Based on observation, record review, and interview , the facility failed to ensure a resident had the right to be free from involuntary seclusion for one (#33) of one sampled resident reviewed for involuntary seclusion. The administrator identified 66 residents in the facility. Findings: A polity titled Abuse, Neglect, Exploitation, dated 10/01/17, documented the facility staff would not use involuntary seclusion. Resident #33 had diagnoses which included congestive heart failure. The resident resided in a room with their spouse. A progress note, dated 10/24/24 at 7:07 a.m., documented the resident was sent to a local hospital. A progress note, dated 10/28/24 at 5:23 p.m., documented the resident returned from the hospital, inquired about their spouse, and was told the spouse was aware of the resident's return to the facility. A progress note, dated 10/29/24 at 7:05 p.m., documented the resident remained on quarantine protocol per readmission. On 10/30/24 at 9:02 a.m. Resident #33 was observed in a room alone. On 10/31/24 at 09:36 a.m., the administrator stated all new residents and all residents returning from the hospital were placed in a five day isolation period. On 11/01/24 at 11:04 a.m., Resident #33 stated on return from the hospital they were not returned to their regular room, but were put into a different room by themselves for five days. They stated they did not understand why they were put into this room. They stated they were told by staff they would be there for five days and then they could return to their old room with their spouse. Resident #33 stated they would rather have been put back in the room with their spouse. They stated it made them sad not to be in the same room with them. They stated they were much happier to be back in the same room with their spouse. On 11/01/24 at 11:16 a.m., LPN#1 stated quarantined residents were isolated in a room for five days. They stated the residents were not allowed to leave their room. They stated the residents ate in their room and therapy came to their room if needed. LPN#1 stated after five days the residents were removed from quarantine and allowed to move about the facility with the other residents. On 11/01/24 at 11:23 a.m., the DON stated quarantined residents could have visitors, but the visitors had to stay in the residents room. They stated they could not take the resident outside of their room. On 11/01/24 at 12:21 p.m., Physician #1 stated unless there was evidence of symptoms or actual illness, isolation or quarantine of residents was not necessary. On 11/01/24 at 2:55 p.m., the administrator stated they were not basing their quarantine policy on any standard of care. They stated it was their facility policy. They stated they did not know if they had a physician order for the quarantine. The administrator stated it was not involuntary seclusion because the residents were aware of their quarantine policy. The administrator was unable to provide documentation of resident consent for the quarantine/ isolation.

Based on record review and interview, the facility failed to ensure that residents receiving antipsychotic medications were monitored for side effects for one (#2) of three residents reviewed for unnecessary medications. The administrator reported the census was 61. Findings: Resdident #2 had diagnoses which included visual hallucinations and unspecified psychosis. A physician order, dated 01/26/24, documented the resident was to receive risperidone (an antipsychotic) 1 mg by mouth twice a day. A review of Resident #2's medical records did not document the resident was being monitored for side effects of antipsychotic medications. On 02/08/24 at 10:55a.m., the DON reported they did not have documentation of side effect monitoring for Resident #2.

Based on observation, record review and interview, the facility failed to ensure the call light was in reach for one (#1) of three residents reviewed for accommodation of needs. The administrator reported the census was 61. Findings: Resident #1 had diagnoses which included chronic kidney disease and edema. A significant change assessment, dated 10/30/23, documented Resident #1 cognitively intact for daily decision making and dependent on staff assistance for transfers. A care plan intervention, dated 04/07/23, documented Strive to keep call light in reach and answer promptly when activated. On 02/05/24 at 10:13 a.m., Resident #1 was observed sitting in a Geri chair in their room, the call light was not in reach. The resident stated staff usually did not leave the call light in reach. On 02/07/24 at 9:05 a.m., the resident was observed in bed, the call light was not in reach. On 02/07/24 at 10:20 a.m., the resident was observed in bed, the call light was not in reach. On 02/07/24 at 1:00 p.m., Resident #1 was observed in bed, the call light was not in reach. On 02/08/24 at 9:00 a.m., Resident #1 was observed in bed, the call light was not in reach. On 02/08/24 at 9:45 a.m., CNA #1 stated the residents call light should always be in reach. On 02/08/24 at 10:00 a.m., LPN #3 stated call lights should be in reach.

Based on record review and interview, the facility failed to document a resident's code status correctly for one (#38) of 14 sampled residents. The Resident Census and Conditions of Residents form documented 63 residents resided in the facility. Findings: Res #38 was admitted to the facility with diagnoses of dementia, HTN, major depressive disorder, and chronic kidney disease stage IV. On 09/28/23 at 9:35 a.m., a review of the resident's clinical record documented the resident's code status as Do Not Resuscitate (DNR). No documented DNR was located in the resident's EHR or paper chart. The resident had an Advanced Directive for Healthcare which documented the resident did not want life extended by life-sustaining treatment, including artificially administered nutrition and hydration. On 09/28/23 at 9:45 a.m., the DON was asked to look at the resident's code status. She reported it stated the resident's status was DNR. The DON was made aware of the only documentation located in the resident's EHR and paper chart was an Advanced Directive for Healthcare. The DON was asked if the code status for the resident was accurate. She reported No, she should be a full code.

Based on record review and interview, the facility failed to provide a SNF ABN to two (#14 and #169) of three sampled residents whose beneficiary notices were reviewed. The MDS Coordinator identified six residents who were discharged from skilled services with Medicare benefit days remaining. Findings: 1. Res #14 was admitted to skilled services on 04/17/23 and discharged from skilled services on 06/08/23 and remained in the facility. A SNF Beneficiary Protection Notification Review documented an ABN was not provided to the resident. 2. Res #169 was admitted to skilled services on 05/22/23 and discharged from skilled services on 07/06/23 and remained in the facility. A SNF Beneficiary Protection Notification Review documented an ABN was not provided to the resident. On 09/27/23 at 2:25 p.m., the MDS coordinator reported Res #12, 14 and #169 were not provided with an ABN because they were not sure when an ABN should be given to a skilled resident.

Based on observation, record review, and interview, the facility failed to: a. attempt appropriate alternatives prior to installing bed or side rails; b. perform an entrapment risk assessment; c. review the risks and benefits with the resident and/or their representative; d. obtain an informed consent; and e. develop a care plan for side rail use for one (#20) of three residents reviewed for accident hazards. The DON identified 13 residents whose beds were equipped with a bed rail of any type. Findings: A Use of Bedrails policy, revised 11/01/22, read in parts, .If side rails are used in this facility, there must first be an interdisciplinary assessment of the resident, consultation with the attending physician and input from the resident and/or legal representative .Consent shall be obtained from the resident's legal representative prior to the use of bed rails .After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised and needs half rail for re-positioning and transfer, and no other reasonable alternatives can be identified .Before using side rails for any reason, the staff shall take measures to reduce related risks and resident and their representative will be advised of risks of falls and entrapment .Side rails shall not be used as protective restraints at any time in this facility . Res #20 was admitted with diagnoses which included lobar pneumonia, pain, and vascular dementia. An admission assessment, dated 09/04/23, documented the resident was moderately cognitively impaired and required extensive two-person assistance with bed mobility and transfer. A care plan, dated 09/18/23, documented the resident was at risk for skin breakdown, bruising, and other skin injuries related to increased dependence on staff for assistance with mobility and transfers. The care plan documented an intervention of the staff to assist with turning and repositioning to promote comfort and circulation. There was no documentation of side rail use in the care plan. There was no documentation of an entrapment risk assessment, alternatives prior to the use of side rails, physician consultation, or resident and/or representative informed consent for side rails found in the clinical record. On 09/26/23 at 7:51 a.m., the resident was observed lying supine in bed with half side rails in the up position on both sides of the head of bed. An attempted interview with the resident was unsuccessful due to the resident's cognition. On 09/27/23 at 8:56 a.m., LPN #1 was asked to provide documentation of an entrapment risk assessment and informed consent of side rail use with explanation of alternatives for the resident. LPN #1 stated the requested documentation should be documented in the electronic health record. On 09/27/23 at 9:57 a.m., the resident was observed lying supine in bed with half side rails in the up position on both sides of the head of bed. An attempted interview with the resident was unsuccessful due to the resident's cognition. On 09/27/23 at 1:49 p.m., the DON stated no entrapment risk assessment for the use of side rails, documentation of alternatives, or informed consent of the use of side rails for the resident had been completed. The DON stated the care plan had not been updated to reflect side rail use. They stated the facility's bed rail policy had not been followed.

Based on record review and interview, the facility failed to complete annual skills competencies for two (CNA #1 and #2) of two CNA's whose employee files were reviewed for skills competencies. There were eight CNA's documented on the staff roster who had been employed over a one year. Findings: CNA #1 was hired on 01/22/21. There was no annual skills competency in CNA #1's employee file. CNA #2 was hired on 03/26/22. There was no annual skills competency in CNA #2's employee file. On 09/27/23 at 9:45 a.m., LPN #1 reported there were no annual skills competencies for CNA #1 and #2. LPN #1 reported they had let annual skills competencies fall by the wayside and needed to start doing competencies again.

