Based on record review and interview, the facility failed to ensure Resident Assessments were accurately coded for two (#58 and #85) of 21 residents reviewed for assessments. The Administrator identified 83 residents resided in the facility. Findings: 1. Resident #58 had diagnoses which included dysphagia following cerebral infarction. A Physician Order, dated 07/17/23, documented admit to hospice for CVA. An Annual Resident Assessment, dated 07/18/24, did not document hospice care was received while the resident was at the facility. On 08/15/24 at 2:16 p.m., MDS Coordinator #1 stated they started with evaluating the resident's cognition, went through the resident's chart, pain, completed all of their interview questions, and reviewed progress notes and assessments to ensure Resident Assessments were accurately coded. On 08/15/24 at 2:17 p.m., MDS Coordinator #1 stated the life expectancy less than six months section and hospice should be checked yes when a resident received hospice care. They stated Resident #58 was receiving hospice care. On 08/15/24 at 2:19 p.m., MDS Coordinator #1 stated the annual resident assessment for Resident #58 did have life expectancy less than six months marked but did not have hospice marked. 2. Resident #85 had diagnoses which included displaced intertrochanteric fracture of the left femur. A Nurses' Note, dated 06/22/24, documented Resident #85 discharged from the facility to home accompanied by family. A Discharge Resident Assessment, dated 06/22/24, documented Resident #85's discharge status was a short-term general hospital. On 08/16/24 at 9:34 a.m., MDS Coordinator #2 stated Resident #85's skilled days were up and the resident discharged home with family. On 08/16/24 at 9:36 a.m., MDS Coordinator #2 reviewed Resident #85's discharge assessment and stated I put hospital.

Based on record review and interview, the facility failed to ensure physician ordered labs were obtained for one (#14) of 12 sampled residents reviewed for lab services. The Administrator identified 83 residents resided in the facility. Findings: A Laboratory Services policy, reviewed 07/02/24, read in part, .The facility must provide or obtain laboratory services when ordered .The facility is responsible for the timeliness of the services. Resident #14 had diagnoses which included stage four pressure wound of the left heel. Wound Evaluation and Management Summary notes, dated 05/15/24, documented HBA1C recommended. The note was signed by the Wound Care Physician. Wound Evaluation and Management Summary notes, dated 05/22, 05/29, 06/05, 06/12, 06/19, 06/28, 07/17, 07/24, 07/31, 08/07, and 08/14/24 documented the HBA1C was pending. The notes were signed by the Wound Care Physician. There was no documentation the HBA1C was ever obtained. On 08/15/24 at 8:40 a.m., the ADON was asked to clarify the recommendation of a HBA1C on Resident #14's wound care notes. On 08/15/14 at 9:32 a.m., the Administrator stated the Wound Care Physician had put the HBA1C under recommendations not orders so the wound care nurse did not see it. They stated they ordered it today. They stated the facility went ahead and did a QA on the HBA1C that started in May and continued on the wound care notes but was never drawn.

Based on observation, record review, and interview, the facilty failed to ensure staff members assisted residents with eating in a dignified manner for two (#12 and #75) of nine sampled residents observed during meal service in the assisted dining room. The DON identified 15 residents who required feeding assistance resided in the the facility. Findings: A Promoting/Maintaining Resident Dignity During Mealtimes policy, revised 07/04/24, read in part, It is the practice of this facility to treat each resident with respect and dignity .All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes .All staff will be seated, if possible, while feeding a resident . 1. Resident #12 had diagnoses which included vascular dementia and obsessive-compulsive behavior. An Annual Resident Assessment, dated 06/09/24, documented Resident #12 had severe cognitive impairment and was dependent on staff for the task of eating. On 08/13/24 at 12:14 p.m., CMA #3 was observed standing over Resident #12 and giving them a bite of their lunch meal. On 08/13/24 at 12:15 p.m., CMA #3 gave Resident #12 a bite of mechanical soft barbeque chicken while standing over the resident on their right side. CMA #3 gave a drink of a pink liquid and instructed the resident to take a drink while standing over the resident. CMA #3 gave the resident a bite of beans instructing them to take a bite while standing to the right of them. 2. Resident #75 had diagnoses which included unspecified dementia and mild neurocognitive disorder. A Quarterly Resident Assessment, dated 07/27/24, documented Resident #75 had severe cognitive impairment and required supervision or touching assistance for the task of eating. On 08/13/24 at 12:28 p.m., CNA #1 walked over to Resident #75, helped the resident move their tray back towards them, and gave the resident bites of beans while standing to the right side of the resident. On 08/13/24 at 12:30 p.m., CNA #1 continued to stand over Resident #75 feeding them bites of beans and attempting to give them a bite of bread. On 08/13/24 at 12:31 p.m., CNA #1 continued to stand over Resident #75 on their right side giving them a bite of chicken and a bite of beans. There was an empty chair observed to the left of the resident. On 08/13/24 at 12:34 p.m., CNA #1 continued to stand over Resident #75 while feeding them a bite of mechanical textured meat. On 08/13/24 at 12:48 p.m., CNA #1 stated they would make sure if a resident needed assistance with their meal, they would help them. On 08/13/24 at 12:49 p.m., CNA #1 stated they were not aware of any policy on where staff were situated while assisting a resident with eating. On 08/14/24 at 10:09 a.m., the DON stated staff should assist residents with eating when needed. They stated staff should be seated while assisting residents with eating.

Based on observation and interview, the facility failed to ensure information to file a formal complaint to the state agency and ombudsman were readily available to 10 of 10 residents that attended the resident group interview. The Administrator reported the census was 83. Findings: On 08/14/24 at 3:15 p.m., ten residents were asked if they knew their Ombudsman. several of the residents questioned what was an Ombudsman. The residents were introduced, then asked if they were familiar with where information was posted to call the ombudsman if they had a concern or complaint. They stated they did not know but the information may be on the bulletin board on C Hall. The residents were asked if they knew how to report a complaint to the state survey office. They stated they did not know, the information may have been posted on the bulletin board on C Hall. On 08/14/24 at 3:46 p.m., the bulletin board on C Hall was observed to have the information to report a complaint to the state office and posting of the Ombudsman. The forms were near the top of the bulletin board, with the bottom of the forms approximately 5 feet above the floor. On 08/14/24 at 3:50 p.m., the Administrator was asked if the information for residents to file a formal complaint to the state agency or contact the Ombudsman were readily available for all residents to view. They stated the forms needed to be lowered.

Based on observation and interview, the facility failed to ensure past survey results were readily available to residents to review for 10 of 10 residents that attended the resident group interview. The Administrator reported the census was 83. Findings: On 08/14/24 at 3:15 p.m., ten residents were asked if they knew where the previous survey results were posted and if the reports were readily available to them, without having to request the information The residents stated they did not know they could look at the reports and did not know where to locate the previous reports. On 08/14/24 at 3:46 p.m., the bulletin board on C Hall was observed to have a binder labeled, Survey Results, in a file bin mounted to the wall. The lower part of the bin was approximately five feet above the floor. The binder was attached to a chain that limited the binder to be lowered approximately three feet above the floor. On 08/14/24 at 3:50 p.m., the Administrator was asked if the previous survey results were readily available to the residents to review, without the assistance of staff. They stated the binder may be too high and needed to be lowered or in a different place.

