Every finding on record at Cross Timbers Nursing and Rehabilitation

Based on observation and interview, the facility failed to ensure: a. prepared food was dated and labeled; and b. prepared food that could not consumed was removed from storage for one of one kitchen observation. The administrator identified 47 residents who received their meals from the kitchen. Findings: On 02/20/25 at 11:50 a.m., during the initial kitchen visit of the six door refrigerator, there were four white bowls of an unknown beige substance on a plastic tray. The unknown substance had greenish/gray center and white edges. They were not dated or labeled. The Food Receiving and Storage policy, revised 12/2008, read in part, Foods shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On 02/20/25 at 11:56 a.m., cook #1 stated the greenish/gray with white edges in the bowls looked like mold. They stated they did not know what the date should be on the bowls. They stated the policy was to label, date, and after 48 hours depending on the food item, to pull it out of rotation. [NAME] #1 stated they did not see the tray with the four bowls. On 02/20/25 at 11:59 a.m., the dietary supervisor observed the four bowls. They stated they had mold on them and should have been thrown away. They stated the unknown substance should have been labeled and dated.

Based on observation, record review, and interview, the facility failed to follow the menu for one of one meal service observed. The administrator identified 47 residents who received their meals from the kitchen. Findings: On 02/25/25 at 9:51 a.m., a lunch menu observed posted in the dining room board showed baked chicken, buttered noodles, peas and mushrooms, roll and apricot parfait. The Menus policy, revised 04/2007, read in part, Menus shall be planned and followed to meet nutritional needs of patients. A Week 2 facility menu, dated 2024-2025, showed residents would be served chicken baked, buttered noodles, peas and mushrooms, white roll, and apricot parfait for Tuesday's lunch menu on 02/25/25. On 02/25/25 at 10:00 a.m., cook #1 stated they would serve fried chicken patties, peas, scalloped potatoes, dinner rolls, and mixed fruit. They stated they changed the menu because they could not locate the chicken to thaw out at that time. They stated they later located the chicken. On 02/25/25 at 10:39 a.m., cook #1 stated they consulted with the administrator before making the changes. They stated scalloped potatoes paired better with the chicken patties. On 02/25/25 at 11:33 a.m., cook #1 was observed to served the above menu items. No mushrooms were observed to be cooked and served during meal service observation. On 02/25/25 at 1:56 p.m., the administrator stated the certified dietary manager was off and they were supervising. On 02/25/25 at 2:05 p.m., the administrator stated they discussed the menu changed with cook #1. On 02/25/25 at 2:08 p.m., the administrator stated they were not sure why the mushrooms were not served. They stated it was an oversight on their part. They stated the dining room menu board should have been updated.

Based on record review and interview, the facility failed to ensure resident assessments were completed and submitted to Centers for Medicare & Medicaid Services for 1 (#60) of 15 sampled residents who were reviewed for resident assessments. The administrator identified 59 residents resided in the facility. Findings: Resident #60's Discharge Assessment, showed the assessment reference date was 10/16/24 and the assessment was completed on 11/01/24. The assessment was not completed within the 14 day allowed time for completion. On 02/21/25 at 2:17 p.m., the director of nursing stated the assessment did not appear to have been submitted on time.

Based on record review and interview, the facility failed to maintain documentation that an alleged violation was thoroughly investigated. The Administrator identified 67 residents resided in the facility Findings: An Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised 09/22, read in part, .All reports of resident abuse .neglect, exploitation, or theft/misappropriation of resident property are .thoroughly investigated by facility management. Findings of all investigations are documented and reported .documents the investigation completely and thoroughly .Witness statements are obtained in writing . Resident #2 had diagnosis which include Parkinson's and schizoaffective disorder, bipolar type. An annual assessment, dated 06/12/24, documented Resident #2's cognition was severely impaired. On 08/28/24 at 4:05 p.m., OSDH received a state reportable which documented CNA #1 was providing care to Resident #2. They photographed Resident #2 and it was later posted on social media by their significant other. There was no documentation of any staff being interviewed by the facility. On 09/06/24 at 8:57 a.m., the Administrator stated they did note have any documentation of staff being interviewed. They stated they did not keep the interviews, the took notes and they would keep them until the investigation was completed and then the notes were discarded.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the required agencies for one (#2) of three sampled resident whose financial records were reviewed. The Administrator identified 67 residents resided in the facility Findings: An Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised 09/22, read in part, .All reports of resident abuse .neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; a. The local/state ombudsman; b. The resident's representative; c. Adult protective services (where state law provides jurisdiction in long-term care); d. Law enforcement officials; e. The resident's attending physician; and f. The facility medical director . Resident #2 had diagnosis which include Parkinson's and schizoaffective disorder, bipolar type. An annual assessment, dated 06/12/24, documented Resident #2's cognition was severely impaired. On 08/28/24 at 4:05 p.m., OSDH received a state reportable which documented CNA #1 was providing care to Resident #2. They photographed Resident #2 and it was later posted on social media by their significant other. The report documented the following agencies were notified of the alleged abuse: Physician, Local Law enforcement and the Nurse Aide Registry. There was no documentation of Adult Protective Services being notified. On 09/05/24 at 11:43 a.m., the Administrator stated these are the complete investigations, I have no other documentation.

Based on record review and interview, the facility failed to consistently employ an RN for at least eight consecutive hours a day and seven days a week for January 2024, February 2024, March 2024. LPN #4 identified 66 residents who resided in the facility. Findings: A PBJ Staffing Data Report, dated 01/01/24 through 03/31/24, documented no RN hours for 01/06/24, 01/07/24, 01/21/24, 02/03/24, 02/04/24, 02/10/24, 02/11/24. 02/17/24, 02/18/24, 02/24/24, 02/25/24, 03/03/24. 03/09/24, 03/10/24, 03/16/24, 03/17/24, 03/23/24, 03/24/24, 03/30/24, and 03/31/24. On 08/23/24 at 10:05 a.m., the nursing service coordinator stated finding weekend RN coverage had been challenging.

Based on record review and interview, the facility failed to ensure MDS assessments were coded accurately for two (#32 and #57) of 17 sampled residents reviewed for assessments. LPN #4 identified 66 residents resided in the facility. Findings: 1. Res #32 had diagnoses which included atherosclerotic heart disease, hypertension, and schizoaffective disorder. A quarterly assessment, dated 05/24/24, documented the resident received an anticoagulant. There was no documentation the resident received an anticoagulant during the review period. On 08/22/24 at 10:00 a.m., the MDS coordinator stated the MDS assessment was coded for an anticoagulant in error. They stated they accidentally coded Plavix as an anticoagulant. 2. Res #57 had diagnoses which included diabetes mellitus, schizophrenia, and hyperlipidemia. An annual assessment, dated 07/26/24, documented the resident received a diuretic. There was no documentation the resident received a diuretic during the review period. On 08/22/24 at 10:05 a.m., the MDS coordinator stated the MDS assessment was coded for a diuretic in error. They stated the resident did not receive a diuretic during the review period.

Based on observation, record review, and interview, the facility failed to ensure O2 was administered as ordered by the physician for one ( #21) of one sampled resident reviewed for respiratory therapy. The administrator identified eight residents who received O2. Findings: Res #21 had diagnosis which included SOB. A physician order, dated 10/05/22, documented O2 at 2 LPM via NC to maintain saturation above 90%. On 08/20/24 at 9:15 a.m., the resident was observed with O2 in place. The O2 concentrator was set at 5 LPM. On 08/20/24 at 9:51 a.m., LPN #1 was asked what was the resident's O2 supposed to be set at. They reviewed the order in the EHR and stated it was supposed to be set at 2 LPM. LPN #1 was asked to verify what the resident's O2 concentrator was set at. They stated 5 LPM and it should be 2.

Based on record review and interview, the facility failed to ensure a PASRR level I assessment was completed and/or included the resident had a serious mental illness for two (#13 and #54) of five sampled residents reviewed for PASRR assessments. LPN #4 identified 66 residents who resided in the facility. Findings: 1. Res #13 had diagnosis of paranoid schizophrenia. There was no documentation a PASRR level I assessment was completed. On 08/21/24 at 1:16 p.m., the SSD stated they could not locate a PASRR level I assessment for the resident. They stated OHCA should have been notified of the paranoid schizophrenia diagnosis to find out if a level II screening was indicated. 34460 2. Res #54 was admitted to the facility on [DATE] with diagnosis which included bipolar disorder. A PASRR level 1 assessment, dated 07/14/23, documented the resident had a primary diagnosis of cerebral infarction and a secondary diagnosis of hemiplegia and hemiparesis. It was documented there was no evidence or diagnosis of a serious mental illness. On 08/22/24 at 11:46 a.m., the SSD stated the resident had a diagnosis of bipolar disorder on admission. They stated the PASRR level I should have documented the resident had a diagnosis of a serious mental illness.

Based on record review and interview, the facility failed to ensure side effect monitoring was conducted for the use of a psychotropic medication for one (#17) of five sampled residents reviewed for medications. LPN #4 identified 66 residents resided in the facility. Findings: Res #17 had diagnosis which included major depressive disorder. A physician order, dated 08/05/24, documented Zoloft (depression medication) 50 mg tab at bedtime. There was no documentation side effects were monitored during the month of August 2024. On 08/22/24 at 10:46 a.m., the DON was asked if side effects were monitored for the resident's use of Zoloft. On 08/23/24 at 7:51 a.m., the DON stated side effects were not monitored and should have been.

Based on record review and interview, the facility failed to ensure thirty day notices of involuntary discharge was provided for three (#4, #5 and #6) of three sampled discharged residents. The administrator identified six residents who were discharged from the facility since 12/01/23 and did not return from the facilty. Findings: An undated facility policy, Transfer or Discharge, Facility-Intimated, read in parts, .notice of transfer or discharge .the resident and his or her representative are given a thirty day (30)- day advance written notice of an impending transfer or discharge from this facility .residents who are sent emergently to an acute care setting, such as a hospital are permitted to return to the facility . 1. Resident #4 had diagnosis of dysphagia, cognitive communication deficit, depression, brief psychotic disorder, Insomnia, and Schizophrenia. A health status progress note, dated 01/08/24 at 2:50 p.m., read in part, .send resident out d/t hgb 6.6 and hct 20.1 . There was no documentation in the clinical record where the resident was discharged to. A discharge assessment, dated 01/08/24, documented the resident had an unplanned discharge and would return to the facility. A social service progress note, dated 01/15/24 at 8:34 p.m., read in part, .called case manager .to follow up on status. Resident is still admitted at [Name deleted hospital] . There was no documentation in the clinical record of a thirty day notice of discharge notice being provided to Resident #4. 2. Resident #5 had diagnosis of hyperlipidemia, depression, end stage renal disease, and anxiety. A discharge summary progress note, dated 01/16/24 at 3:03 p.m., read in part, . Resident could be heard yelling .wants to go to the hospital. This nurse tried to communicate with resident on reason why .Resident stated, I can't breathe, I am going to die .if I lay back down, I will start coughing . A discharge assessment, dated 01/16/24, documented the Resdient had an unplanned discharge and would not return to the facility. A nurse's progress note, dated 01/17/24 at 2:43 a.m., documented the resident was still in the hospital. There was no documentation in the clinical record of a thirty day notice of discharge notice being provided to Resident #5. 3. Resident #6 had diagnosis of Schizophrenia, depression, hypertension and hyperlipidemia. A discharge assessment, dated 02/13/24, documented the Resdient had an unplanned discharge and would return to the facility. A review of Resident #6 progress notes contained no documentation of where the resident was discharged to and what lead to the discharge. There was no documentation in the clinical record of a thirty day notice of discharge notice being provided to Resident #6. On 03/13/24 at 1:57 p.m., the hospital case manger, stated Resident #4 and #5 came from Cross Timbers. The case manager stated they talked with the director of nursing about the residents coming back to the facility because they were ready for discharge. They stated the director of nursing had told them Resident #4 and Resident #5 were not accepting either Resident back. The case manager further stated that the director of nursing when asked about the 30 day notice stated the facility had the provocative to not accept the residents back. On 03/14/24 at 2:25 p.m., MDS Coordinator #1, a Licensed Practical Nurse, stated all residents were required to receive a 30 day notice of discharge. I was told the facility could not meet the residents needs and would not be returning. The MDS Coordinator stated they did not see any documentation for Resident #4, Resident #5 and Resident #6 received a 30 day notice of discharge. On 03/14/2024 at 2:45 p.m., the social service director, stated the facility followed the regulations on discharge from the facility. The social service director stated they did not know where the 30 day notice of dischargers were located for Resident #4, Resident #5 and Resident #6. The social service director stated they would look for the discharge summary for Resident #4, Resident #5 and Resident #6, because they did not know where they were located because they had been off. They looked through the clinical records and stated there were no 30 day discharge notices for any of the residents. On 03/14/24 at 2:55 p.m., the DON stated Resident #5 was sent out to the hospital in January because of being blind and having issues with their ears. He then stated the facility could not provide care appropriately. The DON stated the facility told the hospital they would not take Resident #4 and Resident #5 back from the hospital. The DON stated Resident #4 had gone out to the hospital and there was no additional documentation on the discharge for them. The DON further stated the IDT decided the residents would not come back, and stated the IDT consisted of themselves, the administrator, business office manager and the social service director. When asked about a 30 day discharge notice, the DON stated he did not have any additional information that 30 day notices were provided to Resident #4, Resident #5 and Resident #6. On 03/14/24 at 3:40 p.m., the business office manager stated, Resident #4, Resident #5 and Resident #6 were sent out without the intention to take them back. The Business Office manager stated the residents were not provided with a 30 day notice of discharge. They further stated they had been tasked with issuing the 30 day notices and there was no information in the charts of the need for the discharge. On 03/14/24 at 3:50 p.m., the Administrator stated Resident #5 would be a liability if they came back to the facility. The administrator then stated they did not have any documentation of the discharge and/or of a 30 day notice being provided to Resident #4, Resident #5 and Resident #6. On 03/15/24 at 1:45 p.m., Licensed Therapist #1, stated Cross Timbers brought Resident #6 to their facility without calling and/or consulting with them. The Licensed Therapist stated the facility did not provide them with any information just dropped Resident #6 off. They stated they called and spoke with the social service director who informed them the facility did not want to take Resident #6 back. The Licensed Therapist then stated, I was shocked this was happening.

