Based on observation, record review, and interview, the facility failed to ensure nail care was provided for one (#57) of one sampled resident who was reviewed for ADL care. The nurse manager identified 56 residents who were dependent on staff for nail care. Findings: The Fingernails/Toenails, Care of policy, dated February 2024, read in parts, The purposes of this procedure are to clean the nail bed, to keep nails trimmed .Nail care includes daily cleaning and regular trimming .Documentation .If the resident refused the treatment, the reason(s) why and the intervention taken .Notify the supervisor if the resident refuses the care. Resident #57 had diagnoses which included unspecified dementia. The Care Plan, updated 11/04/24, documented the resident required varied levels of assistance with ADLs due to weakness. The Activity of Daily Living Record, dated December 2024, documented the resident had been offered and/or received nail care five times, including refusals of nail care, out of 93 opportunities. The Activity of Daily Living Record, dated 01/01/25 through 01/07/25, documented the resident had not been offered, refused, or received nail care out of 21 opportunities. On 01/06/25 at 9:38 a.m., Resident #57 was observed in their room. Their fingernails were observed to be approximately a quarter inch long with dark colored debris under the nails. Resident #57 stated they preferred their fingernails to be shorter. On 01/09/25 at 10:37 a.m., Resident #57 was observed in their room. Their fingernails were observed to be approximately a quarter inch long with dark colored debris under the nails. On 01/09/25 at 10:42 a.m., CNA #7 stated the CNAs were responsible to provide nail care for Resident #57. They stated at times the resident refused care and nail care was documented on the ADL record. On 01/09/25 10:44 a.m., LPN #3 stated the CNAs were to provide nail care for Resident #57 because they were dependent on staff for nail care. They observed Resident #57's fingernails and stated they needed to be trimmed and cleaned. They stated the resident refused care at times, but when a resident refused they asked them to sign a refusal form and documented the refusal. On 01/09/25 at 11:03 a.m., the DON stated fingernail care was to be provided on scheduled shower days and as needed and documented on the Activity of Daily Living Record. The DON reviewed the ADL record for December 2024 and January 2025 and stated they would need to check with the staff because fingernail care had not been documented. The DON stated there were some refusals documented, but there should have been more documentation regarding nail care. On 01/09/25 at 11:06 a.m., the DON observed Resident #57's fingernails and stated they did not look good. The DON stated they thought they had dropped the ball and should check resident fingernails more often for care.

Based on observation, record review, and interview, the facility failed to monitor and evaluate a resident's response to an intervention for one (#26) of one sampled resident who was reviewed for quality of care. The administrator identified 78 residents who resided at the facility. Findings: An Abuse Policy and Procedure policy, dated January 2024, read in parts, nursing staff shall document the incident and interventions in the Medical Record .Nursing Assessment. The Director of Nursing or designee is responsible for assessing the victim and shall document findings .in the medical record. Resident #26 had diagnoses which included vascular dementia, Alzheimer's disease, and delusions. Review of the care plan for Resident #26, dated 01/03/23 and updated 04/01/24, 07/01/24, and 07/25/24, documented a concern for alteration in skin due to incontinence and documented to monitor and notify physician and representative of changes such as bruising. The care plan revealed no concern regarding bruising through the review dates. On 01/06/25 at 11:52 a.m., Resident #26 was observed to have a bruise on the left side of their neck approximately the size of a nickel. Review of priority charting for Resident #26 revealed no documentation regarding a bruise to the left side of their neck. Review of physician progress notes for Resident #26 in 2024 and 2025 revealed no progress notes regarding bruising to the neck. On 01/08/25 at 11:01 a.m., LPN #1 stated they were not aware of a bruise on the neck of Resident #26. They stated the bruise would be an injury of unknown origin and they would need to do a report on it. On 01/08/25 at 11:03 a.m., the DON stated they would have to check on the bruising. On 01/08/25 at 11:11 a.m., CMA #2, CMA #3, CNA #5 and CNA #6 working on the memory unit stated Resident #26 would have random bruising on their neck and then the next day the bruising would be gone. They stated they had reported it to the nurse approximately a year ago. On 01/08/25 at 11:16 a.m. the DON and nurse manager came to the memory unit and questioned the staff. The staff stated to the DON they had addressed it before. The DON stated to this surveyor, [They] was on aspirin so [medical director] took [them] off the aspirin. The DON then walked away. On 01/08/25 at 11:53 a.m., the DON stated it was more than a year ago the bruising was addressed and had not been re-addressed because the bruising would resolve without intervention. The physician's progress note which documented the bruising was addressed was requested. On 01/08/25 at 3:52 p.m., the DON stated they had found the progress notes from the medical director and none had documented anything about bruising. The DON requested if they could call the medical director. The DON was informed to follow their protocol. They stated bruising should be reported to the nurse who then assessed and notified the doctor of the issue. The DON did not return with documentation of the bruising being addressed or re-addressed by the physician.

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for the use of bed rails for one (#57) of one sampled resident who was reviewed for bed rails. The DON identified one resident who had bed rails. Findings: The Proper Use of Side Rails policy, dated December 2022, read in parts, Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents .When used for mobility or transfer, an assessment will include a review of the resident's .bed mobility .risk of entrapment from the use of side rails .that the bed's dimensions are appropriate for the resident's size and weight .Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails .The risks and benefits of side rails will be considered for each resident .Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. Resident #57 had diagnoses which included unspecified dementia and hemiparesis of the left side. The admission Data Collection Form, dated 04/05/24, documented a side rail assessment. The assessment was not fully completed and was blank under the recommendations regarding bed rails and intervention areas of the side rail section of the form. The Care Plan, updated 11/04/24, documented the resident required extensive assistance with bed mobility. The care plan did not document the use of bed rails. Review of the clinical record did not reveal documentation the side rails treated a medical condition, a completed assessment had been conducted, alternative interventions had been attempted, that the resident/resident representative had been informed of the benefits and risks of bed rail use, or that consent for the use of bed rails for Resident #57 had been obtained. On 01/06/25 at 9:49 a.m., Resident #57 was observed in bed with half bed rails in the up position bilaterally. Resident #57 stated they did not use the bed rails and they assumed they were applied for safety to keep them in bed. On 01/09/25 at 10:51 a.m., LPN #3 stated Resident #57 utilized the bed rails to assist in repositioning during care. They stated they did not know why the resident had bilateral side rails since they were unable to utilize their left side. On 01/09/25 at 10:59 a.m., the DON stated residents were assessed for the use of bed rails prior to installation. The DON stated they did not obtain consents or discuss risks and benefits of side rail use with the resident and/or the resident representative. The DON stated Resident #57 could move their right hand a little. The DON stated they did not know why Resident #57 had bilateral half bed rails. On 01/09/25 at 11:42 a.m., the DON stated the resident preferred half bed rails bilaterally, but did not require them. The DON stated they did not know why the bed rail assessment had not been completed. On 01/13/25 at 10:01 a.m., the DON stated Resident #57 could not properly utilize the half bed rails bilaterally as a positioning device. On 01/13/25 at 11:29 a.m., the care plan coordinator stated they did not know Resident #57 had half bed rails bilaterally.

Based on observation, record review, and interview, the facility failed to ensure nurse staffing was posted for public view. The administrator identified 78 residents resided at the facility. Findings: A review of the QOC reports for October, November and December 2024 revealed staffing numbers were good with the exception of one day shift in December. On 01/14/25 at 9:20 a.m., the administrator stated they had the staff names and position for each shift on each hall. They stated they did not have the total number of nursing hours posted. On 01/14/25 at 10:32 a.m., the DON stated they had a book for the daily schedule at the nurses desk, but for the time during the survey the book was in their office. They stated total nursing hours were not in the book.

Based on record review and interview, the facility failed to ensure residents did not receive unnecessary medications for one (#22) of five sampled residents who were reviewed for psychotropic medications. The nurse manager identified 78 residents who received medications. Findings: Resident #22 had diagnoses which included Alzheimer's/dementia, anxiety and depression. A review of the clinical record for Resident #22 did not document side effect monitoring or that the physician was provided an MRR or GDR of Risperdal (risperidone) (an antipsychotic) for review and reduction. A Care Plan, dated 07/10/24, for Resident #22 documented a concern for psychotropic drug use and was updated/reviewed 10/08/24. The care plan revealed Resident #22 was taking an antipsychotic Nuedexta, an antidepressant trazodone, and an anti-anxiety medication of Ativan. The care plan was not updated to include Risperdal. The care plan documented approaches to evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. On 01/09/25 at 11:48 a.m., the DON was asked what the facility policy was regarding gradual dose reductions. The DON did not answer. The DON stated the facility was having an issue with medical records and that was why medication regimen reviews and gradual dose reductions were not in the clinical records. On 01/13/25 at 1:01 p.m., the DON was asked for the original start date for Ativan (lorazepam), Risperdal, and Depakote DR (an antiepileptic). The DON stated Resident #22 had started Ativan on 07/18/24, Depakote on 04/13/23 and Risperdal on 06/14/22. No evidence was provided. On 01/13/25 at 5:15 p.m., the pharmacist stated they had not seen an order for Risperdal since they started in April 2023. They stated they had been following Depakote, Ativan, and trazadone for Resident #22 and had no notes about them being on Risperdal recently.

Based on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for two (#24 and #62) of five sampled residents whose labs were reviewed. The DON identified 78 residents who had orders for labs. Findings: The Lab and Diagnostic Test Results - Clinical Protocol policy, dated July 2024, read in part, The staff will process test requisitions and arrange for tests. 1. Resident #24 had diagnoses which included schizoaffective disorder, bipolar type. A Physician's order, dated 02/05/21, documented to obtain a valproic acid level every 3 months in July, October, January, and April. A Physician's order, dated 11/01/23, documented the resident was ordered valproic acid 500 mg at bedtime. Review of the clinical record and labs provided by the DON did not reveal a valproic acid level had been obtained in July 2024 or October 2024. 2. Resident #62 had diagnoses which included vascular dementia. A Physician's Order, dated 02/12/24, documented to obtain a CMP every six months. Review of the clinical record and lab results provided by the DON revealed the last CMP was obtained on 05/31/24. A CMP for November 2024 was not seen in the clinical record or provided by the DON. On 01/09/25 at 11:48 a.m., the DON stated they were responsible to ensure labs were obtained as ordered by the physician. They stated there was a lab report binder in the MDS coordinator's office they would provide. On 01/13/25 at 9:32 a.m., the DON stated they felt there was something wrong with medical records obtaining and filing the lab reports, but they did not think they had any additional lab reports to provide. By the end of the survey the lab report binder or additional lab reports had not been provided for Resident #24 or Resident #62.

