1's employee file was reviewed. The file included the following documentation: A facility 'Performance Deficiency Notice', dated 09/17/14, documented CNA #1 was given a written verbal warning for, "c/o (complaint of) roughness reported via North hall x's (times) 4 residents. Four residents reported during (changing) and repositioning roughness. Discussed (with) (CNA #1) complaints of roughness. Encouraged to slow down take her time (with) residents. Be careful of tone being used. Follow direction of charge nurse (with) 0 (zero) underminding behavior...Suspension x's 3 days if reported once more." The notice was signed by the Assistant Director of Nurses (ADON) and CNA #1. A letter was written on a 'Nurse's Note' form by Licensed Practical Nurse (LPN #1). It was dated 10/03/14. It documented, "To whom it may concern, re: (CNA #1) Residents continue to complain of (CNA #1) 'man-handling' them & cont. (continue) to make rude abuse comments towards residents. After being told to stay out of (2 sets of first and last initials were written) rooms, she cont. to go in there, when I was available to assist in those rooms instead of her. In an emergent situation with (first and last initial written) she refused to assist with anything. Stated she didn't know how to & just sit on his bed when he was having classic s/s (signs and symptoms) of stroke. She refuses to follow any of the rules. One night (initials) asked for pain medicine & Biofreeze she told him there were 5 women dying & the nurse didn't have time to mess (with) him. Her putting (initials) call light out of reach is abuse. She constantly has an attitude & is unprofessional Night before last, (initials) needed a pain pill & asked (CNA #1) to ask me for it. Instead of telling me, I found a note on the nurse's station. By the time I found the note & got her the medicine her pain was out of hand." Signed by LPN #1. A 'Performance Deficiency Notice', dated 10/03/14, documented CNA #1 received a written warning. The reason for the discipline warning was documented as, "Continue to get reports from residents and charge nurse." The facts leading up to filing of the report documented, "Still receiving complaint on repositioning roughness with resident. Still not following direction from charge nurse. Moving employee to 2-10 shift to work and on 30 day probation if not resolved at anytime it will be immediate termination." The notice also documented, "If not correct within 30 day termination will be enforced." This was signed by the administrator and CNA #1. CNA #1 was not suspended for three days as the 09/17/14, 'Performance Deficiency Notice' documented. On 10/23/14 at 8:47 a.m., the administrator was interviewed concerning the above situation. She stated she had spoke with resident #7 and stated the resident had told her CNA #1 had turned her too fast. "No injury was reported, just she is too fast. (CNA #1) was taken off that wing." The administrator was in agreement abuse had been alleged and had not been investigated. She stated she was not aware of the alleged incidents on 10/03/14. She stated CNA #1 was not scheduled to return to work until Friday 10/24/14 for the 2:00 p.m. to 10:00 p.m. shift. At 11:32 a.m., the Director of Nurses (DON) was interviewed concerning the above situation. She stated she was not aware of the note written by LPN #1 in regard to CNA #1. She stated, "I knew there was complaints of (CNA #1) being rough with the residents. (Resident #7) complained she turned her into the side rail. She said she had not done it intentionally. Her voice was just harsh. Other residents had complained of (CNA #1) talking in a harsh tone. (Assistant Director of Nurses-ADON) and the administrator had called (CNA #1) in and had a meeting with her and wrote her up. Inservice day was after (LPN #1) had left note for the administrator. The administrator stated more complaints came and (CNA #1) would be taken off the night shift. As a DON I should have seen it. I should have asked questions." At 12:19 p.m., the ADON stated she came up the evening of 09/17/14 in regard to complaints on CNA #1 and spoke to resident #7 and resident #47. "They stated (CNA #1) was rough in assisting to move them. I didn't feel it was abuse being reported."