Based on record review and interview, the facility failed to ensure discharge summaries were completed for three (#4, #5 and #6) of three sampled discharged residents. The administrator identified 26 residents who were discharged from the facility since 12/01/23. Findings: An undated facility policy, Discharge Summary and Plan read in parts, .when a resident's discharge in anticipated, a discharge summary .is developed .includes a recapitulation of the residents stay at the facility . 1. Resident #4 had diagnosis of dysphagia, cognitive communication deficit, depression, brief psychotic disorder, Insomnia, and Schizophrenia. A health status progress note, dated 01/08/24 at 2:50 p.m., read in part, .send resident out d/t hgb 6.6 and hct 20.1 . A social service progress note, dated 01/15/24 at 8:34 p.m., read in part, .called case manager .to follow up on status. Resident is still admitted at [Name deleted hospital] . There was no documentation in the clinical record a discharge summary was completed for Resident #4 2 Resident #6 had diagnosis of Schizophrenia, depression, hypertension and hyperlipidemia. A discharge assessment, dated 02/13/24, documented the resident had an unplanned discharge and would return to the facility. A review of Resident #6 progress notes contained no documentation of where the resident was discharged to and what lead to the discharge. There was no documentation in the clinical record to indicate the resident had returned to the facility. There was no documentation in the clinical record a discharge summary was completed for Resident #6. On 03/14/24 at 2:25 p.m., the MDS Coordinator #1, stated Resident #4 and #6 did not have discharge summaries completed.

Based on record review and interview, the facility failed to ensure discharged residents clinical record contained documentation of the discharge for three (#4, #5 and #6) of three sampled discharge residents. The administrator identified six residents discharged from the facility since 12/01/23. Findings: 1. Resident #4 had diagnosis of dysphagia, cognitive communication deficit, depression, brief psychotic disorder, Insomnia, and Schizophrenia. A health status progress note, dated 01/08/24 at 2:50 p.m., read in part, .send resident out d/t hgb 6.6 and hct 20.1 . There was no documentation in the clinical record where the resident was discharged to. A discharge assessment, dated 01/08/24, documented the resident had an unplanned discharge and would return to the facility. A social service progress note, dated 01/15/24 at 8:34 p.m., read in part, .called case manager .to follow up on status. Resident is still admitted at [Name deleted hospital] . There was no documentation in the clinical record in the clinical to indicate the facility could not meet the needs of Resident #4. 2. Resident #5 had diagnosis of hyperlipidemia, depression, end stage renal disease, and anxiety. A discharge summary progress note, dated 01/16/24 at 3:03 p.m., read in part, . Resident could be heard yelling .wants to go to the hospital. This nurse tried to communicate with resident on reason why .Resident stated, I can't breathe, I am going to die .if I lay back down, I will start coughing . A discharge assessment, dated 01/16/24, documented the Resident had an unplanned discharge and would not return to the facility. A nurse's progress note, dated 01/17/24 at 2:43 a.m., documented the resident was still in the hospital. There was no documentation in the clinical to indicate the facility could not meet the needs of Resident #5 and involuntarily discharged them. 3. Resident #6 had diagnosis of Schizophrenia, depression, hypertension and hyperlipidemia. A discharge assessment, dated 02/13/24, documented the resident had an unplanned discharge and would return to the facility. A review of Resident #6 progress notes contained no documentation of where the resident was discharged to and what lead to the discharge. There was no documentation in the clinical record to indicate the facility could not meet Resident #6 needs and the facility would not take them back. On 03/14/24 at 2:25 p.m., MDS Coordinator #1, a Licensed Practical Nurse, stated Resident #4, Resident #5 and Resident #6 had no documentation in the clinical record to indicate the facility could not provide care and the facility could not meet the residents needs. On 03/14/24 at 2:45 p.m., the Social Service Director, stated Resident #4, Resident #5 and Resident #6 had no documentation in the clinical record the facility could need meet the needs of the residents. The social service director stated there was no documentation where Resident #6 resident was discharged to.

Based on record review and interview, the facility failed to have two staff present during a bed bath for one (#1) of three sampled residents who required two person assistance with bathing. One staff person left the room during the bad bath and Resident #1 fall from the bed onto the floor. The director of nursing identified 12 residents who required two person assistance with bathing and hygiene. Findings: Resident #1 had diagnosis which included multiple sclerosis, and neurogenic bladder. A quarterly MDS, with reference assessment date of 12/04/23, documented Resident #1 cognition was severly impaired and was dependent on two or more staff for bathing and showering. A care plan, last revised 01/27/23, documented Resident #1 needed assistance with bed mobility and required two person to assist with repositioning. A facility incident report and an incident progress note, dated 02/27/24 at 1:32 p.m., read in part, .This nurse was informed by CNA that resident fell off the bed. CNA x 2 assisting resident with bed bath. One CNA left room to obtain draw sheet, other CNA was whipping water off right side of bed and resident rolled off left side On 03/14/24 at 12:37 p.m., LPN #1 stated Resident #1 was bed bound and required staff asssistance with bathing and grooming. LPN #1 stated the resident required two person asssistance at all times when being bathed. The LPN stated two aides were providing a bed bath, one aide stepped out to get a draw sheet and the resident fell from the bed. On 03/14/24 at 1:55 p.m., CNA #1, stated Resident #1 required staff to do everything for them. CNA #1 stated Resident #1 required two people when being provided a bed bath. They stated on 02/27/24 CNA #2 and themselves were providing a bed bath to the resident and not all the supplies were brought into the room prior to the bed bath. CNA #1 stated CNA #2 left the room to get supplies and the resident fell from the bed. On 03/14/24 at 2:08 p.m., CNA #2 stated they and CNA #1 were providing a bed bath to Resident #1 on 02/27/24. CNA #2 stated they left the room to get supplies that were not brought in before the bath began and by the time they had returned Resident #1 had fallen out of the bed. CNA #2 stated the supplies should have been brought into the room before hand to allow to people in the room while providing the care. On 03/14/24 at 2:25 p.m., the MDS Coordinator #1, stated Resident #1 was a substantial to total assists with bed mobility and transfer. The MDS coordinator stated Resident #1 required two persons throughout the whole bathing process. On 03/14/24 at 2:55 p.m., the DON stated Resident #1 was an extensive assistance of two for all care. The DON stated Resident #1 had a fall in the morning of 02/27/24, and their family was present. The DON stated the fall occurred when one aide went to get supplies and the resident fell from the unattended side. On 03/14/24 at 4:42 p.m., Resident #1 family stated Resident #1 had a fall to the left side when one aide left the room to get supplies.