Based on observation, record review, and interview, the facility failed to ensure resident beds were regularly inspected for safety for one (#57) of one sampled resident who was reviewed for bed rails. The DON identified one resident who had bed rails. Findings: The Bed Safety policy, dated June 2024, read in parts, Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks .Ensure that bedrails are properly installed. Resident #57 had diagnoses which included unspecified dementia and hemiparesis of the left side. Review of the clinical record and maintenance logs did not reveal documentation the resident's bed had been regularly inspected for safety related to the use of side rails. On 01/06/25 at 9:49 a.m., Resident #57 was observed in bed with half bedrails in the up position bilaterally. On 01/13/25 at 10:01 a.m., the DON stated the maintenance staff inspected beds and bed rails for safety. On 01/13/25 at 10:12 a.m., maintenance worker #1 stated they were responsible to review beds for safety. They stated if something was brought to their attention, they checked the bed as soon as possible, otherwise they checked the beds when they did rounds in the facility. They stated they did not document bed safety checks. On 01/13/25 at 4:45 p.m., the administrator stated the maintenance staff were responsible to regularly inspect the residents' beds for safety, but they did not document their inspections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents were provided with privacy curtains. The administrator identified 78 residents resided at the facility. Findings: A Bedrooms policy, reviewed May 2024, read in part, Each room is designed to provide full visual privacy for each resident (in the form of ceiling suspended curtains that extend around the bed) and equipped for adequate nursing care On 01/06/25 at 4:26 p.m., room [ROOM NUMBER] was observed to have no privacy curtain. Resident #24 stated there was no privacy and all activities other than using the restroom were completed in full view of their roommate. On 01/07/25 at 11:52 a.m., room [ROOM NUMBER] was observed to have no privacy curtain. The room had two residents residing in the room. On 01/09/25 at 10:44 a.m., LPN #3 stated a curtain should be in room [ROOM NUMBER] to provide privacy and they did not know why one was not installed. On 01/09/25 at 11:09 a.m., the DON stated one of the resident's in room [ROOM NUMBER] required extensive assist. They stated privacy was provided by closing the door and pulling the curtain. The DON looked in room [ROOM NUMBER] and stated the room had work completed a month ago and maintenance had removed the curtain. They stated privacy was not provided effectively in room [ROOM NUMBER]. On 01/13/25 at 10:17 a.m., maintenance #1 stated they were responsible for the privacy curtains. They stated room [ROOM NUMBER] had no curtain track and they had brought the issue up previously. Maintenance #1 stated they did not know why room [ROOM NUMBER] had no tracks for privacy curtains. They stated neither resident had privacy. On 01/14/25 at 10:35 a.m. the DON stated they were working on the privacy issue. They stated tracking for the privacy curtains needed to be installed.

Based on observation, record review, and interview, the facility failed to ensure activities were provided for four (#18, 22, 26, and #42) of four sampled residents who were reviewed for activities. The administrator identified 78 residents who resided at the facility. Findings: An Activity Programs policy, revised August 2024, read in parts, Activity programs designed to meet the needs of each resident are available on a daily basis .designed to encourage maximum individual participation and are geared to the individual resident's needs .are scheduled 7 (seven) days a week. 1. Resident #18 had diagnoses which included chronic pain, obesity, and limited mobility. On 01/06/25 at 11:18 a.m., Resident #18 stated they could not go to activities because they did not have a wheelchair that worked. They stated the bottom of the wheelchair had a hole in it and was not comfortable, so they did not get up much. On 01/07/25 at 3:46 p.m., CNA #1 stated they did not know if activities were offered or not. On 01/07/25 at 3:47 p.m., RN #1 stated there was an activities person, but they did not know what they did in patient rooms for residents that did not leave their rooms. On 01/07/25 at 3:59 p.m., CMA #4 stated they did not know of or see any activities in resident rooms for those who did not leave their room. On 01/07/25 at 4:00 p.m., CNA #3 stated the activities person passed out coloring books to patients and read cards to them if they got them in the mail. On 01/08/25 3:18 p.m., the activities director stated they had personal relationships with staff and residents. They stated they ensured all residents were offered activities because they knew who did what. The activities director stated Resident #18 got out of their room and went to most of the activities. The activities director stated they checked on bed bound residents at least once or twice a week, visited with them, offered them coloring opportunities, games, nail painting and anything they may be interested in. They stated it would be documented on the activity flow sheet and when completed the flow sheet would be put in the resident record. On 01/09/25 at 9:44 a.m., CNA #4 stated Resident #18 only got up for showers and had no cushion for their wheelchair. The CNA stated the resident stated their wheelchair was very uncomfortable and if they had a comfortable wheelchair they might get up. On 01/09/25 at 10:40 a.m. LPN #1 stated Resident #18 did not like to get out of their room. They stated they had not had anyone tell them anything about the wheelchair for Resident #18 and had not looked at it themselves. On 01/09/25 at 10:45 a.m., RN #1 stated Resident #18 refused to get up for activities. They stated Resident #18 did say something to them about getting a better wheelchair. RN #1 stated the physical therapist or social services director would look at it if they needed more items. They stated they did ask Resident #18 why they did not want to get up and encouraged Resident #18 to try. RN # stated they would go up the chain of command to the DON for possibly getting something different for a resident and it would be charted in the shift report if issues were identified. On 01/09/25 at 10:57 a.m., the DON stated if there were an issue with a wheelchair they would have physical therapy look at it to evaluate it. The DON stated it was the facility's responsibility. On 01/09/25 at 11:14 a.m., the DON accompanied the surveyor to the room of Resident #18 and observed the condition of the wheelchair. They removed the wheelchair and stated they would replace it that day. 2. Resident #22 had diagnoses which included dementia and anxiety. The Care Plan, dated 07/10/24, documented Resident #22 was at risk for alteration in activities due to having little interest or pleasure in doing things related to diagnosis of dementia. The plan documented Resident #22 would maintain activity level and continue to be encouraged to participate in activities at least weekly through review date. The plan documented an intervention was that Resident #22 would maintain alternate methods to engage in sensory stimulation and to provide structured activity program for intellectual stimulation. The September 2024 activity calendar for Resident #22 documented exercise, music therapy, and social visit. The activity note, dated 09/30/24, documented Resident #22 passively attended activities. The note documented Resident #22 wandered the hall and visited with other residents. Resident #22 did not have the attention span to actively participate, but did occasionally watch television a few minutes at a time. The October 2024 activity calendar for Resident #22 documented exercise. An undated note documented Resident #22 loved to keep busy and walk the hall regularly for exercise. The November 2024 activity calendar for Resident #22 documented exercise and social visit. An undated note documented Resident #22 walked a lot for exercise and was unable to do many activities due to health. On 01/06/25 at 11:22 a.m., Resident #22 was observed in bed with their eyes closed and facing the wall and covered with a blanket. On 01/07/25 at 1:54 p.m., Resident #22 was observed in bed. No activity was occurring on the memory unit. On 01/08/25 at 9:15 a.m., Resident #22 was observed in bed, legs over the side of the bed with their feet on the floor, but laying over on their side facing the door. No activities were occurring on the memory unit. On 01/08/25 at 9:18 a.m., a CMA #1 reported Resident #22 was being sent out due to a change in condition. They stated the resident was sleeping more, not eating, or getting up. On 01/13/25 at 11:19 a.m., the activities director was asked what the program activities and goals were for Resident #22. The activities director stated they walked around and visited with Resident #22. They stated Resident #22 would watch, but not get involved. The activity director stated they did not know that anybody monitored the activity documentation, but they reported to the administrator and social services director. 3. Resident #26 had diagnoses which included Alzheimer's disease, dementia, and anxiety. A Care Plan, dated 01/03/23, documented Resident #26 participated in some activities at times such as social events, bingo, birthday parties, but required supervision going to and from activities. The care plan documented Resident #26 would continue with self-directed activities daily through the review date. The interventions/approaches were to introduce Resident #26 to other residents with similar interests, disabilities, or limitations. The September 2024 activity calendar for Resident #26 documented activities for the month to be music, movies, television, and social visit were checked for the month. The activity note, dated 09/30/24, documented Resident #26 was up and out of their room daily. The note documented Resident #26 enjoyed music, TV, and social visits. The October 2024 activity calendar for Resident #26 documented activities for the month to be television and social visits. The note documented Resident #26 loved to hang out with friends and sometimes enjoyed watching television. The November 2024 activity calendar for Resident #26 documented activities for the month to be beauty shop once, movie time, television, and social visit. An undated activity note documented Resident #26 enjoyed watching television and hanging out with friends. On 01/06/25 at 11:54 a.m., no activities were observed on the unit. Residents were observed to be sitting in the dining room waiting for the noon meal and watching television. On 01/13/25 at 11:20 a.m., the activities director was asked what the program activities and goals were for Resident #26. They stated they just sat and visited, and played with their hands. The activities director stated they documented monthly on each resident. They stated the notes probably did need to be dated and they messed up. The activities director stated weekend activities were initiated by residents. 4. Resident #42 had diagnoses which included vascular dementia. A Care Plan, dated 07/23/24, documented Resident #42 had little to no involvement in activities related to cognitive impairment and would participate in at least one activity weekly. It documented to provide one-to-one visits in a quiet location when the resident was unable to tolerate group activities. It documented to provide a structured activity program for intellectual stimulation, when appropriate place Resident #42 in appropriate psychological group activities, give resident verbal reminders of activity before commencement of activity, and establish a daily routine with the same activity personnel/volunteers. A quarterly assessment, dated 09/30/24, documented the daily activity preferences answered by a resident representative for Resident #42 was going outside for fresh air as very important and to keep up with the news and listening to music as somewhat important. The October 2024 activity calendar for Resident #42 documented activities for the month to include television and social visit. An undated and unsigned note documented Resident #42 enjoyed meal time with friends and watching television and Resident #42 really enjoyed puppy time. The November 2024 activity calendar for Resident #42 documented activities for the month to include television. An undated and unsigned activity note documented Resident #42 enjoyed a good visit and looked forward to meal time. The note documented the resident watched television. The December 2024 activity calendar for Resident #42 documented activities for the month to include television. An undated note documented Resident #42 did not leave their room much and listened to the television and enjoyed a good conversation. On 01/06/25 at 11:17 a.m., no activities were observed to be provided. Resident #42 was observed in the dining area watching television. On 01/13/25 at 11:14 a.m., the activities director stated they were responsible to provide and document activities for the residents. They stated they do a survey for the MDS coordinator when a resident was admitted and that lead them to what the resident wanted to do for activities. When asked how that differed from the dementia unit, they stated they spent a lot of time with every resident. The activity director was asked what the program of activities and goals were for Resident #42. They stated they had taken coloring sheets and puzzles to the unit, but Resident #42 could not do any of that. The activities director stated their documentation did not reflect the interventions in the care plan for activities because they did not know that was something they needed to do. They stated their documentation did not reflect their attempts to encourage group activities or refusals by the resident. The activity director stated they had not had any formal training in dementia care, but they would love some. On 01/13/25 at 11:37 a.m., the administrator stated the activity director was responsible to document and complete activities for the facility. They stated the activity director had been hired three months ago. The administrator stated the activity director had been shown and told what to do and when to do it. They stated the documentation should be daily or monitored and tracked daily by the social services director, but they had been out of the facility.