Based on record review and interview, the facility failed to implement a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. The Resident Census and Conditions of Residents documented 63 residents resided in the facility. Findings: The CMS memo 17-30, revised date 06/09/17, documented CMS expects long-term care facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility water systems. On 09/25/23 at 1:00 p.m., the administrator was asked to provide documentation of water management policies and procedures. No documentation of water management policies and procedures were provided. On 09/27/23 at 2:00 p.m., the DON stated the facility had no policy or procedure in place for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. The DON stated having not been aware of the requirement.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#20) of three residents reviewed for accident hazards. The DON identified 13 residents whose beds were equipped with a bed rail of any type. Findings: Res #20's admission assessment, dated 09/04/23, documented the resident was moderately cognitively impaired and required extensive two-person assistance with bed mobility and transfer. On 09/26/23 at 7:51 a.m., the resident was observed lying supine in bed with half side rails in the up position on both sides of the head of bed. An attempted interview with the resident was unsuccessful due to the resident's cognition. On 09/27/23 at 8:56 a.m., LPN #1 was asked to provide documentation of regular bed rail inspections for the resident. On 09/27/23 at 9:57 a.m., the resident was observed lying supine in bed with half side rails in the up position on both sides of the head of bed. An attempted interview with the resident was unsuccessful due to the resident's cognition. On 09/27/23 at 1:55 p.m., the DON stated the facility had not completed regular bed rail inspections but should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to develop and implement the discharge planning process for one (#1) of three residents who were reviewed for discharge planning. The facility identified 15 residents who discharged in the last 60 days. Findings: Resident #1 discharged from the facility on 02/13/21 with diagnoses which included atrial fibrillation, muscle weakness, peripheral vascular disease, and chronic pain. A nurse's note, dated 02/13/21 at 12:26 p.m., documented, Resident's niece, [niece's name omitted], here to take resident home. Resident discharged with meds and belongings. This nurse educated niece on medications, dosages, and times administered. On 05/18/21 at 3:00 p.m., the clinical record for resident #1 was reviewed. There was no documentation of the resident's discharge planning. The care plan was reviewed. There was no care plan related to discharge needs and goals. On 05/18/21 at 4:00 p.m., the assistant Director of Nurses (ADON) was asked to provide any documentation related to the resident's discharge planning. The ADON returned with the resident's closed record and a sheet of paper with a section titled discharge summary. The discharge summary documented, .was admitted on [DATE] has a cell phone with her. Placed on quarantine. admitted on skilled services. Dx [diagnoses]: athersclerosis of native arteries of extremities - bilateral legs. Difficult with transfers d/t pain in legs. HOH [hard of hearing] - wears hearing aids. Able to voice all needs and to let them know of her pain. Received 1:1 visits from activity. 2-8-21 - received 2 vaccine of COVID 19. 2-9-21 - nephew called her will be d/c [discharge] her [sic]. 2-13-21 - [name omitted] called. Gave permission for [niece's name omitted] to pick her up. 2-13-21 - [Name omitted] the niece here to get all meds d/c to her & belongings . There was an additional undated document which listed the resident's medication, directions for administration, administration times, and count. The document was signed by the resident's niece. There was no nurse's signature or date present. On 05/18/21 at 4:05 p.m., the ADON was asked if the facility had discharge documentation which provided a recapitulation of the resident's stay; the development of a discharge plan with input from the resident and/or resident's representative/care providers; a final summary of the resident's status; and a reconciliation of all prior medications and discharge medications. The ADON stated she did not think there was anything like that documented. She stated she would continue to look for more documentation. 05/18/21 at 4:50 p.m., the ADON returned with discharge notes from skilled therapy. She stated she found a note where skilled therapy documented about discharge and a nurse's note which documented the nurse educated family on medication, dosages, and time of administration. The occupational therapy notes, dated 02/09/21 through 02/12/21, documented, .Communication: Care planning conference held with interdisciplinary team this PR period - functional skills ad discharge plans reviewed . The occupational therapy notes documented the discharge recommendations were for 24 hour care, durable medical equipment (e.g. shower chair, long handled sponge, shower head, and reacher), the removal of environmental barriers (e.g. throw rugs), the addition of grab bars, and a home exercise program. The physical therapy notes, dated 02/09/21 through 02/11/21, documented, Communication: Reviewed patient's plan of treatment and treatment services with interdisciplinary team members and Consultation with therapists to facilitate patient's highest level of functional independence . The physical therapy notes documented the discharge recommendations was for 24 hour care. The speech therapy notes, dated 02/11/21, documented, .Communication: Initiated patient discharge/transition planning with team . The speech therapy notes documented the discharge recommendations were for a mechanical soft diet with thin liquids. The recommendation continued for the resident to be supervised during intake and for the resident to perform an effortful swallow and alternate between liquids and solids. The speech therapy notes also recommended for the resident to increase her volume while speaking. The ADON was asked if she knew who was involved in the care plan meeting documented in the skilled therapy notes. She stated no. She was asked if the therapy recommendations were provided to the resident and/or resident representative/caregiver on discharge. She stated she did not know. She was asked if there was documentation of the care plan meeting which listed the participants. She stated there was no other documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to document a discharge summary for one (#1) of three residents whose discharge summaries were reviewed. The facility identified 15 residents who discharged in the last 60 days. Findings: Resident #1 discharged from the facility on 02/13/21 with diagnoses which included atrial fibrillation, muscle weakness, peripheral vascular disease, and chronic pain. A nurse's note, dated 02/13/21 at 12:26 p.m., documented, Resident's niece, [niece's name omitted], here to take resident home. Resident discharged with meds and belongings. This nurse educated niece on medications, dosages, and times administered. On 05/18/21 at 3:00 p.m., the clinical record for resident #1 was reviewed. On 05/18/21 at 4:00 p.m., the assistant Director of Nurses (ADON) was asked to provide any documentation related to the resident's discharge. The ADON returned with the resident's closed record and a sheet of paper with a section titled discharge summary. The discharge summary documented, .was admitted on [DATE] has a cell phone with her. Placed on quarantine. admitted on skilled services. Dx [diagnoses]: athersclerosis of native arteries of extremities - bilateral legs. Difficult with transfers d/t pain in legs. HOH [hard of hearing] - wears hearing aids. Able to voice all needs and to let them know of her pain. Received 1:1 visits from activity. 2-8-21 - received 2 vaccine of COVID 19. 2-9-21 - nephew called her will be d/c [discharge] her [sic]. 2-13-21 - [name omitted] called. Gave permission for [niece's name omitted] to pick her up. 2-13-21 - [Name omitted] the niece here to get all meds d/c to her & belongings . There was an additional undated document which listed the resident's medication, directions for administration, administration time, and count. The document was signed by the resident's niece. There was no nurse's signature or date present. On 05/18/21 at 4:05 p.m., the ADON was asked if the facility had discharge documentation which provided a recapitulation of the resident's stay; the development of a discharge plan with input from the resident and/or resident's representative/care providers; a final summary of the resident's status; and a reconciliation of all prior medications and discharge medications. The ADON stated she did not think there was anything like that documented. She stated she would continue to look for more documentation. There was no further documentation provided which contained the four components of the discharge summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to maintain confidentiality of protected health information for one (#29) of 24 residents who were reviewed for privacy. The facility census was 66 residents. Findings: An undated policy titled, Broken Arrow Nursing Home HIPAA Privacy Policy (Health Infurance Portability and Accountability Act of 1996), documented, .We .are required by applicable Federal and State laws to maintain the privacy of your medical information .All of the following are examples of Protected Health Information: demographic information .medication information that relates to you past, present, or future physical or mental health that is collected, created, or received from you, a health care provider, a health plan . Resident #29 was admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease with heart failure and an anxiety disorder. On 05/11/21 at 11:05 A.M., two documents titled, Pertinent admission Evaluation For Resident Care, were observed in a plastic file bin, which was attached to the wall beside the entry door to resident #29's room. One of the documents was labeled with resident #29's name, the other was labeled with her roommates name. The document contained the resident's name, age, room number, marital status, name of responsible party, where she admitted from, religious preference, and diagnoses, including hypertension and anxiety. The document also contained information related to activities of daily living, including ambulation, diet/eating, dressing, and bathing. It also documented behavior factors and activity preferences. On 05/11/21 at 4:00 p.m., the document was shown to the director of nurses (DON). The DON stated every resident had a document specific to them posted outside of their room so facility staff, unfamiliar with the resident, would have a way to know what level of care the resident required. The DON was asked if any of the information was considered protected health information. She stated most of it would be considered protected health information. She was asked what steps the facility used to ensure the protected health information for a resident was only accessible to those staff needing the information to care for a resident. The DON stated the information should be kept in a secure binder and in a secure setting. She stated the file bin attached to the wall beside each resident's room was not considered secure. She stated the practice started while the facility was in lockdown for COVID. The DON stated anyone could access the bin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to prevent abuse for two (#11 and #168) of four residents reviewed for abuse. The census and condition report documented 66 residents lived in the facility. Findings: 1. Resident #168 was admitted to the facility on admitted on [DATE] with diagnoses which included dementia without behaviors, depression, and anxiety. The admission assessment, dated 07/28/20, documented the resident was severely impaired for daily decision-making, had no behaviors, required supervision for transfers, and extensive assistance for dressing and bathing. The assessment documented the resident was not steady, could stabilize without help, and ambulated with a walker. Physician orders for September 2020 documented the resident received Ativan for anxiety; Lexapro, Sertaline, and Trazadone for major depression; and Restoril for sleep. A witness statement, dated 09/14/20, documented certified medication aide (CMA) #2 went outside to smoke at 12:15 a.m. The statement documented the CMA saw LPN #2 in her van yelling to someone on the phone, the LPN then quickly accelated, drove to the dumpster, and continued down the alley. The statement documented the CMA called LPN #2 and told her to come back and do her job. The statement documented the LPN said she was trying to decompress. The statement documented the LPN drove back, got out of her van with the engine running, yelled at the CMA, and went into the building as she screamed into her phone. The statement documented another staff person was trying to calm her down because the LPN was extremely loud. The statement documented the LPN went into an office and got back on her phone. A witness statement, dated 09/14/20 at 12:45 a.m., documented certified nurse aide (CNA) #3 witnessed LPN #2 being verbally abusive to resident #168 after the resident fell. The CNA stated she heard a bang and went to the resident's room and found her on the floor. The statement