Based on record review and interview, the facility failed to ensure an anticonvulsant medication was administered as ordered which resulted in actual harm when a resident experienced a seizure and/or seizure like activity for one (#26) of five sampled residents reviewed for unnecessary medications. The DON identified 52 residents who received anticonvulsant medication resided in the facility Findings: An Adverse Consequences and Medication Errors policy, revised 04/14, read in part, .Residents receiving any medication that has the potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported .Examples of medications errors include .omission - a drug is ordered but not administered .Facility staff monitor the resident for possible medication-related adverse consequences .An unexplained decline in function or cognition .Acute onset of signs or symptoms worsening of a chronic problem or condition . Resident #26 had diagnoses which included other specified extrapyramidal and movement disorder, epilepsy, schizoaffective disorder bipolar type, and post-traumatic stress disorder. A Physician Order, dated 06/23/23, documented Perampanel oral tablet give eight milligrams by mouth at bedtime for anticonvulsants. The July 2023 MAR documented the Perampanel tablet was administered one time for the entire month. An Administration Note, dated 07/26/23 at 7:05 p.m., documented the pharmacy notified the facility insurance would not pay for the Perampanel eight milligrams by mouth. There was no documentation the physician was notified. The July 2023 Administration Notes for the Perampanel documented the medication was on order/awaiting delivery/or waiting for doctor to send hard script on the 2nd, 3rd, 4th, 5th, 6th, 7th, 9th, 10th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 27th, 28th, 29th, and 31st. There was no documentation the physician was made aware the resident was not receiving the anticonvulsant medication. A Nurse Progress Note, dated 07/05/23 at 9:46 p.m., documented Resident #26 was observed to be having a seizure, fell off their walker, and hit their head on the floor. It documented the resident reported having a seizure. It documented no injuries were observed and the resident was transferred to the hospital for evaluation. An Alert Note, dated 07/05/23 at 8:54 p.m., documented Resident #26 was observed on the floor of another resident's room. It documented the resident was moving their legs back and forth, and it did not appear to be seizure like activity. It documented the resident stated, I don't fake seizures, I have stress induced seizures. Resident #26's After Visit Hospital Summary, dated 07/05/23, documented today's visit diagnoses: blunt head trauma initial encounter, and seizure. A Change of Condition note, dated 07/12/23 at 8:56 p.m., documented Resident #26 reported being dizzy and nauseous and claimed to hit their head. It documented the resident originally reported their whole body was jerking within 60 seconds of the nurse arriving to the resident's side, the resident rolled to their back with their eyes open. It documented the resident was sent to the hospital for evaluation. A Nurse Progress Note, dated 07/21/23 at 9:28 p.m., documented the nurse was alerted by residents that Resident #26 had a seizure on the outside patio smoking area. It documented the resident was observed on the ground on their left side with no injuries noted. It documented the resident was sent to the hospital for evaluation. A Summary for Providers note, dated 07/21/23 at 9:51 p.m., documented change in condition falls/seizure, neurological status evaluation seizure. Resident #26's After Visit Hospital Summary, dated 07/21/23, documented reason for today's visit seizures, diagnosis seizure-like activity. A Nurse Progress Note, dated 07/29/23 at 9:42 p.m., documented the nurse was notified Resident #26 had a seizure on the smoke porch earlier in the shift, had fallen, and had hit their head. It documented the resident was sent to the hospital for evaluation. Resident #26's After Visit Hospital Summary, dated 07/29/23, documented today's visit diagnoses injury of head initial encounter, fall initial encounter, and breakthrough seizure. The August 2023 MAR documented the Perampanel tablet was administered five times for the entire month. The August 2023 Administration Notes for the Perampanel documented the medication was on order/unavailable/or waiting for doctor to send hard script to pharmacy on the 1st, 3rd, 4th, 5th, 6th, 8th, 10th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, and 27th. There was no documentation the physician was made aware the resident was not receiving the anticonvulsant medication. An Incident Note dated 08/05/23 at 9:58 p.m., documented Resident #26 reported to nurse they fell and hit their head and didn't feel well. It documented the resident complained of double vision and dizziness and overall not feeling well. It documented the resident began seizing in the smoke area and fell . It documented the resident was sent to the hospital for evaluation.Resident #26's After Visit Hospital Summary, dated 08/05/23, documented diagnoses right hip pain and closed head injury. An Incident Note, dated 08/19/23 at 5:03 p.m., documented staff had reported Resident #26 was having a seizure. It documented the staff reported the resident fell and staff was unable to catch them. It documented the resident was having a seizure and was shaky. It documented the resident reported they had experienced a seizure, felt an aura when walking to their room, and fell to their left shoulder. It documented the resident reported they did not hit their head, but had a slight headache. An Alert Note dated 08/28/23 at 12:00 p.m., documented the nurse was summoned to the outside smoke area due to Resident #26 reported to have been having a seizure. It documented the resident reported experiencing an aura they couldn't describe and laid down on their side on the ground. It documented the resident was not having any seizure like activity when the nurse arrived. On 11/15/23 at 12:52 p.m., the Director of Clinical Operations and the DON stated staff were to check the medication with the order, and check the five rights of medication administration when administering medications. The Director of Clinical Operations stated staff were to order medications when there was a seven day supply left. On 11/15/23 at 1:05 p.m., the DON stated the July 2023 MAR documented the resident received one dose of the Perampanel. They stated the medication was used to treat epilepsy. On 11/15/23 at 1:07 p.m., the DON read the 07/21/23 note for Resident #26 and stated it documented seizure, change in condition, falls/seizure. The DON stated Resident #26's note on 07/29/23 documented the nurse was notified of the resident having a seizure and emergency personnel arrived. On 11/15/23 at 1:14 p.m., the DON stated the administration notes documented waiting on doctor to send hard script so the doctor knew it needed a hard script. The DON was asked to provide documentation the physician knew the resident was not receiving the anticonvulsant medication. The DON did not provide this documentation prior to survey exit. On 11/15/23 at 1:14 p.m., the DON stated the August 2023 MAR documented the resident received five doses of the Perampanel. On 11/15/23 at 1:18 p.m., the DON stated Resident #26's record documented on 08/05/23, documented the resident began seizing and fell to left side. On 11/15/23 at 1:19 p.m., the DON stated Resident #26 recently had a five day evaluation for seizure activity on 09/26/23. They stated the resident's medications were held to induce seizures, and the resident did not experience a seizure. The Director of Clinical Operations stated they had spoken with psych who can't determine if they were behavior versus seizures, They stated staff could only document what they see. They stated it might be more behavioral, but you don't know. On 11/15/23 at 1:23 p.m., the DON stated per Resident #26's note, the resident experienced a seizure on 08/19/23. On 11/15/23 at 1:25 p.m., the DON stated the 08/28/23 note, documented a seizure was reported to the nurse, but the nurse did not observe a seizure. The DON stated there was usually a recovery period with a seizure. The Director of Clinical Operations stated staff needed to be trained on a true seizure. On 11/16/23 at 7:22 a.m., the DON stated they wanted to retract their statement of it being related to seizures. They stated the resident had a diagnoses of benign paroxysmal vertigo. The DON stated they did not believe there was a relation between the falls from seizures and the anticonvulsant not being given.

Based on record review and interview, the facility failed to notify the physician when: a. pharmacy informed the facility a medication was not covered; b. an anticonvulsant medication was not available to administer; and c. a resident returned to the facility and reported they had been drinking while away for one (#26) of five sampled residents reviewed for unnecessary medications. The Administrator identified 79 residents resided in the facility. The DON identified 52 residents with anticonvulsant medication orders. Findings: Resident #26 had diagnoses which included other specified extrapyramidal and movement disorder, epilepsy, schizoaffective disorder bipolar type, and post-traumatic stress disorder. A Physician Order, dated 06/23/23, documented Perampanel oral tablet give eight milligrams by mouth at bedtime for anticonvulsants. The July 2023 MAR documented the Perampanel tablet was administered one time for the entire month. An Administration Note, dated 07/26/23 at 7:05 p.m., documented the pharmacy notified the facility insurance would not pay for the Perampanel eight milligrams by mouth. There was no documentation the physician was notified. The July 2023 Administration Notes for the Perampanel documented the medication was on order/awaiting delivery/or waiting for doctor to send hard script on the 2nd, 3rd, 4th, 5th, 6th, 7th, 9th, 10th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 27th, 28th, 29th, and 31st. There was no documentation the physician was made aware the resident was not receiving the anticonvulsant medication. The August 2023 MAR documented the Perampanel tablet was administered five times for the entire month. The August 2023 Administration Notes for the Perampanel documented the medication was on order/unavailable/or waiting for doctor to send hard script to pharmacy on the 1st, 3rd, 4th, 5th, 6th, 8th, 10th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, and 27th. There was no documentation the physician was made aware the resident was not receiving the anticonvulsant medication. A Nurse Progress Note, dated 10/22/23 at 8:11 p.m., documented Resident #26 returned to the facility after being with a family member, the resident's speech was slurred and the resident was stumbling. It documented Resident #26 asked nursing staff if they thought their wobbling was because they had been drinking while gone. It documented Resident #26 reported drinking alcohol with their family member. It documented the staff educated the resident on the importance of not mixing medications with alcohol, and the resident did not verbalize understanding. It documented the resident was a very high fall risk at the moment. There was no documentation Resident #26's physician was informed the resident had returned to the facility after consuming alcohol. On 11/15/23 at 12:54 p.m., the Director of Clinical Operations stated staff should notify the physician if a medication was not available to administer to the resident. On 11/15/23 at 12:57 p.m., the Director of Clinical Operations stated staff were to notify the physician with changes in conditions and anything that affected the resident's care which required the skill or notification of a physician including treatments and medications. They stated staff should notify the physician if a medication was not given. On 11/15/23 at 12:59 p.m., the Director of Clinical Operations stated they physician should be notified if a resident returned to the facility and informed staff they had been drinking. The DON reviewed the 10/22/23 note for Resident #26 and stated the physician was not notified. On 11/15/23 at 1:05 p.m., the DON stated the July 2023 MAR documented the resident received one dose of the Perampanel. On 11/15/23 at 1:14 p.m., the DON stated the August 2023 MAR documented the resident received five doses of the Perampanel. On 11/15/23 at 1:16 p.m., the DON stated there was no documentation the physician was notified the Perampanel was not covered by insurance. On 11/15/23 at 1:25 p.m., the DON and the Director of clinical Operations stated they needed to review the records to determine if the physician had been notified of the missed doses of the Perampanel. There was no documentation provided the physician had been notified of the missed doses of Perampanel prior to survey exit.

Based on record review and interview, the facility failed to ensure medications were available to administer as ordered for one (#26) of five sampled residents reviewed for unnecessary medications. The Administrator identified 79 residents resided in the facility. Findings: An Administering Medications policy, revised 04/19, read in part, .Medications are administered in a safe and timely manner, and as prescribed . Resident #26 had diagnoses which included glaucoma, pain, chronic idiopathic constipation, psoriasis, and drug induced subacute dyskinesia. A Physician Order, dated 09/18/21, documented Colace capsule 100 mg give one capsule by mouth two times a day related to chronic idiopathic constipation. A Physician Order, dated 09/02/22, documented Voltaren Gel one percent apply to right shoulder topically two times a day for pain in right shoulder. A Physician Order, dated 09/15/22, documented Brimonidine Tartrate Solution 0.1 percent instill one drop in both eyes two times a day for glaucoma. A Physician Order, dated 11/14/22, documented Taltz solution prefilled syringe 80 mg/ml inject one syringe subcutaneously one time a day every month on the 14th for psoriasis. A Physician Order, dated 12/07/22, documented Cetaphin RestoraDerm lotion apply to both legs topically two times a day for psoriasis. A Physician Order, dated 09/07/23, documented Austedo oral tablet six mg give one tablet by mouth one time a day related to drug induced subacute dyskinesia. Administration Notes, dated 09/22/23, 09/23/23, 09/24/23, 09/25/23, documented Colace capsule 100mg was on order. Administration Notes, dated 10/01/23, 10/02/23, 10/03/23, 10/05/23, documented Austedo oral tablet six milligrams was on order. Administration Notes, dated 10/28/23, 11/11/23, 11/12/23, documented Brimonidine Tartrate Solution 0.1 percent was on order. Administration Notes, dated 11/14/23 , documented Taltz solution prefilled syringe 80 mg/ml was on order. Administration Notes, dated 11/11/23, 11/12/23, 11/13/23 , documented Voltaren Gel 1% medication not available or on order. Administrative Notes, dated 11/11/23, 11/12/23, 11/13/23 , documented Cetaphil RestoraDerm Lotion medication not available or on order. On 11/15/23 at 12:52 p.m., the Director of Clinical Operations and DON stated staff were to check the medication with the order, and check the five rights of medication administration when administering medications. The Director of Clinical Operations stated staff were to order medications when there was a seven day supply left. On 11/15/23 at 12:54 p.m., the Director of Clinical Operations stated if a medication was not available for administration, staff were to look into the e-kit, get an immediate order, and notify the physician if the medication was not administered.

Based on observation, record review and interview, the facility failed to maintain a functioning call light system for three (#8, 30, and #61) of 24 sampled residents reviewed for a functioning call light system. The Administrator identified 79 residents resided in the facility. The DON identified there were 69 residents who could use a call light. Findings: An Answering the Call Light: Addendum facility policy, undated, read in part, Explain to the Resident that the call system is temporarily unavailable. Educate the Resident on using the call system substitution-the doorbell . 1. Resident #30 had diagnoses which included abnormalities of gait and mobility. Resident #30's care plan for falls, revised 07/08/23, documented to place the Resident's call light in reach. On 11/13/23 at 12:12 p.m., Resident #30's call light was observed on the floor by the foot of the bed. Resident #30 stated they used their call light when they needed assistance and pointed to the call light string on the wall. On 11/13/23 at 1:11 p.m., Resident #30's call light was on the floor by the foot of the bed. On 11/13/23 at 1:34 p.m., CNA #2 stated Resident #30 needed assistance with hygiene and transfers. On 11/13/23 at 1:35 p.m., CNA #2 stated Resident #30 was able to use their call light. They stated the resident was a fall risk. On 11/13/23 at 1:36 p.m., CNA #2 stated Resident #30's call light was out of reach. On 11/14/23 at 8:39 a.m., CNA #3 stated Resident #30 did not have a call bell. They stated Resident #30's call light did not work. 2. Resident #61 had diagnoses which included paraplegia and postpolio syndrome. Resident #61's care plan for falls, revised 09/23/23, documented to place the Resident's call light in reach. On 11/13/23 at 1:07 p.m., Resident #61's call light was out of reach. They stated their call light was not working. Resident #61 stated they waited for staff to pass their room to ask for assistance. On 11/13/23 at 1:40 p.m., CNA #4 stated Resident #61 needed assistance with transfers, showers, and toileting. On 11/13/23 at 1:41 p.m., CNA #4 stated Resident #61 was able to use their call light. They stated the Resident was a fall risk. On 11/13/23 at 1:42 p.m., CNA #4 stated all call lights in the facility were not working and residents were given call bells as a substitute. They stated Resident #61 did not have a substitute call bell. Resident #61 stated they were not provided with a call bell. On 11/14/23 at 8:38 a.m., Resident #61 stated they were not provided with a call bell. Resident #61 stated they continued to call out for assistance. 3. Resident #8 had diagnoses which included muscle weakness and depression. Resident #8's care plan for falls, revised 10/09/23, documented to place the Resident's call light in reach. On 11/14/23 at 9:59 a.m., Resident #8 stated they could not locate their call light. They stated they waited for staff to come to ask for assistance. On 11/14/23 at 10:15 a.m., CNA #3 stated Resident #8's call light was not working. They stated Resident #8 did not have a substitute call bell. On 11/14/23 at 1:45 p.m., the DON stated the call light system stopped working on 11/10/23. They stated residents who were able to use their call light were provided with a doorbell as a substitute.