On 10/23/14 at 10:05 a.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to recognize abuse when residents and Licensed Practical Nurse (LPN #1) reported abusive actions of Certified Nurse Aide (CNA #1). The facility also failed to take appropriate actions to protect all residents. At 10:15 a.m., the existence of an IJ was verified with the team coordinator who was present on the survey and verified with the Oklahoma State Department of Health (OSDH). At 10:17 a.m., the facility administrator was notified of the existence of an IJ pertaining to the failure to fully investigate and protect all residents from abuse. On 10/23/14 at 1:30 p.m. the facility submitted an acceptable plan of removal. The facility's plan of removal documented: "Washita Valley Living Center 10/23/14 Plan of correction. All Allegations reported an investigation will be done. 1. Notification of how to report incident of abuse to Administrator and posted at each nursed (sic) station. 2. All allegations will be reported to Administrator immediately at the time of incident and statement from all witness will be done before shift is over and turned into the Administrator. 3. Administrator will immediately interview all residents and staff involved in the allegation. 4. Interview all staff in reference to employee if they have every (sic) witness (sic) any behavior of employee due to allegation. 5. Review all information and make decision if employee will return to work or be terminated. 6. Incident report to state. 7. In-Service to all staff in reference how to report abuse and what is abuse. 8. Employee was terminated and OSDH (Oklahoma State Department of Health) and Nurse Aide Registry (notified). 9. All employee's not able to be in-service today due to wrong phone or left message will be inserviced before returning to work, Administrator and Director of Nurses or Assist Director of Nurses will In-Service before staff before returning to work." On 10/23/14, at 5:50 p.m., the IJ was removed after inservices were completed and staff were interviewed and determined to be knowledgeable concerning the information presented in the inservice. The deficient practice remained at a level of actual harm that was not immediate jeopardy, at a pattern. Based on record review and interviews, it was determined the facility failed to protect all residents from abuse after two (#7 and #47) of 27 sampled residents and Licensed Practical Nurse (LPN #1) made allegations that Certified Nurse Aide (CNA #1) had been abusive. The facility also failed to have an effective plan in place to ensure all residents were safe from abuse. This had the potential to affect all 51 residents residing in the facility. Findings: The facility's policy on abuse documented, "Our goal at Washita Valley Living Center is to ensure that residents are free from any type of abuse. If you suspect abuse or mistreatment of [REDACTED]. We encourage you to report any allegation of abuse as soon as the incident occurs. We are mandated to investigate and notify the appropriate state authorities in a timely manner... ABUSE PREVENTION AND POLICY AND PROCEDURE 1. Screening... 2. Training... 3. Prevention... 4. Identification *Staff to work together to identify any patterns or trends that could constitute abuse. 5. Investigation... *Facility staff will gather information for review from witnesses and/or people that may have information pertinent to the investigation. 6. Protection *The facility staff will insure residents are protected from harm during the investigation process. *Any staff member accused of abuse will be suspended and/or terminated immediately pending the outcome of the investigation... 7. Reporting/Response *Alleged violations and all substantiated incidents will be reported to the state and to other agencies as required. *Staff will take corrective action as necessary. *Staff will analyze data to determine if changes are indicated in policy and procedure to help prevent further occurrence..." 1. Resident #7 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/29/14, documented she was dependent on staff with all activities of daily living and was always incontinent of bowel and bladder. On 10/20/14 at 3:23 p.m., resident #7 stated CNA #1 was rough at times when caring for her and others. She stated she had reported it to other CNA's and the administrator. 2. Resident #47 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 10/09/14, documented her cognition was intact. She was dependent on staff for transfers. She required limited assistance with dressing. She was independent with eating. She required extensive assistance with personal hygiene and bathing and was always continent of bowel. She was frequently incontinent of urine. On 10/23/14 at 10:00 a.m., resident #47 stated CNA #1 had purposely put her call light over by her curtain one evening, out of her reach. CNA #1's employee file was reviewed. The file included the following documentation: A facility 'Performance Deficiency Notice', dated 09/17/14, documented CNA #1 was given a written verbal warning for, "c/o (complaint of) roughness reported via North hall x's (times) 4 residents. Four residents reported during (changing) and repositioning roughness. Discussed (with) (CNA #1) complaints of roughness. Encouraged to slow down take her time (with) residents. Be careful of tone being used. Follow direction of charge nurse (with) 0 (zero) underminding behavior...Suspension x's 3 days if reported once more." The notice was signed by the assistant director of nurses (ADON) and CNA #1. A letter was written on a 'Nurse's Note' form by licensed practical nurse (LPN) #1. It was dated 10/03/14. It documented, "To whom it may concern, re: (CNA #1) Residents continue to complain of (CNA #1) 'man-handling' them & cont. (continue) to make rude abuse comments towards residents. After being told to stay out of (2 sets of first and last initials were written) rooms, she cont. to go in there, when I was available to assist in those rooms instead of her. In an emergent situation with (first and last initial written) she refused to assist with anything. Stated she didn't know how to & just sit on his bed when he was having classic s/s (signs and symptoms) of stroke. She refuses to follow any of the rules. One night (initials) asked for pain medicine & Biofreeze she told him there were 5 women dying & the nurse didn't have time to mess (with) him. Her putting (initials) call light out of reach is abuse. She constantly has an attitude & is unprofessional Night before last, (initials) needed a pain pill & asked (CNA #1) to ask me for it. Instead of telling me, I found a note on the nurse's station. By the time I found the note & got her the medicine her pain was out of hand." Signed by LPN #1. A 'Performance Deficiency Notice', dated 10/03/14, documented CNA #1 received a written warning. The reason for the discipline warning was documented as, "Continue to get reports from residents and charge nurse." The facts leading up to filing of the report documented, "Still receiving complaint on repositioning roughness with resident. Still not following direction from charge nurse. Moving employee to 2-10 shift to work and on 30 day probation if not resolved at anytime it will be immediate termination." The notice also documented, "If not correct within 30 day termination will be enforced." This was signed by the administrator and CNA #1. CNA #1 was not suspended for three days as the 09/17/14, 'Performance Deficiency Notice' documented. On 10/23/14 at 8:47 a.m., the administrator was interviewed concerning the above situation. She stated she had spoke with resident #7 and stated the resident had told her CNA #1 had turned her too fast. "No injury was reported, just she is too fast. (CNA #1) was taken off that wing." The administrator was in agreement abuse had been alleged and had not been investigated. She stated she was not aware of the alleged incidents on 10/03/14. She stated CNA #1 was not scheduled to return to work until Friday 10/24/14 for the 2:00 p.m. to 10:00 p.m. shift. At 11:32 a.m., the Director of Nurses (DON) was interviewed concerning the above situation. She stated she was not aware of the note written by LPN #1 in regard to CNA #1. She stated, "I knew there was complaints of (CNA #1) being rough with the residents. (Resident #7) complained she turned her into the side rail. She said she had not done it intentionally. Her voice was just harsh. Other residents had complained of (CNA #1) talking in a harsh tone. (Assistant Director of Nurses-ADON) and the administrator had called (CNA #1) in and had a meeting with her and wrote her up. Inservice day was after (LPN #1) had left note for the administrator. The administrator stated more complaints came and (CNA #1) would be taken off the night shift. As a DON I should have seen it. I should have asked questions." At 12:19 p.m., the ADON stated she came up the evening of 09/17/14, in regard to complaints on CNA #1 and spoke to resident #7 and resident #47. "They stated (CNA #1) was rough in assisting to move them. I didn't feel it was abuse being reported."

Based on observation, interview and record review, it was determined the facility failed to ensure interventions were put in place to assist in preventing falls for two (#16 and #51) of six sampled residents reviewed for falls. This resulted in harm to resident #16. The resident sustained [REDACTED]. This had the potential to affect all 51 residents residing in the facility. Findings: 1. Resident #16 had [DIAGNOSES REDACTED]. The annual assessment, dated 04/07/14, documented the resident's cognition was moderately impaired. Transfers, dressing and hygiene were a one person physical assist, and ambulation had not taken place. Her eating was set up help only and she was occasionally incontinent of bowel and bladder. Her vision was moderately impaired. Fall risk assessments, dated 04/14/14, 07/14/14, and 10/10/14 documented the resident was a high risk for falls. The care plan for falls, dated 04/14/14, documented: call light within reach, bed and chair alarm, and personal body alarm on at all times. The clinical record documented the resident had 6 falls since 07/13/14. A nurse's note, dated 07/13/14, documented the resident had a fall. She was encouraged to ask for assistance. The fall was added to the resident's care plan. The care plan documented: encourage resident to use call light for assistance and do not ambulate without shoes or non skid socks. An incident report, dated 07/13/14, documented the resident had no shoes on when transferring to the toilet from her wheel chair. A nurse's note, dated 07/19/14, documented the resident fell while changing her clothes. The fall was documented on her care plan and the intervention was to encourage the resident to use her call light and to check her personal alarm frequently due to the resident removed it. No documentation was found to show the resident's personal alarm was checked more frequently. An incident report, dated 08/20/14, documented the resident was getting out of bed and missed her wheelchair, falling onto the floor and scraping her back. The care plan, updated on 08/20/14, documented the resident said she missed her wheelchair while getting out of