Based on interview and record review, the facility failed to ensure the results of abuse investigations were submitted to the State within 24 hours for three (#15, 44, and #51) of five residents reviewed for abuse. The Administrator identified 83 residents resided in the facility. Findings: Resident #15 had diagnoses which included cognitive communication deficit and chronic kidney disease, stage 3. Resident #15's admission assessment, dated 05/22/24, documented Resident #15's cognition was intact. An Initial State Reportable Incident form, faxed on 07/08/24 at 4:37 p.m., documented CNA# 5 reported to administration Resident #15 had reported to them that on 07/03/24 CNA #4 had called Resident #15 an expletive word in the shower room. A Final State Reportable Incident form, faxed on 07/11/24 at 12:57 p.m., documented CNA #4 was immediately put on a three day suspension for verbal abuse allegation during this investigation. All staff were immediately in-serviced over abuse on 07/08/24. On 08/14/24 at 1:17 p.m., RN #1 stated the facility policy for reporting abuse was to report verbal and physical abuse immediately. On 08/14/24 at 1:34 p.m. the DON stated the incident had occurred on 07/03/24. They stated it was report to OSDH within two hours or sooner. On 08/14/24 at 1:37 p.m., the DON stated the incident had occurred on 07/03/24 and was reported to CNA #4 on 07/05/24, the CNA stated that they had forgotten to report it. The DON stated CNA #4 had not reported in a timely manner. On 08/14/24 at 1:40 p.m., the Administrator stated the CNA had not reported the incident to them until 07/08/24. 2. Resident #44 had diagnoses to include mild intellectual disabilities, vascular dementia, hearing loss, visual loss, behavioral and emotional disorder with childhood onset, schizophrenia, and bipolar. A Quarterly Assessment, dated 07/19/24 documented Resident #44 had moderate cognitive impairment, displayed verbal behavioral symptoms toward others and required some substantial to maximum assistance with ADLs. An Incident Report Form, dated 06/26/24 documented a hospice nurse reported Resident #44 stated a staff member was too rough with Resident #44. The resident had reported they had urinated on themselves in the dining room at lunch and the aide had to take the resident out of the dining room to provide care. Resident #44 stated They just jerked me around . The investigative file, documented the event occurred on 06/26/24. A Xerox Confirmation Report documented the initial report was filed on 06/26/24 at 2:18 p.m. A Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment of Misappropriation of Property form documented the an allegation of abuse had been received on 06/26/24 but the Nurse Aide Registry had not been notified until 07/02/24. On 08/15/24 11:35 a.m., in the presence of the administrator, the DON was asked to clarify items on the incident report, dated 06/26/24. The DON stated a hospice nurse had reported to staff Resident #44 reported an allegation of abuse with the staff were too rough. The DON was asked when was the nurse aide registry notified of the abuse allegation and an investigation had been initiated for the nurse aide. The DON stated we have five days to report. An Incident Report Form, dated 08/18/24, documented at approximately 8:30 p.m., Resident #44 was being provided care alleged a CNA had molested Resident #44. The investigative file, contained a Xerox Confirmation Report, that documented an initial report to OSDH had been sent on 08/20/24 at 7:59 a.m., and the Nurse Aide Registry form documented the Nurse Aide Registry had been notified on 08/20/24. On 08/20/24 at 11:17 a.m., the ADON was asked when did facility staff become aware of the allegation of abuse regarding the event on 08/18/24. They stated, management was made aware just after noon on 08/19/24. The ADON was asked when did the facility send a report to OSDH. The ADON stated on 08/19/24, the charge nurse had been aware but did not report to management. The ADON was asked when did the facility report to the Nurse Aide Registry a CNA had an allegation of abuse. They stated on 08/20/24 just be fore 8:00 a.m. The ADON was asked if the LPN had been reported to their licensing board. The ADON stated, they had not. 3. Resident #51 had diagnosis to include Alzheimer's Disease and malignant neoplasm of bronchus and lung. A Progress Note, dated 09/19/23 at 1:17, read in part, .[resident] yelling and swatting at other resident during activities . The clinical record did not contain an incident report to OSDH or other required agencies. A Progress Note, dated 04/04/24 at 6:03 p.m., read in part, .Resident wanted to sit in chair in front of nurse station. Another resident was sitting in the chair Resident {#51] attempted to pull other resident out of chair while insulting [them] . The clinical record did not contain an incident report to OSDH or other required agencies. A Quarterly Assessment, dated 06/14/24, documented Resident #51 had clear speech, understands, is understood, has severe cognitive impairment for daily decision making, displayed inattention and disorganized thinking, and required supervision and cues to perform ADLs. A Progress Note, dated 06/21/24 at 7:16 p.m., read in part, .This nurse was coming out of a resident room and seen [Resident #51] sitting in a chair .with legs opened and [Resident #18} was sitting in front of [Resident #51], rubbing on [Resident #51's] vagina. This nurse told residents that the [sic] can not do that and they stopped. This nurse was sitting a nurses station and seen [Resident #51 and [Resident #18] kissing this nurse went to talk to resident and {Resident #51 was leaning forward trying to pull pants down while {Resident #18 had partial of [their] penis out. This nurse told resident they can not do that in the hallway. Resident got up and sat in front of nurses station .interventions Attempted: told resident they were not allowed to do that in hallway . The clinical record did not contain an incident report sent to OSDH of a sexual interaction between Resident #51 and Resident #18. The facility did not provide an incident report or reportable incident to OSDH. On 08/13/24 at 11:46 a.m., during the noon meal, Resident #51 was seated a a dining table in the main dining room. Resident #72, entered the area from a side door and approached the table where Resident #51 was seated. Resident #51 began to swing their arms, and hit Resident #72. CNA #1 calmly separated the residents and assisted Resident #51 to another table for the noon meal. 08/13/24 at 2:10 p.m., CNA #1 was asked to verify if they had assisted Resident #51 during the noon meal when an altercation occurred between two female residents. They stated they had separated the residents. They stated they did not know what triggered the event but turned and seen Resident #51 hitting Resident #72. CNA #1 was asked if they had reported the event to anyone. They stated not yet, was trying to chargé to they could go home at 2:00 p.m., On 08/15/24 at 4:24 p.m., the DON was asked to explain the events surrounding the progress note dated 06/21/24 at 4:27 p.m. The DON stated it appeared the nurse came out and seen Resident #51 sitting in a chair with their legs opened and Resident #18 was sitting in a wheelchair and were observed to be engaged in sexual touching. The DON was asked if a state reportable incident had been completed as a result of the sexual behavior between two cognitively impaired residents. The DON stated, they understood the residents have a right, so nothing else was put in place. The DON was asked to review the progress notes dated 09/19/23 and 04/02/24 and if the events of resident to resident altercations had been reported to OSDH or other required agencies. They stated they had not. been reported.