documented LPN #2 asked if the resident was broken or bleeding then started to leave. The statement documented the CNA told the LPN to come back. The statement documented LPN #2 flung the door open hitting the resident and the resident exclaimed in pain. The statement documented the LPN was argumentative and yelled at the resident to Get the f**k up [resident name omitted]. This is bulls**t. The statement documented the LPN ripped the resident off the floor by her arm. The statement documented the resident complained of arm and head pain. A witness statement, dated 09/14/20, documented at 1:00 a.m. CNA #5 was eating lunch and heard someone yelling on [NAME] Hall. The statement documented CNA #5 found LPN #2 holding the resident down in her chair and was yelling and cussing at her. The statement documented the LPN got up and left. The statement documented 30 minutes later she heard a bang and staff went to the resident's room. The statement documented the LPN slung the resident's walker out of the way and jerked on the resident. The resident was screaming and crying. The statement documented CNA #5 told LPN #2 to wait so she could help and together they lifted the resident. A witness statement, dated 09/14/20 at 2:00 a.m., documented CNA #6 heard LPN #2 yelling but did not know the reason. The statement documented the CNA tried to get the LPN to calm down and lower her voice. A progress note, dated 09/14/20 at 3:00 a.m., documented the resident requested help to go to the BR and staff assisted her to the bathroom. The note documented the resident's pupils were equal and reactive, her grips were strong and equal, her gait was unsteady and she was able to stabilize with assist. The note documented the resident had a yellow bruise to her left hip and had a yellow hematoma to back of her scalp. The note documented the resident denied pain and discomfort, and did not have nonverbal signs or symptoms of pain or discomfort. An incident reported, dated 09/14/20, documented the resident made an allegation of abuse. The report documented the alleged staff was sent home and terminated immediately when allegation of abuse was reported. The report documented the physician and family were notified. The report documented the allegation was faxed to the state on 09/18/20 at 2:28 p.m. An undated and untimed protective health service report documented the Broken Arrow police were notified. A progress note, dated 9/14/20 at 4:57 p.m., documented the resident was in a recliner resting, woke easily to verbal stimuli, and was able to make needs known. The note documented neurological checks were completed due to post-fall status. The note documented the nurse supervised the resident with her meal and the resident ate 100 percent with constant encouragement. The note documents the call light and fluids were within reach. A progress note, dated 09/14/20 at 10:39 p.m., documented the resident continued on fall follow up. The note documented the resident was crying and walking back and forth from her room to the end of the hallway asking where her room was. The note documented the resident required one person to assist her with walking and had abrasions to left hip, left buttocks, right knee to back of her scalp. A care plan, dated 10/28/20, documented the resident's care needs were identified and interventions were in place. On 05/13/21 at 10:55 a.m., CNA #5 was interviewed. She stated on 09/14/20 she was on her lunch break at 1:00 a.m. and heard a crash in the resident's room. She stated she found the resident on the floor and LPN #2 was aggressively pulling on the walker and the resident. The CNA stated the LPN was yelling at the resident and another CNA was telling the LPN to stop. She stated three CNAs and the LPN were in the room and the LPN was yelling and cussing at the resident. The CNA stated one staff person walked out and the LPN pushed the other staff person out of room. The CNA stated she and the LPN put the resident back in the recliner. The CNA stated the LPN left the room and CNA #5 stayed with the resident for awhile. CNA #5 stated she left the resident's room and while washing her hands she heard the resident yelling out. The CNA stated she went back to the resident's room. She stated she observed LPN #2 was in the room, had the resident's legs pushed up to her abdomen and the resident's glasses were askew. The CNA stated the resident had pressure marks on her face around her eyes from her glasses. The CNA stated she made the LPN leave the room and had one of the CNAs call LPN #1. The CNA stated she stayed with the resident until LPN #1 arrived. On 05/13/21 at 11:10 a.m., CMA #2 was interviewed. The CMA stated she had worked at the facility for years. She stated LPN #2 had outbursts which had become more frequent and was having problems in her personal life. The CMA stated LPN #2 came to work that day and appeared tired and frazzled. The CMA stated she was in the medication room when the incident occurred in the resident's room. She stated she observed the LPN outside after the incident in the resident's room. The CMA stated she went outside to smoke at 12:15 a.m. and saw the LPN was out of control and probably should not have been at work. The CMA stated LPN #1 had already been called when she observed LPN #2 outside. She stated LPN #2 was in the office when LPN #1 arrived. She stated the LPNs talked and LPN #2 was sent home. On 05/13/21 at 1:30 p.m., LPN #1 stated she had been working the evening shift and was relieved by LPN #2 for the night shift. LPN #1 stated she received a call a little after 1:00 a.m. from the facility. She stated she was told LPN #2 verbally abused a resident. The LPN stated she immediately went back to work, checked the resident, and completed an assessment. She stated she and LPN #2 counted carts and then she walked LPN #2 to the door. LPN #1 stated LPN #2 did not leave right away and she heard LPN #2 honking her car horn. LPN #1 stated she went out to talk to to LPN #2 and told her to go home. LPN #1 stated LPN #2 was quiet and then stated she argued with her husband before she came to work. She stated LPN #2 eventually left. LPN #1 stated at 5:00 a.m. LPN #7 completed a full assessment on the resident. She stated the police were called and arrived at 3:00 p.m. The LPN stated other notifications were made on day shift. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses which included a cerebral vascular accident and heart failure. The admission assessment, dated 02/19/21, documented the resident was independent for daily decision-making, did not have delirium, psychosis, or behaviors, and required extensive assistance with ADLs. The care plan, dated 03/03/21, documented the resident's care areas were identified and interventions were in place. Physician orders for March 2021 documented the resident received Norco (for pain) as needed once every 24 hours, Trazadone (an antidepressant), Lasix (a diuretic), and Gabapentin (for pain). A progress note, dated 04/15/2021 at 2:51 p.m., documented the resident reported pain in her left leg, starting above the knee and radiating below the knee. The note documented pain relief included administering acetaminophen, elevating both lower extremities, and placing a warm blanket on the left leg. The note documented the physician was notified and a doppler test was ordered to rule out a deep venous thrombosis. A progress note, dated 04/15/21 at 9:20 p.m., documented the doppler technician performed the venous and arterial doppler test and the family was notified. A progress note, dated 4/15/21 at 10:18 p.m., documented the doppler results were received, sent to the doctor, and the family was notified of the results. An incident report, dated 04/16/21, documented certified nurse aide (CNA #3) placed her hand over the resident's mouth and slapped the residents hand. The report documented the resident reported the incident to the charge nurse. The report documented the CNA was placed on suspension. A fax sheet documented the report was faxed to the state on 04/19/21 at 1:04 PM. A statement, dated 04/16/21 at 12:00 midnight, documented registered nurse (RN) #2 stated the resident was upset and stated she needed to tell the nurse something. The report documented CNA #3 placed her hand on her mouth and then slapped her right hand. A statement, dated 04/15/21 [04/16/21] at 12:30 a.m., documented CNA #2 answered the call light for the resident and the resident told her CNA #3 had put her hand over the resident's mouth so she could not call out. An undated and untimed statement by CNA #3 documented on 04/15/21 at 8 p.m., the CNA went to get the resident ready for her doppler test. The report documented she knocked on the door and the resident did not wake up. The report documented the CNA went to turn off the call light and put her hand on top of the resident's hand to let her know she was there. The statement documented the resident startled when she woke up and the CNA leaned to the resident's good ear to identify herself. The statement documented the resident slapped at the CNA with the television remote. The statement documented the CNA put her hand on the remote to keep from being hit. The statement documented the resident realized who it was and the CNA was able to tell the resident she was getting a scan. A progress note, dated 04/16/21 at 3:58 a.m., documented the resident was having increased pain in her left knee and lower left leg. A progress note, dated 04/16/21 at 4:00 a.m., documented the resident was resting in her recliner with her eyes closed and denied pain or discomfort regarding incident. A progress note, dated 04/16/21 at 8:03 a.m., documented the resident was sent to the hospital for pain in left lower extremity. A fax sheet, dated 04/19/21 at 11:48 a.m., documented the initial report was faxed to the state. An admission summary note, dated 4/20/21 at 7:05 p.m., documented the resident returned to facility via emergency services. An investigative report, dated 04/21/21 at 8:45 a.m., documented the resident was interviewed by administrative staff and the resident was able to state what happened on the evening of 04/16/21. The report documented the resident was able to re-enact what happened. The report documented the resident stated CNA #3 was being a bully, she did not want the CNA to care for her anymore, and she would be scared if the CNA was to care for her. The same report documented the resident reported the allegation of abuse to the charge nurse on 04/15/21 at midnight. The report documented on 04/16/21 at 7:45 a.m. the resident was sent to the hospital and at 8:00 a.m. the allegation of abuse was reported to LPN #3 and LPN #1. The facility timeline documented the investigation was initiated immediately. A five day incident report documented it was faxed to the state on 04/21/21 at 2:25 PM. The report documented the resident was in the hospital for a non-related medical issues. The report documented the administrative staff interviewed the resident when she returned from the hospital on [DATE]. The report documented the CNA remained on suspension and was terminated when the investigation concluded. On 05/11/21 at 11:34 a.m., the resident was observed in her room, in a recliner watching television. She was alert, clean and groomed, and was severely hard of hearing. The resident's lower legs were elevated, had a small amount of edema, small intact vascular blisters, and small reddish patches. The resident's heels did not have redness and were placed on pillow. The resident's legs did not have a wound. The resident smiled and tried to communicate but her hearing made communication difficult. Staff were attentive. A full water pitcher and a small cup of water were on the bedside table. On 05/13/2021 at 1:30 p.m., LPN #1 stated the resident was not interviewed until she came back from the hospital and her statement stayed the same. She stated the administrative staff felt they needed to stay on the side of the resident. The LPN stated the resident told the night nurse about the allegation of abuse at 7:00 a.m. She stated she did not assess resident since she was having leg pain and went to hospital at 8:00 a.m. The nurse stated on 04/21/21 the resident reported a brief was thrown at her and was told to put it on. She stated the night nurse reported the allegation to administrator at 7:45-8:00 a.m. The LPN stated she was not aware the allegation had to be reported to the state within two hours but thought the facility had 24 hours to report. On 05/13/21 at 3:54 p.m., the administrator was interviewed. The administrator stated allegations of abuse were to be immediately reported to the charge nurse. She stated the charge nurse was to immediately report the allegation to LPN #1, LPN #3/QA (quality assurance), and to the administrator. She stated the allegation involving LPN #2 was reported immediately to LPN #1. The administrator stated when an allegation of abuse was reported the staff involved would be suspended immediately, staff and witnesses would be interviewed, video would be reviewed, staff would write out their statements, the police would be called if needed, notifications would be made to families and other entities, and a report would be faxed to the state within 24 hours. A follow-up report would be completed and faxed to the state in five days. The administrator stated appropriate action would be taken and the staff involved would be counseled and educated. The administrator stated abuse prevention included education, screening, background checks, and check references.