bed. She was encouraged to leave the bathroom light on so she could see better. No nurse's note was found for this fall. A nurse's note dated, 08/28/14, documented the resident fell while getting out of bed to go to the bathroom. The fall was added to the care plan and the intervention was to assist the resident with transfers as needed. A nurse's note, dated 09/08/14, documented the resident fell while getting up to use the bathroom. The quarterly assessment, dated 10/06/14, documented the resident's cognition was now severely impaired and the resident was not on a toileting program. A nurse's note, dated 10/16/14, documented the resident was lying on the floor on her back. She complained of pain to her right shoulder and upper arm. A physician's orders [REDACTED]. The nurse from the emergency room reported a significant fracture to her right humerous. The fall was added to the care plan and the intervention was to ensure her call light was in reach and to encourage the resident to use it. A care plan, dated 10/16/14, documented the resident was to have an ice pack to her right shoulder, was to keep immobilizer on right arm, pain medications were to be given as ordered and as needed and staff was to assist her with activities of daily living. A State reportable incident form, dated 10/17/14, documented a pressure sensitive alarm had been placed on the resident's bed to remind her to allow staff to help her with transfers. On 10/20/14 at 10:32 a.m., the resident was observed in her room laying in her bed. She had no bed alarm on her bed, and no personal alarm on. On 10/21/14 at 3:45 p.m., the resident was observed in bed. She had no personal alarm on or bed alarm on her bed. 10/22/14 at 8:50 a.m., LPN (licensed practical nurse) #4 was asked if the resident had a bed alarm. She stated, "Her bed has no alarm on it." At 8:54 a.m., the resident was observed in the dining room and her right arm was not in an immobilizer. She had a personal alarm on and CNA (certified nurse aide) # 11 stated, "It was just put on her, (director of nurses) told me to put it on her this morning." On 10/22/14 at 9:24 a.m. the director of nurses (DON) stated the resident only had a personal alarm right now and a bed alarm had been ordered. At 9:28 a.m., the administrator stated, "She is supposed to have a bed alarm on her bed. I don't know why she doesn't have a bed alarm, let me ask the director of nurses." At 9:30 a.m., CNA #4 stated they had just started using the alarm that morning. At 3:21 p.m., the DON was asked what interventions had been put in place to help prevent the resident from falling. She stated, "We had a pressure relieving device on her bed, it played elevator music and it didn't get anyone's attention so we took it off. We also had another one on her bed that quit working." She went on to state, we moved her closer to the nurse's station so we can check on her more frequently. She was moved on 07/02/14. As far as the other alarms we usually only use one, there is no need for both. It's not on the treatment sheet but the nurses are supposed to check on her more often to make sure her alarm is on. The resident has not tried to get up since she broke her arm. We will get her started on a toileting program in the morning. We will also be going in every 2 hours and checking on her. The clinical record documented the resident only had one fall in January 2014 prior to being moved to a room closer to the nurse's station on 07/02/14. She had 6 falls since being moved to the current room. At 4:28 p.m., the administrator was asked what was the reason for moving the resident to her current room. She stated, "When the closer room became available I called her daughter and asked her if it was ok to move her closer. The daughter was all for it. It wasn't because of the falls, I just thought it would be better for her to be closer to the dining room so she wouldn't have so far to go." 2. Resident #51 had [DIAGNOSES REDACTED]. A care plan for the resident for falls was initiated on 07/03/14. An incident report, dated 07/24/14, documented the resident slid out of his recliner, landing on his bottom in the living area. No injuries were documented. The interventions were the staff was to check him frequently and reposition him as needed. The care plan was updated to include the fall and interventions. No documentation was found to show the staff was checking on the resident more frequently. An incident report, dated 09/02/14, documented the resident slipped out of his chair and landed on his buttocks. He had no injuries. No interventions were put in place to prevent reoccurrence. The fall was added to the care plan without interventions. The quarterly assessment, dated 09/25/14, documented his cognition was moderately impaired, transfers, dressing and hygiene were a one person physical assist, ambulation had not occurred, eating was a one person physical assist, and he was independent with range of motion. He was always incontinent of bowel and bladder. An incident report, dated 10/07/14, documented the resident slipped out of his wheelchair on to the floor. No injuries were documented. The staff was to assist him to his recliner to prevent falls. The fall was added to the care plan on 10/07/14, with the intervention for the staff to assist the resident to his recliner to prevent further falls. On 10/24/14 at 1:30 p.m., the DON was asked about the resident needing to be checked more frequently. She stated there was no documentation to prove he had been. 10/24/14 at 1:53 p.m., the administrator was in agreement that interventions should be put in place when the resident falls.