Based on record review and interview, the facility failed to ensure pharmacist medication regimen reviews were conducted monthly for five (#24, 57, 62, 22, and #59) of five sampled residents who were reviewed for unnecessary medications. The DON identified 78 residents who received medications in the facility. Findings: The Medication Regimen Reviews policy, dated May 2024, read in parts, The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports .Copies of medication regimen review reports .are maintained as part of the permanent medical record. 1. Resident #24 had diagnoses which included schizoaffective disorder, bipolar type. The Care Plan, dated 12/09/24, read in part, Monitor pharmacist's drug regimen review for identification of potential drug interactions. Review of the clinical record and the monthly medication regimen reviews provided by the DON did not reveal the pharmacist had conducted a medication regimen review in January 2024, February 2024, March 2024, or July 2024 for Resident #24. 2. Resident #57 had diagnoses which included unspecified dementia. The Care Plan, dated 11/04/24, read in part, Monitor pharmacist's drug regime review for identification of potential drug interactions. Review of the clinical record and the monthly medication regimen reviews provided by the DON did not reveal the pharmacist had conducted a medication regimen review in December 2023 or March 2024 for Resident #57. 3. Resident #62 had diagnoses which included vascular dementia. The Care Plan, dated 11/08/24, read in part, Monitor pharmacist's drug regimen review for identification of potential drug interactions. Review of the clinical record and the monthly medication regimen reviews provided by the DON did not reveal the pharmacist had conducted a medication regimen review in January 2024 for Resident #62. 4. Resident #22 had diagnoses which included Alzheimer's disease/dementia, anxiety, and depression. The facility provided medication regimen reviews, but were unable to provide January 2024, February 2024, March 2024, and August 2024. One gradual dose reduction was provided for 09/30/24 to reduce trazodone (an antidepressant) to 75 mg every hour of sleep from 100 mg. The physician refused and documented Resident #22 was stable on the current medication. Review of the clinical record revealed the last physician's orders were dated 07/24/24. A Care Plan, dated 07/10/24, documented a concern for psychotropic drug use and was updated/reviewed 10/08/24. The care plan revealed Resident #22 was taking Nuedexta (an antipsychotic), trazodone and Ativan (an anti-anxiety). The care plan was not updated to include Depakote (an antiepileptic) and Risperdal (an antipsychotic). The care plan documented approaches as evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. The care plan documented to monitor pharmacist's drug regimen review for identification of potential drug interactions. The care plan documented to administer Ativan and trazadone as per ordered and monitor for side effects. The care plan documented to monitor Resident #22 for signs of tremor documented and to report onset or increase to physician. The care plan documented to observe the resident's gait for steadiness, balance, muscle coordination, and ability to position and turn. The care plan documented to monitor the resident's mental status function and report any changes. 5. Resident #59 had diagnoses which included dementia and anxiety. Review of the clinical record for Resident #59 revealed missing MRR/GDRs for January, February, March, July, August, September and December 2024. The clinical record did not reveal lab results. An annual assessment, dated 05/21/24, documented Resident #59 had inattention and disorganized thinking with delusions. The assessment documented Resident #59 had rejected care four to six days during the seven day look back period. The assessment documented antipsychotic use and antidepressant use. The assessment documented no gradual dose reduction due to the physician documented a reduction would be clinically contraindicated on 12/15/23. Physician's Orders, dated November 2024, documented Resident #59 was ordered the following medications: duloxetine (an antidepressant) 90 mg every day, olanzapine ODT (an antipsychotic) 10 mg every hour of sleep and trazodone 100 mg every hour of sleep. The physician's orders documented an order for CBC and CMP every six months, HGA1C every three months and a lipid panel yearly. An updated care plan, dated 12/09/24, documented a concern for psychotropic drug use of antipsychotic medications olanzapine/duloxetine. On 01/09/25 at 9:58 a.m., the administrator stated they had not located more gradual dose reductions or medication regimen reviews. On 01/09/25 at 11:48 a.m., the DON was asked what the facility policy was regarding gradual dose reductions. The DON did not answer. The DON stated the facility was having an issue with medical records and that was why medication regimen reviews and gradual dose reductions were not in the clinical records. On 01/13/25 at 1:01 p.m., the DON was asked for the original start date for Ativan, Risperidone, and Depakote DR for Resident #22. The DON stated Resident #22 had started Ativan on 07/18/24, Depakote on 04/13/23 and Risperdal on 06/14/22. No gradual dose reductions or medication regimen reviews were provided by the end of the survey. On 01/13/25 at 5:15 p.m., the pharmacist stated they had not seen an order for Risperidone since they started in April 2023. They stated they had been following Depakote, Ativan, and trazodone for Resident #22 and had no notes about them being on Risperidone recently. The pharmacist stated they did not know how accurate the orders were in the clinical record. They stated they went by the medication administration record to see what the resident had been given and when they found an error, they never go to the actual clinical record because they do not find the record to be helpful at all. The pharmacist stated they had a hard time with labs as well and would ask staff to pull the labs up on the computer and tell them. They stated they had asked for lab access as well because they had not been able to find it in the clinical record. The pharmacist stated the best they could do was see that labs were ordered. They stated they came to the facility once a month toward the end of the month and the turn around was a physical delivery the next day or two. The pharmacist stated they would obtain a signature from administrative staff or a nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to: a. ensure medications were secured for one (300 hall treatment cart) of six medication carts observed; b. ensure medications were dated when opened and/or insulin was discarded after 28 days for two (200 hall treatment cart and 300 hall treatment cart) of three medication carts observed; and c. ensure expired medications were not in use for one (100 hall medication cart) of three medication carts observed. LPN #2 identified six medication carts in the facility. Findings: The Medication Storage policy, dated 07/21/24, read in parts, The facility shall not use .outdated .drugs or biologicals .Compartments (including .carts .) shall be locked when not in use. 1. On 01/07/25 at 4:34 p.m., RN #2 was observed during medication administration to prepare insulin and enter room [ROOM NUMBER]. The 300 hall treatment cart was observed to be left unattended and unlocked. On 01/07/25 at 4:35 p.m., RN #2 was observed to walk to the nurses station to obtain a cup of water. The 300 hall treatment cart was observed to be left unattended and unlocked for approximately 15 to 20 seconds. On 01/07/25 at 4:39 p.m., RN #2 was observed to walk into room [ROOM NUMBER] to administer medication. The 300 hall treatment cart was observed to be left unattended and unlocked. On 01/07/25 at 4:40 p.m., RN #2 returned to the treatment cart, wheeled it to the nurses station, and locked the cart. On 01/08/25 at 9:17 a.m., RN #1 was observed to prepare medications for administration. RN #1 was observed to enter room [ROOM NUMBER]. Four medication cups were observed to be left unattended on top of the 300 hall treatment cart. One cup was observed to contain three capsules, one cup was observed to contain crushed medications, one cup was observed to have a red liquid medication, and one cup was observed to contain a clear liquid medication. On 01/08/25 at 9:19 a.m., RN #1 was observed to return to the treatment cart and obtain the four cups with medications and re-enter room [ROOM NUMBER]. On 01/08/25 at 9:32 a.m., RN #1 was observed to obtain something from the 300 hall medication cart and re-enter room [ROOM NUMBER]. The 300 hall treatment cart was observed to be unattended and unlocked. On 01/08/25 at 9:39 a.m., RN #1 was observed to exit room [ROOM NUMBER]. RN #1 stated they usually locked the 300 hall treatment cart and the carts were to be kept locked when unattended. On 01/13/25 at 3:35 p.m., the DON stated medication carts were to be kept locked when unattended. 2. On 01/13/25 at 2:59 p.m., the 200 hall treatment cart was observed with LPN #2. The following was observed, a. the Trelegy inhaler and albuterol inhaler for Resident #178 were opened, but not dated, b. the Symbicort inhaler and Spiriva inhaler for Resident #49 were opened but not dated, c. the albuterol inhaler for Resident #78 was opened but not dated, d. the Ventolin inhaler for Resident #24 was opened but not dated, e. the Novolog insulin for Resident #66 was opened and dated 12/03/24, f. the Novolog insulin for Resident #16 was dated as opened on 12/03/24, and g. the glucometer test strips were opened and not dated. On 01/13/25 at 3:05 p.m., LPN #2 stated they did not know glucometer test strips were to be dated when opened. LPN #2 stated they kept open insulin for one month and the Novolog insulin for Resident #66 and Resident #16 should have been discarded. On 01/13/25 at 3:09 p.m., the 300 hall treatment cart was observed with RN #2. The glucometer test strips were observed to be open and not dated. On 01/13/25 at 3:35 p.m., the DON stated they did not date opened glucometer test strips and they monitored medication carts to ensure medications were dated when opened. They stated they did not know why medications were not dated when opened or discarded as indicated. 3. On 01/13/25 at 3:13 p.m., the 100 hall medication cart was observed with CMA #4. The following was observed, a. the house stock Tussin DM was observed to have a manufacturer expiration date of 12/2024, and b. the geri-lanta for Resident #179 had an expiration date of 12/20/24 on the label. On 01/13/25 at 3:22 p.m., CMA #4 stated they thought the DON monitored for expired medications on the medication carts. On 01/13/25 at 3:35 p.m., the DON stated they were responsible to monitor medications on the medication carts for expiration dates. They stated it was an oversight for the geri-lanta and the Tussin DM. On 01/13/25 at 3:44 p.m., the DON observed the house stock Tussin DM and stated it expired 12/2024. The DON observed the geri-lanta for Resident #179 and stated a manufacturer expiration date was not available on the bottle so they would reference the expiration date of 12/20/24 on the medication label.