Based on observation, interview, and record review, it was determined the facility failed to provide an environment free from physical restraints for one (#44) of one sampled residents reviewed for restraints. The facility census and condition report identified 34 cognitively impaired residents who lived in the facility. Findings: Resident #44 was admitted to the facility with diagnoses which included Reyes' syndrome, major depressive disorder, pseudobulbar affect, and had a feeding tube. An annual assessment, dated 06/21/20, documented the resident was severely impaired for daily decision-making, did not exhibit behaviors, required extensive to total assistance of one person for transfers, did not ambulate, had impairment for range of motion on upper and lower extremities, required total assistance with a wheelchair for mobility, and was incontinent of bowel and bladder. A care plan, dated 04/13/21, documented the resident was at risk for falls. The care plan documented the resident had diminished cognition, was impulsive, and had poor safety awareness. The care plan documented interventions to prevent falls included assisting the resident up to her wheelchair in the mornings and after tube feedings, checking on the resident every two hours for needs, and anticipating the resident's needs. The care plan documented staff were to monitor the resident for nonverbal communication. On 05/11/21 at 10:25 a.m., the resident's door to the hall was closed. The resident's room was decorated like a play room with foam mats covering most of the floor. The resident was observed sitting on a floor mattress. No staff was present in the room. Childproof door knob covers were in place on all door knobs. On 05/11/21 at 11:22 a.m., the resident's door was closed. The resident was observed across mat from her previous location. The television was turned to an animated movie. She made eye contact when addressed and yelled out. No staff was present in the room. A child proof door knob cover remained on the inside door knob of the door exiting to the hallway. On 05/11/21 at 12:06 p.m., the door to the room was closed. The resident was observed on the floor mat. No staff was present in the room. A childproof door knob cover was on the interior knob of the exit door to the hallway. On 5/11/21 at 2:33 p.m., the door to the room was closed. No staff was present in the room. The resident was on the floor mat and looked when addressed. A childproof door knob cover remained in place. On 05/11/21 at 3:14 p.m., a family member was interviewed and stated the resident was being kept in her room with the door closed since the resident did not receive a Covid-19 vaccination. On 05/12/21 at 10:04 a.m., the door to the room was closed. No staff was present in the room. The resident was lying on the floor mat. The childproof door knob cover remained in place. On 05/12/21 at 11:00 a.m., certified medication aide (CMA) #1 was observed sitting on the floor mat and cradling in her arms and partially supporting the resident with her left leg. The CMA was administering a tube feeding to the resident while talking and singing to the her. The resident's face was lit with emotion. She appeared smiling and laughing. She maintained eye contact with the CMA and appeared engaged in their interaction. The resident provided one word answers to questions the CMA asked and made vocal sounds, as though to sing along with the CMA. The resident called the CMA by her first name. The exit door to her room was closed to the hallway after the CMA left the room. The childproof door knob cover remained in place. On 5/12/21 at 11:15 a.m., CMA #1 was asked why the resident's hallway door was kept closed. She stated the door was closed all the times because the resident would scoot down the hallway on her knees, calling out and looking for CMA #1. The CMA stated the resident was checked on every two hours at least and her tube feeding was administered five times a day. The CMA stated she did all the resident's care through the weekdays. She stated she was the one who woke, fed, changed, and dressed the resident in the morning; she provided her care through the day; and fed, changed, and dressed her in pajamas before tucking her into bed at night. On 05/17/21 at 11:50 a.m., activity assistant (AA) #1 was asked if the door to her room was always closed. She stated the door was usually closed. On 05/17/21 at 4:10 p.m., the resident was observed in her room. No staff was present. The door was closed and the childproof door knob cover remained in place. On 05/17/21 at 1:58 p.m., the director of nursing (DON) was asked why the resident's door was closed all the time. The DON stated she saw the resident outside once and was told she could not be out of her room since she was not vaccinated. She was asked why the childproof doorknob covers were on the exit door. The DON stated the covers were placed to prevent the resident from opening the door. On 05/17/21 at 4:31 p.m., CNA #1, was asked why childproof door covers were on the door. She stated it was to keep the resident from coming out of the room. The CNA stated her door was also kept shut to keep the resident from disturbing other residents when she yelled. The CNA was asked if it was a safety issue with the door closed. She stated yes. The CNA stated the resident was checked every two hours or when the resident called out. On 05/18/21 at 11:46 a.m., LPN #4 was asked how residents who have confusion were managed for safety. She stated the door would be left open for supervision. The LPN was asked if a resident was in a closed room and the door could not be opened by the resident, would checking on them every two hours be sufficient for safety concerns. The nurse stated no. On 05/18/21 at 3:00 p.m., LPN #5 was asked if resident #44 could turn a door knob. She stated yes. The nurse was asked if she thought the resident had the knowledge to know she could leave the room if the door was open. The LPN stated absolutely. She was asked why the childproof doorknob covers were in place. She stated it prevented the resident from leaving her room and wandering. She was asked how often was the door was left shut. The LPN stated often. On 05/18/21 at 3:18 p.m., LPN #6 was asked why the door was closed to the resident's room. She stated to combat noise, and keep the resident from leaving the room since she had become more mobile in the past year. She was asked if the resident could open a door by herself and she stated yes. She was asked if the resident could open it with the childproof doorknob cover on it. The nurse stated no. She was asked if it would be a safety issue with the door being closed and the resident unable to open it herself. She stated yes. On 05/18/21 at 4:56 p.m., the administrator was asked if the resident could open the door if she wanted and she stated yes. The administrator stated when the childproof door knob cover was first placed on the doorknob she thought it was a restraint. On 05/19/21 at 8:45 a.m., the administrator stated she called life safety and was informed the facility could not have objects on the door preventing the resident from exiting the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to implement their abuse policy for two (#11 and #168) for four residents reviewed for abuse. The facility failed to: a) Prevent abuse for residents #168 and #11. b) Protect the resident from continued abuse for resident #168. c) To notify the administrator on call immediately regarding an incident of abuse for resident #168. d) Report an allegation of abuse to the state agency within two hours for resident #168 and #11. e) Screen complete background checks and reference checks for new employees. f) Provide abuse training to new employees hired. The census and conditions report documented 66 residents lived in the facility. Findings: 1. Resident #168 was admitted to the facility on [DATE] with diagnoses which included dementia without behaviors, major depression, and anxiety. The admission assessment, dated 07/28/20, documented the resident was severely impaired for daily decision-making, had no behaviors, required supervision for transfers, and extensive assistance for dressing and bathing. A witness statement, dated 09/14/20 at 12:45 a.m., documented certified nurse aide (CNA) #3 witnessed licensed practical nurse (LPN) #2 verbally abusing resident #168 after the resident fell. The CNA stated she heard a bang and went to the resident's room and found the resident on the floor. The statement documented LPN #2 asked if the resident was broken or bleeding and then started to leave. The statement documented the CNA told the LPN to come back. The statement documented LPN #2 flung the door open, hitting the resident, and the resident exclaimed in pain. The statement documented the LPN was argumentative and yelled at the resident to Get the f**k up [resident name omitted]. This is bulls**t. The statement documented the LPN ripped the resident off the floor by her arm. The statement documented the resident complained of arm and head pain. A witness statement, dated 09/14/20, documented at 1:00 a.m. CNA #5 was eating lunch and heard someone yelling on [NAME] Hall. The statement documented CNA #5 observed LPN #2 holding the resident down in her chair and was yelling and cussing at her. The statement documented the LPN got up and left. The statement documented 30 minutes later she heard a bang and staff went to the resident's room. The statement documented the LPN slung the resident's walker out of the way, jerked the resident, and the resident was screamed and cried. The statement documented CNA #5 told LPN #2 to wait so she could help and together they lifted the resident. An incident reported, dated 09/14/20, documented the resident made an allegation of abuse. The report documented the alleged staff was sent home and terminated immediately when the allegation of abuse was reported. The report documented the physician and family were notified. The report documented it was faxed to the state on 09/18/20 at 2:28 p.m. On 05/13/21 10:55 a.m., CNA #5 was interviewed. She stated on 09/14/21 she was on her lunch break at 1:00 a.m. and heard a crash resident #168's room. She stated she found the resident on the floor and LPN #2 was aggressively pulling on the walker and the resident. The CNA stated the LPN was yelling at the resident. She stated another CNA was telling the LPN to stop. She stated three CNAs and the LPN were in the room and the LPN was yelling and cussing at the resident. The CNA stated one staff person walked out and the LPN pushed the other staff person out of room. The CNA stated she and the LPN put the resident back in the recliner. The CNA stated the LPN left the room and she stayed with the resident for awhile. The CNA stated she left the resident's room and while washing her hands she heard the resident yelling out. The CNA stated she went back to the resident's room. She stated LPN #2 was in the room, had the resident's legs pushed up to her abdomen and the resident's glasses were askew. The CNA stated the resident had pressure marks on her face around her eyes from her glasses. The CNA stated she made the LPN leave the room and had one of the CNAs call the administrator on call which was LPN #1. The CNA stated she stayed with resident until LPN #1 arrived. On 05/13/21 at 11:10 a.m., CMA #2 was interviewed. The CMA stated she had worked at the facility for years. She stated LPN #2 had outbursts which had become more frequent and was having problems in her personal life. The CMA stated LPN #2 came to work that day and appeared tired and frazzled. On 05/13/21 at 1:30 p.m., licensed practical nurse (LPN) #1 stated when LPN #2 came to work she was quiet and stated she had had an argument with her husband. LPN #1 stated she came back to the facility, relieved LPN #2, and completed a full assessment on the resident. LPN #1 stated the resident did not have any new bruising. She stated the police were called and arrived on day shift at 3:00 p.m. The LPN stated other notifications made on day shift. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses which included a cerebral vascular accident and heart failure. The admission assessment, dated 02/19/21, documented the resident was independent for daily decision-making, did not have delirium, psychosis, or behaviors, and required extensive assistance with ADLs. The care plan, dated 03/03/21, documented the resident's care areas were identified and interventions were in place. An incident report, dated 04/16/21, documented certified nurse aide (CNA #3) placed her hand over the resident's mouth and slapped the resident's hand. The report documented the resident reported the incident to the charge nurse. The report documented the CNA was placed on suspension. A fax sheet documented the report was faxed to the state on 04/19/21 at 1:04 p.m. A statement, dated 04/16/21 at 12:00 midnight, documented registered nurse (RN) #2 stated the resident was upset and stated she needed to tell the nurse something. The report documented CNA #3 placed her hand on her mouth and then slapped her right hand. An investigative report, dated 04/21/21 at 8:45 a.m., documented on 04/16/21 at 8:00 a.m. the allegation of abuse was reported to LPN #3 and LPN #1. On 05/11/21 at 11:34 a.m., the resident was observed in her room, in a recliner watching television. She was alert, clean and groomed, and was severely hard of hearing. The resident's lower legs were elevated, had a small amount of edema, small intact vascular blisters, and small reddish patches. The resident's heels did not have redness and were placed on pillow. The resident's legs did not have a wound. The resident smiled and tried to communicate but her hearing made communication difficult. Staff were attentive. A full water pitcher and a small cup of water were on the bedside table. 3. The employee files for seven new employees were reviewed. The files did not document the background checks were not completed as required for CNA #9, for one new dietary employee, and maintenance employee. On 05/13/21 at 2:04 p.m., LPN #3 stated the background checks were not completed when the employees were hired and the reference checks were not completed. 