Based on record review and interview, the facility failed to: a. ensure an allegation of abuse was fully investigated for two (#14 and #51); and b. prevent the potential for further abuse while an investigation was in progress for one (#44) of five sampled residents reviewed for abuse. The Administrator identified 83 residents resided in the facility. Findings: An Abuse Policy, revised 03/24/22, read in part, .Any allegation of abuse will be investigated by the DON, ADON, administrator or designated representative by use of the Abuse Packet. At a minimum they will .Interview any witnesses to the incident .interview the resident .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident if necessary .Interview the roommate, family members, and visitors as able and necessary .Interview other residents to whom the accused employee provides care or services .Employees of this facility who have been accused of resident abuse will be suspended from duty. This action will remain in effect until the investigation has been completed .Any licensed nurse found unfit for service will be reported to the Oklahoma Board of Nursing . 1. Resident #14 had diagnoses which included cognitive communication deficit, anxiety, and persistent mood disorder. A Quarterly Resident Assessment, dated 05/30/24, documented Resident #14's cognition was intact. An Initial State Reportable Incident form, dated 08/04/24, documented on 08/05/24 at 11:35 a.m. the charge nurse reported that resident #14 told hospice nurse that LPN #3 flipped off Resident #14 and stated [explicit word] on 08/04/24. It documented LPN #3 was placed on suspension. A Final State Reportable Incident form, faxed 08/06/24, documented upon interviewing Resident #14, the resident told the Administrator and the ADON they had asked the nurse to complete wound care and the nurse couldn't because they were unable to locate the key to the wound care cart. It documented the resident was mad because the nurse was careless and lost the key. It documented the resident told the nurse [explicit word] and flipped [them] off because [they] were careless to lose the key. It documented Resident #14 said they shouldn't have said anything because they didn't want to get anyone in trouble. The facility completed a referral to APS, notified the police department who did not feel the need to complete a report, and unsubstantiated the complaint because the resident admitted they were the one who told the nurse (explicit word) and flipped them off. It documented witness statements were attached. The report was completed by the Administrator. The investigation included an interview with Resident #48, LPN #3, ADON, and LPN #4. The statements contained the following information: a. Resident #48's statement, undated, documented they were happy with the care LPN #3 provided them. It documented Resident #48 did not have any issues with LPN #3 and was happy with the care they received. b. Resident #14's interview contained the above information on the final report. c. LPN #3's statement, dated 08/05/24, documented Resident #14 had flipped them off and said (explicit word); d. ADON's statement, dated 08/06/24, documented they were informed on 08/04/24 of the misplaced keys to the wound care cart. It documented the ADON arrived at the facility at 12:00 p.m. and provided the keys to the nurse. It did not document any information regarding the allegation of abuse. e. LPN #4's statement, dated 08/05/24, documented the hospice nurse had reported to them that Resident #14 told them they were flipped off over the weekend, and LPN #4 reported the situation to the Administrator and the ADON. It did not document any other staff members or residents were interviewed regarding the abuse allegation involving LPN #3 and Resident #14. A Follow Up State Reportable Incident form, faxed 08/07/24, documented the following additional information: a. on 08/06/24 at approximately 2:00 p.m., the Ombudsman came to the facility and interviewed Resident #14. It documented the resident told the Ombudsman LPN #3 flipped them off and said (explicit word) to the resident. It documented the resident did not want LPN #3 fired. It documented the Ombudsman and the Administrator went to interview Resident #14 who again reported LPN #3 had flipped them off and said (explicit word) to the resident. It documented the resident did not want the nurse fired and the nurse would remain on suspension with possible termination; b. on 08/07/24 at 11:12 a.m. the Administrator spoke to the Ombudsman who talked with their supervisor and they agreed the facility could bring LPN #3 back because the resident was oriented and the resident did not want the nurse fired; c. on 08/07/24 at 11:45 a.m., the Administrator asked Resident #14 if LPN #3 returned to the facility, would the resident be comfortable with LPN #3 providing wound treatment to the resident. It documented the resident stated yes; and d. 08/07/24 would be LPN #3's third day of suspension. It documented the nurse would return to their regular schedule on 08/10/24. There was no documentation the facility conducted any additional interviews with staff or other residents LPN #3 cared for after they received the follow up information where Resident #14 reported it was LPN #3 who flipped them off and cursed at them. There was no documentation LPN #3 had been reported to the Oklahoma State Board of Nursing for this abuse allegation. There was no documentation any additional interviews were held with LPN #3 regarding the incident prior to them returning to work. On 08/12/24 at 8:43 a.m., Entrance Conference was held with the Administrator was asked to provide a copy of the facility's Abuse Prohibition Policy and Procedures. The Abuse Policy revised 03/24/22 was provided to the survey team. On 08/12/24 at 10:21 a.m., Resident #14 stated their abuse concern was over kinda. They stated there was a nurse at the facility that told them (explicit word) last week. They stated it was LPN #3. They stated the facility spoke with the nurse and were going to fire them. Resident #14 stated they didn't want the employee to lose their job. They stated LPN #3 hadn't been in their room since the incident, but they still saw them in the facility. They stated staff had come in and spoke to Resident #14 about the incident, reprimanded LPN #3, and they believed it went down in their record. They stated they didn't think anyone else was around when LPN #3 did it. On 08/14/24 at 9:59 a.m., CMA #2 stated they would report any allegation of abuse to the DON. On 08/14/24 at 10:06 a.m., CNA #6 stated the facility did not tolerate any yelling, screaming, or getting loud. They stated they were to stay calm and collected and approach each resident nicely. They stated they were to report any allegation of abuse to their charge nurse, their supervisor, or anyone above them. On 08/14/24 at 10:10 a.m., the DON stated staff were to notify the charge nurse, if unavailable notify their supervisor, if unavailable the DON, ADON, or Administrator with any allegation of abuse. On 08/14/24 at 10:13 a.m., the Administrator stated the facility didn't allow any abuse or mistreatment. They stated any allegation of abuse was to be reported immediately and the facility would report it within the two hour maximum window as required. On 08/14/24 at 10:15 a.m., the Administrator and the DON stated they shared the responsibility of investigating allegations of abuse. The DON stated if a nurse reported abuse, they would go investigate by interviewing other residents, the aides on the hall, medication aides, the roommate if applicable, and anyone in the vicinity of the incident. They stated they could also review camera footage. On 08/14/24 at 10:17 a.m., the DON stated if a staff member was involved, it would be the same process and they would usually suspend the staff member during the investigation. On 08/14/24 at 10:18 a.m. the DON stated they would report the staff member to the licensing board while completing the State Reportable. The Administrator stated as they were completing the State Reportable, they would report the staff member. On 08/14/24 at 10:18 a.m., the DON stated once they had completed the investigation and determine whether the event did or did not occur and see what the police said to determine if it was safe for a staff member to return to work. On 08/14/24 at 10:19 a.m., the Administrator stated on the abuse investigation involving Resident #14, a hospice staff member had reported the incident to the facility. They stated the resident had reported to hospice a staff member said (explicit word) and flipped them off. They stated it was reported to the charge nurse who reported it to the ADON and Administrator immediately on 08/05/24. On 08/14/24 at 10:24 a.m., the DON stated the allegation was against LPN #3, they were suspended three days and then returned to work after the Administrator spoke to the Ombudsman who told them what to do. On 08/14/24 10:25 a.m., the Administrator stated they did not notify the licensing board of the allegation of abuse involving LPN #3. On 08/14/24 at 10:26 a.m., the Administrator stated they along with the ADON interviewed the resident, the nurse, and then interviewed another resident that the nurse provided care to. The DON stated they did not see any other resident interviews in there. On 08/14/24, at 10:31 a.m., the Administrator stated they did not think any other staff were interviewed. On 08/14/24 at 10:32 a.m. the Administrator and DON stated they believed another resident who had wounds was interviewed but they could not find it in the investigation. On 08/14/24 at 10:34 a.m. the Administrator stated they completed a follow up report because the Ombudsman came to the facility and spoke with Resident #14. They stated the resident reported staff had flipped them off and said (explicit). The Administrator stated at that point, they along with the Ombudsman went to speak to the resident who reported that the nurse said it to [them]. They stated the resident did not want the staff member fired. On 08/14/24 at 10:37 a.m., the Administrator stated they had spoken with the Ombudsman who stated it was safe to bring the staff member back after their suspension. They stated the Ombudsman reported the resident was oriented, they were there for the residents, and that was what the resident wanted. On 08/14/24 at 10:39 a.m., the DON reported LPN #3 was educated by the DON, ADON and Administrator to take a staff member in with them anytime they were providing care to Resident #14. They stated it was verbal and there was no documentation of the conversation. On 08/14/24 at 1:42 p.m., the Administrator provided a new abuse policy revised 07/01/24. 2. Resident #44 had diagnoses to include mild intellectual disabilities, vascular dementia, hearing loss, visual loss, behavioral and emotional disorder with childhood onset, schizophrenia, and bipolar. A Quarterly Assessment, dated 07/19/24 documented Resident #44 had moderate cognitive impairment, displayed verbal behavioral symptoms toward others and required some substantial to maximum assistance with ADLs. An Incident Report Form, dated 06/26/24 documented a hospice nurse reported Resident #44 stated a staff member was too rough with Resident #44. The resident had reported they had urinated on themselves in the dining room at lunch and the aide had to take the resident out of the dining room to provide care. Resident #44 stated They just jerked me around . The investigative file, contained documented of two Nurse Aides, a visitor, the resident's room mate, and a hospice nurse were interviewed. There was no documentation other staff or residents in the facility had been interviewed to ensure the safety of all residents. On 08/15/24 11:35 a.m., in the presence of the administrator, the DON was asked how was it determined the allegation was fully investigated. The DON stated they interviewed the resident, the other people that were in the resident room at the time, a hospice nurse , as well as the resident's room mate at the time - which has since passed away. The DON was asked if the alleged CNA involved had access to other residents. The don stated yes and the CNA that had assisted was from another hall. The DON was asked how was the event fully investigated if other residents being provided care from the staff involved were not interviewed, or if other staff were not interviewed. The DON stated, I thought I had a good investigation at the time, with a lot of interviews, but they are not with the information provided to the surveyor. No further information was provided. 3. Resident #51 had diagnosis to include Alzheimer's Disease and malignant neoplasm of bronchus and lung. A Progress Note, dated 09/19/23 at 1:17, read in part, .[resident] yelling and swatting at other resident during activities . The clinical record did not contain an incident report or investigative notes. A Progress Note, dated 04/04/24 at 6:03 p.m., read in part, .Resident wanted to sit in chair in front of nurse station. Another resident was sitting in the chair Resident {#51] attempted to pull other resident out of chair while insulting [them] . The clinical record did not contain an incident report or investigative notes. A Quarterly Assessment, dated 06/14/24, documented Resident #51 had clear speech, understands, is understood, has severe cognitive impairment for daily decision making, displayed inattention and disorganized thinking, and required supervision and cues to perform ADLs. A Progress Note, dated 06/21/24 at 7:16 p.m., read in part, .This nurse was coming out of a resident room and seen [Resident #51] sitting in a chair .with legs opened and [Resident #18} was sitting in front of [Resident #51], rubbing on [Resident #51's] vagina. This nurse told residents that the [sic] can not do that and they stopped. This nurse was sitting a nurses station and seen [Resident #51 and [Resident #18] kissing this nurse went to talk to resident and {Resident #51 was leaning forward trying to pull pants down while {Resident #18 had partial of [their] penis out. This nurse told resident they can not do that in the hallway. Resident got up and sat in front of nurses station .interventions Attempted: told resident they were not allowed to do that in hallway . The clinical record did not contain an incident report or investigative notes. On 08/15/24 at 02:17 p.m., the DON was asked how resident to resident altercations are handled. They stated usually like all other reportable events. The DON was asked if an investigation was initiated for Resident #51. They were asked to provide a copy of the event and items reported. No further information was provided. On 08/15/24 at 4:24 p.m., the DON was asked if the resident to resident altercations on 09/19/23, 04/02/24, and 06/21/24, had been investigated. They stated there was not a report made so there was not an investigation.

