Every finding on record at Zarrow Pointe

Based on record review and interview, the facility failed to ensure assessments were completed for 1 (#20) of 16 sampled residents whose assessments were reviewed.The administrator identified 55 residents resided in the facility. Findings: A 5-day assessment, dated 02/26/25, showed Resident #20 had a BIMS score of 13 which indicated their cognition was intact and active discharge planning was occurring for the resident to return to the community. A Transfer/Discharge Report, dated 03/14/25, showed Resident #20 had been discharged from the facility to home. Review of the assessments in the electronic clinical record did not show a discharge assessment had been completed. On 08/22/25 at 12:59 p.m., MDS coordinator #1 stated they had reviewed the electronic clinical record and should have completed a discharge assessment for Resident #20.

Based on record review and interview, the facility failed to accurately code a significant change MDS assessment for 1 (#41) of 14 sampled residents who were reviewed for accuracy of assessments. The administrator identified 55 residents resided in the facility. Findings:Resident #41's significant change assessment, dated 07/28/25, showed cognitively intact cognition with a BIMS score of 15. The assessment showed the life expectancy of less than 6 months coded as no.A physician's order, dated 07/22/25, showed to admit Resident #41 to hospice for late affect cerebrovascular accident.On 08/21/25 at 1:34 p.m., MDS coordinator #1 stated the significant change assessment was related to the resident going on hospice. They stated the resident went on hospice services on 07/22/25. MDS coordinator #1 reviewed the MDS and stated the MDS did not have life expectancy of six months coded and was not accurately coded to reflect the resident's status at that time.On 08/21/25 at 1:43 p.m., the administrator stated the MDS was expected to be coded accurately.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed to include the amount of assistance needed for incontinent care and bed mobility for 1 (#1) of 3 sampled residents whose care plans were reviewed. The DON identified 56 residents resided in the facility. Findings: On 05/08/25 at 2:30 p.m., Resident #1 was observed in bed. Signage was observed on the wall by the resident's bed that showed the resident required the assistance of two staff for all personal care while in bed. On 05/12/25 at 2:04 p.m., CMA #1 and CNA #2 were observed to provide incontinent care to Resident #1. A policy titled Care Plans, Comprehensive Person-Centered, dated December 2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; An annual assessment, dated 11/02/24, showed Resident #1 had a BIMS score of 03, which indicated the resident was severely impaired in cognition for daily decision making, was dependent on staff for rolling left to right, and was incontinent of urine. A Documentation Survey Report v2 form, dated January 2025, showed Resident #1 was provided two person assistance for toileting/incontinent care 52 times out of 93 opportunities and was provided two person assistance for bed mobility 77 times out of 93 opportunities. A Documentation Survey Report v2 form, dated February 2025, showed from 02/01/25 through 02/22/25, Resident #1 received two person physical assistance for toileting/incontinent care 38 times out of 66 opportunities and received two person assistance for bed mobility 52 times out of 66 opportunities. A quarterly assessment, dated 02/03/25, showed Resident #1 had a BIMS score of 03, which indicated the resident was severely impaired in cognition for daily decision making, was dependent on staff for rolling left to right, and was incontinent of urine. A care plan, revised 02/06/25, showed the resident required two person assistance for transfers with the mechanical lift, was at risk for falls, had a fall mat beside their bed, and the staff were to follow the fall protocol. The care plan did not show the amount of assistance Resident #1 required for bed mobility or incontinent care. An incident note, dated 02/23/25 at 8:33 a.m., showed at 4:35 a.m., RN #1 had been notified by a CNA that Resident #1 had fallen out of bed during incontinent care. The CNA stated they were standing on the side of the bed where the wall was and when they pulled the draw sheet to turn Resident #1 onto their side, the resident rolled out of bed. The note showed the resident had non skid socks on and the fall mat was present. The note showed Resident #1 had a dark purple hematoma to the back of the right hand between right index finger and right middle finger measuring 8.0 cm x 7.0 cm with a small tear on the hematoma measuring 0.9 cm x 0.3 cm. The note showed first aide was applied to the skin tear, the resident complained of pain to the bilateral lower extremities, neuro checks were initiated, the physician and family member were notified and x-rays were ordered. The note documented Resident #1 was transferred back to bed by the mechanical lift and three staff members. A nurse note, dated 02/23/25 at 10:25 a.m., showed Resident #1 had an increase in pain in the left lower extremity, the physician was notified, and the resident was sent to the hospital at 9:15 a.m. An ODH form 283 incident report, showed an incident dated 02/23/25 for Resident #1. The form showed on 02/23/25 at 4:35 a.m., the resident had fallen out of bed when they were being provided incontinent care. The form showed the CNA (CNA #1) stated as they pulled on the draw sheet to turn the resident onto their side, they rolled out of bed. The form showed the resident had on non skid socks and fall mat was present. The incident report showed the hospital records indicated Resident #1 had a fracture of the left distal femur, the right wrist had bruising and tenderness with scapholunate dissociation, which was degenerative in nature due to arthritis. The incident report form showed staff were inserviced on how to properly transfer and reposition residents while in bed, Resident #1 would require two person assistance for incontinent care and positioning upon return to the facility. The incident report form showed Resident #1 returned to the facility on [DATE], family member #2 stated the resident had not received surgery to repair the fracture due to the risks, and the resident utilized an immobilizer to the left leg. A hospital history and physical, dated 02/23/25, showed the resident had senile osteoporosis, rheumatoid arthritis, generalized osteoarthrosis involving multiple sites, and osteopenia. A care plan intervention, initiated 02/23/25, showed the resident had experienced a fall and two staff were to be present during incontinent care. A care plan intervention, initiated 02/24/25, showed the resident had experienced a fall with major injury and two staff were required for bed mobility and repositioning. An admission summary note, dated 02/26/25 at 2:30 p.m., showed Resident #1 had returned to the facility with a brace to their right forearm and hand, had bruising to the fingers and the top of their hand, and a scab between their first and second knuckle. The note showed the resident had an immobilizer to their left leg. On 05/12/25 at 2:04 p.m., CMA #2 stated they utilized two person assistance for any care for Resident #1 while they were in bed. On 05/12/25 at 4:23 p.m., family member #1 stated Resident #1 should have received two person assistance since admission due to their size. They stated the facility had now posted signage to indicate the resident required two person assistance. On 05/19/25 at 6:35 a.m., CNA #1 stated on 02/23/25 when they went into Resident #1's room to provide incontinent care, the resident was laying in bed on their back moving their legs like they were walking. They stated the resident usually did not move their legs like that. They stated they could not reach the draw sheet on the side of the bed by the wall so they went to that side and when they began angling the draw sheet to position the resident to their right side, the resident rolled out of bed. CNA #1 stated they immediately notified RN #1. CNA #1 stated Resident #1 had always required one person assistance with incontinent care and bed mobility but now required two persons. On 05/19/25 at 7:00 a.m., RN #1 stated prior to the fall on 02/23/25, Resident #1 required one person assistance with incontinent care and bed mobility and currently required two person assistance with all care in bed. On 05/19/25 at 7:09 a.m., RN care coordinator #1 stated Resident #1 required one person assistance with turning, repositioning, and incontinent care prior to the fall on 02/23/25. They stated Resident #1 could move their legs but was unable to roll and reposition from side to side. On 05/19/25 at 7:22 a.m., the DON stated prior to the fall on 02/23/25, the fall interventions that were in place included low bed when they were not performing care and was on the fall protocol. The DON stated the fall protocol consisted of non skid socks, low bed, and a red bandana tied around the call light. They stated after Resident #1 fell they assessed and wrote orders on every resident for the amount of staff assistance needed for incontinent care and bed mobility. On 05/19/25 at 7:45 a.m., CNA #3 stated Resident #1 had not always required two person assistance for incontinent care or bed mobility. They stated Resident #1 had been two person assistance since the fall on 02/23/25. On 05/19/25 at 7:49 a.m., CNA #4 stated they had always utilized two staff members for incontinent care and bed mobility. On 05/19/25 at 8:56 a.m., the MDS coordinator stated they had coded Resident #1 was dependent on staff for all activities of daily living except eating. They stated they had coded the assessment as dependent on staff because the resident required the assistance of two staff persons. The MDS coordinator stated they had not developed a care plan for one person or two person assist with bed mobility or incontinent care for Resident #1 because the resident always required two person assistance with both activities of daily living. On 05/19/25 at 9:06 a.m., the MDS coordinator stated they had reviewed the clinical record and stated at times Resident #1 required one person physical assistance, and at times they required two person assistance with activities of daily living. On 05/19/25 at 9:52 a.m., the MDS coordinator provided the Documentation Survey Report v2 for January 2025 and February 2025. They stated they had reviewed the CNAs documentation on the report and that was why they had indicated on the quarterly assessment the resident required the assistance of two staff members for bed mobility and incontinent care. They reviewed the report and stated documentation in the toileting category was for incontinent care. The MDS coordinator stated they had not developed a care plan for the amount of assistance Resident #1 required for incontinent care or bed mobility because the resident did not have physician orders related to the amount of assistance required. The MDS coordinator stated Resident #1 could assist in activities of daily living sometimes. On 05/19/25 at 10:17 a.m., RN care coordinator #1 stated sometimes they were able to provide incontinent care and bed mobility/repositioning for Resident #1 without the assistance of another staff person. They stated other times they needed another staff member to assist them. They were asked why staff had not been instructed Resident #1 required the assistance of two staff persons when, according to the documentation on the Documentation Survey Report v2, they required two person assistance for more than half of the opportunities in January 2025 and February 2025. They stated they did not know. On 05/19/25 at 10:26 a.m., CNA #2 stated they had always utilized two person assistance incontinent care and bed mobility for Resident #1. They stated there was signage posted on Resident #1's wall now and staff had been inserviced on the resident's care needs. On 05/19/25 at 10:29 a.m., CNA #5 stated Resident #1 had usually always required two person assistance with incontinent care and bed mobility before the fall on 02/23/25. They stated if they could reposition the resident without assistance they would, but sometimes they needed help from another staff member. They stated Resident #1 now required two person assistance for all care when in bed. On 05/19/25 at 10:59 a.m., CNA #6 stated they had always used two person assistance with incontinent care and bed mobility for Resident #1. On 05/19/25 at 11:06 a.m., the DON stated the care plan had not been developed to include the amount of assistance needed for bed mobility and incontinent care because the resident was able to assist with repositioning. The DON stated the care plans were developed if a change was noted with the residents' ability to assist with activities of daily living. They stated Resident #1 had not had a change in their ability to assist with repositioning so the care plan had not been developed to indicate the amount of assistance Resident #1 required.

Based on observation, record review, and interview, the facility failed to ensure residents were free from falls during incontinent care for 1 (#1) of 3 sampled residents who were reviewed for falls. The DON identified 18 residents who required the assistance of two staff during incontinent care. Findings: On 05/08/25 at 2:30 p.m., Resident #1 was observed in bed. The bed was observed to be low with the left side of the bed against the wall and a fall mat was observed to be on the floor on the right side of the bed. Signage was observed on the wall by the resident's bed that showed the resident required the assistance of two staff for all personal care while in bed. On 05/12/25 at 2:04 p.m., CMA #1 and CNA #2 were observed to provide incontinent care to Resident #1. One staff member was observed on each side of the bed during the care. An annual assessment, dated 11/02/24, showed Resident #1 had a BIMS score of 03, which indicated the resident was severely impaired in cognition for daily decision making, was dependent on staff for rolling left to right, was incontinent of urine, had not experienced any falls, was 63 inches tall, and weighed 235 pounds. A Documentation Survey Report v2 form, dated January 2025, showed Resident #1 was provided two person assistance for toileting/incontinent care 52 times out of 93 opportunities and was provided two person assistance for bed mobility 77 times out of 93 opportunities. A fall risk assessment, dated 01/31/25, showed Resident #1 was high risk for falls. A Documentation Survey Report v2 form, dated February 2025, showed from 02/01/25 through 02/22/25, Resident #1 received two person physical assistance for toileting/incontinent care 38 times out of 66 opportunities and received two person assistance for bed mobility 52 times out of 66 opportunities. A quarterly assessment, dated 02/03/25, showed Resident #1 had a BIMS score of 03, which indicated the resident was severely impaired in cognition for daily decision making, was dependent on staff for rolling left to right, was incontinent of urine, had not experienced any falls, was 63 inches tall, and weighed 235 pounds. A care plan, revised 02/06/25, showed the resident required two person assistance for transfers with the mechanical lift, was at risk for falls, had a fall mat beside their bed, and the staff were to follow the fall protocol. An incident note, dated 02/23/25 at 8:33 a.m., showed at 4:35 a.m., RN #1 had been notified by a CNA that Resident #1 had fallen out of bed during incontinent care. The CNA stated they were standing on the side of the bed where the wall was and when they pulled the draw sheet to turn Resident #1 onto their side, the resident rolled out of bed. The note showed the resident had non skid socks on and the fall mat was present. The note showed Resident #1 had a dark purple hematoma to the back of the right hand between right index finger and right middle finger measuring 8.0 cm x 7.0 cm with a small tear on the hematoma measuring 0.9 cm x 0.3 cm. The note showed first aide was applied to the skin tear, the resident complained of pain to the bilateral lower extremities, neuro checks were initiated, the physician and family member were notified and x-rays were ordered. The note documented Resident #1 was transferred back to bed by the mechanical lift and three staff members. A nurse note, dated 02/23/25 at 10:25 a.m., showed Resident #1 had an increase in pain in the left lower extremity, the physician was notified, and the resident was sent to the hospital at 9:15 a.m. An ODH form 283 incident report, showed an incident dated 02/23/25 for Resident #1. The form showed on 02/23/25 at 4:35 a.m., the resident had fallen out of bed when they were being provided incontinent care. The form showed the CNA (CNA #1) stated as they pulled on the draw sheet to turn the resident onto their side, they rolled out of bed. The form showed the resident had on non skid socks and fall mat was present. The incident report showed the hospital records indicated Resident #1 had a fracture of the left distal femur, the right wrist had bruising and tenderness with scapholunate dissociation, which was degenerative in nature due to arthritis. The incident report form showed staff were inserviced on how to properly transfer and reposition residents while in bed, Resident #1 would require two person assistance for incontinent care and positioning upon return to the facility. The incident report form showed Resident #1 returned to the facility on [DATE], family member #2 stated the resident had not received surgery to repair the fracture due to the risks, and the resident utilized an immobilizer to the left leg. A hospital history and physical, dated 02/23/25, showed the resident had senile osteoporosis, rheumatoid arthritis, generalized osteoarthrosis involving multiple sites, and osteopenia. A care plan intervention, initiated 02/23/25, showed the resident had experienced a fall and two staff were to be present during incontinent care. A care plan intervention, initiated 02/24/25, showed the resident had experienced a fall with major injury and two staff were required for bed mobility and repositioning. A policy titled, Fall Policy, dated 02/24/25, read in part, The purpose of the Fall Interdisciplinary Team is: 1. To identify residents at risk for falls. 2. Initiate preventative approaches. 3. To provide appropriate strategies and interventions directed to resident, environmental factors and staff. 4. Monitor and evaluate fall prevention outcome. A fall risk assessment, dated 02/26/25, documented Resident #1 was high risk for falls. A nurse note, dated 02/26/25 at 1:52 p.m., showed family member #2 stated Resident #1 had not walked in over five years and the doctor at the hospital stated their bones were brittle like corn flakes. The note showed they had implemented an intervention of two person assistance with incontinent care and positioning while in bed. An admission summary note, dated 02/26/25 at 2:30 p.m., showed Resident #1 had returned to the facility with a brace to their right forearm and hand, had bruising to the fingers and the top of their hand, and a scab between their first and second knuckle. The note showed the resident had an immobilizer to their left leg. An At Risk Meeting Log, dated 02/28/25, documented Resident #1's fall with fracture which occurred during incontinent care. The log showed the resident was able to assist with bed mobility, had a fall mat, non skid socks, a bandana tied to the call light, and the bed was to be in the low position. The log documented upon return to the facility the resident would require two person assistance with incontinent care and they would provide CNA retraining. A policy titled Policy on Assistance during Incontinent care/turning and repositioning, dated 03/03/25, read in part, Nurses/Care coordinators determines if a resident is one or two person assist during incontinent care or turning and repositioning. Forms titled Procedure 8: Assist resident to move to head of bed, Procedure 3: Supine position, Procedure 4: Lateral position, Procedure 5: Fowler's position, Procedure 6: Semi-fowler's position, and Procedure 7: Sit on edge of bed, were signed by CNA #1 and an instructor on 03/11/25. A form titled QAPI for February, dated 03/25/25, read in part, Recent Fall [with] major injury [Resident #1] .Was staff properly trained: Yes [they] had two week orientation/training on that hall. Intervention ion [sic] place: Yes, fall mat, low bed, non skid socks, red bandana. What could we do to improved [sic]: 1. Plan tore [sic] assess all resident [sic] to determine if 1 or two [with] transfer. See attached Policy on Incontinent care assistance. 1. Re-educate staff involved. A sign in form, dated 03/31/25, showed the North hall was inserviced on the difference between transfers/bed mobility and the amount of assistance. The inservice was signed by 16 direct care staff members. A sign in form, dated 03/31/25, showed the [NAME] hall was inserviced on the status of each resident for bed mobility/incontinent care. The inservice was signed by 18 direct care staff members. A sign in form, dated 03/31/25, showed the South hall was inserviced on the amount of assistance each resident required for bed mobility, positioning, and incontinent care. The inservice was signed by 22 direct care staff members. A Staff Education Inservice form, dated 04/02/25, showed the DON had provided education to 27 direct care staff members. The form read in part, Topic of Discussion: [Residents] needing assistance [with] incontinent care, turning and repositioning now added on Kardex and task as of 4-1-25 and bed mobility to identify/indicate 1 or 2 person assist. On 05/12/25 at 2:04 p.m., CMA #2 stated they utilized two person assistance for any care for Resident #1 while they were in bed. On 05/12/25 at 4:23 p.m., family member #1 stated Resident #1 should have received two person assistance since admission due to their size. They stated the facility has now posted signage to indicate the resident required two person assistance. On 05/19/25 at 6:35 a.m., CNA #1 stated on 02/23/25 when they went into Resident #1's room to provide incontinent care, the resident was laying in bed on their back moving their legs like they were walking. They stated the resident usually did not move their legs like that. They stated they could not reach the draw sheet on the side of the bed by the wall so they went to that side and when they began angling the draw sheet to position the resident to their right side the resident rolled out of bed. CNA #1 stated they immediately notified RN #1. CNA #1 stated Resident #1 had always required one person assistance with incontinent care and bed mobility but now required two persons. On 05/19/25 at 7:00 a.m., RN #1 stated prior to the fall on 02/23/25, Resident #1 required one person assistance with incontinent care and bed mobility and currently required two person assistance with all care in bed. On 05/19/25 at 7:09 a.m., RN care coordinator #1 stated Resident #1 required one person assistance with turning, repositioning, and incontinent care prior to the fall on 02/23/25. They stated Resident #1 could move their legs but was unable to roll and reposition from side to side. On 05/19/25 at 7:22 a.m., the DON stated prior to the fall on 02/23/25 the fall interventions that were in place included low bed when they were not performing care and was on the fall protocol. The DON stated the fall protocol consisted of non skid socks, low bed, and a red bandana tied around the call light. They stated after Resident #1 fell, they assessed and wrote orders on every resident for the amount of staff assistance needed for incontinent care and bed mobility. On 05/19/25 at 7:45 a.m., CNA #3 stated Resident #1 had not always required two person assistance for incontinent care or bed mobility. They stated Resident #1 had been two person assistance since the fall on 02/23/25. On 05/19/25 at 7:49 a.m., CNA #4 stated they had always utilized two staff members for incontinent care and bed mobility. On 05/19/25 at 8:56 a.m., the MDS coordinator stated they had coded Resident #1 was dependent on staff for all activities of daily living except eating. They stated they had coded the assessment as dependent on staff because the resident required the assistance of two staff persons. On 05/19/25 at 9:52 a.m., the MDS coordinator provided the Documentation Survey Report v2 for January 2025 and February 2025. They stated they had reviewed the CNAs documentation on the report and that was why they had indicated on the assessment the resident required the assistance of two staff members for bed mobility and incontinent care. They reviewed the report and stated documentation in the toileting category was for incontinent care. On 05/19/25 at 10:17 a.m., RN care coordinator #1 stated sometimes they were able to provide incontinent care and bed mobility/repositioning for Resident #1 without the assistance of another staff person. They stated other times they needed another staff member to assist them. They were asked why staff had not been instructed Resident #1 required the assistance of two staff persons when, according to the documentation on the Documentation Survey Report v2, they required two person assistance for more than half of the opportunities in January 2025 and February 2025. They stated they did not know. On 05/19/25 at 10:26 a.m., CNA #2 stated they had always utilized two person assistance incontinent care and bed mobility for Resident #1. They stated there was signage posted on Resident #1's wall now and staff had been inserviced on the resident's care needs. On 05/19/25 at 10:29 a.m., CNA #5 stated Resident #1 had usually always required two person assistance with incontinent care and bed mobility before the fall on 02/23/25. They stated if they could reposition the resident without assistance they would but sometimes they needed help from another staff member. They stated Resident #1 now required two person assistance for all care when in bed. On 05/19/25 at 10:59 a.m., CNA #6 stated they had always used two person assistance with incontinent care and bed mobility for Resident #1. They stated they had received an inservice that Resident #1 required two person assist with activities of daily living so all staff should not be using two people when providing incontinent care and for bed mobility. On 05/19/25 at 11:18 a.m., the DON stated Resident #1 required one person assistance with incontinent care and bed mobility before the fall on 02/23/25. The DON reviewed the CNA documentation on the Documentation Survey Report v2 forms, dated January and February 2025, and acknowledged that some CNAs provided incontinent care and bed mobility independently and some documented the resident required two staff members. The DON was asked how the facility ensured residents who required two person assistance for bed mobility and incontinent care received two person assistance to prevent falls with major injury. They stated Resident #1 only required one person assistance and had been on the restorative program. The DON was asked why staff had documented the resident required two person assistance and the quarterly assessment had shown the resident required two person assistance. The DON stated the staff may have been more comfortable using two person assistance for care for Resident #1.

