Based on record review and interview, the facility failed to accurately complete a level l PASARR for one (#20) of one sampled resident reviewed for PASARR. The administrator identified 29 residents resided in the facility. Findings: Resident #20 had diagnoses which included dementia with other behavioral disturbances, delusional disorders, and mood affective disorder. A level l PASARR assessment, dated 01/23/19, documented resident #20 did not have a diagnosis of a serious mental illness. On 12/06/24 at 2:56 p.m., the ADON reviewed the resident's level I PASARR form and stated the question regarding a diagnosis of serious mental illness was answered incorrectly. The ADON stated a level II PASARR referral should have been made to Oklahoma Health Care Authority.

Based on record review and interview, the facility failed to care plan a resident's weight loss for one (#9) of one sampled resident whose care plan was reviewed for weight loss. The DON identified three residents with weight loss. Findings: Resident #9 had diagnoses which included dementia. The registered dietician's note, dated 11/19/24, documented the resident had weight loss of 12.5% in the last three months and 11.6% in the last six months. The note documented the resident received Megace, an appetite stimulant, as a physician ordered intervention for weight loss. On 12/06/24 at 4:40 p.m., Resident #9's clinical record was reviewed. There was no documentation weight loss was care planned. On 12/06/24 at 6:00 p.m., the MDS coordinator stated the resident's weight loss should have been care planned.

Based on observation and interview, the facility failed to maintain a clean ice machine. The administrator identified 29 residents who received ice from the kitchen. Findings: On 12/03/24 at 10:38 a.m., the DM stated the kitchen staff cleaned the storage chest of the ice machine weekly and removed all the ice and cleaned/sanitized the storage chest of the ice machine monthly. The DM stated the kitchen staff did not clean the mechanical workings of the ice machine. The DM stated there was a company which came and ran sanitizer through the ice machine, but did not know how often the company did so. On 12/06/24 at 2:21 p.m., the internal mechanics of the ice machine was observed to have a moist green and black substance along the edges of the water reservoir, covers, inlets, and tubing. On 12/06/24 at 2:22 p.m., the administrator observed the internal mechanics of the ice machine and stated the ice machine needed to be cleaned.

Based on record review and interview, the facility failed to ensure a care plan was updated for one (#17) of one sampled resident who was reviewed for burns. The DON identified one resident who sustained burns within the last six months. Findings: Res #17 was admitted with diagnoses which included Parkinson's disease. A nurse note, dated 06/18/23 at 2:30 p.m., documented Res #17 sustained burns to their coccyx and thighs after spilling hot coffee on their lap. A Hot Liquids Risk Screening, dated 06/21/23, documented in part, .Hot Liquid Risk Interventions - with any hot beverage resident is to use a cup with a lid . An OSDH 283 form, dated 06/23/23, documented in part, .Part C - Sippy cup to prevent reoccurrence and lid coming off .Resident agreed to use sippy cup with all liquids to prevent spills and injury. Staff instructed to ensure hot liquids are cooled prior to giving to resident . Res #17's care plan did not include interventions to prevent burns from hot liquids. On 08/24/23 at 10:45 a.m., the MDS coordinator reported the care plan should have been updated to include interventions to prevent burns.