Based on record review and interview, the facility failed to ensure resident records were complete and accessible for four (#57, 24, 22, and #59) of 18 sampled residents whose records were reviewed. The DON identified 78 residents who resided in the facility. Findings: The Medication Orders policy, dated 06/15/24, read in part, A current list of orders must be maintained in the clinical record of each resident. The Charting and Documentation policy, dated July 2024, read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1. Resident #57 had diagnoses which included unspecified dementia. Review of the clinical record revealed the last gradual dose reduction from the consultant pharmacist was dated 2023, the latest lab report was dated 11/28/23, and the physician's orders were from October 2024. 2. Resident #24 had diagnoses which included schizoaffective disorder, bipolar type. Review of the clinical record revealed the latest physician's orders in the clinical record were dated October 2024. On 01/09/25 at 11:58 a.m., the DON stated they and the MDS coordinator were responsible to ensure clinical records were complete and accessible. They stated current physician's orders, labs, and consultant pharmacist's reports had not been filed by the medical records staff member. The DON stated they did not know how clinical records were monitored to ensure they were complete and accessible. 3. Resident #22 had diagnoses which included Alzheimer's disease/dementia, anxiety, and depression. Review of the clinical record revealed the last physician's orders were dated 07/24/24. The facility provided medication regimen reviews, but were unable to provide January 2024, February 2024, March 2024 and August 2024. None were located in the clinical record for Resident #22. On 01/09/25 at 9:58 a.m., the administrator stated they had not located more gradual dose reductions or medication regimen reviews from medical records. On 01/09/25 at 11:48 a.m., the DON stated the facility was having an issue with medical records and that was why medication regimen reviews and gradual dose reductions were not in the clinical records. On 01/13/25 at 5:15 p.m., the pharmacist stated they had not seen an order for risperidone (an antipsychotic) since they started in April 2023. They stated they had been following Depakote (an antiepileptic), Ativan (an anti-anxiety), and trazadone (an antidepressant) for Resident #22, and had no notes about them being on risperidone recently. The pharmacist stated they did not know how accurate the orders were in the clinical record. They stated they go by the medication administration record to see what the resident had been given and when they found an error, they never go to the actual clinical record because they do not find the record to be helpful at all. The pharmacist stated they had a hard time with labs as well and would ask staff to pull the labs up on the computer and tell them. They stated they had asked for lab access as well because they had not been able to find it in the clinical record. The pharmacist stated the best they could do was see labs were ordered. They stated they came to the facility once a month toward the end of the month and the turn around was a physical delivery the next day or two. The pharmacist stated they would obtain a signature from administrative staff or a nurse. 4. Resident #59 had diagnoses which included dementia and anxiety. Review of the clinical record for Resident #59 revealed missing MRR/GDRs for January, February, March, July, August, September and December 2024. The clinical record did not reveal lab results.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for one (#279) of one sampled resident with a peg tube observed during medication administration. The nurse manager identified two residents who had peg tubes. Findings: The Enhanced Barrier Precautions policy, dated August 2022, read in parts, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tube .) .Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required .PPE is available outside of the resident rooms. Resident #279 had diagnoses which included unspecified severe protein calorie malnutrition. The significant change assessment, dated 05/27/24, documented the resident had a feeding tube. On 01/08/25 at 8:49 a.m., RN #1 was observed to administer medications to Resident #279 through their peg tube. RN #1 was not observed to utilize PPE, except for gloves. Signage to indicate enhanced barrier precautions and PPE was not observed near the resident's room. On 01/08/25 at 9:30 a.m., RN #1 was observed to perform peg tube site care. RN #1 was not observed to utilize PPE, except for gloves. On 01/09/25 at 11:29 a.m., RN #1 stated they would need to find out what the facility's policy was for enhanced barrier precautions. On 01/13/25 at 9:51 a.m., the DON stated they did not understand what enhanced barrier precautions were and needed to review the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure call lights were operational and available for residents. The administrator identified 78 residents who resided at the facility. Findings: A Bedrooms policy, reviewed May 2024, read in part, All resident rooms are equipped with a resident call system that allows residents to call for staff assistance. Review of the maintenance log book revealed on 12/28/24 room [ROOM NUMBER] had a call light ripped from the wall and wires were exposed. The log book documented the date of repair was 12/30/24. The repair was initialed. On 01/08/25 at 11:36 a.m., room [ROOM NUMBER] was observed to have wires coming from the wall where the call light would be. On 01/06/25 at 10:15 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:16 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:18 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:19 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:21 a.m., room [ROOM NUMBER]B was observed to have no call light cord. On 01/06/25 at 10:22 a.m., room [ROOM NUMBER]B was observed to have no call light cord. On 01/06/25 at 10:23 a.m., room [ROOM NUMBER]A was observed to have exposed wires at the wall connection of the call light cord. On 01/08/25 at 11:36 a.m., room [ROOM NUMBER] was observed to have exposed wires at the wall connection of the call light cord. On 01/13/25 at 10:17 a.m., maintenance #1 stated residents removed the call lights and did not put them back. They stated it had been about a month since the call lights were ordered by the administrator. On 01/13/25 at 11:42 a.m., the administrator was asked how residents notify staff when they need assistance if they had no call light. The administrator did not answer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure staff was licensed in accordance with applicable State laws. The DON identified 78 residents who resided in the facility. Findings: On [DATE] at 12:45 p.m., RN #1 was observed at the nurse station. They stated they were working as the charge nurse for the shift. An employee record documented RN #1 had a valid RN license for the state of Texas. There was no record for a valid RN license for the state of Oklahoma. On [DATE] at 10:50 a.m., the administrator reviewed RN #1's employee file noting a Texas RN license. The administrator stated per documentation found on the Oklahoma Board of Nursing website, RN #1's Oklahoma RN license had expired on [DATE]. On [DATE] at 11:10 a.m., the DON stated RN #1 had worked full time hours in the facility since [DATE] with one break in full time status for the month of [DATE]. The DON stated the RN continued full time working status from [DATE] to current. The DON stated they did not know the RN's nursing license had expired for the state of Oklahoma.

Based on record review and interview, the facility failed to ensure assistance with showers was provided for one (#1) of three reviewed for bathing. The DON identified 52 residents who required assistance with bathing. Findings: Resident #1 admitted with diagnoses which included arthropathy, morbid obesity, and cellulitis. On 11/08/23 at 1:32 p.m., Resident #1 stated they were not getting their showers on Monday, Wednesday, and Friday, and had never received three showers in a week. Resident #1 stated they had only had a handful of showers in October. The shower list in the shower book for Hall 200, documented Resident #1 was to receive a shower on the second shift every Monday, Wednesday and Friday. The Activity of Daily Living Record, dated October 2023, documented Resident #1 had received five showers out of 13 opportunities. Review of the shower sheets revealed no refusals in October from Resident #1. In the month of October there were three shower sheets completed. One for 10/13/23, one for 10/16/23, and one for 10/23/23. The 10/23/23 shower sheet documented Resident #1 was in the hospital. This was not a scheduled shower day. On 11/09/23 at 12:51 p.m., the administrator was asked if there were more shower sheets for the month of October. The administrator stated the shower sheets were a tool and once they had been reviewed they were destroyed. On 11/13/23 at 11:50 a.m., the DON was provided the ADL Record for October and asked why Resident #1 had only five showers in the month of October. They stated they did not know and stated the charge nurse may know. The charge nurse, LPN #1, looking at the record with the DON present, stated they did not know and stated the CNA may know. The CNA #5, looking at the record with the DON present, stated Resident #1 received showers on the 2nd shift. CNA #5 was asked what the slash in the box meant on the record. They stated that it was not a shower day for the resident. The S or SH meant the resident had a shower that day, and a blank box meant nothing. CNA #5 was asked how many showers Resident #1 had received in the month of October. They stated five.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement interventions to prevent future falls and failed to update the resident's care plan for one (#21) of one resident reviewed for falls. Findings: Resident #21 had diagnoses which included Alzheimer's disease. An Incident/Accident Report, dated 06/01/23 documented the resident was found on the floor with redness to right eyelid, a swollen upper lip, and bled from an abrasion on the right side of their forehead. An FSI - Fall Scene Investigation Report, dated 06/01/23, documented the resident rolled out of bed and was found on the floor next to their bed. The report documented the CNA performed rounds every two hours. The initial interventions to prevent future falls were lowered bed, non-skin socks, floor mat, and frequent checks. A significant change assessment, dated 07/11/23, documented the resident was severely impaired in cognition and displayed continuous inattention, disorganized thinking, and wandering. The assessment documented the resident walked independently and had a fall with injury in the facility. A care plan, dated 07/20/23, documented the resident was at risk of falls. Facility interventions included supervision with ambulation; properly fitting non-skid shoes when ambulating; observe for adverse side effects/toxicity of medications; maintain an environment free of clutter and safety hazards; and to place frequently used items within easy reach of the resident. The care plan did not document the interventions documented on the FSI report. A state reportable incident report, dated 07/26/23, documented the resident fell out of bed and was bleeding from the right side of their head. The report documented the resident was sent to the hospital and the care plan and fall assessment were to be updated. An FSI report, dated 07/26/23, documented the resident was lying in bed prior to the fall and was found beside the bed. The report documented the resident was observed in bed through three of the CNA's rounds. The report documented the initial interventions to prevent future falls included a floor mat, non-skid socks/shoes, and frequent checks: the same initial interventions documented on the FSI report dated 06/01/23. On 09/28/23 at 4:00 p.m., Resident #21 was observed to ambulate independently, spontaneously standing and wandering about the hall without apparent purpose. The resident wore non-skid socks and long pants which hung a few inches below their feet, causing a possible safety hazard. On 09/28/23 at 4:27 p.m., LPN #1 stated the resident did not have a fall mat in place when they fell from their bed on 06/01/23. LPN #1 stated they did not recall if the resident had a fall mat in place when they fell on [DATE]. On 09/28/23 at 4:55 p.m., the DON stated both falls were unwitnessed and the staff were unable to determine with certainty how the injuries occurred. The DON stated there was no documentation the resident had a fall mat in place for either fall. The DON stated the care plan was not immediately updated after the resident fell on [DATE] to include the interventions listed on the incident report and fall investigation report. The DON stated since the falls were unwitnessed, there was no way to determine if a fall mat beside the bed would have prevented an injury from a fall. The DON stated they considered the frequent resident checks to include the staff to be within hearing distance of a resident and not necessarily to observe the resident more frequently.

Based on observation, record review, and interview the facility failed to ensure proper infection control measures were followed during peg tube care for one, (#4) of two residents sampled for peg tube care. The Resident Census and Conditions of Residents report, dated 08/21/23 documented two residents with peg tubes. Findings: Resident #4 had a diagnosis which included dysphasia. On 08/21/23 at 11:30 a.m., Resident #4 was observed lying supine. LPN #1 was observed to provide peg tube care for resident #4. LPN #1 donned gloves, uncovered the resident's abdomen and removed a dressing around the peg tube, dated 08/17/23. LPN #1 cleansed the area around the peg tube with sterile saline. LPN #1 did not clean their hands prior to donning gloves and providing care. Without changing gloves and sanitizing hands LPN #1 applied clean gauze around the peg tube, secured it with tape, and wrote the date on the tape. LPN #1 then removed their gloves and washed their hands. LPN #1 was asked what the policy was for handwashing related to peg tube care. LPN #1 stated, before putting on gloves you sanitize your hands. LPN #1 was asked when gloves should be changed during a dressing change. They stated, when going from a dirty area to a clean area, but I forgot.