Based on record review and interview, the facility failed to ensure responsible parties were notified immediately after an accident/fall for 1 (#1) of 3 sampled residents who were reviewed for notification after an accident/fall. The DON identified 56 residents resided in the facility. Findings: A policy titled Change in a Resident's Condition or Status, dated May 2017, read in part, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. A quarterly assessment, dated 02/03/25, showed Resident #1 had a BIMS score of 03, which indicated the resident was severely impaired in cognition for daily decision making ,and had a diagnosis of dementia. An incident note, dated 02/23/25 at 8:33 a.m., showed at 4:35 a.m., a CNA (CNA #1) had notified the nurse Resident #1 had fallen out of bed when the CNA (CNA #1) had repositioned the resident. The note showed the resident had a dark purple hematoma to the right hand between right index finger and right middle finger measuring 8.0 cm x 7.0 cm with a small tear on the hematoma measuring 0.9 cm x 0.3 cm. The note showed Resident #1 complained of pain to the bilateral lower extremities, the physician was notified, and x-rays were ordered. The note showed the resident's POA had been notified. On 05/12/25 at 4:23 p.m., family member #1 stated the facility had not notified them of the fall for Resident #1 until 7:30 a.m. on 02/23/25. On 05/19/25 at 7:00 a.m., RN #1 stated they had not notified Resident #1's family of the fall when it had occurred. They stated they had notified family member #1 between 7:00 a.m. and 8:00 a.m. on 02/23/25. RN #1 stated they did not believe there was a time frame to notify the residents' representatives when there had been a fall, just that the responsible party needed to be notified before the end of the nurses shift. On 05/19/25 at 7:09 a.m., RN care coordinator #1 stated once a resident had been assessed after an accident, the physician was notified, orders were received, and the residents' responsible party was to be notified. RN care coordinator #1 stated they did not know why Resident #1's representative had not been notified immediately following the fall on 02/23/25. On 05/19/25 at 7:22 a.m., the DON stated resident representatives were to be notified immediately after an accident and/or fall. They stated for the fall on 02/23/25 at 4:35 a.m., for Resident #1, they did not know why the resident's representative had not been notified until 7:00 a.m. to 8:00 a.m.

Based on observation, record review, and interview, the facility failed to: a. speak to a resident in a respectful manner for one (#28); and b. ensure resident clothing labels were not visible for one (#39) of three sampled residents reviewed for dignity. The DON identified a census of 58. Findings: A Quality of Life-Dignity policy, revised 08/09, read in part, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .Treated with dignity .means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall speak respectfully to residents at all times .Demeaning practices and standards of care that compromise dignity are prohibited . 1. Resident #28 had diagnosis which included Parkinson's and Dementia. On 04/02/24 at 9:10 a.m., CNA #6 was observed asking Resident #28 if they wanted to be fed like a baby, after the resident was observed sitting in wheel chair moving their fork around aimlessly in the air beneath the bedside table. On 04/02/24 at 9:23 a.m., Resident #28 was observed to be eating easily when the spoon was offered. On 04/02/25 at 10:02 AM, CNA #6 stated resident #28 usually went to the dining room and fed themselves. CNA #1 stated Resident #28 had commented they were not a baby when CNA #6 previously offered to assist them. On 04/02/24 at 10:19 a.m., Resident #28 was asked how it made them feel to be asked if they wanted to be fed like a baby. Resident #28's answer was not understood. On 04/03/24 at 2:51 p.m., LPN #2 stated Resident #28 had mentioned statements like I don't want you to feed me, but it had been a long time ago since they had stated that. They sated comments like do you want me to feed you like a baby would not be an appropriate statement at all. On 04/03/24 at 3:02 p.m., the DON stated it depended on the relationship between residents on how they would take the comment of Do you want me to feed you like a baby? 2. Resident #39 had diagnoses which included Alzheimer's disease and anxiety disorder. A Significant Change Resident Assessment, dated 02/29/24, documented the resident's cognition for daily decision making was severely impaired. On 04/01/24 at 10:16 a.m., Resident #39 was observed seated in their wheelchair. The resident's right sock they were wearing had her name label clearly visible. On 04/02/24 at 9:07 a.m., Resident #39 was observed seated in their wheelchair. The resident's right and left sock they were wearing had a label with their name on each one clearly visible. On 04/03/24 at 10:45 a.m., CNA #3 stated they treated resident's with dignity and respect by making sure the door was shut and the curtain was pulled every time they went in to change them. They stated if a resident was wearing a dress, they would place a blanket over them. They stated they would always go in with respect and ask them if they needed anything, make sure they had a drink in reach, and offer drinks to those who could not get one themselves. On 04/03/24 at 10:46 a.m., CNA #3 stated staff would take resident's personal items over to the laundry who would use a label press on the back side of the shirts and pants to label items. On 04/03/24 at 10:46 a.m., CNA #3 stated they would make sure all clothing residents came with were labeled and placed in their closets. On 04/03/24 at 10:47 a.m., CNA #3 stated they were unsure of the reason the top of the resident's socks were labeled unless they were skid free and they didn't want to label the skid free section. On 04/03/24 at 10:50 a.m., Laundry #1 stated when they pick up resident items to be laundered, they made sure clothes had resident names on them. They stated they had a label machine to print out labels. They stated they placed labels on the inside, back section by the brand name. They stated they tried to place it where it didn't look like a label was there when they were wearing it. Laundry #1 stated they didn't use the inside of the socks because it might bother them, They stated they placed labels on the outside so they could read it and they were not bothered by the label. 49701

Based on record review and interview, the facility failed to revise care plans for two (#22 and #37) of 18 sampled residents reviewed for accuracy of care plans. The DON identified a census of 58. Findings: A Care Plans, Comprehensive Person-Centered policy, dated 12/16, read in part, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. Resident #37 had diagnoses which included aftercare following surgical amputation. A progress note, dated 01/15/24, documented Resident #37 was readmitted to skilled care after a left above knee amputation had been performed on 01/11/24. It documented a wound vac was to be in place for seven days. A Care Plan, revised 05/18/23, documented the resident has a venous ulcer of the left lower calf related to peripheral vascular disease. There was no care plan for wound care related to left above knee amputation. On 04/02/24 at 3:33 p.m., MDS Coordinator #1 stated they had started a Performance Improvement Project for care plans. MDS Coordinator #1 stated they care planned relevant new orders every day. 2. Resident #22 had diagnoses which included corticobasal degeneration and hypertension. A Quarterly Resident Assessment, dated 01/11/24, did not document the resident received hospice services. There was no physician order for hospice care in Resident #22's current order summary. A Care Plan, last reviewed 01/30/24, documented the resident had a terminal prognosis which was initiated on 06/12/21 with a goal for comfort to be maintained through the review date with a target date of 04/26/24. On 04/03/24 at 10:01 a.m., LPN #3 stated Resident #22 was on hospice services when they first came to the facility. They stated they were unsure of the exact discharge from hospice date, but they thought it was longer than a year ago. On 04/03/24 at 10:20 a.m., MDS Coordinator #1 stated they printed out orders every morning and used them to update care plans. They stated they had a morning meeting where the Care Coordinators printed a list of everything which needed to be updated related to residents on the hall. On 04/03/24 at 10:21 a.m., MDS Coordinator #1 stated they would complete a care plan for terminal prognosis when the resident received a terminal prognosis. On 04/03/24 at 10:22 a.m., MDS Coordinator #1 stated Resident #22 was not on hospice services. They stated they did not complete the resident's care plan, and the care plan was not updated. They stated they guessed when Resident #22 came off of hospice services, they did not remove it from the resident's care plan. MDS Coordinator #1 stated they had been at the facility approximately one month and had not been able to update every resident's care plan. 49701

Based on observation and interviews, the facility failed to ensure harmful chemicals were secured. The Administrator identified six residents that required wander guards to be worn for safety. The DON identified a census of 58. Findings: On 04/01/24 at 9:58 a.m., an observation of 1/10 of a gallon container of dish detergent, 1/10 of a 32 oz. bottle of lime and calcium remover, 1/2 full spray bottle labeled with black marker cleaner with bleach, and a full 15 oz. aerosol can of stainless steel cleaner were observed sitting on top of the dishwasher in the room which connected the two dining rooms. A one gallon container of dish detergent and a one gallon container of sanitizer on a rack that was attached to the sink were also observed in the room. Both doors to the room were observed to be open. On 04/01/24 at 9:59 a.m., Dietary Aide #1 stated the residents don't come in the room. They stated the staff did not lock the door. On 04/01/24 at 12:08 p.m., the Dietary Manager stated there was no key, so the door did not get locked. They stated staff were in and out of the room all day. The Dietary Manager stated the door was only closed from around 7:00 p.m. to 7:00 a.m.

Based on record review and interview, the facility failed to insure an injury of unknown origin was reported to OSDH for one (#52) of three sampled residents reviewed for abuse. The DON identified a census of 58. Findings: An Abuse Prevention policy, updated 01/01/23, read in part, .[facility name] will make every attempt to protect our Resident's from abuse of any sort by striving to recognize signs and symptoms and potential for abuse or neglect .The facility has policies and procedures in place to identify events, such as suspicious bruising .Once a complaint or situation is identified involving .injuries of unknown source .the incident will be immediately reported .A full report will be prepared and forwarded to officials as required by state and federal regulations . Resident #52 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction and dysphagia. A Significant Change Resident Assessment, dated 01/11/24, documented Resident #58's cognition was moderately impaired. An Incident Report, dated 02/05/24 at 10:56 a.m., documented at approximately 9:30 a.m., CNA staff reported to the nurse to come to Resident #52's room. It documented upon entering the room, the nurse observed the resident in bed receiving incontinent care. It documented the nurse noted dark purple bruising with significant swelling to the resident's left labia majora and minora. It documented the area measured 15 cm in length and eight cm in width which was painful to touch. It documented the physician, DON, Care Coordinator, and POA were all notified. The report was prepared by LPN #1. A Skin/Wound Note, dated 02/06/24 at 5:35 a.m., documented Resident #52's groin area was checked. It documented ecchymosis seen to right side of groin and labia which was purple in color. It documented ecchymosis to the right thigh which was healing and pink in color. An Incident Note, dated 02/06/24 at 10:34 a.m., documented at approximately 9:30 a.m., CNA staff reported to the nurse to come to Resident #52's room. It documented upon entering the room, the nurse observed the resident in bed receiving incontinent care. It documented the nurse noted dark purple bruising with significant swelling to the resident's left labia majora and minora. It documented the area measured 15 cm in length and eight cm in width which was painful to touch. It documented the physician, DON, Care Coordinator, and POA were all notified. The note was created by LPN #1. A Nurses Note, dated 02/06/24 at 6:48 p.m., documented the resident had a right groin bruise and right inner thigh bruise. There was no State Reportable incident located for the above injury of unknown origin for Resident #52. On 04/03/24 at 2:11 p.m., CNA #3 stated if they saw any bruising on a resident that wasn't there the day before, they would immediately notify the charge nurse so they could assess the area. They stated the nurse would complete an incident report. They stated each staff member would also give a statement. On 04/03/24 at 2:15 p.m., CNA #2 stated they would notify their nurse anytime they identified bruising of unknown origin on a resident. On 04/03/24 at 2:17 p.m., LPN #1 stated if bruising of unknown origin was reported to them, they would assess the resident first to see the size and color. They stated they would complete an incident report and determine if the area was raised or painful. They stated they would ensure to inform the oncoming shift, the DON, Care Coordinator, family, POA, and physician. They stated the incident would automatically go in the pink book for Physician #1 to review. On 04/03/24 at 2:20 p.m., LPN #1 stated they remembered the incident involving Resident #52. They stated the CNA had removed the resident's brief during care, and the resident was noted to have a bruise in the pubis. They stated it was good size, and was the first time LPN #1 had seen it. They stated they completed an incident report on it and were never able to determine the cause of it. On 04/03/24 at 2:26 p.m., the DON stated if a resident was noted to have bruising of unknown origin, they would look to see how large the bruise was. They stated they would visit with the resident to see how they got the bruise. They stated if the resident was unable to report, the facility would do an additional investigation. The DON stated they would complete a State Reportable. On 04/03/24 at 2:28 p.m., the DON stated the facility would complete a State Reportable incident on any resident who had a bruise of unknown origin. On 04/03/24 at 2:29 p.m., the DON stated they were the person responsible for completing State Reportable incidents. On 04/03/24 at 2:31 p.m., the DON clarified the nurse note dated 02/06/24 was linked to the incident on 02/05/24. They stated the incident occurred on 02/05/24. On 04/03/24 at 2:36 p.m., the DON was asked what investigation was completed for the bruising of unknown origin. On 04/03/23 at 2:37 p.m., the DON reviewed the State Reportable incidents and did not locate one for the incident involving Resident #52 on 02/05/24. On 04/03/24 at 2:59 p.m., the DON stated they went to Care Coordinator #1 and obtained the facility investigation. The DON provided copied of an inservice related to reporting bruises held on 02/06/24. The DON also provided nine interviews conducted in conjunction with there investigation. The DON was unable to provide documentation OSDH was informed of Resident #52's injury of unknown origin.

Based on record review and interview, the facility failed to ensure a discharge summary was developed for one (#61) of three sampled residents reviewed for discharge. The DON identified a census of 58. Findings: Resident #61 had diagnoses which included pneumonia and bronchitis. A Discharge Summary and Plan policy, dated 12/16, read in part, .a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment .will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident . A Physician Order dated 01/10/24, documented the resident was to be discharged to an assisted living facility as of 01/16/24 with home health to include PT, OT, ST, skilled nursing and a home health aide. Resident #61 had no discharge summary in their medical record. On 04/04/24 at 2:00 p.m., the DON stated a discharge should include the condition of the resident, discharge rehabilitation potential, medications, orders, follow up directions, and reason for leaving. The DON stated it should have been in the progress notes and a discharge summary. The DON stated there was no documentation of the resident's discharge that could be located.

Based on record review and interview, the facility failed to obtain physician ordered labs for one (#56) of five sampled residents reviewed for unnecessary medications. The DON identified a census of 58. Findings: A Laboratory policy, undated, read in part, .It is the policy of this facility to ensure that laboratory .services meet the needs of the residents, that results are reported promptly to the ordering provider . Resident #56 had diagnoses which included severe protein-calorie malnutrition, hypertension, and chronic obstructive pulmonary disease. A Physician Order, dated 02/07/24, documented lab check chem eight for delirium one time only. There was no documentation in the resident's clinical record this lab was obtained. On 04/04/24 at 9:57 a.m., the DON stated if the physician wrote an order for a lab, staff would ensure the order was put in, place the order in the requisition book, and place it in the lab book for them to come and draw it. The DON stated lab came to the building Monday through Friday. On 04/04/24 at 10:38 a.m., the DON stated they were unable to find lab results for the chem eight ordered.