4. The employee files for certified nurse aide (CNA) #8, CNA #9, CNA #3 were reviewed. the files did not document abuse training had been completed for the CNAs. On 05/13/21 at 2:04 p.m., LPN #3 stated she was not able to complete all the items for the employee file. The nurse stated it was not complete because they had not finished the employees' orientations. On 05/13/21 at 3:54 PM, the administrator was interviewed. The administrator stated allegations of abuse were to be immediately reported to charge nurse. The charge nurse was to immediately report the allegation to LPN #1, LPN #3/QA (quality assurance), and to the administrator. She stated the allegation involving LPN #2 was reported immediately to LPN #1. The administrator stated when an allegation of abuse was reported the staff involved would be suspended immediately and a report would be faxed to the state within 24 hours. and A follow-up report would be completed and faxed to the state in 5 days. The administrator stated abuse prevention included education, screening, background checks, and check references.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to report allegations of abuse to the administrator and the state agency with in two hours for two (#168 and #11) of four residents reviewed for abuse. The census and conditions report documented 66 residents lived in the facility. Findings: 1. Resident #168 was admitted to the facility on admitted on [DATE] with diagnoses which included dementia without behaviors. The admission assessment, dated 07/28/20, documented the resident was severely impaired for daily decision-making, had no behaviors, required supervision for transfers and extensive assistance for dressing and bathing. The assessment documented the resident was not steady, could stabilize without help, and ambulated with a walker. A witness statement, dated 09/14/20 at 12:45 a.m., documented certified nurse aide (CNA) #3 witnessed LPN #2 being verbally abusive to resident #168 after the resident fell. The CNA stated she heard a bang and went to the resident's room and found her on the floor. The statement documented LPN #2 asked if the resident was broken or bleeding then started to leave. The statement documented the CNA told the LPN to come back. The statement documented LPN #2 flung the door open hitting the resident and the resident exclaimed in pain. The statement documented the LPN was argumentative and yelled at the resident to Get the f**k up [NAME]. This is bulls**t. The statement documented the LPN ripped the resident off the floor by her arm. The statement documented the resident complained of arm and head pain due to the fall. A witness statement, dated 09/14/20, documented at 1:00 a.m. CNA #5 was eating lunch and heard someone yelling on west hall. The statement documented CNA #5 found LPN #2 holding the resident down in her chair and was yelling and cussing at her. The statement documented the LPN got up and left. The statement documented 30 minutes later she heard a bang and staff went to the resident's room. The statement documented the LPN slung the walker out of the way, jerked the resident, and the resident was screaming and crying. The statement documented CNA #5 told LPN #2 to wait so she could help and together they lifted the resident. An incident reported, dated 09/14/20, documented the resident made an allegation of abuse. The report documented the alleged staff was sent home and terminated immediately when allegation of abuse was reported. The report documented the physician and family were notified. The report documented it was faxed to the state on 09/18/20 at 2:28 p.m. On 05/13/21 at 10:55 a.m., CNA #5 was interviewed. She stated on 09/14/21 she was on her lunch break at 1:00 a.m. and heard a crash in the resident's room. She stated she found the resident on the floor and LPN #2 was aggressively pulling on the walker and the resident. The CNA stated the LPN was yelling at the resident and another CNA was telling the LPN to stop. She stated three CNAs and the LPN were in the room and the LPN was yelling and cussing at the resident. The CNA stated one staff person walked out and the LPN pushed the other staff person out of room. The CNA stated she and the LPN put the resident back in the recliner. The CNA stated the LPN left the room and she stayed with the resident for awhile. The CNA stated she left the resident's room and while washing her hands she heard the resident yelling out. The CNA stated she went back to the resident's room. She stated LPN #2 was in the room, had the resident's legs pushed up to her abdomen and the resident's glasses were askew. The CNA stated the resident had marks on her face around her eyes from glasses. The CNA stated she made the LPN leave the room and had one of the CNAs call LPN #1. The CNA stated she stayed with resident until LPN #1 arrived. On 05/13/21 at 1:30 p.m., LPN #1 stated she had been working the evening shift and was relieved by LPN #2 for the night shift. LPN #1 stated she received a call a little after 1:00 a.m. from the facility. She stated she was told LPN #2 was being verbally abusive to a resident. The LPN stated she immediately went back to work, checked the resident, completed an assessment. LPN #1 stated the resident slept all night. She stated she and LPN #2 counted carts and then she walked LPN #2 to the door. LPN #1 stated LPN #2 did not leave right away and she heard LPN #2 honking her car horn. LPN #1 stated she went out to talk to to LPN #2 and told her to go home. She stated LPN #2 eventually left. LPN #1 stated LPN #2 was quiet and stated she had had an argument with her husband before she came to work. LPN #1 stated at 5:00 a.m. LPN #7 completed a full assessment on the resident and did not have any new bruising. She stated the police were called and arrived at 3:00 p.m. The LPN stated other notifications made on day shift. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses which included a cerebral vascular accident and heart failure. The admission assessment, dated 02/19/21, documented the resident was independent for daily decision-making, did not have delirium, psychosis, or behaviors, and required extensive assistance with ADLs. The care plan, dated 03/03/21, documented the resident's care areas were identified and interventions were in place. An incident report, dated 04/16/21, documented certified nurse aide (CNA #3) placed her hand over the resident's mouth and slapped the residents hand. The report documented the resident reported the incident to the charge nurse. The report documented the CNA was placed on suspension. A fax sheet documented the report was faxed to the state on 04/19/21 at 1:04 PM. A statement, dated 04/16/21 at 12:00 midnight, documented registered nurse (RN) #2 stated the resident was upset and stated she needed to tell the nurse something. The report documented CNA #3 placed her hand on her mouth and then slapped her right hand. On 05/11/21 at 11:34 a.m., the resident was observed in her room, in a recliner watching television. She was alert, clean and groomed, and was severely hard of hearing. The resident's lower legs were elevated, had a small amount of edema, small intact vascular blisters, and small reddish patches. The resident's heels did not have redness and were placed on pillow. The resident's legs did not have a wound. The resident smiled and tried to communicate but her hearing made communication difficult. Staff were attentive. A full water pitcher and a small cup of water were on the bedside table. On 05/13/2021 at 1:30 p.m., LPN #1 stated the resident was not interviewed until she came back from the hospital and her statement stayed the same. She stated the administrative staff felt they needed to stay on the side of the resident. She stated the night nurse reported the allegation to administrator at 7:45 a.m. The LPN stated she was not aware the allegation had to be reported to the state within two hours but thought the facility had 24 hours to report. On 05/13/21 at 3:54 p.m., the administrator was interviewed. The administrator stated allegations of abuse were to be immediately reported to charge nurse. The charge nurse was to immediately report the allegation to LPN #1, LPN #3/QA (quality assurance), and to the administrator. The administrator stated the allegation of abuse would be faxed to the state within 24 hours.

Based on interview and record review, it was determined the facility failed to: a. ensure a resident's representative participated in the care plan process for one (#28) of 24 residents whose care plans were reviewed, and b. ensure a resident's care plan was updated to include the monitoring of oral intake for one (#32) of 24 residents whose care plans were reviewed. The facility census and condition documented 66 residents resided in the facility. 1. Resident #28 was admitted with diagnoses which included unspecified dementia without behavioral disturbance and cachexia. On 05/11/21 at 11:42 a.m., the resident's representative was asked if she participated in the care plan process. She stated she was not made aware of any care plan meetings. On 05/17/21 at 9:00 A.M., the resident's clinical record was reviewed. The record documented the care plan was updated on: ~ 09/04/20 for a new diagnosis and order. ~ 09/22/20 for a new provider order. ~ 11/19/20 for a quarterly review and update. ~ 11/25/20 for a new provider order. ~ 12/18/20 updated and reviewed for a significant change in status related to the resident's admission to hospice. ~ 03/25/21 updated and reviewed care plan, and ~ 03/30/21 updated for a new order. On 05/17/21 at 11:30 a.m., the director of nurses (DON) was asked where the facility documented who participated in the care plan meeting. She stated she would have to look for the care plan meeting notes. She stated the notes were not part of the electronic medical record. She stated care plan meetings were conducted informally since the start of COVID. All care plan meeting notes and participant records were requested for the last year for resident #28. On 05/17/21 at 3:00 p.m., the DON stated there was no documentation for the care plan meetings for resident #28. She stated there were notes documenting the updates to the care plan but nothing that reflected communication and/or participation between healthcare disciplines and/or the family. She stated the facility had conducted informal care plan meetings to which they communicated with resident/family members, talked with direct care staff, physicians, social services, and dietary. She stated skilled therapies, the pharmacist, and the dietician were also part of the interdisciplinary team which participated in the care plan process. She concluded with, I do know if it isn't charted, then it's not done. 2. Resident #32 was admitted to the facility with diagnoses which included diabetes, lymphoma, and use of a gastrostomy tube. The physician order, dated 03/11/21, documented the resident was not to take anything by mouth. The care plan, dated 03/11/21, documented the resident received his nutrition and medications via his gastrostomy tube. The dietician's note, dated 04/27/21, documented the resident's weight was stable and the resident was not to receive anything by mouth. The resident was to receive 237 milliliters (ml) of Isosource 1.5 five times a day by gastrostomy tube to provide 1800 kcal (kilocalories), 77 grams of protein, and 895 ml of fluid per day to the resident. The dietician recommended to continue the current nutritional plan of care and monitor for changes in the resident's weight and tube feeding tolerance. The physician's order, dated 05/05/21, documented the resident was to receive 237 ml Isosource 1.5 calorie, five times a day. The speech therapy notes, dated 05/10/21, documented, .ST [speech therapy] and pt [patient] discussed discharge from therapy services .Pt has been upgraded to regular diet, thin liquids - no straws. Swallow precautions educated and reviewed to increase safety awareness during po [oral] intake in all meals. Discussed with RN/dietary about diet upgrade. Will call family tomorrow to discuss above mentioned information . A physician's order, dated 05/11/21, documented the resident's diet was to change to a regular diet with thin liquids and no concentrated sweets. The dietician's note, dated 5/18/21 at 9:23 a.m., documented the resident's weight (last taken 05/07/21) was stable at 177 pounds. The dietician documented the resident was upgraded to a regular diet with thin liquids and no concentrated sweets. The note documented the dietician recommended the resident receive one can of Isosource 1.5 to supplement any intake of less than 50% of his meal and monitor the resident's weight and meal tolerance. On 05/18/21 at 12:30 P.M., the resident's clinical record was reviewed. There was no documentation of meal percentages recorded. The documented weights were: ~ 03/11/21 at 2:37 P.M., 171.4 pounds by mechanical lift, ~ 03/21/21 at 12:15 P.M., 174.0 pounds, ~ 04/20/21 at 9:49 A.M., 177.0 pounds by mechanical lift, and ~ 05/07/21 at 8:44 A.M., 177.0 pounds. The care plan was reviewed and there was no documentation of the resident's ability to take food/fluid by mouth or the change in his diet from a bolus tube feeding to oral food and fluid consumption. On 05/18/2021 at 2:10 p.m., the assistant director of nurses (ADON) was asked to obtain a current weight on resident #32. She returned at 2:25 p.m., and stated the resident's weight was 180.0 pounds. On 05/18/21 at 4:00 p.m., the DON was asked how the facility monitored a resident whose diet was upgraded from a bolus tube feeding to oral nutritional intake. She stated they would monitor how the resident was tolerating his meals through observation of his intake and documentation of meal percentages and weights. She was asked who was responsible for documenting the observations, meal percentages, and weights. She stated the nurse documented the observation of the meal and the nurse aide documented meal percentages and weights. She was asked how the nurse aide knew to document the resident's meal percentages and weight. She stated the task came up in the nurse aides point of care charting for every resident. She was asked where the documentation was located for resident #32. She reviewed the chart and stated the point of care charting the nurse aide was assigned to complete did not have the task of meal percentages assigned to the resident. She was asked why the task of documenting meal percentages was not assigned. She stated the the care plan generated what the nurse aides were assigned to chart on. She stated since the care plan was not updated from the resident's bolus tube feedings to the new order for regular meals, the computer did not prompt the nurse aide to chart the meal percentages.