On 04/28/22 at 7:26 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to provide an abuse free environment. Observations identified LPN #3 in the common area speaking loudly in a harsh tone to resident #7. LPN #3 was bent over, leaning in the resident's face, demanding the resident come with them to take a shower. Resident #7 was refusing a shower at that time. LPN #3 repeated their demands for the resident to come on, you need to take a shower multiple times, shook a finger in the resident's face, and loudly ordered the resident to come with them. Resident #7 continued to object. The resident looked away from them. LPN #3 took hold of the resident's chin and forced them to turn their face to look at them. The administrator/abuse coordinator witnessed this interaction, and assisted resident #7 to put on their shoe to walk to the shower. The resident then walked with LPN #3 to the shower. At 7:33 p.m., the facility's administrator and regional director were made aware of the IJ situation related to the facility's failure to provide an abuse free environment. A plan of removal of the IJ situation was requested. On 04/29/22 at 5:21 p.m., the administrator provided an acceptable plan of removal. The plan of removal documented: Immediate actions: o Alleged employee was removed from the resident care area and suspended on 4/27/2022 @ 3:15 PM after conversation with nurse, OSDH and administrator indicated that an allegation was being made by the OSDH surveyor. o Resident was interviewed by administrator and assessed by the DON with no negative findings. Resident statement states he did not feel like it was abuse. o Beginning 4/27/2022, investigation started with resident interviews for all cognitive residents and skin audits of non-cognitive residents. Resident investigation completed 4/28/2022 at 3:00 PM o Beginning 4/27/2022, staff interviews of all staff began. ALL staff interviews completed by 6:00 PM_. o 4/28/2022-Admin, BOM, MDS and DON in serviced by Regional Director via phone conference on Abuse policy @ 7:43 PM, including prevention, intervening and reporting. o 4/29/2022-Admin, BOM, MDS and DON re-educated at 1:55 PM on the abuse policy to include all components of abuse and the identification of abuse. Corrective actions: o On 4/28/2022 Inservice started on ALL staff regarding the abuse policy to include prevention, intervening and reporting. 1. Who is the abuse coordinator? 2. What do you do if you witness abuse? 3. What is abuse? 4. Types of abuse. 5. Protecting 6. Investigating 7. Preventing 8. Reporting in services were Completed on all staff at 1:00 PM. On 4/29/2022. o Beginning 4/30/2022 Admin/designee will conduct daily rounds of care areas to check for any concerns or abuse. o Staff will be in serviced at hire and re-educated annually. All immediate actions to be completed on 04/29/2022 by 6:00 PM and monitoring to continue thereafter. All of the findings will be added to QA meeting for further review and recommendations. On 05/02/22, interviews were conducted with a total of 11 employees who worked different shifts and in different departments. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. On 05/02/22 at 12:16 p.m., the administrator was notified the immediacy of the IJ was lifted as of 04/30/22 at 7:00 a.m. The deficient practice remained at a level of isolated harm. Based on record review, observation, and interview, the facility failed to ensure residents were free from abuse for one (#7) of two residents who were reviewed for abuse. LPN #3 was observed in the common area speaking loudly in a harsh tone, demanding Resident #7 go with them to take a shower. Resident #7 was seated and LPN #3 was observed bent over, leaning in the resident's face, demanding the resident come with them to take a shower. Resident #7 was refusing a shower at that time. LPN #3 repeated their demands for the resident to come on, you need to take a shower multiple times, shook their index finger in the resident's face, and ordered the resident to come with them. The resident continued to decline a shower. Resident #7 turned their head away from the LPN, who then took hold of the resident's chin, and forced the resident to turn their face to look at them. The administrator/abuse coordinator witnessed this interaction and assisted the resident to put on their shoe to walk to the shower. The resident then walked with LPN #3 to the shower, however the resident was heard continuing to refuse a shower. The DON identified 57 residents who resided in the facility. Findings: An undated polity titled, Preventing resident abuse, read in part, .our abuse prevention/intervention program includes, but is not necessarily limited to, the following .monitoring staff on all shifts to identify inappropriate behavior toward residents [e.g. using derogatory language, rough handling of residents .] Resident #7 had diagnoses which included anxiety disorder. A quarterly resident assessment, dated 03/08/22 documented the resident was severely impaired in cognition for daily decision making. A care plan, updated 03/23/22, documented Resident #7's wishes and needs will be honored and to approach the resident warmly, positively, and calmly. On 04/27/22 at 2:40 p.m., resident #7 was observed seated in the common area. LPN #3 was observed leaning over the resident, demanding the resident come with them to take a shower. LPN #3 was using a harsh, raised voice. The resident was shaking his head, and saying no, refusing a shower. The LPN repeated their demands multiple times, shook a finger in the resident's face, and ordered the resident to come with them. The resident continued to object to taking a shower. The resident turned their head from the LPN and refused to look at them. LPN #3 took hold of the resident's chin and forcibly turned the residents head so they were face to face. The administrator/abuse coordinator witnessed this interaction, and assisted the resident to put on their shoe to walk to the shower. The resident then walked with the LPN to the shower. On 04/27/22 at 2:53 p.m., the administrator was asked about the incident. The administrator stated LPN #3 was trying to get Resident #7 to take a shower because the resident had removed the bandage from their leg. The administrator stated LPN #3 was speaking loudly to the resident because they were very hard of hearing. They stated they did not see the LPN shake their finger at the resident but did see the LPN turn the resident's face to look at them. The administrator was asked if they thought the interaction was abusive. They stated no. On 04/27/22 at 3:52 p.m., LPN #3 was asked if it was appropriate to force a resident to turn their head and to take a shower. The LPN stated, I think so. If I thought it was inappropriate I wouldn't have done it. That's how we have to do it. On 04/27/22 at 4:04 p.m., resident #7 was asked to describe the incident with the nurse. The resident stated they were having an argument because they wanted them to take a shower. The resident stated they did not want to take a shower at that time, they wanted to take a shower later. The resident stated they had scheduled a shower for 6:00 p.m. with CNA #5. The resident stated LPN #3 wanted them to take a shower now because they had removed their own bandage from their leg. On 04/28/22 at 3:31 p.m., CNA #5 stated LPN #3 was trying to get Resident #7 in the shower when the resident became agitated. The LPN and the resident were arguing because the resident wanted to take a shower at 6:00 p.m. CNA #5 stated the resident requested their shower at that time. CNA #5 stated I was not ok with the situation, I was upset because [LPN #3] forced [Resident #7] to do what they didn't want to do. When asked if it is abusive to force a resident to do something they did not want to do, CNA #5 stated yes. On 05/04/22 at 3:53 p.m., the administrator was asked what the final findings were on the abuse allegation. The administrator stated they had found it unsubstantiated. The administrator was then asked if it a resident had the right to refuse treatment such as showers. The administrator stated yes.

2. Resident #24 was admitted to the facility with diagnoses that included blindness and left hemiplegia. The resident's significant change assessment, dated 03/30/22, documented the resident was cognitively intact for daily decision making, had no current behaviors, and required extensive one person assistance with personal hygiene, including combing hair and brushing teeth. On 04/27/22 at 12:05 p.m., CNA #1 was overheard in resident #24's room. The door was open, and the privacy curtain was pulled. The resident was heard to cry out, Ow, ow, ow! The CNA stated, Well, do you want it done or not? The resident stated, Did I ask for the brush? CNA #1 stated, If I'm going to do this, I'm going to do it now and do it my way. The resident response was not heard. The CNA exited the room, saw the surveyor in the hall, then turned around and reentered the resident's room. The CNA stated to the resident, There are people watching outside your door, I don't need you making trouble. The resident's response was not heard. The CNA's tone of voice was loud and demanding. On 04/27/22 at 12:10 p.m., resident #24 was asked about the conversation with CNA #1 and why CNA #1 was in their room. The resident stated the CNA was brushing their hair. Resident #24 stated they were very tender headed. When the resident was asked if they felt the CNA was using a disrespectful or abusive tone, the resident stated they did not feel the CNA was being abusive. The resident stated the CNA was a friend and checked on them often. The resident stated CNA #1 provided good care. On 04/27/22 at 12:25 p.m., the observation and interview with the resident was communicated to the administrator. On 04/27/22 at 12:45 p.m., CNA #1 was observed in the dining room. On 04/28/22 at 8:37 a.m., CNA #1 was observed in the dining room accepting meal trays for hall 300. On 04/28/22 at 8:48 a.m., CNA #1 was observed to pass meal trays on the 300 Hall. A hand written interview, dated 04/28/22, documented the regional director and BOM interviewed resident #24 from 9:15 a.m. until 9:23 a.m. about the care received by CNA #1. On 04/28/22 at 9:16 a.m., the administrator was asked for copies of the investigation for the allegation regarding resident #24 reported by the surveyor on 04/27/22. The administrator stated the investigation was in their office. The administrator was asked if the allegation was reported to OSDH. The administrator stated they were unable to remember if they had reported the allegation to OSDH. On 04/28/22 at 10:05 a.m., the administrator provided a form, dated 04/27/22, regarding education provided to CNA #1 about tone used when speaking to residents. The administrator was asked what the protocol was for an allegation of abuse. The administrator stated when an allegation was received against an employee the protocol dictated the head of the identified department and the administrator should interview and obtain a statement from the person alleged with abuse. The administrator stated an initial report was to be made to OSDH, an investigation was to be initiated, and the employee was to be suspended pending the outcome of the investigation. The administrator stated the investigation should contain interviews with other staff and residents who received care from the employee. The administrator was asked why the allegation against CNA #1 was not investigated. The administrator stated the protocol was not followed because their focus was off. The administrator was asked where CNA #1 was at that time. The Administrator stated CNA #1 had been sent home. On 04/28/22 at 10:24 a.m., a punch detail was requested for CNA #1 for the dates 04/27/22 and 04/28/22. The BOM stated it would take some time as the report could not be generated because the employee did not clock out. The BOM stated CNA #1's time would need to be manually entered. The punch detail documented on 04/27/22 CNA #1 worked from 6:43 a.m. until 2:00 p.m. and on 04/28/22 CNA #1 worked from 6:45 a.m. until 9:05 a.m. A documented interview with resident #24 and the documentation of education for CNA #1 was the only documentation provided by the end of the survey for the allegation. On 04/28/22 at 7:26 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to provide an abuse free environment. Observations identified LPN #3 in the common area speaking loudly in a harsh tone to resident #7. LPN #3 was bent over, leaning in the resident's face, demanding the resident come with them to take a shower. Resident #7 was refusing a shower at that time. LPN #3 repeated their demands for the resident to come on, you need to take a shower multiple times, shook a finger in the resident's face, and loudly ordered the resident to come with them. Resident #7 continued to object. The resident looked away from them. LPN #3 took hold of the resident's chin and forced them to turn their face to look at them. The administrator/abuse coordinator witnessed this interaction, and assisted resident #7 to put on their shoe to walk to the shower. The resident then walked with LPN #3 to the shower. At 7:33 p.m., the facility's administrator and regional director were made aware of the IJ situation related to the facility's failure to provide an abuse free environment. A plan of removal of the IJ situation was requested. On 04/29/22 at 5:21 p.m., the administrator provided an acceptable plan of removal. The plan of removal documented: Immediate actions: o Alleged employee was removed from the resident care area and suspended on 4/27/2022 @ 3:15 PM after conversation with nurse, OSDH and administrator indicated that an allegation was being made by the OSDH surveyor. o Resident was interviewed by administrator and assessed by the DON with no negative findings. Resident statement states he did not feel like it was abuse. o Beginning 4/27/2022, investigation started with resident interviews for all cognitive residents and skin audits of non-cognitive residents. Resident investigation completed 4/28/2022 at 3:00 PM o Beginning 4/27/2022, staff interviews of all staff began. ALL staff interviews completed by 6:00 PM_. o 4/28/2022-Admin, BOM, MDS and DON in serviced by Regional Director via phone conference on Abuse policy @ 7:43 PM, including prevention, intervening and reporting. o 4/29/2022-Admin, BOM, MDS and DON re-educated at 1:55 PM on the abuse policy to include all components of abuse and the identification of abuse. Corrective actions: o On 4/28/2022 Inservice started on ALL staff regarding the abuse policy to include prevention, intervening and reporting. 1. Who is the abuse coordinator? 2. What do you do if you witness abuse? 3. What is abuse? 4. Types of abuse. 5. Protecting 6. Investigating 7. Preventing 8. Reporting in services were Completed on all staff at 1:00 PM. On 4/29/2022. o Beginning 4/30/2022 Admin/designee will conduct daily rounds of care areas to check for any concerns or abuse. o Staff will be in serviced at hire and re-educated annually. All immediate actions to be completed on 04/29/2022 by 6:00 PM and monitoring to continue thereafter. All of the findings will be added to QA meeting for further review and recommendations. On 05/02/22, interviews were conducted with a total of 11 employees who worked different shifts and in different departments. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. On 05/02/22 at 12:16 p.m., the administrator was notified the immediacy of the IJ was lifted as of 04/30/22 at 7:00 a.m. The deficient practice remained at a level of isolated harm. Based on record review, observation, and interview, the facility failed to implement their abuse policy by protecting, preventing, and identifying an abusive interaction for one (#7) of two residents reviewed for abuse. This resulted in an IJ situation. The facility failed to implement the abuse policy by investigating, protecting, and reporting an allegation of abuse for one (#24) of two residents investigated for abuse. The DON identified 57 residents who resided in the facility. Findings: An undated policy titled, Preventing resident abuse, read in part, .our abuse prevention/intervention program includes, but is not necessarily limited to, the following .monitoring staff on all shifts to identify inappropriate behavior toward residents [e.g. using derogatory language, rough handling of residents .] . An undated policy titled, Abuse investigating and reporting, read in part, .All reports of resident abuse . shall be promptly reported to local, state, and federal agencies [as defined by current regulations] .and thoroughly investigated by facility management . 1. Resident #7 had diagnoses which included anxiety disorder. A quarterly resident assessment, dated 03/08/22 documented the resident was severely impaired in cognition for daily decision making. On 04/27/22 at 2:40 p.m., resident #7 was observed seated in the common area. LPN #3 was observed leaning over the resident, demanding the resident come with them to take a shower. LPN #3 was using a harsh, raised voice. The resident was shaking his head, and saying no, refusing a shower. The LPN repeated their demands multiple times, shook a finger in the resident's face, and ordered the resident to come with them. The resident continued to object to taking a shower. The resident turned their head from the LPN and refused to look at them. LPN #3 took hold of the resident's chin and forcibly turned the residents head so they were face to face. The administrator/abuse coordinator witnessed this interaction, and assisted the resident to put on their shoe to walk to the shower. The resident then walked with the LPN to the shower. On 04/27/22 at 2:53 p.m., the administrator was asked about the incident. The administrator stated the LPN was trying to get the resident to take a shower because the resident had removed the bandage from their leg. The administrator stated LPN #3 was speaking loudly to the resident because they were very hard of hearing. They stated they did not see the LPN shake their finger at the resident but did see the LPN turn the resident's face to look at them. The administrator did not identify the incident as abuse. On 04/27/22 at 3:52 p.m., LPN #3 was asked if it was appropriate to force a resident to turn their head and to take a shower. The LPN stated, I think so. If I thought it was inappropriate I wouldn't have done it. That's how we have to do it. On 04/27/22 at 4:04 p.m., resident #7 was asked to describe the incident with the nurse. The resident stated they were having an argument because they wanted them to take a shower. The resident stated they did not want to take a shower at that time, they wanted to take a shower later. The resident stated they had scheduled a shower for 6:00 p.m. with CNA #5. The resident stated LPN #3 wanted them to take a shower now because they had removed their own bandage from their leg. On 04/28/22 at 3:31 p.m., CNA #5 stated LPN #3 was trying to get Resident #7 in the shower when the resident became agitated. The LPN and the resident were arguing because the resident wanted to take a shower at 6:00 p.m. CNA #5 stated the resident requested their shower at that time. CNA #5 stated I was not ok with the situation, I was upset because [LPN #3] forced [Resident #7] to do what they didn't want to do. When asked if it is abusive to force a resident to do something they did not want to do, CNA #5 stated yes. On 05/04/22 at 3:53 p.m., the administrator was asked what the final findings were on the abuse allegation. The administrator stated they had found it unsubstantiated.