Based on observation and interview, the facility failed to ensure food items were properly secured, dated, and labeled for one of one kitchen observations. The DON identified a census of 58. Findings: A Food Receiving and Storage policy, dated 07/14, read in part, All foods stored in the refrigerator or freezer will be covered, labeled and dated .Other opened containers must be dated and sealed or covered during storage . On 04/01/24 at 9:55 a.m., bread in the dining room refrigerator was observed to have no label present. Dietary Aide #1 stated it was for the birds. On 04/01/24 at 10:03 a.m., a carton of au gratin potatoes was observed open and unlabeled in the dry storage area. The Food and Beverage Director stated the au gratin potatoes were opened and not labeled. On 04/01/24 at 10:07 a.m., frozen bread bowls and tri color pasta was observed in the walk in freezer. The Food and Beverage Director stated the frozen bread bowls and tri-color pasta had no expiration date or label.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#8 and #28) of two residents reviewed for falls and one (#27) of one resident who was reviewed for a PEG (feeding) tube. The Administrator reported 56 residents had falls in the last 12 months and one resident had a PEG tube. Findings: Res #8 was admitted with diagnoses which include hemiplegia and hemiparesis following a CVA and lack of coordination. An incident note, dated 04/17/22, read in parts, Resident found laying beside the bed on the fall mat . An incident note, dated 07/21/22, read in parts, .resident slipped out of her wheelchair onto floor . An incident note, dated 08/04/22, read in parts, Resident has been placed on post fall charting after attempting to transfer self without assistance . An incident note, dated 10/30/22, read in parts, .Resident observed sitting on buttocks on the floor . An incident note, dated 11/28/22, read in parts, Resident was found on the floor . An incident note, dated 12/02/22, read in parts, Resident was found on floor . An incident note, dated 12/12/22, read in parts, Resident was found on floor . An incident note, dated 12/16/22, read in parts, Resident found by this nurse on fall mat . An incident note, dated 12/25/22, read in parts, .Upon entering, observed resident sitting on her bottom in from of her W/C . An incident note, dated 02/5/23, read in parts, .resident sitting on floor . A quarterly assessment, dated 06/10/22, documented no falls since admission/entry, reentry, or the prior assessment (one fall should have been documented). A quarterly assessment, dated 07/23/22, documented no falls since admission/entry, reentry, or the prior assessment (one fall should have been documented). An annual assessment, dated 10/20/22, documented no falls since admission/entry, reentry, or the prior assessment (one fall should have been documented). A quarterly assessment, dated 11/29/22, documented no falls since admission/entry, reentry, or the prior assessment (one fall should have been documented). Resident #28 was admitted with diagnoses which included abnormalities of gait and mobility. An incident report, dated 03/31/22, read in parts, .resident noted sitting on floor beside bed . An incident report, dated 04/10/22, read in parts, .Resident was found on the floor by her bed . An incident report, dated 05/18/22, read in parts, .sitting on floor in front of recliner . An incident report, dated 06/20/22, read in parts, .resident on floor mat beside bed . An incident report, dated 07/25/22, read in parts, .resident on floor .laying next to dresser . An incident report, dated 08/21/22, read in parts, .fell on previous shift . An incident report, dated 08/30/22, read in parts, .Resident found on floor . An incident report, dated 09/06/22, read in parts, .Resident rolled herself out of bed . An incident report, dated 09/08/22, read in parts, .resident observed sitting on floor . An incident report, dated 09/10//22, read in parts, .resident on floor mat beside her bed in her room . An incident report, dated 09/23/22, read in parts, .witnessed non-injury fall occurred at this time . An incident report, dated 10/27/22, read in parts, .CNA was able to control the fall and lowered her to the floor . An incident report, dated 11/22/22, read in parts, Resident observed laying on fall mat on her stomach . An incident report, dated 11/25/22, read in parts, Resident had a non-injury fall out of her bed . An incident report, dated 11/26/22, read in parts, Resident observed sitting on floor . An incident report, dated 02/01/23, read in parts, Resident had a fall on this shift . A quarterly assessment, dated 04/11/22, documented no falls since admission/entry, reentry, or the prior assessment (two or more falls should have been documented). A quarterly assessment, dated 08/05/22, documented no falls since admission/entry, reentry, or the prior assessment (two or more falls should have been documented). A quarterly assessment, dated 11/09/22, documented no falls since admission/entry, reentry, or the prior assessment (two or more falls should have been documented). On 02/24/23 at 8:30 a.m., the MDS Coordinator reported the falls for Res #8 and #28 should have been documented on their resident assessments. Res #27 was admitted with diagnoses which included gastrostomy, Parkinson's disease, and dementia. The Long-Term Care Facility Resident Assessment Instrument 2.0 User's Manual, dated October 2019, read in parts, .Mechanically Altered Diet: A diet specifically prepared to alter the texture or consistency of food to facilitate oral intake .Therapeutic Diet: .diet intervention ordered by a health care practitioner as part of the treatment for a disease or clinical condition manifesting an altered nutritional status, to eliminate, decrease, or increase certain substances in the diet (e.g. sodium, potassium) .Therapeutic diets are not defined by the content of what is provided or when it is served, but why the diet is required. Therapeutic diets provide the corresponding treatment that addresses a particular disease or clinical condition . A physician's order, dated 10/11/22, read in part, NPO diet, N/A texture, N/A consistency. A physician's order, dated 11/20/22, read in parts, Isosource (nutritional formula) 1.5 Give 180ml via PEG tube 5x's daily . A nursing note, dated 10/16/22, read in parts, .Resident is NPO: all meds and nutrition administered via PEG . A nutrition/dietary note, dated 11/22/22, read in parts, .Weight is stable .Diet order is NPO. Continues with Isosource 180ml 5 times/day. No new nutrition interventions are needed. A quarterly assessment, dated 03/12/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A therapeutic diet was documented and should not have been. An annual assessment, dated 06/10/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. A quarterly assessment, dated 09/07/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. A significant change assessment, dated 10/01/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. A significant change assessment, dated 10/17/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. A quarterly assessment, dated 01/16/23, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. On 02/23/23 at 11:05 a.m., LPN #1 stated, As long as Res #27 has been here they have been NPO and received nothing by mouth. On 02/23/23 at 11:10 a.m., CMA #1 reported Res #27 received nothing by mouth. On 02/24/23 at 8:27 a.m., the MDS Coordinator reported mechanically altered diet was documented because staff tried to give Res #27 food by mouth at one time. (MDS Coordinator was unable to provide documentation) The MDS Coordinator reported Res #27 was receiving a mechanically altered diet because the formula they received through the PEG tube was a liquid diet. The MDS Coordinator reported therapeutic diet was documented because Res #27's formula was high in protein and fiber.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#27) of one resident reviewed for a PEG tube, one (#28) of two residents reviewed for falls, and one (#42) of one resident reviewed for a venous ulcer. The Administrator reported one resident had a PEG tube, 56 residents had falls in the last 12 months, and one resident had a venous ulcer. Findings: A policy titled Comprehensive Assessment and the Care Delivery Process, dated 12/16, read in parts, .Define current treatments and services; link with problems/diagnoses . Res #27 was admitted with diagnoses which included gastrostomy, Parkinson's disease, and dementia. A physician's order dated, 10/11/22, read in parts, NPO diet . A physician's order dated, 10/11/22, read in parts, Check for PEG tube placement before medication and free water administration every shift . A physician's order dated, 10/11/22, read in parts, Elevate HOB 30 degrees at all times . A physician's order dated, 10/12/22, read in parts, Cleaned PEG tube site with wound cleanser, apply drain sponge, secure with tape every evening shift . A physician's order dated, 10/27/22, read in parts, Check for residual prior to each feeding. If >100ml, hold feeding and re-check in 1 hr. If < 100ml, provide feeding at that time . A physician's order dated, 11/11/22, read in part, Flush PEG tube with 200ml free water every 4 hours. A physician's order dated, 11/20/22, read in part, Isosource 1.5 Give 180ml via PEG tube 5x's daily . There was no nutrition/PEG tube care plan for Res #27. On 02/24/23 at 8:27 a.m., the MDS/Care Plan Coordinator reported Res #27 should have had a nutrition/PEG tube care plan to include the physician's orders related to the PEG tube. Res #28 was admitted with diagnoses which included abnormalities of gait and mobility. An annual assessment, dated 11/29/22, documented Res #28 had impaired ROM on one side and needed extensive assistance with transfers and bed mobility. The assessment documented Res #28 required limited assistance with walking, their balance with walking was not steady, and they required staff assistance for stabilization. The Morse Fall Scale, completed on 03/28/22, 05/03/22, 08/03/22, 11/03/22 and 02/03/23, documented Res #28 was at high risk for falls. An incident report, dated 03/31/22, read in parts, .resident noted sitting on floor beside bed . An incident report, dated 04/10/22, read in parts, .Resident was found on the floor by her bed . An incident report, dated 05/18/22, read in parts, .sitting on floor in front of recliner . An incident report, dated 06/20/22, read in parts, .resident on floor mat beside bed . An incident report, dated 07/25/22, read in parts, .resident on floor .laying next to dresser . An incident report, dated 08/21/22, read in parts, .fell on previous shift . An incident report, dated 08/30/22, read in parts, .Resident found on floor . An incident report, dated 09/06/22, read in parts, .Resident rolled herself out of bed . An incident report, dated 09/08/22, read in parts, .resident observed sitting on floor . An incident report, dated 09/10//22, read in parts, .resident on floor mat beside her bed in her room . An incident report, dated 09/23/22, read in parts, .witnessed non-injury fall occurred at this time . An incident report, dated 10/27/22, read in parts, .CNA was able to control the fall and lowered her to the floor . An incident report, dated 11/22/22, read in parts, Resident observed laying on fall mat on her stomach . An incident report, dated 11/25/22, read in parts, Resident had a non-injury fall out of her bed . An incident report, dated 11/26/22, read in parts, Resident observed sitting on floor . An incident report, dated 02/01/23, read in parts, Resident had a fall on this shift . There was no fall care plan for Res #28. On 02/24/23 at 8:27 a.m., the MDS/Care Plan Coordinator reported Res #28 should have had a care plan for falls. Res #42 was admitted with diagnoses which included diabetes, venous insufficiency, and non pressure ulcer. A quarterly assessment, dated 12/03/22, documented Res #42 required assistance with activities of daily living, and had one venous ulcer. There was no venous ulcer care plan for Res #42. On 02/23/23 at 2:04 p.m., the MDS coordinator reported the care plan did not include the venous ulcer. On 02/23/23 at 2:16 p.m., RN #1 reported the care plan should have included the venous ulcer. On 02/23/23 at 4:09 p.m., the Administrator reported the venous ulcer should have been included in the care plan.

Based on record review and interview, the facility failed to ensure a fall care plan was revised for two (#8 and #13) of three residents reviewed for falls. The Administrator reported 56 residents had falls in the last 12 months. Findings: Res #8 was admitted with diagnoses which included lack of coordination, hemiplegia, and hemiparesis. A quarterly assessment, dated 11/29/22, documented Res #8 needed extensive assistance with bed mobility, transfers and ambulation. The assessment documented Res #8's balance with walking was not steady and they required staff assistance for stabilization. The Morse Fall Scale, completed on 03/29/22, 06/29/22, 09/29/22, and 12/29/22, documented Res #8 was at high risk for falls. An incident note, dated 04/17/22, read in parts, Resident found laying beside the bed on the fall mat . An incident note, dated 07/21/22, read in parts, .resident slipped out of her wheelchair onto floor . An incident note, dated 08/04/22, read in parts, Resident has been placed on post fall charting after attempting to transfer self without assistance . An incident note, dated 10/30/22, read in parts, .Resident observed sitting on buttocks on the floor . An incident note, dated 11/28/22, read in parts, Resident was found on the floor . An incident note, dated 12/02/22, read in parts, Resident was found on floor . An incident note, dated 12/12/22, read in parts, Resident was found on floor . An incident note, dated 12/16/22, read in parts, Resident found by this nurse on fall mat . An incident note, dated 12/25/22, read in parts, .Upon entering, observed resident sitting on her bottom in from of her W/C . An incident note, dated 02/05/23, read in parts, .resident sitting on floor . A fall care plan for Res #8, last revised on 04/13/21, was not revised for the falls from 04/17/22 through 02/05/23. Res #13 was admitted with diagnoses which included lack of coordination, dementia, and abnormalities of gait. A quarterly assessment, dated 12/17/22, documented Res #13 was mildly cognitively impaired and required extensive assistance with activities of daily living. Incident reports, documented Res #13 had 11 falls from 08/25/22 through 01/03/23. A fall care plan developed on 08/02/22 was not revised for the falls from 08/25/22 through 01/03/23. On 02/22/23 at 3:10 p.m., the MDS coordinator reported the care plan had not been revised with each fall. On 02/23/23 at 3:54 p.m., the interim DON reported the care plan should have been revised with new interventions. On 02/23/23 at 4:04 p.m., the Administrator reported the care plan should have been revised with each fall. On 02/24/23 at 8:30 a.m., the MDS/Care Plan Coordinator reported they had not updated the care plan for Res #8 with each fall, and if they had been provided fall interventions they would have been care planned.

Based on record review and interview, the facility failed to ensure: a. weights were obtained as ordered by the physician for one (#13) of one resident with congestive heart failure; b. a care plan was accurate for one (#27) of one resident reviewed for a PEG tube, and c. communication was documented between hospice and the facility for one (#38) of two residents on hospice. The Administrator reported 13 residents had congestive heart failure, one resident had a peg tube, and two residents were on hospice. Findings: a. Res #13 was admitted with diagnoses which included congestive heart failure. A physician's order, dated 08/03/22, documented in part, Daily Weight every day shift for CHF. A physician's order, dated 10/14/22, documented in parts, Lasix (a diuretic) Tablet 20 MG Give 1 tablet by mouth one time a day related to .CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE .give 60mg per day. A physician's order, dated 10/15/22, documented in parts, Lasix Tablet 40 MG .Give 1 tablet by mouth one time a day for CHF give with 20mg tab to equal 60mg dosing per day. A treatment administration record, dated December 2023, documented 27 weights out of 31 opportunities. Weights for 12/04/22, 12/11/22, 12/23/22, and 12/26/22 were not documented. A treatment administration record, dated January 2023, documented 25 weights out of 31 opportunities. Weights for 01/03/23, 01/04/23, 01/12/23, 01/16/23, 01/26/23, and 01/30/23 were not documented. On 02/22/23 at 3:10 p.m., CNA #1 reported Res #13 required daily weights. CNA #1 reported if the resident refused to be weighed it should have been documented on the treatment administration record. On 02/22/23 at 3:15 p.m., LPN #3 reported the daily weights had not been obtained and documented on the treatment administration record as ordered. On 02/22/23 at 3:59 p.m., the interim DON stated according to documentation the daily weights were not obtained and documented as ordered. On 02/22/23 at 4:02 p.m., the Administrator reported the weights should have been obtained and documented as ordered. b. Res #38 was admitted with diagnoses which included anxiety, hypertension, and dementia. A policy, titled End of Life Care, dated 07/17, read in parts, .Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed . A physician's order, dated 12/07/22, documented in parts, Admit to .Hospice . The hospice medical record for Res #38 did not contain documentation showing communication between the facility and hospice. On 02/23/23 at 10:20 a.m., LPN #1 reported the facility did not have documented communication with hospice. On 02/23/23 at 10:21 a.m., the MDS coordinator reported the facility did not have documented communication with hospice. On 02/23/23 at 10:24 a.m., the Administrator reported the facility should have had documented communication with hospice. 45913 c. Res #27 was admitted on [DATE] with diagnoses which included gastrostomy, Parkinson's disease, and dementia. Physician's orders dated, 05/21/21 and 10/11/22, read in parts, NPO diet . An ADL Care plan, last revised on 08/16/21, read in parts, EATING: Provide finger foods when the resident has difficulty using utensils .Provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate . On 02/23/23 at 11:05 a.m., LPN #1 stated, As long as Res #27 has been here they have been NPO and received nothing by mouth. On 02/23/23 at 11:10 a.m., CMA #1 reported Res #27 received nothing by mouth. On 02/24/23 at 8:30 a.m., the MDS/Care Plan Coordinator reported the eating interventions should not have been care planned since Res #27 had been NPO since admission.

Based on record review and interview, the facility failed to follow their fall protocol policy for three (#8, 13, and #28) of three residents reviewed for falls. The Administrator reported 56 residents had falls in the last 12 months. Findings: A Falls - Clinical Protocol policy, revised March 2018, read in parts, .the staff .will identify pertinent interventions to try to prevent subsequent falls .staff will try various relevant interventions .staff .will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling . Res #8 was admitted with diagnoses which included lack of coordination, hemiplegia, and hemiparesis. A quarterly assessment, dated 11/29/22, documented Res #8 needed extensive assistance with bed mobility, transfers, ambulation. The assessment documented Res #8's balance with walking was not steady and they required staff assistance for stabilization. The Morse Fall Scale, completed on 03/29/22, 06/29/22, 09/29/22, and 12/29/22, documented Res #8 was at high risk for falls. An incident note, dated 04/17/22, read in parts, Resident found laying beside the bed on the fall mat . An incident note, dated 07/21/22, read in parts, .resident slipped out of her wheelchair onto floor . An incident note, dated 08/04/22, read in parts, Resident has been placed on post fall charting after attempting to transfer self without assistance . An incident note, dated 10/30/22, read in parts, .Resident observed sitting on buttocks on the floor . An incident note, dated 11/28/22, read in parts, Resident was found on the floor . An incident note, dated 12/02/22, read in parts, Resident was found on floor . An incident note, dated 12/12/22, read in parts, Resident was found on floor . An incident note, dated 12/16/22, read in parts, Resident found by this nurse on fall mat . An incident note, dated 12/25/22, read in parts, .Upon entering, observed resident sitting on her bottom in from of her W/C . An incident note, dated 02/05/23, read in parts, .resident sitting on floor . A fall care plan, last revised on 04/13/21, did not contain fall interventions for the falls from 04/17/22 through 02/05/23. Res #13 was admitted with diagnoses which included lack of coordination, dementia, and abnormalities of gait. A quarterly assessment, dated 12/17/22, documented Res #13 was mildly cognitively impaired and required extensive assistance with activities of daily living. Incident reports documented Res #13 had 11 falls from 08/25/22 through 01/03/23. A fall care plan developed on 08/02/22 was not revised for the falls from 08/25/22 through 01/03/23. 45913 Res #28 was admitted with diagnoses which included abnormalities of gait and mobility. An annual assessment, dated 11/29/22, documented Res #28 had impaired ROM on one side, needed extensive assistance with transfers, and bed mobility. The assessment documented Res #28 required limited assistance with walking, their balance with walking was not steady, they required staff assistance for stabilization. The Morse Fall Scale, completed on 03/28/22, 05/03/22, 08/03/22, 11/03/22 and 02/03/23, documented Res #28 was at high risk for falls. An incident report, dated 03/31/22, read in parts, .resident noted sitting on floor beside bed . An incident report, dated 04/10/22, read in parts, .Resident was found on the floor by her bed . An incident report, dated 05/18/22, read in parts, .sitting on floor in front of recliner . An incident report, dated 06/20/22, read in parts, .resident on floor mat beside bed . An incident report, dated 07/25/22, read in parts, .resident on floor .laying next to dresser . An incident report, dated 08/21/22, read in parts, .fell on previous shift . An incident report, dated 08/30/22, read in parts, .Resident found on floor . An incident report, dated 09/06/22, read in parts, .Resident rolled herself out of bed . An incident report, dated 09/08/22, read in parts, .resident observed sitting on floor . An incident report, dated 09/10//22, read in parts, .resident on floor mat beside her bed in her room . An incident report, dated 09/23/22, read in parts, .witnessed non-injury fall occurred at this time . An incident report, dated 10/27/22, read in parts, .CNA was able to control the fall and lowered her to the floor . An incident report, dated 11/22/22, read in parts, Resident observed laying on fall mat on her stomach . An incident report, dated 11/25/22, read in parts, Resident had a non-injury fall out of her bed . An incident report, dated 11/26/22, read in parts, Resident observed sitting on floor . An incident report, dated 02/01/23, read in parts, Resident had a fall on this shift . Fall interventions regarding the falls from 03/31/22 through 02/01/23 were not documented due to there being no fall care plan established for Res #28. On 02/22/23 at 3:10 p.m., the MDS coordinator reported the care plan for Res #13 had not been revised with each fall. On 02/23/23 at 3:54 p.m., the interm DON reported new interventions should have been in place for Res #13 after each fall to help prevent future falls. On 02/23/23 at 4:04 p.m., the Administrator reported the care plan for Res #13 should have been revised with each fall and implemented to help decrease risk for falls. On 02/24/23 at 8:30 a.m., the MDS/Care Plan Coordinator reported there should have been a fall care plan for Res #28. The MDS Coordinator reported they had not updated the care plan for Res #8 with each fall because they had not been provided with fall interventions.

Based on record review and interview, the facility failed to develop a baseline care plan for one (#109) of two new admissions reviewed. The Administrator reported 121 residents had been admitted in the last year. Findings: A policy titled Care Plan - Baseline, dated 12/16, read in parts, . A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Res #109 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease, anxiety, and congestive heart failure. A baseline care plan was not developed for Res #109. On 02/23/23 at 4:00 p.m., the MDS coordinator reported a baseline care plan had not been completed for Res #109. On 02/23/23 at 4:10 p.m., the administrator reported the baseline care plan should have been completed within 48 hours of the resident's admission.

Based on record review, observation, and interview, the facility failed to follow physician's orders for two (#5 and #109) of two residents reviewed for oxygen therapy. The Administrator reported 13 residents received oxygen therapy. Findings: Res #5 was admitted with diagnoses which included atrial fibrillation, and hypertension. A physician's order, dated 11/12/21, documented in parts, .CHANGE NASAL CANNULA ON O2 . EVERY WEEK, DATE AND TIME . A physician's order, dated 11/16/22, documented in parts 02 at 2-4 L/M . On 02/21/23 at 10:15 a.m., Res #5 was observed in their room with oxygen in use and the oxygen tubing was not labeled and dated as ordered. On 02/21/21 at 2:43 p.m., Res #5 was observed in their room with oxygen in use and the oxygen tubing was not labeled and dated as ordered. On 02/22/23 at 1:05 p.m., LPN #2 reported the oxygen tubing was ordered to be changed every wednesday night. The LPN observed the oxygen tubing for Res #5 and stated it was dated 01/18/23. LPN #2 reported the oxygen tubing was not changed as ordered. On 02/22/23 at 2:15 p.m., the interim DON reported the oxygen tubing should have been changed as ordered. Res #109 was admitted with diagnoses which included chronic obstructive pulmonary disease, anxiety, and congestive heart failure. A treatment admiministration record, dated 02/23, documented the oxygen tubing had not been labeled and dated. A physician's order, dated 02/17/23, documented in part, oxygen 3lpm via nasal cannula every shift for dyspnea. A physician's order, dated 02/17/23, documented in parts, .change nasal cannula on 02 every week, date and time. On 02/21/23 at 10:08 a.m., Res #109 was observed in their room with oxygen in use and the oxygen tubing was not labeled and dated as ordered. On 02/21/23 at 3:01 p.m., Res #109 was observed in their room with oxygen in use and the oxygen tubing was not labeled and dated as ordered. On 02/22/23 at 1:02 p.m., LPN #2 reported Res #109's oxygen tubing was not labeled and dated as ordered. On 02/22/23 at 1:13 p.m., the Administrator reported the tubing should have been labeled and dated as ordered.