Based on interview and record review, the facility failed to revise care plans for two (#18 and #51) of 21 residents reviewed for care plans. The Administrator identified 83 residents resided in the facility. Findings: A Care Plan Revisions Upon Status Change policy, revised 07/02/24, read in part, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change .The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change .The care plan will be updated with the new or modified interventions . Resident #18 had diagnosis which included unspecified dementia. Resident #18's quarterly assessment dated , 04/20/24, documented Resident #18's cognition was severely impaired. A Behavior Note, dated 09/20/19 at 5:24 p.m., documented, Another resident informed this nurse that resident was in hallway touching penis. List Interventions Attempted: Educated [Resident #18] that resident will need to go inside room in private to do so. A Behavior Note, dated 10/18/19 at 4:49 p.m., documented, ACMA was giving resident eternal feedings when resident got penis out of pants and started touching [themselves]. ACMA asked resident respectfully to wait until after feeding was administered. List Interventions Attempted: ACMA asked resident respectfully to wait until after feeding was administered. This nurse spoke [with] resident and asked if it could wait until after feeding due to being unable to stop feeding. A Behavior Note, dated 10/22/23 at 8:56 p.m., documented, [Resident #18] had penis out during 2030 [8:30 p.m.] smoke break. List Interventions Attempted: CNA [name withheld] firmly told [Resident #18] to put [Resident #18] penis away. A Behavior Note, dated 10/23/23 at 1:01 p.m., documented, During 11 a.m. smoke break resident exposed penis. List Interventions Attempted: CNA/Activities assist [name withheld] instructed resident to put it away now. A Behavior Note, dated 04/21/24 at 10:02 a.m., documented CMA had was finishing feeding [Resident 18] when [Resident 18] ran [Resident 18's] hand up [CMA's] leg and tried to touch [CMAs] private area. List Interventions Attempted: CMA firmly told [Resident #18] to keep [Resident 18's] hands to [themselves]. A Behavior Note, dated 06/21/24 at 7:25 p.m.,, documented, This nurse was coming out of a resident room and [Resident #18] sitting in WC in front of [Resident #51] rubbing on her vagina. This nurse told residents that they can not do that in the hallway and they stopped. This nurse was sitting a [sic] nurses station and seen [Resident #18] and [Resident #51] kissing. This nurse went to talk to residents; [Resident #18] had partial of [their] penis out and Resident #51 was leaning forward trying to pull pants down. This nurse told resident they can not do that in the hallway and [Resident 51] voiced understand and got up and sat in front of nurses station. On 08/15/24 at 5:36 p.m., Resident #18's care plan was reviewed, there was no documentation of sexual behaviors in the care plan. On 08/19/24 at 2:15 p.m., the DON stated the care plan had last been updated on 08/06/24. 3. Resident #51 had diagnosis to include Alzheimer's Disease and malignant neoplasm of bronchus and lung. A Progress Note, dated 09/19/23 at 1:17, read in part, .[resident] yelling and swatting at other resident during activities . The clinical record did not contain an a care plan to address Resident #51's behaviors. A Progress Note, dated 04/04/24 at 6:03 p.m., read in part, .Resident wanted to sit in chair in front of nurse station. Another resident was sitting in the chair Resident {#51] attempted to pull other resident out of chair while insulting [them] . The clinical record did not contain a care plan to address Resident #51's behaviors. A Quarterly Assessment, dated 06/14/24, documented Resident #51 had clear speech, understands, is understood, has severe cognitive impairment for daily decision making, displayed inattention and disorganized thinking, and required supervision and cues to perform ADLs. A Care Plan, last reviewed on 07/05/24, did not address resident specific behaviors or interventions for behaviors. A Progress Note, dated 06/21/24 at 7:16 p.m., read in part, .This nurse was coming out of a resident room and seen [Resident #51] sitting in a chair .with legs opened and [Resident #18] was sitting in front of [Resident #51], rubbing on [Resident #51's] vagina. This nurse told residents that the [sic] can not do that and they stopped. This nurse was sitting a nurses station and seen [Resident #51 and [Resident #18] kissing this nurse went to talk to resident and [Resident #51] was leaning forward trying to pull pants down while [Resident #18] had partial of [their] penis out. This nurse told resident they can not do that in the hallway. Resident got up and sat in front of nurses station .interventions Attempted: told resident they were not allowed to do that in hallway . The clinical record did not contain a care plan to address Resident #51's behaviors On 08/13/24 at 11:46 a.m., during the noon meal, Resident #51 was seated a a dining table in the main dining room. Resident #72, entered the area from a side door and approached the table where Resident #51 was seated. Resident #51 began to swing their arms, and hit Resident #72. CNA #1 calmly separated the residents and assisted Resident #51 to another table for the noon meal. On 08/15/24 at 4:24 p.m., the DON was asked if Resident #51's care plan addressed behaviors that were displayed by Resident #51. They stated, No.

Based on observation, record review, and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week. The Administrator identified 83 residents resided in the facility. Findings: On 08/14/24 at 10:58 a.m., Human Resource #1, provided the requested RN hours for May, June, and July. Review of the RN time punch details documented, the facility did not have RN coverage for eight consecutive hours on the following dates: a. 05/04/24 - 7.68 hours worked, b. 05/05/24 - 7.72 hours worked, c. 05/12/24 - 7.47 hours worked, d. 05/18/24 - 7.45 hours worked, e. 05/19/24 - 7.43 hours worked, f. 05/27/24 - 7.80 hours worked, g. 06/08/24 - 7.60 hours worked, h. 06/23/24 - 7.67 hours worked, i. 07/05/24 - 4.93 hours worked, j. 07/06/24 - 7.60 hours worked, k. 07/07/24 - 7.53 hours worked, l. 07/13/24 - 7.45 hours worked and, m. 07/26/24 - 7.47 hours worked. On 08/15/24 at 11:37 a.m., Human Resource #1 stated if the facility did not have RN coverage, the DON or ADON would need to come in to cover. On 08/15/24 at 11:48 a.m., Human Resource #1 stated the dates listed above did not meet the 8 consecutive RN hours required.

Based on observation, record review, and interview, the facility failed to follow their policy to administer medications via enteral tube for one (#13) of one sampled resident reviewed for medication administration via gastrostomy tube. The Administrator stated 83 residents resided in the facility. The Resident Matrix, dated 08/12/24, documented four residents with a gastric tube resided in the facility. Findings: A Medication Administration via Enteral Tube policy, dated 07/02/24, documented, .flush enteral tube with water per orders prior to administering medications .dilute the solid or liquid medication as appropriate and administer using a clean oral syringe .Flush tube again with water per orders taking into account resident's volume status .repeat with the next medication .flush the tube with a final flush of water . Physician Orders for Resident #13 included: a. On 07/06/23, may crush medications; b. On 08/08/23, clopidogrel bisulfate 75 mg by mouth every day for hypertension; lactulose 10 gm/15 ml give 30 ml by mouth daily; Mylanta maximum strength oral suspension 400-400-40 mg/5 ml give 15 ml by mouth two times a day; c. On 08/14/23, trospium chloride ER 60 mg by mouth every day; d. On 12/05/23, CoQ-10 100 mg by mouth one time a day; docusate 100 mg by mouth every day; e. On 12/18/23, famotidine 40 mg by mouth twice a day; f. On 09/01/23, furosemide 40 mg by mouth every day; g. On 01/25/24, glycolax powder, give 17 gram in orange juice, by mouth every day; h. On 05/02/24, hydroxyzine 50 mg by mouth two times a day; i. On 05/20/24, lorazepam 0.5 mg by mouth two times a day; and j. On 06/12/24, Jevity 1.5 Cal/Fiber one can via gastrostomy tube four times a day, flush with 60 cc of water before and after. On 08/14/24, at 9:00 a.m., CMA #1 was observed to prepare the above orders to be administered to Resident #13. CMA #1 placed the tablets into a medication cup, poured the tablets into a pouch and crushed the medications to a fine powdery substance, and placed the contents into a plastic water cup. No liquids were added into the cup of crushed medications. The lactulose was poured into a medication cup for administration. CMA cleansed their hands, donned gloves and a gown, entered the resident room, and arranged the cups on the bedside table. CMA #1 obtained an eight ounce container of tap water. CMA #1, checked the residual of contents of the gastrostomy tube, removed the plunger from the syringe, placed the syringe into the gastrostomy tube, poured approximately 60 cc of water into the syringe, added water to parts of the Jevity, poured a small amount of the mixture into the syringe and gastrostomy tube, followed by an undetermined amount of dry fine powder substance of the crushed medications, added water, dry crushed medications, Jevity, and repeated the process until the medications and Jevity was been administered through the gastrostomy tube. The tube was then flushed with approximately 60 cc of water. On 08/14/24, at 1:28 p.m., CMA #1 was asked if there was a reason the medications had not been diluted in liquids prior to placing the dry crushed medications in the syringe attached to the gastrostomy tube. CMA #1 stated, I forgot to bring a spoon, CMA #1 stated they were aware the medications could be cocktailed and diluted with water.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 37 medications opportunities were observed, with three errors, for a total error rate of 8.11%. This affected two (#13 and #43) of six residents observed during the medication administration. The Administrator stated 83 residents resided in the facility. Findings: 1. A Physician Order, dated 03/09/24, documented Resident #43 was to be administered a chewable aspirin one time a day for atherosclerotic heart disease. On 08/14/24 at 8:50 a.m., CMA #1 prepared and administered oral medications for Resident #43, to include a chewable aspirin as ordered. CMA placed the chewable aspirin in the same medication cup with other medications for a total of 10 medications. CMA #1 did not provide instruction to Resident #43 regarding the chewable aspirin to be chewed and not swallowed. 2. Physician Orders for Resident #13 included: a. On 07/06/23, may crush medications; b. On 08/08/23, administer Mylanta Maximum Strength oral suspension by mouth two times a day for pneumonitis; and c. On 08/29/23, administer Potassium Chloride ER tablet by mouth one time a day for extremity edema. On 08/14/24 at 9:00 a.m., CMA #1 asked Resident #13 if they preferred their medications to be given by mouth or via gastrostomy tube. Resident #13 requested all medications to be via gastrostomy tube. CMA #1 prepared the medications for Resident #13, and removed the Potassium Chloride ER from the medication cup. CMA #1 stated they needed to obtain Mylanta from the medication room. The CMA went to the medication room in search of the medication, stated the medication must not have been delivered, there was no Mylanta to be offered or administered to Resident #13. On 08/14/24 at 1:28 p.m., CMA #1 was asked why Resident #43 was administered a chewable aspirin and not instructed to chew the tablet as ordered. They stated the resident has always just swallowed it. CMA #1 was asked why resident #1 did not receive the Potassium Chloride as ordered. CMA #1 stated, the medication is coated and cannot be crushed. They were asked if there was an order to hold the medication or to provide a liquid potassium if given through the gastrostomy tube. CMA #1 stated there were no further orders to hold or different form of the medication. Three medication error occurred out of 37 opportunities, which resulted in an error rate of 8.11%.

