Based on observation, record review, and interview, the facility failed to maintain an effective pest control program to limit the number of flies in the facility. The Resident Census and Conditions of Residents form, dated 06/28/23, documented 48 residents resided in the facility. Findings: A facility Pest Control policy, not dated, read in part, .Our facility shall maintain an effective pest control program. On 06/25/23 at 2:45 p.m., a tour of the facility was conducted upon entrance. Multiple flies were observed in the halls, resident rooms, in the dining room, and in the kitchen. Flies were observed on resident's arms, clothing, dining room tables, and bedside tables. Dead flies were observed on the window seals and window ledges in the dining room. On 6/26/23 at 11:30 a.m., kitchen cook #1 was asked if the facility had been having a problem with flies. The cook stated the fly situation had been horrible. On 06/26/23 at 1:56 p.m., an anonymous resident was interviewed in their room. Three or four flies were observed flying around the resident's bed, two were observed to land on the resident's legs. The resident was asked about the flies, if they were bothered by them, and they stated the fly problem had been pretty bad recently. The resident stated they thought it might have been worse related to weather and rain. The resident reported they kept a fly swatter nearby in their nightstand. On 06/26/23 at 4:15 p.m., the double glass doors in the dining room, which lead to the back patio, were observed to have a gap between the two doors. The gap between the doors was measured with a measuring tape, by the surveyor, and found to be a 5/8 inch gap. Six dead flies were observed on the windowsill by the doors leading outside, several dead flies were observed on the floor, and three lives flies were observed in the dining room at that time. On 6/26/23 at 4:50 p.m., the Regional Director of Operations reported pest control had been contacted and they would be implementing measures to decrease the flies in the dining room, such as blue lights to pull the flies away from the doors. They reported maintenance would be replacing the weather stripping between the doors to help with the fly problem. On 06/27/23 at 10:00 a.m., a housekeeper reported they had been working at the facility approximately three months and the flies had been a problem for that period of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to complete a discharge summary for one (#37) of nine closed records reviewed. The facility identified 34 residents lived in the facility. Findings: Resident #37 was admitted to the facility on [DATE] with diagnoses which included essential hypertension, emphysema, chronic obstructive pulmonary disease, and panic disorder. A quarterly assessment, dated 02/09/21, documented the resident was intact with cognition. The assessment documented the resident did not want to speak to anyone about leaving the facility. The assessment documented no community referral was needed. A nurse's progress note, dated 05/12/21, documented the nurse going off shift reported the resident had discharged to another facility. A social services note, dated 05/13/21, documented the resident discharged to another facility the previous day. The clinical record did not contain a discharge summary. On 08/04/21 01:09 PM, the corporate registered nurse reported a discharge summary should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide assistance with meals in a timely manner for one (#23) of two residents reviewed for meal assistance. The facility reported five residents required meal assistance. Findings: Resident #23 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, diabetes mellitus type II, depression, peripheral vascular disease, and obesity. A quarterly assessment, dated 05/28/21, documented the resident was moderately impaired with cognition, exhibited mild depression, rejected care one to three days of the look back period. The assessment documented the resident required extensive assistance with eating. A care plan, dated 06/01/21, documented the resident was at risk for altered nutritional status. The care plan documented for the staff to encourage and assist the resident with oral intake of food and fluids. On 08/02/21 12:34 PM, the resident's lunch tray was observed sitting on her bedside table still covered. The resident was observed lying in bed with her eyes closed. On 08/02/21 12:43 PM, the resident's lunch tray was observed sitting on her bedside table still covered. The resident was observed lying in bed with her eyes closed. On 08/02/21 12:51 PM, the resident's lunch tray was observed sitting on her bedside table still covered. The resident was observed lying in bed with her eyes closed. On 08/02/21 12:58 PM, the assistant director of nurses (ADON) was observed standing outside of the resident's room. On 08/02/21 01:01 PM, certified nurse aide (CNA) #1 reported she had passed the resident's plate and then assisted with others in the dining room. The CNA reported she should have stayed with the resident and fed her when she delivered the lunch plate. On 08/04/21 04:02 PM, the ADON reported the CNA should have began to feed the resident after delivering the plate of food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure one (#20) of five residents reviewed for unnecessary medications was free from unnecessary psychotropic medication. The facility reported 