Based on observation, record review and interview, the facility failed to ensure nutrition via tube feeding was administered as ordered for one (#179) of two sampled residents reviewed for tube feeding. The DON identified three residents with tube feedings resided in the facility. Findings: An Enteral Nutrition policy, revised 11/18, read in part, .Adequate nutritional support through enteral nutrition is provided to residents as ordered . Resident #179 had diagnoses which included myocardial infarction, type two diabetes mellitus, anoxic brain damage and quadriplegia. A Physician Order, dated 11/03/23, documented Diabetasource at 55 ml/hr via feeding pump every shift. On 11/16/23 at 8:32 a.m., Resident #179 was observed lying in bed with their eyes closed. Glucerna was observed running via feeding pump at 55 ml/hr. On 11/16/23 at 8:36 a.m., LPN #1 stated staff would verify the order for peg tube feedings with what was in the computer before administering it. They stated the peg tube system was changed out every day on the night shift. On 11/16/23 at 8:39 a.m., LPN #1 stated Resident #179's tube feeding order was Diabetasource at 55 ml/hr via feeding pump with 100 ml water flush every four hours. On 11/16/23 at 8:40 a.m., LPN #1 entered Resident #179's room and stated Glucerna was hanging at 55 ml/hr with 100 ml flush every four hours. They stated they did not know if they were the same thing. On 11/16/23 10:02 a.m., the DON stated the order had previously been changed because the ordered feeding was not available. They stated the facility did get the original feeding order in house and that was the reason it was hanging. They were asked to provide documentation the Glucerna was approved to be administered as the order was for Diabetasource. There was no documentation provided the Glucerna was approved prior to the surveyor's observation.

Based on observation, record review and interview, the facility failed to ensure food items were dated and labeled in the walk in cooler during one of one kitchen observations. The Administrator identified 79 residents resided in the facility. The DON identified two residents who received nothing by mouth. Findings: A Date Marking for Food Safety policy, dated 2021, read in part, .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly . On 11/13/23 at 1:00 p.m., the ADM stated food should be labeled, but they ran out of labels the day before yesterday. On 11/13/23 at 12:22 p.m., the following items were observed in the walk in cooler: a. a container with small chopped small pieces of a meat product with no label or use by date; b. a bag of the same meat product on the shelf with 8/7 written on it; c. a clear open bag with meat in it with no date or label on it; d. a large container of pink liquid no date or label; e. a large container of brown liquid no date or label; and f. four metal trays of Styrofoam cups containing different colored liquids with no date or label. The ADM stated the small chopped pieces were ham for salads and the container did not have a label on it. The ADM stated it should be dated when removed from the freezer and placed into the container. The ADM stated the bag of chopped ham had no label or date. The ham was moved from the freezer into the cooler. The ADM stated the bag of open meat was bacon. They stated it was not labeled or dated, but had been used for breakfast. The ADM stated the liquids should have a label and date when they were made. They stated the pink liquid was kool aid and the brown liquid was tea.

On 07/27/23 at 4:14 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation existed due to the facilities failure to ensure residents were free abuse and failed to protect from further abuse and neglect. Resident #7 reported on 07/13/23 that Resident #6 had touched her inappropriately on the breast and vaginal area. AN OSDH reportable incident dated 07/13/23 documented an investigation was initiated and Resident #6 would be placed on operation stand by. Operation stand by is 88 hours of close supervision after an incident. There is not consistent documentation this occurred. There is no documentation Resident #6 was interviewed. A SS note on 07/13/23 documented the police had been called, came out and interviewed five other residents along with Resident #7. Two other residents stated they witnessed the incident. Five days later, on 07/18/23, there were nine resident interviews conducted related to abuse. No staff interviews had been conducted. The incident was substantiated. There are not sufficient measures in place to protect residents from further abuse. Observations were made of Resident #6 wandering alone throughout the facility and out in the smoke area on 07/26 and 07/27/23. On two separate occasions, on 07/25/23, Resident #6 was verbally harassing a female resident and there was no documentation of interventions put in place or of investigations. The administrator and acting director of nursing stated the operational stand by was only for 88 hours but it should have continued until the district attorney determined if charges would be filled. 07/27/2023 at 4:25 p.m. the administrator and corporate nurse was informed of the immediate jeopardy situation. On 07/27/23 at 5:15 p.m., an acceptable plan of care was received. The plan of removal documented, Plan of removal for abuse, neglect, & exploitation. 1. On July 27, 2023 started Inservice to all staff on abuse, neglect, & exploitation will be completed on July 28th by 3pm. 2. Will identify residents that are requiring one-on one to ensure the safety of all residents. 3. Inservice staff on the residents that are requiring one-on-one and update care plans. 4. On July 27, 2023 will begin conducting safe surveys of all residents, guided by the regional team. 5. Root cause analysis will be conducted and completed July 28th, 2023 6. Regional Team will be responsible for POC, Plan of removal will be completed by July 28th, 2023 by 3pm. 07/31/23 after interviews with facility staff, review of resident safe surveys, and in-services on abuse, the immediacy was lifted, effective 07/31/23 at 5:00 p.m., when the last in-service was provided. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, record review and interview, the facility failed to ensure residents were free from abuse and neglect for two (#7 and #4) of six sampled residents reviewed for abuse and neglect. Resident #7 was inappositely touched by Resident #6 and the facility failed protect them and all residents from the abuse. Resident #4 was left on a metal bed frame when the air mattress malfunctioned causing the resident to be in pain and screaming until staff placed them in their chair. The Resident Census and Conditions of Residents form, dated 07/26/23, documented 84 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, Exploitation or Misappropriation Prevention Program, revised April 2021, read in part, . Residents have the right to be free from abuse, neglect .this included but is not limited to freedom from verbal, menatl, sexual or physicial abuse . 1. An initial report to the Oklahoma State Department of Health, dated 07/13/23, read in part, staff was notified by [Resident #7] had been in appropriately touched by [Resident #6] {Resident #7] stated that [Resident #6] approached .and placed hand down the front of [Resident #7] shirt while stating 'That's the best breast I have grabbed in a while .pushed [Resident #6] away from [them] .sat down on the floor facing [Resident #7] and reached up and grabbed [Resident #7] vaginal area aggressor on operation standby, visual monitoring for the safety of other residents .investigation concluded that the findings were substantiated. An incident note for Resident #7, dated 07/13/23 at 4:22 p.m., read in part, .Resident complained to Social Worker .that another resident had grabbed [Resident #7] left breast from behind. Psychiatrist in building and will exam male resident. Before dr was able to see either resident Midwest police arrived R/T this resident calling 911 from cell phone. Police officer .spoke with resident [Resident #7] and took copy of [their] daily journal on the event that [Resident #7] claims happened . A social service note for Resident #6, dated 07/13/23 at 8:33 p.m., read in part, .about 2:15 pm, another resident reported [Resident #6] allegedly touched [Resident #7] inappropriately and without consent. That resident's charge nurse and [Resident #6] charge nurse were made aware. PA .Law enforcement was involved. Administration is aware and taking appropriate precautions per state regulations. [Resident #6] was educated on boundaries and he was separated from resident. SSD observed nurses were redirecting [Resident #6] as needed. A late entry note, dated 07/13/23 at , read in part, Thursday resident touched a female resident inappropriately. DON .had psych see the resident same day . The note was entered by the Corporate nurse. A nurse's note for Resident #6, dated 07/14/23 at 1:59 p.m., read in part, .resident continues on monitoring for behaviors and for new orders. no s/s of adverse reaction noted thus far. no new behaviors noted .resident up walking around the facility in great spirits most of shift . An undated written statement from the social service director, read in part, .On Thursday, July 13. 2023 at approximately 2:15 p.m., [Resident #7] reported .[Resident #6] approached [Resident #7] and grabbed [Resident #7] breast and said something like 'this is the most beautiful thing I have ever seen .[Resident #6] .followed [Resident #7] to the smoking patio .sat on the floor directly in front of [Resident #7]. [Resident #6] proceeded to caress [Resident #7] leg. [Resident #7] told [Resident #6] to sop [sic] and [Resident #6] would not listen .stated [Resident #7] instructed [Resident #6] to stop touching [Resident #7] repeatedly. [Resident #6] then allegedly touched [Resident #7] crotch area over [their] pants .[Name deleted] stated she witnessed the situation .police arrived took a report . [Name deleted] stated that [Resident #6] was sitting in front of [Resident #7] and was 'touching on [them]' Sgt .stated that he would make a report and he would leave it up to the district attorney to make a decision . There was no documentation on the statement that Resident #6 was interviewed by the facility regarding the incident. The facility did not interview residents regarding the sexual abuse until 07/18/23, five days after the incident occurred. During the interviews, two residents stated Resident #6 always sits in front of you and begs for cigarettes and the second one stated Resident #6 sat too close to people and would spit on them. There was no documentation the facility had interviewed the aggressor and had documentation they were closely monitoring the resident to protect them from Resident #6. A social service note for Resident #6, dated 07/25/23 at 4:10 p.m. , read in part, .SSD witnessed resident verbally harassing another resident. [Resident #6] was raising .voice at her. The other resident stated, [Resident #6] has been getting in my face all day and cussing at me. DON aware of the situation. There was no documentation the facility had addressed Resident #6's aggressive behaviors towards other residents, protected them, and investigated the observation made by the social service director. On 07/26/23 at 3:30 p.m., Resident #6 was observed in the smoke area with five other residents with no staff present in the smoke area with them. Resident #6 was out in the smoke area until 3:50 p.m., then went back inside and wandered the facility up and down the halls and into the dining room. No staff was observed present in the dining room or within eye sight of the resident while inside the facility. On 07/26/23 from 5:30 p.m. through 6:20 p.m., Resident #6 was observed wandering through out the facility unsupervised going back and forth from their room to common area and out into the smoke area. On 07/27/3 at 9:40 a.m. Resident #6 was observed in the smoke area with other residents and no staff were around or in the the line of site of them. On 07/27/23 at 1:27 p.m., Resident #6 was observed aggressively walking down the hall cursing and yelling at other residents with vulgar threats. On 07/27/23 at 1:39 p.m., the social service director was asked about the incident between Resident #6 and Resident #7. The social service director stated Resdient #6 had grabbed and was being in appropriate with other residents. They than stated they were trying to find other placement for Resident #6. They were asked how other residents were being protected from Resident #6. The social service director stated they did not know what was being done, the administrator would decide on that. The social service director stated they did safe surveys, but could not recall when they were completed. On 07/27/23 at 2:12 p.m., the administrator was asked about the incident between Resident #6 and Resident #7. They stated Resident #6 had been placed on operation stand which meant staff was on stand by for assisting the resident for 88 hours. The administrator was asked to describe the investigation the facilty did and how they were protecting residents. The administrator stated the police came out and completed an investigation. The administrator stated the investigation should have been completed concurrently with the police investigation. The administrator stated Resident #6 should be one on one until we know if charges are being filed or a new placement was found. The administrator was made aware of Resident #6 wandering the facility without one on one supervison and being in the smoke area unattended. The administrator stated they thought the one on one was still being provided, but realized the operation stand by ended after 88 hours. The administrator was asked if Resident #6 was interviewed by anyone during the investigation. They stated the police completed an interview with the Resident and the social service director would have that information. On 07/27/23 at 2:38 p.m., the social service director stated neither they nor the police had interviewed Resident #6. 2. Resident #4 had diagnosis to include quadriplegic, major depression, anxiety, and post traumatic stress disorder. A nurse's progress note, dated 07/07/23 at 9:58 p.m., read in part, .The aide notified the nurse that resident bed is no [sic] working and air was coming out of the mattress .The writer noted a hole on the tube taking air into the air mattress .Resident was screaming a yelling the name of [name deleted] that [Resident #4] told her not to bring [Resident #4] bed right down and that is the reason [Resident #4] mattress leaking air. Resident continue to scream . A nurse's progress note, dated 07/07/23 at 11:11 p.m., read in part, .Res was removed from the bed and placed on the chair as [Resident #4] couldn't stop screaming and yelling . Resident #4's care plan meeting notes, dated 07/12/23, read in part, .staff attitudes with [Resident #4] .want this to stop .[Resident #4] endured mental/physical/emotional abuse .Resident left on a deleted air mattress for (35 min) .discussed .resident should not have been left on a deflated mattress for 30-35 min family and Resident is very disappointed in the lack of nursing care and treatment Resident has endured. Family wants formal abuse complaint filled .members present in meeting [Name deleted family] .[Resident #4] .[social service director] .[Administrator] .[DON] .[Name deleted family member] There was no documentation the facility had investigated a complaint of abuse filed during the care plan meeting on 07/12/23. On 07/26/23 at 1:25 p.m., Resident #4 stated they had been left on their bed without air for 35 minutes and no one would not get them out of the bed off the metal bed frame. Resident #4 stated the facility does nothing about the way they were treated and was told by the DON that only staff could be listened to. Resident #4 stated the facility does nothing complaints you have, they are treated badly by staff. Resident #4 stated they were hurting in pain when left in the bed on the metal frame. A nurse's note, dated 07/26/23 at 9:54 p.m., read in part, .Resident came in from the smoking area outside crying, requested to talk to the nurse and complained that a resident by [Name Deleted] had told him in [their] ears that she will cut him whispering. Resident noted that [they] was going to call and informed the [family memeber withheld]. The nurse asked [Name Deleted] and she said, 'I have not spoken a word to resident today'. There was no documentation the facility had investigated and protected residents from further abuse. On 07/27/23 at 8:15 a.m., Resident #4's POA stated they had a care plan meeting with the DON, Administrator that is no longer at the facility, and social service director. The POA stated they told them all the concerns of mistreatment and they did nothing about it. The POA stated that the DON told them they could not listen to what the resident had to say, or watch the videos, and would only listen to the staff. The POA stated they were afraid someone would die from the mistreatment they complained about and nothing had been done about their concerns. On 07/27/23 at 1:27 p.m., The social service director stated they were present in the care plan meeting on 07/12/123 and confirmed the DON told the family and Resident #4 that they would only believe staff and nothing the resident had to say. She further stated the DON would not take the videos the family had and view them. The social service director stated the family complained of abuse and mistreatment and the former administrator was in there and was not sure if anything was done about the concerns. The SSD stated Resident #4's, POA, complained of the resident being left on the metal frame for a long time and that would be neglect for failing to meet Resident #4 needs. The social service director stated they never followed up to make sure the allegations were being addressed. The social service director than stated without an investigation, the resident was not being protected from neglect. On 07/27/23 at 2:12 p.m., the administrator stated stated they would need to look into the allegations from Resident #4 and the family. They stated the former administrator resigned right after the meeting without notice, but it should have been looked into and reported. The administrator then stated nothing had happened and there was no investigation. On 07/31/23 at 2:23 p.m., the DON stated they did not investigate the complaint because the bed was fixed. The DON stated the resident had refused to get up out bed. The DON stated she did not look at the videos Resident #4 family offered. The DON was asked how long the Resident remained in bed with a defective air mattress. They stated they did not know what happened from the time it was found and the note where the resident was put in their chair. The DON stated the facility should have handled this as an abuse, but nothing was done. They were asked about the minutes from the care plan meeting and the formal abuse complaint being filled. The DON stated residents are not being protected. They were asked if there was an investigation and any protection to residents from the Resident #4 complaint on 07/26/23. The DON stated there was nothing that could be found. On 07/31/23 at 2:56 p.m., RN #1 stated they worked the night Resident #4 bed mattress leaked air. They were asked how long the Resident was in bed with the malfunctioning of the mattress. They stated the Resdient was yelling and yelling and they got them up in a chair. RN #1 stated they did not know how long it took staff to get the resident up out of bed. He stated Resident #4 continued to yell even when they placed duct tape on the tube, and they made a progress note when they were up.