Based on observation, interview and record review, it was determined that the facility failed to provide appropriate restorative care and hand/wrist splints for limited range of motion for one (#51) of one resident reviewed for restorative services. This resulted in harm to the resident. The resident developed contractures to both his hands. This had the potential to affect 6 other residents identified as having developed contractures after admission to the facility as identified on the Resident Census and Conditions of Residents form. Findings: Resident #51 had [DIAGNOSES REDACTED]. The admission assessment, dated 06/27/14, documented his cognition was moderately impaired, all activities of daily living were a one person physical assist, he was completely dependent for eating and was not ambulatory. He was independent with his range of motion. The care plan for restorative care, dated 07/15/14, documented the resident would have no decline in his current function and mobility. The care plan was updated on 09/12/14 to provide splints for left and right wrists and hands. A nurse's note, dated 09/15/14, documented a new physician's order for the resident to receive physical therapy for both wrists and hands and splints for his wrists were to be worn by the resident. No splints could be found for the resident. A facility invoice, dated 09/17/14, documented the wrist splints had been ordered by the facility. The same invoice showed a ship date of 09/23/14, and that the splints had been shipped to a local pharmacy. A physician's order, dated 10/06/14, documented passive range of motion was to be performed on the resident to his bilateral upper extremities, 1 set of 10 repetitions to all planes 3 times a week. A significant change assessment, dated 10/08/14, documented the resident was now dependent with his range of motion. The care plan was updated on 10/13/14, that the resident was to continue restorative care as ordered daily and the wrist splints were placed on hold at that time. There was no physician's order found for the wrist splints to be on hold. No documentation was found in the nurses' notes from 09/15/14 through 10/23/14 that the splints had been used. On 10/23/14 at 8:49 a.m., the resident was observed in the north dining hall in a chair with no splints on his wrists or hands. Both hands were contractured. On 10/24/14 at 8:59 a.m., licensed practical nurse (LPN) #4 stated, "He developed his contractures since he has been here." On 10/24/14 at 9:18 a.m., the resident was observed in the south living area with no splints on his wrists or hands. On 10/24/14 at 10:10 a.m., the director of nurses was asked what they were doing for resident #51's contractures. She stated, "He is doing restorative therapy, and we have splints ordered." On 10/24/14 at 10:42:a.m., certified nurse aide #9, who was a restorative aide, stated she started restorative care with the resident on 10/06/14. She stated, "The resident has refused every day but one day. He says he refuses because of the pain, he refused on 10/6, 10/8,10/10, 10/13, 10/15, 10/17, 10/20, and the 22nd." At 10:53 a.m., certified nurse aide #9 was asked if she had ever reported the resident's complaints of pain to the nurse. She stated, "I've asked the nurse to give him pain pills." At 11:14 a.m., LPN #4 stated, "The restorative aide has never asked me to give him pain medication." The October 2014 Medication Administration Record [REDACTED]. On 10/24/14 at 11:40 a.m., the administrator called the pharmacy about the splints. She stated the pharmacy had stated one splint had been sent to the facility that day. "They had been back ordered." She agreed someone should have followed up on receiving the splints for the resident.

