Every finding on record at Willow Creek Health Care

Based on observation, interview, and facility policy review, the facility failed to ensure food was served at safe temperatures for 50 of 51 residents who received meals from the dietary department. Specifically, the facility did not maintain hot food holding temperatures at 135 degrees Fahrenheit ( F) or above during meal service.Findings included: A facility policy titled, Food Holding and Service, revised 06/01/2019, revealed Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US [United States] Food Codes and HACCP [Hazard Analysis and Critical Control Points] guidelines. Procedure: 1. Serve all hot foods at a temperature of 135 F or greater and all cold food at 41 F or less. Adjust the temperature to account for the time the food will be held prior to service on the steam table and on the tray carts. During a kitchen observation on 07/13/2026 at 11:23 AM, two plates of cheeseburgers and a plate of corndogs were observed sitting out next to the steam table in the kitchen. Using a facility issued digital food thermometer, [NAME] #14 took the temperatures of the food items. The temperature of the cheeseburger was 120 F, and the temperature of the corndogs was 121 F. A bowl of chicken noodle soup was observed to be poured from the can into a bowl to be served. The soup was microwaved to 129 F. During an observation on 07/13/2026 at 12:59 PM, Resident #49 received a cheeseburger at a temperature of 91 F. During a meal observation on 07/15/2026 at 11:23 AM, a hamburger plate and a plate of chicken tenders were observed sitting out next to the steam table in the kitchen. The temperature of the hamburger was 104.5 F, and the temperature of the chicken tenders was 126.3 F. During an interview on 07/15/2026 at 11:43 AM, [NAME] #14 stated they did not reheat the food. When asked why they did not reheat the food, [NAME] #14 stated, residents do not like their food steaming hot. During a meal observation on 07/15/2026 at 11:53 AM, tilapia (fish) was observed on the steam table in the upstairs dining area. The temperature of the tilapia was 109.7 F. Further observation of the meal service revealed Resident #18 was served the tilapia at 12:22 PM. The temperature of the tilapia was 103 F at the time it was served. During an interview on 07/15/2026 at 1:15 PM, the Certified Dietary Manager (CDM) stated the expectation was for the staff to take the temperature of the food once it was finished cooking. The CDM stated that the food temperature was to be taken when the food item finished cooking and before it went up to the unit. The CDM stated the food temperature was to be higher than the holding temperatures, so when it went upstairs, it was held at a higher temperature than the holding temperature of 135 F. The CDM stated the food temperature was to be taken once the meal was set up on the steam table in the upstairs dining area. The CDM stated if the food was not at or above the hot holding temperature of 135 F, the staff were expected to heat the meal to 165 F. During an interview on 07/17/2026 at 1:53 PM, the Administrator stated her expectation was for staff to hold meals above 135 F. The Administrator stated if the temperature of the food was not at the hot holding temperature, she expected staff to reheat the meal or make the meal again. During an interview on 07/17/2026 at 2:23 PM, the Quality Assurance (QA) Corporate Nurse stated that if the meal was not held at the proper hot holding temperature, the food should be reheated to the proper temperatures or remade, especially fish. She stated the staff should know what temperatures the food should be held at and to cook the food accordingly. She stated that not serving the food at the proper temperature had the potential to cause food borne illness. During an interview on 07/17/2026 at 2:26 PM, the Director of Nursing (DON) stated the expectation was for the staff to know the food holding temperatures and maintain food at the appropriate temperatures.

Based on observation, interview, and facility policy review, the facility failed to develop, implement, and maintain a process for monitoring the facility's water system for potential waterborne pathogens. Additionally, nursing assistant students (Students) and dietary staff failed to implement hand hygiene when plating food, serving plates, and assisting residents with meals for 3 of 3 meal service observations.Findings included: 1. A facility policy titled, Infection Prevention and Control Program, revised 07/2024, specified, Water Management: Control measures and testing protocols are in place to address potential hazards associated with the facility's water system. The Maintenance Director oversees the facility's water system. An undated facility policy titled, Legionella Surveillance and Detection, specified, Our facility is committed to the prevention, detection and control of water-borne contaminants. On 07/14/2026 at 11:00 AM, the Maintenance Director stated the facility had last performed annual testing of the facility's water for Legionella on 11/05/2025. The Maintenance Director stated the facility did not have a flow diagram of the facility's water system, had not assessed potential locations in the facility's two-story building water system where water may be held or accumulated, and had not implemented control measures to mitigate any potential waterborne pathogens. On 07/16/2026 at 11:00 AM, the Quality Assurance Corporate Nurse (QACN), who was the Infection Preventionist (IP), stated she was unaware of any control measures to mitigate any potential waterborne pathogens as part of the facility's Infection Control and Prevention Program (ICPP). The QACN stated the ICPP had been last reviewed on 01/13/2026. On 07/17/2026 at 11:25 AM, the Administrator stated the Maintenance Director was hired in April 2026 and did not have any prior long-term care facility experience. The Administrator confirmed the facility did not have a flow diagram or control measures in place to mitigate potential waterborne illnesses. The Administrator stated her expectation would be to develop and institute a monitoring program to meet the regulation. 2. A facility policy titled, Infection Prevention and Control Program, revised 07/2024, specified, Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. An undated facility policy titled, Alcohol-Based Hand Rubs, specified, All personnel are provided with hand hygiene training upon hire and annually thereafter. Hand hygiene competency of staff is measured, including thorough return demonstration to verify technique. All personnel are required to adhere to hand hygiene policies and practices. Staff adherence to hand hygiene is incorporated into infection prevention and control process surveillance and monitored by Infection Preventionist. Alcohol based hand rubs are the preferred method of performing hand hygiene in most situations. Hand hygiene is indicated:- before touching a resident- before preparing or handling food, medications, or parenteral situations- before clean or aseptic procedures- before moving from work on a soiled body site to a clean body site on the same resident- after exposure to blood, body fluids, excretions or contaminated surfaces- after touching a resident- after touching resident's environment or belongings- after glove removal- whenever hands are visibly soiled. Observations on 07/13/2026 at 12:10 PM during lunch service revealed Student #1 and Student #2 were sitting at a table in the dining room with Resident #35 while waiting for the table to be served from the kitchenette adjacent to the dining room. Student #1 was observed touching the Resident #35's bib cover and clothing, and Student #1 was observed touching their scrub clothing prior to service, placing their hands in their lap, and touching their hair. Student #2 was observed touching their scrub clothing prior to service and placing their hands in their lap. Both Students then assisted the resident with a beverage by lifting the cup with the beverage from the table to the resident's mouth so the resident could drink out of the straw. The observation revealed the Student Preceptor intervened and gave the students alcohol-based hand sanitizer (ABHS) to use prior to continuing to assist Resident #35. On 07/13/2026 at 12:12 PM, Dining Aide (DA) #3 was observed serving plates of food from the kitchenette without using repeat hand hygiene between residents. DA #3's hands were touching the edges of the plate including the food area of the plate with her ungloved hand when receiving the plates from the steam table service area then taking them to the resident. The observation revealed DA #3 was wearing a surgical mask during dining service, touched her mask with her hand, and did not repeat hand hygiene prior to receiving another plate of food from the steam table area and delivering the plate to a resident. The observation revealed DA #3 went into the kitchenette office area, touched the doorknob and items inside the office area, and returned to serving residents without repeating hand hygiene prior to taking plated food from the steam table area and delivering the food to the residents at their tables in the dining room. On 07/13/2026 at 12:15 PM, the Student Preceptor stated it was the students' first day in the facility, and the Student Preceptor expected the students to use proper hand hygiene. The Student Preceptor confirmed the students had potentially contaminated their hands by touching the resident, their clothing, and their hair prior to assisting the resident with a beverage. The Student Preceptor stated if students touched anything they should repeat hand hygiene prior to assisting residents with dining. On 07/15/2026 at 12:48 PM, the Certified Dietary Manager (CDM) stated dietary staff normally served the residents in the dining room from the kitchenette. The CDM stated staff did not normally do hand hygiene if holding the plate from the bottom only between serving plates of food to residents. The CDM stated staff were not supposed to touch the plate area where food or eating might occur, and if they did they should perform repeat hand hygiene between residents being served food. The CDM agreed DA #3 had her hands on the side of the plate where food or eating might occur and should have used repeat hand hygiene between residents. On 07/17/2026 at 9:17 AM, the Director of Nursing (DON) stated she expected the nursing assistant students to follow the facility's policy for hand hygiene. On 07/17/2026 at 9:20 AM, the Administrator stated her expectation for staff and students would be to perform hand hygiene before and after interactions with residents, before and after each job function with residents, and before and after each glove use. On 07/17/2026 at 1:20 PM, DA #3 stated hand hygiene should be done during dining service between resident plates since they were touching plates and if they left the area and returned. DA #3 confirmed she did not repeat hand hygiene after she left the area and returned, after she touched her face mask, and after she touched the edges of plates during dining service to residents. 3. A facility policy titled, Infection Prevention and Control Program, revised 07/2024, specified, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. An undated facility policy titled Alcohol-Based Hand Rubs specified, Hand hygiene is indicated:- before touching a resident- before preparing or handling food, medications, or parenteral situations. During an observation of meal service on 07/13/2026 at 12:23 PM, [NAME] #14 repeatedly touched residents' diet roster papers and repeatedly touched and adjusted their mask while preparing the lunch plates for residents. [NAME] #14 was not observed to wash their hands or perform hand hygiene after touching their mask or the papers. During an observation of meal service on 07/13/2026 at 12:46 PM, [NAME] #14 touched the face of a resident's plate, the area of the plate the residents ate from, and then gave the plate of food to the certified nursing assistant (CNA) to give to a resident. The observation revealed [NAME] #14 continued to touch the face of the plates while serving. The observation revealed no hand hygiene was performed by [NAME] #14 between repeatedly touching the diet roster papers, repeatedly adjusting their face mask, and touching the faces of the resident's plates prior to plating the residents' meals. During an interview on 07/17/2026 at 1:24 PM, the Certified Dietary Manager (CDM) stated the staff were supposed to use proper hand washing and sanitizer when touching different surfaces and serving the resident's meals. The CDM stated staff were not supposed to touch the face of the resident's plate. The CDM stated if the staff did touch the face of the plate, they were expected to change the plate. During an interview on 07/17/2026 at 1:53 PM, the Administrator stated the expectation was for staff to practice proper hand hygiene at all times, especially when touching different surfaces. During an interview on 07/17/2026 at 2:23 PM, the Quality Assurance Corporate Nurse (QACN), who was the Infection Preventionist (IP), stated the expectation of the dietary staff was to use hand hygiene just as all staff were required to do. During an interview on 07/17/2026 at 2:26 PM, the Director of Nursing (DON) stated the staff were expected to maintain hand hygiene at all times in the kitchen and while serving food on the unit. The DON stated the dietary staff had access to hand washing and sanitizing resources.

Based on interview, record review, and facility policy review, the facility failed to ensure preadmission screening and resident reviews (PASARRs) were accurate for 2 (Resident #42 and Resident #48) of 3 sampled residents reviewed for PASARR. Findings included: A facility policy titled, Resident Assessment - Coordination with PASARR Program, dated 10/2025, indicated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. A Resident Face Sheet indicated the facility admitted Resident #42 on 10/13/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of anxiety disorder and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/26/2025, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received antianxiety and antidepressant medications during the assessment's seven-day look-back period. Resident #42's diagnoses list revealed that the list included anxiety disorder and depression disorder with an effective date of 10/13/2025. Resident #42's Nursing Facility Level of Care Assessment, dated 10/16/2025, revealed that staff marked No on the resident's Level I PASRR [PASARR] Screen for evidence of serious mental illness, a diagnosis of serious mental illness, and a recent history of mental illness. During an interview on 07/15/2026 at 3:11 PM, the Director of Nursing (DON) stated that the admitting diagnoses of anxiety and depression should have been on Resident #42's PASARR. During an interview on 07/17/2026 at 1:19 PM, the Administrator stated she expected the staff to make sure the PASARRs on admission were correct. 2. A Resident Face Sheet indicated the facility admitted Resident #48 on 09/19/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of anxiety disorder and depression disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2025, revealed Resident #48 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident received antianxiety and antidepressant medications during the assessment's seven-day look-back period. Resident #48's diagnoses list revealed that the list included anxiety disorder and depression disorder effective on 09/19/2025. Resident #48's Nursing Facility Level of Care Assessment, dated 09/29/2025, revealed that staff marked No on the resident's Level I PASRR [PASARR] Screen for evidence of serious mental illness, a diagnosis of serious mental illness, and a recent history of mental illness. During an interview on 07/15/2026 at 3:20 PM, the Director of Nursing (DON) stated that Resident #48's PASARR should have reflected the resident's mental health diagnoses. During an interview on 07/17/2026 at 1:19 PM, the Administrator stated she expected the staff to make sure the PASARRs on admission were correct.

Based on observation, interview, record review, and facility policy review, the facility failed to treat residents with dignity and respect for 2 (Resident #15 and Resident #26) of 2 sampled residents reviewed for dignity. Specifically, Certified Nursing Assistant (CNA) #4 asked Resident #15 if the resident was a gang member, and, while the resident tried to explain, the staff member was not responsive. Additionally, Resident #26 did not receive attentive feeding assistance from CNA #4.Findings included: The facility's undated policy titled, Resident's Rights and Responsibilities, indicated, Every resident shall have the right to receive courteous and respectful care and treatment. 1. A Resident Face Sheet revealed the facility admitted Resident #15 on 04/03/2026. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of generalized anxiety disorder and other recurrent depressive disorders. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/26/2026, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received medication for anxiety disorder and depression. Resident #15's Care Plan included a problem statement, edited 04/22/2026, that indicated the resident had shortness of breath at times. Interventions directed staff to provide a calm environment free of stimuli to reduce/prevent anxiety. Resident #15's Care Plan included a problem statement, created 04/22/2026, that indicated the resident had a hearing loss. Interventions directed staff to face the resident when speaking. During an observation on 07/16/2026 at 11:56 AM, Certified Nursing Assistant (CNA) #4 and Resident #15 were observed sitting at a table in the dining room. The observation revealed CNA #4 asked Resident #15 if they were a gang banger (member of a gang). The observation revealed Resident #15 attempted to answer CNA #4 and explain the history of their tattoos when CNA #4 crossed her arms, appeared to be frustrated, and said she needed a break from the resident. The observation revealed a few minutes later CNA #4 left the table. During an interview on 07/16/2026 at 1:45 PM, CNA #4 stated she did ask Resident #15 if they were a gang banger. CNA #4 stated it was just a conversation. During an interview on 07/16/2026 at 3:58 PM, Resident #15 stated that CNA #4 had asked them if they were part of a gang. Resident #15 stated it was not a nice thing to say to them, but they had been asked that all of their life because of their tattoos. Resident #15 stated they tried to answer and explain to CNA #4, but she would not answer them back, even though she was sitting at the same table. During an interview on 07/17/2026 at 11:32 AM, Licensed Practical Nurse (LPN) #5 stated he was not paying attention to CNA #4 and Resident #15's conversation but did notice Resident #15 try to talk to CNA #4 about the tattoos and CNA #4 did not respond to the resident and later got up and left the table. LPN #5 stated he did not hear what CNA #4 said to Resident #15, but if she had asked Resident #15 if they were part of a gang or gang banger that would not be appropriate. During an interview on 07/17/2026 at 12:54 PM, the Director of Nursing (DON) stated she expected the staff to have appropriate conversations with the residents. The DON stated the conversation that CNA #4 had with Resident #15 was inappropriate. The DON stated she expected the staff to interact with the residents but not to have a conversation that may embarrass a resident. The DON stated she expected staff to treat residents with respect and dignity. During an interview on 07/17/2026 at 1:21 PM, The Administrator stated she expected the staff to have appropriate conversation with the residents, and the dialogue should always be appropriate. The Administrator stated she had reviewed the camera, and, although there was no sound on the video, CNA #4's body language did not appear inviting. The Administrator stated she could see Resident #15's attempt to interact with CNA #4. 2. A Resident Face Sheet indicated the facility admitted Resident #26 on 04/05/2024. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of dementia. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2026, revealed Resident #26 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated the resident was dependent on staff for eating. Resident #26's Care Plan included a problem statement, edited 03/27/2026, that indicated the resident needed assistance with Activities of Daily Living (ADL). Interventions directed staff to provide setup assistance for eating (05/17/2024). Resident #26's Care Plan included a problem statement, edited 04/05/2024, that indicated the resident received a regular diet. Interventions directed staff to encourage the resident during meals as needed (04/05/2024). An observation on 07/13/2026 at 12:15 PM revealed Resident #26 was in the dining room, when CNA #4 sat down beside the resident and assisted the resident with their meal. The observation revealed within a few minutes CNA #4 started a conversation with a visitor and stopped assisting Resident #26 with their meal. The observation revealed Resident #26 began to feel for their plate and use their fingers to eat their food. The observation revealed CNA #4 did not interact with the resident or ask the resident if they needed or wanted assistance with their meal. The observation revealed CNA #4 picked up Resident #26's spoon, and, without speaking to the resident, put the spoon to the resident's mouth, and the resident appeared to be startled when the spoon touched their mouth. An observation on 07/13/2026 at 12:48 PM revealed CNA #4 left Resident #26's table and got herself a plate from the dietary staff. The observation revealed CNA #4 took her plate and sat back down beside Resident #26 and ate her food. The observation revealed CNA #4 did not offer to assist Resident #26 with their meal, but CNA #4 continued to eat her food and talk to the visitor until she finished her food, and then she left the table. A dining observation on 07/16/2026 at 12:38 AM revealed CNA #4 sat down beside Resident #26. The observation revealed Dietary Aide (DA) #3 gave Resident #26 their plate, the resident began to feel for their plate and drinks, and the resident started to eat their food. The observation revealed CNA #4 had conversation with other staff members but no conversation with Resident #26. The observation revealed CNA #4 picked up Resident #26's spoon, put food on the spoon, and attempted to put the spoon in the resident's mouth while the resident was still chewing food. The observation revealed CNA #4 poured sweet and sour sauce on the Resident #26's rice without asking the resident. The observation revealed on multiple occasions CNA #4 put the spoon up to Resident #26's mouth while the resident was still chewing food. CNA #4 was not observed to have any interactions with Resident #26 or to let the resident know she had another bite of food for the resident. CNA #4 was observed to cross her arms in frustration when Resident #26 was still chewing their food. CNA #4 was observed to put the cup up to Resident #26's mouth without notifying the resident of the drink, and the resident was startled when the cup touched their lips. The observation revealed on 07/16/2026 at 12:47 PM CNA #4 got up from the table and left the dining room, and Resident #26 was then observed to feel for their plate and finished their meal. During an interview on 07/16/2026 at 1:06 PM, CNA #10 stated that when they assisted the residents with their meals they were supposed to interact with the residents. CNA #10 stated if they did not communicate with Resident #26 the resident would be startled because the resident could not see the spoon coming towards their mouth until it touched their mouth. CNA #10 stated she should always allow the resident to chew and swallow their food and then offer the resident a drink before trying to give the resident more food. CNA #10 stated it was not okay to eat with a resident if the residents were still eating or needed assistance. CNA #10 stated staff should interact with the residents, and staff should ask the resident if they wanted seasonings, including sweet and sour sauce, before seasoning a resident's food. During an interview on 07/16/2026 at 1:19 PM, CNA #11 stated staff should interact with the residents during meals and should not put any seasoning on the resident's food without asking the resident first. CNA #11 stated it was not appropriate to eat with the residents if the residents were still eating their meal. CNA #11 stated that at no time should staff put more food in a resident's mouth until the resident chewed and swallowed their food. During an interview on 07/16/2026 at 1:36 PM, CNA #12 stated staff should be interacting with residents and should allow the resident to swallow their food before trying to put more food into their mouth. CNA #12 stated the staff should have conversation with the residents who they are assisting and should never season a resident's food without first asking the resident. During an interview on 07/16/2026 at 1:45 PM, CNA #4 stated staff should interact with the resident during meals. CNA #4 stated staff should allow the residents to chew and swallow their food before putting more food in their mouth. CNA #4 stated they thought it was okay to eat with the resident, even while the resident was still eating. CNA #4 stated she should have been more patient and allowed Resident #26 to swallow their food instead of trying to put more food into their mouth. CNA #4 stated she did not ask Resident #26 if they wanted the sweet and sour sauce on their food. During an interview on 07/16/2026 at 1:56 PM, CNA #9 stated staff should allow the resident to chew and swallow their food before offering more food or drinks. CNA #9 stated staff should explain to the residents what the staff member was doing, and staff should ask the resident before seasoning the resident's food. During an interview on 07/17/2026 at 12:54 PM, the Director of Nursing (DON) stated she expected the staff to interact with the residents, ask residents if they needed assistance, and ask the resident if they wanted seasoning on their food prior to seasoning the resident's food. The DON stated she expected the staff to wait until the residents had swallowed their food and then offer the resident more food or a drink. The DON stated she expected the staff to treat the residents with respect and dignity. During an interview on 07/17/2026 1:21 PM, the Administrator stated she expected the staff to interact with the residents during meals and ask the residents if they wanted seasoning on their food before putting seasoning on the residents' food. The Administrator stated she expected the residents to be served their food, and, when all the residents were taken care of, then the staff could get a plate of food. The Administrator stated she expected the staff to wait until the resident had swallowed their food before putting more food into a resident's mouth.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the call light was maintained within reach for 1 (Resident #1) of 1 resident reviewed for tube feeding. Findings included: A facility policy titled, Answering the Call Light, revealed, The purpose of this procedure is to respond to the resident's requests and needs. The policy also indicated, General Guidelines 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. A Resident Face Sheet revealed the facility readmitted Resident #1 on 03/17/2026. The Resident Face Sheet indicated the resident had a medical history that included diagnoses ofcerebral infarction, unspecified dementia, [NAME]-[NAME] gastro-esophageal laceration-hemorrhage syndrome (a condition involving mucosal tears at the gastroesophageal junction), and gastrostomy status. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2026, indicated Resident #1 had severe impairment in cognitive skills for daily decision making and had a short-term and a long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated Resident #1 was dependent on staff for all activities of daily living (ADLs). Resident #1's Care Plan revealed a problem area, edited 03/11/2025, that indicated the resident was at risk for serious injury related to falls due to impaired balance, urinary incontinence, and degeneration of the brain. Interventions directed staff to keep the call light, personal items, and frequently used items within easy reach (08/22/2017). An observation on 07/13/2026 at 11:33 AM revealed Resident #1 lying on their back in bed with a wedge pillow under their right arm. The observation revealed Resident #1's pressure pad call light device was clipped at the top, left side of the bed, out of reach of the resident. An observation on 07/14/2026 at 10:22 AM revealed Resident #1 lying on their back in bed. The observation revealed a pressure pad call light device clipped to the privacy curtain, approximately three feet from the bed, and out of reach of the resident. An observation on 07/15/2026 at 5:57 AM revealed Resident #1 lying on their back in bed with the pressure pad call light device attached to the right top corner of the sheet, hanging over the right top corner of the bed out of reach of the resident. An observation and concurrent interview on 07/15/2026 at 1:09 PM revealed Resident #1 lying on their back in bed with the call light pad placed at the right top of the bed beside the resident's head. Licensed Practical Nurse (LPN) #8 stated the call light pad was at the top of the bed beside Resident #1's head, and the resident could not reach it. LPN #8 stated Resident #1 could have wiggled themself down in bed and out of reach of the call light. LPN #8 stated she expected staff to keep call lights in reach of all residents. An observation on 07/16/2026 at 3:42 PM revealed Resident #1 lying on their back in bed with their eyes open. The observation revealed the pressure pad call light was sitting on the bed beside the resident's head on the left side of the mattress out of reach of the resident. During an interview on 07/17/2026 at 12:46 PM, LPN #6 stated she expected call lights to be kept in reach of all residents. LPN #6 stated it was not appropriate to have the pressure pad call light attached to the privacy curtain because Resident #1 would not be able to reach it. During an interview on 07/17/2026 at 1:21 PM, Certified Nursing Assistant (CNA) #7 stated that call lights should be in residents' reach at all times. CNA #7 stated the call light touch pads should have been placed by Resident #1's arm so the resident could reach it. CNA #7 stated Resident #1 could not reach a call light touch pad placed at the top of the bed beside their head, and the resident could not reach a call light touch pad that was attached to the privacy curtain. The CNA stated that neither placement was appropriate for Resident #1. During an interview on 07/17/2026 at 1:32 PM, the Director of Nursing (DON) stated that she expected call lights to be kept in reach of the resident at all times. The DON stated Resident #1 could use a touch pad call light, but the resident could not reach a call light touch pad positioned beside their head. The DON stated that Resident #1 could not reach a call light touch pad hanging off the top or side of the bed or attached to the privacy curtain. The DON stated none of those were acceptable places to place a call light. During an interview on 07/17/2026 at 2:09 PM, the Administrator stated that she expected call lights to be within residents' reach at all times. The Administrator stated Resident #1 could not reach a call light at the top of the bed, hanging over the top or side of the bed, or attached to the privacy curtain, and those were not appropriate places for a call light.