Based on observation, interview, and record review, it was determined the facility failed to: ~ ensure staffs' proper use of face masks; ~ screen staff for symptoms of COVID-19 before assuming resident care; ~ ensure new admissions were quarantined for 14 days for eight residents ( #1, #2, #3, #4, #5, #6, #7, and #8) of eight new admissions whose records were reviewed; ~ ensure the completion of a facility self-assessment to ensure compliance with CMS and CDC guidelines for infection control; ~ ensure staff education and updates regarding COVID-19; ~ ensure an infection control preventionist on staff; ~ ensure proper use of disinfectants related to the manufacturer's documented contact time; and ~ ensure guidelines regarding staffs' return to work were followed. The facility identified one employee who returned to work after a positive COVID test result. This had the potential to affect all 52 residents who resided in the facility. Findings: The Centers for Disease Control guidance, regarding donning PPE, documented, .Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin . The Centers for Disease Control guidance titled, Preparation for Covid 19 in Nursing Homes, documented, ~ Evaluate and manage healthcare personnel, .Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19 .Actively take their temperature and document absence of symptoms consistent with COVID-19 . ~ Creating a plan for managing new admissions and readmissions .Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . ~ Educate Residents, Healthcare Personnel, and Visitors about Covid 19 .Provide information about COVID-19 (including information about signs and symptoms) and strategies for managing stress and anxiety. Regularly review CDC ' s Infection Control Guidance for Healthcare Professionals about COVID-19 for current information and ensure staff and residents are updated when this guidance changes . 1. On 06/12/20 at 11:50 a.m., assistant activity director #1 was observed assisting a resident in his wheelchair down 100 hall after leaving the activity room. As she spoke with the resident in his room she was observed with her face mask under her chin, not covering her nose or mouth. She was not observed to distance herself 6 feet from the resident. At 11:58 a.m., she exited the resident's room and adjusted her face mask to cover her nose and mouth. At 12:01 p.m., she was asked why her face mask was observed under her chin and not covering her nose and mouth. She stated the resident had trouble understanding her so she pulled the mask down to talk to him. On 06/12/20 at 12:52 p.m., dietary aide #1 was observed in the dining room with her face mask pulled down not covering her nose and mouth. She then walked across the hall to the laundry room. She was asked why her face mask had not been covering her nose and mouth. She stated, I pull it down when residents leave because I get hot. On 06/12/20 at 1:02 p.m., CMA #1 was observed at the medication cart by the nurses station with her face mask positioned below her chin. At 1:03 p.m., she entered the medication room behind the nurses' station then returned to the medication cart. She was asked why her face mask was not covering her nose and mouth. She stated, I just forgot about it. On 06/12/20 at 1:25 p.m., the DON was asked who was responsible to monitor staff for proper use of face masks. She stated she and the other supervisors monitored. She stated if she saw one that was not properly covering the employees nose and mouth she would reeducate them. 2. A Coronavirus COVID-19 Screening Tool, dated 03/13/20, documented, .1. Do you have any of the following symptoms? a. Feeling Feverish? b. Cough? c. Muscle Aches? d. Shortness of Breath .2. Have you recently traveled to a restricted foreign country within the last 14 days? (currently, China, Iran, Italy and South Korea) .3. Have you had contact with someone diagnosed with [REDACTED].? 4. Have you been in a health care facility where COVID-19 was documented? . On 06/02/20 at 9:00 a.m., an employee stationed at the front door of the facility obtained the surveyor's temperature and asked the surveyor to sign in. The employee was informed by another employee that a screening form was required since the surveyor had not visited the facility before. At 9:15 a.m., the administrator was asked how staff was screened prior entering the facility. He stated their temperature was taken at the front door. He was asked if they were screened for symptoms or if they were asked any questions regarding exposure. He stated other than obtaining staffs' temperatures, no other screening was completed for staff. He stated they knew the staff and knew if they did not feel well. 3. A list of new admissions were reviewed which revealed the following residents had been admitted in the past 14 days. The record documented the residents' assigned rooms were on all three halls: ~ Resident #1 was admitted for skilled services on 05/28/20 with [DIAGNOSES REDACTED]. ~ Resident #2 was admitted for skilled services on 05/29/20 with [DIAGNOSES REDACTED]. ~ Resident #3 was admitted for skilled services on 06/08/20 with [DIAGNOSES REDACTED]. Resident #8 was admitted on [DATE] and was in the same room as resident #3; ~ Resident #4 was admitted for skilled services on 06/08/20 with [DIAGNOSES REDACTED]. ~ Resident #5 was admitted for skilled services on 06/08/20 with [DIAGNOSES REDACTED]. ~ Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. ~ Resident #7 was admitted for skilled services on 06/11/20 with [DIAGNOSES REDACTED]. On 06/12/20 at 10:27 a.m., the DON was asked if any residents were quarantined or in isolation. She stated no. She was asked what the process was for quarantine with new admissions. She stated they took the same precautions with new admissions as they did with other residents. On 06/12/20 at 10:55 a.m., CNA #1 was asked if any of his assigned residents were quarantined. He stated no residents were quarantined. He stated the residents were only required to wear a face mask and gloves. At 11:00 a.m., CNA #2 was asked if any of her assigned residents were quarantined. She stated no. At 11:02 a.m., CNA #3 was asked if any of his assigned residents were quarantined. He stated no. At 11:03 a.m., LPN #1 was asked if any resident on the 200 hall were quarantined. She stated no. She was asked what precautions staff took when they provided resident care. She stated they were required to wear a face mask and gloves. At 11:10 a.m., CNA #4 was asked if any of his assigned residents were quarantined. He stated no. At 11:12 a.m., LPN #3 was asked if any residents on the 300 hall were quarantined. She stated no. At 11:58 a.m., LPN #2 was asked if any residents on the 100 hall were quarantined. She stated no. On 06/12/20 at 2:05 p.m., the administrator was asked why new admissions were not quarantined for 14 days. He stated the facility required a negative COVID-19 test from the hospital before admission. He stated the new admissions were skilled and required therapy and they did not have enough therapists to provide therapy in their rooms one at a time. 4. On 06/12/20 at 2:05 p.m., the administrator was asked if they had completed a self assessment to determine compliance with CDC and CMS guidelines for infection control. He stated no. He was asked why the facility had not completed a self survey. He stated he had completed a risk assessment. He was asked when he had completed a risk assessment. He stated he did not remember. He stated he thought he had updated the assessment recently but had not monitored or assessed for compliance with infection control guidelines. 5. On 06/12/20 at 12:59 p.m., CNA #4 was asked what type of education he had received regarding COVID-19. He stated the unit manager had discussed monitoring for cough, shortness of breath, and hand washing during shift change. He was asked when he had received education. He stated about a month and a half ago. He was asked if he had received any further education, training, or inservice. He stated no. On 06/12/20 at 1:05 p.m., CMA #1 was asked what type of education or training she had received regarding COVID-19. She stated there had been a paper passed around one time. She was asked when the paper had been provided. She stated she did not remember. She was asked if she had received any other education or training regarding COVID-19. She stated no. On 06/12/20 at 1:31 p.m., the DON was asked how staff were educated and trained on COVID-19 such as transmission, screening criteria, and work exclusion. She stated she had inserviced the department heads and they were to inservice their staff. She was asked where the inservice was documented. She stated the administrator had the documentation. On 06/12/20 at 2:05 p.m., the administrator was asked how staff were educated and trained on COVID-19. He stated the supervisors educated them. He was asked where the education was documented. He stated the education consisted of a conversation between the supervisor and the employees and had not been documented. He referred to the inservice book and provided the surveyor a COVID-19 policy inservice. He was asked who attended the inservice. He stated there should have been a sign in sheet with the form. Review of the inservice book revealed an inservice was conducted by the administrator on 03/19/20. The topic was resident rights with coronavirus. By the end of survey, no further education and/or training documentation dated after 03/19/20 had been provided. 6. On 06/12/20 at 9:15 a.m., the administrator was asked who the infection control preventionist was for the facility. He stated the DON. At 11:45 a.m., the DON was asked what training she had completed regarding the role of infection control preventionist. She stated she had just begun employment at the facility on 04/06/20 and had not completed all of the modules of the training. She provided a certificate for Module one and Module two which were both dated 07/25/19. At 2:05 p.m., the administrator was asked why there was not an infection control preventionist for the facility. He stated the former DON had been the infection control preventionist prior to the current DON. He stated the current DON had recently began working for the facility and he could not find the documentation of the former DON's completion of the training. 7. On 06/12/20 at 3:13 p.m., the housekeeping supervisor was asked what disinfectant was utilized in the facility. She provided a bottle of HDQ Neutral. The EPA List N documented a ten minute contact time to kill COVID-19. She was asked what the contact time was for the disinfectant. She stated she trained the housekeepers to spray the surface, let it sit for one to three minutes, and then wipe off. She was informed of the ten minute contact time which was documented on the EPAs List N. She stated she was not aware there were specific contact times for disinfectants. At 3:33 p.m., the administrator was asked why the disinfectant, utilized in the facility, was not being used according to List N to kill COVID-19. He stated he was not aware there was a list of disinfectants which were effective against COVID-19. 8. Review of the administrator's list of employee testing documented LPN #2 was tested on [DATE] and received a positive COVID-19 result on 06/07/20. The administrator stated she was retested on [DATE] and received a negative result on 06/10/20 at which time she had returned to work. Review of the time detail revealed LPN #2 returned to work on 06/11/20. The administrator was asked why LPN #2 had been retested . He stated he wanted to confirm the results due to a high volume of false positive results he had heard about. He was asked what the facility's policy was regarding an employees' return to work He stated the facility utilized both symptom-based and test-based criteria for an employee to return to work. He was asked what criteria LPN #2 met to return to work. He stated the employee was asymptomatic, retested with a negative result, the facility monitored her for signs and symptoms of COVID-19, and she was allowed to return to work after the negative result was received on 06/10/20.

On 08/12/13, an Immediate Jeopardy (IJ) situation was determined to exist due to unsecured hazardous chemicals located in the unlocked shower rooms on Hall 100 and Hall 300. On 08/12/13, another IJ situation was determined to exist due to the failure of the facility to provide thickened liquids for residents who had physician's orders [REDACTED]. On 08/12/13, the IJ situations were verified with the Oklahoma State Department of Health (OSDH). At 3:00 p.m., the Administrator and the DON were informed of the IJ situations related to thickened liquids and the unsecured chemicals. The Administrator presented an acceptable plan of removal which was dated 08/12/13, and timed 3:15 p.m. Then plan of removal documented: "Tulsa Jewish Community Retirement and Health Care Center (TJCRHCC) will perform the following in order to ensure all residents receive the appropriate diet and diet type and will ensure all hazardous supplies will be secured: 1.) Every resident chart was audited to ensure that their diet cards matched the order in the chart. Any discrepancies were corrected immediately. (Completed 3:45 P.M. on 08/12/2013) 2.) All resident rooms were inspected to ensure all drinking/food products in rooms match the dietary order in the resident's chart. Also, all special signs related to dietary requirement will be inspected to ensure signs match orders found in charts. (Completed 4:00 P.M. on 08/12/2013) 3.) All bathing areas and housekeeping spaces were inspected for unlocked cleaning and/or bathing products. All cleaning and bathing products will be placed in locked cabinets immediately. (Completed 4:10 P.M. on 08/12/2013) 4.) All staff currently on duty was in-serviced on policies and procedures related to special diets and proper storage of chemicals. (Completed 4:45 P.M. on 08/12/2013) 5.) All personnel not currently on duty will receive the same in-service prior to start of their shift. In addition, in order to prevent future occurrences, the Administrator and/or designee will conduct daily monitoring of diet cards to ensure they match the diet orders located in the charts. The housekeeping supervisor or designee will monitor all bathing areas daily to ensure that all cleaning/bathing supplies are stored in a locked cabinet." On 08/12/13, another IJ situation was determined to exist in regard to a temporary unlocked door on South Hall 100, which led out to a hazardous construction area that was left unattended after 3:30 p.m. The IJ was verified with the Oklahoma State Department of Health (OSDH). At 4:30 p.m. the IJ situation was reported to the Administrator and the Project Manager. On 08/12/13 at 5:30 p.m., the Administrator presented an acceptable Plan of Removal to the survey team as follows: "Tulsa Jewish Community Retirement and Health Care Center (TJCRHCC) will perform the following in order to ensure the safety of all residents: 1. A Velcro "stop sign" will be placed in front of the temporary construction door leading into the construction work area. (Completed 5:35 p.m.) 2. The door will be alarmed so a high pitched audible alarm will sound if the door is opened by anyone for any reason. (Completed 5:35 p.m.)" The immediate jeopardy situations were removed as of 08/14/13 at 11:05 a.m., after all the staff had been inserviced on thickened liquids, storage of hazardous chemicals and the alarm system on the temporary door on Hall 100. The deficient practice remained at no actual harm with potential for more than minimal harm, at a pattern. Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure thickened liquids were provided, as ordered by the physician, for three (#3, 4 and #5) of six sampled residents with a history of aspiration or a [DIAGNOSES REDACTED]. This had the likelihood to affect seven residents identified by the acting DON as having physician's orders [REDACTED]. b) Ensure hazardous chemicals were maintained in a secured manner on two (Hall 100 and Hall 300) of three hallways. This had the likelihood to affect one resident (#2) identified by the DON as having wandering behaviors. c) Ensure a temporary door on south Hall 100 was secured to prevent resident access to a hazardous construction site for one (#2) of one sampled wandering residents. This had the likelihood to affect one resident (#2) identified by the DON as having wandering behaviors. d) Ensure a blanket was placed on the edge of the Broda chair seat, as was previously documented in an incident report as the steps to prevent recurrence (STPR) of skin tears, for one (#4) of seven sampled residents that utilized Broda chairs. This resulted in harm to resident #4. This had the potential to affect 12 residents identified by the DON as utilizing Broda chairs. e) Ensure two residents with a history of altercations between them were not seated at the same dining table, as was previously documented in an incident report as the STPR, for two (#2 and #23) of two sampled residents with behaviors. This had the potential to affect two residents identified by the DON with a history of altercations. f) Ensure transferring of residents between surfaces was provided in a safe manner for two (#1 and #3) of four sampled residents observed being transferred. This had the potential to affect 45 residents identified by the DON as requiring assistance with transfers. g) Ensure a resident that had a high percentage of falls which had occurred in the early morning hours had interventions put in place in a timely manner to prevent furthur falls, for one (#4) of eight sampled residents identified with falls. This had the potential to affect all 47 residents residing in the facility per the DON. Findings: 1. Resident #4 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/09/13 at 12:15 p.m., a nurse's note documented, "Pt having increased coughing/choking during meal & fluid intake- spoke c Dr. (Name deleted)- new orders obtained for change in diet- Mechanical soft & nectar thick fluids..." On 01/09/13, a telephone physician's orders [REDACTED]. (Name deleted) . Dx: coughing while eating/dysphagia." On 05/07/13, a significant change assessment documented the resident had severely impaired cognition, required extensive assistance with eating and was on a mechanically altered diet that required change in texture of food or liquid. On 05/18/13, the facility's care plan had been revised and documented, "Problem: P/F Alteration in Nutrition and Hydration Status R/T: Dementia, mechanically altered diet. Has [DIAGNOSES REDACTED]. Thickened liquids as ordered. Approaches: Dietary to provide fluids daily. Offer fluids with meals, meds, activities, hydration round and prn..." On 08/12/13 at 12:20 p.m., the resident was observed sitting at a feeding assistance table. The resident was observed eating a bowl of unthickened broth based soup. The resident had eaten 3/4 of the bowl. A CNA was observed sitting across the table from the resident. The CNA was asked about the resident's diet. The CNA directed the question toward a dietary staff member. The dietary staff reported the resident was on thickened liquids but the soup would only be thickened if the resident was on a pureed diet. At 12:25 p.m., the DON approached the surveyor and reported the nursing staff was to put crackers in the soup of residents on thickened liquid diets. At 12:55 p.m., a half full pitcher of unthickened ice water was observed sitting on a table in the resident's room. 2. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual assessment, dated 07/02/13, documented the resident had moderately impaired cognition and had set-up only assistance with eating. The CAA Analysis Report, dated 07/02/13, documented "..has a good appetite...diet was recently changed to mechanical soft with nectar liquids due to dx.dysphagia..." The resident's care plan, dated 07/12/13, documented "mech soft with nectar liquids..." A physician's progress note, dated 07/31/13, documented no evidence of pneumonia, likely aspiration pneumonia evaluated by ST on nectar thickened. On 08/12/13 at 10:45 a.m., an observation was made of a water pitcher of unthickened water on the overbed table within reach of the resident. At 10:50 a.m., CNA #7 was interviewed regarding the unthickened water in reach of the resident. CNA #7 reported she had added ice to the thickened water in the resident's room earlier in her shift. At 11:10 a.m., the resident was asked if she had taken any drinks of her iced water. She stated, "Yes." She said she was able to drink without assistance. 3. Resident #5 was admitted to the facility on [DATE]. A care plan, dated 07/08/13, documented the resident had an alteration in nutrition. On 07/14/13, a handwritten diet documented "Mech soft c chopped meat c sauce/gravy c nectar thick liquids." On 07/11/13, a physician's telephone order documented speech therapy to treat 3 x week x 30 days and a diet texture analysis for oral/pharyngeal function and possible radiological dysphagia evaluation. Diagnosis: [REDACTED]. On 07/12/13, a physician's telephone order, changed diet to nectar thick liquids. An admission assessment, dated 07/17/13, documented the resident had a severe cognitive impairment with long and short term memory loss, required extensive assistance of one person with eating, and was on a mechanically altered diet. On 08/12/13 at 12:10 p.m., the resident was observed eating the noon meal in the dining room. The resident had a glass of regular ice water setting out of her reach. The resident asked a CNA to give her a drink of water. The CNA picked up the glass of ice water and was going to give the resident a drink when a surveyor stopped the CNA and asked her if she was sure the ice water was the resident's. The CNA had to call the dietary aide over to ask if the ice water belonged to the resident. The ice water was removed. At 1:30 p.m., a container of unthickened water was observed in the resident's room next to her bed. 4. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual assessment, dated 06/24/13, documented the resident as having a behavior of wandering daily. The 'CAA Analysis Report', dated 06/24/13, documented, "...at times wanders into others space...has shown some behavioral symptoms directed towards others..." The resident's care plan, updated 07/03/13, documented the resident as exhibiting pacing, wandering, agitation, aggression, physical and verbal abusive. On 08/12/13 at 9:35 a.m., an initial tour of the facility was conducted. A W/P room on Hall 300 was observed unlocked. A cabinet next to the W/P was observed unlocked. The cabinet contained an unlabeled 26 ounce spray bottle, which contained a pink substance. At 9:40 a.m., two CMAs were interviewed. The CMAs were asked if the facility had any residents who wandered. The CMAs identified resident #2. At 9:55 a.m., two CNAs were interviewed. The CNAs were asked if the facility had any residents who wandered. The CNAs identified resident #2. The CNAs reported the resident would enter other residents' rooms. At 10:10 a.m., a housekeeping staff member was asked what the pink substance was in the spray bottle. The staff went to look for the MSDS sheet. At 10:30 a.m., the housekeeper provided the surveyor with an MSDS sheet for the substance. The MSDS sheet documented: "Product Name: Clean on the go hdqC2... ...Ratings: Health: 3- Serious... ...Ratings: Health: 3- Serious... Effects of Overexposure- Corrosive. Conditions to Avoid: Causes irreversible eye damage and skin burns: Symptoms may include pain, redness, swelling and tissue damage. May be fatal if absorbed through the skin. Harmful if swallowed. Symptoms may include nausea, vomiting, pain and diarrhea. Inhalation of spray mist may cause respiratory irritation. Breathing spray mist may cause coughing and difficulty breathing. Do not get in eyes, skin or clothing. Do not taste or swallow. Avoid inhalation of spray mist. Wash thoroughly with soap and water after handling...Emergency & First Aid Procedures: ...Eyes:...Call a poison control center or doctor for treatment advice...Ingestion: Call a poison control center or doctor immediately for treatment advice. Have person sip a glass of water if able to swallow. Do not induce vomiting unless told to do so by the poison control center or doctor. Do not give anything by mouth to an unconscious person...Special Precautions: ...Keep out of reach of children..." At 12:50 p.m., LPN #2 was in the dining room and was interviewed regarding the residents' behavior of wandering. LPN #2 reported the resident wandered on a daily basis on all the halls. The LPN further reported the wandering occurred mainly in the evenings and the resident went into other rooms. The LPN reported the resident was capable of opening any door. At 1:00 p.m., the DON was interviewed regarding the use of a wanderguard for the resident. The DON reported the resident wore a wanderguard because of her frequent wandering. The DON then verified the resident was wearing a wanderguard on her left wrist. At 1:05 p.m., CNA #7, was interviewed about the resident's behavior of wandering. The CNA reported the resident wandered everywhere and could open doors without a problem. At 1:15 p.m., LPN #1 was interviewed about the resident's behavior of wandering. LPN #1 reported it had been a while since the resident wandered into another resident's room on the day shift, but it happened on the evening shift probably twice a month. He said a Velcro 'Stop' sign had been placed on several residents' doors to keep the resident from going into their rooms. He said she would never go through the Velcro 'Stop' signs. At 4:10 p.m., CNA #8, who worked the evening shift, was interviewed about the resident's behavior of wandering. CNA #8 reported the resident did a lot of wandering on all three halls. At 4:20 p.m., CNA #1, who worked the evening shift, was interviewed about the resident's behavior of wandering. CNA #1 reported the resident walked up and down each hall and went all the way down the south hall. At 4:25 p.m., CNA # 9, who worked the evening shift, was interviewed about the resident's behavior of wandering. CNA #9 reported the resident wandered everywhere. At 4:50 p.m., LPN #7, who worked the evening shift, was interviewed about the resident's behavior of wandering. LPN #7 reported the resident wandered a lot and went everywhere, "non-stop." At 5:00 p.m., LPN #1, who worked the evening shift, was interviewed about the resident's behavior of wandering. The LPN reported the resident could open any door. The LPN further reported the resident sometimes would try to get out the exit doors when other family members were leaving. At 5:50 p.m., LPN #1 ambulated with resident #2 down the hall to the resident's room. The door to the resident's room was closed and LPN #1 asked the resident to open the door. Resident #2 opened the door without any difficulty and walked into her room. On 08/13/13 at 5:20 p.m., resident #2 was observed walking independently on Hall 100. The resident was observed to enter another resident's room. 5. On 08/12/13 at 9:50 a.m., during the initial tour of the facility, the housekeeping closet door on Hall 100 was unlocked. Citri-terge Spray Cleaner, Bio-Matic Spray Cleaner, Peroxide Spray Cleaner and Neutral Spray Cleaner were on the shelves in the closet. The cleaner labels all documented "Keep Out of Reach of Children." At 9:55 a.m., in the 100 Hall unlocked shower room, a bottle of shampoo and a disposable razor were observed sitting near the sink. The shampoo had the words "Keep Out of Reach of Children" on the label. Inside an unlocked cabinet was a spray bottle of "Clean on the Go hdqC2" cleaner. The label documented, "Keep Out of Reach of Children." At 10:00 a.m., Housekeeper #1 was observed removing chemicals and items from the closet onto a rolling cart. She was asked why the door was left unlocked. She said it was usually not unlocked. She reported she was in the process of moving everything out of this closet into another closet because of the remodeling of the hall. She said it had only been unlocked for a few minutes. On 08/15/13 at 7:15 a.m., the Housekeeping Supervisor was asked if the housekeeping closet should have been left unlocked while the housekeeper was transferring items to another closet. She said the housekeeping closets should never be left unlocked. 6. On 08/12/13 at 9:00 a.m., during the nursing tour on Hall 100, construction workers were observed entering and exiting through the temporary door at the end of the hall. At 4:15 p.m., the temporary door was observed unsecured and opened immediately into a hazardous construction area. Observed in the unsecured construction area were the following hazardous items: A glass mirror approx 2' x 3' leaning against one wall. Five of the rooms under construction had a cut-out area in the floor approx 2.5' x 5' x 5" without a barrier covering the cut-out area. An industrial extension cord extended directly across the construction area floor in front of the door. On 08/12/13 at 4:30 p.m., the ADM and Project Manager were interviewed regarding the unsecured temporary door on Hall 100 not being locked. The Project Manager was asked what time the construction crew left daily. He said around 3:30 p.m. At that time, the ADM was informed the unsecured temporary door was an immediate jeopardy situation due to the wandering resident being able to go through the temporary door and enter the hazardous construction area. The ADM reported he would place an alarm and stop sign on the door immediately, and would inservice the staff. At 5:35 p.m., an alarm and a 'Stop' sign were in place on the temporary door on Hall 100. The Project Manager tested the alarm and the staff quickly responded to verify if a resident was attempting to leave. The alarm was then re-attached. 7. Resident #4 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/01/13 at 11:00 p.m., an 'Incident/Accident Report' documented, "When getting resident up out of her Broda chair to get her ready for bed, noticed skin tear to Lt. calf, aprox 4 cm long. Cleansed and approximated edges and steri stripped. Also has nickle size purplish bruise towards bottom of Lt. calf. Steps taken to prevent recurrence: Put blanket over edge of seat on Broda chair to avoid any friction, as resident has very thin skin." The care plan did not contain documentation of the blanket to be placed on the seat's edge of the Broda chair to prevent skin tears. On 05/07/13, a significant change assessment documented the resident had severely impaired cognition, required extensive assistance with bed mobility and transferring between surfaces, was not ambulatory, was frequently incontinent of bladder and occasionally incontinent of bowel. On 05/12/13 at 10:00 p.m., an 'Incident/Accident Report', documented, "CNA called stating that res has skin tear. Assessed res. Res has skin tear to lower rt leg 3 1/2 x 1 1/2 cm 0 active bleeding. Unable to tell what happened. Skin tear cleansed area, approximated edges, applied steri strips..." On 07/16/13 at 6:30 a.m., an 'Incident/Accident Report', documented, "CNA was transferring resident with a sit to stand lift and scraped her left lower leg on the Broda chair, causing a skin tear- half moon shape and 6 cm long. Cleansed with wound cleaner, approximated steri stripped area and covered with foam dressing for protection. Steps taken to prevent recurrence: Place blanket over edge of broda chair to help avoid skin tears." On 07/16/13, a care plan revision documented, "P/F skin breakdown related to: decreased mobility...(L) lower leg ST...." The care plan did not contain documentation of the steps taken to prevent recurrence of placing a blanket on the Broda chair edge. The August 2013, physician's orders [REDACTED]. Dx: skin tear. (L) lower leg, change steri strips, cover with telfa and wrap with Kerlix prn. Dx: skin tear." On 08/13/13 at 9:30 a.m., LPN #6 was observed providing wound care for the resident. The resident was observed to have a large skin tear on the back of her left calf. The skin tear was dry with a scab. On 08/13/13 at 10:30 a.m., the resident was observed sitting in her Broda chair in the lobby. No blanket was observed on the edge of the Broda chair. On 08/14/13 at 9:45 a.m., CNA #5 and CNA#6 were observed toileting the resident. No blanket was observed on the edge of the Broda chair, before or during the transfer. On 08/16/13 at 10:30 a.m., the DON was interviewed regarding the resident's recurring skin tears on her calves. The DON reported she would contact the nurse that prepared the last incident report and find out the details of the injury. At 3:00 p.m., the DON reported the nurse that prepared the incident/accident reports felt the resident was getting the skin tears from the plastic slats on the Broda chair. The DON was asked if the use of the blanket on the Broda chair should have been care planned. The DON reported a physician's orders [REDACTED]. The DON reported the use of the blanket to prevent the skin tears was not carried through. 8. Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/17/13, documented the resident was severely cognitively impaired and needed extensive assistance with transfers. On 08/13/13 at 11:50 a.m., CNA #4 and CNA #5 were observed assisting the resident from her bed to her wheelchair. The resident was sitting on the side of the bed. CNA #4 applied a gait belt around the resident's waist and positioned the W/C to the left of the resident. CNA #5 positioned the resident's feet beside each other on the floor. CNA #4 put her left hand on the gait belt and right hand under the resident's left armpit. CNA #5 put her right hand under the resident's right armpit and left hand on the resident's back. During the transfer the resident's shoulders were elevated as the CNAs lifted the resident under her arms to her W/C. The resident had partial weight bearing on one LE during the transfer. On 08/14/13 at 3:30 p.m., PT #1 was asked if residents should be lifted under their arms as they are being transferred from one surface to another. The therapist said the staff should not lift the residents under their arms. 9. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual assessment, dated 07/02/13, documented the resident as requiring extensive assistance of one staff member for transfers, and was frequently incontinent of both bowel and bladder. The resident's care plan, updated on 07/17/13, documented, "Resident needs the following assistance with his/her ADLs." The approaches included "...Give assistance to resident when bathing/dressing/transferring, etc." On 08/13/13 at 4:20 p.m., observation was made of CNA #1 transferring the resident from a chair to the resident's bed. The CNA placed his/her hands under the upper arms of the resident and pulled the resident out of the chair. The resident's arms were pulled away from her body at a 45 degree angle and the weight of her body was resting on her upper arms where the CNA was holding her. CNA #1 did not use a gait belt or other assistive device during the transfer. On 08/16/13 at 11:10 a.m., the DON and ADM were interviewed regarding the CNA transferring the resident by lifting her by her arms and not using a gait belt. The DON reported the staff had been inserviced to use gait belts when transferring residents. She further reported the facility had some new hires, so she would repeat the inservice. 10. Resident #4 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/05/13 at 5:40 a.m., an 'Incident/Accident Report', documented, "Bed alarm started to sound. CNA was in the room right next to the resident and went there immediately, but resident was laying on floor mat next to bed. Appears she was trying to get up to go to the bathroom as she had diarrhea on her pad. No apparent injuries at this time. ROM X 4 good. Bed was in low position. Steps taken to prevent recurrence: Continue to use bed alarm. Continue to keep the bed in low position with a mat on the floor." On 02/05/13, a 'Fall Risk Assessment', documented the resident was a high fall risk with a score of '22'. The form documented a total score of '10 or above' represented a high risk. On 02/28/13 at 4:30 a.m., an 'Incident/Accident Report', documented, "Bed alarm sounded. CNA went to resident room and found her laying face down on floor. Must have slipped on her safety mat and fell forward. ROM X 4 good, but has small 1 cm laceration inside right upper lip. Resident said she also bumped her nose. Neuro checks started. Steps taken to prevent recurrence: Continue to use bed alarm, bed in low position, mat on floor. Possibly concave mattress." On 02/28/13, ODH Form 283, in regards to the incident on 02/28/13, was faxed to OSDH, documenting, "...Resident is oriented to self only. She is unaware of her surroundings. She is at high risk for falls with a score of '22'. Her BIMS score is '3'...Hospice was contacted for their DME company to send out a cover with roll bolsters on it to be placed on her bed in attempts to prevent her from falling. Facility will continue with her bed alarm, bed kept in low position & the floor mat next to her bed." On 02/28/13 at 4:30 a.m., a nurse's note documented the above incident. The notes also documented, "Rinsed resident's mouth out and cleansed area. Applied cold pack to try and reduce any swelling. Asked resident what she was trying to do and she said she was trying to go to the bathroom and slipped. She said she's glad she's got strong bones..." On 04/23/13, a care plan revision documented, "Falling leaf program." On 04/26/13 at 3:30 a.m., a nurse's note documented, "Resident kept setting off bed alarm trying to exit bed. Finally had to dress and get resident up in Broda chair. Has been sleeping off and on in the chair. Kept telling caregivers to close the windows that it was getting cold..." On 05/05/13 at 6:15 a.m., a nurse's note documented, "Resident stating she fell from the 6th floor and broke her femur in two but resident does not show any s/s of discomfort then at the same time was saying she was having a baby. Passed to morning nurse to monitor and check see if she actually will show s/s of discomfort or pain. Also advise DON of resident claim." On 05/05/13 at 6:30 a.m., an 'Incident/Accident Report', documented, 'During AM care, resident told CNA that her rt leg hurts. While assessing res. she stated that she fell from sixth floor and broke her femur in two, also stated she was having a baby. ROM x 4 good. 0 s/s of distress at this time. Will order Xray if pain persists. Alert and oriented X 1." The incident/accident report documented the physician had been notified at 7:00 a.m., and documented, "faxed, note to book..." On 05/07/13 at 12:00 p.m., a nurse's note documented, "Hospice CNA reported resident having increased pain. Upon assessment I asked resident where she was hurting and she point to her (L) leg. Resident C/O increased pain when her leg is moved. I applied slight pressure to resident (L) hip and she yelled out in pain. I also noticed a slight temp difference between her (L) and (R) legs. (L) leg was warm to touch c slight swelling. Notified Dr. (Name deleted) of resident condition." At 1:45 p.m., a nurse's note documented, "X-ray results are as follows. Acute intertrochanteric fx to left femur and avulsion fx of lesser trochanter. Notified Dr. (Name deleted) of results. N/O Norco 5/325 mg po TID routine and keep prn order..." On 05/07/13, a significant change assessment documented the resident had severely impaired cognition, required extensive assistance with bed mobility and transferring between surfaces, was not ambulatory, was frequently incontinent of bladder and occasionally incontinent of bowel. On 05/07/13, a care plan, documented, "Problem: Falls...L hip/femur Fx..." On 05/08/13 at 5:00 p.m., a nurse's note documented, "Telephone order for bed alarm. Bed alarm in place and working. TAR updated." On 05/12/13 at 3:00 a.m., a nurse's note documented, "Resident in bed both eyes closed...Incontinent care and reposition every 2 hours and as needed. Bed in lowest position, bed alarm in place and working, fall mat in place..." On 05/19/13 at 8:30 a.m., an 'Incident/Accident Report', documented, " Found resident lying on (R) side of bed mat next to bed. Assessed for ROM, lacerations & ecchymosis, 0 noted. Bed alarm functioning. Assisted c to broda chair to dining room for breakfast...Steps taken to prevent recurrence: Resident up for all meals broda chair c W/C alarm in place." The previous falls had taken place at 4:30 a.m., 5:40 a.m. and 6:15 a.m. On 05/25/13, an 'Interdisciplinary Post-Fall Assessment', documented, "Date of last fall: 5/19/13. Number of falls in the last 30 days: 2...180 days: 8...Recommendations from review by team: Every 2 hr scheduled toileting" On the top of the form was a list of steps the facility was taking to prevent recurrence of incidents. The list included: 2 person assist, sit to stand, Broda chair, chair alarm, bed alarm 5-8, Falling Leaf, scheduled toileting, nonweight bearing Lt hip. This was the first mention of scheduled toileting. On 05/28/13, a telephone physician's orders [REDACTED]." These were not the times the resident had her falls. On 06/02/13 at 7:50 a.m., an 'Incident/Accident Report', documented, "Called to rm 103. Found resident lying on (L) side on floor mat next to bed. Assessed for ROM, laceration & ecchymosis. None noted. Assisted c to back to bed...Steps taken to prevent recurrence: Has low air loss mattress c bolsters in place." This was the first mention of bolsters being used. On 06/21/13, a telephone physician's orders [REDACTED]." On 06/24/13, a 'Interdisciplinary Post-Fall Assessment', documented, "Date of last fall: 6/2/13. Number of falls in the last 30 days: 3, 90 days: 4...Recommendations for review by team: change bolster mattress to concave mattress." The first mention of possibly using a concave mattress was on 02/28/13. Handwritten on the top of the form was a list of steps the facility was taking to prevent recurrence of incidents. The list included: 2 person assist, Falling Leaf, W/C alarm, bed alarm, small Broda chair, bolster mattress, scheduled toileting every 2 hrs while awake. On 06/28/13 at 4:30 a.m., an 'Incident/Accident Report', documented, "Bed alarm sounded, CNAs went to alarm quickly and when arrived to room seen resident had slid off low bed onto safety mat, called for nurse and I responded immediately. Observed resident sitting on landing mat on buttocks. 0 injuries, 0 pain, full ROM, 0 hit head...Steps taken to prevent recurrence: put pillow behind resident's back for now. Suggestion (possible bolster