Based on record review, observation, and interview, the facility failed to report allegations of abuse for one (#24) of two allegations of abuse reviewed. The Resident Census and Conditions of Residents report identified 57 residents lived at the facility. Findings: An undated policy titled, Abuse investigating and reporting, read in part, .All reports of resident abuse .shall be promptly reported to local, state, and federal agencies [as defined by current regulations] . 1. Resident #24 was admitted to the facility with diagnoses that included blindness and left hemiplegia. The resident's significant change assessment, dated 03/30/22, documented the resident was cognitively intact for daily decision making, and required extensive one person assistance with personal hygiene, including combing hair and brushing teeth. On 04/27/22 at 12:05 p.m., CNA #1 was overheard in resident #24's room. The door was open, and the privacy curtain was pulled. The resident was heard to cry out, Ow, ow, ow! The CNA stated, Well, do you want it done or not? The resident stated, Did I ask for the brush? CNA #1 stated, If I'm going to do this, I'm going to do it now and do it my way. The resident response was not heard. The CNA exited the room, saw the surveyor in the hall, then turned around and reentered the resident's room. The CNA stated to the resident, There are people watching outside your door, I don't need you making trouble. The resident's response was not heard. The CNA's tone of voice was loud and demanding. On 04/27/22 at 12:10 p.m., resident #24 was asked about the conversation with CNA #1 and why CNA #1 was in their room. The resident stated the CNA was brushing their hair. Resident #24 stated they were very tender headed. When the resident was asked if they felt the CNA was using a disrespectful or abusive tone, the resident stated they did not feel the CNA was being abusive. The resident stated the CNA was a friend and checked on them often. The resident stated CNA #1 provided good care. On 04/27/22 at 12:25 p.m., the observation and interview with the resident was communicated to the administrator. On 04/28/22 at 9:16 a.m., the administrator was asked for copies of the investigation for the allegation regarding resident #24 reported by the surveyor on 04/27/22. The administrator stated the investigation was in their office. The administrator was asked if the allegation was reported to OSDH. The administrator stated they were unable to remember if they had reported the allegation to OSDH.