Based on interview, record review, and facility policy review, the facility failed to complete preadmission screening and resident reviews (PASARRs) for residents with a newly diagnosed mental illness for 3 (Residents #7, #42, and #48) of 3 sampled residents reviewed for PASARR. Findings included: A facility policy titled, Resident Assessment - Coordination with PASARR Program, dated 10/2025, indicated, 7. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 1. A Resident Face Sheet indicated the facility admitted Resident #7 on 10/02/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of delusional disorders, anxiety disorders due to known physiological condition, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident received antipsychotic and antidepressant medications during the assessment's even-day look-back period. A significant change MDS, with an ARD of 10/27/2025, revealed Resident #7 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Menal Status (SAMS). The MDS indicated that the resident received antipsychotic, antianxiety, and antidepressant medications during the assessment's seven-day look-back period. Resident #7's diagnosis list revealed that the list included anxiety disorders due to known physiological condition with an effective date of 06/04/2025, and depression with an effective date of 12/24/2025. Resident #7's record revealed no new PASARR was completed for the newly identified mental health diagnoses on 06/04/2025 or 12/24/2025. During an interview on 07/15/2026 at 2:59 PM, the Director of Nursing (DON) stated she was the one that completed the PASSARs, and she should have completed a new PASSAR for Resident #7 when they had a new mental health diagnosis of anxiety and depression. During an interview on 07/17/2026 at 1:19 PM, the Administrator stated she expected the staff to complete the PASSARs for a new mental health diagnosis. 2. A Resident Face Sheet indicated the facility admitted Resident #42 on 10/13/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of dysthymic disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2026, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received antianxiety and antidepressant medications during the assessment's seven-day look-back period. Resident #42's diagnosis list revealed that the list included dysthymic disorder with an effective date of 02/14/2026. Resident #42's record revealed no new PASRR was completed for the newly identified mental health diagnosis on 02/14/2026. During an interview on 07/15/2026 at 3:11 PM, the Director of Nursing (DON) stated that she should have completed a new PASSAR for Resident #42 when they had a new mental health diagnosis. During an interview on 07/17/2026 at 1:19 PM, the Administrator stated she expected the staff to complete the PASSARs for a new mental health diagnosis. 3. A Resident Face Sheet indicated the facility admitted Resident #48 on 09/19/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2025, revealed Resident #48 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident received antianxiety and antidepressant medications during the assessment's seven-day look-back period. Resident #48's diagnosis list revealed that the list included major depressive disorder with an effective date of 09/25/2025. Resident #48's record revealed no new PASARR was completed for the newly identified mental health diagnosis on 09/25/2025. During an interview on 07/15/2026 at 3:20 PM, the Director of Nursing (DON) stated she should have completed a new PASSAR for Resident #48 when they had a new mental health diagnosis. During an interview on 07/17/2026 at 1:19 PM, the Administrator stated she expected the staff to complete the PASSARs for a new mental health diagnosis.

Based on interview, and facility document review, the facility failed to complete daily nurse staffing data for each shift to include the facility census, total number of licensed and unlicensed staff, and the actual hours worked by licensed and unlicensed staff who were directly responsible for residents' care for 30 (06/14/2026 through 07/13/2026) of 30 days reviewed for staffing.Findings included: The facility's posted daily nurse staffing data for 06/14/2026 through 07/13/2026 revealed the postings did not include the facility census, total number of licensed and unlicensed staff, and the actual hours worked by licensed and unlicensed staff. During an interview on 07/13/2026 at 10:15 AM, the Assistant Director of Nursing (ADON) stated she had prepared the nurse staffing information and was responsible for the posting.

Based on observation, record review, and interview, the facility failed to ensure staff wore gloves and cleaned the resident's skin prior to injection for one (#28) of one sample resident observed for insulin injection. The administrator identified 51 residents resided in the facility. An undated facility matrix documented eight residents received insulin. Findings: A Subcutaneous Injections policy, dated March 2011, documented to put on gloves and clean the site with alcohol prior to injection. On 12/10/24 at 11:10 a.m., LPN #1 was observed to inject Resident #28 with insulin. LPN #1 was observed not wearing gloves or cleaning the site prior to injection. On 12/10/24 at 11:11 a.m., LPN #1 stated they should have worn gloves and clean the site prior to injection. They confirmed they did not wear gloves or clean the site prior to injection. On 12/10/24 at 11:33 a.m., RN #2 stated staff should wear gloves and use alcohol on the site prior to injection.

Based on record review and interview, the facility failed to ensure pain management was provided for one (#50) of one sampled resident reviewed for pain management. A Resident Census and Conditions of Residents report, dated 09/25/23, identified 54 residents resided in the facility and 35 residents on a pain management program. Findings: A Pain-Clinical Protocol policy, revised March 2018, read in part .the physician and staff will identify individuals who have pain or who are at risk for having pain .the staff will reassess the individual's pain at least each shift for acute pain or significant changes in levels of chronic pain .review should review frequency, duration, mood behavior, sleep pattern . Resident #50 had diagnoses which included dementia, depression, down syndrome, and stage three pressure ulcer. An Admission Assessment, dated 07/17/23, documented the resident's cognition was moderately impaired with daily decision making. A Physician's Order, dated 08/18/23, documented to administer Tylenol 325mg every six hours as needed for pain. A Progress Note, dated 09/01/23 at 6:00 p.m., read in part .resident screams loudly and persistently due to pain of [the resident] peri-anal bed sores. [The resident] writhes and squirms while loudly screaming continuously. [The resident] is miserable . A Progress Note, dated 09/03/23 at 3:19 p.m., read in part .[the resident] screams with pain with every BM or urination . A Progress Note, dated 09/03/23 at 7:31 p.m., read in part .resident has been howling and screaming very loudly for more than an hour due to pain of [their] perineal and sacral area . A Progress Note, dated 09/03/23 at 9:40 p.m., read in part .resident continuing to holler, moaning, and screaming very loudly due to pain. Doctor called and ordered Tylenol 500mg one now for pain .[the resident] was given the Tylenol .[the resident] is still loudly moaning and crying . A Progress Note, dated 09/04/23 at 9:55 p.m., read in part .resident cried, yelled, and hollered out all shift . A Medication Administration History report dated September 2023, did not document any pain medication had been administered for the complaints of pain in the progress notes. On 09/27/23 at 9:09 a.m., the DON was asked what was the policy for pain management. She stated pain was managed every shift by nurses and CMAs. She stated if a PRN pain medication was needed, it was given. She stated the nurses also observed for non-verbal and verbal indications for pain. On 09/27/23 at 9:55 a.m., the DON was asked to review Resident #50's progress notes from 09/01/23 to 09/05/23. The DON was asked what interventions where in place to manage Resident #50's pain. She stated no interventions were put into place, and they should have been.

Based on record review, observations and interviews, the facility failed to review/revise/implement the care plans for three (#15, 30 and #45) of eight sampled residents reviewed for care plans. This affected: The Resident Census and Condition of Residents, dated 11/03/22, documented the facility census was 49. Findings: 1. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APsychological Services Progress Note[s], dated 08/11/22, 08/18/22, 09/01/22, 09/08/22, and 09/29/22, read in parts, .Current Risk Factors .Suicidal/Self Injury: Ideation . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Assessment, dated 10/18/22, documented Resident #15 had clear speech, short/long term memory deficits, and was moderately impaired, made poor decision, and required cues/supervision. A Behavioral Symptom Care Plan, dated 11/01/22, documented to maintained goals for resident to accept assistance for ADL care and state feeling rested. The care plan did not address suicidal ideations/prevention. On 11/03/22 at 9:08 a.m., during medication administration, Resident #15 stated to CMA #1, I had thoughts of suicide last night and had it all planned out. CMA #1 responded to the resident, No you're not. CMA #1 continued to other resident rooms to administer medications and did not report to the charge nurse or supervisor. On 11/04/22 at 10:20 a.m., the DON was asked if Resident #15 had a care plan that included suicidal ideations/plans. After review of the mental health notes and care plan, the DON stated the care plan should have been updated if the resident did have ideations. 2. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Accident/Incident Report, dated 05/22/22, read in parts, .sitting on bed room floor .Recommended steps to prevent recurrence .call light for staff to assist to toilet while diarrhea persists . A Fall Care Plan, dated 5/22/22, read in parts, .Failed attempt at self-transfer .Reminded to use call light for assist . A Quarterly Assessment, dated 07/26/22, documented Resident #30 had severe cognitive impairment, required extensive assistance of staff for transfer, dressing and toileting, and had experienced one fall with no injury, and two or more falls with skin tears, abrasions, lacerations, superficial bruising, hematoma, and sprains: or any fall-related injury that causes the resident to complain of pain. An Accident/Incident Report, dated 08/25/22, read in parts, .no impairments .called for assistance to transfer from bed to wheelchair .said .fell for 4 times already trying to transfer from bed to wheelchair .Recommended steps to prevent recurrence: Reinforced .use call light when transferring from bed to wheelchair . A Fall Care Plan, dated 08/25/22, read in parts, .Self-reported failed attempt to transfer from bed to WC .Reminded resident to use call light when transferring . A Quarterly Assessment, dated 10/18/22, documented Resident #30 had severe cognitive impairment for daily decision making, required extensive assistance for transfers, dressing and toileting, and had one fall since the prior assessment. An Accident/Incident Report, dated 10/27/22, read in parts, .was lying on the floor between her bed and bedside table .abrasion to left outer forearm .Recommended steps to prevent recurrence: check on resident frequent. Take [Resident #30] to the bathroom, set meals up .check q hr . The fall care plan did not include an entry regarding the Accident/Incident Report, dated 10/27/22. It did not include interventions to prevent falls for a resident with severe cognitive impairment regarding the above falls. Resident #30 was observed throughout the survey to self transfer from the bed to wheelchair, self toilet and transfer self from the wheelchair to the bed, without staff assistance. On 11/08/22 at 2:47 p.m., the DON and Administrator were asked if the interventions to tell the resident to use a call light and/or request assistance was an appropriate intervention for a resident with severe cognitive impairment. The DON stated no. They were asked if the interventions appeared to be effective in preventing the resident to fall. The DON stated, No, the care plan needed to be updated. 3. Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nutritional Status Care Plan, dated 11/08/21, read in parts, .monitor/record weight. Notify the health care provider and family of significant weight change . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Hypertension and Elevated Cholesterol Care Plan, dated 04/14/22, read in parts, .will not exhibit complications of [CONDITION(S)] .assess for fluid excess .weight gain . The weight records for Resident #45, documented the following: In 07/2022, weights were not obtained two of four weeks; In 08/2022, weights were not obtained one of four weeks; In 09/2022, no weights were obtained; and In 11/2022, weights were not obtained one of two weeks. The clinical record indicate weights were not attempted on 44 of 47 days from 08/21 to 10/08/22. On 11/01/22 at 02:42 p.m., Resident #45 was observed seated with feet elevated in a recliner and both ankles were observed to be swollen. On 11/07/22 at 10:10 a.m., Resident #45 was seated at a dining table in the common area and both ankles were observed to be swollen. On 11/08/22 at 1:52 p.m., the DON and ADON were asked if the care plan should have included [CONDITION(S)]/swelling of the ankles. The DON stated she would have to check with the care plan to see if it is there. The DON was asked, if the care plan stated to monitor weight gain, did the facility follow/implement the resident care plan. The DON stated, No, the care plan was not followed.

Based on record reviews, observations and interviews, the facility failed to a. re-assess/monitor and intervene for one (#26) of one sampled resident with a change of condition; and b. follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Residents Census and Condition of Residents, dated 11/03/22, documented the facility census was 49. Findings: 1. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 10/08/22 at 3:00 p.m., read in parts, .complaining of having the fuzzy-wuzzies .taking a shower and dropped his washcloth and bent over to pick it up when he had the 'fuzzy-wuzzies' .vital signs: 170/102, 60 .assisted to get into his wheelchair and taken to his room .still a little unsteady while getting into his wheelchair .was told to lie down in his bed for an hour . The clinical record contained no documentation Resident #26 was re-assessed/monitored. The clinical record did not contain documentation the physician was consulted. A progress note, dated 10/27/22 at 1:28 p.m., read in parts, .vomit after lunch . The clinical record did not contain documentation Resident #26 was re-assessed or monitored. On 11/09/22 at 12:35 p.m., the DON was asked to review the progress note, dated 10/08/22, regarding the elevated blood pressure with symptomatic complaints. The DON was asked if Resident #26 was reassessed/monitored or the physician consulted. They stated I do not see anything. The DON was asked if resident #26 was monitored/re-evaluated after the note of experienced emesis, on 10/27/22. They stated there needed to be more information documented. They stated staff should have done a follow-up. 2. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nutritional status care plan, dated 02/10/21, documented Resident #30 was to be offered ice cream milk shake three times a day for prevention of weight loss. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30's weight records for August, 2022, documented the resident weights were deferred on six days, and no documented weights on seven days. Resident #30's weights were not obtained as ordered on 20 of 31 days in August, 2022. The clinical record contained no documentation the physician was made aware daily weights were not being obtained as ordered. Resident #30's weight records for September, 2022, documented the resident was not available one day and no documented weights on 18 days. Resident #30's weights were not obtained as ordered on 28 of 30 days in September 2022. Resident #30's weight records for October, 2022, had no documented weights on six days. Resident #30's weights were not obtained on 10 of 31 days in October, 2022. On 11/08/22 at 2:47 p.m., the DON and ADON were asked if weights had been obtained per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reviewed the record and stated the weights were not obtained as ordered. 3. Resident #34 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The weight record, for Resident #34, contained no weekly weights from 12/27/21 through 05/11/22. Two of four weekly weights were obtained from 05/2022 to 06/2022. The weight record, for Resident #34 contained no weekly weights from 06/08/22 to 07/18/22. The weight record, for Resident #34 contained no weekly weights from 07/18/22 through 11/08/22. A Dietary Progress Note, dated 08/24/22 at 9:58 a.m., read in parts, .Aug wt pending . A Dietary Progress Note, dated 09/26/22 at 10:04 a.m., read in parts, .Sept wt pending . A Dietary Progress Note, dated 10/12/22 at 10:32 a.m., read in parts, .Oct wt pending . On 11/08/22 at 2:15 p.m., the DON and ADON were asked if Resident #34 has been weighed weekly per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They were asked if the physician was aware the weights were not obtained as ordered. No information was provided. 4. Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The weight record did not contain documentation Resident #45 was weighed from 8/21/22 until 10/8/22. The clinical record contained no documentation the physician was aware the weekly weights were not obtained as ordered. On 11/08/22 at 1:52 p.m., the DON and ADON were asked if the physician ordered weekly weights had been obtained as ordered. The DON stated they would have to look at the order to see when the order originated. They were asked, as the orders are currently written, should the facility obtained weekly weights. No information was provided.

Based on record review, observation, and interview, the facility failed to ensure a PRN [CONDITION(S)] medications order was limited to 14 days for one (#26) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 27 residents received psychoactive medications. The Census was 49. Findings: Resident #26 had diagnoses to include major depressive disorder, and [CONDITION(S)]. A Care Plan, dated 02/07/18, read in parts, .[CONDITION(S)] drug use .Has interrupted Sleep patter r/t [CONDITION(S)] .[MEDICATION(S)] ([MEDICATION(S)]) 15 mg PO Q HR PRN . A physician order, dated 11/30/18, documented Resident #26 was to be administered [MEDICATION(S)] 15 mg every evening for [CONDITION(S)]. The order was discontinued, and a new order written on 09/17/21. A physician order, dated 09/17/21, documented Resident #26 was to be administered [MEDICATION(S)] 15 mg PRN at bedtime. The order was discontinued and a new order written on 01/06/22. A physician order, dated 01/06/22 documented Resident #26 was to be administered [MEDICATION(S)] 15 mg PRN at bedtime. The order was discontinued and a new order written on 05/18/22. A Pharmaceutical Consultant Report, labeled psychoactive Gradual Dose Reduction, dated 02/19/22, read in parts, .consider a dose reduction. [MEDICATION(S)] 15 mg HS PRN [CONDITION(S)] .PRN med should be limited to 14 days then reassessed . The physician documented to continue to current dose as above, stating the patient is stable. The physician documented the signature/review date as 02/25/22. The documentation did not include an evaluation/rational for [MEDICATION(S)] to be continued as a PRN dose for greater than 14 days. A physician order, dated 05/18/22, documented Resident #26 was to be administered [MEDICATION(S)] 15 mg PRN at bedtime. The order was discontinued and a new order written on 10/10/22. The MAR for August 2022, documented Resident #26 received [MEDICATION(S)] PRN on 26 of 31 days. The MAR for September 2022, documented Resident #26 received [MEDICATION(S)] PRN on 29 of 30 days. A physician's order, dated 10/10/22, documented Resident #26 was to be administered [MEDICATION(S)] 15 mg PRN at bedtime. The order documented the end/stop date of 04/10/23. The MAR for October 2022, documented Resident #26 received [MEDICATION(S)] PRN on 30 of 31 days. The MAR for November 2022, documented Resident #26 received [MEDICATION(S)] PRN for eight of eight days. The clinical record contained no documentation Resident #26 had been assessed every 14 days for the continued use of PRN [MEDICATION(S)] ordered/administered from 11/30/18 through 11/09/22. On 11/09/22 at 12:35 p.m., the DON was asked if Resident #26 was re-evaluated/assessed by the physician every 14 days and if true, was there documentation to support the need for the continued use of the PRN [MEDICATION(S)] from 02/17/18 to current. The DON stated they would look. No further information was provided to support Resident #26 had been re-evaluated/assessed by the physician every 14 days and/or documentation to support the need for the continued use of the PRN [MEDICATION(S)].

Based on record review and interview, the facility failed to notify the physician of changes in condition for one (Resident #26) of one sampled resident reviewed for change of condition. The Resident Census and Condition of Residents, dated 11/03/22, documented the census was 49. Findings: Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Order, dated 11/09/17, documented resident #26 was to be administered [MEDICATION(S)], 25 mg twice a day. The medications was to be held if the systolic blood pressure was less than 110 and/or the diastolic blood pressure was less than 60. A Physician Order, dated 12/01/17, documented Resident #26 was to be administered [MEDICATION(S)] 20 mg once a day. The medications was to be held if the systolic blood pressure was less than 110 and/or the diastolic blood pressure was less than 60. A Progress Note, dated 10/03/22 at 8:00 a.m., read in part, .Hospital for pacemaker consult . A Progress Note, dated 10/03/22 at 11:51 a.m., read in parts, .new upcoming appointment .heart hospital . A Progress Note, dated 10/08/22 at 3:00 p.m., read in parts, .complaining of having the fuzzy-wuzzies[sic] .taking a shower and dropped his washcloth and bent over to pick it up when he had the fuzzy-wuzzies [sic] .vital signs: 170/102, 60 .still a little unsteady while getting into his wheelchair .was told to lie down in his bed for an hour . The clinical record did not contain documentation the physician had been consulted/notified. A Quarterly Assessment, dated 10/18/22, documented Resident #26 had moderate cognitive impairment for daily decision making; required extensive assistance for bathing, and supervision for transfers, walking locomotion, dressing, eating and hygiene. The Care Plan last edited 10/31/22, read in parts, .Problem Start Date: 02/07/2018 .at risk for cardiac complications r/t pacemaker, arrhythmia, hypertension, [CONDITION(S)], [CONDITION(S)], PVD, atherosclerosis, self manipulation of pacemaker, anticoagulant therapy .will not experience .signs of dizziness, faintness .observe for signs of pacemaker failure .dizziness, faintness, palpitations, hiccups, chest pain .[CONDITION(S)] ([CONDITION(S)]) . On 11/09/22 at 12:35 p.m., the DON was asked to review the Progress Note, dated 10/08/22, regarding the elevated blood pressure with symptomatic complaints. The DON was asked if the physician had been notified of a change of condition. They stated they did not find anything. The DON was asked if the physician had been notified when Resident #26 experienced emesis. They stated staff should have done a follow-up to ensure that physician may have needed to be notified. No further information was provided to support the physician had been notified of a change of condition for Resident #26.

