Based on observation, record review, and interview, the facility failed to ensure standard infection control precautions were used during urinary catheter care for 1 (#9) of 1 sampled resident for urinary catheters. The DON reported 34 residents resided in the facility and two residents had urinary catheters. Findings: On 05/13/25 at 2:07 p.m., CNA #1 was observed to empty Resident #9's urinary catheter bag. CNA #1 removed the catheter bag from the dignity cover to empty the catheter bag into the urinal. CNA #1 layed the catheter bag on the floor while attempting to drain all the urine from the catheter tubing and bag into the urinal. CNA #1 set the urinal on the floor and placed the catheter bag back into the dignity cover. CNA #1 picked up the urinal and placed it on Resident #9's small dresser, near some open chocolate candy. A policy titled Emptying a Urinary Drainage Bag, dated 10/01/10, showed to keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. A physician's order, dated 09/30/24, showed to flush suprapubic catheter with 60 milliliters of normal saline and provide catheter care two times a day. An annual assessment, dated 02/05/25, showed Resident #9's cognition was intact with a brief interview of mental status score of 15. The assessment showed diagnoses which included muscular dystrophy and neurogenic bladder, and the use of a urinary catheter. On 05/13/25 at 2:07 p.m., CNA #1 was asked if they should have done anything differently while emptying the urinary catheter bag. CNA #1 reported they should not have lifted the face shield to see better while emptying the catheter bag. On 05/14/25 at 11:10 a.m., the DON reported the catheter bag should not have been layed on the floor and staff needed to be in-serviced again on infection control techniques.

Based on record review and interview, the facility failed to report a physical abuse incident to the Oklahoma State Department of Health in the required timeframe for one (#1) of three residents reviewed for abuse. The Administrator reported 40 residents resided in the facility. Findings: The facility's Abuse policy and procedure, dated 07/23/21, read in part, Immediate reporting: All allegations of residents maltreatment, including neglect, physical abuse, mental abuse, sexual abuse, involuntary isolation, verbal abuse, injuries of unknown origin, and/or misappropriation of property, must be reported immediately to Administrator by a facility employee or immediate supervisor, who will report incidents to the allegation to the Oklahoma State Department of Health as required by State law or regulation . Time reporting or completing incident and accident reports: An Incident and Accident report form will be completed by the Administrator or Administrator Designee within 24 hours of the incident's discovery .If the incident is required to be reported to the State Department of Health Care, the ODH-283 shall be faxed within 24 hours . Time for completing investigation: The Administrator or Administrative Designee will complete the investigation report within five working days .The ODH 283 form, shall be faxed within five working days of the submission of the Incident and Accident Report . Resident #1 had diagnoses which included aphasia, hemiplegia, anxiety, and chronic pain. A nurse's note, dated 06/29/24, documented At approximately 6:30 p.m., after the evening meal, resident #1 was noted by CMA [name removed] acting weird and had a strange look to face and eyes .The dietary aide on duty at the time voiced to CMA that they had given the resident a 100 mg marijuana chewy .Incident reported to on coming nurse and nurse to observe resident .Reported to doctor [name removed] . A nurse's note, dated 06/30/24 at [no time documented], documented Administrator, DON, dietary supervisor, and weekend RN [name removed] aware of resident #1's incident. A Employee Disciplinary Action form, dated 06/30/24, read in part: Employee Name: [name removed]. Department: Dietary. Date of Occurrence: 06/29/24. Date of Counseling: 06/30/24. Type of Action: Termination. Description of Occurrence: Administering a 100 mg edible to resident #1. Then told the CMA what you had done .CMA [name removed] stated he had already administered the resident's evening meds . An ODH-283 incident report form, dated 06/30/24, documented: Initial report. Incident date: 06/30/24. Incident type: Allegation of abuse/mistreatment. Description of incident: Employee [name removed] stated she had given resident #1 a 100 mg edible marijuana gummy .Resident was glassy eyed, stoic looking, and looked odd .The resident was assessed and monitored throughout the night and the next day. Part C: 5 day and final report had not been completed. The fax cover sheet attached to the incident report documented, the fax transmission was completed at 07/01/24 at 3:14 p.m. A comprehensive assessment, dated 07/15/24, documented resident #1's had severe cognitive impairment. On 07/18/24 at 11:35 a.m., LPN #1 reported resident #1's incident was not reported to the Administrator or DON until the next morning, 06/30/24. On 07/18/24 at 12:00 p.m., the Administrator reported she was notified of resident #1's incident on 06/30/24 at 8:18 a.m. The Administrator reported the incident date on the ODH 283 incident report should have been dated 06/29/24. The administrator reported she had received guidance from the cooperate office and sent the incident report to the Oklahoma State Department of Health on 07/01/24. The Administrator reported she did not do a 5 day follow up or final report since the employee had admitted to giving resident #1 the edible marijuana gummy and the employee had been terminated. The Administrator reported the abuse allegation should have been immediately reported to her, and the initial incident report should have been faxed to the Oklahoma State Department of Health within 24 hours of when the incident occurred.