Based on record review, observation, and interview, the facility failed to thoroughly investigate one (#24) of two residents reviewed for allegations of abuse. The Resident and Census of Conditions of Residents report identified 57 residents lived at the facility. Findings: An undated policy titled, Abuse investigating and reporting, read in part, .All reports of resident abuse .shall be promptly reported .and thoroughly investigated by facility management . 1. Resident #24 was admitted to the facility with diagnoses that included blindness and left hemiplegia. The resident's significant change assessment, dated 03/30/22, documented the resident was cognitively intact for daily decision making, and required extensive one person assistance with personal hygiene, including combing hair and brushing teeth. On 04/27/22 at 12:05 p.m., CNA #1 was overheard in resident #24's room. The door was open, and the privacy curtain was pulled. The resident was heard to cry out, Ow, ow, ow! The CNA stated, Well, do you want it done or not? The resident stated, Did I ask for the brush? CNA #1 stated, If I'm going to do this, I'm going to do it now and do it my way. The resident response was not heard. The CNA exited the room, saw the surveyor in the hall, then turned around and reentered the resident's room. The CNA stated to the resident, There are people watching outside your door, I don't need you making trouble. The resident's response was not heard. The CNA's tone of voice was loud and demanding. On 04/27/22 at 12:10 p.m., resident #24 was asked about the conversation with CNA #1 and why CNA #1 was in their room. The resident stated the CNA was brushing their hair. Resident #24 stated they were very tender headed. When the resident was asked if they felt the CNA was using a disrespectful or abusive tone, the resident stated they did not feel the CNA was being abusive. The resident stated the CNA was a friend and checked on them often. The resident stated CNA #1 provided good care. On 04/27/22 at 12:25 p.m., the observation and interview with the resident was communicated to the administrator. A hand written interview, dated 04/28/22, documented the regional director and BOM interviewed resident #24 from 9:15 a.m. until 9:23 a.m. about the care received by CNA #1. On 04/28/22 at 9:16 a.m., the administrator was asked for copies of the investigation for the allegation regarding resident #24 reported by the surveyor on 04/27/22. The administrator stated the investigation was in their office. On 04/28/22 at 10:05 a.m., the administrator provided a form, dated 04/27/22, regarding education provided to CNA #1 about tone used when speaking to residents. The administrator was asked what the protocol was for an allegation of abuse. The administrator stated when an allegation was received against an employee the protocol dictated the head of the identified department and the administrator should interview and obtain a statement from the person alleged with abuse. The administrator stated an initial report was to be made to OSDH, an investigation was to be initiated, and the employee was to be suspended pending the outcome of the investigation. The administrator stated the investigation should contain interviews with other staff and residents who received care from the employee. The administrator stated the protocol was not followed because, My focus was off. A documented interview with resident #24 and the documentation of education for CNA #1 was the only documentation provided by the end of the survey for the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 04/26/22 at 4:02 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to prevent accident hazards on the memory care unit. Observations revealed a resident was left alone in the shower room with unsecured chemicals. The door handle to the shower room was observed to be broken which made the door unable to be opened from the inside and there was no call light observed in the shower room. Unsecured chemicals were observed in a storage room in the hallway. A room on the hallway which housed a heating and air unit was observed to be unlocked. A room on the hallway which housed a hot water tank and an electrical breaker panel was observed to be unlocked. At 4:11 p.m., the facility's administrator and regional director were made aware of the IJ situation related to the facility's failure to prevent accident hazards on the memory care unit. A plan of removal of the IJ situation was requested. On 04/27/22 at 12:24 p.m., the administrator provided an acceptable plan of removal. The plan of removal documented, Plan of Removal 04/26/2022 On 4/26/2022 Admin/designee began the process of correcting the deficient practices identified by OSDH: to be completed by 6:00PM 4/26/2022. Locks placed on the supply room door, HVAC closet and Hot water heater storage closet. A complete assessment of the facility completed to secure all chemicals appropriately. On 4/26/20222 [sic] - Admin/Designee began the following instant in-services: to be completed by 9:00 PM 4/26/2022 .All Facility Staff in All Departments- maintaining a safe and homelike environment for residents to include safe storage of chemicals, locks on doors that store supplies, equipment and other areas that could be areas of concern for residents. Policy and procedure for storage of Chemicals, hazardous areas and what to do in the event something is broken or not working properly. [IE: Notify nurse and/or Admin and write a maintenance ticket] .All Facility Staff in All Departments Making sure call lights are functioning appropriately- Policy and procedure on call light system reviewed and copy given to staff .Inservice ALL nursing staff on safety and ADL care according to resident needs to include assistance with bathing. Policy and procedure for supervision of resident when bathing P&P update 4-26-2022 to Highlight not leaving resident alone while showering .Door lock to be installed on shower door to be completed 4/26/2022. All immediate actions will be completed by 9:00 PM 4/26/2022 and monitoring to continue thereafter. Beginning 4/27/2022, Admin/designee will conduct facility rounds to check for proper storage of chemicals, locked supply doors and mechanical areas as well as other areas identified by OSDH daily xs [sic] 14 days and weekly until substantial compliance is maintained. DON/Designee will monitor resident care area for adherence to ADL care needs to meet resident needs daily xs [sic] 14 days and weekly until substantial compliance is maintained. All of the findings will be added to QA meeting for further review and recommendations. On 04/27/22 at 2:17 p.m., the shower room on the memory care unit was observed to be unlocked. The door to the employee restroom on the memory care unit was observed to be unlocked with an unsecured chemical (germicidal wipes) in the unlocked cabinet. The label on the germicidal wipes read in part, .Keep out of reach of children . On 04/27/22 at 5:02 p.m., the administrator and regional director were notified the immediacy could not be lifted due to the shower room on the memory care unit was not secure and unsecured chemicals were observed in the unlocked and open employee restroom on the memory care unit. On 04/27/22 at 5:40 p.m., an acceptable amended plan of removal was provided by the administrator. The plan of removal updated that facility staff would be re-inserviced on securing chemicals and keeping the shower room and employee restroom locked on the memory care unit beginning 04/27/22 and would be completed on 04/28/22 at 8:00 a.m. On 04/28/22, interviews were conducted with a total of ten employees who worked different shifts and in different departments. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. On 04/28/22 at 12:56 p.m., the administrator was informed the IJ had been removed as of 04/28/22 at 8:00 a.m. The deficient practice remained at a level of isolated harm. Based on record review, observation, and interview, the facility failed to prevent accident hazards on one (the memory care unit-100 hall) of three halls observed. The facility had unsecured chemicals with 15 residents who wandered on the memory care unit. A resident was observed to be left alone in the shower room with unsecured chemicals. The door handle to the shower room was observed to be broken which made the door unable to be opened from the inside and there was no call light observed in the shower room. A room on the hallway which housed a heating and air unit was observed to be unlocked. A room on the hallway which housed a hot water tank and an electrical breaker panel was observed to be unlocked. This resulted in an IJ situation. The DON identified 15 residents who wandered on the memory care unit. Findings: A form titled, Maintenance Log Page 19, dated 04/19/21 through 04/30/21, read in part, .04/29/21 Shower room [ROOM NUMBER] Hall Door knob needs to replaced [sic] that can lock . The form documented the date of repair was 06/04/21 and was initialed by facility staff. A form titled, Maintenance Log Page, dated 10/05/21 through 10/08/21, read in part, .10/13 Shower room [ROOM NUMBER] Hall Door lock need to put lock .10/20 100 Hall Shower Room need to put a lock on it . The columns for the date of the repair and the facility staff's initials for both entries were blank. 1. Resident #18 had diagnoses which included Alzheimer's disease. A quarterly resident assessment, dated 04/05/22, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance of one staff member for bathing, and wandered daily. A care plan, updated 04/06/22, documented to assign staff to account for the resident's whereabouts at all times and the resident required extensive assistance with bathing. 2. Resident #44 had diagnoses which included Alzheimer's disease. An annual resident assessment, dated 02/04/22, documented the resident was severely impaired in cognition for daily decision making, was always incontinent of bowel and bladder, was totally dependent on staff for toilet use, and wandered daily. A care plan, updated 02/16/22, documented the resident was impaired in cognition, wandered, and to keep the environment free of safety hazards. 3. Resident #11 had diagnoses which included dementia. A significant change resident assessment, dated 03/14/22, documented the resident was severely impaired in cognition for daily decision making, was always incontinent of bowel and bladder, and wandered daily. A care plan, updated 03/28/22, documented the resident wandered, staff were to monitor the resident's whereabouts, and maintain an environment free of safety hazards. On 04/26/22 at 10:16 a.m., resident #18 was observed standing in the shower room wrapped in a towel. The door to the shower room was shut but was not completely latched. The resident did not answer when the surveyor knocked on the door. CNA #3 was asked how many staff were on the memory care unit. They stated there were two CNAs and one CMA. CNA #3 was asked if they were aware a resident was in the shower room. The CNA stated no. CNA #3 went to the shower room and stated to CNA #4, who was in the common area assisting a resident with the morning meal, that resident #18 was in the shower room and was not to be left unattended. On 04/26/22 at 10:19 a.m., CNA #4 approached the shower room and was asked if the resident was safe to shower without staff supervision. They stated the resident wanted to shower independently and another resident required assistance with eating so they assisted the other resident with breakfast. On 04/26/22 at 10:22 a.m., CNA #4 turned the shower on and assisted the resident with the shower. On 04/26/22 at 10:29 a.m., CNA #4 and resident #18 exited the shower room. The door to the shower room was not latched and did not have a lock on it. Upon entrance to the shower room an uncapped, open bottle of hand sanitizer with approximately four ounces of product, was observed on an eye level shelf. The hand sanitizer label read in part, .Keep out of reach of children . A gallon bottle of hair and body wash was observed on the floor with approximately eight ounces of purple liquid in it. As the surveyor turned to exit the shower room the inside door handle was observed to be missing with only a metal, cylindrical piece available to attempt to turn to unlatch and open the door. There was no call light observed in the shower room. The door had to be pried open, by the surveyor grabbing the edge of the door with their fingertips, for the surveyor to exit. On 04/26/22 at 11:06 a.m., CNA #3 was asked if any door knobs were in need of repair on the memory care unit. They stated, Just the shower on the inside. CNA #3 was asked what happened to the door handle. CNA #3 stated they would enter the shower room and jiggle the handle and the handle came off. CNA #3 was asked who jiggled the handle. They stated the residents. CNA #3 stated the door handle required repair every couple of months. CNA #3 was asked how long the door handle had been broken preventing exit. They stated the last time it was repaired and working was a couple of months ago. On 04/26/22 at 11:27 a.m., an unlocked closet was observed on the memory care unit to contain a hot water tank, a drain hole in the floor, and an electrical breaker box. On 04/26/22 at 11:28 a.m., an unlocked closet was observed on the memory care unit to contain a heat/air unit, valves, and cords. On 04/26/22 at 11:30 a.m., CNA #4 was observed sitting in the common area of the memory care unit with residents. CNA #4 was asked where the other staff members were. They stated they did not know. On 04/26/22 at 11:34 a.m., CNA #3 was asked about the unlocked shower room. They stated resident #44 wandered into the shower room when they were sleeping and the staff would have to get them out. On 04/26/22 at 11:37 a.m., an unlocked supply closet was observed to to have a spray bottle unsecured on a shelf, with approximately ten ounces of liquid in it. The spray bottle had Disinfectant hand written on it. The closet also contained a 7.5 ounce bottle of hair and skin cleanser with approximately four ounces of product unsecured on a shelf. The label on the bottle of hair and skin cleanser read in part, .Keep out of reach of children. The door/door knob to the supply closet did not have a lock on it. On 04/26/22 at 11:41 a.m., the DON was asked who many residents wandered on the memory care unit. The DON stated 15. On 04/26/22 at 11:44 a.m., CNA #4 obtained the spray bottle, labeled Disinfectant, from the unlocked supply closet and cleaned a table in the common area. CNA #4 then returned the bottle to the unsecured supply closet. On 04/26/22 at 11:51 a.m., the closet with the hot water tank was observed to be locked. The closet with the heat/air unit across the hall was observed to remain unlocked. On 04/26/22 at 12:25 p.m., the maintenance worker was observed trying to unlock the closet door which housed the hot water tank and electrical breaker box. The maintenance worker was asked why the closet had not been locked during earlier observations. They stated the closet was supposed to be locked. On 04/26/22 at 12:30 p.m., the maintenance worker went into shower room and observed the door handle. They stated the need for repair had not been reported to the maintenance department. The maintenance worker stated if the door was latched someone would be stuck in the shower room with no way to open the door from the inside. On 04/26/22 at 1:13 p.m., resident #45 walked over to the unlocked shower room door and attempted to open it. The resident was not successful and walked back down the hall. On 04/26/22 at 2:03 p.m., CNA #3 was asked about resident #44 walking while asleep. CNA #3 stated the resident wandered really bad when he first woke up. CNA #3 stated the resident's eyes would be half closed when they wandered into the shower room. CNA #3 stated if the resident had not made it to the commons area for breakfast the staff knew they could find them in the shower room. CNA #3 stated resident #44 and resident #11 had both been found in the shower room because they wandered and urinated on the door or urinated inside the shower room on the door. On 05/04/22 at 4:39 p.m., the administrator was asked what type of monitoring occurred to ensure the memory care unit was free from accident hazards. The administrator stated chemicals were supposed to be secured but they had not been monitoring. The administrator was asked about the broken door handle to the shower room on the memory care unit and the absence of the call light. The administrator stated they did not think they had been in the shower room to check for a call light and was unaware the door knob was not functional from the inside of the shower room prior to the survey. The administrator stated during daily rounds they mostly monitored for anything being out of place and the overall condition of the residents.

Based on observation and interview, the facility failed to ensure residents had a call light for one (#7) of 19 sampled residents whose rooms were observed for working call lights. The DON identified 57 residents who resided in the facility. Findings: An undated facility policy titled, Bedrooms, read in part, .All resident rooms are equipped with a resident call system that allows residents to call for staff assistance . Resident #7 had diagnoses which included anxiety. On 04/27/22 at 4:04 p.m., the resident was asked if they were able to utilize a call light. The resident stated yes but they did not have one in the room. The resident's room was observed to not have a call light available. On 05/03/22 at 4:08 p.m., the DON was asked why resident #7 did not have a call light. The DON stated the resident had changed rooms approximately two weeks ago. The DON was asked who was responsible to ensure residents had call lights available in their rooms. The DON stated the maintenance department was responsible to ensure rooms were ready when a resident moved in. The DON stated any staff could request a call light from the maintenance department if they saw a resident needed one.