Based on record review, observation, and interview, the facility failed to ensure staff sanitized the blood pressure cuff after resident use for one (#1) of three sampled residents observed having their blood pressure taken during medication administration. The DON identified 11 residents with infection precautions posted on their room door. The Resident Census and Condition of Residents report, dated 11/01/22, identified 49 residents resided in the facility. Findings: A Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised October 2018, read in parts .resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident . On 11/03/22 at 09:43 a.m., CMA #3 was observed not to sanitize wrist blood pressure cuff after using on prior resident. On 11/03/22 at 10:00 a.m., after gathering resident #1 medications, CMA #3 was observed to hold them in the cup while waiting for resident #1 to get out of the shower. On 11/03/22 at 10:40 a.m., CMA #3 was not observed to disinfect the blood pressure cuff used on a previous resident prior to using it on resident #1. On 11/03/22 at 10:44 a.m., CMA #3 was asked at what point were the blood pressure cuffs to be disinfected. They stated should be sanitized after each person. They were asked if they sanitized the cuff between the last two residents. They stated, yes. CMA #3 was asked what was used to sanitize the cuff. They stated, alcohol prep. They were asked where the alcohol prep was kept. They stated, top drawer of the cart, and begun looking through the drawer. The CMA was observed to have trouble locating one, but did find one to show. Informed CMA they were not observed to disinfect the cuff between the last two residents. CMA #3 had no response. On 11/04/22 at 9:12 a.m., The DON was asked what was the policy for disinfection of medical supplies. They stated there are multiple options like spray, wipes, alcohol pads, and micro kill. They were asked when blood pressure cuffs were to be disinfected. They stated, between every patient. On 11/04/22 at 9:20 a.m., The DON was made aware of the observation of the blood pressure cuff not being sanitized between residents.

Based on record review, observation, and interview, the facility failed to: 1. ensure medication/treatment carts remained locked and keys removed when unattended, and 2. ensure medications that required refrigeration were refrigerated as recommended by the manufacturer for one (#15) of one sampled residents reviewed for refrigerated medications. The Resident Census and Condition of Residents report, dated 11/01/2022, documented 49 residents resided in the facility. Findings: A Security of Medication Cart policy, revised April 2007, read in parts, .Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room . A Storage of Medications policy, revised April 2007, read in parts, .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly . 1. On 11/07/22, at 4:33 p.m., a treatment cart was observed unlocked and unattended on hall 100. The cart was observed to contain insulin needles, insulin, scissors, inhalers, medications and various creams. On 11/07/2022, at 4:54 p.m., RN #2 was observed to approached the unlocked treatment cart on hall 100. RN #2 was asked what the policy was for locking treatment carts. They stated, the cart should be locked all the time when we're not using it. RN #2 stated they forgot to lock it they were changing some items out. On 11/08/22, at 9:43 a.m., the DON was asked what the policy was for treatment/medication cart safety. They stated, they should be locked anytime you walk away. They were asked what were the risks for having an unlocked cart. They stated, anybody could get stuff out of there if they can get it open. The DON was made aware of the observations of the treatment cart being unlocked and unattended. 2. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Probiotic [Floragen] twice a day. On 11/03/22 at 9:05 a.m., during a medication pass, CMA #1 was observed to retrieve a card of medication labeled, Florajen, from the medication cart. The card had a REFRIGERATE sticker on it. On 11/03/22 at 5:10 p.m., CMA #4 was asked to look at resident #15's medications in the cart. They were asked if the probiotic was to be refrigerated. They stated, yes. CMA #4 was asked if the medication was refrigerated. They stated it was when they got it. They were asked when they received it. They stated they were not sure. The CMA #4 was asked if the probiotic was on the cart when they took over the cart. They stated, yes. They were asked how they know what medications require refrigeration. They stated, when there is a sticker on it and it says it on the tag that comes with the medication when it is delivered. CMA #4 was asked what the policy was for medications requiring refrigeration. They stated, if not refrigerated then they waste and would discard the medication. On 11/04/22 at 9:05 a.m., CMA #1 was asked how they know what medications required refrigeration. They stated, normally the order or card states refrigerate, and that the pharmacist has told them that since the cart does not get hot, they could keep them on the cart. CMA #1 was asked what the policy was for medication requiring refrigeration. They stated, to stay in the fridge, but that the pharmacist said it was ok to keep them on the cart. On 11/04/22 at 9:20 a.m., the DON was made aware of the probiotic labeled Refrigerate and being stored in the medication cart. On 11/04/22 at 11:22 a.m., the DON stated the medication refrigeration is specific to manufacturer instruction and stated that after speaking to the pharmacist, the probiotic was refrigeration only and was to educate staff. 3. On 11/07/22 at 4:55 p.m., LPN #3 was observed in the common area working at a treatment cart. LPN #3 gathered items and left the cart, exiting the area. A ring of keys remained inserted into the unlocked/unattended cart. At 4:58 p.m., LPN #3 returned to the treatment cart, pulled the keys, locked the cart, placed the keys in their pocket, and began working on the computer on top of the treatment cart. LPN #3 was asked if the treatment cart was to be locked at all times. They stated, Yes. LPN #3 was asked if there was a reason the treatment cart was to be locked at all times. They stated, So no one can mess with it. LPN #3 was asked what the facility policy was regarding locked carts. LPN #3 stated the policy is for the carts to be locked at all times.

Based on record review, observation and interview, the facility failed to ensure staff were competent to report/follow policy regarding a residents' reports of [CONDITION(S)] with a plan. This affected one (#15) of six sampled resident reviewed for behavioral health and unnecessary medications. The Resident Census and Conditions of Residents, dated 11/03/22, documented the facility census was 49. Findings: The facility's Suicide Threats policy, read in parts, .Resident suicide threats shall be taken seriously and addressed appropriately .staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse .A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident . Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Psychological Services Progress Note[s], dated 08/11/22, 08/18/22, 09/01/22, 09/08/22, 09/29/22, read in parts, .Date of Service .Suicidal/Self Injury: Ideation . On 11/03/22 at 9:08 a.m., during medication administrations, Resident #15 stated to CMA #1, Resident #15 stated, I had thoughts of suicide last night and had it all planned out. CMA #1 responded to the resident, No you're not. CMA #1 continued to other resident rooms to administer medications and did not report to the charge nurse/supervisor, or staff to remain with Resident #15. On 11/03/22 at 10:50 a.m., Resident #15 was laying in bed, with a visitor at the bedside. The visitor introduced self as a friend of the resident and comes to visit weekly. The friend was asked if Resident #15 had struggles with depression. The friend stated, Yes, and the problem had worsened with the progression of dementia and having to leave home to a nursing home. The friend stated the resident frequently talks of suicide and the family was aware but felt Resident #15 was in a safe/controlled environment, resulting without a means to follow-through. On 11:03/22 at 2:05 p.m., the DON was asked if they had received any reported event of a resident with suicidal ideation and a plan. The DON stated, No. The DON was informed of the observations made during the medication pass. The DON stated staff should have reported the event to the charge nurse then a report made to the DON and/or administration.

Based on record review and interviews, the facility failed to provide interventions to prevent repeated falls for one (#30) of three residents reviewed for falls. The Resident Census and Conditions of Residents, dated 11/03/22, the facility census was 49. Findings: Resident #30 had diagnoses to include dementia, atrioventricular block, [CONDITION(S)], and [CONDITION(S)]. A Significant Change of Status Assessment, dated 02/01/22, documented Resident #30 had experienced one fall with no injury, and two or more falls with skin tears, abrasions, lacerations, superficial bruising, hematoma, and sprains: or any fall-related injury that causes the resident to complain of pain. The comprehensive care plan for falls did not contain interventions to remind the resident to use the call light and request assistance were appropriate. An Accident/Incident Report, dated 05/22/22, read in parts, .sitting on bed room floor .Recommended steps to prevent recurrence .call light for staff to assist to toilet while diarrhea persists . A Fall Care Plan, dated 5/22/22, read in parts, .Failed attempt at self-transfer .Reminded to use call light for assist . There was no documentation new interventions had been put in place. A Quarterly Assessment, dated 07/26/22, documented Resident #30 had experienced one fall with no injury, and two or more falls with skin tears, abrasions, lacerations, superficial bruising, hematoma, and sprains: or any fall-related injury that causes the resident to complain of pain. An Accident/Incident Report, dated 08/25/22, read in parts, .no impairments .called for assistance to transfer from bed to wheelchair .said .fell for 4 times already trying to transfer from bed to wheelchair .Recommended steps to prevent recurrence: Reinforced .use call light when transferring from bed to wheelchair . A Fall Care Plan, dated 08/25/22, read in parts, .Self-reported failed attempt to transfer from bed to WC .Reminded resident to use call light when transferring . There was no documentation a new intervention had been put in place. A progress note, dated 08/26/22 at 1:48 a.m., read in parts, .Resident seen on bed, sitting at 11:15PM. Called for an assistance to transfer from bed to wheelchair. Reported that [Resident #30] fell for 4 times already unwitnessed trying to transfer from bed to wheelchair Described that [Resident #30] went black out and fell on the floor landing her buttocks first .Reinforced the use of call light for assistance . A 'Quarterly Assessment, dated 10/18/22, documented Resident #30 had severe cognitive impairment for daily decision making, required extensive assistance for transfers, dressing and toileting, and had one fall since the prior assessment. An Accident/Incident Report, dated 10/27/22, read in parts, .was lying on the floor between her bed and bedside table .abrasion to left outer forearm .Recommended steps to prevent recurrence: check on resident frequent [sic]. Take her to the bathroom, set meals up for her. check q hr on her . The Fall Care Plan, dated 10/26/22, did not include an entry regarding the Accident/Incident Report or any new interventions. On 11/08/22 at 2:47 p.m., the DON and administrator were asked to review Resident #30's care plan for falls. They were asked if the interventions to tell the resident to use a call light and/or request assistance was an appropriate intervention for a resident with severe cognitive impairment. The DON stated no. They were asked if the interventions appeared to be effective in preventing the resident to fall. The DON stated, No.

Based on record review and interview, the facility failed to develop a comprehensive care plan to include interventions to prevent falls for one (#30) of three sampled residents reviewed for care plans. The Resident Census and Condition of Residents, dated 11/03/22, documented the census was 49. Finding: Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Accident/Incident Report, dated 11/16/21, read in parts, .memory impaired .sitting on floor [with] legs under the w/c .moved w/c away from bedside, instructed Resident to call for help when .needs to get up. Showed [Resident #30] where [Resident #30's] call light is . The Fall Care Plan, dated 11/16/21, read in parts, .failed attempt to self transfer .Showed resident call light and to call for help when getting up . An Accident/Incident Report, dated 12/10/21, read in parts, .memory impaired .trying to self-transfer from bed to wc and fell .non-slip socks on, no pants or brief on, wc brakes locked .Remind res to call for assistance . The Fall Care Plan, dated 12/10/21, read in parts, .Failed attempt at self transfer from bed to wc .Intervention: Remind resident to call for assistance when transferring . ASignificant Change of Status Assessment, dated 02/01/22, documented Resident #30 had severe cognitive impairment for daily decision making, required extensive assistance of staff for transfers, and had experienced one fall with no injury, and two or more falls with skin tears, abrasions, lacerations, superficial bruising, hematoma, and sprains. There was no documentation a comprehensive care plan had been completed after the significant change of status assessment. On 11/08/22 at 2:47 p.m., the DON and Administrator were asked to review Resident #30's comprehensive care plan for falls. They were asked if the interventions to tell the resident to use a call light and/or request assistance were appropriate interventions for a resident with severe cognitive impairment. The DON stated no. They were asked if the interventions appeared to be effective in preventing the resident from falls. The DON stated, No, the care plan needed to be updated.

Based on record review and interview, the facility failed to have an effective process to formulate/re-evaluate the resident's rights to formulate advance directives. This affected two (#30 and #45) of two sampled residents reviewed for advanced directives. The Resident Census and Conditions of Residents report, dated 11/03/22, documented the census to be 49. Findings: 1. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A dated 10/25/20, read in part, DNR. The clinical record did not contain an advance directive. There was no documentation the resident and/or representative had been offered information to formulate an advance directive. 2. Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Order, dated 10/22/21, read in part, Code Status: Full Code. The clinical record did not contain an advance directive. There was no documentation the resident and/or representative had been offered information to formulate an advance directive. On 11/03/22 at 4:24 p.m., the Administrator and DON were asked to provide information/documentation Residents #30 and #45, and/or the resident's representatives had been offered written information to formulate/re-evaluate the resident right for an advance directive. The Administrator stated, When an admission comes in, we tell them to bring their advance directive with them. The Administrator stated the facility did not have a system in place to follow up for additional information to be provided or re-evaluate the need to change an advance directive.

Based on interviews and record reviews, it was determined the facility failed to have an effective administration who ensured: ~ residents were not verbally and mentally abused by resident #1 for four (#2, 3, 8 and #12) of five sampled residents reviewed for abuse. This resulted in resident #12 staying in her room rather than face additional altercations with resident #1. Resident #12 reported feeling fearful of falling asleep due to the possibility the resident may hurt her, and she had a decline in her social activities. Additionally, the resident reported a history of spousal abuse, and she stated she felt like she was reliving those events; ~ their abuse policy was implemented and allegations of abuse were reported to the administration and the OSDH (Oklahoma State Department of Health), investigated, and residents were protected from potential further abuse by resident #1 for four (#2, 3, 8 and #12); ~ their abuse policy was implemented and allegations of resident to resident altercations were reported to the administration and the OSDH, investigated, and residents were protected from further abuse for three (#3, 4 and #11); and ~ their abuse policy was implemented and allegations of nonconsensual sexual contact were reported to the administration and the OSDH, investigated, and a resident was protected from further potential abuse by resident #11 for one (#9) of five sampled residents reviewed for abuse. The administrator identified 83 residents who resided in the facility. Findings: A facility policy titled, Abuse Prohibition Policy, documented: .each individual resident has the right to be free from any form of abuse. This facility strictly prohibits any verbal .mental abuse .Identification of events, occurrences, suspicions .that may constitute abuse shall be reported to the facility administrator, the nursing director .and the OSDH (Oklahoma State Department of Health) .All reports of potential abuse will be investigated by the administrator and/or nursing director . A facility policy titled, Resident to Resident Altercations, documented: .All altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Nursing Supervisor, Director of Nursing Services, and to the Administrator .Review the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents .Report incidents, findings, and corrective measures to appropriate agencies . 1. Resident #1 had [DIAGNOSES REDACTED]. A care plan, last updated on 09/03/19, documented the resident had a history of [REDACTED]. The care plan identified the resident had behaviors related to taking food items which did not belong to him and becoming defensive and verbally inappropriate when approached about the food related behaviors. There were no interventions identified related to the resident's verbal and social inappropriate behaviors. An annual assessment, dated 09/13/19, documented the resident was cognitively alert in daily decision making and independent with transfers and ambulation. Nurse's progress notes, dated 10/05/19 and 10/06/19, documented the resident was observed yelling, cussing, and insulting a nurse. The resident was observed yelling, cussing, and threatening a resident (resident #8) saying, I will knock that cane out from under you. CNA (certified nurse aide) #3 intervened and separated the residents. An administrator's note, dated 11/07/19, documented three separate allegations of abuse between resident #1 and three other residents (#2, 3, and #12) were made known to the ADM. The note failed to document a thorough investigation was conducted and residents were protected. Michelle L. Raney, RN, BSN documented actions taken by the ADM once these allegations were known. The note was remarkable for the absence of actions once an allegation of abuse was known. The note documented resident #1 made verbally aggressive remarks to residents #3 and #12. The note documented the residents (#1, 3, and #12) were offered to move to different rooms and the alleged perpetrator was offered the opportunity to move to a different hall and all declined. The note documented the residents met on their own and made amends and then shortly after another verbal incident occurred between resident #1 and #12. The note documented resident #12 reported an allegation of resident #1 mistreating his roommate (resident #2). There was no documentation of reporting the allegations to the OSDH, investigating, or protecting residents from potential further abuse. During the survey cognitively alert residents (#3, 8, 10, 12, 13, and #14) stated they had experienced verbally aggressive behaviors or threats by resident #1. Residents reported they had notified the facility nursing staff and administration staff, and there had been no sufficient action taken to address the concerns. Three residents reported they were afraid of resident #1. One resident stated she had a history of [REDACTED]. She further stated she stayed in her room to avoid the resident. She stated she feared he would come in her room at night while she was asleep and really hurt her. On 11/14/19 at 9:57 a.m., the ADM was asked if a resident was verbally aggressive and calling residents names and making threats towards residents was this considered possible abuse which required reporting, investigating and protecting residents. She stated she really did not consider this abuse. She was asked if she had any OSDH incident reports for resident #1 involving resident to resident altercations due to his verbal/mental abuse. She stated she did not have any reports for resident #1. She was asked if allegations of verbal/mental abuse were investigated involving resident #1. She referred to the ADM note dated 11/07/19. She stated the facility investigated issues with (Named resident #3 and Named resident #1). She said, We looked into (Named resident #1 and Named resident #12). She stated they asked resident #3 and resident #12 if they wanted to move to a different room. She stated they declined to move. She stated they asked resident #1 if he wanted to move to a different hallway and he declined. She said, They (resident #1 and #12) actually met together which is what we were hoping for. So far all is better with them. At 11:37 a.m., resident #1 was asked if he yells, cusses or threatens other residents. He stated he had yelled and cussed at some residents at times. He stated he had yelled and cussed at resident #12, and they had made up and then she got mad again. He said, She thinks I'm mistreating my roommate. He was asked if he had ever threatened to kick a resident's cane out from under him. He stated he had. He stated resident #8 and himself had a problem, but staff talked to them and separated them. At 12:39 p.m., the ADM was asked to discuss resident #1's behaviors. She stated the resident was angry about being in the facility. She stated he often exhibited behaviors if he did not get his way. She stated the resident had been verbally lashing out towards residents #3 and #12 for the last two weeks. She was asked if she was aware resident #1 had threatened resident #8 to kick his cane out from under him. She stated she was not aware of the allegation. She was notified the altercations were documented in resident #1's record and a staff member had intervened on one occasion. She was notified resident #8 reported he had notified staff of the same allegation occurring on three separate occasions. She stated she interviewed staff about allegations reported from residents #3 and #12. She stated there were no staff members who reported witnessing the incidents. She was asked if she had interviewed other residents who resided on resident #1's hall to assess if they felt safe or if they had been verbally abused by the resident. She stated they had not interviewed other residents. She stated resident #12 had reported she felt resident #1 was abusing his roommate, (Named resident #2). She stated the administration staff had talked with resident #2 and all was okay. She was asked if they had documented a statement from the interview with resident #2. She stated they had not. She was asked if the resident's verbally aggressive behaviors had been escalating. She stated they had. She was asked what action had been taken to ensure residents were protected from potential further verbal abuse by resident #1. She said, We put staff on notice for (Named resident #1) to see if he says things to (Named resident #12). She stated staff were to watch their interactions and be aware. She stated if staff observed any concerning interactions they were instructed to notify the DON (director of nurses) or herself. She further stated staff were instructed to keep resident #1 and #12 separated. She did not provide actions to protect other residents from potential further abuse, including residents #2 and #3. She was asked if any resident had reported they were afraid or stated they did not want to leave their room in order to avoid confrontations with resident #1. She stated resident #12 stated she did not want to look at the resident and she stated she was just going to stay in her room. She stated she encouraged resident #12 to, just do your normal stuff and don't let him get to you. During the survey six staff members (CNA (certified nurse aide) #4, 5, 6 and #7, LPN (licensed practical nurse) #1, and the activities director) stated they had witnessed resident #1 verbally abuse or threaten other residents. Three of the staff members reported they did not report the observations to nursing staff or administration. 2. Resident #4 had [DIAGNOSES REDACTED]. A care plan, last updated 07/29/19, documented the resident had a cognitive loss deficit and dementia. The following interventions were identified; remove the resident from other residents rooms and unsafe situations, and when the resident begins to wander provide comfort measures. A nurse's progress note, dated 08/12/19, documented, It was brought to my attention that resident was pushed in the chest by (Named resident #11) on hall 2. Staff reviewed the video footage. Resident was assessed, no injury noted. Resident ambulating in hallway without difficulty. (Named family member) notified on incident . A nurse's progress note, dated 09/23/19, documented, It was brought to my attention that (Named resident #4) was over on hall 1 and had an altercation with another resident. (Named resident #3) from hall 2 stated that (Named resident #4) was swinging at her an one came in contact with her face. (Named resident #3) has been very aggressive during shift and difficult to redirect at times. Both residents were assessed and no injury noted. Will continue to monitor closely. ADM aware of situation, physician notified . There was no documentation the resident to resident altercations, on 08/12/19 and 09/23/19, were reported to the administration staff, reported to the OSDH, investigated, and the residents were protected from further abuse. A quarterly assessment, dated 10/01/19, documented the resident was severely impaired in cognitive skills for daily decision making. She had behaviors of wandering daily during the seven day look back period. On 11/13/19 at 11:20 a.m., resident #3 stated resident #4 hit her a couple of months ago. She stated staff members were aware. She said, They did nothing. She then said, She's not right. Yesterday she was swinging at everyone. On 11/14/19 at 9:57 a.m., the ADM (administrator) was asked what incidents and allegations were reported to the OSDH. She stated resident to resident altercations with injuries which required more than first aide were reported. She was shown three resident to resident physical altercations involving resident (#3, 4, and #11). She acknowledged the altercations were not reported to the OSDH or investigated. She was notified the altercations were documented in resident #4's clinical record. She stated she did not have a completed OSDH incident report and investigation for the documented altercations. She was notified all resident to resident altercations must be reported to the OSDH, investigated and residents must be protected from potential further abuse. She stated she was not aware all allegations of resident to resident altercations must be reported and investigated. She was asked if allegations of abuse or neglect were reported. She stated if the allegation was staff to resident we report. 3. Resident #11 had [DIAGNOSES REDACTED]. An annual assessment, dated 08/23/19, documented the resident was moderately impaired in cognitive skills for daily decision making. He required set up to limited assistance from a staff member for activities of daily living. He did not speak English as a primary language and used an interpreter or communication board to communicate his needs. On 11/14/19 at 9:15 a.m., resident #9 stated she had experienced incidents of nonconsensual sexual contact by resident #11. She was asked when the incidents of nonconsensual sexual contact occurred. She stated both incidents occurred about two weeks ago in the dining room. She stated during the first incident resident #11 came up to her in the dining room, put his hands under her sweater, and touched her breast. She was asked if she told anyone. She stated she told CMA #2 (resident #11's family member who worked at the facility), but nothing happened. She was asked about the second incident of nonconsensual sexual contact by resident #11. She stated they were in the dining room. He came toward me in his wheelchair and tried to grab my crotch. I tried to move him away and I told him to go away. CMA #2 moved him away from me. She further stated she notified CMA #2 what happened, but it did not do any good. She was asked if she was afraid of resident #11. She stated she was. At 10:12 a.m., CNA #2 was asked if she was aware of any nonconsensual sexual contact between resident #11 and any female residents. She stated resident #9 tried to kiss resident #11 and then reported he (resident #11) had touched her chest. She stated resident #9 stated she slapped his hand away. CNA #2 was asked what action did she take to address the allegation of nonconsensual sexual contact by resident #11. She stated she told resident #9 if she did not want to be touched to let resident #11 know. She was asked if she spoke to resident #11 after the allegation of nonconsensual sexual contact. She stated he denied it. She stated she told him to keep his hands to himself. She was asked if she reported the allegation to anyone. She stated she told LPN #3 she had already talked to resident #11 and told him not to do that again. During the survey the administrator and DON were interviewed related to sexual behaviors between residents #9 and #11. They acknowledged the residents had been observed kissing at least one year ago. They stated they were not aware of a recent allegation of resident #11 grabbing resident #9's breast and crotch in the dining room. The ADM was asked what action she would have taken if she had been aware. She stated she would have had a family counseling session with both residents. She stated both residents were cognitively alert and capable of consent. She said she would probably ask (Named resident #9) if she wanted it or not. She stated if resident #9 reported she did not, she would counsel the resident and tell them it was not appropriate. She was asked if this was a potential abuse allegation which required reporting to the OSDH, investigating, and protecting residents during the ongoing investigation to prevent potential further abuse. She said, I wouldn't think so unless (Named resident #9) said she didn't want his advances. She was notified the allegation must be considered an allegation of abuse and the abuse policy must be implemented. She was notified the abuse policy would not need to be implemented if both residents were determined to be capable of providing consent for sexual contact and both agreed to sexual contact between each other. The DON was asked if she was aware of an allegation of nonconsensual sexual contact by resident #11 to resident #9. She stated she was not aware of any recent allegation of nonconsensual sexual contact between the residents. She then reviewed resident #9's [DIAGNOSES REDACTED].#9 had mild intellectual disabilities and had the mind of a nine to [AGE] year old child. During the investigation LPN #3 stated she did not report the allegation of nonconsensual contact between residents #9 and #11 to the administration staff. She said, I probably failed on my part.

