**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify a resident's family member listed as the emergency contact and responsible party of a change in condition for 1 (#4) of 2 sampled residents reviewed for hospitalization. The administrator identified 19 residents resided in the facility. Findings: A policy titled Change in a Resident's Condition or Status, revised 05/2017, read in part, Our facility shall promptly notify the resident, [their] Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. [for example], changes in level of care, billing/payments, resident rights, etc. [and the rest/so forth]). A progress note, dated 02/25/25 at 7:09 p.m., read in part, res was in dining room for evening meal and noted to have gotten choked up on meal, res started coughing and face got reddened, res cont [continue] to cough for several minutes. no s/s [signs/symptoms] distress noted. res was assisted to room and o2 applied o2 sats [saturation] 80% with o2 in place, vital signs: 138/89-95-22-98.7. lungs noted to have wheezes to bilat upper and lower lobes bilat. prn [as needed] breathing tx [treatment] given with ineffective results. dr [name withheld] notified and new order received for two view cxr. call placed to [name withheld] imaging to notify of new order. Res notified of new order and res is own responsible party. A progress note, dated 02/25/25 at 7:43 p.m., read in part, received follow up call from dr [name withheld] to transfer res to [hospital name withheld] er. res refused to go at first then changed their mind and decided to go. call placed to [name withheld] ems [emergency medical services] for ambulance to transfer res to [hospital name withheld] ER at 1937 [7:37 p.m.]. don and administrator notified of res being transferred out to hospital. cxr order cancelled thru [name withheld] imaging. Vital signs: 142/98-88-98.3-22-80-89% with o2 in place. res is own responsible party and notified of ambulance being on way. Resident #4's quarterly resident assessment, dated 04/19/25, showed the resident had severe cognitive impairment with a brief interview for mental status of 03. A care plan, dated 04/22/25, showed the resident had diagnoses which included dementia in other diseases classified elsewhere, severe, with mood disturbance and other speech disturbances. There was no documentation to show representative #1 was only responsible for financial obligations and not the care of the resident. There was no documentation to show representative #1 should not be notified of changes in the resident's condition. On 05/05/25 at 1:21 p.m., representative #1 stated their only concern was the resident went to the hospital a long time ago and was not informed. The hospital was the one that called them. They stated they were not aware Resident #4 went to the hospital this year or last year. On 05/07/25 at 10:29 a.m., LPN #1 stated representative #1 was Resident #4's responsible party and emergency contact. They stated they contacted them when changes occurred. On 05/07/25 at 10:31 a.m., LPN #1 stated the resident could not hold a conversation. On 05/07/25 at 10:35 a.m., LPN #1 stated they believed representative #1 should have been notified of the hospital visit on 02/25/25. On 05/07/25 at 10:37 a.m., the DON stated the person listed on the face sheet as responsible party would be notified of a change in condition. On 05/07/25 at 10:40 a.m., the DON stated representative #1 was only responsible for finances and not the care of the resident, but they called them. On 05/07/25 at 10:45 a.m., the DON stated the resident's representative was not notified of the transfer to the hospital on [DATE]. On 05/07/25 at 12:22 p.m., the administrator stated there was no documentation to show representative #1 was not responsible for the resident's care. They stated they should have been notified of changes in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure medications that were expired were removed from the refrigerator of the medication storage room. Census: 20 Findings: On [DATE] at 10:36 a.m., in the presence of LPN #1 and CMA #1, the refrigerator in the medication storage room was observed to contained two vials of opened tuberculin solution. One vial was dated as opened on [DATE], the second vial was dated as opened on [DATE]. LPN #1 stated the medication is outdated and should have been thrown away. CMA #1 stated our lists shows all vials should be used or destroyed in 45 days.