Based on record review, observation, and staff interview it was determined that the facility failed to ensure the environment remained free of accident hazards for one (#2) of one sampled wandering resident. This had the potential to affect two residents who had been assessed as exhibiting wandering behavior as identified by the MDS Coordinator. Findings: On 10/29/13, at 9:00 a.m., an observation was made of the 'Clean Utility' room on the north hall of the facility. The outer door entering into the utility room was unlocked. The door was very heavy and required the use of body weight to lean against it in order to push it open. The inner door entering into the utility room was unlocked. The door was very heavy and required the use of body weight to lean against it in order to push it open. An observation was made of the following containers of chemicals under the sink in the utility room in an unlocked cabinet: Two containers of: Commercial Clorox Urine Remover. These were labeled as "eye irritant-keep out of reach of children". Two containers of: NABC-non acid disinfectant bathroom cleaner. These were labeled as "eye irritant". One container of: RX 75-Antibacterial Heavy Duty Cleaner and Odor Counteractant. This was labeled as "Keep Out of Reach of Children". One container of: Diversey Profil Floor Cleaner. This was labeled as "eye irritant". One container of: RX 20F-Fabric, Carpet, and Air Freshener. This was labeled as "Eye Irritant. Keep Out of Reach of Children". At 9:30 a.m., the MDS coordinator, Housekeeping supervisor and the ADM were interviewed in the north hall utility room. The MDS coordinator identified resident #2 and an unsampled resident as having previously wandered at times. She further reported both of the residents had exhibited general declines and were no longer wandering and were not capable of opening doors. The ADM was asked if a staff member had been assigned to monitor the room for the presence of chemicals. The ADM reported no staff member had been checking the room because no chemicals had ever been placed in the north hall utility room. The housekeeping supervisor was then asked if she was aware of the chemicals being in the utility room. She reported she had known the chemicals were there but that the housekeeping department no longer had a room on the south hall in which to store chemicals. The ADM was then asked if the facility had a key to lock the north hall utility room. He reported the chemicals would be immediately removed from the north hall utility room and placed in the locked storage room on the south hall.

Based on observation, record review, and staff and resident interview it was determined the facility was not being administered effectively to prevent immediate jeopardy situations. This had the potential to affect all 47 residents residing in the facility. Findings: On 08/12/13, an Immediate Jeopardy (IJ) situation was determined to exist due to unsecured hazardous chemicals located in the unlocked shower rooms on Hall 100 and Hall 300. On 08/12/13, another IJ situation was determined to exist due to the failure of the facility to provide thickened liquids for residents who had physician's orders [REDACTED]. On 08/12/13, the IJ situations were verified with the Oklahoma State Department of Health (OSDH). At 3:00 p.m., the Administrator and the DON were informed of the IJ situations related to thickened liquids and the unsecured chemicals. The Administrator presented an acceptable plan of removal which was dated 08/12/13, and timed 3:15 p.m. Then plan of removal documented: "Tulsa Jewish Community Retirement and Health Care Center (TJCRHCC) will perform the following in order to ensure all residents receive the appropriate diet and diet type and will ensure all hazardous supplies will be secured: 1.) Every resident chart was audited to ensure that their diet cards matched the order in the chart. Any discrepancies were corrected immediately. (Completed 3:45 P.M. on 08/12/2013) 2.) All resident rooms were inspected to ensure all drinking/food products in rooms match the dietary order in the resident's chart. Also, all special signs related to dietary requirement will be inspected to ensure signs match orders found in charts. (Completed 4:00 P.M. on 08/12/2013) 3.) All bathing areas and housekeeping spaces were inspected for unlocked cleaning and/or bathing products. All cleaning and bathing products will be placed in locked cabinets immediately. (Completed 4:10 P.M. on 08/12/2013) 4.) All staff currently on duty was in-serviced on policies and procedures related to special diets and proper storage of chemicals. (Completed 4:45 P.M. on 08/12/2013) 5.) All personnel not currently on duty will receive the same in-service prior to start of their shift. In addition, in order to prevent future occurrences, the Administrator and/or designee will conduct daily monitoring of diet cards to ensure they match the diet orders located in the charts. The housekeeping supervisor or designee will monitor all bathing areas daily to ensure that all cleaning/bathing supplies are stored in a locked cabinet." On 08/12/13, another IJ situation was determined to exist in regard to a temporary unlocked door on South Hall 100, which led out to a hazardous construction area that was left unattended after 3:30 p.m. The IJ was verified with the Oklahoma State Department of Health (OSDH). At 4:30 p.m. the IJ situation was reported to the Administrator and the Project Manager. On 08/12/13 at 5:30 p.m., the Administrator presented an acceptable Plan of Removal to the survey team as follows: "Tulsa Jewish Community Retirement and Health Care Center (TJCRHCC) will perform the following in order to ensure the safety of all residents: 1. A Velcro "stop sign" will be placed in front of the temporary construction door leading into the construction work area. (Completed 5:35 p.m.) 2. The door will be alarmed so a high pitched audible alarm will sound if the door is opened by anyone for any reason. (Completed 5:35 p.m.)" The immediate jeopardy situations were removed as of 08/14/13 at 11:05 a.m., after all the staff had been inserviced on thickened liquids, storage of hazardous chemicals and the alarm system on the temporary door on Hall 100. The deficient practice remained at no actual harm with potential for more than minimal harm, at a pattern. Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure thickened liquids were provided, as ordered by the physician, for three (#3, 4 and #5) of six sampled residents with a history of aspiration or a [DIAGNOSES REDACTED]. This had the likelihood to affect seven residents identified by the acting DON as having physician's orders [REDACTED]. b) Ensure hazardous chemicals were maintained in a secured manner on two (Hall 100 and Hall 300) of three hallways. This had the likelihood to affect one resident (#2) identified by the DON as having wandering behaviors. c) Ensure a temporary door on south Hall 100 was secured to prevent resident access to a hazardous construction site for one (#2) of one sampled wandering residents. This had the likelihood to affect one resident (#2) identified by the DON as having wandering behaviors. d) Ensure a blanket was placed on the edge of the Broda chair seat, as was previously documented in an incident report as the steps to prevent recurrence (STPR) of skin tears, for one (#4) of seven sampled residents that utilized Broda chairs. This resulted in harm to resident #4. This had the potential to affect 12 residents identified by the DON as utilizing Broda chairs. e) Ensure two residents with a history of altercations between them were not seated at the same dining table, as was previously documented in an incident report as the STPR, for two (#2 and #23) of two sampled residents with behaviors. This had the potential to affect two residents identified by the DON with a history of altercations. f) Ensure transferring of residents between surfaces was provided in a safe manner for two (#1 and #3) of four sampled residents observed being transferred. This had the potential to affect 45 residents identified by the DON as requiring assistance with transfers. g) Ensure a resident that had a high percentage of falls which had occurred in the early morning hours had interventions put in place in a timely manner to prevent furthur falls, for one (#4) of eight sampled residents identified with falls. This had the potential to affect all 47 residents residing in the facility, per the DON. Please refer to F323.