Based on interviews and record reviews, it was determined the facility failed to ensure: a. allegations of verbal/mental abuse by resident #1 were investigated and residents were protected from further abuse for four (#2, 3, 8, and #12) of five sampled residents reviewed for abuse. This resulted in resident #12 staying in her room rather than face additional altercations with resident #1. Resident #12 reported feeling fearful of falling asleep due to the possibility the resident may hurt her, and she had a decline in her social activities. Additionally, the resident reported a history of spousal abuse, and she stated she felt like she was reliving those events; b. resident to resident altercations were investigated or thoroughly investigated and residents were protected from further abuse for three (#3, 4 and #11) of five sampled residents reviewed for abuse; and c. allegations of nonconsensual sexual contact by resident #11 were investigated and a resident was protected from further potential abuse for one (#9) of five sampled residents reviewed for abuse. The administrator identified 83 residents who resided in the facility. Findings: A facility policy titled, Abuse Prohibition Policy, documented: .each individual resident has the right to be free from any form of abuse. This facility strictly prohibits any verbal .mental abuse .Employee training will consist of .appropriate interventions to deal with aggressive .reactions of residents .knowledge of what constitutes abuse .Attempts will be made to identify, correct and intervene in situations in which abuse .is more likely to occur .evaluation of the supervision of staff to identify inappropriate behaviors .All reports of potential abuse will be investigated by the administrator and/or nursing director .Action will be taken to protect any potential victim(s) identified during the investigation .The investigation must be documented from the initial report to completion of the investigation. Any action taken with any party involved must be recorded . A facility policy titled, Resident to Resident Altercations, documented: .All altercations, including those that may represent resident to resident abuse, shall be investigated. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents .If two residents are involved .staff will: Separate the residents .Identify what happened .Notify each residents representative and Attending Physician of the incident .Review the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents . 1. Resident #1 had [DIAGNOSES REDACTED]. A care plan, last updated on 09/03/19, documented the resident had a history of [REDACTED]. The care plan identified the resident had behaviors related to taking food items which did not belong to him and becoming defensive and verbally inappropriate when approached about the food related behaviors. There were no interventions identified related to the resident's verbal socially inappropriate behaviors. An annual assessment, dated 09/13/19, documented the resident was cognitively alert in skills for daily decision making. He was independent with transfers and ambulation. He self propelled in a wheelchair. A psychiatric consultation progress note, dated 10/02/19, documented there was no evidence of delusional ideations or perceptual disturbances. The note documented the plan was to continue to closely monitor the resident for any changes in psychiatric stability and risk of harm to self and/or others. A nurse's progress note, dated 10/05/19, documented the resident became angry with staff when the resident observed another resident in the kitchenette. The resident yelled, cussed and insulted the nurse through the hallway and in the dining room. The resident continued the same behavior every time he saw the same staff member. The resident also yelled, cussed, and insulted a member of the dietary staff. The resident ran his chair into the food cart in an attempt to move it out of the way. The resident also yelled, cussed and threatened another resident (resident #8) saying, I will knock that cane out from under you. The note documented the residents were separated and both were safe. A nurse's progress note, dated 10/06/19, documented the resident became angry at another resident (resident #8) and yelled, cussed, and threatened him. The note documented the resident stated he was going to kick his cane out from under him. CNA #3 (certified nurse aide) intervened and separated both residents. The note documented the nurse spoke with the resident and advised him he should not make threats and if he chose to continue to threaten residents there would be consequences. The note documented the resident stated he understood and would not continue the identified behaviors. There was no documentation the resident's verbally aggressive behaviors were investigated and residents were protected from potential further abuse or threats of abuse from resident #1. An administrator's note, dated 11/07/19, documented three separate allegations of abuse between resident #1 and three other residents (#2, 3, and #12) were made known to the ADM. The note failed to document a thorough investigation was conducted and residents were protected. a) The note documented the ADM first became aware resident #1 was cursing at resident #12 on 10/30/19. The note documented on that day, 10/30/19, the ADM offered to move resident #12 to a different hall, but the resident refused this offer saying she shouldn't have to move. Resident #12 stated, since the ADM would not discharge resident #1 from the facility, she (resident #12) would have to find another place to live. The note documented resident #1 also refused to move to another hall but did agree not to speak to resident #12. The note documented, on 11/04/19, resident #1 reported to the ADM he and resident #12 had worked everything out and even prayed together; however, at that time, there was no documentation this agreement had been confirmed with resident #12. The noted documented, on 11/07/19, the ADM followed up with resident #12 to verify resident #1's claims they had reconciled. The note documented resident #12 stated they had made amends at that time but since then a couple of days later resident #1 had said something to her as she went passed his door. The note documented once again resident #12 was offered the opportunity to move to a different hall, but she declined. Other than asking resident #1 not to speak to resident #12 and requesting residents to move, there was no documentation of actions taken to keep resident #12 safe or of an investigation of the alleged abuse. b) The ADM's note documented, on 11/06/19, she first became aware of issues between resident #1 and resident #3. The note documented, resident #3 reported to the ADM resident #1 had asked her if she was an f ing (explicit term) light bulb when she wore a brightly colored shirt. The note documented resident #3 requested resident #1 be kicked out of the facility. The note documented the ADM told resident #3 she could not kick someone out for that, and resident #3 responded by saying she wasn't putting up with it .she was moving out as soon as she could and the ADM could keep her pet. The note documented, when asked by the ADM, resident #1 denied using profanity at resident #3. There was no documentation of actions taken to keep resident #3 safe or of an investigation of the alleged abuse. c) The note documented, on 11/07/19, the ADM first became aware of an allegation resident #1 might be abusing resident #2. The note documented, on 11/07/19, resident #12 reported to the ADM she believed resident #1 was mistreating resident #2 as she saw resident #1 standing, holding a urinal over resident # 2 when he was in bed. The note documented the ADM interviewed resident #2, and he denied being mistreated. There was no documentation of actions taken to keep resident #2 safe or of a thorough investigation of the alleged abuse. On 11/13/19 at 10:32 a.m., resident #8 was interviewed about resident #1. He stated the resident had been verbally abusive to resident #12 many times. He stated resident #12 was moving out of the facility. He stated she was tired of it. He stated the resident (resident #1) called a nurse a b .(explicit term) and a whore. He stated he then told the resident not to be pissy and he laughed at the resident. He stated the resident then came after him in his wheelchair. He said, He was going to hit me and (Named CNA #3 (certified nurse aide)) stepped in between us and he backed off. He stated he told CNA #3 not to stand between him and the resident. He stated he told CNA #3 he would take the hit. He further stated the resident had threatened him three times saying he would kick his cane out from under him. He said, I've had a stroke and I use my cane to get up. He stated he reported the threats to the staff but he was unsure if anything had been done. At 10:35 a.m., resident #12 stated she was passing by the resident's room. She stated she observed the resident walk over to his roommates bedside (resident #2) with a urinal in his hand. She stated she observed the resident pull back resident #2's covers with his urinal in hand. She stated she asked the resident what he was doing and he was startled. She stated she had observed some bruising on his roommate a few times prior to the observation. She reported she notified the nursing staff of her observations. She then stated she had left for an appointment on 10/31/19. She stated when she arrived back at the facility she met the resident in the hallway. She stated the resident put his wheelchair in front of her. She stated the resident called her a f ing (explicit term) b (explicit term). She stated the incident occurred right in front of the nurse's station and the nurses in the station observed the altercation. She then stated she started crying. She stated the administrator came to her room to talk to her about the allegation. She stated the administrator notified her she just needed to ignore the resident because he was mad at the world. She stated the administrator stated she was not moving the resident out of the facility because he had no place to go. She stated he often calls her names such as sorry f ing (explicit term) b (explicit term) and sorry mother f .er (explicit term). She stated she stayed in her room to avoid confrontations from him. She stated she was trying to move out of the facility to another town. She stated she originally came to the facility with her husband but he had passed. She said, I thought this would be my forever home. I don't want to leave my home. She then stated her first husband was abusive. She said, I shouldn't have to put up with this abuse. She further said, I don't like sitting in here. I don't like having to isolate myself. I like to visit with others. At 10:46 a.m., resident #14 stated resident #1 had a short fuse. She stated he called the nurses vulgar names. She stated about a month ago he called resident #12 a sorry mother f ER (explicit term). She stated the staff were present and they just kind of slough it off. At 11:00 a.m., resident #6 stated he was blind. He stated he had heard resident #12 talk to her tablemates during meals about how she was being verbally abused by a resident. At 11:20 a.m., resident #3 stated resident #1 verbally abused her and everyone. She said, F (explicit term) is his favorite word. She stated he was very verbally abusive. She stated staff were aware, but they stated there was nothing they could do about it. She stated herself and other residents were moving out due to his verbally aggressive behaviors. She said, I'm moving out as soon as I can. I didn't come here for that. He's just mean. She then stated recently she was out getting a cup of coffee and the resident wheeled by her in his wheelchair. She stated the resident said, What are you an f ing (explicit term) light bulb? At 11:55 a.m., the resident's roommate (resident #2) was asked if any resident had ever been mean to him. He said, I don't know. He was asked if anyone had talked mean to him or made him feel uncomfortable. He said, Yes. He was asked if he had notified a staff member and he stated no. He was asked if his roommate (resident #1) was ever mean to him. He said, I don't know. At 12:37 p.m., resident #13 stated he was participating in a Bingo activity with staff present when the resident entered from the outside smoke area with another resident. He stated both residents began yelling Bingo! He stated he told the residents to shut up or come get a Bingo card. He stated both residents then began yelling profanities at him. On 11/14/19 at 9:18 a.m., resident #3 was asked if she was afraid of the resident. She stated she was. At 9:57 a.m., the ADM was asked what allegations were investigated. She stated all allegations were investigated including allegations involving staff and injuries of unknown origin. She then stated the facility investigated issues with (Named resident #3 and Named resident #1). She said, We looked into (Named resident #1 and Named resident #12). She stated they asked resident #3 and resident #12 if they wanted to move to a different room. She stated they declined to move. She stated they asked resident #1 if he wanted to move to a different hallway and he declined. She said, They (resident #1 and #12) actually met together which is what we were hoping for. So far all is better with them. She was asked if a resident was verbally aggressive and calling residents names and making threats towards residents was this considered possible abuse which required investigating and protecting residents. She stated she really did not consider this abuse. She was asked if she had completed a thorough investigation for the allegations of verbal abuse and threats made by resident #1 including residents #2, 3 and #12. She stated the only investigative notes she had were included in her administrator notes, dated 11/07/19, which she had already provided to the survey team. At 10:34 a.m., CNA #5 was asked if she had been told of a resident to resident altercation involving resident #1. She stated she was told by another staff member the resident was observed standing over his roommate's bed saying, I wish you would die. She was asked what action did she take. She stated she did not take action because she did not know when the alleged incident occurred or who had actually witnessed the incident. She further stated the resident was generally rude, but she had not witnessed the resident be abusive to other residents. At 10:39 a.m., CNA #6 was asked if she had witnessed resident to resident abuse and what did she do in response. She stated resident #1 was rude and verbally abusive to resident #12 in the hallway. The activity director and her split them up and spoke with each of them. At 11:16 a.m., CMA #3 (certified medication aide) was asked if resident #12 came out for activities and to socialize or if she stayed in her room. She stated she comes out of her room for Bingo and meals. She stated she had recently started staying in her room more often. She stated she was upset with (Named resident #1). She stated they had gotten into an argument. She stated she had heard both residents had worked it out and then heard they had not worked it out. She said, She avoids him. At 11:37 a.m., resident #1 was asked if he yells, cusses or threatens other residents. He stated he had yelled and cussed at some residents at times. He stated he had never threatened another resident. He stated he had yelled and cussed at resident #12 and they had made up and then she got mad again. He said, She thinks I'm mistreating my roommate. He was asked if he had ever threatened to kick a resident's cane out from under him. He stated he had. He stated resident #8 and himself had a problem, but staff talked to them and separated them. At 12:39 p.m., the ADM was asked to discuss resident #1's behaviors. She stated the resident was angry about being in the facility. She stated he often exhibited behaviors if he did not get his way. She stated the resident had been verbally lashing out towards residents #3 and #12 for the last two weeks. She then stated recently resident #3 was wearing a bright orange sweatshirt. She stated the resident told her she looked like a f ing (explicit term) light bulb. She stated resident #3 notified her of the altercation. She was asked if she was aware resident #1 had threatened resident #8 to kick his cane out from under him. She stated she was not aware of the allegation. She was notified the altercations were documented in resident #1's record and a staff member had intervened on one occasion. She was notified the resident stated he had reported the incident had occurred on three different occasions and he had notified staff. She stated she had not completed an investigation because she was not aware of the incident. She stated she recalled a recent incident with resident #1 and another resident interrupting a Bingo game. She stated the activities director reported the residents were being loud and yelling Bingo! She stated the activities director reported she told them to be quiet and they left and nothing further happened. She stated she interviewed staff about allegations reported from residents #3 and #12. She stated there were no staff members who reported witnessing the incidents. She was asked if she had interviewed other residents who resided on resident #1's hall to assess if they felt safe or if they had been verbally abused by the resident. She stated they had not interviewed other residents. She stated resident #12 had reported she felt resident #1 was abusing his roommate, (Named resident #2). She stated the administration staff had talked with resident #2 and all was okay. She was asked if they had documented a statement from the interview with resident #2. She stated they had not. She was asked if the resident's verbally aggressive behaviors had been escalating. She stated they had. She was asked what action had been taken to ensure residents were protected from potential further verbal abuse by resident #1. She said, We put staff on notice for (Named resident #1) to see if he says things to (Named resident #12). She stated staff were to watch their interactions and be aware. She stated if staff observed any concerning interactions they were instructed to notify the DON (director of nurses) or herself. She further stated staff were instructed to keep resident #1 and #12 separated. She did not provide actions taken to ensure other residents on resident #1's hallway were protected, including residents #2 and #3. She was asked if any resident had reported they were afraid or stated they did not want to leave their room in order to avoid confrontations with resident #1. She stated resident #12 stated she did not want to look at the resident and she stated she was just going to stay in her room. She stated she encouraged resident #12 to just do your normal stuff and don't let him get to you. At 12:45 p.m., the activity director stated resident #12 comes to the Bingo activity. She stated she gets irritated with (Named resident #1). She stated she had a decline in her social activities recently. She stated she used to come to other activities and enjoyed going outside. She stated now the resident stayed in her room because she did not want to go down the hallway. The resident's room was in close proximity to resident #1's. She further stated in the last month she had been staying in her room. She stated she currently comes out of her room for meals and Bingo. She said, She's not as social in the last month. She stated sometimes resident #1 will come by the dining room during Bingo and say Hey (Named resident #12). She stated this antagonizes her. She stated about one month ago the residents (resident #1 and #12) crossed paths in the hallway. She stated she heard resident #1 say to resident #12 why are you here you f .ing (explicit term) b (explicit term). She stated this upset resident #12. She said, We comforted her. She then said, Supposedly they reconciled. She stated but she still continued to get irritated with the resident. She stated she tried to avoid him. At 2:27 p.m., resident #8 was asked if he was afraid of resident #1. He stated he was afraid that if there were no staff around and resident #1 knocked him down, he would not be able to get up. He was asked if he thought it was likely resident #1 would try to knock him down. He said, Yes. At 2:35 p.m., resident #12 said, He just glares at me like 'go to hell' or like he could kill me. She was asked if she was afraid of the resident. She said, Yes. I have laid here the last few days thinking he might catch my roommate gone and come in here and hurt me. She stated she felt like her feelings were not considered. She stated to her it seemed like the ADM was more worried about where resident #1 would go. She stated she asked the ADM if the resident could be moved to another room. She stated the ADM threw her hands up and stated she was not throwing him out. She stated when the resident looked at her meanly it made her feel uncomfortable. She said, I am a hard sleeper. He could really hurt me. She further stated her first husband was very abusive. She stated his verbally aggressive behaviors bring back bad memories. She said, I am reliving what I went through with my first husband. The resident then became tearful and started to cry. At 3:00 p.m., LPN #1 (licensed practical nurse) stated he was familiar with the resident. He stated the resident was definitely verbally aggressive towards staff and residents. He then said, When he gets in his moods he is verbal with anyone in his path. He stated he has heard him be verbally aggressive and call residents #3 and #12 names. At 3:01 p.m., CNA #4 stated she was familiar with the resident. She stated she had worked with the resident for almost three years. She stated the resident was known to have verbal outbursts. She stated mainly his verbal aggressions were towards residents #3 and #12. She stated he called them vulgar words. She then was asked to provide the most recent example she could recall. She stated last night he took the last glass of tea in the dining room. She stated he said, I don't want it but I know she (resident #12) does. She stated resident #12 approached her when she was clocking out for work two nights ago. She stated the resident was crying and stated resident #1 had been saying mean and vulgar things to her. She was asked what action she had taken when she received the allegation. She said, I just talked to her and tried to calm her down. She stated the resident reported she had talked to the ADM but nothing had changed. She stated the ADM flung her hands up in the air and said she's not doing anything. At 3:14 p.m., CNA #7 stated he was familiar with resident #1. He stated he had worked with the resident for over a year. He stated he had heard him be verbally aggressive to resident #12 when she was walking in the hallway. He said, I have witnessed him call her the b (explicit term) word in the hallway about three weeks ago. He then said, The charge nurse went with him (resident #1) to the administrator. (Named resident #12) also went to administrator. She was upset and crying and stated the administrator is not gonna do anything. 2. Resident #4 had [DIAGNOSES REDACTED]. A care plan, last updated 07/29/19, documented the resident had a cognitive loss deficit and dementia. The following interventions were identified; remove the resident from other residents rooms and unsafe situations and when the resident begins to wander provide comfort measures. The care plan identified a problem area of psychosocial well-being. The care plan documented the resident had anxiety; pacing, wandering, restlessness, fidgety and hiding behaviors. The following interventions were identified; assess if the resident's behavioral/mood symptoms present a danger to the resident and/or others and intervene if needed. A nurse's progress note, dated 08/12/19, documented, It was brought to my attention that resident was pushed in the chest by (Named resident #11) on hall 2. Staff reviewed the video footage. Resident was assessed, no injury noted. Resident ambulating in hallway without difficulty. (Named family member) notified on incident . A nurse's progress note, dated 09/23/19, documented, It was brought to my attention that (Named resident #4) was over on hall 1 and had an altercation with another resident. (Named resident #3) from hall 2 stated that (Named resident #4) was swinging at her an one came in contact with her face. (Named resident #3) has been very aggressive during shift and difficult to redirect at times. Both residents were assessed and no injury noted. Will continue to monitor closely. ADM aware of situation, physician notified . There was no documentation the resident to resident altercations on 08/12/19 and 09/23/19 were investigated and the residents were protected from further abuse. A quarterly assessment, dated 10/01/19, documented the resident was severely impaired in cognitive skills for daily decision making. She had behaviors of wandering daily during the seven day look back period. She required limited assistance of one staff member with transfers and ambulation. She did not require an assistive device for transfers or ambulation. On 11/13/19 at 11:20 a.m., resident #3 stated resident #4 hit her a couple of months ago. She stated staff members were aware. She said, They did nothing. She then said, She's not right. Yesterday she was swinging at everyone. On 11/14/19 at 9:57 a.m., the ADM was asked what allegations were investigated. She stated all allegations were investigated. She was asked how staff ensured residents were protected from potential further abuse from resident to resident altercations. She stated if a resident altercation became physical staff conducted every 15 minute checks on both residents. She was notified of the altercations documented in resident #4's clinical record. She stated she was not aware the allegations must be investigated if the altercation did not result in an injury which required only first aide. 3. Resident #11 had [DIAGNOSES REDACTED]. An annual assessment, dated 08/23/19, documented the resident was moderately impaired in cognitive skills for daily decision making. He required set up to limited assistance from a staff member for activities of daily living. He did not speak English as a primary language and used an interpreter or communication board to communicate needs. On 11/14/19 at 9:15 a.m., resident #9 stated she had experienced incidents of nonconsensual sexual contact by resident #11. She was asked when the incidents of nonconsensual sexual contact occurred. She stated both incidents occurred about two weeks ago in the dining room. She stated during the first incident resident #11 came up to her in the dining room, put his hands under her sweater, and touched her breast. She was asked if she told anyone. She stated she told CMA #2 (resident #11's family member who worked at the facility), but nothing happened. She was asked about the second incident of nonconsensual sexual contact by resident #11. She stated we were in the dining room. He came toward me in his wheelchair and tried to grab my crotch. I tried to move him away and I told him to go away. CMA #2 moved him away from me. She further stated she notified CMA #2 what happened but it did not do any good. She was asked if she was afraid of resident #11. She stated she was. On 11/18/19 at 10:04 a.m., the ADM was asked if she had been notified of a recent allegation of resident #11 making nonconsensual sexual advances and grabbing at resident #9's breast and crotch. She stated she was not aware of the allegations. She was asked what action she would have taken if she had been aware. She stated she would have had a family counsel session with both residents. She stated both residents were cognitively alert and capable of consent. She stated she would probably ask (Named resident #9) if she wanted it or not. She stated if resident #9 reported she did not she would counsel the resident and tell them it was not appropriate. She was asked if this was a potential abuse allegation which required investigating and protecting residents during the ongoing investigation to prevent potential further abuse. She said, I wouldn't think so unless (Named resident #9) said she didn't want his advances. She was notified the allegation must be considered an allegation of abuse and the abuse policy must be implemented. She was notified the abuse policy would not need to be implemented if both residents were determined to be capable of providing consent for sexual contact and both agreed to sexual contact between each other. At 10:12 a.m., CNA #2 was asked if she was aware of any nonconsensual sexual contact between resident #11 and any female residents. She stated resident #9 tried to kiss resident #11 and then reported he had touched her chest. She stated resident #9 stated she slapped his hand away. CNA #2 was asked what action did she take to address the allegation of nonconsensual sexual contact by the resident. She stated she told resident #9 if she did not want to be touched to let resident #11 know. She was asked if she spoke to resident #11 after the allegation of nonconsensual sexual contact. She stated he denied it. She stated she told him to keep his hands to himself. She stated she notified LPN #3 of the incident. At 10:39 a.m., the DON was asked if she was aware of an allegation of nonconsensual sexual contact by resident #11 to resident #9. She stated she was not aware of any recent allegation of nonconsensual sexual contact between the residents. She then reviewed resident #9's [DIAGNOSES REDACTED]. At 10:51 a.m., CNA #2 was asked when the incident of nonconsensual sexual contact between the residents occurred. She stated about three weeks ago. At 12:00 p.m., an interview was conducted at the bedside with resident #11 and a family member who interpreted (CNA #2). The resident was asked if he had kissed or touched a female resident. He stated he did not and did not remember kissing or touching anyone. The resident was asked if he had been given consent by any female residents to kiss or touch them. He said, No, I don't have any womens. He was asked if anyone had told him not to kiss or touch female residents. He said, No. At 1:27 p.m., LPN #3 was asked if she was aware of any nonconsensual sexual contact between the resident and any female residents. She stated CNA #2 told her about an incident which occurred about three weeks ago. Resident #11 touched resident #9's breast while in the dining room. She further