34 residents lived in the facility. Findings: Resident #20 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, Parkinson's disease, essential hypertension, other specified depressive episodes, generalized anxiety disorder, mood disorder due to known physiological condition, unspecified, adjustment disorder with anxiety, and major depressive disorder, recurrent. A medication regimen review, dated 05/24/21, documented the resident's Zyprexa had been decreased to 5 mg on 04/01/21. The review documented Seroquel 100 mg daily was added on 05/20/21. The review documented both medications were for dementia. The review documented a recommendation to decrease Zyprexa to 2.5 mg every evening. A physician's order, dated 06/11/21, documented Zyprexa 2.5 mg once a day for mood disorder due to known physiological condition. A quarterly assessment, dated 06/12/21, documented the resident had severe cognitive impairment. The assessment documented the resident had no behaviors. The assessment documented the resident required extensive assistance with activities of daily living (ADLs). The assessment documented the resident received an antipsychotic medication for seven days of the seven day look-back period. The assessment documented the date of last gradual dose reduction was 04/01/21. A physician's progress note, dated 06/15/21, documented no depression, anxiety or confusion worse than baseline. The progress note documented to continue treatments as directed, for dementia, to include Zyprexa. A care plan, initiated on 06/16/21, documented the resident was a risk for developing signs and symptoms of side effects/adverse reactions for use of an antipsychotic medication as prescribed related to other specified depressive episodes, generalized anxiety disorder, and mood disorder due to known physiological condition. A medication regimen review, dated 06/29/21, documented Zyprexa was reduced to 2.5 mg daily on 06/11/21, Seroquel 100 mg daily continues, will follow up. Behavior flow sheets for May 2021, June 2021, and July 2021, had no documented behaviors. On 08/04/21 09:59 AM, assistant director of nursing (ADON) reported mood disorder, dementia, depressive episodes, nor anxiety disorder were appropriate clinical indications for the use of the antipsychotic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a resident was free from abuse for one (#39) of three residents reviewed for abuse. The director of nursing (DON) identified 34 residents who resided in the facility. Findings: Resident #39 was admitted to the facility on [DATE] with the diagnoses which included dementia and diabetes mellitus. An admission assessment, dated 9/15/20, documented the resident was severely impaired with cognition, exhibited no behaviors, and required extensive assistance with activities of daily living. An initial incident report form, with an incident date of 12/31/20, documented an employee reported certified nurse aide (CNA) #2 smacked the resident on the leg twice. The report documented the CNA was immediately suspended pending an investigation. A facsimile transmission report documented the report was faxed to the Oklahoma State Department of Health on 12/31/20 at 11:49 p.m. A final incident report, with an incident date of 12/31/20, documented statements were obtained from all parties involved and the facility's cameras were reviewed by the administrator. The report documented the allegation of abuse was substantiated. A final incident report documented the CNA was terminated on 01/06/21. On 08/05/21 at 8:30 a.m., corporate nurse #1 reported CNA #2 had been in-serviced related to the facility abuse policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to complete a thorough investigation of an allegation of abuse for one (#39) of three residents reviewed for abuse. The director of nursing (DON) identified 34 residents who resided in the facility. Findings: Resident #39 was admitted to the facility on [DATE] with diagnoses of dementia and diabetes mellitus. An admission assessment, dated 9/15/20, documented the resident was severely impaired with cognition, exhibited no behaviors, and required extensive assistance with activities of daily living. An initial incident report form, with an incident date of 12/31/20, documented an employee reported certified nurse aide (CNA) #2 smacked the resident on the leg twice. The report documented the CNA was immediately suspended pending an investigation. A facsimile transmission report documented the report was faxed to the Oklahoma State Department of Health on 12/31/20 at 11:49 p.m. A final incident report, with an incident date of 12/31/20, documented statements were obtained from all parties involved and the facility's cameras were reviewed by the administrator. The report documented the allegation of abuse was substantiated. A final incident report documented the CNA was terminated on 01/06/21. On 08/05/21 at 8:30 a.m., corporate nurse #1 reported no in-service related to abuse had been conducted but should have. Corporate nurse #1 and #2 reported no other residents had been interviewed during the investigation but should have according to the facility abuse policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure a resident received adequate supervision and assistance to prevent falls for one (#39) of five sampled residents who were reviewed for falls. The facility failed to modify and evaluate interventions for effectiveness