On [DATE] at 3:37 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure staff responded to a choking resident and provide the Heimlich maneuver according to standards. Resident #9 had diagnosis to include bipolar, dysphagia, protein calorie malnutrition, anxiety, reflux, and malignant neoplasm upper lobe left bronchus lung. On [DATE] a certified nurse aide provided assistance during the noon meal to Resident #9 after being asked. The resident was responding verbally throughout the meal until one bite when the resident took a deep breath and made attempts to cough. The certified nurse aide turned the resident on the side did thrust to back with no success and summoned the licensed practical nurse in charge of the hall of the emergency. During the response, the nurse did not instruct, and/or perform the Heimlich to assist the resident with choking. Staff was interviewed and confirmed the resident was choking, the nurse did not respond, and provide any assistance to Resident #9 such as suctioning and/or the Heimlich Maneuver. The certified nurse aide providing the meal assistance stated the resident struggled for 12 minutes and passed away. On [DATE] at 3:40 p.m., the administrator and Corporate nurse were informed of the immediate jeopardy. On [DATE] at 9:06 p.m., an acceptable plan of care was received. The plan of removal documented, Plan of Removal # 1 for Training on how to respond to choking. 1. On [DATE]nd, 2023 initiated education on the signs of choking for all staff. 2. On [DATE]nd, 2023 initiated education on how to respond to a resident choking for all staff. 3. If staff is not available for in-service, they will not be able to return to work until education done. 4. Will in-service returning (current) agency nurse on signs of choking and how to respond to a resident choking. 5. Will in-service Human resources on including training on signs of choking and resident choking as a mandatory training during orientation. Regional team will provide the in-services to Human resources on putting a system in place for orientation and every 6 months as an ongoing training. 6. Provided staff with policy and procedures for how to respond to choking and first-aide. 7. Root cause analysis will be conducted and completed by [DATE]rd, 2023 8. The Regional Operations Team will be responsible for the plan of correction, and plan of removal will be completed by [DATE]th, 2023, at 12pm. On [DATE] after interviews with facility staff, and review of in-service documentation the immediacy was lifted, effective [DATE] at 12:00 p.m., when the last in-service was provided. The deficient practice remained at an isolated harm to the resident. Based on record review, and interview, the facility failed to ensure staff responded to a choking resident and provide the Heimlich maneuver according to standards. Resident #9 was being assisted with their noon meal on [DATE] when they gasped for air and were choking on their food. LPN #1 did not respond to the choking, no one performed the Heimlich maneuver, and Resident #9 died . The Resident Census and Conditions of Residents form, dated [DATE], documented 84 residents resided in the facility. Findings: An undated facility policy titled, Emergency Procedure-Choking, read in part, .Trained staff will assist the resident who is choking by attempting to expel the forgiven body from the airway .if the resident can not cough .abdominal thrust be performed .report other information in accordance to facility policy and professional standards . Resident #9 was admitted to the facilty with diagnosis to included bipolar, chronic kidney disease, psychotic disorder with disillusions, anxiety, and malignant neoplasm of upper lobe, left lung. LPN #1's employee file documented they were hired on [DATE]. There was no documentation on training and/or certifications for emergencies such as choking. A nurse's progress note, dated [DATE] at 2:32 p.m., read in part, .This nurse was summoned to room after reports from CNA of resident not responding to staff after eating lunch. Assessed resident, no breathing, pulse, or blood pressure registered. Also, no verbal or painful response noted. Sternal rub attempted along with vital signs. Pulse ox 64%. Finger sweep attempted in search of foreign objects, nothing visible or remarkable to show. Resident did not respond verbally or to painful stimuli . A nurse's progress note, dated [DATE] at 6:11 p.m., read in part, .Residents body picked up .Family at bedside obtaining resident's belongings . A discharge assessment, dated [DATE], documented the resident had died in the facility. There was no additional documentation located in the clinical record of what happened to the resident. Their was no documentation the incident had been reported to the Oklahoma State Department of Health. An anonymous written statement, dated [DATE], read in part, .Today during lunch I was helping feed [Resident #9] . [Resident #9] and I were talking about getting [Resident #9] up and into .chair after lunch when [Resident #9] took a breath and started choking .I ran to get the nurse who was in the hallway .[nurse] rolled [nurse] eyes and seemed annoyed when I told [nurse] that I needed her in [Resident #9] room and it was an emergency . When the nurse came into the room I told [nurse] that I was feeding [Resident #9] when [Resident #9] started choking .nurse told me to lay [Resident #9] flat and [nurse] put a pulse ox on her finger and left the room [Resident #9] was still choking and getting any air .face started turning blue while the nurse was away .trying to calm [Resident #9] down and put [Resident #9] head back up. The nurse came back into the room for about a minute then went out to tell the front desk to call the ambulance .The nurse wanted [Resident #9] lying flat on [Resident #9] back Three aids came into the room to assist .two more aids told the nurse [Resident #9] was choking .[Resident #9] turned completely blue and food started coming out of her nose .it was too late .[Resident #9] was fully alert the whole time [Resident #9] as choking and knew what was happening .The nurse moved slowly and with no urgency .was told several times that [Resident #9] was choking .[Resident #9] died a slow painful and panicked death . A written statement from CNA #10, dated [DATE], read in part, .saw the nurse coming out of [Resident #9] room stating that she was unresponsive and to call 911 .follow her back into the room .the nurse put a pulse ox on her finger and lays her flat .[CNA #6] is telling her .she is choking I say I think she is choking .I leave the room [ROOM NUMBER] to 3 mins later the nurse comes out to find who the hospice is and ask the other nurse to cancel EMT . A written statement from LPN #1, dated [DATE], read in part, .At approximately 1220 [12:20 p.m.] I was summoned to [Resident #9] room (201) by CNA's for an emergency. I got into her room and attempted to get her attention she did not reply to verbal stimula. I was told she had gotten choked on her lunch. Her appearance was discolored .performed a sternal rub .attempted a finger sweep down her throat On [DATE] at 10:10 a.m., CNA #8 stated they were the lead nurse aide and assisted with staffing. The CNA stated LPN #1 no longer was employed at the facility and they could not tell why they were no longer employed. On [DATE] at 10:29 a.m., same time as above CNA #6 stated they were agency staff that worked on [DATE] and had assisted Resident #9 with their noon meal. CNA #6 stated Resident #9 usually did not need asssistance with their meal, but they had asked because they had a lot of pain in their arms and hands. CNA #6 stated the resident was talking throughout the meal about getting up in their wheelchair after the meal to go out to the common area. I gave her a bite of mashed potatoes and gravy and Resident #9 took a deep breath and was trying to cough. The CNA stated they made sure Resident #9's head was up and placed the resident on their side after she could not say anything and Resident #9 face was turning red. CNA #6 stated the resident lipped for her to get the nurse and immediately told LPN #1 what was going on. The aide stated LPN #1 was slow to come to the room and placed a pulse ox on, lowered the bed, and left the room. CNA #6 stated there were other aides in the room after the incident started. The CNA identified CNA #7, CNA #9, and CNA #4 as being in the room after the resident started to choke. CNA #6 stated CNA #7 and the other aides raised the head of bed so the Resident was not flat and food started coming out the mouth and noise as well as flem. CNA #6 stated Resident #9 died a very painful death and was conscious looking at us with her eyes. The CNA stated the resident had a scared look on her face and LPN #1 did not do anything. The aide stated they thought when the nurse was in the room they would have provided guidance and assisted the resident with the choking. CNA #6 stated they were in shock and wished they had done more, but really thought the nurse would do the right thing once in the room. CNA #6 stated Resident #9 was trying to get something up and when Resident took a deep breath you could see Resident #6 was terrified by the look on their face. On [DATE] at 11:03 a.m., CNA #7 stated they were an agency aide working at the facility on [DATE] on the 7:00 a.m. through 3:00 p.m. shift. CNA #7 stated they went into Resident #9's room and saw the nurse in there taking her pulse and the Resident was lying flat. The CNA stated they and the other aides raised the head of the bed up and he tapped the back of the resident. CNA #7 stated once the head of bed was up and Resident #9 was not lying flat, food come of the nose and mouth. CNA #7 stated they did not nor did anyone perform the Heimlich or provide suctioning. CNA #7 stated the resident's eyes were open, they were in distress, and it appeared they were choking. CNA #7 stated the nurse left the room and Resident #9 passed away. CNA #7 stated he was provided the option of writing a statement on what happened, but they choose not to because they came in the room after the even started. On [DATE] at 11:21 a.m., the MDS Coordinator #1, stated they were management on duty the day the incident occurred. They stated Resident #9 had passed away and they were not actively dying even though they were on hospice services. The MDS coordinator stated Resident #9 was a DNR, but that did not apply to someone that was choking. The MDS Coordinator stated they asked LPN #1 if they had performed the Heimlich to Resident #9. The MDS Coordinator stated LPN #1 stated Resident #9 was choking and the only tried a finger sweep, toook vital signs and the resident was gone. They stated LPN #1 told them she did not perform the Heimlich on the Resident. The MDS Coordinator then stated she informed LPN #1 they should have known to perform the Heimlich even though Resident #9 was a DNR. The MDS Coordinator #1 then stated the aides felt as though the nurse did not respond to the resident in distress and only took the vital signs and left the room and were asked to write a statement of what happened. On [DATE] at 11:40 a.m., the Hospice RN, stated they received a call from the facility at 12:27 p.m., that Resident #9 was unresponsive. The nurse than stated she was never told Resident #9 had choked. They stated they had received a call from medical examiner asking questions around the choking, but knew nothing about Resident #9 choking. The Hospice RN stated if Resident #9 was choking, they should get help to see if the airway can be cleared. On [DATE] attempts were made to reach LPN #1 for an interview and no calls were returned. On [DATE] at 3:40 p.m., the Corporate RN stated they asked CNA #6 if the resident grabbed her throat and they said no and the resident was not choking since that was a universal sign. On [DATE] at 11:31 a.m., CNA #9 stated they were agency staff working at the facility on [DATE], when they entered the room of Resident #9 and the resident was in distress. They stated CNA #6, #7 and themselves raised the head of bed because the resident was lying flat and they were choking and the nurse kept requesting they keep the resident lying flat. The CNA stated they tried to get a blood pressure and the blood pressure cuff read error. The CNA stated the nurse had left the room when she was trying to take the blood pressure. CNA #9 stated once the resident head of bed was up the resident had food coming from their mouth and nose. CNA #9 stated no one in the room preformed the Heimlich and she did not see the nurse do anything except leave the room.