Based on interviews and record reviews, it was determined the facility failed to ensure one (#1) of two sampled residents with verbally aggressive behaviors did not verbally and mentally abuse other residents for four (#2, 3, 8, and #12) of five sampled residents reviewed for abuse. This resulted in resident #12 staying in her room rather than face additional altercations with resident #1. Resident #12 reported feeling fearful of falling asleep due to the possibility the resident may hurt her, and she had a decline in her social activities. Additionally, the resident reported a history of spousal abuse, and she stated she felt like she was reliving those events. The administrator identified 83 residents who resided in the facility. Findings: A facility policy titled, Abuse Prohibition Policy, documented: .each individual resident has the right to be free from any form of abuse. This facility strictly prohibits any verbal .mental abuse .Employee training will consist of .appropriate interventions to deal with aggressive .reactions of residents .how staff should report .allegations .knowledge of what constitutes abuse .Attempts will be made to identify, correct and intervene in situations in which abuse .is more likely to occur .evaluation of the supervision of staff to identify inappropriate behaviors .evaluation of the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict .Identification of events, occurrences, suspicions .that may constitute abuse shall be reported to the facility administrator, the nursing director .and the OSDH (Oklahoma State Department of Health) .All reports of potential abuse will be investigated by the administrator and/or nursing director .Action will be taken to protect any potential victim(s) identified during the investigation .All alleged violations and all substantiated incidents will be reported to the appropriate authorities and state agencies .Reports shall include .summary of what happened: Name all persons involved and attach witness(es) statements .copy of incident report completed by the charge nurse .copies of all documentation supplied to all outside agencies notified .any other information or documentation pertinent to the investigation .The investigation must be documented from the initial report to completion of the investigation. Any action taken with any party involved must be recorded . A facility policy titled, Resident to Resident Altercations, documented: .All altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Nursing Supervisor, Director of Nursing Services, and to the Administrator. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents .Occurrences of such incidents shall be promptly reported .If two residents are involved .staff will: Separate the residents .Identify what happened .Notify each residents representative and Attending Physician of the incident .Review the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents .make any necessary changes in the care plan approaches to any or all of the involved individuals .Document in the resident's clinical record all interventions and their effectiveness .Complete a Report of Incident/Accident form and document the incident, findings and any corrective measures taken in the resident's medical/clinical record .Report incidents, findings, and corrective measures to appropriate agencies . Resident #1 had [DIAGNOSES REDACTED]. A care plan, last updated on 09/03/19, documented the resident had a history of [REDACTED]. The care plan identified the resident had behaviors related to taking food items which did not belong to him and becoming defensive and verbally inappropriate when approached about the food related behaviors. There were no interventions identified related to the resident's verbally socially inappropriate behaviors. An annual assessment, dated 09/13/19, documented the resident was cognitively alert in skills for daily decision making. He was independent with transfers and ambulation. He self propelled in a wheelchair. A psychiatric consultation progress note, dated 10/02/19, documented there was no evidence of delusional ideations or perceptual disturbances. The note documented the plan was to continue to closely monitor the resident for any changes in psychiatric stability and risk of harm to self and/or others. A nurse's progress note, dated 10/05/19, documented the resident became angry with staff when the resident observed another resident in the kitchenette. The resident yelled, cussed and insulted the nurse through the hallway and in the dining room. The resident continued the same behavior every time he saw the same staff member. The resident also yelled, cussed, and insulted a member of the dietary staff. The resident ran his chair into the food cart in an attempt to move it out of the way. The resident also yelled, cussed and threatened another resident (resident #8) saying, I will knock that cane out from under you. The note documented the residents were separated and both were safe. A nurse's progress note, dated 10/06/19, documented the resident became angry at another resident (resident #8) and yelled, cussed, and threatened him. The note documented the resident stated he was going to kick his cane out from under him. CNA #3 (certified nurse aide) intervened and separated both residents. The note documented the nurse spoke with the resident and advised him he should not make threats and if he chose to continue to threaten residents there would be consequences. The note documented the resident stated he understood and would not continue the identified behaviors. An administrator's note, dated 11/07/19, documented three separate allegations of abuse between resident #1 and three other residents (#2, 3, and #12) were made known to the ADM. The note failed to document a thorough investigation was conducted and residents were protected. 1. The note documented the ADM first became aware resident #1 was cursing at resident #12 on 10/30/19. The note documented on that day, 10/30/19, the ADM offered to move resident #12 to a different hall, but the resident refused this offer saying she shouldn't have to move. Resident #12 stated, since the ADM would not discharge resident #1 from the facility, she (resident #12) would have to find another place to live. The note documented resident #1 also refused to move to another hall but did agree not to speak to resident #12. The note documented, on 11/04/19, resident #1 reported to the ADM he and resident #12 had worked everything out and even prayed together; however, at that time, there was no documentation this agreement had been confirmed with resident #12. The noted documented, on 11/07/19, the ADM followed up with resident #12 to verify resident #1's claims they had reconciled. The note documented resident #12 stated they had made amends at that time but since then a couple of days later resident #1 had said something to her as she went passed his door. The note documented once again resident #12 was offered the opportunity to move to a different hall, but she declined. Other than asking resident #1 not to speak to resident #12 and requesting residents to move, there was no documentation of actions taken to keep resident #12 safe, of an investigation of abuse, or the reporting of verbal abuse to the OSDH. 2. The ADM's note documented, on 11/06/19, she first became aware of issues between resident #1 and resident #3. The note documented, resident #3 reported to the ADM resident #1 had asked her if she was a f ing (explicit term) light bulb when she wore a brightly colored shirt. The note documented resident #3 requested resident #1 be kicked out of the facility. The note documented the ADM told resident #3 she could not kick someone out for that, and resident #3 responded by saying she wasn't putting up with it .she was moving out as soon as she could and the ADM could keep her pet. The note documented, when asked by the ADM, resident #1 denied using profanity at resident #3. There was no documentation of actions taken to keep resident #3 safe, of an investigation of abuse, or the reporting of verbal abuse to the OSDH. 3. The note documented, on 11/07/19, the ADM first became aware of an allegation resident #1 might be abusing resident #2. The note` documented, on 11/07/19, resident #12 reported to the ADM she believed resident #1 was mistreating resident #2 as she saw resident #1 standing, holding a urinal over resident # 2 when he was in bed. The note documented the ADM interviewed resident #2, and he denied being mistreated. There was no documentation of actions taken to keep resident #2 safe, of an investigation of abuse, or the reporting of this allegation to the OSDH. On 11/13/19 at 10:32 a.m., resident #8 was interviewed about resident #1. He stated the resident had been verbally abusive to resident #12 many times. He stated resident #12 was moving out of the facility. He stated she was tired of it. He stated the resident (resident #1) called a nurse a b .(explicit term) and a whore. He stated he then told the resident not to be pissy and he laughed at the resident. He stated the resident then came after him in his wheelchair. He said, He was going to hit me and (Named CNA #3 (certified nurse aide)) stepped in between us and he backed off. He stated he told CNA #3 not to stand between him and the resident. He stated he told CNA #3 he would take the hit. He further stated the resident had threatened him three times saying he would kick his cane out from under him. He said, I've had a stroke, and I use my cane to get up. He stated he reported the threats to the staff, but he was unsure if anything had been done. At 10:35 a.m., resident #12 stated she was passing by resident #1's room. She stated she observed resident #1 walk over to his roommates bedside (resident #2) with a urinal in his hand. She stated she observed resident #1 pull back resident #2's covers with his urinal in hand. She stated she asked resident #1 what he was doing and he was startled. She stated she had observed some bruising on his roommate a few times prior to the observation. She reported she notified the nursing staff of her observations. She then stated she had left for an appointment on 10/31/19. She stated when she arrived back at the facility she met the resident in the hallway. She stated the resident put his wheelchair in front of her. She stated the resident called her a f ing (explicit term) b (explicit term). She stated the incident occurred right in front of the nurse's station and the nurses in the station observed the altercation. She then stated she started crying. She stated the administrator came to her room to talk to her about the allegation. She stated the administrator notified her she just needed to ignore the resident because he was mad at the world. She stated the administrator stated she was not moving the resident out of the facility because he had no place to go. She stated he often calls her names such as sorry f ing (explicit term) b (explicit term) and sorry mother f .er (explicit term). She stated she stayed in her room to avoid confrontations from him. She stated she was trying to move out of the facility to another town. She stated she originally came to the facility with her husband but he had passed. She said, I thought this would be my forever home. I don't want to leave my home. She then stated her first husband was abusive. She said, I shouldn't have to put up with this abuse. She further said, I don't like sitting in here. I don't like having to isolate myself. I like to visit with others. At 10:36 a.m., resident #10 stated resident #1 curses at residents. She said, He's gruff. At 10:46 a.m., resident #14 stated resident #1 had a short fuse. She stated he called the nurses vulgar names. She stated about a month ago he called resident #12 a sorry mother f ER (explicit term). She stated she did not report the incident to staff. She stated the staff were present and they just kind of slough it off. At 11:00 a.m., resident #6 stated he was blind. He stated he had heard resident #12 talk to her tablemates during meals about how she was being verbally abused by a resident. At 11:20 a.m., resident #3 stated resident #1 verbally abused her and everyone. She said, F (explicit term) is his favorite word. She stated he was very verbally abusive. She stated staff were aware but they stated there was nothing they could do about it. She stated herself and other residents were moving out due to his verbally aggressive behaviors. She said, I'm moving out as soon as I can. I didn't come here for that. He's just mean. She then stated recently she was out getting a cup of coffee and the resident wheeled by her in his wheelchair. She stated the resident said, What are you an f ing (explicit term) light bulb? At 11:55 a.m., the resident's roommate (resident #2) was asked if any resident had ever been mean to him. He said, I don't know. He was asked if anyone had talked mean to him or made him feel uncomfortable. He said, Yes. He was asked if he had notified a staff member and he stated no. He was asked if his roommate (resident #1) was ever mean to him. He said, I don't know. At 12:37 p.m., resident #13 stated he was participating in a Bingo activity with staff present when the resident entered from the outside smoke area with another resident. He stated both residents began yelling Bingo! He stated he told the residents to shut up or come get a Bingo card. He stated both residents then began yelling profanities at him. On 11/14/19 at 9:18 a.m., resident #3 was asked if she was afraid of the resident. She stated she was. At 9:57 a.m., the ADM was asked what incidents and allegations were reported to the OSDH. She stated injuries resulting in fractures and resident to resident altercations with injuries which required more than first aide were reported. She was asked if allegations of abuse or neglect were reported. She stated if the allegation was staff to resident we report. She was asked what allegations were investigated. She stated all allegations were investigated including allegations involving staff and injuries of unknown origin. She then stated the facility investigated issues with (Named resident #3 and Named resident #1). She said, We looked into (Named resident #1 and Named resident #12). She stated they asked resident #3 and resident #12 if they wanted to move to a different room. She stated they declined to move. She stated they asked resident #1 if he wanted to move to a different hallway and he declined. She said, They (resident #1 and #12) actually met together which is what we were hoping for. So far all is better with them. She was asked if a resident was verbally aggressive and calling residents names and making threats towards residents was this considered possible abuse which required reporting, investigating and protecting residents. She stated she really did not consider this abuse. She was asked if she had any OSDH incident reports for resident #1 involving resident to resident altercations due to his verbal/mental abuse. She stated she did not have any reports for resident #1. At 10:34 a.m., CNA #5 was asked what action she would take if she observed or if someone told her they had witnessed a resident hitting, cursing, or yelling at another resident. She stated she would ask if the staff member making the report had taken any form of action and if not, she would report it to the nurse. She was asked if she had been told of a resident to resident altercation involving resident #1. She stated she was told by another staff member the resident was observed standing over his roommate's bed saying, I wish you would die. She was asked what action did she take. She stated she did not take action because she did not know when the alleged incident occurred or who had actually witnessed the incident. She further stated the resident was generally rude, but she had not witnessed the resident be abusive to other residents. At 10:39 a.m., CNA #6 was asked what action she would take if she observed or if someone told her they had witnessed a resident hitting, cursing, or yelling at another resident. She stated she would separate or split up the residents and would let the nurse know. She was asked if she had witnessed resident to resident abuse and what did she do in response. She stated resident #1 was rude and verbally abusive to resident #12 in the hallway. The activity director and her split them up and spoke with each of them. She was asked who the incident was reported to. She stated the nurse. At 10:45 a.m., housekeeper #1 was asked what action she would take if she observed or if someone told her they had witnessed a resident hitting, cursing, or yelling at another resident. She stated she would step in and find out what the problem was and report it to the nurse. She was asked if she had been told of a resident to resident altercation involving resident #1. She stated she had not. She further stated the resident was generally verbally rude, gruff, and mumbled a lot. At 11:00 a.m., LPN (licensed practical nurse) #4 was asked what action she would take if she observed or if someone told her they had witnessed a resident hitting, cursing, or yelling at another resident. She stated she would separate the residents and investigate what happened and report it to the oncoming nurse and the DON (director of nurses). At 11:16 a.m., CMA #3 (certified medication aide) was asked if resident #12 came out for activities and to socialize or if she stayed in her room. She stated she comes out of her room for Bingo and meals. She stated she had recently started staying in her room more often. She stated she was upset with (Named resident #1). She stated they had gotten into an argument. She stated she had heard both residents had worked it out and then heard they had not worked it out. She said, She avoids him. At 11:37 a.m., resident #1 was asked if he yells, cusses or threatens other residents. He stated he had yelled and cussed at some residents at times. He stated he had never threatened another resident. He stated he had yelled and cussed at resident #12 and they had made up and then she got mad again. He said, She thinks I'm mistreating my roommate. He was asked if he had ever threatened to kick a resident's cane out from under him. He stated he had. He stated resident #8 and himself had a problem, but staff talked to them and separated them. At 12:39 p.m., the ADM was asked to discuss resident #1's behaviors. She stated the resident was angry about being in the facility. She stated he often exhibited behaviors if he did not get his way. She stated the resident had been verbally lashing out towards residents #3 and #12 for the last two weeks. She then stated recently resident #3 was wearing a bright orange sweatshirt. She stated the resident told her she looked like a f ing (explicit term) light bulb. She stated resident #3 notified her of the altercation. She was asked if she was aware resident #1 had threatened resident #8 to kick his cane out from under him. She stated she was not aware of the allegation. She was notified the altercations were documented in resident #1's record and a staff member had intervened on one occasion. She was notified resident #8 reported he had notified staff of the same allegation occurring on three separate occasions. She stated she recalled a recent incident with resident #1 and another resident interrupting a Bingo game. She stated the activities director reported the residents were being loud and yelling Bingo! She stated the activities director reported she told them to be quiet and they left and nothing further happened. She stated she interviewed staff about allegations reported from residents #3 and #12. She stated there were no staff members who reported witnessing the incidents. She was asked if she had interviewed other residents who resided on resident #1's hall to assess if they felt safe or if they had been verbally abused by the resident. She stated they had not interviewed other residents. She stated resident #12 had reported she felt resident #1 was abusing his roommate, (Named resident #2). She stated the administration staff had talked with resident #2 and all was okay. She was asked if they had documented a statement from the interview with resident #2. She stated they had not. She was asked if the resident's verbally aggressive behaviors had been escalating. She stated they had. She was asked what action had been taken to ensure residents were protected from potential further verbal abuse by resident #1. She said, We put staff on notice for (Named resident #1) to see if he says things to (Named resident #12). She stated staff were to watch their interactions and be aware. She stated if staff observed any concerning interactions they were instructed to notify the DON (director of nurses) or herself. She further stated staff were instructed to keep resident #1 and #12 separated. She did not provide actions to protect other residents on that hall from potential further abuse including residents #2 and #3. She was asked if any resident had reported they were afraid or stated they did not want to leave their room in order to avoid confrontations with resident #1. She stated resident #12 stated she did not want to look at the resident and she stated she was just going to stay in her room. She stated she encouraged resident #12 to just do your normal stuff and don't let him get to you. At 12:45 p.m., the activity director stated resident #12 comes to the Bingo activity. She stated she gets irritated with (Named resident #1). She stated she had a decline in her social activities recently. She stated she used to come to other activities and enjoyed going outside. She stated now the resident stayed in her room because she did not want to go down the hallway. The resident's room was in close proximity to resident #1's. She further stated in the last month she had been staying in her room. She stated she currently comes out of her room for meals and Bingo. She said, She's not as social in the last month. She stated sometimes resident #1 will come by the dining room during Bingo and say, Hey (Named resident #12). She stated this antagonizes her. She stated about one month ago the residents (resident #1 and #12) crossed paths in the hallway. She stated she heard resident #1 say to resident #12 why are you here you f .ing (explicit term) b (explicit term). She stated this upset resident #12. She said, We comforted her. She then said, Supposedly they reconciled. She stated but resident #12 still continued to get irritated with resident #1. She stated resident #12 tried to avoid him. At 2:27 p.m., resident #8 was asked if he was afraid of resident #1. He stated he was afraid that if there were no staff around and resident #1 knocked him down he would not be able to get up. He was asked if he thought it was likely resident #1 would try to knock him down. He said, Yes. At 2:35 p.m., resident #12 said, He (resident #1) just glares at me like 'go to hell' or like he could kill me. She was asked if she was afraid of the resident. She said, Yes. I have laid here the last few days thinking he might catch my roommate gone and come in here and hurt me. She stated she felt like her feelings were not considered. She stated to her it seemed like the ADM was more worried about where resident #1 would go. She stated she asked the ADM if the resident could be moved to another room. She stated the ADM threw her hands up and stated she was not throwing him out. She stated when the resident looked at her meanly it made her feel uncomfortable. She said, I am a hard sleeper. He could really hurt me. She further stated her first husband was very abusive. She stated his verbally aggressive behaviors bring back bad memories. She said, I am reliving what I went through with my first husband. The resident then became tearful and started to cry. At 3:00 p.m., LPN #1 stated he was familiar with the resident. He stated the resident was definitely verbally aggressive towards staff and residents. He then said, When he gets in his moods he is verbal with anyone in his path. He stated he has heard him be verbally aggressive and call residents #3 and #12 names. He stated he was unsure if other staff had observed the incidents. He was asked if he reported this to his charge nurse or the facility administration staff. He said, No, I didn't report it to anyone. At 3:01 p.m., CNA #4 stated she was familiar with the resident. She stated she had worked with the resident for almost three years. She stated the resident was known to have verbal outbursts. She stated mainly his verbal aggressions were towards residents #3 and #12. She stated he called them vulgar words. She then was asked to provide the most recent example she could recall. She stated last night he took the last glass of tea in the dining room. She stated he said, I don't want it but I know she (resident #12) does. She stated resident #12 approached her when she was clocking out for work two nights ago. She stated the resident was crying and stated resident #1 had been saying mean and vulgar things to her. She was asked what action she had taken when she received the allegation. She said, I just talked to her and tried to calm her down. She stated the resident reported she had talked to the ADM but nothing had changed. She stated the ADM flung her hands up in the air and said she's not doing anything. She was asked if she had reported the most recent incidents to her charge nurse or the ADM. She stated she had talked with the staffing coordinator in the past but not for the most recent allegation. At 3:14 p.m., CNA #7 stated he was familiar with resident #1. He stated he had worked with the resident for over a year. He stated he had heard him be verbally aggressive to resident #12 when she was walking in the hallway. He said, I have witnessed him call her the b (explicit term) word in the hallway about three weeks ago. My coworker and I went to the administrator and reported. He then said, The charge nurse went with him (resident #1) to the administrator. (Named resident #12) also went to administrator. She was upset and crying and said, The administrator is not gonna do anything.