Based on record review, and interview, the facility failed notify the OHCA for a resident who received a new diagnosis of Schizophrenia for one (#10) of one sampled resident reviewed for PASRR's. The Resident Census and Conditions of Residents, dated 02/09/23, documented 11 residents had psychiatric diagnoses, and 18 residents resided in the facility. Findings: Resident #10 had diagnoses which included, Schizophrenia, increased aggression, hypertension and congestive heart failure. A State of Oklahoma Oklahoma Health Care Authority Nursing Facility Level of Care Assessment, dated 09/02/22, read in parts, .No Evidence of serious mental illness Diagnosis of serious mental illness .NO PASSRII (sic) NEEDED . A Physician Order, dated 09/22/22, read in parts, .ZyPREXA Oral Tablet 5 MG .Give 1 tablet by mouth in the evening related to Increased aggression . A Physician Order, dated 10/11/22, read in parts, .ZyPREXA Oral Tablet 5 MG .Give 2 tablet by mouth in the evening related to Increased aggression . A Significant Change Assessment, dated 12/07/22, documented the resident was cognitively impaired and had received seven days of an antipsychotic medication. A Physician Order, dated 12/16/22, read in parts, .ZyPREXA Oral Tablet 10 MG .Give 10 mg by mouth in the evening related to SCHIZOPHRENIA . The clinical health record did not document a level II PASRR had been completed after Resident #10 was diagnosed with Schizophrenia. A Physician Order, dated 02/03/22, read in parts, .ZyPREXA Oral Tablet 10 MG .Give 10 mg by mouth two times a day related to SCHIZOPHRENIA . On 02/13/23 at 12:55 p.m., the DON was asked who completed the PASRR'S. They stated, social services. On 02/13/23 at 3:53 p.m., SS was asked when Resident #10 was diagnosed with Schizophrenia, did the facility re-evaluate Resident #10 and contact the state to see if a Level II PASRR was required. They stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a baseline care plan had been completed within 48 hours of admission for one (#18) of one newly admitted residents. The Administrator identified one resident was admitted within the past 30 days. Findings: Resident #18 was admitted to the facility on [DATE], with a diagnosis to include chronic pain. A Baseline Care Plan, dated 02/01/23, documented the care plan was completed and locked on 02/01/23. The care plan documented the pain assessment portion had been completed on 02/01/23 at 6:37 p.m. On 02/13/23 at 12:52 p.m., the DON was asked when Resident #18's baseline care plan was completed. The DON stated Resident #18 had been admitted on [DATE] and the baseline care plan was locked on 02/01/23 but may have been completed and not locked prior to 02/01/23. On 02/13/23 at 3:32 p.m., the DON reported the baseline care plan was not completed until 02/01/23, and was not within the required 48 hours.

Based on record review, observations, and interviews, the facility failed to ensure a care plan was revised to accurately reflect the smoking status for one (#17) of one sampled resident reviewed for smoking. The Administrator identified six residents who smoke that resided in the facility. Resident #17 had diagnoses to include hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. A Quarterly Assessment, dated 11/12/22, documented Resident #17 had moderate cognitive impairment. A Care Plan, dated 02/11/22, did not contain documentation Resident #17 chose to smoke, or a care plan initiated with interventions to ensure safety while smoking. On 02/09/23 at 10:45 a.m., Resident #17 was observed to be seated on the edge of their bed. An unused cigarette was on the over bed table next to the resident. On 02/10/23 at 11:09 a.m., Resident #17 was observed to gather in main dining area with other residents as they prepared to go into the courtyard to smoke. Each resident was provided a cigarette by CMA #1. An unidentified dietary staff escorted Resident #17 and the other residents into the courtyard, assisted to light each of the cigarettes, and remained with the residents while the residents smoked. On 02/10/23 at 11:25 a.m., The DON and LPN #2 were asked if Resident #17 had been assessed and care planned for safe smoking. The DON stated when Resident #17 was admitted from the hospital, the family told the resident they could not afford to smoke so the resident did not smoke for several months. The DON stated, the resident does not have a care plan for smoking. The DON was asked if the resident should have been assessed for the safety of smoking and a care plan put into place. The DON stated it should have been.

Based on record review and interview, the facility failed to monitor for side effects related to the use of an antipsychotic medication for one (#10) of five sampled residents reviewed for the use of unnecessary medications. The Resident Census and Condition of Residents, dated 02/09/23, documented 11 residents received antipsychotic medications, and 18 residents resided in the facility. Findings: A Monitoring of Anti-Psychotics, policy dated 2022, read in parts, .When antipsychotic therapy is instituted, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions . A Antipsychotic Medication Use policy, revised 12/16, read in parts, .Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician . Resident #10 had diagnoses which included, Schizophrenia, and increased aggression. A Physician Order, dated 09/22/22, read in parts, .ZyPREXA Oral Tablet 5 MG .Give 1 tablet by mouth in the evening related for Increased aggression . A Physician Order, dated 10/11/22, read in parts, .ZyPREXA Oral Tablet 5 MG .Give 2 tablet by mouth in the evening related to Increased aggression . Resident #10's TAR, dated November 2022, did not contain any documentation the resident had been monitored for side effects related to the use of Zyprexa. A Significant Change Assessment, dated 12/07/22, documented the resident was cognitively impaired, and had received seven days of an antipsychotic medication. A Physician Order, dated 12/16/22, read in parts, .ZyPREXA Oral Tablet 10 MG .Give 10 mg by mouth in the evening related to SCHIZOPHRENIA . Resident #10's TAR, dated December 2022, did not contain any documentation the resident had been monitored for side effects related to the use of Zyprexa. Resident #10's TAR, dated January 2023, did not contain any documentation the resident had been monitored for side effects related to the use of Zyprexa. A Physician Order, dated 02/03/22, read in parts, .ZyPREXA Oral Tablet 10 MG .Give 10 mg by mouth two times a day related to SCHIZOPHRENIA . On 02/13/23 at 1:13 p.m., the DON was shown the TAR's for November 2022, December 2022, and January 2023, and asked if Resident #10 had been monitored for side effects related to the use of Zyprexa. The DON stated, there was only behavior monitoring. They were asked if Resident #10 should have been monitored for side effects for the use of Zyprexa. They stated, yes.