for a resident who had frequent falls. The director of nursing (DON) identified 34 residents resided in the facility. Findings: Resident #39 was admitted to the facility on [DATE] and with diagnoses which included type 2 diabetes mellitus without complications, other specified depressive disorders, pain, dementia with behavioral disturbance, transient cerebral ischemic attack, and insomnia. An admission assessment, dated 03/15/20, documented the resident had severely impaired cognition. The assessment documented the resident required extensive two person assistance with transfers. The assessment documented the resident was dependent on two person staff for walking in his room. The assessment documented the resident was not stable, only able to stabilize with staff assist when moving from seated to standing position, when walking and during surface to surface transfer. The assessment documented the resident had two or more non-injury falls since admission, and one fall with minor injuries. The assessment documented bed and chair alarms were used daily. A care area assessment (CAA) detail worksheet for falls, dated 03/15/20, documented the resident was non-compliant with using call light and waiting for assistance. The CAA documented the resident had multiple falls since admission. The CAA documented the resident was at risk for falls/injury. A nurses note dated 07/09/20, documented resident had one fall since 03/12/20. The note documented new order received from physician to discontinue bed alarm, chair alarm, and mattress gripper. The clinical record documented the resident had falls on 07/24/20, 08/28/20, 11/04/20, and 12/15/20. A care plan, dated 12/15/20, documented the resident was at risk for falls due to impaired balance. The care plan documented for the staff to ensure call light was within reach, encourage the resident to request assistance, and bed to be in low position at all times if needed. A quarterly assessment, dated 12/17/20, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive two person assistance with transfers, and limited one person assistance with ambulation. The assessment documented the resident was not steady, only able to stabilize with staff assist when moving from seated to standing position, walking, and with surface to surface transfer. The assessment documented the resident was at risk for falls. The assessment documented the resident had more than two falls with no injures since the previous assessment. The assessment documented bed and chair alarms were used daily. The clinical record indicated the resident had a fall on 12/20/20. A new care plan approach, dated 12/21/20, documented the resident was reminded to keep gripper socks on and to use call light. The resident had a fall on 12/24/20. A new care plan approach, dated 12/24/20, documented for the staff to educate resident to use call light and make frequent checks on resident. The clinical record documented the resident fell on [DATE]. A care plan approach, dated 12/30/20, documented nursing restorative range of motion. The clinical record documented the resident fell on [DATE]. A care plan approach, created on 01/04/21, documented a call light was attached to the residents chair and put in his lap and restorative exercises to help with strength. The clinical record documented the resident fell on [DATE]. A care plan approach, created on 01/11/21, documented for staff to encourage resident to get close to items reaching for to prevent sliding from wheelchair. The clinical record documented the resident had a fall on 01/13/21. A care plan approach, created on 01/14/21, documented the resident was instructed on bathroom call light use for transfers onto and off of commode. The clinical record documented the resident fell on [DATE] and 01/25/21. A care plan approach, created on 01/26/21, documented the resident was reminded to use call light and wear non-slip shoes for transfers, and an order was pending for bed alarm. The clinical record documented the resident fell on [DATE]. A care plan approach, created on 01/29/21, documented to re-educate staff to provide for toileting needs every 2 hours. The clinical record documented the resident fell on [DATE]. The care plan contained no new approaches. On 02/11/21 a five day assessment documented the resident remains with severe cognitive cognition. On 08/05/21 the ADON reported the approaches put into place for resident reminders and re-education were inappropriate due to severe cognitive deficit.

Based on observation and interview, it was determined the facility failed to ensure the removal of expired medications from the medication storage room and accurate medication labeling. This had the potential to affect all 34 residents who resided in the facility. Findings: On 08/03/21 at 10:58 a.m., the medication room was observed. Expired medications were found in the facility's medication room for the following: 1. Fluticasone nasal spray with an expiration date of 06/09/21. 2. Saline nasal spray with a use by date of 04/15/21. 3. One bottle of house stock Ibuprofen 200 mg with a use by date of 04/16/21. 4. A zip-lock bag containing two Albuterol inhalers with no label or names on the inhalers. A copy of the pharmacy invoice that received date of 05/24/19 and a start date of 02/02/20. On 08/03/21 at 10:58 a.m., certified medication aide #1 reported the expired medications should have been removed from the medication room.