Based on observation, record review, and interview, it was determined the facility failed to: a.) ensure facility staff safely transferred residents with the required amount of staff for one (#8) of one sampled resident who was transferred via a sit to stand lift. This resulted in an actual harm to the resident. The Resident Census and Condition report identified 77 residents who required extensive to total assistance with transfers. b.) ensure transport drivers securely strapped residents and/or their wheelchairs in the transport van for one (#43) of one sampled resident who was transported via the facility van. This resulted in an actual harm for the resident. This had the potential to affect 85 residents who resided in the facility. c.) ensure one (#91) of one sampled resident who wandered throughout the facility and into other residents' rooms was supervised and monitored to prevent the resident from violating the privacy of other residents. This had the potential to affect 85 residents in the facility. Findings: The "Lifting Machine, Using a Portable" policy documented, "...review the resident's care plan to assess for any special needs of the resident....can be used by one nursing assistant if the resident can participate in the lifting procedures. If not two (2) nursing assistants will be required to perform the procedure..." The facility policy titled "Safety and Supervision of Residents" documented, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.... Policy Interpretation and Implementation...Resident-Oriented Approach to Safety...Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam (examination), observations of the resident, and the MDS (minimum data set)....Resident Risks and Environmental hazards:... These risk factors and environmental hazards include:...Unsafe wandering..." 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident's cognition was moderately impaired, was able to understand others and be understood, required two person extensive assistance with transfers, had upper and lower extremity limitations on one side and was not able to stabilize self without staff assistance. A care plan dated 12/20/13, documented, "Problem: Resident's ability to transfer, walk in room, walk in corridor, dress, eat,...has deteriorated R/T (related to) history of CVA. Goal: Resident will not further deteriorate in ADL (activities of daily living) completion as evidenced by maintaining current level of function. Approach...provide set up to extensive assistance for ADL completion... Problem: Resident is at risk for pain related to history of CVA and depression. Goal: Resident will have decreased pain and unwanted side effects from taking pain medication. Approach...nursing staff to assess pain... Problem: Resident is at risk for falling R/T [DIAGNOSES REDACTED].and instability during transitions. Goal: resident will remain free from injury. Approach..encourage resident to assume a standing position slowly..." The resident's care plan did not address the need for a two person assist with transfers. The medication administration record for January 2014, documented the resident had the following orders for pain medication: Acetaminophen 325 milligrams (mg) two tablets every four hours as needed for pain or elevated temperature. The order was first written on 12/10/13. Lorazepam 0.5 mg one tablet every eight hours as needed (PRN) for anxiety. The order was first written on 12/10/13. Ultram 50 mg one tablet every six hours for pain. The order was first written on 12/10/13. A nurses's note dated 01/11/14 at 11:39 p.m., documented, "Resident complained of severe pain to right knee 12/10 on pain scale. Rt (right) knee appears swollen prn pain medications have already been given and can not be repeated at this time. Ativan given per prn order. Ice pack applied ice pack providing some pain relief. Resident appears to be relaxed and closing her eyes to rest." A review of the staffing assignment for 01/11/14, documented three certified nurse aides and one certified medication aide was working on the East hall, the hall the resident resided on. The census on the hall for the same day was 44. A nurse's note dated 01/12/14 at 12:20 a.m., documented, "Ice pack removed resident no longer complained of pain. No further change noted." A nurse's notes dated 01/12/14 at 2:15 a.m., documented, "Resident awakened with pain to Rt knee 10/10 on pain scale. Rt knee slightly repositioned and supported with pillow. Ultram given per PRN order will monitor." A nurse's note dated 01/12/14 at 4:50 a.m., documented, "Resident awake and asking for ice pack for rt knee. Ice pack applied as requested...." A nurse's note dated 01/12/14 at 10:54 a.m., documented, "Resident cont (continues) to c/o (complain of) pain to right knee. Knee slightly swollen call placed to on call Dr. (Name deleted) N/O (new order) received to send to ER (emergency room ) for eval (evaluation) and Tx. (treatment). Call placed to two numbers to reach son all been disconnected. Call placed to sister (Name deleted) to inform of situation. Resident then transported VIA (by) company vehicle with staff to ER." A nurse's note at 2:49 p.m., documented, "1200 (12:00 p.m.) logan county ER called to report admission to hospital dx (diagnosis) fractured femur. Talked with the nurse... call placed to sister to inform of situation still unable to reach son, sister states she is headed to guthrie and will go by son's house." A signed hand written statement by CNA #11 dated 01/12/14, documented, "I went to (Resident's) room to see if she would come out to the dining room for dinner in which she agreed....I proceeded to getting her ready for dinner but while on the stand up lift (Resident's) right arm began to shake and she complained that her leg hurt as well So I attempted lower her down but it was a delay with the functioning of the lift at this point (Resident) began to slide off the bed so I immediately went to catch her so she wouldn't fall off the bed to hurt herself. I gave...support so that I could put her back on the bed...she again said her leg hurt so I put (Resident) next to the bed with a few pillows...I went out to the hall and asked (CNA #12) to assisted me with (Resident) which she did as I explained to her what happened...a short time after dinner (CNA #12) and I began to get (Resident) ready for bed but again while on the lift...right arm began to start shaking so we put her down in her wheelchair in which we gave...a jump start from the wheelchair to the bed. We changed her got her ready for bed. I checked on her a little while after which she said that her feet hurt so I told the nurse that was in charge about it and the incident that had happened." A signed hand written statement by CNA #12 dated 01/12/14, documented, "I helped other aide with lifting resident off the floor. I came in and saw resident on floor. After we got her up, we got her bottom half way on the bed. I stayed with the resident while the other aide went and got the nurse. Once the nurse observed her then helped us finishing getting her ready for dinner. After dinner...the aide that was taking care of her tried to using the lift again, but the resident was shaking from the pain so the aide came and got me and told me what she was doing. We continued to use the stand up lift, but she couldn't stand all the way. So we quickly...got her in the bed...maybe an hour or so later she pushed her call light and I answered it. She told me to get the nurse cause it felt like something was broken." There was no documentation the facility had notified the physician and the family of the fall and the excruciating pain the resident was experiencing prior to 10:54 a.m. on 01/12/14. CNA #11 identified the pain in the leg and knee occurred on 01/11/14, prior to dinner at approximately 4:00 p.m. There was no documentation the resident was assessed for the pain and the cause of the pain. An emergency department (ED) note dated 01/12/14, documented, "History of present illness (HPI): (Resident) is a 55 yo (year old) female presents to the Ed with a chief complaint of knee pain. HPI comment Pt (patient) in NH (nursing home) due to a CVA and is a max (maximum) assist on transfers. She slid out of the chair yesterday during a transfer and landed on her rt knee. Since has had on going rt knee and rt hip pain. The history is provided by the patient.... Knee pain: This is a new problem. The current episode started yesterday. The problem occurs constantly. The problem has been gradually worsening. The pain is present in the right hip and right knee. The quality of pain is described as aching. The pain is at a severity of 10/10. Associated symptoms are aggravated by activity. Treatments tried pain medications. The treatment provided no relief....reevaluation: Xray showing distal femur fx (fracture)..." An X-ray result dated 01/12/14, documented, "...Interpretation...There is a moderately displaced oblique fracture through the distal femoral shaft. This extends into the lateral femoral condyle. There is comminution of the fracture involving the lateral femoral condyle..." A history and physical dated 01/12/14, documented, "Patient...presents with pain and swelling in her right knee. The patient sedated from pain medicine and unable to answer questions...radiology review: Right distal femur fracture...assessment: active problems...femur fracture...plan admit to inpatient ortho (orthopedic) consulted-plan for surgery tomorrow...pain control..." The medication administration records for January 11th and 12th 2014, documented the resident received the following medications to address pain: Acetaminophen 325 mg on 01/11/14 at 8:26 p.m. and 01/12/14 at 6:27 a.m. Lorazepam 0.5 mg on 01/11/14 at 11:22 p.m. and 01/112/14 at 8:46 a.m. Ultram 50 mg on 01/11/14 at 7:19 p.m., 01/12/14 at 1:43 a.m. and 8:46 a.m. There was no documentation the facility consulted the doctor of the continued excruciating pain that was not relieved with the medications and interventions provided. A "New Summary Referral" dated 01/28/14, documented, "...This female patient is [AGE] years old with a [DIAGNOSES REDACTED]. A nurse's note dated 01/28/14 at 1:29 p.m., documented, "Received report from (Name deleted) over the phone that resident is being discharged back to the facility post L (left) (the right femur was fractured) femur repair..." The resident's care plan was not updated to address the resident's pain associated with the fracture of the femur. The resident's care plan was not updated to address the fall and the fractured femur. A quarterly assessment dated [DATE], documented the resident required extensive assistance of two persons with transfers, had clear speech, made self understood and could understand others. The assessment further documented the resident's cognition was intact and had upper and lower impairment on one side and was able to stabilize with staff assistance when moving from a seated to a standing position. An interview was conducted on 07/18/14 at 2:01 p.m., with the resident. She was asked about sustaining a fractured femur. She was asked how it happened. She stated, "I slid when they were trying to get me to walk to my wheel chair." She was asked who was trying to make her walk. She stated, "The aide was trying to make me walk." She was asked if she could identify who the aide was. She stated she was not sure of the name but it was a male. She was asked if she had any pain or injury at the time of the incident. She stated, "The leg hurt right away. I said, 'Oh man I broke something.'" She was asked if the facility provided her with any medications for the pain. She stated, "They did not give me any medication." An interview was conducted on 07/18/14 at 2:12 p.m., with certified nurse aide (CNA) #11. He was asked if the resident was able to walk with or without assistance. He stated, "No." He was asked if the resident was able to stand on her own. He stated the resident had been able to stand with assistance for a short time. He was asked if the resident had any falls or fractures since being admitted to the facility. He stated, "As far as I know she has not had a broken leg." An interview was conducted on 07/18/14 at 2:26 p.m., with the director of nursing (DON). She was asked about the fractured femur the resident sustained [REDACTED]." A request was made for the investigation into the fracture, and a copy was provided. At 3:36 p.m., a second interview was conducted with CNA #11. He was shown a written statement that he had signed and asked about the incident. He stated, "This happened when I first started here." He was asked about his knowledge of policies and individual residents. He stated, "I really did not know a lot. I just knew the simple stuff." He was asked to describe what had happened. He stated he had the resident on the stand up lift and she started shaking and the lift froze when he tried to put the resident back down on the bed. He stated the resident had said it started to bother her and complained it hurt when she started to shake. He stated the resident had pain. He stated the lift had stopped working and the resident was dangling above the bed and was starting to slide down. He stated he had wrapped his arms around her, removed the sling from the lift, and lowered the resident to the floor. He was asked how many staff was in the room assisting with the transfer. He stated, "I was the only person in the room when using the stand up lift". He was asked what the facility policy was for using the stand up lift if a resident is a two person assist with transfers. He stated, "You have to be 18 to touch and use it and two persons are to be in the room." He was asked about the level of assistance the resident required while being transferred. He stated, "(Resident) is a two person assist." He then added, "I did not know that about her." He was asked what time of day and when the fall and incident happened. He stated, "It happened at dinner time on the eleventh at approximately 4:00 p.m." Once the resident was on the floor he positioned pillows around her to make her comfortable and went to get CNA #12 to assist with lifting the resident from the floor back to the bed. He was asked if he notified anyone of the incident. He stated CNA #12 stayed with the resident as he went and told the nurse the resident complained of pain and needed to be looked at. The nurse came in the room and we left until she was done. The nurse knew the resident had complained of pain and her knee hurting. He was asked what happened after the nurse was in the room. He stated CNA #12 and he got the resident up for dinner. When asked if she continued to complain of pain he stated, "Yes." At 3:56 p.m., the DON was asked how the resident fractured her femur. She stated, "I don't know." She then added she had spoken with a lot of people and interviewed the nurse working that night. She was asked for the findings of the interview of the nurse. She stated, "The resident's range of motion was fine." She then added the resident had gotten up and went to dinner. She was asked about the resident's pain and complaints of knee problems. She stated she had not been notified that it was an issue. She then stated, "I was not aware of a problem until she was sent out to the hospital." She was asked what the policy was for using a lift for someone that required extensive assistance with transfers. She stated, "We care plan what the resident is for assistance with transfers." She then stated the portable lift can be used by one aide if the resident can assist. If they can not assist then with two aides. An interview was conducted on 07/18/14 at 4:25 p.m. with LPN #5. The charge nurse on duty the night of the resident complained of pain. She was asked what shift she worked. She stated the 2:00 p.m. to 10:00 p.m. shift on hall 200. She was asked if she worked on 01/11/14, when the resident had the incident which resulted in pain. She stated she had been. She was asked if the resident had a fall. She stated, "I was not told it was a fall. The lift had let her down." She was asked what CNA #11 had reported to her. She stated, "All I know is they needed help getting her because because she was on the side of the bed." She then added, "He wanted me to check her out because she complained of knee pain." When asked where the resident was located when she entered the room she stated, "She was on the bed when I got to the room." She was asked how she assessed the resident when entering the room. She stated they had to physically move the resident up further in the bed. She then stated she asked the resident if the pain was like before and she said yes. She then stated, "I thought it was just her knee and it had been tweaked when she was moved up." She was asked if she had investigated and questioned the staff who was in the room when the incident occurred. She stated, "I could have done a more thorough investigation." She was asked if the resident had a fracture as a result of this incident. She stated the resident had only complained of knee pain and not leg pain. She was asked if the physician had been notified of the incident and the resident's complaints of pain. She stated, "I faxed the doctor, maybe I put it in the 24 hour report." She was asked to locate all her documentation and verification she had notified the physician of the incident and pain. She stated, "I did not document any of this." She then stated, "I did not notify the doctor and I did not really assess the resident." The only documentation was the note from the nurse on the next shift by RN #1 when she came on at 10:00 p.m. At 4:36 p.m., the DON was asked how she had investigated the fracture to determine the cause. She stated, "We looked at the video surveillance camera and she looked all right when out in the dining room." An interview was conducted on 07/21/14 at 9:29 a.m., with CNA #3. She was asked how long she had been employed by the facility. She stated four years. She was asked to describe the level of assistance the resident needed while being transferred. She stated a stand up lift was used and at times she would be able to pivot. She was asked if the resident required one or two staff while being transferred. She stated, "She will swing her legs over and we lift once the sling is on her. The resident is able to help, she grabs onto the bar and can bear weight with her legs." She then stated she thought the resident required two staff during transfers. She was asked if the resident had sustained any falls since being admitted . She stated, "I remember once, they used the stand up lift and she fell . She had broken her hip I think. She was in the hospital quite awhile due to the broken hip. She had to have surgery." She was asked if she had transferred the resident with additional staff assisting. She stated at times the resident would be transferred with only one aide present. An interview was conducted on 07/21/14 at 9:40 a.m., with certified nurse aide #14. She was asked how long she had worked at the facility. She stated, "Nine months." She was asked what halls she was assigned to? She stated, "I work both halls evenly." She was asked if she was familiar with the care needed to be provided to the resident. She stated, "I am. I have worked with her on hall 200 and 100." She was asked to describe the level of assistance the resident required with transfers. She stated it had been with one and she used to transfer the resident by herself. She then stated it was being changed and all care was an extensive two person and transfers were with an overhead lift. She was asked if there had been anytime the resident had a fracture. She stated, "There was an accident and that's why the stand lift is not being used." She then stated the resident was out of the facility for a long time and added, "I was here the morning she went out the hospital. She was in a lot of pain and vocalized it to me and (LPN #7)." She was asked when it had occurred. She stated, "It happened (01/11/14) sometime after 2:00 p.m., when I got off." An interview was conducted on 07/21/14 at 9:55 a.m., with CNA #10. She was asked what halls she worked on? She was asked what level of assistance the resident required with transfers. She stated, "When she first came we only did it with one person and the stand up lift. When she first came we could transfer her by ourself with the stand lift." An interview was conducted on 07/21/14 at 1:47 p.m., with the DON. She was asked what level of assistance the resident required at the time of the fall. She stated, "Before the fall it was a one person assist." She was asked how the facility assessed the resident's level of assistance for transfers on the admission assessment. She stated, "Two person extensive assistance." She was asked if the care plan addressed two person extensive assistance with transfers. She replied the care plan addressed extensive assistance but did not specify two persons. She stated the care plan reflected just extensive assistance, it doesn't address the number of staff. Was the care plan updated to address the resident's fracture and the pain associated with the fracture? She stated, "I will look." She then stated it did not. She was asked what caused the fracture. She stated, " I really don't know. I am not at liberty to speculate because I am not a doctor." She was asked if it was an injury of unknown source. She stated, "Yes it is." She was asked if the facility completed a thorough investigation into the fractured femur. She stated, "I feel like I did when it was brought to my attention." She was asked if she talked with the resident about what had happened. She stated, "I don't have any documentation we had." She then added the resident was in the hospital and she had not been talked to. She was asked if the aides working at the time the resident complained of pain were interviewed. She stated she did not interview them about the condition of the resident prior to the pain. A request was made for further documentation of the investigation into the fractured femur. No additional documenation was provided. She was asked how the facility assessed the resident's pain and addressed it. She stated, "I will have to look and see what had been done." She then stated the facility had administered pain medication of Ultram and Tylenol. She was asked what level of pain the resident was in. She stated, "Excruciating." She was asked if the physician was notified in a timely manner. She stated, "No sir." When asked what the facility policy was for notification to the physician of a change in a resident's condition, she stated, "A prudent nurse should notify immediately." She was asked if the staff followed the facility's policy and procedure for falls. She stated, "No, but the nurse didn't think it was a fall." She was asked how she ensured aides were properly trained when first hired. She stated through education and pairing them up with someone. She then added if the person who is paired with the new hire is not comfortable we can pair them up for longer. She was asked who completed the skills check list and knowledge of new hires and current employees. She stated, "(CNA #11) was trained at another facility through a nurse aide training program and then came to work here. He was paired up with a staff member for training purpose here. She was asked how she made sure they were trained on the resident specific needs. She stated, "We don't do skill competency checks on employees." 2. Resident #48 was admitted to the facility with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated [DATE], documented the resident had impaired vision, wore corrective lenses, had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact, with no long/short term memory problems. The assessment documented the resident rejected care 1-3 days out of 7, required total staff assist from 2 or more staff for transfers, was non-ambulatory, used a wheelchair for mobility and was independent to propel his wheelchair. The assessment further documented the resident had impaired balance moving from a seated to a standing position and with surface to surface transfers. The resident was documented as having impaired range of motion (ROM) to one upper extremity and the bilateral lower extremities, and had both a bowel and bladder ostomy device. The assessment documented the resident had frequent pain with a score of 8 on a scale of 1-10, and had no falls since the prior assessment. The resident's care plan dated 03/14/14, documented: "Problem ADL (activities of daily living) Functional/Rehabilitation Potential - Resident uses a power chair for mobility. Goal Resident will not have a decline in their ability to use the power chair for mobility by next review. Approach Power chair has seat belt that is used by resident-resident can self-release seat belt - resident demonstrates to nursing 2 times weekly his ability to release belt. Resident will drive at safe speed. Notify maintenance with any mechanical or other issues with the power chair." "Problem Resident's ability to transfer... has deteriorated. Resident requires extensive to total assistance with one to two staff with ADL performance. Resident does not walk related to tetraplegia, multiple sclerosis. Resident required the use of a mechanical lift for transfers. Goal Resident will not further deteriorate in transfers... Approach Place resident in restorative nursing program." "Problem Falls. Resident is at risk for falling related to tetraplegia, multiple sclerosis, neuropathy, and muscle spasms. Resident uses a power chair for mobility. Goal Resident will remain free from injury. Approach Give resident verbal reminders not to ambulate/transfer without assistance." A quarterly assessment dated [DATE], documented the resident required extensive staff assist x 2 or more staff with transfers, had a pain score of 9 on a scale of 1-10, and had no falls since the prior assessment. An incident report dated 06/19/14, documented the resident was being transported in the facility van by transport driver #3. The incident report documented the resident "fell out of his wheelchair" when the transport driver stopped at a stop light. The incident report documented the resident refused to allow the driver to put on the seatbelt due to "hurting his colostomy." The report documented the motorized wheelchair was powered off and the brake applied. The resident sustained [REDACTED]." During the investigation, the resident was interviewed. He stated his motorized wheelchair had not been strapped in and fell over on top of him when transport driver #3 had to stop quickly. An "Orthopedic Surgery Consult" dated 06/19/14, documented, "History of Present Illness 56 yr (year) male with MS (multiple sclerosis) s/p (status [REDACTED]. Pt (patient) reports his chair was going too fast and fell on top of him...Radiology...RLE (right lower extremity) - Distal metaphaseal femur fracture minimally displace, tibial plateau fracture, medial malleolus fracture. LLE (left lower extremity) - Supracondylar femur fracture with comminution, tibial plateau fracture...HPI (history of present illness) Complaint: knee injury (Bilateral), leg injury (Right lower leg), ankle injury (Bilateral) Source of history: patient, caretaker...Mechanism of Injury: Was in wheelchair in back of van, van stopped, motor wheelchair tipped over and landed on Pt." An inservice training dated 06/20/14, was provided to staff regarding "Proper Protocol For Transporting Residents." A statement made by the employee, transport driver #3, dated 06/20/14, documented, "I was approaching a redlight c (with) (Resident #48) and upon stopping his chair tipped forward causing him to go down to his knees c the wheelchair coming to a rest on his back. The light changed green and I (Transport driver #3) pulled into the parking lot of OU (Oklahoma University) medical center. I moved the wheelchair off of him and assessed for injuries before attempting to move him. No external injuries were noticed at the time and (Resident) told me to help him off of his knees and I did. I sat him on his bottom and then called for security to send help. The nurse arrived and helped me to lift (Resident) into his wheelchair and I was instructed to drive him across the parking lot to the emergency room to have him 'checked out.' Prior to leaving the facility I assisted (Resident) into the van where I turned off his wheelchair and instructed him to fasten his safety belt. He declined to fasten it stating 'It rubs on my colostomy bag.' I asked if he was sure and he replied 'Yes.' I believed it to be his right to refuse. also, it is not possible to anchor his chair to the van floor because his wheelchair base is too low to the ground. When the chair is turned off the parking brake is engaged and renders the chair immobile and will not roll. We were driving down I-35 (Interstate 35) and (Resident) insisted I pull over and adjust his arm and I did, before safely merging back onto the highway. I asked (Resident) if he would like me to fasten his seatbelt he replied 'No it rubs my colostomy bag. It will be fine.' A statement made by transport driver #1 dated 06/20/14, documented, "I, (Transport driver #1), use all straps and lap/seat belts when doing transports. When strapping in a wheelchair I'll apply the two straps to the front of the wheelchair, then two straps in the rear. The straps that are placed to the rear of the wheelchair have seat belt straps that are connected to them. I'll run the seatbelt through the arms of the wheelchair and connect the two seat belt pieces together. I'm able to do this with all regular wheelchairs. I haven't had many transports involving electric wheelchairs, but when I do I strap them in as well. I was told to make sure electric wheelchairs were turned off because the brakes automatically engage when turning off the electric chair. I make sure the resident has their lap belt on, then I'll use the straps to lock them in. The electric chairs I have strapped in the van have had a metal frame in the back of the chair that I've been able to hook the straps to." A statement made by the employee, transport driver #3, dated 06/23/14, documented, "It was not an abrupt stop. I applied pressure to the brakes at or about 100 yds (yards) and at the end of the stop his (resident #48) chair tipped forward. I (Transport driver #3) did not abruptly stop. Had (Resident #48) been wearing his seat belt that is attached to his chair (to which he refused several times) It would have caused injury to his super (sp) pubic cath (catheter) and colostomy." A "Notice of Disciplinary Action" dated 06/23/14, for transport driver #3, documented the employee was suspended without pay on 06/20/14 while the investigation was being conducted for the incident involving resident #48 on 06/19/14. The employee was then terminated due to the seriousness of the situation. The employee documented in the section for Employee Remarks, "Terminated from a position I received no training for." A statement dated 06/23/14, made to the administrative assistant on 06/19/14 by trans