On [DATE] at 3:37 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure staff were trained on and responded to a choking resident. Resident #9 had diagnosis to include bipolar, dysphagia, protein calorie malnutrition, anxiety, reflux, and malignant neoplasm upper lobe left bronchus lung. On [DATE] a certified nurse aide provided assistance during the noon meal to Resident #9 after being asked. The resident was responding verbally throughout the meal until one bite when the resident took a deep breath and made attempts to cough. The certified nurse aide turned the resident on the side, did thrust to back with no success, and summoned the licensed practical nurse in charge of the hall of the emergency. During the response, the nurse did not instruct and/or perform the Heimlich to assist the resident with choking. Staff was interviewed and confirmed the resident was choking, the nurse did not respond, and provide any assistance to Resident #9 such as suctioning and/or the Heimlich Maneuver. The Certified nurse aide providing the meal assistance stated the resident struggled for 12 minutes and passed away. They also confirmed no one performed the Heimlich. Facility confirmed there was no system in place for agency staff and facility staff to ensure they were trained and had the skills necessary to respond to a resident that was choking. A review of the LPN employee file contained no documentation they had current certification and training in CPR to include the Heimlich maneuver. The corporate nurse, stated they do not have anything that shows the nurse was certified and/or trained for the Heimlich. On [DATE] at 3:40 p.m., the administrator and Corporate nurse were informed of the immediate jeopardy. On [DATE] at 9:06 p.m., an acceptable plan of care was received. The plan of removal documented, Plan of Removal # 2 for Training and competency in CPR 1. On [DATE]nd, initiated education and instruction on first aide and choking for all staff inclusive of agency staff ( current returning). 2. To ensure all staff are inserviced, staff cannot work until they have been in-serviced. 3. Will have a post test for Heimlich maneuver and return demonstration. 4. Root cause analysis will be conducted and completed by 8.3.23. 5. Will inservice Human resources and provide a check off list of in-services needed to new hires prior to starting in their department. Will begin on 8.3.23 and complete by 5pm on [DATE]rd, 2023. 6. Regional Operations team will be responsible for Plan of correction, and plan of removal will be done and completed by [DATE]th, 23 @ 12pm. On [DATE] after interviews with facility staff, and review of in-service documentation the immediacy was lifted, effective [DATE] at 12:00 p.m., when the last in-service was provided. The deficient practice remained at an isolated harm to the resident. Based on record review and interview, the facility failed to have a system in place to ensure staff were trained on and responded to a choking resident. Resident #9 was being assisted with her noon meal on [DATE] when they gasped for air and was choking on their food. LPN #1 did not respond to the choking and no one performed the Heimlich maneuver and Resident #9 died . The Resident Census and Conditions of Residents form, dated [DATE], documented 84 residents resided in the facility. Findings: Resident #9 was admitted to the facilty with diagnosis to include bipolar, chronic kidney disease, psychotic disorder with disillusions, anxiety, and malignant neoplasm of upper lobe, left lung. LPN #1's employee file documented they were hired on [DATE]. There was no documentation of training and/or certifications for emergencies such as CPR and choking. A nurse's progress note, dated [DATE] at 2:32 p.m., read in part, .This nurse was summoned to room after reports from CNA of resident not responding to staff after eating lunch. Assessed resident, no breathing, pulse, or blood pressure registered. Also, no verbal or painful response noted. Sternal rub attempted along with vital signs. Pulse ox 64%. Finger sweep attempted in search of foreign objects, nothing visible or remarkable to show. Resident did not respond verbally or to painful stimuli . A nurse's progress note, dated [DATE] at 6:11 p.m., read in part, .Residents body picked up .Family at bedside obtaining resident's belongings . On [DATE] at 10:10 a.m., CNA #8 stated they were the lead nurse aide and assisted with staffing. The CNA stated LPN #1 was no longer was employed at the facility and they could not tell why they were no longer employed. On [DATE] at 10:10 a.m., CNA #6 stated they were agency staff that worked on [DATE] and was the one assisting Resident #9 with their noon meal. CNA #6 stated the resident was talking throughout the meal about getting up in their wheelchair after the meal to go out to the common area. They stated they gave Resident #9 a bite of mashed potatoes and gravy and Resident #9 took a deep breath and was trying to cough. The CNA stated they made sure Resident #9's head was up and placed the resident on their side after she could not say anything and Resident #9 face was turning red. CNA #6 stated the resident lipped for her to get the nurse and immediately told LPN #1 what was going on. The aide stated LPN #1 was slow to come to the room and placed a pulse ox on, lowered the bed, and left the room. CNA #6 stated there were other aides in the room after the incident started. The CNA identified CNA #7, CNA #9, and CNA #4 as being in the room after the resident started to choke. CNA #6 stated CNA #7 and the other aides raised the had of bed so the Resident was not flat and food started coming out the mouth and noise as well as flem. CNA #6 stated Resident #9 died in a very painful death and was conscious looking at us with her eyes. The CNA stated the resident had a scared look on her face and LPN #1 did not do anything. The aide stated they thought when the nurse was in the room they would have provided guidance and assisted the resident with the choking. CNA #6 stated they were in shock and wished they had done more but really thought the nurse would do the right thing once in the room. CNA #6 stated Resident #9 was trying to get something up and when Resident took a deep breath you could see Resident #6 was terrified by the look on their face. On [DATE] at 11:03 a.m., CNA #7 stated they were an agency aide working at the facility on [DATE] on the 7:00 a.m. through 3:00 p.m. shift. CNA #7 stated they went into Resident #9 room and saw the nurse in there taking her pulse and the Resident was lying flat. The CNA stated they and the other aides raised the head of the bed up and he tapped the back of the resident. CNA #7 stated once the head of bed was up and Resident #9 was not lying flat food come of the nose and mouth. CNA #7 stated they did not nor did anyone perform the Heimlich or provide suctioning. CNA #7 stated the residents eyes were open and they were in distress and it appeared they were choking. CNA #7 stated the nurse left the room and Resident #9 passed away. On [DATE] at 1:37 p.m., the BOM stated they complete orientation for new hires and set them up to get trained. The BOM stated she will complete the orientation of the new employee on standard practices that are basic and nursing would be responsible for training them on nursing procedures. The BOM office manager stated they do not provide any orientation or training to agency staff and the staffing coordinator would be responsible for making sure they are trained and oriented to the facility. They stated the DON would be responsible to make sure all direct staff are trained on emergency procedures such a resident that was choking. On [DATE] at 1:45 p.m., CNA #8 stated they were the lead certified nurse aide and help with scheduling and getting agency staff when needed. They were asked how they ensured agency staff were proficient in skills such as assistant residents when they were choking. CNA #8 stated they go room to room and talk about the residents but do not make sure they are proficient in any skills and did no formal training or check of skills. On [DATE] at 1:51 p.m., the MDS Coordinator #1 stated the facility will do orientation and go over procedures only and the CPR and procedures for choking are expected all nurses are to have current training on the standards of practice. They stated there should be a process in place to make sure agency staff have the training and skills necessary to perform their duties, but was not sure if the facility was doing that. On [DATE] at 2:05 p.m., the Corporate RN stated there were competency check off for full time staff and would check for them. The Corporate RN then stated the agency staff would send their competency checks off when they come in, and she would provide them. She stated the nurse's should have current CPR certifications and we would have them in the employee file. A request was made for the training and certifications for LPN #1 and competency skills for CNA #6, CNA #7, and CNA #9. On [DATE] at 3:38 pm., the Corporate RN stated they did not have any certification in the employee file for LPN #1 and there was nothing to show the training and competency of the agency aide, CNA #6, CNA #7, CNA #9. On [DATE] at 3:40 p.m., the Corporate RN stated they asked CNA #6 if the resident grabbed her throat and they said no and the resident was not choking since that was a universal sign. She than stated they called the Hospice nurse who said the resident may have choked. On [DATE] at 11:31 a.m., CNA #9 stated they were agency staff working at the facility on [DATE], when they entered the room of Resident #9 and the resident was in distress. They stated CNA #6, #7, and themselves raised the head of bed because the resident was lying flat and they were choking and the nurse kept requesting they keep the resident lying flat. The CNA stated they tried to get a blood pressure and the blood pressure cuff read error. The CNA stated the nurse had left the room when she was trying to take the blood pressure. CNA #9 stated once the resident head of bed was up the resident had food coming from their mouth and nose. CNA #9 stated no one in the room preformed the Heimlich and she did not see the nurse do anything except leave the room.