Based on record review, interviews and observation, it was determined the facility failed to recognize severe weight loss and intervene to prevent further weight loss. This affected 3 (#1, 11 and #16) of 6 sampled residents whose clinical records were reviewed for weight loss. Resident #1 had experienced severe weight loss of 10.97% in 180 days. Resident #11 had experienced severe weight loss of 8.6% in 30 days. Resident #16 had experienced severe weight loss of 10.95% in 180 days. For all 3 residents, the physician had not been notified of the severe weight loss and no interventions had been initiated to prevent further weight loss. For residents #11 and #16, the severe weight loss had not been care planned. The facility's Resident Census and Conditions of Residents documented 5 residents had experienced significant weight loss or gain. Findings: 1. Resident #16 had [DIAGNOSES REDACTED]. The care plan, dated 07/09/12, did not address the resident's severe weight loss. There was no documentation to indicate the care plan had not been reviewed/revised since it was developed on 07/09/12. The facility's weight change history documented the resident's weights were as follows: 05/11/12 - 210 pounds 06/15/12 - 209 pounds 07/18/12 - 204 pounds 08/15/12 - 201 pounds 09/17/12 - 198 pounds 10/17/12 - 192 pounds 11/13/12 - 187 pounds (A severe weight loss of 10.95% in 180 days.) The dietary progress note, dated 11/13/12, written by the certified dietary manager (CDM), documented the resident's weight was 187 pounds. It documented: "(Name deleted, resident #16) comes to the South dining room for most meals. Has a pretty good appetite On regular diet Will continue to monitor." The resident's severe weight loss had not been identified/addressed by the CDM. The quarterly assessment, dated 11/29/12, documented the resident had no cognitive impairment; was independent with eating; required limited assistance with transfers, dressing, personal hygiene and bathing. The assessment documented the resident had not experienced significant weight loss/gain during the 30 days and/or 180 days prior to the assessment. The consultant dietician's report, dated 11/29/12, was reviewed. The resident's severe weight loss had not been identified/addressed by the dietician. There was no documentation in the clinical record to indicate the physician had been notified at any time since 11/13/12, when the facility should have identified the resident's severe weight loss of 10.95% in 180 days. The physician's orders [REDACTED]. There were no orders written pertaining to the resident's weight loss status. On 12/12/12 at 4:38 p.m., the surveyor asked the director of nurses (DON) if the facility was aware the resident had experienced severe weight loss. She stated she was aware. She stated she had noticed the resident's weight of 187 pounds on the weight sheet and had directed her staff to re-weigh the resident. The surveyor asked the DON what the re-weight weight was. The DON stated the weight must have been the same as the initial weight since it was not otherwise documented. There was no documentation the DON had initiated interventions when the weight of 187 pounds was verified. The surveyor asked if the CDM had recognized the resident's severe weight loss as of her note, dated 11/23/12. The DON reviewed the CDM's dietary note and stated, "No." The surveyor asked if the consultant dietician had recognized the resident's severe weight loss as of her consultant visit on 11/29/12. The DON reviewed the consultant dietician's report, dated 11/29/12, and stated, "No." The surveyor asked if the physician had been notified about the resident's severe weight loss at any time since 11/13/12. The DON reviewed the clinical record and stated, "No." The surveyor asked if severe weight loss was a significant change for which the physician should have been notified. The DON stated, "Yes." The surveyor asked the DON if the resident's severe weight loss had been care planned. The DON reviewed the care plan and stated, "No." The surveyor asked if any interventions had been initiated to prevent further weight loss. The DON reviewed the clinical record and stated, "I don't see anything." On 12/12/12 at 4:50 p.m., the surveyor showed the resident's weight record and the quarterly assessment, dated 11/29/12, to the minimum data set (MDS)coordinator. The surveyor asked if the assessment was correct in regard to the documentation the resident had not experienced significant weight loss. She stated, "No, it's not." The surveyor asked if the care plan had been reviewed/revised to address the resident's severe weight loss. She reviewed the care plan and stated, "Not yet." On 12/12/12 at 5:25 p.m., the surveyor observed the resident eating her meal in her room. She was alert/oriented and able to feed herself without staff assistance. The surveyor asked the resident if the facility food tasted good to her. She stated the food was not always good. The surveyor asked if any facility staff had talked with her about her weight loss and/or about her food preferences. She stated, "No." 2. Resident #1 had [DIAGNOSES REDACTED]. The facility's weight change history documented the resident's weight as follows: 05/11/12 - 164 pounds 06/15/12 - 164 pounds 07/18/12 - 160 pounds 08/15/12 - 157 pounds 09/17/12 - 153 pounds 10/17/12 - 150 pounds 11/13/12 - 146 pounds (A severe weight loss of 10.97% in 180 days.) The care plan, dated 09/13/12, documented the resident had a problem with weight loss. The interventions included to notify the physician of any further weight loss for possible new orders. The care plan had not been updated when the resident continued to lose weight. No new interventions had been initiated to prevent further weight loss. The dietary progress note, dated 11/29/12, written by the consultant dietician, documented: "Weight 146 pounds down the past month (11% weight decrease in the past six months). 