On 11/08/12 at 4:45 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure allegations of abuse were thoroughly investigated and residents were protected during an investigation. On 11/08/12 at 4:50 p.m., the Oklahoma State Department of Health was notified. The IJ situation was verified. At 5:00 p.m., the Administrator and the Director of Nursing were notified of the IJ situation. At 6:30 p.m., an acceptable plan of removal was provided to the team. "The Tulsa Jewish Retirement and Healthcare Center will immediately implement a comprehensive In-Service training program on screening, identifying, reporting, and preventing elder abuse. The first training will be today, 11/8/12, on the 3-11 shift. Similar training will take place tonight for the 11-7 shift and again tomorrow for the 7-3 shift. Attendees will understand the facility policy on elder abuse. Further, they will have a clear understanding of how to identify abuse, report abuse, investigate and subsequently prevent or protect the residents from abuse. Any employee not scheduled to work in the next 24 hour period will be in-serviced prior to engaging residents. The facility policy on abuse will be corrected as discussed with the survey team. Specifically, section 3.1 will read, "Any suspected abuse, neglect, or exploitation is to be reported to your immediate supervisor and/or the Director of Nurses and the Administrator immediately." Section 3.2 will read, "An Incident report is completed and given to the Director of Nursing and/or the Administrator during the shift in which the incident occurred..." Section 3.3 will read, "A thorough investigation will be initiated..." The entire policy will be re-written and available to the Survey Team on Friday November 9th 2011 (2012)." On 11/09/12 at 2:45 p.m., an additional allegation of staff to resident abuse was discovered through record review. At 3:00 p.m., OSDH was notified and verified the continuance of the IJ situation. At 3:10 p.m., the Administrator and the Director of Nursing were informed of the continued IJ situation. On 11/09/12 at 4:46 p.m., an acceptable plan of removal was accepted. This was an addendum that had been added to the first plan of removal and documented the following: "Additionally, the employee who allegedly abused a resident has been removed from the facility and will not be permitted back to work until a complete investigation can be performed. Once the case has been resolved, the final report will be submitted to the proper agencies." The immediate jeopardy was removed as of 11/09/12 at 3:00 p.m., after staff had been inserviced and CNA #2 had finished her shift and left the building. The deficient practice remained at actual harm at a pattern. Based on record review, observation, and staff interview, it was determined the facility failed to implement their abuse policy/procedure by failing to: a) thoroughly investigate allegations of abuse for two (#9 and #19) of 12 residents sampled for abuse. b) Put protective/preventive measures in place to protect residents from abuse and prevent recurrence for two (#9 and #19) of 12 residents sampled for abuse. c) Report allegations of abuse to the appropriate state agencies for one (#19) of 12 residents sampled for abuse. d) Check the state's abuse registry in regard to newly hired non-technical service workers. e) Check the state's nurse aide registry in regard to newly hired nurse aides. This had the likelihood to affect all 55 residents. Findings: The facility's original policy and procedure for abuse documented: "Policy: The Tulsa Jewish Retirement and Health Care Center will make every attempt to protect Residents from abuse of any sort by striving to recognize signs/symptoms and potential for abuse... Procedure: Any person having reasonable cause to believe that an elderly person or incapacitated adult is suffering from abuse, neglect (including self-neglect), or exploitation will make a report to the Oklahoma State Department of Health and Adult Protective Services Division of the Department of Human Services... Staff/volunteer suspects the individual has sustained abuse, neglect (including self-neglect), or exploitation. Management: Any suspected abuse, neglect, or exploitation is to be reported to the Director of Nursing or President/CEO. An Incident Report is completed and given to the Director of Nursing or President/CEO within 24 hours. The report will include identifying information, description, type and extent of abuse or neglect, information concerning previous injury, and circumstances leading to suspicion... A thorough investigation will be investigated in a reasonable time period. Statements from witnesses as well as from the person suspected of the deed will be recorded and signed as quickly as possible. Witnesses or the accused may make additions or corrections to statements as needed. Within 24 hours of a report of suspected abuse or neglect, an Oklahoma State Incident Report form will be faxed to the Protection Health Services Division of the Department of Health at [PHONE NUMBER]. A report will also be made to Adult Protective Services at [PHONE NUMBER], or state hotline, [PHONE NUMBER] and/or the Tulsa Police Department, as is appropriate. If photographs are needed, the resident or the responsible party/guardian's consent to required. Prevention: Any individual suspected of abusing or neglecting a resident will be removed from the facility until an investigation can be completed. During the investigation period the accused will not be permitted in the facility. All employees, regardless of their job duties, will be subject to background screening to include but not limited to OSBI, FBI, Abuse Registry, etc." 1. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] and Aspirin for anti-coagulation therapy. These medications are blood thinners and place residents at risk for bruising. The physician's orders [REDACTED]. An incident/accident report, dated 02/05/12 at 11:15 a.m., documented, "Ecchymosis on R inner thigh noted multiple small areas. Rt. hand noted Ecchymosis. R lower abdominal area ecchymosis noted. Palpated abdomen. Soft No reaction or S/S pain...Steps to prevent recurrence: Resident's diaper to be changed in BR. Insulin sites to be rotated. Protective sleeves to hands." An incident/accident report, dated 02/25/12 at 11:15 a.m., "Resident lying in bed. Bruising noted to l foot outer aspect. Assessed for S/S pain. None noted. 1+ [MEDICAL CONDITION] noted to lower ankle leg area. Possible bruising occurred by resident hitting l ft. on wheel of wheelchair." Steps to prevent recurrence: Push resident in wheelchair." An incident/accident report, dated 03/03/12 at 1:30 p.m., "Called to resident rm. Bruise noted to r breast-above areola. Blue/yellow green in color...Steps to prevent recurrence: Use extra care when touching residents skin due to fragility." An incident/accident report, dated 04/17/12 (time unknown), "Sitter (Named deleted) notified that she noted a bruise to r knee on resident. Bruise is 2cm width by 5 cm length. Appearance of yellowing around edges. Unknown origin...Steps to prevent recurrence: Reinforced CNA's/Sitter to be gentle when caring for/transferring resident due to fragile skin." An incident/accident report, dated 05/04/12 at 9:30 a.m., "Sitter called me to room to report bruising found inner r thigh of unknown origin...Step to prevent recurrence: Cont to instruct CNA's on safety and repositioning when providing patient care." An incident/accident report, dated 05/06/12 at 8:30 a.m., "Resident brought to this nurse via W/C. Sm ecchymosis, blue color noted one cm x one cm outer L eye. No s/s present of discomfort noted. No discoloration to L eye on sclera. No swelling. B/P 148/82 P 90 R 18...Steps to prevent recurrence: Possible benefit mitts at HS." An incident/accident report, dated 05/13/12 at 2:00 p.m., "Called to residents rm. by (Name deleted/resident sitter), ecchymosis noted over lt eye 2 cm width x 1.5 cm height. Sclera speckled red inner aspect with darkened ecchymosis area lower aspect L pupil. Ecchymosis blue in color...Steps to prevent recurrence: Resident may benefit from bilateral hand mitts." There was no documentation to show any of these incidents, including the bruising to the inner thigh, breast or eye, had been investigated to find out if there was a correlation to resident care or the anti-coagulant medications. An incident/accident report, dated 06/09/12 at 10:00 p.m., "CNA worked with resident reported to this nurse that had witnessed sitter "spanking" resident on her buttocks. No apparent bruising noted at this time (No) S/S of discomfort...Steps to prevent recurrence: "Suggest to charge sitter, (Name deleted), to address the sitter and also notified DON of the incident." The CNA's statement related to the incident documented, "...I saw her (the sitter) beating (Resident's Name deleted) on the shoulder...she beat her on the buds with her hands. It wasn't the first time that she does that I feel so bad cause I witness before she beat (Resident's Name deleted) on the buds before when I was helping her...I didn't say anything about it." The time of the actual spanking was not documented. The surveyor attempted to call the CNA who had observed the spanking, but could not reach him/her due to both telephone numbers being disconnected. The CNA no longer worked at the facility. A nurse's note, dated 06/10/12 at 10:00 a.m., documented, "Called to N (north) hall shower rm. Resident noted to have a R wrist discoloration. Discoloration light blue in color. 3 cm. width/4.5 cm. length...Steps to prevent recurrence: May benefit from arm protectors." An incident/accident report dated 07/04/12 at 5:00 a.m., documented, "CNA notify me at 0500 that resident had bruise to R knee. Resident assessed, R knee is bruised, dark bluish in color, measuring 7 cm. by 4.5 cm. Visible pain noted upon movement of leg. Resident is unable to explain what happened...Steps to prevent recurrence: "Staff should be gentle when transferring resident." An incident/accident report dated 07/05/12 at 8:00 a.m. "Res pri sitter noticed a bruise above res R eye. Cause of bruise is unknown...Steps to prevent recurrence: Staff to continue to monitor res for bruises." None of these incidents had been investigated to correlate bruising to either resident care or anti-coagulant medications the resident was being administered. A quarterly assessment, dated 08/16/12, documented the resident had severely impaired cognition and required extensive assistance of one staff with dressing, eating, hygiene and bathing. The care plan last revised on 08/18/12, did not address the resident being on [MEDICATION NAME] and aspirin and was at an increased risk for bruising. On 11/08/12 at 11:15 a.m., the ADM and the DON were interviewed regarding their policy and procedure on abuse and investigations of bruising of unknown origin or bruising of a suspicious nature. The policy was presented to the survey team. The ten occurrences of bruising since February 2012, were discussed at that time. The DON was asked if she had conducted any investigations regarding the bruising. The DON stated she had no written investigations or statements from the staff to add to the incident reports. The DON stated, "Why would we investigate bruising. She is on [MEDICATION NAME] and aspirin." The ADM and the DON were asked if they could say whether the bruising was due to the [MEDICATION NAME] or the aspirin or due to actual resident care without investigating. The ADM reported it was a judgement call as to whether an incident would be investigated. The ADM further reported 99% of the investigations were done orally and were not documented. The ADM and DON were asked if the facility QA Committee did tracking and trending on incident/accident reports. The ADM reported the QA committee gave priority to falls and/or fractures. The ADM and DON were asked if they considered bruising to the breast of a resident or to inner thighs to be suspicious in nature. The ADM reported that investigation would be a judgement call of the nurse who filled out the incident report. The DON had no comment to the question. The ADM stated that only sitters gave care to the resident on a 24 hour basis and no facility staff gave the resident care. He stated the sitters are not our staff. There were times during the survey when no sitter was observed sitting with the resident. Facility staff and hospice were also providing care during the times the resident had no sitter. On 11/07/12 at 11:30 a.m., no sitter was observed with the resident. On 11/08/12 at 7:10 p.m., the sitter had already left. The ADM and DON were asked if they had documentation of any in-services given to staff regarding being careful with the resident due to her fragile skin. The ADM reported in-services were usually given on the spot and not documented. The ADM and the DON were asked if they had been aware of the resident's bruising and the resident being spanked by her sitter? They both reported that they were aware. On 11/08/12 at 2:45 p.m., the charge sitter was interviewed. She was asked what care she gives to the resident. She reported she gives all care during the day to the resident unless she is teaching a class next door. She was asked what she meant by 'all care'. She responded bathing, transferring, feeding and providing incontinent care. She reported she is responsible for hiring and firing the other sitters. She was asked how she gets referrals for other sitters. She responded she would check around for people she knew and who she could trust. She was asked if any background checks were done and she stated, "No." She was asked if she or any of the other sitters were trained as CNA's. She stated, "No." At 7:10 p.m., the resident was observed being transferred by two staff members. Bruising was observed to the resident's (R) leg, surrounding the knee. The bruise was yellowish green with a small amount of faded purple, approximately 10 inches in length and 3 inches in width. There was also bruising observed two on the left arm and two on the right arm. The resident did not bear weight on her LE's and no gait belt was utilized in the transfer. On 11/09/12, at 9:30 a.m., the DON was interviewed and asked if she had any additional incident reports for the resident. She reported she did not. The DON was asked to observe the resident's (R) leg. After observing the resident's leg, the DON reported she was not aware of the bruising. The DON reviewed the medical record and confirmed there was no documentation of the presence of the bruising to the resident's knee. She reported she would have the staff complete an incident report. On 11/09/12 at 3:30 p.m., LPN #3 was interviewed regarding the incident of the resident being spanked by the sitter. The LPN reported she had worked a 16 hour shift. On 06/09/12, she began her shift at 2:30 p.m., and worked on 06/10/12, until 7:00 a.m. The LPN reported she was informed of what had happened during her supper break on 06/09/12. She stated, "A CNA informed me she had observed the weekend sitter spanking the resident." The LPN stated, "By the time I learned about it, the sitter had already gone home. I knew the DON was coming in the next day, so I waited to talk with her then." The weekend sitter had worked the day shift on 06/09/12, and again on 06/10/12, on the day shift. The LPN reported she had not been able to reach the charge sitter the evening of the incident of the spanking. The LPN stated, "When I arrived to work the next day at 2:30 p.m., I was informed the weekend sitter was back with the resident and worked the entire shift." She then reported the DON had also come to work about 2:30 p.m., and she had told the DON the weekend sitter had been observed spanking the resident. The LPN stated after she had informed the DON, on 06/10/12 p.m., of the spanking, the DON had told me to call the charge sitter, because the sitters are not our employees. The LPN stated she had been able to reach the charge sitter about 10:00 p.m., that same evening on 06/10/12 (Sunday). The LPN reported the weekend sitter had worked her entire shift the day she had been observed spanking the resident and had also worked her entire shift the next day. She reported the charge sitter terminated the weekend sitter on Monday (06/11/12). The issue was not addressed until the second day after the incident. The facility took no steps to protect the resident. On 11/09/12 at 4:00 p.m., the ADM was interviewed regarding investigations of the bruising. He reported he did not hold his DON accountable for investigating all bruising. The facility could not provide any investigations for the incident on 06/09/12, of the weekend sitter spanking the resident or any conclusions for the multiple suspicious bruises. 2. Resident #19 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A BIMS (brief interview for mental status), dated 08/19/12, documented, "Resident unable or unwilling to participate." A significant change assessment, dated 08/20/12, documented the resident had inadequate short and long term memory, had severely impaired cognition, had continuous behaviors that did not fluctuate, had disorganized thinking, altered level of consciousness, psychomotor [MEDICAL CONDITION], was not ambulatory, was totally dependent on the staff for all ADL's and was always incontinent of bowel and bladder. A CAA analysis report, dated 08/22/12, documented, "(Name deleted resident #19) continues to have severe alterations in his cognition status related to his dx of end stage dementia and [MEDICAL CONDITION] to (Name deleted) hospice for services related to his overall decline and his dx of adult failure to thrive..." A care plan, dated 08/22/12, documented: "Problem...Communication- Resident has a communication deficit of: understanding other, making self understood, nonverbal... Approaches: Adjust environment to reduce noise for communication, to reduce distractions and to amplify sound, if needed. Provide reassurance when he/she attempts to communicate...Speak facing him/her in simple phrases...Allow adequate time for response... Problem: Expected decline- Resident is expected to decline and requires Hospice care due to a terminal condition..." On 10/10/12 at 12:20 p.m., a nurse's note documented, "Resident was in dining room a lunch aide was feeding him & was shaking him to wake him to eat. But it appeared to be abusive report to DON. She stated she will take care of it." The incident/accident reports were reviewed for the shaking and verbally abusive behavior observed by LPN #1 on 10/10/12. There was no incident/accident report written for the incident. LPN #1 who had written the nurse's note on 10/10/12, was interviewed. She was asked to identify the CNA addressed in the nurse's note. The LPN identified (name deleted CNA #2). (Name deleted CNA #2) employee records were reviewed. The record contained seven employee warnings related to the care of the residents by CNA #2. The employee record contained employee warnings that documented the following: On 01/17/12: "...Specific areas of needed improvement: Needs to work on tone of voice, less aggressive in tone while providing care to our resident & talking to family members. Recommendations for profession development (seminars, training, schooling, etc.): Needs to attend counseling sessions offered by company to help deal with personal issues." On 10/10/12: "Description of Violation: Reported being too rough with resident at lunch while attempting to feed him. Were shaking head & shoulder & talking loudly. Actions to be Taken: Suspension for 2 days without pay. If happens again suspension up to termination. Discussed with (Name deleted CNA #2), but she refused to sign." On 11/08/12 at 5:25 p.m., the resident was observed sitting in a Broda chair in the dining room. The resident was being spoonfed by a CNA. On 11/09/12 at 12:00 p.m., LPN #1 who had made the entry in the nurses' notes on 10/10/12, was interviewed. The LPN was asked to describe the incident that had occurred on 10/10/12, with (Name deleted resident #19) and (Name deleted CNA #2). The LPN stated, "(Name deleted CNA #2) was sitting next to (Name deleted resident #19) in the dining room. The LPN reported the CNA put her arm around the resident's shoulder and was observed to be pulling him side to side, and talking very loudly to the resident. The CNA's voice could be heard all over the dining room and other staff and residents were looking at what was going on between the resident and the CNA. The LPN then stated the CNA put the heel of her hand to the side of the resident's head and pushed the resident twice. The LPN reported she immediately went to the CNA and told her to go feed another resident to get her away from (Name deleted resident #19). The LPN stated as soon as lunch was over she went to the DON and reported the incident. The LPN stated the CNA had been overheard by staff and families talking gruff with other residents. She stated the CNA had worked for awhile as a shower aide, but had recently been pulled from doing the showers. She did not know why. The LPN reported there were four residents/families that had requested the CNA not to assist with their care. The LPN reported they had switched the CNA around, so the CNA would not be taking care of those residents. On 11/09/12 at 12:30 p.m., CMA #1 was interviewed. The CMA had been reported as witnessing the incident in the dining room on 10/10/12, between the resident and CNA #2. The CMA was asked to describe her observation. She reported from where she was standing she saw the resident's chair shaking and heard CNA #2 talking loudly to the resident. At 2:00 p.m., the DON was interviewed regarding the incident between resident #19 and CNA #2. She was asked if she had been aware of the incident and had if she conducted an investigation of the allegation of abuse. The DON reported she had come to the conclusion that the shaking and yelling at the resident should had not have occurred. The DON reported LPN #1 had reported the incident to her about 1:00 p.m., the same day of the incident. The DON reported she had talked to CNA #2 about 2:15 p.m., the same day and written her an "Employee Warning Notice", but she had refused to sign it. The DON reported the CNA was rougher in care, but she never meant any harm to the residents. The DON was asked if she had reported the allegation of abuse to OSDH or reported the incident to the family and/or physician. She stated she did not report the incident to anyone and she did not document an investigation of the incident. The time card for CNA #2 dated 10/10/12 (Wednesday), documented the CNA had worked from 6:33 a.m. until 2:57 p.m., her normal shift hours. The incident had been observed during the noon meal. The CNA continued to provide care until the end of her shift at 3:00 p.m. The time card did not document the CNA as working on 10/11/12 (Thursday) or 10/12/12 (Friday) and had been off with pay on 10/15/12 (Monday). On 11/09/12 at 2:20 p.m., the DON was asked what steps had she taken to protect the residents even though she did not do a documented investigation. The DON reported she had suspended the CNA for two days without pay and given her a 'Final Warning.' The DON reported she had also re-assigned the CNA to a different hall when she returned to work on 10/16/12 (Tuesday). On 11/09/12 at 2:30 p.m., an unidentified resident's family was interviewed. The family had been identified as requesting CNA #2 not to provide care for their family member. The family member of the resident was asked about staff treatment of [REDACTED]. The family member reported they had requested (CNA #2's Name deleted) not provide care for their family member. But they had recently noticed the CNA had "worked her way back around" and was now providing care again to their family member. The family member was asked why they had made the request. They reported the CNA had a bad attitude and had been observed being rough when handling their family member. On 11/09/12 at 3:00 p.m., the ADM was interviewed regarding the incident that had occurred on 10/10/12, between CNA #2 and the resident. The ADM was asked if he had been aware of the incident. He said he had knowledge of the incident, but knew the CNA was a good employee and had been with them for years, so he had not been concerned. At 3:30 p.m., the DON was asked if she had thoroughly investigated the incident. She reported she had talked to LPN #1 and CNA #2, but had not documented anything or reported the incident to OSDH. On 11/13/12 at 11:30 a.m., the DON stated she still needed to in-service two additional staff members. The DON stated she had terminated CNA #2, accused of abusive behaviors to a resident, on 11/12/12 at 6:30 a.m. On 11/13/12 at 12:00 p.m., the DON presented the following documentation to the survey team: "On October 10, 2012 it was reported to me by the charge nurse (Name deleted LPN #1), that (Name deleted CNA #2) was being 'rough with (Name deleted resident #19) in the dining room.' (Name deleted LPN #1) stated she was talking loud to (Name deleted resident #19) in attempts to get him to eat lunch. She was touching him on his head trying to get him to wake up to eat. I asked (Name deleted LPN #1) what she meant about touching & she replied (Name deleted CNA #2) was punching on the side of his head to try to wake him up to eat. She stated that other residents were looking at (Name deleted CNA #2) in regard to her being loud. (Name deleted LPN #1) said to ask (Name deleted CMA #1) about it because she had witnessed the event. (Name deleted CNA #2) was removed from the table feeding (Name deleted resident #19) after she had gotten loud. I talked to (Name deleted CMA #1) & she said that (Name deleted CNA #2) was not being that rough with (Name deleted resident #19) that she was trying to wake him up to eat. '(Name deleted CNA #2) doesn't mean any harm to (Name deleted resident #19), she just wants him to eat. She was able to get him to eat.' I spoke to (Name deleted CNA #2) in my office in regards to her talking loud & shaking (Name deleted resident #19) to wake him. I explained at that time that her behavior could be interpreted as abuse by another resident or family member even though she was trying to get him to eat. I told her that her tone of voice sounds gruff because it is harsh sounding. (Name deleted CNA #2) stated she understood. I did suspend her for 2 days without pay & told her to go home & think about the fact that I told her that any & all actions she said or did could be being watched by any family or staff or resident & could be mistaken as abuse. (Name deleted CNA #2) was terminated at 6:30 AM on 11/12/12 by the director of nurses with (LPN #1 Name deleted) present in regard to the incident described as above." On 11/13/12 at 12:30 p.m., the DON was asked if she had interviewed other staff and residents while investigating the allegation of CNA #2 being abusive to resident #19. The DON reported she had only interviewed the three staff members involved in the allegation. 3. On 11/09/12, employee records were reviewed. There was no documentation to show if the names of the nurse aides or non-technical employees were verified on the abuse registry. At 3:35 p.m., the facility's human resources employee was asked if the abuse registry was checked before hiring non-technical staff. She said she did not know she was to check the registry for them and did not know how to check. 4. On 11/09/12, employee records were reviewed. There was no documentation to show if the names of the nurse aides had been verified on the nurse aide registry. At 3:35 p.m., the facility's human resources employee was asked if the nurse aide registry was checked before hiring staff. She said she did not know she was to check the registry and did not know how to check it. At 4:00 p.m., the ADON was asked if the nurse aid registry had been checked for the newly hired nurse aides. She said she used to check, but now the human resources person should be checking. On 11/13/12 at 3:00 p.m., the DON was asked if the nurse aide registry had been checked for the newly hired nurse aides. She said she thought the ADON was checking it.