Based on record review and interview the facility to monitor for side effects related to the use of a. an antidepressant medication for one (#10), and b. an anti-anxiety medication for one (#6) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Resident, dated 02/09/23, documented 13 residents were administered an antidepressant medication and four residents were administered an anti-anxiety medication. Findings: A Monitoring of Anti-Psychotics policy, dated 2022, read in parts, .When antipsychotic therapy is instituted, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions . 1. Resident #10 had diagnoses which included, Schizophrenia, depression, and increased aggression. A Significant Change Assessment, dated 12/07/22, documented the resident was cognitively impaired and had received seven days of an antidepressant medication. A Physician Order, dated 12/19/22, read in parts, .DULoxetine HCL Oral Capsule Delayed Release Sprinkle 60 MG .Give 1 capsule by mouth one time a day for depression . Resident #10 TAR's for December 2022, and January 2023, did not contain any documentation the resident had been monitored for side effects of related to the use of duloxetine. On 02/13/23 at 1:13 p.m., the DON was shown the TAR's for December 2022, and January 2023, and asked if Resident #10 had been monitored for side effects related to the use of duloxetine. The DON stated, there was only behavior monitoring. They were asked if Resident #10 should have been monitored for side effects for the use of duloxetine. They stated, yes. 2. Resident #6 had diagnoses which included, unspecified intracranial injury, dysphagia, and unspecified convulsions. A Physician Order, dated 10/22/21, read in parts, .clonazePAM Tablet 2 MG give one tablet via PEG-tube two times a day related to .UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION . Resident #6's TAR's for November 2022, December 2022, and January 2023 documented Resident #6 had received Clonazepam as directed but did not contain any documentation the resident had been monitored for side effects for the use of anti anxiety medication (Clonazepam). On 02/13/23 at 1:33 p.m., the DON was asked if Resident #6 had received Clonazepam. They stated yes, it was used for psychotic disorder. The DON was asked if Resident #6 should have ben monitored for side effects. They stated, yes.

Based on record review, observation and interview, the facility failed to ensure the dishwasher chemical testing for chlorine was 50-100 ppm to maintain dish sanitization. The Resident Census and Condition of Residents, dated 02/08/23, documented one resident received enteral nutrition and 18 residents resided in the facility. Findings: A Sanitization policy, revised October 2008, read in parts, .Dishwashing machine must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitization) .Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds . On 02/10/23 at 12:02 p.m., the dietary manager was observed to remove a chemical test strip from a clear container and perform a chemical test on the dishwasher machine. The chemical test strip did not change colors. On 02/10/23 at 12: 06 p.m., the dietary manager rechecked the dishwasher machine, using a testing strip from the clear container. The chemical test strip did not change colors, it remained yellow. The dietary manager stated it wasn't turning green according to the container. On 02/10/23 at 12:12 p.m., the dietary manager was asked if there had been any concerns with the dishwashing machine sanitization. They stated about three to four weeks ago there was a concern with the sanitizer not flowing. The contract company sent a maintenance man out and repaired the issue. The dietary manager was asked who had completed the testing this morning. They stated, I did and it wasn't working. They were asked how long had it not been testing correctly. They stated, About three days. On 02/10/23 at 12:40 p.m., the Administrator was asked if there had been any concerns with the dishwasher machine not meeting chemical levels. They stated, We had them come out about a month ago, and they replaced a hose and a new seal. The Administrator was asked if they were aware the sanitizer in the dishwashing machine was not reading to the level of 50-100 ppm. They stated, they were not aware. On 02/13/23 at 9:17 a.m., the Administrator approached and stated, the dietician was in the kitchen and they retested the dishwasher. The Administrator stated, staff had been using the wrong test strips.