Based on record review and interview the facility failed to complete a thorough abuse investigation for one (#1) of three residents reviewed for abuse. The Administrator reported 40 residents resided in the facility. Findings: The facility's Abuse policy and procedure, dated 07/23/21, read in part, Time for completing investigation: The Administrator or Administrative Designee will complete the investigation report within five working days .The ODH 283 form, shall be faxed to the Oklahoma State Department of Health within five working days of the submission of the Incident and Accident Report . The Administrator or Administrative Designee will conduct an investigation of alleged or actual incidents of abuse, neglect, or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the resident was mistreated to whom, and the measures needed to product occupants from further incidents. If the person is able to communicate, the Administrator or Administrative designee shall document, in sufficient detail, the resident's account of the incident, including a description of the perpetrator . Interviews: Identification and investigation of abuse, neglect, or misappropriation of property should include interviews with those persons the investigator determines are related to allegation or incident Resident #1 had diagnoses which included aphasia, hemiplegia, anxiety, and chronic pain. A nurse's note, dated 06/29/24, documented At approximately 6:30 p.m., after the evening meal, resident #1 was noted by CMA [name removed] acting weird and had a strange look to face and eyes .The dietary aide on duty at the time voiced to CMA that they had given the resident a 100 mg marijuana chewy .Incident reported to on coming nurse and nurse to observe resident .Reported to doctor [name removed] . There was no documentation the facility completed a through investigation. A ODH-283 incident report form, dated 06/30/24, documented, Initial report. Incident date: 06/30/24. Incident type: Allegation of abuse/mistreatment. Description of incident: Employee [name removed] stated she had given resident #1 a 100 mg edible marijuana gummy .Resident was glassy eyed, stoic looking, and looked odd .The resident was assessed and monitored throughout the night and the next day. Part C: 5 day and final report investigation had not been completed. A comprehensive assessment, dated 07/15/24, documented resident #1 had severe cognitive impairment. On 07/18/24 at 11:35 a.m., LPN #1 reported resident #1's incident was not reported to the Administrator or DON until the next morning 06/30/24. On 07/18/24 at 12:00 p.m., the Administrator reported she was notified of resident #1's incident on 06/30/24 at 8:18 a.m. The Administrator reported a written statement from LPN#1 of the reported incident was the only statement available. The Administrator reported no other residents or staff had been interviewed related to this incident. The Administrator reported the incident had been reported to the local police and other required entities. The Administrator reported a 5 day follow up or final investigation report had not been completed since the employee had admitted to giving the resident an edible marijuana gummy and the employee had been terminated.

Based on record review and interview, the facility failed to follow their policy to maintain an effective pest control program for one (#3) of three residents reviewed for pest control management. The DON identified the resident census was 38. A Bed Bugs, Preventing and Managing Infestations of policy, revised August 2011, read in parts, .Staff will employ infection control strategies to prevent and manage infestation of bed bugs .Remove and/or treat all infested materials .washing and drying bedding, linens, and clothing at high temperature .vacuuming or steam-cleaning floors, mattresses and any porous surfaces that cannot be machine washed .The following should be documented at the facility level .Identified instances of infestation .Response to the report of infestation .Actions taken including all interventions and strategies to eliminate the infestation .The following should be documented at the resident-level for those directly affected by the infestation .Resident response to the infestation .Interventions and treatment .If complications ensue (bites .) accident/incident reports must be completed . Resident #3 had diagnoses which included, chronic obstructive pulmonary disease, profound intellectual disability and chronic kidney disease. An outside pest control invoice, dated 10/16/23, read in parts, .Bedlam Plus 1.45% .2 found in 138 16 . A Weekly Skin Audit Record, dated 11/01/23, documented by a body diagram with circles the resident had a rash on the back of all four extremities. On 11/16/23 at 10:01 a.m., Maintenance #1 stated they had some bed bugs but not anything recently. They were asked if they did checks after pest control services treated the rooms to ensure there were no more concerns. They stated they were in an out of the residents rooms but did not do specific monitoring. On 11/16/23 at 10:41 a.m., the Administrator was asked what did two found in 138 and 16 mean they stated they did not know. They were asked what had the facility done to follow up to ensure the issue was resolved. They stated pest control had come on 11/03/23. They were asked for the invoice of services. They stated they did not have one. On 11/16/23 at 11:55 a.m., the ADON was asked if there had been any issues with bedbugs in Resident #3's room. They stated there had been. They were asked if they had assessed the resident for any bites. The ADON stated the resident had a rash, but they had not documented what interventions had been implemented. Resident #3's clinical health record did not contain documentation of the room cleaning, assessment, and interventions completed by the facility when staff had notified administration of a suspicion of bed bugs in the resident's room. On 11/16/23 at 1:06 p.m., an invoice for pest control services on 11/03/23 was requested from the Administrator. On 11/16/23 at 1:09 p.m., Resident #3 was observed in their room. They were asked is there had been any issues with bed bugs recently. Resident #3 stated, the first of the month they had some bug bites on their right arm. They were asked how long that had been going on. They stated it started Way back. On 11/16/23 at 1:20 p.m., the Administrator was shown the facility pest management policy and asked if the policy had been followed. They stated No. The Administrator stated they were unaware there was a bed bug policy until today. On 11/16/23 at 2:30 p.m., the DON was asked if they had followed the policy and procedure for pest management. They stated they had not followed the policy. The DON was asked if there had been any other bed bugs found in Resident #3's room after the pest control management had come out on 11/03/23. They stated they were not sure. The Administrator did not provide an invoice from the pest control services on 11/03/23 prior to the end of the investigation.