2. On 08/13/24 at 11:20 a.m., dietary aide #1 obtained a chlorine test strip and placed it in the outer basin of the dish machine to moisten the strip. The strip turned a light lavender in color. On 08/13/24 at 11:24 a.m., dietary aide #1 stated it read 10 ppm. They stated it should read between 50-100 ppm. On 08/13/24 at 11:29 a.m., the dietary manager obtained a chlorine test strip and placed it in the outer basin of the dish machine to moisten the strip. The strip again turned a light lavender in color. The dietary manager stated it should read 120 ppm. On 08/13/24 at 11:34 a.m., the dietary manager stated they had called maintenance and they would be on there way. On 08/13/24 at 11:35 a.m., the dietary manager stated they would use paper serving containers and plastic utensils for lunch service as the dishes were not sanitized properly. Based on observation, record review, and interview, the facility failed to: 1. ensure bare hand contact with food did not occur during the lunch meal service. 2. monitor the dish washing machine to ensure proper sanitation was being conducted. Findings: A Food Service policy, undated, read in part, .All staff in the dining room will wash/sanitize hands with any resident contact, touching other surface or contact with your own person before serving a resident meal tray . 1. Resident #75 had diagnoses which included unspecified dementia and mild neurocognitive disorder. A Quarterly Resident Assessment, dated 07/27/24, documented Resident #75 had severe cognitive impairment and required supervision or touching assistance for the task of eating. On 08/13/24 at 12:19 p.m., CNA #1 picked up Resident #75's slice of bread with their bare hands and asked the resident if they wanted a bite. On 08/13/24 at 12:30 p.m., CNA #1 picked up Resident #75's slice of bread with their bare hands and tried to feed it to them. The resident took the piece of bread from CNA #1 and started feeding themselves. On 08/13/24 at 12:49 p.m., CNA #1 stated they would have to ask another staff member the policy for bare hand contact with food. They stated they would make sure they washed and sanitized their hands. On 08/14/24 at 10:08 a.m., the DON stated staff just had to sanitize their hands before touching food with their bare hands. They stated staff were allowed to touch food with their bare hands to butter toast or something like that.

Based on observation, record review, and interview, the facility failed to: a. handle soiled linens in a manner that prevented cross contamination for one (#14) of one sampled resident observed during wound care; and b. ensure enhanced barrier precautions were utilized when accessing a resident's gastric tube for one (#13) of one sampled resident observed with a gastric tube. The Administrator identified 83 residents resided in the facility. The Resident Matrix, dated 08/12/24, documented four residents with a gastric tube resided in the facility. Findings: A Laundry Services policy, undated, read in part, .All soiled linen should be bagged or put into carts at the location where used .If laundry barrels are used, all linens should be bagged . An Enhanced Barrier Precautions policy, dated 07/24/24, read in part, .Enhanced barrier precautions .(EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .enhanced barrier precautions .for residents with .feeding tubes .necessary when performing high-contact care activities .donned prior to entering the resident's room activities include .feeding tubes .Additional epidemiologically important MDROs may include .ESBL -producing Enterobacterales . 1. Resident #14 had diagnoses which included cognitive communication deficit, anxiety, and persistent mood disorder. A Quarterly Resident Assessment, dated 05/30/24, documented Resident #14 was cognitively intact, dependent on staff for the task of toileting, and always incontinent of bowel and bladder. On 08/12/24 at 9:56 a.m., CNA #7 provided incontinent care to Resident #14. CNA #7 turned Resident #14 on their right side and large soft brown stool was observed on their buttock and up their back. The resident stated Can you believe it went all the way up my back? On 08/12/24 at 10:00 a.m., CNA #7 stated, That's what you have me for, to help you. Stool was observed on the sling that was located under the resident and on the bottom of their shirt. On 08/12/24 at 10:03 a.m., CNA #7 stated, We will get you a new shirt ok. The CNA removed the resident's soiled shirt and sling, and tossed them on the ground by the foot of the bed. Both items had brown stool on them. On 08/12/24 at 10:07 a.m., CNA #7 removed the sling and black shirt from off the ground, and placed the items on the lid of a yellow soiled linen barrel located outside in the hallway. CNA #7 lifted the items off the lid, lifted the lid, and placed the soiled shirt and sling in the yellow barrel. The CNA failed to place the soiled items in a bag prior to transporting them out of the resident's room. On 08/12/24 at 10:08 a.m., CNA #7 stated if items got wet, they would place them in the yellow barrel. They stated if it had diarrhea on it, they would blow it out. They stated the only diarrhea today was on the resident's brief. On 08/14/24 at 10:10 a.m., the DON stated staff should hold soiled items away from the body and of course wear gloves. 2. Resident #13 had diagnoses to include diffuse large B-cell lymphoma, metastatic cancer, ESBL resistance, gastrostomy status, and chronic kidney disease -Stage 4. Physician Orders, dated 06/27/24 documented Resident #13 was to be admitted to hospice services, medications and nutrition could be administered by mouth or gastrostomy tube. On 08/14/24 at 9:00 a.m., CMA #1 was observed to don gloves and gown, enter Resident #13's room with prepared medications, administer medications and a nutritional supplement, remove the gloves and gown, and begin to clean the work area. Resident #13 stated, they did not believe all of the contents placed in the gastrostomy tube had gone in. CMA #1, washed their hands, donned gloves, and opened the cap of the gastrostomy tube. The CMA was asked if there was a reason they did not don a gown when they returned to check the gastrostomy tube. The CMA stated there was not a gold star on the Resident's door to indicate the need for a gown, as they pointed to a green star on the door. The CMA was asked what was the meaning of the green star. They stated, I don't know. On 08/14/24 at 1:34 p.m., LPN #1 was asked how the medication aides were to know what type of PPE was to be worn while administering medications for a resident with a gastrostomy tube. LPN #1 stated, I don't know. The LPN was asked what was the meaning of the green star on the doors. They stated, I would have to ask. On 08/14/24 at 1:39 p.m., LPN #2, having overheard the conversation with LPN #1, stated the green star is to identify EBP and the medication aides are to wear gloves and a gown prior to providing any care to the resident. LPN #2 stated if there had been a gold star, the staff are to don gloves and gowns prior to entering the resident room. The medication aide should have donned gloves and a gown when they check the gastrostomy tube each time the care was provided to Resident #13.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and interview, the facility failed to ensure a resident's DNR form was signed by an individual with the authority to do so for one (#69) of three residents reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 48 residents had advanced directives. Findings: Res #69 had diagnoses which included Alzheimer's disease. A Durable General Power of Attorney form, dated [DATE], read in part, .28. Restrictions on Agent's [NAME] .f. My agent cannot execute on my behalf an Advanced Directive for Health Care, living will or other, similar instrument . An OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM, dated [DATE], was signed by the individual who was documented as the resident's agent in the Durable General Power of Attorney form dated [DATE]. A quarterly assessment, dated [DATE], documented Res #69 was severely impaired in cognitive skills, required extensive to total assistance with ADLs, and was receiving hospice care. A care plan, reviewed on [DATE], documented Res #69 had a DNR order and was not to receive CPR through the next review date. The care plan documented the resident could revoke the DNR order at any time. On [DATE] at 3:47 p.m., the administrator reviewed the two documents and the dates they were signed. The administrator stated the agent did not have authority to sign a DNR form for the resident.

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to OHCA for a PASRR Level II evaluation for one (#41) of two residents reviewed for PASRR. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: A PASRR level one document for Res #41, dated 02/23/15, documented the resident had no mental illness, history of mental illness, or sign of mental illness. The resident's EHR documented Res #41 received diagnoses of recurrent major depressive disorder, unspecified mood affective disorder, and generalized anxiety disorder. The resident's EHR documented Res #41 received a diagnosis of pseudobulbar affect on 08/07/20. The resident's EHR documented Res #41 received a diagnosis of bipolar disorder on 08/11/21. A significant change assessment, dated 06/05/23, documented Res #41 was moderately impaired in cognition, required extensive to total assistance with ADLs, and was not considered by the state level PASRR level II process to have serious mental illness. The assessment documented the resident received antipsychotic, antidepressant, and antianxiety medications, daily during the seven day assessment period. On 07/13/23 at 4:13 p.m., the DON stated OHCA had been contacted by phone and had no record the facility had notified them when the resident received a new diagnosis of mental illness. The DON stated the documentation should have been sent to them when the diagnoses were received.