Based on observation, record review and interviews, it was determined the facility failed to ensure: A. A resident who was in excruciating pain was assessed and provided effective interventions to aide in alleviating the pain for one (#8) of one sampled resident reviewed for pain management. This resulted in an actual harm to the resident. The Resident Census and Condition report, dated 07/14/14, documented 54 residents were on a pain management program. B. Resident #91 was transferred from his gerichair to his bed in a manner that was compatible with the facility's policy. The facility census and conditions form, dated 07/14/14, identified 77 residents who required extensive to total assistance with transfers. Findings: The facility's "Pain-Control Protocol" documented, "...treatment/management...staff .. the staff will evaluate and report how much and how often the individual asks for PRN (as needed) doses or supplement standing doses with PRN doses for breakthrough pain...will provide the elements of a comforting environment and appropriate physicial and complementary interventions...monitoring...staff will discuss significant changes in levels of comfort with the attending physician who will adjust interventions accordingly..." The facility policy for repositioning documented: "Repositioning Purpose The purpose of this procedure is to provide guidelines for the assessment of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chairbound residents... 3. Repositioning is critical for a resident who is immobile or dependent on staff for repositioning.... Preparation 1. Review the resident's care plan to assess for any special needs of the resident.... Assessment for Appropriate Repositioning... 4. Components to assess when a resident is in a chair: a. Does the resident need intervention to maintain postural alignment?... c. Does the resident need devices to maintain postural alignment? Interventions/Care Strategies A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body... 3. Residents who are in a chair should be on a q (every) 1 hour repositioning program.... Repositioning the Resident in a Chair... 4. Assist the resident to change his or her position in the chair. 5. Place the resident in a comfortable position in accordance with the resident's individualized care plan...." 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident's cognition was moderately impaired, was able to understand others and be understood, required two person extensive assistance with transfers, had upper and lower extremity limitations on one side and was not able to stabilize self without staff assistance. A care plan dated 12/20/13, documented, "Problem: Resident is at risk for pain related to history [MEDICAL CONDITION] depression. Goal: Resident will have decreased pain and unwanted side effects from taking pain medication. Approach...nursing staff to assess pain... Problem: Resident is at risk for falling R/T [DIAGNOSES REDACTED].and instability during transitions. Goal: resident will remain free from injury. Approach..encourage resident to assume a standing position slowly..." The Medication Administration Record [REDACTED] a. [MEDICATION NAME] 325 mg (milligrams) two tablets every four hours as needed (PRN) for pain or elevated temperature. The order was first written on 12/10/13. b. [MEDICATION NAME] 0.5 mg one tablet every eight hours as needed for anxiety. The order was first written on 12/10/13. c. [MEDICATION NAME] 50 mg one tablet every six hours for pain. The order was first written on 12/10/13. The medication administration records for January 2014 documented the resident received [MEDICATION NAME] 50 mg on 01/11/14 at 7:19 p.m. to address pain. The medication administration records for January 2014 documented the resident received [MEDICATION NAME] 325 mg on 01/11/14 at 8:26 p.m. to address pain. The medication administration records for January 2014 documented the resident received [MEDICATION NAME] .5 mg on 01/11/14 at 11:22 p.m. to address pain. A nurses's note dated 01/11/14 at 11:39 p.m., documented, "Resident complained of severe pain to right knee 12/10 on pain scale. Rt (right) knee appears swollen prn pain medications have already been given and can not be repeated at this time. [MEDICATION NAME] given per prn order. Ice pack applied ice pack providing some pain relief. Resident appears to be relaxed and closing her eyes to rest." The medication administration records for January 2014 documented the resident received [MEDICATION NAME] 50 mg on 01/12/14 at 1:43 a.m. to address pain. A nurse's notes dated 01/12/14 at 2:15 a.m., documented, "Resident awakened with pain to Rt knee 10/10 on pain scale. Rt knee slightly repositioned and supported with pillow. [MEDICATION NAME] given per PRN order will monitor." A nurse's note dated 01/12/14 at 4:50 a.m., documented, "Resident awake and asking for ice pack for rt knee. Ice pack applied as requested...." The medication administration records for January 2014, documented the resident received [MEDICATION NAME] 325 mg on 01/12/14 at 6:27 a.m. to address pain. The medication administration records for January 2014, documented the resident received [MEDICATION NAME] .5 mg and [MEDICATION NAME] 50 mg on 01/12/14 at 8:46 a.m. to address pain. A nurse's note dated 01/12/14 at 10:54 a.m., documented, "Resident cont (continues) to c/o (complain of) pain to right knee. Knee slightly swollen call placed to on call Dr. (Name deleted) N/O (new order) received to send to ER (emergency room ) for eval (evaluation) and Tx. (treatment). Call placed to two numbers to reach son all been disconnected. Call placed to sister (name deleted) to inform of situation. Resident then transported VIA (by) company vehicle with staff to ER." A nurse's note at 2:49 p.m., documented, "1200 (12:00 p.m.) Logan county ER called to report admission to hospital dx fractured femur. Talked with the nurse ..., call placed to sister to inform of situation still unable to reach son, sister states she is headed to guthrie and will go by son's house." A signed hand written statement by CNA #11 dated 01/12/14, documented, "I went to (Residents) room to see if she would come out to the dining room for dinner in which she agreed....I proceeded to getting her ready for dinner but while on the stand up lift (Resident's) right arm began to shake and she complained that her leg hurt as well So I attempted lower her down but it was a delay with the functioning of the lift at this point (Resident) began to slide off the bed so I immediately went to catch her so she wouldn't fall off the bed to hurt herself. I gave...support so that I could put her back on the bed...she again said her leg hurt so I put (Resident) next to the bed with a few pillows...I went out to the hall and asked (CNA #12) to assisted me with (Resident) which she did as I explained to her what happened...a short time after dinner (CNA #12) and I began to get (Resident) ready for bed but again while on the lift...right arm began to start shaking so we put her down in her wheelchair in which we gave...a jump start from the wheelchair to the bed. We changed her got her ready for bed. I checked on her a little while after which she said that her feet hurt so I told the nurse that was in charge about it and the incident that had happened." A signed hand written statement by CNA #12 dated 01/12/14, documented, "I helped other aide with lifting resident off the floor. I came in and saw resident on floor. After we got her up, we got her bottom half way on the bed. I stayed with the resident while the other aide went and got the nurse. Once the nurse observed her then helped us finishing getting her ready for dinner. After dinner...the aide that was taking care of her tried to using the lift again, but the resident was shaking from the pain so the aide came and got me and told me what he was doing. We continued to use the stand up lift, but she couldn't stand all the way. So we quickly...got her in the bed...maybe an hour or so later she pushed her call light and I answered it. She told me to get the nurse cause it felt like something was broken." There was no documentation the facility had notified the physician and the family of the excruciating pain the resident was experiencing prior to 10:54 a.m. on 01/12/14. CNA #11 and #12 had identified the pain in the leg and knee occurred on 01/11/14, prior to dinner at approximately 4:00 p.m. There was no documentation the resident was assessed for the pain and the cause of the pain. An emergency department (ED) note dated 01/12/14, documented, "History of present illness (HPI): (Resident) is a 55 yo (year old) female presents to the Ed with a chief complaint of knee pain. HPI comment Pt (patient) in NH (nursing home) due to [MEDICAL CONDITION] is a max (maximum) assist on transfers. She slid out of the chair yesterday during a transfer and landed on her rt knee. Since has had on going rt knee and rt hip pain. The history is provided by the patient.... Knee pain: This is a new problem. The current episode started yesterday. The problem occurs constantly. The problem has been gradually worsening. The pain is present in the right hip and right knee. The quality of pain is described as aching. The pain is at a severity of 10/10. Associated symptoms are aggravated by activity. Treatments tried pain medications. The treatment provided no relief....reevaluation: Xray showing distal femur fx (fracture)..." An X-ray result dated 01/12/14, documented, "...Interpretation...There is a moderately displaced oblique fracture through the distal femoral shaft. This extends into the lateral femoral condyle. There is comminution of the fracture involving the lateral femoral condyle..." There was no documentation the facility consulted the doctor of the continued excruciating pain that was not relieved with the medications and interventions provided. A nurse's note dated 01/28/14 at 1:29 p.m., documented, "Received report from (Name deleted) over the phone that resident is being discharged back to the facility post L(left) (was right femur with the fracture) femur repair..." The resident's care plan was not updated to address the resident's pain associated with the [MEDICAL CONDITION]. A quarterly assessment dated [DATE] documented the resident required extensive assistance of two persons with transfers, had clear speech, made self understood and could understand others. The assessment further documented the resident's cognition was intact and had upper and lower impairment on one side and was able to stabilize with staff assistance when moving from a seated to a standing position. An interview was conducted on 07/18/14 at 2:01 p.m. with the resident. The resident was observed in bed and had limited use of her right hand and arm. The resident's arm and hand were contracted. She was asked about sustaining a fractured femur. She was asked how it happened. She stated, "I slid when they were trying to get me to walk to my wheel chair." She was asked who was trying to make her walk. She stated, "The aide was trying to make me walk." She was asked if she could identify who the aide was. She stated she was not sure of the name but it was a male. She was asked if she had any pain or injury at the time of the incident. She stated, "The leg hurt right away. I said, 'Oh man I broke something.'" She was asked if the facility provided her with any medications for the pain. She stated, "They did not give me any medication." At 3:36 p.m., an interview was conducted with certified nurse aide (CNA) #11. He was shown a written statement that he had signed and asked about the incident. He stated, "This happened when I first started here." He was asked about his knowledge of policy and individual residents. He stated, "I really did not know a lot. I just knew the simple stuff." He was asked to describe what had happened. He stated he had the resident on the stand up lift and she started shaking and the lift froze when I tried to put the resident back down on the bed. The resident had said it started to bother her and complained it hurt when she started to shake, the resident had pain. He stated the lift had stopped working and the resident was dangling above the bed and was starting to slide down. I wrapped my arms around her, removed the sling from the lift and lowered the resident to the floor. He was asked what time of day and when the fall and incident happened. He stated, "It happened at dinner time on the eleventh at approximately 4:00 p.m." Once the resident was on the floor he positioned pillows around her to make her comfortable and went to get CNA #12 to assist with lifting the resident from the floor back to the bed. He was asked if he notified anyone of the incident. He stated CNA #12 stayed with the resident as he went and told the nurse the resident complained of pain and needed to be looked at. The nurse came in the room and we left until she was done. The nurse knew the resident had complained of pain and her knee was hurting. He was asked what happened after the nurse was in the room. He stated CNA #12 and he got the resident up for dinner. When asked if she continued to complain of pain, he stated, "Yes." At 3:56 p.m., the DON was was asked about the resident's pain and complaints of knee problems. She stated she had not been notified that it was an issue. She then stated, "I was not aware of a problem until she was sent out to the hospital." An interview was conducted on 07/18/14 at 4:25 p.m. with LPN (licensed practical nurse) #5, the charge nurse on duty the night of the resident's complaint of pain. She was asked what shift she worked. She stated the 2:00 p.m. to 10:00 p.m. shift on hall 200. She was asked if she worked on 01/11/14, when the resident had the incident which resulted in pain. She stated she had been. She was asked if the resident had a fall. She stated, "I was not told it was a fall. The lift had let her down." She was asked what CNA #11 had reported to her. She stated, "All I know is they needed help getting her up because because she was on the side of the bed." She then added, "He wanted me to check her out because she complained of knee pain." She was asked how she assessed the resident when entering the room. She stated they had to physically move the resident up further in the bed. She then stated she asked the resident if the pain was like before and she said yes. She stated, "I thought it was just her knee and it had been tweaked when she was moved up." She was asked if the physician had been notified of the incident and the resident's complaints of pain. She stated, "I faxed the doctor, maybe I put it in the 24 hour report." She was asked to locate all her documentation and verification to show she had notified the physician of the incident and pain. She stated, "I did not document any of this." She then stated, "I did not notify the doctor and I did not really assess the resident." The only documentation was the note from the nurse on the next shift by RN #1 when she came on at 10:00 p.m. An interview was conducted on 07/21/14 at 1:47 p.m., with the DON. She was asked how the facility assessed the resident's pain after it was identified by staff. She stated, "I will have to look and see what had been done." She then stated the facility had administered pain medication of [MEDICATION NAME] and Tylenol. She was asked what level of pain the resident was in. She stated, "Excruciating." She was asked if the physician was notified in a timely manner. She stated, "No sir." When asked what the facility policy was for notification to the physician for a resident's change in condition, she stated, "A prudent nurse should notify immediately." She was asked if the facility fully addressed the resident's excruciating pain that had started the previous day before dinner. She stated the facility had not called the doctor and only provided the PRN medications as ordered. She then added more should have been done when the resident continued to be in pain. The resident suffered in pain from approximately 4:00 p.m. on 01/11/14, until she was sent out to the hospital on [DATE] at 10:54 a.m., without assessments of the pain source and consulting with the physician for additional interventions. 2. Resident #91 had a [DIAGNOSES REDACTED]. The resident's annual assessment, dated 04/21/14, documented the resident understood others, sometimes made himself understood, was severely impaired in cognition and required extensive assistance from one staff member for transfers. On 07/15/14 at 9:07 a.m., the resident was observed sitting in his gerichair in the dining room. He was leaning to his left side, with his left arm hanging over the left arm rest of the gerichair. At 9:40 a.m., the resident was still seated in the dining room. He was resting with his eyes closed. He was leaning to the left side of his gerichair with his left shoulder and elbow hanging off the left side of his gerichair. At 10:08 a.m., the resident was observed leaning to the left side of his gerichair. His head was leaning off the left upper back of the gerichair. His left elbow was hanging off the left side of the gerichair. At 10:12 a.m., the resident's left arm was observed hanging over and down the left side of the arm rest of his gerichair. At 11:40 a.m., the resident was observed leaning to the left side of his gerichair. His shoulder and head were leaning to the left over the left upper portion of the gerichair. On 07/17/14 at 4:30 p.m., resident #91 was observed seated in a gerichair in the dining room. He was scooting down in his gerichair and he was leaning to his left side. His upper body and his left elbow were learning off the left arm rest of the gerichair. At 5:15 p.m., the activities director placed the resident's clothing protector on him. She did not reposition him or ask a staff member to reposition the resident. Staff passed beside him as they were coming and going to the dining room. None of them stopped to reposition the resident. At 5:30 p.m., the resident was repositioned as he was served his food. On 07/21/14 at 7:55 a.m., the resident was observed seated in his gerichair in the dining room. He was leaning to his left side and resting on his left elbow. While he was not in an upright position he was drinking coffee with his right hand. At 8:00 a.m., LPN #2 was interviewed. She was asked if the resident was able to reposition himself. The LPN stated sometimes he did but sometimes he didn't remember to do it. The LPN added sometimes staff repositioned him. The LPN was asked if the facility had developed a care plan or developed interventions to help the resident with positioning. She said not that I am aware of. At 8:03 a.m., LPN #6 was interviewed. She asked how often the resident was to be repositioned by staff. She stated as needed but she added the resident preferred to rest on his left arm. As soon as he was repositioned he returned to leaning on his left side. The LPN was asked if the facility had developed a care plan or other interventions to help the resident with positioning. She stated the staff helped him. The clinical record contained no documentation of a care plan having been developed for repositioning the resident. On 07/18/14 at 5:00 p.m., the resident's care plan was reviewed in the presence of the corporate nurse and LPN # 8. They were asked if a care plan had been developed for the residents need for repositioning. They stated, "They did not see one." .