On 07//27/23 at 11:45 a.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure residents were not missing from the facility and had procedures in place to account for all residents during the shift. Resident #2 had diagnoses which included Schizophrenia, Chronic Obstructive Pulmonary Disease, Senile Degeneration of brain, major depression, and anxiety. The Residents cognition was moderately impaired and they wandered the facilty. The resident had an elopement risk assessment completed on 07/02/23 and the Resdient was at risk for elopement. The care plan did not address wandering or elopement risk for Resident #2. Resident #2 was interviewed and stated they had left the facility by going over the fence because the fire department told them. Resident #2 stated they had walked a long and did not remember who brought them back to the facility. Video surveillance was observed with the maintance supervisor and Resident #2 was last seen on the camera in any part of the facility and/or property at 3:46 p.m. on 07/20/23. On 07/21/23 Resident #2 was found approximately 15 miles from the facility at a hospital and was returned to the facility. The resident was found to have blisters on their feet. Interviews with the staff working on 07/21/23 when the resident eloped were conducted and they had no knowledge the resident was gone from the facility. The staff also stated they knew the resident was at risk for elopement from his history at another facility of leaving the facility. On 07/27/23 at 12:00 p.m., the administrator and Corporate nurse were informed of the immediate jeopardy. On 07/27/23 at 3:40 p.m., an acceptable plan of care was received. The plan of removal documented, Plan of Removal for Cross Timbers Senior Mental Health July 27, 2023 Oklahoma State department of health, we are saddened by the allegation of failure to have a proper system in place to protect residents from an elopement. 1. On July 27, 2023 identified all residents who are at an elopement risk in Cross Timbers nursing and rehabilitation. 2. in-serviced all staff on who is an elopement risk at Cross Timbers Nursing and rehabilitation services. 3. Will place a binder with resident's name and face sheet identifying an elopement risk at nurse's station. 4. Will Inservice all staff on protocol for elopement drill for the safety of the residents and update care plans. 5. Current agency staff will be in serviced on #1 and #3 prior to returning to work shift. 6. Residents who are out in the smoking area will have line of sight during smoke breaks 7. Root cause analysis will be conducted and completed today 7/27/2023. Plan of removal done by 6pm 7.27.23 8. Regional managers will be responsible for the POC. 07/31/23 after interviews with facility staff, review of wandering assessments for all residents, care plans for moderate to high risk residents, and in-services the immediacy was lifted effective 07/31/23 at 5:00 p.m., when the last in-service was provided. The deficient practice remained at an isolated harm to the resident. Based on observation, record review, and interview, the facility failed to have a system in place to account for residents that wandered and at risk for elopement for one (#2) of three sampled residents who were at risk for elopement and wandered the facility. Resident #2 left the faciity on [DATE] at approximately 3:46 p.m., and was gone for over seven hours without staff knowing he was missing. Resident #2 returned to the facility on [DATE] at 12:40 p.m., and was found to have blisters on his feet. The MDS Coordinator identified 72 residents that were at risk for elopement and wandered the facility. Findings: Resident #2 was admitted to the facility on [DATE] with diagnosis of Schizophrenia, Chronic Obstructive Pulmonary Disease, Senile Degeneration of brain, major depression, and anxiety. An elopement risk assessment, dated 07/03/23 documented Resident #2 was at risk for elopement. A review of the clinical record contained no documentation the facility had completed a base-line care plan on admission to address the elopement risk of Resident #2. An admission assessment, dated 07/11/23, documented Resident #2 wandered the facility and was moderately impaired with their cognition. A review of the comprehensive admission care plan, dated 07/06/23, read in part, I have forgetfulness and poor memory. I have trouble making decisions and remembering to do daily care needs. I need verbal direction and reminders and supervision of staff . The care plan did not address Resident #2's wandering and risk for elopement. A police report, dated 07/20/23, read in part, .description missing person .incident status active synopsis .Resident with severe dementia left facility. Entered NCIC and Silver Alert issued .On 7/20/2023 at approximately 2329 hours [11:29 p.m.] , I responded to the area of [Facility] in reference to a missing person. The RP, [LPN #2], told me that a residence, [Resident #2], had possibly left the facility and could not be found . [Resident #2] is a [AGE] year old white male who was last seen wearing a white shirt, black sweat pants and red tennis shoes. He was also wearing a ball cap that was possibly blue in color and adorning a full beard .[LPN #2] explained to me that [Resident #2] has severe dementia and has been in a nursing facility for the last fourteen years .almost non verbal and mumbles lowly .gets extremely confused said [Resident #2] has done this in the past at prior facilities and left the grounds . 07/21/2023 .I watched the surveillance footage with [mainteance supervisor] I saw [Resident 32] go to the smoking area atb1537 [3:37 p.m.] hours and not return While I was at the nursing home other officers were canvassing the area in vehicles and with a drone. Once I finished at the nursing home I started to canvass the area. I stopped by 1300 Buena Vista Ave and spoke to the resident .residence is just north of the nursing home. I told her why I was speaking with her and she asked me for a description of [Resident #2] [Name deleted] told me she saw a man matching [Resident #2] description climb over the north fence. She told me this was yesterday (07/20/2023), sometime in the afternoon. I asked .if it could have been around 1530 to 1600 hours. [Name deleted] stated yes . Zt approx 1152 hours [Resident #2] was located by Oklahoma City Police Dept, at [Name deleted] .on S [NAME] Ave . A nurse's note, dated 07/21/023 at 1:21 a.m., read in part . This nurse was informed by on coming aide that [Resident #2] in his bed. At that time all staff began searching the building and surrounding property. After 20 minutes of searching [Name deleted] police notified. Contacted CMA [CMA #1] who stated she had last seen resident on smoke porch around 2200. Staff continued searching supervisors where notified and police searched building. Contacted residents previous facility who said resident was typically found on main roads and at gas stations. This information was relayed to police. A nurse's progress note, dated 07/21/23 at 12:45 p.m., read in part, .Resident came back to the facility at 1245 ambulating accompanied with one staff .Skin assessment done, resident had little blisters on feet, shoes removed and non-skid socks given to resident to put on .Resident put on 1:1 observation . On 07/26/23 at 3:30 p.m., Resident #2 was observed in the smoke area with five other residents with no staff present in the smoke area with them. Resident #2 was out in the smoke area until 3:50 p.m. went back inside and wandered the facility and into the dining room. No staff was observed present in the dining room or within eye sight of the resident while inside the facility. On 07/26/23 from 5:30 p.m. through 6:20 p.m., Resident #2 was observed wandering through out the facility unsupervised going back and forth from room to dining room and out into the smoke area. On 07/26/23 at 4:45 p.m., CNA #1 stated they worked on hall 200 on the 3:00 p.m. through 11:00 p.m. shift. She stated hall 200 had no resident that were at risk for elopement, but Resident #2 had jumped the fence and escaped and was placed on one on one for a short time. CNA #1 confirmed the worked on the on the 3:00 p.m. through 11:00 p.m. shift on 07/20/23 and did not know of anyone having left the facility. They stated residents are to be checked on every two hours and independent residents, like Resident #2 only when the call light comes on. CNA #1 stated Resident #2 was not in his bed or room each time they checked on him, but he would normally go outside to smoke. CNA #1 stated they did not look for the Resident because he was normally in bed or outside in the smoke area. CNA #1 than stated they do not remember seeing Resident #2 and they did not know when they had escaped over the fence. CNA #1 stated they still do not check on the Resdient unless they used the call light. On 07/26/23 at 5:03 p.m., CNA #2 stated they worked on hall 200 on the 3:00 p.m. through 11:00 p.m. shift and worked a double shift on hall 200 on 07/20/23. When asked to identify any resident on hall 200 that was at risk for elopement, CNA #2 no one on the hall was at risk for elopement. CNA #2 stated they did not see the resident at all on the 3:00 p.m. through 11:00 p.m. shift when they checked the room. They stated they will check every resident every two hours and if not in the room they do not look for them because residents move around so much. CNA #2 than stated she did not find out the resident was missing until the next day when they came in for their shift. On 07/26/23 at 5:16 p.m., CNA #3 they worked 07/20/23 on the 3:00 p.m. through 11:00 p.m. shift. She stated all residents were at risk for elopement because they all walk around the facility. CNA #3 was asked to identify any resident that had left the building on 07/20/23, they stated no one left the building on that night. On 07/26/23 at 5:23 p.m., CNA #4 stated they were not aware of anyone leaving the facility on the evening of 07/20/23. They stated they did work that and worked on hall 200. CNA #4 stated they had worked with Resident #2 as an agency staff and they were a high risk for elopement got away from the other facilities. CNA #4 stated they did not see Resident #2 on the 3:00 p.m. through 11:00 p.m. shift on 07/20/23 and the last time they saw them was in the morning because they worked a double shift. CNA #4 stated they checked on residents every two hours and did not find out until the next day Resident #2 had been missing. On 07/26/23 at 6:00 p.m., RN #1 stated they had worked her for five months. The RN stated they worked on the on the 3:00 p.m. through 11:00 p.m. on 07/20/23 and no one left the facility grounds on that night. They were asked about Resident #2 and their elopement risk and if they have ever left the facility grounds. RN #1 stated they knew nothing about Resident #2 and their elopement risk. On 07/26/23 at 6:10 p.m., CMA #2 stated they were working on the 3:00 p.m. through 11:00 p.m., on 07/20/23. They were asked to identify any resident on hall 200 at risk for elopement. The CMA #2 stated there was a new resident on the hall that wanders all the time and was always by the nurses station and to the smoke area. She was not able to identify the resident and identify Resident #2 at risk for elopement. They were asked to identify any resident who had eloped from the facility on the evening shift of 07/20/23, they stated no one had eloped from the facility that night. The CMA than stated there are a lot of agency staff working on hall 200 and they do not know the residents like staff who work at the facility full time. On 07/27/23 at 9:13 a.m., LPN #1, stated they have worked at the facility for one week and worked on the 3:00 p.m. through 11:00 p.m. on 07/20/23 on the hall Resident #2 resided on. LPN #1 stated Resident #2 did not leave the facility grounds on 07/20/23. The LPN was asked to identify residents that were at risk for elopement and they could not identify any resident including Resident #2 as an elopement risk. The LPN stated on 07/20/23, they did not know any of the residents let a long who would be an elopement risk. LPN #1 stated the night started out hectic because someone had to be sent to the hospital and stated Resident #2 was not one on one and they did not know of them being one on one at any time. On 07/27/23 at 9:39 a.m., CNA #5 was asked where Resident #2 was. The CNA stated they did not know but was out in the smoke area the last time they saw them. On 07/27/3 at 9:40 a.m. Resident #2 was observed in the smoke other residents and no staff were around or in the the line of site of them. On 07/27/23 at 9:50 a.m., the coordinator states someone brought Resident #2 back to the facility the next day and they did not know the exact time. The staffing coordinator stated they did not know when the resident left but they had left and was gone until the next day. They stated they were called in to help look for the resident once staff realized they were missing. On 07/27/23 at 9:57 a.m., MDS Coordinator #1 reviewed the care plan and stated the care plan did not address Resident #2 being at risk for elopement as the facility identified on admission. On 07/27/23 at 10:04 a.m., the administrator stated the resident returned to the facilty the next day in the afternoon. They further stated the Resdient was found several miles from the facility. The administrator stated they did not watch the surveillance video but the police and the maintenance supervisor looked at them. They than stated the medication aide did five the 9:00 p.m. medications to the resident. On 07/27/23 at 10:08 a.m., the BOM stated the police notified the facility the resident was found several miles a way at a hospital. The BOM stated she took the call informing them he had been found and the agency nurse had already picked Resident #2 up and brought him back to the facility. 07/27/2023 from 10:33 a.m. through 11:15 a.m., video surveillance camera footage was observed with maintenance supervisor was observed for the hours of 2:000 p.m. through 12:00 a m., The maintance supervisor stated the video footage was watched and provided to the police department and the last time he had been seen in the facility was around 3:37 p.m. On 07/20/23 the resident was observed in the halls of the facility until 3:467 p.m., when he exited hall 100 to the smoke area. From 3:47 p.m. through 11:30 p.m., the resident was not observed in the halls, or dining room. On 07/31/2023 at 3:23 p.m., LPN #2 stated they were an agency nurse that worked at the facility on 07/20/23 on the 3:00 p.m. to 11:00 p.m. shift. They stated CMA #1 came to here and asked where Resident #2 was located and never came back so I thought they found the resident to give them medications. The LPN stated all the aides had left for the night when someone said Resident #2 was not in his room. LPN #2 stated their was a chair against the fence and the police were called. LPN #2 stated the Resdient was located approximately 15 miles from the facility. LPN #2 stated they did not realize the Resident #2 was missing the night before because they always would ask for cigarettes and they are kept on the cart. LPN #2 stated they knew the resident from another facility and he was a high risk for elopement and was able to get away from the facility more than once. The LPN stated when they took Resident #2 shoes and socks off his feet were red and they had blisters on his toes. When asked about the surveillance camera inside the facility and the resident not being observed on the camera since 3:46 p.m., LPN #2 stated it was hard to believe that she did not notice the resident was gone and that there was another nurse on the hall that was being trained also.