Based on observation, interview, and record review, it was determined the facility failed to provide activities for two (#44 and #52), of four residents sampled for activities. The resident census and conditions report identified 66 residents who resided in the facility. Findings: Resident #44 was admitted with diagnoses of Reyes' syndrome. An annual assessment, dated 06/21/20, documented the resident as severely cognitively impaired, no behaviors, extensive to total assistance of one person for transfers, did not ambulate, impairment on both side of upper and lower extremities, used a wheelchair for mobility with total assistance, incontinent of both bowel and bladder. The assessment documented it was important for the resident to have a family involved in discussion about her care, have books to look at, have music to listen to, and go outside when the weather was good. A care plan, dated 4/13/21, documented staff were to provide one to one activities, pet therapy, read her stories, touch the resident often and give her lots of hugs, take the resident outside, take her to live music events and play recorded music for her. The care plan documented for the staff to observe for her facial/body language and agitation to help determine her likes and dislikes. On 05/11/21 at 10:25 a.m., the resident's door to the hall was closed. The resident's room was decorated like a play room with foam mats covering most of the floor. The resident was observed sitting on a floor mattress. No staff was present in the room. Childproof door knob covers were in place on all door knobs. On 05/11/21 at 11:22 a.m., the resident's door was closed. The resident was observed across mat from her previous location. The television was turned to an animated movie. She made eye contact when addressed and yelled out. No staff was present in the room. A child proof door knob cover remained on the inside door knob of the door exiting to the hallway. On 05/11/21 at 12:06 p.m., the door to the room was closed. The resident was observed on the floor mat. No staff was present in the room. A childproof door knob cover was on the interior knob of the exit door to the hallway. On 5/11/21 at 2:33 p.m., the door to the room was closed. No staff was present in the room. The resident was on the floor mat and looked when addressed. A childproof door knob cover remained in place. On 05/11/21 at 3:14 p.m., a family member was interviewed and stated the resident was being kept in her room with the door closed since the resident did not receive a Covid-19 vaccination. On 05/12/21 at 10:04 a.m., the door to the room was closed. No staff was present in the room. The resident was lying on the floor mat. A childproof door knob cover remained in place. On 05/12/21 at 11:00 a.m., certified medication aide (CMA) #1 was observed sitting on the floor mat and cradling in her arms and partially supporting the resident with her left leg. The CMA was administering a tube feeding to the resident while talking and singing to the her. The resident's face was lit with emotion. She appeared smiling and laughing. She maintained eye contact with the CMA and appeared engaged in their interaction. The resident provided one word answers to questions the CMA asked and made vocal sounds, as though to sing along with the CMA. The resident called the CMA by her first name. The exit door to her room was closed to the hallway after the CMA left the room. The childproof door knob cover remained in place. On 5/12/21 at 11:15 a.m., CMA #1 was asked why the resident's hallway door was kept closed. She stated the door was closed all the times because the resident would scoot down the hallway on her knees, calling out and looking for CMA #1. The CMA stated the resident was checked on every two hours at least and her tube feeding was administered five times a day. The CMA stated she did all the resident's care through the weekdays. She stated she was the one who woke, fed, changed, and dressed the resident in the morning; she provided her care through the day; and fed, changed, and dressed her in pajamas before tucking her into bed at night. On 05/17/21 at 11:50 a.m., the activity assistant (AA) #1 was asked how staff provided activities for the resident. She stated staff kept toys in the activity room to rotate with those toys in the resident's room and the staff played with her. She stated the CMA interacts with the resident while providing care. The AA was asked why the resident was not coming out of her room to activities. She stated the resident went to group activities but had not been since the resident had not received her Covid-19 vaccination. She was asked if the door to her room was always closed. She stated usually. On 05/17/21 at 4:10 p.m., the resident was observed in her room. No staff was present. The door was closed. On 05/17/21 at 1:58 p.m., the director of nurses (DON) was asked if she considered the resident socially isolated and she stated yes. The DON was asked why her door was closed all the times. The DON stated she saw the resident outside of her room once and was told the resident could not be out of her room since the resident had not been vaccinated. On 05/17/21 at 4:00 p.m., the activity director (AD) was asked if the resident went out of her room by herself. She stated no, the resident could not open her door, but once up in her wheel chair and out of her room, she could maneuver independently. The AD stated the resident would not wear her face mask. She was asked if other residents kept their masks on. She stated not always. The AD was asked if those residents were allowed to be in the hallways and common areas and she stated yes. The AD stated activity documentation was on the task flow sheet. The AD stated the resident was smart and could sort by size, shape, and color. The AD stated staff provided one to one activities for the resident for 20 minutes three times a week. She was asked if she thought that was sufficient time for social stimulation. The AD stated three times a week for socialization was not enough for this resident. On 05/17/21 at 4:31 p.m., CMA #1, was asked if the resident would wear a mask. She stated yes, with encouragement as the resident wanted to be like the staff and wear a mask. The CMA was asked who documented the resident being in activities or outside. She stated the activities staff would document when the resident was up and out of the room. On 05/18/21 at 3:00 p.m., LPN #5 stated the resident had not been up in her wheelchair and allowed to be outside her room in the past two months. On 05/18/21 at 3:18 p.m., LPN #6 was asked how often did the resident get up in her wheelchair. The LPN state the resident had not been up in her wheelchair at all since Covid-19 began. She stated the resident used to get up every day for activities. On 05/18/21 at 4:56 p.m., the administrator stated activities should be documented on the activity task sheet but the CMA did most of the activities with the resident and the nurses documented the activity in the progress notes. A review of the activity task sheets did not document activities were provided from March 2021 through May 2021. A review of the progress notes documented the resident had not received one to one visits from the activities department since 11/29/20. The administrator was asked for documentation of activities, which occurred apart from resident care tasks, in which the resident participated. Fifteen progress note entries were provided from 5/01/21 through 05/17/21. The notes did not document any staff one to one interaction or any group activities beyond routine task care. 2. Resident #52 had diagnoses which included major depressive disorder and hypertension. An admission assessment, dated 04/13/21, documented the resident was cognitively intact for daily decision making. The assessment documented the following activity preferences were very important to the resident: ~ having books, newspapers, and magazines to read; ~ being around animals such as pets; ~ keeping up with the news; ~ doing things with groups of people; ~ participating in her favorite activities; and ~ going outside to get fresh air when the weather was good. Review of the activity flow sheet, dated 04/05/21 through 04/30/21, documented the resident attended seven group activities and the staff provided three one to one visits out of 26 days. An activity care plan, dated 05/10/21, documented, .Interventions .I decide which activities I will attend .I enjoy going outside for fresh air when the weather is nice .I ENJOY GOING TO THE BEAUTY SHOP WEEKLY TO HAVE MY HAIR WASHED AND STYLED .I enjoy small and large group activities .I LIKE TO HAVE/ATTEND FANCY NAILS .I LIKE TO PLAY BINGO .INVITE ME TO SCHEDULED ACTIVITIES. POST SCHEDULED ACTIVITIES WHERE I CAN SEE THEM AND DETERMINE WHICH ONES ID [sic] LIKE TO ATTEND . On 05/11/21 at 9:46 a.m., the resident was observed in her room. She was asked about activities. She stated the staff did not inform her of when activities were scheduled. She was asked if the staff provided an activity calendar. She stated no. Observation of the resident's room did not reveal an activity calendar was present. On 05/12/21 at 10:05 a.m., the resident was asked what activities she enjoyed. She stated she attended Bingo on 05/11/21 and enjoyed it. She was asked if she enjoyed any other activities. She stated she did not know what activities the facility had to offer. Review of the activity flow sheet, dated 05/01/21 through 05/16/21, documented the resident attended seven group activities and the staff provided one one to one visit out of 16 days. On 05/17/21 at 12:18 p.m., activity assistant #1 was asked who completed the monthly activity calendars. She stated the activity director. She was asked who provided copies of the activity calendar to the residents. She stated the two activity assistants and the activity director took turns distributing the calendars. On 05/18/21 at 9:54 a.m., the activity director was asked who provided activity calendars to the residents. She stated the activity assistants. She was asked how residents were notified of activities. She stated they notified each resident every morning what activities were scheduled for the day. She was asked where activities were documented. She stated in the electronic medical record. She was asked what activities resident #52 enjoyed. She stated she liked Bingo, social gatherings, coffee and current events, manicures, and reading. She was asked why resident #52 did not have an activity calendar so she could choose to participate in her preferred activities if desired. She stated she would find out. On 05/18/21 at 4:09 p.m., the activity director stated she had checked on the activity calendar for resident #52 and did not know why she had not been provided one. She stated she provided the resident a calendar this morning.

2. Resident #167 had diagnoses which included cerebral infarction, malignant neoplasm of the prostate, and chronic atrial fibrillation. A nurse's note, dated 06/23/20, documented the resident was discontinued from skilled services and was remaining in the facility as a long term care resident. A physician order, dated 06/26/20, documented hospice was to evaluate and treat. A significant change assessment, dated 07/10/21, documented the resident had a condition or chronic disease that may result in a life expectancy of less than six months. Review of the electronic clinical record did not reveal a care plan had been developed for hospice services. On 05/18/21 at 2:35 p.m., MDS (minimum data set) coordinator #1 was asked who was responsible to develop care plans when a resident was placed on hospice. She stated the former DON (director of nurses). She was asked how the facility coordinated care with hospice. She stated the nurses communicated with the hospice and a plan was developed. She was asked why the plan documenting what services hospice would provide and what the facility was responsible for had not been developed. She stated she would check. On 05/18/21 at 3:30 p.m., MDS coordinator #1 stated she had not found a care plan that had been developed for hospice services. She was asked why a care plan had not been developed to address the resident's need for hospice services. She stated they should have developed a plan regarding coordination of care with the hospice provider. Based on interview and record review it was determined the facility failed to: a. monitor the oral intake for one (#32) of one resident whose diet was upgraded from nothing by mouth to food and fluids by mouth, and b. develop a plan for coordination of care for one (#167) of one resident who received hospice services. The facility identified two residents who received tube feedings and 17 residents received hospice services. Findings: 1. Resident #32 was admitted to the facility with diagnoses which included diabetes, lymphoma, and use of a gastrostomy tube. The physician order, dated 03/11/21, documented the resident was not to take anything by mouth. The care plan, dated 03/11/21, documented the resident received his nutrition and medications via his gastrostomy tube. The dietician's note, dated 04/27/21, documented the resident's weight was stable and the resident was not to receive anything by mouth. The resident was to receive 237 milliliters (ml) of Isosource 1.5 five times a day by gastrostomy tube to provide 1800 kcal (kilocalories), 77 grams of protein, and 895 ml of fluid per day to the resident. The dietician recommended to continue the current nutritional plan of care and monitor for changes in the resident's weight and tube feeding tolerance. The physician's order, dated 05/05/21, documented the resident was to receive 237 ml Isosource 1.5 calorie, five times a day. The speech therapy notes, dated 05/10/21, documented, .ST [speech therapy] and pt [patient] discussed discharge from therapy services .Pt has been upgraded to regular diet, thin liquids - no straws. Swallow precautions educated and reviewed to increase safety awareness during po [oral] intake in all meals. Discussed with RN/dietary about diet upgrade. Will call family tomorrow to discuss