Based on record review and interview, it was determined the facility failed to ensure: a. medication hold parameters for blood pressure medications were included on a resident's physician orders/medication administration record for one (#6) of five residents reviewed, and; b. insomnia medication was not given for an extended duration after being discontinued for one (#6) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents, dated 01/10/23, documented 36 residents resided in the facility. Findings: The facility's Consultant Pharmacist Reports policy, dated 01/01/18, read in parts, .The consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards .Recommendations are acted upon and documented by the facility staff and/or the prescriber .Prescriber accepts and acts upon suggestions or rejects and provides an explanation for disagreeing .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician interventions, e.g., monitor blood pressure . The facility's Medication Orders policy, dated 01/01/18, read in part, .The discontinue order is also entered on the physician orders sheet and noted on the medication administration record . Resident # 6 had diagnoses which included coronary artery disease, hypertension, anxiety, depression, and insomnia. A Physician Telephone Order, dated 11/01/22, documented Diltiazem HCL 1 tablet daily, hold if systolic blood pressure is less than 100 or diastolic blood pressure less than 50. A hospice Physician Order, dated 11/08/22, documented to discontinue Melatonin 10 mg at bedtime and start Trazadone 50 mg at bedtime. The resident's Physician Orders for the month of December 2022, documented .Pacerone (Amiodarone HCL) 200 mg tablet everyday .Diltiazem 24 HR ER (Diltiazem HCL) 300 mg cap everyday .Melatonin 10 mg tablet at bedtime for insomnia. The pharmacist's Note to Attending Physician/Prescriber, dated 11/23/22, read in parts, .Do you wish to add a HOLD parameter for Amiodarone based on heart rate? .The doctor agreed on 11/28/22 to hold for heart rate less than 60 beats per minute .Notify physician/clinician if held for 3 sequential doses. The resident's Care Plan, updated 12/29/22, documented in parts .Give me my medication as per orders .see MAR for my frequency and dosage . The resident's January 2023 Medication Administration Record documented, Diltiazem 24HR ER (Diltiazem HCL) 300 mg cap daily .Melatonin 10 mg tablet at bedtime for insomnia .Pacerone (Amiodarone HCL) 200 mg tablet daily, Trazadone 50 mg at bedtime . On 01/11/23 at 3:59 p.m., the DON reported the resident's medical record had been reviewed. The DON reported the heart rate hold parameter for Pacerone (Amiodarone HCL) and the blood pressure hold parameters for Diltiazem HCL should have been added to the resident's physician orders and MAR. The DON reported the order to discontinue Melatonin should have been removed from the resident's physician orders and MAR. The DON reported the resident's MAR and physician's orders had been corrected and a new policy put in place to prevent errors in the future.

Based on record review and interview, the facility failed to electronically transmit resident assessments, within 14 days after completion, for six (#1, 5, 18, 19, 22, and #31) of six residents sampled for resident assessments. The Resident Census and Conditions of Residents, dated 01/10/23, documented 36 residents resided in the facility. Findings: A facility policy, Electronic Transmission of the MDS, revised March 2006, documented in part .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. On 01/10/23 at 4:02 p.m., the Minimum Data Set (MDS) regional coordinator provided a Final Validation Report, which documented the status of the electronic transmission of resident assessments. The Final Validation Report documented the assessment for Resident (Res) #1 was accepted, with a target date of 09/01/22. The report showed a submission date of 09/26/22, and documented, record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #5 was accepted, with a target date of 09/01/22. The report showed a submission date of 09/26/22, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #18 was accepted, with a target date of 09/01/22. The report showed a submission date of 09/26/22, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #19 was accepted, with a target date of 09/02/22. The report showed a submission date of 09/26/22, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #22 was accepted, with a target date of 11/21/22. The report showed a submission date of 01/10/23, and documented record submitted late: the submission date is more than 14 days. The Final Validation Report documented the assessment for Res #31 was accepted, with a target date of 08/29/22. The report showed a submission date of 09/26/22, and documented record submitted late: the submission date is more than 14 days. On 01/10/23 at 4:02 p.m., the Minimum Data Set (MDS) regional coordinator reported the records were submitted late. She reported the facility MDS coordinator was having health issues and was not able to keep up with the required schedule.