2. Resident #24 had diagnoses that included blindness and left sided hemiplegia. The ADL record, dated March 2022, did not document shaving had occurred. The ADL record, dated April 2022, documented the resident was shaved four out of 13 opportunities. A care plan, dated 04/05/22, documented the resident required total assistance with bathing and extensive assistance with personal hygiene. On 05/02/22 at 1:10 p.m., the resident was observed in a hospital gown. The resident was asked if they wanted to wear clothing other than a hospital gown. The resident stated wearing pants with unshaved legs was irritating so they wore a hospital gown. The resident stated their legs had been shaved three times since they were admitted approximately four years ago. The resident stated they were scheduled for showers/baths Monday, Wednesday, and Friday. On 05/02/22 at 2:04 p.m., the resident's legs were observed to have hair over an inch long. When asked, the resident stated they shaved their under arms twice in April but they did not shave their legs. On 05/04/22 at 11:46 a.m., CNA #2 stated if a resident wanted their legs shaved and needed assistance the CNA would be expected to assist during the shower as often as the resident requested. On 05/04/22 at 4:36 p.m., the administrator stated her expectation of staff was to provide the required ADL assistance, including shaving their legs. Based on record review, observation, and interview, the facility failed to ensure dependent residents were provided required assistance with ADL care for two (#18 and #24) of three sampled residents who were reviewed for ADLs. The facility Resident Census and Conditions of Residents report, dated 04/27/22, identified 22 residents who were dependent on staff for bathing. Findings: 1. Resident #18 had diagnoses which included Alzheimer's disease. A quarterly resident assessment, dated 04/05/22, documented the resident was severely impaired in cognition for daily decision making and required extensive assistance of one staff member for bathing. A care plan, updated 04/06/22, documented the resident required extensive assistance with bathing. On 04/26/22 at 10:16 a.m., resident #18 was observed standing in the shower room wrapped in a towel. CNA #3 was asked how many staff were on the memory care unit. They stated there were two CNAs and one CMA. CNA #3 was asked if they were aware a resident was in the shower room. The CNA went to the shower room and stated to CNA #4, who was in the common area assisting a resident with the morning meal, that resident #18 was in the shower room and was not to be left unattended. CNA #4 then approached the shower room and was asked if the resident was safe to shower without staff supervision. The CNA stated the resident wanted to shower independently and they needed to assist another resident with their meal.

Based on observation and interview, the facility failed to ensure sufficient staff to meet the needs of the residents for one (memory care unit) of three halls observed for sufficient staff. The DON identified 16 residents who resided on the memory care unit. Findings: On 04/26/22 at 10:16 a.m., resident #18 was observed in the shower room alone. CNA #4 was observed feeding a resident in the commons area. CNA #3 told CNA #4 that resident #18 was not to be left unattended in the shower and the resident needed to be assisted. CNA #4 stated the resident wanted to shower independently so they assisted a resident with their meal who required assistance from staff. On 04/26/22 at 11:30 a.m., CNA #4 was observed to be the only staff member on the memory care unit. The CNA was asked where the other staff were for the memory care unit. She stated she did not know. On 04/28/22 at 11:27 a.m., CNA #3 was asked how many staff worked on the memory care unit. CNA #3 stated two. CNA #3 was asked how supervision was provided when one staff member left the unit. CNA #3 stated usually one of the CMAs went to the memory care unit until the CNA returned. CNA #3 was asked if there were enough staff on the memory care unit to provide all of the care and supervision the residents required. CNA #3 stated about 75% of the time they had two or three staff members which was sufficient. CNA #3 was asked how the memory care unit was staffed the other 25% of the time. CNA #3 stated if a staff member called in the CMA would assist on the memory care unit but they also had to administer medications to the other halls as assigned. On 05/04/22 at 3:26 p.m., the DON was asked how the facility ensured sufficient staff to provide the care and supervision required on the memory care unit. The DON stated they worked on the memory care unit if needed and other nurses had as well. The DON was asked if the nurses had other halls they were responsible for when they provided care on the memory care unit. They stated sometimes. The DON was asked if the memory care unit had been sufficiently staffed to provide the care and supervision the residents required. The DON stated no.

2. On 05/03/22 at 2:01 p.m., multiple medications in the medication room were observed to be expired. The medications which were expired included: Avonex pen expired in 2019, house stock Flucelvax Quad injection expired on 03/18/21, acetaminophen suppository 650 mg expired on 08/11/21, bisacodyl suppository 10 mg expired on 10/11/21, bisacodyl suppository 10 mg expired on 12/29/21, house stock Senna 8.6 mg (the expiration date was unknown because the part of the label which had the expiration date was missing), and house stock ibuprofen 200 mg expired on 02/17/22. On 05/03/22 at 2:08 p.m., CMA #2 and LPN #1 were asked about the expired medications. CMA #2 stated they usually checked the cabinets for expired medications and prepared them to be destroyed or donated. The CMA stated the expired medications had not been removed from the refrigerator and the expired medications should not have been in the refrigerator or on the shelf. The CMA stated she never checked the refrigerator because they were medications she did not use. LPN #1 stated they had never thought to check them either. On 05/03/22 at 2:24 p.m., the DON stated all licensed staff were responsible for ensuring the expired medications were pulled from the shelf and refrigerator. The DON was asked how the staff knew they were responsible for monitoring for expired medications. The DON stated, I'm sorry. I don't know what to tell you. Based on observation and interview, the facility failed to ensure medications were stored/secured for one of three medication carts observed and ensure expired medications were not available for administration for one of one medication rooms observed. The DON identified 57 residents received medications and the facility census report documented 25 residents resided on the 300 hall. Findings: The facility's policy titled, Storage of Medications, revised April 2007, documented, .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Compartments [including .carts .] containing drugs .shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . On 05/02/22 at 2:38 p.m., the 300 hall medication cart was observed to be unlocked by the nurses station. On 05/02/22 at 3:04 p.m., CMA #3 approached the unlocked medication cart and obtained a pair of gloves from the side of the cart. On 05/02/22 at 3:15 p.m., CMA #3 approached the medication cart, obtained some supplements, and left the cart unlocked. On 05/02/22 at 3:18 p.m., CMA #3 returned to the medication cart and locked it. CMA #3 was asked who was responsible for the medication cart. CMA #3 stated, I am. CMA #3 was asked what the facility protocol was for securing medications. CMA #3 stated medication carts were to kept locked at all times. CMA #3 was asked why the medication cart had been observed to be unlocked from 2:38 p.m. until they had locked it at 3:18 p.m. CMA #3 stated they had gotten distracted assisting the nurse with residents. On 05/02/22 at 4:10 p.m., the DON was told of the above observations and was asked how they ensured medications were secured and properly stored. The DON stated the medication carts were kept locked. The DON was asked how medication carts were monitored to ensure they were secured. They stated they did rounds every two to three hours.

Based on record review, observation, and interview, the facility failed to ensure ordered labs were completed for one (#34) of five sampled residents whose labs were reviewed. The DON identified 53 residents had physician orders for labs. Findings: Resident #34 had diagnoses which included bipolar disorder, hyperlipidemia, and chronic obstructive pulmonary disease. An undated facility policy titled, Lab and Diagnostic Test Results - Clinical Protocol read in part, .The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests . Physician's Orders, dated 01/02/19, documented labs for CBC and CMP every six months, and a lab for a lipid panel yearly. A Physician's Order, dated 09/23/21, documented a lab for Depakote level every three months in October, January, April, and July. On 04/27/22 at 11:12 a.m., the resident's clinical record contained no lab results. On 04/27/22 at 4:00 p.m., the surveyor requested current physician orders and lab results from the DON. On 05/02/22 at 4:07 p.m., the DON provided physician orders but labs for the resident were not provided. The DON was asked for the resident's lab reports. No explanation was given as to why the surveyor had not been provided lab results. On 05/04/22 at 3:30 p.m., the Administrator stated she had not found the requested lab results. By the end of the survey lab results for resident #34 had not been provided to the survey team.

Based on record review and interview, the facility failed to ensure laboratory results were reported to the physician for two (#27 and #38) of five residents whose laboratory reports were reviewed. The DON identified 53 residents who received laboratory services. Findings: 1. Resident #27 had diagnoses which included diabetes mellitus and hyperlipidemia. The laboratory results, dated 07/02/21, documented the resident's glucose and A1C were high and the total protein and HDL were low. The laboratory results, dated 01/26/22, documented the resident's platelets and A1C were both high. A care plan, updated 04/06/22, read in part, .Obtain labs/diagnostic test as ordered and report abnormal results to physician . The laboratory results were not signed by the physician and the clinical record did not document the physician had been notified of the abnormal results. 2. Resident #38 had diagnoses which included hyperlipidemia and edema. The laboratory results, dated 09/30/21, documented the resident's HDL was low. The laboratory results, dated 10/19/21, documented the resident's albumin, total protein, and total bilirubin were low and the sodium and chloride were high. A care plan, dated 02/02/22, read in part, .Lab/Diagnostic test as per ordered .Update physician and responsible party on any changes noted . The laboratory results were not signed by the physician and the clinical record did not document the physician had been notified of the abnormal results. On 05/03/22 at 10:20 a.m., the DON was asked if the physician had addressed/reviewed Resident #27 and #38's laboratory reports. The DON stated they did not know. The DON was asked how they ensured the physician was aware of abnormal laboratory results. The DON stated they had no system in place to obtain laboratory results from the physician once they had been reviewed. They stated if the physician wrote an order regarding a laboratory result they would send an order to the facility but they had no way of knowing if the physician had addressed the laboratory results which did not warrant an order.

Based on record review, observation, and interviews, the facility failed to ensure resident's had privacy curtains for six of six double occupancy rooms reviewed for privacy on the memory care unit. The facility Census List identified six rooms which were double occupancy on the memory care unit. Findings: An undated facility policy titled, Bedrooms, read in part, .Each room is designed to provide privacy for each resident and equipped for adequate nursing care . The maintenance log, dated 07/22/21, documented three rooms on the memory care unit needed privacy curtains. The place on the form to document the date repaired and the staff member's initials was blank. On 04/26/22 at 10:23 a.m., the memory care unit was observed. None of the six double occupancy rooms were observed to have privacy curtains. On 05/02/22 at 4:23 p.m., CNA #3 was asked how privacy was ensured during resident care for residents who had a roommate on the memory care unit. CNA #3 stated the roommate would leave the room or the nurse would ask the resident to step out of the room while care was provided. CNA #3 was asked why there were no privacy curtains on the memory care unit. They stated they thought the residents pulled on them. CNA #3 was asked how long they had not utilized privacy curtains on the memory care unit. They stated approximately one and a half years. On 05/02/22 at 4:28 p.m., LPN #1 was asked how privacy was ensured during resident care for residents who had a roommate on the memory care unit. They stated they took the resident to the restroom to provide care. LPN #1 was asked why privacy curtains were not utilized on the memory care unit. They stated they were in the laundry department being washed. LPN #1 was asked how long they had been in the laundry department. They stated they did not know. On 05/02/22 at 4:31 p.m., the DON was asked how privacy was maintained during resident care on the memory care unit. They stated they had privacy curtains in the room and they changed them out every two weeks. The DON accompanied the surveyor on a tour of the memory care unit and was asked where the privacy curtains were for double occupancy rooms. The DON stated they would check with the director of human resources/BOM. On 05/02/22 at 4:33 p.m., the DON asked the human resources/BOM where the privacy curtains were for the memory care unit. The human resources/BOM stated the curtains had been removed approximately six months ago because residents would pull on them. The DON was asked if alternatives to privacy curtains had been attempted to ensure privacy during resident care. The DON stated no.