Based on observation, record review, and interview, the facility failed to ensure residents received supervision and assistance to prevent falls for one (#47) of four residents sampled for falls. The administrator identified 54 residents who had fallen in the previous six months. Findings: Res #47 had diagnoses which included acute and chronic respiratory failure with hypoxia, lack of coordination, abnormalities of gait and mobility, muscle weakness, osteoarthritis, anemia, and anoxic brain damage. The care plan documented an intervention, dated 12/04/17, to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan intervention included to be sure the staff promptly responded to all requests for assistance. An incident report, dated 11/27/22, documented the experienced a fall in their room between their bed and their room mates bed. The new intervention was documented as place a sign on the resident's wall reading Call, Don't Fall to remind the resident to use her call light. The resident's care plan was updated with this intervention. An annual assessment, dated 12/10/22, documented the resident required extensive assistance with most ADLs and required staff assistance with stabilizing during walking, turning around, moving on and off the toilet, and transferring from surface. The assessment documented the resident had a range of motion impairment on one side of the upper extremities and on both sides of the lower extremities. The assessment documented the resident had experienced one non injury fall, one non-major injury fall, and one major injury fall, since admission or the previous assessment. The CAA triggered falls for care planning. An incident report, dated 01/12/23, documented while being assisted to stand from the toilet the resident would not use her legs and the CNA lowered the resident to floor. The incident report documented an intervention to have a care plan meeting to discuss the resident's behaviors. The facility was unable to provide documentation this care plan meeting occurred and the care plan did not document this or another new intervention to prevent falls. A modification of a quarterly assessment, dated 03/12/23, documented the resident was intact in cognition, required extensive assistance with ADLs, and did not walk. The assessments documented the resident had fallen since the prior assessment, admission/entry, or reentry to the facility. A quarterly assessment, dated 06/12/23, documented the resident was intact in cognition, required extensive assistance with most ADLs, and had not fallen. An incident report, dated 06/13/23, documented the resident was found in the floor in their room with their feet under them. The incident report documented an intervention to educate the resident to call for help and to wait for assistance with toileting. The resident's care plan did not document a new intervention to prevent falls. An incident report, dated 06/27/23, documented the resident was found on the floor after attempting to pick up a dropped comb. The assessment documented an intervention to ask for assistance when they dropped anything. The care plan did not document a new intervention to prevent falls. On 07/18/23 at 11:20 a.m., the resident was observed lying in bed with a tee shirt on. The bed was in the high position and there was a mechanical lift in the room. The resident was unable to be understood for interview. On 07/18/23 at 11:23 a.m., MDS coordinator #1 stated there were no records to document a care plan meeting was conducted in relation to the 01/12/23 fall and resident behaviors. The MDS coordinator stated the MDS team was notified of falls in the morning stand up meeting but the DON and ADON were responsible to put new interventions in the care plan. On 07/18/23 at 12:30 p.m., the DON stated Res #47 had been admitted to the hospital several days after the fall on 01/12/23 fall for an unrelated issue. The DON stated when the resident returned from the hospital they no longer had the behavior of refusing to use their legs when attempting a transfer. The DON confirmed they did not initiate a new intervention at that time. When asked about reusing the intervention of educating the resident to ask for help, the DON stated they were taught they could reuse the intervention if it had been six months since they had last used it. The DON stated they now understood they should have used a different intervention as educating the resident to use the call light and ask for assistance did not work.

Based on record review and interview, the facility failed to ensure a medication regimen review conducted by the consultant pharmacist and agreed on by the physician was acted on for one (#42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 81 residents resided in the facility. Findings: Res #42 had diagnoses which included abnormal weight loss, sarcopenia, and dementia without behavioral disturbances. A physician order, dated 09/14/22, documented to administer mirtazipine (an antidepressant sometimes used to increase a resident's appetite) 7.5 mg one tablet at bedtime for appetite. A medication regimen review, dated 02/10/23, documented a request to decrease mirtazapine from 7.5 mg. A physician response, dated 02/21/23, documented to reduce the resident's dose of mirtazapine from one tablet to 1/2 a tablet at bedtime. A significant change assessment, dated 05/19/23, documented the resident was severely impaired in cognition and required extensive assistance with most ADLs. The assessment documented the resident received antidepressant medication for seven days of the seven day assessment period. A review of the resident's EHR did not document the facility reduced the resident's dose of mirtazapine. On 07/13/23 at 3:38 p.m., the DON stated the medication regimen review, dated 02/10/23, had not been noted by a nurse. On 07/13/23 at 4:11 p.m., the DON stated medication regimen review had not been acted on by the facility staff.

Based on record review and interview, the facility failed to ensure a psychotropic medication was not administered in excessive dosage for one (#42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 46 residents who resided in the facility received antidepressant medications. Findings: Res #42 had diagnoses which included abnormal weight loss, sarcopenia, and dementia without behavioral disturbances. A physician order, dated 09/14/22, documented to administer mirtazipine (an antidepressant sometimes used to increase a resident's appetite) 7.5 mg one tablet at bedtime for appetite. A medication regimen review, dated 02/10/23, documented a request to decrease mirtazapine 7.5 mg. A physician response, dated 02/21/23, documented to reduce the resident's dose of mirtazapine from one tablet to 1/2 a tablet at bedtime. A significant change assessment, dated 05/19/23, documented the resident was severely impaired in cognition and required extensive assistance with most ADLs. The assessment documented the resident received antidepressant medication for seven days of the seven day assessment period. The resident's MAR documented the resident continued to receive the 7.5 mg and had not been reduced. On 07/13/23 at 3:38 p.m., the DON stated the medication regimen review, dated 02/10/23, had not been noted by a nurse. On 07/13/23 at 4:11 p.m., the DON stated medication regimen review had not been acted on by the facility staff and the facility had not reduced the antidepressant as ordered in February of 2023.