On 03/07/23, an IJ situation was determined to exist due to the facility failing to ensure: a. Resident #2 was not exploited by being asked to partake in illegal drug activity, and b. Resident #8 was not exploited by being given $15 to purchase illegal drugs from Resident #1. Resident #2 stated they were threatened with a 30 day eviction notice if they did not participate. Resident #8 stated the Administrator told them they would get kicked out of the facility if they did not participate. On 03/07/23 at 3:57 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 03/07/23 at 4:06 p.m., the administrator was notified of the IJ situation. On 03/08/23 at 3:49 p.m., an acceptable plan of removal was provided. The plan of removal documented: Plan of removal for CrossTimbers Senior Mental Health March 7, 2023 Oklahoma State department of health, we are saddened by the allegation of exploitation of our residents by our administrator. We take all allegations of abuse, neglect, and exploitation seriously our plan to remove the Immediate Jeopardy based on new information and findings by the state surveyor today we have: 1. On March 7, 2023 suspended administrator pending investigation. 2. Regional operations manager will conduct onsite investigation on allegation of exploitation March 8, 2023. 3. Investigation will include speaking with all parties involved: family, residents, APS, surveyors, and administrator. 4. On March 7th, nursing team-initiated in-services for all staff on abuse, neglect, and exploitation Human Resources and designee will complete in-services Completion date of in-services March 8, 2023. 5. Will conduct safe surveys of all residents. Completion date March 8, 2023, guided by regional operations manager. 6. Root cause analysis will be conducted and completed by March 8, 2023 7. Regional operations manager will be responsible for POC. 8. Completion date 3/8/2023 at 8pm. On 03/09/23, interviews were conducted with staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 03/09/23 at 12:15 p.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 03/09/23 at 11:01 a.m. The deficiency remained at a level of potential harm at a pattern. Based on record review and interview, the facility failed to ensure residents weren't exploited for two (#2 and #8) of three sampled residents reviewed for abuse. The Resident Census and Conditions of Residents report, dated 03/06/23, documented 91 residents resided in the facility. Findings: A 2022 Abuse, Neglect and Exploitation policy, read in part, .'Exploitation' means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion .The facility will develop and implement written policies and procedures that .Prohibit and prevent abuse, neglect, and exploitation of residents . 1. Resident #8 had diagnoses which include bipolar disorder. A Resident Grievance form, dated 02/27/23, read in part, .Resident #1 states Resident #8 was in Resident #1's room and Resident #8 asked Resident #1 to buy weed for Resident #8. Resident #8 gave Resident #1 $10 for it. Resident #1's roommate noticed the administrator was standing outside the door when this happened .Resident #8 stated to Resident #1 that Resident #8 was given money by the administrator to buy weed. Resident #8 was caught with weed and was trying to get out of it by helping locate others with weed . On 03/06/23 at 8:35 a.m., Resident #1 stated the Administrator sent a resident with $10 dollars to buy weed from them. Resident #1 stated, I don't even sell weed. On 03/07/23 at 11:40 a.m., the DON was asked how the grievance, dated 02/27/23, had been resolved. She stated, I think we are still working on that because it became an APS issue. She stated they were trying to figure out who was bringing drugs into the building. The DON stated part of the investigation was Resident #8 was to take money to Resident #1 to see if Resident #1 would sell them drugs. On 03/07/23 at 12:03 p.m., the Administrator was asked to explain the grievance made by Resident #1. She stated they were in the process of investigating how drugs were getting in the building. She stated she had given Resident #8 $15 dollars of her own money to see if Resident #1 would sell them weed. The Administrator stated she followed Resident #8 to Resident #1's room and tried to listen to the interaction outside the door. On 03/07/23 at 2:38 p.m., Resident #8 was asked if staff had ever asked them to help set up another resident related to drugs. Resident #8 stated, Yes. Resident #8 stated the Administrator gave them $15 dollars to try to buy weed from Resident #1 about two weeks ago. Resident #8 stated Resident #1 was giving them a hard time now and everyone was calling them a snitch. On 03/07/23 at 3:00 p.m., Resident #8 was asked how they felt being called a snitch. They stated, It is what it is. Resident #8 stated, She told me if I didn't do that, I'd get kicked out. Resident #8 stated, She basically bullied me to do it. Resident #8 stated, I felt like it was my only option. 2. Resident #2 had diagnoses which included quadriplegia, major depressive disorder, anxiety disorder, and post traumatic brain injury. A Quarterly Resident Assessment, dated 12/09/22, documented Resident #2 had moderate cognitive impairment, no behaviors, required total dependence of two-person physical assist for the task of bed mobility, transfer, dressing, toilet use, and bathing. It documented the resident required extensive assistance two-person physical assist for the task of locomotion on unit, locomotion off unit, and personal hygiene. It documented the resident had range of motion impairment on both sides in the upper and lower extremities. A Resident Education form, dated 01/17/23, documented Resident #2 was at risk of a 30-day notice due to smoking inside the facility. A State Reportable incident for Resident #2, incident date 02/17/23, documented a combined initial and final investigation on allegations of abuse/mistreatment and allegations of neglect was sent to OSDH on 02/22/23. Part B documented on 02/22/23, a State Agency worker reported to the Administrator the resident or resident representative made a complaint stating they were given an inappropriate 30-day notice. It documented the resident was asked to set up staff and residents to get them to smoke so they could get fired or kicked out of the facility. The State reportable documented a resident tried to coerce them into smoking weed. It documented the Administrator stated they would try to make it go away. The incident report read in parts, .If [Resident #2] did a sting operation. [They] has [sic] been threatened with a 30 day notice .when everyone else was given a warning .Investigation initiated immediately. Administrator suspended pending investigation . There was no documentation 30 day notices had been given to Resident #2. A final State Reportable to the 02/17/23 incident, documented the facility completed an initial investigation by interviewing the resident and other residents in the area. A safe survey was completed with 10 residents along with staff abuse questionnaire with 13 staff members. Physician, Local Law Enforcement, and Family were notified. The Administrator was suspended pending the investigation. It documented upon completion of the investigation; the facility was unable to substantiate the allegation of abuse. It documented interviews and focused assessments with yielded no clear signs for the substantiation of the allegation. The facility educated all staff on the signs and symptoms of abuse, policies and procedures for reporting allegations of abuse, neglect, and misappropriation. An updated policy and procedure on illegal drug use in the facility was completed. The resident and staff questionnaires, completed for the abuse allegation, did not document residents or staff were asked about threats of 30-day notices. The questionnaires did not document residents or staff were asked if anyone had ever asked them to set up residents or staff members to get them to smoke so they could get fired or kicked out of the facility. There was no documentation of a completed investigation related to the Administrator's involvement in the above abuse allegation provided to the survey team. A Police Call Sheet report, dated 02/22/23, documented the Administrator believed seven residents were smoking marijuana at the facility. It documented staff was unable to find any marijuana in the rooms at this time. On 03/01/23 at 2:34 p.m., Family Member #1 stated last week the Administrator had police come into the facility because she thought Resident #2 was the THC supplier. Family Member #1 stated Resident #2 was not physically capable of putting anything in their own mouth. They stated the Administrator searched the resident's room and bag without the Resident's permission. They stated after the Administrator searched Resident #2's room without consent, the Administrator asked Resident #2 to be an informant to find out who was providing marijuana in the facility. Family member #1 stated because of the above incident, Resident #2 was afraid to leave their room. On 03/01/23 at 3:46 p.m., Resident #2 stated the Administrator and the SSD had come into their room. Resident #2 stopped mid conversation and started to get upset with facial grimacing. The resident then continued stating they came into the room and asked them to set up an employee with a sting operation a couple weeks ago. They stated they wanted them to have a kitchen employee, whose real name they did not know, come into their room which had a video camera in it, and hit some weed. They stated they had told the Administrator and the SSD that they would do it. Resident #2 stated after the conversation, Resident #2 told the kitchen employee about the above conversation. They stated since then, the staff started telling Resident #2 30-day eviction. Resident #2 stated they hadn't done anything wrong, they stated someone else had the marijuana. Resident #2 stated the Administrator and SSD said if they didn't do the sting operation, they would be kicked out of the facility. They stated the staff members kept saying it over and over every day. Resident #2 began getting upset and crying. They stated the kitchen staff member they wanted them to set up was their friend. Resident #2 stated the Administrator and SSD had asked them to get the kitchen staff member to bring Resident #2 weed and get them high. Resident #2 stated the Administrator told them to only hit the weed two times when they bought it. They stated the Administrator wanted them to set up a resident also and as a result, they would Knock off my 30-day notice. On 03/01/23 at 4:00 p.m. Resident #2 stated the Administrator kept saying 30-day notice hanging it over their head. The resident began crying again. Resident #2 stated the 30-day notice was verbal, not written. They stated the Administrator and SSD searched their room multiple times since the above event without their consent. On 03/07/23 at 1:50 p.m., the DON was asked the policy for investigating allegations of abuse. The DON stated an investigation would be completed which included interviewing residents and staff members to see if they had any concerns. The DON stated if a resident made an allegation against a staff member, the staff member would be suspended pending the investigation. The DON stated the physician and family would be notified, and the investigation would continue until a conclusion was reached. The DON was asked to explain the incident, dated 02/17/23, involving Resident #2. The DON stated they were not made aware of the abuse allegation from the State Agency worker until 02/22/23. The DON stated Resident #2 made an allegation of abuse and neglect. The DON stated Resident #2 had been in trouble with drugs multiple times and they were notified of a 30-day notice related to drugs. The DON stated the notice was given verbally by the Administrator. The DON stated the resident admitted to using drugs but refused a drug test. The DON was asked if residents or staff were interviewed regarding a 30-day notice. They stated, No. They were asked what investigation was completed for the 30-day inappropriate notice allegation. The DON stated the wording on the State Reportable came directly from the State Agency worker's report. The DON stated the facility did not investigate the 30-day notice because they were not officially given one. The DON was asked to explain Resident #2 being asked to set up staff/residents to have him smoke so they could get fired in a sting operation which was documented on the State Reportable. The DON stated the Administrator wanted to find out who was bringing in marijuana. The DON stated the Administrator and Resident #2 had a conversation if the resident would smoke with a particular person, they could identify who the person was that was bringing in the drugs. The DON stated it was just asked by the Administrator, but it was never set up. They stated the Administrator had been suspended on the 23rd and returned on the 28th due to the February Abuse allegation involving Resident #2. They were asked how the facility determined it was safe for the Administrator to return to work. The DON stated, I didn't determine that, Corporate determined that. The DON was asked to explain Part C on the combined initial and final report for Resident #2. She stated they were supposed to mark it out. They stated it was a separate incident, and the Final report was the corrected one. The DON was asked if during the investigation, were residents asked if the Administrator had asked them to purchase or use drugs. They stated, I don't believe so. They were asked how the allegation was thoroughly investigated. They stated, I don't know. The DON stated she knew the Administrator had asked specific residents, but as for if she asked other residents, We don't know. The DON was asked if they had any involvement with the setting up or asking any residents to use drugs in the facility. They stated, No. On 03/07/23 at 2:43 p.m., the Administrator was asked to explain the above State Reportable involving Resident #2. She stated, prior to the State Agency worker notifying the facility of the above abuse allegation, the facility was already investigating drugs in the facility. They stated residents were blaming each other. The Administrator stated she had come to Resident #2 because they had audio and video present in their room. They stated Resident #2's family member was present. They stated Resident #2 confessed to smoking weed. The Administrator stated they told Resident #2 they needed to find out who was bringing it in. The Administrator stated the resident stated they didn't want to be a snitch. The Administrator asked Resident #2 to act as they normally would. The Administrator was asked to explain what that meant. They stated whether it was get it [marijuana] or participate, or whatever Resident #2 normally did related to drugs in-front of the camera. The Administrator stated they were trying to catch who was bringing marijuana into the facility/selling it on camera. The Administrator stated they asked to have access to Resident #2's camera to help them catch who was bringing in drugs to the facility. The Administrator stated if Resident #2 was unwilling to tell them who was bringing in the drugs, they still had to proceed with the 30-day notice. They stated, Possible 30-day notice. The Administrator stated Resident #2 was notified they were going to get a 30-day notice via a phone call made by the Administrator to the resident's family members related to drug use. The Administrator stated the family was upset. She stated they hadn't actually issued a 30-day notice, they were just notifying the family which stage of their policy they were in. The Administrator stated she had not seen Resident #2 using drugs in the facility. The Administrator reported they believed the resident had tested positive for drugs. The Administrator was asked to provide this documentation. No documentation of the resident testing positive for drugs was provided during the survey. On 03/07/23 at 3:12 p.m., the DON informed the Administrator the survey team had the Safe Surveys which were completed with residents. They were made aware, upon review of the surveys, there was no documentation residents were asked about 30-day notices or being asked to buy drugs in the Safe Survey. They were informed the survey did not address the specific concerns on the Abuse allegation involving Resident #2. 35749