above mentioned information . A physician's order, dated 05/11/21, documented the resident's diet was to change to a regular diet with thin liquids and no concentrated sweets. On 05/11/21 at 4:13 p.m., the dietary manager documented, .Resident has been evaluated by speech therapy and his diet has been changed to Regular NCS Diet Thin Liquids (no straws). His tube feeding has been d/c [discontinued], but he will kept [sic] the tube in place to make sure that he can tolerate the diet. He can feed himself and has breakfast in his room lunch and supper in the supervised dining area . There was no documentation of how the facility was going to monitor the resident to ensure he maintained his nutritional status while transitioning diets. The dietician's note, dated 5/18/21 at 9:23 a.m., documented the resident's weight (last taken 05/07/21) was stable at 177 pounds. The dietician documented the resident was upgraded to a regular diet with thin liquids and no concentrated sweets. The note documented the dietician recommended the resident receive one can of Isosource 1.5 to supplement any intake of less than 50 percent of his meal and monitor the resident's weight and meal tolerance. On 05/18/21 at 12:30 p.m., the resident's clinical record was reviewed. There was no documentation of meal percentages recorded. The documented weights were: ~ 03/11/21 at 2:37 P.M., 171.4 pounds by mechanical lift, ~ 03/21/21 at 12:15 P.M., 174.0 pounds, ~ 04/20/21 at 9:49 A.M., 177.0 pounds by mechanical lift, and ~ 05/07/21 at 8:44 A.M., 177.0 pounds. The care plan was reviewed and there was no documentation of the resident's ability to take food/fluid by mouth or the change in his diet from a bolus tube feeding to oral food and fluid consumption. On 05/18/2021 at 2:10 p.m., the ADON was asked to obtain a current weight on resident #32. She returned at 2:25 p.m. and stated the resident's weight was 180.0 pounds. On 05/18/21 at 4:00 p.m. the DON was asked how the facility monitored a resident whose diet was upgraded from a bolus tube feeding to oral nutritional intake. She stated they would monitor how the resident was tolerating his meals through observation of his intake and documentation of meal percentages and weights. She was asked who was responsible for documenting the observations, meal percentages, and weights. She stated the nurse documented the observation of the meal, the nurse aide documented meal percentages and weights. She was asked how the nurse aide knew to document the resident's meal percentages and weight. She stated the task came up in the nurse aides point of care charting for every resident. She was asked where the documentation was located for resident #32. She reviewed the chart and stated the point of care charting the nurse aide was assigned to complete did not have the task of meal percentages assigned to the resident. She was asked why the task of documenting meal percentages was not assigned. She stated the the care plan generated what the nurse aides were assigned to chart on. She stated since the care plan was not updated from the resident's bolus tube feedings to the new order for regular meals, the computer did not prompt the nurse aide to chart the meal percentages.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure a resident who was admitted with limited range of motion was provided services to improve range of motion for one (#52) of two sampled residents who were reviewed for range of motion. The facility identified five residents who had decreased range of motion. Findings: Resident #52 was admitted on [DATE] and had diagnoses which included right above the knee amputation and peripheral vascular disease. A physician order, dated 04/05/21, documented, .Activity Status: UP AS TOLERATED .MAY USE WHEELCHAIR FOR MOBILITY PURPOSES . An admission assessment, dated 04/13/21, documented the resident was cognitively intact for daily decision making, had impairment in range of motion on one side of the lower extremities, used a wheelchair, required limited assistance of one person for transfers, was only able to stabilize herself with the assistance of one staff member when moving from a seated to a standing position, when moving on and off the commode, and when transferring from surface to surface. The assessment documented the resident and direct care staff believed the resident was capable of increased independence in at least some activities of daily living. On 05/11/21 at 9:49 a.m., the resident was asked about her range of motion. She stated the facility had told her the insurance she had would not cover physical therapy. She stated she would like to exercise all extremities. On 05/12/21 at 10:05 a.m., the resident stated she thought the facility was working on her getting physical therapy or exercises but she was not sure. Review of the electronic clinical record did not reveal the facility had discussed therapy or restorative services for the resident to maintain/improve her limited range of motion. On 05/17/21 at 2:28 p.m., restorative aide #1 was asked how residents were assessed for restorative services. She stated if a resident had a decline in range of motion physical therapy provided services. She was asked who developed the restorative plans for residents. She stated physical therapy. She was asked if resident #52 received restorative or therapy services. She stated no. On 05/17/21 at 2:39 p.m., the DON (director of nurses) was asked how residents were assessed for restorative services. She stated they communicated with the restorative aide about functional decline to see if the resident required restorative. She was asked who developed restorative plans for the residents. She stated the restorative aide worked with the therapy department. She was asked if resident #52 was on a restorative or therapy program. She stated they had planned on getting the resident evaluated for a prosthesis. She stated the resident required assistance from staff with transfers. She was asked where the evaluation was documented regarding the prosthesis. She stated the MDS (minimum data set) coordinator communicated with therapy. On 05/18/21 at 2:29 p.m., the MDS coordinator was asked how the facility determined who received restorative and/or therapy services. She stated the therapy department and the facility staff discussed the residents needs. She was asked what had been discussed for resident #52. She stated they felt the resident required more aggressive treatment than restorative services. She stated due to the type of insurance the resident currently had the physician had to see the resident to determine if she could get a prosthesis. She was asked why the resident had not received any restorative/therapy services since admission. She stated the resident was now able to transfer herself and did not require restorative services. She stated when the resident was admitted she had asked for assistance in acquiring a prosthesis. She was asked where she had documented the facility had discussed the prosthesis with the resident and/or physician. She stated she verbally discussed the prosthesis with the physician but did not document. On 05/18/21 at 3:55 p.m., the DON stated she had heard last week about the potential for a prosthesis for the resident. She stated she spoke with the restorative aide and it was reported the resident transferred well. She stated they needed to discuss placing the resident on a restorative program to improve her function. She stated the resident had a wound on her heel which was almost healed so they needed to discuss the option for restorative services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to: a) Provide an accessible egress from a resident's room for one (#44) of 21 residents observed for accident hazards, and b) Secure stored chemicals and used razors in a manner to prevent resident accessibility. The facility census and conditions report documented 66 residents resided in the facility. Findings: A facility policy, dated 02/21/20, and titled, Chemical Storage, documented, .All chemicals are a hazard risk to Resident's who may not be aware of what they are and what they are used for and that they may be poisoness [sic] .It is the policy of the Broken Arrow Nursing Home that all chemicals will be kept behind locked doors in an area that cannot be accessed by any Resident . 1. Resident #44 was admitted to the facility with diagnoses which included Reyes' syndrome, major depressive disorder, pseudobulbar affect, and had a feeding tube. An annual assessment, dated 06/21/20, documented the resident was severely impaired for daily decision-making, did not exhibit behaviors, required extensive to total assistance of one person for transfers, did not ambulate, had impairment for range of motion on upper and lower extremities, required total assistance with a wheelchair for mobility, and was incontinent of bowel and bladder. A care plan, dated 04/13/21, documented the resident was at risk for falls. The care plan documented the resident had diminished cognition, was impulsive, and had poor safety awareness. The care plan documented interventions to prevent falls included assisting the resident up to her wheelchair in the mornings and after tube feedings, checking on the resident every two hours for needs, and anticipating the resident's needs. The care plan documented staff were to monitor the resident for nonverbal communication. On 05/11/21 at 10:25 a.m., the resident's door to the hall was closed. The resident's room was decorated like a play room with foam mats covering most of the floor. The resident was observed sitting on a floor mattress. No staff was present in the room. Childproof door knob covers were in place on all door knobs. On 05/11/21 at 11:22 a.m., the resident's door was closed. The resident was observed across mat from her previous location. The television was turned to an animated movie. She made eye contact when addressed and yelled out. No staff was present in the room. A child proof door knob cover remained on the inside door knob of the door exiting to the hallway. On 05/11/21 at 12:06 p.m., the door to the room was closed. The resident was observed on the floor mat. No staff was present in the room. A childproof door knob cover was on the interior knob of the exit door to the hallway. On 5/11/21 at 2:33 p.m., the door to the room was closed. No staff was present in the room. The resident was on the floor mat and looked when addressed. A childproof door knob cover remained in place. On 05/11/21 at 3:14 p.m., a family member was interviewed and stated the resident was being kept in her room with the door closed since the resident did not receive a Covid-19 vaccination. On 05/12/21 at 10:04 a.m., the door to the room was closed. No staff was present in the room. The resident was lying on the floor mat. A childproof door knob cover remained in place. On 05/12/21 at 11:00 a.m., certified medication aide (CMA) #1 was observed sitting on the floor mat and cradling in her arms and partially supporting the resident with her left leg. The CMA was administering a tube feeding to the resident while talking and singing to the her. The resident's face was lit with emotion. She appeared smiling and laughing. She maintained eye contact with the CMA and appeared engaged in their interaction. The resident provided one word answers to questions the CMA asked and made vocal sounds, as though to sing along with the CMA. The resident called the CMA by her first name. The exit door to her room was closed to the hallway after the CMA left the room. The childproof door knob cover remained in place. On 5/12/21 at 11:15 a.m., CMA #1 was asked why the resident's hallway door was kept closed. She stated the door was closed all the times because the resident would scoot down the hallway on her knees, calling out and looking for CMA #1. The CMA stated the resident was checked on every two hours at least and her tube feeding was administered five times a day. The CMA stated she did all the resident's care through the weekdays. She stated she was the one who woke, fed, changed, and dressed the resident in the morning; she provided her care through the day; and fed, changed, and dressed her in pajamas before tucking her into bed at night. On 05/17/21 at 11:50 a.m., activity assistant (AA) #1 was asked if the door to her room was always closed. She stated usually. On 05/17/21 at 4:10 p.m., the resident was observed in her room. No staff was present. the door had been closed and a childproof door knob cover remained in place. On 05/17/21 at 1:58 p.m., the director of nursing (DON) was asked why the resident's door was closed all the time. The DON stated she saw the resident outside once and was told she could not be out of her room since she was not vaccinated. She was asked why the childproof doorknob covers were on the exit door. The DON stated the covers were placed to prevent the resident from opening the door. On 05/17/21 at 4:31 p.m., CNA #1, was asked why childproof door covers were on the door. She stated it was to keep the resident from coming out of the room. The CNA stated her door was also kept shut to keep the resident from disturbing other residents when she yelled. The CNA was asked if it was a safety issue with the door closed. She stated yes. The CNA stated the resident was checked every two hours or when the resident called out. On 05/18/21 at 11:46 a.m., LPN #4 was asked how residents who have confusion were managed for safety. She stated the door would be left open for supervision. The LPN was asked if a resident was in a closed room and the door could not be opened by the resident, would checking on them every two hours be sufficient for safety concerns. The nurse stated no. On 05/18/21 at 3:00 p.m., LPN #5 was asked if resident #44 could turn a door knob. She stated yes. The nurse was asked if she thought the resident had the knowledge to know she could leave the room if the door was open. The LPN stated absolutely. She was asked why the childproof doorknob covers were in place. She stated it prevented the resident from leaving her room and wandering. She was asked how often