3. Res #19 had diagnoses which included diabetes mellitus with other specified complications, renal osteodystrophy, anemia in chronic kidney disease, and end stage renal disease. A care plan, dated 08/02/21, documented the resident was at risk for developing complications due to dehydration and/or potential fluid deficit related to renal dialysis and received dialysis two times a week. A quarterly assessment, dated 05/13/23, documented the resident's cognition was intact and she required minimal assistance with ADLs The assessment documented the resident was on dialysis. On 07/18/23 at 2:35 p.m., MDS Coordinator #1 stated the resident went going to dialysis three times a week. When asked when Res #19 started going to dialysis three times a week the MDS Coordinator #1 stated they were not aware of when the resident changed from two times a week to three times a week. On 07/18/23 at 3:09 p.m., the DON and stated Res #19 went to dialysis on Monday, Wednesday and Friday. The DON stated they knew the resident had been going to dialysis three times a week for awhile. The DON stated Res #19 had been admitted to an acute care facility and while there dialysis was increased to three times a week. The DON confirmed the facility did not change the orders to three times a week when the resident returned to their facility. The DON stated the resident did not have the care plan changed at that time either. Based on observation, record review, and interview, the facility failed to ensure care plans were updated to meet residents' current needs for three (#14, 19, and #47) of 25 sampled residents whose care plans were reviewed. The facility failed to ensure: a. Res #47's care plan was updated with new fall interventions. b. Res #19's care plan was updated with new dialysis orders. c. Res #47 and #14's care plans had input by the required staff members. d. the facility held the required care plan meetings for Res #47 and #14. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: 1. Res #14 had diagnoses which included CHF, dementia, and anxiety disorder. An admission assessment, dated 11/22/23, documented the resident was severely impaired in cognition, required extensive assistance with most ADLs, and did not walk. The assessment did not document the resident had fallen and the CAA did not trigger falls for care planning. The resident's records did not document a care plan meeting occurred after the completion of the admission assessment. A care plan, dated 02/01/23, documented the resident had experienced an actual fall. An incident report, dated 04/30/23, documented the resident was observed by a nurse to stand up from their wheel chair and fall onto their bottom. An intervention documented on the incident report was the employee was educated to toilet the resident and assist them to lay down if the resident requested to lay down. The resident's care plan did not document staff education and/or to toilet and lay the resident down on resident request. An incident report, dated 05/31/23, documented the resident was found on the floor in their room. The incident report documented the resident's bed was in the high position. The incident report documented the resident complained of back pain then shortly after experienced slurred speech, lethargy, refused their medications, and was seen to have been drooling. The incident report documented the resident was sent to the hospital for evaluation. The incident report documented was to educate the CNA on ensuring the bed height was at an appropriate level for the resident. The resident's care plan did not document staff education and/or ensuring the resident's bed was at the appropriate height. On 07/18/23 at 2:40 p.m., Res #14 was observed in their room, in bed, and appeared to be sleeping. The bed was observed in the low position. On 07/18/23 at 3:12 p.m., MDS coordinator #1 provided documentation of a care plan meeting dated 02/10/23. The care plan meeting notes documented two staff members, the SSD and and an LPN, two family members, and one a hospice staff member, attended the care plan meeting. On 07/18/23 at 3:23 p.m., the SSD stated the facility should have had a care plan meeting after the comprehensive care plan had been developed. The SSD reviewed the resident's EHR and stated it was not documented the facility had conducted a care plan meeting after the admission assessment and the comprehensive care plan had been developed. 2. Res #47 had diagnoses which included acute and chronic respiratory failure with hypoxia, lack of coordination, abnormalities of gait and mobility, muscle weakness, osteoarthritis, anemia, and anoxic brain damage. The resident's care plan documented an intervention, dated 12/04/17, to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan intervention included to be sure staff responded promptly to all requests for assistance. An annual assessment, dated 12/10/22, documented the resident required extensive assistance with most ADLs and required staff assistance with stabilizing during walking, turning around, moving on and off the toilet, and transferring from surface to surface. The assessment documented the resident had a range of motion impairment on one side of the upper extremities and on both sides of the lower extremities. The assessment documented the resident had experienced one non injury fall, one non-major injury fall, and one major injury fall since admission or the previous assessment. The care area assessment triggered falls for care planning. An incident report, dated 01/12/23, documented while being assisted to stand from the toilet the resident would not use her legs and the CNA lowered the resident to the floor. The incident report documented an intervention to have a care plan meeting to discuss the resident's behaviors. The facility was unable to provide documentation this care plan meeting occurred and the care plan did not document this or another new intervention to prevent falls. A modification of a quarterly assessment, dated 03/12/23 documented the resident was intact in cognition, required extensive assistance with ADLs, and did not walk. The assessments documented the resident had fallen since the prior assessment, admission/entry, or reentry to the facility. A quarterly assessment, dated 06/12/23, documented the resident was intact in cognition, required extensive assistance with most ADLs, and had not fallen. An incident report, dated 06/13/23, documented the resident was found in the floor in their room with their feet under them. The incident report documented an intervention to educate the resident to call for help and wait for assistance with toileting. The resident's care plan did not document a new intervention to prevent falls. An incident report, dated 06/27/23, documented the resident was found on the floor after attempting to pick up a dropped comb. The assessment documented an intervention to ask for assistance when they drop anything. The care plan did not document a new intervention to prevent falls. On 07/18/23 at 11:20 a.m., the resident was observed lying in bed with a tee shirt on. The bed was in the high position and there was a mechanical lift in the room. The resident was not able to be understood when they spoke. On 07/18/23 at 11:23 a.m., MDS coordinator #1 stated there was no record to document a care plan meeting was conducted in relation to the 01/12/23 fall and resident behaviors. The MDS coordinator stated the MDS team was notified of falls in the morning stand up meeting but the DON and ADON were responsible to put the new interventions in the care plan. On 07/18/23 at 12:20 a.m., MDS coordinator #1 stated the facility should have conducted quarterly care plan meetings. On 07/18/23 at 12:25 p.m., MDS coordinator #2 stated the care plan meetings for Res #47 was attended by the MDS coordinator, the SSD, and the resident's family member who attended over the phone. The MDS coordinator stated the resident was invited but preferred to attend an activity as they did not wish to attend when the family member was there. The MDS coordinator stated an RN and CNA who were responsible for the resident's care did not attend the meetings and they were not aware they were required to participate in the care planning. On 07/18/23 at 12:30 p.m., the DON stated Res #47 was admitted to the hospital several days after the fall on 01/12/23 fall for an unrelated issue. The DON stated when the resident returned from the hospital they no longer had the behavior of refusing to use their legs when attempting a transfer. The DON stated the SSD was responsible for setting up a care plan meeting and a nurse, the SSD, and if the resident is on therapy the therapy staff member would attend. When asked about reusing the intervention of educating the resident to ask for help, the DON stated they were taught they could reuse the intervention if it had been six months since they had last used it. The DON stated they now understood they should have used a different intervention as educating the resident to use the call light and ask for assistance did not work. The DON stated the nurse who attended the care plan meetings was an LPN. The DON stated they do not send an RN, CNA, or dietary to have input at the care plan meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Res #11 had diagnoses which included abnormalities of gait and mobility, lack of coordination, muscle weakness, difficulty in walking, muscle wasting and atrophy, and morbid obesity. A care plan, dated 09/05/2016, documented the resident used positioning bar for repositioning and transfer related to obesity and arthritis. A care plan, dated 12/01/2017, documented the resident would be free of injuries related to positioning bars. A quarterly assessment dated [DATE], documented the resident's cognition was intact and required minimal to limited assistance with ADLs. A five day assessment, dated 05/24/23, documented the resident's cognition was intact and required limited to no assistance with ADLs. On 07/12/23/ at 4:34 p.m., an observation was made of the resident's bed. Grab bars were observed secured to each side of the resident's bed. On 07/17/23 at 09:45 a.m., an interview was conducted with the MDS Coordinator #1 and the MDS coordinator stated the rails on the bed were positioning bars not bed rails. At that time an interview was conducted with the DON stated the bars on the bed were positioning bars only and if the resident could lower the bars to get out of bed then the bars were not considered bed rails. On 07/17/23 at 10:03 a.m., an interview was conducted with Res #11 while the DON and MDS coordinator #1 were in the room. The resident stated they could not let the rails down on the bed and did not want to know how to let the rails down on the bed. On 07/17/23 at 1:00 p.m., the DON provided copies of the side rail assessments and consent forms for Res #11, 15, and #67. After reviewing the documents the DON confirmed the forms did not document the required components and needed to be updated. Based on observation, record review, and interview, the facility failed to ensure assessments and consents for the use of side rails documented the required information for three (#11, 15, and #67) of four residents reviewed for the use of side rails. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: 1. Res #15 had diagnoses which included osteoporosis, rheumatoid arthritis, abnormal posture, muscle wasting, muscle weakness, osteoarthritis, and lack of coordination. A Bed Rail Consent form, dated 03/24/22, read in part, .consent to using half positioning rails a needed/tolerated for mobility. Resident is aware of the potential risk and side effects of having bed rails. Resident continues to wish to use bed rails for positioning at this time. The form did not document, what assessed medical needs was addressed by the use of bed rails, the resident's benefits from the use of bed rails and the likelihood of these benefits; the resident's risks from the use of bed rails and how these risks will be mitigated; and alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate. A physician order, dated 10/19/22, documented the resident was to have a low air loss mattress on their bed at all times as a preventive measure. A care plan, dated 01/21/23, documented the facility was to place positioning bars on both sides of bed to maximize independence with bed mobility and repositioning. A side rail assessment, dated 07/05/23, did not document the resident's medical diagnosis, conditions, symptoms, and/or behavioral symptoms; size and weight; sleep habits; acute medical or surgical interventions; underlying medical conditions; existence of delirium; ability to toilet self safely; cognition; communication; and risk of falling. The assessment documented the reason for the side rails was morbid obesity. An admission/Medicare 5 day assessment, dated 07/06/23, documented the resident was intact in cognition, required extensive to total assistance with most ADLs and did not walk. The assessment documented the resident had no range of motion impairments, had an indwelling urinary catheter, and was frequently incontinent of bowel. The assessment documented restraints were not used with this resident. On 07/13/23 at 8:15 a.m., the resident was observed lying in bed on a low air loss mattress. Grab bars were observed in the up position on both sides of the bed. The resident was asked if they had requested them. The resident stated they did not request them and the facility had just put them on the bed. 2. Res #67 had diagnoses which included paraplegia, congestive heart failure, COPD, sleep apnea, body mass index of 50.0 - 59.9, and pressure ulcer to sacral region. A care plan, dated 11/05/20, documented the resident used rails per the physician order to maximize and independence and turning and repositioning in bed. A care plan, dated 11/11/20, documented the resident used bed rails to assist with tuning and repositioning in the bed as desired. A typed paper, dated 02/13/23, read in part, .consent to using siderail to side of bed for bed mobility. Resident is aware of the potential risks of side rails. Resident wishes to use siderail for positioning. The form did not document, what assessed medical needs was addressed by the use of bed rails, the resident's benefits from the use of bed rails and the likelihood of these benefits; the resident's risks from the use of bed rails and how these risks would be mitigated; and alternatives attempted that failed to meet the resident's needs; and alternatives considered but not attempted because they were considered to be inappropriate. A quarterly assessment, dated 05/23/23, documented the resident was intact in cognition, required extensive to total assistance with ADLs, and did not walk. The assessment documented the resident had a catheter and was always incontinent of bowel. A side rail assessment, dated 07/05/23, did not document the resident's medical diagnosis, conditions, symptoms, and/or behavioral symptoms; size and weight; sleep habits; acute medical or surgical interventions; underlying medical conditions; existence of delirium; ability to toilet self safely; cognition; communication; and risk of falling. On 07/12/23 at 2:12 p.m., the resident was observed lying on their bed which was equipped with a low air loss mattress and quarter side rails up on both sides at the head of the bed. The resident stated they used them to help with turning over. On 07/14/23 at 3:30 p.m., the resident's EHR was reviewed and did not document an order for side rail use. On 07/17/23 at 12:34 p.m., the DON stated the Interview with DON who stated they may have to beef up their assessments. The DON stated they have informed consents for the residents who need side rails. The DON stated the side rails came with the bed and the maintenance department checked them monthly.