75% meal intake. Recommend to increase (Resource) 2.0 to 90 cubic centimeters (cc) four times a day with medication pass." The quarterly assessment, dated 09/12/12, documented the resident had mild cognitive loss; was independent with eating; required no assistance with transfers, dressing, personal hygiene and bathing. The assessment documented the resident had experienced significant weight loss during the 30 days and/or 180 days prior to the assessment. The dietary review recommendations, dated 11/29/12, to the physician, documented: "11% weight loss past 6 months. May we increase (Resource) 2.0 to 90 cc's four times a day with the medication pass?" The recommendation was signed by the dietician. There was no documentation in the clinical record to indicate the physician had been notified at any time since 11/13/12, when the facility should have identified the resident's severe weight loss of 10.97% in 180 days. The resident's Medication Administration Record, [REDACTED]. On 12/11/12 the surveyor asked for the resident's current weight. CNA #1 weighed the resident. She weighed 144 pounds, an additional loss of 2 pounds, which constituted a severe weight loss of 12.19% in 180 days from 6/15/12 to 12/11/12. On 12/11/12 at 2:10 p.m., the surveyor asked the DON about the facility's procedure for obtaining residents' weights. She stated weights were obtained beginning on the 10th of the month and were completed by the 15th. The surveyor asked who received the weights when they were completed. The DON stated she reviewed the weights and notified the family and physician if a resident had experienced significant weight loss. The surveyor showed the DON the resident's weights for the past 6 months and asked her if she agreed the resident had experienced severe weight loss. The DON stated "Yes." The surveyor asked if the resident's physician had been notified about the resident's severe weight loss. The DON stated the physician had been given the dietary review recommendation on 11/30/12. The surveyor asked for documentation to indicate the physician had been given the dietary recommendation. The DON found the original dietary review recommendation, dated 11/29/12, which was written to the physician, in a box under a bench in her office. The recommendation was to increase the resident's supplement to 90 cc's four times a day with the medication pass. The surveyor reviewed the DON's responses with her. The DON had stated the 11/2012 weights had been completed on 11/13/12 and the physician had been given the dietary recommendation on 11/30/12. The surveyor asked if 16 days was a reasonable amount of time to notify the physician about the severe weight loss. The DON stated "No, it's not." The surveyor asked the DON if the resident's care plan had been reviewed/revised to reflect the resident's severe weight loss. She stated, "No." The surveyor asked if the care plan had been followed to notify the physician of the severe weight loss. The DON stated, "No." The surveyor asked if any interventions had been put in place to prevent further weight loss. The DON responded "No." On 12/12/12 at 9:00 a.m., in a telephone interview with the resident's physician, the surveyor reviewed the above findings regarding the severe weight loss. The surveyor asked the physician if she had been notified about the severe weight loss and/or if she had received the dietary recommendation letter, dated 11/29/12. She stated she had not been notified about the severe weight loss and had not received the dietary recommendation letter. 3. Resident #11 had [DIAGNOSES REDACTED]. The facility's weight change history documented the resident's weights were as follows: 10/17/12 - 151 pounds 11/13/12 - 138 pounds (A severe weight loss of 8.6% in thirty days.) The care plan, dated 09/10/12, addressed the resident's risk for weight loss. An approach was to notify the physician of any significant weight loss for possible new orders. The care plan had not been revised to reflect the residents actual severe weight loss as of 11/13/12. No new interventions had been initiated to prevent further weight loss. The quarterly assessment, dated 10/31/12, documented the resident had no cognitive impairment and was independent with transfers, dressing and eating. The assessment documented the resident had not experienced significant weight loss/gain during the 30 days and/or 180 days prior to the assessment. The dietary progress note, dated 11/23/12, written by the CDM, documented, " weight 138, (name deleted, resident #11) eats in room with husband has a good appetite and eats snacks throughout the day. Will continue to monitor." The consultant dietician's report, dated 11/29/12, was reviewed. The resident's significant weight loss had not been identified/addressed by the dietician. The physician's telephone orders, dated 11/13/12 through 12/10/12, were reviewed. There were no orders written pertaining to the resident's weight loss. On 12/12/12 at 2:45 p.m., the surveyor asked the DON if the facility was aware of the resident's severe weight loss. She stated she was aware. The surveyor asked if she could show where the weight loss had been recognized in the resident's clinical record. The DON reviewed the clinical record and stated, "No." The surveyor asked if the physician had been notified of the severe weight loss at any time since 11/13/12. The DON stated, "No." The surveyor asked if the physician should have been notified of the severe weight loss. She responded, "Yes." The surveyor asked the DON if the resident's severe weight loss had been care planned. The DON reviewed the care plan and stated, "No." The surveyor asked if any interventions had been initiated to prevent further weight loss. The DON responded, "No."