Based on observation and interview, it was determined the facility failed to ensure food had been prepared in a sanitary manner for pureed residents. The facility reported four residents received a pureed diet. Findings: On 08/03/21 at 11:30 a.m., the dietary manager (DM) was observed to place corn bread with milk into a blender. The blender had an opening in the top where a plastic cover had been broken off. The DM picked up a dirty rag off of the counter top and covered the opening while the food had been pureed. After the blender was cleaned, the DM placed beans with ham in the blender, wiped the counter off with the same dirty rag and placed it over the opening of the blender to puree the food. The DM then cleaned the blender and placed turnip greens into the blender. The staff member again wiped off the counter and then placed the same dirty rag over the top of the blender a third time. On 08/03/21 at 11:45 a.m., the DM reported the plastic cover had broken off. The DM stated, I usually use a napkin to cover it, I just wasn't thinking. On 08/03/21 at 12:00 p.m., the administrator was informed of the above findings. The administrator reported, it would be taken care of.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #20 was admitted to the facility on [DATE], with the diagnoses which included unspecified dementia without behavioral disturbance, Parkinson's disease, essential hypertension, moderate protein-calorie malnutrition, and other specified depressive disorders. On 08/04/21 at 3:52 P.M., wound care was observed for resident #20. The wound care doctor was observed entering the resident's room already wearing gloves. The wound care doctor cleaned off a corner of a table using an alcohol prep pad. The doctor wearing the soiled gloves then set clean supplies on the table. The wound care doctor was observed to move the resident's trash can to the end of the resident's bed wearing the same soiled gloves. The wound care doctor was observed to measure the resident's wound and then sprayed it with normal saline solution wearing the same soiled gloves. The wound care doctor was observed to debride the wound using a sterile scalpel and sterile gauze pads but continued to wear the same soiled gloves. On 08/05/21 at 8:30 a.m., the corporate nurse #1 reported the wound care doctor should have changed gloves several times throughout the procedure. Based on observation, interview, and record review, it was determined the facility failed to ensure infection control was maintained during wound care for two (#23 and #20) of three sampled residents who were reviewed for wound care. The facility identified four residents who had wounds. Findings: A facility dressing change guideline, documented for the staff to don gloves utilizing aseptic technique, cleanse wound, remove gloves and wash hands and don clean gloves prior to dressing the wound. The guideline documented when more than one wound gloves should be removed, hands washed, and fresh gloves applied for each wound. 1. Resident #23 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, diabetes mellitus type II, depression, peripheral vascular disease, and obesity. A quarterly assessment, dated 05/28/21, documented the resident was moderately impaired with cognition, exhibited mild depression, rejected care one to three days of the look back period. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident required an indwelling catheter. The assessment documented the resident was always incontinent of bowel. The assessment documented the resident had two unstageable deep tissue injuries. A care plan, dated 06/01/21, documented the resident had multiple pressure areas to the left lower extremity and left buttock. The care plan documented for the staff provide wound care as ordered by the physician. A physician's order, dated 07/22/21. documented for the staff to apply betadine swabsticks to the left heel and left lateral foot daily. The order documented for the staff to apply a Maxorb Extra Dressing with special instructions to apply triple antibiotic ointment to the portion of leg wound that had granulation tissue. The order documented do not apply to eschar. The order documented for the staff to apply Mesalt to the debrided portion of the wound that had slough, cover with calcium alginate and a gauze dressing. The order documented for the staff to apply Maxorb Extra Dressing with special instructions to apply anasept to the buttock wound, cover with calcium alginate and a gauze dressing. On 08/02/21 11:03 AM, the resident was observed lying on pressure relieving mattress. On 08/03/21 10:50 AM, registered nurse (RN) #1 was observed to provide wound care to the resident's three wounds. The RN applied betadine to the eschar on the left heel. The RN then cleaned around the eschar with 4 X 4 gauze soaked in normal saline solution (NSS). The RN then applied triple antibiotic ointment with soiled gloves. The RN reported she normally changed gloves between cleaning the wound and applying the treatment. The RN then cleansed the wound to the left outer leg with NSS. The nurse applied triple antibiotic ointment with a Qtip applicator to the wound on the outer left leg. The RN then applied Mesalt gauze, calcium alginate, 4 X 4 gauze, and wrapped the left lower leg wound with kerlix. The RN did not change her soiled gloves prior to applying the clean dressing. The RN then removed the soiled gloves used hand gel and applied clean gloves prior to cleansing the coccyx area with NSS. The RN then applied skin prep with soiled gloves. The RN then applied an antiseptic gel with a Qtip applicator. The RN applied calcium alginate with the same soiled gloves. The RN applied border gauze with the same soiled gloves. The RN was asked once cleaned the wound were the gloves considered dirty. The RN stated, Yes they are dirty. The RN reported she should have hand gelled and changed gloves between cleaning the wounds and applying the medication and dressing. 08/03/21 04:18 PM, the corporate nurse reported the RN should have changed her soiled gloves throughout the wound care.