Based on observation, record review, and interview, the facility failed to ensure residents' assessments were accurate for four (#3, 5, 12 and #18) of 16 sampled residents whose assessments were reviewed for accuracy. The Resident Census and Conditions of Residents, dated 08/21/23, documented a census of 36 residents. Findings: 1. Res #3 was admitted with diagnoses which included weakness and fracture of the right femur. On 08/20/23 at 4:00 p.m., Res #3 was observed sitting on the edge of the bed. A 1/8 side rail was up on the left side of bed. On 08/20/23 at 4:00 p.m., Res #3 reported they used the side rail to assist them in getting out of bed at times. The resident reported they had requested the rail a long time ago and the doctor had approved it. The resident reported they didn't feel the side rail restricted their movement. On 08/21/23 at 11:01 a.m., Res #3 was observed ambulating in the hallway with a rolling walker. On 08/22/23 at 2:40 p.m., the MDS coordinator reported they had documented the 1/8 side rails requested by Res #3 for positioning as restraints on the resident assessment. They reported Res #3 did not have restraints. A quarterly assessment, dated 06/22/23, documented Res #3 was cognitively intact, ambulatory with the use of a walker, and had no impaired range of motion. The assessment documented Res #3 used restraints daily in the form of side rails. 2. Res #5 was admitted with diagnoses which included cerebral palsy. On 08/21/23 at 9:35 a.m., Res #5 was observed in bed against the wall and 1/8 partial rail up one side. Res #5 frequently used the side rail for bed mobility and shifting their weight while in bed. A physician order, dated 06/16/21, read in part, Resident may have special half side rail added to HOB (head of bed) to promote bed mobility per self. A quarterly assessment, dated 07/24/23, documented the resident had impaired range of motion to both lower extremities and required extensive assistance with two person assist for bed mobility. The resident assessment also documented Res #5 used restraints in bed daily in the form of side rails. On 08/22/23 at 3:00 p.m., the MDS coordinator reported Res #5's partial bed rails were for positioning and did not act as a physical restraint for the resident. The MDS Coordinator reported they were not aware of the coding instructions for the restraint section of the resident assessment. 3. Res #12 was admitted with diagnoses which included weakness and polio. On 08/21/23 at 2:25 p.m., Res #12 was observed sitting on the side of the bed with 1/8 side rail up on left side of bed. On 08/22/23 at 9:45 a.m., Res #12 reported they had requested the side rail to assist them in getting out of bed and to reposition while in bed. The resident reported the side rail did not restrict their movements. A physician order, dated 08/13/21, documented, Resident may have 1/8 partial rails added to HOB to assist with self positioning, safety, and mobility. A quarterly assessment, dated 05/03/23, documented Res #12 was cognitively intact, non ambulatory, and required extensive assistance with transfers and bed mobility. The assessment documented Res #12 used restraints in bed daily in the form of side rails. On 08/22/23 at 3:00 p.m., the MDS coordinator reported Res #18's partial side rails were for positioning and did not act as a physical restraint for the resident. The MDS coordinator reported they were not aware of the coding instructions for the restraint section of the resident assessment. 4. Res #18 was admitted with diagnoses which included Parkinson's disease. On 08/21/23 at 8:45 a.m., Res #18 was observed in bed with 1/8 partial rails up on bed. Res #18 was able to use the partial rails for bed mobility. A physician order, dated 07/15/16, read in part, Resident may have 1/8 partial rails to the right and left upper side of bed to assist with self positioning, safety and mobility. On 08/22/23 at 3:00 p.m., the MDS coordinator reported Res #18's partial bed rails were for positioning and did not act as a physical restraint for the resident. The MDS coordinator reported they were not aware of the coding instructions for the restraint section of the resident assessment. On 08/22/23 at 3:10 p.m., the MDS coordinator reported the facility was a restraint free facility. The MDS coordinator reported they had misinterpreted the assessment manual instructions as documenting side rails were restraints. They reported all four residents documented as having restraints had 1/8 side rails per resident request, had a completed side rail assessment, and had signed a consent.