was the door was left shut. The LPN stated often. On 05/18/21 at 3:18 p.m., LPN #6 was asked why the door was closed to the resident's room. She stated to combat noise, and keep the resident from leaving the room since she had become more mobile in the past year. She was asked if the resident could open a door by herself and she stated yes. She was asked if the resident could open it with the childproof doorknob cover on it. The nurse stated no. She was asked if it would be a safety issue with the door being closed and the resident unable to open it herself. She stated yes. On 05/18/21 at 4:56 p.m., the administrator was asked if the resident could open the door if she wanted and she stated yes. The administrator stated when the childproof door knob cover was first placed on the doorknob she thought it was a restraint. On 05/19/21 at 8:45 a.m., the administrator stated she called life safety and was informed the facility could not have objects on the door preventing the resident from exiting the room. 2. On 05/12/21 at 11:15 a.m., a can of Microban 24 hour sanitizing spray was observed on top of the vending machine in the common room near the entry to New Hall. At 11:18 a.m., an unoccupied office was observed with the door opened to the common room. The following chemicals were stored on the floor of the office: ~ one gallon of 70% isopropyl alcohol, ~ one can of Microban 24 hour sanitizing spray, ~ 16 ounce bottle of 91% isopropyl alcohol, ~ one gallon of antiseptic gel hand rub, ~ one 17.5 ounce can of Raid Ant and Roach spray, ~ one 28 ounce spray bottle of Instant Hand Sanitizer containing 80% alcohol along with glycerin, hydrogen peroxide, and water. At 12:20 p.m., a bottle of [NAME] solutions Surface TB Hard Surface Disinfectant; Cleaner, Deoderizer, Disinfectant, Virucide, Tuberculocidal was observed on top of the housekeeping cart on [NAME] Hall. The housekeeper was in a resident room and out of sight of the cart. There was no staff or resident in the immediate area. At 12:25 p.m., an unoccupied office was observed with the door opened to the common room. The following chemicals were stored on the floor of the office: ~ one gallon of 70% isopropyl alcohol, ~ one can of Microban 24 hour sanitizing spray, ~ 16 ounce bottle of 91% isopropyl alcohol, ~ one gallon of antiseptic gel hand rub, ~ one 17.5 ounce can of Raid Ant and Roach spray, ~ one 28 ounce spray bottle of Instant Hand Sanitizer containing 80% alcohol along with glycerin, hydrogen peroxide, and water. At 3:00 p.m., a black bag was observed hanging from the side arm of the clean linen cart on South Hall. Sticking out of the top of the bag was a can of Clorox 4 in One Spray Disinfectant and Sanitizer and an unlabeled spray bottle containing a blue colored liquid inside. At 3:05 p.m., a metal seven foot tall cabinet located in the common area and used to store hospice charts was observed to be unlocked. A small sharps container stored on a lower middle shelf was observed to be overflowing with used blue disposable razors, four of which had handles sticking out of the top of the sharps container and three of which had razor heads sticking out of the top of the sharps container. At 3:08 p.m., an unoccupied office was observed with the door opened to the common room. The following chemicals were stored on the floor of the office: ~ one gallon of 70% isopropyl alcohol, ~ one can of Microban 24 hour sanitizing spray, ~ 16 ounce bottle of 91% isopropyl alcohol, ~ one gallon of antiseptic gel hand rub, ~ one 17.5 ounce can of Raid Ant and Roach spray, ~ one 28 ounce spray bottle of Instant Hand Sanitizer containing 80% alcohol along with glycerin, hydrogen peroxide, and water. On 05/12/21 at 3:30 p.m., certified nurse aide (CNA) #7 was asked how chemicals were to be stored. The CNA stated chemicals were to be stored under lock and key and out of reach of residents. On 05/12/21 at 3:33 p.m., CMA#1 was asked how chemicals were to be stored. She stated chemicals should be locked up in carts with keys in your possession and large bottles of stock chemicals should be stored locked in the housekeeping closet. On 05/12/21 at 3:35 p.m., Housekeeper #1 was asked how chemicals were to be stored. She stated chemicals were stored locked and out of reach. She stated she never left chemicals on the top of the housekeeping cart. She stated she was told never to leave chemicals unsecured. She stated it was hazardous to leave chemicals out where residents could access them. She stated, If someone was to drink it, it could make them real sick or if it was spilt on them, it could ruin their clothes. On 05/12/21 at 3:45 p.m., the DON was asked how were chemicals to be stored in the facility. She stated chemicals should be stored locked and not accessible to residents. The DON was brought to the open office door located in the common area. There was no staff present in the office and no staff in the common area with the exception of the DON. There were eight residents sitting or moving about in the common area. The chemicals stored on the office floor were still present. The DON was shown the chemicals in the office which were viewable from the common area. The DON stated they needed to be stored securely somewhere else. The DON continued and stated chemicals should not be stored near a heat source or where sparks may ignite them. She was shown the can of Microban on top of the vending machine. She stated she thought the chemical was placed there to be out of reach but still accessible to those coming in the door to clean their feet. She stated they needed to find a better place to store it. She was shown the inside of the file cabinet containing the sharps containing overflowing with used disposable razors. She appeared shocked and asked if the razors were used and why someone would stick the used razors inside the cabinet. She was asked if she considered the way the used razors were stored as an accident hazard. She stated yes. She was asked if the file cabinet should be locked. She stated yes. She was shown the hide a key stored on top of the cabinet and she attempted to lock the cabinet but the key appeared to not fit and she was unable to lock the cabinet. On 05/12/21 at 4:00 p.m., hospice RN#1 was asked if hospice locked the filing cabinet. She stated yes but the key often did not work so she found the cabinet was not always locked. She was asked if she communicated to the facility the file cabinet could not be locked. She stated she had just arrived but had not communicated the difficulty they were having with locking the file cabinet in the past.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure a gradual dose reduction ordered by a physician was completed for one (#62) of five residents reviewed for medications. The census and conditions report documented 52 residents received psychotropic medications. Findings: Resident #62 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia and major depression. The quarterly assessment, dated 10/17/20, documented the resident was independent for daily decision-making, had symptoms of psychosis, and had behaviors toward others. The care plan, dated 11/25/20, documented the resident's behavior patterns, psychotropic medications, and symptoms to monitor. The physician orders for May 2021 documented an order for Trazadone 25 milligrams (mg) at bedtime for insomnia. A pharmacy consultation report for March 2021 documented a recommendation for Trazadone 25 mg to be gradually reduced. The report documented the physician agreed and was signed by the physician. The report was noted by the nurse on 03/29/21. On 05/11/21 at 2:32 p.m., the resident was interviewed and observed. the resident stated she could not go to activities because she was too sick and had abdominal issues. She stated she prefered to stay in her room. the resident stated the staff help her daily with personal care. The resident was groomed, clean, and did not have odors. The resident had a flat expression, focused on abdmonial issues, and kept the door closed. On 05/17/21 at 12:50 p.m., licensed practical nurse (LPN) #1 stated when a pharmacy recommendation come back to the facility from the physician the day charge nurse would write an order to discontinue the older order and inputs the new order. She stated the new order would automatically go to the pharmacy. The LPN stated the nurse would make a note in the progress notes, note the new order, and the give the order and pharmacy consult report to medical records. The LPN stated she cloud not find documentation the Trazadone reduction had been implemented and the resident was still receiving Trazadone 25 mg at bedtime.

Resident #44 was admitted with diagnoses of Reyes' syndrome. An annual assessment, dated 06/21/20, documented it was important for the resident to have a family involved in discussion about her care, have books to look at, have music to listen to, and go outside when the weather was good. A care plan, dated 4/13/21, documented staff were to provide one to one activities, pet therapy, read her stories, touch the resident often and give her lots of hugs, take the resident outside, take her to live music events and play recorded music for her. The care plan documented for the staff to observe for her facial/body language and agitation to help determine her likes and dislikes. From 05/11/21 to 05/12/21 the resident was observed on five occassions. On each occassion the door to the resident's room was closed. The resident was observed on the floor mat. No staff was present in the room. A childproof door knob cover was on the interior knob of the exit door to the hallway. On 05/17/21 at 11:50 a.m., the activity assistant (AA) #1 was asked how staff provided activities for the resident. She stated staff kept toys in the activity room to rotate with those toys in the resident's room and the staff played with her. She stated the CMA interacts with the resident while providing care. The AA was asked why the resident was not coming out of her room to activities. She stated the resident went to group activities but had not been since the resident had not received her Covid-19 vaccination. She was asked if the door to her room was always closed. She stated usually. On 05/17/21 at 4:10 p.m., the resident was observed in her room. No staff was present. The door was closed. On 05/17/21 at 4:00 p.m., the activity director (AD) stated activity documentation was on the task flow sheet. The AD stated the resident was smart and could sort by size, shape, and color. The AD stated staff provided one to one activities for the resident for 20 minutes three times a week. On 05/18/21 at 4:56 p.m., the administrator stated activities should be documented on the activity task sheet but the CMA did most of the activities with the resident and the nurses documented the activity in the progress notes. A review of the activity task sheets did not document activities were provided from March 2021 through May 2021. A review of the progress notes documented the resident's last activity was provided on 11/29/20. The administrator was asked for documentation of activities, which occurred apart from resident care tasks, in which the resident participated. Fifteen progress note entries were provided from 5/01/21 through 05/17/21. The notes did not document any staff one to one interaction or any group activities beyond routine task care. Based on interview and record review, it was determined the facility failed to ensure clinical records were complete for two (#44 and #167) of 23 sampled residents whose records were reviewed. This had the potential to affect all 66 residents who resided in the facility. Findings: 1. Resident #167 had diagnoses which included cerebral infarction and malignant neoplasm of the prostate. A nurse note, dated 07/26/20, documented the resident had pulled his peg tube out and the nurse replaced the peg tube. The note did not document the physician had been notified. Review of the resident's physician orders did not reveal an order had been obtained for the replacement of the peg tube. On 05/18/21 at 2:35 p.m., MDS (minimum data set) coordinator #1 was asked about the resident's peg tube being replaced. She stated she was working the day the peg tube had been pulled out. She stated the nurse on duty had notified the physician and replaced the peg tube. She was asked where physician notification and the order to replace the peg tube was documented. She stated she would review the clinical record. On 05/18/21 at 2:49 p.m., the DON (director of nurses) was asked what the facility protocol was if a peg tube had been pulled out. She stated the nurse was to notify the physician to obtain an order to send the resident to the hospital for replacement or to obtain an order for the facility staff to replace it. On 05/18/21 at 3:30 p.m., MDS coordinator #1 stated she had not found documentation the physician had been notified of the peg tube displacement or an order to replace the peg tube. On 05/18/21 at 4:01 p.m., LPN (licensed practical nurse) #3 was asked about the resident's peg tube. She stated she instructed the nurse to call the physician. She stated the nurse called the physician and he gave orders to replace the peg tube. On 05/18/21 at 4:56 p.m., the physician was asked if he was notified when the resident's peg tube had been pulled put. He stated the nurse had notified him and he had given a telephone order to replace the peg tube. He stated he did not know why the nurse had not documented the notification or the telephone order.

Based on interview and record reviewd, it was determined the facility failed to provide abuse training for three of seven employees whose files were reviewed. The facility identified 11 new employees who had been hired since January 2021. Findings: The files for certified nurse aide (CNA) #8, CNA #9, CNA #3 were reviewed and did not document abuse training on hire for the CNAs. On 05/13/21 at 2:04 p.m., licensed practical nurse #3 stated he was not able to complete all the items for the employee file. The nurse stated it was not complete because they had not finished the employees' orientations.