Based on record review, observation and interview, the facility failed to ensure a garbage container near the food preparation table was covered with a lid. The Resident Census and Condition of Residents, dated 02/09/23, documented one resident received enteral nutrition and 18 residents resided in the facility. Findings: A Sanitization policy, revised October 2008, read in parts, .Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily . On 02/10/23 at 11:47 a.m., during meal service an uncovered trash can was observed between the steam table and the three compartment sink. On 02/10/23 at 12:40 p.m., the Administrator was asked if the trash cans should be covered in the kitchen area. They stated, the can should have been covered. On 02/13/23 at 5:07 p.m., an uncovered trash can was observed between the steam table and the three compartment sink. [NAME] #2 was asked what the policy was regarding the trash can being left uncovered. They stated, it shouldn't be uncovered.

Based on record review and interview, the facility failed to submit accurate data regarding direct care staffing information to CMS. The Resident Census and Condition of Residents, dated 02/09/23, documented 18 residents resided in the facility. Findings: A PBJ report for the fourth quarter of 2022, documented the facility failed to have adequate licensed nursing staff 24 hours a day for the following days: 07/03; 07/09; 07/10; 07/17; 07/23; 07/24; 07/30; 07/31; 08/06; 08/07; 08/13; 08/14; 08/20; 08/21; 08/27; 09/03; 09/04; 09/10; 09/17; 09/18; 09/24; and 09/25. The time sheets for the identified time, documented licensed nursing coverage. On 02/14/23 at 10:35 a.m., the Administrator and BOM were asked if there had ever been a time the facility did not have an LPN or an RN to provide licensed coverage for the 24 hour day. They stated there have not had any issues with having a licensed nurse in the building. The Administrator and BOM stated corporate staff enter the data into the system and do not know why the PBJ report would have documented the facility did not have licensed staffing 24 hours/day. They stated the PBJ report was not accurate.

Based on record review and interview, the facility failed to have a system in place to monitor water management to identify and prevent water-borne illnesses to include Legionella. The Resident Census and Condition of Residents, dated 02/09/23, documented 18 residents resided in the facility. Findings: A Legionella Water Management Program policy, dated July 2017, read in parts, .prevention, detection and control of water-borne contaminants, including Legionella .facility has a water management program, which is overseen by the water management team .to identify areas in the water system where Legionella bacteria can grow and spread, and reduce the risk of legionnaire's disease . A Legionella Surveillance and Detection policy, dated July 2017, read in parts, .Legionnaire's disease will be included as part of our infection surveillance activities .Clinical staff will be trained on .signs and symptoms associated with pneumonia and Legionnaire's . On 02/14/23 at 11:20 a.m., the Administrator provided facility policies for Legionella surveillance and water management as requested during the entrance conference. The Administrator stated, We do have a policy but we are not doing what we should to ensure water safety.

Based on record review and interviews, the facility failed to ensure RN coverage for eight consecutive hours, seven days a week for October, November, December 2022, and for January and February 2023. The Resident Census and Conditions of Residents, dated 02/09/23, documented 18 residents resided in the facility. Findings: The Schedule Sheet, for the nursing department, dated October 2022, documented an RN was not scheduled to work on 10/16, 22, 23, 29, and 30. The Schedule Sheet, for the nursing department, dated November 2022, documented an RN was not scheduled to work on 11/05, 06, 12, 13, 19, 20, and 26. The Schedule Sheet, for the nursing department, dated December 2022, documented an RN was not scheduled to work on 12/03, 04, 10, 11, 17, 18, 24, 25, and 31. The Schedule Sheet, for the nursing department, dated January 2023, documented an RN was not scheduled to work on 01/01, 07, 08, 14, 15, 21, 22, 28, and 29. The Schedule Sheet, for the nursing department, dated February 2023, documented an RN was not scheduled to work on 02/04, 05, 11, and 12. On 02/14/23 at 10:35 a.m., the Administrator and BOM were asked how many RN staff were currently employed. The Administrator stated only one, the RN/DON. They were asked what the facility was doing for weekend RN coverage. The Administrator stated, We haven't been. The Administrator and BOM were asked what was the last weekend to have RN coverage. The BOM stated the last day their weekend RN was paid was on 10/09/22. On 02/14/23 at 11:08 a.m., the DON was asked when was last time an RN provided weekend coverage. The DON stated the weekend RN last worked on 10/09/22 but the RN/DON provided RN coverage on 10/15/22. The DON stated there had not been an RN work on weekends after 10/15/22.