Based on observation, record review, and interview, the facility failed to ensure care plans were developed for three (#3, 5, and #18) of three sampled residents who used bed rails and one (#11) of one sampled resident reviewed for falls. The DON identified seven residents who used side rails and 19 residents who had fallen in the last six months. Findings: 1. Res #3 was admitted with diagnoses which included weakness and fracture of the right femur. On 08/20/23 at 4:00 p.m., Res #3 was observed sitting on the edge of the bed. A 1/8 side rail was up on the left side of bed. On 08/20/23 at 4:00 p.m., Res #3 reported they used the side rail to assist them in getting out of bed at times. The resident reported they had requested the rail a long time ago and the doctor had approved it. The resident reported they didn't feel the side rail restricted their movement. On 08/21/23 at 11:01 a.m., Res #3 was observed ambulating in the hallway with a rolling walker. On 08/22/23 at 2:40 p.m., the MDS coordinator reported they had documented the 1/8 side rails requested by Res #3 for positioning as restraints on the resident assessment. They reported Res #3 did not have restraints. A care plan with a review date of 03/04/23, did not document the use of side rails for Res #3. A quarterly resident assessment, dated 06/22/23, documented Res #3 was cognitively intact, ambulatory with the use of a walker, and had no impaired range of motion. The assessment documented Res #3 used restraints daily in the form of side rails. 2. Res #5 was admitted with diagnoses which included cerebral palsy. On 08/21/23 at 9:35 a.m., Res #5 was observed in bed against the wall and 1/8 partial rail up one side. Res #5 frequently used the side rail for bed mobility and shifting their weight while in bed. A physician order, dated 06/16/21, read in part, Resident may have special half side rail added to HOB to promote bed mobility per self. The side rails for Res #5 were not care planned. On 08/22/23 at 3:05 p.m., the MDS coordinator reported Res #5's side rails should have been care planned and were not. 3. Res #18 was admitted with diagnoses which included Parkinson's. On 08/21/23 at 8:45 a.m. Res #18 was observed in bed with 1/8 partial rails up on bed. Res #18 was able to use the partial rails for bed mobility. A physician order, dated 07/15/16, read in part, Resident may have 1/8 partial rails to the right and left upper side of bed to assist with self positioning, safety and mobility. On 08/22/23 at 3:05 p.m., the MDS coordinator reported Res #18's side rails should have been care planned and were not. 4. Res #11 was admitted with diagnoses which included anxiety disorder, hallucinations, unspecified dementia and depression. A care plan, last updated 07/24/23, documented in part, .ensure [name withheld] is wearing appropriate footwear (e.g. shoes, bedroom slippers, nonskid socks) when ambulating or up in chair . A care plan, last updated 08/18/23, documented in part, .Flag and identify [name withheld] is a high risk for falls. * Yellow star - High fall risk * Red star - [name withheld] has had a fall in the last 3 months . A nurse's note, dated 08/18/23 at 11:04 a.m., as a late entry, documented at 9:45 a.m., Res #11 was alone in the room trying to self transfer from the recliner to the bed and was found on their knees. A CNA and student nurse tried to assist the resident to bed, the resident refused, and was assisted to the floor. On 08/23/23 at 8:00 a.m., Res #11 was observed sitting in a recliner with bare feet. On 08/23/23 at 8:00 a.m., there was no yellow or red star on Res #11's doorway or outside the room to designate the resident was at risk for falls. On 08/20/23 at 8:05 a.m., CNA #1 was asked if there was a yellow or red star on Res #11's door to indicate the resident was at risk for falls. The CNA reported there was no signage to indicate fall risk for Res #11. On 08/20/23 at 8:10 a.m., the AD was asked if there was a yellow or red star on Res #11's door to indicate the resident was at risk for falls. The AD reported there was no signage to indicate fall risk for Res #11. On 08/20/23 at 8:15 a.m., the DON reported there was no yellow or red star on Res #11's door to indicate the resident was at risk for falls. The DON reported a red star should have been on the door as documented in the care plan, due to the resident falling earlier in the week. The DON also reported the resident should have been wearing nonskid socks as documented in the care plan to decrease the risk for falling.

Based on record review, observation, and interview, the facility failed to ensure a wound care plan was developed for one (#29) of one resident whose care plan was reviewed. The Matrix for Providers dated, 07/19/22, documented two residents with wounds. Findings: A comprehensive care plan dated, 06/04/22, did not document Res #29's wound to left foot. A history and physical from acute care dated, 06/18/22, read in parts, .left foot stage 3 ulcer . A physician's order, dated 06/27/22, read in parts, .monitor top of left foot for S/S of infection daily. A physician's order, dated 07/12/22, read in part, Cleanse top of left foot with NSS (normal saline solution), pat dry, apply collagen powder to wound bed, cover with super absorbent dressing once daily. On 7/19/22 at 10:25 a.m., and throughout the survey, Res #29 was observed with a dressing to the top of their left foot. On 07/22/22, at 3:30 p.m., the DON reported the wound should have been care planned.

Based on record review and interview the facility failed to ensure the hospice chart was up to date for one (#36) of one resident who was reviewed for hospice services. The Matrix for Providers dated, 07/19/22, documented three residents were receiving hospice services. Findings: Res #36 was admitted to hospice services on 06/14/21 for a diagnosis of congestive heart failure. The last hospice nursing note in the hospice chart was dated 09/22/21 at 4:58 p.m. On 07/22/22 at 11:39 a.m., the DON reported the last hospice nursing note was from 09/22/21. On 07/22/22 at 2:38 p.m., LPN #1 reported if there were current hospice nursing notes in the chart she would have read them, LPN #1 also stated, I don't even know what the hospice nurse is assessing or finding if they don't tell me.