On 11/08/12 at 4:45 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure allegations of abuse were thoroughly investigated and residents were protected during the investigation. On 11/08/12 at 4:50 p.m., the Oklahoma State Department of Health was notified. The IJ situation was verified. At 5:00 p.m., the Administrator and the Director of Nursing were notified of the IJ situation. At 6:30 p.m., an acceptable plan of removal was provided to the team. "The Tulsa Jewish Retirement and Healthcare Center will immediately implement a comprehensive In-Service training program on screening, identifying, reporting, and preventing elder abuse. The first training will be today, 11/8/12, on the 3-11 shift. Similar training will take place tonight for the 11-7 shift and again tomorrow for the 7-3 shift. Attendees will understand the facility policy on elder abuse. Further, they will have a clear understanding of how to identify abuse, report abuse, investigate and subsequently prevent or protect the residents from abuse. Any employee not scheduled to work in the next 24 hour period will be in-serviced prior to engaging residents. The facility policy on abuse will be corrected as discussed with the survey team. Specifically, section 3.1 will read, "Any suspected abuse, neglect, or exploitation is to be reported to your immediate supervisor and/or the Director of Nurses and the Administrator immediately." Section 3.2 will read, "An Incident report is completed and given to the Director of Nursing and/or the Administrator during the shift in which the incident occurred..." Section 3.3 will read, "A thorough investigation will be initiated..." The entire policy will be re-written and available to the Survey Team on Friday November 9th 2011 (2012)." On 11/09/12 at 2:45 p.m., an additional allegation of staff to resident abuse was discovered through record review. At 3:00 p.m., OSDH was notified and verified the continuance of the IJ situation. At 3:10 p.m., the Administrator and the Director of Nursing were informed of the continued IJ situation. On 11/09/12 at 4:46 p.m., an acceptable plan of removal was received. This was an addendum that had been added to the first plan of removal and documented the following: "Additionally, the employee who allegedly abused a resident has been removed from the facility and will not be permitted back to work until a complete investigation can be performed. Once the case has been resolved, the final report will be submitted to the proper agencies." The immediate jeopardy was removed as of 11/09/12 at 3:00 p.m., after staff had been inserviced and CNA #2 had finished her shift and left the building. The deficient practice remained at actual harm at a pattern. Based on record review, observation, and family, residents and staff interviews, it was determined the facility failed to: a) Protect residents and investigate allegations of abuse for two (#9 and #19) of 12 residents sampled for abuse. b) Put preventive measures in place to prevent recurrence for two (#9 and #19) of 12 residents sampled for abuse. c) Report allegations of abuse to the appropriate state agencies for two (#9 and #19) of 12 residents sampled for abuse This had the likelihood to affect all 55 of 55 residents residing in the facility. Findings: The facility's original policy and procedure for abuse documented: "Policy: The Tulsa Jewish Retirement and Health Care Center will make every attempt to protect Residents from abuse of any sort by striving to recognize signs/symptoms and potential for abuse... Procedure: Any person having reasonable cause to believe that an elderly person or incapacitated adult is suffering from abuse, neglect (including self-neglect), or exploitation will make a report to the Oklahoma State Department of Health and Adult Protective Services Division of the Department of Human Services... Staff/volunteer suspects the individual has sustained abuse, neglect (including self-neglect), or exploitation. Management: Any suspected abuse, neglect, or exploitation is to be reported to the Director of Nursing or President/CEO. An Incident Report is completed and given to the Director of Nursing or President/CEO within 24 hours. The report will include identifying information, description, type and extent of abuse or neglect, information concerning previous injury, and circumstances leading to suspicion... A thorough investigation will be investigated in a reasonable time period. Statements from witnesses as well as from the person suspected of the deed will be recorded and signed as quickly as possible. Witnesses or the accused may make additions or corrections to statements as needed. Within 24 hours of a report of suspected abuse or neglect, an Oklahoma State Incident Report form will be faxed to the Protection Health Services Division of the Department of Health at [PHONE NUMBER]. A report will also be made to Adult Protective Services at [PHONE NUMBER], or state hotline, [PHONE NUMBER] and/or the Tulsa Police Department, as is appropriate. If photographs are needed, the resident or the responsible party/guardian's consent to required. Prevention: Any individual suspected of abusing or neglecting a resident will be removed from the facility until an investigation can be completed. During the investigation period the accused will not be permitted in the facility. All employees, regardless of their job duties, will be subject to background screening to include but not limited to OSBI, FBI, Abuse Registry, etc." 1. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] and Aspirin for anti-coagulation therapy. These medications are blood thinners and place residents at risk for bruising. The physician's orders [REDACTED]. An incident/accident report, dated 02/05/12 at 11:15 a.m., documented, "Ecchymosis on R inner thigh noted multiple small areas. Rt. hand noted Ecchymosis. R lower abdominal area ecchymosis noted. Palpated abdomen. Soft No reaction or S/S pain...Steps to prevent recurrence: Resident's diaper to be changed in BR. Insulin sites to be rotated. Protective sleeves to hands." An incident/accident report, dated 02/25/12 at 11:15 a.m., documented, "Resident lying in bed. Bruising noted to l foot outer aspect. Assessed for S/S pain. None noted. 1+ [MEDICAL CONDITION] noted to lower ankle leg area. Possible bruising occurred by resident hitting l ft. on wheel of wheelchair." Steps to prevent recurrence: Push resident in wheelchair." An incident/accident report, dated 03/03/12 at 1:30 p.m., documented, "Called to resident rm. Bruise noted to r breast-above areola. Blue/yellow green in color...Steps to prevent recurrence: Use extra care when touching residents skin due to fragility." An incident/accident report, dated 04/17/12, documented, "...Time of incident/accident unknown...Sitter (Named deleted) notified that she noted a bruise to r knee on resident. Bruise is 2cm (width) by 5 cm length. Appearance of yellowing around edges. Unknown origin...Steps taken to prevent recurrence: Reinforced CNA's/Sitter to be gentle when caring for/transferring resident due to fragile skin." An incident/accident report, dated 05/04/12 at 9:30 a.m., documented, "Sitter called me to room to report bruising found inner r thigh of unknown origin...Step to prevent recurrence: Cont to instruct CNA's on safety and repositioning when providing patient care." An incident/accident report, dated 05/06/12 at 8:30 a.m., documented, "Resident brought to this nurse via W/C. Sm ecchymosis, blue color noted one cm x one cm outer L eye. No s/s present of discomfort noted. No discoloration to L eye on sclera. No swelling. B/P 148/82 P 90 R 18...Steps to prevent recurrence: Possible benefit mitts at HS." An incident/accident report, dated 05/13/12 at 2:00 p.m., documented, "Called to residents rm. by (Name deleted/resident sitter), ecchymosis noted over lt eye 2 cm width x 1.5 cm height. Sclera speckled red inner aspect with darkened ecchymosis area lower aspect L pupil. Ecchymosis blue in color...Steps to prevent recurrence: Resident may benefit from bilateral hand mitts." There was no documentation to show any of these incidents, including the bruising to the inner thigh, breast or eye, had been investigated to find out if there was a correlation to resident care or the anti-coagulant medications. An incident/accident report, dated 06/09/12 at 10:00 p.m., documented, "CNA worked with resident reported to this nurse that had witnessed sitter "spanking" resident on her buttocks. No apparent bruising noted at this time (No) S/S of discomfort...Steps to prevent recurrence: "Suggest to charge sitter, (Name deleted), to address the sitter and also notified DON of the incident." The CNA's statement related to the incident documented, "...I saw her (the sitter) beating (Resident's Name deleted) on the shoulder...she beat her on the buds with her hands. It wasn't the first time that she does that I feel so bad cause I witness before she beat (Resident's Name deleted) on the buds before when I was helping her...I didn't say anything about it." The time of the actual spanking was not documented. The surveyor attempted to call the CNA who had observed the spanking, but could not reach him/her due to both telephone numbers being disconnected. The CNA no longer worked at the facility. The facility did not document a conclusion to their investigation or notify OSDH of the conclusion to their investigation. A nurse's note, dated 06/10/12 at 10:00 a.m., documented, "Called to N (north) hall shower rm. Resident noted to have a R wrist discoloration. Discoloration light blue in color. 3 cm. width/4.5 cm. length...Steps to prevent recurrence: May benefit from arm protectors." An incident/accident report dated 07/04/12 at 5:00 a.m., documented, "CNA notify me at 0500 that resident had bruise to R knee. Resident assessed, R knee is bruised, dark bluish in color, measuring 7 cm. by 4.5 cm. Visible pain noted upon movement of leg. Resident is unable to explain what happened...Steps to prevent recurrence: "Staff should be gentle when transferring resident." An incident/accident report dated 07/05/12 at 8:00 a.m. "Res pri sitter noticed a bruise above res R eye. Cause of bruise is unknown...Steps to prevent recurrence: Staff to continue to monitor res for bruises." There was no documentation to show any of these incidents had been investigated to find out if there was a correlation to resident care or the anti-coagulant medications. A quarterly assessment, dated 08/16/12, documented the resident had severely impaired cognition and required extensive assistance of one staff with dressing, eating, hygiene and bathing. The care plan last revised on 08/18/12, did not address the resident being on [MEDICATION NAME] and aspirin and was at an increased risk for bruising. On 11/08/12 at 11:15 a.m., the ADM and the DON were interviewed regarding the policy and procedure on abuse and investigating abuse. The policy was presented to the survey team. The ten occurrences of bruising since February 2012, were discussed at that time. The DON was asked if she had conducted any investigations regarding the bruising. The DON stated she had no written investigations or statements from the staff to add to the incident reports. The DON stated, "Why would we investigate bruising. She is on [MEDICATION NAME] and aspirin." The ADM and the DON were asked if they could say whether the bruising was due to the [MEDICATION NAME] or the aspirin or due to actual resident care without investigating. The ADM reported it was a judgement call as to whether an incident would be investigated. The ADM further reported 99% of the investigations were done orally and were not documented. The ADM and DON were asked if the facility QA Committee did tracking and trending on incident/accident reports. The ADM reported the QA committee gave priority to falls and/or fractures. The ADM and DON were asked if they considered bruising to the breast of a resident or to inner thighs to be suspicious in nature. The ADM reported that investigation would be a judgement call of the nurse who filled out the incident report. The DON had no comment to the question. The ADM stated that only sitters gave care to the resident on a 24 hour basis and no facility staff gave the resident care. He stated the sitters are not our staff. There were times during the survey when no sitter was observed sitting with the resident. Facility staff and hospice were also providing care during the times the resident had no sitter. On 11/07/12 at 11:30 a.m., no sitter was observed with the resident. On 11/08/12 at 7:10 p.m., the sitter had already left. The ADM and DON were asked if they had documentation of any in-services given to staff regarding being careful with the resident due to her fragile skin. The ADM reported in-services were usually given on the spot and not documented. The ADM and the DON were asked if they had been aware of the resident's bruising and the resident being spanked by her sitter? They both reported that they were aware. On 11/08/12 at 2:45 p.m., the charge sitter was interviewed. She was asked what care she gave to the resident. She reported she gave all care during the day to the resident unless she was teaching a class next door. She was asked what she meant by 'all care'. She responded bathing, transferring, feeding and providing incontinent care. She reported she was responsible for hiring and firing the other sitters. She was asked how she received referrals for other sitters. She responded she would check around for people she knew and who she could trust. She was asked if any background checks were done and she stated, "No." She was asked if she or any of the other sitters were trained as CNA's. She stated, "No." At 7:10 p.m., the resident was observed being transferred by two staff members. Bruising was observed to the resident's (R) leg, surrounding the knee. The bruise was yellowish green with a small amount of faded purple, approximately 10 inches in length and 3 inches in width. There was also bruising observed on the left arm and two on the right arm. The resident did not bear weight on her LE's and no gait belt was utilized in the transfer. On 11/09/12, at 9:30 a.m., the DON was interviewed and asked if she had any additional incident reports for the resident. She reported she did not. The DON was asked to observe the resident's (R) leg. After observing the resident's leg, the DON reported she was not aware of the bruising. The DON reviewed the medical record and confirmed there was no documentation of the presence of the bruising to the resident's knee. She reported she would have the staff complete an incident report. On 11/09/12 at 3:30 p.m., LPN #3 was interviewed regarding the incident of the resident being spanked by the sitter. The LPN reported she had worked a 16 hour shift. On 06/09/12, she began her shift at 2:30 p.m., and worked on 06/10/12, until 7:00 a.m. The LPN reported she was informed of what had happened during her supper break on 06/09/12. She stated, "A CNA informed me she had observed the weekend sitter spanking the resident." The LPN stated, "By the time I learned about it, the sitter had already gone home. I knew the DON was coming in the next day, so I waited to talk with her then." The weekend sitter had worked the day shifts on 06/09/12, and again on 06/10/12. The LPN reported she had not been able to reach the charge sitter the evening of the incident of the spanking. The LPN stated, "When I arrived to work the next day at 2:30 p.m., I was informed the weekend sitter was back with the resident and worked the entire shift." She then reported the DON had also come to work about 2:30 p.m., and she had told the DON the weekend sitter had been observed spanking the resident. The LPN stated after she had informed the DON, on 06/10/12 p.m., of the spanking, the DON had told me to call the charge sitter, because the sitters are not our employees. The LPN stated she had been able to reach the charge sitter about 10:00 p.m., that same evening on 06/10/12. The LPN reported the weekend sitter had worked her entire shift the day she had been observed spanking the resident and had also worked her whole shift the next day. She reported the charge sitter terminated the weekend sitter on Monday (06/11/12). The issue was not addressed until the second day after the incident. The facility took no steps to protect the resident. On 11/09/12 at 4:00 p.m., the ADM was interviewed regarding investigations of the bruising. He reported he did not hold his DON accountable for investigating bruising. The facility could not provide any investigations for the incident on 06/09/12, of the weekend sitter spanking the resident or any conclusions for the multiple bruises. 2. Resident #19 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A BIMS (brief interview for mental status), dated 08/19/12, documented: "Resident unable or unwilling to participate." A significant change assessment, dated 08/20/12, documented the resident had inadequate short and long term memory, had severely impaired cognition, had continuous behaviors that did not fluctuate, had disorganized thinking, altered level of consciousness, psychomotor [MEDICAL CONDITION], was not ambulatory, was totally dependent on the staff for all ADL's and was always incontinent of bowel and bladder. A CAA analysis report, dated 08/22/12, documented, "(Name deleted resident #19) continues to have severe alterations in his cognition status related to his dx of end stage dementia and [MEDICAL CONDITION] to (Name deleted) hospice for services related to his overall decline and his dx of adult failure to thrive..." A care plan, dated 08/22/12, documented: "Problem...Communication- Resident has a communication deficit of: understanding other, making self understood, nonverbal... Approaches: Adjust environment to reduce noise for communication, to reduce distractions and to amplify sound, if needed. Provide reassurance when he/she attempts to communicate...Speak facing him/her in simple phrases...Allow adequate time for response... Problem: Expected decline- Resident is expected to decline and requires Hospice care due to a terminal condition..." On 10/10/12 at 12:20 p.m., a nurse's note documented, "Resident was in dining room a lunch aide was feeding him & was shaking him to wake him to eat. But it appeared to be abusive report to DON. She stated she will take care of it." The incident/accident reports were reviewed for the shaking and verbally abusive behavior observed by LPN #1 on 10/10/12. There was no incident/accident written for the incident. LPN #1 who had written the nurse's note on 10/10/12, was interviewed. She was asked to identify the CNA addressed in the nurse's note. The LPN identified (Name deleted CNA #2). (Name deleted CNA #2) employee records were reviewed. The record contained seven employee warnings related to the care of the residents by CNA #2. The employee record contained employee warnings that documented the following: On 01/17/12: "...Specific areas of needed improvement: Needs to work on tone of voice, less aggressive in tone while providing care to our resident & talking to family members. Recommendations for profession development (seminars, training, schooling, etc.): Needs to attend counseling sessions offered by company to help deal with personal issues." On 10/10/12: "Description of Violation: Reported being too rough with resident at lunch while attempting to feed him. Were shaking head & shoulder & talking loudly. Actions to be Taken: Suspension for 2 days without pay. If happens again suspension up to termination. Discussed with (Name deleted CNA #2), but she refused to sign." On 11/08/12 at 5:25 p.m., the resident was observed sitting in a G/C in the dining room. The resident was being spoonfed by a CNA. On 11/09/12 at 12:00 p.m., LPN #1 who had made the entry in the nurses' notes on 10/10/12, was interviewed. The LPN was asked to describe the incident that had occurred on 10/10/12, with (Name deleted resident #19) and (Name deleted CNA #2). The LPN stated, "(Name deleted CNA #2) was sitting next to (Name deleted resident #19) in the dining room. The LPN reported the CNA put her arm around the resident's shoulder and was observed to be pulling him side to side, and talking very loudly to the resident. The CNA's voice could be heard all over the dining room and other staff and residents were looking at what was going on between the resident and the CNA. The LPN then stated the CNA put the heel of her hand to the side of the resident's head and pushed the resident twice. The LPN reported she immediately went to the CNA and told her to go feed another resident to get her away from (Name deleted resident #19). The LPN stated as soon as lunch was over she went to the DON and reported the incident. The LPN stated the CNA had been overheard by staff and families talking gruff with other residents. She stated the CNA had worked for awhile as a shower aide, but had recently been pulled from doing the showers. She did not know why. The LPN reported there were four residents/families that had requested the CNA not to assist with their care. The LPN reported they had switched the CNA around, so the CNA would not be taking care of those residents. On 11/09/12 at 12:30 p.m., CMA #1 was interviewed. The CMA had been reported as witnessing the incident in the dining room on 10/10/12, between the resident and CNA #2. The CMA was asked to describe her observation. She reported from where she was standing she saw the resident's chair shaking and heard CNA #2 talking loudly to the resident. At 2:00 p.m., the DON was interviewed regarding the incident between resident #19 and CNA #2. She was asked if she had been aware of the incident and if she had conducted an investigation of the allegation of abuse. The DON reported she had come to the conclusion that the shaking and yelling at the resident should not have occurred. The DON reported LPN #1 had reported the incident to her about 1:00 p.m., the same day of the incident. The DON reported she had talked to CNA #2 about 2:15 p.m., the same day and written her an "Employee Warning Notice", but she had refused to sign it. The DON reported the CNA was rougher in care, but she never meant any harm to the residents. The DON was asked if she had reported the allegation of abuse to OSDH or reported the incident to the family and/or physician. She stated she did not report the incident to anyone and she did not document an investigation of the incident. The time card for CNA #2 dated 10/10/12 (Wednesday), documented the CNA had worked from 6:33 a.m. until 2:57 p.m., her normal shift hours. The incident had been observed during the noon meal. The CNA continued to provide care until the end of her shift at 3:00 p.m. The time card did not document the CNA as working on 10/11/12 (Thursday) or 10/12/12 (Friday) and had been off with pay on 10/15/12 (Monday). On 11/09/12 at 2:20 p.m., the DON was asked what steps had she taken to protect the residents even though she did not do an investigation. The DON reported she had suspended the CNA for two days without pay and given her a 'Final Warning.' The DON reported she had also reassigned the CNA to a different hall when she returned to work on 10/16/12 (Tuesday). On 11/09/12 at 2:30 p.m., an unidentified resident's family was interviewed. The family had been identified as requesting CNA #2 not to provide care for their family member. The family member was asked about staff treatment of [REDACTED]. The family member reported they had requested (CNA #2's Name deleted) not provide care for their family member. But they had recently noticed the CNA had, "worked her way back around" and was now providing care again to their family member. The family member was asked why they had made the request. They reported the CNA had a bad attitude and had been observed being rough when handling their family member. On 11/09/12 at 3:00 p.m., the ADM was interviewed regarding the incident that had occurred on 10/10/12, between CNA #2 and the resident. The ADM was asked if he had been aware of the incident. He said he had knowledge of the incident, but knew the CNA was a good employee and had been with them for years, so he had not been concerned. At 3:30 p.m., the DON was asked if she had thoroughly investigated the incident. She reported she had talked to LPN #1 and CNA #2, but had not documented anything or reported the incident to OSDH. On 11/13/12 at 11:30 a.m., the DON stated she still needed to in-service two additional staff members. The DON stated she had terminated CNA #2, accused of abusive behaviors to a resident, on 11/12/12 at 6:30 a.m. On 11/13/12 at 12:00 p.m., the DON presented the following documentation to the survey team: "On October 10, 2012 it was reported to me by the charge nurse (Name deleted LPN #1), that (Name deleted CNA #2) was being 'rough with (Name deleted resident #19) in the dining room.' (Name deleted LPN #1) stated she was talking loud to (Name deleted resident #19) in attempts to get him to eat lunch. She was touching him on his head trying to get him to wake up to eat. I asked (Name deleted LPN #1) what she meant about touching & she replied (Name deleted CNA #2) was punching on the side of his head to try to wake him up to eat. She stated that other residents were looking at (Name deleted CNA #2) in regard to her being loud. (Name deleted LPN #1) said to ask (Name deleted CMA #1) about it because she had witnessed the event. (Name deleted CNA #2) was removed from the table feeding (Name deleted resident #19) after she had gotten loud. I talked to (Name deleted CMA #1) & she said that (Name deleted CNA #2) was not being that rough with (Name deleted resident #19) that she was trying to wake him up to eat. '(Name deleted CNA #2) doesn't mean any harm to (Name deleted resident #19), she just wants him to eat. She was able to get him to eat.' I spoke to (Name deleted CNA #2) in my office in regards to her talking loud & shaking (Name deleted resident #19) to wake him. I explained at that time that her behavior could be interpreted as abuse by another resident or family member even though she was trying to get him to eat. I told her that her tone of voice sounds gruff because it is harsh sounding. (Name deleted CNA #2) stated she understood. I did suspend her for 2 days without pay & told her to go home & think about the fact that I told her that any & all actions she said or did could be being watched by any family or staff or resident & could be mistaken as abuse. (Name deleted CNA #2) was terminated at 6:30 AM on 11/12/12 by the director of nurses with (LPN #1 Name deleted) present in regard to the incident described as above." On 11/13/12 at 12:30 p.m., the DON was asked if she had interviewed other staff and residents while investigating the allegation of CNA #2 being abusive to resident #19. The DON reported she had only interviewed the three staff members involved in the allegation.