Based on observation, record review, and interviews, it was determined the facility failed to ensure staff were proficient in skills and techniques necessary to provide care to residents who required the assistance of staff for transfers for two (#8 and #91) of two sampled residents whose clinical records were reviewed for transfers. This resulted in an actual harm for resident (#8). The Resident Census and Condition report, dated 07/14/14, documented 77 residents required extensive to total assistance with transfers. Findings: The facility policy for transfers documented: "Safe Lifting and Movement of Residents... Policy Interpretation and Implementation 1....Except during an emergency or unavoidable circumstance, manual lifting is not permitted..." 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident's cognition was moderately impaired, was able to understand others and be understood, required two person extensive assistance with transfers, had upper and lower extremity limitations on one side and was not able to stabilize self without staff assistance. A care plan dated 12/20/13, documented, "Problem: Resident's ability to to transfer, walk in room, walk in corridor...has deteriorated R/T (related to) history of [MEDICAL CONDITION]. Goal: Resident will not further deteriorate in ADL (activities of daily living) completion as evidenced by maintaining current level of function. Approach...provide set up to extensive assistance for ADL completion... Problem: Resident is at risk for falling R/T [DIAGNOSES REDACTED].and instability during transitions. Goal: resident will remain free from injury. Approach: encourage resident to assume a standing position slowly..." The resident's care plan did not address the need for a two person assist with transfers. A signed hand written statement by CNA #11 dated 01/12/14, documented, "I went to (Residents) room to see if she would come out to the dining room for dinner in which she agreed....I proceeded to getting her ready for dinner but while on the stand up lift (Resident's) right arm began to shake and she complained that her leg hurt as well So I attempted lower her down but it was a delay with the functioning of the lift at this point (Resident) began to slide off the bed so I immediately went to catch her so she wouldn't fall off the bed to hurt herself. I gave...support so that I could put her back on the bed...she again said her leg hurt so I put (Resident) next to the bed with a few pillows...I went out to the hall and asked (CNA #12) to assisted me with (Resident) which she did as I explained to her what happened...a short time after dinner (CNA #12) and I began to get (Resident) ready for bed but again while on the lift...right arm began to start shaking so we put her down in her wheelchair in which we gave...a jump start from the wheelchair to the bed. We changed her got her ready for bed. I checked on her a little while after which she said that her feet hurt so I told the nurse that was in charge about it and the incident that had happened." A signed hand written statement by CNA #12 dated 01/12/14, documented, "I helped other aide with lifting resident off the floor. I came in and saw resident on floor. After we got her up, we got her bottom half way on the bed. I stayed with the resident while the other aide went and got the nurse. Once the nurse observed her then helped us finishing getting her ready for dinner. After dinner...the aide that was taking care of her tried to using the lift again, but the resident was shaking from the pain so the aide came and got me and told me what she was doing. We continued to use the stand up lift, but she couldn't stand all the way. So we quickly...got her in the bed...maybe an hour or so later she pushed her call light and and I answered it. She told me to get the nurse cause it felt like something was broken." An emergency department (ED) note dated 01/12/14, documented, "History of present illness (HPI): (Resident) is a 55 yo (year old) female presents to the Ed with a chief complaint of knee pain. HPI comment Pt (patient) .... is a max assist on transfers. She slid out of the chair yesterday during a transfer and landed on her rt knee. Since has had on going rt knee and rt hip pain. The history is provided by the patient...." An X-ray result dated 01/12/14, documented, "...Interpretation...There is a moderately displaced oblique fracture through the distal femoral shaft. This extends into the lateral femoral condyle. There is comminution of the fracture involving the lateral femoral condyle..." A nurse's note dated 01/12/14 at 2:49 p.m., documented, "1200 (12:00 p.m.) logan county ER called to report admission to hospital dx (diagnosis) fractured femur." A quarterly assessment dated [DATE] documented the resident required extensive assistance of two persons with transfers, had upper and lower impairment on one side and was able to stabilize with staff assistance when moving from a seated to a standing position. An interview was conducted on 07/18/14 at 2:01 p.m. with the resident. She was asked about sustaining a fractured femur. She was asked how it happened. She stated, "I slid when they were trying to get me to walk to my wheel chair." She was asked who was trying to make her walk. She stated, "The aide was trying to make me walk." She was asked if she had any pain or injury at the time of the incident. She stated, "The leg hurt right away. I said, 'Oh man I broke something.'" An interview was conducted on 07/18/14 at 2:12 p.m. with certified nurse aide (CNA) #11. He was asked if the resident was able to walk with or without assistance. He stated, "No." He was asked if the resident was able to stand on her own. He stated the resident had been able to stand with assistance for a short time. On 07/18/14 at 3:36 p.m., an interview was conducted with CNA #11. He was asked to describe what had happened. He stated he had the resident on the stand up lift and she started shaking and the lift froze when tried to put the resident back down on the bed. He stated the resident had said it started to bother her and complained it hurt when she started to shake. He stated the resident had pain. He stated the lift had stopped working and the resident was dangling above the bed and was starting to slide down. He stated he had wrapped his arms around her, removed the sling from the lift, and lowered the resident to the floor. He was asked how many staff was in the room assisting with the transfer. He stated, "I was the only person in the room when using the stand up lift." He was asked what the facility policy was for using the stand up lift if a resident is a two person assist with transfers. He stated, "You have to be 18 to touch and use it and two persons are to be in the room." He then said he had never been trained on the policy. He was asked about the level of assistance the resident required while being transferred. He stated, "(Resident) is a two person assist." He then added, "I did not know that about her." At 3:56 p.m., the DON was asked what the policy was for using a lift for someone that required extensive assistance with transfers. She stated, "We care plan what the resident is for assistance with transfer." She then stated the portable lift can be used by one aide if the resident can assist. If they can not assist then with two aides. An interview was conducted on 07/18/14 at 4:36 p.m. The DON was asked how she had investigated the fracture to determine the cause. She stated, "We looked at the video surveillance camera and she looked all right when out in the dining room." An interview was conducted on 07/21/14 at 9:29 a.m. with CNA #3. She was asked to describe the level of assistance the resident needed while being transferred. She stated a stand up lift was used and at times she would be able to pivot. She was asked if the resident required one or two staff while being transferred. She stated, "She will swing her legs over and we lift once the sling is on her. The resident is able to help, she grabs onto the bar and can bear weight with her legs." She then stated she thought the resident required two staff during transfers. She was asked if the resident had sustained any falls since being admitted . She stated, "I remember once, they used the stand up lift and she fell . She had broken her hip I think. She was in the hospital quit awhile due to the broken hip. She had to have surgery." She was asked if she had transferred the resident with additional staff assisting. She stated at times the resident would be transferred with only one aide present. An interview was conducted on 07/21/14 at 9:40 a.m. with certified nurse aide #14. She was asked to describe the level of assistance the resident required with transfers. She stated it had been with one and she used to transfer the resident by herself. She then stated it was being changed and all care was an extensive two person and transfers were with an overhead lift. She was asked if there had been anytime the resident had a fracture. She stated, "There was an accident and that's is why the stand lift is not being used." An interview was conducted on 07/21/14 at 9:55 a.m. with CNA #10. She was asked what level of assistance the resident required with transfers. She stated, "When she first came we only did it with one person and the stand up lift. When she first came we could transfer her by our self with the stand lift." An interview was conducted on 07/21/14 at 1:47 p.m. with the DON. She was asked what level of assistance the resident required at the time of the fall. She stated, "Before the fall it was a one person assist." She was asked how the facility assessed the resident's level of assistance for transfers on the admission assessment. She stated, "Two person extensive assistance." She was asked if the care plan addressed two person extensive assistance with transfers. She replied the care plan addressed extensive assistance but did not specify two persons. She was asked how the facility ensured the aides were properly trained in resident care. She stated education and pair them up with someone. She was asked who was responsible for completing the annual skills check list for certified nurse aides. She stated an aide who has shown competency trains the other aides, they are called "Charge aides. She stated CNA #11 was trained at another facility through a nurse aide training program and then came to work at the facility. She stated he was paired up with a staff member for training purpose. She was asked how the facility made sure the aides were trained on resident specific needs and had the competency in skills necessary to fulfill their duties. She stated, "We don't do skill competency checks on employees." An interview was conducted on 07/21/14 at 10:32 a.m. with licensed practical nurse (LPN) #6. She was asked who was responsible for ensuring yearly competency reviews were completed on each employee. She stated, "We don't do them that I'm aware of." She was asked how employees skills were checked for proficiency. She stated, "We pair them up with an aide on the floor and they are trained that way. They are to be shown proper technique and the charge aides will report to me if there is a problem. As a facility we do not check to make sure they are proficient to work on their own we rely on the one working the floor with them. An interview was conducted on 07/21/14 at 1:47 p.m. with the DON. She was asked how the facility ensured aides were properly trained and able to demonstrate competency in the areas necessary to meet the needs of residents. She stated the one they were paired with would need to let them know if there was a problem and/or they don't know what to do. She was asked who was responsible for ensuring aides received their yearly competency skills review. She stated, "We don't do them. We do audits to check peri-care and transfers nothing else." She then stated not all aides are checked, it was random checks only. 2. Resident # 91 had [DIAGNOSES REDACTED]. The resident's annual assessment, dated 04/21/14, documented the resident understood others, sometimes made himself understood, was severely impaired in cognition and required extensive assistance from one staff member for transfers. On 07/18/14 at 8:20 a.m., the resident was observed seated in his gerichair in the dining room. He was transported by LPN #6 and CNA #9 to his room. The resident's gerichair was positioned beside his bed. During the transfer the back of the resident's pants were grabbed and pulled up as the resident was pivoted into position by the LPN. The LPN and the CNA placed their arms under the resident's axilla and lifted him onto his bed by his upper arms. The CNA was interviewed. She was asked if they had transferred the resident per facility policy. The CNA stated, "I don't know, that is the way we always do it." The LPN was asked if they had transferred the resident per facility policy. The LPN stated, "We are a no lift facility." She was asked if the facility policy required the use of a gait belt to manually transfer a resident. She said, "Yes but the resident tries to hold on to the gait belt." The LPN was asked if it was the facility policy to lift the resident by the back of his pants and pull up. She said, "No." They were both asked if a resident was to be transferred by lifting his arms and axilla. They both said, "No." At 5:00 p.m., the corporate nurse was asked if this was a facility approved transfer. She stated it was not. She stated they should have used a gait belt.

Based on observation, record review and interviews, it was determined the facility failed to ensure there was sufficient staff to meet the needs of the residents. This had the potential to affect all 85 residents who resided in the facility. Findings: An interview was conducted on 07/23/14 at 4:30 p.m. with LPN #6, the staffing developer. She was asked how she determined the number of staff to have on the halls each shift to provide the care based on individualized care plans. She stated, "Based upon my handy dandy sheet. It tells me by census how many I need on each shift." She was asked if the sheet was for state minimum staffing ratios. She stated, "It is based on the state minimum mandate ratio. Some days I have a lot of extra." She was asked how she could see what the daily census was on each end of the building. She stated, "We can get the daily census but it does not break it down by each end of the building. On 01/11/14, there were 70 residents in house." A copy of the daily census was provided for the day of 01/11/14, the day resident #8 had sustained her fracture. Three were three certified nurse aides (CNAs), one certified medication aide (CMA) and one charge nurse assigned to the hall resident #8 resided on. She was asked how many residents could reside on the east end of the building. She stated, "I could not tell you." She was asked when she did the schedule, how she factored in the acuity of care? She stated, "I know hall 100 is the heavier care area because of the number of residents that need assistance. My needy ones are on hall 100. I always try to put an extra aide on hall 100." She was asked how the aides were able to get their work done with three aides working on the hall. She stated, "They are assigned based on acuity. Some of each type of residents who require no care, some intermediate care and some total care. If they need help they can go and grab another aide. They will need to find an aide that's not busy." She was asked how long should a resident have to wait when wanting to go to bed and receive care. She stated, "No more than ten minutes." She was made aware of the twenty minute wait observed when resident #62 waited twenty minutes. She then stated, "Ten minutes top to get a second person and be able to properly take care of the resident." On 07/23/14 at 5:18 p.m., the director of nursing (DON) was interviewed regarding staffing. She was asked how staffing was determined. She stated, "We go off this form, from the minimum state ratios." She was asked how do you ensure the staff are able to meet the care needs with the number of staff working each shift. She stated, "Based on acuity. If one is heavier and there are five aides, three goes to the higher acuity of care. Hall one has been the heavier care hall since I have been here." She was asked how do you determine who is working what section. She stated there was one aide for each section. She was asked how long should a resident have to wait to be placed in bed and provided care. She stated, "Each resident's care should be meet promptly. Twenty minutes is too long to wait for care. I don't know how to fix it. My expectation is you find someone to help a charge nurse to get them in bed right away." 1. The facility failed to ensure there was sufficient staff to follow a resident's care plan for splints and restorative services for one sampled resident reviewed for range of motion deficits. This had the potential to affect 15 residents identified by the restorative aide who received services. Refer to F-318. 2. The facility failed to ensure there was sufficient staff to follow resident care plans for completing AIMS (abnormal involuntary movement scale) quarterly for two sampled residents reviewed for antipsychotic medication use. The facility census and condition report, dated 07/14/14, documented 24 residents received antipsychotic medication Refer to F-282. 3. The facility failed to ensure there was sufficient staff to provide two person transfers for a resident who required extensive two person transfer with a lift. Refer to F-323.

An immediate jeopardy situation was determined to exist related to the facility's failure to ensure residents were not endangered by the steam tables that were in the Hall 100 and Hall 200 dining rooms. The steam tables were left on from 6:30 a.m. until 7:30 p.m. The temperature of the frame and the water temperature measured 162 degrees Fahrenheit on Hall 200 and measured 147 degrees Fahrenheit on Hall 100 after being turned off. On 06/20/12, at 3:46 p.m. the OSDH was notified and verified the existence of the immediate jeopardy situation. On 06/20/12, at 3:50 p.m., the administrator and the DON were notified of the immediate jeopardy situation. They were informed the immediate jeopardy constituted substandard quality of care. On 06/20/12, at 4:20 p.m. an acceptable plan of removal was provided to the survey team. The plan of removal documented the following: "Plan of Removal: Steam Table 1) Steam tables are under 24 hour observation by nursing staff. 2) Steam tables will be attended by staff at all times while turned on. 3) Steam tables will be attended by staff at all times while plugged in until reaches temperature below 115 degrees. 4) Temperature will be monitored using a standard probe thermometer 5) Protection wall will be built around steam tables to keep residents away from steam tables at all times. 6) In-service all facility staff on monitoring steam tables at all times will (sic) plugged in and while unplugged until temperature is below 115 degrees. Plan of Removal submitted 06/20/2012 at 4:20 p.m." The immediate jeopardy situation was removed on 06/20/12, at 7:06 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm that was not immediate jeopardy, isolated. Based on observation, clinical record review, and interviews, it was determined the facility failed to ensure; a. steam table temperatures were not an accident hazard for residents in the dining rooms on Hall 100 and Hall 200. This had the likelihood to affect 37 residents who dined in Hall 100 dining room and 36 residents who dined in the Hall 200 dining room. b. residents' safety while being pushed in their wheelchairs for one (#12) of 13 sampled residents identified by the facility as utilizing a wheelchair for mobility. This had the potential to affect 79 residents identified by the facility as utilizing a wheelchair for mobility. This resulted in actual harm for resident #12 who sustained a fractured nose when she fell face first from a wheelchair. The resident was being pushed in a wheelchair without foot rests and put her feet down. 1. On 06/20/12 at 3:00 p.m., the surveyor was leaning over to speak with a resident sitting in her geri-chair in the dining room on Hall 200. The surveyor placed her right hand on top of the steam table located in the dining room. The surveyor removed her hand very quickly to avoid being burned. The resident was positioned 33 inches from the steam table. The surveyor measured the temperature of the frame of the steam table and the water temperature. Each measured 162 degrees Fahrenheit in the dining room on Hall 200. The surveyor then measured the temperature on the frame of the steam table and the water temperature in the steam table in the dining room on Hall 100 each measured 147 degrees Fahrenheit. The staff went ahead of the surveyor and turned the steam table off before the surveyor could get an accurate temperature on the steam table and the water temperature on Hall 100. At 3:05 p.m., an interview was conducted with the administrator and the DON regarding the temperature of the steam tables. The administrator was asked when the steam tables were to be turned off. She stated, "I think it should be turned off between meals." She then stated she was not sure. At 3:10 p.m., an interview was conducted with the dietary manager regarding the steam tables being left on after a meal. The dietary manager stated she turns the steam tables on in both dining rooms around 6:30 a.m., and turns them off after the evening meal around 7:00 p.m. She stated this is how she has always done it. She also stated they never turn the steam tables off during the day. At 4:45 p.m., an interview was conducted with the social services director regarding residents going near the steam tables. She stated, "When the residents who are diagnosed with [REDACTED]." At 4:48 p.m., an interview was conducted with LPN #2 regarding the residents going near the steam tables. She stated she has two residents who go near the table and she has told them they would get burned and she has to redirect them away from the steam table, on Hall 100. She also stated no one had received any burns from the tables to her knowledge. 2. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan dated 03/30/09, and updated on 05/28/12, documented, "Problems: Mobility: I use a wheelchair for my primary mode of transportation about the facility. I use a wheelchair for positioning and comfort. Goal: I will have no decline in my positioning and comfort by next review. Approach: Continue to use my wheelchair that was purchased by family. Communicate with family any repairs or concerns over wheelchair. Assess resident positioning and comfort while in wheelchair. Help me to change my position q 2 hrs and prn to help promote circulation and prevent skin breakdowns..." A care plan dated 11/25/09, and undated 04/23/12, documented, "Problems: I have a dx: of [DIAGNOSES REDACTED] spasms and have limited mobility. I require extensive assist with locomotion of w/c on and off unit... Goals: My needs will be met by the staff and I will remain clean, dry and odor free. I will be kept safe and will have no skin breakdown by next review. Approach: Allow me to propel my wheelchair as far as I can to help maintain my strength and independence, but when I get tired then offer to push me the rest of the way... Broda chair c foot rests. PT to eval and adjust current wheelchair - Broda chair." An annual comprehensive assessment dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired and she had long and short term memory problems. The assessment also documented the resident was totally dependent and required one person assistance for locomotion on and off the unit. The assessment documented the resident did not walk and utilized a wheelchair for mobility. The assessment documented the resident had limitations in range of motion for upper and lower extremities on both sides. An incident report dated 03/30/12, documented the resident was being pushed to the dining room in her wheelchair. She fell forward out of the wheelchair. She had an abrasion to her forehead. The report documented the physician and family were notified. Neuro checks were initiated and remained within normal limits. No other injuries were noted. The report documented the resident did not exhibit signs and symptoms of pain. Grimacing was noted later in the shift and pain was controlled with routine Tylenol. The report also documented, "On 4.3.12 RN called to room for unrelated issue and noticed bruising near her nose and right corner of eye. (res. name deleted) was sent to emergency room for possible pneumonia. Hospital responded with [DIAGNOSES REDACTED]. A nurse's note dated 03/30/12 at 8:02 p.m., documented, "I was in WC on the way to dining room when her toe catch (sic) the carpet and she fell out of WC. Abrasion to forehead on the right side. VS 97.8-88-16-132/60 O2 sat 94%...Pupils equal and reactive. Head area cleaned with NSS and TAO applied.. Doctor notified and sister called. neurochecked sheet started... No other injuries noted at this time... No other problems at this time." A nurse's note, dated 03/31/12 at 2:56 a.m., documented, "...Neuro check d/t fall is stable. No s/s of fever or discomfort..." A nurse's note, dated 03/31/12 at 1:02 p.m., documented, "Fall FU- grimminacing noted, has routine Tylenol given with relief. Abrasion and bruising noted to forehead, brushing to right corner of eye. Neuro checks WNL." A nurse's note, dated 04/01/12 at 3:36 a.m., documented, "F/u falls no noted injuries. Cont with the abrasion to the right forehead and bruising to the inner corner of the right eye. Neuro checks WNL..." A nurse's note, dated 04/01/12 at 9:28 a.m., documented, "...Fall FU, brushing noted to corner right eye, abrasion to right forehead..." A nurse's note, dated 04/02/12 at 9:20 a.m., documented, "...Fall FU bruising remains to right corner of eye, abrasion to right forehead. No s/s pain noted. A review of the resident's CT Head without contrast completed on 04/03/12 at 1:51 p.m., documented, "...No abnormal extraaxil fluid collections are present. Skull, scalp, orbits, and paranasal sinuses are within normal limits." A review of the resident's CT Facial Bones without contrast completed on 04/03/12 at 2:53 p.m., documented, "...Findings: There is a mildly depressed comminuted nasal bone fracture slightly deviated to the left. The nasal septum is midline. Overlying soft tissue swelling is present. The orbits appear symmetric. The globes are intact. Scattered opacities within the etrmoid air cells with mucoperiosteal thickening within the floor of the left maxillary sinus. The orbital floors are intact. The mandible is intact. No other fractures are identified. Surrounding soft tissues are normal. Impression: Comminuted mildly depressed nasal bone fracture. A nurses note dated 04/03/12 at 6:22 p.m., documented, "Back from (name withheld) hospital. To resume all previous orders and to add Levaquin 500 mg daily for 7 days. DX: poss pneumonia... No distress noted." On 06/21/12 at 9:00 a.m., an interview was conducted with the DON regarding the incident on 03/30/12, with resident #12 falling out of her wheelchair. The DON was asked if the resident was being transported without footrests on her wheelchair. She stated, "Yes she was." She stated the resident was holding her feet up during transport and suddenly dropped her feet and fell out of the wheelchair. She also stated the facility had this on film and did an inservice that day regarding transporting residents via their wheelchairs. She was asked if the resident had muscle spasms from time to time. She stated, "Yes she does." She was then asked if she thought the resident should have the footrests on her wheelchair when she was transported. She stated, "Yes, she should." She was then asked if the resident could self propel herself in the wheelchair. She stated she could push herself backward in her chair about three or four months before the incident. She stated the resident had declined in her abilities to self propel herself. The DON was asked why the resident was sent to the hospital on [DATE]. She stated the resident had a congested chest. She also stated she sent her out to the hospital to rule out possible pneumonia. On 06/21/12 at 10:00 a.m., LPN #3 was asked why the resident did not have footrests on her wheelchair when the accident occurred. She stated it was too hard for the aides to use the lift and place the resident in her wheelchair with the footrests in the way.

Based on observation, record review and interview, it was determined the facility failed to provide supervision to prevent falls and failed to identify and implement interventions to prevent falls for one (#17) of seven sampled residents who had a history of [REDACTED]. Findings: The Falls and fall risk managing policy statement documented the following: "Policy interpretation and implementation 1. The IDT (Interdisciplinary Team) will identify appropriate interventions to reduce the risk of falls. If an evaluation identifies several possible interventions, the staff may choose to prioritize interventions... 2. Examples of approaches might include ...rearrangement of room furniture... 4. If falling continues despite interventions, facility will implement additional interventions, or indicate why the current approach remains relevant. 5. If underlying causes can't be readily identified or corrected, staff will try various interventions, based on assessment, until falling is reduced or until the reason for the continuation of falling is identified as unavoidable. 6. The IDT will identify and implement interventions to try to minimize serious consequences of falling. 7. The IDT will monitor and document, as appropriate, residents responses to interventions to reduce falling and risks for falls... 9. If a resident continues to fall, staff will re-evaluate continuing and changing current interventions that are in place... Fall risk assessment: The IDT will seek to identify and document, as appropriate, residents risk factors for falls... Assessing falls and their causes: The purpose of this procedure is a guideline to assist with assessing a resident after a fall and to assist with identifying causes of falls. Falls are a leading cause of morbidity and mortality among the elderly. Approximately 50% of residents fall annually and 10% of these falls result in serious injury... ...Environmental issues should be addressed accordingly. Care planning and documentation CAA (Care Area Assessment) Process Identify Trigger Identify Care Area Analysis of CAAs Decision Making Care Plan IDT should clarify and update information per regulatory requirements as needed and appropriate..." Resident #17 was admitted with [DIAGNOSES REDACTED]. The care plan updates documented: "11/5/10 I use a low bed & fall matts (mat) to prevent falls & injury. 11/5/10 I use a gerichair (sic) for positioning & mobility..." On 12/08/10 at 12:00 p.m., an incident report documented: "...Res at dining Rm (room) table for Lunch. Slipped out of W/C. No obvious injuries... Recommended steps to prevent recurrence: (1) Utilize geri-chair (2) Assess use of geri-chair & make further interventions (3) Personal alarm..." On 12/30/10 at 6:30 a.m., an incident report documented: "...Resident rolled out of bed onto Matt (floor mat)/floor. Bed alarm on and working. Right elbow S/T (skin tear)...No other injuries noted..." No recommendations to prevent recurrence were documented. On 01/07/11 at 3:15 p.m., an incident report documented: "...CMA going down the hall bed alarm sounded She entered the room Resi (resident) was sitting on floor mat she called for my assist...(No) noted injuries... Recommended steps to prevent recurrence: Check & make sure pt is in middle of bed. Bed on low setting, mat remains on the floor for safety (sic) continue (with) restorative nursing..." On 01/09/11 at 3:35 p.m., an incident report documented: "...OBSERVED RESIDENT LYING ON (left) side on MAT next to bed. No APPARENT INJuries... Recommended steps to prevent recurrence: (1) Restorative nursing (2) Res likes to crawl on floor. She is putting herself on the floor..." The most recent care plan, dated 01/26/11, did not address falls. On 02/03/11 at 4:30 a.m., an incident report documented: "...Resident found on mat on floor. Apparently struck face on trash can. 1 cm laceration/Abrasion noted on left face... Recommended steps to prevent recurrence: Continue close monitoring to prevent moving to attempt to place self on floor..." On 04/28/11 at 7:20 p.m., the resident's roommate was observed and heard telling LPN #1 that her roommate was trying to get out of her bed. At 7:30 p.m., the resident was observed in bed, positioned on her right side close to the edge of the bed with both feet hanging over the edge of the bed. At 7:35 p.m., the resident was found on the floor beside her bed. At 7:36 p.m., LPN #1 was informed the resident had fallen onto the floor. He asked, "Where?" He was informed of the resident's room. He stated, "She scoots out of bed." At 8:00 p.m., the administrator told a surveyor the resident probably had to go to the bathroom, that she always attempted to get out of bed if she had to go to the bathroom. The resident had been incontinent of bowel at the time of the fall.