Based on record review and interview the facility failed to provide residents with an advance directive acknowledgement for six (#1, 9, 19, 24, 36, and #190) of eight residents reviewed for advance directives. The Resident Census and Conditions of Residents documented 38 residents resided in the facility. Findings: An advance directive acknowledgement was not the paper or electronic health record (EHR) for residents #1, 9, 19, 24, 36, and #190. On 07/20/22 at 10:00 a.m., the BOM reported she was not aware they needed to give the residents an advance directive acknowlgement. She also reported the admission packet only contained the advance directive form.

Based on record review and interview, the facility failed to review and revise a care plan for two (#24 and #36) of six residents whose care plans were reviewed. The Resident Census and Conditions of Residents documented 38 residents resided in the facility. Findings: Res #24 was admitted with diagnoses which included type 2 diabetes. A care plan dated, 02/16/22, read in parts, . Blood sugars as ordered with sliding scale coverage; report to MD as indicated . The EHR did not include a physician's order for Res #24 to receive sliding scale insulin. On 07/21/22 at 11:37 a.m., the DON reported that Res #24 had not been on sliding scale insulin in a while and it should have been removed from the care plan. Res #36 was admitted to Hospice services on 06/14/21 for a diagnosis of congestive heart failure. A care plan dated, 06/25/21, read in parts, .Hospice aide to provide shower as tolerated . On 07/22/22 at 11:39 a.m., the DON reported that Res #36 had not had a hospice aide in a long time and the care plan should have been updated to reflect that.

Based on record review and interview the facility failed to ensure the physician responded to the pharmacist reviews regarding anti-psychotic medications for two (#9 and #24) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented five residents had orders for anti-psychotic medication. Findings: Resident #9 was admitted with diagnoses which included Non-Alzheimer's dementia and dementia with behavioral disturbance. The pharmacist reviews dated, 12/28/21 and 06/20/22, read in parts, Is a dosage reduction attempt possible for any of the following: .Vraylar (an anti-psychotic medication) from 3mg to 1.5mg daily, Olanzapine (an anti-psychotic medication) from 5mg to 2.5 mg daily? The pharmacist recommendations did not contain documented responses from the physician. Resident #24 was admitted with diagnoses which included dementia with behavioral disturbance. The pharmacist reviews dated 11/22/21 and 05/19/22, read in parts, Is a dosage reduction attempt possible for any of the following: .Olanzapine from 2.5mg daily to every other day .Vraylar from 1.5mg daily to every other day . The forms did not contain documented responses from the physician. On 07/22/22 at 2:00 p.m., the DON, reported the physician did not respond to the pharmacist reviews, the DON stated she was aware they needed to address the pharmacist reviews with the physician and document their response.

Based on observation and interview, the facility failed to ensure controlled substances were stored in a permanently affixed compartment in the medication refrigerator for one (New Wing Medication Room) of two medication rooms. The DON reported controlled substances were stored in the refrigerator in one (New Wing Medication Room) of two medication rooms. Findings: On 07/22/22 at 11:10 a.m., a black plastic box on a shelf in the New Wing Medication Room refrigerator was not affixed to the refrigerator. The black plastic box contained two bottles of liquid lorazepam (a controlled substance). On 07/22/22 at 11:15 a.m., LPN #1 reported she was unaware the box should have been permanently affixed. On 07/22/22 at 11:20 a.m., the DON reported the facility had attempted to permanently affix the box without success.

Based on record review and interview, the facility failed to develop a QAPI plan. Findings: A QAPI attendance form, dated 03/31/22, documented the IP, DM and AD were the attendees. On 07/22/22 at 1:48 p.m., the IP reported the facility did not have a current QAPI plan. On 07/22/22 at 2:22 p.m., the administrator reported the QAPI plan was not current, the meetings were not regular and the committee was in the process of being re-vamped.

Based on record review and interview, the facility failed to establish and maintain a QAA committee. Findings: A QAPI attendance form, dated 03/31/22, documented the IP, DM and AD were the attendees. On 07/22/22 at 1:48 p.m., the IP reported the facility did not have a current QAPI plan. On 07/22/22 at 2:22 PM the administrator reported the QAPI plan was not current, the meetings were not regular and the committee was in the process of being re-vamped.