On 11/08/12 at 4:45 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's failure to protect residents and investigate alleged abuse. At 4:50 p.m., the Oklahoma State Department of Health was notified and the IJ situation was verified. At 5:00 p.m., the Administrator and Director of Nursing were notified of the IJ situation. On 11/09/12 at 4:46 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "The Tulsa Jewish Retirement and Healthcare Center will immediately implement a comprehensive In-Service training program on screening, identifying, reporting, and preventing elder abuse. The first training will be today, 11/8/12, on the 3-11 shift. Similar training will take place tonight for the 11-7 shift and again tomorrow for the 7-3 shift. Attendees will understand the facility policy on elder abuse. Further, they will have a clear understanding of how to identify abuse, report abuse, investigate and subsequently prevent or protect the residents from abuse. Any employee not scheduled to work in the next 24 hour period will be in-serviced prior to engaging residents. The facility policy on abuse will be corrected as discussed with the survey team. Specifically, section 3.1 will read, "Any suspected abuse, neglect, or exploitation is to be reported to your immediate supervisor and/or the Director of Nurses and the Administrator immediately." Section 3.2 will read, "An Incident report is completed and given to the Director of Nursing and/or the Administrator during the shift in which the incident occurred..." Section 3.3 will read, "A thorough investigation will be initiated..." The entire policy will be re-written and available to the Survey Team on Friday November 9th, 2012. The plan of removal was signed by the Administrator. On 11/09/12 at 2:45 p.m., an additional allegation of staff to resident abuse was discovered through record review. At 3:00 p.m., OSDH was notified and verified the continuance of the IJ situation. At 3:10 p.m., the Administrator and the Director of Nursing were informed of the continued IJ situation. On 11/09/12 at 4:46 p.m., an acceptable plan of removal was accepted. This was an addendum that had been added to the first plan of removal and documented the following: "Additionally, the employee who allegedly abused a resident has been removed from the facility and will not be permitted back to work until a complete investigation can be performed. Once the case has been resolved, the final report will be submitted to the proper agencies." The immediate jeopardy was removed as of 11/09/12 at 3:00 p.m., after staff had been inserviced and CNA #2 had finished her shift and left the building. The deficient practice remained at actual harm at a pattern. Based on observation, record review, and interviews, it was determined the administrator failed to: a) Administer the facility in a manner to enable residents to reside in an environment free from abuse. b) Ensure allegations of abuse were immediately acted upon, and to ensure protective measures were put into place and a thorough investigation was conducted. c) Ensure the abuse policies were utilized as effective tools against abuse including the protection of the residents, investigation, and reporting to the proper entities. d) Ensure an effective QA program was provided to identify problems and concerns and correct quality deficiencies. This had the potential to affect 55 of 55 residents who resided in the facility. Findings: Based on record review, observation, and family, residents and staff interviews, it was determined the facility failed to: a) Protect residents and investigate allegations of abuse for two (#9 and #19) of 12 residents sampled for abuse. b) Put preventive measures in place to prevent recurrence for two (#9 and #19) of 12 residents sampled for abuse. c) Report allegations of abuse to the appropriate state agencies for two (#9 and #19) of 12 residents sampled for abuse This had the likelihood to affect all 55 of 55 residents residing in the facility. This resulted in an IJ situation. Refer to F225 In addition, based on record review, observation, and staff interview, it was determined the facility failed to implement their abuse policy/procedure by failing to: a) thoroughly investigate allegations of abuse for two (#9 and #19) of 12 residents sampled for abuse. b) Put protective/preventive measures in place to protect residents from abuse and prevent recurrence for two (#9 and #19) of 12 residents sampled for abuse. c) Report allegations of abuse to the appropriate state agencies for one (#19) of 12 residents sampled for abuse. d) Check the state's abuse registry in regard to newly hired non-technical service workers. e) Check the state's nurse aide registry in regard to newly hired nurse aides. This had the likelihood to affect all 55 residents. This resulted in an IJ situation. Refer to F226 In addition, based on record review and interview, it was determined the facility failed to: a) Ensure an effective quality assessment and assurance program was in place to identify problems and develop and implement plans of action to correct quality deficiencies. b) Identify and implement a plan of action to correct system failures related to identifying abusive behaviors and ensuring interventions were initiated to prevent further abuse. Refer to F520

Based on record reviews, observation and interviews, it was determined the facility failed to: a) Identify safety hazards and implement appropriate interventions necessary to prevent recurrence of injuries for two (#10 and #14) of nine sampled residents. This caused harm to the two residents. This had the potential to affect three residents with falls during July 2012, 18 residents with falls during the month of August 2012, and nine residents with falls during the month of November 2012, identified by the DON. b) Provide transfer assistance in a safe manner for two (#9 and #19) of four sampled residents non-weight bearing and observed being transferred. This had the potential to affect five residents identified by the DON as being non-weight bearing and requiring assistance for transfers. Findings: 1. Resident #10 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A fall risk assessment, dated 02/03/12, documented the resident was a high risk for falls. On 02/10/12, an incident/accident report, documented, "Blue colored bruising present back of (L) hand. Bruise of unknown origin. She verbalized that it hurts at times. STPR: Will continue to assist resident with ADL's & transfers." The incident/accident report did not contain appropriate, individualized interventions to prevent recurrence. On 04/08/12 at 4:00 p.m., an incident/accident report documented, "Room 301 Chair alarm sounded. CNA called this nurse. Found resident laying on her right side. Assessed for injuries ROM x 4 good. 0 (no) raised areas noted an old looking bruise on rt arm 5 x 5 cm and rt wrist 2.2 x 1 cm. Assisted res to W/C. STPR: Encouraged resident to call for help." STPR were not appropriate for the resident who had short and long term memory loss and had been diagnosed with [REDACTED]. The form faxed to OSDH documented the resident had a (R) hip fracture as a result of the fall on 04/08/12. A significant change assessment, dated 04/26/12, documented the resident experienced short and long term memory loss, had moderately impaired cognition, was not ambulatory, required extensive assistance with dressing, eating, hygiene and bathing and was frequently incontinent of bowel and bladder. On 05/13/12 at 11:30 a.m., an incident/accident report documented, "Called to residents rm by son & daughter. Multiple ecchymotic areas noted on (R) lower leg. Lg area on (R) inner aspect blue in color. STPR: Resident may benefit from protective stockings." The medical record did not contain documentation of the protective stockings as ever being implemented to protect the lower legs. On 06/09/12 at 6:15 p.m., an incident/accident report, documented, "Chair alarm sounding in lobby carpeted area, resident found laying on her left side, has a laceration to (L) eye about 1 cm long depth 0.1 mm. ROM x4 denies pain. Area cleansed with wound cleanser steri strips applied no swelling. STPR: Have resident brush teeth and be laid down as soon as possible." The incident/accident report did not contain an investigation to the cause of the fall or have appropriate STPR. Reported to OSDH. On 06/09/12, a care plan meeting note, documented, "Resident's chair alarm sounding in the lobby area that is carpeted, resident was found on the floor laying to her left side, has a laceration by (L) eye, where it appears got cut open by her glasses, 0 swelling at this time." There were no STPR documented. On 06/10/12 at 11:30 a.m., an incident/accident report, documented, "Son to nurses station. States, 'Last night when mother fell did she knock out her tooth?' (L) lower front tooth broken. No c/o pain, discomfort or bleeding noted. STPR: (area blank)." On 07/09/12 at 7:00 a.m., an incident/accident report documented, "Hospice CNA reports bruise to res. RLE. Upon assessment I noticed a bruise purple in color 8 cm x 4 cm. No c/o pain or discomfort. Cause of bruise is unknown. STPR: Reinforced transfer safety c CNA's." There was no in-service documented to re-inforce the transfer safety with the CNA's as the above STPR documented. On 08/01/12 at 6:20 a.m., an incident/accident report documented, "Called to shower room by hospice CNA. She indicated resident had a skin tear on her leg and that it must have happened in bed. Found no evidence of that. Appears it must have been bumped on the W/C. It is U shaped and approx 2 cm and bruised. STPR: Staff should be gentle when transferring resident." There was no in-service documented to re-inforce the transfer safety with the CNA's as the above STPR documented. On 08/17/12 at 1:00 a.m., an incident/accident report, documented, "When CNA was making incontinent care rounds @ 0100...notify of bruise to resident's (L) wrist, reddish in color, measuring 4.5 cm 0 pain to area. Will continue to monitor. STPR: Staff should be gentle when handling resident." There was no in-service documented to re-inforce the transfer safety with the CNA's as the above STPR documented. The October 2012, physician's orders [REDACTED]. On 10/26/12, a quarterly assessment documented the resident had inadequate short term memory, adequate long term memory, had moderately impaired cognition, was not ambulatory, required extensive assistance with dressing, eating, hygiene and bathing and was always incontinent of bowel and frequently incontinent of bladder. The care plan, dated 10/29/12, documented, "Falls: Resident is at risk for falls... Approach: Encourage use of call light. Assist c transfers, ambulation, bed mobility, alarm on W/C &/or bed." On 11/06/12 at 10:00 a.m., the resident was observed sitting in a W/C in the main lobby. A chair alarm was observed on the back of the resident's W/C. On 11/09/12 at 3:15 p.m., the DON was interviewed related to the resident's repeated falls/transfers and the bruising/skin tears which had occurred. She was asked for information regarding the approaches to be utilized, documented on the incident/accident reports. She was also asked for any documented in-services given to the CNA's on how to transfer and handle fragile residents. The incident/accident reports, the resident's medical records and in-services were reviewed with the DON. She then said she did not have documentation of any in-services and there was no documentation the interventions had ever been put into place such as the protective sleeves and the protective stockings. 2. Resident #14 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 03/11/12, an admission assessment documented the resident had inadequate short and long term memory, severely impaired cognition, was totally dependent on staff for bed mobility, transferring between surfaces, ADL's, was not ambulatory and was always incontinent of bowel and bladder. On 03/12/12, the CAA analysis report documented, "(Name deleted resident #14) is at risk for falls related to a history of falls and having some balance difficulties with sitting balance and is using either a Geri Chair or a reclining wheelchair in a reclining position for safety..." On 03/27/12 at 6:30 a.m., an incident/accident report documented, "Was called to room by CNA to show me a bruise that was red in color with size 8 cm x 5.5 cm and it had a skin tear in the middle of the bruise that was 3 cm x .5 cm unsure how bruise occurred...Lt. arm above elbow. STPR: Residents skin is fragile, maybe arm protectors." Arm protectors were never initiated. The monthly nurses' progress note dated 03/01/12 thru 03/31/12, documented, "...full body lift & geri chair..." On 04/13/12 at 9:50 p.m., an incident/accident report documented, "Resident found on his knees @ bedside c head lying on bed-Alert, assisted back to bed-bruising noted to both knees. STPR: Poss consider bed alarm." The bed alarm had not been initiated at that time. The monthly nurses' progress note, dated 04/01/12 thru 04/30/12, documented, "...full body lift & geri chair..." On 05/05/12 at 11:45 p.m., an incident/accident report documented, "CNA came to say that resident on floor mat by bedside. Resident sleeping laying left side, resident's head by TV stand 0 apparent injury neuro check initiated ROM good x 4, bed in lowest position mat on floor, call light within reach. STPR: Bed alarm to warn staff if getting out of bed - Removed TV stand from head of bed and put to the foot of bed." Second time bed alarm had been documented as a STPR and never initiated. On 05/05/12, a skin monitoring sheet documented, "The arms have some bruising on both arms has no skin tears." On 05/15/12 at 4:00 p.m., an incident/accident report documented, "Called to room by CNA- resident lying on his (L) side on bedside mat- alert, no apparent injuries assisted back on bed c 3 person assist. STPR: Try when placing in bed to center him more in bed so he's not close to side of bed." STPR were not appropriate. The monthly May 2012, nurses' progress note, documented, "...dependent upon staff for assistance with all ADL's uses full body lift for transfers, with assist x 2 people; Geri chair used for mobility..." On 06/09/12 at 7:00 a.m., an incident/accident report documented, "CNA reported that resident rolled out of his bed. Bed was low position CNA had just finished dressing res was picking up the floor mat to put down beside bed. Res rolled fell on his back hit his head on the floor. Assessed for injuries ROM x 4 good. Noted some redness and swelling 4 x 2 cm on the back of his head. Denies feeling pain at this time. Assist c lift to bed, alert, confused, neuro checks initiated. STPR: needs a concave mattress and bolsters." STPR of a concave mattress and bolsters were never initiated. Reported incident to OSDH. On 06/11/12, the care plan documented: "Falls...Approach: Encourage to use call light. Assist with transfers, ambulation, bed mobility. Call light in reach...Remind to utilize assistive devices if needed.." On 06/21/12 at 10:00 a.m., an incident/accident report documented, "Hospice CNA's discovered bruising to (L) side of chest. Bruising purple in color 4 cm x 1.5 cm. CNA states resident leans to (L) side in sit-to-stand lift during transfers. No s/s of pain noted at this time. STPR: Resident to be full body lift." The hazard was never identified such as the lift being utilized wrong or the wrong lift being used. The April 2012, nurse's progress note documented the CNA's were to use a full body lift to transfer the resident. On 06/27/12 at 10:00 a.m., an incident/accident report documented, "Noticed that resident has a bruise starting from (L) axillary area down the left side of trunk. Axillary area is green and yellow in color and side of trunk is dark purple. Unknown origin. STPR: reinforce proper lift/transfer techniques." The monthly May 2012, nurses' progress note, documented, "...uses full body lift..." The June 2012, ADL flowsheet documented, "Transfer: 2 person sit-to-stand, Total Body..." On 07/10/12 at 5:30 a.m., an incident/accident report documented, "CNA making round @ 0530 notify me of S/T to resident's arm. Resident assessed, S/T 3 cm noted to (R) F/A...STPR: Staff should be gentle when assisting resident." Arm protectors were never implemented as recommended on March 27, 2012. On 07/12/12 at 2:10 p.m., an incident/accident report documented, "After transferring resident to bed, aide noticed ST (R) wrist origin unknown. Edges approximated approx 6 cm in length in a 1/2 circle shape. STPR: Reminded/reviewed c aide to watch where ext are while transferring patient." Arm protectors were never implemented as recommended on March 27, 2012. On 07/25/12 at 2:45 p.m., an incident/accident report documented, "Aides provided care and when turning resident they noticed ST present (L) elbow area ST (L) elbow 3 1/2 cm approximated edges. STPR: Educated staff on the importance of placement of extremities during care to prevent ST." Arm protectors were never implemented as recommended on March 27, 2012. On 09/05/12, a 'Summary of Course of Treatment in Care Center', documented, "...required extensive to total assist c his ADL functions Rt Hx of chronic OA c limited ROM (L) shoulder...health status remained stable until around 03/01/12. He began to have a slow progressive decline and passed away peacefully c family @ his bedside on 09/05/12..." On 10/23/12, the discharge summary documented, "...required extensive to total assist with his ADL functions related to history of chronic osteoarthritis, with limited ROM left shoulder. Cause of death: Vascular dementia." On 11/09/12 at 9:30 a.m., the DON was interviewed. The DON was asked if arm protectors had been placed on the resident after the first skin tear on 03/27/12. The DON reviewed the records and reported they had not been implemented. The DON was asked if the bed alarm had been initiated after the fall on 4/13/12. She stated, "I don't know when it was implemented. I'll have to check." The DON returned at 3:00 p.m., and reported the bed alarm had not been implemented after the fall. The DON was asked if the concave mattress or bolsters had been implemented after the first of four times the resident had rolled out of the bed. The DON reviewed the records and reported the concave mattress nor the bolsters had ever been implemented, as steps to prevent recurrences of falls out of the bed. The DON was asked how the resident was to be transferred prior to the incident on 06/21/12, in which there was bruising to (L) side of chest. The bruising was purple in color 4 cm x 1.5 cm. The DON responded he should have been transferred using a full body lift with the Hoyer lift. The DON was then asked if she had investigated the cause of the bruising. The DON stated, "All the documentation I have is there (referring to the paperwork laying on the desk). I didn't document a full investigation." The DON was asked how the skin tears had happened on 07/25/12. She was asked if the protective sleeves had been implemented as documented on the STPR on the 03/27/12, incident report. She reported she did not know. She stated, "The LPN completed the form." The DON then stated, "I need to in-service my staff on steps to prevent recurrence." 3. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/16/12, assessed the resident as requiring extensive assistance of one staff member for transfers. On 11/08/12 at 7:10 p.m., the resident was observed being transferred by CNA #1 and LPN #2. Both staff members each placed an arm underneath the resident's arms in the axillae area. They then lifted the resident out of the W/C by pulling up on her arms. The resident did not bear weight. A gait belt was observed but was not used during the transfer. On 11/09/12 at 10:00 a.m., the DON was interviewed regarding the transfer. The DON reported the staff should be using a gait belt to transfer the resident. She further reported all staff members have been given gait belts. 4. Resident #19 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 08/20/12, a significant change assessment, documented the resident had inadequate short and long term memory, was severely cognitively impaired, was totally dependent on staff for bed mobility, transferring between surfaces, ADLs, bathing, eating and was not ambulatory. On 08/22/12, the care plan documented, "Expected Decline. Resident is expected to decline and requires Hospice care due to a terminal condition..." The October and November 2012, ADL sheets documented the resident was totally dependent on staff for transfers between surfaces. On 11/09/12 at 10:35 a.m., CNA #3 was observed to provide incontinent care for the resident. After the CNA had completed the care, the CNA reported she had to go get help to transfer the resident into a G/C, because he was a two person transfer. The CNA left the room and returned with CNA #4. The CNA's were observed to transfer the resident from his low bed into a Broda chair. The staff members each placed an arm underneath the resident's arms in the axillae area and then lifted the resident, placing pressure underneath the resident's arms. The resident's legs were observed bent at the knees and his feet did not touch the floor. The resident did not bear weight on his LE's. Neither of the CNA's were observed to have gait belts at the time of the observation. On 11/13/12 at 2:30 p.m., the DON was interviewed regarding the observation of the resident being transferred from the bed to the chair by picking him up underneath his arms. She reported the CNA's had gait belts to use.