Based on observation, record review, and interview, the facility failed to ensure the medication error did not exceed five percent. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: 1. A physician order for Res #72, dated 07/10/23, documented the facility was to administer two drops of ciprfloxacin HCL ophthalmic solution three percent in the resident's right eye four times a day for seven days due to an eye infection. On 07/13/23 at 2:33 p.m., CMA #1 was observed to place two drops of ciprofloxin ophthalmic solution in both eyes of Res #72. On 07/13/23 at 2:36 p.m., CMA #1 stated she started putting the drops in both eyes yesterday. On 07/14/23 at 1:13 p.m., the DON confirmed the order for stated to administer the eye drops in the right eye. 2. Res #49's physician order documented to administer one 20 mEq of potassium chloride twice daily. On 07/14/23 at 7:57 a.m., CMA #2 was observed to administer two tablets of 20 mEq potassium chloride to Res #49. The medication card documented to administer two tablets of 20 mEq of potassium chloride three times daily. On 07/14/23 at 12:30 p.m., the DON was observed to review the resident's medication card for potassium with CMA #2. The DON removed the card and compared it with the new order in the EHR. The DON stated the new directions were not updated on the card when the order was changed. The DON stated a medication error report would have to be filled out and the physician would be notified.

Based on observation, interview, and record review, it was determined the facility failed to implement an effective pest control program for the facility. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: The facility pest control records for the previous six months documented the pest control service had treated the facility monthly for cockroaches, rodents, bed bugs, and flies. There was no documentation provided by the facility for pest for the month of June 2023. On 07/12/23 at 11:44 a.m., during the initial tour of the kitchen a live cockroach was observed crawling across the floor while the staff was preparing to serve the noon meal. On 07/12/23 at 12:49 p.m., a live cockroach was observed crawling on the dining room floor while residents were eating their meal. On 07/12/23 at 01:25 p.m., the DM stated the facility had a pest control company come in and spray every two weeks. The DM stated the company was spraying every week but had just changed it to every two weeks.

Based on observation and interview, the facility failed to ensure food was stored in a sanitary manner and dishes were dried completely before storing them. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: On 07/12/23 at 11:44 a.m., an initial tour of the kitchen was conducted. The following were observed: a. A scoop was observed stored in a large container which was filled with flour. b. Condensation was on plastic containers which were stacked on a shelf. On 07/12/23 at 11:49 a.m., the DM stated scoops should never be left inside any container which stored food. The DM stated the plastic containers should not have been stacked while drying. The DM stated containers should have been left on a shelf to dry and once completely dry then stacked.

Based on record review, observation, and interview, the facility failed to ensure the resident's physician documented a rationale in the resident's medical record when denying a recommendation to reduce a psychotropic medication and failed to ensure the medication regimen review (MRR) policy documented a time frame for the different steps in the process for one (#44) of five residents reviewed for unnecessary medications. The Census and Conditions of Residents form documented 66 residents resided in the facility. Findings: An undated facility policy, titled Monthly Drug Regimen Review, did not document a time frame a resident's physician to respond to a MRR recommendation for a GDR request. Resident (Res) #44 had diagnoses which included insomnia, rheumatoid arthritis, and basal cell carcinoma. A physician order, dated 06/04/20, documented the facility was to administer trazodone (an antidepressant medication) 50 mg at bedtime for insomnia. A consultant pharmacist recommendation, dated 08/21/21, documented a request to reduce Res #44's dose of trazodone from 50 mg to 25 mg at bedtime. A physician response, dated 08/31/21, documented Res #44's physician disagreed with the recommendation but did not document a rational for not attempting a gradual dose reduction. A quarterly MDS assessment, dated 02/16/22, documented Res #44 was intact in cognition, was independent or required set up for most ADLs, and received an antidepressant medication for seven days of the seven day assessment period. A care plan, last reviewed on 02/21/22, documented Res #44 had a hard time sleeping related to insomnia and to administer trazodone as ordered. On 03/24/22 at 11:01 a.m., the DON stated if a physician disagreed with a GDR request but did not document a rational for a resident to remain on a dosage of a psychotropic medication, they did not follow up with the physician regarding a rational for the refusal to decrease the medication. At that time, the DON reviewed the facility policy titled ''Monthly Drug Regimen Review'' and stated it did not document a time frame for the physician to respond to a GDR request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to protect residents' rights to accept or refuse treatment for two (#60 and #63) of three residents sampled for advanced directives. The facility failed to: a. ensure a current copy of a resident's Do-Not-Resuscitate (DNR) consent was in the resident's medical record for resident #63. b. provide information regarding advanced directives once a resident was able to receive and understand the information for resident #60. The Resident Census and Conditions of Residents report documented 66 residents resided in the facility. Findings: An undated facility policy titled Code Status Policy read, When a person admits to our facility for Long Term Care or Skilled services with a completed DNR Confirmation form, or chooses upon admission to full out one, we will honor the DNR form, which indicates there is a documented plan of treatment for no CPR. CPR will not be initiated in the event of cardiorespiratory arrest. The policy did not address provision to provide a resident who was unable to understand information regarding Code Status once he or she was able to receive and understand such information. 1. Resident (Res) #63 was admitted on [DATE] with diagnoses which included aphasia and dysphagia following cerebral infarction. A physician order, dated [DATE], documented the resident's code status was DNR. An admission assessment, dated [DATE], documented the resident was severely cognitively impaired and required limited to extensive assistance with ADLs, (Does this help with info r/t DNR) The care plan, dated [DATE], documented the resident's code status was DNR. The care plan documented to ensure a copy of the DNR consent was available at all times. The resident's medical record was reviewed. A DNR consent form was not found in the record. On [DATE] at 1:39 p.m., LPN #3 stated the resident's code status was changed to full code because they did not have a DNR consent in the building; and stated the hospital orders listed him as a DNR. The nurse stated she was unaware of how that was missed, as there were multiple staff responsible for ensuring the code status was accurate at admission. On [DATE] at 9:01 a.m., Res #63 was lying in bed and was unable to answer detailed questions and not oriented to time. On [DATE] at 10:13 a.m., the DON stated the nurse who entered the DNR order had used the hospital orders to enter the code status of the new resident. 2. Resident (Res) #60 had diagnoses which included combined chronic heart failure, chronic obstructive pulmonary disease, and diabetes type II. An Oklahoma Do-Not-Resuscitate (DNR) Consent Form, signed by Res #60's DPOA for financial only and dated [DATE], was present in Res #60's EMR. A physician order, dated [DATE], documented the facility was not to resuscitate Res #60 in the event of cardio-pulmonary arrest. A care plan, dated [DATE], documented Res #60 did not wish to be resuscitated and if she was found without a pulse, she instructed the facility not to give her CPR. A quarterly MDS assessment, dated [DATE], documented Res #60 was intact in cognition, was independent to requiring limited assistance with most ADLs. (Does this help with info r/t DNR) On [DATE] at 10:27 a.m., the DON reported she did not know why the DNR was signed by the DPOA as Res #60 was able to consent for herself. On [DATE] at 10:32 a.m., the social service (SS) director reported Res #60's DNR had been signed by a family member who was the financial DPOA. The SS director confirmed the resident was able to make decisions for herself at this time and she had not consulted with Res #60 as to whether or not she wished to not be resuscitated if needed. On [DATE] at 3:00 p.m., Res #60 was observed sitting in a chair at the bedside and was interviewed at that time. Res #60 stated they had been unable to sign their admission paperwork when she was admitted to the facility and a family member signed the paperwork. Res #60 was asked if she wanted the facility to attempt to resuscitation if the need arose. Res #60 stated she had not thought about it and no one from the facility had asked about being a DNR.

Based on observation and interview, the facility failed to store, prepare, and serve food in a sanitary manner. The Resident Census and Conditions of Residents report documented 66 residents resided at the facility. Findings: On 03/22/22 at 9:58 a.m., a tray of apple crisp dessert cups, with a date of 03/16/22, were observed in the refrigerator. Eight of the dessert cups were without lids and open to air. On 03/22/22 at 10:00 a.m., the containers which stored bulk dry goods were observed on the prep counter close to the three compartment sink. The lids to the containers were observed to be covered with a dark debris. One of the container's lid was not secured correctly. At that time [NAME] #1 secured the lid on the container and stated the debris on the lids came from the grill brick which was stored behind the containers on the wall. On 03/28/22 at 10:34 a.m., the dietary consultant stated she thought the facility discarded their leftovers after 48 hours, but she would discard leftovers after 24 hours and especially if the food was open to air. She stated the bulk dry good containers should not be close to the sink and all the lids should have been properly secured on the containers. On 03/28/22 at 11:54 a.m., dietary staff were observed to take a plate from the clean plates by the serving line for an alternate meal. When they plated the alternate meal, the staff returned the plate, and set it on the clean plates by the serving line. Three observations were made of this practice. On 03/28/22 at 11:56 a.m., the dietary consultant stated the plates should not be sat back on the clean plates used for meal service after being handled by the staff.