Based on record review and interview, it was determined the facility failed to notify the physician of a change in condition. This affected 3 (#1, 11 and #16) of 14 sampled residents whose clinical records were reviewed. The 3 residents had experienced severe weight loss as of 11/13/12, and the physician had not been notified. Fifty-nine residents resided in the facility. Findings: 1. Resident #16 had [DIAGNOSES REDACTED]. The facility's weight change history documented the resident's weights were as follows: 05/11/12 - 210 pounds 06/15/12 - 209 pounds 07/18/12 - 204 pounds 08/15/12 - 201 pounds 09/17/12 - 198 pounds 10/17/12 - 192 pounds 11/13/12 - 187 pounds (A severe weight loss of 10.95% in 180 days.) There was no documentation in the clinical record to indicate the physician had been notified at any time since 11/13/12, when the facility should have identified the resident's severe weight loss of 10.95% in 180 days. The physician's orders [REDACTED]. There were no orders written pertaining to the resident's weight loss status. On 12/12/12 at 4:38 p.m., the surveyor reviewed the above findings with the director of nurses (DON) and asked if the physician had been notified about the resident's severe weight loss at any time since 11/13/12. The DON reviewed the clinical record and stated, "No." The surveyor asked if severe weight loss was a significant change for which the physician should have been notified. The DON stated, "Yes." 2. Resident #1 had [DIAGNOSES REDACTED]. The facility's weight change history documented the resident's weight as follows: 05/11/12 - 164 pounds 06/15/12 - 164 pounds 07/18/12 - 160 pounds 08/15/12 - 157 pounds 09/17/12 - 153 pounds 10/17/12 - 150 pounds 11/13/12 - 146 pounds (A severe weight loss of 10.97% in 180 days.) The care plan, dated 09/13/12, documented the resident had a problem with weight loss. The interventions included to notify the physician of any further weight loss for possible new orders. The care plan had not been updated when the resident continued to lose weight. No new interventions had been initiated to prevent further weight loss. The quarterly assessment, dated 09/12/12, documented the resident had mild cognitive loss; was independent with eating; required no assistance with transfers, dressing, personal hygiene and bathing. The assessment documented the resident had experienced significant weight loss during the 30 days and/or 180 days prior to the assessment. There was no documentation in the clinical record to indicate the physician had been notified at any time since 11/13/12, when the facility should have identified the resident's severe weight loss of 10.97% in 180 days. On 12/11/12 at 2:10 p.m., the surveyor asked the DON if the resident's physician had been notified about the resident's severe weight loss. The DON stated the physician had been given a dietary review recommendation by the consultant dietician on 11/30/12. The surveyor reviewed the DON's responses with her. The DON had stated the 11/2012 weights had been completed on 11/13/12 and the physician had been given the dietary recommendation on 11/30/12. The surveyor asked if 16 days was a reasonable amount of time to notify the physician about the severe weight loss. The DON stated "No, it's not." On 12/12/12 at 9:00 a.m., in a telephone interview with the resident's physician, the surveyor reviewed the above findings regarding the severe weight loss. The surveyor asked the physician if she had been notified about the severe weight loss and/or if she had received the dietary recommendation letter, dated 11/29/12. She stated she had not been notified about the severe weight loss and had not received the dietary recommendation letter. 3. Resident #11 had [DIAGNOSES REDACTED]. The facility's weight change history documented the resident's weights were as follows: 10/17/12 - 151 pounds 11/13/12 - 138 pounds (A severe weight loss of 8.6% in thirty days.) The care plan, dated 09/10/12, addressed the resident's risk for weight loss. An approach was to notify the physician of any significant weight loss for possible new orders. The care plan had not been revised to reflect the residents actual severe weight loss as of 11/13/12. No new interventions had been initiated to prevent further weight loss. The quarterly assessment, dated 10/31/12, documented the resident had no cognitive impairment and was independent with transfers, dressing and eating. The assessment documented the resident had not experienced significant weight loss/gain during the 30 days and/or 180 days prior to the assessment. On 12/12/12 at 2:45 p.m., the surveyor asked if the physician had been notified of the severe weight loss at any time since 11/13/12. The DON stated, "No." The surveyor asked if the physician should have been notified of the severe weight loss. She responded, "Yes."